UNICEF, New York, USA ; Centre for Population Health Sciences and Global Health Academy, The University of Edinburgh Medical School, Edinburgh, Scotland, UK.
J Glob Health. 2012 Jun;2(1):010406. doi: 10.7189/jogh.02.010406.
One of the most unexpected outcomes arising from the efforts towards maternal and child mortality reduction is that all too often the objective success has been coupled with increased inequity in the population. The aim of this study is to analyze the determinants of the complex interplay between cost-effectiveness and equity and suggest strategies that will promote an impact on mortality that reduce population child health inequities.
We developed a conceptual framework that exposes the nature of the links between the five key determinants that need to be taken into account when planning equitable impact. These determinants are: (i) efficiency of intervention scale-up (requires knowledge of differential increase in cost of intervention scale-up by equity strata in the population); (ii) effectiveness of intervention (requires understanding of differential effectiveness of interventions by equity strata in the population); (iii) the impact on mortality (requires knowledge of differential mortality levels by equity strata, and understanding the differences in cause composition of overall mortality in different equity strata); (iv) cost-effectiveness (compares the initial cost and the resulting impact on mortality); (v) equity structure of the population. The framework is presented visually as a four-quadrant graph.
We use the proposed framework to demonstrate why the relationship between cost-effectiveness and equitable impact of an intervention cannot be intuitively predicted or easily planned. The relationships between the five determinants are complex, often nonlinear, context-specific and intervention-specific. We demonstrate that there will be instances when an equity-promoting approach, ie, trying to reach for the poorest and excluded in the population with health interventions, will also be the most cost-effective approach. However, there will be cases in which this will be entirely unfeasible, and where equity-neutral or even inequity-promoting approaches may be substantially more cost-effective. In those cases, investments into health system development among the poorest that would increase the quality and reduce the cost of intervention delivery would be required before intervention scale-up is planned.
The relationships between the most important determinants of cost-effectiveness and equitable impact of health interventions used to reduce maternal and child mortality are highly complex, and the effect on equity cannot be predicted intuitively, or by using simple linear models.
从降低母婴死亡率的努力中产生的最出人意料的结果之一是，目标的成功往往伴随着人口中不平等程度的增加。本研究的目的是分析成本效益和公平性之间复杂相互作用的决定因素，并提出将对死亡率产生影响的策略，以减少人口儿童健康的不平等。
我们开发了一个概念框架，揭示了在规划公平影响时需要考虑的五个关键决定因素之间的联系的本质。这些决定因素是：（i）干预措施扩大规模的效率（需要了解人口中不同公平阶层干预措施扩大规模的成本增加情况）；（ii）干预措施的效果（需要了解人口中不同公平阶层干预措施的效果差异）；（iii）对死亡率的影响（需要了解不同公平阶层的死亡率水平差异，并了解不同公平阶层总体死亡率的病因构成差异）；（iv）成本效益（比较初始成本和对死亡率的影响）；（v）人口的公平结构。该框架以四象限图的形式呈现。
我们使用提出的框架来展示为什么干预措施的成本效益和公平影响之间的关系不能直观地预测或轻松地规划。五个决定因素之间的关系是复杂的，通常是非线性的，具体取决于背景和干预措施。我们证明，在某些情况下，促进公平的方法，即试图用卫生干预措施覆盖人口中最贫穷和被排斥的人群，也将是最具成本效益的方法。然而，在某些情况下，这将是完全不可行的，而公平中立甚至不公平促进的方法可能会更具成本效益。在这些情况下，需要在规划干预措施扩大规模之前，对最贫穷的人群进行卫生系统发展投资，以提高干预措施的质量并降低其成本。
用于降低母婴死亡率的卫生干预措施的成本效益和公平影响的最重要决定因素之间的关系非常复杂，对公平性的影响不能直观地预测，也不能使用简单的线性模型来预测。
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