The Epidemiology of Birth Defects

639–641Keywords: efavirenz, effectiveness, modelling, nevirapine, safety,sub-Saharan AfricaCombination antiretroviral therapy (ART) with eitherefavirenz (EFV) or nevirapine (NVP), both nonnucleo-side reverse transcriptase inhibitors (NNRTIs), and twonucleoside reverse transcriptase inhibitors (NRTI) isrecommended by the WHO as first-line therapy inresource-limited countries [1]. Compared with NVP,EFV is easier to monitor, is relatively well tolerated, hasless frequent and less severe rash and hepatic toxicity thanNVP, and can be administered once daily. Whereas NVPandEFVhavegenerallycomparableclinicalandvirologicefficacy [2–5], because of lower drug–drug interactions,EFV-based ART is associated with superior virologicoutcome compared with NVP-based ART in individualswith tuberculosis (TB) receiving anti-TB therapycontaining rifampicin. Therefore, efavirenz is theNNRTI antiretroviral drug of choice of TB-coinfectedindividuals [6–9]. However, there have been concernsregarding potential for central nervous system birthdefects with first-trimester exposure to EFV based onstudiesinpregnantrhesusmacaquesandretrospectivecasereportsinhumansthathavelimitedEFVuseinwomenofchildbearing age. This is a problem in many resource-limitedsettings,wherewomenconstitute50%or moreofHIV-infected individuals and TB is endemic, but there islimited access to contraception or women may wish tobecome pregnant.In this issue, Ouattara and colleagues use a computersimulation model to evaluate the risks and benefits ofusing EFV and NVP in women of childbearing age inresource-limited countries [10]. Using the previouslyvalidated Cost-Effectiveness of Preventing AIDS Com-plications (CEPAC) International model, the authorssimulated the trade-off between potential excess birthdefects and potential long-term clinical benefits forwomen starting EFV-based versus NVP-based ART inCote d’Ivoire. In a ‘hypothetical’ cohort of 100000women starting ARTwith EFV, the authors found that adrug with lower toxicity and requiring less regimenswitching led to approximately 911 more women aliveafter 10 years compared with those starting with NVP, animprovement in survival of approximately 1%. However,over thesameperiod,therewere59morebirthdefectsinwomen initiating EFV-based ART than those startingwith NVP. The authors concluded that in Cote d’Ivoire,initiating ART with EFV instead of NVP is likely to

IssuePublic health Institutes (PHIs) need to build on traditional approaches to capture and measure their value and impact. As we transfer into the COVID-19 recovery phase, it is important to maximise the value of the health impact but also the social, economic and environmental impact of PHIs. Exploration is required to understand how the social value and impact of PHIs is, or can be, captured and measured. Existing research has illustrated the potential link between Health Impact Assessment (HIA) which assesses health and well-being through the lens of the determinants of health, and economic methods such as Social Return on Investment (SROI). This research aims to understand the current role which PHIs have, in order to strengthen advocacy for investment in public health and prevention in order to protect and improve population health.Description of the problemA scoping survey was designed and distributed digitally to national and regional PHIs via international networks. Semi-structured interviews were also used to add a qualitative value to the research to allow for triangulation of results. The survey data was analysed descriptively and interview data analysed thematically and coded.ResultsThe results of the research present an understanding of the meaning of investment, social value and health impact within PHIs including how it is measured using SROI and HIA. It also highlights whether PHIs have considered how capturing social value and health impact can contribute to the recovery from COVID-19, and whether they believe that SROI and HIA have a role in achieving this.LessonsThis innovative work aims to develop a picture of how PHIs are capturing and measuring the wider social, economic and environmental value of their programmes and services. Survey results will be used to help develop a framework for capturing the wider impact and value of public health at an international level, with an aim to achieving sustainable investment in future public health.Key messages Making the case for investing in public health by illustrating its social, economic and environmental value is vital.Understanding how to capture and measure the wider value of public health is imperative to aid the recovery from COVID-19.

