Family play, reading, and other stimulation and early childhood development in five low-and-middle-income countries.

This paper used longitudinal data from five studies conducted in Bangladesh, Bhutan, Cambodia, Ethiopia, and Rwanda to examine the links between family stimulation and early childhood development outcomes (N = 4904; Mage = 51.5; 49% girls). Results from random-effects and more conservative child-fixed effects models indicate that across these studies, family stimulation, measured by caregivers' engagement in nine activities (e.g., reading, playing, singing), predicted increments in children's early numeracy, literacy, social-emotional, motor, and executive function skills (standardized associations ranged from 0.05 to 0.11 SD). Study-specific models showed variability in the estimates, with null associations in two out of the five studies. These findings indicate the need for additional research on culturally specific ways in which caregivers may support early development and highlight the importance of promoting family stimulation to catalyze positive developmental trajectories in global contexts. RESEARCH HIGHLIGHTS: Research on the links between family stimulation and early childhood development in low-and-middle-income countries (LMICs) is limited. We used longitudinal data from studies conducted in five LMICs to examine the links between family stimulation and early childhood development outcomes. Results suggest that family stimulation predicted increments in children's numeracy, literacy, social-emotional, motor, and executive function skills. We found variability in the observed estimates, with null associations in two out of the five studies, suggesting the need for additional research in LMICs.

Financial burden of prostate cancer in the Iranian population: a cost of illness and financial risk protection analysis.

BACKGROUND: Prostate cancer is the second most common cancer in males worldwide and the third most common among Iran's male population. However, there is a lack of evidence regarding its direct and indirect costs in low and middle-income countries. This study intends to bridge the gap using a cost of illness approach, assessing the costs of prostate cancer from the perspectives of patients, society, and the insurance system. METHODS: Two hundred ninety seven patients were included in the study. Data for a 2-month period were obtained from patients registered at two hospitals (Tabriz, Tehran) in Iran in 2017. We applied a prevalence-based, bottom-up approach to assess the costs of the illness. We used the World Health Organization methods to measure the prevalence and investigate the determinants of catastrophic and impoverishing health expenditures. RESULTS: We determined the total costs of the disease for the patients to be IRR 68 million (PPP $ 5,244.44). Total costs of the disease from the perspective of the society amounted to IRR 700,000 million (PPP $ 54 million). Insurance companies expended IRR 20 million (PPP $ 1,558.80) per patient. Our findings show that 31% of the patients incurred catastrophic health expenditure due to the disease. Five point forty-four percent (5.44%) of the patients were impoverished due to the costs of this cancer. CONCLUSION: We found an alarmingly high prevalence of catastrophic health expenditures among prostate cancer patients. In addition, prostate cancer puts a substantial burden on both the patients and society.

Cost of Delivering 12-Dose Isoniazid and Rifapentine Versus 6 Months of Isoniazid for Tuberculosis Infection in a High-Burden Setting.

BACKGROUND: Successful delivery and completion of tuberculosis preventive treatment are necessary for tuberculosis elimination. Shorter preventive treatment regimens currently have higher medication costs, but patients spend less time in care and are more likely to complete treatment. It is unknown how economic costs of successful delivery differ between longer and shorter regimens in high-tuberculosis-burden settings. METHODS: We developed survey instruments to collect costs from program and patient sources, considering costs incurred from when household contacts first entered the health system. We compared the cost per completed course of preventive treatment with either 6 months of daily isoniazid (6H) or 3 months of weekly isoniazid and rifapentine (3HP), delivered by the Indus Health Network tuberculosis program in Karachi, Pakistan, between October 2016 and February 2018. RESULTS: During this period, 459 individuals initiated 6H and 643 initiated 3HP; 39% and 61% completed treatment, respectively. Considering costs to both the program and care recipients, the cost per completed course was 394 US dollars (USD) for 6H and 333 USD for 3HP. Using a new 2020 price for rifapentine reduced the cost per completed course of 3HP to 290 USD. Under varying assumptions about drug prices and costs incurred by care recipients, the cost per completed course was lower for 3HP in all scenarios, and the largest cost drivers were the salaries of clinical staff. CONCLUSIONS: In a high-burden setting, the cost of successful delivery of 3HP was lower than that of 6H, driven by higher completion.

Global estimates of the implications of COVID-19-related preprimary school closures for children's instructional access, development, learning, and economic wellbeing.

