Why is there a gap in self-rated health among people with hypertension in Zambia? A decomposition of determinants and rural‒urban differences.

BACKGROUND: Hypertension affects over one billion people globally and is one of the leading causes of premature death. Low- and middle-income countries, especially the sub-Saharan Africa region, bear a disproportionately higher share of hypertension globally. Recent evidence shows a steady shift in the burden of hypertension from more affluent and urban populations towards poorer and rural communities. Our study examined inequalities in self-rated health (SRH) among people with hypertension and whether there is a rural‒urban gap in the health of these patients. We then quantified factors driving the health gap. We also examined how much HIV accounts for differences in self-rated health among hypertension patients due to the relationship between HIV, hypertension and health in sub-Saharan Africa. METHODS: We utilized the Zambia Household Health Expenditure and Utilization Survey for data on SRH and other demographic and socioeconomic controls. District HIV prevalence information was from the Zambia Population-Based HIV Impact Assessment (ZAMPHIA) survey. We applied the Linear Probability Model to assess the association between self-rated health and independent variables as a preliminary step. We then used the Blinder-Oaxaca decomposition to identify self-rated health inequality between urban and rural patients and determine determinants of the health gap between the two groups. RESULTS: Advanced age, lower education and low district HIV prevalence were significantly associated with poor health rating among hypertension patients. The decomposition analysis indicated that 45.5% of urban patients and 36.9% of rural patients reported good self-rated health, representing a statistically significant health gap of 8.6%. Most of the identified health gap can be attributed to endowment effects, with education (73.6%), district HIV prevalence (30.8%) and household expenditure (4.8%) being the most important determinants that explain the health gap. CONCLUSIONS: Urban hypertension patients have better SRH than rural patients in Zambia. Education, district HIV prevalence and household expenditure were the most important determinants of the health gap between rural and urban hypertension patients. Policies aimed at promoting educational interventions, improving access to financial resources and strengthening hypertension health services, especially in rural areas, can significantly improve the health of rural patients, and potentially reduce health inequalities between the two regions.

The economic costs of orthopaedic services: a health system cost analysis of tertiary hospitals in a low-income country.

BACKGROUND: Traumatic injuries are rising globally, disproportionately affecting low- and middle-income countries, constituting 88% of the burden of surgically treatable conditions. While contributing to the highest burden, LMICs also have the least availability of resources to address this growing burden effectively. Studies on the cost-of-service provision in these settings have concentrated on the most common traumatic injuries, leaving an evidence gap on other traumatic injuries. This study aimed to address the gap in understanding the cost of orthopaedic services in low-income settings by conducting a comprehensive costing analysis in two tertiary-level hospitals in Malawi. METHODS: We used a mixed costing methodology, utilising both Top-Down and Time-Driven Activity-Based Costing approaches. Data on resource utilisation, personnel costs, medicines, supplies, capital costs, laboratory costs, radiology service costs, and overhead costs were collected for one year, from July 2021 to June 2022. We conducted a retrospective review of all the available patient files for the period under review. Assumptions on the intensity of service use were based on utilisation patterns observed in patient records. All costs were expressed in 2021 United States Dollars. RESULTS: We conducted a review of 2,372 patient files, 72% of which were male. The median length of stay for all patients was 9.5 days (8-11). The mean weighted cost of treatment across the entire pathway varied, ranging from $195 ($136-$235) for Supracondylar Fractures to $711 ($389-$931) for Proximal Ulna Fractures. The main cost components were personnel (30%) and medicines and supplies (23%). Within diagnosis-specific costs, the length of stay was the most significant cost driver, contributing to the substantial disparity in treatment costs between the two hospitals. CONCLUSION: This study underscores the critical role of orthopaedic care in LMICs and the need for context-specific cost data. It highlights the variation in cost drivers and resource utilisation patterns between hospitals, emphasising the importance of tailored healthcare planning and resource allocation approaches. Understanding the costs of surgical interventions in LMICs can inform policy decisions and improve access to essential orthopaedic services, potentially reducing the disease burden associated with trauma-related injuries. We recommend that future studies focus on evaluating the cost-effectiveness of orthopaedic interventions, particularly those that have not been analysed within the existing literature.

