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'Working in Health' addresses two key questions related to health workforce policy in developing countries: • What is the impact of government wage bill policies on the size of the health wage bill and on health workforce staffing levels in the public sector? • Do current human resources management policies and practices lead to effective use of wage bill resources in the public sector? Health workers play a key role in increasing access to health services for poor people in developing countries. Global and country level estimates show that staffing levels in many developing countries—particularly in sub-Saharan Africa—are far below what is needed to deliver essential health services to the population. One factor that potentially limits scaling up the health workforce in developing countries is the government overall wage bill policy which sometimes creates restrictions. Through a review of literature, analysis of data, and country case studies in Kenya, Zambia, Rwanda, and the Dominican Republic, this book examines the process that determines the health wage bill budget in the public sector, how this is linked to overall wage bill policies, how this affects staffing levels in the health sector, and the relevant policy options. But staff numbers are not everything and more money for the health wage bill alone will not solve the health workforce problems of developing countries. 'Working in Health' looks at how effectively governments use the available wage bill resources in the health sector and policy options. Policies and practices in recruitment, deployment, promotion, transfer, sanctioning, and remuneration for health workers are reviewed to identify their influence on budget execution rates, geographic distribution, and productivity of health workers.

Specialist groups have often advised health ministers and other decision makers in developing countries on the use of social health insurance (SHI) as a way of mobilizing revenue for health, reforming health sector performance, and providing universal coverage. This book reviews the specific design and implementation challenges facing SHI in low- and middle-income countries and presents case studies on Ghana, Kenya, Philippines, Colombia, and Thailand.

Most antibiotic use is for livestock, and it is growing with the increase in global demand for meat. It is unclear what the increase in demand for antibiotics means for the occurrence of drug resistance in animals and risk to humans. Van Boeckel et al. describe the global burden of antimicrobial resistance in animals on the basis of systematic reviews over the past 20 years (see the Perspective by Moore). There is a clear increase in the number of resistant bacterial strains occurring in chickens and pigs. The current study provides a much-needed baseline model for low- and middle-income countries and provides a “one health” perspective to which future data can be added. Science , this issue p. eaaw1944 ; see also p. 1251 Growing demand for meat in developing economies increases antibiotic consumption and fuels the risk of antibiotic resistance. The global scale-up in demand for animal protein is the most notable dietary trend of our time. Antimicrobial consumption in animals is threefold that of humans and has enabled large-scale animal protein production. The consequences for the development of antimicrobial resistance in animals have received comparatively less attention than in humans. We analyzed 901 point prevalence surveys of pathogens in developing countries to map resistance in animals. China and India represented the largest hotspots of resistance, with new hotspots emerging in Brazil and Kenya. From 2000 to 2018, the proportion of antimicrobials showing resistance above 50% increased from 0.15 to 0.41 in chickens and from 0.13 to 0.34 in pigs. Escalating resistance in animals is anticipated to have important consequences for animal health and, eventually, for human health.

This contribution offers a thorough analysis of challenges and opportunities related to the adoption of sustainable energy policies in specific developing countries (i.e., Albania, Brazil, India, Kenya). The use of renewable energy sources must be increased if the world is to meet its climate goals and alleviate the negative effects of fossil fuel consumption. However, due to fiscal restrictions, institutional barriers, and technology limitations, developing countries face particular challenges in adopting such policies. In order to help these countries move towards a sustainable energy future, this study analyses these issues and suggests viable solutions for policymakers.

