Applying an equity lens to child health and mortality

Statistics show that poor children die earlier. According to this paper, in high-income countries, 6 of every 1000 children die before their 5th birthday; in the developing world, the rate is 88 per 1000; and in the world's poorest countries, the rate is 120 per 1000. Poorer children are exposed to risks for disease in the form of inadequate water and sanitation, indoor air pollution, crowding, poor housing, and high exposure to disease vectors. They are also more likely to have lower resistance to infectious diseases because they are undernourished. Further, their health is compromised by low coverage levels for preventive interventions. Once sick, they are not as likely to be taken to a health care facility; if they are, they are less likely to receive proper care.

Some approaches that have been used to address this problem include: improving knowledge and changing behaviour in poor mothers (such as handwashing for diarrhoea prevention and nutrition counselling), improving access to water and sanitation, commercial-sector marketing (such as for soap and mosquito nets), empowering women through microcredit (income-generating) programmes, making health care more affordable to poor households (through cash transfers, fee-waiver schemes, and health insurance), making health facilities more accessible (such as through partnership with NGOs in underserved areas), enhancing human and other resources in health facilities, using providers who speak the language of poor indigenous groups and understand their customs, and allocating resources according to disease burden. The authors claim that "effective large-scale implementation is the next challenge". New programmes, they say, must ensure both that interventions address, or "target" poor people - and that these people take advantage of those interventions that do come their way.

Specifically, the authors review 2 strategies for increasing child survival intervention coverage in poor communities: targeting and universal coverage. Direct targeting involves identifying poor households or individuals and developing ways of getting services specifically to them. Indirect targeting focusses programme efforts on geographic areas that are particularly poor. Rapid, universal coverage is the second approach. An example of this approach is immunising an entire community against infectious disease, without worrying about ensuring that the poor are vaccinated first. While there is a worry that universal coverage initiatives may lose momentum before reaching poor people, the pitfall of differential service quality is avoided here. The decision of which strategy to pursue must be made, the authors say, on a case-by-case basis.

Poverty-oriented approaches like these, according to this paper, are more likely to succeed in settings in which programme managers and policymakers are committed to health as a basic human right. Providing these personnel - along with poor people, NGOs, and health professionals - with accurate information about health inequities, the authors suggest, is key. They review 3 ways of communicating this information: measurement of health status and programme use according to socioeconomic status, gender, or ethnic group; establishment and monitoring of health objectives in terms of health status or service use among the poor; and development of tools to track progress among those groups.

The authors also urge change at the international level. They say that agencies such as WHO and UNICEF must work to build knowledge and competency among their staff on poverty and equity issues, advise governments on what they can do, and categorise health data according to socioeconomic, gender, and geographic categories (rather than just presenting national averages). Multilateral and bilateral agencies, they urge, must ensure that equity considerations are integral to the design of all new projects, address equity issues in dialogue with countries, and ensure that impact evaluations provide data on equity.

In short, the authors claim, "Socioeconomic status gaps in child mortality are not simply inequalities, they are also inequities--inequalities that are unjust and unfair."

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This paper is part of a 5-part series on child survival published by The Lancet. Click here to access an overview of that series.

Source:

Summarised and reprinted with permission from Elsevier (The Lancet, 2003, Vol No 362, pages 233-41). Click here for the Lancet Home Page.