BACKGROUND:The Sustainable Development Goals (SDGs) include ending the epidemics of HIV, tuberculosis, and malaria by 2030. With 5 years remaining to meet this goal, and with the Global Fund to Fight AIDS, Tuberculosis and Malaria seeking funding for programmes in 2027-29, establishing what can be achieved through continued investment in combatting these diseases is crucial. We aimed to estimate the potential for impact by analysing the funding landscape and epidemiological situations of these three diseases, the costs of key programmes, and the extent of possible future progress in the countries eligible for Global Fund support. METHOD:In this modelling study, we developed estimates of the financial resources needed in Global Fund-supported countries to combat HIV, tuberculosis, and malaria from the global plans produced by UNAIDS, the Stop TB Partnership, and WHO. Estimates of available resources in the coming years were obtained by assuming that national expenditure on the three diseases would grow in line with general governmental expenditures, that the Global Fund would contribute an additional $18·0 billion, and that other developmental assistance would be at the same level in real terms as the average in the period 2020-22. Epidemiological and costing models for each of the three diseases were used to quantify the possible impact in Global Fund-eligible countries (including on aggregated mortality and incidence rates). The return on investment (ROI) was computed considering both the intrinsic value of health and the direct economic benefits of the reduced risk of morbidity and premature mortality. The analysis was completed at the end of 2024 with the latest available data, which pertained to the year 2023. The focus of the projection period was 2027-29, a period for which scale-up plans and funding have not yet been committed and the period when most of the resources raised by the eighth replenishment of the Global Fund would be used. FINDINGS:The total resource needs for the three diseases were estimated to be US$140·6 billion in 2027-29. We calculated that $111·3 billion (79%) of this need could be met from domestic financing ($69·7 billion), the Global Fund ($18·0 billion), and other external donors ($23·6 billion). Optimal use of these available resources could save 23 million lives and avert 400 million cases and new infections during 2027-29. The trajectory of the combined mortality rate for all diseases was projected to approach that needed to reach the SDG for 2030 (with a difference between the target in 2030 and the projection at the end of 2029 of between 1·5% and 15·5% of the normalised aggregated mortality rate), inequality in life expectancy between countries would be 7% lower by 2029, and 189 million fewer hospital days and 572 million fewer outpatient visits would be needed in 2027-29, saving $1·1 billion. For every $1·00 invested, there could be up to $19·00 in intrinsic health value created or $3·50 in direct economic benefits. INTERPRETATION:Continued investments to combat HIV, tuberculosis, and malaria could yield enormous health gains and a high return on investment. Realising these benefits will require continued growth in national expenditure and a broad maintenance of external financing for these diseases, including a successful replenishment of the Global Fund in 2025. FUNDING:The Global Fund.

Many children do not receive a full schedule of childhood vaccines, yet there is limited evidence on the cost-effectiveness of strategies for improving vaccination coverage. Evidence is even scarcer on the cost-effectiveness of strategies for reaching 'zero-dose children', who have not received any routine vaccines. We evaluated the cost-effectiveness of periodic intensification of routine immunization (PIRI), a widely applied strategy for increasing vaccination coverage. We focused on Intensified Mission Indradhanush (IMI), a large-scale PIRI intervention implemented in India in 2017-2018. In 40 sampled districts, we measured the incremental economic cost of IMI using primary data, and used controlled interrupted time-series regression to estimate the incremental vaccination doses delivered. We estimated deaths and disability-adjusted life years (DALYs) averted using the Lives Saved Tool and reported cost-effectiveness from immunization programme and societal perspectives. We found that, in sampled districts, IMI had an estimated incremental cost of 2021US$13.7 (95% uncertainty interval: 10.6 to 17.4) million from an immunization programme perspective and increased vaccine delivery by an estimated 2.2 (-0.5 to 4.8) million doses over a 12-month period, averting an estimated 1413 (-350 to 3129) deaths. The incremental cost from a programme perspective was $6.21 per dose ($2.80 to dominated), $82.99 per zero-dose child reached ($39.85 to dominated), $327.63 ($147.65 to dominated) per DALY averted, $360.72 ($162.56 to dominated) per life-year saved and $9701.35 ($4372.01 to dominated) per under-5 death averted. At a cost-effectiveness threshold of 1× per-capita GDP per DALY averted, IMI was estimated to be cost-effective with 90% probability. This evidence suggests IMI was both impactful and cost-effective for improving vaccination coverage, though there is a high degree of uncertainty in the results. As vaccination programmes expand coverage, unit costs may increase due to the higher costs of reaching currently unvaccinated children.