Should We Worry About Spillover Effects of Sugar Sweetened Beverage Taxation Policies? Comment on "Understanding Marketing Responses to a Tax on Sugary Drinks: A Qualitative Interview Study in the United Kingdom, 2019".

Taxes on sugar sweetened beverages (SSBs) have been widely implemented and heralded as a panacea in reversing the growing burden of non-communicable diseases (NCDs). Using a qualitative research methodology, Forde et al explored how sugary drink companies respond to changes in taxation positing that relative effectiveness of sugar taxes will not only depend on how prices are affected, and how consumers respond, but also how producers respond by reformulating their products or engaging in counteractive marketing strategies. They argue that these responses may undermine the public health goal. We discuss some of the key issues that arise in their paper and conclude that company responses may not be sufficient in undermining the public health goal, and that consumption of sugary drinks fall after imposition of taxes, though demand is inelastic. We argue that inelasticity of demand for SSB may require a combination of interventions to sufficiently reduce excess consumption of sugar drinks.

Why is there a gap in self-rated health among people with hypertension? A decomposition of determinants and rural-urban differences.

Background: Hypertension affects over one billion people globally and is one of the leading causes of premature death. The low- and middle-income countries, especially the sub-Saharan Africa region, bear a disproportionately higher share of hypertension globally. Recent evidence shows a steady shift in the burden of hypertension from the more affluent and urban population towards the poorer and rural communities. Our study examined inequalities in self-rated health among people with hypertension and whether there is a rural-urban gap in the health of these patients. We then quantified factors driving the health gap. We also examined how much HIV accounts for differences in self-rated health among hypertension patients due to the relationship between HIV, hypertension and health in sub-Saharan Africa. Methods: We utilized the Zambia Household Health Expenditure and Utilization Survey for the data on SRH and other demographic and socioeconomic controls. District HIV prevalence information was from a previous study. The linear probability model provided a preliminary assessment of the association between self-rated health and independent variables. We then used the Blinder-Oaxaca decomposition to identify self-rated health inequality between urban and rural patients and determine determinants of the health gap between the two groups. Results: Advanced age, lower education and low district HIV prevalence were significantly associated with poor health rating among hypertension patients. The decomposition analysis indicated that 45.5% of urban patients and 36.9% of rural patients reported good self-rated health, representing a statistically significant health gap of 8.6%. Most of the identified health gap can be attributed to endowment effects, with education (62%), district HIV prevalence (26%) and household expenditure (12%) being the most important determinants that explain the health gap. Conclusions: Urban hypertension patients have better SRH than rural patients in Zambia. Educational interventions, financial protection schemes and strengthening hypertension health services in rural areas can significantly reduce the health gap between the two regions.

Motivation and retention of primary healthcare workers in rural health facilities: An exploratory qualitative study of Chipata and Chadiza Districts, Zambia.

Rural areas have the greatest health needs and yet they face the largest shortage of human resources for health which negatively impacts health systems capacity to deliver quality care as they struggle to motivate and retain healthcare workers in such settings. This study explored factors that shape motivation and retention of primary healthcare workers in rural health facilities in Chipata and Chadiza Districts of Zambia using a phenomenological research design. The data consisted 28 in-depth interviews with rural primary healthcare workers and were analysed using thematic analysis. Three main themes of factors shaping motivation and retention of rural primary healthcare workers were identified. Firstly, professional development with emergent themes of career advancement and opportunities for attending capacity-building workshops. Secondly, the work environment with emergent themes of challenging and stimulating tasks, availability of opportunities for promotion and co-workers' recognition and supportive relationships. Thirdly, rural community dynamics with emergent themes of reduced cost of living, community recognition and support, and easy access to farmland for economic and consumption purposes. Interventions that are contextually relavant, which can streamline career progression pathways, enhance rural working environments, offer suitable incentives, and rally community support for rural primary healthcare workers are required.

Social cost of mining-related lead (Pb) pollution in Kabwe, Zambia, and potential remediation measures.

