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BackgroundAntenatal care (ANC) is essential for ensuring the well-being of pregnant women and their fetuses. This study models the association between achieving adequate ANC and various health and health-seeking indicators across wealth quintiles in low- and middle-income countries (LMICs).Methods and findingsWe analyzed data from 638,265 women across 47 LMICs using available Demographic and Health Surveys from 2010 to 2022. Via multilevel logistic regression analyses adjusted for a series of confounding variables and country and wealth quintile fixed effects, we estimated the projected impact of achieving adequate ANC utilization and quality on a series of health and health care indicators: facility birth, postnatal care, childhood immunizations, and childhood stunting and wasting. Achieving adequate levels of ANC utilization and quality (defined as at least 4 visits, blood pressure monitoring, and blood and urine testing) was positively associated with health-seeking behavior across the majority of countries. The strongest association was observed for facility birth, followed by postnatal care and child immunization. The strength of the associations varied across countries and wealth quintiles, with more significant ones observed in countries with lower baseline ANC utilization levels and among the lower wealth quintiles. The associations of ANC with childhood stunting and wasting were notably less statistically significant compared to other indicators. Despite rigorous adjustments for potential confounders, a limitation to the methodology is that it is possible that unobserved variables may still impact outcomes.ConclusionsStrengthening ANC is associated with improved use of other health care in LMICs. ANC could serve as a critical platform for improving health outcomes for mothers and their children, emphasizing its importance beyond direct impact on maternal and neonatal mortality.

Abstract Background Aggregate trends can be useful for summarizing large amounts of information, but this can obscure important distributional aspects. Some population subgroups can be worse off even as averages climb, for example. Distributional information can identify health inequalities, which is essential to understanding their drivers and possible remedies. Methods Using publicly available Demographic and Health Survey (DHS) data from 41 sub-Saharan African countries from 1986 to 2019, we analyzed changes in coverage for eight key maternal and child health indicators: first dose of measles vaccine (MCV1); Diphtheria-Pertussis-Tetanus (DPT) first dose (DPT1); DPT third dose (DPT3); care-seeking for diarrhea, acute respiratory infections (ARI), or fever; skilled birth attendance (SBA); and having four antenatal care (ANC) visits. To evaluate whether coverage diverged or converged over time across the wealth gradient, we computed several dispersion metrics including the coefficient of variation across wealth quintiles. Slopes and 5-year moving averages were computed to identify overall long-term trends. Results Average coverage increased for all quintiles and indicators, although the range and the speed at which they increased varied widely. There were small changes in the wealth-related gap for SBA, ANC, and fever. The wealth-related gap of vaccination-related indicators (DPT1, DPT3, MCV1) decreased over time. Compared to 2017, the wealth-gap between richest and poorest quintiles in 1995 was 7 percentage points larger for ANC and 17 percentage points larger for measles vaccination. Conclusions Maternal and child health indicators show progress, but the distributional effects show differential evolutions in inequalities. Several reasons may explain why countries had smaller wealth-related gap trends in vaccination-related indicators compared to others. In addition to service delivery differences, we hypothesize that the allocation of development assistance for health, the prioritization of vaccine-preventable diseases on the global agenda, and indirect effects of structural adjustment programs on health system-related indicators might have played a role.

Ethiopia has made significant progress in the last two decades in improving the availability and coverage of essential maternal and child health services including childhood immunizations. As Ethiopia keeps momentum towards achieving national immunization goals, methods must be developed to analyze routinely collected health facility data and generate localized coverage estimates. This study leverages the District Health Information Software (DHIS2) platform to estimate immunization coverage for the first dose of measles vaccine (MCV1) and the third dose of diphtheria-pertussis-tetanus-Hib-HepB vaccine (Penta3) across Ethiopian districts ("woredas"). Monthly reported numbers of administered MCV1 and Penta3 immunizations were extracted from public facilities from DHIS2 for 2017/2018-2021/2022 and corrected for quality based on completeness and consistency across time and districts. We then utilized three sources for the target population (infants) to compute administrative coverage estimates: Central Statistical Agency, DHIS2, and WorldPop. The Ethiopian Demographic and Health Surveys were used as benchmarks to which administrative estimates were adjusted at the regional level. Administrative vaccine coverage was estimated for all woredas, and, after adjustments, was bounded within 0-100%. In regions with the highest immunization coverage, MCV1 coverage would range from 83 to 100% and Penta3 coverage from 88 to 100% (Addis Ababa, 2021/2022); MCV1 from 8 to 100% and Penta3 from 4 to 100% (Tigray, 2019/2020). Nationally, the Gini index for MCV1 was 0.37, from 0.13 (Harari) to 0.37 (Somali); for Penta3, it was 0.36, from 0.16 (Harari) to 0.36 (Somali). The use of routine health information systems, such as DHIS2, combined with household surveys permits the generation of local health services coverage estimates. This enables the design of tailored health policies with the capacity to measure progress towards achieving national targets, especially in terms of inequality reductions.

Abstract Background Financial risk protection (FRP) is a key component of universal health coverage (UHC): all individuals must be able to obtain the health services they need without experiencing financial hardship. In many low-income and lower-middle-income countries, however, the health system fails to provide sufficient protection against high out-of-pocket (OOP) spending on health services. In 2018, OOP health spending comprised approximately 40% of current health expenditures in low-income and lower-middle-income countries. Methods We model the household risk of catastrophic health expenditures (CHE), conditional on having a given disease or condition—defined as OOP health spending that exceeds a threshold percentage (10, 25, or 40%) of annual income—for 29 health services across 13 disease categories (e.g., diarrheal diseases, cardiovascular diseases) in 34 low-income and lower-middle-income countries. Health services were included in the analysis if delivered at the primary care level and part of the Disease Control Priorities, 3rd edition “highest priority package.” Data were compiled from several publicly available sources, including national health accounts, household surveys, and the published literature. A risk of CHE, conditional on having disease, was modeled as depending on usage, captured through utilization indicators; affordability, captured via the level of public financing and OOP health service unit costs; and income. Results Across all countries, diseases, and health services, the risk of CHE (conditional on having a disease) would be concentrated among poorer quintiles (6.8% risk in quintile 1 vs. 1.3% in quintile 5 using a 10% CHE threshold). The risk of CHE would be higher for a few disease areas, including cardiovascular disease and mental/behavioral disorders (7.8% and 9.8% using a 10% CHE threshold), while lower risks of CHE were observed for lower cost services. Conclusions Insufficient FRP stands as a major barrier to achieving UHC, and risk of CHE is a major problem for health systems in low-income and lower-middle-income countries. Beyond its threat to the financial stability of households, CHE may also lead to worse health outcomes, especially among the poorest for whom both ill health and financial risk are most severe. Modeling the risk of CHE associated with specific disease areas and services can help policymakers set progressive health sector priorities. Decision-makers could explicitly include FRP as a criterion for consideration when assessing the health interventions for inclusion in national essential benefit packages.

Public policies often aim to improve welfare, economic injustice and reduce inequality, particularly in the social protection, labour, health and education sectors. While these policies frequently operate in silos, the education sphere can operate as a cross-sectoral link. Schools represent a unique locus, with globally hundreds of millions of children attending class every day. A high-profile policy example is school feeding, with over 400 million students worldwide receiving meals in schools. The benefits of harmonising interventions across sectors with a common delivery platform include economies of scale. Moreover, economic evaluation frameworks commonly used to assess policies rarely account for impact across sectors besides their primary intent. For example, school meals are often evaluated for their impact on nutrition, but they also have educational benefits, including increasing attendance and learning and incorporating smallholder farmers into corporate value chains. To address these gaps, we propose the introduction of a comprehensive value-for-money framework for investments toward school systems that acknowledges the return to a common delivery platform—schools—and the multisectoral returns (eg, education, health and nutrition, labour, social protection) emerging from the rollout of school-based programmes. Directly building on benefit-cost analysis methods, this framework could help identify interventions that yield the highest gains in human capital per budget expenditure, with direct implications for finance ministries. Given the detrimental impact of COVID-19 on schoolchildren and human capital, it is urgent to build back stronger and more sustainable welfare systems.

