Barriers to access to child health care - WPRO | WHO ... · Barriers to access to child health care ... also found in the number of children fully immunized before the age of one

CHALLENGES FOR CHILD HEALTH IN THE WESTERN PACIFIC REGION

Barriers to access to child health care

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30 BARRIERS TO ACCESS TO CHILD HEALTH CARE

Barriers to access to child health careAnumberoffinancialandnon-financialbarriersmaydelayorpreventpoorhouseholdsfromseekinghealthcarefortheirsickinfantsandchildren.Suchbarriersincludegeographicalaccessordistance;financialbarriers;sociocultural,languageandethnicity-relatedbarriers;andlackofknowledgeandawareness,whichcantogetherleadtolowdemandforanduseofservices,particularlybythepoor.Eachoftheseisbrieflydiscussedbelow.

7.1 Geographical distance

DistanceandlongtraveltimestohealthfacilitiesremainkeybarrierstoaccessinmanyruralcommunitiesintheRegion.AstudyofdemandforantenatalcareamongpregnantwomeninCebu,inthePhilippines,foundthathealthcareserviceswerelessaccessibleforruralthanurbanwomen.Thestudyshowedthatruralwomenfacedsignificantlylongertraveltimesthanwomenlivinginurbanareasandthatthetravelcostsinruralareaswerealmostdoublethoseinurbanareas.156Similarly,a1996householdsurveyinPapuaNewGuineafoundthattraveltimetothenearestaidpost(nursingstation/clinic)ranged

from67minutesinPapua/SouthCoastto28minutesinNewGuineaIsland.157

Thecoverageofcost-effectivechildhealthinterventionsinthedevelopingcountriesoftheRegionisverylow,andthistypicallydisadvantageschildreninpoorerandmoremarginalizedareas.InCambodia,only38%oftheruralpoorpopulationwasreachedbymeaslesimmunizationin2000.Incomparison,theaveragecoverageratewas63%amongtheruralnon-poorand66%amongtheurbannon-poorCambodianpopulationduringthesameyear.158Urban-ruraldisparitiesinthecoverageofmeaslesvaccinationarealsoevidentinVietNam,andsignificantrural-urbandifferencesarealsofoundinthenumberofchildrenfullyimmunizedbeforetheageofoneyearinthePhilippines.159Evidencepointstosimilarinequalitiesinthecoverageofchildhealthinterventionsamongmarginalizedpopulations.Forexample,aUNICEFbaselinesurveyinVietNamrevealedthatthecoverageofmeaslesvaccinationwassignificantlylowerintheNorthernUplandprovinces,withthegapincoveragebetweentheKinhmajorityandethnicminoritiesrangingfrom27-49percentagepoints.160AnalysisfromCambodiaindicatesthatthereasonsthatcertainareasandpopulationsareunderservedwithimmunizationservicesarepredominantlysocioeconomic,includingdistancefromthehealthfacility,ethnicstatus,povertyandloweducation.161

7.2 Financial barriers

Evenwherehealthcareservicesareavailable,thecostofseekingcaremaydelayorpreventpoorhouseholdsfromaccessingthem.Thecostofseekingcaremaybethoughtofascomprisingdirectcosts(suchasuserfees),indirectcosts(suchascosts


31BARRIERS TO ACCESS TO CHILD HEALTH CARE

fortransportation)andopportunitycosts(suchaslostwages).Suchcostsweighmoreheavilyuponpoorhouseholdsthannon-poor.AsurveyfromthePhilippines,forexample,reportsthatthepoorpaylessthanthenon-poorinabsoluteamounts,withtherichspending,onaverage,10timesmoreonhealthcarethanthepoor.However,meanhealthexpenditurecomprisesahighershareofhouseholdexpenditureforthepoor(7%)thanfortherich(5%).162InNorthernMindanao,CaragaandtheAutonomousRegionforMuslimMindanao,allinthesouthernPhilippines,morethan80%ofwomencitedlackofmoneyfortreatmentofillnessasthemostseriousprobleminobtaininghealthservices.163AcasestudyinanortherndistrictofVietNamfoundthecostoftransportationalonetobeequivalenttoone-thirdofmonthlyexpenditureinthelocality.164Theopportunitycostofseekinghealthcareislikewiserelativelyhigherforpoorerthanwealthierhouseholds.Thisisbecausethepooroftenearnincomedirectlyfromtheirlabour.Caringforsickchildrenmaydivertthelabourandtimeofpoorparentsawayfromincome-generatingactivities,therebyreducinghouseholdincome.

Insurancecanprovidefinancialprotectionintimesofillhealth.However,inthePhilippinesandVietNam,asinothercountries,thepoorareunderrepresentedininsurancecoverage.165InthePhilippines,only11.3%ofmembersofthePhilippineHealthInsuranceCorporation(PHIC)arepoor.166Lackinginsuranceandsavings,poorhouseholdsmustoftenborrowmoneyathighratesofinterestorsellproductiveassetstocoverthecostofseekingcare.Forexample,astudyinCambodiaestimatedthatasmuchas40%ofnewlandlessnessmaybeduetothecostsofhealthcare.167

Inmanysocieties,womenaretheprimarycaregiversforchildren.Yet,thisroleissometimesconstrainedbytheadditionalfinancialconstraintswomenmayfacewhenseekingcare.Ananalysisoftheurbancomponentofthe1998ChinaNationalHealthSurveydatashowsthatasignificantlysmallerpercentageofwomen(41.9%)thanmen(46.3%)werecoveredundertheGovernmentInsuranceSchemeortheLabourInsuranceScheme.ThestudysuggeststhatthisisbecausewomeninChinaarelesslikelytobeemployedintheformalsector,morelikelytobelaid-offandlesslikelytoberehiredthanmen.168Acrosscountries,womenoftenhavelesscontrolovertheallocationofhouseholdassets,suchasincomeandhouseholdtime,thanmen.169Thisarisesfromtheirgenerallylowerintrahouseholdbargainingpowerrelativetothatoftheirmalepartners.Theabilityofwomentomakedecisionsbenefitingtheirhealthandthatoftheirchildrenmaythusbecurtailed.Forexample,althoughhigherhouseholdincomehasbeenfoundtoincreasethelikelihoodofwomenreceivingantenatalcareandskilledassistanceduringdelivery,170evidencefromIndonesiashowsthatuseofhealthcareservices,asmeasuredbyantenatalvisitsandvisitsduringthefirsttrimesterofpregnancy,islesscommonamongwomenwhohaverelativelylittlecontroloverhouseholdresources.171Further,thetimethatwomenareabletodevotetoseekinghealthcareforthemselvesandtheirchildrenisoftenconstrainedbytheheavydemandsplacedontheirtimebytheirmultipleproductiveandreproductiveroles.