Observational data collected prior to the pandemic (between 2004 and 2019) were used to simulate the potential consequences of early childhood care and education (ECCE) service closures on the estimated 167 million preprimary-age children in 196 countries who lost ECCE access between March 2020 and February 2021. COVID-19-related ECCE disruptions were estimated to result in 19.01 billion person-days of ECCE instruction lost, 10.75 million additional children falling "off track" in their early development, 14.18 million grades of learning lost by adolescence, and a present discounted value of USD 308.02 billion of earnings lost in adulthood. Further burdens associated with ongoing closures were also forecasted. Projected developmental and learning losses were concentrated in low- and lower middle-income countries, likely exacerbating long-standing global inequities.

Community health workers at the dawn of a new era: 4. Programme financing.

BACKGROUND: This is the fourth of our 11-paper supplement on "Community Health Workers at the Dawn of New Era". Here, we first make the case for investing in health programmes, second for investing in human resources for health, third for investing in primary healthcare (PHC) workers, and finally for investing in community health workers (CHWs). METHODS: Searches of peer-reviewed journals and the grey literature were conducted with a focus on community health programme financing. The literature search was supplemented with a search of the grey literature for information about national health sector plans, community health strategies/policies, and costing information from databases of various countries' ministries of health, and finally a request for information from in-country partners. RESULTS: The global shortage of human resources for health is projected to rise to 18 million health workers by 2030, with more acute shortages in Africa and South Asia. CHWs have an important role to play in mitigating this shortage because of their effectiveness (when properly trained and supported) and the feasibility of their deployment. Data are limited on the costs of current CHW programmes and how they compare to government and donor expenditures for PHC and for health services more broadly. However, available data from 10 countries in Africa indicate that the median per capita cost of CHW programmes is US$ 4.77 per year and US$ 2574 per CHW, and the median monthly salary of CHWs in these same countries is US$ 35 per month. For a subset of these countries for which spending for PHC is available, governments and donors spend 7.7 times more on PHC than on CHW programming, and 15.4 times more on all health expenditures. Even though donor funding for CHW programmes is a tiny portion of health-related donor support, most countries rely on donor support for financing their CHW programmes. CONCLUSION: The financing of national CHW programmes has been a critical element that has not received sufficient emphasis in the academic literature on CHW programmes. Increasing domestic government funding for CHW programmes is a priority. In order to ensure growth in funding for CHW programmes, it will be important to measure CHW programme expenditures and their relationship to expenditures for PHC and for all health-related expenditures.

Development assistance for community health workers in 114 low- and middle-income countries, 2007-2017.

OBJECTIVE: To estimate the level and trend of development assistance for community health worker-related projects in low- and middle-income countries between 2007 and 2017. METHODS: We extracted data from the Organisation for Economic Co-operation and Development's creditor reporting system on aid funding for projects to support community health workers (CHWs) in 114 countries over 2007-2017. We produced estimates for projects specifically described by relevant keywords and for projects which could include components on CHWs. We analysed the pattern of development assistance by purpose, donors, recipient regions and countries, and trends over time. FINDINGS: Between 2007 and 2017, total development assistance targeting CHW projects was around United States dollars (US$) 5 298.02 million, accounting for 2.5% of the US$ 209 277.99 million total development assistance for health. The top three donors (Global Fund to Fight AIDS, Tuberculosis and Malaria, the government of Canada and the government of the United States of America) provided a total of US$ 4 350.08 million (82.1%) of development assistance for these projects. Sub-Saharan Africa received a total US$ 3 717.93 million, the largest per capita assistance over 11 years (US$ 0.39; total population: 9 426.25 million). Development assistance to projects that focused on infectious diseases and child and maternal health received most funds during the study period. CONCLUSION: The share of development assistance invested in the CHW projects was small, unstable and decreasing in recent years. More research is needed on tracking government investments in CHW-related projects and assessing the impact of investments on programme effectiveness.

Measuring early childhood development with The Early Human Capability Index (eHCI): a reliability and validity study in China.

