Gaps in child mortality between rich and poor are unacceptably wide and growing. Poorer children face disadvantages at every step from exposure and resistance to infectious disease, through care-seeking, to effective treatment. How can policy-makers close these gaps? An international team of researchers explore the options of targeting and universal coverage.

Socio-economic gaps in child survival are inequities – inequalities that are unjust and unfair. Compared with their better-off peers, poorer children suffer from:

• greater exposure to disease risks through inadequate water and sanitation, indoor air pollution, overcrowding, poor housing conditions and contact with animals carrying disease
• lower disease resistance due to poor nutrition
• higher rates of micronutrient deficiencies, low birthweight and recurrent disease episodes
• poorer coverage of vaccination, vitamin A supplementation and insecticide-treated nets.

Once they are sick poor children are less likely to be taken to a healthcare provider and to receive appropriate care. Even within poor rural areas, use of appropriate healthcare varies with wealth. The disadvantages linked to poverty also include lower levels of education, lack of coverage of public or private health insurance, high time costs when seeking healthcare and poorer quality health services.

The authors insist that the damaging effects of poverty on child health can be reduced by well-designed policies. Despite the need for more and better evidence, we know enough now to move ahead to reduce health inequities in children. Potential approaches include:

• improving knowledge and changing behaviour among poor mothers
• increasing access to water and sanitation
• empowering poor women
• making healthcare more accessible and affordable for low-income households
• enhancing the resources and improving the user-friendliness of facilities serving poor people
• making budget allocations more relevant to the burden of disease suffered by disadvantaged groups.

Effective large-scale implementation is the next challenge. Two basic approaches can raise coverage in poor population groups. Targeting focuses on directing programmes or interventions so that these mainly benefit poor communities or poor families within a community. Although often effective, targeted programmes can be difficult to administer, stigmatising or unethical. The alternative is universal coverage of activities that address conditions that particularly affect the poor. However, these initiatives may lose momentum before reaching disadvantaged groups.

The authors recommend that health policy-makers who are trying to tackle inequities in child survival should:

• aim for high coverage of a few interventions rather than mediocre coverage of several interventions
• take account of the local epidemiological and health system characteristics and measure health status and programme use in different socio-economic groups
• consider both targeting and universal coverage approaches
• build knowledge and competency among their staff on poverty and equity issues
• ensure that equity is considered in all new projects.

Source(s):
'Applying an equity lens to child health and mortality: more of the same is not enough', The Lancet 362: 233-241, by C.G. Victora et al, 2003
'Explaining trends in inequities? Evidence from Brazilian child health studies', The Lancet 356: 1093-1098, by C.G. Victora et al, 2000
'How well do health programmes reach the poor?', The Lancet 361: 540-541, by D.R. Gwatkin, 2003

Funded by: Bill and Melinda Gates Foundation; UK Department for International Development

id21 Research Highlight: 28 August 2003

Further Information:
Cesar Victora
Universidade Federal de Pelotas
CP464
96001-970 Pelotas
Brazil

Contact the contributor: cvictora@terra.com.br

Other related links:
'Maternal and child healthcare reform in China: bypassing the poor?' >

'Children in least developed countries: forever mired in poverty?' >

'Health or economic growth: saving children’s lives in the developing world.' >

'Children in developing countries face new health threats' >

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