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Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping:
A Framework for Discussion
Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping:
A Framework for Discussion
Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping: A Framework for Discussion
PAHO HQ Library Cataloguing-in-Publication Data ********************************************************************************* Pan American Health Organization. Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping: A Framework for Discussion. Washington, DC : PAHO, 2013. 1. Adolescent. 2. Reproductive Health. 3. Vulnerable Populations. 4. Risk Groups. I. Title. II. Salud Mesoamrica 2015 Initiative/InterAmerican Development Bank III. Joint United Nations Programme on HIV/AIDS (UNAIDS). IV. United Nations Population Fund (UNFPA). V. United States Agency for International Development (USAID). VI. World Bank. VII. Ellen Wasserman. ISBN 978-92-75-11779-8 (NLM Classification: WA 310.1
The Pan American Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and inquiries should be addressed to the Department of Knowledge Management and Communications (KMC), Pan American Health Organization, Washington, D.C., U.S.A. (pubrights@paho.org). The Family, Gender and Life Course Department/Healthy Life Course Unit will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. Pan American Health Organization, 2013. All rights reserved. Publications of the Pan American Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights are reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the Pan American Health Organization concerning the status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the Pan American Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the Pan American Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the Pan American Health Organization be liable for damages arising from its use.
Acknowledgments
This publication was made possible thanks to the collaboration of colleagues from numerous technical areas and agencies. Acknowledgment is due to: The Joint United Nations Programme on HIV/AIDS (UNAIDS): Andrea Boccardi Vidarte, Ruben Antonio Pages, Claudia Velasquez. Pan American Health Organization/World Health Organization (PAHO/WHO): Gisele Almeida, Amanda Browne, Mnica Alonso Gonzales, Steven Ault, Sonja Caffe, Mario Cruz, Carolina Danovaro Alfaro, Adrin Daz, Pablo Durn, Jos Antonio Escamilla, Rubn Grajeda, Alejandro Giusti, Reynaldo Holder, Chessa Lutter, Sukhna Matharu, Philippe Monfiston, Bremen De Mucio, Oscar J. Mujica, Ajibola Oyeleye, Carmelita Luca Pacis, Freddy Prez, Mara Dolores Prez-Rosales, Patricia Ruz, Martha Saboy, Carlos Samayoa, Antonio Sanhueza, Patricia Soliz Sanchez, Gina Tambini, Renato Tasca, Lauren Vulanovic. Salud Mesoamrica 2015 Initiative/Inter-American Development Bank: Emma Margarita Iriarte Carcamo. The United Nations Population Fund (UNFPA): Alma Virginia Camacho. United Nations Childrens Fund Regional Office for Latin America and the Caribbean (UNICEF/TACRO): Enrique Paz. The United States Agency for International Development (USAID): Peg Marshall, Susan Thollaug, Vernica Valdivieso. The World Bank: Amparo Gordillo Tobar. Team Leader: Christopher Drasbek, PAHO/WHO Author: Ellen Wasserman, PAHO/WHO consultant Design/Layout: Bola Oyeleye PAHO/WHO Miki Fernndez
Contents
Executive Summary v Introduction 3 PART I. THE COIA INDICATORS: WHERE WE STAND Indicator 1. Maternal mortality 8 Indicator 2. Child and neonatal mortality 11 Indicator 3. DPT3 among 1223 month old children 13 Indicator 4. Childhood stunting 14 Indicator 5. Increase the proportion of demand for family planning satisfied (met need for contraception) 17 Indicator 6. Antenatal care coverage at least four times during pregnancy 18 Indicator 7. Antibiotic treatment for suspected pneumonia in children under 5 years of age 18 Indicator 8. Postnatal care for mothers and babies within two days of birth 18 Indicator 9. Antiretroviral (ARV) prophylaxis among HIV-positive pregnant women to prevent HIV transmission and antiretroviral therapy for women who are treatment-eligible 19 Indicator 10. Increase the proportion of births attended by a skilled attendant 19 Indicator 11. Increase the proportion of newborns who receive exclusive breastfeeding for the first six months 21 PART II. EQUITY MAPPING, A FRAMEWORK FOR DISCUSSION Universal health coverage 26 Categories of socioeconomic disparities 27 Challenges in data generation and analysis for informed decision-making 29 Improving participation in health systems and inclusion in national policy design 31 Identifying strategic shifts needed to reduce inequities 32 References 35
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Pan American Health Organization
Executive Summary
he following review of evidence has been prepared for the A Promise Renewed meeting in Panama in September 2013, to help frame discussions and inform subsequent policy design. The review applies an equity focus to assess progress on indicators chosen by the Commission on Information and Accountability (COIA) for Womens and Childrens Health (1). The Commission met in 2010, reviewed the Millennium Development Goals (MDG) for maternal and child health set for 2015, and evaluated the available evidence. Commission members then selected and recalibrated 11 indicators to enable intensified tracking and reporting in a handful of countries (COIA countries) where reproductive, maternal, and child health were in danger of falling behind. That set of COIA indicators, which we apply to the Region as a whole in this review, includes three that assess progress in terms of impact on overall health status (maternal mortality, under-5 and neonatal mortality, and stunting in children under 5 years of age) and eight that track advances in service coverage. The COIA indicators are directly relevant to renewed efforts to improve child health through the global A Promise Renewed campaign. As we quickly approach the 2015 deadline for achieving the Millennium goals, this review presents a timely, evidence-based appraisal of where we stand, areas of progress, remaining challenges, and setbacks for the 11 key indicators. Also, in addition to reporting findings for the indicators, this review addresses the underlying challenge of data quality and use. It identifies persisting critical data issues in the Region, including the need for better standardization and completeness of data gathering to allow comparison across groups, geography, and over time, and improved data analysis to guide programs and policy. Without quality data and systematic analysis, evidence-based strategic policy design and resources deployment is not possible. Notwithstanding the need to improve information systems, the American Region now has enough of an evidence base to recognize distinct patterns of variability in outcomes, services, and systems that reveal systematic inequities among groups of people. Indeed, the evidence of stark health
inequities in the Region has been mounting for decades. The structural nature of these inequities adds a strong human rights dimension to the aim of improving the quality of health for women and children throughout their life course in keeping with a strategy of universal health coverage. Innovative approaches have now worked in enough countries across the Region that there is evidence, too, that policy commitment and creative integration of program strategies do succeed in establishing effective models based on a healthy life course approach with equity and universal health care as its compass. This review demonstrates the urgent need for a careful mapping of the landscape of barriers to equity and identifying the paths to overcome them. It is expected that this review will inform discussion at the A Promise Renewed meeting for
the American Region and the development of both regionwide and country roadmaps. With appropriate adaptations, this review may also be used at the national and subnational levels to guide tracking and to consolidate evidence in the technical and legislative facets of the A Promise Renewed campaign. In these ways, the information presented here is intended to contribute to a renewed mobilization to end of preventable child and maternal deaths and enhance the longevity and quality of life of women and children in our Region. These are formidable goals. Going forward, the agencies that sponsored the meeting and are signatories to the Panama Declaration are committed to work in close and sustained partnership with governments, other agencies, and the private sector to marshal the political will and resources to achieve them.
vi
Introduction
Introduction
any countries in the Americas have made marked progress in stopping the needless, preventable deaths of women and children, yet too many of these deaths continue to occur. This is happening mainly because they are poor, from ethnically or other socially and politically excluded groups, or for some other reason have insufficient access to enough food, safe water, clean surroundings, and quality health services that are already in operation and available to others in the same country. The number of women and children whose lives are cut short for want of access to the know-how and resources available has shrunk thanks to a concerted effort to stop this preventable tragedy. But despite the overall economic improvement in many countries, there are gaping differences in the distribution of wealth, life expectancy and quality of life between them. And no matter how improved its national average, almost every country has subgroups of its population that fare as poorly as those in countries that remain at the low end of the social and economic development spectrum. The obstacles to saving women and childrens lives and improving their quality of life are modifiable and their persistence need not be insurmountable. To secure the drive to stanch the loss of thousands of the Regions next generation, delegations from some 30 countries backed by a partnership of bilateral and international agencies and civil society organizations is publicly joining forces at the A Promise Renewed meeting in Panama from 10 to 12 September 2013. Participants will renew their pledge to safeguard the advances in reproductive, maternal, neonatal, infant, and child health achieved to date, review the evidence available, and pinpoint the gaps in access and coverage that must be addressed. The work plan laid out in Panama will interpret the evidence available and devise strategies to achieve established goals according to a set of criteria that reflect the larger landscape where inequities prevent access to universal integrated, life-course coverage by health and other services. Meanwhile, acknowledging that progress takes concerted political will to ensure backing and accountability for the technical commitment, the ministries of health of the Americas have begun to create or enhance legal and policy frameworks for the human rights protections needed to ensure an Integrated Child Health approach. In September of 2012, the governments of the Region passed a resolution mandating PAHO/WHO to lead the monitoring of compliance with this effort. The approach follows the precepts of a continuum of care in an integrated healthy life course view
of child development and advocates for the human rights of children and women by taking into account the effects of social exclusion based on gender, ethnicity, income position, and other inequities that are underlying causes of the unequal distribution of preventable mortality and disability. The focus challenges constraints that prevent women, their babies and children of all social groups from living as long and healthily as their more privileged fellow citizens, and in so doing endorses the active role of health in social development. Cooperative work on integrated life course development therefore becomes the health core around which equitable social development is constructed.
Where we stand now

