Cost-effectiveness and budget impact of decentralising childhood tuberculosis diagnosis in six high tuberculosis incidence countries: a mathematical modelling study.

Background: The burden of childhood tuberculosis remains high globally, largely due to under-diagnosis. Decentralising childhood tuberculosis diagnosis services to lower health system levels could improve case detection, but there is little empirically based evidence on cost-effectiveness or budget impact. Methods: In this mathematical modelling study, we assessed the cost-effectiveness and budget impact of decentralising a comprehensive diagnosis package for childhood tuberculosis to district hospitals (DH-focused) or primary health centres (PHC-focused) compared to standard of care (SOC). The project was conducted in Cambodia, Cameroon, Côte d'Ivoire, Mozambique, Sierra Leone, and Uganda between August 1st, 2018 and September 30th, 2021. A mathematical model was developed to assess the health and economic outcomes of the intervention from a health system perspective. Estimated outcomes were tuberculosis cases, deaths, disability-adjusted life years (DALYs) and incremental cost-effectiveness ratios (ICERs). We also calculated the budget impact of nationwide implementation. The TB-Speed Decentralization study is registered with ClinicalTrials.gov, NCT04038632. Findings: For the DH-focused strategy versus SOC, ICERs ranged between $263 (Cambodia) and $342 (Côte d'Ivoire) per DALY averted. For the PHC-focused strategy versus SOC, ICERs ranged between $477 (Cambodia) and $599 (Côte d'Ivoire) per DALY averted. Results were sensitive to TB prevalence and the discount rate used. The additional costs of implementing the DH-focused strategy ranged between $12.8 M (range 10.8-16.4) (Cambodia) and $50.4 M (36.5-74.4) (Mozambique), and between $13.9 M (12.6-15.6) (Sierra Leone) and $134.6 M (127.1-143.0) (Uganda) for the PHC-focused strategy. Interpretation: The DH-focused strategy may be cost-effective in some countries, depending on the cost-effectiveness threshold used for policy making. Either intervention would require substantial early investment. Funding: Unitaid.

Gimme shelter. Social distancing and income support in times of pandemic.

Stay-at-home orders feature high in the set of policies used to curb the spread of epidemics such as COVID-19, but are potentially less efficient among poor people who must continue to work during pandemics. We examine how income support programs help poor people comply with stay-at-home order and thereby generate positive health externalities. We use data on work-related mobility in 2020 and on poverty rates for 729 subnational regions of Africa, Latin America and Asia. We focus on within-country differential mobility changes between higher- and lower-poverty regions. Accounting for all time-variant country-level factors, we show that lockdowns have decreased mobility significantly less in poorer regions. In turn, emergency income support programs have helped reduce this difference, mitigating the regional poverty gap in virus exposure through work mobility.

Impact of small farmers' access to improved seeds and deforestation in DR Congo.

Since the 1960s, the increased availability of modern seed varieties in developing countries has had large positive effects on households' well-being. However, the effect of related land use changes on deforestation and biodiversity is ambiguous. This study examines this question through a randomized control trial in a remote area in the Congo Basin rainforest with weak input and output markets. Using plot-level data on land conversion combined with remote sensing data, we find that promotion of modern seed varieties did not lead to an increase in overall deforestation by small farmers. However, farmers cleared more primary forest and less secondary forest. We attribute this to the increased demand for nitrogen required by the use of some modern seed varieties, and to the lack of alternative sources of soil nutrients, which induced farmers to shift towards cultivation of land cleared in primary forest. Unless combined with interventions to maintain soil fertility, policies to promote modern seed varieties may come at the cost of important losses in biodiversity.

Accelerating technical change through ICT: Evidence from a video-mediated extension experiment in Ethiopia.

Despite enthusiasm around applications of information and communications technologies (ICTs) to smallholder agriculture in many lower-income countries, there are still many questions on the effectiveness of ICT-based approaches. This study assesses the impacts of video-mediated agricultural extension service provision on farmers' adoption of improved agricultural technologies and practices in Ethiopia using data from a two-year randomized experiment. Our results show that the video-mediated extension approach significantly increases uptake of recommended technologies and practices by improving extension access and farmer knowledge. Specifically, we find that video-mediated extension reaches a wider audience than the government's conventional extension approach and leads to higher levels of farmer understanding and uptake of the subject technologies in those locations randomly assigned to the program. While our results also point to greater extension access and greater knowledge among female spouses in locations where both male and female spouses were targeted by the program, we do not find clear evidence that a more inclusive approach translates into higher uptake of the subject technologies. Finally, we find that the video-mediated approach becomes less costly as the scale of operation increases.

The impact of the use of new technologies on farmers' wheat yield in Ethiopia: evidence from a randomized control trial.

In 2013, Ethiopia's Agricultural Transformation Agency introduced the Wheat Initiative to increase smallholder productivity. In this article, we measure the impacts of the Wheat Initiative package of technologies, and its marketing assistance component alone, on yields among a promotional group of farmers. The package includes improved techniques, improved inputs, and a guaranteed market for the crop. Relying on crop-cut measures and farmers' own assessments, we find that full package led to an average 14% higher yields. Implementation of the Wheat Initiative was successful in making certified seed and fertilizer accessible to farmers and increasing their uptake, though only 61% of the intervention group adopted row planting and few farmers received marketing assistance. The measured yield difference may underestimate the true yield difference associated with the technology because of incomplete adoption of the recommended practices by intervention farmers and adoption of some practices by control farmers.

Delivery of iron-fortified yoghurt, through a dairy value chain program, increases hemoglobin concentration among children 24 to 59 months old in Northern Senegal: A cluster-randomized control trial.

BACKGROUND: Innovative strategies are needed to enhance the nutritional impact of agriculture. Value chain approaches, which use supply chains to add value (usually economic) to products as they move from producers to consumers, can be used to increase access to nutritious foods and improve nutritional status. This study tested whether a dairy value chain could be used to distribute a micronutrient-fortified yoghurt (MNFY) (conditional upon the producer supplying a minimum amount of cow milk/day) to improve hemoglobin and reduce anemia among preschool children in a remote area in Northern Senegal. METHODS: A cluster randomized control trial was used to compare 204 children (24 to 59 months of age at baseline) from households who received the MNFY coupled to a behavior change communication (BCC) campaign focusing on anemia prevention to 245 children from a control group (receiving BCC only) after one year. Randomization was done at the level of the family concession (households from the same family) (n = 321). Eligible households had a child of the target age and were willing to deliver milk to the dairy factory. Changes in anemia and hemoglobin between groups were assessed using mixed regression models. KEY FINDINGS: Anemia prevalence was very high at baseline (80%) and dropped to close to 60% at endline, with no differences between intervention groups. Hemoglobin increased by 0.55 g/dL, 95%CI (0.27; 0.84) more in the intervention compared to the control group after one year, in models that controlled for potentially confounding factors. The impact was greater (0.72 g/dL, 95%CI (0.34; 1.12)) for boys, compared to girls (0.38 g/dL, 95%CI (-0.03; 0.80)). CONCLUSION: The dairy value chain was a successful strategy to distribute MNFY among pastoralists in Northern Senegal, and increase Hb concentrations among their children. This study is one of the first proofs of concept showing that a nutrition-sensitive agriculture value chain approach can contribute to improved child nutrition in a remote pastoralist population. TRIAL REGISTRATION: ClinicalTrials.gov NCT02079961.