BACKGROUND: With the importance of early childhood development more recognized by the international society, low-cost and cross-culturally comparable measures of early childhood development is in great demand, both in China and worldwide. In this study, we aim to test the psychometrics of the Chinese version of The Early Human Capability Index (eHCI), which is designed as a measurement for school readiness in large population. METHODS: We evaluated the internal consistency, test-retest reliability, inter-rater reliability, factor structure, criterion-related validity, and discriminant validity of the eHCI in 20,324 preschool children in Shanghai. We also compared eHCI scores with test result of ASQ in 815 children in Yexian and EAP-ECDS in 6947 children in Daming. RESULTS: The ICC between parents and teachers were 0.83 and 0.63 for Literacy Numeracy and Overall Development. The confirmatory factor analyses showed good model fit (χ2 = 509,323, p < 0.001; CFI = 0.901; RMSEA = 0.038). The correlations between the scores of eHCI and other ECD metrics ranged between r = - 0.42 and r = 0.53. The scale discriminated between children's developmental level based on sex, parental education, family income, family assets, and nutrition status. CONCLUSIONS: Results from Chinese population suggested that eHCI is valid and reliable for measuring early childhood development in children aged 3-6 years. The eHCI can be applied to map the global distribution of early childhood development for allocating scarce resources to help those in greatest demand. Longitudinal studies are warranted to test its predictive validity for later outcomes.

On assessing binary regression models based on ungrouped data.

Assessing a binary regression model based on ungrouped data is a commonly encountered but very challenging problem. Although tests, such as Hosmer-Lemeshow test and le Cessie-van Houwelingen test, have been devised and widely used in applications, they often have low power in detecting lack of fit and not much theoretical justification has been made on when they can work well. In this article, we propose a new approach based on a cross-validation voting system to address the problem. In addition to a theoretical guarantee that the probabilities of type I and II errors both converge to zero as the sample size increases for the new method under proper conditions, our simulation results demonstrate that it performs very well.

Assessing national and subnational inequalities in medical care utilization and financial risk protection in Rwanda.

BACKGROUND: Ensuring equitable access to medical care with financial risk protection has been at the center of achieving universal health coverage. In this paper, we assess the levels and trends of inequalities in medical care utilization and household catastrophic health spending (HCHS) at the national and sub-national levels in Rwanda. METHODS: Using the Rwanda Integrated Living Conditions Surveys of 2005, 2010, 2014, and 2016, we applied multivariable logit models to generate the levels and trends of adjusted inequalities in medical care utilization and HCHS across the four survey years by four socio-demographic dimensions: poverty, gender, education, and residence. We measured the national- and district-level inequalities in both absolute and relative terms. RESULTS: At the national level, after controlling for other factors, we found significant inequalities in medical care utilization by poverty and education and -in HCHS by poverty in all four years. From 2005 to 2016, inequalities in medical care utilization by the four dimensions did not change significantly, while the inequality in HCHS by poverty was reduced significantly. At the district level, inequalities in both medical care utilization and HCHS were larger than zero in all four years and decreased over time. CONCLUSIONS: Poverty and poor education were significant contributors to inequalities in medical care utilization and HCHS in Rwanda. Policies or interventions targeting poor households or households headed by persons receiving no education are needed in order to effectively reduce inequalities in medical care utilization and HCHS.

Global child and adolescent mental health: The orphan of development assistance for health.

In an analysis of data from the Creditor Reporting System, Chunling Lu and colleagues investigate the level of development assistance from high-income countries towards child and adolescent mental health in low- and middle-income countries.

Investing in the foundation of sustainable development: pathways to scale up for early childhood development.

Building on long-term benefits of early intervention (Paper 2 of this Series) and increasing commitment to early childhood development (Paper 1 of this Series), scaled up support for the youngest children is essential to improving health, human capital, and wellbeing across the life course. In this third paper, new analyses show that the burden of poor development is higher than estimated, taking into account additional risk factors. National programmes are needed. Greater political prioritisation is core to scale-up, as are policies that afford families time and financial resources to provide nurturing care for young children. Effective and feasible programmes to support early child development are now available. All sectors, particularly education, and social and child protection, must play a role to meet the holistic needs of young children. However, health provides a critical starting point for scaling up, given its reach to pregnant women, families, and young children. Starting at conception, interventions to promote nurturing care can feasibly build on existing health and nutrition services at limited additional cost. Failure to scale up has severe personal and social consequences. Children at elevated risk for compromised development due to stunting and poverty are likely to forgo about a quarter of average adult income per year, and the cost of inaction to gross domestic product can be double what some countries currently spend on health. Services and interventions to support early childhood development are essential to realising the vision of the Sustainable Development Goals.

Early childhood development coming of age: science through the life course.