Lead (Pb) pollution has been one of the major environmental problems of worldwide significance. It is a latent factor for several fatal illnesses, whereas the exposure to lead in early childhood causes a lifetime IQ loss. The social cost is the concept to aggregate various adverse effects in a single monetary unit, which is useful in describing the pollution problem and provides foundation for the design of interventions. However, the assessment of the social cost is scarce for developing countries. In this study, we focus on the lead pollution problem of a former mining town, Kabwe, Zambia, where mining wastes abandoned near residential areas has caused a critical pollution problem. We first investigated the social cost of lead pollution that future generations born in 2025-2049 would incur in their lifetime. As the channels of the social cost, we considered the lost income from the IQ loss and the lost lives from lead-related mortality. The results showed that the social cost would amount to 224-593 million USD (discounted to the present value). Our results can be considered conservative, lower bound estimates because we focused only on well-identified effects of lead, but the social cost was still substantial. Then we examined several engineering remediation measures. The results showed that the social cost can be reduced (the benefits of remediations) more than the costs of implementing remediation measures. This study is the first to investigate the social cost of mining-related lead pollution problem in developing countries. Our interdisciplinary approach utilises the micro-level economic, health and pollution data and integrates the techniques in economics, toxicology and engineering.

Factors that influence married/partnered women's decisions to use contraception in Zambia.

According to the Demographic and Health Surveys (DHSs), Zambia has shown an increasing trend in the percentage of married women using contraceptives in the last three decades. As of 2018, this percentage increased from 34.2% in 2001 to 40.8% in 2007 and from 45% in 2013 to 48% in 2018. Despite the increasing trend in contraceptive use, the unmet needs remain relatively high. The low percentage of contraception use translates into 20% of women of reproductive age who are either married/partnered and want to stop or delay childbearing but are not using contraception. This study analyzed factors other than availability that influence women's ability to make or influence the decision to use contraception using logistic regression using data from the Zambia 2013/2014 and 2018 DHSs. Furthermore, adjusted odds ratios and predicted probabilities were estimated using the fitted logistic regression. Data on 8,335 women were analyzed, and 13.7% (n = 1,145) had their husband as the sole decision maker for contraception use, while 86.3% (n = 7,189) made the decisions or participated in making the decision. Contrary to most literature, those with primary or secondary school education were less likely to decide than those without education. The data also associate women who contribute to daily household decisions to having a say in deciding to use contraception. Lastly, women using reversible contraception methods, other methods, hormonal methods, and fertility awareness were associated with less likelihood to decide on using contraceptives than those using barrier methods. Women with lower household decision-making powers are less likely to make or influence decisions to use contraception. Consequently, there is a need to prioritize such women in interventions aimed at increasing contraception use decision-making. Furthermore, more studies are required to investigate why uneducated women in Zambia are more likely to choose contraception. Also, the vast odds ratio difference between all other methods compared to barrier methods (condoms) indicates underlying factors that play a role, which warrants further studies.

Monetary Incentives and Early Initiation of Antenatal Care: A Matched-Pair, Parallel Cluster-Randomized Trial in Zambia.

Monetary incentives are often used to increase the motivation and output of health service providers. However, the focus has generally been on frontline health service providers. Using a cluster randomized trial, we evaluate the effect of monetary incentives provided to community-based volunteers on early initiation of antenatal care (ANC) visits and deliveries in health facilities in communities in Zambia. Monetary incentives were assigned to community-based volunteers in treatment sites, and payments were made for every woman referred or accompanied in the first trimester of pregnancy during January-June 2020. We find a significant increase of about 32 percent in the number of women completing ANC visits in the first trimester but no effect on service coverage rates. The number of women accompanied by community-based volunteers for ANC in the first trimester increased by 33 percent. The number of deliveries in health facilities also increased by 22 percent. These findings suggest that the use of health facilities during the first trimester of pregnancy can be improved by providing community-based volunteers with monetary incentives and that such incentives can also increase deliveries in health facilities, which are key to improving the survival of women and newborns.

Estimating district HIV prevalence in Zambia using small-area estimation methods (SAE).

