Marketing of commercial milk formula: a system to capture parents, communities, science, and policy.

Despite proven benefits, less than half of infants and young children globally are breastfed in accordance with the recommendations of WHO. In comparison, commercial milk formula (CMF) sales have increased to about US$55 billion annually, with more infants and young children receiving formula products than ever. This Series paper describes the CMF marketing playbook and its influence on families, health professionals, science, and policy processes, drawing on national survey data, company reports, case studies, methodical scoping reviews, and two multicountry research studies. We report how CMF sales are driven by multifaceted, well resourced marketing strategies that portray CMF products, with little or no supporting evidence, as solutions to common infant health and developmental challenges in ways that systematically undermine breastfeeding. Digital platforms substantially extend the reach and influence of marketing while circumventing the International Code of Marketing of Breast-milk Substitutes. Creating an enabling policy environment for breastfeeding that is free from commercial influence requires greater political commitment, financial investment, CMF industry transparency, and sustained advocacy. A framework convention on the commercial marketing of food products for infants and children is needed to end CMF marketing.

First-food systems transformations and the ultra-processing of infant and young child diets: The determinants, dynamics and consequences of the global rise in commercial milk formula consumption.

The inappropriate marketing and aggressive promotion of breastmilk substitutes (BMS) undermines breastfeeding and harms child and maternal health in all country contexts. Although a global milk formula 'sales boom' is reportedly underway, few studies have investigated its dynamics and determinants. This study takes two steps. First, it describes trends and patterns in global formula sales volumes (apparent consumption), by country income and region. Data are reported for 77 countries, for the years 2005-19, and for the standard (0-6 months), follow-up (7-12 m), toddler (13-36 m), and special (0-6 m) categories. Second, it draws from the literature to understand how transformations underway in first-food systems - those that provision foods for children aged 0-36 months - explain the global transition to higher formula diets. Total world formula sales grew by 115% between 2005 and 2019, from 3.5 to 7.4 kg/child, led by highly-populated middle-income countries. Growth was rapid in South East and East Asia, especially in China, which now accounts for one third of world sales. This transition is linked with factors that generate demand for BMS, including rising incomes, urbanisation, the changing nature of woman's work, social norms, media influences and medicalisation. It also reflects the globalization of the baby food industry and its supply chains, including the increasing intensity and sophistication of its marketing practices. Policy and regulatory frameworks designed to protect, promote and support breastfeeding are partially or completely inadequate in the majority of countries, hence supporting industry expansion over child nutrition. The results raise serious concern for global child and maternal health.

Demand for family planning satisfied with modern methods among sexually active women in low- and middle-income countries: who is lagging behind?

BACKGROUND: Family planning is key for reducing unintended pregnancies and their health consequences and is also associated with improvements in economic outcomes. Our objective was to identify groups of sexually active women with extremely low demand for family planning satisfied with modern methods (mDFPS) in low- and middle-income countries, at national and subnational levels to inform the improvement and expansion of programmatic efforts to narrow the gaps in mDFPS coverage. METHODS: Analyses were based on Demographic and Health Survey and Multiple Indicator Cluster Survey data. The most recent surveys carried out since 2000 in 77 countries were included in the analysis. We estimated mDFPS among women aged 15-49 years. Subgroups with low coverage (mDFPS below 20%) were identified according to marital status, wealth, age, education, literacy, area of residence (urban or rural), geographic region and religion. RESULTS: Overall, only 52.9% of the women with a demand for family planning were using a modern contraceptive method, but coverage varied greatly. West & Central Africa showed the lowest coverage (32.9% mean mDFPS), whereas South Asia and Latin America & the Caribbean had the highest coverage (approximately 70% mean mDFPS). Some countries showed high reliance on traditional contraceptive methods, markedly those from Central and Eastern Europe, and the Commonwealth of Independent States (CEE & CIS). Albania, Azerbaijan, Benin, Chad and Congo Democratic Republic presented low mDFPS coverage (< 20%). The other countries had mDFPS above 20% at country-level, yet in many of these countries mDFPS coverage was low among women in the poorest wealth quintiles, in the youngest age groups, with little education and living in rural areas. Coverage according to marital status varied greatly: in Asia & Pacific and Latin America & the Caribbean mDFPS was higher among married women; the opposite was found in West & Central Africa and CEE & CIS countries. CONCLUSIONS: Almost half of the women in need were not using an effective family planning method. Subgroups requiring special attention include women who are poor, uneducated/illiterate, young, and living in rural areas. Efforts to increase mDFPS must address not only the supply side but also tackle the need to change social norms that might inhibit uptake of contraception.

