Statistical Yearbook for Asia and the Pacific 2011
 
People - Health
Child health
Data sources: WHO Global Health Observatory Database (WHO/GHO), World Health Statistics. UN MDG Indicators Database.

The likelihood of a child born in Asia and the Pacific surviving beyond his or her fifth birthday has improved dramatically over the past two decades. However, wide disparities still exist at the country level, and child mortality rates remain stubbornly high in a large number of countries in the region.

The under-five mortality rate (U5MR) in Asia and the Pacific was reduced from 86 per 1,000 live births in 1990 to 49 per 1,000 in 2009. While this is an impressive improvement, many countries are unlikely to achieve Millennium Development Goal 4 (MDG-4), which targets a two-thirds reduction in U5MR between 1990 and 2015.

The infant mortality rate (IMR – an approximation of the number of deaths per 1,000 children born alive who die within their first year) was reduced by over one third, from its 1990 level of 63 deaths per 1,000 live births to 38 in 2009, slightly better than the world average of 43. The Asia-Pacific region thus falls between Africa, with an IMR of roughly the double, and Latin America and the Caribbean, with an IMR of roughly half that of Asia and the Pacific.

The most disturbing IMR and U5MR in the Asia-Pacific region occured in South and South- West Asia at 52 and 69, respectively, in 2009. Although considerately above the Asia-Pacific average, the rates are still lower than the average rates of Africa; and they represent remarkable improvements of 40% and 43% respectively since 1990.

At the other end of the spectrum, East and North-East Asia registered the lowest IMR, at 16, in the region and the lowest U5MR, at 18, in 2009. North and Central Asia had an IMR of 22 and U5MR of 24. Notably, both subregions have reduced their rates by more than or almost half since 1990.

Figure I.10 – Infant mortality rate, Asia and the Pacific, 1990 and 2009

Figure I.10 – Infant mortality rate, Asia and the Pacific, 1990 and 2009

Not surprisingly, the low and lower middleincome countries have higher IMR and U5MR, in general, illustrating how death rates among infants and children are critically related to a country’s economic progress.

Variations in IMR and U5MR are seen across subregions as well as among countries within subregions. The average IMR for the entire Asia-Pacific region has been reduced by 39% from its 1990 level. Whereas East and North-East Asia shows the largest reduction at 54%, the Pacific subregion has reduced its rates only by 21%. Although the Pacific has seen only moderate improvements in IMR and U5MR during the past two decades, the Pacific region had the lowest IMR in 1990 and is still much below the regional average as of 2009. However, there are some alarming cases in the Pacific, such as Nauru which experienced a threefold increase in IMR between 1990 and 2009. In the Asia- Pacific region, Afghanistan is an outlier with the highest IMR in 2009, at 134; although this is an alarmingly high rate, it still represents a reduction of 20% from the 1990 level of 167.

Notably, a few LDC and LLDC countries have already achieved the MDG-4 target in reducing their U5MR by two-thirds; specifically, Mongolia (101 to 29), Timor-Leste (184 to 56), and the Maldives (113 to 13). One reason behind such impressive gains is that those countries had very high rates in 1990 that benefitted from successful delivery of key child-survival interventions. The extraordinary success of Maldives deserves mention – it is the only country in Asia and the Pacific to have reduced child mortality by nearly 90%. Although some countries are likely to achieve the MDG-4 target, many still lag far behind, particularly in North and Central Asia and in the Pacific.

Across Asia and the Pacific, U5MR has been reduced by a remarkable 43%. However, disparities exist at the subregional and country levels. Asian subregions registered a 43-58% reduction (depending on the subregion), while the Pacific subregion reduced its rate by only 22%. The U5MR in East and North-East Asia countries ranged from 3 (Japan) to 33 (Democratic People’s Republic of Korea) in 2009.

