Chunling Lu

Background: Economic burdens of tuberculosis (TB) in high-income settings remain overlooked. None of the 40 countries reporting TB cost surveys to the World Health Organization (WHO) were high-income. We conducted the first such survey in a high-income country, Taiwan, to assess WHO End TB Strategy’s zero catastrophic total cost target.Methods: Nationwide cross-sectional survey data were collected from households sampled from 2018 National TB Registry. Following WHO’s protocol, we extrapolated costs throughout the TB episode. Catastrophic total cost was defined as total costs, consisting of direct medical and direct non-medical and indirect costs, exceeding 20% of annual household income. Predictors of catastrophic total cost were assessed using multivariable logistic regression.Findings: Of 481 people with drug-susceptible TB (DS‑TB) and 64 with multidrug-resistant TB (MDR‑TB), 72% were male; mean age was 65. Mean total costs (95% Confidence Interval, CI) were US$2,316 (US$2,083-2,550) for DS‑TB and US$6,665 (US$4,460-8,869) for MDR‑TB. For DS‑TB, indirect, non‑medical, and medical costs comprised 57%, 29%, and 14%; for MDR‑TB, 67%, 29%, and 4%. Catastrophic total cost affected 23% (95% CI: 19-27%) of DS‑TB households and 52% (39-64%) of MDR‑TB households. Household income below the minimum cost of living, diagnosis of MDR-TB, and lack of private health insurance were the predictors of catastrophic total costs.Interpretation: Despite the well-functioning national TB program and national health insurance, a subset of TB-affected households in Taiwan faced substantial financial burdens. Integrated strategies tailored to different cost components are essential to achieve the End TB goal.

To assess the cost of co-creating an adaptation of the International Guide for Monitoring Child Development (intervention for use by community health workers (CHWs)) in rural Guatemala and India. We developed survey instruments to capture the costs, from health-system and societal perspectives, of adapting the guide with local partners and international experts in the two sites. We included the costs of human resources, information technology, and infrastructure and logistic support. To improve the transparency and comparability of cost estimates, we reported the required resources for adaptation, such as time and expertise of human resources, and the quantity, function and usage time of the resources used. Adaptation of the guide took 14 months in India and 18 months in Guatemala during 2021–2022. Total costs by site were 38 174.57 United States dollars (US$) in Guatemala, US$ 39 287.15 in India and US$ 81 846.59 for international consultants. International consultants accounted for about half of the costs, and the Guatemala and India sites each accounted for about a quarter of the costs. Human resources were the largest contributor to the adaptation costs in both sites (90.1%; 34 398.20/38 174.57 in Guatemala and 94.8%; 37 262.74/39 287.15 in India) followed by infrastructure support and information technology. Since most of the required steps to adapt the guide for use by CHWs have now been done by our study, we expect future adaptation costs to be lower. The methods used in this study provide an example of how to cost intervention adaptations in the future.

Introduction: We aimed to determine the impact of antenatal interventions to optimise maternal nutrition and infection management on birth outcomes in Ethiopia. Methods: We conducted a pragmatic, open-label, 2×2 factorial randomised clinical effectiveness study among pregnant women enrolled <24 weeks gestation in 12 rural health centres in Amhara, Ethiopia. Eligible health centres were randomised to deliver an enhanced nutrition package (ENP) (iron-folic acid, iodised salt and targeted micronutrient fortified balanced energy protein (BEP) supplementation for undernourished women) or routine nutrition care (iron-folic acid only). Individual women were randomised to receive an enhanced infection management package (EIMP) (genitourinary tract infection screening-treatment and enhanced deworming) or routine infection care (syndromic management). The primary outcomes were birth weight and length; secondary outcomes were gestational age, preterm delivery, small-for-gestational-age, low birth weight, stillbirth, newborn weight-for-age and length-for-age z-scores, newborn head circumference, and maternal anemia. Analysis was intention to treat. Results: From August 2020 to December 2021, 2392 women were randomised (604 ENP+EIMP, 600 ENP alone, 593 EIMP alone and 595 neither package) and followed until June 2022, with 2170 pregnancy outcomes analysed (565 ENP+EIMP, 549 ENP, 525 EIMP, 531 neither). In the ENP arm, 427 (36%) women were eligible for BEP and consumed on average 74 days. The prevalence of genitourinary tract infection was low (4.9%), while parasitic stool infections were common (31%). There was no difference in birth weight (ENP vs not-ENP: adjusted mean difference −4 g (−83 to 75); EIMP vs not-EIMP: 18 g (−35 to 70); ENP+EIMP vs neither: 14 g (−81 to 109)) or birth length (ENP: −0.3 cm (−1.1 to 0.5); EIMP: 0.2 cm (−0.1 to 0.5); ENP+EIMP: −0.1 cm (−1.2 to 1.1)) between study arms. In the ENP+EIMP group, the stillbirth rate was lower compared with the arm receiving neither package (7.1/1000 vs 24.7/1000 births; adjusted relative risk: 0.29 (0.09 to 0.94)). The packages did not significantly affect other secondary outcomes. Conclusions: In this pragmatic study implemented within the Ethiopian health system, enhanced nutrition and infection packages did not affect birth weight or length. While stillbirth rates were lower in the group receiving both packages, these findings need to be supported by additional studies. Trial registration number: ISRCTN15116516.