BackgroundVaccine-preventable diseases (VPDs) remain major causes of morbidity and mortality in low- and middle-income countries (LMICs). Universal access to vaccination, besides improved health outcomes, would substantially reduce VPD-related out-of-pocket (OOP) expenditures and associated financial risks. This paper aims to estimate the extent of OOP expenditures and the magnitude of the associated catastrophic health expenditures (CHEs) for selected VPDs in Ethiopia.Methods and findingsWe conducted a cross-sectional costing analysis, from the household (patient) perspective, of care-seeking for VPDs in children aged under 5 years for pneumonia, diarrhea, measles, and pertussis, and in children aged under 15 years for meningitis. Data on OOP direct medical and nonmedical expenditures (2021 USD) and household consumption expenditures were collected from 995 households (1 child per household) in 54 health facilities nationwide between May 1 and July 31, 2021. We used descriptive statistics to measure the main outcomes: magnitude of OOP expenditures, along with the associated CHE within households. Drivers of CHE were assessed using a logistic regression model. The mean OOP expenditures per disease episode for outpatient care for diarrhea, pneumonia, pertussis, and measles were $5·6 (95% confidence interval (CI): $4·3, 6·8), $7·8 ($5·3, 10·3), $9·0 ($6·4, 11·6), and $7·4 ($3·0, 11·9), respectively. The mean OOP expenditures were higher for inpatient care, ranging from $40·6 (95% CI: $12·9, 68·3) for severe measles to $101·7 ($88·5, 114·8) for meningitis. Direct medical expenditures, particularly drug and supply expenses, were the major cost drivers. Among those who sought inpatient care (345 households), about 13·3% suffered CHE, at a 10% threshold of annual consumption expenditures. The type of facility visited, receiving inpatient care, and wealth were significant predictors of CHE (p-value < 0·001) while adjusting for area of residence (urban/rural), diagnosis, age of respondent, and household family size. Limitations include inadequate number of measles and pertussis cases.ConclusionsThe OOP expenditures induced by VPDs are substantial in Ethiopia and disproportionately impact those with low income and those requiring inpatient care. Expanding equitable access to vaccines cannot be overemphasized, for both health and economic reasons. Such realization requires the government's commitment toward increasing and sustaining vaccine financing in Ethiopia.

Summary: Background: Epidemiological and economic estimates suggest that the global burden of mental disorders is considerable, both in its impacts on human health and losses to societal welfare. The availability of additional data and the emergence of new approaches present an opportunity to examine these estimates, which form a critical part in making the investment case for global mental health. Methods: This study reviews, develops, and incorporates new estimates and methods in quantifying the global burden of mental illness. Using a composite estimation approach that accounts for premature mortality due to mental disorders and additional sources of morbidity and applying a value of a statistical life approach to economic valuation, we determine global and regional estimates of the economic cost that can be associated with mental disorders, building on data from the 2019 Global Burden of Disease study. Findings: We estimate that 418 million disability-adjusted life years (DALYs) could be attributable to mental disorders in 2019 (16% of global DALYs)—a more than three-fold increase compared to conventional estimates. The economic value associated with this burden is estimated at about USD 5 trillion. At a regional level, the losses could account for between 4% of gross domestic product in Eastern sub-Saharan Africa and 8% in High-income North America. Interpretation: The burden of mental illness in terms of both health and economic losses may be much higher than previously assessed. Funding: None.

Abstract Background We develop a framework for quantifying monetary values associated with changes in disease-specific mortality risk in low- and middle-income countries to help quantify trade-offs involved in investing in mortality reduction due to one disease versus another. Methods We monetized the changes in mortality risk for communicable and non-communicable diseases (CD and NCD, respectively) between 2017 and 2030 for low-income, lower-middle-income, and upper-middle-income countries (LICs, LMICs, and UMICs, respectively). We modeled three mortality trajectories (“base-case”, “high-performance”, and “low-performance”) using Global Burden of Disease study forecasts and estimated disease-specific mortality risk changes relative to the base-case. We assigned monetary values to changes in mortality risk using value of a statistical life (VSL) methods and conducted multiple sensitivity analyses. Results In terms of NCDs, the absolute monetary value associated with changing mortality risk was highest for cardiovascular diseases in older age groups. For example, being on the low-performance trajectory relative to the base-case in 2030 was valued at $9100 (95% uncertainty range $6800; $11,400), $28,300 ($24,200; $32,400), and $30,300 ($27,200; $33,300) for females aged 70–74 years in LICs, LMICs, and UMICs, respectively. Changing the mortality rate from the base-case to the high-performance trajectory was associated with high monetary value for CDs as well, especially among younger age groups. Estimates were sensitive to assumptions made in calculating VSL. Conclusions Our framework provides a priority setting paradigm to best allocate investments toward the health sector and enables intersectoral comparisons of returns on investments from health interventions.

Ethiopia raised taxes on tobacco products in early 2020, increasing the overall price of the typical pack of cigarettes by about 67%. We quantify the potential impacts of Ethiopia's tobacco tax hike on various outcomes—life years, tax revenues, cigarette expenditures and catastrophic health expenditures (CHE). Using parameters like price elasticity of demand for cigarettes and smoking prevalence in Ethiopia from the existing literature and secondary data sources, we model the potential implications of the reform at the population level and for different wealth quintiles. We focus only on men since a small proportion of Ethiopian women smoke. Results indicate that Ethiopia's tax hike could induce a significant proportion of current smokers to quit smoking and thereby save almost eight million years of life in the current population. The reform is also likely to increase tax revenues by USD26 million in the first year after its introduction. The richest quintile will bear the greatest share of this higher tax burden and the poorest will bear the least. Additionally, deaths due to the main diseases associated with smoking will fall. This is expected to avert up to 173,000 CHE cases due to the out-of-pocket costs that would have been incurred in obtaining medical treatment. This analysis highlights that cigarette tax hikes in countries that have low smoking prevalence can reduce smoking even further, and thereby protect against the future health and financial costs of smoking. Importantly, the effects of these policies can be progressive across the income spectrum.

Abstract Background Expansion of designated cycling networks increases cycling for transport that, in turn, increases physical activity, contributing to improvement in public health. This paper aims to determine whether cycle-network construction in a large city is cost-effective when compared to the status-quo. We developed a cycle-network investment model (CIM) for Oslo and explored its impact on overall health and wellbeing resulting from the increased physical activity. Methods First, we applied a regression technique on cycling data from 123 major European cities to model the effect of additional cycle-networks on the share of cyclists. Second, we used a Markov model to capture health benefits from increased cycling for people starting to ride cycle at the age of 30 over the next 25 years. All health gains were measured in quality-adjusted life years (QALYs). Costs were estimated in US dollars. Other data to populate the model were derived from a comprehensive literature search of epidemiological and economic evaluation studies. Uncertainty was assessed using deterministic and probabilistic sensitivity analyses. Results Our regression analysis reveals that a 100 km new cycle network construction in Oslo city would increase cycling share by 3%. Under the base-case assumptions, where the benefits of the cycle-network investment relating to increased physical activity are sustained over 25 years, the predicted average increases in costs and QALYs per person are $416 and 0.019, respectively. Thus, the incremental costs are $22,350 per QALY gained. This is considered highly cost-effective in a Norwegian setting. Conclusions The results support the use of CIM as part of a public health program to improve physical activity and consequently avert morbidity and mortality. CIM is affordable and has a long-term effect on physical activity that in turn has a positive impact on health improvement.

