Using equitable impact sensitive tool (EQUIST) to promote implementation of evidence informed policymaking to improve maternal and child health outcomes: a focus on six West African Countries

As the United Nations (UN) Millennium Development Goals (MDGs) initiative of 2000 rounded off in 2015, available reports indicated that most countries made various levels of progress towards achieving the MDGs 4 and 5 (reducing child mortality and improving maternal health, respectively) [1]. Recent statistics from the WHO Global Health Observatory showed that in Africa, infant, neonatal and under-five mortality rates per 1000 live births reduced from 93.5, 40.9 and 154 in 2000 to 53.9, 27.7 and 79.5 in 2015 respectively [2]. Similarly, the maternal mortality ratio (MMR) per 100,000 live births in Africa reduced from 840 in 2000 to 542 in 2015 [3]. Despite these appreciable, the current infant mortality rate (IMR), neonatal mortality rate (NMR), under-five mortality rate (U5MR) and MMR in Africa are still unacceptably high.

Of all the sub-regions of Africa, the West-Africa with a population of more than 357million (about 1/3 of entire African population) [4, 5], is among the worst performing regions in terms of addressing maternal and child mortality. The MMR of some of the West African countries are among the highest in the world such as Sierra Leone (1360/100,000), Nigeria (814/100,000), Liberia (725/100,000) and The Gambia (706/100,000) [5]. Similarly, the sub-region has countries which records U5MR that are among the highest in the world including Sierra Leone (118/1000), Mali (114/1000), Nigeria (108/1000) and Benin (100/1000) [5].

Recent studies sponsored by the West African Health Organization (WAHO) report that contextual barriers such as road conditions, culture, knowledge of risks and the status of women, and health systems barriers including geographic distance of health centres, services delivery organisation, the availability and ability of health services, and the quality of care, all act together to increase maternal and child mortality in the sub-region [6, 7]. It has been argued that any effort to improve maternal and child mortality in West Africa must not only focus on investing in interventions but more importantly on strengthening health systems and context to enable efficient and effective implementation of proven life-saving interventions [6]. Among the most critical health systems components that is often neglected in health systems strengthening efforts to improve MNCH outcomes in Africa is the concept of equity [8]. Wilunda and co-workers [9] have noted that dramatic inequities in maternal and child care in Africa are now being increasingly recognized and addressed in strategic documents, action plans and related indicators, but unfortunately are seldom translated into concrete actions.

Evidence abound which showed that decrease in maternal and child mortality in low and middle-income countries (LMICs) including the African region has been accompanied by increased inequity in health outcomes between the poor and those better off [10‐13]. Consequently, the United Nations Children’s Fund (UNICEF) has strongly advocated against the ‘mainstream approach’ where scaling–up of health interventions favour wealthier groups in the society, but rather is promoting an ‘equity–focused’ approach in which interventions are targeted at the poorest in the society [14]. In a recent publication [13], UNICEF made a strong case for equitable investment and argued that since most maternal and child deaths in LMIC could have been prevented with practical, high-impact, and, low-cost health interventions, extending services to the most deprived and marginalized communities would not only avert more deaths, but would also do so more cost-effectively.

To this end, a number of tools have been developed to assess the relationship between cost–effectiveness and equitable impact in maternal and child mortality reduction [14]. Some of these tools included the Marginal Budgeting for Bottlenecks (MBB) [15], Choice of Interventions that are Cost–Effective (CHOICE) [16], and the Lives Saved Tool (LiST) [17]. According to Waters and colleagues [18], the major limitation of these tools is that they make no allowance for income-related inequalities in countries and therefore cannot fully address equitable impact considerations. To address this limitation, the UNICEF designed the EQUitable Impact Sensitive Tool (EQUIST) to enable the global health community improve equity in MNCH and reduce health disparities between the most marginalized mothers and young children and the better-off [18, 19]. EQUIST is an online tool (http://​equist.​info/​en/​pages/​home), which has been described as a medium-term strategic planning, modelling and monitoring platform that serves to improve child and maternal health as well as nutrition equity in LMICs [18‐22].

The purpose of this study was to use EQUIST to provide reliable evidence, based on globally available demographic health surveys (DHS) on cost–effectiveness and equitable impact that will facilitate the implementation of interventions that will improve MNCH outcomes in West Africa with a focus on six West African countries (Benin, Burkina Faso, Ghana, Mali, Nigeria and Senegal). The goal was to provide decision makers and global health community with scientific information that will enable them think about issues of equity in MNCH in a more systematic and evidence-informed way, in order to design health intervention strategies that will lead to stronger, more resilient health systems in West Africa. In this study, we used EQUIST to: (i). create an accurate picture of the health status of the most deprived children and women in Benin, Burkina Faso, Ghana, Mali, Nigeria and Senegal; (ii). identify which populations are at greatest risk, why they are at risk, and how many lives can be saved with appropriate action; (iii). identify the highest impact, most cost-effective strategies to level disparities; and (iv). measure the potential effects in terms of lives saved and costs.