BackgroundMeasuring the broader health impacts and social value of public health initiatives is crucial for demonstrating value and securing sustainable funding. This research investigates the use of Health Impact Assessment (HIA) and Social Return on Investment (SROI) as tools to highlight the potential social, economic, and health outcomes of public health investments. The study focuses on integrating these tools to create more comprehensive evaluations and support policy decisions that foster a Well-being Economy.MethodsThe research employed a mixed-methods approach, including systematic scoping reviews of peer-reviewed and grey literature to assess the application of HIA and SROI in public health. In-depth case studies, expert interviews, and a national survey of Public Health Institutes (PHIs) provided additional insights. The study also explored the practical integration of HIA and SROI, including a case study of a self-administered service for Sexually Transmitted Infections.FindingsThe findings reveal that while HIA and SROI are typically used independently, their combined use can offer a more holistic view. However, challenges remain in standardising methodologies, particularly in stakeholder engagement and outcome valuation. The research identified key barriers, such as limited resources and a lack of expertise in PHIs, hindering the full potential of these frameworks. A case study demonstrated the practical application of both frameworks.ConclusionsThis research promotes the value of integrating HIA and SROI and emphasises the importance of fostering greater awareness and understanding of these frameworks. The research provides practical recommendations for advancing the use of HIA and SROI, including policy levers, workforce development, and standardised practices. The findings advocate for a Well-being Economy, where the value of public health is recognised beyond financial returns, fostering long-term investment.Key messages• Using both Health Impact Assessment and Social Return on Investment provides a comprehensive evaluation of public health initiatives, capturing both health outcomes and broader social value.• To capture the wider impacts and social value of investment in public health, greater awareness, standardised practices, and policy levers are essential for securing long-term investment.

Historically, Ontario has lagged well behind other jurisdictions in Canada in its ability to survey congenital anomalies within the province. Birth defect registries or programs exist in several provinces, namely, British Columbia, Alberta, Manitoba, Prince Edward Island, Nova Scotia and Newfoundland. While Ontario does track cases of Down syndrome, neural tube defects (NTDs) and trisomy 18 through its Maternal Serum Screening database, it has not had a province-wide program to survey birth defects until recently. Therefore, Dr Kim and other members of the Fetal Alert Network (FAN) (1) of Ontario are to be applauded for taking the first step in developing a birth defects registry that goes beyond the traditional model, by aiming to track anomalies detected before birth and linking them to postnatal outcomes. This approach recognizes the huge advances in prenatal detection and diagnosis of birth defects that have taken place in recent years. Fetal anomaly data will be critical in analyzing the effectiveness of various modalities that result in either a reduction in the incidence of birth defects or an improvement in health outcomes. Analysis of birth defect data without comparable data from prenatally diagnosed cases may lead to some false conclusions. A case in point: efforts to determine the relative contributions of primary versus secondary prevention of NTDs in British Columbia have shown that the declining birth rate of NTDs in the late 1990s was not primarily due to prenatal folic acid supplementation and food fortification, as might have been assumed before the study. Instead, the data showed that enhanced detection of NTDs by maternal serum screening and prenatal ultrasound was responsible for the decline (2). Surveys of prenatally diagnosed cases will also aid in determining prognostic factors for many congenital anomalies, as well as the effectiveness of various fetal medical and surgical therapeutic interventions, and the impact of mode, timing and location of delivery on morbidity for infants with birth defects. Similarly, the data could be used to track risk factors such as maternal age, health, ethnic background and socioeconomic status, exposure to teratogens, family history and other risk categories. Why track birth defects? Congenital anomalies are major contributors to paediatric morbidity and mortality, accounting for approximately one in 10 paediatric hospitalizations (3) and 30% of infant deaths (4). The rise in prominence of birth defects in infant mortality statistics appears to be related to a decline in deaths due to other causes, specifically, sudden infant death syndrome, respiratory distress syndrome, sepsis and asphyxia, as a result of public health campaigns and improvements in perinatal care. At the same time, overall infant mortality rates have declined sharply over the past 15 years, primarily due to advances in prenatal diagnosis and pregnancy termination of congenital anomalies (4). Ontario is Canada’s most populous province, with approximately 40% of the country’s annual births. Clearly, without data from Ontario, Canada-wide statistics would not be possible. While most of the population consists of urbanites, a substantial proportion live in rural settings in geographically diverse regions of the province. As in other areas of the country, prenatal health care providers vary from academic obstetricians in ‘downtown’ teaching hospitals to family doctors in small towns to nurse practitioners in remote nursing units in the far north. Increasingly, midwives are also providing obstetrical care. Data derived from the FAN will allow comparisons with other provinces and countries, as well as highlighting regional variations within the province. Such data may be used to determine, for example, if the incidence of specific anomalies varies with geographical location. These data will be critical in planning appropriate resources to allow optimal access to health care, both diagnostic and therapeutic, for the obstetrical patient population. One of the primary goals of the FAN is to gather data on all birth defects in the province. To date, collection of data has been restricted to patients referred to one of five regional perinatal centres, in which the FAN database is housed. The relatively recent introduction of perinatal centres in major centres has provided an important tertiary level service for complex maternal-fetal problems. However, a significant proportion of pregnancies with fetal anomalies are managed outside the perinatal centres. Genetics play a key role in the etiology of congenital anomalies in almost all cases. Whether it is the dominant factor as in chromosomal anomalies and single gene disorders, or one of a series of factors in single birth defects such as cleft lip and palate or congenital heart defects, understanding genetics is necessary to understanding birth defects. Clinical geneticists and genetic counsellors have and will continue to have a primary role in prenatal diagnosis and management of fetal anomalies. Through a network of clinics, both in major centres as well as outreach clinics in small communities throughout Ontario, the genetics community has provided prenatal genetics services for at least 30 years. It will, therefore, be critical for the FAN to access data from each of the genetics centres and clinics to come close to collecting data on the majority of prenatally detected anomalies. Another of the FAN’s primary goals is to improve access and coordination of health care service delivery for pregnant women whose babies have birth defects. To achieve this plan, a Web site with contact information for each of the five perinatal centres, complete with downloadable referral forms, is provided. Similar referral forms could be provided for each of the listed genetic centres and clinics as well. In addition, it would be helpful if providers were given guidance on which referrals are best directed to genetics clinics and which referrals should be sent to maternal-fetal medicine clinics. In relation to the access issue, a somewhat surprising finding in the FAN study was the late average gestation time for detection of fetal anomaly (21 weeks) and the even later average gestational age when patients were first assessed (24.7 weeks). At most genetics clinics, fetal anomalies are usually referred before 20 weeks and are seen immediately after referral. Little data are given about the spectrum of anomalies in the study group or whether the almost four-week lag time between first detection of the anomaly and consultation in a perinatal centre is due to a delay in referral or a problem with wait times. The FAN provides an exciting opportunity to survey congenital anomalies, both prenatally and after birth. The FAN will bring together a wide range of experts, all of whom have special knowledge and skills in diagnosing and treating congenital anomalies. In addition to experts in genetics, paediatrics and maternal-fetal medicine, surgeons, radiologists and paediatric pathologists will all undoubtedly play an important role. We look forward to the next phase of the project where attempts will be made to capture the majority of all birth defects identified in pregnancies and newborns in Ontario.

