Millions of children's lives are being "cut short" because countries are failing to tackle health inequality, research has found.
The study, published in Nature, mapped death rates at the district level in 99 low and middle-income countries and found that despite the huge progress made in cutting the number of child deaths over recent years, there are still great differences, even within the same country.
The study – the first to map death rates at such a targeted level – found that nearly half of the 5.4 million children under the age of five who died in 2017 would be alive today if countries improved the health of children in their worst performing districts to the same level as the best performing districts.
The number of children dying before their fifth birthday has plummeted in the last 20 years, falling from 9.8 million deaths in 2000 to 5.4 million in 2017.
This fall has been put down to a range of factors including improved maternal and neonatal care, the widespread introduction of vaccines and improvements in the treatment of infectious diseases.
However, the study shows that region and country-level statistics often mask the huge disparities that exist within countries.
Researchers at the Institute for Health Metrics and Evaluation at the University of Washington found that in Vietnam, for example, there was a five-fold difference in death rates between the worst and best performing districts.
One district in Ho Chi Minh City, had a rate of 6.9 deaths per 1,000 births, compared to one of 39.7 per 1,000 live births in a district in the north west of the country.
The district with the highest death rate across all the 99 countries was in the north west of Nigeria, which had an under-five mortality rate of 195 per 1,000 live births.
This inconsistency shows how differences in health policy, access to health care and economic development “ultimately contribute to millions of lives cut short”, the study said.
In 2017, the countries with the highest number of deaths were India, Nigeria and Pakistan. In Pakistan more than half of the deaths took place in just one province, Punjab.
Rwanda made remarkable progress between 2000 and 2017 – the death rate in its best performing district was 144 per 1,000 live births in 2000. By contrast its worst performing district in 2017 had a rate of 57.2.
Despite this success, the worst and best performing districts in Rwanda were the same over the study period.
The study also found that death rates were improving more quickly in older children, meaning that the proportion of deaths in children in the first four weeks of life increased. In 2000 37 per cent deaths occurred in the youngest age group, compared to 43.7 per cent in 2017.
Nathaniel Henry, one of the report’s authors and a geospatial researcher at Oxford University, said improvements for older children were probably due to improved vaccination coverage, better treatment for infectious diseases such as HIV and malaria and improved water and sanitation.
He said researchers had been expecting disparities but not to this extent and said it was due to a range of factors such as poor access to health care, weak governance and long-term structural issues.
He added: “Now we have produced this set of estimates we hope we can connect with in-country experts to start investigating why these disparities exist and what can be done.”
He said that is was hard to pinpoint why such disparities existed but said districts with poor child death rates were likely to have poorer general health.
“There’s a saying in global health that a maternal health is also child health. I wouldn’t necessarily say that there’s a one to one relationship but it’s an important way of understanding health as a whole,” he said.
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