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Acknowledgements :
The main contributors to this document were: Sarah Coll-Black (consultant and principal author), Anjana Bhushan(Poverty, Gender and Human Rights), Carmen Casanovas, Carolyn Maclennan, Emmalita Maalac andMarianna Trias (Child and Adolescent Health) of the World Health Organization Regional Office for the WesternPacific.
The team gratefully acknowledges the technical comments and other inputs received from Hilary Brown,Catherine Malsi, Guillermo Paraje, Robert Scherpbier, Niko Speybroeck, Marcus Stahlhofer, Nicole Valentine,Jeanette Vega and Eugenio Villar. Roslyn Stirling edited the document. Design and layout were done byZando Escultura.
Photograph credits: pp. 11 FAO/19738/G. pp. 23 Bizzarri; FAO/19743/G. Bizzarri; pp.1 2001 EvaCanoutas, Courtesy of Photoshare; pp.51 2001 Lutheran World Relief Shao Pingping/The Amity Foundation,Courtesy of Photoshare; pp. 29, 37 www.sxc.hu; cover, inside cover page, 5, 7, 14, 19, 20, 21, 26, 27, 30,31, 32, 33, 34, 38, 39, 40, 52, inside back cover page WHO/WPRO.
WHO Library Cataloguing in Publication Data
Reaching the poor : challenges for child health in the Western Pacific Region
1. Child health services. 2. Child welfare. 3. Child mortality. 4. Poverty.
ISBN 978 92 9061 246 9 (NLM Classification: WA 320)
World Health Organization 2007All rights reserved.
The designations employed and the presentation of the material in this publication do not imply the expression ofany opinion whatsoever on the part of the World Health Organization concerning the legal status of any country,territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lineson maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers products does not imply that they are endorsed
or recommended by the World Health Organization in preference to others of a similar nature that are notmentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capitalletters.
The World Health Organization does not warrant that the information contained in this publication is completeand correct and shall not be liable for any damages incurred as a result of its use.
Publications of the World Health Organization can be obtained from Marketing and Dissemination,World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476;fax: +41 22 791 4857; e-mail: [email protected]). Requests for permission to reproduce WHOpublications, in part or in whole, or to translate them - whether for sale or for noncommercial distribution -should be addressed to Publications, at the above address (fax: +41 22 791 4806; e-mail: [email protected]).For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed toPublications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000,Manila, Philippines, Fax. No. (632) 521-1036, e-mail: [email protected].
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7/40CHALLENGES FORCHILD HEALTH IN THE WESTERN PACIFIC REGION
i
Table of Contents
List of abbreviations iiForeword iii
Executive summary v
1. Introduction 1
2. Poverty and child health 5
3. Inequalities in childhood morbidity 73.1 Inequalitiesinchildhoodmorbiditybetweencountries 83.2 Inequalitiesinchildhoodmorbiditywithincountries 9
4. Inequalities in childhood mortality 11
5. Inequalities in access to health care services 145.1 Inversecarelawandtheallacyoequitableimpact 155.2 Inequalitiesinaccesstotheexpandedprogrammeonimmunization 16
5.3 Inequalitiesinaccesstoantenatalcareandskilledbirthassistance 16
6. Poverty-related determinants of child health 196.1 Macro-levelactors 206.2 Micro-level(communityandhousehold)actors 23
7. Barriers to access to child health care 297.1 Geographicaldistance 307.2 Financialbarriers 307.3 Sociocultural,languageandethnicity-relatedbarriers 327.4 Lackoknowledgeandawareness 327.5 Inequalitiesinqualityocare 32
8. Ill health among children leads to greater poverty 34
8.1 Poorerchildhealthleadstogreaterpovertyinthatgeneration 358.2 Poorerchildhealthleadstogreaterpovertyinthenextgeneration 35
9. The importance of tackling inequalities in child health 37
10. Addressing inequalities in child health 4010.1 Mainstreamchildhealthandsurvivalinnationalandinternationalpoverty-reductionstrategies 4110.2 Ensureaocusonpovertyandequityinchildhealthinterventions 43
11. Conclusion 51
References 53
Endnotes 62
Figures
Figure1: Under-vemortalityrateper1000livebirthsinselectedcountriesintheRegion(mostrecentdata 1999-2005)rankedaccordingtoWorldBankincomegroupings 2Figure2 Under-vemortalityrateinselectedcountriesintheRegion,1990-2003orlatestyearavailable 3Figure3 Under-vemortalitydisparities,selectedcountries 3Figure4: Prevalenceodiarrhoeaandacuterespiratoryinection(ARI)amongchildrenbyincomequintilein thePhilippines,1998 8Figure5: Proportionounder-vessueringromunderweight(
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ii
Figure11:MeaslesimmunizationbyincomequintilesinMalaysia,thePhilippinesandVietNam 17Figure12:Proportionowomeninthepoorestandrichestincomequintilesreceivingdeliveryassistancerom adoctorornurse/midwieinCambodia,thePhilippinesandVietNam 17Figure13:SkilledantenatalcarebyincomequintilesinMalaysia,thePhilippinesandVietNam 18Figure14:SkilledbirthattendancebyincomequintilesinMalaysia,thePhilippinesandVietNam 18Figure15: Improveddrinkingwatercoverage(%)inselectedcountriesintheRegion,2002 24Figure16:Improvedsanitationcoverage(%)inselectedcountriesintheRegion,2002 25
Tables
able1: Inantmortalityrateamongprovinceswithahighconcentrationoethnicminoritiescomparedwiththe nationalaveragesintheLaoPeoplesDemocraticRepublicandVietNam 13able2: LiteracyratesamongmenandwomenromethnicminoritiesandthetotalpopulationsinCambodia, theLaoPeoplesDemocraticRepublicandVietNam 22
Boxes
Box1: Teestimatedcostoscalingupimmunizationandtreatmentordiarrhoeaandacuterespiratoryinections 42
Box2: MicrocreditinBangladesh 43Box3: Preventiveinterventionsinselectedlow-incomecountries 44Box4: ContractingnongovernmentalorganizationstodeliverchildhealthinterventionsinCambodia 45Box5: PrimaryhealthcareintheLaoPeoplesDemocraticRepublic 46Box6: ReducingnancialbarrierstochildhealthinterventionsinYunnanProvince,China 47Box7: Outreachstrategiescanimprovetheaccessibilityochildhealthinterventionsorthepoor 48Box8: BehaviouralchangeinVietNam 48Box9: Improvedcasemanagementintwodistrictsoanzania 49
TABLE OF CONTENTS
List of Abbreviations ADB AsianDevelopmentBank
ARI Acuterespiratoryinection
BMI Bodymassindex
CRC ConventionontheRightsotheChild
DALY Disability-adjustedlieyear
DHS Demographicandhealthsurvey
DP Diphtheria-tetanus-pertussis
EPI Expandedprogrammeonimmunization
GAVI GlobalAllianceorVaccinesandImmunization
IEC Inormation,educationandcommunication IMCI Integratedmanagementochildhoodillness
IMR Inantmortalityrate
LBW Lowbirthweight
MDG MillenniumDevelopmentGoal
MMR Maternalmortalityratio
NGO Nongovernmentalorganization
OR Oralrehydrationtherapy
PRSP PovertyReductionStrategyPaper
U5MR Under-vemortalityrate
UNDP UnitedNationsDevelopmentProgramme
UNICEF UnitedNationsChildrensFund
WHO WorldHealthOrganization
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9/40CHALLENGES FORCHILD HEALTH IN THE WESTERN PACIFIC REGION
iiiFOREWORD
Foreword
TeWHOWesternPacicRegionhasachieved
impressivegainsinchildsurvival.Butitisbecomingincreasinglyclearthatchildrenlivinginpoor
householdsandcommunitieshaveenjoyedsignicantly
ewerbenetsromthenumerousprovenand
cost-eectivechildhealthinterventionsthathavebeen
initiated.Tatactismaniestedinthepersistentand
growinginequalitiesinchildsurvivalacrossandwithin
countriesintheRegion.Suchinequalitiesarenot
theresultoinadequateknowledgeorineectivechildhealthinterventions;rather,
thestrategiesemployedtodeliverthoseinterventionsappeartohaveallenshorto
reachingthechildrenandhouseholdsmostinneed.Greatereortsarethusrequired
toaddresstheimpactthatpovertyandinequalityhaveonthehealthochildren,therebyreducinginequalitiesinchildsurvival.
