Microfinance has become one of the most promising tools for development and poverty alleviation over the past two decades. Millions of borrowers around the globe have utilized microcredit to start or expand their small businesses and raise their household income. One poverty-induced problem microfinance could potentially alleviate is child labor. Despite international legislation prohibiting it, child labor continues to deprive millions of children of their right to education. Without education, there is little hope for a country to increase productivity and wealth in the future. A number of scholars have highlighted a negative correlation between credit rationing and child labor. However, there are no studies that examine whether or not children are less likely to work in households that participate in microfinance programs. In some circumstances, microcredit may increase household income and induce parents to withdraw their children from work while in others, raising the household income level may lead children to work more. In low-income countries with numerous microfinance institutions, many children work despite their parents’ access to credit. In order to examine this paradoxical phenomenon, this thesis presents a number of econometric models which analyze both child labor and credit at the household level. Though these models are vital in explaining the relevant trends, a purely economic analysis fails to capture the political and cultural factors that also engender child labor. To illustrate this complex relationship between economics and mores, this thesis highlights the impact of microfinance on child labor in Bangladesh. Bangladesh is an ideal country for this study because microfinance and child labor are both endemic. Finally, conclusions drawn from this analysis inform policy recommendations to amplify the effectiveness of microfinance on diminishing child labor.

Aim: The overall aim of this thesis was to generate further knowledge about prosthetic and orthotic services in developing countries. In particular, the thesis focused on patient mobility and satisfaction with prosthetic and orthotic devices, satisfaction with service delivery, and the views of staff regarding clinical practice and education. Methods: Questionnaires, including QUEST 2.0, were used to collect self-reported data from 83 patients in Malawi and 139 patients in Sierra Leone. In addition, 15 prosthetic/orthotic technicians in Sierra Leone and 15 prosthetists/orthotists in Pakistan were interviewed. Results: The majority of patients used their prosthetic or orthotic devices (90% in Malawi, and 86% in Sierra Leone), but half of the assistive devices in use needed repair. Approximately one third of patients reported pain when using their assistive device (40% in Malawi and 34% in Sierra Leone). Patients had difficulties, or could not walk at all, with their prosthetic and/or orthotic device in the following situations; uneven ground (41% in Malawi and 65% in Sierra Leone), up and down hills (78% in Malawi and 75% in Sierra Leone), on stairs (60% in Malawi and 66% in Sierra Leone). Patients were quite satisfied or very satisfied with their assistive device (mean 3.9 in Malawi and 3.7 in Sierra Leone out of 5) and the services provided (mean 4.4 in Malawi and 3.7 in Sierra Leone out of 5), (p<0.001), but reported many problems (418 comments made in Malawi and 886 in Sierra Leone). About half of the patients did not, or sometimes did not, have the ability to access services (71% in Malawi and 40% in Sierra Leone). In relation to mobility and service delivery, orthotic patients and patients using above-knee assistive devices in Malawi and Sierra Leone had the poorest results. In Sierra Leone, women had poorer results than men. The general condition of devices and the ability to walk on uneven ground and on stairs were associated with both satisfaction of assistive devices and service received. Professionals’ views of service delivery and related education resulted in four themes common to Sierra Leone and Pakistan: 1) Low awareness and prioritising of prosthetic and orthotic services; 2) Difficulty managing specific pathological conditions and problems with materials; 3) The need for further education and desire for professional development; 4) Desire for improvements in prosthetic and orthotic education. A further two themes were unique to Sierra Leone; 1) People with disabilities have low social status; 2) Limited access to prosthetic and orthotic services. Conclusion: High levels of satisfaction and mobility while using assistive devices were reported in Malawi and Sierra Leone, although patients experienced pain and difficulties when walking on challenging surfaces. Limitations to the effectiveness of assistive devices, poor comfort, and limited access to follow-up services and repairs were issues that needed to be addressed. Educating prosthetic and orthotic staff to a higher level was considered necessary in Sierra Leone. In Pakistan, prosthetic and orthotic education could be improved by modifying programme content, improving teachers’ knowledge, improving access to information, and addressing issues of gender equality.

Zugl.: Diss. rer. pol. Bern, 1979. / Berner Dissertation.