The 11 indicators selected by the Commission on Information and Accountability for Womens
and Childrens Health in 2010 include three that aim to assess progress in impact (maternal mortality, under-5 and neonatal mortality, and stunting) and eight meant to track advances in service coverage. The American Region has made large strides in improving the health of its women, infants, and children and is on track to meet the regionwide goals set for 2015. In fact, if the countries of the hemisphere stay on course with the current annual rates of improvement for selected indicators, regional averages will surpass many of the achievement aims. This is not true, however, for all indicators, and the inadequate rate of improvement for some must be accelerated across the Region. Nor will every individual country attain goals that the Region as a whole will meet. Moreover, even within countries that are on a par with the regional averages, there are geographic areas and population subgroups that are lagging behind (2).
Indicators for Maternal, Neonatal and Child Health*

Maternal Mortality ratio (75% reduction from 1990 by 2015).
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Under-five child mortality (two thirds reduction from 1990 by 2015). Track the proportion due to newborn deaths. Increase coverage of 3 doses of combined diphtheria-tetanus-pertussis (DTP3) immunization coverage in 12 to 23 month-old infants. Reduction by 50% of prevalence of stunting in children under 5 years of age. Increase the proportion of demand for family planning satisfied (met need for contraception). Antenatal care coverage at least four times during pregnancy. Antibiotic treatment for suspected pneumonia in children under 5 years of age. Postnatal care for mothers and babies within two days of birth. Antiretroviral (ARV) prophylaxis among HIV-positive pregnant women to prevent HIV transmission and antiretroviral therapy for women who are treatment-eligible. Increase the proportion of births attended by a skilled attendant. Increase the proportion of newborns who receive exclusive breastfeeding for the first six months.
*Commission on Information and Accountability for Womens and Childrens Health 2011.
Policy Indicators for Integrated Child Health (ICH)

Strategy and Plan of Action Indicators of progress in national plans, laws and community mobilization to protect and enhance childrens health, rights, and development: Number of countries that have established a national ICH policy, strategy, or plan consistent with their legal frameworks and regulations. Number of countries with an ICH program that have a medium- to longterm plan of action, with resources allocated and a focal person assigned. Number of countries that have a national policy, strategy, or plan for strengthening the capacity of the health system to scale up effective ICH interventions.
Number of countries with ICH programs that have developed technical guidelines and norms based on PAHO/WHO models. Number of countries with an established and operational human resource and management training program for ICH. Number of countries implementing ICH evidenced-based interventions using PAHO/WHO tools and materials. Number of countries with established mechanisms and/or strategies for promoting community participation for the implementation of intervention-based ICH programs. Number of countries that have an operational plan to scale up and extend to new districts the community and family component, which promotes parenting skills, social mobilization, and community participation in ICH. Number of countries with a national information system that delivers annual information on ICH indicators and data.
The quantity and quality of data gathered and analyzed to determine trends and assess progress are variable and a vast body of literature on how to streamline and improve the process is emerging. In the meantime, decisions must be made based on the information available. The tracking data currently on hand provide a sufficient evidentiary basis to reach some conclusions about the uneven achievement of the goals. They also point to a critical feature that will shape progress to come: the reporting and analysis of the necessary data are incomplete and often do not reflect a uniform interpreta-
tion of the indicator criteria. Incomplete as they may be, however, the tracking data sketch the contours of the task ahead, and point to underlying conditions that demand cross-sectoral attention if the health goals are to be met. The health indicator data available today therefore point to critical areas of social and political investment while simultaneously providing the footing necessary to hone in on specific improvements the surveillance and analysis systems require. Improving these systems in turn will enhance accountability and precision in policy design and resource allocation.
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Dario Vulanovic
Part I The COIA Indicators: Where We Stand
Indicator 1: Maternal mortality