Early childhood development programmes vary in coordination and quality, with inadequate and inequitable access, especially for children younger than 3 years. New estimates, based on proxy measures of stunting and poverty, indicate that 250 million children (43%) younger than 5 years in low-income and middle-income countries are at risk of not reaching their developmental potential. There is therefore an urgent need to increase multisectoral coverage of quality programming that incorporates health, nutrition, security and safety, responsive caregiving, and early learning. Equitable early childhood policies and programmes are crucial for meeting Sustainable Development Goals, and for children to develop the intellectual skills, creativity, and wellbeing required to become healthy and productive adults. In this paper, the first in a three part Series on early childhood development, we examine recent scientific progress and global commitments to early childhood development. Research, programmes, and policies have advanced substantially since 2000, with new neuroscientific evidence linking early adversity and nurturing care with brain development and function throughout the life course.

Decomposing health inequality with population-based surveys: a case study in Rwanda.

BACKGROUND: Ensuring equal access to care and providing financial risk protection are at the center of the global health agenda. While Rwanda has made impressive progress in improving health outcomes, inequalities in medical care utilization and household catastrophic health spending (HCHS) between the impoverished and non-impoverished populations persist. Decomposing inequalities will help us understand the factors contributing to inequalities and design effective policy instruments in reducing inequalities. This study aims to decompose the inequalities in medical care utilization among those reporting illnesses and HCHS between the poverty and non-poverty groups in Rwanda. METHODS: Using the 2005 and 2010 nationally representative Integrated Living Conditions Surveys, our analysis focuses on measuring contributions to inequalities from poverty status and other sources. We conducted multivariate logistic regression analysis to obtain poverty's contribution to inequalities by controlling for all observed covariates. We used multivariate nonlinear decomposition method with logistic regression models to partition the relative and absolute contributions from other sources to inequalities due to compositional or response effects. RESULTS: Poverty status accounted for the majority of inequalities in medical care utilization (absolute contribution 0.093 in 2005 and 0.093 in 2010) and HCHS (absolute contribution 0.070 in 2005 and 0.032 in 2010). Health insurance status (absolute contribution 0.0076 in 2005 and 0.0246 in 2010) and travel time to health centers (absolute contribution 0.0025 in 2005 and 0.0014 in 2010) were significant contributors to inequality in medical care utilization. Health insurance status (absolute contribution 0.0021 in 2005 and 0.0011 in 2010), having under-five children (absolute contribution 0.0012 in 2005 and 0.0011 in 2010), and having disabled family members (absolute contribution 0.0002 in 2005 and 0.0001 in 2010) were significant contributors to inequality in HCHS. Between 2005 and 2010, the main sources of the inequalities remained unchanged. CONCLUSIONS: Expanding insurance coverage and reducing travel time to health facilities for those living in poverty could be used as policy instruments to mitigate inequalities in medical care utilization and HCHS between the poverty and non-poverty groups.

Is the medical financial assistance program an effective supplement to social health insurance for low-income households in China? A cross-sectional study.

BACKGROUND: China uses both social health insurance (SHI) programs and a medical financial assistance (MFA) program to protect the poor from illness-induced financial risks. The MFA provides a dual benefit package targeting low-income families: subsidizing these families' participation in SHI programs, and providing cash aid to protect them from catastrophic health expenditure (CHE). This study aims to investigate: (1) the association between MFA subvention for SHI enrollment and SHI enrollment; (2) the association between MFA cash aid and CHE; and (3) the association between SHI enrollment and CHE in low-income households in China. METHODS: Using nationally representative data from a comprehensive survey of low-income households in 2014, we construct an estimate of CHE based on out-of-pocket health spending data. Controlling for other covariates, we estimate the three associations using a three-level logistic model. RESULTS: The MFA program subsidizes 50.1% of low-income households to aid their enrollment in SHI programs and provides cash aid to 24.1% of these households. Multilevel logistic analysis reveals that MFA subvention has no significant association with low-income households' SHI enrollment, that MFA cash aid has no significant association with CHE, and that full SHI enrollment is inversely associated with CHE status. CONCLUSIONS: The MFA program is currently not an effective supplement to SHI programs in China in terms of promoting SHI enrollment and providing financial risk protection. The Chinese government needs to invest more funds to expand further low-income household enrollment in SHI programs and to widen the benefit package of MFA cash aid.

Multidrug-resistant tuberculosis treatment failure detection depends on monitoring interval and microbiological method.

