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Objective: Young people living with HIV (YPLWH) experience increased morbidity and mortality compared to all other age groups. Adolescence brings unique challenges related to sexual reproductive health, the elevated importance of peer groups, and often, emerging symptoms of emotional distress. Failure to address this unique life stage for YPLWH can lead to worse HIV and mental health outcomes. Herein lies the protocol for a hybrid-type-1 effectiveness-implementation trial designed to evaluate a mental health and life skills intervention that aims to address these needs for YPLWH in Tanzania., Methods: This is an individually randomized group-treatment trial designed to evaluate the effectiveness of Sauti ya Vijana (SYV: The Voice of Youth) toward improving viral suppression (HIV RNA <400 copies/mL) and mental health outcomes and to assess implementation including acceptability, feasibility, fidelity, and cost-effectiveness of the manualized intervention. The trial is being conducted across four geographically distinct regions of Tanzania. Peer group leaders (PGL) with lived HIV experience deliver the 10-session group-based intervention and two individual sessions during which participants describe their disclosure narrative (when they learned they live with HIV) and value-based goal setting. Caregiver or chosen supportive adults are encouraged to attend two specific group sessions with their youth. Participants are 10-24 years of age, prescribed antiretroviral therapy for at least 6 months, fully aware of their HIV status, able to commit to session attendance, and able to understand and meaningfully contribute to group sessions. Participant study visits occur at 5 time points for evaluation: baseline, 4-, 6-, 12-, and 18-months post baseline. A single booster session is conducted before the 12-month visit. Study visits evaluate mental health, adverse childhood events, interpersonal violence, resilience, stigma, HIV knowledge, substance use, sexual relationships, ART adherence, and HIV RNA. Implementation outcomes evaluate feasibility and acceptability through attendance, intervention session notes, focus discussion groups and qualitative interviews. Fidelity to the intervention is measured using fidelity checklists by a PGL observer at each group session. Cost effectiveness is calculated using an incremental cost-effectiveness ratio that utilizes a patient cost questionnaire and financial records of study costs., Significance: Few mental health interventions for YPLWH have demonstrated effectiveness. Results from this study will provide information about effectiveness and implementation of a peer-led intervention for delivering a mental health and life skills intervention in low-income settings., Trial Identifier: This trial is registered at clinicaltrials.gov NCT05374109., Competing Interests: All authors have declared that no competing interests exist., (Copyright: © 2024 Mollel et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Purpose: Young people living with HIV (YPLWH) face the burden of navigating the unique physical, psychological, and social challenges of adolescence while coping with a stigmatized infectious disease that requires lifelong care. Consequently, YPLWH experience worse HIV outcomes compared to children and adults. This systematic review seeks to collate evidence on the health and economic impact of HIV interventions targeting YPLWH and to identify gaps in the available evidence that may inform future economic evaluations of interventions for YPLWH., Methods: We searched the MEDLINE, Embase, Scopus, and Global Index Medicus databases for peer-reviewed articles published through April 24, 2022 (PROSPERO ID: CRD42022356244). Our inclusion criteria encompassed economic evaluations of HIV interventions that report health and economic outcomes among individuals ages 10-24 years. Three investigators screened articles at the title, abstract, and full-text levels. The data were extracted in accordance with the Consolidated Health Economic Evaluation Reporting Standards 2022., Results: Of the 3,735 unique articles retrieved through our search, 32 met our inclusion criteria. Of these 32 articles, 8 (25%) evaluated a behavioral, educational, or financial intervention, 6 (19%) voluntary medical male circumcision, 5 (16%) HIV screening or testing, 4 (13%) pre-exposure prophylaxis, 3 (9%) a hypothetical HIV vaccine, 2 (6%) antiretroviral therapy, 1 (3%) condom distribution, and 3 (9%) a combination of interventions. Twenty-two studies (69%) focused on Africa, 9 (28%) on North America, and 1 (3%) on Europe. Thirty studies (94%) were cost-effectiveness analyses and 2 (6%) were cost-utility analyses. Of the intervention types captured by this review, most were deemed cost-saving or cost-effective. Only two studies-one evaluating a financial intervention and one evaluating HIV testing-concluded that the intervention was not cost-effective., Discussion: Evidence presented by this review suggests that investments in HIV prevention and treatment for young people can be a cost-effective, and sometimes cost-saving, solution to combating the global HIV epidemic. However, additional evaluations of HIV interventions targeting young people, which adhere to standardized reporting practices, are needed to permit comparability of cost-effectiveness outcomes between interventions and settings., (Copyright © 2024 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Following the marketization of China's health system in the 1980's, the government allowed public hospitals to markup the price of certain medications by 15% to compensate for reduced revenue from government subsidies. This incentivized clinicians to induce patient demand for drugs which resulted in higher patient out-of-pocket payments, higher overall medical expenditure, and poor health outcomes. In 2009, China introduced the Zero Markup Drug Policy (ZMDP) which eliminated the 15% markup. Using Shanghai as a case study, this paper analyzes emerging and existing evidence about the impact of ZMDP on hospital expenditure and revenue across secondary and tertiary public hospitals. We use data from 150 public hospitals across Shanghai to examine changes in hospital expenditure and revenue for various health services following the implementation of ZMDP. Our analysis suggests that, across both secondary and tertiary hospitals, the implementation of ZMDP reduced expenditure on drugs but increased expenditure on medical services, exams, and tests thereby increasing hospital revenue and keeping inpatient and outpatient costs unchanged. Moreover, our analysis suggests that tertiary facilities increased their revenue at a faster rate than secondary facilities, likely due to their ability to prescribe more advanced and, therefore, more costly procedures. While rigorous experimental designs are needed to confirm these findings, it appears that ZMDP has not reduced instances of medical expenditure provoked by provider-induced demand (PID) but rather shifted the effect of PID from one revenue source to another with differential effects in secondary vs. tertiary hospitals. Supplemental policies are likely needed to address PID and reduce patient costs., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Zhang, Zimmerman, Lai, Zhang, Tang, Tang and Ogbuoji.)

Background: Cardiovascular diseases (CVD) remains a leading cause of mortality in Myanmar. Despite the burden, CVD preventive services receive low government and donor budgets, which has led to poor CVD outcomes., Methods: We conducted a cost-effective analysis and a budget impact analysis on CVD prevention strategies recommended by the WHO. A Markov model was used to analyse the cost and quality-adjusted life year (QALY) from healthcare provider and societal perspectives. We calculated transition probabilities from WHO CVD risk data and obtained treatment effects and costs from secondary sources. Subgroup analysis was performed on different sex and age groups. We framed the budget impact analysis from a healthcare provider perspective to assess the affordability of providing CVD preventive care., Findings: The most cost-effective strategy from the healthcare provider perspective varied. The combination of screening, primary prevention, and secondary prevention (Sc-PP-SP) (incremental cost-effectiveness ratio [ICER]: US$1574/QALY) is most cost-effective at the three times gross domestic product (GDP) per capita threshold, while at one time the GDP per capita threshold, secondary prevention is the most cost-effective strategy (ICER: US$160/QALY). Sc-PP-SP is the most cost-effective strategy from the societal perspective (ICER: US$647/QALY). Among age groups, intervention at age 45 years appeared to be the most cost-effective option for both men and women. The budget impact revealed the Sc-PP-SP would avert 55,000 acute CVD events and 28,000 CVD-related deaths with a cost of US$157 million for the first year of CVD preventive care., Interpretation: A combination of screening, primary prevention, and secondary prevention is cost-effective to reduce CVD-related deaths in Myanmar. This study provides evidence for the government and development partners to increase investment in and support for CVD prevention. These findings not only provide a basis for efficient resource allocation but also underscore the importance of adopting a total cardiovascular risk approach to CVD prevention, in alignment with global health goals., Funding: Pilot grant from Duke Global Health Institute, USA., Competing Interests: This project was funded by a pilot grant from Duke Global Health Institute, USA. WM, OO and GY have received grants from WHO, and Bill and Melinda Gates Foundation (payments made to Centre for Policy Impact in Global Health, Duke University); ZM, TT, ZLK, and PYP have received grants from Bill and Melinda Gates Foundation (payments made to Community Partners International through Centre for Policy Impact in Global Health, Duke University). Authors declare no other conflicts of interest., (© 2024 The Author(s).)

