Child Health Status of Nepal : Social Exclusion Perspective

Introduction: Nepal has achieved a spectacular success in child health over the last decades but the achievement is not uniform across different social groups. Therefore, there is urgent need to identify the groups who are excluded from access of child health services which would give us population at risk to prioritize and utilize the scarce resources available in health sector more effectively and efficiently. Methods: The study was descriptive type and was based on review of secondary data of different studies done in past. The study used World Bank framework of dimension of exclusion to analyze social exclusion in child health in Nepal. The health differentials in child health across different social groups were analyzed using simple descriptive analysis like percentage and ratios. The trends of the child health disparities over the ten years were done comparing the data of NFHS1996 and NDHS 2006. Results: The study showed there were disparities in child health status by ethnicity, location, wealth status. In most of the cases, the trends of disparities are increasing for mortality indicators and malnutrition status. Interestingly, the gaps in accessibility indicators of child health services are becoming narrowed down. Conclusion: This study showed the discrepancies in child health status in different social groups. The inequality in childhood mortality and malnutrition are increasing over the period for different groups where as it is decreasing for accessibility indicators of childhood health services.


Introduction
N epal has achieved a spectacular success in child health over the last decades.Under fi ve mortality is reduced from 118 in 1996 to 61 in 2006.Infant mortality rate is reduced from 79 to 48 during this period.Immunization coverage is increased from 43% in 1996 to 83% in 2006. 1,2The most likely causes of the decline in child mortality are improvement in management of diarrhea and Acute Respiratory Infection (ARI), improved immunization and Vitamin A supplementation 3 .If the present progress continues, it seems likely that Nepal will achieve Millennium Development Goal (MDG) related to child health.However, the achievement is not uniform across different social groups.Therefore, there is urgent need to identify the groups who are excluded from access of child health services.Identifi cation of excluded groups would give us population at risk to prioritize and utilize the scarce resources available in health sector more effectively and effi ciently.Since the interim constitution has proclaimed provision of universal health right 4 , the issues of social exclusion and inequity in health are becoming more pronounced in health sector development of Nepal.This paper tries to critically analyze the child health status of Nepal from social exclusion lens.Social exclusion has been a prominent feature of Nepali history and is rooted in the traditional state and society of Nepal.It is a process through which individuals or groups are wholly or partly excluded from full participation in the society in which they live 5 .

Methods
The study was descriptive type and was based on review of secondary data of different studies done in past.Basically the study did further analysis of Nepal family Health Survey (NFHS)1996, and Nepal Demographic and Health Survey (NDHS) 2006 data to critically analyze social exclusion in child health.Besides, the documents published by Ministry of Health (MOH), United Nation Development Program (UNDP), Department for International Development (DFID) and the World Bank were also reviewed.The electronic journals and reports were accessed using Pub med/Medline and Google scholar to prepare this paper.The study used World Bank framework of dimension of exclusion 6 to analyze social exclusion in child health in Nepal.The framework summarized the dimension of exclusion on following four areas: caste/ethnicity, gender, location and poverty.Location was further divided in to area of residence, ecological zone and development region.This study used main child health indicators-mortality indicators, prevalence of childhood illness, childhood nutritional status, child health service coverage like Vitamin A and immunization coverage as a measure of child health status.The health differentials in child health across different social groups were analyzed using simple descriptive analysis like percentage and ratios.The trends of the child health disparities over the ten years were done comparing the data of NFHS1996 and NDHS 2006.In this study, poorest/wealthiest ratio, rural/urban ratio and female/male ratio were used to summarize the level and trend of inequality over the time period.

Gender
Infant mortality was slightly higher for girls (61) than boys (60).But, under-fi ve mortality rate for girls (78) was lower than boys (80).Similarly neonatal mortality for male was higher (39) than female children (37).There was slight difference in nutritional status of children between male and female children.Prevalence of diarrhea was slightly higher for male (12.8%) than female children (10.9%).Immunization coverage for males was slightly higher (84.9%) than females (80.6%).(Table 1).Gender wise there was no signifi cant difference in Vitamin A coverage, treatment of ARI. 1 In most of the indicators, the gender inequality was reducing except prevalence of diarrhea and medical treatment of ARI and diarrhea.(Table 1)

