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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
Globalization and Healthvolume 14, Article number: 104 (2018)
United Nations Children’s Fund (UNICEF) designed EQUitable Impact Sensitive Tool (EQUIST) to enable global health community address the issue of equity in maternal, newborn and child health (MNCH) and minimize health disparities between the most marginalized population and the better-off. The purpose of this study was to use EQUIST to provide reliable evidence, based on demographic health surveys (DHS) on cost–effectiveness and equitable impact of interventions that can be implemented to improve MNCH outcomes in Benin, Burkina Faso, Ghana, Mali, Nigeria and Senegal.
Using the latest available DHS data sets, we conducted EQUIST Situation Analysis of maternal and child health outcomes in the six countries by sub-national categorization, wealth and by residence. We then identified the poorest population class within each country with the highest maternal and child mortality and performed EQUIST Scenario Analysis of this population to identify intervention package, bottlenecks and strategies to address them, cost of the intervention and strategies as well as the number of deaths avertible.
Under-five mortality was highest in Atlantique (Benin), Sahel (Burkina Faso), Northern (Ghana), Sikasso (Mali), North-West (Nigeria), and Diourbel (Senegal). The number of under-five deaths was considerably higher among the poorest and rural population. Neonatal causes, malaria, pneumonia and diarrhoea were responsible for most of the under-five deaths. Ante-partum, intra-partum, and post-partum haemorrhages, and hypertensive disorder, were responsible for highest maternal deaths. The national average for improved water source was highest in Ghana (82%). Insecticide treated nets ownership percentage national average was highest in Benin (73%). Delivery by skilled professional is capable of averting the highest number of under-five and maternal deaths in the six countries. Redeployment/relocation of existing staff was the strategy with highest costs in Burkina Faso, Nigeria and Senegal. Ghana recorded the least cost per capita ($0.39) while the highest cost per capita was recorded in Benin ($4.0).
EQUIST highlights the most vulnerable and deprived children and women needing urgent health interventions as a matter of priority. It will continue to serve as a tool for maximizing the number of lives saved; decreasing health disparities and improving overall cost effectiveness.
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) . 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 . Similarly, the maternal mortality ratio (MMR) per 100,000 live births in Africa reduced from 840 in 2000 to 542 in 2015 . 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) . 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) .
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 . 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 . Wilunda and co-workers  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 [10,11,12,13]. 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 . In a recent publication , 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 . Some of these tools included the Marginal Budgeting for Bottlenecks (MBB) , Choice of Interventions that are Cost–Effective (CHOICE) , and the Lives Saved Tool (LiST) . According to Waters and colleagues , 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 [18,19,20,21,22].
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.
Geographically, the West African sub-region is bounded by the Atlantic Ocean in the west and by the Gulf of Guinea in the south and is characterised by a very rich ethnic and social diversity. Most of the countries of West Africa are classified as poor and their economies are not very well developed or diversified with the Human Development Index (HDI) rank among the poorest in the world . The 2014 HDI rank of Benin, Burkina Faso, Ghana, Mali, Nigeria and Senegal out of 188 countries were 166, 183, 140, 179, 152, and 170 respectively . The health situation in these six countries like all others in West Africa region is a reflection of the development stage which most of the countries in the region are at. These six countries were selected for this investigation because there are the countries in which the West African Health Organization is implementing the Moving Evidence to Policy (MEP) project in maternal and child health.
An explanation of the main concepts, assumptions and default data sources used in EQUIST are presented in the EQUIST technical note , while the step-wise procedure of performing the analysis is described in the EQUIST user’s guide . EQUIST is linked to LiST, estimate cost using MBB, and uses data globally available such as DHS , and is based on a simple seven-step theory of change [21, 23]. This theory of change assumes that investments in, and implementation of, equity-focused strategies that remove quantifiable health system bottlenecks will lead to improvements in the coverage of high-impact health interventions and improved health outcomes for target populations .
EQUIST situational analysis
EQUIST is pre-loaded with DHS data sets and we used the latest available DHS data sets of the six West African countries we considered in this study. The DHS are country-wide household survey that are nationally-representative and which provide a wide range of systematic information on health indicators and health services. We used the 2011 DHS data set of Benin, 2010 of Burkina-Faso, 2014 of Ghana, 2013 of Mali, 2013 of Nigeria and 2014 of Senegal to perform both profile and frontier situational analysis . We conducted a general EQUIST situation analysis of maternal and child health outcomes in the six countries by sub-national categorization, by wealth and by residence. We then identified the poorest population class within each country with the highest maternal and child mortality and performed EQUIST scenario analysis of this population in order to identify the intervention package, the bottlenecks and strategies to address them, the cost of the intervention and strategies as well as the number of deaths avertible and lives saved per US$ invested.