Although the sociodemographic and economic contributors to under-five mortality are well established, very little research has been done to assess the levels of disadvantage under-five children in Nigeria face along these dimensions. Nigeria has the second-highest under-five mortality rate (U5MR) in the world (111 deaths per 1000 live births) and contributed to the highest number of annual under-five deaths globally in 2020 (844,321 deaths). The country has also implemented several decades of policy interventions to reduce under-five mortality by improving sociodemographic and economic conditions at the household level. In this paper, we assess the sociodemographic and economic disadvantages that households with children under-five face compared to other households and discuss the implications for health policy. Using the Nigeria Living Standard Survey 2018-19, we conducted a bivariate analysis to compare the sociodemographic and economic characteristics of households with and without under-five children. We performed independent samples t-test and proportions test to assess whether these sociodemographic and economic factors were significantly different for both groups. We found that households with under-five children typically had larger sizes (6.6 vs. 3.6), lower mean adult age (36.5 vs. 45.3), and male household heads (91.3% vs. 71.5%) than households without under-five children. Furthermore, households with under-five children were less likely to have access to improved drinking water (77.2% vs. 86.0%) and sanitation sources (54.0% vs. 61.9%) than those without under-five children. Despite having more adult working members, 71.2% of households with under-five children lived below the poverty line compared to 37.7% of other households. Although their total consumption expenditure was lower than households without under-five children, they spent a higher proportion of their expenditure on health care and were at a higher risk of experiencing catastrophic health expenditure. Our study has shown that households with children under five are disproportionately disadvantaged than other households in Nigeria. The households with under-five children are larger, younger, and poorer than those without children. We also show a wide variation in the proportion of households with children under five by state. Any efforts to reduce under-five mortality and morbidity in Nigeria should recognize these sociodemographic and economic differences., Competing Interests: OO has received grants and consultation fees from the Partnership for Maternal Newborn and Child Health (PMNCH)., (Copyright: © 2024 Deshpande, Ogbuoji. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Over 1.7 billion children lack access to surgical care, mostly in low- and middle-income countries (LMICs), with substantial risks of catastrophic health expenditures (CHE) and impoverishment. Increasing interest in reducing out-of-pocket (OOP) expenditures as a tool to reduce the rate of poverty is growing. However, the impact of reducing OOP expenditures on CHE remains poorly understood. The purpose of this study was to estimate the global impact of reducing OOP expenditures for pediatric surgical care on the risk of CHE within and between countries. Our goal was to estimate the impact of reducing OOP expenditures for surgical care in children for 149 countries by modeling the risk of CHE under various scale-up scenarios using publicly available World Bank data. Scenarios included reducing OOP expenditures from baseline levels to paying 70%, 50%, 30%, and 10% of OOP expenditures. We also compared the impact of these reductions across income quintiles (poorest, poor, middle, rich, richest) and differences by country income level (low-income, lower-middle-income, upper-middle-income, and high-income countries).Reducing OOP expenditures benefited people from all countries and income quintiles, although the benefits were not equal. The risk of CHE due to a surgical procedure for children was highest in low-income countries. An unexpected observation was that upper-middle income countries were at higher risk for CHE than LMICs. The most vulnerable regions were Africa and Latin America. Across all countries, the poorest quintile had the greatest risk for CHE. Increasing interest in financial protection programs to reduce OOP expenditures is growing in many areas of global health. Reducing OOP expenditures benefited people from all countries and income quintiles, although the benefits were not equal across countries, wealth groups, or even by wealth groups within countries. Understanding these complexities is critical to develop appropriate policies to minimize the risks of poverty., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Smith et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Over the past decade, Nigeria has seen major attempts to strengthen primary health care, through the Saving One Million Lives (SOML) initiative, and to move towards universal health care, through the National Health Act. Both initiatives were successfully adopted, but faced political and institutional challenges in implementation and sustainability. We analyse these programmes from a political economy perspective, examining barriers to and facilitators of adoption and implementation throughout the policy cycle, and drawing on political settlement analysis (PSA) to identify structural challenges which both programmes faced. The SOML began in 2012 and was expanded in 2015. However, the programme's champion left government in 2013, a key funding source was eliminated in 2015, and the programme did not continue after external funding elapsed in 2021. The National Health Act passed in 2014 after over a decade of advocacy by proponents. However, the Act's governance reforms led to conflict between health sector agencies, about both reform content and process. Nine years after the Act's passage, disbursements have been sporadic, and implementation remains incomplete. Both programmes show the promise of major health reforms in Nigeria, but also the political and institutional challenges they face. In both cases, health leaders crafted evidence-based policies and managed stakeholders to achieve policy adoption. Yet political and institutional challenges hindered implementation. Institutionally, horizontal and vertical fragmentation of authority within the sector impeded coordination. Politically, electoral cycles led to frequent turnover of sectoral leadership, while senior politicians did not intervene to support fundamental institutional reforms. Using PSA, we identify these as features of a 'competitive clientelist' political settlement, in which attempts to shift from clientelist to programmatic policies generate powerful opposition. Nonetheless, we highlight that some policymakers sought to use health reforms to change institutions at the margin, suggesting future avenues for governance-oriented health reforms., (© The Author(s) 2023. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

China's private hospital market has experienced rapid growth over the last decade, with private hospitals now outnumbering public hospitals by a factor of two. This policy analysis uses available data and existing literature to analyze China's rapidly changing hospital market, identify key challenges resulting from rapid private hospital growth, and present recommendations to ensure future sustainable private hospital development in the country. Our analysis shows that while private hospitals outnumber public hospitals, outpatient visits and hospitalizations remain higher among public hospitals, while per-patient expenditure remains higher among private hospitals. Key challenges to private hospital development include limited government financial support, high tax burdens, difficulty in workforce recruitment and retainment, poor government regulation and oversight, and dissipating public trust. Recommendations to address these challenges include opening government contract bidding to private hospitals, creating a system that allows private hospitals to enter national health insurance schemes, reducing tax pressure on private hospitals, defining a legal system for market entry and exit of private hospitals, improving a system of supervision, and monitoring and evaluation of private hospital operation and performance., Competing Interests: The authors report no conflicts of interest., (© 2023 The Authors.)

Background: Snakebite envenoming (SBE) affects nearly three million people yearly, causing up to 180,000 deaths and 400,000 cases of permanent disability. Brazil's state of Amazonas is a global hotspot for SBE, with one of the highest annual incidence rates per 100,000 people, worldwide. Despite this burden, snake antivenom remains inaccessible to a large proportion of SBE victims in Amazonas. This study estimates the costs, and health and economic benefits of scaling up antivenom to community health centers (CHCs) and hospitals in the state., Methods: We built a decision tree model to simulate three different antivenom scale-up scenarios: (1) scale up to 95% of hospitals, (2) scale up to 95% of CHCs, and (3) scale up to 95% of hospitals and 95% of CHCs. We consider each scenario with and without a 10% increase in demand for antivenom among SBE victims. For each scenario, we model the treatment costs averted, deaths averted, and disability-adjusted life years (DALYs) averted from a societal, health system, and patient perspective relative to the status quo and over a time horizon of one year. For each scenario and perspective, we also calculate the incremental cost per DALY averted and per death averted. We use a willingness to pay threshold equal to the 2022 gross domestic product (GDP) per capita of Brazil., Findings: Scaling up antivenom to 95% of hospitals averts up to 2022 DALYs, costs up to USD $460 per DALY averted from a health system perspective, but results in net economic benefits up to USD $4.42 million from a societal perspective. Scaling up antivenom to 95% of CHCs averts up to 3179 DALYs, costs up to USD $308 per DALY averted from a health system perspective, but results in net economic benefits up to USD $7.35 million from a societal perspective. Scaling up antivenom to 95% of hospitals and CHCs averts up to 3922 DALYs, costs up to USD $328 per DALY averted from a health system perspective, but results in net economic benefits up to USD $8.98 million from a societal perspective., Interpretation: All three antivenom scale up scenarios - scale up to 95% of hospitals, scale up to 95% of CHCs, and scale up to 95% of hospitals and 95% of CHCs - avert a substantial proportion of the SBE burden in Amazonas and are cost-saving from a societal perspective and cost-effective from a health system perspective., Funding: W.M. and J.S. were funded by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq productivity scholarships). W.M. was funded by Fundação de Amparo à Pesquisa do Estado do Amazonas (PRÓ-ESTADO, call n. 011/2021-PCGP/FAPEAM, call n. 010/2021-CT&I ÁREAS PRIORITÁRIAS, call n. 003/2022-PRODOC/FAPEAM, POSGRAD/FAPEAM) and by the Ministry of Health, Brazil (Proposal No. 733781/19-035). Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health under Award Number R21TW011944. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health., Competing Interests: CJG reports research funding from Ophirex Inc. for other studies., (© 2023 The Authors.)

Global campaigns to control HIV, tuberculosis, malaria, and vaccine-preventable illnesses showed that large-scale impact can be achieved by using additional international financing to support selected, evidence-based, high-impact investment areas and to catalyse domestic resource mobilisation. Building on this paradigm, we make the case for targeting additional international funding for selected high-impact investments in primary health care. We have identified and costed a set of concrete, evidence-based investments that donors could support, which would be expected to have major impacts at an affordable cost. These investments are in: (1) individuals and communities empowered to engage in health decision making, (2) a new model of people-centred primary care, and (3) next generation community health workers. These three areas would be supported by strengthening two cross-cutting elements of national systems. The first is the digital tools and data that support facility, district, and national managers to improve processes, quality of care, and accountability across primary health care. The second is the educational, training, and supervisory systems needed to improve the quality of care. We estimate that with an additional international investment of between US$1·87 billion in a low-investment scenario and $3·85 billion in a high-investment scenario annually over the next 3 years, the international community could support the scale-up of this evidence-based package of investments in the 59 low-income and middle-income countries that are eligible for external financing from the World Bank Group's International Development Association., Competing Interests: Declaration of interests TK, GY, SD, KKMcD, JL, CL, MMD, OO, PP, CS, AT, AZ, and CB declare grant funding from the Bill & Melinda Gates Foundation to support this work. TK declares consulting fees in the past 36 months from WHO Eastern Mediterranean Regional Office on models of care for primary health care and from the World Bank Group on integration of primary health care and pandemic prevention, preparedness, and response. KKMcD and GY declare other grants for global health research in the past 36 months from WHO, the Bill & Melinda Gates Foundation, The Carnegie Corporation of New York, the United Nations Economic and Social Commission for Asia and the Pacific, the Alliance for Health Policy and Systems Research, and the New Venture Fund. OO declares other grants for global health research in the past 36 months from WHO, the Bill & Melinda Gates Foundation, the National Institutes of Minority Health and Disparities, Duke REACH Equity, and the Alliance for Health Policy and Systems Research. LNA declares funding from SEEK Development to support this work; in the past 36 months he reports consulting fees from the World Bank to support country-level non-communicable disease (NCD) policy implementation, and consulting fees from WHO to support international and country-level NCD policy implementation. CS declares grants in the past 36 months from WHO and the Medicines for Malaria Venture (MMV) for various strategy consulting projects relating to global health, and consulting fees from the Bill & Melinda Gates Foundation, WHO, and MMV for various strategy consulting projects related to global health. CL and SD declare consulting fees in the past 36 months from the Bill & Melinda Gates Foundation for various strategy consulting projects related to global health. BT declares that she was previously Executive Director of the Primary Health Care Performance Initiative, funded by the Bill & Melinda Gates Foundation, while this work was being conducted. She works at the United States Agency for International Development, which has broad interest in development assistance for health/primary health care (she is co-authoring this paper in her personal capacity). DJ is supported by the London School of Hygiene & Tropical Medicine Takeda Chair in Global Child Health and declares grant funding from WHO and UKRI Innovation Fund. RN declares grant support from WHO for NCD implementation science research in association with a WHO Technical Advisory Group and from the World Bank for NCD research and policy development in the Europe and Central Asia (ECA) and sub-Saharan Africa (SSA) regions. DS declares that employment as Chief Digital Officer for the international NGO PATH supported the opportunity and ability to contribute to this article (PATH has a PHC programme and works to strengthen PHC in countries around the world). DS also declares board membership of Medic (governance role, uncompensated). DS is Co-Chair of the Leadership and Governance Committee (advisory role, uncompensated) for Transform Health Coalition. PB declares that he is currently the Global Director of Policy Advocacy and Communication at the Bill & Melinda Gates Foundation. He did not review or approve the grant that supported this work. He was a member of the international expert advisory group. All other authors declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