No matter which estimate is chosen to approximate the reality of maternal mortality in the Region, the underlying pattern is similar: preventable maternal mortality has declined but remains far in excess of the established goal as a Region and especially among certain population groups. Joint WHO, UNICEF, UNFPA, and the World Bank (MMEIG) estimates (3) are the official numbers used to track progress toward the Millennium Development Goal of reducing preventable maternal deaths by 75% from 1990 to 2015. The MMEIG reported that by 2010 the maternal mortality ratio had declined 42.9%, from 140 per 100,000 live births in 1990 to 80 per 100,000. Attaining the Millennium Development Goal using this joint estimate would mean that the ratio for the Region would average 35 per 100,000 live births in 2015. Unattainable at the current annual rate of reduction (-2.6%), even if it were reached this goal would still amount to almost three times the current ratio in Canada (12/100,000), and would be seven-fold higher than in Finland (5/100,000). That is, even if the goal of 35/100,000 deaths were attained, 23 to 30 of the 35 maternal deaths would continue to be preventable, or excess, mortality. There is considerable variation in the point estimates available for a given year, but all databases reveal progress whose pace is too slow (Figure 1.1). Official health ministry data reported to PAHO place the regional average at 125/100,000 live births in 1990 and 75/100,000 in 2010, a decline of 44% (4). The WHO Global Health Observatory (5) places the ratio at 100/100,000 live births in 1990 and 63/100,000 in 2010. This represents a slower decline but, given the starting point, would result in a goal of 25/100,000 by 2015. The
Institute for Health Metrics and Evaluation (IHME) publishes estimates based on internally consistent methods of data verification and modeling for under-reporting and misclassification by subregion and individual countries (6). Its assessment is similar to the official MMEIG estimate. Variation among estimates is due to a number of factors, including differences in calculating the degree of likely under-reporting or misclassification of maternal deaths and in validating survey data on which estimates are based (7). Countries have invested in improving surveillance and reporting of maternal deaths and the quality of the data is gradually improving and the divergence between estimates is narrowing. All of the estimates have uncertainty intervals that are wide enough to include the others. Therefore, although the wide intervals capture lack of precision, their width also provides a worst case/best case basis to plan shifts in resources, upgrades in service patterns, and other measures needed to attain the desired outcome. The successful reduction of preventable maternal deaths in some countries underscores the interplay between health knowledge and services on one hand and social policies that explicitly address disparities. Given that coverage of antenatal visits and skilled attendance during labor are both reportedly high (see the corresponding indicators 6 and 10), the maternal mortality data suggest that it is not merely a matter of access to services but also the quality of care that requires urgent attention. Even when there is access, the lack of properly trained personnel in sufficient numbers to staff all settings means that access per se is no guarantee of a better outcome (8,9).
PART I The COIA Indicators: Where We Stand
FIGURE 1.1. Maternal mortality ratio, Region of the Americas, 19902010.
Maternal mortality (per 100,000 live births)
140
100
60 Joint Estimate GHO 20
of pregnant women are anemic. Iron deficiency accounts for about half of all anemias and iron deficiency anemia contributes to some 20% of maternal deaths during labor as well as increasing the risk of low birthweight and neonatal mortality (10). The proportion of maternal deaths related to obesity is not well studied, although the increased risks of maternal morbidity, preterm birth, and infant death are becoming apparent (10). The prevalence of overweight and obesity in women of childbearing age in the Americas was estimated at 70% in 2008. FIGURE 1.2. Maternal mortality ratio according to gross national income, Region of the Americas, 19902010.
1990
1995
2000
2005
2010 Maternal mortality (per 100,000 live births)
700 600 500 400 300 200 100 0 0.0 1990 2010
Point estimates differ but the trends converge over time. Sources: Interagency joint estimate http://www. childinfo.org/maternal_mortality_ratio.php. WHO Global Health Observatory. http://apps.who.int/gho/data/view. main.1370?lang=en.
Accelerating the pace toward meeting the goal for 2015 is not just a numbers game; lowering preventable maternal deaths reflects improving access to social and economic resources and the civic voice that comes with them. Improved access to education, nutrition, clean water, and sanitation go hand-in-hand with quality prenatal and delivery care to prevent deaths related to pregnancy. The same sectors of the population that tend to lack one are more likely to lack the others. Iron deficiency anemia (<110 g/L), for instance was reported to affect an average of 15.2% (11.7% 18.6%) pregnant women in the Americas in 2011, a rate similar to that found in Europe (10). Yet country estimates released between 2000 and 2009 and published recently by PAHO (11) show that the range at the national level is wide: depending on the country, 6% to 57%
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Country-level gradient defined by income
Source: GINI index data. The World Bank, Development Research Group PovcalNet. http://iresearch.worldbank. org/PovcalNet/index.htm.
Maternal mortality ratios vary markedly between countries. Among other determinants, differences may be observed according to gross national income. Figure 1.2 graphs the mortality ratio according to the gradient formed by national incomes, illustrating one determinant of unequal national mortality ratios.
FIGURE 1.3. Maternal mortality ratio by country GINI coefficient grouping, Region of the Americas, 19902011.
Maternal mortality (per 100,000 live births) 200
2010, reflecting a slightly rising income share (from 51.3% to 52.6%) for those already in the highest 20% bracket and a drop for the lowest 20% (4.91% to 3.91%), an essentially stagnant profile over almost 25 years (13). Just as national maternal mortality ratios may be better or worse than the Regions as a whole, there are variations by geographic region, income, maternal age, marital status, ethnic background, and other determinants within each country. For example, adolescents and younger women are at a greater risk of dying from pregnancy-related causes, perinatal deaths are 50% more likely if newborns mothers are younger than 20 compared to those in the 2029 age range, and the babies of adolescent mothers often are born at a low birth weight, with the attendant risks. Yet an average of 66/1,000 girls aged 1519 became mothers in the Americas in the 20052010 period, an adolescent fertility rate that is the second highest in the world (14). Adolescents in the lowest income quintile have higher pregnancy rates than do those in the highest income quintile (15). Violence against women, poverty, lack of education, and other forms of social limits all intersect in this trend, overlapping especially behind the under-reported number of pregnant girls between the ages of 10 and 14 (15). Maternal mortality is estimated to be threefold higher among Indigenous than nonIndigenous women. Despite the fact that such deaths are largely preventable, they are so common among tribal women that it is customary to say Women who give life walk in the shadow of death, according to Bolivian Aymara leader Martha Gonzles Cochi (16,17). The inequities that lie at the root of this grossly unequal outcome extend beyond single-track technical or program interventions, reaching into cross-sectoral,
150
100
50
1990
2000
2011
Source: WHO, UNICEF, UNFPA, The World Bank. Trends in maternal mortality: 1990-2010. Geneva: WHO, 2012 and Gross National Income: Institute for Health Metrics and Evaluation (IHME) Data Exchange file: Additional file 3: Annex 3.xlsx. http://www.pophealthmetrics.com/imedia/1668401071660847/supp3.xlsx.
However, a countrys maternal mortality ratio does not only reflect economic resources, but also reveals social policies and other determinants. For instance, Costa Rica, Cuba, and Jamaica, all belonged to the World Bank upper middle income country group in 2010 (12), yet there was a considerable difference in their maternal mortality ratios (40, 73, and 110 per 100,000 live births respectively). When countries are grouped according to another measure, the internal distribution of national wealth as expressed in the GINI index, worse outcomes for women correlate with worse (higher) GINI coefficients. Figure 1.3 displays the gaps and gradient of disparities in average maternal deaths when the countries of Latin America and the Caribbean are grouped according to GINI index. In one country, for example, the GINI index worsened from 45.7 in 1986 to 48.1 in
10
legislative, cultural, and policy commitments. Breaking down barriers that exclude and harm population subgroups calls for an integrated approach backed by an evidence-based policy and legislative framework. In sum, although far from complete and often inconsistent, enough data have now been obtained, reported, and monitored over time to confirm that in the Americas, as in other parts of the world, putting an end to excess maternal mortality is a human rights imperative (18). Lagging progress in arresting the preventable deaths of women reflects inequalities in the access to resources, including social services, as well as differences in the quality of services when access is not the issue. Both the availability and caliber of programs, and facilities, can be lifesaving; they can enhance or detract from wellbeing throughout the life course. Rising income per capita, higher female educational attainment, and reduced fertility rates have been credited with a recent positive effect on lowering maternal mortality (19).
Health program efforts to make the most of the general economic and social momentum to intensify progress in this indicator would sharply reduce preventable mortality while anchoring broader achievements in infant and childhood health in a context of broader social and economic equality. Severe, possibly lifelong, morbidity from acute near miss (near death) complications of pregnancy is a related classification for which registration and evaluation is essential to improving the quality of antenatal and labor care, thereby reducing mortality (20). Monitoring, classifying, and reporting these events would afford the opportunity to interview surviving women and improve the classification of causes of maternal deaths, providing the evidence basis to upgrade the quality of care at health facilities, particularly referral hospitals, including revising protocols. A pilot study currently underway to review near-miss data in the Americas found insufficient baseline aggregates of clinic and hospital records of such events at the national level (21).
Indicator 2. Child and neonatal mortality

The Millennium Development Goal of reducing mortality rates in children younger than 5 years of age by two thirds from 1990 to 2015 appears to be (Figure 1.4) within reach as a regional average. Although the numbers differ slightly in various databases, a reduction of roughly 57.2% had been attained by 2010 according to WHO/GHO data (22). If this rate of reduction is maintained, the 2/3rd goal will have been handily surpassed by 2015. Neonatal mortality (from birth to 28 days of age) also is declining, albeit at a somewhat slower pace (51.4%) so that it now represents a larger relative share (some 48%) of the deaths of children under 5 years of age than it did in 1990 (about 42%). Differences in child mortality rates can be sizeable between countries as well as between population groups within countries. Whereas the regionwide average mortality in children younger than 5 years of age was 17.8/1,000 as of 2010, in some countries it reached 130/1,000, and in others it was as low as 6/1,000. Not surprisingly, within countries the rate varies according to the economic position or asset wealth of population subgroups: a countrys
11
FIGURE 1.4. Child and neonatal mortality, Region of the Americas, 19902010.
< 5 and neonatal deaths per 1,000 live births 45 40 35 30 25 20 15 10 5 0 1990 < 5 deaths Neonatal deaths Neonatal (%) 1995 2000 2005 2010 52 < 5 deaths per 1,000 live births 50 48 46 44 42 40 38 Neonatal deaths as % of < 5 deaths
FIGURE 1.5. Mortality rates in children under 5 years old, by family wealth quintile.
140 120 100 80 60 40 20 0 Bolivia 2003 Peru 2003 Colombia 2005
Source: U.N. Inter-agency Group for Child Mortality Estimation. http://www.childinfo.org/mortality_tables.php.
Source: Gwatkin et al., eds. World Bank 2007.
national average of 60.4/1,000 may mask a rate of 17.6/1,000 in the wealthiest fifth of the population and 92.6/1,000 among the poorest 20% (23). The highest income groups share similar access to quality care, nutrition, and environmental conditions adding up to a quality of life that leads to similar outcomes across countries. Children who are born into poor families, on the other hand, may be more than five times more likely to die before their fifth birthday than they would be if their families were wealthy. In Figure 1.5, wide discrepancies between groups within a country can be seen from recently published Demographic Health Survey data (23). When comparing income subgroups in Bolivia, the poorest children are three times more likely to die before their fifth birthday than are their well-off peers. Although the average child mortality rates are lower in Peru, the gap between rich and poor is even more pronounced (childhood mortality rates 5.3 times higher among the poorest than among the richest), whereas in Colombia, also in the World Banks lower middle income economic
group in 2005 (24), a pattern of less inequality (2.5 times higher among the poorest) as well as lower absolute numbers is reported (Figure 1.6). As may be seen in the graphs, the gap between the lowest and highest quintiles is the greatest but, with few exceptions, a measurable gradient of gaps occurs from quintile to quintile as well. The stark contrast between the unequal health status of rich and poor children reveals conclusively that nearly all causes of their deaths before the age of 5 years are preventable. The improvement over time in some countries illustrates that social policies have an impact (25). Preventing child deaths in all families is a matter of equitable access to the social resources, equal coverage by health and public services, such as water and sanitation, maternal education, and timely and proper treatment for respiratory or gastrointestinal infections and injuries. In 2010, roughly 48% of under-5 mortality occurred in the neonatal age group. Of these deaths during the first 4 weeks of life,
12
FIGURE 1.6. Mortality rates in children under 5 years old, by family wealth quintile, Colombia, 19952010.
60 < 5 deaths per 1,000 live births 50 40 30 20 10 0
1995
2000
2005
2010
Source: WHO. Global Health Observatory Data Repository. http://apps.who.int/gho/data/view.main.947485.
31% were due to infections and 29% to birth asphyxia (26). Deaths in the one-month to one-year-old age group accounted for 29% of the total under-5 mortality. The principal causes include acute respiratory infections (48%), diarrheal diseases (36%), and undernutrition (9%), also largely preventable (27). An estimated 10.4% of deaths in all age groups are under-registered and it is probable that neonatal and childhood deaths are disproportionately under-reported, especially
among the same population groups for which births are often not registered. Vital registration has improved thanks to efforts such as the campaign for universal birth registration (28, 29). Nonetheless, the overall under-registration rate among children under five was still 10% in 2011 (down from about 18% in 2006) adding up to 6.5 million children for whom there are no birth certificates. This regional average suggests that there are countries with far higher under-registration and that this is especially likely to be the case inpoorer or excluded population sectors that already bear the burden of child mortality (30). This is in fact what was found in a study published in 2006: some countries have far higher underregistration than others, rural residents are more likely to be under-registered than urban dwellers, poor, single, and teen-aged mothers are less likely to register the birth of their infants or receive antenatal care (31). Without formal identities, children are not counted, and if they do not exist on paper, they have difficulty accessing the health system when needed, attain lower levels of education, and often cannot be hired in the formal sector, all of which in turn affects their health throughout the life course. Needless to say, such underregistration makes the precision of tracking indicators all the more problematic.
Indicator 3. DPT3 coverage among 1223-month-old children

