How can corporate taxes contribute to sub-Saharan Africa's Sustainable Development Goals (SDGs)? A case study of Vodafone.

BACKGROUND: The COVID-19 pandemic and the climate emergency threaten progress in reaching many of the Sustainable Development Goal (SDG) targets by 2030. The under-5 mortality and maternal mortality rates are well below the targets, and if we progress at the current pace, there is a high risk of not meeting the 2030 goals. Furthermore, the initial progress in the decline in child and maternal mortality since 1990 is likely to be eroded. Much of this progress has resulted from increased sanitation, drinking water, education, and health service coverage. The adequate provision of public services is possible if there is sufficient government funding. When governments have more income, they spend more on public services, which increases access to fundamental economic and social rights and, thus, contributes to the SDGs. One of the key drivers of government financing, taxation, constitutes 70% of government revenue in low- and lower-middle-income countries. Corporate income tax constitutes 18.8% of tax revenue in African countries compared to 10% of tax revenue in OECD countries. Therefore, it plays a critical role in SDG progress. This paper aims to quantify the contribution of one large taxpayer, that publishes their tax payments, (Vodafone Group Plc) on progress towards SDGs in six African countries. We use econometric modelling to estimate the impact of an increase in government revenue equivalent to Vodafone's average tax paid between 2007-2017. RESULTS: We find that government revenue equivalent to Vodafone's taxes made a significant contribution to progress in attaining selected SDGs. We found that the revenue equivalent to Vodafone's taxes allowed 966,188 people to access clean water and 1,371,972 people to access basic sanitation each year. Over the time period studied, 858,054 children spent an extra year in school and 54,275 children under five years and 3,655 mothers survived. In just one of these countries, Tanzania, the revenue equivalent to Vodafone's tax contribution allowed 174,121 people to access clean water and 223,586 to access sanitation each year. Over the time studied 187,023 children spent an additional year at school, 6,569 additional children under five and 625 additional mothers survived. CONCLUSIONS: These findings demonstrate that the reported contributions from a single multinational corporation drive SDG progress. Furthermore, it highlights the importance of transparent taxes and explores the responsibilities of global institutions, governments, investors, and multinational corporations.

Financing child rights in Malawi.

BACKGROUND: Nearly all countries have ratified the United Nations Convention on the Rights of the Child and, therefore, support children having access to their rights. However, only a small minority of children worldwide have access to their environmental, economic, and social rights. The most recent global effort to address these deficits came in 2015, when the United Nations General Assembly agreed to a plan for a fairer and more sustainable future by 2030 and outlined the Sustainable Development Goals (SDGs). One remediable cause is the lack of revenue in many countries, which affects all SDGs. However, illicit financial flows from low-income to high-income countries, including international tax abuse, continue unabated. METHODS: Using the most recent estimates of tax abuse perpetuated by multinational companies and tax evasion through offshore wealth, and precise econometric modelling, we illustrate the potential regarding child rights (or progress towards the SDGs) if there was an increase in revenue equivalent to tax abuse in Malawi, a low-income country particularly vulnerable to climate change. The Government Revenue and Development Estimations model provides realistic estimates of government revenue changes in developmental outcomes. Using panel data on government revenue per capita, it models the impact of increased revenue on governance and SDG progress. RESULTS: If cross-border tax abuse and tax evasion were curtailed, the equivalent increase in government revenue in one country, Malawi, would be associated with 12,000 and 20,000 people having access to basic water and sanitation respectively each year. Each year, an additional 5000 children would attend school, 150 additional children would survive, and 10 mothers would survive childbirth. CONCLUSIONS: More children would access their economic and social rights if actions were taken to close the gap in global governance regarding taxation. We discuss the responsibility of duty bearers, the need for a global body to arbitrate and monitor international tax matters, and how the Government of Malawi could take further domestic action to mitigate the gaps in global governance and protect itself against illicit financial flows, including tax abuse.

