Selective Primary Health Care Research Articles

Gestão do trabalho e o cuidado na Atenção Primária à Saúde durante pandemia de COVID-19 no município de São Paulo (SP), Brasil

Abstract The municipality of São Paulo has historically been marked by a heterogeneous implementation and coexistence of conflicting models of SUS management and Primary Health Care (PHC). The administration of health services management contracts was consolidated and associated with a productivist rationale. The selective PHC weaknesses tend to be pronounced during the COVID-19 pandemic. Thus, the present article aims to analyze work management and care in PHC during the COVID-19 pandemic in the municipality of São Paulo through a multicenter qualitative research anchored in the Paideia theoretical framework. We conducted 31 in-depth interviews with PHC clients and workers, along with participant observation. We noted the municipal management’s authoritarian and managerialist stance when conducting the responses, with little room for listening and dialogue. We identified weakened collective spaces and service-community bond, bureaucratization and precariousness of work processes, and NASF’s dismantling. In this setting, care was characterized by significantly reducing the expanded and shared clinical practice and the distancing from the territorial and community-based PHC guidelines.

Creating an Applied, Multi-disciplinary Research Field: The World Health Organization and Health Systems Research 1960–2000

Summary From the 1960s, the World Health Organization (WHO) sought to reconcile ambitious international goals with scarce resources and the socio-economic realities of low- and middle-income countries by developing a field called Health Systems Research (HSR). This field remained small, marginal and largely confined to WHO during the second half of the twentieth century. The WHO worked to promote HSR, apply it to concrete problems and define its scope and methodologies while linking it to policymaking. Results were seriously limited by lack of interest from policymakers, confusion about its scope and methods, and competition from numerous disciplines working on overlapping subjects, notably economic analysis. This latter rivalry originated with debates about Primary Health Care versus Selective Primary Healthcare in the late 1970s and was overcome, rhetorically, in the late 1980s. Tensions however remained, and by the end of the twentieth century, economic analysis had temporarily triumphed at the WHO.

A Framework to Determine the Extent to Which Regional Primary Healthcare Organisations Are Comprehensive or Selective in Their Approach.

Background: There is an increasing emphasis on the importance of comprehensive primary healthcare (CPHC) in improving population health and health equity. There is, therefore, a need for a practical means to determine how comprehensive regional primary healthcare organisations (RPHCOs) are in their approach. This paper proposes a framework to provide such a means. The framework is then applied to assess the comprehensiveness of Australian RPHCOs. Methods: Drawing on a narrative review of the broader literature on CPHC versus selective primary healthcare (SPHC) and examples of international models of RPHCOs, we developed a framework consisting of the key criteria and a continuum from comprehensive to selective interventions. We applied this framework to Australian RPHCOs using data from the review of their planning documents, and survey and interviews with executive staff, managers, and board members. We used a spidergram as a means to visualise how comprehensive they are against each of these criteria, to provide a practical way of presenting the assessment and an easy way to compare progress over time.Results: Key criteria for comprehensiveness included (1) focus on population health; (2) focus on equity of access and outcomes; (3) community participation and control; (4) integration within the broader health system; (5) inter-sectoral collaboration; and (6) local responsiveness. An examination of Australian RPHCOs using the framework suggests their approach is far from comprehensive and has become more selective over time.Conclusion: The framework and spidergram offer a practical means of gauging and presenting the comprehensiveness of RPHCOs, and to identify gaps in comprehensiveness, and changes over time.

Disease in a Debt Crisis: Financing Global Health, Development and AIDS between WHO and World Bank, 1978–87

This article examines how international organisations with mandates in health and development interpret global economic crises and respond to disease. It contributes the perspective of World Bank to emerging scholarship on the various factors leading to the decline of the World Health Organization (WHO) and its Health for All (HFA) mission during structural adjustment. It does so by telling a story of collaboration and conflict between WHO and World Bank’s Population, Health and Nutrition (PHN) Department following the ambitious Alma Ata Declaration in 1978 until the initial global AIDS response. As debt crises emerged in Latin America in the early 1980s, WHO tried to find a way forward for HFA. However, the African crisis of 1985 fractured the international community’s support, causing WHO and PHN to dialogue more closely regarding health sector financing. As AIDS became a global crisis, this culminated in their 1987 joint research on the disease’s macroeconomic and demographic impact. However, observing WHO’s continued hesitance regarding financing and its decision to act as a donor gatekeeper, the Bank ultimately opted to work separately in AIDS. Thus, the themes of the Alma Ata versus Selective Primary Health Care debate of the late 1970s continued throughout the 1980s into the early years of the global AIDS response: a perennial conflict of financing within resource constraints and the appropriate role of donors in the grand project of health and development.

