Expanding access to contraceptive services by making them available in pharmacies and drug shops is a family planning high-impact practice. In 2018, Kenya's Ministry of Health amended its family planning guidelines to allow pharmacists and pharmaceutical technologists throughout the country to provide subcutaneous and intramuscular depot medroxyprogesterone acetate. Amending the policy did not necessarily mean that the policy would be implemented. The Advance Family Planning project launched an advocacy campaign to engage key stakeholders to work with the Ministry of Health to implement the policy. Consequently, a family planning training package for pharmacists and pharmaceutical technologists was developed and rolled out. The advocacy process also led to strengthening family planning reporting by the trained pharmacists and pharmaceutical technologists. To further enhance sustainability by ensuring a continuous pool of pharmacy professionals equipped with skills to provide family planning services, Advance Family Planning and its partners advocated with universities and the Pharmacy and Poisons Board to revise the pre-service training curriculum to include family planning as a competence area for pharmacists and pharmaceutical technologists. A key lesson learned is that policy formulation does not necessarily translate to policy implementation. Advocacy is often needed to move policy to practice, especially where resources are required. Policy implementation also requires incremental achievement of milestones and the need for advocacy for each step in the process. Implementation of the policy provision that allows pharmacists and pharmaceutical technologists to provide injectable contraceptives has implications beyond family planning programs. It provides a point of reference for allowing pharmacists to offer other primary health care services, such as immunization, injectable HIV prophylaxis, and other interventions that might not be provided for in policy. In low-Several studies have been documented to show the feasibility of provision of contraceptive services through pharmacies and drug shops. Currently, many users of short-term contraceptive methods, specifically contraceptive pills and condoms, access them through pharmacies and drug shops. In NigerFollowing the World Health Organization's guidance, many countries, including Kenya, embraced task sharing and shifting in FP program to allow pharmacists and drug shops to offer injectable contraceptives. In 2018, Kenya's Ministry of Health (MOH) amended its FP guidelines for service providers to allow pharmacists and pharmaceutical technologists (P&PT) throughout the country to provide subcutaneous and intramuscular depot medroxyprogesterone acetate (DMPA-SC and DMPA-IM) . DespiteAware that translating policies into practice can be a challenge, the Advance Family Planning (AFP) project, which focused on policy and budget advocacy, spearheaded measures to operationalize the policy to allow pharmacists and drug shops to offer injectable contraceptives and to ensure that the policy is implemented as was envisaged. This article outlines the process that AFP, in collaboration with pharmaceutical associations and other stakeholders, took to advocate for the policy to be implemented. In this article, we document our advocacy experience in implementation of the national guidelines that allowed P&PT to provide injectable contraceptives that led to the development of training packages and inclusion of the module in the preservice training curriculum. We believe this process can be applied to other sectors and other countries that are struggling to translate policy into action.2.2.1.Prior to 2018, the Kenya Family Planning Guidelines for Service Providers only allowed P&PT to provide condoms and contraceptive pills. For more than three years, AFP's local partner, Jhpiego, worked with the Pharmaceutical Society of Kenya and other key stakeholders to successfully advocate to have the guidelines amended to allow P&PT to provide injectable contraceptives. Consequently, Kenya's 2018 National Family Planning Guidelines for Service Providers (6th edition) recognizes that FP trained pharmacists and pharmaceutical technologists can counsel and provide injectable contraceptives in addition to pills and condoms and refer for long acting and permanent methods.Despite the 2018 policy amendment, a win that assured an enabling policy environment, the policy lacked an implementation plan. Advocacy was needed to translate the new amendment into practice . For ins2.2.AFP successfully advocated for the MOH to develop a FP training package for P&PT by making a case to the head of the Division of Reproductive and Maternal Health on the rationale and need to establish a technical committee that would lead the drafting of the training package. Subsequently, in April 2019, the MOH, through the Division of Reproductive Health and Maternal Health, established a technical committee with a clear mandate to lead the development of the training package under the oversight of the division. The committee included members from the Division of Reproductive and Maternal Health; the Pharmacy and Poisons Board (PPB), the regulatory body for drugs and the pharmacy practice; Kenya Pharmaceutical Association (KPA), which represents pharmaceutical technologists; Pharmaceutical Society of Kenya (PSK), which represents pharmacists; and key FP implementing partners.The committee developed a draft training package that includes the trainers' manual, which guides the facilitators in conducting the training; the participants' manual, which contains detailed reference information for trainees; and the logbook, in which a trainee logs all procedures they will need for certification. The training package was pretested and validated by key stakeholders in December 2019. Core elements of the training package included anatomy and physiology, counselling, medical eligibility criteria, contraceptive methods, and infection prevention and control. It also covered integration and referrals, reporting, commodity management, and pharmacovigilance. The package clearly outlines issues of accreditation for pharmacy outlets and certification of trainees.There was a pause in activity following the transition of the Head of the Department of Family Health. In June 2020, AFP partner Jhpiego mobilized other stakeholders inside and outside the MOH to brief the new head; he signed off on the training package a month later.2.3.Following the development of the training package, the technical manager in-charge of FP at the MOH engaged County Directors of Health and the County Reproductive Health Coordinators to get their buy-in to roll out the training. This was essential because following the training, the pharmacists and pharmaceutical technologists were expected to report to the counties. The national training coordination committee spearheaded the training of master trainers, the heads of pharmacy departments in higher (Universities)—and tertiary institutions such as Kenya Medical Training Colleges, and service providers from community pharmacies. A team led by PSK, KPA, and the PPB selected and identified training participants who were selected from Kenya's eight geographical regions . The team also worked to balance the composition between pharmaceutical technologists and pharmacists. Participants were required to be registered and enrolled by PPB and to have expressed an interest in the training, which ensured that the program was demand driven and not a push system and created ownership among the interested pharmacists. 2.4.The national MOH and the counties' Department of Health took the central lead in coordinating training, specifically the county Reproductive Health Coordinator and the County Pharmacist in counties where practicums were held. Health facilities with high numbers of FP consumers were selected to be practicum sites. The training covered all aspects in the training package and included theory sessions, practicums for skills transfer through use of humanistic models, and skills training in the health facilities. The MOH provided FP commodities for the practicum.Following the completion of the five-day in-person FP training, which involved three days of theory and two days of clinical skill practicum followed by clinical assessment, the trainees were awarded a certificate of participation. Both the certificate and logbook are co-signed by the MOH and the PSK and the KPA.2.5.Until recently, private pharmacies were not reporting in the national health information reporting system the FP services they provided. While the PPB Act requires P&PT to report to the national health management information system, compliance was weak. As a result, the MOH did not have comprehensive data to inform decision-making, especially in areas such as commodity forecasting and quantification.Following advocacy by AFP, the MOH established a reporting subcommittee within the broader FP pharmacy training coordination committee that included staff from the FP program within Division of Reproductive and Maternal Health, PSK members, and AFP staff. The subcommittee advocated for the establishment of a pharmacy reporting platform within the national health information with the leadership of the MOH Department of Monitoring, Evaluation, and Informatics and the PPB. As a result, the Department of Monitoring, Evaluation and Informatics developed a pharmacy reporting platform prototype through a co-creation approach with stakeholders. The prototype used unique identifiers for registered and licensed pharmacists supplied by the PPB. The department aligned the prototype with health facility FP reporting tools. The pharmacy reporting platform was further enhanced, pretested, and validated by stakeholders.Upon finalization of the pharmacy reporting platform, the Director General of the MOH issued a circular to all counties in Kenya describing the system and next steps. The Department of Monitoring, Evaluation and Informatics took advantage of the FP P&PT training to conduct orientation on the new reporting platform. Follow-on support was also provided to the trainees by the department post-orientation. Regular progress review meetings that brought trainees together also provided an opportunity to assess progress, troubleshoot reporting challenges, interact with the reporting system, and offer real-time system support. According to the reporting platform about 40 percent were reporting on the pharmacy platform as of December 2022.2.6.To sustain FP training and enable a continuous pool of pharmacy professionals equipped with skills to provide FP services, it was imperative that training be included in the PPB's pre-service core curriculum that provides a minimum package for training for P&PT. Universities and middle-level colleges in Kenya draw from this curriculum when developing their own curricula.AFP, the MOH Department for Family Health, and PSK engaged with the Training Technical Committee of the PPB to advocate for review of the core curriculum with a view to including FP. AFP had earlier conducted a landscape assessment that showed that the core curriculum was last revised in 2014, and