Fortunately,thereisarenewedcommitmentandemphasisonreducingchildmortality
intheWesternPacicRegion.CatalysedbythelaunchotheUnitedNations
MillenniumDevelopmentGoalsin2000,theWHORegionalCommitteeor
theWesternPacic,atitsty-ourthsessioninSeptember2003,calledonMember
Statestopositionchildhealthhigherontheirpolitical,economicandhealthagendas.
TeWHORegionalOceortheWesternPacicwaschargedwithleadingthedrive
towardsreducingtheunder-5mortalityrateintheRegionbytwothirds,rom1990to
2015,therebymeetingMillenniumDevelopmentGoal4onchildmortalityreduction.
Inresponse,theWHORegionalOceortheWesternPacicandUNICEFs
RegionalOceorEast-AsiaandPacichavedevelopedajointWHO/UNICEF
RegionalChildSurvivalStrategytoaccelerateeortstoimprovechildsurvivaland
reduceinequities.
Reachingpoororunderservedcommunitieswithexistinglie-savinginterventions
remainsoneothebiggestchallengesinreducingchildmortality.TeRegionis
thusseekingtointegrateapro-poorocusintochildsurvival-relatedprogrammes.
Tispublicationisastepinthatdirection.Primarilytargetingnationalprogramme
managersandpolicy-makersworkingonchildsurvivalincountriesandareasin
theWesternPacicRegion,itaims,basedonareviewotheliterature,toincreaseawarenessotherelationshipbetweenchildhealth,povertyandequity,andsuggests
strategiestoaddressthoselinks,withreerencetotheRegioningeneraland,more
particularly,tocountrieswithhighchildmortality.Italsoseekstoprovide
anevidencebaseortheimplementationoactionsoutlinedintheWHO/UNICEF
childsurvivalstrategytoassistMemberStatesindesigningandimplementingpolicies
andprogrammestoimprovechildsurvival,withanappropriateocusonpoorand
underservedareasandgroups.
Shigeru Omi, MD, Ph.D.Regional Director
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iv
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11/40CHALLENGES FORCHILD HEALTH IN THE WESTERN PACIFIC REGION
vEXECUTIVE SUMMARY
Executive Summary
TeWesternPacicRegionhasseenremarkableimprovementinchildsurvivalrates,
however,evidenceincreasinglyshowspersistentandgrowinginequalitiesinchildhealthstillexistsacrosscountriesintheRegion.Numerousstudiesdescribehow
childrenlivinginpoorhouseholdsacegreaterexposuretotherisksoillhealth.
Temultipledimensionsopovertyhavebeenoundtohaveasignicantnegative
impactonchildsurvival,includinglowincomeandsocialexclusion;limited
educationalattainment,particularlyamongwomen;inadequatelivingconditions;and
undernutrition.Childrenresidinginpoorandvulnerablehouseholdsthussuer
adisproportionateburdenomorbidity.
Althoughhealthcareappearstobeaneectivemeansoreducinginequalitiesin
theburdenochildhooddisease,evidenceincreasinglysuggeststhatpoorand
vulnerablechildrenbenetlessromhealthcareinterventionsthanthosewhoarebettero.Variousstudieshaveoundthatwhenchildrenrompoorhouseholdsall
sick,theyarelesslikelytobetakentoanappropriatehealthcareproviderandless
likelytoreceivequalitycarethanchildrenromnon-poorhouseholds.Evidence
increasinglydemonstratesthatinequalitiesinaccesstohealthcaremayariserom
anumberonancialandnon-nancialbarriersthatmaydelayorpreventpoor
householdsromseekingcareortheirsickchildren.Tecumulativeeectolivingin
povertyismaniestedinthehigherratesomortalityamongpoorchildrenthanamong
theirbetter-ocounterparts.
CasestudiesacrosstheRegionhaveoundthatthecostsoseekinghealthcareurther
impoverishalreadypoorhouseholds.Studieshavealsoobservedthatmorbidityin
earlychildhoodisassociatedwithlowerproductivityandotherdisadvantagesin
adulthood.Tus,aggregatedtothenationallevel,thecostsopoorchildhealthmay
bestaggeringlyhigh.
Inequalitiesinchildhealthdonotappeartobetheresultoinadequateknowledgeor
ineectivechildsurvivalinterventions.Rather,mountingevidenceshowsthatalack
oinvestmentsinchildsurvivalingeneral,andalackoocusonaddressingthose
ingreatestneedinparticular,havecontributedtotheexistenceosuchinequalities.
Renewedeortsarethusrequiredtoaddresstheimpactthatpovertyandinequality
haveonchildrenintheRegion,buildingontheexperienceostrategiesthathavebeensuccessulinreachingpoororunderservedchildren.Oten,thiscallsora
cross-sectoralresponsetoaddressthemultipledeterminantsochildhealththatlie
beyondthehealthsector.Atthesametime,withinthehealthsector,prioritizing
childsurvivalinterventionsthatdisproportionatelybenetpoorchildreninresource
allocation,andadoptingdeliverystrategiesthataimtoincreasetheaccessibility
ohealthcareservicesorpoorchildren,mayresultinaconcretemovetowards
improvingtheeciencyandequityochildsurvivalinterventions.Teultimate
goalisuniversalcoverageoressentiallie-savingchildhealthinterventionstoensure
achievementoMDG4,onchildmortalityreduction.
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Introduction
1
CHALLENGES FORCHILD HEALTH IN THE WESTERN PACIFIC REGION
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2 INTRODUCTION
Introduction
Overall, the Western Pacific Region has realized impressive reductions in child
mortality. e under-five mortality rate (U5MR) fell from 154 per 1000 live
births in 1955-1959 to 48 in 1995-1999.1 at decline mirrored the worldwide
reduction in child deaths to a global average of 83 per 1000 live births in 2000.2
Yet, an estimated 10.8 million children died worldwide in 2000, and 3.9 million of
those deaths occurred in the first 28 days of life.3
Recent child and neonatal health
data from the Western Pacific Region show a yearly average of approximately 1.02
million deaths from 2000-2003, with 3000 children under five in the Region dying
every day.4,5
Global and regional averages often mask large variations in child health outcomes
between countries, with the burden of child mortality weighing more heavily on
developing countries in the Region (Figure 1). Six countries in the Western PacificRegion Cambodia, China, the Lao Peoples Democratic Republic, Papua New
Guinea, the Philippines and Viet Nam account for over 75% of child deaths.6
Notably, these countries are classified as low-income economies, with the exception
of China and the Philippines, which are categorized as lower-middle income
economies.7
Considering a more comprehensive measure of development, the Human
Development Indices of these countries dominate the lower ranks of countries with
middle human development.8
As many as 800 000 children under five will continue
to die every year in these countries if current trends continue.9
Japan*
New
Caled
onia*
New
Zeala
nd*
Republic
ofK
orea*
Malay
sia**
American
Samoa**
Chi
na***
Fiji*
**
Phili
ppin
es***
Tong
a***
Vanu
atu***
Cam
bodia****
Lao
PDR****
Mon
golia
****
Paua
New
Guinea****
Viet
Nam
****
Australi
a*
Figure 1: Under-five mortality rate per 1000 live births in selected countries in the Western Pacific Region (data
1999-2005) ranked according to World Bank income groupings
Source: Country Health Information Profiles (CHIPS). Manila, WHO Regional Office for the Western Pacific, 2006. (http://www.wpro.who.int/countries/Countries.htm)110
100
90
80
70
60
50
40
30
20
10
0
* High-income economies (GNI per capita>US$ 10 726)** Upper-middle income economies (US$ 3466 10 725)*** Lower-middle income economies (US$ 876 3465)**** Low-income economies (US$ 875 or
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3INTRODUCTION
It is becoming increasingly apparent that variations in child survival between countries
in the Region are reproduced within countries as well: children living in poor households
and communities seem to suffer higher rates of morbidity and mortality than their
better-off peers.10
Importantly, evidence suggests that differences in U5MR between
and within some countries may even be widening.11 For example, in the last decade,the rate of child mortality increased in Cambodia
12and showed little change in Papua
New Guinea13
, Kiribati and the Philippines14
(see Figure 2). Based on the published
Demographic Health Survey (DHS) and National Statistics Office data, large disparities
in under-five mortality within countries can be noted, as shown in Figure 3.
Traditionally, poverty
has been defined in
terms of low income
and consumption.
However, more
recently, poverty has
been conceptualized
as being
multidimensional.
In the discussion
that follows, poverty
is considered to
encompass, not just
low income, but
also lack of access
to education, skills,services and resources;
vulnerability;
insecurity;
voicelessness; and powerlessness. An important aspect of poverty is that it often
overlaps with and reinforces other types of social exclusion, such as those based on
race, ethnicity, geographical location (urban/rural) and gender.
