Prevalence and changes of intimate partner violence against women aged 15 to 49 years in 53 low-income and middle-income countries from 2000 to 2021: a secondary analysis of population-based surveys.

BACKGROUND: In low-income and middle-income countries (LMICs), intimate partner violence poses a substantial barrier to accomplishing target 5.2 of the Sustainable Development Goals: to eliminate all forms of violence against women and girls. Our study aimed to assess the prevalence and changes of intimate partner violence against women in LMICs. We also explored the association between women's empowerment and intimate partner violence. METHODS: In this secondary analysis of population-based surveys, we obtained data from the nationally representative Demographic and Health Surveys conducted in LMICs between 2000 and 2021. We selected countries with available data on the domestic violence module, and women aged 15 to 49 years who currently or formerly had a husband or partner, and who had provided information about intimate partner violence, were included in the analysis. We first estimated the weighted prevalence of intimate partner violence in LMICs with available data, and then we assessed the average annual rate of change using Poisson regression with robust error variance in a subset of countries with at least two surveys. We used multilevel analysis to investigate the association between intimate partner violence and women's empowerment measured at both the country and individual levels. Country-level empowerment was measured by gender inequality index, while individual-level empowerment considered social independence, decision making, and attitude to violence. FINDINGS: A total of 359 479 women aged 15 to 49 years were included from 53 LMICs. 336 811 women from 21 countries with two surveys provided data for assessing the trends of intimate partner violence. The weighted prevalence of any type of intimate partner violence was 37·2% (95% CI 36·6 to 37·8). A significant overall decline in the prevalence of any type of intimate partner violence was observed with an average annual rate of change of -0·2% (95% CI -0·4 to -0·03); however six countries showed significant increasing trends, with average annual rates of change ranging from 1·2% (95% CI 0·7 to 1·7) in Nigeria to 6·6% (5·3 to 7·8) in Sierra Leone. Notably, the prevalence of psychological intimate partner violence has risen (average annual rate of change, 2·3% [95% CI 2·1 to 2·6]), reflected in increased rates across eight countries. Higher levels of country-level women's empowerment were associated with a lower risk of intimate partner violence: women from countries with the highest tertile of gender inequality index had an increased odds of any type of intimate partner violence (odds ratio 1·58 [95% CI 1·12 to 2·23]). Similarly, better individual-level women's empowerment also showed significant associations with a lower risk of intimate partner violence. INTERPRETATION: The prevalence of intimate partner violence remains high, and some countries have shown an increasing trend. The strong relationship between both country-level and individual-level women's empowerment and the prevalence of intimate partner violence suggests that accelerating women's empowerment could be one strategy to further reduce intimate partner violence against women. FUNDING: National Natural Science Foundation; Vanke School of Public Health, Tsinghua University; and Sanming Project of Medicine in Shenzhen.

The association of a disability-targeted cash transfer programme with disability status and health-care access: a quasi-experimental study using a nationwide cohort of 4·3 million Chinese adults living with severe disabilities.