was due for review in 2019, hence the time was ripe for a revision. In addition, there was a growing concern within the pharmacy profession for the need to change the perception of pharmacists from simply dispensers of drugs to providers of care. There was also an emerging appreciation of the need to make education more practical and less theoretical. Following the advocacy efforts, the Training Technical Committee and the Chief Executive Officer of the PPB sanctioned the revision of the core curriculum.The Training Technical Committee embarked on the revision of the core curriculum for both universities and middle-level colleges, which was reviewed by external experts drawn mainly from education institutions. Once input from the experts had been incorporated in the curricula, the draft curricula was then subjected to validation. The curriculum was validated by key stakeholders, including the Kenya Qualification Authority, Commission for University Education, technical and vocational training regulatory bodies, individual universities and colleges offering pharmacy, and professional bodies, specifically PSK and KPA.The validated core curriculum included new elements such as FP, immunization, supply chain, gender and health, and governance and leadership, among others. The curriculum shifted towards practicums and care aspects of the pharmacy practice to align it to emerging needs and current realities.AFP worked through PSK to advocate for implementation of pharmacists' FP training module within the pharmacists' training curriculum as a pilot within institutions of higher learning. A key aspect of this training focused on injectable contraceptives, including the associated counselling and clinical skills. Five public and private universities engaged in the pre-service training conversations: Mount Kenya University, Jomo Kenyatta University of Agriculture and Technology, United States International University, Kabarak University, and Kenyatta University. To enhance the prospect of incorporating FP in individual university curricula and training, AFP, working with the MOH and PSK, conducted training using the MOH in-service FP training package. The trainees were drawn from deans and lecturers in the pharmacy departments of the five participating institutions; each institution developed an implementation action plan for FP training.Regular quarterly reviews were conducted to assess progress on the action plans' implementation. By the end of 2022, one university had amended its curriculum to include FP, four universities had included FP in their student rotation/attachment logbooks, and one university had trained 130 of its students in FP, including clinical skills on how to provide injectable contraceptives. It is envisaged that the pre-service core curriculum by the PPB will spur additional universities and colleges to implement FP training in their respective schools of pharmacy.2.7.•Certification: Once a P&PT trainee has successfully completed the training, they will be awarded a certificate of participation by the MOH and the PSK or KPA. A health facility and a preceptor/mentor will be identified to supervise recording of completed procedures in a trainee's logbook, which they receive at the start of training to track the number of procedures needed to acquire competency. After trainees complete the number of recommended procedures, they submit their logbook to the MOH for verification. Trainees will then be awarded a certificate of competency co-signed by the MOH and the PSK or KPA.•Eligibility Criteria: The target group for this course is P&PT who will be involved in providing FP services. Selection of P&PT who will be FP providers will be based on whether they are accredited by PPB. P&PT will submit a letter of good standing from PSK or KPA. They should be working in a PPB-licensed premise at the time of admission to training and be a registered pharmacist or an enrolled pharmaceutical technologist with the PPB and an up-to-date member of PSK or KPA.The MOH's national FP program is mandated to ensure quality of FP services and build the capacity of and provide technical assistance to counties in the delivery of quality FP services. To ensure quality of training and FP service provision, the following were considered:3.3.1.Advocacy for the implementation of the policy that allowed P&PT to provide injectable contraceptives resulted in the MOH developing and rolling out an in-service FP training package and developing a pharmacy reporting platform within the national health information system.At the pre-service level, advocacy resulted in revision of the PPB's core curriculum to include FP. The revision also incorporated other important aspects such as gender, supply chain, immunization, and leadership and governance. An initial group of five universities are at various stages of implementing FP training within their respective pharmacy departments given that the module has been included in the national preservice curriculum.3.2.AFP faced several challenges along the advocacy journey. Transitions of key decision-makers within the MOH meant that advocates had to continually bring the new leaders on board, which slowed the process. There were also many key stakeholders who advocates needed to get buy-in from to move together as a team. Even after amendment of the FP guidelines to allow P&PT to provide injectable contraceptives, dissemination of training, and issuance of a circular on pharmacy reporting platform, there were actors and cadres within the MOH who were unaware of these developments. Some of these assumed pharmacists were providing services illegally by offering injectable contraceptives. To allay fears, the MOH issued certificates to those trained in providing FP services, including injectable contraceptives. The media was also engaged to increase visibility of the policy change.Introduction of a new pharmacy reporting platform to a cadre that rarely reported to the national health information system also meant that the Department of Monitoring, Evaluation and Informatics had to continually orient and provide support services to the newly trained P&PT.3.3.Engaging the PSK—a professional organization representing pharmacists—as an advocacy ally accelerated buy-in by pharmacists and pharmacy departments in educational institutions. Given that policy implementation involves many processes that require resources, the establishment of technical and coordination committees that included implementing partners helped to leverage resources.Engaging the PPB, which is highly revered, at the very onset of policy implementation helped to advance consensus and a harmonious working relationship, which were vital in achieving milestones. It also preempted formation of barriers that often emerge when critical stakeholders are not involved.Overall leadership by the MOH's Department of Family Health in the development of the pharmacists' FP training package increased ownership by government and deepened understanding of the issues and content of the package by technical managers within the department. These managers played a key role in engaging with other departments and regulatory bodies to make a case for achieving other milestones during the policy implementation advocacy phase.Proper timing on when to advocate for each implementation milestone increased the chances for actualizing desired outcomes. For example, engaging the PPB to review the pre-service core curriculum when there was a growing ideological shift to improve the training and pharmacy practice helped to advance the curriculum review.3.4.Based on our experience, the following are key considerations and lessons learned that can facilitate adoption of this task-sharing model in other similar contexts.3.4.1.While the World Health Organization had issued guidelines that recommended task sharing in provision of injectable contraceptives by pharmacists, advocacy was needed to translate the global guidance into Kenya's policy. Because task sharing may not be easily adopted, due to the interests of the various cadres, advocacy with all players can be essential for buy-in.3.4.2.Regulatory bodies are mandated to set standards for the education, training, and practice of the various health cadres and to monitor the practices of health workers, to ensure that they comply with those standards. Given that P&PT were not allowed to provide injectable contraceptives as per their scope of practice, engagement of regulatory bodies, specifically the PPB, at the onset of this process was imperative to ensure expansion of services provided by this cadre.3.4.3.Almost all health cadres have professional associations that champion their members' interest. Regulatory changes that culminate into policies are not adequate for implementation. Policy changes that affect health cadres need to get buy-in from the members through their association. It is against this backdrop that the project engaged the PSK (for pharmacists) and KPA  for ownership of this process.3.4.4.The MOH must lead and commit to implementing policy changes related to task sharing. In-service training of P&PT who were already providing services was led by the MOH, including quality assurance of service providers, linkage with the public sector for referrals, and reporting.3.4.5.To ensure the sustainability of the policy change, it was essential to engage academia in promoting pre-service training for students. Working with academic institutions that train P&PT led to the incorporation of a FP module into their curriculum. Incorporating FP-related content into P&PT's education was essential to improving and strengthening FP service delivery, as it allows students to develop a solid foundation of core knowledge and skills in FP. This has the potential to reduce the cost of in-service training.4.Policy formulation does not necessarily translate to policy implementation. Advocacy is often needed to move policy to practice, especially when resources are required. Policy implementation also demands the incremental achievement of different milestones, hence the need for advocacy at every step along the way. Implementation of the policy that not only allows and but also supports P&PT to provide injectable contraception in Kenya has implications for other programs and other countries, especially in an era where there is a high unmet need for FP and health workers are under-resourced and over-burdened. For women and teenagers who might be hesitant to get contraception at medical facilities, the policy reform provides an alternative place for them to receive care. Additionally, it increases the private sector's contribution to mitigating commodities shortages.Conversely, implementation of the policy that allows P&PT to provide injectable contraception in Kenya provides a reference and a way forward for allowing pharmacists to offer other primary health care services, such as immunization, injectable HIV prophylaxis, and other injection-oriented services not provided for in policy.Private pharmacies can provide an alternative point of access for FP during public sector industrial strikes, disease outbreaks, and other public health emergencies, which can reduce missed opportunities for providing FP care. In addition, private pharmacists who source their own injectable contraceptives may reduce public health commodity expenditures in a context where injectables are the most popular method in Kenya and in sub-Saharan Africa, a move that promotes a total market approach.Introducing FP training, including injectable contraceptives, during pre-service education is likely to reduce the cost of in-service training and contribute to sustainability of FP programs. Educational institutions can plough the cost of such training into the regular training, which can reduce the need for donor support to finance training—a common phenomenon for in-service training. Moreover, the data from the pharmacy reporting platform will eventually help with commodity forecasting and financing and can create an opportunity for other reporting areas that may be required of the pharmacy practice.


