Assessing the impact of the president's emergency plan for AIDS relief on all-cause mortality.

This study estimated the impacts of PEPFAR on all-cause mortality (ACM) rates (deaths per 1,000 population) across PEPFAR recipient countries from 2004-2018. As PEPFAR moves into its 3rd decade, this study supplements the existing literature on PEPFAR 's overall effectiveness in saving lives by focusing impact estimates on the important subgroups of countries that received different intensities of aid, and provides estimates of impact for different phases of this 15-year period study. The study uses a country-level panel data set of 157 low- and middle-income countries (LMICs) from 1990-2018, including 90 PEPFAR recipient countries receiving bilateral aid from the U.S. government, employing difference-in-differences (DID) econometric models with several model specifications, including models with differing baseline covariates, and models with yearly covariates including other donor spending and domestic health spending. Using five different model specifications, a 10-21% decline in ACM rates from 2004 to 2018 is attributed to PEPFAR presence in the group of 90 recipient countries. Declines are somewhat larger (15-25%) in those countries that are subject to PEPFAR's country operational planning (COP) process, and where PEPFAR per capita aid amounts are largest (17-27%). Across the 90 recipient countries we study, the average impact across models is estimated to be a 7.6% reduction in ACM in the first 5-year period (2004-2008), somewhat smaller in the second 5-year period (5.5%) and in the third 5-year period (4.7%). In COP countries the impacts show decreases in ACM of 7.4% in the first period attributed to PEPFAR, 7.7% reductions in the second, and 6.6% reductions in the third. PEPFAR presence is correlated with large declines in the ACM rate, and the overall life-saving results persisted over time. The effects of PEFAR on ACM have been large, suggesting the possibility of spillover life-saving impacts of PEPFAR programming beyond HIV disease alone.

Analysis of economic and educational spillover effects in PEPFAR countries.

The United States President's Emergency Plan for AIDS Relief (PEPFAR) has been credited with saving millions lives and helping to change the trajectory of the global human immunodeficiency virus (HIV) epidemic. This study assesses whether PEPFAR has had impacts beyond health by examining changes in five economic and educational outcomes in PEPFAR countries: the gross domestic product (GDP) per capita growth rate; the share of girls and share of boys, respectively, who are out of school; and female and male employment rates. We constructed a panel data set for 157 low- and middle-income countries between 1990 and 2018 to estimate the macroeconomic impacts of PEPFAR. Our PEPFAR group included 90 countries that had received PEPFAR support over the period. Our comparison group included 67 low- and middle-income countries that had not received any PEPFAR support or had received minimal PEPFAR support (<$1M or <$.05 per capita) between 2004 and 2018. We used differences in differences (DID) methods to estimate the program impacts on the five economic and educational outcome measures. This study finds that PEPFAR is associated with increases in the GDP per capita growth rate and educational outcomes. In some models, we find that PEPFAR is associated with reductions in male and female employment. However, these effects appear to be due to trends in the comparison group countries rather than programmatic impacts of PEPFAR. We show that these impacts are most pronounced in COP countries receiving the highest levels of PEPFAR investment.

Analysis of maternal and child health spillover effects in PEPFAR countries.

