Access, Bottlenecks, Costs, and Equity

Access, Bottlenecks, Costs, and Equity (ABCE) is a multicountry and multipronged project to provide quality evidence for improving the equity and cost effectiveness of health systems. The ABCE project’s outputs and analyses will support policymakers, development partners, and national stakeholders in achieving better and more equitable outcomes for children and their families.

 

The project will help countries build a compelling equity investment case for health coverage by promoting a better understanding of how their systems operate and interact with populations. 

 

Principal collaborators include IHME, UNICEF, ministries of health, and other national research organizations. The project is also supported in part by the Disease Control Priorities Network. In selected countries, collaborators may include a consortium of Australian universities and the World Bank. 

 

ABCE consists of four components. Each component contributes to strategy and policy formulation. ABCE will provide a conceptual framework that ties the following four components together, in order to provide clarity on how to interpret the empirical evidence: 

 

 

For each country that participates in all four components, ABCE will produce two documents: a technical report specifying the methods used and a complete data analysis, and an equity investment case for the country, developed in dialogue with governments and other partners. This investment case will detail health service bottlenecks and cost effective policy and strategy options for improving equity in health.

 

The progress made by many countries toward national-level Millennium Development Goals (MDGs) in the areas of health and nutrition has been well-documented and analyzed. These reviews suggest better data, among other factors, have led to more informed policy decisions and ultimately superior outcomes.

 

During the past decade, many initiatives have contributed evidence on which interventions (such as drugs, vaccines, and procedures) can improve health and nutrition status. The World Health Organization and the Disease Control Priorities in Developing Countries project (DCP2) have attempted to relate the costs of scaling these interventions to their potential benefits.

 

UNICEF and the World Bank developed the Marginal Bottleneck Budgeting (MBB) tool, which has helped decision-makers with two issues. First, MBB identifies key bottlenecks that limit the delivery of the most effective technologies. Second, it helps select strategies to remove those bottlenecks and to budget for their implementation. More recently, the Lives Saved Tool (LiST) uses systematic literature reviews to compute the expected benefits of increased coverage. This provides decision-makers with information on the expected efficacy of strategies for improving child health.  

 

These analyses and tools have advanced our understanding of opportunities for policymakers to improve health outcomes in large segments of their populations. However, the persistence of intra- and intercountry inequities suggests that our understanding remains insufficient. More and better data are needed to understand the costs and bottlenecks that mediate the gap between efficacy in trials and effectiveness in real populations, especially those who are deprived and hard to reach.

 

When allocating their scarce resources, policymakers should be able to depend on analyses that report the benefits and costs of improving equity in health and nutrition outcomes in real health systems. Unfortunately, that is not the case today. The source of the varied conclusions amongst existing tools can be traced to weak empirical evidence of costs and bottlenecks. To improve these tools, we must collect more and better local information.  

 

In 2010, UNICEF called for a renewed focus on improving equity as an approach that is both “right in principle” and constitutes a cost effective way to accelerate progress towards the MDGs. This focus requires the creation of sound evidence-based investment cases and intensifies the imperative to strengthen national capacities to collect and analyze disaggregated information on cost, bottlenecks, and impact. UNICEF and IHME are sponsoring the ABCE project to address these concerns.

 

ABCE aims to strengthen the evidence base for overcoming bottlenecks that deprive children and families of access to high-impact interventions. By simultaneously considering both supply and demand, ABCE will help develop the next generation of tools to inform equity-focused policy and strategy choices. This collaboration will substantially address both the need for interventions and the costs and constraints of delivering them to those most in need.

 

The overarching goal is to provide policymakers, development partners, and national stakeholders with a systematic approach to making informed decisions.

 

The project will accomplish that goal by employing a multidisciplinary, quantitative approach to harness all available information. Crucially, data will be collected at the subnational level across many countries and in all regions of the developing world. The project will bring together supply-side and demand-side bottlenecks in ways that have previously been only partially addressed.

 

Current models depend upon large numbers of critical assumptions, many of which may fail to hold in reality. For example, reaching the underserved rural poor in low-resource settings may require the expansion of existing primary care and district hospital infrastructure, but the diseconomies of scale from such expansions are only partially captured by existing tools. 

 

ABCE will develop new standards and enhanced tools for costing and analysis for the public domain. We believe these contributions will be valued by policymakers who are tasked with planning, prioritizing, and evaluating universal access to health systems.