Primary healthcare implementation in practice: Evidence from primary healthcare managers in Ghana.

BackgroundPrimary healthcare (PHC) is a core part of healthcare in developing countries. However, the implementation of PHC since its inception in developing countries has been lethargic, inconsistent and marred by controversies.AimThis study investigates some of the controversies surrounding PHC implementation. It also examines how PHC is being implemented in Ghana as well as how the approaches adopted by PHC implementers influence PHC outcomes in developing countries.SettingThis study is set in Ghana and involves national, regional and district managers of PHC.MethodsA qualitative case study was used to gather information from 19 frontline PHC managers through semi-structured interviews. Interviews were recorded and transcribed. They were then qualitatively analysed using the thematic framework analyses approach.ResultsFindings uncover a lack of clear meaning of what PHC is and how it should be approached amongst key implementers. It also shows discrepancies between official policy documents and directives, and actual PHC practices. Findings also show a gradual shift from Alma Ata’s comprehensive PHC towards a more selective and intervention-specific PHC. Whilst donor and external stakeholders’ influence are the key determinants of PHC policy implementation, their support for vertical and other medicine-based interventions have gradually medicalised PHC.ConclusionThere is a need to pay more attention to understanding and addressing the gaps in PHC implementation and its inconsistencies. Furthermore, the role and control of donors and external development partners in PHC policy formulation and implementation, and their concomitant effects on community participation and empowerment, must be critically examined.

Strife of Interests: Constraints on integrated and co-ordinated comprehensive PHC in Australia.

The 1978 World Health Organisation Alma Ata Declaration on Primary Health Care (PHC) emphasised a comprehensive view which stressed the importance of cure, prevention, promotion and rehabilitation delivered in a way that involved local communities and considered a social, economic and political perspective on health. Despite this, selective approaches have dominated. This paper asks why this has been the case in Australia through a multi-method study of regional PHC organisations. Interviews with senior policy players, focus groups with non-government organisations and document analysis inform an institutional and power analysis of PHC. The findings indicate that there are different interests competing for attention in PHC but that medical perspectives prove the most powerful and are reinforced by the actors, ideas and institutions that shape PHC. Community perspectives which stress lived experience and social perspectives on health are marginal concerns in the implementation of PHC. The other important interest is that of a neo-liberal perspective on health policy which stresses cost-containment, close measurement of activity and fragmented contracting out of services. This perspective is not compatible with a social determinants of health perspective and can also conflict with a medical view. The result of the interplay between competing interests and the distribution of power is a selective PHC system that is not likely to change without radical shifts in power and perspectives.

Improve education for health professionals to enhance the ability to communicate and work effectively with people living with disability

The 1978 World Health Organisation Alma Ata Declaration on Primary Health Care (PHC) emphasised a comprehensive view which stressed the importance of cure, prevention, promotion and rehabilitation delivered in a way that involved local communities and considered a social, economic and political perspective on health. Despite this, selective approaches have dominated. This paper asks why this has been the case in Australia through a multi-method study of regional PHC organisations. Interviews with senior policy players, focus groups with non-government organisations and document analysis inform an institutional and power analysis of PHC. The findings indicate that there are different interests competing for attention in PHC but that medical perspectives prove the most powerful and are reinforced by the actors, ideas and institutions that shape PHC. Community perspectives which stress lived experience and social perspectives on health are marginal concerns in the implementation of PHC. The other important interest is that of a neo-liberal perspective on health policy which stresses cost-containment, close measurement of activity and fragmented contracting out of services. This perspective is not compatible with a social determinants of health perspective and can also conflict with a medical view. The result of the interplay between competing interests and the distribution of power is a selective PHC system that is not likely to change without radical shifts in power and perspectives.

Back to the future with PACK

On 25 October 2018, the world’s governments convene again at Astana on the 40 anniversary of the Declaration of Alma-Ata. The draft Declaration for this Second International Conference on Primary...

