GRADE project and model for assessing impact of increased government revenue on maternal and child health

27 November, 2020

Below is an introduction to the GRADE Project initiated by Dr Bernadette O'Hare from St Andrews University in Scotland & Malawi College of Medicine. I think it should be of interest to colleagues on this forum. As explained below, the focus is on so-called upstream causes of mortality and morbidity in low resource countries but it also identifies how increased resources would improve health and clinical services which are aspects of the main determinants of health along with education, water, sanitation and adequate nutrition. It has implications for child health professionals in both low and high resource countries.


(Government Revenue and Development)

The primary focus in global health approaches to child and maternal morbidity and mortality has been on evidence-based curative and preventive interventions such as bed nets. These ‘downstream’ interventions, while necessary, are insufficient as they fail to address deprivation of the ‘upstream’ determinants of health (DOH), clean water, sanitation, education and healthcare, that is driving the high rates of child and maternal morbidity and mortality in low- and low-middle income countries (LICs & LMICs).

Bernadette O’Hare, Senior Lecturer in Global Health at the University of St Andrews, Scotland and Senior Lecturer in Paediatrics and Child Health, The College of Medicine, Malawi, working with econometricians, has developed this project which models the relationship between government revenue, maternal and child mortality and access to the determinants of health, (DOH); clean water, sanitation, education and healthcare. DOH are fundamental economic and social rights.

The models, based on data from population-based panel studies in 191 countries, show that those countries with low levels of revenue per capita will witness substantial decreases in mortality and increases in coverage of the DOH if additional revenue becomes available. For example, the model estimates that a 10% For example, a 10% increase in per capita government revenue in Afghanistan in 2002 ($24.49 million) is associated with a reduction in the under-5 mortality rate (U5MR) by 12.35 deaths per 1000 births and 13,094 lives saved. This increase is associated with a decrease in the maternal mortality ratio of 9.3 deaths per 100,000 live births and 99 maternal deaths averted. These gains in child and maternal mortality are secondary to improvements in coverage of clean water, sanitation, education, and healthcare.

GRADE, by focusing on government revenue rather than Gross National Product (GNP), goes to the heart of why some LICs & LMICs have limited resources to ensure all children have access to DOH. Tax incentives and treaties, international corporate tax avoidance, repayment of debt and corruption all contribute to reducing revenue especially in these poorer countries. Increasing government revenue and realising the gains in maternal and child survival estimated by the models will require action on these issues by governments in HICs where multinational corporations have their bases as well as by governments in the LICs and LMICs.

GRADE interactive model with a brief explanatory video can be downloaded at the link below. You can select your country and view the estimated impact of increased government revenue on U5MR and maternal mortality.

Nick Spencer

Professor Nick Spencer, Emeritus Professor of Child Health,

Division of Mental Health and Wellbeing,

Warwick Medical School,

University of Warwick,

Coventry CV4 9JD, UK

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CHIFA profile: Nick Spencer is Emeritus Professor of Child Health at the School of Health and Social Studies, University of Warwick in the UK. N.J.Spencer AT