The outcome of the EQUIST analysis generally showed that the six West African countries have unacceptably high maternal and child mortality that is perhaps among the worst in the world. Santi and Weigert [25] noted in their report that West Africa lags behind the other regions of Africa in terms of women health as gender-disaggregated indicators showed that the status of women has hardly improved. The regions that consistently recorded the highest maternal, under-five and neonatal mortality included Atlantique in Benin, Sikasso in Mali, North West in Nigeria, and Diourbel in Senegal. Using the EQUIST analysis, the picture of the health status of these regions were highlighted as having the most vulnerable and deprived children and women and needing urgent health interventions as a matter of priority.

Available reports from Nigeria support the outcome of the EQUIST situational analysis which indicated the highest maternal and child mortality in the North-West region of the country [26]. The Nigeria National Population Commission (NPC), noted in a previous report that there exist substantial variations across the Nigeria’s six geopolitical zones in terms of social, cultural, and economic status [27]. The North-East and North-West regions of Nigeria are noted to be characterized by high level of non-formal education, polygamous marriage, early/teenage marriage/pregnancy, poor access and utilization of modern health facility, and very high proportion of extremely poor rural population [28]. These factors contribute significantly to the very poor MNCH outcomes in the North-West and North-East Nigeria [26‐28].

In Mali, a recent report confirms that the Sikasso is among the regions with the worst health statistics, having the highest infant mortality rate and under-five mortality rate in the country [29]. According to Daou and colleagues, the main factors that are significantly associated with child mortality in Sikasso Mali, included the level of education of parents, the age of the mothers and the lack of skilled health care resources [30]. In Senegal, and especially in Diourbel region, child marriage is reported to be a major contributor to the very high maternal and child mortality [31, 32].

The EQUIST situational analysis showed that the rural dwellers and poorest quintile population had consistently higher maternal and child mortality in all the six countries. Also, higher number of deaths due to epidemiological causes were recorded among the rural dwellers and poorest quintile population. In an earlier report on maternal mortality and access to obstetric services in West Africa, Ronsmans and co-workers noted that most rural women give birth at home in the absence of skilled care, while urban women tend to give birth in a hospital with a skilled attendant, consequently, maternal mortality is extremely high in rural areas, and substantially lower in urban areas [33]. In addition to this, higher maternal and child deaths are recorded in West African rural areas because of low quality of services at government facilities, inadequate outreach services, self-medication and client preferences for traditional medicine because traditional beliefs and practices remain strong in the region [34].

The EQUIST situational analysis showed that neonatal causes, malaria, pneumonia, and diarrhoea were the major causes of under-five mortality in all the six countries. Result also showed that sepsis, asphyxia, and prematurity were the leading causes of neonatal mortality in the countries. Both under-five mortality and neonatal mortality were highest among the poorest and the rural dwellers in the six countries. Available evidence from previous studies conducted in Nigeria indicated that these diseases were responsible for the highest under-five and neonatal mortality numbers in various parts of the country especially among the rural and the poorest [26, 27]. A similar trend was also reported in other West African countries [35].

EQUIST analysis showed that obstetric hemorrhage is the leading cause of maternal mortality in all the six countries. Of the three types of Obstetric haemorrhage, post-partum haemorrhage was responsible for the highest number of maternal mortality. In a previous study on maternal mortality undertaken in northern Nigeria, post-partum haemorrhage was a leading cause of maternal mortality, contributing 75% of the cases [36]. Reports from Mali, Senegal and other parts of West Africa, noted that post-partum haemorrhage was a major cause of maternal death [37, 38].

The EQUIST situational and scenario equity and operational frontier analysis showed that thousands of under-five and maternal deaths could have been averted if the countries had equalized coverage values for the least disadvantaged within the most disadvantaged population (poorest quintile). According to the UN Chronicle report, universal coverage of scientifically proven cost-effective interventions are capable of reducing child deaths from about 2 million to just 650,000 [39]. According to Partnership for Maternal, Newborn & Child Health, the majority of maternal and child mortality and morbidity are preventable with interventions that are effective and affordable which prevent or treat the most common causes of illness [40]. A recent World Bank report indicated that scaling up all interventions in the packages of maternal and newborn health, plus folic acid before pregnancy, and child health from the existing rate of coverage to 90% would avert 149,000 maternal deaths; 849,000 stillbirths; 1,498,000 neonatal deaths; and 1,515,000 child deaths [41]. There is therefore, an international consensus that improving the coverage and quality of these interventions should be the focus of policies and associated programmes [40].

In terms of the coverage of intervention package to improve maternal and child health outcomes, EQUIST analysis revealed that Ghana, Senegal and Mali had higher national average of 82%, 81% and 73% respectively compared to the remining three countries. A recent report indicated that Ghana achieved its Millennium Development Goal (MDG) water target about a decade before the 2015 deadline [42]. As in Ghana, substantial donor support as well as institution of effective water policy reforms are major contributors to the very high percentage national water coverage also witnessed in Senegal and Mali [43, 44].

