Child Survival and Equity: A Global Overview

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1 Child Survival and Equity: A Global Overview Abdelmajid Tibouti, Ph.D. Senior Adviser UNICEF New York Consultation on Equity in Access to Quality Health Care For Women and Children 7 11 April 2008 Halong Bay - Viet Nam

2 Overview 1. Overall Progress in Child Health and Nutrition Has Been Encouraging 2. Faster Progress Will Be Required to Achieve the Health MDGS 3. Poor Children Will Not Necessarily Be the Principal Beneficiaries of Faster Progress 4. Inequalities Between Poor and Better-off Children Within Developing Countries Are Responsible For Half or More of Global Gap in U5MR 5. Interventions in the Health Sector Reach the Better-off Before the Poor 6. The Shape of the Inequity Curve and its Policy Implications in Terms of Universal and Targeted Approaches.

3 Gaps in health and nutrition outcomes

4 Unacceptable Health Inequalities Continue to Exist Among Countries Deaths before the Age of Five per 1,000 Live Births E.Europe E.Asia E.&S.Africa M.East&N.Af. S.Asia L.America W.&C.Africa Ind. Countries

5 Unacceptable Health Inequalities Also Continue to Exist Within Countries U5MR by Economic Quintile within Countries: Average of 56 Low- and Middle-Income Countries, c Deaths before the Age of Five per 1,000 Live Births Under-five mortality falls across economic quintiles. In the lowest quintile, the rate is 138, almost twice as high as the rate of 75 experienced in the top quintile. 60 Lowest Middle Highest Economic Quintile of the Population

6 Under 5 Mortality Rate URBAN-RURAL DISPARITIES Rural Under 5 mortality is higher than urban in all regions E.Europe Illustration One: U5MR E.Asia E.&S.Africa M.East&N.Af. S.Asia L.America W.&C.Africa GLOBAL Urban Rural

7 GENDER DISPARITIES Global Averages for U5MR and Malnutrition Deaths before the Age of Five per 1,000 Live Births U5MR: (Unweighted) Average: 13% Higher among Boys Percent of Children Suffering from Second-Degree Stunting Malnutrition: (Unweighted) Average: 6% Higher among Boys Boys Girls 16 Boys Girls

8 GENDER DISPARITIES U5MR and Malnutrition in India U5MR: 7% Higher among Girls Malnutrition: 7% Higher among Girls Deaths before the Age of Five per 1,000 Live Births Percent of Children Suffering from Second-Degree Stunting Boys Girls 30 Boys Girls

9 Equity gaps in underfive mortality Sub-Saharan Africa South Asia Middle East, North Africa Latin America, Caribbean Europe, Central Asia East Asia, Pacific Mortality gap between the poorest (red) and richest (blue) quintiles (per 1,000) Source: DHS, analyzed by Gwatkin et al, 2007

10 Equity gaps in stunting prevalence Sub-Saharan Africa South Asia Middle East, North Africa Latin America, Caribbean Europe, Central Asia Prevalence gap between the poorest (red) and richest (blue) quintiles (%) Source: DHS, analyzed by Gwatkin et al, 2007

11 Gaps in coverage

12 Even Basic Services Designed for The Poor Are Not Reaching Them as Well as They Are The Better-Off Relative Coverage of Basic MCH Interventions Across Quintiles within Developing Countries: Average of 55 Countries, c COVERAGE RATES IN THE TOP QUINTILE ARE 20-80% HIGHER THAN IN THE BOTTOM QUINTILE Ratio of Coverage Rate in Higher Quintiles to Rate in Lowest Quintile ORT Drug Treat of Fever Full Immunization Med.Facility Treat. Of ARI Attended Deliveries 1 Lowest Middle Highest Economic Quintile of the Population

