Taking an equity focused

approach to achieving the MDGs:

right in principle; right in practice?

Unequal
progress
2/3 countries that have
made progress in
reducing U5MR have
shown worsening
inequalities
(i.e gaps between better
off and worse off have
increased)
Indicates : delivery and
financing of health and
nutrition services as well
as demand / use of
these
ese favor
a o the
e be
better
e o
off
UNICEF Progress for Children 2010

HYPOTHESIS
C
Conventional
ti
l wisdom
i d
h b
has
been th
thatt it iis ttoo costly
tl
and too difficult to go into poor, hard to reach
communities; reaching better off
off, easier to reach
children has been considered more cost effective.
Hypothesis tested : Because the needs are greatest
amongst the unreached, and new, innovative,
efficient strategies
g
and tools exist to reach them,, the
benefits of concentrating on them could outweigh the
additional costs of reaching them.
This would mean a greater equity focus would :
a) be more cost effective and
b) accelerate progress towards MDGs

Testing the Hypothesis

R
Review
i
off lit
literature:
t
h d d off rigorous
hundreds
i
controlled studies on equity focused strategies
Reviewed
R i
d effective
ff ti llarge scale
l programmes
Devised an equity-focused approach building on
the literature and Alma Ata Declaration(1978)
Designed an analytical framework for modeling
Undertook
U d t k modeling
d li exercise
i
- used data from 15 out of 60 countries reviewed
- analyzed
l
d 180
180,000
000 d
data points
i
- compared equity focused approach and the
currentt path
th in
i tterms off costt effectiveness
ff ti
by
b 2015
and contribution to health related MDGs

Two model strategies were compared q y

approach
pp
Current and Equity-focused
Modeled equity-focused approach - adds ways to
ensure the most deprived children are reached
(a) Different ways of delivering services:
Shifting treatment of main child killers to communities
Providing maternal and newborn services closer to communities
Incentives for improved distribution and performance of health workers

(b) Reducing financial barriers for the poor

Reducing costs of drugs and other commodities
Insurance or free provision of services for the poor
Subsidizing indirect costs for using services e.g. through cash transfers

(c) Empowering communities

Community participation and organization
C
Community
it b
based
d promotion
ti
off positive
iti health-related
h lth l t d practices
ti
Intensified communication e.g face to face

Cost effective p
proven interventions are known
- strategies differ in the way these are
delivered, promoted and financed

Child
2003
Newborn
2005

Maternal
Series
2006

Child
develop
ment
series
2007
Reproductive
Health
Series
2006

Nutrition
series
2008

250
200

60%

150

40%

100

20%

50

0%

Lowest Second Middle

Fourth Highest

100
60%

80

40%

60
40

20%

Lowest Second Middle

40%
20%
0%
Lowest Second Middle Fourth Highest

Fourth Highest

*Benin, Kenya, Nigeria,,Zimbabwe, Ghana

100
90
80
70
60
50
40
30
20
10
-

100%
verage deficit
% Cov

60%

Wealth Quintiles

Under 5 morrtality per 1,00

biirths

% Cove
erage deficit

80%

20

0%

*Niger, Mali, Rwanda, Uganda

100%

120

80%

Wealth Quintiles

Equity Typology B2

Equity Typology C

80%
60%
40%
20%
0%
Lowest Second Middle

Fourth Highest

Wealth Quintiles

*Honduras, Bangladesh, Pakistan

Coverage Deficit score

140

*Philippines, Vietnam South Africa

Under five Mortality rate

70
60
50
40
30
20
10
-

Under 5 morrtality per 1,00

births

80%

100%

% Coverage Deficit

E it Typology
Equity
T
l
A

Under 5 mortality per 1,00

birth
hs

% Coverrage Deficit

100%

Under 5 morta
ality per 1,00
birth
hs

Distribution patterns for mortality and

deprivation in 15 countries 4 typologies
Equity Typology B1

Using MBB (WB-UNICEF) Supply and Demand

bottlenecks for most / least deprived
p
areas analyzed
y
100%

SupplyBottleneck
75%

(esp.midwivesshortage)

Demand
Bottleneck(esp.
Financialaccess)

50%

25%

0%
COMMODITIES: % HUMAN RES: %
ACCESS: %
UTILISATION: % CONTINUITY: % EFFECTIVE COV:
health centres with
facilities with
families living near deliveries assisted deliveries with i) % of SBA deliveries
no perinatal supply sufficient workers health facility with by trained worker SBA ii) weighed & occur within a ANCstock-outs
daily service
iii) receive 3
qualified health
provision
postnatal care visits
facility

Mortality: causes in poor compared to rich

children
(Under Five Mortality Rate per 1000 Live Births)
250

200

Others
Injuries

21.6

AIDS

4.9
36.7

150

Pneumonia
6.6

Measles
56.3

Malaria

100
50

50

8.8
16
1.6
13.9
1.6
22.1
11

40.7

26.9

0
Nigeria: Nigeria Q1

Nigeria: Nigeria Q5 (richest)

Diarrhea
Neonatal

Analytical Framework
Coverage
35%
30%
25%
20%
15%
10%
5%

Inputs/costs
35 30

25

20

15

Low

10

0
10
102
103
104
105
106

High

MDG
10
progress
7

Impact
5% 10% 15% 20% 25% 30% 35%

Under 5 m
U
mortality p
per 1,000 live births

Impact on child mortality in most

and least deprived areas
100
90
80

Baseline

70
60

Current

50
40
30

Equity
Focused

20
10
Most Deprived Areas

Least Deprived Areas

Progress towards MDG 4

Unde
er 5 mortaliity per 1,00
00 live birth
hs

160
140
141
120

Historical path

100

Current Path

88
80

Equity
q y
Focused

60

MDG Target
40
20
1990

1995

2000

2005

2010

2015

Per $1m additional invested - equity-focused

strategies can avert more child deaths
Equity Typology B1

Equity Typology A
140

120

120

100

100

80

80
60
60
40

40
20

20

Current

Equity Focused

Current

*Niger, Mali, Rwanda, Uganda

Equity Focused

*Benin, Kenya, Nigeria, Zimbabwe, Ghana

Equity Typology C

Equity Typology B2

30

70

25

60

20

50

15

40
30

10

20
5

10

Current

Equity Focused

*Honduras, Bangladesh, Pakistan

Current

Equity Focused

*Philippines, Vietnam South Africa

Conclusion
An equity-focused approach improves returns on
investment, averting many more child and maternal deaths
and
d episodes
i d off stunting
t ti than
th th
the currentt path.
th
Using an equity focused approach,
approach a US $1 million
investment in reducing under-five deaths in a low-income,
high-mortality country would avert an estimated 60% more
d th th
deaths
than th
the currentt approach.
h
Because national burdens of disease
disease, ill health and
malnutrition are concentrated in the most excluded and
deprived child populations, providing these children with
essential services can accelerate progress towards the
health related MDGs and reduce disparities within nations.