Author: Vinh Duc Nguyen, Vietnam Academy of Social Sciences
The infant and child mortality rate has declined remarkably in most countries since 1950.
But despite worldwide efforts, the target laid down in the Millennium Development Goals (MDG) — to reduce the under-five mortality rate by two-thirds between 1990 and 2015 — appears to be unachievable, not only at the global level but also in Asia.According to recent UN estimates, the under-five mortality rate in Asia fell by almost half between 1990 and 2011, from 82 to 42 deaths per 1000 live births. At a regional level, the corresponding reductions were from 48 to 15 in East Asia, 76 to 42 in Central Asia, 116 to 61 in South Asia, 69 to 29 in Southeast Asia and 63 to 30 in West Asia. The average annual rate of decline in under-five mortality in Asia in the period from 1990 to 2011 was 3.2 per cent. The regional rate of decline was highest in East Asia (5.4 per cent), followed by Southeast Asia, West Asia, South Asia, and lowest in Central Asia (2.8 per cent). Although the reductions slightly accelerated in the last decade, this pace of decline is not fast enough for Asia and most Asian sub-regions, except East Asia, to achieve their MDG targets in child survival.
At the national level in 2011, under-five mortality rates ranged widely across countries in Asia, from 2.6 deaths per 1000 live births in Singapore and 3.4 in Japan to 54 in Timor-Leste, 72 in Pakistan and 101 in Afghanistan. Only 23 of 49 countries in Asia are on track to meet the MDG target on child survival. Twelve of them, including Bangladesh, Timor-Leste, China, UAE, Mongolia, Laos, Cyprus, Lebanon, Saudi Arabia, Turkey, Oman and the Maldives already achieved this MDG target by 2011. On the other hand, among the countries that had an under-five mortality rate of more than 20 deaths per 1000 live births in 1990, Iraq, DPR of Korea, Uzbekistan, Yemen, Pakistan and Myanmar have the lowest rates of decline in under-five mortality (less than 42 per cent) in the period 1990–2011.
It is worth examining the key determinants of child mortality in Asia. First, levels of socioeconomic development can be a proxy for many causes of child mortality. It seems clear that under-five mortality rates, which vary greatly across Asian countries, are strongly associated with levels of gross national income (GNI) per capita, especially in the groups of the most- and least-developed countries.
But UN and World Bank figures show that the pace of child mortality decline and GNI per capita may not be so strongly related. In the period 1990–2011, marked growths in GNI per capita may have significantly contributed to the steep decline in under-five mortality rates in the Thailand, Singapore, China, Laos, Timor-Leste, Turkey, the Maldives, Oman, and Lebanon but were less effective in Indonesia, Sri Lanka and most countries in Central Asia (Tajikistan, Georgia, Kazakhstan, Turkmenistan, and Azerbaijan). Of the countries with relatively low levels of economic growth, the child survival rate has increased only slightly in Myanmar, DPR of Korea and Iraq, but markedly in Mongolia, Bangladesh and Nepal. It suggests that other factors of socio-economic development may be more important than GNI per capita in influencing the decline of child mortality in most Asian countries.
Fertility and child mortality are related, particularly as demography changes, so it is not surprising that a decline in fertility contributes to the increase of child survival. Previous research confirmed that preceding birth interval, an indicator closely reflecting fertility in many populations, has considerable impacts on child survival. In nine of the twelve Asian countries that already meet the MDG target on under-five mortality by 2011, fertility rates have dropped by more than one-third since 1990.
Socio-economic development promotes child survival primarily because living conditions and access to healthcare improve. For instance, according to the UN, immunisation programs in Vietnam and Bangladesh, as well as the promotion of breastfeeding in Cambodia, have significantly contributed to declines of child mortality in these countries. The remarkable achievement of Mongolia and Nepal in child survival over the last two decades may not be strongly related to national income or educational attainment, but to their improvement of access to clean water and other hygienic conditions. Meanwhile, the slow decline in the under-five mortality rate in Iraq, Myanmar and some countries in Central Asian in the period 1990-2011 may be put down to their national economic conditions and/or their little improvement in education and healthcare. In developed countries, not only clean water and other hygienic conditions but high quality of healthcare and childcare is necessary for the decrease in under-five mortality rates to less than 10 deaths per 1000 live births.
Isolated successes in parts of Asia suggest that it is possible to reduce infant and child mortality rates quickly even without high rates of economic growth. It is reasonable that a decline in fertility rates would increase rates of child survival, especially in countries with relatively high fertility rates. Further investments on primary healthcare and basic living conditions are still necessary, but once a relatively low rate of infant mortality has been achieved such investments have little effect. The decline in child mortality rates will decelerate when countries have relatively low fertility rates, high vaccination coverage, and easy access to clean water. At that stage, the focus needs to shift to improving the quality of education, healthcare and childcare, even if these improvements seem difficult to achieve without extensive economic development.
Vinh Duc Nguyen is Doctor of Demography at the Institute of Sociology, Vietnam Academy of Social Sciences.