BACKGROUND: The HIV/AIDS pandemic has had a very devastating impact at a global level, with the Eastern and Southern African region being the hardest hit. The considerable geographical variation in the pandemic means varying impact of the disease in different settings, requiring differentiated interventions. While information on the prevalence of HIV at regional and national levels is readily available, the burden of the disease at smaller area levels, where health services are organized and delivered, is not well documented. This affects the targeting of HIV resources. There is need, therefore, for studies to estimate HIV prevalence at appropriate levels to improve HIV-related planning and resource allocation. METHODS: We estimated the district-level prevalence of HIV using Small-Area Estimation (SAE) technique by utilizing the 2016 Zambia Population-Based HIV Impact Assessment Survey (ZAMPHIA) data and auxiliary data from the 2010 Zambian Census of Population and Housing and the HIV sentinel surveillance data from selected antenatal care clinics (ANC). SAE models were fitted in R Programming to ascertain the best HIV predicting model. We then used the Fay-Herriot (FH) model to obtain weighted, more precise and reliable HIV prevalence for all the districts. RESULTS: The results revealed variations in the district HIV prevalence in Zambia, with the prevalence ranging from as low as 4.2% to as high as 23.5%. Approximately 32% of the districts (n = 24) had HIV prevalence above the national average, with one district having almost twice as much prevalence as the national level. Some rural districts have very high HIV prevalence rates. CONCLUSIONS: HIV prevalence in Zambian is highest in districts located near international borders, along the main transit routes and adjacent to other districts with very high prevalence. The variations in the burden of HIV across districts in Zambia point to the need for a differentiated approach in HIV programming within the country. HIV resources need to be prioritized toward districts with high population mobility.

Effects of performance based financing on facility autonomy and accountability: Evidence from Zambia.

Several low and lower- middle income countries have been using Performance-Based Financing (PBF) to motivate health workers to increase the quantity and quality of health services. Studies have demonstrated that PBF can contribute to improved health service delivery and health outcomes, but there is limited evidence on the mechanisms through which PBF can necessitate changes in the health system. Using difference-in-difference and synthetic control analytical approaches, we investigated the effect of PBF on autonomy and accountability at service delivery level using data from a 3-arm cluster randomised trial in Zambia. The arms consisted of PBF where financing is linked to outputs in terms of quality and quantity (intervention 1), input financing where funding is fully provided to finance all required inputs regardless of performance (intervention 2), and the current standard of care where there is input financing but with possible challenges in funding (pure control). The results show an increase in autonomy at PBF sites compared to sites in the pure control arm and an increase in accountability at PBF sites compared to sites in both the input-financing and pure control arms. On the other hand, there were no effects on autonomy and accountability in the input-financing sites compared to the pure control sites. The study concludes that PBF can improve financial and managerial autonomy and accountability, which are important for improving health service delivery. However, within the PBF districts, the magnitude of change was different, implying that management and leadership styles matter. Future research could examine whether personal attributes, managerial capacities of the facility managers, and the operating environment have an effect on autonomy and accountability.

Impact of night travel ban on road traffic crashes and fatalities in Zambia: an interrupted time series analysis.

BACKGROUND: The burden of road traffic crashes (RTCs) and road traffic fatalities (RTFs) has been increasing in low-income and middle-income countries (LMICs). Most RTCs and RTFs happen at night. Although few countries, including Zambia, have implemented night travel bans, there is no evidence on the extent to which such policies may reduce crashes and fatalities. METHODS: We exploit the quasi-experimental set up afforded by the banning of night travel of public service vehicles in Zambia in 2016 and interrupted time series analysis to assess whether the ban had an impact on both levels and trends in RTCs and RTFs. We use annual administrative data for the period 2006-2020, with 10 pre-intervention and 4 post-intervention data points. In an alternative specification, we restrict the analysis to the period 2012-2020 so that the number of data points are the same pre-interventions and post-interventions. We also carry out robustness checks to rule out other possible explanation of the results including COVID-19. RESULTS: The night travel ban was associated with a reduction in the level of RTCs by 4131.3 (annual average RTCs before the policy=17 668) and a reduction in the annual trend in RTCs by 2485.5. These effects were significant at below 1%, and they amount to an overall reduction in RTCs by 24%. The policy was also associated with a 57.5% reduction in RTFs. In absolute terms, the trend in RTFs reduced by 477.5 (Annual average RTFs before the policy=1124.7), which is significant at below 1% level. Our results were broadly unchanged in alternative specifications. CONCLUSION: We conclude that a night travel ban may be an effective way of reducing the burden of RTCs and RTFs in Zambia and other LMICs. However, complementary policies are needed to achieve more gains.