Background: In this paper, the effect of receiving a non-trivial cash grant and mentorship for business practice on individual earnings in Afghanistan was assessed. Methods: This randomized control trial(RCT) included 2177 individuals (n=2177), with the age range of 18-35 years. The amount of cash grant was approximately equal to the gross domestic product (GDP) per capita in the country (500 USD). By a process of lottery, eligible applicants were equally divided into the group that received the grant (treatment group) and the group that did not (control group). The regression estimation was conducted for the analysis. Results:The percentage of increased annual income to the size of this cash grant almost two years after this study was approximately 173 % and 69 % for males and females, respectively. This result was much higher than the estimated percentage reported in previous literature assessing the effect of microfinance loans and cash grants in other countries. The treatment group had a 7 percentage point higher probability of having an officially registered business than the control group. The treatment group also increased labor supply and employed additional workers, compared to the control group. The male treatment group bought more capital equipment  than the male control group, while the female treatment group bought more domestic animals. Conclusion: A non-trivial cash grant has a strong positive effect on the earnings of the recipient of the cash grant in Afghanistan. If the state of increased income continues for the next few years, the sum of increased income will be more than the sum of the administration cost, the interest cost and the amount of cash grant given. It implies that the project passes the standard criteria to determine the appropriateness of government program. Additionally, we did not find any economically and statistically significant positive effect of mentorship on income. Lack of adequately paying jobs has become a major challenge in Afghanistan. In 2016–2017, according to Afghanistan Living Conditions Survey, 25% of the population were unemployed and 54% lived below the poverty line . Even amHowever, the prevalence of informal microenterprise is not unique to Afghanistan but common among the majority of developing countries . Thus, tIn the last decade, through randomized experiments, a growing number of studies have indicated the strong and positive effect of cash grants on income growth and microenterprise activities in developing countries . In AfghIn this paper, we have analyzed the effects of receiving a non-trivial amount of cash grant in Afghanistan for individuals aged 18–35 on their income growth.Our study has several unique aspects. First, most previous studies with the same topic were conducted in relatively peaceful countries, except for post-conflict studies in Uganda byWith the high population growth rate of Afghanistan and the security situation, providing reasonable jobs to people becomes challenging because lower security condition makes it difficult to conduct businesses and decreases the incentive to start a new business and to purchase equipment. According to Afghanistan Living Conditions Survey 2016–2017 , unemploThe security condition in Afghanistan is getting worse. According to the Special Inspector General for Afghanistan Reconstruction, in 2017, the middle year in the experiment, approximately 59.7% of the country's 407 districts were under Afghanistan government control or influence; 11.1% of total districts were under insurgent control or influence; 29.2% of all districts were contested districts. . Accordi In terms of education, there is a substantial disparity between males and females, depending on the area. For example, in urban areas, 66.9% of males and 40.8% of females are literate, whereas in rural areas these values decrease to 45.6% and 13.1% for males and females, respectively. The poverty rate is also severe in Afghanistan. In 2016, it was reported that 54% of households had expenditure less than the poverty threshold.Gender roles in both intra-household and business in Afghanistan are influenced by socio-political aspects . MoreoveThe "Purda" principle restricts women's mobility outside the house. This principle is derived from the Pashtunwali; a quasi-legal system practiced among the Pashto ethnic in Afghanistan and Pakistan . . Accordiwomen are inferior beings who are subordinate to men and must be strictly protected for males' honor .The implementation of the Salafi (a branch of Sunni Islam) religious sect has negatively impacted women's access and control over resources at both domestic and community levels. Therefore, this interpretation emphasizes restoring the lifestyle and tradition of the Prophet Muhammad (from the 7th century AD) and fighting against any religious innovation  in terms of interpretation  Abiraf, includiDue to those two aspects, there were no changes in individuals' attitudes about women's role in the intra-household decision-making and the general status of women in society in the past two decades. Meanwhile, increasing insecurity exacerbated restrictions on women's mobility. Furthermore, no positive effect was found concerning the positive attitude toward women's participation in the village governance in Pashto-majority areas, and this attitude difference was significant compared with other ethnolinguistic districts.  project in Bangladesh from 2007 to 2011,In a randomized trial control conducted in Tanzania,In connection to alleviating capital constraints,In an experiment conducted byIn summary, those studies demonstrate the positive impact of unconditional cash transfers on self-employment and promoting small-scale entrepreneurship in developing countries. However, the positive effects depends on additional elements such as gender, frequency and amount of cash transfers, and the inclusion of other initiatives such as business training. Furthermore, based on the obtained results, despite all the conditions being the same, the outcome among female recipients was less clear than male recipients, suggesting the more significant influence of gender differences affecting the return of unconditional cash transfers.The program "Promoting Entrepreneurship among the Youth in Afghanistan" (PEYA) was an RCT-based project funded by the Afghan Reconstruction Trust Fund. It was launched in August 2015 and closed in July 2018. The PEYA program was implemented by the Ministry of Labor and Social Affairs of Afghanistan in Balkh, Kabul, and Nangarhar provinces. The program's objective was to help establish new micro-enterprises or expand existing businesses by providing a cash grant of USD 500 ), which is equivalent to 2017 GDP per capita in the country to zero or low education individuals. In this study, 3490 eligible applicants were chosen depending on their business proposals. Based on a lottery process, half of the study participants (1745) were assigned to the treatment group where they received a cash grant, whilst the other half who were assigned to the control group did not receive a cash grant. The lottery and the baseline interview were conducted in August 2016. Due to the potential lack of sufficient numbers of mentors who could give mentorship on businesses, mentorship on businesses was randomly given to the half of individuals who received the cash grant and lived in Kabul . As presented inThe selection process of the grantees started by providing information about the intervention and eligibility criteria. Four districts in each province were specified. The operation teams were assigned to mobilize the communities in these areas. This process lasted for 30 days, and each community was visited twice. During the initial briefing (week 1) and refresher briefing (week 2), information about the objective and selection criteria was also shared with local authorities, such as the governor's office staff, provincial councils, and community leaders.The application form was a three-page questioner containing 19 questions that covered six sections  (Underlying data) . The ansConsidering the low level of literacy within the communities, application forms printed on large banners were also provided in addition to conventional brochures and posters. Subsequently, the applicants were selected based on an evaluation of their initial submitted business plan, which included information, such as education, age, demographic characteristics, income, work experience, business type, and their plans on how they would spend the grant. In many cases, the applicants were assisted by other family members, neighbors, etc., who had a higher level of education and were able to convey the information in the application form. The applications with a higher score than the threshold level of the score become qualified for the lottery process. After the qualified applicants were selected, scheduled meetings for baseline interviews and lottery were announced to be held in each province. At the meetings, professionally trained interviewers conducted the baseline interviews. After which each qualified applicant draws a lottery number that determines the receipt of the cash grant.Given the amount of the cash grant and concern about corruption in the process of choosing the recipients, it was important that all applicants understood that the recipients of cash grants were chosen fairly. Thus, the process of lottery took place in the presence of representatives from provincial councils, provincial governors, the Implementing Partner Agency (IPA), ESCs, and representatives of provincial directorates of labor and social affairs. After determining the recipients of the grant, a three-member panel verified the information provided, and the grant agreement was signed. Finally, the full grant was transferred in one transaction to the grantees' submitted bank account.Regarding the endline, the evaluation teams started to interview individuals among those who participated at the baseline in June 2018 and closed in July 2018. The teams interviewed 3005 individuals. However, due to miscommunication between the Ministry of Labor and Social Affairs and the external teams, the external team did not record the ID numbers for some surveyed individuals in the endline which could match individuals