The impact of conditional cash transfers on health outcomes and use of health services in low and middle income countries.

BACKGROUND: Conditional cash transfers (CCT) provide monetary transfers to households on the condition that they comply with some pre-defined requirements. CCT programmes have been justified on the grounds that demand-side subsidies are necessary to address inequities in access to health and social services for poor people. In the past decade they have become increasingly popular, particularly in middle income countries in Latin America. OBJECTIVES: To assess the effectiveness of CCT in improving access to care and health outcomes, in particular for poorer populations in low and middle income countries. SEARCH STRATEGY: We searched a wide range of international databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, in addition to development studies and economic databases. We also searched the websites and online resources of numerous international agencies, organisations and universities to find relevant grey literature. The original searches were conducted between November 2005 and April 2006. An updated search in MEDLINE was carried out in May 2009. SELECTION CRITERIA: CCT were defined as monetary transfers made to households on the condition that they comply with some pre-determined requirements in relation to health care. Studies had to include an objective measure of at least one of the following outcomes: health care utilisation, health expenditure, health outcomes or equity outcomes. Eligible study designs were: randomised controlled trial, interrupted time series analysis, or controlled before-after study of the impact of health financing policies following criteria used by the Cochrane Effective Practice and Organisation of Care Group. DATA COLLECTION AND ANALYSIS: We performed qualitative analysis of the evidence. MAIN RESULTS: We included ten papers reporting results from six intervention studies. Overall, design quality and analysis limited the risks of bias. Several CCT programmes provided strong evidence of a positive impact on the use of health services, nutritional status and health outcomes, respectively assessed by anthropometric measurements and self-reported episodes of illness. It is hard to attribute these positive effects to the cash incentives specifically because other components may also contribute. Several studies provide evidence of positive impacts on the uptake of preventive services by children and pregnant women. We found no evidence about effects on health care expenditure. AUTHORS' CONCLUSIONS: Conditional cash transfer programmes have been the subject of some well-designed evaluations, which strongly suggest that they could be an effective approach to improving access to preventive services. Their replicability under different conditions - particularly in more deprived settings - is still unclear because they depend on effective primary health care and mechanisms to disburse payments. Further rigorous evaluative research is needed, particularly where CCTs are being introduced in low income countries, for example in Sub-Saharan Africa or South Asia

Heat and risk of myocardial infarction: hourly level case-crossover analysis of MINAP database.

OBJECTIVE: To quantify the association between exposure to higher temperatures and the risk of myocardial infarction at an hourly temporal resolution. DESIGN: Case-crossover study. SETTING: England and Wales Myocardial Ischaemia National Audit Project (MINAP) database. PARTICIPANTS: 24,861 hospital admissions for myocardial infarction occurring in 11 conurbations during the warmest months (June to August) of the years 2003-09. MAIN OUTCOME MEASURE: Odds ratio of myocardial infarction for a 1 °C increase in temperature. RESULTS: Strong evidence was found for an effect of heat acting 1-6 hours after exposure to temperatures above an estimated threshold of 20 °C (95% confidence interval 16 °C to 25 °C). For each 1 °C increase in temperature above this threshold, the risk of myocardial infarction increased by 1.9% (0.5% to 3.3%, P=0.009). Later reductions in risk seemed to offset early increases in risk: the cumulative effect of a 1 °C rise in temperature above the threshold was 0.2% (-2.1% to 2.5%) by the end of the third day after exposure. CONCLUSIONS: Higher ambient temperatures above a threshold of 20 °C seem to be associated with a transiently increased risk of myocardial infarction 1-6 hours after exposure. Reductions in risk at longer lags are consistent with heat triggering myocardial infarctions early in highly vulnerable people who would otherwise have had a myocardial infarction some time later ("short term displacement"). Policies aimed at reducing the health effects of hot weather should include consideration of effects operating at sub-daily timescales

Age-dependent health risk from ambient air pollution: a modelling and data analysis of childhood mortality in middle-income and low-income countries.

BACKGROUND: WHO estimates that, in 2015, nearly 1 million children younger than 5 years died from lower respiratory tract infections (LRIs). Ambient air pollution has a major impact on mortality from LRIs, especially in combination with undernutrition and inadequate health care. We aimed to estimate mortality due to ambient air pollution in 2015, particularly in children younger than 5 years, to investigate to what extent exposure to this risk factor affects life expectancy in different parts of the world. METHODS: Applying results from a recent atmospheric chemistry-general circulation model and health statistics from the WHO Global Health Observatory, combined in integrated exposure-response functions, we updated our estimates of mortality from ambient (outdoor) air pollution. We estimated excess deaths attributable to air pollution by disease category and age group, particularly those due to ambient air pollution-induced LRIs (AAP-LRIs) in childhood. Estimates are presented as excess mortality attributable to ambient air pollution and years of life lost (YLLs). To study recent developments, we calculated our estimates for the years 2010 and 2015. FINDINGS: Overall, 4·55 million deaths (95% CI 3·41 million to 5·56 million) were attributable to air pollution in 2015, of which 727 000 deaths (573 000-865 000) were due to AAP-LRIs. We estimated that AAP-LRIs caused about 237 000 (192 000-277 000) excess child deaths in 2015. Although childhood AAP-LRIs contributed about 5% of air pollution-attributable deaths worldwide, they accounted for 18% of losses in life expectancy, equivalent to 21·5 million (17 million to 25 million) of the total 122 million YLLs due to ambient air pollution in 2015. The mortality rate from ambient air pollution was highest in Asia, whereas the per capita YLLs were highest in Africa. We estimated that in sub-Saharan Africa, ambient air pollution reduces the average life expectancy of children by 4-5 years. In Asia, all-age mortality increased by about 10% between 2010 and 2015, whereas childhood mortality from AAP-LRIs declined by nearly 30% in the same period. INTERPRETATION: Most child deaths due to AAP-LRIs occur in low-income countries in Africa and Asia. A three-pronged strategy is needed to reduce the health effects of ambient air pollution in children: aggressive reduction of air pollution levels, improvements in nutrition, and enhanced treatment of air pollution-related health outcomes. FUNDING: None