UN member states have committed to universal health coverage (UHC) to ensure all individuals and communities receive the health services they need without suffering financial hardship. Although the pursuit of UHC should unify disparate global health challenges, it is too commonly seen as another standalone initiative with a singular focus on the health sector. Despite constituting the cornerstone of the health-related Sustainable Development Goals, UHC-related commitments, actions, and metrics do not engage with the major drivers and determinants of health, such as poverty, gender inequality, discriminatory laws and policies, environment, housing, education, sanitation, and employment. Given that all countries already face multiple competing health priorities, the global UHC agenda should be used to reconcile, rationalise, prioritise, and integrate investments and multisectoral actions that influence health. In this paper, we call for greater coordination and coherence using a UHC+ lens to suggest new approaches to funding that can extend beyond biomedical health services to include the cross-cutting determinants of health. The proposed intersectoral co-financing mechanisms aim to support the advancement of health for all, regardless of countries' income., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 World Health Organization. Published by Elsevier Ltd. All rights reserved. This is an Open Access article published under the CC BY-NC-ND 3.0 IGO license which permits users to download and share the article for non-commercial purposes, so long as the article is reproduced in the whole without changes, and provided the original source is properly cited. This article shall not be used or reproduced in association with the promotion of commercial products, services or any entity. There should be no suggestion that WHO endorses any specific organisation, products or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.)

Background: When countries reach the middle-income threshold, many multilateral donors, including Gavi, the Vaccine Alliance (Gavi), begin to withdraw their official development assistance (ODA), known as graduation. We hypothesised that bilateral donors might follow Gavi's lead, except in countries where they have strategic interests. We aim to understand how bilateral donors behave after a recipient country graduates from Gavi support and how bilateral donors might treat Gavi support countries differently, based on 'strategic interest'. We also aim to identify countries that were more vulnerable to 'simultaneous' transitions and financial cliffs after Gavi transition., Methods: This is an observational dyadic analysis using longitudinal data. We collected country-level data on 77 Gavi-eligible countries between 2009 and 2018 and paired donor and recipient country in a specific year to conduct dyadic analysis. We included Gavi graduation status and Gavi disbursement as explanatory variables. We controlled for (1) donor-recipient relationship variables that represent potential strategic relationships (eg, distance between donor and recipient country) and (2) recipient-level characteristics (eg, population, income). We used Odinary Least Squares regression, Tobit and two-part model in Stata SE 15.0., Findings: We found a country would receive $3.1 million less all sector ODA from a bilateral donor, and $0.6 million less health ODA, after they graduate from Gavi. For every additional 1% ODA a country would receive from Gavi, it would receive 0.14% more ODA and 0.16% more health ODA from individual bilateral donors. Gavi's graduation status or disbursement brought more change in percentage term to health ODA than to total ODA. Additionally, Gavi's graduation was observed to have a larger negative impact on bilateral ODA in the longer term. Countries that sent more migrants, had been colonised, and received more US military assistance tended to receive more ODA. There are similarities and differences across different donors and bilateral donors tend to provide more ODA to nearby countries and countries receiving fewer exports from the donor. We found that former colonies did not see a decline in aid after Gavi graduation., Conclusion: Bilateral donors behave in a similar manner to Gavi when it comes to funding health systems in low and middle-income countries. Therefore, some countries may be at risk of losing donor resources for health from a multitude of sources around the same time. However, countries that have a strategic interest in bilateral donors may be spared from such funding cliffs. This research has important implications for global health donors' funding policies and approaches in addition to recipient countries' transition planning., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Importance: Over-the-counter (OTC) hearing aids are now available in the US; however, their clinical and economic outcomes are unknown., Objective: To project the clinical and economic outcomes of traditional hearing aid provision compared with OTC hearing aid provision., Design, Setting, and Participants: This cost-effectiveness analysis used a previously validated decision model of hearing loss (HL) to simulate US adults aged 40 years and older across their lifetime in US primary care offices who experienced yearly probabilities of acquiring HL (0.1%-10.4%), worsening of their HL, and traditional hearing aid uptake (0.5%-8.1%/y at a fixed uptake cost of $3690) and utility benefits (0.11 additional utils/y). For OTC hearing aid provision, persons with perceived mild to moderate HL experienced increased OTC hearing aid uptake (1%-16%/y) based on estimates of time to first HL diagnosis. In the base case, OTC hearing aid utility benefits ranged from 0.05 to 0.11 additional utils/y (45%-100% of traditional hearing aids), and costs were $200 to $1400 (5%-38% of traditional hearing aids). Distributions were assigned to parameters to conduct probabilistic uncertainty analysis., Intervention: Provision of OTC hearing aids, at increased uptake rates, across a range of effectiveness and costs., Main Outcomes and Measures: Lifetime undiscounted and discounted (3%/y) costs and quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs)., Results: Traditional hearing aid provision resulted in 18.162 QALYs, compared with 18.162 to 18.186 for OTC hearing aids varying with OTC hearing aid utility benefit (45%-100% that of traditional hearing aids). Provision of OTC hearing aids was associated with greater lifetime discounted costs by $70 to $200 along with OTC device cost ($200-$1000/pair; 5%-38% traditional hearing aid cost) due to increased hearing aid uptake. Provision of OTC hearing aids was considered cost-effective (ICER<$100 000/QALY) if the OTC utility benefit was 0.06 or greater (55% of the traditional hearing aid effectiveness). In probabilistic uncertainty analysis, OTC hearing aid provision was cost-effective in 53% of simulations., Conclusions and Relevance: In this cost-effectiveness analysis, provision of OTC hearing aids was associated with greater uptake of hearing intervention and was cost-effective over a range of prices so long as OTC hearing aids were greater than 55% as beneficial to patient quality of life as traditional hearing aids.

Background: The United Kingdom (UK) used to be the second largest bilateral provider of official development assistance (ODA) for health. However, in 2021 the UK government cut its annual aid budget by 30%. We aim to understand how these cuts might affect financing for health systems in UK aid recipient countries., Methods: We conducted a retrospective analysis of domestic and external funding for 134 countries that received UK aid for the 2019-2020 budget year. We grouped countries into two cohorts: those that continued to receive aid in 2020-2021 ("budget") and those that did not ("no budget"). Data was collected from publicly available datasets and we compared UK's ODA, UK's health ODA with total ODA, general government expenditures and domestic general government health expenditure to assess the donor dependency and donor concentration of budget and no budget countries., Findings: Budget countries are more reliant on external aid to finance their governments and health systems than no budget countries, with a handful of exceptions. While the UK does not appear to be a major ODA contributor among most no budget countries, it is in many budget countries. Two no budget countries in particular may be faced with health systems financing challenges given their high ratios of UK health aid to domestic government health expenditures: the Gambia (1.24:1) and Eritrea (0.33:1). Although "safe" for this budget cycle, a number of low-income countries in Sub-Saharan Africa have very high ratios of UK health aid to domestic government health expenditures, including South Sudan (3.15:1), Sierra Leone (0.48:1), and the Democratic Republic of Congo (0.34:1)., Interpretation: The 2021-2022 UK aid cuts could have negative impacts in a few countries highly dependent on UK health aid. Its departure could leave these countries with rather large funding gaps to fill and create a more concentrated donor climate., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 McDade, Mao, Prizzon, Huang and Ogbuoji.)

