Bridging the equity gap in maternal and child health

Editor—As an adviser to district health managers on priority setting, I am concerned with the constant return to a call for more research on cost effectiveness as the solution to improved implementation of health services in developing countries.¹ Cost effectiveness information is useful, but it is far from adequate when a district health manager needs to make a decision and include stakeholders for priority setting.

To know if one intervention against malaria is more cost effective than another against HIV/AIDS, is for all practical purposes useless information to a district policy maker. This type of information is only really useful when they have to choose between two interventions tackling the same challenge. The district health manager is up against a range of stakeholders, all with differing values and criteria for setting priorities. Cost effectiveness is only one of them.² Unless they have tools to also measure and include other values such as equity, trust, and human rights, we cannot expect that the priorities reached will be trusted or implemented by the various stakeholders.

More research is therefore needed on how to ensure trust and equity, even at the possible expense of cost effectiveness. We are conducting this type of research using the accountability for reasonableness frame-work in Tanzania, Zambia, and Kenya.³,⁴ The same framework is also being assessed in terms of its usefulness to district health managers in Tanzania, in which we are aiming at providing capacity building for fair priority setting.⁵

For a district health manager more of the same is not the answer. They need research and tools enabling them to implement efficient interventions through a priority setting process that is fair. The values and criteria behind the priorities set need to be explicit and with a wide ownership among the stakeholders affected.