Public spending can improve population well-being, for example, by averting or reducing poverty. We aim to conceptualize monetary benchmarks for health sector investments oriented towards poverty alleviation in low- and lower middle-income countries. These benchmarks are meant to indicate the approximate range of health sector costs incurred to avert a single case of poverty across countries. Such conceptualizations could help identify the health interventions that are worthwhile investing in from financial risk protection and social welfare standpoints. We sourced secondary data from the World Bank for low-income and lower-middle-income countries over 2002-2019, including: per capita government expenditures on health, the proportion of a country's population living under the international poverty line ($1.90 per day, 2011 Purchasing Power Parity), and the features of national social protection programs whose primary intent is poverty reduction. We then examined the associations between poverty headcount and per capita government health spending to gauge the potential relationship between this spending and poverty reduction. Subsequently, we derived a range of plausible poverty reduction benchmarks (PRBs). We also computed the per capita costs of national poverty reduction programs so as to contrast these with the estimated range of PRBs. Priority setting in low- and lower-middle-income countries could be informed by health-sector PRBs, in addition to burden of disease and cost-effectiveness considerations. The computed PRBs, expressed in dollars per poverty case averted, can possibly be viewed in a manner akin to economic evaluation thresholds which are usually expressed in dollars per disability-adjusted life year averted.

Immunization is one of the most effective public health interventions, saving millions of lives every year. Ethiopia has seen gradual improvements in immunization coverage and access to child health care services; however, inequalities in child mortality across wealth quintiles and regions remain persistent. We model the relative distributional incidence and mortality of four vaccine-preventable diseases (VPDs) (rotavirus diarrhea, human papillomavirus, measles, and pneumonia) by wealth quintile and geographic region in Ethiopia. Our approach significantly extends an earlier methodology, which utilizes the population attributable fraction and differences in the prevalence of risk and prognostic factors by population subgroup to estimate the relative distribution of VPD incidence and mortality. We use a linear system of equations to estimate the joint distribution of risk and prognostic factors in population subgroups, treating each possible combination of risk or prognostic factors as computationally distinct, thereby allowing us to account for individuals with multiple risk factors. Across all modeling scenarios, our analysis found that the poor and those living in rural and primarily pastoralist or agrarian regions have a greater risk than the rich and those living in urban regions of becoming infected with or dying from a VPD. While in absolute terms all population subgroups benefit from health interventions (e.g., vaccination and treatment), current unequal levels and pro-rich gradients of vaccination and treatment-seeking patterns should be redressed so to significantly improve health equity across wealth quintiles and geographic regions in Ethiopia.

Background The COVID-19 pandemic has caused profound health, economic, and social disruptions globally. We assessed the full costs of hospitalization for COVID-19 disease at Ekka Kotebe COVID-19 treatment center in Addis Ababa, the largest hospital dedicated to COVID-19 patient care in Ethiopia. Methods and findings We retrospectively collected and analysed clinical and cost data on patients admitted to Ekka Kotebe with laboratory-confirmed COVID-19 infections. Cost data included personnel time and salaries, drugs, medical supplies and equipment, facility utilities, and capital costs. Facility medical records were reviewed to assess the average duration of stay by disease severity (either moderate, severe, or critical). The data collected covered the time-period March-November 2020. We then estimated the cost per treated COVID-19 episode, stratified by disease severity, from the perspective of the provider. Over the study period there were 2,543 COVID-19 cases treated at Ekka Kotebe, of which, 235 were critical, 515 were severe, and 1,841 were moderate. The mean patient duration of stay varied from 9.2 days (95% CI: 7.6–10.9; for moderate cases) to 19.2 days (17.9–20.6; for critical cases). The mean cost per treated episode was USD 1,473 (95% CI: 1,197–1,750), but cost varied by disease severity: the mean cost for moderate, severe, and critical cases were USD 1,266 (998–1,534), USD 1,545 (1,413–1,677), and USD 2,637 (1,788–3,486), respectively. Conclusions Clinical management and treatment of COVID-19 patients poses an enormous economic burden to the Ethiopian health system. Such estimates of COVID-19 treatment costs inform financial implications for resource-constrained health systems and reinforce the urgency of implementing effective infection prevention and control policies, including the rapid rollout of COVID-19 vaccines, in low-income countries like Ethiopia.

Abstract Background Global health priority setting increasingly focuses on understanding the functioning of health systems and on how they can be strengthened. Beyond vertical programs, health systems research should examine system-wide delivery platforms (e.g. health facilities) and operational elements (e.g. supply chains) as primary units of study and evaluation. Methods We use dynamical system methods to develop a simple analytical model for the supply chain of a low-income country’s health system. In doing so, we emphasize the dynamic links that integrate the supply chain within other elements of the health system; and we examine how the evolution over time of such connections would affect drug delivery, following the implementation of selected interventions (e.g. enhancing road networks, expanding workforce). We also test feedback loops and forecasts to study the potential impact of setting up a digital system for tracking drug delivery to prevent drug stockout and expiration. Results Numerical simulations that capture a range of supply chain scenarios demonstrate the impact of different health system strengthening interventions on drug stock levels within health facilities. Our mathematical modeling also points to how implementing a digital drug tracking system could help anticipate and prevent drug stockout and expiration. Conclusion Our mathematical model of drug supply chain delivery represents an important component toward the development of comprehensive quantitative frameworks that aim at describing health systems as complex dynamical systems. Such models can help predict how investments in system-wide interventions, like strengthening drug supply chains in low-income settings, may improve population health outcomes.

Abstract Background Malaria is a public health burden and a major cause for morbidity and mortality in Ethiopia. Malaria also places a substantial financial burden on families and Ethiopia’s national economy. Economic evaluations, with evidence on equity and financial risk protection (FRP), are therefore essential to support decision-making for policymakers to identify best buys amongst possible malaria interventions. The aim of this study is to estimate the expected health and FRP benefits of universal public financing of key malaria interventions in Ethiopia. Methods Using extended cost-effectiveness analysis (ECEA), the potential health and FRP benefits were estimated, and their distributions across socio-economic groups, of publicly financing a 10% coverage increase in artemisinin-based combination therapy (ACT), long-lasting insecticide-treated bed nets (LLIN), indoor residual spraying (IRS), and malaria vaccine (hypothetical). Results ACT, LLIN, IRS, and vaccine would avert 358, 188, 107 and 38 deaths, respectively, each year at a net government cost of $5.7, 16.5, 32.6, and 5.1 million, respectively. The annual cost of implementing IRS would be two times higher than that of the LLIN interventions, and would be the main driver of the total costs. The averted deaths would be mainly concentrated in the poorest two income quintiles. The four interventions would eliminate about $4,627,800 of private health expenditures, and the poorest income quintiles would see the greatest FRP benefits. ACT and LLINs would have the largest impact on malaria-related deaths averted and FRP benefits. Conclusions ACT, LLIN, IRS, and vaccine interventions would bring large health and financial benefits to the poorest households in Ethiopia.

Health management information systems (HMIS) are a crucial source of timely health statistics and have the potential to improve reporting in low-income countries. However, concerns about data quality have hampered their widespread adoption in research and policy decisions. This article presents results from a data verification study undertaken to gain insights into the quality of HMIS data in Ethiopia. We also provide recommendations for working with HMIS data for research and policy translation. We linked the HMIS to the 2016 Emergency Obstetric and Newborn Care Assessment, a national census of all health facilities that provided maternal and newborn health services in Ethiopia. We compared the number of visits for deliveries and caesarean sections (C-sections) reported in the HMIS in 2015 (January–December) to those found in source documents (paper-based labour and delivery and operating theatre registers) in 2425 facilities across Ethiopia. We found that two-thirds of facilities had ‘good’ HMIS reporting for deliveries (defined as reporting within 10% of source documents) and half had ‘very good’ reporting (within 5% of source documents). Results were similar for reporting on C-section deliveries. We found that good reporting was more common in urban areas (OR: 1.30, 95% CI 1.06 to 1.59), public facilities (OR: 2.95, 95% CI 1.38 to 6.29) and in hospitals compared with health centres (OR: 1.71, 95% CI 1.13 to 2.61). Facilities in the Somali and Afar regions had the lowest odds of good reporting compared with Addis Ababa and were more likely to over-report deliveries in the HMIS. Further work remains to address remaining discrepancies in the Ethiopian HMIS. Nonetheless, our findings corroborate previous data verification exercises in Ethiopia and support greater use and uptake of HMIS data for research and policy decisions (particularly, greater use of HMIS data elements (eg, absolute number of services provided each month) rather than coverage indicators). Increased use of these data, combined with feedback mechanisms, is necessary to maintain data quality.