OBJECTIVES: This study examined whether the US President's Emergency Plan for AIDS Relief (PEPFAR) funding had effects beyond HIV, specifically on several measures of maternal and child health in low-income and middle-income countries (LMICs). The results of previous research on the question of PEPFAR health spillovers have been inconsistent. This study, using a large, multicountry panel data set of 157 LMICs including 90 recipient countries, adds to the literature. DESIGN: Seven indicators including child and maternal mortality, several child vaccination rates and anaemia among childbearing-age women are important population health indicators. Panel data and difference-in-differences estimators (DID) were used to estimate the impact of the PEPFAR programme from inception in 2004 to 2018 using a comparison group of 67 LMICs. Several different models of baseline (2004) covariates were used to help balance the comparison and treatment groups. Staggered DID was used to estimate impacts since all countries did not start receiving aid at PEPFAR's inception. SETTING: All 157 LMICs from 1990 to 2018. PARTICIPANTS: 90 LMICs receiving PEPFAR aid and cohorts of those countries, including those required to submit annual country operational plans (COP), other recipient countries (non-COP), and three groupings of countries based on cumulative amount of per capita aid received (high, medium, low). INTERVENTIONS: PEPFAR aid to combat the HIV epidemic. PRIMARY OUTCOME MEASURES: Maternal mortality and child mortality rates, vaccination rates to protect children for diphtheria, whooping cough and tetanus, measles, HepB3, and tetanus, and prevalence of anaemia in women of childbearing age. RESULTS: Across PEPFAR recipient countries, large, favourable PEPFAR health effects were found for rates of childhood immunisation, child mortality and maternal mortality. These beneficial health effects were large and significant in all segments of PEPFAR recipient countries studied. We also found significant and favourable programme effects on the prevalence of anaemia in women of childbearing age in PEPFAR recipient countries receiving the most intensive financial support from the PEPFAR programme. Other recipient countries did not demonstrate significant effects on anaemia. CONCLUSIONS: This study demonstrated that important health indicators, beyond HIV, have been consistently and favourably influenced by PEPFAR presence. Child and maternal mortality have been substantially reduced, and childhood immunisation rates increased. We also found no evidence of 'crowding out' or negative spillovers in these resource-poor countries. These findings add to the body of evidence that PEPFAR has had favourable health effects beyond HIV. The implications of these findings are that foreign aid for health in one area may have favourable health effects in other areas in recipient countries. More research is needed on the influence of the mechanisms at work that create these spillover health effects of PEPFAR.

Costing of HIV services, Uganda and United Republic of Tanzania.

Objective: To evaluate resource allocation and costs associated with delivery of human immunodeficiency virus (HIV) services in Uganda and the United Republic of Tanzania. Methods: We used time-driven activity-based costing to determine the resources consumed and costs of providing five HIV services in Uganda and the United Republic of Tanzania: antiretroviral therapy (ART); HIV testing and counselling; prevention of mother-to-child transmission; voluntary male medical circumcision; and pre-exposure prophylaxis. Findings: Country-based teams undertook time-driven activity-based costing with 1119 adults in Uganda and 886 adults in the United Republic of Tanzania. In Uganda, service delivery costs ranged from 8.18 United States dollars (US$) per visit for HIV testing and counselling to US$ 43.43 for ART (for clients in whom HIV was suppressed). In the United Republic of Tanzania, these costs ranged from US$ 3.67 per visit for HIV testing and counselling to US$ 28.00 for voluntary male medical circumcision. In both countries, consumables were the main cost driver, accounting for more than 60% of expenditure. Process maps showed that in both countries, registration, measurement of vital signs, consultation and medication dispensing were the steps that occurred most frequently for ART clients. Conclusion: Establishing a rigorous, longitudinal system for tracking investments in HIV services that includes thousands of clients and numerous facilities is achievable in different settings with a high HIV burden. Consistent engagement of implementation partners and standardized training and data collection instruments proved essential for the success of these exercises.

National Evaluation of HIV Service Resource Allocation in Tanzania.

Using time-driven activity-based costing (TDABC), we examined resource allocation and costs for HIV services throughout Tanzania at patient and facility levels. This national, cross-sectional analysis of 22 health facilities quantified costs and resources associated with 886 patients receiving care for five HIV services: antiretroviral therapy, prevention of mother-to-child transmission, HIV testing and counseling, voluntary medical male circumcision, and pre-exposure prophylaxis. We also documented total provider-patient interaction time, the cost of services with and without inclusion of consumables, and conducted fixed-effects multivariable regression analyses to examine patient- and facility-level correlates of costs and provider-patient time. Findings showed that resources and costs for HIV care varied significantly throughout Tanzania, including as a function of patient- and facility-level characteristics. While some variation may be preferable (e.g., needier patients received more resources), other areas suggested a lack of equity (e.g., wealthier patients received more provider time) and presented opportunities to optimize care delivery protocols.

