Fast track — ArticlesInequities among the very poor: health care for children in rural southern Tanzania
Introduction
Health inequities occur at many levels: between regions of the world, between countries in regions, between provinces or states in countries, between districts, towns, or cities in provinces, and between social groups. Sub-Saharan Africa has the poorest overall health indicators of any region of the world.1 Its estimated under-5-year mortality rate of 173 per thousand live births is almost twice that of south Asia, the second-highest mortality region, and nearly 30 times higher than the rate in developed countries.2 Furthermore, uniquely among world regions, child mortality rates in sub-Saharan Africa seem to be increasing, partly because of AIDS, but also because of other diseases.3
In spite of this disturbing picture, few studies have been done to assess socioeconomic inequities in health in African countries. Such studies have important policy and programme implications. We searched Medline and found only 102 articles on equity or inequity in Africa, compared with 1151 in the Americas. Of these articles, virtually all had to do with equity issues relevant to health-sector reform and financing, or with inequities in South Africa, especially between ethnic groups. None of the studies described inequities in health outcomes or care-seeking behaviour in rural child populations. We use the term care-seeking following the usual convention, for what might better be termed care-obtaining: the part of health-seeking behaviour that is successful in obtaining the help that is sought.
The World Bank's health, nutrition, and population programme has supported re-analysis, focused on inequities, of the results of demographic and health surveys in several African countries.4 These analyses include urban and rural populations, often showing important differentials between richer and poorer households in mortality, nutrition, and care-seeking behaviour. The results, however, have not been widely disseminated to a public health audience. The apparent lack of interest on equity issues in Africa by health researchers might arise from the erroneous perception that families living in rural villages are fairly homogeneous with respect to socioeconomic status. In rural Africa, signs of social or economic stratification are often hard for outsiders to recognise. For example, most houses are fairly simple constructions and inequalities in land tenure are not obvious.
Health inequity refers to health inequalities that are unjust according to some theory of social justice. Thus, the study of health equity involves a value judgment.5 Awareness is increasing of the importance of development efforts that not only improve the overall burden of disease, but also measure the proportion of this burden borne by poor people and the difference in burden between rich and poor. The aim of these efforts is to work towards keeping inequity to a minimum while health problems are tackled through new initiatives.
Baseline community surveys of families with young children are being done in three countries as part of the multicountry evaluation of the integrated management of childhood illnesses (IMCI) strategy.6 IMCI combines prevention and treatment of the most common childhood illnesses into simple guidelines and messages for use in health facilities and households. Countries adapt these guidelines to meet their needs, and use them to train health workers, improve supervision, ensure essential drugs are available, and mobilise families and communities in support of child health. In a household survey in Tanzania of children younger than 5 years, we aimed to assess inequalities in the use of child health-care services with respect to sex and socioeconomic status in two districts in the early phase of IMCI implementation and in two others without this programme.
Section snippets
Study area
Kilombero, Morogoro Rural, Rufiji, and Ulanga Districts are in southern Tanzania (6–8° south, 36–39°east) and have a total population of about 1·2 million people.7 Kilombero and Rufiji are low-lying (<300 m above sea level) and much of the land is in the fertile flood plain of the Kilombero and Rufiji rivers; Morogoro Rural and Ulanga have mountainous areas as well as low-lying plains. There are two main rainy seasons, October–December and February–May. There is a broad mix of ethnic groups:
Results
The survey included 2246 households in 115 rural clusters in four districts: 21 households (1%) refused to take part, a further 137 (6%) were unavailable for interview. 1321 (63%) of the remaining 2088 households had one or more children under 5 years. 2006 children were included in the main analysis, of whom 1008 (50%) were boys and 489 (24%) were infants (table 1). The sample of children was broadly representative of the population7 with regard to age and sex (data not shown).
In the 2 weeks
Discussion
In a very poor area of rural Tanzania, with high morbidity and mortality rates, our results suggest that the main difference between the poorest children and those who are better off is not in the likelihood of falling ill, but in the probability of obtaining suitable treatment once ill. Carers of children from wealthier families had better knowledge about danger signs, were more likely to bring their children to a health facility when ill, and were more likely to have had a shorter journey to
References (19)
- et al.
Mortality by cause for eight regions of the world: Global Burden Of Disease Study
Lancet
(1997) - et al.
Meeting international goals in child survival and HIV/AIDS
Lancet
(2002) State of the world's children 2001
(2000)- et al.
Socioeconomic differences in health, nutrition and population in Tanzania. World Bank
The concepts and principles of equity and health
Int J Health Serv
(1992)Integrated approach to child health in developing countries
Lancet
(1999)Population and health in developing countries. Vol 1: population, health and survival at INDEPTH sites
(2002)National health accounts: draft final report
(2001)World development report 1997: the state in a changing world
(1997)
Cited by (341)
Economic-related inequalities in child health interventions: An analysis of 65 low- and middle-income countries
2021, Social Science and MedicineImpact of out-of-pocket medical expenditure after major illness in the family on food consumption of a household
2023, Nutrition and Food ScienceCurrent status, utilization, and geographic distribution of MRI devices in Jordan
2023, Applied Nanoscience (Switzerland)Poor Adherence to the Integrated Community Case Management of Newborn and Child Illness Protocol in Rural Ethiopia
2022, American Journal of Tropical Medicine and Hygiene
Other members listed at end of paper