DECOMPOSING THE SOCIOECONOMIC INEQUALITIE IN CHILD ...pideorgp/pdf/Health... · five MR= 89 (PDHS, 2012-13), Very far from MDGS Target Inadequate literature on child mortality inequality

Muhammad Arif

M.Phil Health Economics (2012-14)

Supervised by

Dr. Mahmood Khalid

Mr. Ajmal Jahangeer

Friday, November 20, 2015

DECOMPOSING THE SOCIOECONOMIC

INEQUALITIE IN CHILD MORTALITY IN

PAKISTAN

INTRODUCTION

Inequalities in health discovered in 19th century, But, from two decades received meticulous attention in developing countries(Wagstaff, 2000)

Leading Health Economic issue in higher-, middle- and low -income countries(Mackenbach, 2006), as well as in Pakistan (Alam, Nishtar, Amjad, & Bile, 2010)

Goal of several international, national organizations and governments to reduce inequalities

e,g. World Bank, WHO, Government programmes, policies (WHO, 2013)

“economic inequalities in health ” Effects different social groups, economy, and development of a country (Wagstaff, 2000)

poor segment of population become more vulnerable to disease, dies more than rich, (Marmot & Wilkinson 1999)

2

INTRO----CONT..

Since neonatal, post-neonatal and under-five mortality

in more developed countries have progressively

dropped and presently have been reduced to nearly negligible points

However, in Pakistan, not encouraging

as neonatal MR =55, post-neonatal MR=19 and under-

five MR= 89 (PDHS, 2012-13), Very far from MDGS Target

Inadequate literature on child mortality inequality with

reference to Pakistan,

It is likely need to investigate the levels and underlining

reasons, drivers behind these inequalities, which helps to reduce health inequalities and derive the related

policy implications

3

OBJECTIVE OF THE STUDY

The objective of this study is

To measure the economic-related inequalities

in child mortality, and,

To quantify the determinant’s contribution to

child mortality inequality

4

RESEARCH QUESTIONS

Does child mortality inequality between

the poor and rich exist in Pakistan?

What are the major contributing factors

to inequality in child mortality?

5

HYPOTHESES

The study test the following hypotheses:

There is no inequality in child mortality

between poor and non-poor in Pakistan

Socioeconomic determinants have no

significant contribution in child mortality

inequality

Demographic determinants do not have

any significant contribution in child

mortality inequality

6

SIGNIFICANCE OF THE STUDY

May fill the knowledge gap on

inequalities in health in Pakistan

The finding may help to support better

design of health policies that aim at

reducing inequalities in child health

The study will help policy makers and

programmers to allocate resources

equitably and efficiently.

7

THEORETICAL FOUNDATION

Mosely and Chen (1984) presented an

analytical framework for the study of

child survival in developing countries

Production Function of health

8

9

ECONOMIC

-RELATED

INEQUALITY

Environmental

Geographic

and cultures

Demographic

Socioeconomic

HEALTH OUT-

COMES

Demographic, socioeconomic, geographic and

cultural Determinants of health

A Simplified Conceptual Framework of the Relationship between economic-related Inequality and Health

Outcomes

OUTCOME VARIABLES

Neonatal mortality: - Deaths of the newborn baby within the first

month of life (0-28 days)

Post-neonatal mortality: - It is the difference between the infant

and neonatal mortality. Deaths at age 1-11 months (from

completed age 1 month till before completed age 12 months)

Under-five mortality: – Deaths from birth till completed age 60

months is considered as deaths under the age of five

10

DETERMINANTS

Child characteristics

Gender, Birth order of the child

Parental Characteristics

Maternal age at time of birth,

Type of delivery( normal , C-section)

Birth interval (Risky, non risky)

Mother’s previous history of pregnancy loss

Antenatal care (prenatal visits)

Parental Education

Job/employment

House Hold characteristics

Economic status/ wealth index (quintile)

Type of fuel used for coking(solid, Gas, electricity & liquid)

Type of drinking water (improved, not improved)

Toilet facility (unhygienic and Hygienic)

Area of residence (rural/urban),

Region (Provinces)

11

DATA

PDHS (2012-2013)

Ever married questioner

Data set “Kids Record” Children under-Five

Sample of under-five children born a live 11,763

Neonatal deaths 551

Post-Neonatal deaths 277

Under-five deaths 828

12

Methodology

13

Concentration curve

L(p) concentration curve

Line of equality (45˙ line)

Y-axis=cumulative proportion of outcome variable

X-axis=cumulative proportion of individuals ranked by economic status

If concentration curve is above the diagonal, the concentration index value will be is negative and concentrated to poor and vice versa

the concentration curve coinciding with the diagonal, the value of the concentration index is zero.