Costs and cost-effectiveness of a comprehensive tuberculosis case finding strategy in Zambia.

INTRODUCTION: Active-case finding (ACF) programs have an important role in addressing case detection gaps and halting tuberculosis (TB) transmission. Evidence is limited on the cost-effectiveness of ACF interventions, particularly on how their value is impacted by different operational, epidemiological and patient care-seeking patterns. METHODS: We evaluated the costs and cost-effectiveness of a combined facility and community-based ACF intervention in Zambia that utilized mobile chest X-ray with computer-aided reading/interpretation software and laboratory-based Xpert MTB/RIF testing. Programmatic costs (in 2018 US dollars) were assessed from the health system perspective using prospectively collected cost and operational data. Cost-effectiveness of the ACF intervention was assessed as the incremental cost per TB death averted over a five-year time horizon using a multi-stage Markov state-transition model reflecting patient symptom-associated care-seeking and TB care under ACF compared to passive care. RESULTS: Over 18 months of field operations, the ACF intervention costed $435 to diagnose and initiate treatment for one person with TB. After accounting for patient symptom-associated care-seeking patterns in Zambia, we estimate that this one-time ACF intervention would incrementally diagnose 407 (7,207 versus 6,800) TB patients and avert 502 (611 versus 1,113) TB-associated deaths compared to the status quo (passive case finding), at an incremental cost of $2,284 per death averted over the next five-year period. HIV/TB mortality rate, patient symptom-associated care-seeking probabilities in the absence of ACF, and the costs of ACF patient screening were key drivers of cost-effectiveness. CONCLUSIONS: A one-time comprehensive ACF intervention simultaneously operating in public health clinics and corresponding catchment communities can have important medium-term impact on case-finding and be cost-effective in Zambia. The value of such interventions increases if targeted to populations with high HIV/TB mortality, substantial barriers (both behavioral and physical) to care-seeking exist, and when ACF interventions can optimize screening by achieving operational efficiency.

Addressing Challenges in Health Technology Assessment Institutionalization for Furtherance of Universal Health Coverage Through South-South Knowledge Exchange: Lessons From Bhutan, Kenya, Thailand, and Zambia.

Health Technology Assessment (HTA), a tool for priority setting, has emerged as a means of ensuring the sustainability of a Universal Health Coverage (UHC) system. However, setting up an effective HTA system poses multiple challenges and knowledge exchange can play a crucial role in helping countries achieve their UHC targets. This article reports the results of the discussion during a preconference session at the 2019 HTAsiaLink Conference, an annual gathering of HTA agencies in Asia, which supports knowledge transfer and exchange among HTA practitioners. As part of this discourse, 3 main HTA challenges were identified based on experiences of selected countries in Asia and Africa, namely Bhutan, Kenya, Thailand, and Zambia: availability of funding, building technical capacity, and achieving buy-in among stakeholders for successful translation of HTA research into UHC policy. The potential solutions identified through this South-South engagement included establishing a legal mandate for HTA, building local technical capacity through partnerships and enhancing strategic communication with stakeholders to increase awareness, among others. South-South Knowledge Exchange can therefore be instrumental in sharing lessons learned from common challenges and offer potential solutions to address capacity building initiatives for HTA in LMICs.

Walking and perceived lack of safety: Correlates and association with health outcomes for people living with HIV in rural Zambia.