Growing international commitment to tackling all
dimensions of poverty has led to a greater concern
for the health of the poor. Health is increasingly
understood to play a central role in human developmentand poverty reduction.
15at belief is supported by
a growing body of evidence on the interrelationship
between poverty and health at the household,
community and national levels. e poor consistently
identify good health as central to their survival, and
vulnerability to the impoverishing effects of ill health
as a key dimension of their poverty.16
Evidence is
also mounting on the strong linkages between a lower
burden of disease and increased economic growth and
poverty reduction at the level of country or society.
e Commission on Macroeconomics and Health, for example, called attention to
the powerful linkages between health, economic development and poverty reduction.17
Figure 2: Under-five mortality rate in selected countries in the Region, 1990-2003 orlatest year available
180
160
140
120
100
80
60
40
20
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Source: UNICEF, The State of the World's Children, 2005 and previous issues.
LAO PDR CAMBODIA PAPUA NEW GUINEA MONGOLIA KIRIBATI
CHINA PHILIPPINES VIET NAM MALAYSIA
Deathsper1000livebirths
Figure 3: Under-five mortality disparities, selectedcountries
Source: DHS and National Statistics Office data
250
200
150
100
50
0
MAXIMUM AVERAGE MINIMUM
Deathsper1000
livebirths
Viet Nam China Philippines Papua New Cambodia2002 2000 2003 Guinea 2000 2000
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4 INTRODUCTION
Teuniversalenjoymentogoodhealthisalsoacknowledgedasaundamentalhuman
right,asembodiedintheConventionontheRightsotheChild(CRC).
Teinterrelationshipbetweenhealth,humandevelopmentandpovertyreductionis
specicallyrefectedintheUnitedNationsMillenniumDevelopmentGoals(MDG):therstsevengoals,owhichthreeaimtoimprovehealthoutcomes,aremutually
reinorcingandaredirectedatreducingthemultipledimensionsopoverty.Tus,
progresstowardsreachingtheourthgoal,whichaimstoreducechildmortalityby
reducingtheunder-vemortalityratebytwo-thirdsbetween1990and2015,is
contingentonprogresstowardsreachingtheothergoalsandtargets,specicallythose
orpovertyreduction,maternalmortalityreduction,increasedgenderequalityand
improvedaccesstosaedrinkingwaterandsanitation.18Recentestimatesby
theWorldBanksuggest,however,thatonly17%othepopulationinEastAsiaand
thePacicregionresideincountriesthatareontracktowardsreachingthegoalor
under-vemortality,andprogresshasbeenslowestinthepoorestcommunities.19
Concertedeortisthusrequiredtoensurethatchildhealthinterventionsreachthose
childrenmostinneed.
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Poverty and child health
2
CHALLENGES FORCHILD HEALTH IN THE WESTERN PACIFIC REGION
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6 POVERTY AND CHILD HEALTH
Poverty and child health
Teinterrelationshipbetweenpovertyandhealthcanberepresentedbytwo
reinorcingcycles:
Teviciouscycle:
Povertybreedsillhealth.
Illhealthcausespoverty.
Tevirtuouscycle:
Higherincomeislinkedtogoodhealth.
Goodhealthislinkedtohigherincomeandwelare.
Whetheratthehousehold,communityornationallevel,povertyisseentobeamajor
determinantoillhealth.Childrenareespeciallyvulnerabletothecumulativeadverse
eectsolivinginpoverty.Borntowomenwhoareotenundernourishedandinill
healththemselves,inantsinpoorandmarginalizedhouseholdsaretypicallyweaker
thantheirbetter-opeers,whosemothersaremorelikelytobebetternourishedand
tohavereceivedappropriateantenatalcare.Inantsrompoorhouseholdshavelower
survivalratesandmaydieintherstweeksormonthsolie.Shouldtheysurvive
inancy,poorchildrenacegreaterexposuretotherisksoillhealthbyvirtueo
growingupinpoorhouseholds,andarethereoremorelikelytoallsickthanchildren
bornintowealthieramilies.
Althoughappropriatehealthcareisaneectivemeansoaddressinginequalitiesin
theburdenochildhoodmorbidity,evidencesuggeststhat,oncesick,poorchildrentypicallyhaveloweraccesstoqualityhealthcareservicesthannon-poorchildren.Even
wherehealthservicesareavailable,thecostsoseekinghealthcaremaybemorethan
apooramilycanbear,therebydelayingorpreventingthemromseekingcareortheir
sickchildren.Suchasituationotenresultsinahigherincidenceolie-threatening
diseaseandmortalityamongpoorandmarginalizedchildrenthanamongtheir
non-poorpeers.Tecostsoseekinghealthcaremayalsodrivepoorchildrenand
theiramiliesintogreaterpoverty.Illhealthinchildhoodhasbeenshowntohave
long-termrepercussionsongrowthanddevelopment,whichmayresultinchronic
illness,lowerproductivityandotherdisadvantagesinadulthood.Tus,periodsoill
healthinchildhoodmayleadtoacontinuingcycleopovertyandillhealth.
Ontheotherhand,economicgrowthtranslatesintobetterhealth.InChina,
TailandandVietNam,theproportionoundernourishedpeopledeclinedthrough
the1990s,withsustainedeconomicgrowthexceeding7%inmostyears,lowinfation
andunemployment,andstableexchangerates.20Atthesametime,decliningertility
releaseswomenromchild-rearingactivitiesandenablesthemtoenterthelabour
orce.21Withhigherincomes,theyareabletocontributetohouseholdeducation,
nutritionand,consequently,goodhealth.
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3
CHALLENGES FORCHILD HEALTH IN THE WESTERN PACIFIC REGION
Inequalities inchildhood morbidity
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8 INEQUALITIES IN CHILDHOOD MORBIDITY
Inequalities in childhood morbidity
Withincountries,childrenrompoor
householdsandcommunitiestypically
suerahigherburdenodiseaseandare
otensickerthanchildrenrom
non-poorhouseholds,asseenin
Figure4ontheprevalenceodiarrhoea
andARIamongchildrenbyincome
quintileinthePhilippinesin1998.
InVietNam,childrenlivinginpoor
ruralareassueraburdenodisease,
asmeasuredindisability-adjusted
lieyears(DALYs)per1000,thatis
estimatedtobe27timesgreaterthanthatexperiencedbychildrenresiding
inurbanareas.22Morespecically,in
1997,theprevalenceodiarrhoeaand
acuterespiratoryinection(ARI)amongVietnamesechildrenromthepoorestquintile
wasestimatedtobe10.1%and14%respectively,incomparisonwith6.2%and
10.1%amongchildrenromtherichestquintile.23InCambodia,theproportiono
childrenunderveyearsoagewithdiarrhoeain2000wasoundtobehigheramong
thosewhosemothershadreceivednoeducation(18.8%)thanamongthosewhose
mothershadbenetedromsecondarylevelorhighereducation(16.1%).24
3.1 Inequalities in childhood morbidity between countries
Undernutritionisacontributingactorinaround50%ochildhooddeathsin
developingcountries.25Morespecically,asmuchas50%-70%otheburdeno
diarrhoealdiseases,measles,malariaandlowerrespiratoryinectionsinchildhoodcan
beattributedtoundernutrition.26Evenmildundernutritionplaceschildrenatrisk.
SomeothepoorestcountriesintheRegionacethehighestratesoundernutrition
andsevereunderweightamongchildrenunderveyearsoage(seeFigure5).
Analysisothe2000DemographicandHealthSurvey(DHS)inCambodiareveals
that,comparedwithaninternationalscale,45%ochildrenwerestunted,45%
underweightand15%toothinortheirheight.27Similarly,highratesostunting
areobservedinPapuaNewGuinea,wheremorethan40%ochildrenunderveare
stunted.28Importantly,UNICEFreportsthat,overthepastdecade,theprevalenceo
undernutritionamongchildreninCambodiaandMongoliaappearstohaveincreased,
whileintheLaoPeoplesDemocraticRepublicithasdecreasedonlyslightly.29
Decienciesinmicronutrientsarelikewisecommonamongyoungchildrenin
developingcountriesintheWesternPacicRegion.RecentsurveysinCambodiaand
theLaoPeoplesDemocraticRepublicshowthattheratesoanaemiaamongchildren
youngerthanveyearsare63%and46%,respectively.30TeNationalHealth
Survey2000-2001ortheLaoPeoplesDemocraticRepublicoundseverevitamin
Adeciencyamong44.7%ochildrenunderve.
