HEALTHCARE DESERTS Severe healthcare deprivation among children in developing countries
Summary More than 40 million children are living in healthcare deserts, denied the most basic of healthcare services and left exposed to easily preventable and often fatal diseases. Research by Save the Children using the last DHS Surveys has uncovered healthcare deserts in 25 developing countries around the world, where up to one-third of all children do not receive any of the six essential vaccinations for childhood killer diseases or basic treatment for diarrhoea, one of the main causes of child mortality in the developing world. A new report, Healthcare Deserts: Severe healthcare deprivation among children in developing countries, reveals that: 14% of all children in the 25 countries included in the report live in healthcare deserts In some of the countries included in the report, the numbers of children in healthcare deserts rose at points during the last decade. In Ethiopia 38% and in Nigeria 33% of children are classed as severely healthcare deprived, with the numbers rising from 2000 05 in Ethiopia and 2003 08 in Nigeria. Out of the 25 countries included in this report, India has the highest number of children in healthcare deserts, with 13 million not receiving childhood vaccinations or treatment for diarrhoea. Children are recommended to visit a health worker at least 17 times in their first five years of life, yet many of those living in healthcare deserts will never be seen by a doctor, nurse or midwife. Poorer children are three times as likely to be in a healthcare desert than children from richer households and face a greater chance of dying before their fifth birthday Children from rural areas are also more likely to be in a healthcare desert than those from urban centres. A global shortage of 3.5 million healthcare workers is fuelling the existence of healthcare deserts around the world. According to the World Health Organization, the minimum number of doctors, nurses and midwives required to deliver basic essential health services is 23 health workers per 10,000 people. Most of the 25 countries included in this report fell way below this minimum. Despite the fact that global child mortality rates are falling globally, the existence of healthcare deserts highlights the fact that millions of children remain exposed to life-threatening conditions. It is the poorest who are the most likely to be sidelined. Poorer children are three times as likely to live in healthcare deserts and sometimes three times as likely to die before their fifth birthday than children from richer households. Every child living in a healthcare desert needs to be put in reach of a health worker, trained, equipped and supported to tackle the key causes of child deaths, if the world is to meet the global child mortality targets set out in the Millennium Development Goals. What is a healthcare desert? A healthcare desert is defined as when a child has not received any of the six routine immunisations, including diphtheria, whooping cough and tetanus, or received medical treatment or advice for diarrhoea. New Save the Children research using data from Demographic and Health Surveys, has calculated that one-in-seven children around 40 million live in healthcare deserts in the 25 developing countries included in this report. In some instances healthcare deserts indicate a geographical issue, where areas are too remote to be reached by healthcare services. In most cases the term describes a situation where services are unaffordable, unavailable or of such poor quality that people are not using them. 2
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WHAT IS THE PROBLEM? New Save the Children research has revealed healthcare deserts in 25 developing countries around the world where one-in-seven children an estimated 40 million - are living without even the most basic healthcare services. Access to healthcare and healthcare workers are crucial to keeping more children alive. Diarrhoea, pneumonia and malaria all largely preventable and treatable with adequate medical care account for 40% of under-five deaths with a further 36% of deaths caused by neonatal complications and infections. Thanks to new global initiatives to cut infant deaths, fewer children are missing out on life-saving healthcare. There is now there is now 70% global vaccine coverage for measles and DPT and 40% of children receive recommended treatment for diarrhoea in developing countries. Yet Save the Children has found that 14% of children in 25 developing countries around the world are in healthcare deserts and are not receiving any of the six essential childhood vaccinations or even basic oral rehydration treatment for diarrhoea one of the main causes of child mortality in the developing world. Economic progress has not translated into access to healthcare for these children. All but one of the countries included in this report have registered economic growth in the past five years. India, one of the world s fastest growing economies, has the largest number of children in healthcare deserts an estimated 13 million. In fact in some of the countries included in the report, the number of children in healthcare deserts