International corporate tax avoidance and domestic government health expenditure.

OBJECTIVE: To compare estimated losses from international corporate tax avoidance in individual countries and domestic government health expenditure, with reference to the annual threshold of 86 United States dollars (US$) per capita required to achieve universal health coverage. METHODS: I obtained and compared estimates of international corporate tax avoidance and domestic government health expenditure for 2013. FINDINGS: Data were available for 100 countries: 24 low-, 28 lower-middle-, 21 upper-middle- and 27 high-income countries. Domestic government health expenditure was under US$ 86 per capita in all 24 low-income countries and in 24 of 28 lower-middle-income countries. International corporate tax lost per capita was higher than domestic government health expenditure in 19 low-income and 10 lower-middle-income countries. If the revenue lost to tax avoidance were recouped and allocated to the health sector, average annual government health expenditure could increase from US$ 8 to US$ 24 per capita in the low-income countries studied and from US$ 54 to US$ 91 per capita in the lower-middle-income countries. CONCLUSION: Recouping losses due to international corporate tax avoidance and allocating them to the health sector would help low- and lower-middle-income countries achieve universal health coverage, a target of sustainable development goal (SDG) 3. Tackling tax avoidance requires cooperation between the governments of all countries, multinational corporations and investors, including private individuals. International cooperation to improve domestic resource mobilization is the focus of SDG target 17.1.

Using international human rights law to improve child health in low-income countries: a framework for healthcare professionals.

BACKGROUND: The Committee on Economic, Social and Cultural Rights states that the right to health is closely related to, and dependent upon, the realization of other human rights, including the right to food, water, education and shelter which are important determinants of health. Children's healthcare workers in low income settings may spend the majority of their professional lives trying to mitigate deficiencies of these rights but have little influence over them. In order to advocate successfully at a local level, we should be aware of the proportion of children living in our catchment population who do not have access to their basic rights. In order to carry out a rights audit, a framework within which healthcare workers could play their part is required, as is an agreed minimum core of rights, a timeframe and a set of indicators. DISCUSSION: A framework to assess how well states and their developmental partners are adhering to human rights principles is discussed, including the role that a healthcare worker might optimally play. A minimum core of economic and social rights seeks to establish a legal minimum set of protections, which should be available with immediate effect and applicable to all nations despite very different resources. Minimum core rights and the impact that progressive realisation may have had on the right to health is discussed, including what they should include from the perspective of children's health. A set of absolute rights are suggested, based on physiological needs and aligned with the corresponding articles of the United Nations Convention on the Rights of the Child. The development indicators which are likely to be used to monitor progress towards the Sustainable Development Goals is suggested as a way to monitor rights. We consider the ways in which the healthcare worker could use a rights audit to advocate with, and for their community. These audits could achieve several objectives. They may legitimise healthcare workers' interests in the determinants of health and, as they are often highly respected by their community, this may facilitate them to be agents for change at a local level. This may raise awareness on basic human rights and their importance to health and contribute to a needed change in mind-set from one of development needs to absolute rights. The results may catalyse colleagues to analyse further the upstream reasons why children, and the families in which they live, are not having their rights met.

Task sharing within a managed clinical network to improve child health in Malawi.