of the endline with those in the baseline. To ensure that correct matching was implemented, we included only individuals whose ID number and national identity number were matched in the baseline and the endline data in the final analysis sample. As a result, the final sample size was 2177 individuals (n=2177) in this study, with the number of the individuals in the treatment group (1146) slightly higher than that of the control group (1031) at the endline , implyinAs the PEYA program is a Randomized Control Trial (RCT)- Experiment, we estimate the effect of the policy by estimating the intent to treat (ITT) with the following analysis of covariates specification:i,AY is the outcome variable in the endline period  for individual i,i,BY is the outcome variable at the baseline of individual i, andiGrant is the dummy variable which is equal to one if individual i received the grant and zero if not.where i is the index of an individual,β1 captures the impact of the cash grant;i,BX is a set of control variables at baseline, which includes age group dummy, province dummy, years of schooling, and zero education dummy; andiε refers to the individual error term. We estimate the above equation using ordinary least squares (OLS). In order to address the potential bias that can occur due to the high attrition rate, several robust bounding methods are applied in this study .Panel C shows income-related information at the baseline. The results indicate that 92 % of the individuals in our study were new to business, implying that they had not started their businesses yet at the baseline. Specifically, the average income in the last month at the baseline was approximately 4,000 Afs. The P-value of the joint significant test, which is 0.412, shows that our analysis sample was balanced.In our analysis sample, according toDespite the high attrition rate, overall, the balancing tests ofIn(48000/33500) × 100 = 143%.Column (2) displays the effect of receiving a cash grant on monthly earnings in the male group. It shows that receiving the cash grant increased the monthly earnings by about 4839 Afs, and therefore the percentage of the increased annual income to the amount of the cash grant for this group was 173 %.Column 3 displays the effect of receiving the grant on monthly income on the female group. The column shows that receiving the cash grant increased the monthly earnings by about 1900 Afs, which is less than half of the estimated effect on the male group. It implies that the percentage of the increased annual income to the amount of the cash grant for this group was 69 %.Thus, in either of three cases, if the state of increased income continues for the next few years, the sum of increased income will be more than the sum of the administration cost, the interest cost and the amount of cash grant given. It implies that the project passes the standard criteria to determine the appropriateness of government program.In columns 4 – 6, we added several important covariates and checked whether our estimated coefficients were sensitive to the inclusion of those control variables. These columns indicate that the estimated coefficients of the grant variable reported in columns 1 – 3 are not sensitive to the inclusion of various control variables (Extended data) . AdditioAs mentioned previously, the endline study sample size was much smaller than that of the baseline due to the administrative error during the data collection. One concern was whether such attrition of the sample affects the estimated coefficients. Therefore, we controlled for the attrition by applying the inverse probability weighted (IPW) estimation  Table , Panel AInInTo further correct for attrition bias, Lee's treatment effect bounds for receiving the cash grant on monthly earnings was estimated , Panel COverall, analysis based on several estimation methods demonstrates that the effect of receiving the cash grant on monthly earnings was economically and statistically significant.Panel B shows the effect of the cash grant on the number of household members working for a micro-enterprise. Panel B shows that an individual who received the cash grant increased the number of household members working for their microenterprise by 0.2 persons on average. Column 2 of Panel A, a male individual who received the cash grant increased the number of family members working for their microenterprise by 0.18 persons on average. Column 3 shows that a female individual who received the cash grant increased the number of family members working for their micro-enterprise by 0.254 persons on average.Panel C shows the effect of the cash grant on the number of non-household members working for a micro-enterprise. Column 1 shows an individual who received the cash grant increased the number of non-family members who work for their microenterprise by 0.23 persons. Column 2 shows that, for the male group who had received the cash grant, the employment number of non-family members increased by 0.232 persons. The results in column 3 show that, for the female group who had received the cash grant, the number of non-family members who were employed for their microenterprise increased by 0.229 persons.When starting or extending a business, additional equipment, such as a phone, a truck, and a cart, might be needed. Panel D shows the effect of receiving cash grants on the general asset index for production. To calculate the general asset index for production, we first standardized the level of each asset for production. Then, through the principal component analysis, we determined the weight for each asset and calculated the weighted index . As showResults in Panel E display the index of assets for consumption. Columns 2 and 3 show that receiving the cash grant increased the index of assets for consumption by 0.1 standard deviation for the male group, and decreased it by 0.02 standard deviation for the female group. When the control variables were included in the estimation, the estimated coefficient and statistical significance did not change. Columns 5 and 6 show that the cash grant increased the index of assets for consumption for the male group by 0.094 standard deviation and decreased it by 0.073 standard deviation for the female group. Thus, for the male group, receiving the cash grant increased the index of assets for consumption. However, our results do not reflect the same for the female group.Islamic Republic of Afghanistan ended on August 15, 2021 . The facIn contrast, the results of this study have shown that the effect of a non-trivial cash grant on income is substantial in Afghanistan. The percentage of increased annual income to the size of this cash grant almost two years after receipt of the cash grant was approximately 173% for males and 69% for females. The treatment group had a 7 percentage point higher probability of having an officially registered business than the control group. The treatment group also increased labor supply and employed additional workers, compared to the control group. The male treatment group bought more capital equipment  than the male control group, while the female treatment group bought more domestic animals. Our results are consistent with the previous studies in other countries which similarly show a positive effect of cash grants on income . HoweverWe would like to emphasize, however, that this study had some limitations. First, the endline survey was conducted almost two years after the study. Thus, the short-term effect of cash grants was measured. As we discussed in the introduction, initially we had a concern that giving cash grants may not enhance economic activities in Afghanistan due to negative perception toward women's business and the prevalence of corruption. First, our estimation results show that although the effect of the cash grant on female individuals is lower than the effect of the grant on male individuals, the effect on earnings of female individuals is strong enough to justify the cash grant. Second, despite the prevalence of corruption in Afghanistan, the effect of the cash grant is strong. One possible reason for the effectiveness of this program might be through the transparency of the selection of the recipients of the cash grants. For choosing the recipients of the cash grant, the project paid special attention to the lottery process so that they were determined randomly. This implies that although the lottery process prevents the project from choosing the best candidates, it also prevents the project from choosing corrupted, incapable individuals, which often happen in the government contracts in Afghanistan . This inFourth, in this experiment, the receipt of the cash grant is randomized at each individual level instead of each village level. This implies that if there is a positive (negative) externality of the cash grant and if treatment individuals and control individuals tended to live in the same village, the effect of the cash grant is underestimated (overestimated). In our context, a positive externality is likely if the recipient of the cash grant starts a new business, employs other individuals and increases the income of other individuals as well as his/her own income. A negative externality is likely if the recipient of the cash grant starts a new business and a new entry to an existing market decreases the profit of the control individuals. In other studies, using GPS information of each individual, we examined how the distance of each individual to the nearest treatment individual affects the estimated coefficient of the cash grant dummy. We found that there is no systematic correlation between the distance and the estimated size of the coefficient of the cash grant dummy. This suggests that it is unlikely that the experimental design that uses individual level randomization induce a systematic bias.  