Single intervention efforts such as vaccination coverage have done relatively well in reaching the vast majority of the intended infant beneficiaries. Remarkable achievements in eradicating or eliminating what not long ago were scourges of childhood, such as smallpox, poliomyelitis, rubella, and measles (32), have been followed by other immunization programs successfully targeting whooping cough, neonatal tetanus, and diphtheria. As may be seen in Figure 1.7, coverage with three doses of DPT among 1223 month-old childrena demanding service indicator for vaccines because of the three contacts requiredincreased progressively at an average annual rate of roughly
13
FIGURE 1.7. Trend in percent coverage with DPT3 at 1223 months of age, Region of the Americas, 19902010.
Percent DPT3 coverage 95
technology obstacles, encounters other determinants that stall even higher coverage and will require creative approaches to identify and reach those who are still missed. It should be noted that the indicator for three doses of DPT, as specified by the COIA, stipulates that they be administered by the time children are 1223 months old. DPT coverage data reported to PAHO refer to doses administered to infants younger than one year of age, the schedule to which the Region adheres. The detailed surveillance and reporting systems of national vaccination programs backed by seasoned cold chain logistics and laboratory networks, provide a wealth of opportunities for cross-program and cross-sectoral efforts to record and report other indicators that could otherwise be missed. The beginnings of such collaboration are being developed in some countries to monitor vitamin A, helminth infection prevalence and treatment, and breastfeeding practices.
80
65
1990
1995
2000
2005
2010
Source: WHO/UNICEF coverage estimates 1980-2011 http://www.childinfo.org/immunization_trends.php.
6.7% (33). However, even this robustly funded, limited interface intervention with strong logistical support and good tracking data hit a ceiling and seems to have leveled off starting in 2005, leaving some 7% of toddlers unvaccinated yearly. This gap is far from an immunization program failure. Rather, it illustrates that even a limited focus program with no major funding, supply, personnel or
Indicator 4. Childhood stunting