ImportanceTwo in 5 US hospital stays result in rehabilitative postacute care, typically through skilled nursing facilities (SNFs) or home health agencies (HHAs). However, a lack of clear guidelines and understanding of patient and caregiver preferences make it challenging to promote high-value patient-centered care.ObjectiveTo assess preferences and willingness to pay for facility-based vs home-based postacute care among patients and caregivers, considering demographic variations.Design, Setting, and ParticipantsIn September 2022, a nationally representative survey was conducted with participants 45 years or older. Using a discrete choice experiment, participants acting as patients or caregivers chose between facility-based and home-based postacute care that best met their preferences, needs, and family conditions. Survey weights were applied to generate nationally representative estimates.Main Outcomes and MeasuresPreferences and willingness to pay for various attributes of postacute care settings were assessed, examining variation based on demographic factors, socioeconomic status, job security, and previous care experiences.ResultsA total of 2077 adults were invited to participate in the survey; 1555 (74.9%) completed the survey. In the weighted sample, 52.9% of participants were women, 6.5% were Asian or Pacific Islander, 1.7% were American Indian or Alaska Native, 11.2% were Black or African American, 78.4% were White; the mean (SD) age was 62.6 (9.6) years; and there was a survey completion rate of 74.9%. Patients and caregivers showed a substantial willingness to pay for home-based and high-quality care. Patients and caregivers were willing to pay an additional $58.08 per day (95% CI, 45.32-70.83) and $45.54 per day (95% CI, 31.09-59.99) for HHA care compared with a shared SNF room, respectively. However, increased demands on caregiver time within an HHA scenario and socioeconomic challenges, such as insecure employment, shifted caregivers’ preferences toward facility-based care. There was a strong aversion to below average quality. To avoid below average SNF care, patients and caregivers were willing to pay $75.21 per day (95% CI, 61.68-88.75) and $79.10 per day (95% CI, 63.29-94.91) compared with average-quality care, respectively. Additionally, prior awareness and experience with postacute care was associated with willingness to pay for home-based care. No differences in preferences among patients and caregivers based on race, educational background, urban or rural residence, general health status, or housing type were observed.Conclusions and RelevanceThe findings of this survey study underscore a prevailing preference for home-based postacute care, aligning with current policy trends. However, attention is warranted for disadvantaged groups who are potentially overlooked during the shift toward home-based care, particularly those facing caregiver constraints and socioeconomic hardships. Ensuring equitable support and improved quality measure tools are crucial for promoting patient-centric postacute care, with emphasis on addressing the needs of marginalized groups.

Abstract This chapter presents and highlights critical elements related to the purpose and design of immunization costing studies. Core concepts on the scope and boundaries of costing the program which is often integrated with other services are explored. In addition, the perspective of the costing exercise and whether costs reflect those of the provider, the funder or society are presented. This chapter discusses data collection approaches, particularly for key elements such as labor time and allocation of other health systems and shared costs. Methods and data sources on prices are included. Readers are provided resources for sample questionnaires and interview techniques. Importantly, this chapter discusses sampling strategies and provides an example of a sampling procedure.

Immunization program costs are generally derived from a detailed analysis of inputs, multiplied by unit prices, and adjusted for whether inputs are shared with other health services. This chapter presents a range of methods for generating robust estimates of immunization costs. Approaches for annualizing and discounting of the value of inputs that have a useful life longer than a year are also discussed in the chapter. Many costing studies collect information from a sample of sites, and approaches for aggregating costs to the national level are explored in this chapter. Techniques for weighting of sample site information is also discussed. As cost estimates are based on assumptions, the chapter concludes with a discussion of approaches for evaluating uncertainty and sensitivity analysis.