31
HighratesomicronutrientdeciencieshavealsobeenoundinsomePacicislandcountries.Forexample,in
theMarshallIslands,acommunity-basedsurvey,conductedin1994-1995and
18
16
14
12
10
8
6
4
2
0
Figure 4: Prevalence of diarrhoea and acute respiratory infection (ARI)among children by income quintile in the Philippines, 1998
Source: Gwatkin D et al. Socio-economic differences in health, nutrition and populationin the Philippines. Washington, D.C.,World Bank HNP Poverty Thematic Group, 2000.
PERCENT OF CHILDREN WITH DIARRHOEAIN THE PRECEDING TWO WEEKS
PERCENT OF CHILDREN WITH ARIIN THE PRECEDING TWO WEEKS
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21/40CHALLENGES FORCHILD HEALTH IN THE WESTERN PACIFIC REGION
9INEQUALITIES IN CHILDHOOD MORBIDITY
involvingchildrenromonetoveyearso
agerom10atolls,oundthat55%o
thechildrenwerevitamin-A-decientand
theprevalencesoanaemia
(haemoglobin
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0 INEQUALITIES IN CHILDHOOD MORBIDITY
improvednutritionledtodeclinesinthepercentageounderweightchildreninChina
rom19%to7.88%andinstuntingrom33%to14.3%between1990to2002,
morethan40%ochildreninwesternChinaweremildtomoderatelystunted.Also,
theprevalenceoundernutritioninruralareasisthreetoourtimeshigherthanin
theurbanareas.41
Higherratesoundernutritionhavealsobeenobservedamongethnicminoritiesin
theRegion.InVietNam,ethnicminoritiesexperiencearateoundernutritionthatis
15%greaterthanthatintheKinhmajority.42Astudycarriedoutin1999toestimate
theprevalenceoprotein-energyundernutritionamongchildrenundersevenyears
oageinoureconomicallydisadvantagedruralminoritycommunitiesinYunnan
ProvinceinthesoutheastoChinareportedratesounderweightandstuntingabove
thenationalaverage.43Testudyalsoobservedanincreasedriskostuntingamong
childrenbelongingtotheMiao,YiandHaniethnicminoritiescomparedwiththose
romtheHanmajority.
AlthoughundernutritionintheWesternPacicRegionissteadilydecreasing,progress
isunevenlydistributed.InVietNam,orexample,thedeclineinchildundernutrition
rom1992to1997wasreportedtobegreatestamongtherichestincomequintile.44
Usingdataromthe1992-1993and1997-1998VietNamLivingStandardsSurveys,
asecondstudysuggeststhat,notonlywastherateostuntingandunderweighthigher
amongchildrenrompoorhouseholds,butthatchildrenrompoorhouseholds
hadexperiencedasmallerrateoreductioninstuntingandunderweightbetween
1992-1993and1997-1998thanthoseromhouseholdsaboveoratthepovertyline.
Similarinequalitieswerereportedorhouseholdsinruralareasandamongethnic
minorities.
45
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4
CHALLENGES FORCHILD HEALTH IN THE WESTERN PACIFIC REGION
Inequalities inchildhood mortality
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2 INEQUALITIES IN CHILDHOOD MORTALITY
Inequalities in childhood mortality
e main causes of under-five mortality in high-mortality areas (U5M>50 per
1000 live births) of the Western Pacific Region are shown in Figure 6. Acute lower
respiratory infections are the single most important cause of death, accounting for
20% of deaths among children under five years of age, with diarrhoea accounting for
18% and measles for 2.4%. Malaria does not account for a large share of total child
deaths in the Region, but is a cause of high child mortality in some countries, such
as the Lao Peoples Democratic Republic, Papua New Guinea and some provinces
of Cambodia. HIV/AIDS is an emerging problem and is related to about 1% of
mortality among children under five. Neonatal deaths account for 32% of deaths.46
e cumulative effect of a childhood spent
in persistent poverty is manifested in lower
survival rates among children living in poorhouseholds, as Figure 7 shows. e risk of death
in childhood is estimated to be 10 times higher
among the poorest 20% of the global population
than among the richest 20%.47
Data from
the 2003 DHS in the Philippines show that
the infant mortality rate (IMR) was 2.3 times
higher among households in the poorest
quintile than that among those from the richest
quintile, while the under-five mortality rate
(U5MR) was 2.7 times higher.48
In Viet Nam in
2000, the mortality rate among children whosemothers had received no education was found to
be double that of children whose mothers had
completed higher secondary education.49
An inverse association between
infant mortality and maternal education has also been observed in Cambodia
and the Philippines. e IMR among children whose mothers had received no
education was 103 per 1000 live births in Cambodia in 2000, while children whose
mothers had completed secondary education or higher experienced an IMR of 60 per
1000 live births.50
Data from the 2003 DHS in the Philippines show that the IMR
among children with mothers who had received
a college education was 15, compared to
65 per 1000 live births for mothers with no
education.51
In other countries in the Region, mortality
rates likewise tend to be higher among children
residing in rural communities than among
children in better-off urban areas. For example,
in 1999, the average IMR in the poorer western
provinces of China was 26.1 per 1000 live
births in comparison with 17.1 in the wealthier
eastern provinces. U5MR mirrored thistrend, reaching, on average, a high of 46.9 per
1000 live births in the western provinces
Figure 6: Cause-specific mortality in high-mortality areas,Western Pacific Region, 20002003
Source: CAH/EIP CHERG estimates
Others 27%
HIV/AIDS 1%
Diarrhoea 18%
Measles 2.4%
Malaria 0.2%
Respiratory Infection 20%
Neonatal32%
UNDER
NUTRITION
Figure 7: Under-five mortality rate by selected income
quintiles in Cambodia, the Philippines and Viet Nam
Source: Gwatkin D et al 2003. In: Carr D. Improving the health of the world's poorestpeople. Washington, D.C., Population Reference Bureau, 2004 (Health Bulletin 1).
160
140
120
100
80
60
40
20
0
POOREST FIFTH MIDDLE FIFTH RICHEST FIFTH
Cambodia Philippines Viet Nam2000 1998 2000
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13INEQUALITIES IN CHILDHOOD MORTALITY
andanaverageoonly20.9intheeasternprovinces.52Similarly,inthe1999
VietNamPopulationCensus,theIMRinpoormountainousprovincesinthenorth
andcentralregionswasestimatedtobeuptoeighttimeshigherthanthatinlarge
urbancentres,suchasHoChiMinhCity.53In2003,theAsianDevelopmentBank
reportedthattheIMRwas2.5timeshigherinruralthaninurbanareasoPapuaNewGuinea.