Countdown to 2015 and beyond: fulfilling the health agenda for women and children.

The end of 2015 will signal the end of the Millennium Development Goal era, when the world can take stock of what has been achieved. The Countdown to 2015 for Maternal, Newborn, and Child Survival (Countdown) has focused its 2014 report on how much has been achieved in intervention coverage in these groups, and on how best to sustain, focus, and intensify efforts to progress for this and future generations. Our 2014 results show unfinished business in achievement of high, sustained, and equitable coverage of essential interventions. Progress has accelerated in the past decade in most Countdown countries, suggesting that further gains are possible with intensified actions. Some of the greatest coverage gaps are in family planning, interventions addressing newborn mortality, and case management of childhood diseases. Although inequities are pervasive, country successes in reaching of the poorest populations provide lessons for other countries to follow. As we transition to the next set of global goals, we must remember the centrality of data to accountability, and the importance of support of country capacity to collect and use high-quality data on intervention coverage and inequities for decision making. To fulfill the health agenda for women and children both now and beyond 2015 requires continued monitoring of country and global progress; Countdown is committed to playing its part in this effort.

Child immunization status according to number of siblings and birth order in 85 low- and middle-income countries: a cross-sectional study.

Background: Identification of unvaccinated children is important for preventing deaths due to infections. Number of siblings and birth order have been postulated as risk factors for zero-dose prevalence. Methods: We analysed nationally representative cross-sectional surveys from 85 low and middle-income countries (2010-2020) with information on immunisation status of children aged 12-35 months. Zero-dose prevalence was defined as the failure to receive any doses of DPT (diphtheria-pertussis-tetanus) vaccine. We examined associations with birth order and the number of siblings, adjusting for child's sex, maternal age and education, household wealth quintiles and place of residence. Poisson regression was used to calculate zero-dose prevalence ratios. Findings: We studied 375,548 children, of whom 13.7% (n = 51,450) were classified as zero-dose. Prevalence increased monotonically with birth order and with the number of siblings, with prevalence increasing from 11.0% for firstborn children to 17.1% for birth order 5 or higher, and from 10.5% for children with no siblings to 17.2% for those with four or more siblings. Adjustment for confounders attenuated but did not eliminate these associations. The number of siblings remained as a strong risk factor when adjusted for confounders and birth order, but the reverse was not observed. Among children with the same number of siblings, there was no clear pattern in zero-dose prevalence by birth order; for instance, among children with two siblings, the prevalence was 13.0%, 14.7%, and 13.3% for firstborn, second, and third-born, respectively. Similar results were observed for girls and boys. 9513 families had two children aged 12-35 months. When the younger sibling was unvaccinated, 61.9% of the older siblings were also unvaccinated. On the other hand, when the younger sibling was vaccinated, only 5.9% of the older siblings were unvaccinated. Interpretation: The number of siblings is a better predictor than birth order in identifying children to be targeted by immunization campaigns. Zero-dose children tend to be clustered within families. Funding: Gavi, the Vaccine Alliance.

Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries.

BACKGROUND: Countdown to 2015 tracks progress towards achievement of Millennium Development Goals (MDGs) 4 and 5, with particular emphasis on within-country inequalities. We assessed how inequalities in maternal, newborn, and child health interventions vary by intervention and country. METHODS: We reanalysed data for 12 maternal, newborn, and child health interventions from national surveys done in 54 Countdown countries between Jan 1, 2000, and Dec 31, 2008. We calculated coverage indicators for interventions according to standard definitions, and stratified them by wealth quintiles on the basis of asset indices. We assessed inequalities with two summary indices for absolute inequality and two for relative inequality. FINDINGS: Skilled birth attendant coverage was the least equitable intervention, according to all four summary indices, followed by four or more antenatal care visits. The most equitable intervention was early initation of breastfeeding. Chad, Nigeria, Somalia, Ethiopia, Laos, and Niger were the most inequitable countries for the interventions examined, followed by Madagascar, Pakistan, and India. The most equitable countries were Uzbekistan and Kyrgyzstan. Community-based interventions were more equally distributed than those delivered in health facilities. For all interventions, variability in coverage between countries was larger for the poorest than for the richest individuals. INTERPRETATION: We noted substantial variations in coverage levels between interventions and countries. The most inequitable interventions should receive attention to ensure that all social groups are reached. Interventions delivered in health facilities need specific strategies to enable the countries' poorest individuals to be reached. The most inequitable countries need additional efforts to reduce the gap between the poorest individuals and those who are more affluent. FUNDING: Bill & Melinda Gates Foundation, Norad, The World Bank.

