Using cash transfers to promote child health equity: an analysis of Lesotho's Child Grants Program.

Cash transfers (CTs) are increasingly popular tools for promoting social inclusion and equity in children in sub-Saharan Africa. However, less is known about their implications for reducing the health gap between the beneficiary and non-beneficiary children in the community. Using Lesotho's Child Grants Program (CGP) as a case study, we aim to understand better the potential for CT programmes to reduce the gap in child health in the targeted communities. Using a triple difference model, we examine to what extent CGP improved child health outcomes in eligible households compared with non-eligible households in treatment communities vs control communities and to what extent this effect varied in different population subgroups. We find that the child health gap by beneficiary children's health outcomes catching-up on the health of non-beneficiary children narrowed but that eduction was not statistically significant. However, such a 'catch-up' effect among beneficiaries was observed for selected nutrition outcomes amongst female-headed households and subjective child health assessment for comparatively more food-secure households. This study highlights the potential and limitations of CT programmes like the CGP to address health inequalities in preschool children for selected population subgroups in the community.

Exploring health equity in Lesotho's Child Grants Programme.

Despite their growing popularity, little is known about how cash transfers (CTs) can affect health equity in targeted communities. Lesotho's Child Grants Programme (CGP) is an unconditional CT targeting poor and vulnerable households with children. Started in 2009, the CGP is one of Lesotho's key programmes in developing the country's social protection system. Using the CGP's early phases as a case study, this research aims to capture how programme stakeholders understood and operationalized the concept of health equity in Lesotho's CGP. The qualitative analysis relied on the triangulation of findings from a desk review and semi-structured key informant interviews with programme stakeholders. The programme documents were coded deductively and the interview transcripts inductively. Both materials were analysed thematically before triangulating their findings. We explored determining factors for differences or disagreements within a theme according to the programme's chronology, the stakeholders' affiliations and their role(s) in the CGP. The definitions of health equity in the context of the CGP reflected an awareness among stakeholders of these issues and their determinants but also the challenges raised by the complex (or even debated) nature of the concept. The most common definition of this concept focused on children's access to health services for the most disadvantaged households, suggesting a narrow, targeted approach to health equity as targeting disadvantages. Yet, even the most common definition of this concept was not fully translated into the programme, especially in the day-to-day operations and reporting at the local level. This operationalization gap affected the study of selected health spillover effects of the CGP on health equity and might have undermined other programme impacts related to specific health disadvantages or gaps. As equity objectives become more prominent in CTs, understanding their meaning and translation into concrete, observable and measurable applications in programmes are essential to support impact.

Exploring economic empowerment and gender issues in Lesotho's Child Grants Programme: a qualitative study.

Cash transfers (CTs) have been increasingly used in low- and middle-income countries as a poverty reduction and social protection tool. Despite their potential for empowering vulnerable groups (especially women), the evidence for such outcomes remains unclear. Additionally, little is known about how this broad concept fits into and is perceived in such programmes. For example, Lesotho's Child Grants Programme (CGP) is an unconditional CT targeting poor and vulnerable households with children. The CGP has been presented as one of the Lesotho's flagship programmes in developing the country's social safety net system. Using the CGP's early phases as a case study, this research aims to capture how programme stakeholders understood and operationalized the concept of economic empowerment (especially women's) in Lesotho's CGP. The qualitative analysis relied on the triangulation of information from a review of programme documents and semi-structured key informant interviews with programme stakeholders. First, the programme documents were coded deductively, while the interview transcripts were coded inductively, and then both materials were analysed thematically. Finally, differences or disagreements within each theme were explored individually according to the programme's chronology, the stakeholders' affiliation and their role in the CGP. The complexity of economic empowerment was reflected in the diversity of definitions found in the desk review and interviews. Economic empowerment was primarily understood as improving access to economic resources and opportunities and, less so, as agency and social and economic inclusion. There were stronger disagreements on other definitions as they seemed to be a terminology primarily used by specific stakeholders. This diversity of definitions impacted how these concepts were integrated into the programme, with particular gaps between the strategic vision and operational units as well as between the role this concept was perceived to play and the effects evaluated so far.

