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The Importance of Targeting Interventions Toward the Poor

Emmanuela Gakidou, PhD; Shefali Oza, SB; Cecilia Vidal Fuertes, MA; Amy Y. Li, AB; Diana K. Lee, BS; Angelica Sousa, MS; Margaret C. Hogan, AB; Stephen Vander Hoorn, MSc; Majid Ezzati, PhD

JAMA. 2007;298:1876-1887.

Context  The United Nations Millennium Development Goals (MDGs) set targets related to important global poverty, health, and sustainability issues. A critical but underinvestigated question for planning and allocating resources toward the MDGs is how interventions related to one MDG might affect progress toward other goals.

Objectives  To estimate the reduction in child mortality as a result of interventions related to the environmental and nutritional MDGs (improving child nutrition and providing clean water, sanitation, and fuels) and to estimate how the magnitude and distribution of the effects of interventions vary based on the economic status of intervention recipients.

Design, Setting, and Population  Population-level comparative risk assessment modeling the mortality effects of interventions on child nutrition and environmental risk factors, stratified by economic status. Data on economic status, child underweight, water and sanitation, and household fuels were from the nationally representative Demographic and Health Surveys for 42 countries in Latin America and the Caribbean, South Asia, and sub-Saharan Africa. Data on disease-specific child mortality were from the World Health Organization. Data on the hazardous effects of each MDG-related risk factor were from systematic reviews and meta-analyses of epidemiological studies.

Main Outcome Measure  Child mortality, stratified by comparable international quintiles of economic status.

Results  Implementing interventions that improve child nutrition and provide clean water and sanitation and clean household fuels to all children younger than 5 years would result in an estimated annual reduction in child deaths of 49 700 (14%) in Latin America and the Caribbean, 0.80 million (24%) in South Asia, and 1.47 million (31%) in sub-Saharan Africa. These benefits are equivalent to 30% to 48% of the current regional gaps toward the MDG target on reducing child mortality. Fifty percent coverage of the same environmental and nutritional interventions, as envisioned by the MDGs, would reduce child mortality by 26 900, 0.51 million, and 1.02 million in the 3 regions, respectively, if the interventions are implemented among the poor first. These reductions are 30% to 75% larger than those expected if the same 50% coverage first reached the wealthier households, who nonetheless are in need of similar interventions.

Conclusions  Interventions related to nutritional and environmental MDGs can also provide substantial gains toward the MDG of reducing child mortality. To maximize the reduction in childhood mortality, such integrated management of interventions should prioritize the poor.

Author Affiliations: Initiative for Global Health, Harvard University, Cambridge, Massachusetts (Drs Gakidou and Ezzati and Mss Oza, Vidal Fuertes, Li, Lee, and Sousa); Institute for Health Metrics and Evaluation, University of Washington, Seattle (Ms Hogan); School of Population Health, University of Queensland, Brisbane, Australia (Ms Hogan); Clinical Trials Research Unit, University of Auckland, Auckland, New Zealand (Mr Vander Hoorn); and Harvard School of Public Health, Boston, Massachusetts (Dr Ezzati). Dr Gakidou is now with the Institute for Health Metrics and Evaluation, University of Washington.

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