Elsevier

The Lancet

Volume 380, Issue 9850, 13–19 October 2012, Pages 1341-1351
The Lancet

Series
The comparative cost-effectiveness of an equity-focused approach to child survival, health, and nutrition: a modelling approach

https://doi.org/10.1016/S0140-6736(12)61378-6Get rights and content

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.

Introduction

Substantial recent global progress in reducing childhood mortality and undernutrition has been accompanied by increasing within-country inequities.1 For example, 18 of 26 countries with the largest decreases in under-5 mortality show a simultaneous widening of the mortality gap between the least and most deprived wealth quintiles.1, 2 The global burden of childhood mortality, morbidity, and undernutrition is now increasingly concentrated in the most deprived and underserved populations within countries,1, 2, 3 partly as a result of inequitable coverage of key maternal and child health and nutrition interventions.4, 5

Much of the encouraging progress in reducing childhood mortality and undernutrition can be attributed to the identification and roll out of highly effective evidence-based interventions over the past decades.6 Failing to ensure that marginalised communities benefit from these improvements in knowledge threatens the achievement of the fourth Millennium Development Goal (MDG). Yet countries as diverse as Brazil,7, 8 Chile,9 Mozambique,10, 11 Niger,12, 13 and Thailand14 have shown that a reduction of both overall child mortality and inequities is possible. Advances in technology and community-based programming have generated innovative strategies with the potential to reach the underserved in a cost-effective manner.15, 16 The convergence of these trends raises the possibility that the perceived trade-off between equity and efficiency no longer applies for child nutrition and survival—that an equity-focused approach that prioritises services for the poorest and most marginalised can be more effective and cost effective than mainstream approaches that incrementally increase coverage from the easier to the more difficult to reach populations.

We aimed to build a case for this hypothesis using a mathematical modelling approach,17 noting its use to predict the effect and cost-effectiveness of several maternal and child-health strategies.18, 19, 20, 21, 22

Section snippets

Study design

We compared two strategic approaches to reducing under-5 mortality and malnutrition across 14 countries and one province: one approach that we have labelled a mainstream approach to delivering services and the other, labelled as an equity-focused approach that prioritised operational strategies to reach the most deprived populations. Figure 1 provides a schematic description of the main factors we assessed that affect the ability of health services to reduce child deaths and undernutrition. On

Modelling outcomes

The model suggests that the equity-focused approach results in higher increases in coverage of high-impact interventions among the most deprived populations, as compared with the least deprived. These findings were consistent across different country typologies with increased coverage ranging from 104% in the most deprived areas versus 75% in the least deprived areas in type A countries to 100% in the most deprived areas versus 57% in the least deprived areas in type C countries.

Figure 4 shows

Conclusions

Even though substantial gains in survival can be made through increased investments with existing delivery strategies, our model supports the contention that across a wide range of countries, a focus on reaching the most deprived populations will save more lives and avert more episodes of stunting and decrease health inequities within countries. Our model also suggests that focusing on the most deprived is the most cost-effective way to deliver services to both narrow the gaps in access to

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