BackgroundMost low- and middle-income countries have limited access to cost data that meets the needs of health policy-makers and researchers in health intervention areas including HIV, tuberculosis, and immunization. Unit cost repositories (UCRs)-searchable databases that systematically codify evidence from costing studies-have been developed to reduce the effort required to access and use existing costing information. These repositories serve as public resources and standard references, which can improve the consistency and quality of resource needs projections used for strategic planning and resource mobilization. UCRs also enable analysis of cost determinants and more informed imputation of missing cost data. This report examines our experiences developing and using seven UCRs (two global, five country-level) for cost projection and research purposes.DiscussionWe identify advances, challenges, enablers, and lessons learned that might inform future work related to UCRs. Our lessons learned include: (1) UCRs do not replace the need for costing expertise; (2) tradeoffs are required between the degree of data complexity and the useability of the UCR; (3) streamlining data extraction makes populating the UCR with new data easier; (4) immediate reporting and planning needs often drive stakeholder interest in cost data; (5) developing and maintaining UCRs requires dedicated staff time; (6) matching decision-maker needs with appropriate cost data can be challenging; (7) UCRs must have data quality control systems; (8) data in UCRs can become obsolete; and (9) there is often a time lag between the identification of a cost and its inclusion in UCRs.ConclusionsUCRs have the potential to be a valuable public good if kept up-to-date with active quality control and adequate support available to end-users. Global UCR collaboration networks and greater control by local stakeholders over global UCRs may increase active, sustained use of global repositories and yield higher quality results for strategic planning and resource mobilization.

Abstract This chapter presents and highlights critical elements related to the purpose and design of immunization costing studies. Core concepts on the scope and boundaries of costing the program which is often integrated with other services are explored. In addition, the perspective of the costing exercise and whether costs reflect those of the provider, the funder or society are presented. This chapter discusses data collection approaches, particularly for key elements such as labor time and allocation of other health systems and shared costs. Methods and data sources on prices are included. Readers are provided resources for sample questionnaires and interview techniques. Importantly, this chapter discusses sampling strategies and provides an example of a sampling procedure.

Background Cost-effectiveness analysis (CEA) is a standard tool for evaluating health programs and informing decisions about resource allocation and prioritization. Most CEAs evaluating health interventions in low- and middle-income countries adopt a health sector perspective, accounting for resources funded by international donors and country governments, while often excluding out-of-pocket expenditures and time costs borne by program beneficiaries. Even when patients’ costs are included, a companion analysis focused on the patient perspective is rarely performed. We view this as a missed opportunity. Methods We developed methods for assessing intervention affordability and evaluating whether optimal interventions from the health sector perspective also represent efficient and affordable options for patients. We mapped the five different patterns that a comparison of the perspective results can yield into a practical framework, and we provided guidance for researchers and decision-makers on how to use results from multiple perspectives. To illustrate the methodology, we conducted a CEA of six HIV treatment delivery models in Mozambique. We conducted a Monte Carlo microsimulation with probabilistic sensitivity analysis from both patient and health sector perspectives, generating incremental cost-effectiveness ratios for the treatment approaches. We also calculated annualized patient costs for the treatment approaches, comparing the costs with an affordability threshold. We then compared the cost-effectiveness and affordability results from the two perspectives using the framework we developed. Results In this case, the two perspectives did not produce a shared optimal approach for HIV treatment at the willingness-to-pay threshold of 0.3 × Mozambique’s annual GDP per capita per DALY averted. However, the clinical 6-month antiretroviral drug distribution strategy, which is optimal from the health sector perspective, is efficient and affordable from the patient perspective. All treatment approaches, except clinical 1-month distributions of antiretroviral drugs which were standard before Covid-19, had an annual cost to patients less than the country’s annual average for out-of-pocket health expenditures. Conclusion Including a patient perspective in CEAs and explicitly considering affordability offers decision-makers additional insights either by confirming that the optimal strategy from the health sector perspective is also efficient and affordable from the patient perspective or by identifying incongruencies in value or affordability that could affect patient participation.