BACKGROUND: Eighty per cent of Malawi's 8 million children live in rural areas, and there is an extensive tiered health system infrastructure from village health clinics to district hospitals which refers patients to one of the four central hospitals. The clinics and district hospitals are staffed by nurses, non-physician clinicians and recently qualified doctors. There are 16 paediatric specialists working in two of the four central hospitals which serve the urban population as well as accepting referrals from district hospitals. In order to provide expert paediatric care as close to home as possible, we describe our plan to task share within a managed clinical network and our hypothesis that this will improve paediatric care and child health. PRESENTATION OF THE HYPOTHESIS: Managed clinical networks have been found to improve equity of care in rural districts and to ensure that the correct care is provided as close to home as possible. A network for paediatric care in Malawi with mentoring of non-physician clinicians based in a district hospital by paediatricians based at the central hospitals will establish and sustain clinical referral pathways in both directions. Ultimately, the plan envisages four managed paediatric clinical networks, each radiating from one of Malawi's four central hospitals and covering the entire country. This model of task sharing within four hub-and-spoke networks may facilitate wider dissemination of scarce expertise and improve child healthcare in Malawi close to the child's home. TESTING THE HYPOTHESIS: Funding has been secured to train sufficient personnel to staff all central and district hospitals in Malawi with teams of paediatric specialists in the central hospitals and specialist non-physician clinicians in each government district hospital. The hypothesis will be tested using a natural experiment model. Data routinely collected by the Ministry of Health will be corroborated at the district. This will include case fatality rates for common childhood illness, perinatal mortality and process indicators. Data from different districts will be compared at baseline and annually until 2020 as the specialists of both cadres take up posts. IMPLICATIONS OF THE HYPOTHESIS: If a managed clinical network improves child healthcare in Malawi, it may be a potential model for the other countries in sub-Saharan Africa with similar cadres in their healthcare system and face similar challenges in terms of scarcity of specialists.

An analysis of the potential for achieving the fourth millennium development goal in SSA with domestic resources.

BACKGROUND: The importance of good health is reflected in the fact that more than half of the eight Millennium Development Goals (MDGs) are aimed at improving health status. Goal 4 (MDG4) aims to reduce child mortality. The progress indicator for goal 4 is the under-five mortality rate (U5M), with a targeted reduction of two thirds by 2015 from 1990 levels. This paper seeks to compare the time (in years) Sub Saharan African (SSA) countries will take to reach their MDG4 target at the current rate of decline, and the time it could have taken to reach their target if domestic resources had not been lost through illicit financial flows, corruption and servicing of debt since 2000. METHODS: We estimate the amount by which the Gross Domestic Product (GDP) per capita would increase (in percentage terms) if losses of resource through illicit financial flows, corruption and debt servicing, were reduced. Using the income elasticity of U5M, a metric which reports the percentage change in U5M for a one percent change in GDP per capita, we estimate the potential gains in the annual reduction of the under-five mortality if these resource losses were reduced. RESULTS: At the current rate of reduction in U5M, nine countries out of this sample of 36 SSA countries (25%) will achieve their MDG4 target by 2015. In the absence of the leakages (IFF, corruption and debt service) 30 out of 36 (83%) would reach their MDG4 target by 2015 and all except one country, Zimbabwe would have achieved their MDG4 by 2017 (97%). In view of the uncertainty of the legitimacy of African debts we have also provided results where we excluded debt repayment from our analysis. CONCLUSIONS: Most countries would have met MDG4 target by curtailing these outflows. In order to release latent resources in SSA for development, action will be needed both by African countries and internationally. We consider that stemming these outflows, and thereby reducing the need for aid, can be achieved with a more transparent global financial system.

Quality of governance, public spending on health and health status in Sub Saharan Africa: a panel data regression analysis.