The picture that emerges on inadequate nutrition illustrates a facet of the need for a comprehensive, cross-sectoral life course approach to human development. Stunting in children under the age of 5 years is a long-standing, reliable measure of nutritional deprivation, especially in the first two years of life (34). Childhood stunting is a telling sign of a constellation of intergenerational poverty and lack of access to education, water and sanitation in addition to food security (35). Stunting contributes to 17% of all deaths in children under the age of five years of age, even as obesity is on the rise in the same age group and also is more common among poor children (10, 36). The combination of insufficient food, poor dietary quality, and repeated, often untreated, infections that impede nutrient absorption causes lower than average growth rates, and may impair cognitive and neuromuscular function (37). If the pregnant mother is herself undernourished the damage may begin during gestation, resulting in fetal growth restriction and the increased likelihood of neonatal death or postnatal stunting.
14
FIGURE 1.8. Prevalence of stunting in children under 5 years of age (%), regional and Guatemala, 19902010.
60 Prevalence (%) of stuning
affected over 50% of children the same age and continued to occur among 48% in 2010, almost 10 years later (40). The rates improved from 1990 onward but the 20% decline by 2010 represents a modest yearly reduction, and most of that took place in the first ten years, after which progress all but stagnated. The prevalence of stunting does not usually decline in response to single-approach strategies (41). Multiple, interacting, effects of nutrient deficiency, inadequate health care, infections, and other environmental insults are more common among the poor. Large disparities may be seen within countries when the prevalence of childhood stunting is analyzed according to the wealth quintile to which the family belongs. In Peru in 2000 for example, 47% of children in the poorest 20% of the population were stunted, whereas just over 4.5% of those in the richest 20% of the population were, roughly a ten-fold difference (42). After no improvement for most of the decade, by 2010 stunting was less prevalent in both groups (35.9% vs. 2.9%) but it declined more steeply among the wealthy (Figure 1.9) (43). In Bolivia, as illustrated in Figure 1.10, stunting declined for all income groups between 1998 and 2008, yet the improvement was unequal, dropping 30% among the richest and only 7% among the poorest people (23). In other countries, stunting prevalence declined over time, and also improved notably, among the poorest segments of society. In the Dominican Republic, for example, the 26.7% prevalence of stunting among the poorest children in 1996 had dropped to 16.4%a 38.6% reductionby 2007 (44). However, stunting reportedly increased over the same period among children of the wealthiest 20%, a change that cannot readily be interpreted. In Brazil, meanwhile, the prevalence of stunting diminished successively over
40
Guatemala* Regional*
20 *some years interpolated 0 1990 1995 2000 2005 2010
Sources: UNICEF-WHO-The World Bank: Joint child malnutrition estimates. http://www.who.int/nutgrowthdb/statistical_tables.pdf. WHO Global Health Observatory Data Repository. Child Malnutrition. http://apps.who.int/gho/ athena/data/download.xsl?format=xml&target=GHO/MDG _0000000027&profile=excel&filter=COUNTRY:*;SEX:*;RE GION:AMR.
As may be seen in Figure 1.8 (38), the prevalence of stunting in children under the age of 5 years dropped by about 44% regionwide, from 24.6% in 1990 to 13.8% in 2010. This represents an average annual reduction of 2.25% over the 20-year period. Should this rate be maintained, the Region as a whole will achieve the 50% reduction goal set for 2015. Nonetheless, the regional average masks patterns of intractable nutritional risk that emerge when the rates of individual countries are examined (39). The World Bank country income group categories afford one way to see the differences. In the United Statesa high income countryfor instance, the prevalence of stunting among children under the age of 5 years was 3.9% (roughly the frequency expected due to genetic variation) in 2001, whereas for the same year in Guatemala classified as lower middle incomestunting
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FIGURE 1.9. Prevalence of stunting in children under 5 years of age, by wealth quintile, Peru.
50 40 30 20 10 0
FIGURE 1.10. Prevalence of stunting in children under 5 years of age, by wealth quintile, Bolivia.
50 40 30 20 10 0
Prevalence (%) of stuning
2000
2005
2010
Prevalence (%) of stuning
1998
2003
2008
Source: WHO Health Equity Database. http://apps.who.int/ gho/data/node.main.HE-1540.
Source: WHO Health Equity Database. http://apps.who.int/ gho/data/node.main.HE-1540.
a 10-year period, due to multiple overlapping factors, including increased maternal schooling, increased purchasing power, expansion of access to healthcare, and improvements in sanitation (45). Not only did the overall prevalence drop by half overall from 1996 to 2006, but the greatest decline took place in population groups that had the highest rates of stunting at baseline. The impact of providing conditioned cash transfers to poor families (Bolsa Familia) on reducing stunting and other health outcomes is under review but, as is the case with other approaches, appears to be limited unless enhanced with concurrent interventions (46). To date, 15 countries in the Americas have instituted similar cash transfer programs with varying impact (15). A detailed evaluation of the Mexican Oportunidades program found that its impact was marked and significant overall and on the reduction of anemia in children in particular but the availability of cash in itself had a less pronounced effect than the accompanying social marketing and provision of fortified weaning foods (47).
In all, the evidence available indicates that a high prevalence of stunting and underlying nutritional risks persist but can be remedied by instituting cross-sectoral efforts that require close monitoring and adjustment. The contrasts that exist between countries and between population groups within them (Figure 1.11) provide a clear example of the need to review current approaches, integrate nutrition with other social and health services, and frame policy formulation in light of the distribution of disparities that affect individuals full life course. The data also signal a need for quality review and investigation of inconsistencies in order to interpret trends for policy and programmatic purposes, especially to address inequities. According to the 2008/2009 National Health Survey 65.9% of Guatemalas Indigenous children were stunted (48). On average, up to 95% of Indigenous children are malnourished (under or over), stunting is 20% more prevalent among them, their life expectancy is 7 to 13 years shorter than the average for their
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country, and they have a ten-fold higher likelihood of dying before their first birthday (49). Soil-transmitted helminth infections (STH) are diseases of poverty that cause morbidity and contribute, along with concurrent risk factors, to stunting as well as impaired intellectual growth of children (50). Although infection prevalence data are not widely available, it is estimated that 13.9 million preschool children are at risk of helminth infections in 30 countries of the Region. Despite the likelihood of reinfection, periodic deworming confers benefits, including reducing micronutrient loss and improving nutritional absorption (51). If women in endemic areas are dewormed once or twice during the pregnancy (after the first trimester), substantial reductions in maternal anemia result, along with higher birthweight and lower infant mortality at six months (52).
FIGURE 1.11. Change in prevalence of stunting in children under 5 years of age, by wealth quintile, Colombia, 19952010.
35 30 % of children < 5 stunted 25 20 15 10 5 0 1995 2000 2005 2005
Source: WHO Global Health Observatory Data Repository. http://apps.who.int/gho/data/view.main.94120.
Indicator 5. Increase the proportion of demand for family planning satisfied (met need for contraception)
The countries of the Americas have not reported sufficient data on this indicator for long enough to ascertain whether there has been a trend for the better in the Region as a whole. WHO (53) data estimate that 91.9% of the women of the Americas had their need for family planning met in 2005 and again in 2008. Contraceptive prevalence was reported at 74.5% for each of those years with a wide range among countriescontraceptive use was estimated to be around 25% in Bolivia, for example. In a sample of 12 countries, CEPAL reported that the unmet need for family planning ranged from 4.7% to 37.3% (15). Unwed teenagers in all countries are less likely to avail themselves of family planning services and are more likely to have unintended pregnancies and to suffer complications, including death from abortion (54). Pregnancies among 1519 year old adolescents are under-recorded. The 11 countries for which there are data between 2006 and 2010 reported that 11.6% to 25.2% of young women in that age group were pregnant or already had children. It is not clear what the unmet need for contraception is among other minority or socially excluded groups of women. As is the case with other indicators in reproductive, maternal, and child health, there are gaps in service coverage depending on population wealth quintile. In Colombia, one of the few countries consistently reporting these data over time, Figure 1.12 illustrates a gap in met need for family planning that has gradu-
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FIGURE 1.12. Met need for family planning, by wealth quintile, Colombia, 19952010.
100 80 60 40 20 0
% of women with met need
ally narrowed. The met need was reported at 86.3% in 1990 and 92.0% in 2010 for the country as a whole and the gaps were not as pronounced as for other services. Nonetheless, despite a narrowing disparity, the poorer groups continued to lag behind in 2010.
1995
2000
2005
2010
Source: WHO Global Health Observatory from DHS. http:// apps.who.int/gho/data/node.main.HE-1611?lang=en.
Indicator 6. Antenatal care coverage at least four times during pregnancy

The percentage of women in the Region who reportedly received antenatal care at least 4 times before delivery in 2008 was 84%, increasing to 87% in 2009 (see the discussion of Indicator 10) (55). Data tracking over the 19902010 timeframe are not available for most countries of the Region.
Indicator 7. Antibiotic treatment for suspected pneumonia in children under 5 years of age
Regional data are not available for this indicator in the Americas.
Indicator 8. Postnatal care for mothers and babies within two days of birth
Regional data are not available for this indicator in the Americas.
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Indicator 9. Antiretroviral (ARV) prophylaxis among HIV-positive pregnant women to prevent HIV transmission and antiretroviral therapy for women who are treatment-eligible
Coverage with antiretroviral treatment to prevent vertical transmission of HIV increased by 94% in the Region between 2005 and 2011, the years for which data have been consolidated. In 2005, 36% coverage had been attained regionwide, with 42% in Latin America and 14% in the Caribbean. By 2011, coverage had increased to 70% (15,300 women), reflecting 67% in Latin America and 79% in the Caribbean (56). Coverage of HIV testing among pregnant women increased from 29% in 2005 to 53% in 2008 and 66% in 2011 (57). Some countries report that 20% to 30% of infants exposed perinatally to HIV are lost to follow up. Estimated regional trends indicate that HIV testing and treatment are having an impact: the number of children acquiring HIV infection has declined by 32% in the Caribbean and 24% in Latin America from 2009 to 2011. Several countries (Costa Rica, Panama, and Uruguay) have achieved mother-to-child, or vertical transmission, rates below 2% (virtual elimination). Overall, mother-to-child transmission of HIV in Latin America and the Caribbean was estimated at 14.2% (5.8%18.5%) for 2011, a rate that is somewhat lower than the 18.6% (10.5%22.9%) estimated for 2010. As may be noted from the overlapping uncertainty intervals, however, the models used to calculate the estimates are imprecise. Country-level information systems report counts of pregnant women or those giving birth who test positive and are treated. These numerators, however, are then used in models for which the estimated denominator may give coverage ranges of 22%88%, making the indicator of questionable practical use for policy and resource deployment at this time. Data for the second measure in the COIA indicator (treatment-eligible women who receive antiretroviral therapy) are not reported systematically. In part, this may be due to limited capacity of information systems to provide sex disaggregated data and may also be because of the expense entailed in systematic data monitoring and quality control. Other program costs can be high, especially when test kits and antiretroviral supplies are purchased outside of the PAHO/WHO Strategic Fund network, at a far higher cost.
Indicator 10. Increase the proportion of births attended by a skilled attendant