Maternal and child health in Brazil: progress and challenges.

In the past three decades, Brazil has undergone rapid changes in major social determinants of health and in the organisation of health services. In this report, we examine how these changes have affected indicators of maternal health, child health, and child nutrition. We use data from vital statistics, population censuses, demographic and health surveys, and published reports. In the past three decades, infant mortality rates have reduced substantially, decreasing by 5·5% a year in the 1980s and 1990s, and by 4·4% a year since 2000 to reach 20 deaths per 1000 livebirths in 2008. Neonatal deaths account for 68% of infant deaths. Stunting prevalence among children younger than 5 years decreased from 37% in 1974-75 to 7% in 2006-07. Regional differences in stunting and child mortality also decreased. Access to most maternal-health and child-health interventions increased sharply to almost universal coverage, and regional and socioeconomic inequalities in access to such interventions were notably reduced. The median duration of breastfeeding increased from 2·5 months in the 1970s to 14 months by 2006-07. Official statistics show stable maternal mortality ratios during the past 10 years, but modelled data indicate a yearly decrease of 4%, a trend which might not have been noticeable in official reports because of improvements in death registration and the increased number of investigations into deaths of women of reproductive age. The reasons behind Brazil's progress include: socioeconomic and demographic changes (economic growth, reduction in income disparities between the poorest and wealthiest populations, urbanisation, improved education of women, and decreased fertility rates), interventions outside the health sector (a conditional cash transfer programme and improvements in water and sanitation), vertical health programmes in the 1980s (promotion of breastfeeding, oral rehydration, and immunisations), creation of a tax-funded national health service in 1988 (coverage of which expanded to reach the poorest areas of the country through the Family Health Program in the mid-1990s); and implementation of many national and state-wide programmes to improve child health and child nutrition and, to a lesser extent, to promote women's health. Nevertheless, substantial challenges remain, including overmedicalisation of childbirth (nearly 50% of babies are delivered by caesarean section), maternal deaths caused by illegal abortions, and a high frequency of preterm deliveries.

Backsliding on a key health investment in Latin America and the Caribbean: the case of breastfeeding promotion.

OBJECTIVES: We examined trends in breastfeeding promotion investments, breastfeeding promotion activities, and breastfeeding duration in Latin America and the Caribbean from the 1980s to the 2000s. METHODS: We obtained financial data from the United States Agency for International Development and the International Code Documentation Center, and we obtained breastfeeding promotion data from surveys of breastfeeding coordinators with ministries of health and with the International Baby Food Action Network. We obtained breastfeeding data from nationally representative surveys conducted between 1986 and 2008. RESULTS: Investment in breastfeeding promotion declined in the 2000s relative to earlier years. For all countries, breastfeeding duration increased between the first and last survey. Of the 12 countries represented in the interval when investment in breastfeeding promotion was high, breastfeeding duration decreased in 1 country. Of the 12 countries represented in the interval when investment was low, breastfeeding duration decreased in 3 countries. Nonetheless, the average annual change in breastfeeding duration for the 2 intervals was positive and similar (0.16 months and 0.21 months). CONCLUSIONS: Breastfeeding promotion likely resulted in large improvements in breastfeeding. Investments in breastfeeding promotion have declined, but this does not appear to have adversely affected breastfeeding duration.

Finding Children with High Risk of Non-Vaccination in 92 Low- and Middle-Income Countries: A Decision Tree Approach.