Introduction: Poverty-related and neglected diseases (PRNDs) cause over three million deaths annually. Despite this burden, there is a large gap between actual funding for PRND research and development (R&D) and the funding needed to launch PRND products from the R&D pipeline. This study provides an economic evaluation of a theoretical global pooled-funding mechanism to finance late-stage clinical trials of PRND products., Methods: We modelled three pooled-funding design options, each based on a different level of coverage of candidate products for WHO's list of PRNDs: (1) vaccines covering 4 PRNDs, (2) vaccines and therapeutics covering 9 PRNDs and (3) vaccines, therapeutics and diagnostics covering 30 PRNDs. For each option, we constructed a discrete event simulation of the 2019 PRND R&D pipeline to estimate required funding for phase III trials and expected product launches through 2035. For each launch, we estimated global PRND treatment costs averted, deaths averted and disability-adjusted life-years (DALYs) averted. For each design option, we calculated the cost per death averted, cost per DALY averted, the benefit-cost ratio (BCR) and the incremental cost-effectiveness ratio (ICER)., Results: Option 1 averts 18.4 million deaths and 516 million DALYs, has a cost per DALY averted of US$84 and yields a BCR of 5.53. Option 2 averts 22.9 million deaths and 674 million DALYs, has a cost per DALY averted of US$75, an ICER over option 1 of US$49 and yields a BCR of 3.88. Option 3 averts 26.9 million deaths and 1 billion DALYs, has a cost per DALY averted of US$114, an ICER over option 2 of US$186 and yields a BCR of 2.52., Conclusions: All 3 options for a pooled-funding mechanism-vaccines for 4 PRNDs, vaccines and therapeutics for 9 PRNDs, and vaccines, therapeutics and diagnostics for 30 PRNDs-would generate a large return on investment, avert a substantial proportion of the global burden of morbidity and mortality for diseases of poverty and be cost-effective., Competing Interests: Competing interests: All authors report grants from the Bill & Melinda Gates Foundation during the conduct of this study., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Maternal and newborn mortality rates in Nigeria are among the highest globally, and large socioeconomic inequalities exist in access to maternal, newborn, and child health (MNCH) services in the country. Inequalities also exist in catastrophic health expenditure among households in Nigeria. We aimed to estimate the health and financial risk protection benefits across different wealth groups in Nigeria if a policy of public financing of MNCH interventions were to be introduced., Methods: We did an extended cost-effectiveness analysis to estimate the health and financial risk protection benefits, across different household wealth quintiles, of a public-financing policy that assumes zero out-of-pocket costs to patients at the point of care for 18 essential MNCH services. We projected health outcomes (deaths in children aged <5 years [under-5 deaths] and maternal deaths) and private expenditure averted using the Lives Saved Tool with data extracted from national surveys. We modelled three scenarios: 1) coverage expansion at a rate equal to the trend observed between 2013 and 2018 (status quo); 2) annual coverage expansion by 5% compared with the status quo (uniform scale-up scenario); and 3) annual coverage expansion by 10%, 8%, 6%, 4%, and 2% compared with the status quo from the poorest to the wealthiest quintiles, respectively (pro-poor scale-up scenario)., Findings: Our analysis shows that, if an additional 5% increase in coverage was provided for all wealth quintiles between 2019 and 2030, this uniform scale-up policy would prevent more than 0·11 million maternal deaths and 1·05 million under-5 deaths, avert US$1·8 billion in private expenditure, and avert 3266 cases of catastrophic health expenditure. The incremental cost effectiveness ratio would be $44 per life-year gained, which is highly cost-effective when compared with the gross domestic product per capita of Nigeria for 2018 ($2028). The policy would prevent a higher number of under-5 deaths and catastrophic health expenditure cases in poorer quintiles, but would prevent more maternal deaths and private expenditure in wealthier quintiles. If poorer populations experienced a greater increase in service coverage (ie, the pro-poor scale-up scenario), more maternal and under-5 deaths would be prevented in the poorer quintiles and more private expenditure would be averted than would be under previous scenarios., Interpretation: Public financing of essential MNCH interventions in Nigeria would provide substantial health and financial risk protection benefits to Nigerian households. These benefits would accrue preferentially to the poorest quintiles and would contribute towards reduction of health and socioeconomic inequalities in Nigeria. The distribution would be more pro-poor if public financing of MNCH interventions could target poor households., Funding: WHO Partnership for Maternal, Newborn, and Child Health., Competing Interests: Declaration of interests MLS was an employee at the Partnership for Maternal, Newborn and Child Health (PMNCH) hosted by WHO during the execution of this research; she is currently an employee at The Lancet, but was recused from all editorial discussions about this manuscript. MS reports grants from PMNCH, Bill & Melinda Gates Foundation, Save the Children, Plan International, and WHO. OO reports grants from PMNCH during the conduct of the study; grants from the Gates Foundation, the National Institute of Minority Health and Health Disparities, WHO, and Gavi, the Vaccine Alliance; and personal fees from PMNCH and Save the Children outside the submitted work; and is a member of the Merck for Mothers Strengthening Systems for Safer Childbirth Advisory Committee and the Africa CDC Health Economics Unit Technical Advisory Group (both unpaid). All other authors declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Amid the dwindling donor support for HIV in Nigeria, there is an urgent need for additional domestic HIV funding. This study estimates the required financial resources for people living with HIV (PLHIV) and the potential magnitude of domestic resources for HIV through the National Health Insurance Scheme (NHIS) and by prioritizing HIV within the health budget., Methods: We estimated the resource needs for providing antiretroviral therapy (ART) to adults, children, and pregnant women living with HIV under 3 scenarios: current coverage rates, coverage rates based on historical trends, and a rapid scale-up situation. We conducted a fiscal space analysis to estimate the potential contribution from macroeconomic growth, the NHIS, and prioritizing HIV within the health budget from 2020 to 2025., Results: At current coverage rates, the annual treatment costs for adults would range between US$ 505 million in 2020 to US$ 655 million in 2025; for children, it ranges from US$ 33.5 million in 2020 to US$ 32 million in 2025. The annual costs of providing PMTCT at current coverage rates range from US$ 65 million in 2020 to US$ 72 million in 2025. An additional US$ 319 million could potentially be generated between 2020 and 2025 through the NHIS for HIV. Prioritizing HIV within the health budget can generate an additional US$ 686 million., Conclusion: Substantial domestic funds can be mobilized by these means to sustain the HIV response. However, because this additional funding may not be sufficient to cover all PLHIV, a phased approach, initially prioritizing certain populations such as children or pregnant women, is recommended., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: This study aimed to assess Nigeria's preparedness to finance and drive the universal health coverage (UHC) agenda within the context of changing health conditions and resource needs associated with the disease, demographic and funding transitions.Nigeria is undergoing transitions in the healthcare system that include a double burden of infectious and non-communicable diseases, and transition from concessional donor assistance towards domestic financing for health. These transitions will affect Nigeria's attainment of UHC., Design and Setting: We conducted a qualitative study, including semistructured interviews with relevant stakeholders at national and subnational levels in Nigeria. Data from the interviews were analysed using thematic analysis., Participants: Our study involved 18 respondents from government ministries, departments, and agencies, development partners, civil society organisations and academia., Results: Capacity gaps identified by respondents included limited knowledge to implement health insurance schemes at subnational levels, poor information/data management to monitor progress towards UHC and limited communication and interagency collaboration between government agencies and ministries. Furthermore, participants in our study expressed those current policies driving major health reforms like the National Health Act (basic healthcare provision fund) appear adequate to support UHC advancement in theory, but policy implementation is a key challenge due to a lack of policy awareness, low government spending on health and poor evidence generation for information to support decisions., Conclusion: Our study found major gaps in knowledge and capacity for UHC advancement in the context of Nigeria's demographic, epidemiological and financing transitions. These included poor knowledge of demographic transitions, poor capacity for health insurance implementation at subnational levels, low government spending on health, poor policy implementation and poor communication and collaboration among stakeholders. To address these challenges, collaborative efforts are needed to bridge knowledge gaps and increase policy awareness through targeted knowledge products, improved communication and interagency collaboration., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Background: While 60% of older adults have hearing loss (HL), the majority have never had their hearing tested., Objective: We sought to estimate long-term clinical and economic effects of alternative adult hearing screening schedules in the USA., Design: Model-based cost-effectiveness analysis simulating Current Detection (CD) and linkage of persons with HL to hearing healthcare, compared to alternative screening schedules varying by age at first screen (45 to 75 years) and screening frequency (every 1 or 5 years). Simulated persons experience yearly age- and sex-specific probabilities of acquiring HL, and subsequent hearing aid uptake (0.5-8%/year) and discontinuation (13-4%). Quality-adjusted life-years (QALYs) were estimated according to hearing level and treatment status. Costs from a health system perspective include screening ($30-120; 2020 USD), HL diagnosis ($300), and hearing aid devices ($3690 year 1, $910/subsequent year). Data sources were published estimates from NHANES and clinical trials of adult hearing screening., Participants: Forty-year-old persons in US primary care across their lifetime., Intervention: Alternative screening schedules that increase baseline probabilities of hearing aid uptake (base-case 1.62-fold; range 1.05-2.25-fold)., Main Measures: Lifetime undiscounted and discounted (3%/year) costs and QALYs and incremental cost-effectiveness ratios (ICERs)., Key Results: CD resulted in 1.20 average person-years of hearing aid use compared to 1.27-1.68 with the screening schedules. Lifetime total per-person undiscounted costs were $3300 for CD and ranged from $3630 for 5-yearly screening beginning at age 75 to $6490 for yearly screening beginning at age 45. In cost-effectiveness analysis, yearly screening beginning at ages 75, 65, and 55 years had ICERs of $39,100/QALY, $48,900/QALY, and $96,900/QALY, respectively. Results were most sensitive to variations in hearing aid utility benefit and screening effectiveness., Limitation: Input uncertainty around screening effectiveness., Conclusions: We project that yearly hearing screening beginning at age 55+ is cost-effective by US standards., (© 2022. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Objective: Tracking global health funding is a crucial but time consuming and labor-intensive process. This study aimed to develop a framework to automate the tracking of global health spending using natural language processing (NLP) and machine learning (ML) algorithms. We used the global common goods for health (CGH) categories developed by Schäferhoff et al. to design and evaluate ML models., Methods: We used data curated by Schäferhoff et al., which tracked the official development assistance (ODA) disbursements to global CGH for 2013, 2015, and 2017, for training and validating the ML models. To process raw text, we implemented different NLP techniques, such as removing stop words, lemmatization, and creation of synthetic text, to balance the dataset. We used four supervised learning ML algorithms-random forest (RF), XGBOOST, support vector machine (SVM), and multinomial naïve Bayes (MNB) (see Glossary)-to train and test the pre-coded dataset, and applied the best model on dataset that hasn't been manually coded to predict the financing for CGH in 2019., Results: After we trained the machine on the training dataset ( n = 10,534), the weighted average F1-scores (a measure of a ML model's performance) on the testing dataset ( n = 2,634) ranked 0.79-0.83 among four models, and the RF model had the best performance (F1-score = 0.83). The predicted total donor support for CGH projects by the RF model was $2.24 billion across 3 years, which was very close to the finding of $2.25 billion derived from coding and classification by humans. By applying the trained RF model on the 2019 dataset, we predicted that the total funding for global CGH was about $2.7 billion for 730 CGH projects., Conclusion: We have demonstrated that NLP and ML can be a feasible and efficient way to classify health projects into different global CGH categories, and thus track health funding for CGH routinely using data from publicly available databases., Competing Interests: Author MS was employed by Open Consultants. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Dixit, Mao, McDade, Schäferhoff, Ogbuoji and Yamey.)

Importance: Adult hearing screening is not routinely performed, and most individuals with hearing loss (HL) have never had their hearing tested as adults., Objective: To project the monetary value of future research clarifying uncertainties around the optimal adult hearing screening schedule., Design, Setting, and Participants: In this economic evaluation, a validated decision model of HL (DeciBHAL-US: Decision model of the Burden of Hearing loss Across the Lifespan) was used to simulate current detection and treatment of HL vs hearing screening schedules. Key model inputs included HL incidence (0.06%-10.42%/y), hearing aid uptake (0.54%-8.14%/y), screening effectiveness (1.62 × hearing aid uptake), utility benefits of hearing aids (+0.11), and hearing aid device costs ($3690). Distributions to model parameters for probabilistic uncertainty analysis were assigned. The expected value of perfect information (EVPI) and expected value of partial perfect information (EVPPI) using a willingness to pay of $100 000 per quality-adjusted life-year (QALY) was estimated. The EVPI and EVPPI estimate the upper bound of the dollar value of future research. This study was based on 40-year-old persons over their remaining lifetimes in a US primary care setting., Exposures: Screening schedules beginning at ages 45, 55, 65, and 75 years, and frequencies of every 1 or 5 years., Main Outcomes and Measures: The main outcomes were QALYs and costs (2020 US dollars) from a health system perspective., Results: The average incremental cost-effectiveness ratio for yearly screening beginning at ages 55 to 75 years ranged from $39 200 to $80 200/QALY. Yearly screening beginning at age 55 years was the optimal screening schedule in 38% of probabilistic uncertainty analysis simulations. The population EVPI, or value of reducing all uncertainty, was $8.2 to $12.6 billion varying with willingness to pay and the EVPPI, or value of reducing all screening effectiveness uncertainty, was $2.4 billion., Conclusions and Relevance: In this economic evaluation of US adult hearing screening, large uncertainty around the optimal adult hearing screening schedule was identified. Future research on hearing screening has a high potential value so is likely justified.