At a regional level, this indicator would be difficult to track or interpret even if the data were reported for successive years. The data available at PAHO/WHO generally are point estimates for one or two years for each country averaging 93% of births that were reportedly attended by skilled health personnel. Almost every country reports that skilled attendant coverage during labor is greater than 80% and many countries record that it is about 100%. The few that published coverage rates of less than 80% were Bolivia
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FIGURE 1.13. Causes of maternal mortality (%), Region of the Americas, 2000 and 2007.
Indirect obstetric causes Complications predominantly related to the puerperium Complications mainly of pregnancy and childbearing Hemorrhage in pregnancy, children, and the puerperium Edema, proteinuria, and hypertensive disorders in pregnancy, childbirth, and the puerperium Abortion 05 10 15 20 25 30
Cause of death (%)
Source: PAHO Health in the Americas. Washington D.C. PAHO 2012.
(71.1% in 2008), Guatemala (51.3% in 2009), Haiti (26.1% in 2006), and Honduras (66.3% in 2006). Given the contrast between the reported near perfect coverage of births attended by skilled attendants and the glaring excess of preventable maternal and neonatal deaths, it may be necessary to provide a more specific formulation of the criteria for skilled and/or clarification of the clinical conditions and essential medical supplies required to fulfill the indicators intent. After reviewing the evidence, the Commission for Information and Accountability for Womens and Childrens Health determined that the skill of care makes a difference and reworded the MDG indicator accordingly. The inconsistency between the reported high coverage levels for antenatal care and attended labor on the one hand and the unacceptably high maternal and neonatal mortality on the other lends support to the COIA view and suggests possibly inaccurate data, marked differences between national and regional averages, regional averages
composed from few reporting countries, and other data quality issues in addition to inadequate criteria for the quality of care and skilled services. In November 2003 the International Confederation of Midwives (ICM) and the International Federation of Gynecologists and Obstetricians (FIGO) issued a joint statement specifying the standard of care for the third stage of labor in recognition that medical, nursing, or other training doesnt necesFIGURE 1.14. Four antenatal care visits to a doctor, by family wealth quintile, three countries, 2005.
100 % of pregnant women covered 80 60 40 20 0
Bolivia
Peru
Colombia
Source: The World Bank. Gwatkin et al 2007.
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sarily ensure the skills needed to save women from dying of hemorrhage (57). Even if all those attending labor were fully skilled, the lack of a guaranteed safe blood supply, especially in outlying areas, means that transfusions may not be available when needed in emergencies (58). There are no systematic records of such instances, the adequacy of blood supply quantity and quality, storage conditions, supplies of oxytocin and magnesium sulphate, equipment, attendant skills in administering transfusions, or other related data that would help identify critical needs in this life saving component of attending birth. In 2007 abortion ranked among the top six causes of mortality in pregnant women, a reality that requires attention and may be significantly under-reported. This is especially true if an unintended pregnancy resulted from violence or abuse. Half of the pregnancies that occur in such circumstances are aborted, often
in unsafe conditions (59). Latin America and the Caribbean have the highest rate of abortions and the highest proportion of unsafe abortions in the world (60). The resulting death rate is 12% overall and in some countries abortion accounts for 30% of all maternal deaths (61). A view of antenatal care by family wealth position shows large gaps between rich and poor in some countries and less pronounced gaps in others, again suggesting that even when the difficult-to-consolidate regional data are relatively uninformative, mapping indicators according to social equity grids helps focus on clusters of inequalities in both services and outcomes. Quantification of the quality of services is a missing dimension without which analytic comparison of service gaps is even more uncertain.
Indicator 11. Increase the proportion of newborns who receive exclusive breastfeeding for the first six months
Consolidated data over time are not available for this indicator in the WHO data repository for all of the countries of the Region (62). One unpublished WHO survey (63) provides regional averages for the period spanning 1990 to 2010 based on a small subset of countries. Regional averages are of limited analytical use given the large variation between countries. For instance, in 2010 the Dominican Republic reported that 7.7% of infants were breastfed exclusively for the first six months after birth. In the same year, Peru reported that 68.3% of infants were being breastfed exclusively. A recent consolidation of data from 17 countries that started tracking and reporting for this indicator will be published later this year (64). FIGURE 1.15. Percent of children under 6 months of age breastfed exclusively, selected countries, Region of the Americas, 19902010.
40 Proportion breastfed exclusively 35 30 25 20 15 10 5 0 1990 1995 2000 2005 2010
Source: The World Bank. Gwatkin et al 2007.
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FIGURE 1.16. Percentage of infants exclusively breastfed during the first 6 months, Colombia and Peru, 19902010.
100 Proportion breastfed excluively 80 60 40 20 0
Peru
Colombia
Source: Organizacin Panamericana de la Salud. Situacin actual y tendencia de la lactancia materna en Amrica Latina y el Caribe: Implicaciones polticas programticas. Washington DC: OPS (forthcoming).
In Colombia, a marked increase in the proportion of women breastfeeding their infants exclusively started in 1995, when the percentage was about 11.4%, and continued a steep trend upward until 2005, when it reached 46.8% (65). At that point, a slight reversal of the trend was observed, declining to 42.8% (see Figure 1.16). Data indicating an increase in the practice of breastfeeding imply that promotion programs are succeeding. Where there is strong advocacy for breastfeeding, monitoring its practice also is
more likely. Some countries reporting the highest rate for this indicator also have some of the highest rates of childhood stunting. Since early and exclusive breastfeeding protects against infectious diarrhea and nutrient deficiency in infants, promotional efforts may be more concentrated in known risk areas, leading to higher rates. NGOs strongly active in countries with large Indigenous populations with high rates of child mortality are among the strongest proponents of breastfeeding, for example. However, one study found that, despite promotion efforts, exclusive breastfeeding did not always increase in poorer areas and raised the question of how to improve the equity of outreach efforts (66). A recent review of the evidence found that the long-term developmental effects of breastfeeding and complementary feeding require more robust documentation (67). Among other factors, monitoring breastfeeding practice provides insights into the boundaries where health services and health behavior may be constrained by social policy. An article paper in April 2013 noted that where national legislation exists to guarantee breastfeeding breaks at the workplace, a significantly higher percentage of women practice exclusive breastfeeding during the first six months after giving birth (see Table 1.1) (68).
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TABLE 1.1. Precentage of infants breastfed exclusively during first six months, 17 Latin American countries, 19902010.
Country Bolivia Brazil Chile Colombia Costa Rica Dominican Republic Ecuador El Salvador Guatemala Haiti Honduras Mexico Nicaragua Paraguay Peru Uruguay Venezuela 27.6 7.8 33.4 28.4 60 50.7 4.8 28.8 10.8 25.7 7.4 28.7 15 46.1 2.5 14.8 34.8 15.8 38.8 23.6 33.1 20.3 21.8 31.1 21.9 63.9 54.1 34.9 11.9 1990 50.5 2.5 44.2 11.4 1995 43.1 2000 50.3 29.4 51 25.9 58.1 46.8 44.3 10.3 39.6 24 50.6 31.4 49.6 40.7 29.7 22.3 30.6 24.4 68.3 57.1 27.9 2005 53.6 2010 60.4 38.6 62.7 42.8 53.1 7.7
Source: Organizacin Panamericana de la Salud. Situacin actual y tendencia de la lactancia materna en Amrica Latina y el Caribe: Implicaciones polticas programticas. Washington DC: OPS (forthcoming).
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Part II Equity Mapping, a Framework for Discussion
n light of the evidence that has accrued to dateand that which may be lackingthe A Promise Renewed meeting will apply a human rights and equity framework to review current conditions and socially determined health gradients to identify necessary strategic shifts for improving gains and accountability consistent with universal health coverage. The framework presented here provides one of a number of possible approaches to mapping socioeconomic gradients in health status, access to type and quality of services, and possible underlying inequities in service coverage as well as other determinants of health. The framework arrays the evidence according to five categories or analytic layers that can be applied to the current landscape and its challenges. The same categories can be used to chart policies, redirect resources, fine tune data reporting and interpretation, and guide accountability as efforts are focused on reproductive, maternal, and child health outcomes that also are markers of larger health and social disparities. As the previous discussion of the COIA indicators suggests, assessing them according to these criteria will require expanding individual technical program approaches and developing innovations toward the crossprogram and cross-sectoral use of resources, data, and quality improvement strategies. When the layers are applied, systematic outcome gradients may emerge which suggest underlying inequities that need to be addressed. The goal for each indicator, within the larger context of universal coverage, will be the target toward which policies, resource deployment, and accountability (69) standards will be aimed, not just as regional averages but on a country and subnational level.
The five layers are: 1. Universal health coverage 2. Categories of socioeconomic disparities 3. Challenges in data generation and analysis for informed decision-making 4. Improving participation in health systems and inclusion in national policy design 5. Identifying strategic shifts needed to reduce inequities
Universal health coverage

