Tuesday, 17th of December 2013 |
NEW THIS WEEK: EXPLAINING EQUITY GAINS IN CHILD SURVIVAL IN BANGLADESH
The Lancet, Volume 382, Issue 9909, Pages 2027 - 2037, 14 December 2013
Published Online: 21 November 2013
Copyright © 2013 Elsevier Ltd All rights reserved.
Explaining equity gains in child survival in Bangladesh: scale, speed, and selectivity in health and development
Original Text
Prof Alayne M Adams PhD a , Atonu Rabbani PhD b, Shamim Ahmed MPH c, Shehrin Shaila Mahmood MA a, Ahmed Al-Sabir PhD d, Prof Sabina F Rashid PhD e, Prof Timothy G Evans MD f
Summary and introduction below; full text, with tables, is best viewed at
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62060-7/fulltext
By disaggregating gains in child health in Bangladesh over the past several decades, significant improvements in gender and socioeconomic inequities have been revealed. With the use of a social determinants of health approach, key features of the countrys development experience can be identified that help explain its unexpected health trajectory. The systematic equity orientation of health and socioeconomic development in Bangladesh, and the implementation attributes of scale, speed, and selectivity, have been important drivers of health improvement. Despite this impressive pro-equity trajectory, there remain significant residual inequities in survival of girls and lower wealth quintiles as well as a host of new health and development challenges such as urbanisation, chronic disease, and climate change. Further progress in sustaining and enhancing equity-oriented achievements in health hinges on stronger governance and longer-term systems thinking regarding how to effectively promote inclusive and equitable development within and beyond the health system.
This is the fourth in a Series of six papers about innovation for universal health coverage in Bangladesh
Introduction
Over the past four decades, Bangladesh has made remarkable gains in population health and is on course to meet most of its millennium development goals (MDGs). These gains are noteworthy in light of the challenging development context of Bangladesh, characterised by relative declines in the share of public investment in health over time, rapid population growth, and lacklustre improvements in poverty and income inequality.
This paper disaggregates gains in child health, revealing significant improvements in gender and socioeconomic inequities over time. Using a social determinants of health approach, key features of the countrys development experience are identified that help explain its unexpected health trajectory. The systematic equity orientation of health and socioeconomic development in Bangladesh, and the implementation attributes of scale, speed, and selectivity, have been important drivers of health achievements especially for women and the rural poor. The experience of Bangladesh supports the view that a deliberate policy and programmatic focus on equity in health yields the greatest population-level improvements,1, 2 and creates the conditions for long-term economic growth and security.3, 4 However, current and emerging challenges ranging from chronic diseases to rapid urbanisation and climate change are creating new fault lines of inequity that require urgent systems-level action if progress is to be sustained.
Methods
Analysis is framed by an approach that views equity in health in a broader sociostructural context.5 This framework extends beyond health-care services, and takes into account the effect of social, political, and economic factors in stratifying the population in terms of socioeconomic position and opportunities for health. Attention to this broader context is crucial in explaining Bangladeshs experience in health and is addressed through case studies of non-health interventions and the discussion of secular changes.
Key messages
Measuring health equity
Analysis focuses on trends in child survival (infant mortality rate, child mortality rate, and under-5 mortality) and coverage of priority interventions for maternal and child health. The primary stratifiers for equity analysis are the sex of the child and household socioeconomic status expressed as an asset quintile, although geographic, urban residential (slum vs non-slum), and education strata are also acknowledged. Various equity measures are used to describe the distribution and size of differences across social groups and over time. Absolute or difference measures capture the actual size of the gap between two social groups (male vs female, or high vs low asset quintiles), whereas relative or ratio measures such as the slope index of inequality and the relative concentration index5—8 take into account the relative disadvantage of different groups across the entire population. To assess gender inequities in child survival, a shortfall measure is used that compares the expected difference in male and female survival to the actual difference.5
Scale, speed, and selectivity
Supplementing the social determinants framework is attention to how health and development programmes have been implemented. Drawing on both formal literature9—12 and the tacit knowledge of health and development programme implementers, three attributes of programme implementation—scale, speed, and selectivity—emerge as common characteristics of programmes that are linked to equity gains in health.
Scale refers to the practice of thinking and acting in orders of magnitude that correspond with the size of the nation. Bangladesh is one of the most densely populated countries in the world and, since independence, its population has doubled in size, with UN projections estimating almost 200 million people by 2050.13 This population growth, coupled with endemic poverty, has put a premium on simple, easy-to-implement interventions amenable to scale.
Speed, or the rapid rollout of health and development interventions, is the second feature of service implementation in Bangladesh that is essential to equity. Expectations for rapid change linked to achieving targets, a widespread institutional culture of results-based performance, and sustained support from donor partners, have enabled efficiencies in implementing interventions and achieving outcomes that benefit poor and disadvantaged populations. Reported to have more non-governmental organisations (NGOs) per person than any other developing country, Bangladeshs strategic public-private partnerships have also enhanced the pace and scale of implementation.14
Selectivity refers to the deliberate development priority accorded to two important strata of the population—the poor and women—that has permeated the way in which specific programmes are designed, implemented, and evaluated. This focus is reflected in the policy statements and strategic priorities of government and development partners, and characterises the values, mission, and programmes of much of Bangladeshs immense NGO sector.15—17
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