Importance: Some individuals experience persistent symptoms after initial symptomatic SARS-CoV-2 infection (often referred to as Long COVID)., Objective: To estimate the proportion of males and females with COVID-19, younger or older than 20 years of age, who had Long COVID symptoms in 2020 and 2021 and their Long COVID symptom duration., Design, Setting, and Participants: Bayesian meta-regression and pooling of 54 studies and 2 medical record databases with data for 1.2 million individuals (from 22 countries) who had symptomatic SARS-CoV-2 infection. Of the 54 studies, 44 were published and 10 were collaborating cohorts (conducted in Austria, the Faroe Islands, Germany, Iran, Italy, the Netherlands, Russia, Sweden, Switzerland, and the US). The participant data were derived from the 44 published studies (10 501 hospitalized individuals and 42 891 nonhospitalized individuals), the 10 collaborating cohort studies (10 526 and 1906), and the 2 US electronic medical record databases (250 928 and 846 046). Data collection spanned March 2020 to January 2022., Exposures: Symptomatic SARS-CoV-2 infection., Main Outcomes and Measures: Proportion of individuals with at least 1 of the 3 self-reported Long COVID symptom clusters (persistent fatigue with bodily pain or mood swings; cognitive problems; or ongoing respiratory problems) 3 months after SARS-CoV-2 infection in 2020 and 2021, estimated separately for hospitalized and nonhospitalized individuals aged 20 years or older by sex and for both sexes of nonhospitalized individuals younger than 20 years of age., Results: A total of 1.2 million individuals who had symptomatic SARS-CoV-2 infection were included (mean age, 4-66 years; males, 26%-88%). In the modeled estimates, 6.2% (95% uncertainty interval [UI], 2.4%-13.3%) of individuals who had symptomatic SARS-CoV-2 infection experienced at least 1 of the 3 Long COVID symptom clusters in 2020 and 2021, including 3.2% (95% UI, 0.6%-10.0%) for persistent fatigue with bodily pain or mood swings, 3.7% (95% UI, 0.9%-9.6%) for ongoing respiratory problems, and 2.2% (95% UI, 0.3%-7.6%) for cognitive problems after adjusting for health status before COVID-19, comprising an estimated 51.0% (95% UI, 16.9%-92.4%), 60.4% (95% UI, 18.9%-89.1%), and 35.4% (95% UI, 9.4%-75.1%), respectively, of Long COVID cases. The Long COVID symptom clusters were more common in women aged 20 years or older (10.6% [95% UI, 4.3%-22.2%]) 3 months after symptomatic SARS-CoV-2 infection than in men aged 20 years or older (5.4% [95% UI, 2.2%-11.7%]). Both sexes younger than 20 years of age were estimated to be affected in 2.8% (95% UI, 0.9%-7.0%) of symptomatic SARS-CoV-2 infections. The estimated mean Long COVID symptom cluster duration was 9.0 months (95% UI, 7.0-12.0 months) among hospitalized individuals and 4.0 months (95% UI, 3.6-4.6 months) among nonhospitalized individuals. Among individuals with Long COVID symptoms 3 months after symptomatic SARS-CoV-2 infection, an estimated 15.1% (95% UI, 10.3%-21.1%) continued to experience symptoms at 12 months., Conclusions and Relevance: This study presents modeled estimates of the proportion of individuals with at least 1 of 3 self-reported Long COVID symptom clusters (persistent fatigue with bodily pain or mood swings; cognitive problems; or ongoing respiratory problems) 3 months after symptomatic SARS-CoV-2 infection.

As countries graduate from low-income to middle-income status, many face losses in development assistance for health and must 'transition' to greater domestic funding of their health response. If improperly managed, donor transitions in middle-income countries (MICs) could present significant challenges to global health progress. No prior knowledge synthesis has comprehensively surveyed how donor transitions can affect health systems in MICs. We conducted a scoping review using a structured search strategy across five academic databases and 37 global health donor and think tank websites for literature published between January 1990 and October 2018. We used the World Health Organization health system 'building blocks' framework to thematically synthesize and structure the analysis. Following independent screening, 89 publications out of 11 236 were included for data extraction and synthesis. Most of this evidence examines transitions related to human immunodeficiency virus/Acquired Immune Deficiency Syndrome (AIDS; n = 45, 50%) and immunization programmes (n = 14, 16%), with a focus on donors such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (n = 26, 29%) and Gavi, the Vaccine Alliance (n = 15, 17%). Donor transitions are influenced by the actions of both donors and country governments, with impacts on every component of the health system. Successful transition experiences show that leadership, planning, and pre-transition investments in a country's financial, technical, and logistical capacity are vital to ensuring smooth transition. In the absence of such measures, shortages in financial resources, medical product and supply stock-outs, service disruptions, and shortages in human resources were common, with resulting implications not only for programme continuation, but also for population health. Donor transitions can affect different components of the health system in varying and interconnected ways. More rigorous evaluation of how donor transitions can affect health systems in MICs will create an improved understanding of the risks and opportunities posed by donor exits., (© The Author(s) 2022. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

This study aimed to determine levels of health insurance coverage in low- and middle-income countries and how coverage varies by people's sociodemographic characteristics. We conducted a population size-weighted, one-stage individual participant data meta-analysis of health insurance coverage, using a population-based sample of 2,035,401 participants ages 15-59 from nationally representative household surveys in fifty-six countries during the period 2006-18. One in five people (20.3 percent) across the fifty-six countries in our study had health insurance. Health insurance coverage exceeded 50 percent in only seven countries and 70 percent in only three countries. Substantially more people had public health insurance than private health insurance (71.4 percent versus 28.6 percent). We found that men and older, more educated, and wealthier people were more likely to have health insurance; these sociodemographic gradients in health insurance coverage were strongest in sub-Saharan Africa and followed traditional lines of privilege. Low- and middle-income countries need to massively expand health insurance coverage if they intend to use insurance to achieve universal health coverage.

