Equity and community child health.

Paediatricians have always played a leading part in ensuring that local child health services are of the best possible quality and are most suited to the needs of the local population. Three important dimensions of the quality of health services are that they should be effective and that they should be delivered efficiently and equitably. 2 These three dimensions apply to the child health services as to any other.3 An effective service is one that achieves the greatest improvement in health outcome, whereas an efficient service is one that provides the most effective services for a given input of resources (that is, money and staff). The recent health service reforms45 attempt to address the two former dimensions. Whether or not they have led to any improvements in efficiency and effectiveness is under debate,6' but the drive to improve efficiency combined with the relative paucity of measures to improve equity in the reforms may result in a widening of inequities. Efficiency and equity are not always compatible and in some circumstances one may need to be traded off against the other.2 The purpose of this paper is to discuss the concept of equity in relation to community child health services, why those of us responsible for providing these services are in a position to ensure equitable provisions, and how this may be achieved. needs are different. To give a hypothetical example, assume that speech therapy services are available only for children with greater than two years of language delay relative to their chronological age. An equivalent level of need for physiotherapy might be judged to be a child not walking by 3 years of age. Horizontal equity requires all children with greater than two years oflanguage delay to be receiving speech therapy; vertical equity requires that if speech therapy could only be provided for children with greater than two years language delay, then only children over 3 years of age and not walking would receive physiotherapy. It is apparent, from the triteness of these examples, that equity is a complicated notion to conceptualise, let alone measure. Nevertheless, examples of inequity abound; for instance, poorer access to health care in some inner cities and in rural communities, differences in the use ofchild health services by families from different ethnic backgrounds, lower immunisation rates in children from deprived, homeless, and travelling families, and social class differences in preventable conditions such as childhood accidents. These examples also illustrate that equity may be considered in terms ofprovision of services, access to services, use of services, or outcome.9