Using the EQUIST Profile analysis, we assessed the general extent, nature and implications of inequities as they affect MNCH in the six countries. Under the Demographic Parameters of the Sector Category, we examined under-five mortality and neonatal mortality with reference to the key drivers of inequity, the underlying factors that explain inequities (wealth quintile, geography, and location) and analysed the scale of inequity (deprivation mostly concentrated in poorest quintile and in rural areas). Under the Epidemiological Parameters of the Sector Category, we performed EQUIST Profile analysis to determine the key epidemiological causes and the specific number of under-five, neonatal and maternal mortality each of them causes.
Under the Theme Category, we also performed EQUIST Profile analysis of the percentage of Effective Coverage of maternal and child health interventions including: (i). Family care practices (WASH, ITNs/Environmental safety, neonatal/infant care); (ii). Preventive services (immunization plus); (iii). Curative services (IMNCI, delivery by skilled professionals, EMONC). We related these interventions and effective coverage to the six countries by wealth (poorest and richest) and by residence (rural and urban).
Using the EQUIST Frontier analysis, we identified the factors most likely to drive inequity, and compared the number of Under-five and maternal deaths that could be averted in the poorest wealth quintile in the six West African countries. Under the Frontier, we performed two analyses.
First, we performed the Equity Frontier analysis to identify how many under-five and maternal lives that could have been saved if the six countries equalize coverage values for the least disadvantaged within the most disadvantaged population (poorest quintile). This was to enable us know the number of deaths that will be averted if the coverage gaps for the most disadvantaged population was equivalent to that of the richest in each of the countries’ context.
Second, we performed the Operational Frontier analysis to determine the number of under-five and maternal deaths that could be averted if effective coverage of evidence based high impact interventions are implemented and if their bottlenecks are reduced with the same proportion as observed in the most disadvantaged quintiles in best- performing countries.
EQUIST scenario analysis
We conducted EQUIST scenario analysis for the six selected West African countries by wealth focusing on the poorest quintile.
Analysis of epidemiological priorities
Using the EQUIST epidemiological priorities we identified three categories of mortality and their main causes in the poorest quintile as follows: (i). Neonatal mortality (asphyxia, prematurity, sepsis, pneumonia, diarrhoea, tetanus); (ii). Post-neonatal and child mortality (diarrhoea, malaria, meningitis, pneumonia, asphyxia, sepsis, measles, tetanus, pertussis, prematurity); (iii). Maternal mortality (antepartum haemorrhage, complicated abortion, obstructed labour, postpartum haemorrhage, sepsis infection).
Analysis of interventions
We identified the priority interventions with which to address the epidemiological issues we selected. The interventions are grouped in nine “packages” further grouped into three service delivery modes: family care practices, preventive services, and curative services.
Analysis of bottlenecks, causes & recommendations
We identified the priority bottlenecks to implementing the interventions we selected. We related the priority bottle necks with the eight EQUIST scenario coverage determinants including: (i) Availability of commodities, (ii) availability of human resources, (iii) geographical accessibility, (iv) financial affordability, (v) sociocultural acceptability, (vi) initial utilization, (vii) adequate coverage, and, (viii) effective coverage. The bottleneck analysis framework in EQUIST assumes that eight conditions (coverage determinants) must be met to provide effective coverage of any health intervention . Using the EQUIST bottleneck analysis, we determined the severity of bottlenecks based on the indicators used to measure the level of compliance with each condition for utilization, as well as the relationship between initial utilization, adequate coverage. For each intervention, we identified the coverage determinant, bottleneck, cause of the bottleneck and recommendations to address them.
Analysis of enabling environment and strategies to address bottlenecks and their causes
We performed the analysis of the enabling environment which is classified into four (social norms; legislation/policy; budget/expenditure; management/coordination) and identified the direct causes. We also performed the analysis of the strategies classified into five health systems building blocks (financing; service delivery; medical products, vaccines and technologies; health workforce; governance/leadership; information) to address the bottlenecks.