32 BARRIERS TO ACCESS TO CHILD HEALTH CARE

7.3 Sociocultural, language and ethnicity-related barriers

Besideswomen’suniquefinancialbarriers,variousothergender-relatedbarriersmaylikewiseconstrainwomeninseekinghealthcareforthemselvesandtheirchildren.Theirmalepartners’dominanceorlackofsupportandprejudiceaffectwomen’sandchildren’saccesstohealthandothercommunityservices.172AstudyconductedinDiandongCountyinruralChina,forexample,foundthat45%to55%ofwomenrespondentsrequiredtheirhusbands’permissiontogotothemarket,clinicornatalvillage.173Inaddition,poorwomenhavebeenfoundtobeparticularlysensitivetothebehaviourofhealthstaffandmaynotaccessformalserviceswhentheyperceivehealthcareprovidersasdisrespectfulandinsensitivetotheirneeds.174

EthnicminoritiesandothermarginalizedgroupsmayfaceparticularbarrierswhenseekinghealthcareintheRegion.AstudyfromVietNamthatwaspublishedin2002observedthatethnicminoritiesusehealthcarefacilitieslessoften(24%)thanthemajorityethnicgroup(34%).Itissuggestedthatthisisbecauseoftheirlimitedknowledgeofthemajoritylanguageandthehighcostoftransportation.175Otherstudiesexplainthathealthcareprovidersmaybeunresponsivetoormaynotunderstandtheneedsofethnicminorities.176

7.4 Lack of knowledge and awareness

Thegenerallylowerlevelsofhealth-relatedknowledgeandawarenessamongpoorandmarginalizedgroupsmayresultinlowdemandforhealthcareservices.Torealizethebenefitsofseekingcareforsickchildren,caregiversmustknowwhereandwhentoseekappropriatehealthcare.Delaysinseekinghealthcarehavebeenestimatedtocontributeupto70%ofchilddeaths.177However,healthinformationmaynotreachpoorandmarginalizedpopulationsforavarietyofreasons,includingphysicaldistancetohealthcentresandlimitedoutreachinmanyareas.Lowlevelsofeducationandlinguisticorculturalbarriersmay

likewisemakehealthinformationorotherhealth-relatedinformation,educationandcommunication(IEC)inaccessible.Thismaybeespeciallytrueforethnicminorities,whooftenliveinruralandremoteareasandfaceuniqueculturalandlinguisticbarriers.Women’stypicallylowerlevelsofliteracymaylikewiseplacemanyformsofhealthinformation,suchasprintmedia,beyondtheirreach,whilerestrictionsontheirmobilitymaylimittheirexposuretonewhealth-relatedideasandpractices.

7.5 Inequalities in quality of care

Evenwhenchildrenfrompoorfamiliesaresuccessfulinaccessinghealthcarefacilities,theyoftenreceivelowerqualitycarethantheirnon-poorcounterparts,asthequalityofcareextendedbyhealthfacilitiesservingpoorandmarginalizedpopulationsistypicallylowerthanofthoseservingnon-poorpopulations.178Facilitiesservingpoorcommunitiesarelesslikelytohavewelltrainedstaffortobestockedwith


33BARRIERS TO ACCESS TO CHILD HEALTH CARE

appropriatedrugsandequipmentthanfacilitieslocatedinbetter-offcommunities.PoorhouseholdsinVietNamexplainthatthelowqualityofservicesdetersthemfromseekingcareinpublicfacilities,although97%ofcommuneshaveahealthcentre.179InthePhilippines,satisfactionwiththequalityofcareinpublichealthfacilitieswasfoundtobelowestforprimaryhealthcarefacilities,whichtypicallyservepoorpopulations.Insuchfacilities,diagnosiswasdescribedaspoor,thusnecessitatingrepeatedvisits,andmedicineandsupplieswerereportedasoftenbeingoutofstock,especiallyinruralareas.Primaryheathcarestaffwereperceivedaslackinginmedicalandpeopleskills,waitingtimeswerelong,schedulesveryinconvenientandfacilitiesrundown.180

Lowqualityhealthcarecontributestothelowersurvivalratesamongpoorchildren.Forexample,aprospectivesystematicreviewofconsecutivedeathsinchildrenovera24-monthperiod(April1998-March2000)inaruralhospitalintheEasternHighlandProvinceofPapuaNewGuineasuggeststhatalackofskilledmaternalcarewasafactorin39.6%ofallneonataldeaths.181Demandforchildhealthinterventionsisthusconstrainedbytheactualorperceivedlowqualityofthehealthcaresystemingeneral,andofchildhealthinterventionsinparticular.


Ill health among children leads to greater poverty

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35ILL HEALTH AMONG CHILDREN LEADS TO GREATER POVERTY

Ill health among children leads to greater poverty8.1 Poorer child health leads to greater poverty in that generation

Forthepoor,thelinkbetweenpovertyandillhealthisclear:illhealthleadstogreaterpovertyandgoodhealthiskeytoensuringhigherproductivityandincreasedincome.Theconsequencesofillhealthareakeyreasonforimpoverishmentamongmanyofthepoor.182Forexample,seriousdiseasehasforced15%ofhouseholdstothebrinkofpovertyorintopovertyinMongolia.183Impoverishmentarisesbecausethecostofseekingmedicaltreatmentweighsmoreheavilyonthepoorthanthenon-poor,asbrieflydiscussedabove.Theimpactcanbeespeciallysevereifpoorhouseholdsareforcedtosellproductiveassets,suchaslandorlivestock,ortoremovetheirchildrenfromschool.Variousestimatessuggestillnessasaprimarycauseofimpoverishmentamong20%-50%ofhouseholdslivingbelowthepovertylineinruralChina.184Povertycanalsobemeasuredbythechangeinthepovertyheadcount,i.e.,theproportionofthepopulationinpoverty.InVietNam,whichhasafood-basedpovertyline,overallspendingonhealthcareaddedapproximately4.4%tothepovertyheadcountin1993and3.4%in1998.185Morespecifically,casestudiesfromLaoCai,aprovinceinnorthernVietNam,suggesttheimpoverishingeffectsonhouseholdsofseekinghealthcarefortheirchildren.186

Morbidityandmortalityinchildhoodmayreducehouseholdincomebycompellingparents,morefrequentlymothers,tosubstituteincome-generatingactivitieswithcaringfortheirsickchild.Limitedassetsandaccesstoresourcesforcepoorhouseholdstorelymainlyontheirlabourfortheirlivelihood.Adecreaseinproductivityortimeawayfromworkcanthusresultdirectlyinareductioninhouseholdincome.Besides,illnessandundernutritioninchildhoodareincreasinglyassociatedwithlowerproductivityinthelongerterm.Poorerhealthoutcomesandlimitededucationalattainmenttogetherresultinlowerlevelsofhumancapital,whichhasbeenshowntobethebasisofanindividual’seconomicproductivity.187Undernutrition,micronutrientdeficienciesandillnessinchildhoodhavebeenfoundtoimpaircognitivedevelopment,schoolattendanceandlearningcapabilities.188,189InCebu,inthePhilippines,childrenwhowerestuntedattheageoftwoyearswereobservedtohavesignificantlylowertestscoresthantheirpeers.Withinthestudypopulation,stuntedchildrentendedtostartschoollater,andbyageeleven,theywerethreetimesmorelikelytohavedroppedoutofschool,1.8timesmorelikelytohaverepeatedagradeand1.2timesmorelikelytohavebeenabsentinthemonthbeforetheinterviewthantheirpeers.190Poorhealth(ordisability)wasthemainreasoncitedforschooldropout,followedbyeconomicconstraints.191

