标题：Inequities in Coverage of Preventive Child Health Interventions: The Rural Drinking Water Supply Program and the Universal Immunization Program in Rajasthan, India
摘要：Objectives. I assessed whether the Rural Drinking Water Supply Program (RDWSP) and the Universal Immunization Program (UIP) have achieved equitable coverage in Rajasthan, India, and explored program characteristics that affect equitable coverage of preventive health interventions. Methods. A total of 2460 children presenting at 12 primary health facilities in one district of Rajasthan were enrolled and classified into economic quartiles based on possession of assets. Immunization coverage and prime source of drinking water were compared across quartiles. Results. A higher access to piped water by wealthier families ( P < .001) was compensated by higher access to hand pumps by poorer families ( P <.001), resulting in equal access to a safe source ( P =.9). Immunization coverage was inequitable, favoring the wealthier children ( P <.001). Conclusions. The RDWSP has achieved equitable coverage, while UIP coverage remains highly inequitable. Programs can make coverage more equitable by formulating explicit objectives to ensure physical access to all, promoting the intervention’s demand by the poor, and enhancing the support and monitoring of frontline workers who deliver these interventions. Rural populations in developing countries access curative care from a range of private and public providers. For preventive care, however, they are largely dependent on public systems. There is a reasonable consensus that the government should continue to play a major role in financing those interventions that are for the public good and those with large positive externalities (as when immunization also benefits the nonimmunized by preventing the spread of a disease) 1 ; most preventive interventions fall into this category. Interventions to prevent illnesses among children are well established; they include immunization, micronutrient supplementation, nutrition counseling, safe water and sanitation, and insecticide-treated bed nets. While children of the poorest families are most likely to need these interventions, the existing (albeit limited) evidence from developing countries suggests that they are less likely to receive them, especially for several years after their introduction. 2 Failure to receive these interventions not only adversely affects the health and survival of the poorer children, but also pushes their families into indebtedness and poverty owing to the high cost of seeking care for their illnesses. In view of the high potential impact of these services on child health and survival, inequitable coverage is likely to translate into disparities in health outcomes. Describing inequities in the coverage of preventive health services would therefore be useful for guiding child health programs that wish to achieve equity. In this article, I examine 2 public health programs in Rajasthan—the Rural Drinking Water Supply Program and the Universal Immunization Program—that have huge potential for promoting child health. I assess whether these programs have achieved equitable coverage and then discuss the possible reasons why they have or have not. Rajasthan, located in northwestern India, is the largest state in the country in terms of geographical area. Its population of about 56 million lives in a nonnucleated, dispersed pattern of settlement. The physiography ranges from desert and semi-arid regions to hilly tribal tracts. Literacy levels among women (44%) are among the lowest in the country. 3 The infant mortality rate was estimated to be 80 per 1000 live births in the period 1998 to 1999. 4