Kenneth Warren and the Great Neglected Diseases of Mankind Programme: The Transformation of Geographical Medicine in the US and Beyond by Conrad Keating

Reviewed by: Kenneth Warren and the Great Neglected Diseases of Mankind Programme: The Transformation of Geographical Medicine in the US and Beyond by Conrad Keating George Weisz Conrad Keating. Kenneth Warren and the Great Neglected Diseases of Mankind Programme: The Transformation of Geographical Medicine in the US and Beyond. Cham, Switzerland: Springer International, 2017. xx + 150 pp. Ill. $29.00 (978-3-319-50145-1). Kenneth Warren is a largely forgotten name in global health (GH) circles. But during the 1970s and 1980s, he was a force to be reckoned with. A researcher of some note in the field of parasitology, he was appointed in 1978 as director of health sciences at the Rockefeller Foundation, marking that institution's return, after several decades absence, to intense activity and significant influence in international Health. Under his tutelage, two major programs were introduced. The Great Neglected Diseases of Mankind Program (GND) in 1977, conceived of and led by Warren himself, sought to stimulate sophisticated biomedical molecular research on diseases of the Global South. The program offered ten years of guaranteed funding for handpicked scientists in various fields to work on parasitic and other mainly tropical diseases, with required annual meetings of the entire network. The scientific results were impressive, according to some path-breaking, although critics claimed that Warren took credit for discoveries that had been mainly financed by other agencies, with only minimal contributions from GND. Meanwhile, his deputy, Kerr White, a pioneer of Health Services Research at Johns Hopkins University, set up the International Clinical Epidemiology Network, or INCLEN, to create and strengthen in medical schools training programs providing physicians with the expertise—first in epidemiology, and later also in health economic and social sciences—needed to manage scarce health resources in developing countries. Outside the tropical disease research community, Warren is best remembered as co-author of an influential article offering an alternative to the flagship program of the World Health Organization. Under the direction of its charismatic director general, Halfdan Mahler, the organization developed a proposal for Primary Health Care (PHC) famously endorsed in the Alma Ata Declaration of 1978. This was an ambitious vision for bringing the essential conditions for good health—from sanitation and food supply to family planning and the treatment of common ailments—to even the poorest, of the world's populations. Soon after, Warren and Julia Walsh presented and then published a paper arguing that PHC, as formulated in Alma Ata, was not feasible "in an age of diminishing resources." They proposed an "interim" strategy, Selective Primary Health Care' (SPHC), for identifying a few priority measures on the basis of their low cost and high impact on widespread causes of morbidity and mortality. Although this strategy was taken up by several international donors, notably UNICEF, Warren and his supporters increasingly focused less on specific measures and more on methods of determining both priorities for research and action and the most effective and least expensive solutions to a large variety of health problems. Both judgments were best made through use of metrics. There is a direct link between SPHC and [End Page 402] the World Bank's World Development Report of 1993, widely considered the most influential GH text of the 1990s. Keating's book is a curious hybrid. On one hand it has been funded by a foundation headed by Anthony Cerami, Warren's close friend and colleague. It is clearly meant to re-establish Warren's reputation as a pioneering figure. On the other, it is very professionally done. Keating is Writer-Residence at the Wellcome Unit for the History of Medicine at Oxford University and author of a previous biography of Sir Richard Doll. The result is a book that is heavy on personal recollections of colleagues and friends, with lots of photos, many repetitious but a few quite priceless. (I think especially of the one of Warren in intense conversation with Halfdan Mahler on p.69.) There is much excessive detail based on these recollections. Few readers will care that his wife was an excellent gardener. On the other hand, there is the occasional witty and perceptive image; his friend and colleague Michael Sela said of him that "he was...

What is the difference between comprehensive and selective primary health care? Evidence from a five-year longitudinal realist case study in South Australia

BackgroundSince the WHO’s Alma Ata Declaration on Primary Health Care (PHC) there has been debate about the advisability of adopting comprehensive or selective PHC. Proponents of the latter argue that...

Primary health care reform, dilemmatic space and risk of burnout among health workers.