Householdsincountriesthatexperiencehighinfantmortalityratestendtohavebiggerfamilies.Havingmorechildrencanlowertheabilityoffamiliestoadequatelyinvestinthehealthandeducationofeachchild.192

8.2 Poorer child health leads to greater poverty in the next generation

Theeffectsofpoorchildhealthalsospilloverintothenextgeneration.Adultswhosurviveundernutritionandillnessduringchildhoodarephysicallyandintellectually

36 ILL HEALTH AMONG CHILDREN LEADS TO GREATER POVERTY

lessproductivethanadultswhowerewellnourishedaschildren.Acrossdevelopingcountries,studieshaveshownthatadultheightisstronglyandpositivelycorrelatedwithadultearnings.193InthePhilippines,studiesofagriculturalworkersreportthatadultswhoarestuntedduetopoorchildhoodnutritionarelessproductiveandearnlowerwagesthanadultsofaverageheight.194Further,adultswhowereundernourishedaschildrenarelikelytosufferhigherlevelsofchronicillnessanddisabilitythantheirbetternourishedcounterparts.195Reducedproductivityandfewerhoursspentworkingresultinlowerindividuallabourincome.196Atthenationallevel,poorpopulationhealthdepressesthereturnsoninvestmentsinbusinessandinfrastructure.Thisarisesfromabsenteeismandhighemployeeturnover,resultinginincreasedhiring,forexample.197

Coupledwiththelong-termcostsofreducedhouseholdinvestmentsinchildren,theaggregatedsocialcostsofpoorchildhealtharestaggeringlyhigh.ThehighcostofpoorchildhealthtocountriesisconfirmedbyaUNICEFstudyofeconomicgrowthin49countriesfrom1990to2001.Thestudyfoundthatcountrieswithabaselineoflowinfantmortalityandincomepovertyin1980achievedthehighestratesofeconomicgrowthwithinthedecade.Conversely,countrieswithhighlevelsofinfantmortalityand/orhighlevelsofincomepovertyin1980experiencedadecadeofeconomicdecline.198


The importance of tackling inequalities in child health

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38 THE IMPORTANCE OF TACKLING INEQUALITIES IN CHILD HEALTH

The importance of tackling inequalities in child healthAsthediscussionaboveshows,althoughtheWesternPacificRegionhasrealizedimpressivegainsinchildhealthoutcomes,inequalitiesinthesurvivalprospectsbetweenchildrenlivinginlessandmoreadvantagedhouseholdspersistandevenappeartobegrowinginsomecases.Thissuggeststhat,althoughmanycost-effectivechildhealthinterventionsarebeingimplementedintheRegion,theircoverageisstilllow,particularlyamongthepoor.Renewedeffortsarethereforerequiredtoaddresspovertyandinequalityinchildhealth.

Thereareatleastthreemainargumentsforincreasedeffortsintacklinginequalitiesinchildhealth:efficiency,equityandhumanrights.

RecentestimatesfromtheWorldBankrevealthatonly17%ofthepopulationintheEastAsiaandPacificregionresidesincountriesthatareontracktowardsreachingtheMDG4targetforchildmortalityreduction.199Pro-poorchildhealthinterventionsthataimtotacklethemajorcausesofdiseaseanddeathsufferedbypoorchildrenmayprovideamoreefficientmeansofreducingtheaverageburdenofchildmortalityincountries.EffortsaimedateliminatinginequalitiesinchildhealthmaythusbeaneffectivemeansofmeetingMDG4.Forexample,estimatessuggestthat

achievingMDG4inVietNammaybechallengingbecauseoftheslowrateofdeclineinchildmortalityamongthepoorerincomequintiles.200AddressingthevariousfactorsaffectinghigherchildmortalityamongthepoorinVietNammayalsomeantakingstepstoattaintheotherMDGs.Collectively,sucheffortscanresultinmorerapidprogresstowardsachievingtheMDG4targetforchildmortalityreduction.Besides,therearelinkagesbetweenimprovedchildhealthoutcomesandpovertyreductionatthehousehold,communityandnationallevels.ArecentstudyfromthePhilippinesestimatesthataUS$1.00investmentinanearlychildhoodnutritionprogrammewouldyieldatleasta43%returninhigherincomeandbettereducationaloutcomesamongthebeneficiariesoftheprogramme.201Thisislinkedwithpreventingtheperpetuationofintergenerationalpoverty.

Equityconstitutesanotherstrongrationaleforaddressingtheneedsofthepoorinchildhealthprogrammesmoreeffectively.Inequalitiesinchildhealthoutcomesareincreasinglythoughttoamounttoinequities,whicharedeemedtobeavoidableandthusunfairorunjust.Inequitiesinchildhealthareunderstoodtoreflectunderlyinginequitiesinthedistributionofwealth,resourcesandsocialprivilegeinsociety,ratherthanindividualchoiceorbehaviour.Effortsarethereforerequiredtotackleinequitiesintheburdenofmorbidityandmortalityamongpoorchildren.

Finally,thereisacompellinghumanrightsrationalefordevelopingandimplementingmorepro-poorchildhealthpolicies,strategiesandprogrammes.Therighttothe


39THE IMPORTANCE OF TACKLING INEQUALITIES IN CHILD HEALTH

highestattainablestandardofphysicalandmentalhealth,ortherighttohealth,isrootedintheUniversalDeclarationofHumanRightsandinWHO’sConstitutionandisfurthersupportedbytheConventionontheRightsoftheChild,whichrecognizeseverychild’srighttohealthandhealthcare.Article24oftheConventionobligatesratifyingpartiesto“pursuefullimplementationofthisrightand,inparticular,[to]takeappropriatemeasures…todiminishinfantandchildmortality.”202TheConventionanditsmonitoringmechanismscanpotentiallypromotetheaccountabilityofstakeholdersforimprovingchildhealth.Todate,everycountryintheworldispartytoatleastonehumanrightstreatythataddresseshealth-relatedrights.203Ahuman-rights-basedapproachtochildhealthrequiresthatservicesmustbeaccessible,affordable,appropriateandofgoodqualityforall.


Addressing inequalities in child health

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41ADDRESSING INEQUALITIES IN CHILD HEALTH

Addressing inequalities in child healthCost-effectivetechnicalinterventionsexistformanyofthemajorcausesofchildhoodmorbidityandmortality.Arecentanalysisofchildhealthinterventionsconcludedthatatleastonelevel-onecurativeorpreventiveinterventionthatisappropriatefordeliveryinlow-incomesettingsexistsforeachofthemaincausesofchildmortality,exceptforbirthasphyxia.Further,iflevel1(sufficientevidenceofeffect)orlevel2(limitedevidence)interventionswereuniversallyavailable,63%ofchilddeathscouldbeprevented.204However,experiencesuggeststhatinterventionsorprogrammesalonewillnotbringsignificantgains.Morethantechnicalinterventions,whatseemstobemissingareadequateresources,politicalcommitmentandappropriatehealthsystemstoensurethattheseinterventionsreachthepoorandachieveacceptablecoveragelevelsthatcanleadtosignificantreductionsinchildmortality.