Analysis of impact and cost
The EQUIST impact and cost analysis was performed to determine the following: (i). The operational frontier for maternal, under-five and neonatal mortality: that is amenable deaths if the deprived population coverage value was equal to the best performing countries, (ii). The equity frontier for maternal, under-five and neonatal mortality: that is amenable deaths if the deprived population coverage value was equal to the non-deprived population coverage value; (iii). Amenable under-five and maternal deaths among the poorest by intervention package in the six West African countries; (iv). The cost of strategies to avert both maternal and under-five mortality; (v). The cost per capita averting the number of deaths.
Outcome of situational analysis
The EQUIST profile analysis of under-five mortality by sub-national regions under the demographic parameters of the sector category in the six West African countries showed the regions recorded the highest mortality Atlantique (Benin), Sahel (Burkina Faso), Northern (Ghana), Sikasso (Mali), North West (Nigeria), and Diourbel (Senegal). The number of deaths/1000 live births in these regions were more than twice the number recorded in the regions with the lowest number of deaths/1000 live births and the values were considerably higher than the national average in the six countries (Table 1). The number of under-five deaths/1000 live births was considerably higher among the poorest compared to the richest and among the rural compared to the urban population (Table 1).
The outcome of profile analysis of neonatal mortality by sub-national regions, wealth and residence under the demographic parameters of the sector category is summarized in Table 2. The number of neonatal deaths/1000 live births was consistently higher among the poorest compared to the richest and among the rural compared to the urban population except in Ghana. The six countries under-five mortality by epidemiological cause under the Sector Category is presented in Table 3. The four diseases responsible for most of the deaths are neonatal causes, malaria, pneumonia and diarrhoea. The rural dwellers as well as the poorest had higher under-five mortality numbers across the six West African countries (Table 3).
The poorest and the rural dwellers across the six countries had the highest number of neonatal deaths (Table 4). The four diseases responsible for the highest neonatal mortality included sepsis, asphyxia, prematurity and congenital disorders. Prematurity was the major killer of the neonates in all the six countries with the mortality considerably higher among the rural compared to the urban population in Benin (2151 vs. 1622), Burkina Faso (4457 vs. 1175), Mali (4510 vs. 1828), Nigeria (49,314 vs. 33,432) and Senegal (2951 vs. 1125). An exception was in Ghana where the neonatal mortality due to prematurity was higher among the urban (4771) compared to the rural population (3680) (Table 4).
The six diseases responsible for the highest maternal mortality included ante-partum haemorrhage, intra-partum haemorrhage, post-partum haemorrhage, hypertensive disorder, maternal sepsis and complicated abortion. Considerably higher maternal mortality was recorded in the rural compared to the urban population across all the countries except in Ghana (Table 5).
The percentage national average for WASH (improved water source) was higher in Ghana (82%), Mali (73%), and Senegal (81%), compared to the remaining three countries. ITN ownership percentage national average was highest in Benin (73%) and Mali (61%) but lowest in Nigeria (13%). The percentage of the ITN ownership was lower among the poorest compared to the national average in Benin (73% vs. 68%), Burkina-Faso (47% vs. 42%), Mali (61% vs. 56%), Nigeria (13% vs. 9%) and Senegal 43% vs. 38%) (Table 6). Ghana recorded the highest percentage of national average of exclusive breast feeding (52%) compared to the other five countries. The highest percentage coverage of DTP3 immunization was recorded in Burkina Faso (90%) and Ghana (89%), with the least in Benin (0.74%). In all the six countries, the percentage coverage of DTP3 immunization among the poorest was lower than the national average (Table 6). In terms of the curative services (essential care and case management of premature babies), the percentage coverage was low across the countries except in Benin (80% and 100% respectively), also the percentage coverage among the poorest was generally lower than the national average.
The outcomes of the analysis of avertible deaths by epidemiological cause and equity/operational frontier for under-five children in the six countries are shown in Table 7. In the Burkina Faso and Nigeria, the three main diseases responsible for the highest number of avertible under-five deaths by equity and operational frontiers are malaria, pneumonia, and diarrhoea. In Ghana, Mali and Nigeria, the four main diseases responsible for the highest number of avertible maternal deaths by equity and operational frontiers are sepsis, hypertensive disorders, post-partum haemorrhage and intra-partum haemorrhage (Table 7).
