Reaching the Poor

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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].


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



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



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



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



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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


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



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


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



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



Inequalities in accessto health care services

5



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


28/40

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




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


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



30/40

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


Figure 13: Skilled antenatal care by incomequintiles in Malaysia, the Philippines and Viet Nam



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


Figure 14: Skilled birth attendance by incomequintiles in Malaysia, the Philippines and Viet Nam



Percentageofwomenattendedatbirth

byskilledpersonnel

GNP/Capita (US $)

Malaysia - 3 780 Philippines - 1 080 Viet Nam - 480



Poverty-relateddeterminants of child health

6


32/40

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



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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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




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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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




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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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




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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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

Reaching the Poor

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