Introduction: Myanmar, a conflict-affected geographically and ethnically diverse lower middle-income country, was in the donor transition phase for health prior to the political unrest of the last year. This study analyses the distribution of benefit and utilisation of basic childhood vaccinations from the highly donor-dependent Expanded Program on Immunization for populations of different socioeconomic status (SES)., Methods: We conducted a benefit incidence analysis with decomposition analysis to assess the equity of benefit. We used basic childhood immunisations-BCG, measles, diphtheria, pertussis and tetanus (DPT)/pentavalent, oral polio vaccine (OPV) and full vaccination-as measurements for healthcare use. Childhood immunisation data were collected from Myanmar Demographic and Health Survey. Cost of vaccines was obtained from UNICEF document and 'Immunization Delivery Cost Catalogue' and adjusted with regional cost variations. We reported Concentration Index (CI) and Achievement Index (AI) by SES, including wealth quintiles, maternal education and across geographic areas., Results: Nationally, better-off households disproportionately used more services from the programme (CI-Wealth Index (CI-WI) for BCG, measles, DPT/pentavalent, OPV and full immunisation: 0.032, 0.051, 0.120, 0.091 and 0.137, respectively). Benefits had a pro-poor distribution for BCG but a less pro-rich distribution than utilisation for all other vaccines (CI-WI: -0.004, 0.019, 0.092, 0.045 and 0.106, respectively). Urban regions had a more pro-rich distribution of benefit than that in rural areas, where BCG and measles had a pro-poor distribution. Subnational analysis found significant heterogeneity: benefit was less equitably distributed, and AI was lower in conflict-affected states than in government-controlled areas. The major contributors to vaccine inequality were SES, antenatal care visits and paternal education., Conclusion: Donors, national government and regional government should better plan to maintain vaccine coverage while improving equity of vaccine services, especially for children of lower SES, mothers with less antenatal care visits and lower paternal education living in conflicted-affected remote regions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Objective: In a pandemic, government assistance is essential to support the most vulnerable households as they face health and economic challenges. However, government assistance is effective only when it reaches vulnerable households in time. In this paper, we estimated the timeliness of government assistance for the most vulnerable households (ie, the poor households) in Ethiopia during its COVID-19 response of 2020. In particular, we conducted a time-to-event analysis to compare the time to receive government assistance between poor and non-poor households in Ethiopia., Methods: We used a semiparametric Cox proportional model to evaluate whether the time to first receipt of government assistance during the COVID-19 response in 2020 differed between poor and non-poor Ethiopian households. We used the Schoenfeld test to check the proportionality assumption and conducted the stratified Cox regression analysis to adjust for non-proportional variables. The data from World Bank's High-Frequency Phone Surveys on COVID-19 and the 2019 Ethiopian Socioeconomic Survey were used for this analysis., Results: We found that the poor households in rural areas were 88% (HR: 1.88; 95% CI: 1.19 to 2.98) more likely to receive government assistance than non-poor households at any point within 10 months after the start of the pandemic. However, there was no significant difference between urban poor and non-poor households' likelihood of receiving government assistance during this timeframe., Conclusion: The Ethiopian government has leveraged its existing social protection network to quickly reach poor households in rural areas during the COVID-19 response of 2020. The country will need to continue strengthening and scaling the existing social protection systems to accurately target the wider vulnerable population in urban areas., Competing Interests: Competing interests: OO, WM, MMD and ASD report grants from Bill & Melinda Gates Foundation outside the submitted work., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Investing in late-stage clinical trials, trial sites, and production capacity for new health products could improve access to vaccines, therapeutics, and infectious disease diagnostics in middle-income countries. This study assesses the case for such investment in three of these countries: India, Kenya, and South Africa., Methods: We applied investment case modelling and assessed how many cases, deaths, and disability-adjusted life years (DALYs) could be averted from the development and manufacturing of new technologies (therapeutics and vaccines) in these countries from 2021 to 2036, for five diseases-HIV, tuberculosis, malaria, pneumonia, and diarrhoeal diseases. We also estimated the economic benefits that might accrue from making these investments and we developed benefit-cost ratios for each of the three middle-income countries. Our modelling applies two investment case perspectives: a societal perspective with all costs and benefits measured at the societal level, and a country perspective to estimate how much health and economic benefit accrues to each middle-income country for every dollar invested in clinical trials and manufacturing by the middle-income country government. For each perspective, we modelled two scenarios: one that considers only domestic health and economic benefits; and one that includes regional health and economic benefits. In the regional scenarios, we assumed that new products developed and manufactured in India would benefit eight countries in south Asia, whereas new products developed and manufactured in Kenya would benefit all 21 countries in the Common Market for Eastern and Southern Africa (COMESA). We also assumed that all 16 countries in the Southern African Development Community (SADC) would benefit from products developed and manufactured in South Africa., Findings: From 2021 to 2036, product development and manufacturing in Kenya could avert 4·44 million deaths and 206·27 million DALYs in the COMESA region. In South Africa, it could prevent 5·19 million deaths and 253·83 million DALYs in the SADC region. In India, it could avert 9·76 million deaths and 374·42 million DALYs in south Asia. Economic returns would be especially high if new tools were produced for regional markets rather than for domestic markets only. Under a societal perspective, regional returns outweigh investments by a factor of 20·51 in Kenya, 33·27 in South Africa, and 66·56 in India. Under a country perspective, the regional benefit-cost ratios amount to 60·71 in India, 8·78 in Kenya, and 11·88 in South Africa., Interpretation: Our study supports the creation of regional hubs for clinical trials and product manufacturing compared with narrow national efforts., Funding: Bill & Melinda Gates Foundation., Competing Interests: Declaration of interests All authors report grants from the Bill & Melinda Gates Foundation during the conduct of the study. RK also serves as chairman of the steering committee of the Coalition for Health Research & Development, a policy and advocacy coalition that is funded by the Bill & Melinda Gates Foundation. This is a voluntary position that does not have any direct renumeration., (Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: There is no published decision model for informing hearing health care resource allocation across the lifespan in low- and middle-income countries. We sought to validate the Decision model of the Burden of Hearing loss Across the Lifespan International (DeciBHAL-I) in Chile, India, and Nigeria., Methods: DeciBHAL-I simulates bilateral sensorineural hearing loss (SNHL) and conductive hearing loss (CHL) acquisition, SNHL progression, and hearing loss treatment. To inform model inputs, we identified setting-specific estimates including SNHL prevalence from the Global Burden of Disease (GBD) studies, acute otitis media (AOM) incidence and prevalence of otitis-media related CHL from a systematic review, and setting-specific pediatric and adult hearing aid use prevalence. We considered a coefficient of variance root mean square error (CV-RMSE) of ≤15% to indicate good model fit., Findings: The model-estimated prevalence of bilateral SNHL closely matched GBD estimates, (CV-RMSEs: 3.2-7.4%). Age-specific AOM incidences from DeciBHAL-I also achieved good fit (CV-RMSEs=5.0-7.5%). Model-projected chronic suppurative otitis media prevalence (1.5% in Chile, 4.9% in India, and 3.4% in Nigeria) was consistent with setting-specific estimates, and the incidence of otitis media-related CHL was calibrated to attain adequate model fit. DeciBHAL-projected adult hearing aid use in Chile (3.2-19.7% ages 65-85 years) was within the 95% confidence intervals of published estimates. Adult hearing aid prevalence from the model in India was 1.4-2.3%, and 1.1-1.3% in Nigeria, consistent with literature-based and expert estimates., Interpretation: DeciBHAL-I reasonably simulates hearing loss natural history, detection, and treatment in Chile, India, and Nigeria. Future cost-effectiveness analyses might use DeciBHAL-I to inform global hearing health policy., Funding: National Institutes of Health (3UL1-TR002553-03S3 and F30 DC019846)., Competing Interests: The authors have no conflicts of interest to declare., (© 2022 The Authors.)

Objectives: Nigeria is one of the 30 high-burden countries for TB and currently, recurrent costs of TB treatment services are largely dependent on donor-funding, with government providing the health facilities. This study aims to assess the benefit incidence of TB treatment services so as to determine if the poor and rural dwellers preferentially benefit from such services that were subsidized by government and donors., Methods: A survey of patients (n = 202) accessing TB treatment services was conducted between 2019 and 2020 in five purposively selected rural and urban health facilities in Enugu state. Socio-economic status (SES) was estimated using household assets ownership. Benefits of TB services were measured by multiplying the unit cost of utilization of different services while the net benefit was calculated by subtracting out-of-pocket (OOP) payments incurred from the benefits. We estimated the benefit for 1 month and the benefit for the whole TB treatment course (6 months). Concentration index was used to determine the level of equity in spending across the socio-economic quintiles., Results: 56.4% of the respondents were from urban facilities. 100% had used TB drugs in the past months, 73% had undergone a Gene-Xpert test, and 67% had had a consultation. All patients received TB drugs without OOP payment, but 90% paid for X-ray. Urban respondents captured a disproportionally higher share of benefit from TB services. The concentration index was -0.025 for net benefit from TB services across different quintiles, indicating the pro-poor distribution of TB services in Nigeria., Conclusions: The benefit from TB services had a pro-poor distribution, but urban respondents obtained a disproportionally higher share of gross and net benefit from TB services. Funding for TB services needs to be secured to promote the equitable access to TB services., (© 2022 John Wiley & Sons Ltd.)

Many Low-income countries depend on development assistance for health (DAH) to finance the health sector. The transition of these countries to middle-income status has led to reduction in effective aid from development partners while these countries are expected to graduate from global funding agencies such as Gavi the vaccine alliance, with implications for service delivery. The aim of this study was to explore the perspectives of frontline health workers regarding the implications of Ghana's transition to middle-income status on service delivery, the likely impact and opportunities it presents to the country. This exploratory qualitative study employed in-depth interviews to collect data from 16 health workers at three hospitals in the Greater Accra Region; one at the regional level and two at the district level. The study was conducted from December 2019 to July 2020. Data from interviews were transcribed, coded and analysed using thematic analysis in NVivo Qualitative Analysis Software version 12. The level of awareness among frontline workers about the transition and decline in DAH was generally low. Nonetheless, frontline health workers perceived that the country seems inadequately prepared for transition as donors continue to be major financiers for the sector and even for emergencies such as the current COVID-19 global pandemic. Potential challenges facilities would face due to transition may include difficulty in funding health programs, human resource challenges and delays in logistics and medicines. The implications for these will be poor health outcomes, defective monitoring and evaluation, and lapses in training programs. In addition, the perceived barriers to transition identified were poor management of resources, political interference and lack of technical expertise. While opportunities such as improvement of the health sector prioritization and efficiency, private sector involvement and autonomy could be gained. Gaps in the health intervention monitoring resulting from DAH transition could pose affect health outcomes, particularly in respect of HIV, tuberculosis and malaria. The country's preparedness to transition from DAH could be better improved with development of a clear transition plan agreed by stakeholders, including government and in-country development partners. For the health sector, the eligibility for DAH transition should not simply be based on economic growth, but importantly on a country's ability to sustain ongoing and upcoming health programs., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Appiah-Kubi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Under-five malaria in Nigeria is a leading cause of global child mortality, accounting for 95,000 annual child deaths. High out-of-pocket medical expenditure contributes to under-five malaria mortality by discouraging care-seeking and use of effective anti-malarials in the poorest households. The significant inequity in child health outcomes in Nigeria stresses the need to evaluate the outcomes of potential interventions across socioeconomic lines., Methods: Using a decision tree model, an extended cost-effectiveness analysis was done to determine the effects of subsidies covering the direct and indirect costs of case management of under-five malaria in Nigeria. This analysis estimates the number of child deaths averted, out-of-pocket (OOP) expenditure averted, cases of catastrophic health expenditure (CHE) averted, and cost of implementation. An optimization analysis was also done to determine how to optimally allocate money across wealth groups using different combinations of interventions., Results: Fully subsidizing direct medical, non-medical, and indirect costs could annually avert over 19,000 under-five deaths, 8600 cases of CHE, and US$187 million in OOP spending. Per US$1 million invested, this corresponds to an annual reduction of 76 under-five deaths, 34 cases of CHE, and over US$730,000 in OOP expenditure. Due to low initial treatment coverage in poorer socioeconomic groups, health and financial-risk protection benefits would be pro-poor, with the poorest 40% of Nigerians accounting for 72% of all deaths averted, 55% of all OOP expenditure averted, and 74% of all cases of CHE averted. Subsidies targeted to the poor would see greater benefits per dollar spent than broad, non-targeted subsidies. In an optimization scenario, the strategy of fully subsidizing direct medical costs would be dominated by a partial subsidy of direct medical costs as well as a full subsidy of direct medical, nonmedical, and indirect costs., Conclusion: Subsidizing case management of under-five malaria for the poorest and most vulnerable would reduce illness-related impoverishment and child mortality in Nigeria while preserving limited financial resources. This study is an example of how focusing a targeted policy-intervention on a single, high-burden disease can yield large health and financial-risk protection benefits in a low and middle-income country context and address equity consideration in evidence-informed policymaking., (© 2022. The Author(s).)