14

CONCENTRATION INDEX

𝐶 =2

𝜇 𝐶𝑜𝑣(𝑦𝑖 , 𝑟)

µ= mean health outcome,

y=health outcome variable,

r =is the rank of the individual in the wealth distribution

It measures the values between -1 and +1.

Negative sign =pro-poor

Positive sign = pro-rich

0=No inequalities

15

DECOMPOSITION OF CONCENTRATION

INDEX

Decomposition analysis helps to measure the pure

contribution of the determinant of health outcome

variable

Adam Wagstaff Suggested

𝑦𝑖 = 𝛼 + 𝛽 𝑋𝑖 + 𝜀𝑡 ,

𝑦𝑖 =health outcome variable,

𝑋𝑖= set of socioeconomic determinants of health

outcome,

𝛽 is coefficient of determinant of 𝑋𝑖 and 𝜀𝑡 is a residual

term

16

Steps in Decomposition In the first step regression model of health outcome variable (y) on all

explanatory variable (x) was estimated and saved the β𝑘 coefficients of each explanatory variable X𝑘𝑖.

In the next step the mean of 𝑿 𝒌 of each 𝑿𝒌𝒊 and mean 𝝁 of outcome variable 𝑦𝑖 were calculated.

Then calculated the concentration index (CI) of outcome variable as well as the concentration index (CI) for each of the explanatory variable.

In this step the elasticity of 𝒚𝒊 with respect to each of X𝑘𝑖 were estimated.

𝑒𝑙𝑎𝑠 𝑦

𝑥𝑘 = β𝑘 𝑋 𝑘 / 𝜇

The pure contribution of each explanatory variable X𝑘𝑖 to the concentration index of outcome variable CI(𝑦𝑖 ) was estimated by multiplying the elasticity to concentration index of each determinant.

𝑐𝑜𝑛𝑡 X𝑘𝑖/CI(𝑦𝑖 ) = 𝑒𝑙𝑎𝑠 𝑦

𝑥𝑘 ∗ 𝐶𝐼(X𝑘𝑖)

The last step was to obtain the percentage contribution of an explanatory variable x to the concentration index of the outcome variable, simply the contribution is divided by concentration index of outcome variable and multiplied by 100.