BACKGROUND: The population in Sub Saharan Africa (SSA) suffers poor health as manifested in high mortality rates and low life expectancy. Economic growth has consistently been shown to be a major determinant of health outcomes. However, even with good economic growth rates, it is not possible to achieve desired improvements in health outcomes. Public spending on health (PSH) has long been viewed as a potential complement to economic growth in improving health. However, the relationship between PSH and health outcomes is inconclusive and this inconclusiveness may, in part, be explained by governance-related factors which mediate the impact of the former on the latter. Little empirical work has been done in this regard on SSA. This paper investigates whether or not the quality of governance (QoG) has a modifying effect on the impact of public health spending on health outcomes, measured by under-five mortality (U5M) and life expectancy at birth (LE), in SSA. METHODS: Using two staged least squares regression technique on panel data from 43 countries in SSA over the period 1996-2011, we estimated the effect of public spending on health and quality of governance U5M and LE, controlling for GDP per capita and other socio-economic factors. We also interacted PSH and QoG to find out if the latter has a modifying effect on the former's impact on U5M and LE. RESULTS: Public spending on health has a statistically significant impact in improving health outcomes. Its direct elasticity with respect to under-five mortality is between -0.09 and -0.11 while its semi-elasticity with respect to life expectancy is between 0.35 and 0.60. Allowing for indirect effect of PSH spending via interaction with quality of governance, we find that an improvement in QoG enhances the overall impact of PSH. In countries with higher quality of governance, the overall elasticity of PSH with respect to under-five mortality is between -0.17 and -0.19 while in countries with lower quality of governance, it is about -0.09. The corresponding semi elasticities with respect to life expectancy are about 6 in countries with higher QoG and about 3 in countries with lower QoG. DISCUSSION: Public spending on health improves health outcomes. Its impact is mediated by quality of governance, having the higher impact on health outcomes in countries with higher quality of governance and lower impact in countries with lower quality of governance. This may be due to increased efficiency in the use of available resources and better allocation of the same as QoG improves. CONCLUSION: Improving QoG would improve health outcomes in SSA. The same increase in PSH is twice as effective in reducing U5M and increasing LE in countries with good QoG when compared with countries with poor QoG.

Impact of higher-income countries on child health in lower-income countries from a climate change perspective. A case study of the UK and Malawi.

Climate change is the number one threat to child health according to the World Health Organisation. It increases existing inequalities, and lower-income countries are disproportionately affected. This is unjust. Higher-income countries have contributed and continue to contribute more to climate change than lower-income countries. This has been recognised by the United Nations Committee on the Rights of the Child, which has ruled that states can be held responsible if their carbon emissions harm child rights both within and outside their jurisdiction. Nevertheless, there are few analyses of the bilateral relationship between higher- and lower-income countries concerning climate change. This article uses the UK and Malawi as a case study to illustrate higher-income countries' impact on child health in lower-income countries. It aims to assist higher-income countries in developing more targeted policies. Children in Malawi can expect more food insecurity and reduced access to clean water, sanitation, and education. They will be more exposed to heat stress, droughts, floods, air pollution and life-threatening diseases, such as malaria. In 2019, 5,000 Malawian children died from air pollution (17% of under-five deaths). The UK needs to pay its 'fair share' of climate finance and ensure adaptation is prioritised for lower-income countries. It can advocate for more equitable and transparent allocation of climate finance to support the most vulnerable countries. Additionally, the UK can act domestically to curtail revenue losses in Malawi and other lower-income countries, which would free up resources for adaptation. In terms of mitigation, the UK must increase its nationally determined commitments by 58% to reach net zero and include overseas emissions. Land use, heating systems and renewable energy must be reviewed. It must mandate comprehensive scope three emission reporting for companies to include impacts along their value chain, and support businesses, multinational corporations, and banks to reach net zero.

Evidence of improving antiretroviral therapy treatment delays: an analysis of eight years of programmatic outcomes in Blantyre, Malawi.

BACKGROUND: Impressive achievements have been made towards achieving universal coverage of antiretroviral therapy (ART) in sub-Saharan Africa. However, the effects of rapid ART scale-up on delays between HIV diagnosis and treatment initiation have not been well described. METHODS: A retrospective cohort study covering eight years of ART initiators (2004-2011) was conducted at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi. The time between most recent positive HIV test and ART initiation was calculated and temporal trends in delay to initiation were described. Factors associated with time to initiation were investigated using multivariate regression analysis. RESULTS: From 2004-2011, there were 15,949 ART initiations at QECH (56% female; 8% children [0-10 years] and 5% adolescents [10-20 years]). Male initiators were likely to have more advanced HIV infection at initiation than female initiators (70% vs. 64% in WHO stage 3 or 4). Over the eight years studied, there were declines in treatment delay, with 2011 having the shortest delay at 36.5 days. On multivariate analysis CD4 count <50 cells/µl (adjusted geometric mean ratio [aGMR]: aGMR: 0.53, bias-corrected accelerated [BCA] 95% CI: 0.42-0.68) was associated with shorter ART treatment delay. Women (aGMR: 1.12, BCA 95% CI: 1.03-1.22) and patients diagnosed with HIV at another facility outside QECH (aGMR: 1.61, BCA 95% CI: 1.47-1.77) had significantly longer treatment delay. CONCLUSIONS: Continued improvements in treatment delays provide evidence that universal access to ART can be achieved using the public health approach adopted by Malawi However, the longer delays for women and patients diagnosed at outlying sites emphasises the need for targeted interventions to support equitable access for these groups.