To discuss the value of intrapartum operation in management of birth defects and the prognosis. From August 2008 to November 2009, 11 fetuses were identified with birth defects through 3D color Doppler ultrasound and confirmed by MRI and fetal karyotype in the Maternal Fetal Medicine Center, Affiliated Shengjing Hospital, China Medical University including three lymphangiomas, two congenital diaphragmatic hernias (CDH), one sacrococcygeal teratoma, three omphalocele and two gastroschisi. All the above identified birth defects were indications for surgery. All fetuses were born abdominally and received intrapartum operations, including three intrapartum fetal operations with placental infusion (two repairs of CDH, one sacrococcygeal teratoma resection), six ex-utero intrapartum treatment (EXIT; two repairs of omphalocele, two repairs of gastroschisi, two lymphangioma resection) and two surgeries in house (one omphalocele repair and one lymphangioma resection). Both the mothers and fetuses were regularly followed up. (1) OPERATIONS: the average operating time for the three intrapartum fetal operations was 89 minutes, 5.5 minutes for the six EXIT, during which EXIT was performed first, followed by blocking the umbilical circulation and neonatal surgery, and 37 minutes for the two surgeries in house. All neonates survived except for one death from severe CDH at 3.5 hours after the operation. The average blood loss for cesarean section and fetal operation was 275 ml. All mothers recovered soon without fever or infection and were discharged three to five days after the operation. (2) Follow-ups: the ten survived neonates were followed up at 1-18 months at the pediatric clinics and all were growing and developing normally except for one baby with gastroschisi suffered from enteral torsion and feeding intolerance showed lower weight than babies at the same age, but caught up to normal at four months old after posture therapy. One baby with mild CDH developed pulmonary infection at two months after operation with 1/4 pneumothorax on chest X-ray, and were hospitalized for two weeks. At six months old, patent ductus arteriosus was diagnosed in the same baby and chest X-ray was normal. The baby with omphalocele was complicated with ventricular septal defect before operation and the cardiac function was normal during follow-ups for one year. The baby with sacrococcygeal teratoma was reported to have no automatic micturition, but recovered to normal at one month of age. Babies with certain birth defects can be managed through intrapartum operation with better outcomes.