The efficacy of daily co-trimoxazole, an antifolate used for malaria chemoprevention in pregnant women living with HIV, is threatened by cross-resistance of Plasmodium falciparum to the antifolate sulfadoxine–pyrimethamine. We assessed whether addition of monthly dihydroartemisinin–piperaquine to daily co-trimoxazole is more effective at preventing malaria infection than monthly placebo plus daily co-trimoxazole in pregnant women living with HIV. We did an individually randomised, two-arm, placebo-controlled trial in areas with high-grade sulfadoxine–pyrimethamine resistance in Kenya and Malawi. Pregnant women living with HIV on dolutegravir-based combination antiretroviral therapy (cART) who had singleton pregnancies between 16 weeks' and 28 weeks' gestation were randomly assigned (1:1) by computer-generated block randomisation, stratified by site and HIV status (known positive vs newly diagnosed), to daily co-trimoxazole plus monthly dihydroartemisinin–piperaquine (three tablets of 40 mg dihydroartemisinin and 320 mg piperaquine given daily for 3 days) or daily co-trimoxazole plus monthly placebo. Daily co-trimoxazole consisted of one tablet of 160 mg sulfamethoxazole and 800 mg trimethoprim. The primary endpoint was the incidence of Plasmodium infection detected in the peripheral (maternal) or placental (maternal) blood or tissue by PCR, microscopy, rapid diagnostic test, or placental histology (active infection) from 2 weeks after the first dose of dihydroartemisinin–piperaquine or placebo to delivery. Log-binomial regression was used for binary outcomes, and Poisson regression for count outcomes. The primary analysis was by modified intention to treat, consisting of all randomised eligible participants with primary endpoint data. The safety analysis included all women who received at least one dose of study drug. All investigators, laboratory staff, data analysts, and participants were masked to treatment assignment. This trial is registered with ClinicalTrials.gov, NCT04158713. From Nov 11, 2019, to Aug 3, 2021, 904 women were enrolled and randomly assigned to co-trimoxazole plus dihydroartemisinin–piperaquine (n=448) or co-trimoxazole plus placebo (n=456), of whom 895 (99%) contributed to the primary analysis (co-trimoxazole plus dihydroartemisinin–piperaquine, n=443; co-trimoxazole plus placebo, n=452). The cumulative risk of any malaria infection during pregnancy or delivery was lower in the co-trimoxazole plus dihydroartemisinin–piperaquine group than in the co-trimoxazole plus placebo group (31 [7%] of 443 women vs 70 [15%] of 452 women, risk ratio 0·45, 95% CI 0·30–0·67; p=0·0001). The incidence of any malaria infection during pregnancy or delivery was 25·4 per 100 person-years in the co-trimoxazole plus dihydroartemisinin–piperaquine group versus 77·3 per 100 person-years in the co-trimoxazole plus placebo group (incidence rate ratio 0·32, 95% CI 0·22–0·47, p<0·0001). The number needed to treat to avert one malaria infection per pregnancy was 7 (95% CI 5–10). The incidence of serious adverse events was similar between groups in mothers (17·7 per 100 person-years in the co-trimoxazole plus dihydroartemisinin–piperaquine group [23 events] vs 17·8 per 100 person-years in the co-trimoxazole group [25 events]) and infants (45·4 per 100 person-years [23 events] vs 40·2 per 100 person-years [21 events]). Nausea within the first 4 days after the start of treatment was reported by 29 (7%) of 446 women in the co-trimoxazole plus dihydroartemisinin–piperaquine group versus 12 (3%) of 445 women in the co-trimoxazole plus placebo group. The risk of adverse pregnancy outcomes did not differ between groups. Addition of monthly intermittent preventive treatment with dihydroartemisinin–piperaquine to the standard of care with daily unsupervised co-trimoxazole in areas of high antifolate resistance substantially improves malaria chemoprevention in pregnant women living with HIV on dolutegravir-based cART and should be considered for policy. European and Developing Countries Clinical Trials Partnership 2; UK Joint Global Health Trials Scheme (UK Foreign, Commonwealth and Development Office; Medical Research Council; National Institute for Health Research; Wellcome); and Swedish International Development Cooperation Agency.

Snapshots from four nations struggling to limit deaths faster than the United States and other wealthy countries. Snapshots from four nations struggling to limit deaths faster than the United States and other wealthy countries.

In recent years, electrification has reemerged as a key priority in low-income countries, with a particular focus on electrifying households. Yet the microeconomic literature examining the impacts of electrifying households on economic development has produced a set of conflicting results. Does household electrification lead to measurable gains in living standards or not? Focusing on grid electrification, we discuss how the divergent conclusions across the literature can be explained by differences in methods, interventions, potential for spillovers, and populations. We then use experimental data from Lee, Miguel, and Wolfram (2019)—a field experiment that connected randomly selected households to the grid in rural Kenya—to show that impacts can vary even across individuals in neighboring villages. Specifically, we show that households that were willing to pay more for a grid electrification may gain more from electrification compared to households that would only connect for free. We conclude that access to household electrification alone is not enough to drive meaningful gains in development outcomes. Instead, future initiatives may work better if paired with complementary inputs that allow people to do more with power.

Undernutrition and micronutrient malnutrition remain problems of significant magnitude in large parts of the developing world. Improved nutrition requires not only better access to food for poor population segments, but also higher dietary quality and diversity. Because many of the poor and undernourished people are smallholder farmers, diversifying production on these smallholder farms is widely perceived as a useful approach to improve dietary diversity. However, empirical evidence on the link between production and consumption diversity is scarce. Here, this issue is addressed with household-level data from Indonesia, Kenya, Ethiopia, and Malawi. Regression models show that on-farm production diversity is positively associated with dietary diversity in some situations, but not in all. When production diversity is already high, the association is not significant or even turns negative, because of foregone income benefits from specialization. Analysis of other factors reveals that market access has positive effects on dietary diversity, which are larger than those of increased production diversity. Market transactions also tend to reduce the role of farm diversity for household nutrition. These results suggest that increasing on-farm diversity is not always the most effective way to improve dietary diversity in smallholder households and should not be considered a goal in itself. Additional research is needed to better understand how agriculture and food systems can be made more nutrition-sensitive in particular situations.

We explore the impact of reduced transaction costs on risk sharing by estimating the effects of a mobile money innovation on consumption. In our panel sample, adoption of the innovation increased from 43 to 70 percent. We find that, while shocks reduce consumption by 7 percent for nonusers, the consumption of user households is unaffected. The mechanisms underlying these consumption effects are increases in remittances received and the diversity of senders. We report robustness checks supporting these results and use the four-fold expansion of the mobile money agent network as a source of exogenous variation in access to the innovation.