Abstract Background Financial risk protection (FRP) is a key objective of national health systems and a core pillar of universal health coverage (UHC). Yet, little is known about the disease-specific distribution of catastrophic health expenditure (CHE) at the national level. Methods Using the World Health Surveys (WHS) from 39 countries, we quantified CHE, or household health spending that surpasses 40% of capacity-to-pay by key disease areas. We restricted our analysis to households in which the respondent used health care in the last 30 days and categorized CHE into disease areas included as WHS response options: maternal and child health (MCH); high fever, severe diarrhea, or cough; heart disease; asthma; injury; surgery; and other. We compared disease-specific CHE estimates by income, pooled funding as a share of total health expenditure, share of the population affected by the different diseases, and poverty status. Results Across countries, an average of 45.1% of CHE cases could not be tied to a specific cause; 37.6% (95% UI 35.4–39.9%) of CHE cases were associated with high fever, severe cough, or diarrhea; 3.9% (3.0–4.9%) with MCH; and 4.1% (3.3–4.9%) with heart disease. Injuries constituted 5.2% (4.2–6.4%) of CHE cases. The distribution of CHE varied substantially by national income. A 10% increase in heart disease prevalence was associated with a 1.9% (1.3–2.4%) increase in heart disease CHE, an association stronger than any other disease area. Conclusions Our approach is comparable, comprehensive, and empirically based and highlights how financial risk protection may not be aligned with disease burden. Disease-specific CHE estimates can illuminate how health systems can target reform to best protect households from financial risk.

In Ethiopia, despite the introduction of new vaccines and a steady increase in access to immunization services over the last decade, considerable coverage gaps have persisted leading to a heavier vaccine-preventable disease (VPD) burden among poorer households. In this paper, we present a brief overview including available evidence and published studies on vaccine economics in Ethiopia, covering the topics of cost-effectiveness analysis, cost of illness associated with VPDs, equitable access to vaccines, and immunization financing. We can then point that large disparities in vaccine access exist by geographic location, socioeconomic and maternal educational status. Ethiopian households, especially the poorest, can incur impoverishing out-of-pocket expenditures for VPDs. Financing for immunization services has shown modest improvements in Ethiopia over recent years prior to the COVID-19 pandemic. A number of economic evaluation studies have pointed to the potentially pro-poor benefits of immunization programs in Ethiopia, yielding health and financial risk protection gains among the poorest households.

In Cambodia, diabetes caused nearly 3% of the country’s mortality in 2016 and became the fourth highest cause of disability in 2017. Providing sufficient financial risk protection from health care expenditures may be part of the solution towards effectively tackling the diabetes burden and motivating individuals to appropriately seek care to effectively manage their condition. In this study, we aim to estimate the distributional health and financial impacts of strategies providing financial coverage for diabetes services through the Health Equity Funds (HEF) in Cambodia. The trajectory of diabetes was represented using a Markov model to estimate the societal costs, health impacts, and individual out-of-pocket expenditures associated with six strategies of HEF coverage over a time horizon of 45 years. Input parameters for the model were compiled from published literature and publicly available household survey data. Strategies covered different combinations of types of diabetes care costs (i.e., diagnostic services, medications, and management of diabetes-related complications). Health impacts were computed as the number of disability-adjusted life-years (DALYs) averted and financial risk protection was analyzed in terms of cases of catastrophic health expenditure (CHE) averted. Model simulations demonstrated that coverage for medications would be cost-effective, accruing health benefits ($27 per DALY averted) and increases in financial risk protection ($2 per case of CHE averted) for the poorest in Cambodia. Women experienced particular gains in health and financial risk protection. Increasing the number of individuals eligible for financial coverage also improved the value of such investments. For HEF coverage, the government would pay between an estimated $28 and $58 per diabetic patient depending on the extent of coverage and services covered. Efforts to increase the availability of services and capacity of primary care facilities to support diabetes care could have far-reaching impacts on the burden of diabetes and contribute to long-term health system strengthening.

Introduction: Globally, there are 370 million children receiving school meals every day. Coverage is least in low-income countries, where the need is greatest and where program costs are viewed as high in comparison with the benefits to public health alone. Here we explore the policy implications of including the returns of school feeding to other sectors in an economic analysis.Methods: We develop an economic evaluation methodology to estimate the costs and benefits of school feeding programs across four sectors: health and nutrition; education; social protection; and the local agricultural economy. We then apply this multi-sectoral benefit-cost analytical framework to school feeding programs in 14 countries (Botswana, Brazil, Cape Verde, Chile, Côte d'Ivoire, Ecuador, Ghana, India, Kenya, Mali, Mexico, Namibia, Nigeria, and South Africa) for which input data are readily available.Results: Across the 14 countries, we estimate that 190 million schoolchildren benefit from school feeding programs, with total program budgets reaching USD11 billion per year. Estimated annual human capital returns are USD180 billion: USD24 billion from health and nutrition gains, and USD156 billion from education. In addition, school feeding programs offer annual social protection benefits of USD7 billion and gains to local agricultural economies worth USD23 billion.Conclusions: This multi-sectoral analysis suggests that the overall benefits of school feeding are several times greater than the returns to public health alone, and that the overall benefit-cost ratio of school feeding programs could vary between 7 and 35, with particular sensitivity to the value of local wages. The scale of the findings suggests that school feeding programs are potentially much more cost-beneficial when viewed from the perspective of their multi-sectoral returns, and that it would be worthwhile following up with more detailed analyses at the national level to enhance the precision of these estimates.

Introduction The identification of spatial–temporal clusters of forced migrant mortality is urgently needed to inform preventative policies and humanitarian response. As a first step towards understanding the geography of forced migrant mortality, this study investigates spatial–temporal patterns in death at a global scale.Methods We used information on the location and dates of forced migrant deaths reported in the International Organization for Migration’s Missing Migrant Project from 2014 to 2018. Kulldorff’s spatial–temporal and seasonal scans were used to detect spatial–temporal and temporal heterogeneity in mortality.Results A total of 16 314 deaths were reported during the study period. A preponderance of deaths occurred at sea each year (range 26%–54% across 5 years). Twelve spatial–temporal clusters of forced migrant mortality were detected by maximum likelihood testing. Annually, the period of August–October was associated with a 40-percentage-point increase in the risk of mortality, relative to other time periods.Conclusions Death during forced migration occurs close to national borders and during periods of intense conflict. This evidence may inform the design of policies and targeting of interventions to prevent forced migration-related deaths.

In health outcomes terms, the poorest countries stand to lose the most from these disruptions. In this paper, we make the case for a rational approach to public sector health spending and decision making during and in the early recovery phase of the COVID-19 pandemic. Based on ethics and equity principles, it is crucial to ensure that patients not infected by COVID-19 continue to get access to healthcare and that the services they need continue to be resourced. We present a list of 120 essential non-COVID-19 health interventions that were adapted from the model health benefit packages developed by the Disease Control Priorities project.