BACKGROUND: Cash transfer is a crucial policy tool to address inequality. The objective of this study was to investigate the association between China's disability-targeted cash transfer programme and disability status, as well as equitable access to rehabilitation and medical services. METHODS: For this quasi-experimental study, we drew data from the nationwide administrative cohort of individuals with disabilities between Jan 1, 2015, and Dec 31, 2019. Individuals were enrolled in the cohort if they were aged 18 years or older, had severe disabilities as defined by the Chinese Government, and had available cash transfer information for at least 4 consecutive years, without having started receiving cash transfer benefits at the time of enrolment. We used a quasi-experimental design with propensity score matching to estimate the effects of cash transfers on disability status, access to rehabilitation services, and access to medical treatment. The primary outcomes were development of new disability and reduction of existing disabilities. Secondary outcomes were use of rehabilitation services, financial barriers as a major obstacle to accessing rehabilitation services, use of medical services by individuals who had an illness in the previous 2 weeks, and financial barriers as a major obstacle to accessing medical services. FINDINGS: From an initial pool of 51 356 125 individuals with disabilities registered in the administrative system, 2 686 024 individuals were eligible for analysis, of whom 2 165 335 (80·6%) were cash transfer beneficiaries and 520 689 (19·4%) non-beneficiaries. After propensity score matching, the cohort included 4 330 122 adults with severe disabilities. Cash transfer beneficiaries had significantly lower odds of developing new disabilities over time than non-beneficiaries (odds ratio [OR] 0·90, 95% CI 0·86-0·94; p<0·0001) and higher odds of having a reduced number of disabilities over time (1·17, 1·10-1·25; p<0·0001). Compared with non-beneficiaries, cash transfer beneficiaries were more likely to use rehabilitation services (2·12, 2·11-2·13; p<0·0001) and medical services (1·74, 1·69-1·78; p<0·0001), and less likely to report financial hardship to access rehabilitation services (0·53, 0·52-0·54; p<0·0001) and medical services (0·88, 0·84-0·93; p<0·0001) at the study endpoint. INTERPRETATION: The receipt of cash transfers was associated with improved disability status and increased access to disability-related services. The findings suggest that cash transfers could be a potential method for promoting universal health coverage among individuals living with disabilities. FUNDING: China National Natural Science Foundation.

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.

Assessing household financial burdens for preprimary education and associated socioeconomic inequalities: a case study in China.

BACKGROUND: Providing young children with universal access to preprimary education (PPE) is considered a powerful tool for human capital development and eliminating the intergenerational transmission of poverty. To remove household financial barrier for achieving universal PPE, this study proposed a measure to identify households incurring 'heavy financial burdens from paying for PPE' (HBPPE) and conducted a case study in China. METHODS: Using nationally representative data in 2019, we estimated the percentage of households with HBPPE (spent 7% or more of their total annual expenditure) and associated socioeconomic inequalities. We also applied a three-level logit regression model to investigate the factors associated with the probabilities of households incurring HBPPE. RESULTS: Half of the sampled households spent 7% or more of their expenditures on PPE. Households in the lowest wealth quintile (54%) or households with children attending private PPE (55%) had higher percentages of HBPPE than households in other wealth quintiles (eg, 51% in the highest wealth quintile) or households with children attending public kindergartens (41%). Logit regression analysis shows that the poorest households and households with children attending private kindergarten were more likely to incur HBPPE than their counterparts. CONCLUSION: To ensuring universal access to PPE in China, future policy should consider increasing the enrolment of children from low-income families in public kindergartens and increasing governmental investments in low-income households by subsidising children attending PPE.

Impact of out-of-pocket expenses for surgical care on households in rural Haiti: a mixed-methods study.

OBJECTIVES: This study aimed to report household catastrophic spending on surgery and the experiences of patients and families seeking surgical care in rural Haiti. DESIGN: The study used an explanatory, sequential mixed-methods approach. We collected both quantitative and qualitative data from the participants through interviews. SETTING: A rural tertiary hospital (St. Boniface Hospital) in southern Haiti. PARTICIPANTS: There were 200 adult Haitian surgical patients who entered the study. Of these, 41 were excluded due to missing variables or health expenditure outliers. The final sample included 159 participants. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcomes were (1) direct and indirect payments for surgical care; (2) the rate of catastrophic health expenditure (CHE) (as defined by the Sustainable Development Goals (10% of total household expenditure) and WHO (10%, 20%, 30% and 40% of household capacity to pay)) due to surgical care; and (3) common themes across the lived experiences of households of surgical patients seeking care. RESULTS: The median household expenditure on surgery-related expenses was US$385.6, slightly more than half of per capita gross domestic product in Haiti (US$729.3). Up to 86% of households experienced CHE, as defined by the Sustainable Development Goals, due to receiving surgical care. Patients commonly paid for surgical costs through loans and donations (69.8%). The qualitative analysis revealed prominent themes related to barriers to care including the burden of initiating care-seeking, care-seeking journeys and social suffering. CONCLUSIONS: CHE is common for Haitian surgical patients, and the associated care-seeking experiences are often arduous. These findings suggest that low, flat fees in non-profit hospital settings may not be sufficient to mitigate the costs of surgical care or the resulting challenges that patients experience.