Reducing vaccination inequalities is a key goal of the Immunization Agenda 2030. Our main objective was to identify high-risk groups of children who received no vaccines (zero-dose children). A decision tree approach was used for 92 low- and middle-income countries using data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys, allowing the identification of groups of children aged 12-23 months at high risk of being zero dose (no doses of the four basic vaccines-BCG, polio, DPT and measles). Three high-risk groups were identified in the analysis combining all countries. The group with the highest zero-dose prevalence (42%) included 4% of all children, but almost one in every four zero-dose children in the sample. It included children whose mothers did not receive the tetanus vaccine during and before the pregnancy, who had no antenatal care visits and who did not deliver in a health facility. Separate analyses by country presented similar results. Children who have been missed by vaccination services were also left out by other primary health care interventions, especially those related to antenatal and delivery care. There is an opportunity for better integration among services in order to achieve high and equitable immunization coverage.

Assessing the overlap between immunisation and other essential health interventions in 92 low- and middle-income countries using household surveys: opportunities for expanding immunisation and primary health care.

BACKGROUND: Unvaccinated children may live in households with limited access to other primary health care (PHC) services, and routine vaccination services may provide the opportunity to bring caregivers into contact with the health system. We aimed to investigate the overlap between not being vaccinated and failing to receive other PHC services in low- and middle-income countries (LMICs). METHODS: Using Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) data between 2010-2019 from 92 LMICs, we analysed six vaccination indicators based on the bacille Calmette-Guérin (BCG), polio, diphtheria-pertussis-tetanus (DPT) and measles vaccines and their overlap with four other PHC indicators - at least four antenatal care (ANC) visits, institutional delivery, careseeking for common childhood illnesses or symptoms and place for handwashing in the home - in 211,141 children aged 12-23 months. Analyses were stratified according to wealth quintiles and World Bank income levels. FINDINGS: Unvaccinated children and their mothers were systematically less likely to receive the other PHC interventions. These associations were particularly marked for 4+ ANC visits and institutional delivery and modest for careseeking behaviour. Our stratified analyses confirm a systematic disadvantage of unvaccinated children and their families with respect to obtaining other health services in all levels of household wealth and country income. INTERPRETATION: We suggested that lack of vaccination goes hand in hand with missing out on other health interventions. This represents an opportunity for integrated delivery strategies that may more efficiently reduce inequalities in health service coverage. FUNDING: Bill & Melinda Gates Foundation, Gavi, the Vaccine Alliance, The Wellcome Trust, Associação Brasileira de Saúde Coletiva and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior.

Patterns in Wealth-related Inequalities in 86 Low- and Middle-Income Countries: Global Evidence on the Emergence of Vaccine Hesitancy.

INTRODUCTION: Coverage of health interventions usually shows social gradients with higher levels among wealthy than among poor individuals. Owing to the upsurge of vaccine hesitancy in high-income countries, the authors hypothesized that the social gradient may also be changing over time in the low- and middle-income countries and set out to test this hypothesis. METHODS: In January 2020, surveys conducted from 2010 to 2018 in 86 low- and middle-income countries were analyzed to assess full immunization coverage in children aged 12-23 months. The authors calculated full immunization coverage point estimates and 95% CIs for each country and wealth quintile. To explore wealth-related inequalities, the authors estimated the slope index of inequality and calculated the Pearson correlation coefficient between these values and per capita gross domestic product. Time trends were analyzed in 10 countries with recent evidence of hesitancy. RESULTS: Pro-poor patterns were defined as significant slope index of inequality values with higher coverage among poor children, and pro-rich patterns were defined as the reverse pattern. A total of 11 countries showed pro-poor patterns in the most recent survey, accounting for 20% of upper middle- and 7% of low-income countries. The correlation between the slope index of inequality and log per capita gross domestic product was -0.38 (p<0.001). Among the 10 countries with recent evidence of hesitancy, 5 showed full immunization coverage declines over time in the wealthiest quintiles, and 4 switched from pro-rich to pro-poor patterns throughout the years. CONCLUSIONS: Lower full immunization coverage was found among the wealthy than among the poor in 10 countries, especially in the upper middle-income group, consistent with the emergence of vaccine hesitancy. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

A public health approach for deciding policy on infant feeding and mother-infant contact in the context of COVID-19.