Issue In 2019, the government of the Canadian province of Ontario announced major changes to the structure, governance and funding of public health services. Throughout these changes, publicly funded local and regional public health organizations are still expected to provide effective, evidence-informed programming to their communities. The National Collaborating Centre for Methods and Tools (NCCMT) has facilitated collaborations to support Ontario public health through this transition. Description of the problem In order to support evidence-informed public health in Ontario during this transition, the NCCMT reached out to current and potential partners, within and beyond the public health sector for a multidisciplinary approach. We conducted a needs assessment for an evidence review repository, which would allow public health practitioners to share and build upon each other's work. Finally, demonstrating the value of public health to policymakers can be inherently challenging as the return on investment in public health is often very long term. We partnered with health units in varying capacities to find and synthesize evidence to advocate for continued investment in public health. Results This initiative has provided important lessons in developing and maintaining strong partnerships. Looking beyond the public health sector can establish mutually beneficial partners and allies in other disciplines. A key finding was the need to establish infrastructure to support collaboration and resource sharing. Finally, we learned that big picture questions like demonstrating the value of public health require many different perspectives, inputs and areas of expertise. Lessons Through this initiative, we have developed a multidisciplinary, collaborative approach to supporting evidence-informed public health through times of major restructuring. This approach can be applied to future changes to public health on smaller or larger scales, or within other geographic regions. Key messages Multidisciplinary approaches can support collaboration, unity and advocacy in times of change. Establishing infrastructure to support collaboration and sharing of resources is valuable.

Peter Rickham was one of the first to recognize the advantages of centralized care for newborn infants with birth defects. A founder of the Liverpool Neonatal Surgical Center, he is currently surgeon in chief at the Zurich, Switzerland, Children's Hospital. The second edition of<i>Neonatal Surgery</i>summarizes his experiences as well as those of a number of other surgeons who work in these two centers. The nursing care, physiology, and general principles of surgical management of newborn infants are well discussed. The text is organized by regional anatomy, ie, the head and neck, chest and abdomen, rather than along "problem-oriented" lines, which seems to be a more effective teaching method. Each birth defect is discussed with reference to historical aspects, embryology, pathology, diagnosis, treatment, and results. The text is well illustrated with photographs and x-ray films, but line drawings illustrating operative technique are sparse and poorly done. In fact, there

Assisted reproductive technology (ART) has increased the incidences of multiple gestations and low birth weights, which frequently warrant pediatric surgery. ART may have also increased the rate of birth defects. In this study, we aimed to determine whether infants conceived after ART required neonatal surgery more frequently compared with naturally conceived infants. Our study population comprised 1891 infants (160 ART (+) and 1731 ART (-)) who were admitted to our neonatal intensive care unit during a 5-year period (January 2006-December 2010); of these, 198 infants (9 ART (+) and 189 ART (-)), with diseases requiring surgery, were referred to pediatric surgeons (consultation cases). We examined the following: (i) factors potentially increasing the requirement for surgery; (ii) frequency of birth defects; and (iii) maternal factors that may increase the need for surgery. A significantly higher incidence of multiple gestation and low birth weight was observed in the ART (+) group than the ART (-) group. However, ART did not yield a higher rate of surgery and birth defects: overall, the rate of surgery was 4% (7/160) in the ART (+) group and 8% (143/1731) in the ART (-) group. Of 198 consultation cases, the percentage of infants actually requiring surgery was approximately the same in the ART (+) group (7/9 [78%]) and the ART (-) group (143/189 [76%]). Infants conceived after ART comprised a small proportion of neonatal surgery cases, and did not require surgery more frequently.