Evidenceoneffectiveandefficientstrategiestodeliverthoseinterventionstopoorandunderservedcommunitiesandhouseholdsisslim.However,theevidencebaseisslowlybeingaugmentedandrefinedthroughvariouspro-poordeliverystrategiesthatareemergingandbeingpilotedincommunitiesaroundtheworld,includingtheWesternPacificRegion.Similarly,lessonsonmethodstostimulatedemandforchildhealthinterventionsamongpoorandmarginalizedcommunitiesareslowlybeinglearnt.Basedonsuchexperience,thediscussionbelowseekstoidentifypossibleapproachestoreducinginequalitiesinchildmortality.ItaimstobuildonsuccessfulexperiencesgatheredfromdiversecountriesthroughouttheRegionandtosuggestsomepossiblewaysforward.

Therearetwobroadstrategiesthatmaybefollowedtoaddressinequalitiesinchildsurvival.Whiledistinct,thestrategiesmaycomplementoneanotherinimportantwaysifapproachedsimultaneously.Suchsynergiesmayresultingreateropportunities,supportandresourcesfortacklinginequalitiesinchildhealth.Thetwobroadstrategiesareoutlinedbelow.

10.1 Mainstream child health and survival in national and international poverty-reduction strategies

Improvedhealthinchildhoodisincreasinglyviewedasacornerstoneofhumandevelopmentandpovertyreduction.Safeguardinghealthearlyinlifehasbeenshowntobeakeyelementinbuildinghumancapital,increasingproductivityandenhancingeconomicgrowth.Betterchildhealthlikewisemovestowardsprotectinghouseholdsagainsttheimpoverishingcostsofseekinghealthcare,inboththeshortandlongerterm.Thereisgrowinginternationalsupportforincreasedinvestmentinchildhealthinterventionsasaneffectivepoverty-reductionstrategy.ThisisclearfromtheincreasingrecognitionoftheimportanceoftheMDGs,andalsofromtherecommendationsoftheCommissiononMacroeconomicsandHealth.Byaffordingacentralplacetochildsurvival,theMDGshighlighttheinterrelationshipbetweenchildhealth,povertyanddevelopment:improvedchildhealthisavitalaspectandeffectivemeansoftacklingpoverty.TheCommissiononMacroeconomicsandHealthhascalledattentiontothepowerfullinkagesbetweenhealthbeginninginchildhood,andeconomicdevelopment.Buildingonthatconcept,childhealthneedstobepromotedascentraltohumandevelopmentandpovertyreduction.

42 ADDRESSING INEQUALITIES IN CHILD HEALTH

IntegratedManagementofChildhoodIllness(IMCI)isastrategyforimprovingchildhealthanddevelopmentthroughthecombineddeliveryofessentialchildhealthinterventions.However,financialinvestmentstoaddresstheconstraintstoeffectiveimplementationofIMCIhavebeeninadequate.205Mountingevidenceontheassociationbetweenimprovedchildhealthoutcomesandpovertyreductionmaylikewisebeharnessedtoadvocatefornewandincreasedresourcesforchildsurvivalinterventions.Variousexamplesofsuchglobalinitiativesalreadyexist.MoreresourcesforchildhealtharebeingmadeavailablethroughEPIandtheGlobalAllianceforVaccinesandImmunization(GAVI).RollBackMalaria,theGlobalFundtoFightAIDS,TuberculosisandMalaria(GFATM)andthe3x5Initiativemayalsoleadtoimprovedfundingforchildhealthinitiativeswithinthebroaderframeworkfortacklinginfectiousdiseases,specificallyAIDSandmalaria.TheBellagioStudyGrouponChildSurvivalexplains,however,thatalthoughthesehealthinitiativeshaveincreasedfundingforinterventionstoreducechildmortality,theyhavedonesosolelyinadisease-specificcontext.Greateradvocacyisthusrequiredtofocusnewandincreasedresourcestowardsamorecoordinatedandcomprehensiveapproachtochildsurvivalandmaternalhealthinterventionsthatincludeshealthsystemsstrengthening.206

Effortstoenhancetheallocationofresourcestowardschildhealthinterventionsarelikewiserequiredatthecountrylevel.TheongoingPovertyReductionStrategyPapers(PRSP)processwasanticipatedtobeaneffectivevehicleforincreasingtheallocationofgovernmentresourcestowardsthehealthsector.However,recentdeskreviewof21finalPRSP,undertakenbyWHO,concludesthatPRSPareunlikelytoresultinlargeincreasesinresourcesavailableforhealth.ThereviewfindsthateventhemoreoptimisticassessmentsofthelevelofhealthfundingthatmaybemadeavailablethroughthePRSPprocessfallshortofthoseadvocatedbytheCommissiononMacroeconomicsandHealth(seeBox1).207AnotherassessmentsuggeststhatveryfewPRSPscompletedtodatecontainastronghealthcomponentsupportedbyresourceallocationacrosssectorsthatwouldincreasetheprobabilityofrealizingimprovedchildhealthoutcomes.208

Whileincreasedresourcescanimprovechildsurvivalinterventionsdeliveredwithinthehealthsector,across-sectoralresponse

isalsorequiredtoaddressthemultipledeterminantsofchildhealththatliebeyondthehealthsector.Suchcross-sectoralstrategiesaimtoreducetheexposureofpoorchildrentotherisksofillhealth.Improvementsinchildhealththusalsodependoncross-sectoralcollaborationonarangeofstrategies,includingeliminatinginequalities

Box 1: The estimated cost of scaling up immunization and treatment for diarrhoea and acute respiratory infections

The Commission on Macroeconomics and Health has estimated the cost of scaling up essential health interventions that are required to eliminate much of the avoidable mortality in low-income countries. The estimates are based on coverage targets and the full economic cost of scaling up those critical interventions. The Commission explains that the coverage targets may be considered conservative as they reflect increased health-sector investment based on existing levels of infrastructure and trained personnel. Further, the cost is estimated to include the full economic cost of scaling up critical interventions, including the direct cost of medicines and health services, capital investments, management, support and training costs.

Among other health interventions, the Commission has estimated the cost of scaling up immunization and treatment for ARI and diarrhoea. The coverage targets for immunization (including the provision of vitamin A) were set at 90% by 2007, while those for diarrhoea and ARI coverage were set at 70%. Based on those targets, the annual incremental costs of scaling up child health interventions to reach the 2007 targets were estimated to be US $1 billion for immunization coverage and US $4 billion for diarrhoea and ARI.

Source: World Health Organization 2001



inincome,educationalattainmentandnutritionalstatus;ensuringaccesstowaterandsanitationandsafeandadequatehousing;developingappropriateagriculturalpolicy;improvingthestatusofwomen;andpromotingsocialprotectionforvulnerablepopulations.ThePRSPprocesspotentiallyprovidesanarenaforsuchacross-sectoralapproach.Effectivecross-sectoralpartnershipsmayalsobedevelopedatthecommunitylevel(seeBox2).