The COVID-19 pandemic has raised concern about the possibility and effects of mother-infant transmission of SARS-CoV-2 through breastfeeding and close contact. The insufficient available evidence has resulted in differing recommendations by health professional associations and national health authorities. We present an approach for deciding public health policy on infant feeding and mother-infant contact in the context of COVID-19, or for future emerging viruses, that balances the risks that are associated with viral infection against child survival, lifelong health, and development, and also maternal health. Using the Lives Saved Tool, we used available data to show how different public health approaches might affect infant mortality. Based on existing evidence, including population and survival estimates, the number of infant deaths in low-income and middle-income countries due to COVID-19 (2020-21) might range between 1800 and 2800. By contrast, if mothers with confirmed SARS-CoV-2 infection are recommended to separate from their newborn babies and avoid or stop breastfeeding, additional deaths among infants would range between 188 000 and 273 000.

Global report on preterm birth and stillbirth (4 of 7): delivery of interventions.

BACKGROUND: The efficacious interventions identified in the previous article of this report will fail unless they are delivered at high and equitable coverage. This article discusses critical delivery constraints and strategies. BARRIERS TO SCALING UP INTERVENTIONS: Achieving universal coverage entails addressing major barriers at many levels. An overarching constraint is the lack of political will, resulting from the dearth of preterm birth and stillbirth data and the lack of visibility. Other barriers exist at the household and community levels, such as insufficient demand for interventions or sociocultural barriers; at the health services level, such as a lack of resources and trained healthcare providers; and at the health sector policy and management level, such as poorly functioning, centralized systems. Additional constraints involve weak governance and accountability, political instability, and challenges in the physical environment. STRATEGIES AND EXAMPLES: Scaling up maternal, newborn and child health interventions requires strengthening health systems, but there is also a role for focused, targeted interventions. Choosing a strategy involves identifying appropriate channels for reaching high coverage, which depends on many factors such as access to and attendance at healthcare facilities. Delivery channels vary, and may include facility- and community-based healthcare providers, mass media campaigns, and community-based approaches and marketing strategies. Issues related to scaling up are discussed in the context of four interventions that may be given to mothers at different stages throughout pregnancy or to newborns: (1) detection and treatment of syphilis; (2) emergency Cesarean section; (3) newborn resuscitation; and (4) kangaroo mother care. Systematic reviews of the literature and large-scale implementation studies are analyzed for each intervention. CONCLUSION: Equitable and successful scale-up of preterm birth and stillbirth interventions will require addressing multiple barriers, and utilizing multiple delivery approaches and channels. Another important need is developing strategies to discontinue ineffective or harmful interventions. Preterm birth and stillbirth interventions must also be placed in the broader maternal, newborn and child health context to identify and prioritize those that will help improve several outcomes at the same time. The next article discusses advocacy challenges and opportunities.

Global report on preterm birth and stillbirth (7 of 7): mobilizing resources to accelerate innovative solutions (Global Action Agenda).

BACKGROUND: Preterm birth and stillbirth are complex local and global health problems requiring an interdisciplinary approach and an international commitment. Stakeholders developed recommendations for a Global Action Agenda (GAA) at the 2009 International Conference on Prematurity and Stillbirth. The primary goal of this GAA is to forge a collaborative effort toward achieving common goals to prevent preterm birth and stillbirth, and to improve related maternal, newborn, and child health outcomes. CONFERENCE PARTICIPANTS: GAPPS co-convened this four-day conference with the Bill & Melinda Gates Foundation, March of Dimes, PATH, Save the Children, UNICEF and the World Health Organization. Participants included about 200 leading international researchers, policymakers, health care practitioners and philanthropists. A near-final draft of this report was sent three weeks in advance to help co-chairs and participants prepare for workgroup discussions. GLOBAL ACTION AGENDA: Twelve thematic workgroups, composed of interdisciplinary experts, made recommendations on short-, intermediate-, and long-term milestones, and success metrics. Recommendations are based on the following themes: (1) advance discovery of the magnitude, causes and innovative solutions; (2) promote development and delivery of low-cost, proven interventions; (3) improve advocacy efforts to increase awareness that preterm birth and stillbirth are leading contributors to the global health burden; (4) increase resources for research and implementation; and (5) consider ethical and social justice implications throughout all efforts. SUMMARY: The conference provided an unprecedented opportunity for maternal, newborn and child health stakeholders to create a collaborative strategy for addressing preterm birth and stillbirth globally. Participants and others have already completed or launched work on key milestones identified in the GAA. Updates will be provided at www.gapps.org.