Location
There was huge gap between urban and rural child mortality rates.Infant mortality for rural and urban area was 64 and 37 respectively.The gap was increasing over the decades with rural/urban ratio 1.56 in 1996 to 1.72 in 2006.The rural/urban inequality was also increasing in case of under-fi ve and neonatal mortality.(Table 2) The stunting for children in rural area was higher (51.1%) than urban area (36.1%) with increasing inequality over the period.(Table 2) Similarly stunting was higher in children from the mountain (62%) than terai terai regions (46.3%).The situation of acute malnutrition was highest in terai (17%).The children in mid western region had highest (58%) and eastern region had lowest stunting rate (40%).Eastern terai had lowest (37%) and Western Mountain had highest stunting rate (67%) 1 .
There was no difference in prevalence of diarrhea and ARI in rural and urban area.Ecological zone wise, the terai region had lower (4%) ARI prevalence than, the mountain regions (6%).Developmental region wise, central region had lowest (4%) and far western had highest ARI prevalence (7%).Prevalence of diarrhea was highest for the mountains (16%) and lowest for the terai (11%).Sub-region wise, mid-western region (7%) had lowest prevalence of diarrhea and eastern mountain region had the highest (23%). 1 Immunization coverage was slightly lower for rural area (82.4%) than urban area (86.3%) but the trend showed that gap to be reducing.The rural/urban ratio in immunization coverage in 1996 was 0.58 which was 0.95 in 2006.(Table 2) Immunization coverage was higher for the terai (86%) than the mountains (71%).Western mountain had lowest (74%) and far western terai (94%) had the highest immunization coverage.Vitamin A coverage was higher for rural areas (89%) than urban areas (81%) where as there was no big difference according to ecological zone and development region. 1

Poverty
Infant mortality rate was highest among the poorest quintile (71) than that in the wealthiest quintile (40).Similarly, under-fi ve mortality rate was highest in poorest quintile (98) than wealthiest (47).There was growing income inequality in child survival: in 1996, infant mortality in the poorest quintile was 50% higher than that in the wealthiest; by 2006 it was 78% higher.Similar trend was observed in under-fi ve mortality.(Table 3) Neonatal mortality rate was highest in poorest (43) than wealthiest (26). 1 Inequality in levels of severe stunting had increased over time, with poorest/ wealthiest ratio was increased over the study period from 1.86 in 1996 to 3.08 in 2006. 9No signifi cant difference in prevalence of ARI and diarrhea was seen between poorest and wealthiest households.Immunization coverage was low for lowest quintile (68%) compared to that in the wealthiest quintile (93.5%).Medical treatment of ARI and diarrhea was high among highest quintile with decreasing gaps over the period.(Table 3) No signifi cant difference in Vitamin A and de-worming coverage was seen between poorest and wealthiest households 1 .

Discussion
The study shows that there is inequality in child health status by cast/ethnicity, poverty, residence, ecological zone and development region.The above results showed that there were disparities in child mortality by ethnic origins, rural/urban, and wealth status.The data also showed the disparities in child mortality is widening over the period for rural/urban and poorest/wealthiest.The gender wise data showed comparatively a low under-fi ve and neonatal mortality among girls children than boys.If we look at the trends,  the gender gap in child mortality is reducing.DHS study conducted at Cambodia showed that at every period, male children experienced higher mortality than female children 10 .The excess mortality among male children is a universal phenomenon presumably due to a higher biological risk of death during the fi rst months of life.Different studies showed discrepancies in child mortality by ethnicity, gender, area of residence and wealth status 10,11,12,13,14,15 .
If we look at the nutritional status of children, the disparities by rural/urban, poorest/wealthiest was existed and the trends of disparities were widening over the period.The situation of stunting in Western Mountain was devastating far above the national average.Terai had high acute malnutrition.There was no data available according to ethnicity.Similarly, there were no marked difference in prevalence of diarrhea and ARI according to rural/urban and wealth status.The prevalence of both child hood diseases was comparatively low among female children.
Finally, when we looked at the accessibility indicators like immunization and Vitamin coverage, mixed results could be seen.There were discrepancies in immunization coverage by ethnicity, gender, location and wealth status.Similar fi ndings were shown by various other studies 15,16 .However, Vitamin A coverage was uniform across all socio-economic groups.Similarly, data on medical treatment of ARI and Diarrhea showed the gaps by rural/urban and wealth status.In all accessibility indicators, the gaps across different social groups were narrowing over the period.
Above fi nding show that, there are disparities in child health status by ethnicity, location and wealth status.In most of the cases, the trends of disparities are increasing for mortality indicators and malnutrition status.Interestingly, the gaps in accessibility indicators of child health services are becoming narrowed down for example immunization coverage, Vitamin A coverage and medical treatment for child hood diseases.The reducing gap in accessibility indicators over the years might be due to the expansion of child health services up to community level in recent times.
This study used data from secondary sources mostly from NDHS and analysis was descriptive in nature.Data on some variables like ethnicity was not adequately available.More in-depth study on the socioeconomic differentials on child health status using standard statistical tools is necessary.

Conclusion
This study showed that there are discrepancies in child health status in different social groups.The inequality in childhood mortality and malnutrition are increasing over the period for different groups where as it is decreasing for accessibility indicators of childhood health services.

Fig 1 :
Fig 1: Disparities in Mortality Rates by Caste/Ethnicity

Table 1 :
Gender differentials in child health

Table 3 :
Wealth Differentials in Child Health Status