17

DESCRIPTIVE STATISTICS

18

CHILD CHARACTERISTICS

Pearson’s Chi Square𝑋2=Significant

49.1 50.9

4.7 4.5 2.3 2.3 7.1 6.9

FEMALE MALE

CHILD MORTALITY

BY SEX OF CHILD

Live BirthsNeonatal MortalityPost-Neonatal MortalityUnder-Five Mortality

22.4 19.8

16.2

12.5

29

4.8 3.3 4.1 4.3 6

1.4 2.1 1.9 2.6 3.3 6.3 5.5 6 6.9

9.4

1 2 3 4 5+

CHILD MORTALITY BY BIRTH

ORDER

Live Births (%) Neonatal Mortality

Post-Neonatal Mortality Under Five Mortality

Pearson’s Chi Square𝑋2=Insignificant

PARENTAL CHARACTERISTICS


Pearson’s Chi

Square𝑋2=Insignificant

87.8

12.1 4.7 4.2 2.4 1.8 7.1 6

NORMAL DELIVERY CAESAREAN

SECTION

CHILD MORTALITY

BY TYPE OF DELIVERY

Live Births

Neonatal Mortality

Post-Neonatal Mortality

Under Five Mortality

39.9 42

14

3.3 4.8 4.3 5.3 4.8 2.7 2.5 1.1 1 7.5 6.8 6.5 5.8

UNDER 19 20-24 25-29 30 AND ABOVE

CHILD MORTALITY BY AGE OF

MOTHER AT TIME OF BIRTH

Live Births Neonatal Mortality



Pearson’s Chi

Square𝑋2=Significant

16.2

6.8 7.9

44.5

24.5

5.1 3.3 3.6 5.7 3.2 2.4 1.4 1.2 3.4 1.2 7.5

4.7 4.8

9.1

4.3

NO VISIT 1 VISIT 2 VISITS 3 VISITS 4 + VISITS

CHILD MORTALITY BY PRENATAL VISITS


Post-Neonatal Mortality Under-Five Mortality

70.9

29

3.7 6.9 1.5 4.2 5.3 11.1

NON RISKY

INTERVAL

RISKY BIRTH

INTERVAL

CHILD MORTALITY BY

BIRTH INTERVALS

Live BirthsNeonatal MortalityPost-Neonatal MortalityUnder Five Mortality

Pearson’s Chi SquareX2=Significant Pearson’s Chi Square𝑋2=Significant

67.7

32.3

4.1 5.8 1.8 3.4 5.9 9.3

EDUCATED UN-EDUCATED

CHILD MORTALITY BY

FATHER’S EDUCATION

Live Births

Neonatal Mortality



57.2

14.3 17.6

10.8 5.4 4.7 3.8 2.4 3.01 2.5 1.2 0.5 8.4 7.2 5.01 2.9

NO EDUCATION PRIMARY SECONDARY HIGHER

CHILD MORTALITY BY MOTHER’S

EDUCATION LEVEL



Pearson’s Chi Square𝑋2=Significant Pearson’s Chi Square𝑋2=Insignificant

78.8

21.2

4.2 6.4 2.1 3.3 6.3 9.6

NOT WORKING WORKING

CHILD MORALITY BY MOTHER’S

WORKING STATUS

Live Births (%)Neonatal MortalityPost-Neonatal MortalityUnder Five Mortality

97.5

2.5 4.7 3.4 2.4 2.4 7.07 5.7

WORKING NOT WORKING

CHILD MORTALITY BY FATHER’S

WORKING STATUS


Pearson’s Chi Square𝑋2=Insignificant Pearson’s Chi Square𝑋2=Significant

92.8

7.2 4.6 4.7 2.4 1.8 7.1 6.6

MALE FEMALE

CHILD MORTALITY BY HEAD

OF HOUSEHOLD


68.2

31.8

4.5 5.1 2.2 2.7 6.6 7.8

NOT LOST LOST PREGNANCY

CHILD MORTALITY BY PREVIOUS

HISTORY OF PREGNANCY LOSS

Live Births (%)

Neonatal Mortality



HOUSEHOLD CHARACTERISTICS


23.4

20 19.3

18.6 18.5

6 5.3

4.7 3.8

3 3.6

2.8 2 1.8 0.9

9.7

8.1 6.7

5.6

3.9

POOREST POOR MIDDLE RICH RICHEST

CHILD MORTALITY BY ECONOMIC STATUS OF

HOUSEHOLD

Live Births (%) Neonatal Mortality Post-Neonatal Mortality Under Five Mortality

15.1

84.8

4.3 4.7 2.8 2.2 7.2 7

NOT IMPROVED IMPROVED

CHILD MORTALITY BY TYPE

OF DRINKING WATER



Pearson’s Chi Square𝑋2=Insignificant

42.3

57.7

3.9 5.2 1.8 2.6 5.8 7.9

URBAN RURAL

CHILD MORTALITY BY AREA

OF RESIDENCE




Pearson’s Chi Square𝑋2=Significant Pearson’s Chi Square𝑋2=Significant

38.9

61.1

3.7 5.2 1.6 2.7 5.4 8

LIQUID, GAS & OTHER SOLID COOKING FUEL

CHILD MORTALITY BY TYPE OF

COOKING FUEL



69.3

30.7

4.2 5.7 1.9 3.2 6.2 8.9

IMPROVED TOILET FACILITY UN-IMPROVED TOILET

FACILITY

CHILD MORTALITY BY TYPE OF

TOILET FACILITY




27.7

21.4

19.3

16.2

9.3

6.03 5.7 5

3.1

5.3 4.2

2.6 2.05 2.7 1.9 3.3 2.8 0.5

7.7 7.7

5.1

8.6

7

3.2

PUNJAB SINDH KHYBER

PAKHTUNKHWA

BALOCHISTAN GILGIT-

BALTISTAN

ISLAMABAD (ICT)