# Background The burden of non-communicable diseases (NCDs) is rapidly increasing in low- and middle-income countries, but remains largely unknown among people living with HIV (PLWH) in most sub-Saharan African countries. # Methods We estimated the proportion of PLWH in Uganda with raised blood pressure and high total cholesterol, and used a modified cardiovascular disease (CVD) risk prediction model (Globorisk) to assess the 10-year risk of atherosclerotic cardiovascular disease using individual-level data on cardiometabolic risk factors, population-level data on HIV prevalence and ART coverage, and the impact of HIV on blood pressure and cholesterol. # Results Among PLWH aged 30 to 69 years, the prevalence of raised blood pressure was 30% (95% uncertainty range, UR=27-33%) in women and 26% in men (95% UR=23-29%). The predicted mean 10-year CVD risk was 5% for HIV-infected women, and 6% for HIV-infected men. Five percent (n=41,000) of PLWH may experience a CVD event from 2016 to 2025 with an estimated 38% of these events being fatal. Full ART coverage would have little effect on the predicted number of CVD cases. # Conclusions Despite having a high prevalence of raised blood pressure, the burden of atherosclerotic CVD among PLWH in Uganda remains low. ART programs should prioritize routine screening and treatment of raised blood pressure. An approach of using HIV treatment delivery platforms to deliver care for NCDs may miss the larger burden of disease among HIV-uninfected individuals that are not routinely seen at health facilities.

Objectives The rate of change in key health indicators (eg, intervention coverage) is an understudied area of health system performance. Rates of change in health services indicators can augment traditional measures that solely involve the absolute level of performance in those indicators. Growth curves are a class of mathematical models that can parameterise dynamic phenomena and estimate rates of change summarising these phenomena; however, they are not commonly used in global health. We sought to characterise the changes over time in antiretroviral therapy (ART) coverage in sub-Saharan Africa using growth curve models.Design This was a retrospective observational study. We used publicly available data on ART coverage levels from 2000 to 2017 in 42 sub-Saharan African countries. We developed two ordinary differential equations models, the Gompertz and logistic growth models, that allowed for the estimation of summary parameters related to scale-up and rates of change in ART coverage. We fitted non-linear regressions for the two models, assessed goodness of fit using the Bayesian information criterion (BIC), and ranked countries based on their estimated performance drawn from the fitted model parameters.Results We extracted country performance in rates of scale-up of ART coverage, which ranged from ≤2.5 percentage points per year (South Sudan, Sudan, and Madagascar) to ≥8.0 percentage points per year (Benin, Zimbabwe and Namibia), using the Gompertz model. Based on BIC, the Gompertz model provided a better fit than the logistic growth model for most countries studied.Conclusions Growth curve models can provide benchmarks to assess country performance in ART coverage evolution. They could be a useful approach that yields summary metrics for synthesising country performance in scaling up key health services.

BACKGROUND:Education and health are both constituents of human capital that enable people to earn higher wages and enhance people's capabilities. Human capabilities may lead to fulfilling lives by enabling people to achieve a valuable combination of human functionings-i.e., what people are able to do or be as a result of their capabilities. A better understanding of how these different human capabilities are produced together could point to opportunities to help jointly reduce the wide disparities in health and education across populations. METHODS AND FINDINGS:We use nationally and regionally representative individual-level data from Demographic and Health Surveys (DHS) for 55 low- and middle-income countries (LMICs) to examine patterns in human capabilities at the national and regional levels, between 2000 and 2017 (N = 1,657,194 children under age 5). We graphically analyze human capabilities, separately for each country, and propose a novel child-based Human Development Index (HDI) based on under-five survival, maternal educational attainment, and measures of a child's household wealth. We normalize the range of each component using data on the minimum and maximum values across countries (for national comparisons) or first-level administrative units within countries (for subnational comparisons). The scores that can be generated by the child-based HDI range from 0 to 1. We find considerable heterogeneity in child health across countries as well as within countries. At the national level, the child-based HDI ranged from 0.140 in Niger (with mean across first-level administrative units = 0.277 and standard deviation [SD] 0.114) to 0.755 in Albania (with mean across first-level administrative units = 0.603 and SD 0.089). There are improvements over time overall between the 2000s and 2010s, although this is not the case for all countries included in our study. In Cambodia, Malawi, and Nigeria, for instance, under-five survival improved over time at most levels of maternal education and wealth. In contrast, in the Philippines, we found relatively few changes in under-five survival across the development spectrum and over time. In these countries, the persistent location of geographical areas of poor child health across both the development spectrum and time may indicate within-country poverty traps. Limitations of our study include its descriptive nature, lack of information beyond first- and second-level administrative units, and limited generalizability beyond the countries analyzed. CONCLUSIONS:This study maps patterns and trends in human capabilities and is among the first, to our knowledge, to introduce a child-based HDI at the national and subnational level. Areas of chronic deprivation may indicate within-country poverty traps and require alternative policy approaches to improving child health in low-resource settings.

Emerging demographic, epidemiological and health system changes in low-income countries require revisions of national essential health services packages in accordance with standard healthcare priority setting methods. Policy makers are in need of explicit and user-friendly methods to compare impact of multiple interventions. We provide experiences of country contextualisation of WHO-CHOICE methods and models to a country level. Results from three contextualised cost-effectiveness analyses (CEAs) are presented, and we discuss how this evidence can inform priority setting in Ethiopia. Existing models for a range of interventions in obstetric and neonatal care, psychiatric and neurological treatment and prevention and treatment of cardiovascular diseases are contextualised to the Ethiopian setting. CEAs are defined as contextualised if they include national analysts and use country-specific input for either costs, epidemiology, demography, baseline coverage or effects. Interventions (n=61) are ranked according to incremental cost-effectiveness rates (ICERs), and expected health outcomes (Disability Adjusted Life Years (DALYs) averted) and budget impacts are presented for each intervention. Dominated interventions (n=30) were excluded. A US$2.8 increase per capita in the annual health budget is needed in Ethiopia (currently at US$28 per capita) for increasing coverage by 20%–75% for all the 22 interventions with positive net health benefits. This investment is expected to give a net benefit at around 0.5 million DALYs averted in return in total, with a willingness to pay threshold at US$2000 per DALY averted. In particular, three interventions, neonatal resuscitation, kangaroo mother care and antibiotics for newborn sepsis, stand out as best buys in an Ethiopian setting. Our method of contextualised CEAs provides important information for policy makers. Rank ordering of interventions by ICERs, together with presentations of expected budget impact and net health benefits, is a clear and policy friendly illustration of possible efficient stepwise pathways towards universal health coverage.

Abstract Background Equitable access to vaccines has been suggested as a priority for low- and middle-income countries (LMICs). However, it is unclear whether providing equitable access is enough to ensure health equity. Furthermore, disaggregated data on health outcomes and benefits gained across population subgroups are often unavailable. This paper develops a model to estimate the distribution of childhood disease cases and deaths across socioeconomic groups, and the potential benefits of three vaccine programs in LMICs. Methods For each country and for three diseases (diarrhea, measles, pneumonia), we estimated the distributions of cases and deaths that would occur across wealth quintiles in the absence of any immunization or treatment programs, using both the prevalence and relative risk of a set of risk and prognostic factors. Building on these baseline estimates, we examined what might be the impact of three vaccines (first dose of measles, pneumococcal conjugate, and rotavirus vaccines), under five scenarios based on different sets of quintile-specific immunization coverage and disease treatment utilization rates. Results Due to higher prevalence of risk factors among the poor, disproportionately more disease cases and deaths would occur among the two lowest wealth quintiles for all three diseases when vaccines or treatment are unavailable. Country-specific context, including how the baseline risks, immunization coverage, and treatment utilization are currently distributed across quintiles, affects how different policies translate into changes in cases and deaths distribution. Conclusions Our study highlights several factors that would substantially contribute to the unequal distribution of childhood diseases, and finds that merely ensuring equal access to vaccines will not reduce the health outcomes gap across wealth quintiles. Such information can inform policies and planning of programs that aim to improve equitable delivery of healthcare services.