Assessing the long-term effects of Basic Medical Insurance on catastrophic health spending in China.

Many developing countries have implemented social health insurance programmes to protect their citizens against the financial risks of seeking healthcare. While many studies have explored how individual insurance enrolments affect catastrophic health spending (CHS) in the short term, there is a lack of evidence on the long-term macro-level effects of social health insurance on CHS in low- and middle-income countries. This study examines the long-term effects of Basic Medical Insurance (BMI) on individual CHS in China, a middle-income country that has witnessed one of the highest worldwide increases in CHS rates despite its remarkable achievement of universal health insurance coverage. Specifically, we used existing longitudinal data from 1989 to 2015, therein assessing BMI policy effects by constructing two macro-level indicators, including the year of BMI presence at the prefectural level and number of years relative to BMI introduction. We employed a three-level difference-in-differences approach for the estimation. There were two main findings. First, BMI policy did not significantly reduce the probability of incurring CHS for BMI enrollees over time. Years after BMI was introduced, the policy even predicted a significant increase in the probability of incurring CHS for individuals who shifted their enrolments from traditional insurance to BMI. Second, BMI policy had spillover effects on the increase in the probability of incurring CHS for non-BMI individuals a few years after its inception. We believe there are three possible explanations for these findings: (1) shrinking BMI service coverage compared to pre-existing government-funded insurance schemes, (2) a profit-driven hospital reform that induces the overuse of expensive medicines and diagnostic tests and (3) the absence of strategic purchasing among local BMI agencies. We also discuss how relevant policy interventions may alleviate insurance-driven financial risks.

Assessing costs of developing a digital program for training community health workers to deliver treatment for depression: A case study in rural India.

Digital technology has emerged as a promising approach for training and building capacity of community health workers in low-income and middle-income countries (LMICs). Little is known about the cost of developing digital training programs in LMICs, which hinders the adoption, implementation, and scaling up of the programs in routine primary care settings. This study assessed the costs of developing a digital program for training community health workers to deliver a psychological treatment for depression in a rural district of Madhya Pradesh, India. We developed survey instruments to document required resources in development, including involved personnel (their roles, responsibilities, time spent, and salaries or payments), information technologies (e.g., smartphones, software programs), and infrastructure-related costs (e.g., vehicle, office space, utilities). Costs were estimated from an accounting perspective. Over a 10-month developmental period, the total costs were 208,814 USD, with the largest portion on human resources (61%, with 14% on management and supervision), followed by information technologies (33%), and infrastructure-related costs (6%). These findings could inform policymakers in LMICs on costs of developing online-training programs, which will be especially useful during the COVID-19 pandemic.

Economic evaluation and costs of telepsychiatry programmes: A systematic review.

OBJECTIVE: Telepsychiatry involves use of telecommunications technology to deliver psychiatric care and offers promise to reduce costs and increase access to mental health services. This systematic review examined cost reporting of telepsychiatry programmes for mental healthcare. METHODS: We systematically searched electronic databases for studies reporting costs, including economic evaluations such as cost-effectiveness analyses, or costs of developing telepsychiatry programmes for clinical care of mental disorders. Included studies enrolled participants with mental disorders and involved telepsychiatry for depression, anxiety disorders, serious mental illnesses including schizophrenia spectrum disorders and bipolar disorder, post-traumatic stress disorder, dementia or epilepsy. RESULTS: Twenty-six unique studies met inclusion criteria (17,967 participants), with most targeting depression (n = 7; 27%), general mental disorders and screening (n = 7; 27%), child mental health (n = 4; 15%) and geriatric mental health (n = 4; 15%). Nearly all studies (n = 25; 96%) compared telepsychiatry programme costs with either standard in-person consultation or usual care, with 15 (60%) reporting that telepsychiatry programmes were less expensive, and 8 (32%) showing telepsychiatry programmes were more expensive. Three studies reported cost-effectiveness analyses, favouring telepsychiatry programmes, but at highly elevated cost-effectiveness thresholds. Few studies reported costs of developing or delivering telepsychiatry programmes. CONCLUSION: Costs of telepsychiatry programmes varied widely, with substantial heterogeneity in how costs were defined and reported. Some programmes cost less than in-person services while others cost more. Therefore, rigorous cost-effectiveness studies following established standards in economic evaluation are needed to inform implementation and sustainability of these programmes in health systems.