&lt;p dir="ltr"&gt;&lt;b&gt;Objective: &lt;/b&gt;To assess clinical, economic, and social impacts of treating obesity among adult Medicaid beneficiaries, including budget implications and value of intensive lifestyle management, obesity medications, and metabolic/bariatric surgery.&lt;/p&gt;&lt;p dir="ltr"&gt;&lt;b&gt;Research Design and Methods: &lt;/b&gt;A Markov-based microsimulation model estimated 5-year (2025-2029) outcomes associated with evidence-based obesity treatments. The model simulated changes in body weight and cardiometabolic risk factors, projecting impacts on disease incidence and resulting social benefits—medical cost savings, productivity improvements, quality-adjusted life years, and mortality reductions. Model inputs were informed by clinical trials, economic studies, and nationally representative datasets.&lt;/p&gt;&lt;p dir="ltr"&gt;&lt;b&gt;Results: &lt;/b&gt;Obesity treatment could generate social return on investment of $3.81 per dollar nationally and $8.57 from states' perspective. Among 9.6 million Medicaid adults with obesity lacking qualifying obesity-related complications, 5.9 million could be referred for intervention, yielding approximately 2 million treatment person-years over five years. Treatment would produce 75,800 quality-adjusted life years ($7 billion value), $11.8 billion in mortality reductions, $847 million in productivity benefits, and nearly $1 billion in medical cost savings—totaling $15 billion in net social value nationally. Based on modeled treatment initiation and continuation rates, achieving these benefits would cost $5.4 billion nationally ($2.3 billion for states).&lt;/p&gt;&lt;p dir="ltr"&gt;&lt;b&gt;Conclusions: &lt;/b&gt;While medical savings offset only a portion of treatment costs, obesity interventions generate substantial social value through improved long-term health and productivity. These findings support expanded Medicaid coverage as a strategic investment in population health, demonstrating value that challenges conventional short-term budget-focused coverage decisions which currently limit access to evidence-based obesity treatments for millions of adults.&lt;/p&gt;&lt;p&gt;&lt;br&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;&lt;b&gt;Article Highlights&lt;/b&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;· &lt;b&gt;Why did we undertake this study?&lt;/b&gt; Limited evidence exists on obesity treatment's economic value within Medicaid populations, complicating coverage decisions.&lt;/p&gt;&lt;p dir="ltr"&gt;· &lt;b&gt;What is the specific question we wanted to answer?&lt;/b&gt; What are the clinical, economic, and social impacts of evidence-based obesity treatments among Medicaid adults over five years?&lt;/p&gt;&lt;p dir="ltr"&gt;· &lt;b&gt;What did we find?&lt;/b&gt; Obesity treatment would cost $5.4 billion nationally but generate $20.4 billion in social value through medical savings ($1 billion), productivity gains ($847 million), quality of life improvements ($7 billion), and mortality reductions ($11.8 billion), yielding a $3.81 return per dollar invested.&lt;/p&gt;&lt;p dir="ltr"&gt;· &lt;b&gt;What are the implications?&lt;/b&gt; Obesity treatment delivers significant social benefits surpassing medical cost savings, underscoring the need for expanded Medicaid coverage as a strategic investment in public health and population wellbeing rather than a budgetary concern.&lt;/p&gt;

The paper examines the effects on growth of both private and public investment in health, schooling and culture: in short, education.These expenditures exert two effects on the growth rate: (i)they increase labour and capital stock productivity through a positive externality, and (ii) they modify saving and investment decisions through the substitutability between education and private consumption.The different effects on economic growth of publicly financed education and private investment in education are investigated.The optimal growth rate depends on households' preferences for education.Moreover, there will be always an optimal tax rate that produces the same rate of growth in alternative regimes, private and public, of education financing.Universalistic public education exerts a strong positive externality on the economic efficiency butunlike private investments -it does not create sufficient incentives through income differentials to change consumer preferences for education.

Despite having achieved an average life expectancy of 75 years, much the same as that of more developed countries, Mexico entered the 21st century with a health system mared by its failure to offer financial protection in health to more than half of its citizens; this was both a result and a cause of the social inequalities that have marked the development process in Mexico. Several structural limitations have hampered performance and limited the progress of the health system. Conscious that the lack of financial protection was the major bottleneck, Mexico has embarked on a structural reform to improve health system performance by establishing the System of Social Protection in Health (SSPH), which has introduced new financial rules and incentives. The main innovation of the reform has been the Seguro Popular (Popular Health Insurance), the insurance-based component of the SSPH, aimed at funding health care for all those families, most of them poor, who had been previously excluded from social health insurance. The reform has allowed for a substantial increase in public investment in health while realigning incentives towards better technical and interpersonal quality. This paper describes the main features and initial results of the Mexican reform effort, and derives lessons for other countries considering health-system transformations under similarly challenging circumstances.