A comparison of clinical outcomes among people living with HIV of different age groups attending queen Elizabeth central hospital outpatient ART Clinic in Malawi.

Introduction: Adherence to Antiretroviral Treatment (ART) in children and adolescents living with HIV in low-resource settings is not extensively studied in large cohort studies including both adults and pediatric patients. We compared rates of virological suppression, adherence and defaulting among children, adolescents and adults attending a family ART clinic at Queen Elizabeth Central Hospital; a tertiary hospital situated in the southern region of Malawi. Methods: The study was longitudinal and made use of routinely collected data for all 27,229 clinic attendees. Clinical information obtained at routine clinical visits entered electronically since 2008 was extracted in February 2017. This data was used to ascertain differences across the different age groups. Logistic regression and Cox regression models were fitted to compare rates of Virological Suppression (VS), adherence, and defaulting, respectively. Results: Younger and older adolescents (ages 10-14 years and 15-19 years respectively) were less likely to achieve VS compared to adults in the final model AOR 0.4 (0.2-0.9, 95% CI) and AOR 0.2 (0.1-0.4, 95% CI) respectively. Young children (ages 0-4 years), older children (ages 5-9 years) and younger adolescents were less adherent to ART compared to adults AOR 0.1 (0.1-0.2, 95% CI), AOR 0.2 (0.1-0.3, 95% CI), and AOR 0.4 (0.3-0.5, 95% CI) respectively. Young adults and younger children had an increased likelihood of defaulting compared to adults. Conclusion: Poor performance on ART of children and adolescents highlights unaddressed challenges to adherence. Ongoing research to explore these potential barriers and possible interventions needs to be carried out. The adherence assessment methods used and strategies for improving it among children and adolescents need to be revised at the clinic.

An analysis of tax abuse, debt, and climate change risk in low-income and lower-middle-income countries.

INTRODUCTION: Climate change is exacerbating a pre-existing child rights crisis. Lower- (low- and lower-middle-) income countries have borne 99% of the disease burden from the crisis, of which children under five carry 90%. In response, much of the recent global policy efforts focus on climate action. However, unsustainable levels of debt and tax abuses are draining countries of crucial revenue to handle the crisis. Like the climate crisis, these are primarily facilitated by entities domiciled within higher- (upper-middle- and high-) income countries. This paper aims to review these revenue leaks in countries where children are at the greatest risk of climate change to identify opportunities to increase climate change resilience. METHODS: We compiled data on tax abuse, debt service and climate risk for all lower-income countries with available data to highlight the need for intervention at the global level. We used the Climate Change Risk Index (CCRI), developed by UNICEF. Additionally, we used figures for tax abuse and debt service as a percentage of government revenue. RESULTS: We present data on 62 lower-income countries with data on revenue losses, of which 55 have CCRI data. Forty-two of these 62 countries (67.7%) are at high risk of lost government revenues. Forty-one (74.5%) of the 55 countries with CCRI data are at high risk of climate change. Thirty-one countries with data on both (56.4%) are at high risk of both climate change and revenue losses. Most countries at high risk of both are located in sub-Saharan Africa. This shows that countries most in need of resources lose money to arguably preventable leaks in government revenue. DISCUSSION: Higher-income countries and global actors can adopt policies and practices to ensure that they do not contribute to human rights abuses in other countries. Highlighting the impact of a failing global economic model on children's economic and social rights and one which increases their vulnerability to the climate emergency could help drive the transition towards a model that prioritises human rights and the environment on which we all depend.