The EQUIST analysis indicated that the percentage of the ITN ownership, DTP3 immunization and curative services such as essential care and case management of premature babies was lower among the poorest compared to the national average in most of the countries. A recent study on equity trends in ownership of ITNs involving eight West African countries (including Benin, Burkina Faso, Mali, Nigeria, Senegal etc.) and 11 other sub-Saharan African countries, showed that richer households were more likely to own ITNs than the poorest households [45]. The relatively lower percentage of ITNs possession by the population of the poorest quintile has been attributed to their inability to afford the cost of the ITNs and probably as a result of low access to health care among the poorest populations [46]. Similarly, regarding routine immunization, disparities in coverage within countries also exist between poor and wealthy populations, where children in poor households are at much greater risk of dying from vaccine-preventable diseases than children in relatively wealthier households [46, 47].

The EQUIST scenario analysis for mortality by intervention package showed that delivery by skilled professionals has the potential of averting the highest number of under-five and maternal mortality in all the six countries. Findings from a number of previous studies have shown that between 13 and 33% of maternal deaths and up to 25% of newborn deaths could be averted by the availability of skilled attendant at delivery [48, 49]. According to UNICEF, the very high NMR, IMR and U5MR recorded in LMICs are caused by diseases and medical conditions which can easily be prevented by skilled care during delivery and immediate neonatal period [50].

One of the major strengths of the EQUIST scenario analysis is the estimation of the actual cost of the strategies to avert the mortality. Redeployment/relocation of existing staff and task-shifting/task sharing are the strategies with the highest costs in Burkina Faso, Nigeria and Senegal. According to Santi and Weigert, the health sector is skilled-labour-intensive and in all countries of the West African region, the increase and effective management of health staff is crucial to the improvement of health systems [25]. Insight from the EQUIST analysis can help to prioritize this domain, of which emphasis must be laid on territorial equity in order to address the human resource shortage in rural areas, where the poorest people live but which still harbour the greatest health risks [25]. EQUIST scenario analysis also showed the cost per capita averting the number of deaths was least in Ghana ($0.39) and highest in Benin ($4.0). This outcome was not a surprise, among the six countries in this study, Ghana had the least total expenditure on health as percentage GDP, least private expenditure on health as percentage of total expenditure on health and least poverty headcount ratio and the best Human Development Index rank [5].

Carrera and colleagues [12] have noted that a better understanding of the effectiveness, impact, and costs of the operational strategies and service delivery modes that can be used to overcome existing bottlenecks (especially those faced by people living in low-income and lower-middle-income countries) is required to ensure that deprived populations receive low cost, high impact interventions.

Although EQUIST can be described as a valuable tool which can assist decision makers to engage equity-focused approaches to improving MNCH outcomes, the knowledge and application of the tool is not yet wide-spread in LMICs. This study is the first attempt to demonstrate the usefulness of the EQUIST in the provision of scientific evidence on equity–focused approaches to health interventions to improve MNCH outcomes in West Africa. It has been argued that this type of information is very crucial as it supports an evidence-based prioritization of vulnerable populations and priority interventions, as well as an initial understanding of the broad health system issues that will need to be addressed in order to reduce health disparities in a region like West Africa [23].

Throughout the world and especially in LMICs, policy makers and other key stakeholders in the health sector have come to the realization that resources for scaling up cost–effective MNCH interventions in their populations are scarce. Consequently, they are faced with the complex task of identifying and implementing the most efficient and cost-effective interventions that will results to more deaths averted per fixed investment [53, 54]. According to Sridhar and co-workers [51], health investors usually like to know how many deaths (or episodes of disease) could be averted for a fixed level of investment. EQUIST not only provides this vital information but also disaggregates data to reveal inequities that are often masked by national averages [13].

EQUIST will continue to serve as a tool for maximizing the number of lives saved; decreasing health disparities and improving overall cost effectiveness [23]. The importance of this cannot be overstated because even if current rates of decline in under-five mortality are sustained, without additional investment in reaching the poorest, nearly 70 million newborns, infants and young children will still die from preventable causes by 2030 [13]. In this study EQUIST analysis has helped in identifying the country’s populations that are disadvantaged, why they are disadvantaged, and which combination of evidence based high impact interventions and health system strengthening strategies would produce the best results. The West African policymakers will find this very valuable. We recommend EQUIST to national decision makers in LMICs who are interested in conducting an in-depth analysis of the situation of the disadvantaged or underserved populations in their countries. If the national decision makers are also interested in bridging implementation gaps and in the development of policies that are based on a thorough assessment of how the health system is functioning, particularly with regards to producing equitable health outcomes, then EQUIST is highly imperative.