CHILD MORTALITY BY REGION

Live Births (%) Neonatal Mortality Post-Neonatal Mortality Under Five Mortality

MEASURES OF INEQUALITY

29

CONCENTRATION CURVES

30

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0.00 0.20 0.40 0.60 0.80 1.00

Cu

mu

lativ

e %

of o

utc

om

e

va

ria

ble

Cumulative % of population, ranked from poorest to richest

Line of equality

under five mortality

neonatal mortality

post-neonatal

Concentration Curve & Concentration Index of Neonatal, Post-neonatal and Under-Five Mortality in Pakistan

Outcome Variables Concentration Index

Neonatal Mortality -.1528

Post-Neonatal Mortality -.2443

Under Five Mortality -.1834

DECOMPOSITION RESULTS

31

32

Regression

Result

Significant, at *1%. **5%, ***10%

Determinants

Neonatal Post-Neonatal Under-Five

Coef. P value Coef. P value Coef. P value

Child is Male -0.034* 0.000 -0.006 0.156 -0.007 0.233

Birth Order of Child 2 -0.051* 0.000 -0.003 0.292 -0.032* 0.000

Birth Order of Child 3 0.028 0.115 0.005*** 0.077 0.001 0.948

Birth Order of Child 4 -0.051* 0.002 -0.009 0.429 -0.013*** 0.073

Birth Order of Child 5 plus -0.020** 0.058 0.001 0.815 0.008 0.287

Age of Mother at Time of Birth -0.033* 0.000 -0.003 0.125 -0.004 0.633

Head of Household is Female -0.013 0.292 0.003 0.653 -0.009 0.432

Delivery by Caesarean 0.005* 0.003 0.007* 0.001 0.054*** 0.075

Father is Uneducated 0.052* 0.000 0.010* 0.002 0.004 0.457

Mother is Uneducated 0.062* 0.002 0.010** 0.032 0.013 0.564

Mother’s Primary Edu. -0.037** 0.041 -0.014* 0.000 -0.013 0.506

Mother’s Secondary Edu . -0.030*** 0.08 -0.005*** 0.077 -0.002 0.934

Father is Working -0.366* 0.000 -0.006 0.219 -0.004 0.85

Mother is Working 0.007 0.487 0.007* 0.006 0.008 0.378

Risky Birth Intervals 0.032* 0.000 0.025* 0.000 0.053* 0.000

History of Pregnancy Loss 0.049* 0.000 0.007 0.227 0.000 0.935

Prenatal one visit -0.036** 0.017 -0.011*** 0.082 -0.023* 0.002

Prenatal two visits -0.030** 0.037 -0.013 0.13 -0.008 0.443

Prenatal three visits 0.018*** 0.095 0013** 0.057 0.031* 0.000

Prenatal four plus visits 0.066* 0.001 -0.001 0.876 0.003 0.693

Poorest 0.017 0.503 0.007 0.26 0.024** 0.044

Poor 0.068* 0.000 0.013 0.231 0.029** 0.024

Middle 0.022** 0.043 0.002 0.725 0.008 0.433

Rich -0.018*** 0.084 -0.004*** 0.066 -0.000 0.951

Solid cooking Fuel 0.010 0.266 0.000 0.92 0.009 0.152

Un Hygienic toilet -0.011 0.384 -0.006 0.371 -0.003 0.551

Improved drinking Water -0.031** 0.021 -0.002 0.653 -0.021* 0.000

Rural 0.038* 0.002 -0.001 0.787 0.007 0.378

Sindh 0.001 0.956 0.008* 0.004 0.022 0.244

KPK -0.018** 0.053 0.014* 0.004 -0.001 0.846

Balochistan 0.028** 0.014 0.011* 0.003 0.013 0.276

Gilgit-Baltistan 0.097** 0.002 0.009** 0.052 -0.002 0.825

Islamabad -0.009 0.584 -0.006** 0.026 -0.030* 0.000

Determinants of Neonatal Mortality

Elasticity Concentration

Index Contribution

Percentage Contribution

Agrigated percentage contribution

