LiST: using epidemiology to guide child survival policymaking and programming

Abstract

in the series 2 included a formal attempt to estimate how many deaths could be saved by each intervention then available. This modelling exercise took into account the levels and causes of deaths in 42 low- and middle-income countries, and the effectiveness of interventions against each of these causes, providing estimates of how many lives could be saved if the current coverage levels could be scaled up to reach all mothers and children. These calculations were carried out using a series of spreadsheets where the best existing data were inserted. 2 The results were remarkable—no fewer than two-thirds of all under-five deaths or 46 million a year could be saved if every mother and child received a handful of proven interventions. The Bellagio spreadsheets were sufficiently accurate for the purposes of this initial exercise, and made an important contribution to placing child survival back on the international agenda. However, from a methodological standpoint there was substantial room for improvement. The articles in the recent supplement of the International Journal of Epidemiology report on the methods and assumptions behind the Lives Saved Tool (LiST). This software was inspired by the Bellagio exercise, but went much further in terms of the background mortality data used, the quality of the literature reviews on intervention effectiveness and of the modelling process itself. LiST is relatively userfriendly and is becoming widely used at country level to identify how much impact can be achieved by scaling up different interventions. 3 A potential critique of LiST is that, by estimating the likely impact of each intervention, it would contribute to the implementation of vertical programmes in the spirit of what used to be known as selective primary health care. 4 As such, it would detract from efforts to build up horizontal, primary health-care systems providing multiple preventive and curative interventions against multiple diseases. However, recent experience of countries that have managed to reduce child mortality rapidly, shows that initial focus on a few priority diseases and interventions is not incompatible with the strengthening of health systems for providing universal primary health care—the combination of these strategies has been described as the ‘diagonal approach’. 5–7 Furthermore, use of LiST can counteract current emphasis on one-size-fits-all intervention packages, by suggesting which specific interventions are more likely to have an impact under different conditions.