Abstract Information regarding the cost of immunization services can be useful for policymakers, program managers, and the global health community. Cost information can be incorporated into strategic planning and budgets, as well as utilized to improve performance and efficiency of the program. Advocacy and resource mobilization goals incorporate costs for achieving targets. Cost data are included in evaluations to set priorities within the health sector. This chapter reviews the uses of immunization cost information and provides resources for the reader on available methods, guidance, and tools related to costing methodologies and application to field-based studies.

As bilateral and multilateral donors transition the role of funding HIV programs to the governments of low- and middle-income countries, pressure to manage scarce resources can mount. Yet many countries face challenges in quantifying the costs of future programs, ensuring that cost data are accurate and accessible, and optimizing planned activities for cost-effectiveness and technical efficiency. We designed this roadmap to help countries respond to such challenges. We have based the contents of this document on our experience supporting costing efforts in multiple countries, covering three main dimensions of costing capacity and practices: data & tools, knowledge & skills, and processes & governance. This roadmap adopts Kotter's 8-Step Process for Leading Change for the purposes of costing improvement—from diagnosing weaknesses and creating a sense of urgency, to removing barriers to success and sustaining long-term changes. We developed a baseline assessment with corresponding suggestion sheets to assist with the initial steps of the change process. Countries aiming to improve their costing capabilities, particularly within organizations responding to HIV, can follow this 8-step process before, during, and after donor transition. In fact, we recommend that countries revisit the assessment and change process regularly to make continuous improvements. The roadmap concludes with examples of the change efforts underway in two countries to demonstrate that different aspects of costing may be at different points along the 8-step process. These country descriptions also show that improvements in costing can yield benefits in other aspects of a country’s HIV response.

Access to treatment for acute malnutrition remains a challenge, in part due to the fragmentation of treatment programmes based on case severity. This paper evaluates utilization patterns, outcomes and associated costs for treating acute malnutrition cases among a cohort of children in Burkina Faso. This study is a secondary analysis of a proof-of-concept trial, called Optimizing treatment for acute Malnutrition (OptiMA), conducted in Burkina Faso in 2016. A total of 4958 eligible children whose mid-upper arm circumference (MUAC) was less than 125 mm or with oedema were followed weekly and given ready-to-use therapeutic foods (RUTF). We evaluated the service utilization and outcomes among patients and estimated resource use and variable cost per patient, and examined factors driving variation in resource use. Children with lower initial MUAC level grew faster but required more time to recover than those with higher initial MUAC level. They also had higher rates of death, default and nonresponse. The simplified OptiMA approach for treating acute malnutrition achieved high rates of recovery overall (84%), especially among less severe cases, with modest quantities of RUTF. The average overall variable cost per child admitted was US$38.0 (SD: 20.5) half of which was accounted for by the cost of RUTF. Cost per recovered case was correlated with case severity, ranging from US$35.1 to US$132.8. If simplified integrated programmes using severity-based RUTF dosing can increase access to treatment at earlier, less severe stages of acute malnutrition, they can help avoid more serious and costlier cases.

Background Differences in definitions and methodological approaches have hindered comparison and synthesis of economic evaluation results across multiple health domains, including immunization. At the request of the World Health Organization’s (WHO) Immunization and Vaccines-related Implementation Research Advisory Committee (IVIR-AC), WHO convened an ad hoc Vaccine Delivery Costing Working Group, comprising experts from eight organizations working in immunization costing, to address a lack of standardization and gaps in definitions and methodological guidance. The aim of the Working Group was to develop a consensus statement harmonizing terminology and principles and to formulate recommendations for vaccine delivery costing for decision making. This paper discusses the process, findings of the review, and recommendations in the Consensus Statement. Methods The Working Group conducted several interviews, teleconferences, and one in-person meeting to identify groups working in vaccine delivery costing as well as existing guidance documents and costing tools, focusing on those for low- and middle-income country settings. They then reviewed the costing aims, perspectives, terms, methods, and principles in these documents. Consensus statement principles were drafted to align with the Global Health Cost Consortium costing guide as an agreed normative reference, and consensus definitions were drafted to reflect the predominant view across the documents reviewed. Results The Working Group identified four major workstreams on vaccine delivery costing as well as nine guidance documents and eleven costing tools for immunization costing. They found that some terms and principles were commonly defined while others were specific to individual workstreams. Based on these findings and extensive consultation, recommendations to harmonize differences in terminology and principles were made. Conclusions Use of standardized principles and definitions outlined in the Consensus Statement within the immunization delivery costing community of practice can facilitate interpretation of economic evidence by global, regional, and national decision makers. Improving methodological alignment and clarity in program costing of health services such as immunization is important to support evidence-based policies and optimal resource allocation. On the other hand, this review and Consensus Statement development process revealed the limitations of our ability to harmonize given that study designs will vary depending upon the policy question that is being addressed and the country context.