54Dataromthe2003DHSinthePhilippinesrevealthattheIMRwas36
per1000livebirthsandtheU5MRwas52amongchildrenlivinginruralareas,while
theirurbancounterpartsexperiencedanIMRo24andanU5MRo30.55
Althoughdisaggregateddataare
scarce,ratesochildsurvivalin
theRegionarealsogenerallylower
amongmarginalizedcommunities,
suchasethnicminorities,thanamong
majorityethnicgroups.Provinces
withahighconcentrationoethnic
minoritiesintheLaoPeoples
DemocraticRepublicandVietNam,
orexample,generallyexperience
poorerchildhealththanthenational
average,asseeninable1.More
specically,theU5MRamongethnicminoritiesinVietNamhasbeenestimated
tobehigherthanthatamongthemajorityKinh.56IntheLaoPeoplesDemocratic
Republic,thenationalIMRis70,whileinLuangPrabangprovinceintheHighlands
itiscloseto90.57
RecentevidenceromanumberocountriesintheWesternPacicRegionsuggests
thatinequalitiesinchildmortalitymaybeincreasing.Between1980and1998,
theIMRdeterioratedinoverhalotheprovincesinPapuaNewGuinea.58
TedeclineinchildsurvivalinPapuaNewGuineahasbeenattributedtothecollapse
othehealthsystemollowinglawandorderproblems.59Growingregionaldisparities
havelikewisebeenobservedinVietNam.Intheearly1990s,theIMRinruralareas
was80%greaterthanthatinurbanareas.However,duetoamorerapiddeclinein
theIMRinurbanareas,theurban-ruralgaphadincreasedto125%by1998.60
Wideninginequalitiesbetweenthesurvivalprospectsopoorandnon-poorchildren
inVietNamhavealsobeenobserved,andhavebeenattributedtoareductioninthecoverageosomehealthcareservicesamongthepoor.61InChina,evidence
indicatesthattheurban-ruralIMRratioincreasedrom1.67in1981to1.75in
1990.Basedonapopulationsamplingsurveyconductedin1995,theratiomayhave
increasedto2.1.62
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Inequalities in accessto health care services
5
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15INEQUALITIES IN ACCESS TO HEALTH CARE SERVICES
Inequalities in access to health careservices
5.1 Inverse care law and the fallacy of equitable impact
Providing access to appropriate health care is an effective means of reducing
the burden of disease among poor children. For example, a positive relationship has
been observed between the availability of child health services and a reduction in
child mortality in Viet Nam.63
Despite the greater risk of ill health and higher rates of
morbidity poorer children face compared with their wealthier counterparts, evidence
suggests that they benefit less from health care interventions. e lower access to
health care services by poorer households is known as the inverse care law, which
states, e availability of good medical care tends to vary inversely with the need
for it in the population served.64
Studies show that, once sick, children from poor
families are less likely to be taken to an appropriate health care provider or facility,such as a village health worker, a dispensary, a health centre, a hospital or a private
doctor, than children from non-poor families.65
Since childhood diseases are primarily concentrated among poor populations, health
interventions targeting such conditions are often assumed to disproportionately benefit
the poor. Gwatkin terms this the fallacy of equitable impact: the assumption that
interventions against conditions that are concentrated primarily among the poor can
be expected to benefit primarily the poor victims of those conditions.66
However, it
is becoming increasingly apparent that effective child health interventions, such as
immunization, deliveries attended by medically trained personnel and antenatal visits,
may not be reaching those most in need. A study of over 40 countries reveals that child
health interventions thought to be pro-poor, such as oral rehydration therapy (ORT)
and immunization, have generally achieved higher rates of coverage among wealthier
children than among poor children. Other health services, such as attended deliveries,
exhibit even larger inequalities in coverage between poor and non-poor households.67
e inverse care law and the fallacy of equitable
impact are revealed in evidence on the proportion
of children with diarrhoea and ARI who are
taken to health facilities in the Western Pacific
Region. e 2003 DHS from the Philippinesshows that 46.3% of Filipino children with ARI
and/or fever in the two weeks preceding
the survey were taken to a health facility or
health care provider. However, children whose
mothers had a higher level of education or
belonged to a higher asset index quartile were
more likely to seek care than their counterparts
with lower income or education.68
Inequalities
in access to health care between poor and non-
poor children with ARI in the Philippines were
also observed in the analysis of 1998 DHS data, as seen in Figure 8. is analysissuggests that, in the Philippines, children in poor households are less likely to be
Figure 8: Treatment of acute respiratory infection (%) byincome quintiles, the Philippines, 1998
Source: Gwatkin D et al. Socio-economic differences in health, nutrition and populationin the Philippines. Washington, DC., World Bank HNP Poverty Thematic Group, 2000.
80
70
60
50
40
30
20
10
0
PREVALENCE SEEN MEDICALLY % SEEN IN A PUBLIC FACILITY
Poorest Second Middle Fourth Richest
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6 INEQUALITIES IN ACCESS TO HEALTH CARE SERVICES
taken to an appropriate health care provider than children from better-off households,
although the prevalence of ARI is higher among poor children. A similar trend is
observed in Viet Nam, where children from wealthier families seek care 45% more
frequently than children from the poorest group.69
In Cambodia, the proportion of
children with diarrhoea who consulted a health care facility in 2000 was found to bepositively associated with maternal education. On average, only 20.1% of children
with diarrhoea whose mothers had received no education sought care in a medical
facility, in comparison with 31.1% of those whose mothers had received a secondary
education or higher.70
A number of studies have shown the generally incomplete coverage of successful
preventive and curative child health interventions.71
Inequalities in access to
cost-effective and proven interventions suggest that such initiatives have been unable
to reach poor and vulnerable populations in particular. is is reflected in disparities
in immunization coverage and access to antenatal care and skilled delivery assistance
between poor and non-poor households, between rural and urban areas, and among
ethnic minorities in the Region.
5.2 Inequalities in access to the expanded programme on
immunization
e expanded programme on immunization
(EPI), for example, has achieved high coverage
rates in many countries in the Western Pacific
Region. However, inequalities in coverage
across provinces, communities and households
still exist. Figure 9 presents the proportion of
children fully vaccinated by income quintile
in Cambodia, the Philippines and Viet Nam.
Similarly, Figures 10 and 11 reveal inequalities
by income quintiles in the status of
diphtheria-tetanus-pertussis (DTP3)
immunization and measles immunization
in three countries in the Region with
widely varying per capita incomes, using
data from various surveys. Again, although
immunization coverage in Papua New Guinea is generally low, coverage in the WesternProvinces (27%) is less than half that achieved nationwide (60%), according to
the National Health Plan 2001-2010.72
Further, the proportion of Cambodian
children aged 12-23 months who received measles vaccinations in 2000 ranged from
45.6% among those whose mothers had received no education to 71.1% among those
whose mothers had benefited from a secondary education or higher. Notably,
the coverage of measles vaccination appeared to be the lowest among poor girl
children, at only 35%.73
5.3 Inequalities in access to antenatal care and skilled birth assistance
Antenatal care and skilled assistance at birth increase the likelihood that an infantwill be born healthy. A recent meta-analysis of infant and child mortality and child
Figure 9: Proportion of children fully vaccinated, by selectedincome quintiles, in Cambodia, the Philippines and Viet Nam
Source: Gwatkin D et al 2003. In: Carr D. Improving the health of the world's poorestpeople. Washington, D.C., Population Reference Bureau, 2004 (Health Bulletin 1).
100
90
80
70
60
50
40
30
20
10
0
POOREST FIFTH MIDDLE FIFTH RICHEST FIFTH
Cambodia Philippines Viet Nam2000 1998 2000
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17INEQUALITIES IN ACCESS TO HEALTH CARE SERVICES
nutrition found that the likelihood of survival is greater among infants and children
whose mothers receive antenatal care, either from a physician or midwife. e study
also found that infants born in health facilities are less likely to die than those born
at home.74
Yet, coverage of antenatal care in the Region varies widely. In 2003,
UNICEF reported that, in developing countries in the Region, the coverage of
antenatal care ranged from lows of 27% in the Lao Peoples Democratic Republic and
38% in Cambodia to a high of 97% in Mongolia.75
In general, wealthier households and communities have
greater access to skilled health personnel than do poor
households and communities (see Figure 12).
e proportion of women from the poorest income
quintile who received at least one antenatal care
consultation from a medically trained person was found
to be 71.5% in the Philippines and 78.5% in Viet Nam,
in comparison with over 97% of women from the richest
income quintile in both countries. e association of
number of antenatal visits to skilled birth assistance was
also analysed. In the Philippines, among women with
less than four antenatal visits, only 33.9% had skilledassistance during delivery, compared with as many as
72.3% among those who had four or more antenatal
visits.76
Inequalities in deliveries attended by medically
trained personnel were even starker: only 21.2% of births
among women from the poorest income quintile in
the Philippines were assisted by a doctor, nurse or trained midwife, while over 91%
of women from the richest income quintile received such assistance. Figure 12 shows
similar findings in Cambodia and Viet Nam. Conversely, over 90% of women from
the poorest quintile in the Philippines gave birth at home, while a mere 20% of those
from the richest quintile chose home births.77
Similarly, women in the richest income
quintile in Viet Nam were over 150% more likely to have deliveries in health facilitiesthan those from the poorest quintile.
78
Figure 10: DTP3 immunization by income quintilesin Malaysia, the Philippines and Viet Nam
Source: Vega J. Presentation on Commission on SocialDeterminants of Health. 89th Consultation of WHO Representatives
and Country Liaison Officers, Manila, WHO Regional Office for theWestern Pacific, 2004 (PowerPoint presentation).
90
80
70
60
50
40
30
20Q1 Q2 Q3 Q4 Q5
Percentageofunder5childrenwho
received3dosesofDTPvaccination
MALAYSIA PHILIPPINES VIET NAM
Figure 11: Measles immunization by incomequintiles in Malaysia, the Philippines and Viet Nam
Source: Vega J. Presentation on Commission on SocialDeterminants of Health. 89th Consultation of WHO Representativesand Country Liaison Officers, Manila, WHO Regional Office for the
Western Pacific, 2004 (PowerPoint presentation).90
80
70
60
50
40
30Q1 Q2 Q3 Q4 Q5
Percentageofunder5childrenwho
receivedmeaslesvaccination
MALAYSIA PHILIPPINES VIET NAM
Figure 12: Proportion of women in the poorest
and richest income quintiles receiving deliveryassistance from a doctor or nurse/midwife inCambodia, the Philippines and Viet Nam
Source: Gwatkin D et al 2003. In: Carr D. Improving the health of theworld's poorest people. Washington, D.C., Population Reference Bureau,
2004 (Health Bulletin 1).