Costing of HIV services, Uganda and United Republic of Tanzania

Objective To evaluate resource allocation and costs associated with delivery of human immunodeficiency virus (HIV) services in Uganda and the United Republic of Tanzania. Methods We used time-driven activity-based costing to determine the resources consumed and costs of providing five HIV services in Uganda and the United Republic of Tanzania: antiretroviral therapy (ART); HIV testing and counselling; prevention of mother-to-child transmission; voluntary male medical circumcision; and pre-exposure prophylaxis. Findings Country-based teams undertook time-driven activity-based costing with 1119 adults in Uganda and 886 adults in the United Republic of Tanzania. In Uganda, service delivery costs ranged from 8.18 United States dollars (US$) per visit for HIV testing and counselling to US$ 43.43 for ART (for clients in whom HIV was suppressed). In the United Republic of Tanzania, these costs ranged from US$ 3.67 per visit for HIV testing and counselling to US$ 28.00 for voluntary male medical circumcision. In both countries, consumables were the main cost driver, accounting for more than 60% of expenditure. Process maps showed that in both countries, registration, measurement of vital signs, consultation and medication dispensing were the steps that occurred most frequently for ART clients. Conclusion Establishing a rigorous, longitudinal system for tracking investments in HIV services that includes thousands of clients and numerous facilities is achievable in different settings with a high HIV burden. Consistent engagement of implementation partners and standardized training and data collection instruments proved essential for the success of these exercise

Disparities in intimate partner violence among women at the intersection of disability and HIV status in South Africa: a cross-sectional study.

OBJECTIVE: Previous research suggests a significant relationship between intimate partner violence (IPV) and HIV infection in women and that the risk of IPV is heightened in women with disabilities. Women with disabilities, particularly those residing in low-income and middle-income countries, may experience additional burdens that increase their vulnerability to IPV. We aimed to examine the association between having disability and HIV infection and the risk of IPV among women in South Africa. DESIGN: Using the 2016 South Africa Demographic and Health Survey, we calculated the prevalence of IPV and conducted modified Poisson regressions to estimate the unadjusted and adjusted risk ratios of experiencing IPV by disability and HIV status. PARTICIPANTS: Our final analytical sample included 1269 ever-partnered women aged 18-49 years, who responded to the IPV module and received HIV testing. RESULTS: The prevalence of IPV was twice as high in women with disabilities with HIV infection compared with women without disabilities without HIV infection (21.2% vs 50.1%). Our unadjusted regression analysis showed that compared with women without disabilities without HIV infection, women with disabilities with HIV infection had almost four times higher odds (OR 3.72, 95% CI 1.27 to 10.9, p<0.05) of experiencing IPV. It appeared that women with disabilities with HIV infection experience compounded disparity. The association was compounded, with the OR for the combination of disability status and HIV status equal to or more than the sum of each of the individual ORs. CONCLUSIONS: Women with disabilities and HIV infection are at exceptionally high risk of IPV in South Africa. Given that HIV infection and disability magnify each other's risks for IPV, targeted interventions to prevent IPV and to address the complex and varied needs of doubly marginalised populations of women with disabilities with HIV infection are critical.

The economics of vision impairment and its leading causes: A systematic review.