13 Equity gaps in skilled delivery care Sub-Saharan Africa South Asia Middle East, North Africa Latin America, Caribbean Central Asia, Europe East Asia, Pacific Coverage gap between the poorest (red) and richest (blue) quintiles (%) Source: DHS, analyzed by Gwatkin et al, 2007

14 Equity gaps in vitamin A supplementation Sub-Saharan Africa South Asia Latin America, Caribbean East Asia, Pacific Source: DHS, analyzed by Gwatkin et al, Coverage gap between the poorest (red) and richest (blue) quintiles (%)

15 Equity gaps in oral rehydration therapy Sub-Saharan Africa South Asia Middle East, North Africa Latin America, Caribbean Europe, Central Asia East Asia, Pacific Coverage gap between the poorest (red) and richest (blue) quintiles (%) Source: DHS, analyzed by Gwatkin et al, 2007

16 Equity gaps in exclusive breastfeeding Sub-Saharan Africa South Asia Middle East, North Africa Latin America, Caribbean East Asia, Pacific Prevalence gap between the poorest (red) and richest (blue) quintiles (%) Source: DHS, analyzed by Gwatkin et al, 2007

17 Equity gaps in bottle feeding Sub-Saharan Africa South Asia Middle East, North Africa Latin America, Caribbean Europe, Central Asia East Asia, Pacific Prevalence gap between the poorest (red) and richest (blue) quintiles (%) Source: DHS, analyzed by Gwatkin et al, 2007

18 Gaps in Co-coverage Is every underfive child getting all the preventive interventions s/he should receive? Source: C Victora, B Fenn, J Bryce, B Kirkwood

19 % <5 children receiving 6+ child survival interventions, by wealth quintile and country 100% 80% 60% 40% 20% 0% Poorest 2nd 3rd 4th Least poor Cambodia

20 Percent of U5 children receiving six or more child survival interventions 100% 80% 60% 40% 20% 0% Poorest 2nd 3rd 4th Least poor Brazil Cambodia

21 Percent of underfive children receiving six or more child survival interventions 100% Bottom inequity 80% 60% 40% 20% 0% Top inequity Poorest 2nd 3rd 4th Least poor Bangladesh Benin Brazil Cambodia Eritrea Haiti Malawi Nepal Nicaragua

22 Co-coverage: policy implications More lives will be saved by universal coverage with few interventions than by adding new ones to an inequitable situation Packaging is efficient but unless coverage is very high it may increase inequities Universal coverage is the ultimate goal Targeting may be useful in bottom inequity situations

23 Equity in Health Financing

24 Annual Health Expenditure of Selected Asia Pacific Countries Proportion of total health expenditure 100% 80% 60% 40% 20% Total expenditure on health as a percentage of GDP International (PPP) dollars 0% Burma Pakistan Nepal India Bangladesh Laos Cambodia Indonesia Viet Nam Bhutan Sri Lanka Tuvalu Philippines Solomon Islands Vanuatu Mongolia East Timor China Papua New Guinea Fiji Niue Thailand Samoa Malaysia Kiribati Micronesia Tonga Cook Islands Marshall Islands Nauru Palau New Zealand Australia 0 Proportion public Proportion privateper capita public Per capita total

25 Number of People with Catastrophic Expenditures and Impoverishment Due to Health Spending (early 2000) EMR AFR impoverishment catastrophic EUR SEA AMR WPR Source: Ke Xu, WHO Number of people (million)

26

27 Conclusions (1) 1. Progress in Child Survival is clear in certain areas 2. Accelerated progress is required to achieve MDGs 3. Systems strengthening required for further progress 4. Poorest children will not automatically benefit from accelerated efforts 5. The shape of the inequity curve has policy implications

28 Conclusions (2) 6. Interventions delivered through health facilities are more inequitable than those delivered in the community 7. Heavy reliance on out-of-pocket payments for health ia associated with high incidence of catastrophic expenditures and drives many into poverty 8. A new approach is needed for poor children to benefit fully from faster progress towards the health MDGs.

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