Background: Hearing loss affects over 50% of people in the US across their lifespan and there is a lack of decision modeling frameworks to inform optimal hearing healthcare delivery. Our objective was to develop and validate a microsimulation model of hearing loss across the lifespan in the US., Methods: We collaborated with the Lancet Commission on Hearing Loss to outline model structure, identify input data sources, and calibrate/validate DeciBHAL-US (Decision model of the Burden of Hearing loss Across the Lifespan). We populated the model with literature-based estimates and validated the conceptual model with key informants. We validated key model endpoints to the published literature, including: 1) natural history of sensorineural hearing loss (SNHL), 2) natural history of conductive hearing loss (CHL), and 3) the hearing loss cascade of care. We reported the coefficient of variance root mean square error (CV-RMSE), considering values ≤15% to indicate adequate fit., Findings: For SNHL prevalence, the CV-RMSE for model projected male and female age-specific prevalence compared to sex-adjusted National Health and Nutrition Examination Survey (NHANES) data was 4.9 and 5.7%, respectively. Incorporating literature-based age-related decline in SNHL, we validated mean four-frequency average hearing loss in the better ear (dB) among all persons to longitudinal data (CV-RMSE=11.3%). We validated the age-stratified prevalence of CHL to adjusted NHANES data (CV-RMSE=10.9%). We incorporated age- and severity-stratified time to first hearing aid (HA) use data and HA discontinuation data (adjusted for time-period of use) and validated to NHANES estimates on the prevalence of adult HA use (CV-RMSE=10.3%)., Interpretation: Our results indicate adequate model fit to internal and external validation data. Future incorporation of cost and severity-stratified utility data will allow for cost-effectiveness analysis of US hearing healthcare interventions across the lifespan. Further research might expand the modeling framework to international settings., Funding: This study was funded by the National Institute on Deafness and Other Communication Disorders and the National Institute on Aging (3UL1-TR002553-03S3 and F30 DC019846)., Competing Interests: JRD reports grants from the National Institutes of Health, participation on the National Institute on Deafness and Other Communication Disorders Data Safety Monitoring Board (DSMB) and the National Institute on Aging ACHIEVE (Aging and Cognitive Health Evaluation in Elders) DSMB, and participation on the Board of Directors of the Hearing Health Foundation and on the Executive Council of the Acoustical Society of America. All other authors declare no competing interests., (© 2021 Published by Elsevier Ltd.)

Immediate initiation of antiretroviral therapy (ART) for all people living with HIV has important health benefits but implications for the economic aspects of patients' lives are still largely unknown. This stepped-wedge cluster-randomized controlled trial aimed to determine the causal impact of immediate ART initiation on patients' healthcare expenditures in Eswatini. Fourteen healthcare facilities were randomly assigned to transition at one of seven time points from the standard of care (ART eligibility below a CD4 count threshold) to the immediate ART for all intervention (EAAA). 2261 patients living with HIV were interviewed over the study period to capture their past-year out-of-pocket healthcare expenditures. In mixed-effects regression models, we found a 49% decrease (RR 0.51, 95% CI 0.36, 0.72, p < 0.001) in past-year total healthcare expenditures in the EAAA group compared to the standard of care, and a 98% (RR 0.02, 95% CI 0.00, 0.02, p < 0.001) decrease in spending on private and traditional healthcare. Despite a higher frequency of HIV care visits for newly initiated ART patients, immediate ART initiation appears to have lowered patients' healthcare expenditures because they sought less care from alternative healthcare providers. This study adds an important economic argument to the World Health Organization's recommendation to abolish CD4-count-based eligibility thresholds for ART., (© 2021. The Author(s).)

Background: Achieving universal health coverage (UHC) requires increased domestic financing of health by low-income countries (LICs) and middle-income countries (MICs). It is critical to understand how much governments have devoted to health from domestic sources and how much growth might be realistic over time. Methods: Using data from WHO's Global Health Expenditure Database, we examined how the composition of current health expenditure changed by financing source and the sources of growth in health expenditures from 2000-2015 across different income groups. We disaggregated how much growth in government expenditures on health from domestic sources was due to economic growth, growth in government spending as a share of GDP, and reallocations in government expenditures towards health. Results: Lower MICs (LMICs) and upper MICs (UMICs), as a group, saw a significant reduction in out-of-pocket expenditures and a significant growth in government expenditures on health from domestic sources as a share of current health expenditures over the period. This trend indicates likely progress in the pathway to UHC. For LICs, these trends were more muted. Growth in government expenditure on health from domestic sources was driven primarily by economic growth in LICs, LMICs, and UMICs. Growth in government expenditure on health due to increased government spending as a share of GDP was high in UMICs. For the high-income country group, where economic growth was relatively slower and government spending was already high with strong tax bases, the largest driver of growth in government expenditure on health from domestic sources was reallocation of the government budget towards health. Conclusions: Dialogue on domestic resource mobilization needs to emphasize overall economic growth and growth in the government spending as a share of GDP as well as the share of health in the government budget., Competing Interests: No competing interests were disclosed., (Copyright: © 2021 Saxenian H et al.)

In the coming years, about a dozen middle-income countries are excepted to transition out of development assistance for health (DAH) based on their economic growth. This anticipated loss of external funds at a time when there is a need for accelerated progress towards universal health coverage (UHC) is a source of concern. Evaluating country readiness for transition towards country ownership of health programmes is a crucial step in making progress towards UHC. We used in-depth interviews to explore: (1) the preparedness of the Nigerian health system to transition out of DAH, (2) transition policies and strategies that are in place in Nigeria, (3) the road map for the implementation of these policies and (4) challenges and recommendations for making progress on such policies. We applied Vogus and Graff's expanded transition readiness framework within the Nigerian context to synthesize preparedness plans, gaps, challenges and stakeholders' recommendations for sustaining the gains of donor-funded programmes and reaching UHC. Some steps have been taken to integrate and institutionalize service delivery processes toward sustainable immunization and responsive primary healthcare in line with UHC. There are ongoing discussions on integrating human immunodeficiency virus (HIV) services with other services and the possibility of covering HIV services under the National Health Insurance Scheme (NHIS). We identified more transition preparedness plans within immunization programme compared with HIV programme. However, we identified gaps in all the nine components of the framework that must be filled to be able to sustain gains and make significant progress towards country ownership and UHC. Nigeria needs to focus on building the overall health system by identifying systematic gaps instead of continuing to invest in parallel programmes. Programmes need to be consolidated within the overall health system, health financing priorities and policies. A comprehensive and functional structure will provide continuity even in the event of decreasing external funds or donor exits., (© The Author(s) 2021. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Background: Health policy interventions were expected to improve access to health care delivery, provide financial risk protection, besides reducing inequities that underlie geographic and socio-economic variation in population access to health care. This article examines whether health policy interventions and accelerated health investments in India during 2004-2018 could close the gap in inequity in health care utilization and access to public subsidy by different population groups. Did the poor and socio-economically vulnerable population gain from such government initiatives, compared to the rich and affluent sections of society? And whether the intended objective of improving equity between different regions of the country been achieved during the policy initiatives? This article attempts to assess and provide robust evidence in the Indian context., Methods: Employing Benefit-Incidence Analysis (BIA) framework, this paper advances earlier evidence by highlighting estimates of health care utilization, concentration and government subsidy by broader provider categories (public versus private) and across service levels (outpatient, inpatient, maternal, pre-and post-natal services). We used 2 waves of household surveys conducted by the National Sample Survey Organisation (NSSO) on health and morbidity. The period of analysis was chosen to represent policy interventions spanning 2004 (pre-policy) and 2018 (post-policy era). We present this evidence across three categories of Indian states, namely, high-focus states, high-focus north eastern states and non-focus states. Such categorization facilitates quantification of reform impact of policy level interventions across the three groups., Results: Utilisation of healthcare services, except outpatient care visits, accelerated significantly in 2018 from 2004. The difference in utilisation rates between poor and rich (between poorest 20% and richest 20%) had significantly declined during the same period. As far as concentration of healthcare is concerned, the Concentrate Index (CI) underlying inpatient care in public sector fell from 0.07 in 2004 to 0.05 in 2018, implying less pro-rich distribution. The CI in relation to pre-natal, institutional delivery and postnatal services in government facilities were pro-poor both in 2004 and 2018 in all 3 groups of states. The distribution of public subsidy underscoring curative services (inpatient and outpatient) remained pro-rich in 2004 but turned less pro-rich in 2018, measured by CIs which declined sharply across all groups of states for both outpatient (from 0.21 in 2004 to 0.16 in 2018) and inpatient (from 0.24 in 2004 to 0.14 in 2018) respectively. The CI for subsidy on prenatal services declined from approximately 0.01 in 2004 to 0.12 in 2018. In respect to post-natal care, similar results were observed, implying the subsidy on prenatal and post-natal services was overwhelmingly received by poor. The CI underscoring subsidy for institutional delivery although remained positive both in 2018 and 2004, but slightly increased from 0.17 in 2004 to 0.28 in 2018., Conclusions: Improvement in infrastructure and service provisioning through NHM route in the public facilities appears to have relatively benefited the poor. Yet they received a relatively smaller health subsidy than the rich when utilising inpatient and outpatient health services. Inequality continues to persist across all healthcare services in private health sector. Although the NHM remained committed to broader expansion of health care services, a singular focus on maternal and child health conditions especially in backward regions of the country has yielded desired results., (© 2021. The Author(s).)

Wenhui Mao and coauthors discuss possible implications of the COVID-19 pandemic for health aspirations in low- and middle-income countries., Competing Interests: Competing interests: We have read the journal’s policy and the authors of this manuscript have the following competing interests: WM, OO, II, KKM, and GY declare that the Center for Policy Impact in Global Health has received research funding from multiple funders that support achievement of grand convergence: the Bill & Melinda Gates Foundation; Gavi, the Vaccine Alliance; the WHO; TDR; and the New Venture Fund. F-G Z owns stocks in six start-up companies—Axonics, DiaNavi, Nurotron, Syntiant, Velox and Xense (these have no relation to the paper)—and also receives funding from the National Institutes of Health (1R01 AG067073; 5R01 DC015587).

Background: Hearing loss is a common and costly medical condition. This systematic review sought to identify evidence gaps in published model-based economic analyses addressing hearing loss to inform model development for an ongoing Lancet Commission., Methods: We searched the published literature through 14 June 2020 and our inclusion criteria included decision model-based cost-effectiveness analyses that addressed diagnosis, treatment, or prevention of hearing loss. Two investigators screened articles for inclusion at the title, abstract, and full-text levels. Data were abstracted and the studies were assessed for the qualities of model structure, data assumptions, and reporting using a previously published quality scale., Findings: Of 1437 articles identified by our search, 117 unique studies met the inclusion criteria. Most of these model-based analyses were set in high-income countries ( n  = 96, 82%). The evaluated interventions were hearing screening ( n  = 35, 30%), cochlear implantation ( n  = 34, 29%), hearing aid use ( n  = 28, 24%), vaccination ( n  = 22, 19%), and other interventions ( n  = 29, 25%); some studies included multiple interventions. Eighty-six studies reported the main outcome in quality-adjusted or disability-adjusted life-years, 24 of which derived their own utility values. The majority of the studies used decision tree ( n  = 72, 62%) or Markov ( n  = 41, 35%) models. Forty-one studies (35%) incorporated indirect economic effects. The median quality rating was 92/100 (IQR:72-100)., Interpretation: The review identified a large body of literature exploring the economic efficiency of hearing healthcare interventions. However, gaps in evidence remain in evaluation of hearing healthcare in low- and middle-income countries, as well as in investigating interventions across the lifespan. Additionally, considerable uncertainty remains around productivity benefits of hearing healthcare interventions as well as utility values for hearing-assisted health states. Future economic evaluations could address these limitations., Funding: NCATS 3UL1-TR002553-03S3., Competing Interests: All authors report no conflicts of interest., (© 2021 The Authors.)