Vision impairment (VI) can have wide ranging economic impact on individuals, households, and health systems. The aim of this systematic review was to describe and summarise the costs associated with VI and its major causes. We searched MEDLINE (16 November 2019), National Health Service Economic Evaluation Database, the Database of Abstracts of Reviews of Effects and the Health Technology Assessment database (12 December 2019) for partial or full economic evaluation studies, published between 1 January 2000 and the search dates, reporting cost data for participants with VI due to an unspecified cause or one of the seven leading causes globally: cataract, uncorrected refractive error, diabetic retinopathy, glaucoma, age-related macular degeneration, corneal opacity, trachoma. The search was repeated on 20 January 2022 to identify studies published since our initial search. Included studies were quality appraised using the British Medical Journal Checklist for economic submissions adapted for cost of illness studies. Results were synthesized in a structured narrative. Of the 138 included studies, 38 reported cost estimates for VI due to an unspecified cause and 100 reported costs for one of the leading causes. These 138 studies provided 155 regional cost estimates. Fourteen studies reported global data; 103/155 (66%) regional estimates were from high-income countries. Costs were most commonly reported using a societal (n = 48) or healthcare system perspective (n = 25). Most studies included only a limited number of cost components. Large variations in methodology and reporting across studies meant cost estimates varied considerably. The average quality assessment score was 78% (range 35-100%); the most common weaknesses were the lack of sensitivity analysis and insufficient disaggregation of costs. There was substantial variation across studies in average treatment costs per patient for most conditions, including refractive error correction (range $12-$201 ppp), cataract surgery (range $54-$3654 ppp), glaucoma (range $351-$1354 ppp) and AMD (range $2209-$7524 ppp). Future cost estimates of the economic burden of VI and its major causes will be improved by the development and adoption of a reference case for eye health. This could then be used in regular studies, particularly in countries with data gaps, including low- and middle-income countries in Asia, Eastern Europe, Oceania, Latin America and sub-Saharan Africa.

Between a Rock and a Hard Place: How poverty and lack of agency affect HIV risk behaviors among married women in 25 African countries: A cross-sectional study.

BACKGROUND: Gender inequality and poverty exacerbate the burden of HIV/AIDS among women in Africa. AIDS awareness and educational campaigns have been inadequate in many countries and rates of HIV testing and adherence to condom use remains considerably low, especially among married women. We investigate whether higher HIV knowledge is equally effective in lowering risky behaviors among groups of women with different levels of wealth and agency. METHODS: Pooled data on 113 151 adult married women from Demographic and Health Surveys (DHS) in 25 African countries was used (2010 to 2016). Agency was defined as women's ability to refuse sex and ask her partner to use a condom, plus have a role in decision making in household spending and health-related issues. The lowest tertile of DHS wealth index defined poverty. Questions about HIV prevention and mother-to-child transmission were used to create a scale for knowledge (0-5). Use of condom, HIV testing, absence of sexually transmitted disease (STD), and having one partner were dependent variables. Regression models investigated the effect of agency and knowledge as predictors of behaviors. Separate additional models were run to measure associations of each behavior with knowledge scores on groups of women divided by agency and poverty. Analyses were adjusted for demographic factors, history of pregnancy, wife-beating attitude, and country dummies. RESULTS: Significantly higher risk and lower level of protective factors exist for poor women who lack agency. Knowledge had positive associations with a better score in behavior, higher rate of condom use and testing for HIV both among poor and not poor women. When examining compound effects of agency and poverty, absence of agency reduces the positive effect of knowledge on lowering STD rate and overall behavior score among poor women. It also nullifies the effect of knowledge on condom use in both wealth groups. CONCLUSION: Knowledge of HIV does not exert its potential protective effect when women live in poverty compounded with lack of agency. Success of anti-HIV programs should be tailored to dynamics of risk and sociocultural and economic context of target populations.

Utilization of HIV testing and counselling services by women with disabilities during antenatal care in Uganda: analysis of 2016 demographic and health survey.

