Bridging the equity gap in maternal and child health
http://www.100md.com
《英国医生杂志》
Will depend on health systems research as well as action
We cannot allow it to be said by history that the difference between those who lived and died...was nothing more than poverty, age, or skin colour.
John Lewis, Congressman from Georgia, on the devastation caused by hurricane Katrina.1
That we live in a world with vastly unequal distribution of wealth and resources was cruelly underscored by the recent disaster in New Orleans, proving that income inequality often translates into huge gaps in access to care and support during crises. In the wealthiest nation of the world, income inequality has been climbing steadily, with more than 50% of income going to the top 20% of households, 37 million people living below the poverty line, and 45.8 million lacking health insurance.2 These disparities may be much wider in many developing and middle income countries.
Differences in health status caused by such disparities in wealth are often avoidable and unjust, and inequities in maternal and child health are the starkest examples. Just as many children die in Africa every month, mostly from preventable and easily treatable diseases, as were lost in the Asian tsunami last year. Of the 10 million deaths every year among children aged under 5, more than 40% occur in sub-Saharan Africa, mostly among malnourished children.3 Five countries in South Asia account for almost 38% of the global burden of deaths among newborns,4 and most of the 500 000 maternal deaths which occur each year world wide happen in just 13 countries.5 In addition to these large differences between countries and regions, some of the greatest inequalities in mortality are seen between the rich and poor within developing countries. As interventions and programmes are implemented, failure to recognise and act on such differentials may actually worsen inequity.6
In the words of Stephen Matlin, the executive director of the Global Forum for Health Research, "The great challenge today is to move from describing the problems to acting upon them—and then accurately measuring results."7 Several recent reviews suggest that simple, cost effective interventions can prevent many maternal and child deaths,8 9 but the poor populations at greatest need too often lack access to such help.10
Research has to be relevant, and there are several prerequisites for this. Firstly, the development of large scale, evidence based interventions depends on information derived from sound systematic reviews, which is in turn based on synthesis of appropriate information. Recent attempts at summarising such information on the survival of newborns and children show that much of the "evidence" is collated only from studies of the efficacy of treatment.8 9 There is too little research on health systems and services, and few effectiveness trials describe what works in sufficiently representative settings.11 Consequently nobody knows how best to develop and implement large scale interventions within health systems, particularly those approaches which promote equitable distribution of benefits to health.
To illustrate, the abysmally short supply of skilled health workers in many parts of the world, such as sub-Saharan Africa, means that health care must be delivered by other types of community workers. Moreover, failure to understand the sociocultural determinants of health and disease may considerably impede health programmes, especially in societies where the health and rights of women and children are closely intertwined. Although these problems are of largely local relevance, they are vitally important and should be investigated. Yet few qualitative studies and systematic reviews on such issues are available. We do not simply need more research; we also need the right kind of research.
Achieving the millennium development goals—international commitments to tackle poverty and hunger, ill health, gender inequality, lack of education, lack of access to clean water, and environmental degradation—will also depend on health systems research and will require huge investments by donors and national governments.12 The international community was asked 15 years ago to invest at least 2% of national health expenditures and at least 5% of development aid for research and for strengthening the capacity for research,w1 recommendations that were endorsed at the WHO summit on health research in Mexico in November 2004.w2
Progress since the Mexico summit has been painfully slow. Despite a rousing speech by Bill Gates at the World Health Assembly in May on the importance of strategies to deliver health interventions, the Gates Foundation and other bodies funding research have yet to allocate suitable funding for health systems research. Notably, of the 43 projects funded under the Gates Foundation's Grand Challenges scheme, none relate to operational research and large scale strategies for healthcare delivery and only one focuses on developing tools to measure health outcomes.w3 Furthermore, the first four funding cycles of the Global Fund to Fight AIDS, Tuberculosis and Malaria, which provided grants of more than $850m, (￡460m, 685m), did not focus either on assessing the impact of interventions or on a robust programme for health systems research.w4 If the global agenda to reduce the burden of disease among poor children is to progress, evidence based interventions must be accompanied by meticulous documentation of impact and a clear process for learning.
This week has witnessed one of the largest assemblies of public health workers and partners at the ninth meeting of the Global Forum for Health Research in Mumbai, as well as the launch at the UN Summit in New York of the new global Partnership for Maternal, Newborn and Child Health. Both of these well intentioned events underscore the need to reduce the inequity in global child health through concerted action and appropriate research. It is now time to translate rhetoric into action.