increased at points during the last decade. In Ethiopia 38% and in Nigeria 33% of children are classed as severely healthcare deprived, with the numbers rising between 2000-2005 in Ethiopia and 2003-2008 in Nigeria. The poorest children are still dying The report also shows a direct connection between poverty, child mortality and a lack of access to vaccines, medical advice and treatment. Poorest children are the most likely to be exposed to disease and bad health through factors like poor housing, lack of safe drinking water and malnutrition. They also have a greater chance of dying before their fifth birthday than children from richer households. In India the under-five mortality rate for the poorest children is three times that of richest. Yet those most at need are the ones most likely to be deprived of basic healthcare. Poor children are three times as likely to be in healthcare deserts than richer children. Children living in rural areas are also more likely to be severely healthcare deprived than those in urban areas. In Liberia children in rural locations are over twice as likely to be living in a healthcare desert than those living in urban areas. Behind the impressive progress that many countries have made in reducing overall child mortality, the report shows that 40 million of the poorest and most vulnerable are being left out of health and vaccination programmes designed to cut childhood deaths. 4
For example, using the last DHS Surveys, Ethiopia and Nigeria show they have cut their overall child mortality rate year-on-year, yet the proportion of children in healthcare deserts rose during the same period. In both countries it is the poor who are those living in healthcare deserts. Healthcare deprivation is concentrated in the bottom 80% of the population in Ethiopia and the bottom 60% in Nigeria. Children from the poorest households in Ethiopia are twice as likely not to have received any vaccines and 1.5 times as likely not to have received any treatment for diarrhoea compared to children from the richest households. In Nigeria children under five years old from rich families were six times more likely to have received vaccines and five times more likely to have treatment for diarrhoea than poor children. These inequalities in healthcare are directly mirrored by inequalities in child survival. Poor children are over twice as likely to die before their fifth birthday in Nigeria and 1.5 times as likely in Ethiopia. Reductions in child mortality were also predominantly in the richer segments of both countries populations. This pattern of inequality is not unique to Ethiopia and Nigeria. Similar trends can also be found in two-thirds of developing countries analysed by Save the Children in a 2010 report, A Fair Chance at Life. Garba* with his three children, in Katsina, Nigeria. Garba s wife died after giving birth. Their twin babies died during the delivery. (* name has been changed) (photo: Pep Bonet/Noor) Healthcare in Ethiopia Ethiopia s child mortality rate halved from the MDG baseline year of 1990 to 2009, from about 20% to about 10%. Yet more than 300,000 young children still die in Ethiopia each year. Based on the last two DHS surveys, the proportion of severely healthcare-deprived children in Ethiopia rose by 14% between 2000 and 2005. The proportion of children who had not received any of the six routine immunisations increased from 24% in 2000 to 32% in 2005, while the proportion of children who suffered from diarrhoea and did not receive medical advice or treatment slightly rose from 50% to 51%. In 2003, however, the government of Ethiopia launched a Health Extension Programme (HEP) aimed at providing good-quality healthcare to all segments of the population, especially to mothers and children. It also aims to train 30,000 health extension workers (HEWs) by 2009 to be deployed in rural areas. By the end of 2007, it had reached more than 50% of the country s villages. A recent evaluation shows that children are now 10% more likely to be fully immunised in those villages covered by the HEP. Therefore, it must be noted that the point-in-time analysis from the DHS does not capture the recent developments in the country s healthcare. The results of the 2010 DHS in Ethiopia will show more conclusively whether access to healthcare has improved since 2005 5
HEALTHCARE WORKERS A global shortage of 3.5 million health workers is feeding the severe healthcare deprivation faced by the 40 million children living in healthcare deserts in the 25 countries analysed by Save the Children. It is extremely difficult to get preventive and curative care to children without the presence of trained and equipped health workers. Although children are recommended to see a healthcare worker 17 times in their first five years, across the world one billion people, including millions of the world s poorest children, will never see a doctor, nurse of midwife in their whole lives and have no access to a functioning healthcare service or facility. According to the World Health Organization, the minimum number of doctors, nurses and midwives required to deliver basic essential health services is 23 health workers per 10,000 people. Most of the 25 countries included in this