La tuberculose est une cause majeure de mortalité chez les enfants infectés par le VIH, représentant plus d'un tiers de la mortalité chez ceux-ci. Il n'existe actuellement pas d’estimation précise de la prévalence du VIH dans le million de cas de tuberculose pédiatrique annuel. Cependant, les décès liés au VIH pourraient représenter jusqu'à 1/5 de tous les décès dus à la tuberculose chez les enfants. Le diagnostic de la tuberculose est difficile chez les enfants du fait de sa nature paucibacillaire et des difficultés de recueil d’échantillons respiratoires. Il constitue un obstacle majeur à l'accès au traitement. Plus de 96% des décès pourraient survenir chez des enfants non traités. Les enfants infectés par le VIH présentent des difficultés diagnostiques accrues et une mortalité plus élevée. Notre objectif principal était de contribuer à l'amélioration du diagnostic de la tuberculose chez les enfants infectés par le VIH par le développement d'un algorithme diagnostic. Ce travail est basé sur l'étude ANRS 12229 PAANTHER 01 qui a recruté 438 enfants séropositifs âgés de 0 à 13 ans suspects de tuberculose dans 8 hôpitaux du Burkina Faso, du Cambodge, du Cameroun et du Vietnam d'avril 2011 à mai 2014. La mortalité était élevée (19,6%) chez les enfants naïfs de traitement antirétroviral (TARV), malgré l'accès au traitement. Elle était plus élevée les cas confirmés par l’Xpert MTB/RIF (Xpert) ou la bacilloscopie. Le traitement antituberculeux était associé à une diminution de la mortalité chez les tuberculoses confirmées et non confirmées et à un retard problématique au début du TARV, celui-ci étant associé à une réduction massive de la mortalité quand débuté durant le premier mois de suivi. L'évaluation de la performance diagnostique de l’Xpert sur des échantillons alternatifs, y compris des aspirations naso-pharyngées (ANP), des échantillons de selles et le string test a montré que la combinaison d’un ANP et d’un échantillon de selles avait une faisabilité (100%) et une sensibilité (75,9%) élevées par rapport aux méthodes standards (crachats ou aspirations gastriques). L’algorithme diagnostique a inclus 11 prédicteurs dont des symptômes et des signes, le contage, les résultats de radiographie pulmonaire (RP) et d'échographie abdominale, ainsi que les résultats du Quantiferon Gold In-Tube (QFT). L’aire sous la courbe de ROC était de 0,866 lorsque Xpert était inclus. Le score développé à partir du modèle avait une bonne performance diagnostique globale. L'interprétation de la RP avait un accord inter-relecteurs médiocre à passable pour la détection de lésions compatibles avec la tuberculose chez les 403 enfants avec toutes les revues disponibles, et une précision diagnostique limitée (sensibilité 71,4%, spécificité 50,0%) pour le diagnostic de la tuberculose chez 51 cas et 151 contrôles vivants sans traitement à 6 mois. Enfin, nous présentons des travaux sur l'utilisation chez les enfants infectés par le VIH du standard de référence recommandé pour les études diagnostiques sur la tuberculose, décrivant les changements dans la classification résultant d'une mise à jour récente et soulignant les limites de ces standards. Ce travail souligne la nécessité d'un diagnostic rapide de la tuberculose chez les enfants infectés par le VIH afin de réduire la mortalité. Il propose d'améliorer le diagnostic par une approche alternative à la confirmation microbiologique et le développement d'un algorithme rapide de décision de traitement chez les enfants à haut risque de mortalité. Il met en évidence les défis pratiques et méthodologiques liés à l'utilisation de la RP et du standard de référence diagnostique dans cette population. Le projet TB Speed permettra la validation externe de l'algorithme chez les enfants infectés par le VIH et contribuera à l'amélioration du diagnostic de la tuberculose et à la réduction de la mortalité chez les enfants en décentralisant la confirmation microbiologique et le diagnostic dans des pays à faible revenu. / Tuberculosis remains a major cause of death in HIV-infected children, accounting for more than 1/3 of mortality in this group. There are currently no estimates of HIV prevalence in the one million childhood tuberculosis cases every year. However, it is estimated that HIV-related deaths account for up to 1/5 of all tuberculosis deaths in children. Due its paucibacillary nature and difficulties in collecting respiratory specimen, tuberculosis diagnostic is challenging in children and is a major barrier hampering access to treatment. It is estimated that more than 96% of tuberculosis death could occur in children not receiving treatment. HIV-infected children present greater diagnostic challenges in a context of higher mortality. The main objective of this thesis was to contribute to the improvement of tuberculosis diagnosis in HIV-infected children by the development of a diagnostic algorithm. This work is based on the ANRS 12229 PAANTHER 01 study which enrolled 438 HIV infected children aged 0 to 13 years presenting with a suspicion of tuberculosis in 8 hospitals from Burkina Faso, Cambodia, Cameroon, and Vietnam from April 2011 to Mai 2014. The mortality was high [50 deaths (19.6%)] in 266 art-naïve children from this study, despite access to antiretroviral and tuberculosis treatment. It was significantly higher in those with bacteriological confirmation by Xpert MTB/RIF (Xpert) or smear microscopy. Introduction of tuberculosis treatment led to decreased mortality in both confirmed and unconfirmed tuberculosis and to delayed ART introduction, which is a problem, as ART was associated with a more than 10-fold reduction in mortality when started during the first month of follow-up. The assessment of the diagnostic performance of Xpert on alternative specimens including nasopharyngeal aspirates (NPA), stool samples, and string tests showed that a combination of NPA and stool samples had high feasibility (100%) and sensitivity (75.9%) and a yield similar to standard specimen collection methods consisting in sputum samples or gastric aspirates. We developed a tuberculosis diagnostic algorithm for HIV-infected children. The model identified 11 predictors including some symptoms and signs, history of contact, chest radiograph (CXR) and abdominal ultrasonography findings, and Quantiferon TB Gold In-Tube (QFT) results. Its area under the receiver operating characteristic curves was 0.839, and 0.866 when Xpert was included. The score developed from the model had a good diagnostic performance overall. CXR interpretation showed poor to fair inter-reader agreement for the detection of lesions consistent with tuberculosis in 403 children with all reviews available, and limited diagnostic accuracy (sensitivity 71.4%; specificity 50.0%) for the diagnosis of tuberculosis in 51 culture confirmed cases and 151 controls alive without treatment at 6 months. At last, we present work on the use of the recommended tuberculosis reference standard for diagnostic studies in HIV-infected children, describing changes in classification occurring from a recent update and highlighting limitations of these reference standards. Overall, this work contributes to highlight the need for an accurate and timely tuberculosis diagnosis in HIV-infected children to reduce mortality. It proposes two major ways to improve diagnosis by an alternative approach to microbiological confirmation and the development of an algorithm for prompt treatment decision in children with a high risk of mortality. It also highlights practical and methodological challenges related to the use of CXR and diagnostic reference standards in this population. The newly funded TB Speed project will enable external validation of the algorithm in HIV-infected children. By decentralizing Xpert performed on NPA and stool in district health systems in low-income countries, it will further contribute to the overall goal of improving tuberculosis diagnosis and reducing mortality in children.