Recognizingthatsocialdisadvantagestronglyinfluenceshealth,WHOrecentlylaunchedtheCommissiononSocialDeterminantsofHealth.Here,WHOdefinessocialdeterminantsofhealthasall“factorsinfluencinghealththatareshapedbypeople’sdifferentpositionsinsociety.”209TheCommissionwillgatherevidenceonthepathwaysthroughwhichsocialdeterminantsleadtoillhealthandhealthpoliciesandinterventionstosuccessfullyaddressthosesocialdeterminants.

10.2 Ensure a focus on poverty and equity in child health interventions

Inequalitiesinchildsurvivalarenottheresultofalackoftechnologicalsolutions.Rather,poorchildrencontinuetosufferbecausecost-effectivechildhealthinterventionsfailtoreachthem.Ithasbeenestimatedthattakingexistingchildhealthinterventionstoscalecanresultinatwo-thirdsreductioninchildmortality,ensuringachievementoftheMDG4targetforchildmortalityreduction.210

Significantlyinsufficientinvestmentsandotherfactorsdescribedintheprevioussectionhavepreventedchildhealthinterventionsfromreachingchildreninpoorhouseholdsandcommunities.Withinthebasketofeffectivechildsurvivalinterventions,however,somehavebeenmoresuccessfulinreachingpoorchildrenthanothers.AWorldBankanalysisusingDHSdatafromover40countries,forexample,suggeststhatgreaterprogresshasbeenmadeinreachingpoorchildrenthroughprofessionallydeliveredinterventions(skilledbirthattendance,treatmentofcommonchildhoodillnesses)thanthroughhome-deliveredinterventions(breastfeedingandtimelycomplementaryfeeding).211EvidencesuggestingthatIMCIhasledtoimprovedequalityinchildsurvivalhasrecentlybecomeavailablethroughtheIMCIMulti-countryEvaluationonitscosteffectivenessandimpact.IMCI-basedcare,forexample,offersanopportunitytoreduceout-of-pocketpaymentsamongtheruralpopulationofSouthernTanzania,mainlythroughmorerationaluseofantibiotics.Thishasledtoimprovementsinchildhealththatdidnotoccurattheexpenseofequity.212

Childhealthpolicyandprogrammegoalsandtargetsaregenerallyformulatedintermsofmaximizinghealthgainsamongchildrenwithinagivenpopulationintheaggregate.

Box 2: Microcredit in Bangladesh

Since 1978, approximately half of the villages in the Matlab district of Bangladesh have been served by the maternal and child health and family planning (MCH-FP) project of the International Center for Diarrhoeal Disease Research, Bangladesh (ICDDR,B). In 1992, BRAC (formerly the Bangladesh Rural Advancement Committee) launched a women-focused development project targeting very poor women in a number of villages covered by MCH-FP. In the following decade, a study recorded a larger decline in the mortality rate among infants whose mothers participated in the BRAC project compared with infants of non-participating women with similar socioeconomic backgrounds. The study suggests that the BRAC inputs, including savings, credit, skills development, leadership roles and social awareness, led to greater self-confidence and the ability to allocate resources more effectively among participants. These may have positively impacted the many determinants of child survival.

Source: Bhuiya A., Chowdhury M. 2002


Forexample,theaverageIMRorU5MRarecommonlyusedindicators.Sinceachievementsaretracedattheaggregatelevel,itistheoreticallypossiblethatthosegoalsmaybeachievedwithlittleornoimprovementinthehealthofpoorchildren.SuchconcernhasbeenexpressedregardingtheMDGforchildhealth,whichrequiresareductionintheU5MRbytwo-thirdsbetween1990and2015.213Reformulatingchildhealthgoalstospecificallyrecognizetheneedtoimprovethehealthofchildrenfrompoorandmarginalizedhouseholdscanhelpensurethatmeasurableprogresswillsimultaneouslybemadeamongthosepopulations.Suchgoalsalsoprovidetheframeworkforpro-poorchildhealthservicedeliverystrategies.Whenreformulatingchildhealthgoals,effortisrequiredtoensurethattheterms‘poverty’and‘poorchildren’areclearlydefinedandunderstoodtorefertospecificgroups,suchasincome-poorhouseholds,urbanslumpopulations,ruralcommunitiesorethnicminorities,asappropriatewithinthegivenlocalorcountrycontext.

Whencombinedwithcasestudiesofsuccessfulchildhealthservicedeliverystrategies,theevidencebeginstosuggestpossiblemeansofincreasingtheaccessibilityofchildhealthinterventionsforthepoor.Inequalitiesintheburdenofchildhooddiseasemaybetackledbyensuringthatthepoorareabletobenefitatleastproportionatelyfromhealthsectorresourcesallocatedtochildsurvivalinterventions.Thismaybeachievedbyprioritizinginnovativechildsurvivalinterventionsthataimtoimprovetheaccessibilityofhealthcareforpoorchildren.Few,ifanyoftheexamplesofchildhealthservicedeliverystrategiesoutlinedbelowhavebeentakentoscaleandthequalityandquantityofevidenceavailabletoevaluatethemisvariable.However,theysuggestsomewaysforward(seeBox3).

Box 3: Preventive interventions in selected low-income countries

Using data from the Integrated Management of Childhood Illness (IMCI) Multi-Country Evaluation (MCE) baseline surveys in Bangladesh, Northeast Brazil and Tanzania, a recent study investigates the distribution of key preventive interventions among children under five years of age Specifically, the study seeks to assess whether preventive child survival interventions were concentrated among some children at the expense of others. The coverage of six preventive interventions was considered: having received one dose of BCG vaccine, three doses of DTP, and one dose of measles vaccine; having slept under a mosquito net on the night preceding the survey (except in Brazil, where there was a lack of information on the coverage of mosquito nets); having taken one capsule of vitamin A in the preceding six months; and having received nutrition counselling or growth monitoring interventions. Households were ranked according to a country-specific asset index.

The results show that at least five interventions reached 7% of children in Tanzania, 16% in Bangladesh and 13% in Brazil. The proportion of children failing to receive any intervention was 13% in Tanzania and 2% in Bangladesh, while in Brazil every child received at least one intervention. A clear association between the number of interventions children received and their household socioeconomic status was observed in Tanzania and Bangladesh, while a weaker association was found between socioeconomic status and access to child health interventions in Brazil, which might be explained by the near universal coverage of many interventions in that country.

The paper hypothesizes that mediocre coverage levels with several interventions delivered simultaneously may result in increasing inequalities. The study questions whether the strategy of delivering a few child health interventions at high coverage is a better goal than seeking to deliver several interventions simultaneously, which may achieve only low coverage.