Assessing the Inequality of Early Child Development in China - A Population-Based Study.

BACKGROUND: As a country with the second largest child population in the world, China has little population-level evidence on who has been left behind in early childhood development (ECD). Knowledge of inequalities in ECD will inform the Chinese government in policies on promoting ECD and guide global-level monitoring on ECD progress. METHODS: Using data from the first wave of ECD surveys conducted in China at the least-developed region, most-developed region, and a megacity (Shanghai) in 2017 and 2018, we measured population-level ECD with early Human Capability Index for a total of 63,559 children aged 36-59 months old. A child was classified as developmentally on track if his/her overall development score was above the 20th percentile of the pooled populations. We measured inequalities in ECD with the absolute inequality in five domains: gender/sex, family income, maternal schooling, residential Hukou, and migrant- or left-behind status. Besides observed inequalities, we used a multilevel logistic regression model to generate adjusted inequalities. FINDINGS: Children developmentally on track ranges from 71% (95% CI 70 to 72%) in the least-developed region, 82% (95% CI 81 to 83%) in the most-developed region, and 86% (95% CI 85 to 87%) in Shanghai. Significant unadjusted inequalities in ECD were observed in all five dimensions. After controlling for other socioeconomic factors, significant differences remained in three dimensions: those living in the poorest families, or with lower maternal schooling, or boys were less likely to be developmentally on track than their counterparts (lower by 10[95% CI 8 to 11]-15[95% CI 13 to 17], 7[95% CI 5 to 10]-10[95% CI 7 to 12], and 5[95% CI 4 to 6]-6[95% CI 5 to 8] percentage points respectively). INTERPRETATION: Efforts of reducing ECD inequalities in China shall focus primarily on reducing poverty and improving maternal education. FUNDING: National Natural Science Foundation of China (81773443), Shanghai Committee of Science and Technology (2018SHZDZX05), Shanghai Municipal Health Commission (GWV-10.1-XK07; GDEK201708), Shanghai Education Committee, Chinese Social Science Foundation (BFA140046), Macao Tong Chai Charity Association, Beijing Sany Charitable Foundation, China Medical Board (#20-388), UNICEF, Faculty Grant of Brigham & Women's Hospital, Economic and Social Research Council [grant reference number ES/T003936/1'] as a UKRI Collective Fund Award "UKRI GCRF Harnessing the Power of Global Data to Support Young Children's Learning and Development Collaborative."

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.

Measuring and forecasting progress in education: what about early childhood?

A recent Nature article modelled within-country inequalities in primary, secondary, and tertiary education and forecast progress towards Sustainable Development Goal (SDG) targets related to education (SDG 4). However, their paper entirely overlooks inequalities in achieving Target 4.2, which aims to achieve universal access to quality early childhood development, care and preschool education by 2030. This is an important omission because of the substantial brain, cognitive and socioemotional developments that occur in early life and because of increasing evidence of early-life learning's large impacts on subsequent education and lifetime wellbeing. We provide an overview of this evidence and use new analyses to illustrate medium- and long-term implications of early learning, first by presenting associations between pre-primary programme participation and adolescent mathematics and science test scores in 73 countries and secondly, by estimating the costs of inaction (not making pre-primary programmes universal) in terms of forgone lifetime earnings in 134 countries. We find considerable losses, comparable to or greater than current governmental expenditures on all education (as percentages of GDP), particularly in low- and lower-middle-income countries. In addition to improving primary, secondary and tertiary schooling, we conclude that to attain SDG 4 and reduce inequalities in a post-COVID era, it is essential to prioritize quality early childhood care and education, including adopting policies that support families to promote early learning and their children's education.

