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BackgroundPreterm birth is the leading cause of death in children younger than 5 years worldwide. WHO recommends kangaroo mother care (KMC); however, its effects on mortality in sub-Saharan Africa and its relative costs remain unclear. We aimed to compare the effectiveness, safety, costs, and cost-effectiveness of KMC initiated before clinical stabilisation versus standard care in neonates weighing up to 2000 g.MethodsWe conducted a parallel-group, individually randomised controlled trial in five hospitals across Uganda. Singleton or twin neonates aged younger than 48 h weighing 700-2000 g without life-threatening clinical instability were eligible for inclusion. We randomly assigned (1:1) neonates to either KMC initiated before stabilisation (intervention group) or standard care (control group) via a computer-generated random allocation sequence with permuted blocks of varying sizes, stratified by birthweight and recruitment site. Parents, caregivers, and health-care workers were unmasked to treatment allocation; however, the independent statistician who conducted the analyses was masked. After randomisation, neonates in the intervention group were placed prone and skin-to-skin on the caregiver's chest, secured with a KMC wrap. Neonates in the control group were cared for in an incubator or radiant heater, as per hospital practice; KMC was not initiated until stability criteria were met. The primary outcome was all-cause neonatal mortality at 7 days, analysed by intention to treat. The economic evaluation assessed incremental costs and cost-effectiveness from a disaggregated societal perspective. This trial is registered with ClinicalTrials.gov, NCT02811432.FindingsBetween Oct 9, 2019, and July 31, 2022, 2221 neonates were randomly assigned: 1110 (50·0%) neonates to the intervention group and 1111 (50·0%) neonates to the control group. From randomisation to age 7 days, 81 (7·5%) of 1083 neonates in the intervention group and 83 (7·5%) of 1102 neonates in the control group died (adjusted relative risk [RR] 0·97 [95% CI 0·74-1·28]; p=0·85). From randomisation to 28 days, 119 (11·3%) of 1051 neonates in the intervention group and 134 (12·8%) of 1049 neonates in the control group died (RR 0·88 [0·71-1·09]; p=0·23). Even if policy makers place no value on averting neonatal deaths, the intervention would have 97% probability from the provider perspective and 84% probability from the societal perspective of being more cost-effective than standard care.InterpretationKMC initiated before stabilisation did not reduce early neonatal mortality; however, it was cost-effective from the societal and provider perspectives compared with standard care. Additional investment in neonatal care is needed for increased impact, particularly in sub-Saharan Africa.FundingJoint Global Health Trials scheme of the Department of Health and Social Care, Foreign, Commonwealth and Development Office, UKRI Medical Research Council, and Wellcome Trust; Eunice Kennedy Shriver National Institute of Child Health and Human Development.

BackgroundPreterm birth complications result in > 1 million child deaths annually, mostly in low- and middle-income countries. A World Health Organisation (WHO)-led trial in hospitals with intensive care reported reduced mortality within 28 days among newborns weighing 1000-1799 g who received immediate kangaroo mother care (iKMC) compared to those who received standard care. Evidence is needed regarding the process and costs of implementing iKMC, particularly in non-intensive care settings.MethodsWe describe actions undertaken to implement iKMC, estimate financial and economic costs of essential resources and infrastructure improvements, and assess readiness for newborn care after these improvements at five Ugandan hospitals participating in the OMWaNA trial. We estimated costs from a health service provider perspective and explored cost drivers and cost variation across hospitals. We assessed readiness to deliver small and sick newborn care (WHO level-2) using a tool developed by Newborn Essential Solutions and Technologies and the United Nations Children's Fund.ResultsFollowing the addition of space to accommodate beds for iKMC, floor space in the neonatal units ranged from 58 m2 to 212 m2. Costs of improvements were lowest at the national referral hospital (financial: $31,354; economic: $45,051; 2020 USD) and varied across the four smaller hospitals (financial: $68,330-$95,796; economic: $99,430-$113,881). In a standardised 20-bed neonatal unit offering a level of care comparable to the four smaller hospitals, the total financial cost could be in the range of $70,000 to $80,000 if an existing space could be repurposed or remodelled, or $95,000 if a new unit needed to be constructed. Even after improvements, the facility assessments demonstrated broad variability in laboratory and pharmacy capacity as well as the availability of essential equipment and supplies.ConclusionsThese five Ugandan hospitals required substantial resource inputs to allow safe implementation of iKMC. Before widespread scale-up of iKMC, the affordability and efficiency of this investment must be assessed, considering variation in costs across hospitals and levels of care. These findings should help inform planning and budgeting as well as decisions about if, where, and how to implement iKMC, particularly in settings where space, devices, and specialised staff for newborn care are unavailable.Trial registrationClinicalTrials.gov, NCT02811432 . Registered: 23 June 2016.