Health system changes may increase primary health care workers' dilemmatic space, created when reforms contravene professional values. Dilemmatic space may be a risk factor for burnout. This study partnered with six Australian primary health care services (in South Australia: four state government-managed services including one Aboriginal health team and one non-government organisation and in Northern Territory: one Aboriginal community-controlled service) during a period of change and examined workers' dilemmatic space and incidence of burnout. Dilemmatic space and burnout were assessed in a survey of 130 staff across the six services (58% response rate). Additionally, 63 interviews were conducted with practitioners, managers, regional executives and health department staff. Dilemmatic space occurred across all services and was associated with higher rates of self-reported burnout. Three conditions associated with dilemmatic space were (1) conditions inherent in comprehensive primary health care, (2) stemming from service provision for Aboriginal and Torres Strait Islander peoples and (3) changes wrought by reorientation to selective primary health care in South Australia. Responses to dilemmatic space included ignoring directives or doing work 'under the radar', undertaking alternative work congruent with primary health care values outside of hours, or leaving the organisation. The findings show that comprehensive primary health care was contested and political. Future health reform processes would benefit from considering alignment of changes with staff values to reduce negative effects of the reform and safeguard worker wellbeing.

Analysis of the enablers of capacities to produce primary health care-based reforms in Latin America: a multiple case study.

BackgroundPrimary health care (PHC)-based reforms have had different results in Latin America. Little attention has been paid to the enablers of collective action capacities required to produce a comprehensive PHC approach.ObjectiveTo analyse the enablers of collective action capacities to transform health systems towards a comprehensive PHC approach in Latin American PHC-based reforms.MethodsWe conducted a longitudinal, retrospective case study of three municipal PHC-based reforms in Bolivia and Argentina. We used multiple data sources and methodologies: document review; interviews with policymakers, managers and practitioners; and household and services surveys. We used temporal bracketing to analyse how the dynamic of interaction between the institutional reform process and the collective action characteristics enabled or hindered the enablers of collective action capacities required to produce the envisioned changes.ResultsThe institutional structuring dynamics and collective action capacities were different in each case. In Cochabamba, there was an ‘interrupted’ structuring process that achieved the establishment of a primary level with a selective PHC approach. In Vicente López, there was a ‘path-dependency’ structuring process that permitted the consolidation of a ‘primary care’ approach, but with limited influence in hospitals. In Rosario, there was a ‘dialectic’ structuring process that favoured the development of the capacities needed to consolidate a comprehensive PHC approach that permeates the entire system.ConclusionThe institutional change processes achieved the development of a primary health care level with different degrees of consolidation and system-wide influence given how the characteristics of each collective action enabled or hindered the ‘structuring’ processes.

Review of Selective Primary Health Care Efforts in an Urban Health Center Area in Guntur City of Andhra Pradesh

Review of Selective Primary Health Care Efforts in an Urban Health Center Area in Guntur City of Andhra Pradesh

Shifting Focus of Primary Health Care in the Context of Health Systems Reform in Resource Poor Settings

Purpose:To review the concepts of Primary Health Care (PHC) and provide evidence for a shift in its focus and implementation in the resource poor setting. Sources of data:Desk and internet based review of relevant articles and official documents. Data extraction:Search themes were ‘concepts and models of PHC’, contextual issues in PHC and health care reforms aimed at achieving the universally accepted core social values of health care delivery. Results:Four main concepts and approaches to PHC include selective PHC, primary care; Alma-Ata comprehensive PHC and health and human rights approach. The concept of PHC in resource poor settings is oversimplified and restrictive. This is in contrast with the situation in well-resourced contexts where primary care concept is practiced.The World Health Organisation recommends a shift in focus of PHC through four sets of reforms in the health system, universal coverage reforms, service delivery reforms, public policy reforms and leadership reforms. This shift should bridge the gap between citizens’ expectations and performance of the health care system. Conclusion:Inability of health services to deliver levels of national coverage that meet stated demands and changing needs has been a source of worry. The health systems need to respond better and faster to the challenges of a changing world.