Salud mental y atención primaria en México. Posibilidades y retos

Background The elderly population of India has been growing exponentially over the past few decades, caused by a decline in fertility and an increase in life expectancy. The growth eventually has transcended the disease burden on the public healthcare system. This calls for a need to evaluate the healthcare utilization pattern of the elderly based on their socioeconomic and working condition. Methods Study used access to public and private healthcare services to measure healthcare utilization. Descriptive analysis and multivariable logistic regression were used to understand utilization patterns by working status and some selected sociodemographic parameters. All the results were reported at a 95% confidence interval. Results Using the data from the first wave of Longitudinal Ageing Study in India (LASI) with a sample of 22,680 older persons 60 years and above. The study identified that 50% of the working elderly access private services; however, 26% access public healthcare services. It was found that the working status of the elderly alone did not influence access to healthcare services, but education is also an essential indicator for utilizing healthcare services. Further, factors such as gender, marital status, religion, wealth, tobacco usage, self-rated health, ADL and IADL were significant predictors of healthcare services’ utilization for the elderly. Conclusion This study suggests that there are not many differences found among working and non-working status with healthcare utilization, although some sociodemographic indicators are associated with the utilization of healthcare services, highlighting that increasing health needs among the elderly requires strengthening the quality and appropriate public investment in health.

BackgroundA paradigm shift in global health policy on user fees has been evident in the last decade with a growing consensus that user fees undermine equitable access to essential health care in many low and middle income countries. Changes to fees have major implications for human resources for health (HRH), though the linkages are rarely explicitly examined. This study aimed to examine the inter-linkages in Zimbabwe in order to generate lessons for HRH and fee policies, with particular respect to reproductive, maternal and newborn health (RMNH).MethodsThe study used secondary data and small-scale qualitative fieldwork (key informant interview and focus group discussions) at national level and in one district in 2011.ResultsThe past decades have seen a shift in the burden of payments onto households. Implementation of the complex rules on exemptions is patchy and confused. RMNH services are seen as hard for families to afford, even in the absence of complications. Human resources are constrained in managing current demand and any growth in demand by high external and internal migration, and low remuneration, amongst other factors. We find that nurses and midwives are evenly distributed across the country (at least in the public sector), though doctors are not. This means that for four provinces, there are not enough doctors to provide more complex care, and only three provinces could provide cover in the event of all deliveries taking place in facilities.ConclusionsThis analysis suggests that there is a strong case for reducing the financial burden on clients of RMNH services and also a pressing need to improve the terms and conditions of key health staff. Numbers need to grow, and distribution is also a challenge, suggesting the need for differentiated policies in relation to rural areas, especially for doctors and specialists. The management of user fees should also be reviewed, particularly for non-Ministry facilities, which do not retain their revenues, and receive limited investment in return from the municipalities and district councils. Overall public investment in health needs to grow.

In 2004 the United Nations University World Institute for Development Economics Research (UNU-WIDER) embarked on a large-scale research project on the ‘Impact of Globalization on the World’s Poor’ co-directed by Machiko Nissanke and Erik Thorbecke. The first conference was essentially conceptual in nature, meant to understand better the various mechanisms and channels through which globalization affects the poor either directly or indirectly. The other three conferences focused on each of the major regions of the developing world: Asia, Africa and Latin America. Theobjectivesofthisintroductionarethreefold:first,toreviewbrieflyhow the forces of globalization influence poverty in general; second, to describe and discuss the main transmission channels and mechanisms; and third to analyze the impact of globalization on Africa and present an overview of the six Africa case studies included in this issue. 1. The Impact of Globalization on the World’s Poor Globalization provides a strong potential for a major reduction in poverty in the developing world because it creates an environment conducive to fastereconomicgrowthandtransmissionofknowledge. 1 However,structural factors and policies within the world economy and national economies have impeded the full transmission of the benefits of the various channels of globalization for poverty reduction. In particular sub-Saharan Africa (SSA) hasbeenrelativelylessaffectedbytheforcesofglobalizationthanotherparts of the world. World income distribution continues to be very unequal and many poor countries particularly in Africa are stagnating. Moreover, there is much empirical evidence that openness contributes to more within-country