Abstract Background The transmission of malaria through population inflows from highly endemic areas with limited control efforts poses major challenges for national malaria control programmes. Several multilateral programmes have been launched in recent years to address cross-border transmission. This study assesses the potential impact of such a programme at the Angolan–Namibian border. Methods Community-based malaria prevention programmes involving bed net distribution and behaviour change home visits were rolled-out using a controlled, staggered (stepped wedge) design between May 2014 and July 2016 in a 100 × 40 km corridor along the Angolan–Namibian border. Three rounds of survey data were collected. The primary outcome studied was fever among children under five in the 2 weeks prior to the survey. Multivariable linear and logistic regression models were used to assess overall programme impact and the relative impact of unilateral versus coordinated bilateral intervention programmes. Results A total of 3844 child records were analysed. On average, programme rollout reduced the odds of child fever by 54% (aOR: 0.46, 95% CI 0.29 to 0.73) over the intervention period. In Namibia, the programme reduced the odds of fever by 30% in areas without simultaneous Angolan efforts (aOR: 0.70, 95% CI 0.34 to 1.44), and by an additional 62% in areas with simultaneous Angolan programmes. In Angola, the programme was highly effective in areas within 5 km of Namibian programmes (OR: 0.37, 95% CI 0.22 to 0.62), but mostly ineffective in areas closer to inland Angolan areas without concurrent anti-malarial efforts. Conclusions The impact of malaria programmes depends on programme efforts in surrounding areas with differential control efforts. Coordinated malaria programming within and across countries will be critical for achieving the vision of a malaria free world.

Abstract Background This study aims at quantifying the level and changes over time of inequality in age-specific mortality and life expectancy between the 19 Norwegian counties from 1980 to 2014. Methods Data on population and mortality by county was obtained from Statistics Norway for 1980–2014. Life expectancy and age-specific mortality rates (0–4, 5–49 and 50–69 age groups) were estimated by year and county. Geographic inequality was described by the absolute Gini index annually. Results Life expectancy in Norway has increased from 75.6 to 82.0 years, and the risk of death before the age of 70 has decreased from 26 to 14% from 1980 to 2014. The absolute Gini index decreased over the period 1980 to 2014 from 0.43 to 0.32 for life expectancy, from 0.012 to 0.0057 for the age group 50–69 years, from 0.0038 to 0.0022 for the age group 5–49 years, and from 0.0009 to 0.0006 for the age group 0–4 years. It will take between 2 and 32 years (national average 7 years) until the counties catch up with the life expectancy in the best performing county if their annual rates of increase remain unchanged. Conclusion Using the absolute Gini index as a metric for monitoring changes in geographic inequality over time may be a valuable tool for informing public health policies. The absolute inequality in mortality and life expectancy between Norwegian counties has decreased from 1980 to 2014.

Purpose: Noncommunicable diseases, prominently cancer, have become the second leading cause of death in the adult population of Ethiopia. A population-based cancer registry has been used in Addis Ababa (the capital city) since 2011. Availability of up-to-date estimates on cancer incidence is important in guiding the national cancer control program in Ethiopia. Methods: We obtained primary data on 8,539 patients from the Addis Ababa population-based cancer registry and supplemented by data on 1,648 cancer cases collected from six Ethiopian regions. We estimated the number of the commonest forms of cancer diagnosed among males and females in Ethiopia and computed crude and age-standardized incidence rates. Results: For 2015 in Ethiopia, we estimated that 21,563 (95% CI, 17,416 to 25,660) and 42,722 (95% CI, 37,412 to 48,040) incident cancer cases were diagnosed in males and females, respectively. The most common adult cancers were: cancers of the breast and cervix, colorectal cancer, non-Hodgkin lymphoma, leukemia, and cancers of the prostate, thyroid, lung, stomach, and liver. Leukemia was the leading cancer diagnosis in the pediatric age group (age 0 to 14 years). Breast cancer was by far the commonest cancer, constituting 33% of the cancers in women and 23% of all cancers identified from the Addis Ababa cancer registry. It was also the commonest cancer in four of the six Ethiopian regions included in the analysis. Colorectal cancer and non-Hodgkin lymphoma were the commonest malignancies in men. Conclusion: Cancer, and more prominently breast cancer, poses a substantial public health threat in Ethiopia. The fight against cancer calls for expansion of population-based registry sites to improve quantifying the cancer burden in Ethiopia and requires both increased investment and application of existing cancer control knowledge across all segments of the Ethiopian population.

Abstract—The majority of Armenian adult males smoke, yet tobacco taxes in Armenia are among the lowest in Europe and Central Asia. Increasing taxes on tobacco is one of the most cost-effective public health interventions, but many opponents often cite regressivity as an argument against tobacco taxation. We use a mixed-methods approach to study the potential regressivity of tobacco taxation and the extent to which the regressivity argument hindered increases in tobacco taxation in Armenia. First, we pursued an extended cost-effectiveness analysis (ECEA) to assess the health, financial, and distributional consequences (by consumption quintile) of increases in the excise tax on cigarettes in Armenia. We simulated a hypothetical price hike leading to a tax rate of about 75% of the retail price of cigarettes, which would be fully passed on to consumers. Second, we conducted a series of stakeholder interviews to examine the importance of the regressivity argument and identify the factors that allowed tobacco tax increases to be adopted as public policy in Armenia. We show that increased excise taxes would bring large health and financial benefits to Armenian households. Half of tobacco-related premature deaths and 27% of associated poverty cases averted would be concentrated among the bottom 40% of the population. Though regressivity was raised as a concern at the initial stages of the policy adoption process, our qualitative stakeholder analysis indicates that the recent accession to the Eurasian Economic Union and the fiscal constraints faced by the government created a window of opportunity for tobacco taxation to be placed on the policy agenda and adopted as government policy, and the ECEA findings were an important input into the process.

Abstract Background Decreasing trends in measles mortality have been reported in recent years. However, such estimates of measles mortality have depended heavily on assumed regional measles case fatality risks (CFRs) and made little use of mortality data from low- and middle-income countries in general and India, the country with the highest measles burden globally, in particular. Methods We constructed a dynamic model of measles transmission in India with parameters that were empirically inferred using spectral analysis from a time series of measles mortality extracted from the Million Death Study, an ongoing longitudinal study recording deaths across 2.4 million Indian households and attributing causes of death using verbal autopsy. The model was then used to estimate the measles CFR, the number of measles deaths, and the impact of vaccination in 2000–2015 among under-five children in India and in the states of Bihar and Uttar Pradesh (UP), two states with large populations and the highest numbers of measles deaths in India. Results We obtained the following estimated CFRs among under-five children for the year 2005: 0.63% (95% confidence interval (CI): 0.40–1.00%) for India as a whole, 0.62% (0.38–1.00%) for Bihar, and 1.19% (0.80–1.75%) for UP. During 2000–2015, we estimated that 607,000 (95% CI: 383,000–958,000) under-five deaths attributed to measles occurred in India as a whole. If no routine vaccination or supplemental immunization activities had occurred from 2000 to 2015, an additional 1.6 (1.0–2.6) million deaths for under-five children would have occurred across India. Conclusions We developed a data- and model-driven estimation of the historical measles dynamics, CFR, and vaccination impact in India, extracting the periodicity of epidemics using spectral and coherence analysis, which allowed us to infer key parameters driving measles transmission dynamics and mortality.

