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Background There is sufficient evidence that psychosocial stimulation (PS) benefits children’s neurocognitive behavior, however, there is no information on how it works when delivered through an Unconditional Cash Transfer (UCT) platform for poor rural population in developing countries. The objective of this study is to measure effects of adding PS for children of lactating mothers enrolled to receive UCT with health education (HE) on neurocognitive behavior of children in rural Bangladesh. Methods The study will be conducted at 11 unions of Ullapara sub-district in Bangladesh. The study is a cluster randomized controlled trial with three-arms; (i) PS and UCT with HE (ii) UCT with HE and iii) Comparison arm. The cluster will be considered as an old Ward of a Union , the lowest tier of local government system in rural Bangladesh. There are three old Wards in a union . These three clusters will be randomized to one of the three arms. Similarly, randomization will be done for each 11 Unions and then 11 clusters will be assigned to an arm. Eighteen participants will be recruited from each cluster randomly ( n  = 196 in each arm). The intervention designed for one year includes UCT with HE for the poor as a safety net program in rural Bangladesh with or without PS. An age-based curriculum of PS is already available for Bangladeshi children and this will be administered by trained local women; play leaders (PL) in intervention clusters. The government of Bangladesh is providing UCT of taka 500 ($6.25) as maternity allowance per month with HE. The primary outcomes will be cognitive, motor and language composite scores measured by Bayley-III and behavior using Wolke’s behavior rating scale. The secondary outcomes will be children and mothers’ growth, family food security status, health seeking behavior, mothers’ depressive symptoms and self-esteem and violence against mothers. Discussion The study will provide a unique opportunity to assess an integrated early childhood development intervention using UCT platform to mitigate developmental delays in poor vulnerable children of rural Bangladesh. Trial registration number ClinicalTrials.gov NCT03281980, registered on September 13, 2017.

Background Poor governance and accountability compromise young democracies’ efforts to provide public services critical for human development, including water, sanitation, health, and education. Evidence shows that accountability agencies like superior audit institutions can reduce corruption and waste in federal grant programs financing service infrastructure. However, little is know about their effect on compliance with grant reporting and resource allocation requirements, or about the causal mechanisms. This study protocol for an exploratory randomized controlled trial tests the hypothesis that federal and state audits increase compliance with a federal grant program to improve municipal service infrastructure serving marginalized households. Methods/Design The AUDIT study is a block randomized, controlled, three-arm parallel group exploratory trial. A convenience sample of 5 municipalities in each of 17 states in Mexico ( n =85) were block randomized to be audited by federal auditors ( n =17), by state auditors ( n =17), and a control condition outside the annual program of audits ( n =51) in a 1:1:3 ratio. Replicable and verifiable randomization was performed using publicly available lottery numbers. Audited municipalities were included in the national program of audits and received standard audits on their use of federal public service infrastructure grants. Municipalities receiving moderate levels of grant transfers were recruited, as these were outside the auditing sampling frame – and hence audit program – or had negligible probabilities of ever being audited. The primary outcome measures capture compliance with the grant program and markers for the causal mechanisms, including deterrence and information effects. Secondary outcome measure include differences in audit reports across federal and state auditors, and measures like career concerns, political promotions, and political clientelism capturing synergistic effects with municipal accountability systems. The survey firm and research assistants assessing outcomes were blind to treatment status. Discussion This study will improve our understanding of local accountability systems for public service delivery in the 17 states under study, and may have downstream policy implications. The study design also demonstrates the use of verifiable and replicable randomization, and of sequentially partitioned hypotheses to reduce the Type I error rate in multiple hypothesis tests. Trial registration Controlled-trials.com Identifier ISRCTN22381841: Date registered 02/11/2012

Brazil is a country of continental dimensions with widespread regional and social inequalities. In this report, we examine the historical development and components of the Brazilian health system, focusing on the reform process during the past 40 years, including the creation of the Unified Health System. A defining characteristic of the contemporary health sector reform in Brazil is that it was driven by civil society rather than by governments, political parties, or international organisations. The advent of the Unified Health System increased access to health care for a substantial proportion of the Brazilian population, at a time when the system was becoming increasingly privatised. Much is still to be done if universal health care is to be achieved. Over the past 20 years, there have been other advances, including investments in human resources, science and technology, and primary care, and a substantial decentralisation process, widespread social participation, and growing public awareness of a right to health care. If the Brazilian health system is to overcome the challenges with which it is presently faced, strengthened political support is needed so that financing can be restructured and the roles of both the public and private sector can be redefined.