Sanitation provision can in many low-income countries be regarded as a complex collective action problem, and is often managed through complex actor constellations. The theory of ‘polycentric order’ has been proposed for the governance of such constellations, describing ordered systems of interacting but autonomous actors. However, empirical data is largely lacking on how this concept can be applied to contribute to governance analysis in low-economy contexts. This paper uses polycentric systems theory to combine a broad assessment of system order with an evaluation of functional aspects associated with polycentricity. The theories are tested against a case study of the sanitation planning and implementation system of Kampala, Uganda, where responsibilities are split between multi-level authorities, NGOs, private sector actors and local landlords. Interviews with sector representatives indicate a system which is largely polycentric, but also to some extent lacks the essential aspect of common and enforced rules. While the diverse set of actors do show adaptive capacity, the analysis exemplifies how this capacity may give sub-optimal or even counteractive solutions if not matched by relevant incentive mechanisms at each level. Furthermore, the actor diversity is found to give enhanced capacity and sometimes function as a flexible ‘safety net’ in service provision, but also risk giving adverse effects in terms of equity and distribution. While some of these outlined problems may be alleviated by well-designed institutions, others are expected to come at a trade-off between flexibility and stability in actor roles. Conclusively, this study gives an empirical illustration of how a polycentric perspective can allow for a wider analysis of systemic problems in a decentralized, low-income governance context.