Role of the Global Fund in national HIV/AIDS response in Myanmar: a qualitative study.

BACKGROUND: The Global Fund has been a major funding source for HIV/AIDS programs in Myanmar. In this qualitative study, we aim to understand the impact of Global Fund on national HIV/AIDS response in Myanmar during the era of Millennium Development Goals (MDGs). METHODS: We conducted individual in-depth interviews by recruiting key informants through purposive snowball sampling. The respondents were engaged in the national/subnational response to HIV/AIDS in Myanmar and worked for the United Nations agencies, non-governmental organizations (NGOs), and civil society. Interview questions were organized around the role of Global Fund in strengthening national response to HIV/AIDS in the six building blocks of the Myanmar's health system. Transcripts from the key informants were synthesized into specific themes through a deductive approach. RESULTS: We found that the Global Fund has provided substantial support to (1) finance the national HIV/AIDS response in Myanmar, and (2) strengthen leadership and governance at the central level through improving coordination and collaboration, including more stakeholders (e.g. civil society, NGOs) in decision making process, and catalyzing policy changes on scaling-up key interventions. Yet, its role remains limited in addressing new demands at the township level in terms of capacity building, staffing, and medical supply resulting from rapid scale-up of HIV interventions and decentralization of service delivery in the public sector. CONCLUSION: There was a missed opportunity for Myanmar to capitalize on the use of the Global Fund's funding to strengthen the health system. Deliberate planning is required to optimize the use of those scarce resources to provide universal coverage for HIV/AIDS.

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.

Economic Evaluations of Internet-Based Psychological Interventions for Anxiety Disorders and Depression: A Systematic Review.

BACKGROUND: Internet-based interventions show clinical effectiveness for treating anxiety disorders and depression and could make mental healthcare more affordable. METHODS: We searched databases including PubMed; EMBASE; Cochrane Central; PsychINFO; CINAHL; EconLit; and Web of Science from January 1, 2000 to August 21, 2020. Inclusion criteria were: 1) pertained to the treatment or prevention of anxiety disorders or depression; 2) evaluated the use of an internet-delivered psychological intervention; 3) recruited participants; and 4) reported costs or cost-effectiveness. RESULTS: Of the 6,069 articles identified, 33 targeted anxiety (N=13) and depression (n=20) and met final inclusion criteria. All studies were from high-income countries. The control conditions and cost components included were heterogeneous. Only eight studies reported costs of developing the intervention. Of 27 studies that made a conclusion about cost-effectiveness, 81% of interventions were cost-effective. The quality of studies included was high based on a quality assessment checklist of economic evaluations, although many studies did not include definitions of cost components or differentiate between patient-side and system-level costs. LIMITATIONS: Studies varied in methodology, making conclusions about cost-effectiveness difficult. The generalizability of these results is unclear as studies were clustered in a small number of high-income countries and costs vary over time and between regions. CONCLUSIONS: Internet-delivered interventions appeared to be cost-effective although control conditions and cost component reporting were variable. We propose a checklist of cost components for future cost analyses to better compare intervention costs. More research is needed to describe development costs, cost-effectiveness in low-resource settings, and cost-effectiveness of newer technologies.

Assessment of Knowledge of HIV/AIDS and Association With Socioeconomic Disparities Among Young Women in Low- and Middle-Income Countries, 2003 to 2018.

