The Lancet Series – Equity in Child Survival, Health, and Nutrition

The Lancet  
Oct 13, 2012  Volume 380  Number 9850  p1281 – 1358

Equity in Child Survival, Health, and Nutrition
Strategies to improve health coverage and narrow the equity gap in child survival, health, and nutrition
Mickey Chopra, Alyssa Sharkey, Nita Dalmiya, David Anthony, Nancy Binkin, on behalf of the UNICEF Equity in Child Survival, Health and Nutrition Analysis Team

Implementation of innovative strategies to improve coverage of evidence-based interventions, especially in the most marginalised populations, is a key focus of policy makers and planners aiming to improve child survival, health, and nutrition. We present a three-step approach to improvement of the effective coverage of essential interventions. First, we identify four different intervention delivery channels—ie, clinical or curative, outreach, community-based preventive or promotional, and legislative or mass media. Second, we classify which interventions’ deliveries can be improved or changed within their channel or by switching to another channel. Finally, we do a meta-review of both published and unpublished reviews to examine the evidence for a range of strategies designed to overcome supply and demand bottlenecks to effective coverage of interventions that improve child survival, health, and nutrition. Although knowledge gaps exist, several strategies show promise for improving coverage of effective interventions—and, in some cases, health outcomes in children—including expanded roles for lay health workers, task shifting, reduction of financial barriers, increases in human-resource availability and geographical access, and use of the private sector. Policy makers and planners should be informed of this evidence as they choose strategies in which to invest their scarce resources.

Equity in Child Survival, Health, and Nutrition
The comparative cost-effectiveness of an equity-focused approach to child survival, health, and nutrition: a modelling approach
Carlos Carrera, Adeline Azrack, Genevieve Begkoyian, Jerome Pfaffmann, Eric Ribaira, Thomas O’Connell, Patricia Doughty, Kyaw Myint Aung, Lorena Prieto, Kumanan Rasanathan, Alyssa Sharkey, Mickey Chopra, Rudolf Knippenberg, on behalf of the UNICEF Equity in Child Survival, Health and Nutrition Analysis Team

Progress on child mortality and undernutrition has seen widening inequities and a concentration of child deaths and undernutrition in the most deprived communities, threatening the achievement of the Millennium Development Goals. Conversely, a series of recent process and technological innovations have provided effective and efficient options to reach the most deprived populations. These trends raise the possibility that the perceived trade-off between equity and efficiency no longer applies for child health—that prioritising services for the poorest and most marginalised is now more effective and cost effective than mainstream approaches. We tested this hypothesis with a mathematical-modelling approach by comparing the cost-effectiveness in terms of child deaths and stunting events averted between two approaches (from 2011—15 in 14 countries and one province): an equity-focused approach that prioritises the most deprived communities, and a mainstream approach that is representative of current strategies. We combined some existing models, notably the Marginal Budgeting for Bottlenecks Toolkit and the Lives Saved Tool, to do our analysis. We showed that, with the same level of investment, disproportionately higher effects are possible by prioritising the poorest and most marginalised populations, for averting both child mortality and stunting. Our results suggest that an equity-focused approach could result in sharper decreases in child mortality and stunting and higher cost-effectiveness than mainstream approaches, while reducing inequities in effective intervention coverage, health outcomes, and out-of-pocket spending between the most and least deprived groups and geographic areas within countries. Our findings should be interpreted with caution due to uncertainties around some of the model parameters and baseline data. Further research is needed to address some of these gaps in the evidence base. Strategies for improving child nutrition and survival, however, should account for an increasing prioritisation of the most deprived communities and the increased use of community-based interventions.