With 663 million people still without access to an improved drinking water source, there is no room for complacency in the pursuit of Sustainable Development Goal (SDG) Target 6.1: “universal and equitable access to safe and affordable drinking water for all” by 2030 (WHO, 2017). All of the current efforts related to water supply service delivery will require continued enthusiasm in diligent implementation and thoughtful evaluation. This cannot be over-emphasized in relation to rural inhabitants of low-income countries (LICs), as they represent the largest percentage of those still reliant on unimproved drinking water sources. In that lies the motivation and value of this thesis research- improving water supply service delivery in LICs. Manually operated suction pumps, being relatively robust, low cost, and feasible to manufacture locally, are an important technology in providing access to improved drinking water sources in LICs, especially in the context of Self-supply. It seems widely accepted that the water-lifting limit of suction pumps as reported in practice is approximately seven meters. However, some observations by our research group of manually operated suction pumps lifting water upwards of nine meters brought this “general rule of thumb” limit into question. Therefore, a focused investigation on the capabilities of a manually operated suction pump (a Pitcher Pump) was conducted in an attempt to address these discrepancies, and in so doing, contribute to the understanding of this technology with the intent of providing results with practical relevance to its potential; that is, provide evidence that can inform the use of these pumps for water supply. In this research, a simple model based on commonly used engineering approaches employing empirical equations to describe head loss in a pump system was used to estimate the suction lift limit under presumed system parameters. Fundamentally based on the energy equation applied to incompressible flow in pipes, the empirically derived Darcy-Weisbach equation and Hydraulic Institute Standards acceleration head equation were used to estimate frictional and acceleration head losses. Considering the theoretical maximum suction lift is limited to the height of a column of water that would be supported by atmospheric pressure, reduced only by the vapor pressure of water, subtracting from this the model was used to predict the suction lift limit, also referred to herein as the practical theoretical limit, assuming a low (4 L/min) and high (11 L/min) flow rate for three systems: 1) one using 1.25-inch internal diameter GI pipes, 2) one using 1.25-inch internal diameter PVC pipes, and 3) one using 2-inch internal diameter PVC pipes. In all considered cases, with an elevation equal to sea level, the suction lift limit was estimated to be over nine meters. At a minimum, the suction lift limit was estimated to be approximately 9.4 meters for systems using 1.25-inch internal diameter pipe and 9.8 meters for systems using 2-inch internal diameter pipe, with essentially no discernable effects noticed between pipe material or pipe age. Additionally, laboratory (field) trials using a Simmons Manufacturing Picher Pump and each of the aforementioned pipe specifications were conducted at the University of South Florida (Tampa, FL, USA) to determine the practical pumping limit for these systems. Results from the pumping trials indicated that the practical pumping limit- the greatest height at which a reasonable pumping rate could be consistently sustained with only modest effort, as perceived by the person pumping- for a Pitcher Pump is around nine meters (9 meters when using 1.25-inch internal diameter GI or PVC pipe and 9.4 meters when using 2-inch internal diameter PVC pipe). Therefore, results from this research present two pieces of evidence which suggest that the practical water-lifting limit of manually operated suction pumps is somewhere around nine meters (at sea level), implying that reconsideration of the seven-meter suction lift limit commonly reported in the field might be warranted.

SUMMARY Background: The practice of hand hygiene by nurses is important in preventing and decreasing hospital-associated infections. There are guidelines from WHO available about correct hand hygiene and it is not clear if nurses in low-income countries follow these guidelines. Aim: The aim of this review was to describe the challenges related to hand hygiene these nurses experience. Method: A qualitative literature review was conducted using twelve articles that were analysed using Friberg’s five-step analysis. The search was done in databases CINAHL, MEDLINE and PubMed. Results: The results were categorised into three categories; Challenges in education, Challenges in the working environment and Challenges in compliance. Most nurses in low-income countries were well-informed about hand hygiene, but many had undermined the practice due to lack of regular training, lack of necessary resources, feedback and role models. Conclusion: The study revealed that these nurses had knowledge about hand hygiene, although some of them showed confusion in hand hygiene products and routine. The review identified hindrances to effective hand hygiene practices in low-income countries. Regular courses about effective hand hygiene for nurses are recommended. Further research on qualitative data on hand hygiene while focusing on nurses’ experience in low-income countries is needed. / SAMMANFATTNING Bakgrund: Sjuksköterskan handhygien är viktigt för förbyggande och minskning av vårdrelaterade infektioner. Det finns riktlinjer från WHO om korrekt handhygien men det är inte tydligt om sjuksköterskor i låginkomstländer följer dessa riktlinjer. Syfte: Syftet var att beskriva de utmaningar som sjuksköterskor i låginkomstländer upplever relaterat till handhygien. Metod: En kvalitativ litteraturöversikt genomfördes där tolv artiklar analyserades med Fribergs femstegsanalys. Sökningen av artiklar utfördes i databaserna; CINAHL, MEDLINE och PubMed.  Resultat: Resultatet delades in i tre kategorier; Utmaningar i utbildning, Utmaningar i arbetsmiljö och Utmaningar i följsamhet. De flesta sjuksköterskor i låginkomstländer var välinformerade om handhygien, men många undervärderade god handhygien på grund av oregelbunden utbildning, brist på nödvändiga resurser, feedback och förebilder. Slutsats: Studien visade att sjuksköterskorna ofta hade kunskap om handhygien, men att en del sjuksköterskor var konfunderade angående produkter för handhygien och rutiner. Regelbundna kurser om effektiv handhygien för sjuksköterskor rekommenderas och vidare forskning av kvalitativ data om handhygien med fokus på sjuksköterskors erfarenheter i låginkomstländer efterfrågas.