Source: Victora C. et al. Co-coverage of child survival intervention and implications for child-survival strategies: evidence from national surveys, Lancet, 2003.



a. Prioritize underserved areas in resource allocation

Ingeneral,lowcoverageofchildhealthinterventionsamongpoorormarginalizedpopulationgroupsisobservedinmanycountriesintheRegion.Childrenresidinginurbanareasandinbetter-offhouseholdsareoftenmoresuccessfulinaccessingcarethanchildrenlivinginruralareasorinpoorhouseholds.Theresultinginequalitiesinaccesstochildhealthservicesmayperpetuateinequalitiesinchildsurvival.Redirectingresourceallocationforchildsurvivalinterventionstowardsunderservedpopulationsandremoteandisolatedcommunitiesmaythusbenefitpoorchildren.Apopulationorneeds-basedformulamaybeemployedtoreallocatechildhealthresourcestowardsruralorotherwiseunderservedareas.Childhealthservicesmayalsobeexpandedintounderservedareasbyofferingfinancialincentivestonongovernmentalorganizations(NGOs)orprivateproviders.ServicesbyNGOsinparticularmaybemoreaccessibleforthepoorandmorelikelytoserveruralorremotepopulations(seeBox4).

b. Invest in primary health care

Evidencesuggeststhatthepoorbenefitmorefrompublicspendingonprimaryhealthcarethanfromtotalpublichealthspending.214Inthe2003HumanDevelopmentReport,theUnitedNationsDevelopmentProgramme(UNDP)reportsthat,incountrieswherethepoorest20%ofthepopulationbenefitsfrommorethan25%of

Box 4: Contracting nongovernmental organizations to deliver child health interventions in Cambodia

Based on recent evidence from Cambodia, contracting NGOs to deliver primary health care services may be an effective and equitable means of increasing the coverage of child health interventions in rural areas.

Beginning in 1998, two contracting models were assessed in Cambodia: contracting-out and contracting-in. For contracted-out districts, the contracted NGOs had complete responsibility for the delivery of specified services, employed health care staff directly and had full management control. In contrast, contracted-in NGOs provided management support to health staff retained by the Government, which also provided for recurring costs. The contracted districts received a budget supplement of approximately US$ 0.25 per capita, the allocation and management of which fell to the contracted NGOs (within government rules and regulations). The control districts received a comparable budget supplement. Three operational districts were contracted-in, two operational districts were contracted-out and four served as control districts.

The results of an evaluation in 2001 show that, within 2.5 years, the contracted districts performed significantly better than the control districts. For example, the use of antenatal care increased by 401.5% in the contracted-out districts, 233.3% in the contracted-in districts and 160.1% in the control districts. Further, the evaluation shows that poor households benefited disproportionately in the contracted districts, where much of the increased utilization of health care services was a result of increased uptake among the poor.

Immunization coverage increased in all nine districts and inequalities in coverage between children in poor and non-poor households appeared to have decreased. The likelihood of being fully vaccinated was found to be lowest among children from the poorest 50% of households overall, although children in the contracted districts fared better than children in the control districts. Among children from the poorest 50% of households, 59% of those in the contracted districts were immunized by the time of the evaluation, compared with 47.8% of those in the government-run districts. The contracted districts thus appear to have achieved greater success in targeting children from poor households than the control districts.

Source: Bhushan I., Keller S., Schwartz B. 2002; Schwartz J., Bhushan I. 2004


publicspendingonprimaryhealthcare,fewerthan70per1000childrendiebeforetheageoffiveyears.Conversely,incountrieswherethepoorest20%receivelessthan15%ofpublicspendingonprimaryhealthcare,theunder-fivemortalityrateisabove140.215Inmanycountries,thecostsassociatedwithseekinghealthcarearelowerwhenaccessingprimarycarethanhigherlevelsofcare.Thusimprovingthequalityandcoverageofchildhealthserviceslocatedinprimaryhealthcarethroughgreaterresourceallocationmaybeaneffectivemeansofenhancingtheaccessibilityofhealthcareservicesforthepoor(seeBox5).IMCIbuildsonthisapproachbyenhancingthecapacityofhealthworkerswhomanagechildhoodillnessesinprimaryhealthcarefacilitiesandstrengtheninghealthsystemstosupportimplementation.

c. Reduce financial barriers

Thecostofseekinghealthcareforsickchildrenmaybemorethanpoorhouseholdscanbear.Methodstoreducethatcostmaythereforeimprovetheaccessibilityofhealthcareservicesforpoorchildren.TheWHO-UNICEFRegionalChildSurvivalStrategyrecommendsthatthedirectcostsofseekingcareanduserfeesshouldbereducedthroughtax-basedsystems,socialhealthinsurance,privatehealthinsurance(includingcommunity-basedhealthinsurance)ormixesofthese.Insurance,inparticular,canofferprotectiontopoorhouseholdsagainstcatastrophichealthcarecosts,asitseparatespaymentsfromutilization(seeBox6).Extendinginsurancetopoorandvulnerablepopulationsmaythusimprovethecoverageofhealthcareservicesforpoorchildren.216Communityhealthinsuranceschemesoffersuchapossibility.However,evidencesuggeststhatcommunity-basedhealthinsuranceschemestendtomisstheverypoorestamongthepopulation,whosubsistfromdaytoday,becausepremiumsareoftenrequiredtobepaidinadvance.217

d. Prioritize health conditions affecting poor children

Poorchildrensufferadisproportionateburdenofmorbidityandmortality.Anestimated70%ofchilddeathsarecausedbypneumonia,diarrhoea,measles,malariaandundernutrition.Allocatingresourcestowardsinterventionstargetingthoseconditionsisthoughttobenefitchildrenfrompoorhouseholds.Variousexamplesofthisstrategyexist,includingEPI,GAVIandIMCI.

TheIMCIapproachcombinesanumberofcomplementaryessentialchildsurvivalinterventionsatthehealthfacility,communityandreferrallevelstoaddresstheconditionsresponsibleforthemajorityofchilddeathsindevelopingcountries.EvidencefromtheIMCIMulti-countryEvaluationshowsthatIMCItrainingleadstoimprovedqualityofcareamongprimaryhealthcareworkersmanagingchildren.

Box 5: Primary health care in the Lao People’s Democratic Republic

In the Lao People’s Democratic Republic, improved access to quality primary health care in Sayaburi Province has been found to lead to improved rates of child survival. Located in a remote and mountainous area along the Thai border and populated by numerous ethnic minorities, the health system in Sayaburi Province was rudimentary and virtually non-existent prior to the introduction of the Primary Health Care Project, funded by the Australian Agency for International Development (AusAID), in 1992. Implemented by Save the Children Australia in partnership with the Ministry of Health, the project has resulted in improved maternal and child health at the community, district and provincial levels. More than 60% of children less than one year old have been immunized and almost 70% of women have been immunized against tetanus. The infant mortality rate and maternal mortality ratio in the project areas are now less than half the national averages.

Source: Annual report 2003. Hawthorn East, Save the Children Australia, 2003; Global Education. Primary health care in Laos: case study. Australian Agency for International

development (AusAID).



Forexample,theevaluationcarriedoutinTanzaniashowsthatIMCItrainingwasassociatedwithsignificantlybettercasemanagementthanexistingtrainingapproaches.218

e. Target service delivery towards poor populations

Childhealthservicedeliverystrategiesshouldaimtoefficientlyandequitablyallocateresourcesinwaysthatbenefitpoorchildren.However,thisdoesnotalwayshappen.Forexample,althoughdiarrhoeaandARIarediseasesofpovertyandinterventionsareavailable,childrenwiththoseconditionsfrombetter-offhouseholdsaremorelikelytobetakentoatrainedhealthcareproviderthanthosefrompoorhouseholds.Ontheotherhand,poorchildrenwhoaresickmaynotbetakenforcareormaybetakentofacilitieswithuntrainedhealthpersonnelorlimitedresources.Theaforementionedinterventionsshouldbedeliveredthroughvariouspro-poorstrategiestoincreasetheaccessibilityofhealthservicesforpoorchildren.Targetingpoorchildrenandtailoringservicedeliverytomeettheneedsofpoorhouseholdsaremovestowardsincreasingtheaccessibilityofchildsurvivalinterventions.