A systematic review of strategies adopted to scale up COVID-19 testing in low-, middle- and high-income countries.

OBJECTIVE: We undertook a systematic review of strategies adopted to scale up COVID-19 testing in countries across income levels to identify successful approaches and facilitate learning. METHODS: Scholarly articles in English from PubMed, Google scholar and Google search engine describing strategies used to increase COVID-19 testing in countries were reviewed. Deductive analysis to allocate relevant text from the reviewed publications/reports to the a priori themes was done. MAIN RESULTS: The review covered 32 countries, including 11 high-income, 2 upper-middle-income, 13 lower-middle-income and 6 low-income countries. Most low- and middle-income countries (LMICs) increased the number of laboratories available for testing and deployed sample collection and shipment to the available laboratories. The high-income countries (HICs) that is, South Korea, Germany, Singapore and USA developed molecular diagnostics with accompanying regulatory and legislative framework adjustments to ensure the rapid development and use of the tests. HICs like South Korea leveraged existing manufacturing systems to develop tests, while the LMICs leveraged existing national disease control programmes (HIV, tuberculosis, malaria) to increase testing. Continent-wide, African Centres for Disease Control and Prevention-led collaborations increased testing across most African countries through building capacity by providing testing kits and training. CONCLUSION: Strategies taken appear to reflect the existing systems or economies of scale that a particular country could leverage. LMICs, for example, drew on the infectious disease control programmes already in place to harness expertise and laboratory capacity for COVID-19 testing. There however might have been strategies adopted by other countries but were never published and thus did not appear anywhere in the searched databases.

Tax abuse-The potential for the Sustainable Development Goals.

Governments generally provide the services that allow people to access the critical determinants of health: water, sanitation, and education. These are also Sustainable Development Goals and fundamental economic and social human rights. Studies show that governments spend more on public services and health determinants with more revenue. However, governments in low and lower-middle-income countries have small budgets, and tax abuse (avoidance and evasion) contributes to revenue leaks. Researchers have estimated that four countries enable more than half of global tax abuse. We used estimates on tax abuse with a model of the relationship between government revenue and the determinants of health to quantify the potential for progress towards the Sustainable Development Goals 3, 4, 5, and 6. The increase in government revenue equivalent to global tax abuses is associated with 36 million people having access to basic sanitation and 18 million having access to basic drinking water. Additionally, over a ten year period, this increase would be associated with over 600,000 children and almost 80,000 mothers surviving. Thus, curtailing tax abuses would significantly contribute to progress towards the Sustainable Development Goals. Countries that enable tax abuses must review and modify policies to ensure progress towards these goals.

Addressing inequities in child health and development: towards social justice.

Inequities have a profound impact on the health and development of children globally. While inequities are greatest in the world's poorest countries, even in rich nations poorer children have poorer health and developmental outcomes. From birth through childhood to adolescence, morbidity, mortality, growth and development are socially determined, resulting in the most disadvantaged having the highest risk of poor health outcomes. Inequities in childhood impact across the life course. We consider four categories of actions to promote equity: strengthening individuals, strengthening communities, improving living and working conditions, and promoting healthy macropolicies. Inequities can be reduced but action to reduce inequities requires political will. The International Society for Social Paediatrics and Child Health (ISSOP) calls on governments, policy makers, paediatricians and professionals working with children and their organisations to act to reduce child health inequity as a priority. ISSOP recommends the following: governments act to reduce child poverty; ensure rights of all children to healthcare, education and welfare are protected; basic health determinants such as adequate nutrition, clean water and sanitation are available to all children. Paediatric and child health organisations ensure that their members are informed of the impact of inequities on children's well-being and across the life course; include child health inequities in curricula for professionals in training; publish policy statements relevant to their country on child health inequities; advocate for evidence-based pro-equity interventions using a child rights perspective; advocate for affordable, accessible and quality healthcare for all children; promote research to monitor inequity as well as results of interventions in their child populations. Paediatricians and child health professionals be aware of the impact of social determinants of health on children under their care; ensure their clinical services are accessible and acceptable to all children and families within the constraints of their country's health services; engage in advocacy at community and national level.