Overall, the lowest U5MR levels (below 10) in the region occur in Australia, Brunei Darussalam, Japan, Malaysia, New Zealand, the Republic of Korea, and Singapore. The highest U5MR (likewise the highest IMR) is found in Afghanistan – a shocking 199 per 1,000 live births. This statistic stands in contrast to the three next highest, which are an order of magnitude below that of Afghanistan: Cambodia (88), Pakistan (87) and Bhutan (79).

Figure I.11 – Under-five mortality rate, Asia and the Pacific, 1990 and 2009

Figure I.11 – Under-five mortality rate, Asia and the Pacific, 1990 and 2009

Nutrition

Child health, survival and development are causally and directly linked to nutritional status. The evidence to date suggests that reducing malnutrition levels will reduce child mortality. That relationship is explained by a complex set of variables, including underlying factors related to poverty, including food security, care of children, health services and environmental conditions. The prevalence of underweight children under 5 years of age is a key measure of malnutrition, and is one of the nine indicators used in monitoring progress towards the MDG-1 target of eradicating extreme poverty and hunger.

Unfortunately, data on the prevalence of underweight children is not available at regular time intervals for most Asia-Pacific countries. Conclusions based on this data are hence difficult to make.

In Asia and the Pacific, progress has been limited in reducing the prevalence of underweight children. However, based on available data, 10 countries have seen a 30% or more decrease in the proportion of underweight children (Bangladesh, China, Islamic Republic of Iran, Kazakhstan, Malaysia, Mongolia, Thailand, Turkey, Uzbekistan and Viet Nam).

South and South-West Asia has the most countries with a high prevalence of underweight children. Four of ten countries in the subregion have a prevalence of underweight children of 40% or more, Afghanistan (40% in 2004), Bangladesh (46% in 2007), India (48% in 2005) and Nepal (45% in 2006). Outside South and South-West Asia, only one country has a prevalence of underweight children of more than 40%: Timor-Leste (49% in 2007).

Keep in mind, that such estimates must be interpreted with caution, owing to the limitations of recent data, particularly at the country level. Nonetheless, the seriousness of the issues is clear. Data aggregated by economic grouping demonstrate an obvious pattern of higher-income countries showing better progress and lower levels than countries in lower-income groupings.

Figure I.12 – Children under 5 underweight, Asia and the Pacific, earliest and latest

Immunization

In the struggle to improve child mortality rates, a powerful preventive measure is availability of, and access to, effective immunizations. Vaccinepreventable childhood diseases include measles, polio, hepatitis B, diphtheria, pertussis, and tetanus. Vaccines for diphtheria, pertussis and tetanus are administered together in a combination called DPT; the third and final dose of this vaccine, DPT3, is considered the best population-based measure of children reached with routine childhood immunizations. In Asia and the Pacific, DPT3 coverage has been high for the past decade; the coverage in 2009 was 83% (when the global average was 82%), up from 79% in 1990. The best performing subregions are East and North-East Asia (97%) and North and Central Asia (96%), followed closely by South-East Asia (88%) where the rate has improved remarkably from 75% in 1990.

The most stubborn DPT3 immunization rates are in South and South-West Asia; these are low as a direct consequence of the decline in DPT3 immunization coverage in India, which currently stands at 66%, down from 70% in 1990. All other countries in the subregion have seen an increase in DPT3 immunization.

Other low performers in the Asia-Pacific region, with DPT3 coverage below 70%, are the Lao People’s Democratic Republic (57%), which has raised its coverage notably from 18% in 1990, and the Pacific island countries of Papua New Guinea (64%), Palau (49%) and Vanuatu (68%), all of which have registered declining coverage rates.

