Elsevier

The Lancet

Volume 362, Issue 9379, 19 July 2003, Pages 233-241
The Lancet

Series
Applying an equity lens to child health and mortality: more of the same is not enough

https://doi.org/10.1016/S0140-6736(03)13917-7Get rights and content

Summary

Gaps in child mortality between rich and poor countries are unacceptably wide and in some areas are becoming wider, as are the gaps between wealthy and poor children within most countries. Poor children are more likely than their better-off peers to be exposed to health risks, and they have less resistance to disease because of undernutrition and other hazards typical in poor communities. These inequities are compounded by reduced access to preventive and curative interventions. Even public subsidies for health frequently benefit rich people more than poor people. Experience and evidence about how to reach poor populations are growing, albeit largely through small-scale case studies. Successful approaches include those that improve geographic access to health interventions in poor communities, subsidised health care and health inputs, and social marketing. Targeting of health interventions to poor people and ensuring universal coverage are promising approaches for improvement of equity, but both have limitations that necessitate planning for child survival and effective delivery at national level and below. Regular monitoring of inequities and use of the resulting information for education, advocacy, and increased accountability among the general public and decision makers is urgently needed, but will not be sufficient. Equity must be a priority in the design of child survival interventions and delivery strategies, and mechanisms to ensure accountability at national and international levels must be developed.

Section snippets

Why do poor children die earlier?

The breakdown of national household survey data by socioeconomic status (panel 4)18, 19, 20, 21 has contributed greatly to our understanding of why poor children are less likely to survive than their better-off peers. Results of systematic analyses of demographic and health surveys show consistent inequities in child health across dozens of countries.6, 7

By contrast with children born to better-off families, poor children are more exposed to risks for disease through inadequate water and

Can policy makers reduce child survival gaps?

Poor countries–and poor people within countries–have multiple deprivations. These, in turn, account for the high levels of exposure, low levels of resistance, inadequate careseeking, and low probabilities of receiving prompt and effective treatment described in the preceding section. For a start, poor people tend to have less money than those better off. They are the least able to afford water connection and usage charges, non-polluting heating and cooking fuels, and houses of appropriate size.

Translating knowledge into action at national and subnational levels

The preceding sections show that several approaches have been proposed for improvement of health conditions in poor people. Yet few, if any, of these approaches have been implemented on a large scale. Effective large-scale implementation is the next challenge.

Surmounting that challenge will require adoption of suitable health strategies and creation of a conducive policy environment.

Child survival interventions do not take place in a vacuum, but rather are implemented in societies in which

Increasing coverage in poor communities with child survival interventions

Two basic approaches can raise coverage in poor population groups. One approach focuses on particular programmes or interventions that mainly benefit poor people, usually referred to as targeting. The other approach achieves universal coverage with programmes or interventions that address conditions that are especially important for disadvantaged groups. Table 2 presents characteristics of situations that affect decisions about the choice of approach. Both targeting or universal coverage

Improvement of accountability

Poverty-oriented approaches–like those just described–are much more likely to be accepted in environments characterised by a strong commitment to equity among policy makers and programme managers. Even in societies in which other inequalities are tolerated, health is usually seen as a basic human right meriting special attention. Development and maintenance of a commitment to equity is more likely if policy makers, programme managers, and communities have a role in policy formulation.

The challenge at international level

We have shown that inequities in child health are unacceptably wide, both between and within countries. In many cases, they are rising. Health and other services that could lessen these inequities are generally reinforcing them instead, by reaching upper-income children more effectively than disadvantaged ones. This targeting is happening despite avowed commitments of international agencies, and despite repeated attempts to make diseases of the poor a priority.

This occurrence is why more of the

Search strategy

On inequalities in proximate determinants, we aimed to reflect medical and social scientific published work on: (a) the proximate determinants; and (b) their socioeconomic distribution. On the role of policy makers, we aimed to reflect medical and social scientific published work on: (a) the underlying determinants of child-health outcomes; (b) their socioeconomic distribution; and (c) the effect and socioeconomic aspects of child health and related programmes–eg, maternal and child-health

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