Interventionsmaybetargetedatpoorchildrendirectly,throughmeanstesting,orindirectly,onthebasisofsomecharacteristic,suchasgeographicallocationormembershipofavulnerablegroup,includingethnicminorities,streetchildrenorlandlessfarminghouseholds.Giventhatinequalitiesinaccesspersistbetweenurbanandruralareas,withruralareasgenerallypoorerthanurbanareas,expandingchildsurvivalinterventionsintoruralandremoteareascanimproveaccessibilityforpoorchildren.Regularoutreachanddeploymentofmobileteamsinunderserved,remoteormountainousareasmayalsoimprovetheaccessibilityofchildhealthinterventions

Box 6: Reducing financial barriers to child health interventions in Yunnan Province, China

A voucher system may be an effective method of protecting poor households from the impoverishing cost of seeking health care. A poverty alleviation fund established in Yunnan Province in China through a World Bank-supported maternal and child health project appears to have increased the utilization of health services among poor households.

The fund was used to subsidize health care costs for the poorest 5% of households in the project area. Beneficiaries were identified through a participatory process, using criteria developed by local councils. Pregnant women from the identified households were then given vouchers that could be used to obtain ante- and post-natal care, delivery attendance and medical treatment for common childhood illnesses. The poverty alleviation fund reimbursed health facilities for the cost of services obtained by poor women through the vouchers.

Preliminary results reveal that the voucher system had a significant impact on the usage of health care services by poor households. For example, among poor households in Nanhua, the proportion of children with diarrhoea receiving treatment increased from 67.3% in the year before the introduction of the voucher system to 81.1% in the year following its introduction. During that period, the proportion of non-poor children with diarrhoea receiving treatment increased from 77.2% to 82.5%. While the proportion of children from non-poor households in Huize, a control area, increased from 75.0% to 77.4% during the same period, the increase among poor households was marginal (63.1% to 64.1%). Thus, reducing the direct cost of health services in the project areas seems to have contributed to improved health-seeking behaviour among poor households.

Source: Du K., Zhang K., Tang S. Draft report on MCHPAF study in China. Washington, D.C., World Bank, 2001.


bybringingcareclosertopoorhouseholds.Thecoverageofchildhealthinterventionsmayalsobeexpandedthroughnetworksofcommunityhealthworkersorlocalorganizations.Servicedeliveryneedstobetailoredtoreachunderservedpopulations,suchasthechildrenofurbanpoorhouseholds,migrantsandlandlesslabourers.SuchstrategiesmaybeundertakenincollaborationwithNGOsandprivatepractitioners(seeBox7).

f. Promote information, education and communication

AppropriateIECstrategiesmayincreaseknowledgeandawarenesstochangebehaviouramongpoorhouseholdsonkeyfamilyandcommunitypractices,suchasexclusivebreastfeeding,appropriatecomplementaryfeedingandimprovedhygiene.Enhancedawarenessandunderstandingofchildhoodillnessesandwhereandwhentoseekpreventiveandcurativeservicescanlikewiseleadtogreaterdemandforhealthcareservices.However,lowlevelsofeducationandliteracy,togetherwithlimitedaccesstostandardmodesof

masscommunication(radio,television)insomecommunities,mayplacemuchoftraditionalIECbeyondthereachofpoorfamilies.Distance,aswellasculturaland

Box 7: Outreach strategies can improve the accessibility of child health interventions for the poor

There are various examples of delivery strategies that are being implemented in the Region to increase access to child health services for poor households. The Primary Health Care Project in the Lao People’s Democratic Republic outlined above, for example, has mobile outreach clinics that visit remote villages every three months. The mobile clinics offer vaccinations, family planning services, antenatal care, and health education for malaria and diarrhoea prevention in particular. In Papua New Guinea, Save the Children Australia and New Zealand are implementing the East Sepik Women’s and Children’s Health Project. The project has trained and supported a network of women volunteers who provide health care to their communities in five districts where other health services are mostly absent. A second Save the Children project in Papua New Guinea seeks to increase vaccine coverage in remote areas of the Lufa district in the Eastern Highlands. The Health Services and Faith Mission project uses foot patrols to deliver immunization services to 18 villages.

Source: Save the Children Australia 2003. Choy R., Duke T. 2000

Box 8: Behavioural change in Viet Nam

In 1993, Save the Children US implemented a poverty-alleviation and nutrition project (PANP) in ten rural communities in Thanh Hoa Province in Viet Nam. The project included four components: community registration; growth monitoring and promotion; positive deviation inquiry; and a nutritional education and rehabilitation programme. Village members and project staff used the positive deviation inquiry approach to identify families which had an older child who had received better nutrition through a previous PANP intervention and a younger child who had not participated. The control group of families had two children, neither of which had received a nutrition intervention. Such an approach is seen to be effective because it identifies behaviour changes in the project group that are affordable, acceptable and likely to be sustainable. Families in the project group were then interviewed and observed to identify feeding and child care practices that could account for the better nutritional status of their children. Findings from the positive deviation inquiry approach formed the content of the nutritional education and rehabilitation programme, which aimed to rehabilitate malnourished children and teach caregivers to sustain improvements.

The long-term impact of the project was assessed in 1998 and 1999. The results of the two surveys show that, in the four communities covered, the nutritional status of children who had participated in the PANP and their younger siblings was better than that among children in a control commune. Feeding, hygiene and health-seeking practices were also observed to be better among mothers in the four communities covered by the project than in the control district. For example, more mothers in the project communities were found to be breast-feeding (41%) in 1998 than mothers in the comparison community (20%). The success of the poverty-alleviation and nutrition project in improving the nutritional status of children has resulted in its replication in communities across the country.

