Optimizing community case management strategies to achieve equitable reduction of childhood pneumonia mortality: An application of Equitable Impact Sensitive Tool (EQUIST) in five low- and middle-income countries

Abstract

Background: The aim of this study was to populate the Equitable Impact Sensitive Tool (EQUIST) framework with all necessary data and conduct the first implementation of EQUIST in studying cost-effectiveness of community case management of childhood pneumonia in 5 low- and middle-income countries with relation to equity impact.

Methods: Wealth quintile-specific data were gathered or modelled for all contributory determinants of the EQUIST framework, namely: under-five mortality rate, cost of intervention, intervention effectiveness, current coverage of intervention and relative disease distribution. These were then combined statistically to calculate the final outcome of the EQUIST model for community case management of childhood pneumonia: US$ per life saved, in several different approaches to scaling-up.

Results: The current 'mainstream' approach to scaling-up of interventions is never the most cost-effective. Community-case management appears to strongly support an 'equity-promoting' approach to scaling-up, displaying the highest levels of cost-effectiveness in interventions targeted at the poorest quintile of each study country, although absolute cost differences vary by context.

Conclusions: The relationship between cost-effectiveness and equity impact is complex, with many determinants to consider. One important way to increase intervention cost-effectiveness in poorer quintiles is to improve the efficiency and quality of delivery. More data are needed in all areas to increase the accuracy of EQUIST-based estimates.

Figure 1

Conceptual framework for EQUIST [6], demonstrating a hypothetical planning exercise assessing the cost–effectiveness of delivery of a new intervention to different equity strata in the population (quintile Q2 vs Q3 vs Q4) with a fixed budget.

Figure 2

Exemplar countries used in the study.

Figure 3

U5MR and inequity by wealth quintiles in exemplar countries.

Figure 4

Community case management (CCM) coverage estimates by wealth quintiles in exemplar countries.

Figure 5

Non–antibiotic cost estimate model.

Figure 6

Case fatality rates by wealth quintiles in exemplar countries.

Figure 7

Cost of community case management (CCM) treatment by wealth quintile in exemplar countries.

Figure 8

Effectiveness/Potential Impact Fraction (PIF) model for community case management (CCM).

Figure 9

Effectiveness/Potential Impact Fraction (PIF) model for community case management (CCM) in each country by wealth quintiles in exemplar countries.

Figure 10

Modelled cause–specific child mortality by wealth quintiles in exemplar countries.

Figure 11

Estimated cost per life saved in exemplar countries.

Figure 12

Estimated number of lives saved in Mainstream vs Equity–promoting models for the same investment.