Zulfiqar A Bhutta, Husein Lalji Dewraj professor
Department of Paediatrics and Child Health, Aga Khan University, Karachi 74800, Pakistan (zulfiqar.bhutta@aku.edu)
References w1-w4 are on bmj.com
This article was posted on bmj.com on 9 September 2005: http://bmj.com/cgi/doi/10.1136/bmj.38603.526644.47
Competing interests: None declared.
References
Balls A, Waldmeir P. Poor, old and black forced to stay behind as hurricane struck. Financial Times 2005 Sept 4: 2.
US Census Bureau. Income, poverty and health insurance coverage in the United States 2004. www.census.gov/prod/2005pubs/p60-229.pdf (accessed 6 Sep 2005).
Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003;361: 2226-34.
Lawn JE, Cousens S, Zupan J, Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: when? where? why? Lancet 2005;365: 891-900.
AbouZahr C. Global burden of maternal death and disability. Br Med Bull 2003;67: 1-11.
Gwatkin DR. How much would poor people gain from faster progress towards the millennium development goals for health? Lancet 2005;365: 813-7.
Matlin S. Poverty, equity and health research. www.globalforumhealth.org/filesupld/news/SAM%20intro%20for%20hif-net.pdf (accessed 6 Sep 2005).
Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003;362: 65-71.
Darmstadt GL, Bhutta Z, Cousens SN, De Bernis L, Adam T, Walker, et al. Evidence-based, cost-effective interventions that matter: how many newborns can we save and at what cost? Lancet 2005; 365: 977-88.
Victora CG, Hanson K, Bryce J, Vaughan JP. Achieving universal coverage with health interventions. Lancet 2004;364: 1541-8.
World Health Organization. World report on knowledge for better health: strengthening health systems. Nov 2004. www.who.int/rpc/meetings/world_report_on_knowledge_for_better_health.pdf (accessed 7 Sep 2005).
Travis P, Bennett S, Haines A, Pang T, Bhutta Z, Hyder AA, et al. Overcoming health-systems constraints to achieve the millennium development goals. Lancet 2004;364: 900-6.
We cannot allow it to be said by history that the difference between those who lived and died...was nothing more than poverty, age, or skin colour.
John Lewis, Congressman from Georgia, on the devastation caused by hurricane Katrina.1
That we live in a world with vastly unequal distribution of wealth and resources was cruelly underscored by the recent disaster in New Orleans, proving that income inequality often translates into huge gaps in access to care and support during crises. In the wealthiest nation of the world, income inequality has been climbing steadily, with more than 50% of income going to the top 20% of households, 37 million people living below the poverty line, and 45.8 million lacking health insurance.2 These disparities may be much wider in many developing and middle income countries.
Differences in health status caused by such disparities in wealth are often avoidable and unjust, and inequities in maternal and child health are the starkest examples. Just as many children die in Africa every month, mostly from preventable and easily treatable diseases, as were lost in the Asian tsunami last year. Of the 10 million deaths every year among children aged under 5, more than 40% occur in sub-Saharan Africa, mostly among malnourished children.3 Five countries in South Asia account for almost 38% of the global burden of deaths among newborns,4 and most of the 500 000 maternal deaths which occur each year world wide happen in just 13 countries.5 In addition to these large differences between countries and regions, some of the greatest inequalities in mortality are seen between the rich and poor within developing countries. As interventions and programmes are implemented, failure to recognise and act on such differentials may actually worsen inequity.6
In the words of Stephen Matlin, the executive director of the Global Forum for Health Research, "The great challenge today is to move from describing the problems to acting upon them—and then accurately measuring results."7 Several recent reviews suggest that simple, cost effective interventions can prevent many maternal and child deaths,8 9 but the poor populations at greatest need too often lack access to such help.10
Research has to be relevant, and there are several prerequisites for this. Firstly, the development of large scale, evidence based interventions depends on information derived from sound systematic reviews, which is in turn based on synthesis of appropriate information. Recent attempts at summarising such information on the survival of newborns and children show that much of the "evidence" is collated only from studies of the efficacy of treatment.8 9 There is too little research on health systems and services, and few effectiveness trials describe what works in sufficiently representative settings.11 Consequently nobody knows how best to develop and implement large scale interventions within health systems, particularly those approaches which promote equitable distribution of benefits to health.