Background: The divorce rate has increased globally and in China. Literature from developed countries and few developing countries has shown the negative impact of parental divorce on children’s health and development. This cross-sectional study aimed to examine the association between parental divorce and early childhood development (ECD) in China. Method: This study used data collected from four provinces in China and reported by parents or other caregivers of 62 899 children, aged 3–5 years old, in 2017 and 2018. We constructed three types of ECD outcomes: (1) overall score of the early Human Capability Index (eHCI), (2) score of each domain of the eHCI, and (3) a dichotomous variable indicating a child developmentally on track, defined by ranking above the 20th percentile of overall eHCI scores in the corresponding age group in the pooled dataset. To understand the link between parental divorce and ECD outcomes, we used the propensity score matching method to match children from divorced families to those from intact families. We applied generalised linear regression models in data analysis using both the full sample and matched sample. Results: A total of 3.8% (N=2409) of young children came from divorced families. Children whose parents divorced had significantly lower overall eHCI scores (OR: 0.95, 95% CI 0.92 to 0.98) and lower odds of being developmentally on track (OR: 0.79, 95% CI 0.71 to 0.89), compared with their counterparts after matching. Statistically significant differences were observed in nearly all of nine domains of eHCI, especially for physical health, reading and social and emotional skills. Subgroup analyses showed more prominent associations in Shanghai. Conclusion: Children from divorced families showed slower early sociopsychological and physical development than their peers. Efforts are needed to help this vulnerable group minimise the differences.

Introduction Low- and middle-income countries (LMICs) often dedicate limited domestic funds to expand quality early childhood care and education (ECCE), making complementary international donor support potentially important. However, research on the allocation of international development assistance for ECCE has been limited. Methods We analysed data from the Creditor Reporting System on aid projects to assess global development assistance for ECCE in 134 LMICs from 2007 to 2021. By employing keyword-searching and funding-allocation methods, we derived two estimates of ECCE aid: a lower-bound estimate comprising projects primarily focusing on ECCE and an upper-bound estimate comprising projects with both primary and partial ECCE focus, as well as those that could benefit ECCE but did not include ECCE keywords. We also assessed aid directed to conflict-affected countries and to ECCE projects integrating COVID-19-related activities. Results Between 2007 and 2021, the lower-bound ECCE aid totaled US$3646 million, comprising 1.7% of the total US$213 279 million allocated to education. The World Bank led in ECCE aid, contributing US$1944 million (53.3% out of total ECCE aid). Low-income countries received less ECCE aid per child before 2016, then started to catch up but experienced a decrease from US$0.8 (2020) per child to US$0.6 (2021) per child. Funding for ECCE projects with COVID-19 activities decreased from a total of US$50 million in 2020 to US$37 million in 2021, representing 11.4% and 6.6% of annual total ECCE aid, respectively. Over 15 years, conflict-affected countries received an average of US$0.3 per child, a quarter of the aid received by non-conflict-affected countries (US$1.2 per child). Conclusion Although ECCE aid increased significantly between 2007 and 2021, its proportion of total educational aid fell short of UNICEF’s suggested 10% minimum. Recommendations include increasing the share of ECCE aid in total educational aid, increasing aid to low-income and conflict-affected countries, and investing more in preparing ECCE programmes for future global crises.

Providing quality early childhood care and education (ECCE) is widely recognized as a fundamental strategy for lifelong individual and societal benefits. However, the expansion of ECCE in low- and middle-income countries (LMICs) is impeded by limited financial resources. Little is known about the levels and trends of global development assistance (DA) allocated to ECCE in LMICs between 2007 and 2021. We extracted data from the Creditor Reporting System (CRS) on aid projects in 134 LMICs from 2007 to 2021. Using keyword-searching and funding-allocation methods, we generated two estimates of ECCE aid: one for DA primarily focused on ECCE, and another for DA both primarily and partially focused on ECCE as well as DA not explicitly targeting ECCE but benefiting ECCE. We analyzed the patterns and time trends of ECCE aid by donors, recipients, CRS sectors, implementing agencies, and aid-flow types. We calculated ECCE aid as a percentage of educational aid at both annual and aggregative levels, comparing it to UNICEF’s recommended allocation of at least 10% of educational aid to the ECCE sector in LMICs. Additionally, we explored the alignment of aid with addressing children’s learning losses during global crises by examining ECCE aid to projects involving COVID-19 prevention and mitigation, along with ECCE aid to conflict-affected countries. From 2007 to 2021, primary ECCE-focused DA amounted to US$3,646 million, accounting for 1.7% of the total US$213,279 million allocated to education. The World Bank led all donors with US$1,944 million in ECCE aid (53.3%). Low-income countries consistently received less ECCE aid per child before 2016, then started to catch up, but subsequently experienced a decrease from US$0.8 (2020) to US$0.6 (2021). In contrast, lower-middle-income and upper-middle-income countries saw an increase from US$0.4 (2020) to US$0.6 (2021) and from US$1.0 (2020) to US$1.3 (2021), respectively. ECCE aid to projects with COVID-19 activities declined from US$50 million in 2020 to US$37 million in 2021, representing 11.4% and 6.6% of annual ECCE aid. Over 15 years, conflict-affected countries received an average of US$0.3 per child, only a quarter of the aid received by non-conflict-affected countries (US$1.2 per child). Although ECCE aid increased significantly between 2007 and 2021, its share of total educational aid remained small and fell far short of the recommended minimum of 10%. Our recommendations include increasing the share of ECCE aid in total educational aid, raising aid to low-income and conflict-affected countries, and investing more in preparing ECCE programs for future global crises.