Abstract Cardiovascular and cerebrovascular diseases (CVDs) related to overwork are common in Asia, as is death from overwork, known as karoshi. Japan was the first country in the world to introduce criteria for recognizing overwork-related CVDs in 1961. Taiwan followed Japan in putting in place new policies and then updating these in 2010. We aimed to investigate the effect of introducing the new criteria for recognizing overwork-related CVDs in both countries. We defined the baseline period as the 5 years before launch of the new criteria, then collected data to 5 years after the new criteria. We applied a Poisson regression model to analyze the longitudinal change in rates of overwork-related CVDs before and after, adjusting for indicators of working conditions. Implementation of the new criteria was associated with a 2.58-fold increase in the rate of overwork-related CVDs (p-value

Summary: Background: In the 21st century, increases in immunisation coverage and decreases in under-5 mortality have substantially reduced the global burden of measles mortality. However, the assessment of measles mortality burden is highly dependent on estimates of case-fatality ratios for measles, which can vary according to geography, health systems infrastructure, prevalence of underlying risk factors, and measles endemicity. With imprecise case-fatality ratios, there is continued uncertainty about the burden of measles mortality and the effect of measles vaccination. In this study, we aimed to update the estimations of case-fatality ratios for measles, to develop a prediction model to estimate case-fatality ratios across heterogeneous groupings, and to project future case-fatality ratios for measles up to 2030. Methods: We did a review of the literature to identify studies examining measles cases and deaths in low-income and middle-income countries in all age groups from 1980 to 2016. We extracted data on case-fatality ratios for measles overall and by age, where possible. We developed and examined several types of generalised linear models and determined the best-fit model according to the Akaike information criterion. We then selected a best-fit model to estimate measles case-fatality ratios from 1990 to 2015 and projected future case-fatality ratios for measles up to 2030. Findings: We selected 124 peer-reviewed journal articles published between Jan 1, 1980, and Dec 31, 2016, for inclusion in the final review—85 community-based studies and 39 hospital-based studies. We selected a log-linear prediction model, resulting in a mean case-fatality ratio of 2·2% (95% CI 0·7–4·5) in 1990–2015. In community-based settings, the mean case-fatality ratio was 1·5% (0·5–3·1) compared with 2·9% (0·9–6·0) in hospital-based settings. The mean projected case-fatality ratio in 2016–2030 was 1·3% (0·4–3·7). Interpretation: Case-fatality ratios for measles have seen substantial declines since the 1990s. Our study provides an updated estimation of case-fatality ratios that could help to refine assessment of the effect on mortality of measles control and elimination programmes. Funding: Bill & Melinda Gates Foundation.

BACKGROUND:Female breast cancer is the most common cancer in Latin American and Caribbean (LAC) countries and is the leading cause of cancer deaths. The high mortality-to-incidence ratio in the regions is associated with mainly the high proportion of advanced stage diagnosis, and also to inadequate access to health care. In this study we aimed to systematically review the proportion of advanced stage (III-IV) at diagnosis (pas) and the five-year stage-specific survival estimates of breast cancer in LAC countries. METHODS:We searched MEDLINE, Embase, and LILACS (Latin American and Caribbean Health Science Literature) to identify studies, in any language, indexed before Nov 5, 2018. We also conducted manual search by reviewing citations of papers found. pas was summarized by random effects model meta-analysis, and meta-regression analysis to identify sources of variation. Stage-specific survival probabilities were described as provided by study authors, as it was not possible to conduct meta-analysis. PROSPERO CRD42017052493. RESULTS:For pas we included 63 studies, 13 of which population-based, from 22 countries comprising 221,255 women diagnosed from 1966 to 2017. The distribution of patients by stage varied greatly in LAC (pas 40.8%, 95%CI 37.0% to 44.6%; I2 = 99%; p

BackgroundNeglected tropical diseases (NTDs) account for a large disease burden in sub-Saharan Africa. While the general cost-effectiveness of NTD interventions to improve health outcomes has been assessed, few studies have also accounted for the financial and education gains of investing in NTD control.MethodsWe built on extended cost-effectiveness analysis (ECEA) methods to assess the health gains (e.g. infections, disability-adjusted life years or DALYs averted), household financial gains (out-of-pocket expenditures averted), and education gains (cases of school absenteeism averted) for five NTD interventions that the government of Madagascar aims to roll out nationally. The five NTDs considered were schistosomiasis, lymphatic filariasis, and three soil-transmitted helminthiases (Ascaris lumbricoides, Trichuris trichiura, and hookworm infections).ResultsThe estimated incremental cost-effectiveness for the roll-out of preventive chemotherapy for all NTDs jointly was USD125 per DALY averted (95% uncertainty range: 65-231), and its benefit-cost ratio could vary between 5 and 31. Our analysis estimated that, per dollar spent, schistosomiasis preventive chemotherapy, in particular, could avert a large number of infections (176,000 infections averted per $100,000 spent), DALYs (2,000 averted per $100,000 spent), and cases of school absenteeism (27,000 school years gained per $100,000 spent).ConclusionThis analysis incorporates financial and education gains into the economic evaluation of health interventions, and therefore provides information about the efficiency of attainment of three Sustainable Development Goals (SDGs). Our findings reveal how the national scale-up of NTD control in Madagascar can help address health (SDG3), economic (SDG1), and education (SDG4) goals. This study further highlights the potentially large societal benefits of investing in NTD control in low-resource settings.

Background: Despite rapid economic development, child stunting remains a persistent problem in China. Stunting prevalence varies greatly across geographical regions and wealth groups. To address child undernutrition, the Ying Yang Bao (YYB) nutritional package has been piloted in China since 2001. Objective: We aimed to evaluate the distributional impact of a hypothetical rollout of the YYB nutritional package on child stunting across provinces and wealth groups in China, with a specific focus on equity. Methods: We used data from China Family Panel Studies and built on extended cost-effectiveness analysis methods. We estimated the distributional impact of a 12-month YYB program targeting children aged 6–36 months across 25 provinces and two wealth groups along three dimensions: the cost of the YYB program; the number of child stunting cases averted by YYB; and the cost per stunting case averted. Children in each province were divided into poverty and non-poverty groups based on the international poverty line of $5.50 per day. We also conducted a range of sensitivity analyses. Results: We showed that 75% coverage of YYB could avert 1.9 million stunting cases among children aged 6–36 months, including 1.3 million stunting cases among children living under the poverty line, at a total cost of ¥5.4–6.2 billion ($1.5–1.8 billion) depending on the type of YYB delivery. The cost per stunting case averted would greatly vary across Chinese provinces and wealth groups, ranging from ¥800 (around $220, Chongqing province) to ¥23,300 (around $6600, Jilin province). In most provinces, the cost per stunting case averted would be lower for children living under the poverty line. Conclusions: YYB could be a pro-poor nutritional intervention package that brings substantial health benefits to poor and marginalized Chinese children, but with large variations in value for money across provinces and wealth groups. This analysis points to the need for prioritization across provinces and a targeted approach for YYB rollout in China.

Following publication of the original article [1], the authors flagged an error in Addition file 6.

Background: Co-infection with malaria and other infectious diseases has been shown to increase viral load and accelerate HIV disease progression. A recent study in Kenya demonstrated that providing long-lasting insecticide-treated bednets (LLIN) and water filters (WF) to HIV-positive adults with CD4 >350 cells/mm3 significantly reduced HIV progression. Design: We conducted a cost analysis to estimate the potential net financial savings gained by delaying HIV progression and increasing the time to antiretroviral therapy (ART) eligibility through delivering LLIN and WF to 10% of HIV-positive adults with CD4 >350 cells/mm3 in Kenya. Results: Given a 3-year duration of intervention benefit, intervention unit cost of US$32 and patient-year ART cost of US$757 (2011 US$), over the lifetime of ART patients, in Kenya, we estimated the intervention could yield a return on investment (ROI) of 11 (95% uncertainty range [UR]: 5–23), based on a cost of about US$2 million and savings in ART costs of about US$26 million (95% UR: 8–50) (discounted at 3%). Our findings were subjected to a number of sensitivity analyses. Of note, deferral of time to ART eligibility could potentially result in 3,000 new HIV infections not averted by ART and thus decrease ART cost savings to US$14 million, decreasing the ROI to 6. Conclusions: Provision of LLIN and WF could be a cost-saving and practical method to defer time to ART eligibility in the context of highly resource-constrained environments experiencing donor fatigue for HIV/AIDS programs.