Performance-based financing: the need for more research

While several developing countries have been implementing PBF as a strategy to finance health services, a polarized debate between the “proponents” and “opponents” of this approach is gaining prominence.1–4 Ireland et al.5 provide a critical view on the paper by Meessen et al.,6 mainly opposing the argument that PBF, on its own, can be considered as a strategy to reform health systems in developing countries. One of their main criticisms is the lack of evidence. Evidence, of course, should ideally be central to any health sector reform but applying this rule rigorously can lead to inertia. Looking back on the history of public health, we note that many important health reforms implemented in Africa – such as selective primary care for child survival or the health district strategy – were not developed based on recommendations from rigorous experimental studies.7 Health reformers should carefully consider different opportunities based on their potential to maximize the delivery and uptake of proven maternal and child health interventions.8 As African public health experts, we believe that PBF is interesting due to its potential. Having said this, we agree that implementing health reforms based on evidence is crucial. For example, some components of selective primary health care, such as growth monitoring, were implemented even though little was known about their cost-effectiveness.7 However, a recent evaluation of the primary-care approach has shown interesting results9 and the global public health community has since gained important knowledge on successful interventions in primary health care. We think that Ireland et al. minimize the growing body of evidence on PBF implementation produced in recent years. Many studies have been published providing details on how to implement PBF and one experimental study has been published on the impact of the approach.10 Clearly, rigorous research is still needed, especially more theoretical and qualitative studies that address the “how and why” and test hypotheses of potential adverse effects of PBF. Continuous checking and integration of the PBF approach is needed during implementation and this should be informed by operational research aimed at aligning PBF with the existing health system. The World Bank, through a grant from the Government of Norway, has launched several PBF initiatives in developing countries, systematically accompanied with an impact evaluation strategy using different innovative research designs.11 These initiatives should include formative research to address the rapidly changing social and political context that may influence policy implementation.12 The debate around PBF should be evidence-based with critical appraisal. Both proponents and opponents should avoid taking a dogmatic position. Both parties have agreed that PBF is not a panacea. The provision of input items and other key interventions, such as provider training, supervision and health-system strengthening, should continue with the aim of producing results. A research agenda and an effective community of practice embracing all views on PBF is critical to understanding more about its potential for helping developing countries to reach some of the United Nations Millennium Development Goals.

Terapia ocupacional em reabilitação na atenção primária à saúde: possibilidades e desafios

The goal of this paper is to contribute with ideas that may help to strengthen the actions Occupational Therapy (OT) has been able to develop in Primary Health Care (PHC) in the field of rehabilitation of people with disabilities. This proposition is based on both literature review and on the practical experience of REATA- Laboratory for Studies in Rehabilitation and Assistive Technology in the period from 1999 to 2010. We took into consideration the existing care models, Selective and Broad PHC, and the nature of these practices within the historical and practical-organizational context. Next, we describe the experiences developed by REATA in the PHC, which motivated the presentation of these ideas as an OT work proposition. We advocate the need for a shift from the occupational therapeutic interventions instituted under standardized, biomedical framework, or built within the public health hygienist design; towards the establishment of actions/strategies that address holistic aspects of the subjects and the territory, and with light technology adequate for the demands, as foreseen by the Broad PHC. Finally, we present possible OT contributions regarding their technological potential based on the premise that actions from this profession can contribute in promoting access and long-term health care and thus assist in the completeness and equity within the Basic Health System (SUS).

Primary Healthcare: People, Practice, Place

Contents: Thinking geographically about primary health care, Valorie A. Crookes and Gavin J. Andrews Geographical perspectives on health care: ideas, disciplines, progress, Gavin J. Andrews and Valorie A. Crookes Part 1 Practice and Delivery: Access and utilization reconsidered: towards a broader understanding of the spatial ordering of primary health care, Neil Hanlon The effects of population density, physical distance and socio-economic vulnerability on access to primary health care in rural and remote British Columbia, Canada, Nadine Schuurman The role of scale in conceptualizing primary health care practice: considering social and institutional structures and systems, Janine L. Wiles and Mark W. Rosenberg Cloaked selective primary health care? Local observations of rural primary health care clinics in PerA * , Leah Gold. Part 2 People: Geographies of family medicine: describing the family doctor's practice-based landscape of care, Gina Agarwal The place of nursing in primary health care, Jennifer Lapum Sandra Chen, Jessica Peterson, Doris Leung and Gavin J. Andrews Reinventing primary care: the New Zealand case compared, Ross Barnett and Pauline Barnett New health geographies of complementary, alternative and traditional medicines in primary health care, Daniel Hollenberg and Ivy Bourgeault. Part 3 Places and Settings: Considering the clinical environment: implications for practice and primary health care, Valorie A. Crookes and Gina Agarwal Within and beyond clinics: primary health care and community participation, Robin Kearns and Pat Neuwelt Providers of care in the home: sustainable partners in primary health care?, Nicole M. Yantzi and Mark W. Skinner On the street: primary health care for difficult to reach populations, David Conradson and Graham Moon. Part 4 Agenda Setting: The geographies of primary health care: a summary and agenda, Valorie A. Crookes and Gavin J. Andrews Index.