Objectives Lack of anaesthesia services is a frequent barrier to emergency surgeries such as caesarean delivery in Kenya. This study aimed to estimate the survival gains and cost-effectiveness of scaling up the Every Second Matters (ESM)-Ketamine programme that trains non-anaesthetist providers to administer and monitor ketamine during emergency caesarean deliveries.Setting Hospitals in Kenyan counties with low rates of caesarean delivery.Participants Patients needing emergency caesarean delivery in settings without availability of standard anaesthesia service.Interventions Simulated scales up of the ESM-Ketamine programme over 5 years (2020–24) was compared with status quo.Outcome measures Cost of implementing the programme and corresponding additional emergency caesarean deliveries. Maternal and fetal/neonatal deaths prevented, and corresponding life-years gained due to increased provision of emergency caesarean procedures. Cost-effectiveness was assessed by comparing the cost per life-year gained of the ESM-Ketamine programme compared with status quo.Results Over 5 years, the expected gap in emergency caesarean deliveries was 157 000. A US$1.2 million ESM-Ketamine programme reduced this gap by 28 700, averting by 316 maternal and 4736 fetal deaths and generating 331 000 total life-years gained. Cost-effectiveness of scaling up the ESM-Ketamine programme was US$44 per life-year gained in the base case and US$251 in the most pessimistic scenario—a very good value for Kenya at less than 20% of per capita GDP per life-year gained.Conclusion In areas of Kenya with significant underprovision of emergency caesarean delivery due to a lack of availability of traditional anaesthesia, an ESM-Ketamine programme is likely to enable a substantial number of life-saving surgeries at reasonable cost.

# Background After years of increased human immunodeficiency virus (HIV) investments in Tanzania, the United States Presidents Emergency Program for the AIDS Response (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) have signaled that their financing will plateau or decline in the coming years, despite remaining challenges to reaching the Fast-Track 95-95-95 goals. To plan for these challenges, the Tanzania Ministry of Health and local partners requested an update to the country’s HIV investment case, recognizing that domestic financing will also be severely constrained over the coming decade. # Methods Using the Goals model, five program scenarios (2019-30) were modeled and their health impacts and costs compared. Two scenarios were coverage-driven, Constant Coverage (CC) and the National Strategy (NS) while the three remaining scenarios explored how limited resources could be optimized through prioritization of prevention interventions, raising efficiency of treatment, and expanding cost-effective testing modalities. The resource envelopes used for resource-constrained scenarios were: same funding as the CC scenario, declining donor funds, and declining donor funds offset by domestic resource mobilization. # Results Implementing the NS is estimated to cost US$8.1 billion over 2019-30, a 40% increase over the CC scenario. If the same funds needed to maintain CC were optimized, the NS goals could be achieved for US$2.5 billion less. If donor funds decline and domestic funding is not mobilized, even with optimization new HIV infections would increase by 7% and acquired immunodeficiency syndrome (AIDS)-related deaths by 24%. However, if the government can mobilize an average year on year increase of US$10.8 million, optimization would allow the country to achieve its ambitious Fast-Track goals. # Conclusions If donor funds for HIV decline as announced, the Government needs to proactively optimize the response and invest more domestic resources to compensate, in order to achieve HIV epidemic control. Otherwise, national goals could be compromised. Other high burden countries can consider a similar investment case approach in the current era of fiscal constraints, which have been further exacerbated by COVID-19.