First do no harm: the impact of recent armed conflict on maternal and child health in Sub-Saharan Africa.

OBJECTIVES: To compare the rates of under-5 mortality, malnutrition, maternal mortality and other factors which influence health in countries with and without recent conflict. To compare central government expenditure on defence, education and health in countries with and without recent conflict. To summarize the amount spent on SALW and the main legal suppliers to countries in Sub-Saharan African countries (SSA), and to summarize licensed production of Small Arms and Light Weapons (SALW) in these countries. DESIGN: We compared the under-5 mortality rate in 2004 and the adjusted maternal mortality ratio in SSA which have and have not experienced recent armed conflict (post-1990). We also compared the percentage of children who are underweight in both sets of countries, and expenditure on defence, health and education. SETTING: Demographic data and central government expenditure details (1994-2004) were taken from UNICEF's The State of the World's Children 2006 report. MAIN OUTCOME MEASURES: Under-5 mortality, adjusted maternal mortality, and government expenditure. RESULTS: 21 countries have and 21 countries have not experienced recent conflict in this dataset of 42 countries in SSA. Median under-5 mortality in countries with recent conflict is 197/1000 live births, versus 137/1000 live births in countries without recent conflict. In countries which have experienced recent conflict, a median of 27% of under-5s were moderately underweight, versus 22% in countries without recent conflict. The median adjusted maternal mortality in countries with recent conflict was 1000/100,000 births versus 690/100,000 births in countries without recent conflict. Median reported maternal mortality ratio is also significantly higher in countries with recent conflict. Expenditure on health and education is significantly lower and expenditure on defence significantly higher if there has been recent conflict. CONCLUSIONS: There appears to be an association between recent conflict and higher rates of under-5 mortality, malnutrition and maternal mortality. Governments spend more on defence and less on health and education if there has been a recent conflict. SALW are the main weapon used and France and the UK appear to be the two main suppliers of SALW to SSA.

Bedside paediatric HIV testing in Malawi: Impact on testing rates.

Background: Provider initiated testing and counselling (PITC) is recommended for all inpatients in Malawi if they have not been tested in the previous 3 months. However testing rates remain low among children. We audited the effect of implementing a bedside diagnostic HIV testing service to determine if it would improve testing rates amongst paediatric inpatients. Methods: We audited the existing HIV testing service to determine the numbers of children being tested for HIV. This was followed by the introduction of a bedside diagnostic service followed by re-audit. Bedside testing was facilitated by health systems strengthening measures including identification of suitable counsellors, appropriate supervision and remuneration. Results: In the initial audit in March-April 2014, 85 (63%) of 135 children had documented HIV tests.. Following implementation of the bedside HIV testing service, there was a significant increase in the proportion of children whose HIV status was known. On re-audit in July 2015, 110 (94.8%) of 116 children had documented HIV tests (p<0.001). Of those with documented tests, 94.5% had been tested within the last 3-months compared to 61% in 2014. Following the introduction of the service, the proportion of children tested for HIV during admission increased from 31.9% to 68.1% (p<0.001). Conclusions: Implementation of a bedside testing service at Queen Elizabeth Central Hospital significantly increased HIV testing among paediatric inpatients. This has important implications in establishing earlier treatment, reducing HIV-associated morbidity and mortality.