Background The population in Sub Saharan Africa (SSA) suffers poor health as manifested in high mortality rates and low life expectancy. Economic growth has consistently been shown to be a major determinant of health outcomes. However, even with good economic growth rates, it is not possible to achieve desired improvements in health outcomes. Public spending on health (PSH) has long been viewed as a potential complement to economic growth in improving health. However, the relationship between PSH and health outcomes is inconclusive and this inconclusiveness may, in part, be explained by governance-related factors which mediate the impact of the former on the latter. Little empirical work has been done in this regard on SSA. This paper investigates whether or not the quality of governance (QoG) has a modifying effect on the impact of public health spending on health outcomes, measured by under-five mortality (U5M) and life expectancy at birth (LE), in SSA. Methods Using two staged least squares regression technique on panel data from 43 countries in SSA over the period 1996–2011, we estimated the effect of public spending on health and quality of governance U5M and LE, controlling for GDP per capita and other socio-economic factors. We also interacted PSH and QoG to find out if the latter has a modifying effect on the former’s impact on U5M and LE. Results Public spending on health has a statistically significant impact in improving health outcomes. Its direct elasticity with respect to under-five mortality is between −0.09 and −0.11 while its semi-elasticity with respect to life expectancy is between 0.35 and 0.60. Allowing for indirect effect of PSH spending via interaction with quality of governance, we find that an improvement in QoG enhances the overall impact of PSH. In countries with higher quality of governance, the overall elasticity of PSH with respect to under-five mortality is between −0.17 and −0.19 while in countries with lower quality of governance, it is about −0.09. The corresponding semi elasticities with respect to life expectancy are about 6 in countries with higher QoG and about 3 in countries with lower QoG. Discussion Public spending on health improves health outcomes. Its impact is mediated by quality of governance, having the higher impact on health outcomes in countries with higher quality of governance and lower impact in countries with lower quality of governance. This may be due to increased efficiency in the use of available resources and better allocation of the same as QoG improves. Conclusion Improving QoG would improve health outcomes in SSA. The same increase in PSH is twice as effective in reducing U5M and increasing LE in countries with good QoG when compared with countries with poor QoG.

Background: Saudi Arabia has invested heavily in its health care system by establishing health care infrastructures to improve health of the nation. However, it remains to be seen whether it is efficient and effective in providing health care services needed. Primary health care, which is the basis of universal health coverage, needs to be assessed on its performance, challenges and future opportunities to serve the Saudi Arabian population. Aims: This review aimed to identify challenges within the Saudi Arabian health care system with a focus on primary health care services, and to analyse the interrelated factors in order to suggest remedial reforms to further strengthen and improve the health care system. Methods: A narrative review of previous studies and governmental reports was undertaken to extract, analyse, synthesize and report the findings. Results: The review found a number of key areas for improvement in the primary health care system. These areas include: the scope, structure, infrastructure, financing, increased demand, increased costs and workforce capacity. Other critical challenges include inequitable access to health services, quality and safety of services, the growing burden of chronic diseases, lack of an effective information system, management and leadership issues, and gaps in the referral system. Conclusion: The Saudi Arabian health care system needs comprehensive reform with a focus on primary health care.

Background UNAIDS estimated that US$29 billion will be required by 2025 to meet HIV/AIDS service demands, with 53 percent expected to come from domestic sources. The PEPFAR-funded, USAID-implemented Sustainable Financing Initiative for HIV/AIDS (SFI), starting in 2014, supported domestic resources mobilization efforts and activities to strengthen countries' public financial management (PFM) systems, positively contributing to much-needed increase in domestic resources for health and HIV. Program approach SFI was implemented in 12 countries, supporting activities to build the capacity of governments to mobilize domestic resources for HIV, improve budget absorption, and maximize resource use and develop and use evidence for advocacy to increase domestic government funds for HIV/AIDS. SFI measured impact by agreed upon indicators and estimated return on investment (ROI). Results Eight countries focused on building capacity to improve budgeting and execution of health and HIV/AIDS funds; five experienced increases in budget allocation and spending. Kenya country governments spent an additional US$180 million and US$8.7 million on health and HIV, respectively. This contributed to US$60 mobilized and spent for every SFI dollar invested. Eight countries focused on using evidence to advocate for more domestic resources for health and HIV/AIDS from government budgets, increase budget execution, and identify areas for efficiency. Cambodia saw an increase in government commitments for ARVs from US$1.5 million annually from 2018–2020 to US$5 million by 2023. Lessons learned Robust data are needed for evidence-based advocacy to increase domestic government funding for HIV/AIDS and to strengthen PFM systems for more efficient and effective resource use; institutionalizing capacity building efforts allows for locally-led technical assistance; policy-related work is a multi-year endeavor; PFM success can be stymied by political transitions, political will, and donor commitments; COVID-19 brought new challenges and new opportunities; measurable results can lead to greater impact; and results are not necessarily solely project attributions with possible inflation of ROI estimates given there was no counterfactual. Conclusion Strengthening PFM systems can increase domestic resources for health and HIV through increased revenue and improved efficiency; closing the investment gap to end the HIV/AIDS epidemic by 2030.