Background: This study estimated cost of COVID-19 vaccine introduction and deployment in Ghana. Methods: Using the WHO-UNICEF COVID-19 Vaccine Introduction and deployment Costing (CVIC) tool Ghana's Ministry of Health Technical Working Group for Health Technology Assessment (TWG-HTA) in collaboration with School of Public Health, University of Ghana, organized an initial two-day workshop that brought together partners to deliberate and agree on input parameters to populate the CVIC tool. A further 2-3 days validation with the Expanded Program of Immunization (EPI) and other partners to finalize the analysis was done. Three scenarios, with different combinations of vaccine products and delivery modalities, as well as time period were analyzed. The scenarios included AstraZeneca (40%), Johnson & Johnson (J&J) (30%), Moderna, Pfizer, and Sputnik V at 10% each; with primary schedule completed by second half of 2021 (Scenario 1); AstraZeneca (30%), J&J (40%), Moderna, Pfizer, and Sputnik V at 10% each with primary schedule completed by first half of 2022 (Scenario 2); and equal distribution (20%) among AstraZeneca, J&J, Moderna, Pfizer, and Sputnik V with primary schedule completed by second half of 2022 (Scenario 3). Results: The estimated total cost of COVID-19 vaccination ranges between $348.7 and $436.1 million for the target population of 17.5 million. These translate into per person completed primary schedule cost of $20.9-$26.2 and per dose (including vaccine cost) of $10.5-$13.1. Again, per person completed primary schedule excluding vaccine cost was $4.5 and $4.6, thus per dose excluding vaccine also ranged from $2.2 - $2.3. The main cost driver was vaccine doses, including shipping, which accounts for between 78% and 83% of total cost. Further, an estimated 8,437-10,247 vaccinators (non-FTEs) would be required during 2021-2022 to vaccinate using a mix of delivery strategies, accounting for 8-10% of total cost.

Despite widespread adoption of decentralization reforms, the impact of decentralization on health system attributes, such as access to health services, responsiveness to population health needs, and effectiveness in affecting health outcomes, remains unclear. This study examines how decision space, institutional capacities, and accountability mechanisms of the Intensified Mission Indradhanush (IMI) in India relate to measurable performance of the immunization program. Data on decision space and its related dimensions of institutional capacity and accountability were collected by conducting structured interviews with managers based in 24 districts, 61 blocks, and 279 subcenters. Two measures by which to assess performance were selected: (1) proportion reduction in the DTP3 coverage gap (i.e., effectiveness), and (2) total IMI doses delivered per incremental USD spent on program implementation (i.e., efficiency). Descriptive statistics on decision space, institutional capacity, and accountability for IMI managers were generated. Structural equation models (SEM) were specified to detect any potential associations between decision space dimensions and performance measures. The majority of districts and blocks indicated low levels of decision space. Institutional capacity and accountability were similar across areas. Increases in decision space were associated with less progress towards closing the immunization coverage gap in the IMI context. Initiatives to support health workers and managers based on their specific contextual challenges could further improve outcomes of the program. Similar to previous studies, results revealed strong associations between each of the three decentralization dimensions. Health systems should consider the impact that management structures have on the efficiency and effectiveness of health services delivery. Future research could provide greater evidence for directionality of direct and indirect effects, interaction effects, and/or mediators of relationships.

BACKGROUND:The Botswana Combination Prevention Project tested the impact of combination prevention (CP) on HIV incidence in a community-randomized trial. Each trial arm had ∼55,000 people, 26% HIV prevalence, and 72% baseline ART coverage. Results showed intensive testing and linkage campaigns, expanded antiretroviral treatment (ART), and voluntary male medical circumcision referrals increased coverage and decreased incidence over ∼29 months of follow-up. We projected lifetime clinical impact and cost-effectiveness of CP in this population. SETTING:Rural and periurban communities in Botswana. METHODS:We used the Cost-Effectiveness of Preventing AIDS Complications model to estimate lifetime health impact and cost of (1) earlier ART initiation and (2) averting an HIV infection, which we applied to incremental ART initiations and averted infections calculated from trial data. We determined the incremental cost-effectiveness ratio [US$/quality-adjusted life-years (QALY)] for CP vs. standard of care. RESULTS:In CP, 1418 additional people with HIV initiated ART and an additional 304 infections were averted. For each additional person started on ART, life expectancy increased 0.90 QALYs and care costs increased by $869. For each infection averted, life expectancy increased 2.43 QALYs with $9200 in care costs saved. With CP, an additional $1.7 million were spent on prevention and $1.2 million on earlier treatment. These costs were mostly offset by decreased care costs from averted infections, resulting in an incremental cost-effectiveness ratio of $79 per QALY. CONCLUSIONS:Enhanced HIV testing, linkage, and early ART initiation improve life expectancy, reduce transmission, and can be cost-effective or cost-saving in settings like Botswana.

