Elsevier

The Lancet

Volume 369, Issue 9564, 10–16 March 2007, Pages 850-855
The Lancet

Articles
Reductions in child mortality levels and inequalities in Thailand: analysis of two censuses

https://doi.org/10.1016/S0140-6736(07)60413-9Get rights and content

Summary

Background

Thailand's progress in reducing the under-five mortality rate (U5MR) puts the country on track to achieve the fourth Millennium Development Goal (MDG). Whether this success has been accompanied by a widening or narrowing of the child mortality gap between the poorest and richest populations is unknown. We aimed to measure changes in child-mortality inequalities by household-level socioeconomic strata of the Thai population between 1990 and 2000.

Methods

We measured changes in the distribution of the U5MR by economic strata using data from the 1990 and 2000 censuses. Economic status was measured using household assets and characteristics. The U5MR was estimated using the Trussell version of the Brass indirect method.

Findings

Average household economic status improved and inequalities declined between the two censuses. There were substantially larger reductions in U5MR in the poorer segments of the population. Excess child mortality risk between the poorest and richest quintile decreased by 55% (95% CI 39% to 68%). The concentration index, measured using percentiles of economic status, in 1990 was −0·20 (−0·23 to −0·18), whereas in 2000 it had dropped to −0·12 (−0·15 to −0·08), a 43% (22% to 63%) reduction.

Interpretation

These findings draw attention to the feasibility of incorporating equity measurement into census data. Thailand has achieved both an impressive average decrease in U5MR and substantial reductions in U5MR inequality over a 10 year period. Contributing factors include overall economic growth and poverty reduction, improved insurance coverage, and a scaling-up and more equitable distribution of primary health-care infrastructure and intervention coverage. Understanding the factors that have led to Thailand's success could help inform countries struggling to meet the fourth MDG and reduce inequality.

Introduction

Over the past five decades there have been substantial improvements in the health of Thai children, with reductions in the under-five mortality rate (U5MR) from above 160 per thousand in the 1950s and 60s to below 40 per thousand by 1990.1, 2 A further 24% reduction from 1990 to 20002 puts Thailand well on track to achieve the Millennium Development Goal (MDG) of a two-thirds reduction in U5MR between 1990 and 2015.3 This is in stark contrast to many other countries, particularly those in sub-Saharan Africa and southern Asia where varied progress towards this target has led to much doubt as to whether the goal can be achieved.4, 5, 6

As the MDGs focus on average levels, one unanswered question is whether the success in reducing the average U5MR has been accompanied by a reduction in the disparity in child health between subgroups of the Thai population. This notion is in line with global calls for routine monitoring of equity in health outcomes.7, 8, 9 Many other countries provide examples of increasing life expectancy and decreasing child mortality while inequalities between the rich and the poor remain10 or worsen.11 Although Thailand has experienced substantial economic growth over the past two decades (with some interruption due to the 1997 economic crisis), income inequality persists at a relatively high level.12 A critical question is how this has affected the distribution of child mortality. Although Thailand might be, on average, set to meet the MDGs for child health, relatively deprived segments of the population might be lagging behind.

We aimed to measure changes in child mortality inequalities by household-level socioeconomic strata of the Thai population using data from the 1990 and 2000 population censuses obtained from the National Statistics Office, Thailand.

Section snippets

Population data

The 1990 and 2000 Thai population censuses were full enumerations of the Thai population. For both censuses, a random 20% sample of households completed a more detailed questionnaire on household characteristics and the analysis conducted here was limited to this sample (table 1).

The data from the Thai census have been used in other studies;2, 13 completeness is very high and quality is regarded to be good.14 The housing and population censuses can be linked through the use of several

Results

Economic status at the provincial level was highly correlated with gross provincial product; Spearman's rank correlation coefficient was 0·87 (p<0·0001) in 1990 and 0·78 (p<0·0001) in 2000. Mean economic status in Thailand increased from 1990 to 2000 and was accompanied by a narrowing of the distribution at the household level (coefficient of variation 0·40 in 1990 to 0·29 in 2000), as shown in figure 1.

Average U5MR was 27·4 (95% CI 26·8 to 28·0) per 1000 livebirths in the 1990 census and 18·7

Discussion

Between 1990 and 2000, in addition to successfully reducing the average level of under-five mortality by about 30%, Thailand approximately halved inequality between the poorest and the richest populations. This remarkable reduction in child-mortality inequality across economic strata is shown by all three measures used in this analysis—the rate ratio, the absolute difference, and the concentration index. The 55% reduction in the excess child-mortality risk between the poorest and richest

References (48)

  • Health and the millennium development goals

    (2005)
  • The Millennium Development Goals report 2005

    (2005)
  • KA Moser et al.

    How does progress towards the child mortality millennium development goal affect inequalities between the poorest and least poor? Analysis of Demographic and Health Survey data

    BMJ

    (2005)
  • Knowledge into action for child survival

    Lancet

    (2003)
  • World Health Organization. The world health report 2000—Health systems: improving performance. Geneva, Switzerland,...
  • AM Balisacan et al.

    Inequality in Asia: a synthesis of recent research on the levels, trends, effects and determinants of inequality in its different dimensions

    (2006)
  • D Bohning et al.

    Analysis of geographical heterogeneity in live-birth ratio in Thailand

    J Epidemiol Biostat

    (1999)
  • Suwee W, Santipaporn S. Utilization of the 2000 population and housing census of Thailand. 20th Population Census...
  • BD Ferguson et al.

    Estimating permanent income using indicator variables

  • AR Hosseinpoor et al.

    Socioeconomic inequality in infant mortality in Iran and across its provinces

    Bull World Health Organ

    (2005)
  • R Pongou et al.

    Health impacts of macroeconomic crises and policies: determinants of variation in childhood malnutrition trends in Cameroon

    Int J Epidemiol

    (2006)
  • Gross provincial product, 2004 edn

  • Manual X: indirect techniques for demographic estimation

    (1983)
  • AJ Coale et al.

    Regional model life tables and stable populations, 2nd edn

    (1983)
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