Health equity a matter of life, death

While estimates place the death rate at ten people per thousand, it is thought to be up to ten times higher for infants. This, in itself, signals a crisis that needs urgent attention.

But hidden within the averages lies a more alarming tale of social inequality.

As a World Health Organisation (WHO) report released this week shows, there are huge disparities in child death rates between different social groups.

Nairobi has been cited as one of the cities with the highest disparities in the under-five death rate — the probability of a child dying by age five — as a result of poverty. While the rate is below 15 per thousand in high-income areas, thus approaching the national average for people of all ages, in the city’s slums the rate is 254 per thousand.

Only one or two in a hundred of the children of the rich die, while the poor lose one in four.The need for primary healthcare to bridge this shameful disparity cannot be exaggerated.

Interventions such as the widespread provision of treated bednets to prevent malaria in children have gone a long way in reducing child deaths from the disease. But there are huge shortfalls in primary healthcare to be addressed to prevent deaths in other areas. An ongoing crisis over stocks of children’s vaccines and other medicines in public hospitals is symptomatic of this.


A Johns Hopkins University study of child deaths in Kenya found that matters took a turn for the worse in the 1990s.

"After Independence, child mortality (deaths) fell rapidly. Until around 1980, the under five mortality rate... fell at an annual rate of about four per cent.

"This rate of decline slowed in the early 1980s, to about two per cent per annum. Recent data from the 1998 Kenya Demographic and Health Survey showed that, far from declining, the rate increased by as much as 25 per cent from the late 1980s to the mid 1990s.

"This trend coincided with a number of other adverse trends: stagnation in growth of per capita income, declining levels of immunisation, falling school enrolment and the emergence of an HIV/Aids epidemic."

Rolling back these trends need not be a herculean task: The HIV/Aids problem is considered the most probable cause for the rise in child deaths. With initiatives to care for the infected, reduce mother-to-child transmission and stop new infections, we are off to a good start.

Renewed child immunisation drives address the second most important health factor that is considered significant.


Dr Margaret Chan, Director-General of the World Health Organisation, says the inequalities we see here are common to many nations: "The World Health Report (titled ‘Primary Health Care: Now More Than Ever’) looks at the way health care is organised, financed, managed, and delivered around the world. It finds striking inequalities in health outcomes, access to care and what people pay for care. Many problems arise from the way health systems are organised and how resources are managed."

Chan’s prescription is greater emphasis on principles agreed on at the International Conference on Primary Health Care in Alma-Ata in September 1978.

"A primary health care approach is the most efficient, fair, and cost-effective way to organise a health system," she said in a speech released on Tuesday. "It can prevent much of the disease burden, and it can also prevent people with minor complaints from flooding hospitals. Decades of experience tell us that primary health care produces better outcomes, at lower costs, and with higher user satisfaction."

As Government spending on health increases, the emphasis should be on reducing health inequalities by bringing care as close as possible to where people live and work.

Maternal care, particularly for the urban poor and other groups with unusually high death rates, will help reduce the iniquitous disparities WHO reports. All children, rich and poor, deserve a decent chance at life.

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