To illustrate, the abysmally short supply of skilled health workers in many parts of the world, such as sub-Saharan Africa, means that health care must be delivered by other types of community workers. Moreover, failure to understand the sociocultural determinants of health and disease may considerably impede health programmes, especially in societies where the health and rights of women and children are closely intertwined. Although these problems are of largely local relevance, they are vitally important and should be investigated. Yet few qualitative studies and systematic reviews on such issues are available. We do not simply need more research; we also need the right kind of research.
Achieving the millennium development goals—international commitments to tackle poverty and hunger, ill health, gender inequality, lack of education, lack of access to clean water, and environmental degradation—will also depend on health systems research and will require huge investments by donors and national governments.12 The international community was asked 15 years ago to invest at least 2% of national health expenditures and at least 5% of development aid for research and for strengthening the capacity for research,w1 recommendations that were endorsed at the WHO summit on health research in Mexico in November 2004.w2
Progress since the Mexico summit has been painfully slow. Despite a rousing speech by Bill Gates at the World Health Assembly in May on the importance of strategies to deliver health interventions, the Gates Foundation and other bodies funding research have yet to allocate suitable funding for health systems research. Notably, of the 43 projects funded under the Gates Foundation's Grand Challenges scheme, none relate to operational research and large scale strategies for healthcare delivery and only one focuses on developing tools to measure health outcomes.w3 Furthermore, the first four funding cycles of the Global Fund to Fight AIDS, Tuberculosis and Malaria, which provided grants of more than $850m, (￡460m, 685m), did not focus either on assessing the impact of interventions or on a robust programme for health systems research.w4 If the global agenda to reduce the burden of disease among poor children is to progress, evidence based interventions must be accompanied by meticulous documentation of impact and a clear process for learning.
This week has witnessed one of the largest assemblies of public health workers and partners at the ninth meeting of the Global Forum for Health Research in Mumbai, as well as the launch at the UN Summit in New York of the new global Partnership for Maternal, Newborn and Child Health. Both of these well intentioned events underscore the need to reduce the inequity in global child health through concerted action and appropriate research. It is now time to translate rhetoric into action.
Zulfiqar A Bhutta, Husein Lalji Dewraj professor
Department of Paediatrics and Child Health, Aga Khan University, Karachi 74800, Pakistan (zulfiqar.bhutta@aku.edu)
References w1-w4 are on bmj.com
This article was posted on bmj.com on 9 September 2005: http://bmj.com/cgi/doi/10.1136/bmj.38603.526644.47
Competing interests: None declared.
References
Balls A, Waldmeir P. Poor, old and black forced to stay behind as hurricane struck. Financial Times 2005 Sept 4: 2.
US Census Bureau. Income, poverty and health insurance coverage in the United States 2004. www.census.gov/prod/2005pubs/p60-229.pdf (accessed 6 Sep 2005).
Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003;361: 2226-34.
Lawn JE, Cousens S, Zupan J, Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: when? where? why? Lancet 2005;365: 891-900.
AbouZahr C. Global burden of maternal death and disability. Br Med Bull 2003;67: 1-11.
Gwatkin DR. How much would poor people gain from faster progress towards the millennium development goals for health? Lancet 2005;365: 813-7.
Matlin S. Poverty, equity and health research. www.globalforumhealth.org/filesupld/news/SAM%20intro%20for%20hif-net.pdf (accessed 6 Sep 2005).
Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003;362: 65-71.
Darmstadt GL, Bhutta Z, Cousens SN, De Bernis L, Adam T, Walker, et al. Evidence-based, cost-effective interventions that matter: how many newborns can we save and at what cost? Lancet 2005; 365: 977-88.
Victora CG, Hanson K, Bryce J, Vaughan JP. Achieving universal coverage with health interventions. Lancet 2004;364: 1541-8.
World Health Organization. World report on knowledge for better health: strengthening health systems. Nov 2004. www.who.int/rpc/meetings/world_report_on_knowledge_for_better_health.pdf (accessed 7 Sep 2005).
Travis P, Bennett S, Haines A, Pang T, Bhutta Z, Hyder AA, et al. Overcoming health-systems constraints to achieve the millennium development goals. Lancet 2004;364: 900-6.