120
100
80
60
40
20
0
POOREST QUINTILE RICHEST QUINTILE
Cambodia Philippines Viet Nam2000 1998 2000
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8 INEQUALITIES IN ACCESS TO HEALTH CARE SERVICES
Similarly, Figures 13 and 14 reveal inequalities by income quintile in the proportion
of women receiving skilled antenatal care and skilled attendance during delivery
in Malaysia, the Philippines and Viet Nam, which have widely varying per capita
incomes, using data from various surveys.
100
90
80
70
60
50
40
30
20
10
0Q1 Q2 Q3 Q4 Q5
MALAYSIA PHILIPPINES VIET NAM
Figure 13: Skilled antenatal care by incomequintiles in Malaysia, the Philippines and Viet Nam
Source: Vega J. Presentation on Commission on SocialDeterminants of Health. 89th Consultation of WHO Representatives
and Country Liaison Officers, Manila, WHO Regional Office for theWestern Pacific, 2004 (PowerPoint presentation).
Percentageofwomenreceivingskilled
antenatalcareduringpregnancy
GNP/Capita (US $)
Malaysia - 3 780 Philippines - 1 080 Viet Nam - 480
80
70
60
50
40
30
20
10
0Q1 Q2 Q3 Q4 Q5
MALAYSIA PHILIPPINES VIET NAM
Figure 14: Skilled birth attendance by incomequintiles in Malaysia, the Philippines and Viet Nam
Source: Vega J. Presentation on Commission on SocialDeterminants of Health. 89th Consultation of WHO Representatives
and Country Liaison Officers, Manila, WHO Regional Office for theWestern Pacific, 2004 (PowerPoint presentation).
Percentageofwomenattendedatbirth
byskilledpersonnel
GNP/Capita (US $)
Malaysia - 3 780 Philippines - 1 080 Viet Nam - 480
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Poverty-relateddeterminants of child health
6
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20 POVERTY-RELATED DETERMINANTS OF CHILD HEALTH
Poverty-related determinants of childhealth
Povertyismultidimensionalandencompassesmanydeterminantsochildhealth.Tenumerousdimensionsopoverty,suchaslowhouseholdincomeandsocial
exclusion,lowlevelsomaternaleducation,inadequatelivingconditionsand
undernutrition,canincreasetheriskochildrenallingill.Tesedeterminantsmay
becategorizedintotwobroadsets:thosethatrelatetothemacroenvironmentand
thosethatrelatetomicroenvironment,thatiscommunity-levelandhousehold-level
conditionsandbehaviour.Suchactorsreinorceoneanotherincrucialwaysand,
together,typicallyleadtooverallworsehealthoutcomesamongpoorchildren.
6.1 Macro-level factors
a. Income
Lowincomeisgenerallyassociatedwithworse
healthoutcomesamongchildrenatthenational,
regionalandhouseholdlevels.Estimatessuggest
thatasmuchas70%othevarianceininant
mortalityobservedacrossandwithincountries
canbeattributedtodierencesinincome.79As
discussedabove,developingcountriesin
theWesternPacicRegionbearahigherburdeno
childmortalitythandevelopedcountries.Masked
bynationalaverages,thesurvivalprospectso
childrenlivinginmarginalizedprovincesandregions
withincountriesareotenworsethanthoseliving
inbetter-oprovincesandregions.Forexample,
about37%othevariationinchildundernutritionacrossprovincesinVietNamcan
beexplainedbydierencesinprovincialpovertylevels.80Temostrecenthousehold
surveyconductedinVietNamin2004showsthatpovertyhasdecreasedtolessthan
halothatin1993.However,extremepovertypersistsinremoteareasandthose
dominatedbyethnicminorities.Despiteoveralleconomicgrowth,incomedisparities
betweengeographicalareasandethnicgroupsarewidening.81
StudiesromthePhilippinesandVietNamalsorevealapositiveassociationbetween
incomeandchildsurvivalatthehouseholdlevel.Astudyseekingtounravel
theunderlyingcausesochildhoodsurvivalinCebu,inthePhilippines,oundthat
householdincomewasthemostimportantcontributingactortoinequalitiesin
childsurvival.82InthePhilippines2003DHS,67%owomenreportedobtaining
moneyortreatmentasthemainconstraintinaccessinghealthcare.Womenin
thepoorestincomequintileandthosenotpaidincashweremorelikelytoacethis
constraint.83AstudyanalysingVietNamLivingStandardsSurvey(VLSS)data
rom1992-1993and1997-1998largelyattributesincreasinginequalitiesinchild
undernutritionrom1992-1993to1997-1998torisinginequalitiesinhousehold
consumption.84
Inaddition,the2004VietNamHouseholdLivingStandardsSurveyshowsthatundernutritionremainshigh,with23%othepopulationbeingcurrently
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21POVERTY-RELATED DETERMINANTS OF CHILD HEALTH
orpotentiallyoodinsecure.Undernutritionishigherinareasdominatedbyethnic
minoritiesandamongtheruralpoor.Tepoorestincomequintile,whichincludes
almostallethnicminoritychildren,makesup30%oallundernourishedchildren.85
Terelationshipbetweenhouseholdincomeandchildsurvivalisurthersubstantiated
byarecentmeta-analysisthatcombinestheresultsostudiesoinantandchildmortalityandchildnutritionutilizinghouseholdsurveydata.
86Analysingtheresults
o38studiesoninantandchildmortalityand35studiesonchildnutritionrom
countriesinArica,Asia,EuropeandCentralandSouthAmerica,thestudyconcludes
thathouseholdincomeisapoweruldeterminantochildhealthandchildnutrition
outcomes.87
Teassociationbetweenlowincomeandpoorerchildsurvivalprospectsat
thehouseholdleveloperatesthroughanumberopathways:orexample,lowincome
householdsaretypicallyalsodisadvantagedwithregardtootherdeterminantsochild
health,suchasmaternaleducationandnutritionaloutcomes.Indevelopingcountries,
higherincomeisassociatedwithimprovedinantandyoungchildeedingpractices,
bettersanitationpracticesandmorerequentandintenseuseomodernhealthcare
services.88Conversely,womenrompoorhouseholdsaremorelikelytoexperience
earlychild-bearing,shortbirthspacingandhighparitybirths,allowhichhavebeen
identiedascommonactorsorriskybirths.89
b. Education
Educationishighlycorrelatedwith
income.Recentevidencerom
VietNam,orexample,suggeststhat
loweducationallevelsareincreasingly
concentratedamongthepoor.90In
turn,educationalachievementis
positivelyassociatedwithbetterhealth
outcomes.UNICEFreportsthat
childrenwhogotoschoolaremore
likelytolearnhowtostayhealthy,
suchasbyprotectingthemselves
romdisease.91Inpoorhouseholds,
knowledgecanmakethedierence
betweentakingadvantageopipedwatertowashhandsornotdoingso.
92Inthismanner,pipedwaterhasbeenound
tohavealargerimpactontheprevalenceodiarrhoeaamongchildreninbetter-o
andeducatedhouseholdsinIndiathanamongchildreninpoorer,less-educated
households.93
Inparticular,educatinggirlsisunderstoodtohaveaar-reachingimpactonhuman
developmentingeneral,andonhealthspecically.94Anumberostudiesrom
countriesintheRegionrevealasignicantpositiveassociationbetweenincreased
levelsomaternaleducation,measuredbyliteracyoryearsoschooling,and
improvedchildsurvival.Forexample,astudyromCebu,inthePhilippines,
observedthattheprobabilityoachildsurvivingbeyondhisorherrstbirthdayincreasessignicantlywiththelevelothemotherseducation.