According to International Monetary Fund (IMF), the lending interest rate in Afghanistan in 2016 was 15% . Given tNon-trivial cash grants had a substantial effect on the monthly earnings of the treatment group two years after this study. The percentage of increased annual income to the size of this cash grant two years after the Experiment is approximately 173% for males and 69% for females. We did not find evidence that receiving mentorship on business increases monthly earnings. The reulsts could indicate that the cash grant is useful tool to increase income in a country that suffers from a lack of security, a high level of corruption, a low level of literacy, and gender inequalities.It is still not clear as to why receiving a large amount of cash grant has such a significant effect on the monthly earnings. To investigate, further longitudinal studies are needed to not only confirm the results of this study but to utilise quantitative and qualitative strategies to assess how such a large cash grants can affect the economy of a household. Authors added a more comprehensive literature review on the impact of cash grants and provided recommendations. The research is interesting and timely; it relates in a coherent and cogent way to issues of real-world significance. The authors evaluated the effect of implementing a government program and conducted research on how the prevalence of informal microenterprises can be transformed into an opportunity for income and employment growth. In Afghanistan, where a quarter of the population is unemployed and more than half of the population lives below the poverty line, the government implemented a program that helped establish new microenterprises by providing a cash grant. The authors make an original contribution to knowledge by investigating the effect of cash grants on income growth in the context of Afghanistan. The uniqueness of this research is that it focuses on a country that suffers from a lack of security, a high level of corruption, a low level of literacy, and gender inequalities. Afghanistan is an Islamic country with rigid social norms and a high female unemployment rate due to a negative attitude toward women empowerment and a lack of support for women in business. Nevertheless, research found that cash grant has a strong positive effect on the earnings of the recipients. However, this research found that the increase in annual income was 2.5 times higher for males than females. The article demonstrates the applicability, relevance, and effectiveness of the program and will be useful for other fragile or war-torn countries that need reconstruction. Also, receiving a cash grant, which does not involve the repayment of principal and interest, would be effective in Islamic countries. Conclusions are clear and insightful, as they are drawn from the data,Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?I cannot comment. A qualified statistician is required.Are all the source data underlying the results available to ensure full reproducibility?No source data requiredIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:NAI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. The research is interesting and timely; it relates in a coherent and cogent way to issues of real-world significance. The authors evaluated the effect of implementing a government program and conducted research on how the prevalence of informal microenterprises can be transformed into an opportunity for income and employment growth. In Afghanistan, where a quarter of the population is unemployed and more than half of the population lives below the poverty line, the government implemented a program that helped establish new microenterprises by providing a cash grant. The authors make an original contribution to knowledge by investigating the effect of cash grants on income growth in the context of Afghanistan. The uniqueness of this research is that it focuses on a country that suffers from a lack of security, a high level of corruption, a low level of literacy, and gender inequalities. Afghanistan is an Islamic country with rigid social norms and a high female unemployment rate due to a negative attitude toward women empowerment and a lack of support for women in business. Nevertheless, research found that cash grant has a strong positive effect on the earnings of the recipients. However, this research found that the increase in annual income was 2.5 times higher for males than females. The article could be enriched by a literature review of previous research on the effect of cash grants in other countries and a discussion on culture-specific differences in gender roles at home and in the business in Afghanistan. The article demonstrates the applicability, relevance, and effectiveness of the program and will be useful for other fragile or war-torn countries that need reconstruction. Also, receiving a cash grant, which does not involve the repayment of principal and interest, would be effective in Islamic countries. Conclusions are clear and insightful, as they are drawn from the data, but could be expanded by recommendations. Minor proofreading and check results by qualified statisticians are suggested.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?I cannot comment. A qualified statistician is required.Are all the source data underlying the results available to ensure full reproducibility?No source data requiredIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:Cross-cultural differences, education, oil and gas industry, sustainabilty.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Reply to the second referee Thank you for reading our manuscript and providing constructive comments.Comment 1: “The article could be enriched by a literature review of previous research on the effect of cash grants in other countries and a discussion on culture-specific differences in gender roles at home and in the business in Afghanistan.”Reply: On page 3, we added a section regarding the literature on the effect of cash grants and provided a comprehensive literature survey. Furthermore, on page 2, we discuss culture-specific differences in gender roles at home and in business in Afghanistan. We hope that our literature survey and discussion on the role of culture in women’s lives are satisfactory.Comment 2: ”Conclusions are clear and insightful, as they are drawn from the data, but could be expanded by recommendations. Minor proofreading and check results by qualified statisticians are suggested.”Reply: We provide some recommendations in the Conclusion section. More specifically, we wrote, “The results could indicate that the cash grant is a useful tool to increase income in a country that suffers from a lack of security, a high level of corruption, a low level of literacy, and gender inequalities.” We also asked a professional company to proofread our revised manuscript. The research field of one of the authors is applied econometrics. In the past, Naito conducted theoretical research on econometrics and published a paper. He checked the econometric aspects of this paper thoroughly. etc. and the challenges they face. The paper is based on an interesting issue pertaining to economic empowerment through micro enterprises. The gender inequalities in terms of access to  income was apparent in case of women. The paper would have benefitted more from literature highlighting the gendered constraints of women .The paper has highlighted that the percentage of annual income to the size of cash grant was greater for males in comparison to females. The reason for this could have provided a fresh insight into the study, for example women's access to resources, finances The paper definitely raises certain questions that need more in depth research in future. On the whole, the paper is based on a very important topic and may be considered for indexing after checking the statistical part from trained statisticians. As the authors have clearly indicated that further studies on qualitative aspects are required. I would suggest to explore the qualitative aspects with a focus on gender dimensions particularly contextualizing women in fragile contexts may be in another paper in future.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?I cannot comment. A qualified statistician is required.Are all the source data underlying the results available to ensure full reproducibility?No source data requiredIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:gender and labour market research, unpaid work,time use studies, gender ,labour laws and international labour standardsI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Reply to the first referee Thank you for reading our manuscript, approving it, and giving constructive comments. As you suggested, in our future research, we are planning to explore the points you suggested, that is, the qualitative aspect of gender in Afghanistan. Thank you.


Damage to the central nervous system can occur in adulthood, for example, due to stroke, trauma, tumours, or chronic diseases. After damage to the central nervous system, cognitive impairments occur in addition to physical limitations. Occupational therapy is most often prescribed for neurological diagnoses, including stroke and traumatic brain injury.  The health technology assessment (HTA) report this HTA article is based on investigates the clinical effectiveness, cost-effectiveness, and patient-related, social and ethical aspects of occupational therapy for patients with cognitive impairments compared to no occupational therapy. In addition, the effects of different occupational therapy interventions with and without cognitive components were compared in an explorative overview. Patients with moderate or severe dementia are excluded from the assessment. Systematic overviews, that is, systematic reviews of systematic reviews, were conducted. For the evaluation of clinical effectiveness, a total of nine systematic reviews were included. No systematic review was identified for the assessment of costs or cost-effectiveness. Five systematic reviews were included for the assessment of patient and social aspects. For the assessment of clinical effectiveness compared with no occupational therapy, five systematic reviews comprising 20 randomised controlled trials with a total of 1,316 subjects reported small positive effects for the outcomes “global cognitive function” and “activities of daily living” as well as a non-quantified positive effect on the outcomes “health-related quality of life” and “behavioural control”. No effect was found for individual components of cognition and measures of perception. The quality of the evidence for all outcomes is low due to a high risk of bias. In the supplementary presentations, no positive effects could be demonstrated on the basis of the available evidence. The quality of this evidence was not assessed. For the assessment of patient and social aspects, five systematic reviews on patients with a stroke or a traumatic brain injury – without specification regarding cognitive deficits or studies with their relatives – were included. It was reported that patients and family caregivers go through different phases of rehabilitation in which the discharge home is a decisive turning point. The discharge home represents a crucial breaking point. Regaining an active, self-determining role is a process that requires therapists to find the right level of support for patients and relatives. For the assessment of ethical aspects, nine documents were included. We identified ethical problem-solving models for occupational therapy and 16 ethical aspects in occupational therapy for cognitive deficits. The central theme of the analysis is the limited autonomy due to the consequences of the disease as well as the resulting tensions with those treating the patient. Based on this systematic overview, it can neither be proven nor excluded with certainty that occupational therapy for cognitive impairment is an effective therapy for adult patients with central nervous system injuries compared to no occupational therapy. There is a lack of randomised trials with sufficient sample size, well-defined interventions, and comparable concomitant therapies in the control groups, but there is also a lack of well-designed observational studies in routine care and health economic studies. The identified systematic reviews on patient and social aspects provide information on the needs of patients after stroke or traumatic brain injury and their relatives, but there is a lack of studies on