The World Health Organization’s (WHO’s) World Health Report 2010, “Health systems financing, the path to universal coverage,” promoted universal health coverage (UHC) as an aspirational objective for country health systems. Yet, in addition to the dimensions of services and coverage, distribution of coverage in the population, and financial risk protection highlighted by the report, the consideration of the budget constraint should be further strengthened in the ensuing debate on resource allocation toward UHC. Beyond the substantial financial constraints faced by low- and middle-income countries, additional considerations, such as the geographical context, the underlying country infrastructure, and the architecture of health systems, determine the feasibility, effectiveness, quality and cost of healthcare delivery. Therefore, increased production and use of local evidence tied to the criteria of health benefits, equity, financial risk protection, and costs accompanying health delivery are needed so that to highlight pathways and acceptable trade-offs toward UHC.

Background: Vaccines are one of the most successful interventions in improving population health in low-income and middle-income countries (LMICs). In addition to the direct improvements in health outcomes, we are interested in their distributional effects—that is, whether vaccines promote or reduce health equity across socioeconomic groups. Empirical data on incidence and mortality of vaccine-preventable diseases across socioeconomic groups is not available. Therefore, we developed a method to estimate the distribution of childhood diseases and deaths across income groups and the benefits of three vaccines—for diarrhoea, measles, and pneumonia—in 41 LMICs. Methods: For every country and disease (diarrhoea, measles, pneumonia), we estimated the distribution of cases and deaths that would occur in each income quintile had there been no immunisation or treatment programme, using both the prevalence and relative risk of a set of risk and prognostic factors. Building on these baseline estimates, we assessed the effect of three vaccines (first dose of measles vaccine, pneumococcal conjugate vaccine, and rotavirus vaccine) under five scenarios based on sets of quintile-specific immunisation coverage and uptake of disease treatment. Findings: Because the prevalence of risk factors is higher in the poorest two quintiles than in the rest of the population, more disease cases and deaths would occur in the poorest two quintiles for all three diseases when vaccines or treatment are unavailable. However, we noted that current immunisation coverage and treatment utilisation rates have resulted in greater inequity in the distribution of cases and deaths. Even if in absolute terms the poorest quintiles benefit more from vaccines, the wealthier two quintiles sees a higher percentage decrease in cases and deaths. Thus, in terms of overall distribution of remaining cases and deaths with vaccine coverage, the poorest quintiles would see a higher comparative burden of disease than they would without vaccine coverage. Country-specific context, including how the baseline risks, immunisation coverage, and treatment utilisation are currently distributed across quintiles, affects how different policies translate to improvements in the distribution of cases and deaths. Interpretation: Our analysis highlights several factors, including risk and prognostic factors, and vaccine and treatment coverage that would substantially contribute to the unequal distribution of childhood diseases, and we found that merely ensuring equal access to vaccines will not reduce the health outcomes gap between income quintiles. Such information can inform policies and planning of programmes that aim to improve equitable delivery of healthcare services. Funding: Bill & Melinda Gates Foundation.

Background: Global efforts to increase births at health-care facilities might not reduce maternal or newborn mortality if quality of care is insufficient. However, little systematic evidence exists for the quality at health facilities caring for women and newborn babies in low-income countries. We analysed the quality of basic maternal care functions and its association with volume of deliveries and surgical capacity in health-care facilities in five sub-Saharan African countries. Methods: In this analysis, we combined nationally representative health system surveys (Service Provision Assessments by the Demographic and Health Survery Programme) with data for volume of deliveries and quality of delivery care from Kenya, Namibia, Rwanda, Tanzania, and Uganda. We measured the quality of basic maternal care functions in delivery facilities using an index of 12 indicators of structure and processes of care, including infrastructure and use of evidence-based routine and emergency care interventions. We regressed the quality index on volume of births and confounders (public or privately managed, availability of antiretroviral therapy services, availability of skilled staffing, and country) stratified by facility type: primary (no caesarean capacity) or secondary (has caesarean capacity) care facilities. The Harvard University Human Research Protection Program approved this analysis as exempt from human subjects review. Findings: The national surveys were completed between April, 2006, and May, 2010. Our sample consisted of 1715 (93%) of 1842 health-care facilities that provided normal delivery service, after exclusion of facilities with missing (n=126) or invalid (n=1) data. 1511 (88%) study facilities (site of 276 965 [44%] of 622 864 facility births) did not have caesarean section capacity (primary care facilities). Quality of basic maternal care functions was substantially lower in primary (index score 0·38) than secondary care facilities (0·77). Low delivery volume was consistently associated with poor quality, with differences in quality between the lowest versus highest volume facilities of −0·22 (95% CI −0·26 to −0·19) in primary care facilities and −0·17 (−0·21 to −0·11) in secondary care facilities. Interpretation: More than 40% of facility deliveries in these five African countries occurred in primary care facilities, which scored poorly on basic measures of maternal care quality. Facilities with caesarean section capacity, particularly those with birth volumes higher than 500 per year, had higher scores for maternal care quality. Low-income and middle-income countries should systematically assess and improve the quality of delivery care in health facilities to accelerate reduction of maternal and newborn deaths. Funding: None.

Background: The post-2015 End TB Strategy sets global targets of reducing tuberculosis incidence by 50% and mortality by 75% by 2025. We aimed to assess resource requirements and cost-effectiveness of strategies to achieve these targets in China, India, and South Africa. Methods: We examined intervention scenarios developed in consultation with country stakeholders, which scaled up existing interventions to high but feasible coverage by 2025. Nine independent modelling groups collaborated to estimate policy outcomes, and we estimated the cost of each scenario by synthesising service use estimates, empirical cost data, and expert opinion on implementation strategies. We estimated health effects (ie, disability-adjusted life-years averted) and resource implications for 2016–35, including patient-incurred costs. To assess resource requirements and cost-effectiveness, we compared scenarios with a base case representing continued current practice. Findings: Incremental tuberculosis service costs differed by scenario and country, and in some cases they more than doubled existing funding needs. In general, expansion of tuberculosis services substantially reduced patient-incurred costs and, in India and China, produced net cost savings for most interventions under a societal perspective. In all three countries, expansion of access to care produced substantial health gains. Compared with current practice and conventional cost-effectiveness thresholds, most intervention approaches seemed highly cost-effective. Interpretation: Expansion of tuberculosis services seems cost-effective for high-burden countries and could generate substantial health and economic benefits for patients, although substantial new funding would be required. Further work to determine the optimal intervention mix for each country is necessary. Funding: Bill & Melinda Gates Foundation.

Background: Supplementary immunization activity (SIA) campaigns provide children with an additional dose of measles vaccine and deliver other interventions, including vitamin A supplements, deworming medications, and oral polio vaccines. Objective: To assess the cost-effectiveness of the full SIA delivery platform in South Africa (SA). Design: We used an epidemiologic cost model to estimate the cost-effectiveness of the 2010 SIA campaign. We used province-level campaign data sourced from the District Health Information System, SA, and from planning records of provincial coordinators of the Expanded Programme on Immunization. The data included the number of children immunized with measles and polio vaccines, the number of children given vitamin A supplements and Albendazole tablets, and costs. Results: The campaign cost $37 million and averted a total of 1,150 deaths (95% uncertainty range: 990–1,360). This ranged from 380 deaths averted in KwaZulu-Natal to 20 deaths averted in the Northern Cape. Vitamin A supplementation alone averted 820 deaths (95% UR: 670–1,040); measles vaccination alone averted 330 deaths (95% UR: 280–370). Incremental cost-effectiveness was $27,100 (95% UR: $18,500–34,400) per death averted nationally, ranging from $11,300 per death averted in the Free State to $91,300 per death averted in the Eastern Cape. Conclusions: Cost-effectiveness of the SIA child health delivery platform varies substantially across SA provinces, and it is substantially more cost-effective when vitamin A supplementation is included in the interventions administered. Cost-effectiveness assessments should consider health system delivery platforms that integrate multiple interventions, and they should be conducted at the sub-national level.