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Why is child mortality so different across countries and regions with similar income levels ? Peter Boone May 2005 Slide 2 Questions: Why is child mortality so different across countries and regions with similar income levels ? Is it possible to replicate the low levels observed in some countries quickly in a RCT ? (at low cost ?) Slide 3 Slide 4 Child mortality and income Ln PPP GDP per capita Child Mortality Rate Slide 5 Case Study: Kerala State created in 1956 Communist government elected 1957 1993 and 1998/9 FHS provide large database Literature reports improvements in almost every area of health as reason for Keralas relative success Slide 6 Child mortality in Indian States Slide 7 Focus on ARI and Diarrhoea Source: Black et. Al. 2005 33% 32% 13% Cause of non-neonatal child death by major disease/syndrome Slide 8 Pathogens causing diarrhoea PresentationOrganism Acute watery diarrhoea Salmonella, Staphylococci, B. cereus, C. perfringens, V. parahaemolyticus, Ecoli, Rotavirus + other enterovirsues, Cryptosporidium, V. cholerae Acute bloody diarrhoea Shigella sp., C. jejuni Chronic diarrhoea G. intestinalis Chronic diarrhoea with blood E. Histolytica, B. coli, S. mansoni Source: Webber (2005) Slide 9 Pathogens causing ALRI PresentationOrganism PneumoniaStreptococcus pneumoniae, Haemophilius influenzae, Influenza A or B, RSV, Adenoviruses, Morbillivirus, Metapneumorvirus, and many more.. MeningitisNeisseria meningitis, Haemophilius influenzae, Streptococcus pneumoniae, Mycobacterium tuberculosis, Staphlycocci, Escherichia coli, Group B streptococci, Mumps virus, Rubella virus, and many more. Source: Webber (2005) Slide 10 Steps to child mortality and possible interventions Clinical Manifestation Exposure Treatment Outcome Raise immune response: Better nutrition and vaccines Improve sanitation, water, hygiene Improve health seeking decisions: education, proximity of services, cost of services Raise healthcare worker training and incentives, medical supplies, new treatments Slide 11 Which stage is best targeted ? No consistent answer in the literature Low CMR countries intervened in all areas Cuba, Sri Lanka, Kerala, Former communist block, Costa Rica Consensus that vaccines (Measles, DPT, BCG) have been highly successful but Diarrhoea and ALRI not easy targets Controlled trials demonstrate potential large impact of interventions at every stage Cost effectiveness work (e.g. World Bank 1993) helps allocate resources across interventions but cant capture synergies, social and institutional issues that could lead to a different package. Slide 12 Two alternative hypotheses For groups with similar income levels: A.Healthier populations have reduced exposure to disease, and hence less morbidity and less mortality. B.Healthier populations have similar morbidity but lower case fatality rates. Slide 13 Exposures & Morbidity DHS surveys compare disease incidence across low income countries. Sanitation, water and hygiene are the main interventions aimed to reduce pathogen exposures. International data is available. Slide 14 ARI and Diarrhoea Incidence (31 low income countries) Diarrhoea: average cases per year per child ARI: average cases per year per child Slide 15 Mortality and Disease Incidence Ln (Child Mortality Rate) Coef SE Ln (PPP GDP per capita) -3.073 ** 1.906 Ln (PPP GDP per capita) 2 0.184** 0.127 Diarrhoea (under age 5 cases per yr) 0.057 0.050 ARI (under age 5 cases per yr) 0.017 0.041 Measles vaccine (proportion popn) -1.005 ++ 0.488 Doctors per 100,000 -0.279 ++ 0.133 R2R2 0.732 N 31 ** : Jointly significant at 5% level ++: Significant at 5% level Slide 16 Mortality and Sanitation/Water Ln (Child Mortality Rate) Coef SE Ln (PPP GDP per capita) 1.057** 0.546 Ln (PPP GDP per capita) 2 -0.103** 0.032 Improved Sanitation (proportion popn) -0.163 0.218 Improved Water (proportion popn) -0.160 0.311 Measles vaccine (proportion popn) -0.103** 0.646 DPT Vaccine (proportion popn) -1.051** 0.577 Doctors per 100,000 -0.202 ++ 0.044 R2R2 0.869 N 103 **: Jointly significant at 1% level (vaccines; income measures grouped separately) ++: Significant at 1% level Slide 17 Mortality and Latrine Access (103 countries) Slide 18 India: ARI and Diarrhoea Incidence (26 States, children aged