this aspect in German-speaking countries. For the ethical assessment, in addition to the identified theoretical models for solving ethical conflicts in occupational therapy, more empirical studies on ethical aspects with patients with cognitive deficits and their relatives as well as occupational therapists are needed. This health technology assessment (HTA) article examines occupational therapy for persons with cognitive limitations caused by an injury to the central nervous system in adulthood. Injuries in adulthood can be caused, for example, by a stroke, trauma, tumors or chronic diseases like Parkinson’s disease or multiple sclerosis. These injuries can cause a wide spectrum of symptoms, which may be physical impairments but also cognitive limitations.Occupational therapy is most commonly prescribed for neurological diagnoses, including stroke and traumatic brain injury . In 2018According to the definition by the German Society for Psychiatry, Psychotherapy and Neurology  and the German Society for Neurology (Deutsche Gesellschaft für Neurologie), occupational therapy is an intervention for the improvement and support of everyday functions and of the capacity to act with the goal of improvement in participation and in the health-related quality of life within the individual’s daily activities and life context . OccupatMany interventions in occupational therapy are multimodal and include various therapies targeting the individual needs of each patient. For impairments of the central nervous system, the primarily prescribed interventions are sensomotoric-perceptive treatment, motoric-functional treatment and the neuropsychological-oriented treatment/training of cognitive performance .This HTA article examines the effectiveness, cost-effectiveness, and patient-related, social and ethical aspects of occupational therapy in patients with cognitive limitations. The study excludes patients with moderate to severe dementia. For this population, a DIMDI HTA report has already been published .In order to evaluate the clinical efficacy, the following research questions were investigated: how effective are occupational therapy interventions for patients with a cognitive impairment in terms of improving or maintaining cognitive abilities and improving independence, self-determination, and health-related quality of life in inpatient care in social institutions or in outpatient care? Occupational therapy for moderate to severe dementia was not the focus of this article and is, therefore, excluded for all questions.The following research questions were investigated to evaluate economic aspects: does the use of occupational therapy change the resources of inpatient or outpatient nursing and care required for patients with cognitive impairment? Are occupational therapy interventions in the context of inpatient or outpatient care of patients with cognitive impairments cost-effective? The evaluation of patient and social aspects examined the following research questions: which specific patient and social aspects  have to be taken into account when using occupational therapy in the context of the care of patients with cognitive impairments?The ethical evaluation examined the following research questions: which ethical aspects on an individual, societal and professional level have to be considered when applying occupational therapy to patients with cognitive impairments?To assess clinical efficacy, a systematic review was conducted based on published systematic reviews from the last ten years.The target population studied includes patients with cognitive impairments caused by diseases of the central nervous system after the age of 18 . The inThe bibliographic databases MEDLINE, EMBASE, Cochrane Library, and INAHTA database were searched from January 1, 2010, to May 5, 2020, and October 8, 2020, respectively. The search strategy was composed of three units of free text words and controlled vocabulary from the respective database, joined together with an AND operator. The first unit concerned diseases of the central nervous system, the second unit concerned the intervention searched for, and the third unit restricted the search to systematic reviews, meta-analyses and HTA reports.The references identified in the search were checked in two stages  by two reviewers for compliance with the inclusion criteria. Conflicting assessments by the two reviewers were resolved through discussion. Reasons for exclusion were documented and the selection process was presented in the form of a PRISMA diagram  in the cFor reviews that included other types of studies in addition to RCTs, only the description of the RCTs that met the inclusion criteria for population and intervention were relevant for this overview. One reviewer performed the data extraction and a second reviewer checked their accuracy. The characteristics and results of the primary studies were taken from the included reviews.The assessment of the methodological quality of the included systematic reviews was performed using the AMSTAR 2 tools . For theThe evidence synthesis of results concerning clinical efficacy was provided in form of a summary text; in the comprehensive HTA report evidence tables are shown in addition . The finThis overview summarises the evidence of the clinical efficacy of occupational therapy for cognitive impairment from published systematic reviews across indications. A summary of clinical efficacy across varying causes of illness seems justified because occupational therapy is often delivered in mixed groups with patients who had a stroke and patients with TBI. This suggests that similar limitations are present and similar types of therapy are used. The available evidence is based on clinical trials with patients after a stroke, with an acquired brain injury, with Parkinson’s disease or with multiple sclerosis.Primarily, this overview compares the clinical efficacy of occupational therapy as opposed to no occupational therapy. For this comparison, five systematic reviews , 12], , , 14], ,  with 20 A small positive effect of occupational therapy for patients with cognitive impairment compared to no occupational therapy is reported from a meta-analysis with nine RCTs with 708 subjects . For a cConflicting evidence for a positive effect on health-related quality of life of a non-quantified size comes from two RCTs , 15], , , 17] wi wi17] wiThe effectiveness of the intervention on individual components of cognition  cannot be proven with the available evidence. Five RCTs , 15], , , 20], , , 22], ,  with a tThe evidence for the outcome measures of attention , was not possible, as the majority of the included systematic reviews do not provide any information on the care setting or summarize the evidence across the board.In a supplementary presentation, we summarise the evidence comparing occupational therapy with a cognitive component to occupational therapy without a cognitive component to give an overview of studies that examine the contribution of specific cognitive function training to the effect. Assessments of risk of bias were not extracted, therefore we do not assess the quality of the evidence. A total of seven systematic reviews , 12], , , 27], , , 29], ,  with sevIn a further supplementary presentation, this overview also summarises the evidence on the comparative effectiveness of different forms of occupational therapy for cognitive impairment. Five systematic reviews , 12], , , 15], ,  with 20 The methodological quality of the nine included systematic reviews was examined with the AMSTAR 2 instrument , which aOverall, the sample sizes of the studies were small. The median number of sample size was 40 subjects with a range between 12 and 334. This means that most of the studies have a limited statistical power and only relatively large effects can achieve statistical significance.It is also problematic that the method for the meta-analysis in Park et al.  is not dNo intervention studies in the healthcare systems of German-speaking countries were found in the identified reviews. However, as the application of occupational therapy in everyday practice is influenced by local treatment patterns, remedy guidelines, and local professional organisations, it may not be justified to transfer the results to the German-speaking setting.This work has several limitations. Occupational therapy is a complex intervention consisting of several components. It is characterised by the fact that its aim is not only to improve individual functions, but to improve the performance of everyday activities. The selection of relevant everyday activities is made together with the patient. Often, different treatment methods are combined (e.g. compensatory methods and such interventions that address the recovery of specific functions), so that different interventions can be included under the same definition of “occupational therapy”. Rehabilitation interventions for cognitive disorders caused by the CNS diseases we are looking at use occupational therapy together with other therapeutic interventions, such as drug therapy and physiotherapy. The estimation of the effects of occupational therapy is therefore problematic, since the multidisciplinary integration of occupational therapy can influence the effect. The same applies, to some extent, to possible comparative interventions in rehabilitation with or without cognitive components. This complex definition of occupational therapy and the comparative therapies already poses a challenge in the design, conduct, and interpretation of primary studies, but confronts systematic reviews with additional obstacles because of the further reduction in information provided by systematic reviews compared to primary studies.Thus, the results on the outcomes are reported across indications. However, a summary of clinical efficacy across causes of illness seems justified in that occupational therapy is often provided in mixed groups with patients after stroke and patients with traumatic brain injury. This indicates that similar limitations are present and similar forms of therapy are applied.One difficulty with this overview was to include all reviews in which results on RCTs of occupational therapy interventions with a cognitive aspect can be found, but on the other hand to stick to the methodology of the overview, which takes its statements exclusively from the included reviews without resorting to the primary studies. Ultimately, both the completeness of the evidence and the accuracy of the synthesis suffer from this format. The expectation in selecting the methods for this overview was that we would find a large number of good quality systematic reviews on our topic. This impression came from the systematic reviews and overviews already listed in the Cochrane Database on the diseases we were looking for , on the one hand, and on cognitive rehabilitation and occupational therapy, on the other. In the end, this expectation could not be fulfilled. Some cognitive rehabilitation measures have been included in the therapeutic treatment methods of occupational therapy in recent years. However, occupational therapy should still be seen as a separate form of treatment, even though it