BACKGROUND: HIV testing and counselling during antenatal care (ANC) is critical for eliminating mother-to-child transmission of HIV. We investigated disparity in utilization of HIV testing and counselling services (HTC) between women with and without disabilities in Uganda. METHODS: We conducted a retrospective study using the nationally representative 2016 Uganda Demographic and Health Survey. The study sampled 10,073 women between age 15-49 who had a live birth in the last 5 years. We estimated unadjusted and adjusted odds ratio for receiving pre-test HIV counselling, obtaining an HIV test result, and post-test HIV counselling by disability status using logistic regressions. RESULTS: We found that women with disabilities were less likely to receive pre-test HIV counselling (59.6 vs 52.4), obtain an HIV test result (68.2 vs 61.4), receive post-test HIV counselling (55.5 vs 51.6), and all HTC services (49.2 vs 43.5). From the regression analysis, women with disabilities were less likely to receive pre-test counselling [AOR = 0.83; CI = 0.74, 0.93] and obtain an HIV test result [AOR = 0.88; CI = 0.78, 0.99]. CONCLUSIONS: Our findings revealed that women with disabilities are less likely to receive HTC service during ANC and highlighted the need for disability-inclusive HIV and reproductive health services. Government, non-governmental organizations, and other stakeholders should consider funding inclusive campaigns and identifying other mechanisms for disseminating health information and behavioral interventions to women with disabilities.

The compounding effect of having HIV and a disability on child mortality among mothers in South Africa.

BACKGROUND: Previous research on the association between maternal HIV status and child mortality in sub-Saharan Africa was published between 2005-2011. Findings from these studies showed a higher child mortality risk among children born to HIV-positive mothers. While the population of women with disabilities is growing in developing countries, we found no research that examined the association between maternal disability in HIV-positive mothers, and child mortality in sub-Saharan Africa. This study examined the potential compounding effect of maternal disability and HIV status on child mortality in South Africa. METHODS: We analyzed data for women age 15-49 years from South Africa, using the nationally representative 2016 South Africa Demographic and Health Survey. We estimated unadjusted and adjusted risk ratios of child mortality indicators by maternal disability and maternal HIV using modified Poisson regressions. RESULTS: Children born to disabled mothers compared to their peers born to non-disabled mothers were at a higher risk for neonatal mortality (RR = 1.80, 95% CI:1.31-2.49), infant mortality (RR = 1.69, 95% CI:1.19-2.41), and under-five mortality (RR = 1.78, 95% CI:1.05-3.01). The joint risk of maternal disability and HIV-positive status on the selected child mortality indicators is compounded such that it is more than the sum of the risks from maternal disability or maternal HIV-positive status alone (RR = 3.97 vs. joint RR = 3.67 for neonatal mortality; RR = 3.57 vs. joint RR = 3.25 for infant mortality; RR = 6.44 vs. joint RR = 3.75 for under-five mortality). CONCLUSIONS: The findings suggest that children born to HIV-positive women with disabilities are at an exceptionally high risk of premature mortality. Established inequalities faced by women with disabilities may account for this increased risk. Given that maternal HIV and disability amplify each other's impact on child mortality, addressing disabled women's HIV-related needs and understanding the pathways and mechanisms contributing to these disparities is crucial.

Estimating the global cost of vision impairment and its major causes: protocol for a systematic review.

INTRODUCTION: Vision impairment (VI) places a burden on individuals, health systems and society in general. In order to support the case for investing in eye health services, an updated cost of illness study that measures the global impact of VI is necessary. To perform such a study, a systematic review of the literature is needed. Here we outline the protocol for a systematic review to describe and summarise the costs associated with VI and its major causes. METHODS AND ANALYSIS: We will systematically search in Medline (Ovid) and the Centre for Reviews and Dissemination database which includes the National Health Service Economics Evaluation Database. No language or geographical restriction will be applied. Additional literature will be identified by reviewing the references in the included studies and by contacting field experts. Grey literature will be considered. The review will include any study published from 1 January 2000 to November 2019 that provides information about costs of illness, burden of disease and/or loss of well-being in participants with VI due to an unspecified cause or due to one of the seven leading causes globally.Two reviewers will independently screen studies and extract relevant data from included studies. Methodological quality of economic studies will be assessed based on the British Medical Journal checklist for economic submissions adapted to costs of illness studies. This protocol has been prepared following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocols and has been published prospectively in Open Science Framework. ETHICS AND DISSEMINATION: Formal ethical approval is not required, as primary data will not be collected in this review. The findings of this study will be disseminated through peer-reviewed publications, stakeholder meetings and inclusion in the ongoing Lancet Global Health Commission on Global Eye Health. REGISTRATION DETAILS: https://osf.io/9au3w (DOI 10.17605/OSF.IO/6F8VM).