LiST: using epidemiology to guide child survival policymaking and programming

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.

Primary Heealth Care Development: Where is Nepal after 30 years of Alma Ata Declaration??

The year 2008 has witnessed the global conversation to return to tenets of Alma-Ata and to review its 30 years of journey. We reviewed Nepal's journey on Primary Health Care development: policy formulation, structure development, progress and constraints. Though Nepal has institutionalised the PHC approach in health policy, strategy and health care delivery system, this has not been effectively translated into actions, and the results are mixed. Nepal has gained impressive achievements in selective primary health care markers: 45.43% maternal mortality and 62.34% child mortality reduction during 1990-2005. But gain in comprehensive health care markers is not impressive: 18.7% Skilled Birth Attendant (4% in poorest quintile and 45% in richest quintile), 39% having access to improved sanitation and 55.7% of females are literate as compared to males. Socio-political environment until recently was not favourable for comprehensive primary health care, allowing limited health sector decentralisation and community empowerment. Health activities were focussed more on selective health care strategy in the form of disease control, immunisation, vitamin A supplementation, oral rehydration solution use and contraceptive use. Nepal's rural hilly geography posed great challenge on logistic supply, communication and retention of health workers rendering public health centres of low quality with negative perceptions of consumers. Nepal is on the pathway to build equitable comprehensive primary health care.

Commentary: LiST: using epidemiology to guide child survival policymaking and programming

At the turn of the millennium, there was a widespread feeling in the child health community that the over 10 million annual deaths of under five children were not receiving the attention they deserved.1 A group of concerned scientists and policymakers gathered for a week in Bellagio, Italy, to prepare a series of articles arguing for increased funding for child survival actions, which became known as the Lancet Child Survival Series. The second article in the series2 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 then 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 over 6 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 this supplement 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 user-friendly and is becoming widely used at the 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. Critics also argue that by emphasizing biomedical, proximate interventions, LiST does not take into account the impact of broader social determinants of health. I do not believe this is a fair criticism. First, modelling the effects of social and economic change on child mortality in different contexts is not straightforward, not to say unwise. Secondly, most of the effect of broad social determinants on child mortality will be mediated by interventions included in LiST—such as improved water and sanitation, better antenatal and delivery care, improved nutrition and greater access to high-quality case management of diseases such as pneumonia, diarrhoea and malaria. The fact that a tool such as LiST is directed at a certain level of determinants of child survival does not imply that broader determinants—or the causes of causes—are not equally or more important.8 The judicious use of LiST can even help narrow down social inequalities in child health by promoting universal access to life-saving interventions. However, LiST can be improved. It is more user-friendly than the previous models that I have used, but it is still relatively easy to make mistakes when inputting the data or running the models. LiST currently assumes a single coverage level for each intervention across all social groups, and also assumes that all groups have similar levels and causes of mortality, which we know not to be true.9 If the poor have higher baseline mortality as well as lower coverage (even after the coverage target is reached for the population as a whole), ignoring such inequities when running the model may lead to incorrect results. One of the articles in this volume suggests that LiST may be useful in planning and assessing the extent to which specific constellations of interventions and delivery strategies are most likely to reach the poorest mothers and children.10 Work is currently underway to allow LiST to provide separate estimates of lives saved according to, e.g. maternal education or family wealth quintiles. Finally, LiST has now been expanded to incorporate maternal mortality, and to estimate the costs of different interventions. I have had the opportunity to use LiST in a few countries, and I share the enthusiasm of its developers about its potential impact on policies and programmes. Sitting in front of a screen with national counterparts, one can discuss which interventions are available, which are more likely to be scaled up rapidly, what coverage targets are achievable, and what is the likely impact on mortality of different interventions, delivery channels and packages. In some early applications, this has led to a change in short-term priorities at the country level.3 Conflict of interest: None declared.