adopts cognitive methods from neuropsychology. In some reviews, occupational therapy is defined as a treatment used by occupational therapists, and in others as occupational therapy treatment catalogues. The present overview includes these definitions, as well as descriptions that suggest occupational therapy character, such as “occupation-oriented rehabilitation”. Systematic reviews were also included if they did not focus exclusively on occupational therapy treatments, but were nevertheless included and labelled as such. However, many systematic reviews had to be excluded because they did not specify whether the cognitive rehabilitation methods studied should be considered occupational therapy.Another limitation was that occupational therapy is often a part of multidisciplinary rehabilitation, and often the multidisciplinary intervention is the subject of reviews without the contribution of occupational therapy being identifiable. These reviews or primary studies also had to be excluded. Other reviews found in the preliminary literature selection process met the criterion of disease area and treatment with occupational therapy, but ultimately did not contain a description suggestive of individuals with cognitive impairment, and therefore had to be excluded. This overview also included studies that did not explicitly address cognitive impairment in the study population, but did use cognitive interventions or did report cognitive outcome measures. Cognitive impairment may be the reason why activities of daily living, such as dressing or walking, are impaired. Therefore, activities of daily living may be the only endpoint for cognitive interventions. Studies of this type are included in this overview because cognitive interventions suggest that at least some patients had cognitive impairment. Our definition is, therefore, somewhat vague.The definition of occupational therapy and its differentiation from other, e.g. neuropsychological interventions in cognitive rehabilitation was done based on the evidence of the authors of the systematic reviews. A large number of reviews on cognitive rehabilitation are available – but they do not refer to occupational therapy, or they consider occupational therapy as a method of cognitive rehabilitation. It cannot be ruled out that other rehabilitation interventions were not considered that would certainly have been suitable for inclusion in an occupational therapy program. In addition to Cochrane reviews, this overview also includes other systematic reviews that differ from the Cochrane reviews in their methodological approach. In particular, systematic reviews were included that did not provide quantitative information on effects and their statistical uncertainty, as well as systematic reviews that had not conducted a risk of bias assessment of the primary studies. In addition to the disadvantage of not being able to conduct a separate meta-analysis due to the reduced information, this makes it impossible to assess the confidence of the overall evidence comprehensively on an outcome measure, as can be done with the GRADE methodology , for exaThe supplementary presentation of the two comparisons of different forms of occupational therapy was not part of the pre-defined research question. The intention here was to provide a first exploratory overview of the therapy comparisons, which becomes particularly relevant in the situation where occupational therapy is increasingly an already established form of therapy. We did not extract risk of bias assessments, or conduct an assessment of the overall evidence per outcome measure or the quality of the evidence.The included meta-analyses used standardised effect sizes as effect measures. To assess whether the effect sizes found were clinically significant effects, Cohen’s rule of thumb  was usedIn order to limit the scope of this review, interventions and outcome measures for visuospatial impairments and perceptual impairments were not considered, although these also belong to the domain of cognition. We thus followed previous reviews by Hoffmann et al. , and ReiThe fact that positive effects of the interventions are difficult to prove could be due to the great clinical heterogeneity of the included studies, which are summarized in this overview: the diversity of the interventions, the type and severity of the present brain injuries and limitations, the age of patients as well as the environment of the interventions  and parallel treatment with medication and other forms of therapy. It can be assumed that the variation in effects is large as a result.The present overview cannot include this level of detail and cannot conduct an investigation of heterogeneity. However, even at the level of primary studies, the small number of studies limits an investigation of the influence of heterogeneity.The literature search on which the overview is based limited the publication languages to German and English. This may have led to relevant studies not being identified. However, since at the same time the applicability of the evidence found to the health care systems in German-speaking countries should be given, the restriction of the publication language seems less relevant.Furthermore, it cannot be ruled out that small studies without statistically significant effects were not published at the level of the primary studies (publication bias), which would lead to an overestimation of a positive effect, especially in meta-analyses.The same inclusion and exclusion criteria for study population, intervention, and comparator as for the assessment of clinical efficacy were used to assess the costs and cost-effectiveness of occupational therapy for cognitive disorders. Outcome measures include changes in resource usage, additional costs of occupational therapy, and additional costs per life year gained or quality-adjusted life years gained. All health economic study types are included. The evaluations must relate to German-speaking countries.The search included the same databases and the same search period as the search for clinical efficacy. The assessment of methodological quality only takes place with regard to the question of whether a comprehensive, reproducible literature search and selection took place. For this purpose, the AMSTAR 2 instrument is used in a modified form. The extraction of the results for the included systematic reviews is carried out analogously to the assessment of clinical efficacy. However, instead of the outcome measures for clinical efficacy, the health economic outcome measures are now extracted from the reviews.No suitable systematic reviews on the costs or cost-effectiveness of occupational therapy in adult patients with cognitive deficits due to neurological diseases (except dementia) were identified. Therefore, no conclusions can be made about costs and cost-effectiveness.® of the European network for Health Technology Assessment , , , 45], ,  were ideThe following aspects were highlighted by the analyses and data syntheses:Peoples et al.  examinedSatink et al.  examinedMartin-Saez et al.  used theFrostad et al.  investigLuker et al.  examinedEssentially, after a stroke or a traumatic brain injury both the patients and the caregiving relatives seem to go through certain phases during rehabilitation and after discharge, during which health professionals can contribute more or less to successful coping. First, patients experience a loss of their abilities and a discontinuity with their former life at the level of body, ego, and roles. This is followed by reassessment, readjustment, a regaining of roles, and, finally, a continuation of one’s own life. A decisive turning point is the discharge home. It is associated with a transition to increased control and self-management by the patient, but also with the loss of the protected, supportive environment in the rehabilitation facility and with uncertainty. Regaining an active, self-determining role is a process that requires therapists to find the right level of support from patients and relatives.Patients in the studies wanted individual and sufficient information, especially about the cause of the disease, the individual progress, the evaluation of the treatment plan and decisions about discharge and aftercare. They wanted more attention to be paid to their psychosocial needs: regaining their roles, the practical needs of managing at home, preparing for a return to work, adapting to life situations, and transitioning to independence.In the studies, relatives wanted to be understood and involved as stakeholders in the patient’s recovery process and also wanted to receive the information they needed from professionals in order to do so, such as: information on prognosis of recovery, assessment outcomes, rehabilitation and therapy, how best to support and manage the stroke survivor, sexuality after stroke, and preparation for discharge. The information was to be offered in different formats, individually tailored and jargon-free. They wanted to be contacted proactively.In principle, it is in line with the client-centred approach of occupational therapy to take wishes into account. The present systematic review has several limitations. We could not identify any systematic reviews that examined patient and social aspects specifically regarding occupational therapy for adult patients with cognitive deficits due to neurological disorders of the central nervous system. The systematic reviews that we consider partially transferable to our target population, and which we have therefore included in a supplementary presentation, do not differentiate between the forms of therapy in rehabilitation and do not limit their study populations to people with cognitive deficits. However, it must be assumed that not all systematic reviews to which the extended inclusion criteria apply were found. The search strategy used was linked to terms for occupational therapy, and systematic reviews that only specified rehabilitation as an intervention were, thus, not found. A new search and reselection of significantly more hits for the expanded topic was not feasible considering the given resources and would also have gone beyond the research question posed.The quality of the included systematic reviews was good in that they had clear questions, comprehensible inclusion criteria, well-described included studies, as well as comprehensible results. Above all, shortcomings existed in the duplicate study selection and data extraction.However, both the systematic reviews and the patients of the included studies did not come from Germany or German-speaking countries, but from Northern Europe and the Anglo-Saxon countries. Therefore, it is questionable to what extent the experiences of patients and relatives in particular can be transferred to the specialist staff and the rehabilitation facilities. Qualitative and quantitative studies, e.g. surveys and interviews, should be conducted in German-speaking countries to find out whether the needs and preferences of patients and their relatives are similar to those in the studies from Northern European and Anglo-Saxon countries. At the same time, possible barriers to client-centred care should be investigated