BackgroundThere are 2.5 million neonatal deaths each year; the majority occur within 48 h of birth, before stabilisation. Evidence from 11 trials shows that kangaroo mother care (KMC) significantly reduces mortality in stabilised neonates; however, data on its effect among neonates before stabilisation are lacking. The OMWaNA trial aims to determine the effect of initiating KMC before stabilisation on mortality within seven days relative to standard care. Secondary objectives include exploring pathways for the intervention's effects and assessing incremental costs and cost-effectiveness between arms.MethodsWe will conduct a four-centre, open-label, individually randomised, superiority trial in Uganda with two parallel groups: an intervention arm allocated to receive KMC and a control arm receiving standard care. We will enrol 2188 neonates (1094 per arm) for whom the indication for KMC is 'uncertain', defined as receiving ≥ 1 therapy (e.g. oxygen). Admitted singleton, twin and triplet neonates (triplet if demise before admission of ≥ 1 baby) weighing ≥ 700-≤ 2000 g and aged ≥ 1-

Case management of malaria in Africa has evolved markedly over the past 20 years and updated cost estimates are needed to guide malaria control policies. We estimated the cost of malaria illness to households and the public health service and assessed the equity of these costs in Uganda. From December 2021 to May 2022, we conducted a costing exercise in eight government-run health centres covering seven sub-regions, collecting health service costs from patient observations, records review and a time-and-motion study. From November 2021 to January 2022, we gathered data on households' cost of illness from randomly selected households for 614 residents with suspected malaria. Societal costs of illness were estimated and combined with secondary data sources to estimate the total economic burden of malaria in Uganda. We used regression analyses and concentration curves to assess the equity of household costs across age, geographic location and socio-economic status. The mean societal economic cost of treating suspected malaria was $15.12 [95% confidence interval (CI): 12.83–17.14] per outpatient and $27.21 (95% CI: 20.43–33.99) per inpatient case. Households incurred 81% of outpatient and 72% of inpatient costs. Households bore nearly equal costs of illness, regardless of socio-economic status. A case of malaria cost households in the lowest quintile 26% of per capita monthly consumption, while a malaria case only cost households in the highest quintile 8%. We estimated the societal cost of malaria treatment in Uganda was $577 million (range: $302 million–1.09 billion) in 2021. The cost of malaria remains high in Uganda. Households bear the major burden of these costs. Poorer and richer households incur the same costs per case; this distribution is equal, but not equitable. These results can be applied to parameterize future economic evaluations of malaria control interventions and to evaluate the impact of malaria on Ugandan society, informing resource allocations in malaria prevention. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to present a preliminary, qualitative review of a therapeutic programme for preschool children and their parents in severely under-resourced contexts to aid the development of the underlying skills required to be ready for formal school. A team of two pairs, each comprising an occupational therapist and a community worker, responded to teachers' requests to assist struggling children in their classes. This led to the development of a programme focusing on Grade R classes, by firstly helping teachers to develop their capability and confidence in assessing and assisting children to develop the abilities underlying vital school-readiness skills during whole-class, therapeutic group sessions. Secondly, parent group sessions were added to empower parents to understand and support their children's development needs at home and so to complement the work done by teachers in the classroom. This second aspect, of working with the parents, developed owing to observations of the children's irregular school attendance, scant parent-school contact, and teachers' reports indicating that parents were not aware of, nor equipped to deal with, the challenges faced by their children. Implications for practice, for planning and for further research are discussed.