report fell way below this minimum. Africa accounts for one-third of the world s disease burden but only 3% of the world s doctors, nurses and midwives. In 2008 Liberia had a total of 1,029 doctors, nurses and midwives for a population of 3.9 million people 2.8 health workers per 10,000 people. Guinea has 1,341 health workers working out at just 1.4 health workers per 10,000 people. In Uganda more than two-thirds of children are not immunised against DPT3, a clear sign that they are not having regular access to healthcare workers as the vaccine requires three doses and repeated contact with a health professional. Within countries, the uneven distribution of healthcare workers feeds the existence of healthcare deserts experienced by millions of children. In Liberia children in rural locations are over twice as likely to be living in a healthcare desert than those living in urban areas. The majority of doctors, nurses and midwives are clustered in urban centres, leaving children in poor rural areas isolated from professional healthcare workers. In Ghana there are six healthcare workers for every one health worker outside the capital. On third of all nurses in Bangladesh serve 15% of the population who live in four cities. This has been attributed to poor working conditions for health workers in rural locations, a lack of housing and schooling for their children, poor pay and management and little prospect for career development. Health workers in Sierra Leone (photo: Anna Kari) 6
CASE STUDY: ESTHER AND MAYBE, LIBERIA Esther s son, Maybe, died from pneumonia when he was just one year old. Two weeks earlier he d fallen sick but there are no health services where the family lives. The closest health facility is the Totota clinic in Bong Country, more than two hours walk from their village. As subsistence farmers, Esther and her husband said they had no money to pay for the transport costs of getting there. During the war they fled their village and lived in the bush. When the fighting ended, they returned home and found their house had been burnt and they had lost everything. My child got very sick for two weeks, says Esther. He would get very, very hot and had fast, fast breathing. He would cough at night. I was confused and did not know what to do. I live in the bush. I have no one to help me. Esther s other two children nine-year old Jeremaih and four-year old Tina have never received any vaccines. Before he died Maybe had been given the polio vaccine but had never completed the course. When he fell sick with pneumonia, Esther used traditional medicines to treat her baby but this wasn t enough to save him. After Maybe died Esther pledged to find a way of getting her other children to Totota if they fall sick. The Totota clinic sees up to 80 patients a day, some of whom have walked three hours to reach the facility as there are no health services closer to where they live. The seven staff working at the clinic are all supported by Save the Children and given on-going mentoring. Although Malaria is the biggest problem treated by the staff at the clinic, up to 15 patients arrive with pneumonia every day. Save the Children has also provided motorbikes and cars to help health workers get out to remote villages and farms, and try and treat more children like Maybe who live out of the reach of health services. Vaccines are important, says Esther. When they give a child a vaccine the child is always well. They feel good. It is good for us if they bring the vaccine to us. (photo: Jane Hahn/Panos) 7
CONCLUSION AND RECOMMENDATIONS The world has made impressive progress towards the Millennium Development Goal of cutting child mortality by 2015. Whereas 12 million children a year died in 1990, this number has now fallen to 8 million. Yet while child survival rates may be improving, health programmes continue to benefit easier-to-reach and better-off children first. A vast immunisation gap continues to leave 40 million of the poorest children living in healthcare deserts, exposed to preventable but life-threatening diseases. Addressing the global shortage of 3.5 million health workers, and ensuring that new and existing health workers are properly deployed, trained and equipped to tackle the causes of child mortality, will be critical to ending the current situation in healthcare deserts and achieving the MDGs. Recommendations Donor and governments must ensure that all vaccines reach the poorest children, who are most vulnerable to vaccine-preventable disease, and close the immunisation gap Governments must invest in basic health care and in long term recruitment and training of health workers, providing a living wage and improving the deployment, training and equipment of existing staff. Donors should give more aid, more effectively, to support low-income country governments facing the most critical shortage of health workers. Save the Children works in more than 120 countries. We save children s lives. We fight for their rights. We help them achieve their potential. Contacts: Save the Children, 1 St John s Lane, London, EC1M 4AR Tel: +44 (0)20 7012 6400 Fax: +44 (0)20 7012 6963 savethechildren.org.uk Registered charity England and Wales (213890) Scotland (SC039570) 8