Importance: Knowledge of HIV/AIDS among the younger population is crucial for long-term control. Little research has been done on which groups of young women (aged 15-24 years) in low- and middle-income countries (LMICs) have been left behind with respect to obtaining this knowledge. Objective: To provide an up-to-date assessment of the levels of and changes in knowledge of HIV/AIDS and its associations with socioeconomic disparity among young women in LMICs. Design, Setting, and Participants: This cross-sectional study used nationally representative Demographic and Health Surveys with available data on HIV/AIDS knowledge in 51 LMICs between 2003 and 2018. The final data set contained 282 757 young women. For 40 LMICs with multiple surveys available, we examined changes in knowledge and socioeconomic disparities. Analyses of the survey data were conducted between December 1, 2019, and July 31, 2020. Main Outcomes and Measures: The percentage of young women who were able to (1) correctly identify the 2 major ways of preventing the sexual transmission of HIV, (2) reject the 2 most common local misconceptions about HIV transmission and (3) know that a healthy-looking person can transmit HIV. The level of and changes in young women's knowledge of HIV/AIDS as well as knowledge disparities by residential area, wealth status, and level of education on the aggregate and country levels were assessed. Results: Of a total of 282 757 young women from 51 LMICs, 29.3% (95% CI, 24.1% to 34.5%) reported having knowledge of HIV/AIDS in the latest years, ranging from 1.0% (95% CI, 0.7% to 1.3%) in Afghanistan in 2015 to 64.9% (95% CI, 63.3% to 66.5%) in Rwanda in 2014 to 2015. Those living in rural areas, living in households in the lowest income quintile, or with low levels of education reported less knowledge about HIV/AIDS than their counterparts (-12.8 [95% CI, -10.6 to -14.9] percentage points; -21.8 [95% CI, -18.3 to -25.3] percentage points; and -19.4 [95% CI, -16.6 to -22.2] percentage points, respectively). Among the 40 countries that had undertaken at least 2 surveys during the period, the surveys indicated that there was a significant increase in knowledge of HIV/AIDS among young women in 24 countries (60.0%), but a significant decrease in 10 countries (25.0%). Less than half of countries experienced significant reductions in disparities associated with residential area (8 countries [20.0%]), wealth (5 countries [12.5%]), or education (17 countries [42.5%]). Conclusions and Relevance: This cross-sectional study of women in 51 LMICs found low levels and large gaps in knowledge of HIV/AIDS between groups, suggesting that future HIV-prevention campaigns should emphasize providing easily accessible information to socioeconomically disadvantaged groups.

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.

Financing Adolescent Health in China: How Much, Who Pays, and Where It Goes.

PURPOSE: Adolescent health has been gaining increasing attention in the Sustainable Development Goals era. Data on adolescent health financing are essential for evidence-based policy planning and evaluation. Little is known on national expenditure on adolescent health in China. To inform decision-making on national strategies of adolescent health and development, this study estimated expenditure on adolescent health-care utilization in China and identified funding sources and their allocation among different health functions. METHODS: We constructed and implemented an institutional survey and collected primary financial data from health institutions in the nine selected administrative provinces in 2014. We used the collected data to generate estimate of proportion of health spending on adolescent health and its breakdowns by health-care functions, health-care financing schemes, and diseases based on primary diagnosis. We applied the proportion estimates to the 2014 national-level health expenditure data and estimated national-level estimates of spending on adolescent health and breakdowns in aforementioned areas. RESULTS: Spending on adolescents health in 2014 amounted to CNY82.1 billion (USD 13.4 billion) or 2.6% of the total health expenditures in the year. Per adolescent health expenditures was CNY525 (USD 85.5), less than per capita health spending (CNY2349, USD382.4). National spending on adolescent health was 73.1% on curative care and 10.3% on preventive care. Out-of-pocket spending is the major source of adolescent health financing, contributing to 57.9% of total spending on adolescent health. Spending on respiratory, digestive, injury and poisoning, genitourinary diseases, and neoplasms accounted for 59.8% of curative care expenditures on adolescents. CONCLUSIONS: Current financing mechanism on adolescent health stressed on curative care and imposed a large portion of financial burden on households. Future investment on adolescent health shall focus more on preventive care. Financing schemes shall be adjusted so as to reduce household out-of-pocket spending on medical care used by adolescents.

