Tracking Progress in Child Survival

Addressing Inequities

Mushtaque Chowdhury, PhDDean, James P. Grant School of Public Health,

BRAC University and

Professor of Population and Family Health,

Mailman School of Public Health, Columbia University

Outline

• Intra-country inequities in health

• Lack of equity focus in health MDGs

• Need for tracking progress for all groups in population, particularly the marginalized

• A road-map for tracking progress

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Vietnam Philippines

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ort

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ty r

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0 Richest 20% Poorest 20%

Source: Victora et al (2004)

Children Under 1 Year of Age Immunized for Different Groups in Bangladesh (1999-2001)

0

10

20

30

40

50

60Pe

rcen

tLow-lying area

Chittagong Hill Tracts

Bangladeshi ownedtea estates

Foreign owned teaestates

National

Source: Chowdhury et al (2002)

Improving Equity Within Countries Would Prevent 40% of All Child Deaths

0% 10% 20% 30% 40% 50% 60% 70% 80%

Bolivia 1998

Egypt 1995-6

Dominican Rep 1996

Guatemala 1995

Nicaragua 1997-8

Cameroon 1991

Bangladesh 1996-97

Pakistan 1990-1

Nigeria 1990

Kyrgyz Rep 1997

Tanzania 1996

Zambia 1996

Kenya 1998

Burkina Faso 1992-3

Chad 1996-7

India 54%

Brazil 41%

Victora C: Analyses based on DHS data

Indonesia 59%

Source: Victora et al (2004)

Assuming that every child has the same mortality level

as the richest 20% in their own country

Health MDGs Lack Equity Safeguard

• Goal 4: Reduce child mortality• Goal 5: Improve maternal health

Does achievement of the goals measures success?

• It is possible to reach the MDGs with little or no improvement of the health condition of the poor (Gwatkin)

“If health is central to poverty reduction, then issues of equity must be central to

health” – UN MDG Task Force on Child health and Maternal health

Need to track progress for all groups in the population, particularly the marginalized

ones.

Pro-poor vs. Pro-equity

• Place of residence (incl. Urban slums)• Religion• Occupation• Gender• Race/Ethnicity• Education• Socio-economic status incl. income• Social capital/NetworthsCourtesy: Tim Evans (WHO)

Tracking Progress in Child Survival for Equity

What Needs to be Done?

Reframe MDG TargetsGoal 4• Reduce by two-thirds, between 1990 and 2015, the under-

five mortality rate, ensuring faster progress among the poor and other marginalized groups.

Goal 5 • Reduce by three quarters, between 1990 and 2015, the

maternal mortality ratio, ensuring faster progress among the poor and other marginalized groups.

• Universal access to reproductive health services by 2015 through the PHC system, ensuring faster progress among the poor and other marginalized groups.

Source: Freedman et al (2005)

Track Indicators for the Marginalized Groups

• MDG Indicators

• Additional indicators including• Newborn mortality

• Access to other services (e.g., reproductive health)

• Quality of care

• Resource allocation

• Health system indicators such as access to EmOC and human resources availability

Link Research to Action• Identify problem areas (e.g., Groups that are

poorly reached)• Initiate action research to find what works• Implement innovative ways to reach the

disadvantaged, and scale up• Study the delivery mechanism on a continuous

basis for further refinements• Report trend in inequities• Do advocacy and activism (e.g., popular writing)

Develop Innovative Monitoring Methods

• Simple

• Rapid

• Reliable

• Replicable

• Affordable

Monitoring Utilization of Health Services by the Poorest in Bangladesh

• A pilot project by MoH, ICDDRB & BRAC• To identify an equity sensitive rapid assessment tool for

day-to-day use by hospital administrators• A community survey establishes % poor and

administrators assess if their patients comprise more or less of this %

• Initial results show most outpatients come from the poorest and richest quintiles

• A challenge is to identify one robust poverty indicator for use by the administrators

Track other MDG Targets that Affect Health

• Poverty (Food security, Microfinance, etc.)• Nutrition• Education• Women’s empowerment• Water & Sanitation• Access to medicines

100 million impoverished annually due to lack of access to healthcare (The income erosion thesis)

BRAC’s Women-focused Poverty Alleviation Programme Reduces Inequity in Child Survival,

Matlab, Bangladesh 1993-1996

0.82

0.84

0.86

0.88

0.9

0.92

0.94

0.96

0.98

1

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0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60

Cu

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Poor BRAC member

Poor non-member

Non-poor non-member

Age in months Source: Bhuiya et al 2001

Track Changes in Capacities

• Capacity to implement programmes

• Capacity to monitor progress

• Coordination

At Country-Level, 1. Start with an exhaustive baseline inequity analysis (data available)2. Continue monitoring child survival with an equity lens (as outlined above)

3. Publish on a 2-yearly basis a report onState of Progress in Child Survival, including simple equity analysis on ‘Who gains how much and why?’

Thank you!