Introduction: Geographic inaccessibility disproportionately affects health outcomes of rural populations due to lack of suitable transport, prolonged travel time, and poverty. Rural patients are left with few transport options to travel to a health facility. One common option is to travel by foot, which may present additional challenges, such as perceived lack of safety while transiting. We examined the correlates of perceived lack of safety when walking to a health facility and its association with treatment and psychosocial outcomes among adults living with HIV. Methods: Data were collected from 101 adults living with HIV in Eastern Province, Zambia. All participants were receiving antiretroviral therapy at one of two health clinics. Perceived lack of safety was measured by asking respondents whether they felt unsafe traveling to and from the health facility in which they were receiving their HIV care. Outcomes included medication adherence, perceived stress, hope for the future, and barriers to pill taking. Linear and logistic regression methods were used to examine the correlates of perceived safety and its association with health outcomes. Results: Being older, a woman, having a primary education, living farther from a health facility, traveling longer to reach a health facility, and owing money were associated with higher likelihood of feeling unsafe when traveling by foot to health facility. Perceived lack of safety was associated with medication nonadherence, higher level of stress, lower level of agency, and more barriers to pill taking. Conclusions: Perceived lack of safety when traveling by foot to a health facility may be a barrier to better treatment and psychosocial outcomes, especially among rural patients. Practitioners and policymakers should consider implementation of differentiated HIV service delivery models to reduce frequent travel to health facilities and to alleviate ART patients' worry about lack of safety when traveling by foot to a health facility.

Modelling malaria reduction in a highly endemic country: Evidence from household survey, climate, and program data in Zambia.

Substantial efforts have seen the reduction in malaria prevalence from 33% in 2006 to 19.4% in 2015 in Zambia. Many studies have used effect measures, such as odds ratios, of malaria interventions without combining this information with coverage levels of the interventions to assess how malaria prevalence would change if these interventions were scaled up. We contribute to filling this gap by combining intervention coverage information with marginal predictions to model the extent to which key interventions can bring down malaria in Zambia. We used logistic regression models and derived marginal effects using repeated cross-sectional survey data from the Malaria Indicator Survey (MIS) datasets for Zambia collected in 2010, 2012 and 2015. Average monthly temperature and rainfall data were obtained from climate explorer a satellite-generated database. We then conducted a counterfactual analysis using the estimated marginal effects and various hypothetical levels of intervention coverage to assess how different levels of coverage would affect malaria prevalence. Increasing IRS and ITNs from the 2015 levels of coverage of 28.9% and 58.9% respectively to at least 80% and rising standard housing to 20% from the 13.4% in 2015 may bring malaria prevalence down to below 15%. If the percentage of modern houses were increased further to 90%, malaria prevalence might decrease to 10%. Other than ITN and IRS, streamlining and increasing of the percentage of standard houses in malaria fight would augment and bring malaria down to the levels needed for focal malaria elimination. The effects of ITNs, IRS and Standard housing were pronounced in high than low epidemiological areas.

A needs assessment for postgraduate training in selected public health disciplines: evidence from health services organisations in Lusaka, Zambia.

BACKGROUND: As most low and middle-income countries seek to achieve universal health coverage targets, there is an ever-increasing need to train human resources with the required core skills and competencies. This study reports on a needs assessment conducted among health services organisations (HSOs) to understand postgraduate training needs and service gaps for selected public health disciplines - Health Policy and Systems, Health Economics, and Healthcare Management and Planning - at the University of Zambia. METHODS: The study adopted a cross-sectional design, comprising qualitative and quantitative components. Data were collected using semi-structured questionnaires administered to 32 representatives of purposively sampled public and private health service organisations based in Lusaka Zambia. The health services organisations included regulatory authorities, research institutions, government ministries, insurance firms and other cooperating partners. RESULTS: Overall (n = 22), more than 68% of the stakeholders reported that they had no employees that were formally trained in the three disciplines. More than 90% of the stakeholders opined that training in these disciplines would be beneficial in providing competencies to strengthen service provision. The horizontal skills mismatch for health economics, and health services management and planning were found to be 93 and 100%, respectively. Among the critical public health training needs were: policy development and analysis, economic evaluation, and strategic management. CONCLUSIONS: This study confirms that introducing post-graduate training in the proposed public health disciplines will not only benefit Zambian health services organisations but also help strengthen the health systems in general. For other empirical contexts, the findings imply the need for the introduction of academic programmes which respond to ever-changing public health skills demanded. They should be matched with local priorities and service delivery.

