What difference do the new WHO child growth standards make for the prevalence and socioeconomic distribution of undernutrition?

BACKGROUND: The World Health Organization has recently established revised child growth standards. OBJECTIVE: To assess how the use of these new standards affects the estimated prevalence and socioeconomic distribution of stunting and underweight among children in a large number of low- and middle-income countries. METHODS: We analyzed Demographic and Health Survey data for stunting and underweight in 41 low- and middle-income countries employing these new standards and compared the results with those produced by analyses of the same data using the old growth references. RESULTS: For all 41 countries, the prevalence of stunting increases with the adoption of the new standards, by 5.4 percentage points on average (95% CI: 5.1, 5.7). The prevalence of underweight decreases in all but two of the countries, by an average of 2.9 percentage points (95% CI: 2.7, 3.2). The impact of using the new standards on socioeconomic inequalities is mixed. For stunting, inequalities tend to rise in absolute terms but tend to decline in relative terms. The impact on underweight is inconsistent across countries. Poor children suffer most from undernutrition, but even among the better-off children in developing countries, undernutrition rates are high enough to deserve attention. CONCLUSIONS: These results suggest that the adoption of the new WHO standards in itself is unlikely to affect policies dramatically. They do confirm, however, that different strategies are likely to be required in these countries to effectively address undernutrition among children at different socioeconomic levels.

A new hope: from neglect of the health sector to aspirations for Universal Health Coverage in Myanmar.

Myanmar's health sector has received low levels of public spending since 1975. Combined with the country's historic political and economic isolation, poor economic management and multiple internal armed conflicts, these limited resources have translated into low coverage of even the most basic services and into poor health outcomes with wide disparities. They have also resulted in out-of-pocket payments for health as a proportion of total health spending being among the highest in the world. The Government of Myanmar has now affirmed its commitment to moving toward Universal Health Coverage. This commitment is reflected in the National Health Plan 2017-2021. Drawing upon analysis of data from the Myanmar Poverty and Living Conditions Survey 2015 and using the country's revised methodology to estimate poverty, this paper explores some of the consequences of Myanmar's excessive reliance on out-of-pocket funding as the main source of health financing. Around 481 000 households in Myanmar experienced catastrophic health spending in 2015. Of this group, 185 000 households lived below the national poverty line. Households that experienced catastrophic health spending spent, on average, 54.7% of their total capacity to pay on health. Of all Myanmar households that went to a health facility in 2015, ∼28% took loans and ∼13% sold their assets to cover health spending. In that same year, ∼1.7 million people fell below the national poverty line due to health spending. The paper then discusses how ongoing reforms could help alleviate the financial hardship associated with care-seeking. With current political will to reform the health system, a conducive macro-economic environment, and the relatively limited vested interests, Myanmar has a window of opportunity to achieve significant progress towards UHC. Continued high-level political support and strong leadership will be needed to keep reforms on track.

Measurement of Health Program Equity Made Easier: Validation of a Simplified Asset Index Using Program Data From Honduras and Senegal.

Equitable access to programs and health services is essential to achieving national and international health goals, but it is rarely assessed because of perceived measurement challenges. One of these challenges concerns the complexities of collecting the data needed to construct asset or wealth indices, which can involve asking as many as 40 survey questions, many with multiple responses. To determine whether the number of variables and questions could be reduced to a level low enough for more routine inclusion in evaluations and research without compromising programmatic conclusions, we used data from a program evaluation in Honduras that compared a pro-poor intervention with government clinic performance as well as data from a results-based financing project in Senegal. In both, the full Demographic and Health Survey (DHS) asset questionnaires had been used as part of the evaluations. Using the full DHS results as the "gold standard," we examined the effect of retaining successively smaller numbers of variables on the classification of the program clients in wealth quintiles. Principal components analysis was used to identify those variables in each country that demonstrated minimal absolute factor loading values for 8 different thresholds, ranging from 0.05 to 0.70. Cohen's kappa statistic was used to assess correlation. We found that the 111 asset variables and 41 questions in the Honduras DHS could be reduced to 9 variables, captured by only 8 survey questions (kappa statistic, 0.634), without substantially altering the wealth quintile distributions for either the pro-poor program or the government clinics or changing the resulting policy conclusions. In Senegal, the 103 asset variables and 36 questions could be reduced to 32 variables and 20 questions (kappa statistic, 0.882) while maintaining a consistent mix of users in each of the 2 lowest quintiles. Less than 60% of the asset variables in the 2 countries' full DHS asset indices overlapped, and in none of the 8 simplified asset index iterations did this proportion exceed 50%. We conclude that substantially reducing the number of variables and questions used to assess equity is feasible, producing valid results and providing a less burdensome way for program implementers or researchers to evaluate whether their interventions are pro-poor. Developing a standardized, simplified asset questionnaire that could be used across countries may prove difficult, however, given that the variables that contribute the most to the asset index are largely country-specific.