95Alsoin
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22 POVERTY-RELATED DETERMINANTS OF CHILD HEALTH
thePhilippines,thelikelihoodoachildreceivingthesixvaccinesispositively
associatedwiththemotherseducation.Asmanyas83%ochildreninthestudy
whosemothershadcompletedcollegeorahighereducationhadreceivedall
thebasicvaccines,comparedwithlessthan70%ochildrenwhosemothershadnot
reachedthecollegelevel.96TeIMRorchildrenwhosemothershadreceivednoeducationwas65deathsper1000livebirths,comparedwith15orchildrenwhose
mothershadacollegeorhigherdegree.TeU5MRwasalsohigher,at105,among
childrenomotherswithnoeducation,comparedwith18amongthosewhose
mothershadacollegeeducationorhigher.97Across-sectionalsurveyconductedin
1996-1997intheGulProvinceoPapuaNewGuinea,anareacharacterizedby
limitedcashincomeandlowliteracylevels,revealedastrongassociationbetween
maternaleducationandchildnutritionalstatus.98Teimpactowomenseducation
onthehealthotheirchildrenisurthersubstantiatedbyastudyo63countries,
includingChina,theLaoPeoplesDemocraticRepublic,Malaysia,thePhilippines
andVietNam.Analysingnationallyrepresentativehouseholdsurvey-basedunderweightprevalencedata,thestudyconcludesthatimprovementsinwomens
educationaccountedor44%othetotalreductionintheprevalenceochild
undernutritionrom1970-1995.99
Tepositiveimpactogirlseducation
hasbeenshowntotranscend
generations.Itresultsinbetter
healthoutcomesamongwomen,
theirchildrenandeventuallytheir
grandchildren.100Evidencesuggests
thatwomenwithhigherlevelsoeducationaremorelikelytoseekcare
duringpregnancyandchildbirth,
tohaveimprovednutritionandto
increasespacingbetweenbirths.101
Usingretrospectivedatacovering
PeninsularMalaysiarom
1950-1998,PanisandLillardexplain
thatimprovededucationhadastrong
positiveeectonawomansdecision
toobtainantenatalcareandtodeliverinaclinicorhospital,whichwereoundto
improvetheprobabilityochildsurvival.102
However,educationingeneral,andamonggirlsandwomeninparticular,isunevenly
distributedwithincountriesintheRegion.able2presentsliteracyratesamongmen
andwomenromethnicminoritiesandthegeneralpopulationinCambodia,
theLaoPeoplesDemocraticRepublicandVietNam.
c. Social exclusion
Socialexclusion,suchasthatbasedongender,race,ethnicityandgeographical
location(urban/rural),appearstobeanimportantdeterminantochildsurvival.
TroughouttheRegion,poorpopulationsareconcentratedinruralareas,whicharetypicallyunderservedandexperienceworsehealthoutcomes.
103Childrenoamilies
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23POVERTY-RELATED DETERMINANTS OF CHILD HEALTH
livinginruralareasandinurbanslumshaveagreaterriskodyinginchildhoodthan
dochildrenlivinginurbanareas.104Tesocialexclusionoethnicminoritiesin
theRegionisrefectedintheirconcentrationinrural,remoteandisolatedareasand
theiroverepresentationamongthepoor.105InthePhilippines,orexample,
theincidenceopovertyishighestintheAutonomousRegionoMuslimMindanao.Correspondingly,theU5MRinthatregionis72,whichisthehighestamongall
theregionsandmuchhigherthanthenationalaverageo42.106InVietNam,
althoughethnicminoritiesaccountor14%othetotalpopulation,theyrepresented
29%othepopulationlivingbelowthenationalpovertylinein1998.107Furthermore,
ethnicminoritiesinVietNamareisolated(anestimated75%liveinmountainous
areas),withlimitedparticipationingovernmentstructuresandpubliclie,lowlevels
oeducationandpoorhealthoutcomes.108Asaresultosocialexclusion,60%o
childreninthe42countriesaccountingorover90%otheglobalburdenochild
mortalitydonotreceiveantibiotictreatmentorpneumonia,33%donotreceive
vitaminA,and70%othosewithmalariadonotreceivetreatment.
109
6.2 Micro-level (community and household) factors
a. Living conditions
Livingconditionsorpoorchildrenareoten
characterizedbyinadequatehousingand
overcrowded,unsaeandunhygienicenvironments.
Suchenvironmentsplacechildrenatgreaterrisk
oillness.Poorhouseholdsotenusecoalor
biomassuelsorcookingandheating,which,
whencombinedwithinadequateventilation,
produceindoorairpollution.110Arecentsurvey
inMongoliarevealedadirectcorrelationbetween
gerheatingandtheincidenceorespiratorydisease
amongchildren.111Studieshavealsoobserved
anassociationbetweenindoorairpollutionand
anincreasedriskomaternaldeathandlowbirth
weight.112Inaddition,urbanslumdwellersotenhavetocontendwithpollutedliving
andworkingenvironments.Poorerhouseholdsaretypicallylocatedincommunities
thatareunderserved,havelimitedornoinrastructureandmaybepronetofooding.
Community-levelactorsareimportantdeterminantsochildsurvival.113
Whilerecognizingtheimportanceocommunitynorms,thediscussionhereocuses
onaccesstosaedrinkingwaterandimprovedsanitation.Poorchildrenareatgreater
riskowaterbornediseasethannon-poorchildrenbecausetheytypicallylivein
householdsthatarelesslikelytohaveaccesstocleanwaterandsanitation.WHO
estimatesthatingestionounsaewater,inadequatewaterorhygieneandlacko
sanitationaccountor88%othe1.8milliondeathsromdiarrhoealdiseasesannually.
Anestimated90%othosedeathsoccuramongchildrenunderve,generallyin
developingcountries.114WithintheWesternPacicRegion,however,sincemost
casesodiarrhoeaaretreatedathomeandarenotreportedbyhealthacilities,itis
challengingtodeterminewhetherestimatesotheburdenodiseaseattributabletounsaewaterandsanitationareaccurate.
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24 POVERTY-RELATED DETERMINANTS OF CHILD HEALTH
b. Access to safe drinking water
ree-quarters of the worlds poor live in Asia, with one of every three people in
the region lacking a safe source of water supply.115
An estimated 1.7 million children
die each year because of unsafe water, and poor sanitation and hygiene, with 9 out of10 of these deaths occurring in children, primarily through infectious diarrhoea.
116
Contaminated drinking water is a problem even in some capital cities in the Region,
but more so in rural areas, where water is not treated.117
Despite its known benefits, coverage
of improved drinking water remains
incomplete in the Region.118
Some of
the lowest coverage rates are found in
Cambodia (34%), Papua New Guinea
(39%), the Lao Peoples Democratic
Republic (43%), Mongolia (60%) and
Kiribati (64%).119
Inequities in access to
improved drinking water also persist within
countries across the Region. For example,
the proportion of households with access
to safe water in the Philippines ranges from
97% on the island of Luzon to just 29%
in the Autonomous Region of Muslim
Mindanao.120
Rural-urban inequalities in
the Region are particularly striking. For
example, 85% of the urban populationin Vanuatu has access to improved water,
compared with only 52% of the rural
population. In Viet Nam, the proportion
of the population without access to safe
drinking water is only 1.2% in
Ho Chi Minh City, but it rises to as high as 86.6% in the province of Dong ap.121
Figure 15 shows the coverage of improved drinking water sources in rural and urban
areas in selected countries in the Region.
Although improved drinking water coverage is generally higher in urban than rural
areas, urban poor communities face particular constraints in accessing safe drinkingwater. A 1995 survey in the Philippines showed that 72% of urban slum dwellers had
access to piped water or tube wells. However, improper handling, transportation and
storage contaminated 36% of the water at point of consumption, in comparison with
17% contamination at source.122
In 2000, poor households in the Philippines were
found, on average, to be allocating a greater proportion of their monthly expenditure
to vended water (9%) than wealthier households (5%).123
c. Access to adequate sanitation
In many countries in the Western Pacific Region, the coverage of improved sanitation
is even lower than that achieved for improved drinking water.124
Four countries inthe RegionCambodia, the Lao Peoples Democratic Republic, the Federated States
Figure 15: Improved drinking water coverage (%) in selectedcountries in the Region, 2002
Source:Meeting the MDG drinking water and sanitation target: a mid-termassessment of progress. Geneva, WHO/UNICEF Joint Monitoring Programme,
2004.
RURAL URBAN
0 10 20 30 40 50 60 70 80 90 100
Cambodia
China
Kiribati
Lao PDR
Mongolia
Papua New Guinea
Philippines
Samoa
Solomon Islands
Tonga
Vanuatu
Viet Nam
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25POVERTY-RELATED DETERMINANTS OF CHILD HEALTH
of Micronesia and Solomon Islandsrank
among the 27 countries worldwide where
coverage of improved sanitation was
one-third or less in 2002.125
Urban-rural
inequalities in the coverage of improvedsanitation facilities are especially stark, as
seen in Figure 16. Significant differences in
the coverage of improved sanitation between
rural areas/outer islands and urban areas
have been found among many Pacific island
countries. In Solomon Islands, for example,
improved sanitation facilities reach 98% of
the urban population, compared with only
18% of the rural population. Importantly,
the coverage of improved sanitation amongthe Pacific islands is below that required to
meet the MDG sanitation target.126
d. Effect of education on
coverage of safe drinking water
and sanitation
Inequalities in the coverage of improved
drinking water and sanitation in the Region
typically operate to the disadvantage of
poor households. Lower levels of educationand knowledge among poorer households, particularly among mothers, may further
exacerbate the impact of such inequalities on the health of poor children. Limited
education and knowledge may prevent caregivers from practising proper hygiene and
making optimal use of available water and sanitation. Estimates suggest that improved
hand washing might reduce the number of diarrhoeal cases globally by up to 35%.127
Women with some formal education are more likely to adopt improved sanitation
practices.128
e precise mechanisms by which health depends on maternal education
are unknown, but it is plausible that the adoption of hygienic practices is important.129
A 1990 study in the Philippines showed that the effect of maternal education on
overall infant mortality depended on the source of drinking water and the availability
of toilets, whereas its effect on child mortality depended on the availability ofhousehold income and toilets.
