Determinants of under-5 mortality among the poor and the rich: a cross-national analysis of 43 developing countries.
BACKGROUND
Under-5 mortality is unacceptably high in many countries, the burden of which is mainly borne by the poor. Whereas country characteristics are known to influence under-5 mortality, it is unknown whether these have a different impact on the poor and the rich. We aimed to describe how the association between under-5 mortality and socioeconomic, political, and health care factors varies in strength between richer and poorer children.


METHODS
Cross-national analysis of 43 developing countries using wealth-group specific under-5 mortality rates as outcome. Relative effects were estimated using OLS regression; differences in associations between wealth groups were tested.


RESULTS
Higher national incomes were associated with lower under-5 mortality rates. This association was significantly weaker for the poor compared with the rich (P = 0.014). Ethnic fragmentation was significantly more strongly associated with higher under-5 mortality among the poor compared with the rich (P = 0.027). The association between public spending on health and under-5 mortality was stronger for the poor (P = 0.0001). Skilled delivery attendance and immunization coverage among the poor were significantly more strongly related to public spending on health than such health care use among the rich (P = 0.0001 and P = 0.045, respectively). No differentials in the relative effect of female literacy, democracy, and state strength were observed.


CONCLUSIONS
Our results suggest that economic growth is associated with widening poor-rich disparities in under-5 mortality. Increased public spending on health might partly remedy this effect.
Houweling
Tanja A J
TA
Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands. a.houweling@erasmusmc.nl
Caspar
Anton E Kunst
AE
Looman
W N
WN
Mackenbach
Johan P
JP
D046688:Child Mortality; D002675:Child, Preschool; D003906:Developing Countries; D004522:Educational Status; D005006:Ethnicity / Q000706:statistics & numerical data; D005260:Female; D005102:Health Expenditures / Q000706:statistics & numerical data; D006306:Health Surveys; D006801:Humans; D007114:Immunization / Q000706:statistics & numerical data; D007182:Income / Q000706:statistics & numerical data; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D008297:Male; D011057:Politics; D011203:Poverty / Q000706:statistics & numerical data; D012959:Socioeconomic Factors