Universal health coverage refers to universal access to comprehensive, quality, peoplecentered services without the risk of impoverishment due to illness. Universal health coverage addresses social determinants, and thus requires strengthening health systems, including financing and human resources, with a human rights and social protection approach. This overlay examines tracking data for the eleven indicators from the standpoint of an ideal 100% access to the quality health programs, interventions (services), and resources needed to live healthily throughout the life course as a fully integrated member of the society. Thus, if universal access to quality health services with universal health coverage is applied to analyze a population, the areas or subgroups where such access does not occur can be traced and compared. It may be that the services exist but their quality varies so that access does not mean access to the same quality or even quantity of services, for example. Or, access to services may be available for DPT3 immunization, single-encounter immunization days, active case finding, or helminth control interventions, but not be within reach for multiple-encounter pre- and post-natal care, especially if services by trained and certi-
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PART II Equity Mapping, a Framework for Discussion
FIGURE 2.1. Proportion of deaths of children under 5 years of age, by access to improved water services, Region of the Americas, 1990 and 2010.
1.0 Child deaths (cummulative proportion) 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 0.00 .1 0.20 .3 0.40 .5 0.60 .7 0.80 1990 2010 .9 1.0
tary income per capita or family unit, is one measure (Figure 2.1) and at the extremes of a spectrum it suffices to affect health status. However, a gradient of gaps often may be observed along the wealth spectrum in addition to the pronounced gap between richest and poorest. The wealth quintiles used by way of example in this discussion paper reflect an index of assets rather than reported monetary income (71). However, even such a construction of health outcomes along the poverty-wealth gradient is not sufficient to explain barriers to universal access. There are those, for instance, who may be poor but by virtue of living in an agricultural setting with access to clean water and intergenerational community support fare better than others who appear to be wealthier yet cannot afford to purchase the food they need and are exposed to greater environmental hazards, such as violence, HIV infection, and biohazard contaminated surroundings. Within the same wealth grouping, social discrimination and exclusionas is frequently seen to occur to political and ethnic minoritiesmay prevent families from using health services that policymakers believe to be available and accessible by coverage legislation. People who have been displacedwhether for economic reasons, natural disasters, or to escape political or domestic violenceoften migrate to areas where they are subjected to the additional burdens of geographic isolation, stigma, and discrimination even if it is within the same country. The disparities in gains attained in reducing child mortality are not only apparent between countries and between income groups within countries, but also can be mapped to the local levels where the unequal outcomes may be due to factorssuch as geographic, cultural, or ethnic isolationother than those seen at a lower
Country-level gradient defined by access to water
Source: WHO-UNICEF Joint Monitoring Program.
fied personnel in adequately equipped facilities are involved. Inadequate cultural sensitivity to the requirements of minority groups or unmarried teen-aged, or HIV-positive mothers may diminish the real universality of quality services even access exists on paper. Recognition of financial barriers to services and pharmaceuticals prompted a number of countries to actively promote subsidies and other means to extend coverage. Yet despite increases in the utilization of services, in most countries the wealthy continue to be more likely to seek care than the poor for the same health condition, and social position disparities in the utilization of services persist even in countries where public coverage is now almost universal (greater than 90%) (70).
Categories of socioeconomic disparities

Socioeconomic disparities often have complex, interacting roots. Wealth, as measured in mone-
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FIGURE 2.2. Probablility a newborn child will die before the age of 5 years, by municipality, Peru (ca. 2005).
% DPT3 < 5 deaths per 1,000 live births
60
30
0
tn o Lo ue eq An de am av ur ac u az ba oq Tu U Li be M C rta d Pi ur a Ta cn a Li m a no co ac sh ho as n n Ic a s to e a re us ca im qu gu nu on ar Pu uc el D Ju ca Pa ar ui ye m be s La li pa co ic a ya io sc ca
Ap
nc
Ay
Am
Ar
Sa
re
ua
ad
Source: Peru DHS data http://www.statcompiler.com.
La
resolution. Figure 2.2 illustrates a clear gradient in mortality rates for children under the age of 5 years by municipal jurisdiction in Peru, the effect of multiple overlapping categories. Such variations in categories of disparities mean that if maternal mortality is analyzed only from the standpoint of financial resources or wealth quintiles, underlying inequities that are not necessarily reflected in financial measures may inadvertently be overlooked. Overlooking the different categories of socioeconomic disparities and their interplay, in turn would hamper creative designs to improve health outcomes throughout the life course. As may be seen in the concentration curve in Figure 2.3, by way of example, there is an association between the average years of schooling in a countrys female population and the same countrys maternal mortality ratio. If the risk of
FIGURE 2.3. Maternal deaths according to education level attained by female population, Region of the Americas, 1990 and 2010.
1.0 Maternal deaths (cummulative proportion) 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 1990 2010
Source: Health Metrics and Evaluation Data Exchange file: Educational attainment by country, sex and age in relation to child mortality 1970-209_IHME_0910.xls.
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aj
maternal mortality were the same irrespective of female educational level, there would be no line above the diagonal (equal proportions for each educational level). Instead, inequalities in the distribution of maternal mortality are observed: when the cumulative proportion of maternal deaths is ranked by female educational attainment, the least educated female population (left end of the horizontal axis) has a considerably higher burden of death than those with higher levels of education. The excess mortality in 1990 (about 40% of maternal deaths occurred among the 20% with the least schooling) had dropped somewhat by 2010 (about 32% of maternal deaths were likely to occur in the same education level group) but still demonstrate an overlap: the burden of deaths due to pregnancy and labor remains heaviest among the least educated.
sect. Yet some indicators may be more informative in some nations or provinces than in others. In the data analysis phase, different criteria are understandably applied depending on the purpose, agency, or government conducting the interpretation, and at what level. One of the challenges in the current landscape is at the national or subnational level, where overworked and understaffed health teams who often are also underequipped and undertrained are required to report to multiple different places on numerous different forms, sometimes on paper and other times electronically. Neonatal health programs may find that it is all that they can do to identify and stay in touch with expectant mothers, and ensure their proper antenatal and postnatal care, much less fill out the paperwork with correct information. The worse the compounding components of social and economic disparities, the more problematic accurate data reporting and analysis will be. Less accurate or missing data, meanwhile, could occur more frequently in some areas than others, thereby exacerbating the inequities their collection and analysis are intended to help remedy with policies that use the data as guideposts. The set of indicators reflecting nearly 95% childhood immunization coverage, for example, may mistakenly be interpreted as adequate access to all services, thereby missing service coverage during the neonatal or pregnancy periods (Figure 2.4). The need for capacity building to strengthen and standardize data gathering, reporting and analysis for policy led to a university-private sector-USAID-PAHO partnership (RELACSIS) to form a Spanish language network (see www.relacsis.org) to exchange methods and approaches for metrics and evaluation, including those to better classify causes of mortality
Challenges in data generation and analysis for informed decision-making

Indicator data do not tell all of a story or describe all the essential details, but the slogan better data for better results adopted in 2011 by the Commission on Information and Accountability for Womens and Childrens Health captures a critical need succinctly: resources cannot be allocated wisely or reassigned in a timely manner without the right information (evidentiary basis). All sorts of data are increasingly abundant yet key indicators to assess progress toward goals and the corresponding resource and legislative policies often are not regularly monitored or are gathered or interpreted inconsistently. The 11 COIA indicators have been chosen carefully with the intent to flag successes or hurdles in a large, often complex, set of metrics where health programs, social policies, economic position, and environmental conditions inter-
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FIGURE 2.4. Almost every country shows disparities in health service coverage rates. The pie charts below illustrate DPT3 coverage rates as the proportion of national jurisdictions with low (< 80%), medium (8094%), and high ( 95%) coverage at the age of 12 months. Municipality population densities vary.
Source: CL Pacis, PAHO/WHO.
DPT3 coverage ranges
n < 80%
n 8094% n 95
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and morbidity. Improvements in tracking and reporting of maternal mortality are expected and the system is expected to expand into the English and Francophone countries. Establishing surveillance and reporting systems with quality laboratory backup and routine quality control is a major, difficult undertaking in vaccination programs, outbreak investigations, and other temporally focused undertakings. Yet these program activities rapidly avail themselves of established, coordinated surveillance systems that apply at regional, national, subnational, and local levels. With these in mind, as well as the experiences in countries that have successfully managed data monitoring and analysis streamlining for reproductive, maternal, neonatal, and child health, the A Promise Renewed meeting will explore ways to look at each life course program for deficits that can be improved, lessons that can be learned, and ways to unify criteria and approaches to the collection and interpretation of the relevant numbers in a way that can be readily collected, recorded, analyzed, interpreted, and acted upon. Several large agencies represented at the A Promise Renewed meeting have begun the process of sharing data and standardizing their presentation and interpretation. At the national level more needs to be done to inform the process at the subsequent levels of consolidation and analysis. For example, despite recent efforts to improve data gathering and analysis, national data often are not disaggregated by ethnicity. In the Americas, a large group in the ethnic category is made up of the 48.5 million or so indigenous peoples. The human rights imperative of improving reproductive, maternal, and child health is universally acknowledged as all the more urgent among children and women who
belong to these groups, which historically have been systematically excluded from social integration, social services, and the possibility of advancement. The only way to determine whether systematic exclusion occurs is to examine the evidence. The account of health conditions among the Indigenous peoples of the Americas is incomplete and the same groups who are excluded from access are likely to not be counted in attempts to ascertain coverage. Averages, such as those in the COIA indicators, provide a first general appraisal, but are insufficient to determine where resource allocations need changing, and where inequities may lie. Such policies require that tracking data be analyzed according to strata such as the commonly used socioeconomic position, sex or gender, ethnicity, and geographic area, in addition to education, access to water and sanitation, and/or other informative social determinants of health status throughout an individuals life course. When tracking indicators are analyzed, gaps between the groups within the strata should narrow over time as the health status indicators value improves. Two and three-way tables are an approach for which there are published examples (72).
Improving participation in health systems and inclusion in national policy design

