title: Understanding the determinants of the complex interplay between cost-effectiveness and equitable impact in maternal and child mortality reduction.
abstract: BACKGROUND
  One of the most unexpected outcomes arising from the efforts towards maternal and child mortality reduction is that all too often the objective success has been coupled with increased inequity in the population. The aim of this study is to analyze the determinants of the complex interplay between cost-effectiveness and equity and suggest strategies that will promote an impact on mortality that reduce population child health inequities.
  
  
  METHODS
  We developed a conceptual framework that exposes the nature of the links between the five key determinants that need to be taken into account when planning equitable impact. These determinants are: (i) efficiency of intervention scale-up (requires knowledge of differential increase in cost of intervention scale-up by equity strata in the population); (ii) effectiveness of intervention (requires understanding of differential effectiveness of interventions by equity strata in the population); (iii) the impact on mortality (requires knowledge of differential mortality levels by equity strata, and understanding the differences in cause composition of overall mortality in different equity strata); (iv) cost-effectiveness (compares the initial cost and the resulting impact on mortality); (v) equity structure of the population. The framework is presented visually as a four-quadrant graph.
  
  
  RESULTS
  We use the proposed framework to demonstrate why the relationship between cost-effectiveness and equitable impact of an intervention cannot be intuitively predicted or easily planned. The relationships between the five determinants are complex, often nonlinear, context-specific and intervention-specific. We demonstrate that there will be instances when an equity-promoting approach, ie, trying to reach for the poorest and excluded in the population with health interventions, will also be the most cost-effective approach. However, there will be cases in which this will be entirely unfeasible, and where equity-neutral or even inequity-promoting approaches may be substantially more cost-effective. In those cases, investments into health system development among the poorest that would increase the quality and reduce the cost of intervention delivery would be required before intervention scale-up is planned.
  
  
  CONCLUSIONS
  The relationships between the most important determinants of cost-effectiveness and equitable impact of health interventions used to reduce maternal and child mortality are highly complex, and the effect on equity cannot be predicted intuitively, or by using simple linear models.
authors.affiliation: UNICEF, New York, USA ; Centre for Population Health Sciences and Global Health Academy, The University of Edinburgh Medical School, Edinburgh, Scotland, UK.
authors.forename: Mickey
authors.initials: M
authors.lastname: Chopra
authors.forename: Harry
authors.initials: H
authors.lastname: Campbell
authors.forename: Igor
authors.initials: I
authors.lastname: Rudan