130Among disadvantaged groups, even where mothers
were highly educated but had low incomes or lived in unsanitary environments,
children were likely to be exposed to higher risks of infant and child mortality. Having
a college education was not found be sufficient, unless the education led to higher
income.131
e. Undernutrition
Hunger and undernutrition are closely associated with poverty. Undernutrition
is estimated to contribute to 50% of child deaths.132
Although the risk is present
across all stages of the life cycle, undernutrition in infancy and early childhood areof special concern, as its effects on human development accumulate. Improved
Figure 16: Improved sanitation coverage (%) in selected countriesin the Region, 2002
Source:Meeting the MDG drinking water and sanitation target: a mid-termassessment of progress. Geneva, WHO/UNICEF Joint Monitoring Programme,
2004.
RURAL URBAN
0 10 20 30 40 50 60 70 80 90 100
Cambodia
China
Fiji
Kiribati
Lao PDR
Marshall Islands
Mongolia
Palau
Papua New Guinea
Philippines
Solomon Islands
Tuvalu
Vanuatu
Viet Nam
Micronesia(Federated States of)
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26 POVERTY-RELATED DETERMINANTS OF CHILD HEALTH
nutritionalstatusromconceptiontothersttwoyearsoliereducesprivate
andpublichealthcareexpendituresthroughouttheliecycle.133Undernutrition
encompassesdeciencies,notjustinprotein-energy,butalsoinmicronutrients,such
asiron,vitaminA,iodineandzincinparticular,whichareessentialorthehealth
anddevelopmentochildren. 134
Genderinequalityisotenmaniestedinagreaterrisk
oundernutritionamonggirlsthanboys.135Although
muchresearchongenderinequalitiesinnutritional
statusoriginatesromSouthAsia,thereissomeevidence
tosuggestthatgenderinequalitiesoccurintheWestern
PacicRegionaswell.InVietNam,agreaterpercentage
owomenthanmensuerromsecond-andthird-
degreechronicenergydeciency,signiyingthatthey
havebeensubjecttochronicundernutrition.136
AsmallstudyinPreahVihear,Cambodia,alsoshowed
thateedingpracticesdierorgirlsandboys,leadingto
higherratesoundernutritionamonggirls.137
Areviewostudiesexploringtherelationshipbetweenundernutritionandchild
mortalityndsthatundernutritionisstronglyassociatedwithanincreasedrisko
mortalityromdiarrhoeaandARI,includingpneumonia.138Datarom
thelongitudinalstudyochildrenconductedin1988-1991inCebu,in
thePhilippines,revealthatnutritionalstatus,asmeasuredbyweight-or-age,is
asignicantriskactororbothacutelowerrespiratoryinectionsanddiarrhoea
mortalityinthersttwoyearsolie.
139
Evenwhenbetternutritionisachievedlaterinlie,theeectsoundernutritioninchildhoodmayneverbeovercomeand
mayinactbetransmittedacrossgenerations.Anunderweightgirlismorelikelyto
growintoastuntedadolescentandstuntedwoman,whoismorelikelytohave
low-birth-weight(LBW)babies.RecentevidenceromSouthAsiaalsosuggestsalink
betweenintrauterinegrowthretardation(leadingtolowbirthweight)andchronic
diseasesinadulthood.140
f. Low birth weight
Formanychildrenrompooramilies,undernutritionbeginsin utero,otenleadingto
lowweightatbirth.LBWiscommonlyattributedtoshortgestationand/orintra-uterinegrowthretardation.However,thecausesarecomplexandarecommonly
theresultopoverty.Povertyandgenderinequalityimpingeonthehealthand
nutritionalstatusowomen,whichhasbeenoundtobeakeycontributingactor
toLBW.InCambodia,therateoundernutrition(denedasBMI
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27POVERTY-RELATED DETERMINANTS OF CHILD HEALTH
neverbeullyredressedlaterinlie.144Teyalsotendtobesmaller(morestunted)and
toaceahigherburdenodiseasethroughoutchildhoodandintoadulthood.145
g. Breastfeeding and other feeding practices
Evidenceshowsthatbreasteedingoersaprotective
eectagainstundernutritionthatisstrongestin
therstyearolieandhasbeenobservedtobe
especiallysuccessulamongthepoor.146WHO
recommendsexclusivebreasteedingortherstsix
monthsandcontinueduptotwoyearsandbeyond.
Yet,theproportionoinantslessthanourmonths
oldinPacicislandcountrieswhoenjoythebenets
oexclusivebreasteedingvarieswidely,rom19%in
CookIslandsto65%inSolomonIslands.Onlyan
estimated12%oinantsbelowsixmonthsoage
inCambodia,23%intheLaoPeoplesDemocratic
Republicand37%inthePhilippinesareexclusively
breasted.147
Atersixmonthsoage,inantsshouldreceivenutritiouscomplementaryoodso
appropriateconsistencyandsucientqualitytomeetthenutritionaldemandso
growth.However,inanteedingpracticesintheWesternPacicRegionareoten
inadequate.InVietNam,aNationalInstituteoNutritionreviewoundsuboptimal
inanteedingpractices.Specically,thestudyoundaprevalenceoearlyweaning
practicesandtheearlyintroductionocomplementaryoods,generallycustomaryoodswithlimitednutritionalvalue.
148Similarly,growthalteringamongchildren
inPapuaNewGuineahasbeenattributedtoinadequateweaningpractices,thelate
introductionosolidoods,andtheinadequacyosupplementaryoods.149Further
evidenceshowsthatcomplementaryeedingvarieswithsocioeconomicstatus,
theavailabilityoproperoodsandmothersknowledgeohow,whatandwhento
eedtheirchildren.150
Astudyusingdataromalongitudinalsurveyonearly10000childreninCebu,
inthePhilippines,examinedtheeectsolackobreasteedingonchildmortality
amongchildrenundertwoyearsoage.Notbreasteedinghadagreatereecton
mortalityromdiarrhoeathanonmortalityduetoARI.TestudyalsorevealedthattheriskomortalityassociatedwithnotbreasteedingwasgreaterorLBWinants
whosemothershadlittleormaleducation.Atersixmonths,theprotectiveeecto
breasteedingdroppeddramaticallyamongallchildren.151
h. Intrahousehold income distribution and decision-making
Evidencealsosuggeststhattheintrahouseholddistributionoandcontroloverincome
hasanimportantimpactonchildhealthoutcomes.Morespecically,higherlevels
oincomehavebeenoundtohaveagreaterimpactonthehealthochildrenin
householdswherewomenexertagreaterdegreeocontroloverhouseholdincomeand
participatemoreactivelyinhouseholddecision-makingthaninthosewherewomensdecision-makingpowerisweak.
152,153Muchevidenceshowsthat,whenwomenhave
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28 POVERTY-RELATED DETERMINANTS OF CHILD HEALTH
asayintheallocationohouseholdresources,theytendtoallocatemoreresourcesto
thehealthandnutritionochildrenandtodiscriminatelessagainstgirls.154Tese
ndingspointtoanassociationbetweenthestatusowomenwithintheirhouseholds
andcommunitiesandchildhealthoutcomes.Tisassociationiscorroboratedby
arecentstudythatexploredtherelationshipbetweenwomensstatusandthenutritionalstatusochildrenunderthreeyearsoageusingDHSdatarom36
developingcountriesinLatinAmericaandtheCaribbean,SouthAsiaandsub-Saharan
Arica.Testudyusedtwomeasuresowomensstatus,denedastheirpowerrelative
tomen(womensdecision-makingpowerrelativetothatotheirmalepartners),and
thedegreeoequalitybetweenmenandwomenintheircommunity.Teresults
clearlydemonstratethatimprovementsinthesetwomeasuresowomensstatusare
signicantlycorrelatedwithimprovednutritionalstatusamongchildrenunderthree
yearsoage.Testudyexplainsthatthisisbecausewomenwithhigherstatushave
betternutrition,arebettercaredorand,thus,arebetterabletocareortheirchildren
thanwomenwithlowerstatus.
155