Sustainable economic growth is vital to reduce poverty and a challenge to development. To aim and maintain a greater level of economic growth that will assist African countries in reducing poverty, they must investigate the specific determinants of economic growth. In this paper, we determine the impact of economic freedom, political freedom, and foreign direct investment on the gross domestic product. The gross domestic product was observed over a nine year-time period on a sample of 38 low-income and upper-income countries in Africa.

This thesis consists of three essays that address various aspects of the economics of maternal health care. The first two essays examine the determinants of utilization of maternal health care services in low-income countries, while the third essay examines the determinants of utilization of prenatal ultrasonography in Canada. The first essay examines the influence of prenatal attendance (as well as a wide array of observed individual-, household- and community-level characteristics) on a woman’s decision to give birth at a health facility or at home for thirty-two low-income countries (across Asia, Sub-Saharan Africa and Latin America). This empirical investigation employs the Demographic and Health Surveys (DHS) data and a two-level random intercept model. The results show that prenatal attendance has a substantial influence on the use of facility delivery in all three geographical regions. Women having four prenatal visits were 7.3 times more likely to deliver at a health facility than those with no prenatal care. The second essay addresses two related questions: what factors determine a woman’s decision to seek prenatal care; and are those the same factors that determine the frequency of care? This investigation also utilizes Demographic and Health Surveys (DHS) data for thirty-two low-income countries (across Asia, Sub-Saharan Africa and Latin America) and applies a two-part and multi-level model to that data. The results suggest that, though a wide range of factors influence both decisions, that influence varies in magnitude across the two decisions, as well as across the three geographical regions. The third essay examines the influence of various socioeconomic and demographic factors on the frequency of prenatal ultrasounds in Canada, while controlling for maternal risk profiles. This investigation utilizes data from the Maternity Experience Survey (MES) of the Canadian Perinatal Surveillance System and employs a count data regression model (the Poisson distribution) to estimate the effect of various factors on the number of prenatal ultrasounds. The results of this investigation suggest that, even after controlling for maternal risk factors, the type of health-care provider, province of prenatal care, and timings of first ultrasound are the strongest predictors of number of ultrasounds.

After decades of decrease, maternal mortality rates have shown a slight increase in Europe. Immigrants, especially Africans, have shown to be at higher risk than native women. This could not be explained solely by well-known obstetric and socio-economic risk factors. The aim of this thesis was to study incidence, classification and quality of care of maternal deaths in Sweden, with focus on the foreign-born population. The study population was identified through linkage of the Cause of Death Register, Medical Birth Register, and National Patient Register, and medical records obtained from hospitals. Data from registers, death certificates, and medical records were reviewed. Suboptimal care was studied by structured implicit review of medical records. Differences between foreign- and Swedish-born women were analysed by relative risks, Chi2- and Fisher’s exact test. Underreporting of maternal mortality was shown to be substantial: as compared to the official statistics, 64% more maternal deaths were identified. Women born in low-income countries were identified as being at highest risk of dying during reproductive age in Sweden. The relative risk of dying from diseases related to pregnancy was 6.6 (95% confidence interval 2.6–16.5) for women born in low-income countries, as compared to Swedish-born women. Major and minor suboptimal factors related to care-seeking, accessibility, and quality of care were found to be associated with a majority of maternal deaths and significantly more often to foreign-born women. Suboptimal factors identified included non-compliance, communication barriers, and inadequate care. The rate of suicides during pregnancy or within one year after delivery did not change during the last three decades, and was higher for foreign-born women. A majority of women who committed suicide had been under psychiatric care, but such documentation at antenatal care was inconsistent, and planning for follow-up postpartum was generally lacking. The conclusion of this thesis is that foreign-born women are a high-risk group for maternal death and morbidity that calls for clinical awareness with respect to their somatic and psychiatric history, care-seeking behaviour, and communication barriers. Cross-disciplinary care is necessary, both in obstetric emergencies and in cases of maternal psychiatric illness, to avert maternal death and suicide.