Source: Mackintosh U., Marsh D., Schroeder D. Sustained positive deviant childcare practices and their effect on child growth in Vietnam. Food and Nutrition Bulletin, 2002, 23 (4s): 16-25. 2002



linguisticbarriers,mayalsopreventIECmessagesfromreachingpoorcommunities,suchasethnicminorities.Focusedeffortsarethusrequiredtoensurethatthestrategies,methodsandmessagesusedaretailoredtoensureaccessibilityforthepoor.Thismayincludematerialsdesignedforlowliteracylevelsormessagesthatareculturallyappropriateanddeliveredinlocallanguages.IECmaybecombinedwithoutreachorotheractivitiestosupportbehaviouralchangeamongthetargetpopulation(seeBox8).

g. Improve system responsiveness

Inmanyareas,mobilizingdemandforchildsurvivalinterventionsthroughIECactivitiesmaybeineffectiveiftheactualorperceivedqualityofgeneralhealthcareservicesislow.Effortsarethereforerequiredtoimprovetheresponsivenessandqualityofhealthcareservicesingeneralandofhealthworkerswhomanagechildhealthinparticular(seeBox9).Forexample,monetaryandnon-monetaryperformance-basedincentivesmaybeusedtoimprovethequalityofhealthcareproviders.Beyondimprovingthegeneralqualityofservicesprovided,effortstoenhanceresponsivenessmayincludeimprovingstaffattitudesandcommunicationskills,decreasingwaitingtimes,andincreasingconfidentiality,tonameafew.Inparticular,effortsshouldbemadetoincreasetheawareness,sensitivityandskillsofhealthcareprovidersindealingwithpoorandmarginalizedcommunities,toensurethatallclients,especiallythepoor,aretreatedwithdignityandrespect.Forexample,providerswhospeaklocallanguagesandunderstandthecultureandcustomsofminoritygroupsmaybemoreresponsivetotheirneeds,therebyincreasingdemandforhealthcareservicesamongthosecommunities.

h. Ensure appropriate monitoring and evaluation

Akeyconstraintinaddressinginequitiesinchildhealthisthegenerallackofdisaggregateddataandinformationatthenationalandsubnationallevels.Disaggregateddataarerequiredtoanalyseinequalitiesinchildhoodmorbidityandmortality,andinaccesstochildhealthservices,byvarioussocioeconomicindicators.Suchananalysisprovidesthebasisfortargetingthedeliveryofinterventionstopoororotherwisemarginalizedchildren.Tomeetthisneed,childhealthdatathatarecollectedwithinthehealthsectorneedtobedisaggregatedandanalysedbygender,urban-rurallocation,ethnicity,incomelevelofhousehold,regionorprovince,orwhateverotherindicatorsofsocialexclusionmaybepracticallyfeasible.Wherepossible,recordingthelevelof

Box 9: Improved case management in two districts of Tanzania

A health facility survey was conducted in 2000 to assess the quality of case management and health system support indicators in four districts in Tanzania. Two of the districts had been implementing IMCI since 1997, while the other two had not yet adopted the IMCI strategy. Using data from the survey on the quality of care and health facility support for children between two months and four years of age, a recent study reports that children in the IMCI districts appear to have been receiving better case management than those in the areas without IMCI. More specifically, nearly all the indicators assessed suggest that children in the IMCI area were receiving more thorough assessments, were more likely to be correctly classified, and were more likely to receive appropriate treatment than children in the comparison districts. For example, 95% of children in the IMCI districts were checked for cough, diarrhoea and fever, compared with only 36% of children in the non-IMCI districts. Similarly, significantly more children in the IMCI areas (75%) were correctly treated for pneumonia than in the areas without IMCI (40%). Counselling and communication skills were reported to be better among IMCI-trained health workers than among health workers who had not been trained in IMCI. Concerning parental knowledge, higher levels of correct knowledge about how to care for their sick children were reported among caregivers in the IMCI areas than among caregivers in the areas without IMCI.

Source: Tanzania IMCI Multi-Country Evaluation Health Facility Survey Study Group. The effect of integrated management of childhood illness on observed quality of care of

under-fives in rural Tanzania. Health Policy and Planning, 2004, 19(1):1-10.

ADDRESSING INEQUALITIES IN CHILD HEALTH50

educational,occupationalorsocioeconomicstatusofchildren’shouseholdsallowsforamorecomprehensiveanalysis.Thedatamaybesupplementedbycasestudiestoidentifyvariousfinancialandnon-financialbarrierspoorchildrenmayfacewhenaccessinghealthcare.Disaggregateddatamayalsobeusedtomonitorchangesovertimeandprogresstowardsmeetingpro-poorchildsurvivalgoals.Alongwithbetterqualitydisaggregatedinformation,itisimportanttomovetowardsgreatercommunityparticipationinthemonitoringandevaluationprocess.Suchparticipationcanpotentiallyimproveaccountabilityandpromotetheempowermentofcommunities.


Conclusion

11


ConclusionThepersistentandgrowinginequalitiesinchildsurvivalthatarewitnessedthroughouttheRegiondemandrenewedcommitmentandconcertedactionforchildhealth.Increasedeffortsarerequiredtoensurethatchildsurvivalinterventionsreachpoorandvulnerablechildren.SucheffortsmaybeguidedbytheexperienceofvariouscountriesacrosstheRegionandbeyondonhealthservicedeliverystrategiesthathaveproventobeeffectiveinbenefitingpoorhouseholds.Whilemuchofthatexperiencehasbeenbuiltthroughsmall-scalecontext-specificinterventions,itsuggestssomewaysforward.Theevidencebaseforpro-poorhealthservicedeliverystrategiesmaybeaugmentedthroughthecollectionandanalysisofdisaggregatedchildhealthdataandmorerigorousevaluationofchildhealthservicedeliverystrategiesbeingimplementedintheRegion.Greatercommitmenttoeffective,equitableandsustainablechildhealthservicedeliverystrategieswillmeanaconcretemovetowardsmeetingtheMillenniumDevelopmentGoalforchildmortalityreduction.


53CONCLUSIONS

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4 BryceJet al.WHOestimatesofthecausesofdeathsinchildren,The Lancet,2005,365:1147-1152.

5 WHO/UNICEFregionalchildsurvivalstrategy:acceleratedandsustainedactiontowardsMDG4.Manila,WorldHealthOrganizationRegionalOfficefortheWesternPacific,2006.

6 Ibid.7 TheWorldBankusestheWorldBankAtlasmethod

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8 UnitedNationsDevelopmentProgramme(http://hdr.undp.org/statistics/data/indic/indic_8_1_1.html)

9 Op.cit.Ref.510 WagstaffA.Povertyandhealthsectorinequalities.

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12 United Nations development goals: Cambodia.PhnomPenh,UnitedNationsCountryTeam,2001(www.undp.org/mdg/Cambodia.pdf )

13 NaraqiS,FelingB,LeederS.DiseaseanddeathinPapuaNewGuinea.Medical Journal of Australia,2003,178(1):7-8.(http://www.mja.com.au/public/issues/178_01_060103/nar10150_fm.html)

14 UnitedNationsChildren’sFund.The State of the World’s Children 2005. NewYork,UnitedNationsChildren’sFund,2005.

15 OrganisationforEconomicCo-operationandDevelopmentandWorldHealthOrganization.DAC Guidelines and Reference Series: Poverty and Health.Paris,OECDDevelopmentAssistanceCommittee,2003.

16 NarayanDet al.Voices of the poor: can anyone hear us?NewYork,OxfordUniversityPress,2000.

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19 Ibid.20 Reportfromthe27thFAORegionalConferencefor

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66 ENDNOTES

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195Op cit.Ref99.196Op cit.Ref18.197Op cit.Ref17.198Op cit.Ref29.199Op cit.Ref18.200Op cit.Ref61.201Op cit.Ref18.202 SeetheConventionontheRightsoftheChild,

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214UnitedNationsDevelopmentProgrammeHuman development report 2003 Millennium Development Goals: a compact among nations to end human poverty.NewYork,OxfordUniversityPress,2003.

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