Barriers to participation in health systems and policies may compound barriers to universal health coverage. If population subgroups who are traditionally underserved or excluded from service coverage also are excluded from the education and training that would enable them to take part in the health system workforce, the barriers to services will not be overcome. Exclusion from participation in the system as doctors, nurses, pharmacists, accountants, building architects, managers, and the like
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excludes the cultural, gender, linguistic, geographic, and other particular knowledge and insights from being incorporated in the health systems interface with the population, gathering of data, and their interpretation. Staff recruitment and retention in areas requiring a greater effort or a shift in focus may also be impaired. If the legislative framework set by policymakers at the national level doesnt take into account the system issues that emerge in an inventory of barriers, an inequitable distribution of supplies and equipment may result, and similar effects might be seen along the cold chain, laboratory networks, or other logistical and system components. Some of the apparently technical obstacles may be there because the systems and national policy setting do not allow for adequate funding and training of health, nutrition, surveillance, and other personnel. By way of example, little is accomplished by testing women during antenatal visits if there is no adequate laboratory support or transportation to ensure processing, timely feedback, and appropriate treatment, if necessary. Moreover, health system decision making will respond to the needs of a population or region more effectively if representatives of the communities being served participate as formal voting members of advisory boards, management review committees, and legislative and other health system policy and oversight bodies. Even if programs seek to identify and cover specific traditionally excluded groups with targeted outreach strategies, those groups may not be represented in the staffing, hierarchy, or policy levels of the health systems nor be identified in policies intended to make catch up possible. No matter how clear what has to be done may be to those on the ground, therefore, it may not be possible to do it
sustainably if the necessary inclusion provisions have not been made at a system or policy level. Execution and accountability are therefore not on solid footing. This is one of the reasons that the health ministries of the Region approved the 2012 Strategy and Plan of Action mentioned in the Introduction (73).
Identifying strategic shifts needed to reduce inequities

When reviewing coverage and health outcome data for given programs, such as antenatal care or immunizations and the respective changes in maternal mortality or childhood infection rates, inequities may be seen more clearly in one than another. If vaccination with three doses of DPT by the age of 23 months reaches over 90% coverage nationally, it may be difficult to ascertain that inequities underlie systematic disparity in access to this service in some populations unless the 10% not covered are analyzed in the context of nutritional status, antenatal care, maternal schooling, family wealth position, the percent of children who are breastfed during the first six months of life or other indicators often examined separately. Overlapping gaps in services suggest systematic exclusions. The nature of the exclusion, if not already known, is then ready to be identified. Geographic isolation, ethnic minority, sex, poverty driven invisibility from vital registration, low water and sanitation coverage, low educational attainment, other determinantseach of these, or specific combinations, inform decision makers about the degree and kind of increase in effort required. When gaps signal the need for strategic shifts, the best selection and execution of the shifts may be significantly improved by comparing notes with those who have done something similar successfully and, just as important, those who have tried an approach, failed to
32
obtain the desired outcome, and documented the reasons. The A Promise Renewed meeting in Panama will approach strategic shifts in programs and interventions by applying the equity overlays systematically in a cross-sectoral effort to drill down on the gaps in coverage, quality of data, and other hurdles. Participants will share accounts of successful strategies to slash preventable disparities in reproductive, maternal, neonatal, and child health. The planned outcome will be a cross-disciplinary, cross-agency, cross-sectoral plan for the future that cuts
across national boundaries, cultural divides and institutional barriers to define a health landscape by quantifiable equity criteria that can be traced along a continuum of coverage for a healthy life course. The initial mapping charted at the A Promise Renewed meeting will provide the first draft to be fleshed out, improved upon, and put into effect at the country level over the next two years. The government and institutional delegations who will craft this new approach are pledging their political will to see it accomplished as set out in the Panama Declaration.
33
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Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping:

A Framework for Discussion

A Framework for Discussion

Pan American Health Organization

Pan American Health Organization

Where we stand now

Indicators for Maternal, Neonatal and Child Health*

Policy Indicators for Integrated Child Health (ICH)

Part I The COIA Indicators: Where We Stand

Indicator 1: Maternal mortality

PART I The COIA Indicators: Where We Stand

FIGURE 1.1. Maternal mortality ratio, Region of the Americas, 19902010.

Maternal mortality (per 100,000 live births)

60 Joint Estimate GHO 20

2010 Maternal mortality (per 100,000 live births)

Country-level gradient defined by income

PART I The COIA Indicators: Where We Stand

Indicator 2. Child and neonatal mortality

Source: U.N. Inter-agency Group for Child Mortality Estimation. http://www.childinfo.org/mortality_tables.php.

Source: Gwatkin et al., eds. World Bank 2007.

PART I The COIA Indicators: Where We Stand

Source: WHO. Global Health Observatory Data Repository. http://apps.who.int/gho/data/view.main.947485.

Indicator 3. DPT3 coverage among 1223-month-old children

Source: WHO/UNICEF coverage estimates 1980-2011 http://www.childinfo.org/immunization_trends.php.

Indicator 4. Childhood stunting

PART I The COIA Indicators: Where We Stand

20 *some years interpolated 0 1990 1995 2000 2005 2010

Prevalence (%) of stuning

Prevalence (%) of stuning

Source: WHO Health Equity Database. http://apps.who.int/ gho/data/node.main.HE-1540.

Source: WHO Health Equity Database. http://apps.who.int/ gho/data/node.main.HE-1540.

PART I The COIA Indicators: Where We Stand

Source: WHO Global Health Observatory Data Repository. http://apps.who.int/gho/data/view.main.94120.

% of women with met need

Source: WHO Global Health Observatory from DHS. http:// apps.who.int/gho/data/node.main.HE-1611?lang=en.

Indicator 6. Antenatal care coverage at least four times during pregnancy

PART I The COIA Indicators: Where We Stand

Indicator 10. Increase the proportion of births attended by a skilled attendant

Cause of death (%)

Source: PAHO Health in the Americas. Washington D.C. PAHO 2012.

Source: The World Bank. Gwatkin et al 2007.

PART I The COIA Indicators: Where We Stand

Source: The World Bank. Gwatkin et al 2007.

PART I The COIA Indicators: Where We Stand

Part II Equity Mapping, a Framework for Discussion

Universal health coverage

PART II Equity Mapping, a Framework for Discussion

Country-level gradient defined by access to water

Source: WHO-UNICEF Joint Monitoring Program.

Categories of socioeconomic disparities

% DPT3 < 5 deaths per 1,000 live births

Source: Peru DHS data http://www.statcompiler.com.

PART II Equity Mapping, a Framework for Discussion

Challenges in data generation and analysis for informed decision-making

Source: CL Pacis, PAHO/WHO.

DPT3 coverage ranges

PART II Equity Mapping, a Framework for Discussion

Improving participation in health systems and inclusion in national policy design

Identifying strategic shifts needed to reduce inequities

PART II Equity Mapping, a Framework for Discussion

Pan American Health Organization

association between stunting and overweight in Latin American and

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