Assessing the impact of the president's emergency plan for AIDS relief on all-cause mortality.

This study estimated the impacts of PEPFAR on all-cause mortality (ACM) rates (deaths per 1,000 population) across PEPFAR recipient countries from 2004-2018. As PEPFAR moves into its 3rd decade, this study supplements the existing literature on PEPFAR 's overall effectiveness in saving lives by focusing impact estimates on the important subgroups of countries that received different intensities of aid, and provides estimates of impact for different phases of this 15-year period study. The study uses a country-level panel data set of 157 low- and middle-income countries (LMICs) from 1990-2018, including 90 PEPFAR recipient countries receiving bilateral aid from the U.S. government, employing difference-in-differences (DID) econometric models with several model specifications, including models with differing baseline covariates, and models with yearly covariates including other donor spending and domestic health spending. Using five different model specifications, a 10-21% decline in ACM rates from 2004 to 2018 is attributed to PEPFAR presence in the group of 90 recipient countries. Declines are somewhat larger (15-25%) in those countries that are subject to PEPFAR's country operational planning (COP) process, and where PEPFAR per capita aid amounts are largest (17-27%). Across the 90 recipient countries we study, the average impact across models is estimated to be a 7.6% reduction in ACM in the first 5-year period (2004-2008), somewhat smaller in the second 5-year period (5.5%) and in the third 5-year period (4.7%). In COP countries the impacts show decreases in ACM of 7.4% in the first period attributed to PEPFAR, 7.7% reductions in the second, and 6.6% reductions in the third. PEPFAR presence is correlated with large declines in the ACM rate, and the overall life-saving results persisted over time. The effects of PEFAR on ACM have been large, suggesting the possibility of spillover life-saving impacts of PEPFAR programming beyond HIV disease alone.

Analysis of maternal and child health spillover effects in PEPFAR countries.

OBJECTIVES: This study examined whether the US President's Emergency Plan for AIDS Relief (PEPFAR) funding had effects beyond HIV, specifically on several measures of maternal and child health in low-income and middle-income countries (LMICs). The results of previous research on the question of PEPFAR health spillovers have been inconsistent. This study, using a large, multicountry panel data set of 157 LMICs including 90 recipient countries, adds to the literature. DESIGN: Seven indicators including child and maternal mortality, several child vaccination rates and anaemia among childbearing-age women are important population health indicators. Panel data and difference-in-differences estimators (DID) were used to estimate the impact of the PEPFAR programme from inception in 2004 to 2018 using a comparison group of 67 LMICs. Several different models of baseline (2004) covariates were used to help balance the comparison and treatment groups. Staggered DID was used to estimate impacts since all countries did not start receiving aid at PEPFAR's inception. SETTING: All 157 LMICs from 1990 to 2018. PARTICIPANTS: 90 LMICs receiving PEPFAR aid and cohorts of those countries, including those required to submit annual country operational plans (COP), other recipient countries (non-COP), and three groupings of countries based on cumulative amount of per capita aid received (high, medium, low). INTERVENTIONS: PEPFAR aid to combat the HIV epidemic. PRIMARY OUTCOME MEASURES: Maternal mortality and child mortality rates, vaccination rates to protect children for diphtheria, whooping cough and tetanus, measles, HepB3, and tetanus, and prevalence of anaemia in women of childbearing age. RESULTS: Across PEPFAR recipient countries, large, favourable PEPFAR health effects were found for rates of childhood immunisation, child mortality and maternal mortality. These beneficial health effects were large and significant in all segments of PEPFAR recipient countries studied. We also found significant and favourable programme effects on the prevalence of anaemia in women of childbearing age in PEPFAR recipient countries receiving the most intensive financial support from the PEPFAR programme. Other recipient countries did not demonstrate significant effects on anaemia. CONCLUSIONS: This study demonstrated that important health indicators, beyond HIV, have been consistently and favourably influenced by PEPFAR presence. Child and maternal mortality have been substantially reduced, and childhood immunisation rates increased. We also found no evidence of 'crowding out' or negative spillovers in these resource-poor countries. These findings add to the body of evidence that PEPFAR has had favourable health effects beyond HIV. The implications of these findings are that foreign aid for health in one area may have favourable health effects in other areas in recipient countries. More research is needed on the influence of the mechanisms at work that create these spillover health effects of PEPFAR.

A private hospital-based study assessing knowledge, attitudes, practices and costs associated with dengue illness in Surat, India.

We conducted a descriptive cross-sectional study at a private children’s and general hospital in Surat,India, during the 2006 dengue season (June to December 2006). We examined knowledge, attitudes and practices of patients associated with dengue and estimated the cost of a dengue episode for the study sample. Of 62 patients with suspected dengue, 40 consented to participate in this study. We interviewed 27 retrospectively in their homes and 13 prospectively during their hospitalization. Among the respondents, 75% were male, 85% were under the age of 14, 63% reported familiarity with dengue, but only 25% correctly knew that clean stagnant water is a breeding place for the dengue vector, and 23% did not know the mode of transmission for dengue infection. While 78% said that they take preventive steps against dengue, only 48% believed dengue to be a preventable illness. There was no significant relationship between their knowledge and prevention practices. Economic costs were measured in 2007 US dollars. For an average dengue episode, the mean costs were US$ 439.44 for direct medical care and US$ 146.13 for indirect costs, with a total cost of US$ 585.57. The indirect costs reflect an average burden of 50 days on a household due to days lost from school,work, and other activities by the patient and their caretakers. While other studies have examined public institutions, this is one of the first studies using data from a private hospital. This study shows that the cost of a dengue episode imposes substantial challenges, even on middle-class households.

Disparities in utilization of coronary artery disease treatment by gender, race, and ethnicity: opportunities for prevention.

Racial, ethnic, (R/E) and gender disparities in access to health services in the United States and their relationship to adverse health outcomes are well established. Despite an increase in evidence-based cardiovascular treatment, gender, racial, and ethnic disparities in coronary artery disease (CAD) treatment persist. There is neither currently a comprehensive framework for understanding why disparities occur in cardiovascular disease care, nor viable solutions for intervention. This article synthesizes the literature on disparities in coronary artery disease with a conceptual model for understanding chronic disease disparities. This article follows the natural history of disease to observe where differences arise, beginning with health risk management, screening, diagnosis, treatment, and rehabilitation. Racial, ethnic, and gender differences were found at every step of this continuum, including a higher burden of risk factors and a less likelihood of receiving needed lifesaving cardiac procedures. Unfortunately, there is a dearth of intervention strategies to reduce racial, ethnic, and gender disparities in coronary artery disease. Comprehensive solutions will require addressing the barriers at the system, the provider, and the patient level. An early intervention approach that addresses multiple risk factors should be a high priority.

Guest editors' introduction: implementing evidence-based mental health practices and performance measures in Massachusetts.

In September 2005, a one day educational forum on implementing evidence-based mental health practices and performance measures in Massachusetts was held at Brandeis University. Factors for successful implementation are reviewed. Papers in this issue cover theory, concrete actions, and best practices that will aid policy makers, providers, and consumers in improving their behavioral health services.

Managed behavioral health care: lessons from Massachusetts.

Since implementing the first statewide carve-out for behavioral health care in 1992, Massachusetts has achieved sustained reductions in cost, increases in access, and improvements in major quality measures. This introduction to a special issue describes the context, linkages with primary care, consumer satisfaction, unmet need, performance incentives (a key component of the success), stakeholder perspectives, and impacts on special populations.