Maternal healthcare coverage for first pregnancies in adolescent girls: a systematic comparison with adult mothers in household surveys across 105 countries, 2000-2019.

BACKGROUND: Effective maternal service delivery for adolescent mothers is essential in achieving the targets for maternal mortality under the Sustainable Development Goals. Yet little is known about levels of maternal service coverage in adolescents compared with adult mothers. METHOD: We used data from 283 Demographic and Health Surveys or Multiple Cluster Indicator Surveys for 105 countries between 2000 and 2019 to estimate the levels and trends of inequality in coverage of five maternal health services between adolescent girls (aged 15-19) and adult mothers (aged 20-34), including receiving four or more antenatal care visits, delivering with skilled birth attendants and receiving a postnatal check-up within 24 hours of delivery. RESULTS: We analysed data from 0.9 million adolescent girls and 2.4 million adult mothers. Using the most recent data, we found adolescent girls had poorer coverage across all indicators, with receipt of four or more antenatal care visits 6.5 (95% CI 6.3 to 6.7) percentage points lower than adult mothers, delivery with skilled birth attendants 3.6 (95% CI 3.4 to 3.8) lower and having a postnatal check-up within 24 hours of delivery 3.2 (95% CI 2.8 to 3.6) lower. The coverage was 54.2% (95% CI 53.9 to 54.5) among adolescents for four or more antenatal care visits, 69.7% (95% CI 69.4 to 70.0) for delivery with skilled birth attendants and only 30.0% (95% CI 29.3 to 30.7) for receiving a postnatal check-up within 24 hours of delivery. Country-specific coverage of the maternal services increased over time in most countries, but age-related differences persisted and even worsened in some, particularly in the Western Pacific (eg, Vietnam, Lao, Cambodia and Philippines). CONCLUSION: Even though their pregnancies are of higher risk, adolescent girls continue to lag behind adult mothers in maternal service coverage, suggesting a need for age-appropriate strategies to engage adolescents in maternal care.

Inequalities in early childhood care and development in low/middle-income countries: 2010-2018.

Background: Inequalities in early childhood development (ECD) tend to persist into adulthood and amplify across the life course. To date, little research on inequalities in early childhood care and development in low/middle-income countries has been available to guide governments, donors and civil society in identifying which young children and families should be targeted by policies and programmes to improve nurturing care that could prevent them from being left behind. Methods: Using data from 135 Demographic and Health Surveys and Multiple Indicator Cluster Surveys between 2010 and 2018, we assessed levels and trends of inequalities in exposure to risks of stunting or extreme poverty (under age 5; levels in 85 and trends in 40 countries), early attendance of early care and education programmes (36-59 months; 65 and 17 countries), home stimulation (36-59 months; 62 and 14 countries) and child development according to the Early Childhood Development Index (36-59 months; 60 and 13 countries). Inequalities within countries were measured as the absolute gap in three domains-child gender, household wealth and residential area-and compared across regions and country income groups. Results: 63% of children were not exposed to stunting or extreme poverty; 39% of 3-4-year olds attended early care and education; and 69% received a level of reported home stimulation defined as adequate. Sub-Saharan Africa had the lowest proportion of children not exposed to stunting or extreme poverty (45%), attending early care and education (24%) and receiving adequate home stimulation (47%). Substantial gaps in all indicators were found across country income groups, residential areas and household wealth categories. There were no significant reductions in gaps over time for a subset of countries with available data in two survey rounds. Conclusions: Available data indicate large inequalities in early experiences and outcomes. Efforts of reducing these inequalities must focus on the poorest families and those living in rural areas in the poorest countries. Improving and applying population-level measurements on ECD in more countries over time are important for ensuring equal opportunities for young children globally.