Protecting essential health services in low-income and middle-income countries and humanitarian settings while responding to the COVID-19 pandemic.

In health outcomes terms, the poorest countries stand to lose the most from these disruptions. In this paper, we make the case for a rational approach to public sector health spending and decision making during and in the early recovery phase of the COVID-19 pandemic. Based on ethics and equity principles, it is crucial to ensure that patients not infected by COVID-19 continue to get access to healthcare and that the services they need continue to be resourced. We present a list of 120 essential non-COVID-19 health interventions that were adapted from the model health benefit packages developed by the Disease Control Priorities project.

Assessing the population-wide exposure to lead pollution in Kabwe, Zambia: an econometric estimation based on survey data.

This study quantitatively assessed the population-wide lead poisoning conditions in Kabwe, Zambia, a town with severe lead pollution. While existing data have reported concerning blood lead levels (BLLs) of residents in pollution hotspots, the data representing the entire population are lacking. Further, selection bias is a concern. Given the lack of compulsory testing schemes, BLLs have been observed from voluntary participants in blood sampling surveys, but such data can represent higher or lower BLLs than the population average because of factors simultaneously affecting participation and BLLs. To illustrate the lead poisoning conditions of the population, we expanded the focus of our surveys and then econometrically estimated the BLLs of individuals representing the population, including those not participating in blood sampling, using background geographic, demographic, and socioeconomic information. The estimated population mean BLL was 11.9 µg/dL (11.6-12.1, 95% CI), lower than existing data because of our wide focus and correction of selection bias. However, the scale of lead poisoning remained immense and 74.9% of residents had BLLs greater than 5 µg/dL, the standard reference level for lead poisoning. Our estimates provide a deeper understanding of the problem and a foundation for policy intervention designs.

Patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa: a systematic review.

BACKGROUND: Morbidity and mortality due to pregnancy and childbearing are high in developing countries. This study aims to estimate patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa. METHODS: A systematic review of the literature was conducted to identify costing studies published and unpublished, from January 2000 to May 2019. The search was done in Pubmed, EMBASE, Cinahl, and Web of Science databases and grey literature. The study was registered in PROSPERO with registration No. CRD42019119316. All costs were converted to 2018 US dollars using relevant Consumer Price Indices. RESULTS: Out of 1652 studies identified, 48 fulfilled the inclusion criteria. The included studies were of moderate to high quality. Spontaneous vaginal delivery cost patients and health systems between USD 6-52 and USD 8-73, but cesarean section costs between USD 56-377 and USD 80-562, respectively. Patient and health system costs of abortion range between USD 11-66 and USD 40-298, while post-abortion care costs between USD 21-158 and USD 46-151, respectively. The patient and health system costs for managing a case of eclampsia range between USD 52-231 and USD 123-186, while for maternal hemorrhage they range between USD 65-196 and USD 30-127, respectively. Patient cost for caring low-birth weight babies ranges between USD 38-489 while the health system cost was estimated to be USD 514. CONCLUSION: This is the first systematic review to compile comprehensive up-to-date patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa. It indicates that these costs are relatively high in this region and that patient costs were largely catastrophic relative to a 10 % of average national per capita income.

Health equity and COVID-19: global perspectives.

The COVID-19 is disproportionally affecting the poor, minorities and a broad range of vulnerable populations, due to its inequitable spread in areas of dense population and limited mitigation capacity due to high prevalence of chronic conditions or poor access to high quality public health and medical care. Moreover, the collateral effects of the pandemic due to the global economic downturn, and social isolation and movement restriction measures, are unequally affecting those in the lowest power strata of societies. To address the challenges to health equity and describe some of the approaches taken by governments and local organizations, we have compiled 13 country case studies from various regions around the world: China, Brazil, Thailand, Sub Saharan Africa, Nicaragua, Armenia, India, Guatemala, United States of America (USA), Israel, Australia, Colombia, and Belgium. This compilation is by no-means representative or all inclusive, and we encourage researchers to continue advancing global knowledge on COVID-19 health equity related issues, through rigorous research and generation of a strong evidence base of new empirical studies in this field.