Child is Male 0.032 0.003 0.000 -0.1 -0.1

Birth Order of Child 2 -0.12 0.094 -0.011 7.4

12 Birth Order of Child 3 -0.074 0.054 -0.004 2.6

Birth Order of Child 4 -0.06 -0.036 0.002 -1.4

Birth Order of Child 5 plus 0.026 -0.196 -0.005 3.4

Age of Mother at Time of Birth 0.2 0.059 0.012 -7.7 -7.7

Head of Household is Female 0.02 0.037 0.001 -0.5 -0.5

Delivery by Caesarean 0.034 0.449 0.015 -10 -10

Father is Uneducated -0.073 -0.377 0.027 -18 -18

Mother is Uneducated 0.31 -0.294 -0.091 59.5

39.8 Mother’s Primary Edu. 0.064 0.16 0.01 -6.7

Mother’s Secondary Edu . 0.048 0.415 0.02 -13

Father is Working 0.169 0.005 0.001 -0.6 -0.6

Mother is Working 0.058 -0.248 -0.014 9.5 9.5

Risky Birth Intervals 0.266 -0.077 -0.02 13.4 13.4

History of Pregnancy Loss -0.034 -0.022 0.001 -0.5 -0.05

Prenatal one visit -0.02 -0.225 0.004 -2.9

-5.3 Prenatal two visits -0.01 -0.039 0.000 -0.3

Prenatal three visits 0.196 -0.029 -0.006 3.7

Prenatal four plus visits 0.024 0.372 0.009 -5.8

Poorest 0.111 -0.793 -0.088 57.6

64.6 Poor 0.067 -0.341 -0.023 14.9

Middle 0.064 0.071 0.004 -2.9

Rich 0.017 0.467 0.008 -5

Solid cooking Fuel 0.045 -0.325 -0.015 9.6 9.6

Un Hygienic toilet 0.048 -0.463 -0.022 14.4 14.4

Improved drinking Water 0.248 0.054 0.013 -8.7 -8.7

Rural 0.014 -0.276 -0.004 2.5 2.5

Sindh -0.026 -0.046 0.001 -0.8

-10.8 KPK -0.057 0.036 -0.002 1.3

Balochistan -0.051 -0.236 0.012 -7.8

Gilgit-Baltistan -0.039 -0.351 0.014 -9.1

Islamabad -0.015 0.579 -0.009 5.6

Total Observed 103.7 103.7

Residual 0.006 -3.7 -3.7

Total 100 100

33

Determinants of Post-Neonatal

Mortality Elasticity

Concentration

Index Contribution

Percentage

Contribution

Aggregated

percentage

contribution

Child is Male -0.138 0.003 0 0.1 0.1 Birth Order of Child 2 -0.023 0.094 -0.002 0.9

3.2 Birth Order of Child 3 -0.033 0.054 -0.002 0.7

Birth Order of Child 4 0.048 -0.036 -0.002 0.7


Age of Mother at Time of Birth -0.224 0.059 -0.013 5.4 5.4 Head of Household is Female 0.009 0.037 0 -0.1 -0.1 Delivery by Caesarean 0.038 0.449 0.017 -7 -7

Father is Uneducated 0.144 -0.377 -0.054 22.2 22.2 Mother is Uneducated 0.237 -0.294 -0.07 28.6


Mother’s Secondary Edu . 0.039 0.415 0.016 -6.5

Father is Working 0.237 0.005 0.001 -0.5 -0.5 Mother is Working 0.064 -0.248 -0.016 6.5 6.5 Risky Birth Intervals 0.306 -0.077 -0.023 9.6 9.6 History of Pregnancy Loss 0.091 -0.022 -0.002 0.8 0.8 Prenatal one visit -0.033 -0.225 0.007 -3

0.9 Prenatal two visits -0.045 -0.039 0.002 -0.7

Prenatal three visits 0.252 -0.029 -0.007 3

Prenatal four plus visits -0.01 0.372 -0.004 1.6

Poorest 0.068 -0.793 -0.054 21.9

30.5 Poor 0.107 -0.341 -0.037 14.9

Middle 0.013 0.071 0.001 -0.4

Rich 0.031 0.467 0.014 -5.9

Solid cooking Fuel -0.009 -0.325 0.003 -1.2 -1.2 Un Hygienic toilet -0.074 -0.463 0.034 -14.1 -14.1 Improved drinking Water 0.078 0.054 0.004 -1.7 -1.7 Rural -0.024 -0.276 0.007 -2.7 -2.7 Sindh 0.074 -0.046 -0.003 1.4