Objectives Despite global concern over the quality of maternal care, little is known about the time requirements to complete the essential birth practices. Using three microcosting data collection methods within the BetterBirth trial, we aimed to assess time use and the specific time requirements to incorporate the WHO Safe Childbirth Checklist into clinical practice. Setting We collected detailed survey data on birth attendant time use within the BetterBirth trial in Uttar Pradesh, India. The BetterBirth trial tested whether the peer-coaching-based implementation of the WHO Checklist was effective in improving the quality of facility-based childbirth care. Participants We collected measurements of time to completion for 18 essential birth practices from July 2016 through October 2016 across 10 facilities in five districts (1559 total timed observations). An anonymous survey asked about the impact of the WHO Checklist on birth attendants at every intervention facility (15 facilities, 83 respondents) in the Lucknow hub. Additionally, data collectors visited facilities to conduct a census of patients and birth attendants across 20 facilities in seven districts between June 2016 and November 2016 (six hundred and ten 2-hour facility observations). Primary and secondary outcome measures The primary outcome measure of this study is the per cent of staff time required to complete the essential birth practices included in the WHO Checklist. Results When birth attendants were timed, we found practices were completed rapidly (18 s to 2 min). As the patient load increased, time dedicated to clinical care increased but remained low relative to administrative and downtime. On average, WHO Checklist clinical care accounted for less than 7% of birth attendant time use per hour. Conclusions We did not find that a coaching-based implementation of the WHO Checklist was a burden on birth attendant’s time use. However, questions remain regarding the performance quality of practices and how to accurately capture and interpret idle and break time. Trial registration number NCT02148952 .

BACKGROUND:The past two decades have seen expansion of childhood vaccination programmes in low-income and middle-income countries (LMICs). We quantify the health impact of these programmes by estimating the deaths and disability-adjusted life-years (DALYs) averted by vaccination against ten pathogens in 98 LMICs between 2000 and 2030. METHODS:16 independent research groups provided model-based disease burden estimates under a range of vaccination coverage scenarios for ten pathogens: hepatitis B virus, Haemophilus influenzae type B, human papillomavirus, Japanese encephalitis, measles, Neisseria meningitidis serogroup A, Streptococcus pneumoniae, rotavirus, rubella, and yellow fever. Using standardised demographic data and vaccine coverage, the impact of vaccination programmes was determined by comparing model estimates from a no-vaccination counterfactual scenario with those from a reported and projected vaccination scenario. We present deaths and DALYs averted between 2000 and 2030 by calendar year and by annual birth cohort. FINDINGS:We estimate that vaccination of the ten selected pathogens will have averted 69 million (95% credible interval 52-88) deaths between 2000 and 2030, of which 37 million (30-48) were averted between 2000 and 2019. From 2000 to 2019, this represents a 45% (36-58) reduction in deaths compared with the counterfactual scenario of no vaccination. Most of this impact is concentrated in a reduction in mortality among children younger than 5 years (57% reduction [52-66]), most notably from measles. Over the lifetime of birth cohorts born between 2000 and 2030, we predict that 120 million (93-150) deaths will be averted by vaccination, of which 58 million (39-76) are due to measles vaccination and 38 million (25-52) are due to hepatitis B vaccination. We estimate that increases in vaccine coverage and introductions of additional vaccines will result in a 72% (59-81) reduction in lifetime mortality in the 2019 birth cohort. INTERPRETATION:Increases in vaccine coverage and the introduction of new vaccines into LMICs have had a major impact in reducing mortality. These public health gains are predicted to increase in coming decades if progress in increasing coverage is sustained. FUNDING:Gavi, the Vaccine Alliance and the Bill & Melinda Gates Foundation.