Cost Effectiveness of Mobile Health for Antenatal Care and Facility Births in Nigeria.

BACKGROUND: The use of mobile technology in the health sector, often referred to as mHealth, is an innovation that is being used in countries to improve health outcomes and increase and improve both the demand and supply of health care services. This study assesses the actual cost-effectiveness of initiating and implementing the use of the mHealth as a supply side job aid for antenatal care. The study also estimates the cost-effectiveness ratio if mHealth was also used to encourage and track women through facility delivery. METHODS: The methodology utilized a retrospective, micro-costing technique to extract costing data from health facilities and administrative offices to estimate the costs of implementing the mHealth antenatal care program and estimate the cost of facility delivery for those that used the antenatal care services in the year 2014. Five different costing tools were developed to assist in the costing analysis. FINDINGS: The results show that the provision of tetanus toxoid vaccination and malaria prophylaxis during pregnancy and improved labor and delivery during facility delivery contributed the most to mortality reductions for women, neonates and stillbirths in mHealth facilities versus non-mHealth facilities. The cost-effectiveness ratio of this program for antenatal care and no demand-side generation for facility delivery is US$13,739 per life saved. The cost-effectiveness ratio adding in an additional demand-side generation for facility births reduces to US$9,806 per life saved. CONCLUSION: These results show that mHealth programs are inexpensive and save a number of lives for the dollar investment and could save additional lives and funds if women were also encouraged to seek facility delivery.

Costing essential services package provided by a non-governmental organization network in Bangladesh.

The health profile of Bangladesh has improved remarkably, yet gaps in delivering quality health care remain. In response to the need for evidence to quantify resources for providing health services in Bangladesh, this study estimates unit costs of providing the essential services package (ESP) in the not-for-profit sector. This study used a stratified sampling approach to select 18 static clinics, which had fixed facilities, from 330 non-profit clinics under Smiling Sun network in Bangladesh. Costs were estimated from the providers' perspective, using both top-down and bottom-up methods, from July 2014 to June 2015. In total, there were 1115 observations (clients) for the 13 primary care services analysed. The estimated 2015 average costs per visit were: antenatal care ($7.03), postnatal care ($4.57), control of diarrheal diseases ($1.32), acute respiratory infection ($1.53), integrated management of child illness ($2.02), sexually transmitted infections ($4.70), reproductive tract infections ($3.56), tuberculosis ($41.65), limited curative care ($4.30), immunization ($2.23), family planning ($0.72), births by normal delivery ($29.45) and C-section ($114.83). Unit costs varied widely for each service, both between individual patients and among clinic level means. The coefficient of variation for the 13 services averaged 66%, implying potential inefficiencies. In addition, 32.9% of clients were not offered any lab test during the first antenatal visit. The unit cost of essential services differed by the type and location of clinics. Ultra clinics, on average, incurred 37% higher costs than vital (outpatient type) clinics, and urban clinics spent 40% more than rural clinics to deliver a unit of service. The study suggests that inefficiency and quality concerns exist in health service delivery in some facilities. Increasing the volume of clients through demand-side mechanisms and standardization of services would help address those concerns. Unit costs of services provide essential information for estimating resource needs for scaling up the ESPs.

The Economic Transition of Health in Africa: A Call for Progressive Pragmatism to Shape the Future of Health Financing.