Debate persists about monitoring method (culture or smear) and interval (monthly or less frequently) during treatment for multidrug-resistant tuberculosis (MDR-TB). We analysed existing data and estimated the effect of monitoring strategies on timing of failure detection.We identified studies reporting microbiological response to MDR-TB treatment and solicited individual patient data from authors. Frailty survival models were used to estimate pooled relative risk of failure detection in the last 12 months of treatment; hazard of failure using monthly culture was the reference.Data were obtained for 5410 patients across 12 observational studies. During the last 12 months of treatment, failure detection occurred in a median of 3 months by monthly culture; failure detection was delayed by 2, 7, and 9 months relying on bimonthly culture, monthly smear and bimonthly smear, respectively. Risk (95% CI) of failure detection delay resulting from monthly smear relative to culture is 0.38 (0.34-0.42) for all patients and 0.33 (0.25-0.42) for HIV-co-infected patients.Failure detection is delayed by reducing the sensitivity and frequency of the monitoring method. Monthly monitoring of sputum cultures from patients receiving MDR-TB treatment is recommended. Expanded laboratory capacity is needed for high-quality culture, and for smear microscopy and rapid molecular tests.

Community-Based Health Financing and Child Stunting in Rural Rwanda.

OBJECTIVES: We analyzed the likelihood of rural children (aged 6-24 months) being stunted according to whether they were enrolled in Mutuelles, a community-based health-financing program providing health insurance to rural populations and granting them access to health care, including nutrition services. METHODS: We retrieved health facility data from the District Health System Strengthening Tool and calculated the percentage of rural health centers that provided nutrition-related services required by Mutuelles' minimum service package. We used data from the 2010 Rwanda Demographic and Health Survey and performed multilevel logistic analysis to control for clustering effects and sociodemographic characteristics. The final sample was 1061 children. RESULTS: Among 384 rural health centers, more than 90% conducted nutrition-related campaigns and malnutrition screening for children. Regardless of poverty status, the risk of being stunted was significantly lower (odds ratio = 0.60; 95% credible interval = 0.41, 0.83) for Mutuelles enrollees. This finding was robust to various model specifications (adjusted for Mutuelles enrollment, poverty status, other variables) or estimation methods (fixed and random effects). CONCLUSIONS: This study provides evidence of the effectiveness of Mutuelles in improving child nutrition status and supported the hypothesis about the role of Mutuelles in expanding medical and nutritional care coverage for children.

On the spread and control of MDR-TB epidemics: an examination of trends in anti-tuberculosis drug resistance surveillance data.

BACKGROUND: Multidrug resistant tuberculosis (MDR-TB) poses serious challenges for tuberculosis control in many settings, but trends of MDR-TB have been difficult to measure. METHODS: We analyzed surveillance and population-representative survey data collected worldwide by the World Health Organization between 1993 and 2012. We examined setting-specific patterns associated with linear trends in the estimated per capita rate of MDR-TB among new notified TB cases to generate hypotheses about factors associated with trends in the transmission of highly drug resistant tuberculosis. RESULTS: 59 countries and 39 sub-national settings had at least three years of data, but less than 10% of the population in the WHO-designated 27-high MDR-TB burden settings were in areas with sufficient data to track trends. Among settings in which the majority of MDR-TB was autochthonous, we found 10 settings with statistically significant linear trends in per capita rates of MDR-TB among new notified TB cases. Five of these settings had declining trends (Estonia, Latvia, Macao, Hong Kong, and Portugal) ranging from decreases of 3% to 14% annually, while five had increasing trends (four individual oblasts of the Russian Federation and Botswana) ranging from 14% to 20% annually. In unadjusted analysis, better surveillance indicators and higher GDP per capita were associated with declining MDR-TB, while a higher existing absolute burden of MDR-TB was associated with an increasing trend. CONCLUSIONS: Only a small fraction of countries in which the burden of MDR-TB is concentrated currently have sufficient surveillance data to estimate trends in drug-resistant TB. Where trend analysis was possible, smaller absolute burdens of MDR-TB and more robust surveillance systems were associated with declining per capita rates of MDR-TB among new notified cases.

Tracking rural health facility financial data in resource-limited settings: a case study from Rwanda.

Chunling Lu and colleagues describe a project for tracking health center financial data in two rural districts of Rwanda, which could be adapted for other low- or middle-income countries. Please see later in the article for the Editors' Summary.