Early use of corticosteroids in infants with a clinical diagnosis of Pneumocystis jiroveci pneumonia in Malawi: a double-blind, randomised clinical trial.

BACKGROUND: Pneumocystis jiroveci pneumonia (PJP) is the most common opportunistic infection in infants with vertically acquired HIV infection and the most common cause of death in HIV-infected infants. OBJECTIVES: To determine whether early administration of adjuvant corticosteroids in addition to standard treatment reduces mortality in infants with vertically acquired HIV and clinically diagnosed PJP when co-infection with cytomegalovirus and other pathogens cannot be excluded. METHODS: A double-blind placebo-controlled trial of adjuvant prednisolone treatment in HIV-exposed infants aged 2-6 months admitted to Queen Elizabeth Central Hospital, Blantyre who were diagnosed clinically with PJP was performed. All recruited infants were HIV-exposed, and the HIV status of the infant was confirmed by DNA-PCR. HIV-exposed and infected infants as well as HIV-exposed but non-infected infants were included in the study. The protocol provided for the addition of prednisolone to the treatment at 48 h if there was clinical deterioration or an independent indication for corticosteroid therapy in any patient not receiving it. Oral trimethoprim-sulfamethoxazole (TMP/SMX) therapy and full supportive treatment were provided according to established guidelines. Primary outcomes for all patients included survival to hospital discharge and 6-month post-discharge survival. RESULTS: It was planned to enroll 200 patients but the trial was stopped early because of recruitment difficulties and a statistically significant result on interim analysis. Seventy-eight infants were enrolled between April 2012 and August 2014; 36 infants (46%) were randomised to receive corticosteroids plus standard treatment with TMP/SMX, and 42 infants (54%) received the standard treatment plus placebo. In an intention-to treat-analysis, the risk ratio of in-hospital mortality in the steroid group compared with the standard treatment plus placebo group was 0.53 [95% CI 0.29-0.97, p = 0.038]. The risk ratio of mortality at 6 months was 0.63 (95% CI 0.41-0.95, p = 0.029). Two children who received steroids developed bloody stools while in hospital. CONCLUSION: In infants with a clinical diagnosis of PJP, early use of steroids in addition to conventional TMP/SMX therapy significantly reduced mortality in hospital and 6 months after discharge.

Rapid Diagnostic Testing of Hospitalized Malawian Children Reveals Opportunities for Improved HIV Diagnosis and Treatment.

Recent World Health Organization (WHO) guidelines recommend antiretroviral therapy (ART) for all HIV-infected people; previously CD4+ T lymphocyte quantification (CD4 count) or clinical staging determined eligibility for children ≥ 5 years old in low- and middle-income countries. We examined positive predictive value (PPV) of a rapid diagnostic test (RDT) algorithm and ART eligibility for hospitalized children with newly diagnosed HIV infection. We enrolled 363 hospitalized Malawian children age 2 months to 16 years with two serial positive HIV RDT from 2013 to 2015. Children aged ≤ 18 months whose nucleic acid testing was negative or unavailable were later excluded from the analysis (N = 16). If RNA PCR was undetectable, human immunodeficiency virus (HIV) enzyme immunoassay (EIA) and western blot (WB) were performed. Those with negative or discordant EIA and WB were considered HIV negative and excluded from further analysis (N = 6). ART eligibility was assessed using age, CD4 count, and clinical HIV stage. Among 150 patients with HIV RNA PCR results, 15 had undetectable HIV RNA. Of those, EIA and WB were positive in nine patients and negative or discordant in six patients. PPV of serial RDT was 90% versus RNA PCR alone and 96% versus combined RNA PCR, EIA, and WB. Of all patients aged ≥ 5 years, 8.9% were ineligible for ART under previous WHO guidelines. Improved HIV testing algorithms are needed for accurate diagnosis of HIV infection in children as prevalence of pediatric HIV declines. Universal treatment will significantly increase the numbers of older children who qualify for ART.