Outcome of scenario analysis
The number of amenable/avertible under-five deaths if the deprived population coverage value was equal to (i). the best performing countries (operational frontier) and (ii) the non-deprived population coverage value (equity frontier) are shown in Table 8. An additional chart file of the six West African countries shows this in more detail [see Additional files 1, 2, 3, 4, 5, 6]. In the six countries, pneumonia, diarrhoea and asphyxia were responsible for the highest number of amenable under-five deaths by operational and equity frontiers.
Asphyxia is responsible for the highest number of amenable neonatal deaths by operational and equity frontiers in the six countries. Ante-partum haemorrhage, intra-partum haemorrhage, post-partum haemorrhage and hypertensive disorders are the diseases responsible for the highest number of amenable maternal deaths among the poorest quintile in Ghana, Mali and Nigeria (Table 8).
Amenable deaths among the poorest by intervention package and equity/operational frontier for under-five and maternal mortality in six West African countries are shown in Table 9. Delivery by skilled professional is a major intervention capable of averting the highest number of under-five and maternal mortality in all the six countries. IMNCI, ITNs/Environmental safety, WASH and Immunization plus are capable of averting under-five deaths ranging from 35 in Ghana to 15,599 in Nigeria. An additional chart file of the six West African countries shows this in more detail [see Additional files 1, 2, 3, 4, 5, 6].
The cost of intervention strategies to avert the mortality as provided by the EQUIST impact and cost analysis are presented in Table 10. The strategies with the highest costs in Burkina Faso, Nigeria and Senegal are Redeployment/relocation of existing staff. Ghana recorded the least cost per capita ($0.39) while the highest cost per capita was recorded in Benin ($4.0) (Table 10). The avertible under-five, neonatal and maternal mortality by cause and by intervention package as well as the estimates of cost generation for the analysis and cost per capta of avertible number of deaths in the scenario in all the six countries are shown in more detail as an additional chart file [see Additional files 1, 2, 3, 4, 5, 6].
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  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 . 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 . 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 . These factors contribute significantly to the very poor MNCH outcomes in the North-West and North-East Nigeria [26,27,28].
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 . 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 . 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 . 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 .
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 .
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 . 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 . 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 . 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 . There is therefore, an international consensus that improving the coverage and quality of these interventions should be the focus of policies and associated programmes .
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 . 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 . 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 . 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 .
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 . 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 . 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 .
Carrera and colleagues  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.
The major limitation of this study is that it is entirely based on DHS data. The weakness of information collected in DHS are well-established [51, 52]. One important weakness is that virtually all data obtained through DHS is subject to reporting and recall biases. Furthermore, DHS can only measure limited health indicators and health services and so misclassification biases are known to occur and the magnitude of the bias is often unknown and very difficult to correct . As can be seen from this study, some of the DHS information from some of the countries could not be obtained for others due to the challenges associate with data collection process from the various target populations. Despite the limitation, DHS provide valuable and high-quality data base on various of health indicators in LMICs which in many cases are the only reliable source of scientific information for health policymaking and implementation.
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 .
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 , 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 .
EQUIST will continue to serve as a tool for maximizing the number of lives saved; decreasing health disparities and improving overall cost effectiveness . 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 . 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.
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Authors wish to thank UNICEF for access to the EQUIST, the user guide and the technical note. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of the UNICEF, WAHO or governments of the countries studied.
This study was one of the outcomes of the “Moving Maternal, Neonatal and Child Health Evidence into Policy in West Africa” (MEP) project undertaken by the West African Health Organization. The project and publication costs were funded by the International Development Research Centre Canada (Reference: IDRC 107892_001).
Availability of data and materials
The authors confirm that all data underlying the findings are fully available without restriction upon reasonable request, which should be made to the corresponding author.
Ethics approval and consent to participate
Ethical clearance for this study was obtained from the University Research Ethics Committee of Ebonyi State University Nigeria (the institution of the principal author) (Ref No: EBSU/UREC/015/10/03).
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Outcome of EQUSIT Scenario analysis for poorest quintile in Benin. (PDF 345 kb)
Outcome of EQUSIT Scenario analysis for poorest quintile in Burkina Faso. (PDF 345 kb)
Outcome of EQUSIT Scenario analysis for poorest quintile in Ghana. (PDF 345 kb)
Outcome of EQUSIT Scenario analysis for poorest quintile in Mali. (PDF 345 kb)
Outcome of EQUSIT Scenario analysis for poorest quintile in Nigeria. (PDF 345 kb)
Outcome of EQUSIT Scenario analysis for poorest quintile in Senegal. (PDF 345 kb)