Abstract-The new financing landscape for the Sustainable Development Goals has a larger emphasis on domestic resource mobilization. But, given the significant role of donor assistance for health, the fungibility of government health spending, and the downward revision of global growth, this article looks at what is possible with regard to a country's own ability to finance priority health services. Using cross-sectional and longitudinal economic and health spending data, we employ a global multilevel model with regional and country random effects to develop gross domestic product (GDP) projections that inform a dynamic panel data model to forecast health spending. We then assess sub-Saharan African countries' abilities to afford to finance their own essential health needs and find that there are countries that will still rely on high out-of-pocket or donor spending to finance an essential package of health services. To address this, we discuss policy opportunities for each set of countries over the next 15 years. This longer-term view of the economic transition of health in Africa stresses the imperative of engaging policy now to prioritize customized strategies and institutional arrangements to increase domestic financing, improve value for money, and ensure fairer and sustainable health financing. We address the need for rhetoric on UHC to incorporate "progressive pragmatism," a proactive joint approach by developing country governments and their development partners to ensure that policies designed to achieve universal health coverage align with the economic reality of available domestic and donor financing.

Quality maternity care for every woman, everywhere: a call to action.

To improve maternal health requires action to ensure quality maternal health care for all women and girls, and to guarantee access to care for those outside the system. In this paper, we highlight some of the most pressing issues in maternal health and ask: what steps can be taken in the next 5 years to catalyse action toward achieving the Sustainable Development Goal target of less than 70 maternal deaths per 100 000 livebirths by 2030, with no single country exceeding 140? What steps can be taken to ensure that high-quality maternal health care is prioritised for every woman and girl everywhere? We call on all stakeholders to work together in securing a healthy, prosperous future for all women. National and local governments must be supported by development partners, civil society, and the private sector in leading efforts to improve maternal-perinatal health. This effort means dedicating needed policies and resources, and sustaining implementation to address the many factors influencing maternal health-care provision and use. Five priority actions emerge for all partners: prioritise quality maternal health services that respond to the local specificities of need, and meet emerging challenges; promote equity through universal coverage of quality maternal health services, including for the most vulnerable women; increase the resilience and strength of health systems by optimising the health workforce, and improve facility capability; guarantee sustainable finances for maternal-perinatal health; and accelerate progress through evidence, advocacy, and accountability.

The Effect of Demand- and Supply-Side Health Financing on Infant, Child, and Maternal Mortality in Low- and Middle-Income Countries.

-Demand- and supply-side health financing programs that improve maternal and child health are being implemented more frequently; however, there is limited evidence estimating their impact on maternal, infant, and child mortality at the macro level. The purpose of the study was to determine the impact of four specific types of demand- and supply-side health financing programs on infant, child, and maternal mortality at the global level and by county income categories. The following four demand- and supply-side health financing programs were chosen for inclusion in the analysis: conditional cash transfer programs, voucher programs, community-based health insurance, and pay-for-performance schemes. A fixed effects model was estimated, using panel data for 147 countries over the period 1995-2010, to measure the impact of these four demand- and supply-side health financing programs on infant, under-five, and maternal mortality. The model was estimated for all countries and for three country income categories: low, lower-middle, and upper-middle income. The implementation of demand- and supply-side health financing programs has increased over time, with 45 out of 147 countries in the data set implementing at least one of these programs by 2010. The results show that there is a significant decline in infant and under-five mortality from community-based health insurance when examined across all countries. There is also an impact from demand- and supply-side health financing when examined across the three country income classifications, with vouchers and pay-for-performance showing a varying impact on reduced infant, under-five, and maternal mortality depending on the country income classification. Health insurance schemes with a broad population reach, such as community-based health insurance, can have a large impact on infant and under-five mortality. Demand- and supply-side health financing programs, such as pay-for-performance and voucher programs, have a varying impact on infant, under-five, and maternal mortality depending on the income level of the country.