The proportion of children 1 year old or younger immunized against measles is a standard MDG-4 monitoring indicator. Measles is highly contagious; and in order to prevent devastating outbreaks, immunization coverage rates must be consistently high. The global measles elimination goal is that countries must achieve 95% coverage of measles vaccine. In Asia and the Pacific, the percentage of children 1 or under who were vaccinated against measles in 2009 was 83%, which is much below the recommended 95%. The subregions of South and South-West Asia (at 76%), the Pacific (80%) and South-East Asia (88%) are still more than five percentage points below the 95% recommendation. As observed in DPT3 data, India has a high percentage of unvaccinated children; only 71% of children 1 or younger are vaccinated against measles.

Functional national childhood immunization programmes are considered an egalitarian publichealth service provided to all classes of people in developing countries. Immunization rates are therefore a good indicator of the extent of inequalities that prevail in any given area/country. In terms of economic status, the population in the poorest quintile in Asian and Pacific countries generally had much lower rates of measles immunization coverage than those in the richest. Specifically in India, the immunization rate of the poorest quintile was 40% (the lowest in the Asia- Pacific) while the immunization rate of the richest quintile was 85% (a level similar to many other Asia-Pacific countries).

Causes of Under-five Mortality in Asia and the Pacific

In Asia and the Pacific, the major causes of child mortality are largely preventable; yet, in 2008, over 3 million infants and an additional 0.6 million children under 5 continued to die each year1. The Child Health Epidemiology Research Group of WHO and UNICEF have comprehensively reviewed the causes of child mortality worldwide and produced evidence-based estimates related to time and cause of child mortality for each country for 2008. Based on this research, two out of every five child deaths (38.4%) occur during the neonatal period, from birth to 28 days of life. Those deaths were the result, in descending order, of preterm birth complications (14.4%), birth asphyxia (11.4%), neonatal sepsis (6.9%), congenital abnormalities (5.0%), and neonatal tetanus (0.7%). Neonatal deaths are closely linked to maternal deaths that in turn are related to standards of antenatal care and whether skilled health providers attend childbirth. Maternal and child health programmes need to be directed at both the pregnant mother and the newborn in order to improve these indices.

Pneumonia and diarrhoea cause 19.5% and 13.1%, respectively, of under-five mortality after the neonatal period (including neonatal deaths due to those diseases), representing a huge unfinished agenda. Together they account for 1.26 million or about one third of all child deaths in the Asia-Pacific region. These leading killers of children are largely preventable with simple and effective interventions such as antibiotics for pneumonia and oral rehydration solutions for diarrhoea. Yet public health systems in many countries struggle to deliver timely interventions to a large proportion of their child populations. Access, especially for the most deprived, is a result of both supplyand demand-side barriers that need to be overcome.

Childhood diseases such as measles, pertussis and meningitis that are preventable by existing vaccines account for another 6.8% of the under-five deaths in Asia and the Pacific – despite routine childhood immunization programmes that operate in all countries. An additional proportion (13.5%) of under-five deaths is caused by a variety of infectious diseases, likely reflecting poor socio-economic status and harmful environmental conditions, compounded by lack of health service access. Two such diseases, malaria and HIV, cause 0.8% of child deaths – in contrast to the situation in Africa, where they cause 20% of child deaths. Finally, childhood injuries as a result of drowning and other accidents are an important preventable cause of under-five deaths comprising 4.3% of the U5MR burden. Although under-nutrition, which includes stunting, severe wasting, and deficiencies of vitamin A and zinc, is not presented as a direct cause of death in these statistics, it has been found to be an underlying cause of under-five deaths. Inadequate breastfeeding is often part of the under-nutrition problem.

Under-five deaths by cause, Asia and the Pacific, 2008

Under-five deaths by cause, Asia and the Pacific, 2008


Notes: All countries in the Asia-Pacific region for which data are published were grouped together for this analysis; the countries without data are the Pacific island countries or areas of American Samoa, French Polynesia, Guam, New Caledonia and Northern Mariana Islands. The “other infections” category includes some deaths due to preterm birth complications, birth asphyxia, and other prenatal causes.

1 The data in this text box is from: Black, Robert E., and others (2010). Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet, 375: 1969-87.
 
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