The adoption of the shared prosperity goal by the World Bank in 2013 and Sustainable Development Goal 10, on inequality, by the United Nations in 2015 should strengthen the focus of development interventions and cooperation on the income growth of the bottom 40 percent of the income distribution. This paper contributes to the incipient literature on within-country allocations of development institutions and assesses the geographic targeting of World Bank projects to the bottom 40 percent. Bivariate correlations between the allocation of project funding approved over 2005-14 and the geographical distribution of the bottom 40 as measured by survey income or consumption data are complemented by regressions with population and other potential factors affecting the within-country allocations as controls. The correlation analysis shows that, of the 58 countries in the sample, 41 exhibit a positive correlation between the shares of the bottom 40 and World Bank funding, and, in almost half of these, the correlation is above 0.5. Slightly more than a quarter of the countries, mostly in Sub-Saharan Africa, exhibit a negative correlation. The regression analysis shows that, once one controls for population, the correlation between the bottom 40 and World Bank funding switches sign and becomes significant and negative on average. This is entirely driven by Sub-Saharan Africa and not observed in the other regions. Hence, the significant and positive correlation in the estimations without controlling for population suggests that World Bank project funding is concentrated in administrative areas in which more people live (including the bottom 40) rather than in poorer administrative areas. Furthermore, capital cities receive disproportionally high shares of World Bank funding on average.

Since the discovery of the secondary preventive benefits of antiretroviral therapy, national and international governing bodies have called for countries to reach 90% diagnosis, ART engagement and viral suppression among people living with HIV/AIDS. The US HIV epidemic is dispersed primarily across large urban centers, each with different underlying epidemiological and structural features. We selected six US cities, including Atlanta, Baltimore, Los Angeles, Miami, New York, and Seattle, with the objective of demonstrating the breadth of epidemiological and structural differences affecting the HIV/AIDS response across the US. We synthesized current and publicly-available surveillance, legal statutes, entitlement and discretionary funding, and service location data for each city. The vast differences we observed in each domain reinforce disparities in access to HIV treatment and prevention, and necessitate targeted, localized strategies to optimize the limited resources available for each city’s HIV/AIDS response.

There is little evidence to demonstrate the impact on local health outcomes of spending that occurs outside the health care sector. We leveraged novel data from the US census Bureau to measure the independent impact of a community's health and nonhealth expenditures on a broad measure of overall health-the County Health Rankings-over time. Using lagged longitudinal models that accounted for correlations of health outcomes and expenditures within counties, we found significant positive associations between expenditures and County Health Rankings for seven of the fourteen expenditure categories examined: community health care and public health, public hospitals, fire protection, K-12 education, corrections, libraries, and housing and community development. These areas of social spending have modest but detectable positive associations with population health, whether or not they primarily target health. Achieving improved health outcomes through a culture-of-health ethos should involve the consideration of public expenditures in both health and other social service areas.

All people in the United States deserve the same level of public health protection, making it crucial that every health department across the country has a core set of foundational capabilities. Current research indicates an annual cost of$32 per person to support the foundational public health capabilities needed to promote and protect health for everyone across the nation. Yet national investment in public health capabilities is currently about $ 19 per person, leaving a$13-per-person gap in annual spending. To “create the conditions in which people can be as healthy as possible” and to protect national security, this gap must be filled. The Public Health Leadership Forum convened national experts in the public health, public policy, and other partner sectors to develop options for long-term, sustainable financing. The group aligned around core principles and criteria necessary to establish a sustainable financing structure. Informed by the work of the expert panel, the authors recommend a Public Health Infrastructure Fund for state, territorial, local, and tribal governmental public health, that would provide $ 4.5 billion of new, permanent resources needed to fully support core public health foundational capabilities.