Women's political empowerment and child health in the sustainable development era: A global empirical analysis (1990-2016).

Empowering women is presented as a key strategy to achieve several goals of the sustainable development (SDG) agenda, including child health. However, the literature on the subject shows mixed results and is limited regarding political empowerment. Responding to this gap, we explore whether women's political empowerment is associated with positive health outcomes for children under 5 years of age. We use the V-Dem project's 'Women's Political Empowerment Index' (WPEI) in combination with selected SDG indicators of child health from the Institute for Health Metrics and Evaluation's 2017 Global Burden of Disease, for 161 countries, between 1990 and 2016. We estimate fixed-effects regressions for the WPEI against child mortality, stunting and immunisation coverage, controlling for structural and socio-economic indicators from the SDGs and potential lagged effects. The WPEI is associated with improved nutrition and immunisation but its substantive effect is small. High-, low-income and least developed countries benefit more from the effect of women's political empowerment on child mortality. The effect of women's political empowerment on stunting is stronger in middle-income countries while its effect on immunisation is more relevant to low-income and least developed countries. Our study demonstrates the complexity of the relations between women's political empowerment and child health.

Which public health interventions are effective in reducing morbidity, mortality and health inequalities from infectious diseases amongst children in low- and middle-income countries (LMICs): An umbrella review.

Despite significant progress in the last few decades, infectious diseases remain a major threat to child health in low- and middle-income countries (LMICs)-particularly amongst more disadvantaged groups. It is imperative to understand the best available evidence concerning which public health interventions reduce morbidity, mortality and health inequalities in children aged under five years. To address this gap, we carried out an umbrella review (a systematic reviews of reviews) to identify evidence on the effects of public health interventions (promotion, protection, prevention) on morbidity, mortality and/or health inequalities due to infectious diseases amongst children in LMICs. Ten databases were searched for records published between 2014-2021 alongside a manual search of gray literature. Articles were quality-assessed using the Assessment of Multiple Systematic Reviews tool (AMSTAR 2). A narrative synthesis was conducted. We identified 60 systematic reviews synthesizing 453 individual primary studies. A majority of the reviews reported on preventive interventions (n = 48), with a minority on promotion (n = 17) and almost no reviews covering health protection interventions (n = 2). Effective interventions for improving child health across the whole population, as well as the most disadvantaged included communication, education and social mobilization for specific preventive services or tools, such as immunization or bed nets. For all other interventions, the effects were either unclear, unknown or detrimental, either at the overall population level or regarding health inequalities. We found few reviews reporting health inequalities information and the quality of the evidence base was generally low. Our umbrella review identified some prevention interventions that might be useful in reducing under five mortality from infectious diseases in LMICs, particularly amongst the most disadvantaged groups.

Parental education and inequalities in child mortality: a global systematic review and meta-analysis.