Religious affiliation and immunization coverage in 15 countries in Sub-Saharan Africa.

BACKGROUND: Although religious affiliation has been identified as a potential barrier to immunization in some African countries, there are no systematic multi-country analyses, including within-country variability, on this issue. We investigated whether immunization varied according to religious affiliation and sex of the child in sub-Saharan African (SSA) countries. METHODS: We used data from 15 nationally representative surveys from 2010 to 2016. The major religious groups were described by country in terms of wealth, residence, and education. Proportions of fully immunized and unvaccinated children were stratified by country, maternal religion, and sex of the child. Poisson regression with robust variance was used to assess whether the outcomes varied according to religion, with and without adjustment for the above cited sociodemographic confounders. Interactions between child sex and religion were investigated. RESULTS: Fifteen countries had >10% of families affiliated with Christianity and >10% affiliated with Islam, and four also had >10% practicing folk religions. In general, Christians were wealthier, more educated and more urban. Nine countries had significantly lower full immunization coverage among Muslims than Christians (pooled prevalence ratio = 0.81; 95%CI: 0.79-0.83), of which seven remained significant after adjustment for confounders (pooled ratio = 0.90; 0.87-0.92). Four countries had higher coverage among Muslims, of which two remained significant after adjustment. Regarding unvaccinated children, six countries showed higher proportions among Muslims, all of which remained significant after adjustment [crude pooled ratio = 1.83 (1.59-2.07); adjusted = 1.31 (1.14-1.48)]. Children from families practicing folk religions did not show any consistent patterns in immunization. Child sex was not consistently associated with vaccination. CONCLUSION: Muslim religion was associated with lower vaccine coverage in several SSA countries, both for boys and girls. The involvement of religious leaders is essential for increasing immunization coverage and supporting the leave no one behind agenda of the Sustainable Development Goals.

Mind the gap: equity and trends in coverage of maternal, newborn, and child health services in 54 Countdown countries.

BACKGROUND: Increasing the coverage of key maternal, newborn, and child health interventions is essential if Millennium Development Goals (MDG) 4 and 5 are to be reached. We have assessed equity and trends in coverage rates of a key set of interventions through a summary index, to provide overall insight into past performance and progress perspectives. METHODS: Data from household surveys from 54 countries in the Countdown to 2015 for Maternal, Newborn and Child Survival initiative during 1990-2006 were used to compute an aggregate coverage index based on four intervention areas: family planning, maternal and newborn care, immunisation, and treatment of sick children. The four areas were given equal weight in the computation of the index. Standard measures were applied to assess current levels and trends in the coverage gap measure by wealth quintile. FINDINGS: The overall size of the coverage gap ranged from less than 20% in Tajikistan and Peru to over 70% in Ethiopia and Chad, with a mean of 43% for the most recent surveys in the 54 countries. Large intracountry differences were noted, with a country mean coverage gap of 54% for the poorest quintiles of the population and 29% for the wealthiest. Differences between the poorest and the wealthiest were largest for the maternal and newborn health intervention area and smallest for immunisation. In 40 countries with more than one survey, the coverage gap had decreased by an average of 0.9 percentage points per year since the early 1990s. Declines greater than 2 percentage points per year were seen in only three countries after 1995: Cambodia, Mozambique, and Nepal. Country inequity patterns were remarkably persistant over time, with only gradual changes from top inequity (disproportionately smaller gap for the wealthiest) in countries with coverage gaps exceeding 40%, to linear patterns and bottom inequity (disproportionately greater gap for the poorest) in surveys with gaps below 40%. INTERPRETATION: Despite most Countdown countries having made gradual progress since 1990, coverage gaps for key interventions remain wide and, in most such countries, the pace of decline needs to be more than doubled to reach levels of coverage of these and other interventions needed in the context of MDG 4 and 5. In general, in-country patterns of inequality are consistant and change only gradually if at all, which has implications for the targeting of interventions.