at the micro, meso and health system levels so that appropriate interventions can be developed to improve care.The inclusion criteria for systematic reviews assessing ethical aspects correspond to the inclusion criteria for clinical efficacy for the target population and intervention, but different criteria were used for the comparator. Studies with any comparative intervention and non-comparative studies could be included. Outcome measures are ethical aspects such as morality, conscience, responsibility, justice, autonomy, equity, fairness, informed consent, and human rights. In addition to systematic reviews, professional ethical standards and codes or other documents containing frameworks with criteria for addressing ethical issues for occupational therapists are included.The literature search was based on the same databases used to search for clinical efficacy and patient and social issues. In addition, an internet search was conducted. The sources found were screened by one person and checked for their relevance to ethical questions. The selection was reviewed by a second person. Identified frameworks with criteria for weighing ethical aspects in occupational therapy and the ethical principles underlying them are described. Specific ethical aspects of occupational therapy for people with cognitive impairment due to neurological conditions were tabulated from the included documents by one person and categorised according to the identified normative frameworks. A second person checked the evaluation. Discrepancies were resolved by discussion.The search for professional codes of ethics and guidelines via the websites of the professional associations and professional societies of occupational therapists in German-speaking countries and of European and worldwide umbrella organisations, resulted in six documents , 48], , , 50], , , 52] fr fr52] frThe professional codes refer to the four principles of biomedical ethics according to Beauchamp and Childress : respectA problem solving model for ethical conflicts was developed by the European umbrella organisation COTEC , adoptedThree systematic reviews , 55], ,  were ideThe autonomy of the patients and their restriction due to the consequences of the disease, as well as the resulting tensions with and for the therapists, are the central theme of the ethical analysis. Due to sensomotoric, communicative and/or cognitive limitations, the patients’ ability to express themselves may be restricted. Cognitive limitations and a restricted perception of their own deficits can, furthermore, especially affect their ability to make decisions. This is a particular challenge for occupational therapy professionals because client-centred goal setting is a central professional standard of the professional self-image of occupational therapists. The opposite situation can also occur when the continuing (limited) decision-making competence is not included in health-related decisions. An attempt is made to take into account the loss or regaining of autonomy on behalf of the patient, firstly by considering rehabilitation as a process of regaining autonomy and consciously handing over decision-making competences to the patient, but also secondly by trying to involve patients in the phase of limited decision-making competence, or at least to find out their preferences by other existing means, e.g. by involving relatives. It is also pointed out that, in the dependency phase, the patient’s perception of autonomy depends on the relationship between the patient, the caregiver and the environment. Furthermore, it is pointed out that the integration of disabilities and limitations into the patient’s identity is an important goal of rehabilitation and serves the patient’s self-realisation.In the ethical aspects listed, the autonomy principle can come into conflict with the principle of beneficence, the principle of non-maleficence and the integrity, as well as the professional self-image, of occupational therapy professionals.The autonomy of the patient and its restriction due to the consequences of the disease, as well as the resulting tensions with and for the therapists, are the central themes of the ethical analysis. Due to sensorimotor, communicative and/or cognitive limitations, the patients’ ability to express themselves may be restricted. Cognitive limitations and a restricted perception of one’s own deficits can also especially affect the ability to make decisions. This is a particular challenge for occupational therapy professionals because client-centred goal setting is a central professional standard of the professional self-understanding of occupational therapists. In the present article, we were only able to identify an ethical analysis of one specific cognitive deficit: “unawareness” about one’s own deficits in patients with acquired brain damage. Here, studies comparing the different intervention strategies would be desirable: whether a reduction of “unawareness” should be aimed at first before therapy goal-setting is carried out with the patient and when the appropriate time for this would be; or whether client-centred goal-setting should be carried out immediately, but possibly splitting it into realistic short-term and more unrealistic long-term goals, or whether it should be carried out with the help of relatives.In addition, a systematic review of primary studies on ethical aspects in occupational therapy for patients with cognitive deficits should be conducted. If appropriate, studies could also be included here that deal generally with the rehabilitation of cognitive deficits in the included indications because it can be assumed that many aspects are transferable to occupational therapy. The present overview on ethical aspects of occupational therapy in patients with cognitive deficits as a result of neurological diseases has some limitations. We did not find any systematic reviews on ethical aspects in this target population in the bibliographic databases. Concerning the internet search, very few empirical studies with patients with cognitive deficits and occupational therapy treatment were available in the systematic reviews, too. This might have been partly due to the limited search on the internet. Thus, we have relatively detailed recommendations on ethical problem solving in occupational therapy, but few empirical examples. In addition, the systematic reviews had only rudimentary descriptions, if any, of the included studies. However, it could be seen that all primary studies had been conducted outside the German-speaking area and, therefore, the transferability to the healthcare system in German-speaking countries must be questioned. Based on this systematic overview, it cannot be demonstrated with certainty that occupational therapy for cognitive impairment is an effective therapy for adult patients with central nervous system injuries. The available evidence shows a small positive effect on cognitive functioning, functioning in activities of daily living and health-related quality of life compared to not using occupational therapy. However, the confidence level of the evidence is low as far as can be understood from the overview methodology. In an exploratory supplementary presentation, which included comparisons of different forms of occupational therapy with and without cognitive components, there were predominantly no statistically significant differences between the forms of therapy for cognitive performance enhancement. An assessment of the risk of bias was not carried out in the supplementary presentation.On the other hand, the efficacy of occupational therapy cannot be ruled out either because most of the included studies have a relatively small sample size and limited statistical power, and, therefore, smaller effects may not be demonstrated. In addition, the heterogeneity of study populations, interventions, and comparisons suggests a high variance of effects. Since none of the included studies were conducted in the health care systems of the German-speaking countries, the transferability of the results also appears questionable. Based on these results, we recommend the continuation of occupational therapy research RCTs with patient-relevant outcomes and with a sufficient sample size. For future RCTs on occupational therapy, the exact definition and description of the form of occupational therapy investigated is important, as well as the comparability of the concomitant therapies carried out in parallel in the intervention and control groups. We also recommend the implementation and registration of well-planned observational studies in the care routine. In the study design of such studies, an appropriate collection of potential confounders should be taken into account, for which adjustments can be made in the analysis.Future studies should also integrate health economic components on resource use and costs.Systematic reviews can especially support the planning of new studies. For future systematic reviews, instead of conducting an overview, we recommend going back to the primary studies and adding a new search for primary studies in each disease area to the primary studies already assessed in Cochrane Reviews and HTA reports of similar methodology.With regard to patient and social aspects, both patients after a stroke or a traumatic brain injury and their family caregivers seem to go through certain phases during rehabilitation and after discharge. In this process, medical professionals can contribute to a greater or lesser extent to successful coping. In qualitative studies from Northern European and Anglo-Saxon countries, patients and relatives have expressed wishes for better communication and more client-centred rehabilitation measures, which may generally be assumed to be shared by patients and relatives in German-speaking countries as well. Moreover, the expressed wishes are in line with the understanding of client-centred treatment in occupational therapy. Therefore, in addition to verifying the needs of patients and relatives during and after rehabilitation through surveys of patients and relatives in German-speaking countries, investigations should also be carried out into what hinders the implementation of client-centred therapy in patients with cognitive deficits after neurological diseases of the central nervous system and what interventions could promote it.In the present article, some solution models for ethical conflicts as well as16 ethical aspects could be identified, but there were only few systematic reviews on ethical aspects from the perspective of patients, relatives, and professionals based on empirical primary studies. Therefore, a systematic review of primary studies on ethical aspects in occupational therapy for people with cognitive deficits, their relatives, and professionals should be conducted. If appropriate, studies could also be included here that deal generally with the rehabilitation of cognitive deficits in the included indications because it can be assumed that many ethical aspects are transferable to occupational therapy. This article is the short version of the HTA report of the same title .The authors declare that they have no competing interests.