BACKGROUND: The educational attainment of parents, particularly mothers, has been associated with lower levels of child mortality, yet there is no consensus on the magnitude of this relationship globally. We aimed to estimate the total reductions in under-5 mortality that are associated with increased maternal and paternal education, during distinct age intervals. METHODS: This study is a comprehensive global systematic review and meta-analysis of all existing studies of the effects of parental education on neonatal, infant, and under-5 child mortality, combined with primary analyses of Demographic and Health Survey (DHS) data. The literature search of seven databases (CINAHL, Embase, MEDLINE, PsycINFO, PubMed, Scopus, and Web of Science) was done between Jan 23 and Feb 8, 2019, and updated on Jan 7, 2021, with no language or publication date restrictions. Teams of independent reviewers assessed each record for its inclusion of individual-level data on parental education and child mortality and excluded articles on the basis of study design and availability of relevant statistics. Full-text screening was done in 15 languages. Data extracted from these studies were combined with primary microdata from the DHS for meta-analyses relating maternal or paternal education with mortality at six age intervals: 0-27 days, 1-11 months, 1-4 years, 0-4 years, 0-11 months, and 1 month to 4 years. Novel mixed-effects meta-regression models were implemented to address heterogeneity in referent and exposure measures among the studies and to adjust for study-level covariates (wealth or income, partner's years of schooling, and sex of the child). This study was registered with PROSPERO (CRD42020141731). FINDINGS: The systematic review returned 5339 unique records, yielding 186 included studies after exclusions. DHS data were compiled from 114 unique surveys, capturing 3 112 474 livebirths. Data extracted from the systematic review were synthesized together with primary DHS data, for meta-analysis on a total of 300 studies from 92 countries. Both increased maternal and paternal education showed a dose-response relationship linked to reduced under-5 mortality, with maternal education emerging as a stronger predictor. We observed a reduction in under-5 mortality of 31·0% (95% CI 29·0-32·6) for children born to mothers with 12 years of education (ie, completed secondary education) and 17·3% (15·0-18·8) for children born to fathers with 12 years of education, compared with those born to a parent with no education. We also showed that a single additional year of schooling was, on average, associated with a reduction in under-5 mortality of 3·04% (2·82-3·23) for maternal education and 1·57% (1·35-1·72) for paternal education. The association between higher parental education and lower child mortality was significant for both parents at all ages studied and was largest after the first month of life. The meta-analysis framework incorporated uncertainty associated with each individual effect size into the model fitting process, in an effort to decrease the risk of bias introduced by study design and quality. INTERPRETATION: To our knowledge, this study is the first effort to systematically quantify the transgenerational importance of education for child survival at the global level. The results showed that lower maternal and paternal education are both risk factors for child mortality, even after controlling for other markers of family socioeconomic status. This study provides robust evidence for universal quality education as a mechanism to achieve the Sustainable Development Goal target 3.2 of reducing neonatal and child mortality. FUNDING: Research Council of Norway, Bill & Melinda Gates Foundation, and Rockefeller Foundation-Boston University Commission on Social Determinants, Data, and Decision Making (3-D Commission).

Which public health interventions are effective in reducing morbidity, mortality and health inequalities from infectious diseases amongst children in low-income and middle-income countries (LMICs): protocol for an umbrella review.

INTRODUCTION: Despite significant progress in the last few decades, infectious diseases remain a significant threat to children's health in low-income and middle-income countries. Effective means of prevention and control for these diseases exist, making any differences in the burden of these diseases between population groups or countries inequitable. Yet, gaps remain in our knowledge of the effect these public health interventions have on health inequalities in children, especially in low-income and middle-income countries. This umbrella review aims to address some of these gaps by exploring which public health interventions are effective in reducing morbidity, mortality and health inequalities from infectious diseases among children in low-income and middle-income countries. METHODS AND ANALYSIS: An umbrella review will be conducted to identify systematic reviews or evidence synthesis of public health interventions that reduce morbidity, mortality and/or health inequalities due to infectious diseases among children (aged under 5 years) in low-income and middle-income countries. The interventions of interest are public health interventions targeting infectious diseases or associated risk factors in children. We will search for reviews reporting health and health inequalities outcomes in and between populations. The literature search will be undertaken using the Cochrane Library, Medline, EMBASE, the CAB Global Health database, Health Evidence, the Campbell Collaboration Library of Systematic Reviews, International Initiative for Impact Evaluation Systematic review repository, Scopus, the Social Sciences Citation Index and PROSPERO. Additionally, a manual search will be performed in Google Scholar and three international organisations websites (UNICEF Office of Research-Innocenti, UNICEF, WHO) to capture grey literature. Data from the records meeting our inclusion/exclusion criteria will be collated using a narrative synthesis approach. ETHICS AND DISSEMINATION: This review will exclusively work with anonymous group-level information available from published reviews. No ethical approval was required.The results of the review will be submitted for publication in academic journals and presented at international public health conferences. Additionally, key findings will be summarised for dissemination to a wider policy and general public audience as part of the Centre for Global Health Inequalities Research's policy work. PROSPERO REGISTRATION NUMBER: CRD42019141673.