The global burden of sickle cell disease in children under five years of age: a systematic review and meta-analysis.

BACKGROUND: Sickle cell disease (SCD) is a common haematological disorder, affecting millions of people worldwide. It is most prevalent in malarial endemic areas in the tropics where outcomes are often poor due to resource constraints, resulting in most children dying before reaching adulthood. As increasing progress is made towards reducing under 5 mortality from infectious causes, non-communicable diseases (NCDs) including SCD have risen to the forefront of the global health agenda. Despite this, the global mortality burden of SCD remains poorly understood. This study aimed to estimate the incidence and mortality of SCD in children under 5 years of age in order to inform policy and develop sustainable strategies to improve outcomes. METHODOLOGY: We performed a systematic literature search of Medline, EMBASE, Journals@Ovid, and Web of Science for studies on the incidence and mortality of SCD in children under 5, with search dates set from January 1980 and July 2017. We conducted random effects meta-analysis to obtain pooled meta-estimates of birth prevalence and mortality rates globally, and for each World Health Organization (WHO) region. RESULTS: 67 papers were found with relevant data. 52 contained data on incidence and prevalence and 15 contained data on mortality. The overall pooled estimate of mortality from the limited data available was 0.64 per 100 years of child observation (95% CI = 0.28-1.00) with the highest rate seen in Africa 7.3 (95% CI = 4.03-10.57). The global meta-estimate for the birth prevalence of homozygous sickle cell disease was 112 per 100 000 live births (95% CI = 101-123) with a birth prevalence in Africa of 1125 per 100 000 (95% CI = 680.43-1570.54) compared with 43.12 per 100 000 (95% CI = 30.31-55.92) in Europe. CONCLUSION: There were a number of limitations in the depth and breadth of available data however it is clear that both the highest prevalence and highest mortality of SCD is in Africa. In order to address this burden, there is a need for national comprehensive newborn screening to identify patients, and the development of holistic SCD care programmes to provide therapeutics and education for families and children with SCD. This targeted funding should form part of a broader increased global focus on NCDs in childhood.

Structural, institutional and organizational factors associated with successful pay for performance programmes in improving quality of maternal and child health care in low and middle income countries: a systematic literature review.

BACKGROUND: Pay for Performance (P4P) mechanisms to health facilities and providers have been implemented in several low- and middle-income countries (LMIC) to improve maternal and child health (MCH). These are tied to predetermined quality and quantity indicators. There is limited synthesized information on the structural, institutional and organizational factors that influence the success of P4P programmes with respect to quality of care. This review, which builds on a previously published review sets out to synthesize existing literature on the factors that influence the outcome of P4P programmes and quality of care. METHODS: A literature review was conducted of published studies documenting implementation of P4P interventions and quality of care in low and middle income countries. Records published between June 2014 and September 2017 were selected and combined with articles from January 1990 to June 2014 previously identified by colleagues. RESULTS: 13 studies were included in the final analysis. The majority of studies found a positive impact on quality of care scores and at least one study showed significant reductions in mortality outcomes in newborns. One study from Afghanistan did not show any positive effects. Structural factors associated with likely success of P4P programmes included: explicit acceptance and understanding by health workers; limiting the number of indicators measured with inputs from health workers. Organisational factors included sufficient incentive payments. Notably the main positive outcome identified was facility financial autonomy from additional payments. Verification by external assessors revealed no major manipulation to achieve payment trigger levels. The primary institutional factors identified that P4P programmes fared better when introduced alongside other health reforms and increased funding. CONCLUSIONS: This review has found that P4P is not a uniform intervention, but rather a range of approaches with a substantial variation and complexity in how programmes incorporate quality of care considerations. P4P has shown to have an impact on the quality of a number of limited aspects of maternal and child health care. Further research is needed to understand whether additional aspects of the quality of MCH care could be positively influenced by P4P programmes and how health worker motivation and acceptance are linked to this.

Global and regional child deaths due to injuries: an assessment of the evidence.

BACKGROUND: Injuries result in substantial number of deaths among children globally. The burden across many settings is largely unknown. We estimated global and regional child deaths due to injuries from publicly available evidence. METHODS: We searched for community-based studies and nationally representative data reporting on child injury deaths published after year 1990 from CINAHL, EMBASE, IndMed, LILACS, Global Health, MEDLINE, SCOPUS, and Web of Science. Specific and all-cause mortality due to injuries were extracted for three age groups (0-11 months, 1-4 years, and 0-4 years). We conducted random-effects meta-analysis on extracted crude estimates, and developed a meta-regression model to determine the number of deaths due to injuries among children aged 0-4 years globally and across the World Health Organization (WHO) regions. RESULTS: Twenty-nine studies from 16 countries met the selection criteria. A total of 230 data-points on 15 causes of injury deaths were retrieved from all studies. Eighteen studies were rated as high quality, although heterogeneity was high (I2 = 99.7%, P < 0.001) reflecting variable data sources and study designs. For children aged 0-11 months, the pooled crude injury mortality rate was 29.6 (95% confidence interval (CI) = 21.1-38.1) per 100 000 child population, with asphyxiation being the leading cause of death (neonatal) at 189.1 (95% CI = 142.7-235.4) per 100 000 followed by suffocation (post-neonatal) at 18.7 (95% CI = 11.8-25.7) per 100 000. Among children aged 1-4 years, the pooled crude injury mortality rate was 32.7 (95% CI = 27.3-38.1) per 100 000, with traffic injuries and drowning the leading causes of deaths at 10.8 (95% CI = 8.9-12.8) and 8.8 (95% CI = 7.5-10.2) per 100 000, respectively. Among children under five years, the pooled injury mortality rate was 37.7 (95% CI = 32.7-42.7) per 100 000, with traffic injuries and drowning also the leading causes of deaths at 10.3 (95% CI = 8.8-11.8) and 8.9 (95% CI = 7.8-9.9) per 100 000 respectively. When crude mortality changes over age, WHO regions, and study period were accounted for in our model, we estimated that in 2015 there were 522 167 (95% CI = 395 823-648 630) deaths among children aged 0-4 years, with South East Asia (SEARO) recording the highest number of deaths at 195 084 (95% CI = 159476-230502), closely followed by the Africa region (AFRO) with 176523 (95% CI = 115 040-237 831) deaths. Globally, traffic injuries and drowning were the leading causes of under-five injury fatalities in 2015 with 142 661 (22.0/100 000) and 123 270 (19.0/100 000) child deaths, respectively. The exception being burns in AFRO with 57 784 deaths (38.6/100 000). CONCLUSIONS: Varying study designs, case definitions, and particularly limited country representation from Africa and South-East Asia (where we reported higher estimates), imply a need for more studies for better population representative estimates. This study may have however provided improved understanding on child injury death profiles needed to guide further research, policy reforms and relevant strategies globally.