15.8

KPK 0.112 0.036 0.004 -1.6

Balochistan 0.073 -0.236 -0.017 7

Gilgit-Baltistan 0.037 -0.351 -0.013 5.3

Islamabad -0.016 0.579 -0.009 3.7

Total Observed 84.4 84.4 Residual -0.038 15.6 15.6 Total 100 100

34

Determinants of Under-five Mortality Elasticity Concentrat

ion Index Contribution

Percentage

Contribution

Agrigated

percentage

contribution

Child is Male 0.024 0.003 0 0 -0.1 Birth Order of Child 2 -0.089 0.094 -0.008 4.6

9.9 Birth Order of Child 3 -0.047 0.054 -0.003 1.4

Birth Order of Child 4 -0.032 -0.036 0.001 -0.6


Age of Mother at Time of Birth 0.095 0.059 0.006 -3.1 -3.1

Head of Household is Female 0.011 0.037 0 -0.2 -0.2

Delivery by Caesarean 0.036 0.449 0.016 -8.8 -8.8 Father is Uneducated 0.018 -0.377 -0.007 3.8 3.8 Mother is Uneducated 0.309 -0.294 -0.091 49.5


Mother’s Secondary Edu . 0.044 0.415 0.018 -10

Father is Working 0.146 0.005 0.001 -0.4 -0.4 Mother is Working 0.065 -0.248 -0.016 8.8 8.8 Risky Birth Intervals 0.279 -0.077 -0.021 11.7 11.7 History of Pregnancy Loss -0.024 -0.022 0.001 -0.3 -0.3 Prenatal one visit -0.013 -0.225 0.003 -1.6

-8.3 Prenatal two visits -0.006 -0.039 0 -0.1

Prenatal three visits 0.29 -0.029 -0.008 4.6

Prenatal four plus visits 0.055 0.372 0.021 -11.2

Poorest 0.072 -0.793 -0.057 31.3

36.3 Poor 0.067 -0.341 -0.023 12.4

Middle 0.034 0.071 0.002 -1.3

Rich 0.024 0.467 0.011 -6.1

Solid cooking Fuel -0.022 -0.325 0.007 -3.9 -3.9 Un Hygienic toilet 0.045 -0.463 -0.021 11.3 11.3 Improved drinking Water 0.111 0.054 0.006 -3.3 -3.3 Rural 0.017 -0.276 -0.005 2.6 2.6 Sindh 0.009 -0.046 0 0.2

6.4

KPK -0.027 0.036 -0.001 0.5

Balochistan 0.013 -0.236 -0.003 1.6

Gilgit-Baltistan -0.003 -0.351 0.001 -0.6

Islamabad -0.015 0.579 -0.009 4.7

Total Observed 94.9 94.9 Residual -0.009 5.2 5.2 Total 100 100

35

36

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Determinants

Decomposition of Concentration Index of Neonatal, Post-

Neonatal and Under-five Mortality,(Pakistan 2012-13)

Neonatal Post-Neonatal Under-Five

CONCLUSION

Findings Indicate that in the socioeconomic Inequality in child morality the major positively contributing determinants are

Economic status

Education

Risky Birth Intervals

Birth order of child

Unhygienic toilets

Living in rural area

Negatively contributing determinants

Delivery by caesarean section

Prenatal visits

Improved drinking water

37

POLICY IMPLICATIONS

Economic Status Eradicate Poverty

Distribution of resources Equality and Need

Maternal Education

Adult Literacy

Improve antenatal care services

Access to Health care services

Invest in water and sanitation infrastructure and

programmes

38

References

Agha, S. (2000). The determinants of infant mortality in Pakistan. Social Science and medicine, 199-208. Retrieved from www.elsevier.com/locate/socsimed

Akram, M., & Khan, F. J. (2007). Health Care Services and Government Spending in Pakistan. PIDE Working Papers.

Alam, A. Y. (2011). Health equity, quality of care and community based approaches are key to maternal and child survival in Pakistan. JPMA Journal of Pakistan Medical Association.

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DECOMPOSING THE SOCIOECONOMIC INEQUALITIE IN CHILD ...pideorgp/pdf/Health... · five MR= 89 (PDHS, 2012-13), Very far from MDGS Target Inadequate literature on child mortality inequality