Introduction: Global surgical care is increasingly recognized in the global health agenda and requires multidisciplinary engagement. Despite high interest among medical students, residents and other learners, many surgical faculty and health experts remain uniformed about global surgical care., Methods: We have operated an interdisciplinary graduate-level course in Global Surgical Care based on didactics and interactive group learning. Students completed a pre- and post-course survey regarding their learning experiences and results were analyzed using the Wilcoxon signed-rank test., Results: Fourteen students completed the pre-course survey, and 11 completed the post-course survey. Eleven students (79%) were enrolled in a Master's degree program in global health, with eight students (57%) planning to attend medical school. The median ranking of surgery on the global health agenda was fifth at the beginning of the course and third at the conclusion (p = 0.11). Non-infectious disease priorities tended to stay the same or increase in rank from pre- to post-course. Infectious disease priorities tended to decrease in rank (HIV/AIDS, p = 0.07; malaria, p = 0.02; neglected infectious disease, p = 0.3). Students reported that their understanding of global health (p = 0.03), global surgery (p = 0.001) and challenges faced by the underserved (p = 0.03) improved during the course. When asked if surgery was an indispensable part of healthcare, before the course 64% of students strongly agreed, while after the course 91% of students strongly agreed (p = 0.3). Students reported that the interactive nature of the course strengthened their skills in collaborative problem-solving., Conclusions: We describe an interdisciplinary global surgery course that integrates didactics with team-based projects. Students appeared to learn core topics and held a different view of global surgery after the course. Similar courses in global surgery can educate clinicians and other stakeholders about strategies for building healthy surgical systems worldwide., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2021 The Author(s).)

Competing Interests: Competing interests: None declared.

Background: Ghana's shift from low-income to middle-income status will make it ineligible to receive concessional aid in the future. While transition may be a reflection of positive changes in a country, such as economic development or health progress, a loss of support from donor agencies could have negative impacts on health system performance and population health. We aimed to identify key challenges and opportunities that Ghana will face in dealing with aid transition, specifically from the point of view of country-level stakeholders., Methods: We conducted key informant interviews with 18 stakeholders from the government, civil society organisations and donor agencies in Ghana using a semistructured interview guide. We performed directed content analysis of the interview transcripts to identify key themes related to anticipated challenges and opportunities that might result from donor transitions., Results: Overall, stakeholders identified challenges more frequently than opportunities. All stakeholders interviewed believe that Ghana will face substantial challenges due to donor transitions. Challenges include difficulty filling financial gaps left by donors, the shifting of national priorities away from the health sector, lack of human resources for health, interrupted care for beneficiaries of donor-funded health programmes, neglect of vulnerable populations and loss of the accountability mechanisms that are linked with donor financing. However, stakeholders also identified key opportunities that transitions might present, including efficiency gains, increased self-determination and self-sufficiency, enhanced capacity to leverage domestic resources and improved revenue mobilisation., Conclusion: Stakeholders in Ghana believe transitioning away from aid for health presents both challenges and opportunities. The challenges could be addressed by conducting a transition readiness assessment, identifying health sector priorities, developing a transition plan with a budget to continue critical health programmes and mobilising greater political commitment to health. The loss of aid could be turned into an opportunity to integrate vertical programmes into a more comprehensive health system., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Competing Interests: Competing interests: GY declares that he was a member of the COVID-19 Vaccine Development Taskforce, hosted by the World Bank, and participated in the consultation process that led to the launch of COVAX. GY and OO have received grant funding from Gavi, the Vaccine Alliance.

Background: Evidence for the effectiveness of continuous quality improvement (CQI) in resource-poor settings is very limited. We aimed to establish the effects of CQI on quality of antenatal HIV care in primary care clinics in rural South Africa., Methods and Findings: We conducted a stepped-wedge cluster-randomised controlled trial (RCT) comparing CQI to usual standard of antenatal care (ANC) in 7 nurse-led, public-sector primary care clinics-combined into 6 clusters-over 8 steps and 19 months. Clusters randomly switched from comparator to intervention on pre-specified dates until all had rolled over to the CQI intervention. Investigators and clusters were blinded to randomisation until 2 weeks prior to each step. The intervention was delivered by trained CQI mentors and included standard CQI tools (process maps, fishbone diagrams, run charts, Plan-Do-Study-Act [PDSA] cycles, and action learning sessions). CQI mentors worked with health workers, including nurses and HIV lay counsellors. The mentors used the standard CQI tools flexibly, tailored to local clinic needs. Health workers were the direct recipients of the intervention, whereas the ultimate beneficiaries were pregnant women attending ANC. Our 2 registered primary endpoints were viral load (VL) monitoring (which is critical for elimination of mother-to-child transmission of HIV [eMTCT] and the health of pregnant women living with HIV) and repeat HIV testing (which is necessary to identify and treat women who seroconvert during pregnancy). All pregnant women who attended their first antenatal visit at one of the 7 study clinics and were ≥18 years old at delivery were eligible for endpoint assessment. We performed intention-to-treat (ITT) analyses using modified Poisson generalised linear mixed effects models. We estimated effect sizes with time-step fixed effects and clinic random effects (Model 1). In separate models, we added a nested random clinic-time step interaction term (Model 2) or individual random effects (Model 3). Between 15 July 2015 and 30 January 2017, 2,160 participants with 13,212 ANC visits (intervention n = 6,877, control n = 6,335) were eligible for ITT analysis. No adverse events were reported. Median age at first booking was 25 years (interquartile range [IQR] 21 to 30), and median parity was 1 (IQR 0 to 2). HIV prevalence was 47% (95% CI 42% to 53%). In Model 1, CQI significantly increased VL monitoring (relative risk [RR] 1.38, 95% CI 1.21 to 1.57, p < 0.001) but did not improve repeat HIV testing (RR 1.00, 95% CI 0.88 to 1.13, p = 0.958). These results remained essentially the same in both Model 2 and Model 3. Limitations of our study include that we did not establish impact beyond the duration of the relatively short study period of 19 months, and that transition steps may have been too short to achieve the full potential impact of the CQI intervention., Conclusions: We found that CQI can be effective at increasing quality of primary care in rural Africa. Policy makers should consider CQI as a routine intervention to boost quality of primary care in rural African communities. Implementation research should accompany future CQI use to elucidate mechanisms of action and to identify factors supporting long-term success., Trial Registration: This trial is registered at ClinicalTrials.gov under registration number NCT02626351., Competing Interests: The authors have declared that no competing interests exist.

Background: Since 2015, the World Health Organisation (WHO) recommends immediate initiation of antiretroviral therapy (ART) for all HIV-positive patients. Epidemiological evidence points to important health benefits of immediate ART initiation; however, the policy’s impact on the economic aspects of patients' lives remains unknown., Methods: We conducted a stepped-wedge cluster-randomised controlled trial in Eswatini to determine the causal impact of immediate ART initiation on patients’ individual- and household-level economic outcomes. Fourteen healthcare facilities were non-randomly matched into pairs and then randomly allocated to transition from the standard of care (ART eligibility at CD4 counts of <350 cells/mm3 until September 2016 and <500 cells/mm3 thereafter) to the ‘Early Initiation of ART for All’ (EAAA) intervention at one of seven timepoints. Patients, healthcare personnel, and outcome assessors remained unblinded. Data were collected via standardised paper-based surveys with HIV-positive adults who were neither pregnant nor breastfeeding. Outcomes were patients’ time use, employment status, household expenditures, and household living standards., Results: A total sample of 3019 participants were interviewed over the duration of the study. The mean number of participants approached at each facility per time step varied from 4 to 112 participants. Using mixed-effects negative binomial regressions accounting for time trends and clustering at the level of the healthcare facility, we found no significant difference between study arms for any economic outcome. Specifically, the EAAA intervention had no significant effect on non-resting time use (RR = 1.00 [CI: 0.96, 1.05, p=0.93]) or income-generating time use (RR = 0.94, [CI: 0.73,1.20, p=0.61]). Employment and household expenditures decreased slightly but not significantly in the EAAA group, with risk ratios of 0.93 [CI: 0.82, 1.04, p=0.21] and 0.92 [CI: 0.79, 1.06, p=0.26], respectively. We also found no significant treatment effect on households’ asset ownership and living standards (RR = 0.96, [CI 0.92, 1.00, p=0.253]). Lastly, there was no evidence of heterogeneity in effect estimates by patients’ sex, age, education, timing of HIV diagnosis and ART initiation., Conclusions: Our findings do not provide evidence that should discourage further investments into scaling up immediate ART for all HIV patients., Funding: Funded by the Dutch Postcode Lottery in the Netherlands, Alexander von Humboldt-Stiftung (Humboldt-Stiftung), the Embassy of the Kingdom of the Netherlands in South Africa/Mozambique, British Columbia Centre of Excellence in Canada, Doctors Without Borders (MSF USA), National Center for Advancing Translational Sciences of the National Institutes of Health and Joachim Herz Foundation., Clinical Trial Number: NCT02909218 and NCT03789448., Competing Interests: JS, SK, KM, FW, EM, CL, CW, AH, OO, SV, JD, SM, VO, TB, PG No competing interests declared, (© 2020, Steinert et al.)

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and declare that all the authors have no relevant interest to declare.

Competing Interests: Competing interests: GY and OO are principal investigators of a study funded by the Bill & Melinda Gates Foundation on the transition of middle-income countries from development assistance for health; in this work they partner with research institutions in Nigeria.