Research Article: Explaining changes in child health inequality in the run up to the 2015 Millennium Development Goals (MDGs): The case of Zambia

Date Published: February 7, 2017

Publisher: Public Library of Science

Author(s): Peter Hangoma, Arild Aakvik, Bjarne Robberstad, Umberto Simeoni.


Child health interventions were drastically scaled up in the period leading up to 2015 as countries aimed at meeting the 2015 target of the Millennium Development Goals (MDGs). MDGs were defined in terms of achieving improvements in average health. Significant improvements in average child health are documented, but evidence also points to rising inequality. It is important to investigate factors that drive the increasing disparities in order to inform the post-2015 development agenda of reducing inequality, as captured in the Sustainable Development Goals (SDGs). We investigated changes in socioeconomic inequality in stunting and fever in Zambia in 2007 and 2014. Unlike the huge literature that seeks to quantify the contribution of different determinants on the observed inequality at any given time, we quantify determinants of changes in inequality.

Data from the 2007 and 2014 waves of the Zambia Demographic and Health Survey (DHS) were utilized. Our sample consisted of children aged 0–5 years (n = 5,616 in 2007 and n = 12,714 in 2014). We employed multilevel models to assess the determinants of stunting and fever, which are two important child health indicators. The concentration index (CI) was used to measure the magnitude of inequality. Changes in inequality of stunting and fever were investigated using Oaxaca-type decomposition of the CI. In this approach, the change in the CI for stunting/fever is decomposed into changes in CI for each determinant and changes in the effect—measured as an elasticity—of each determinant on stunting/fever.

While average rates of stunting reduced in 2014 socioeconomic inequality in stunting increased significantly. Inequality in fever incidence also increased significantly, but average rates of fever did not reduce.

To curb the increase in inequality of stunting and fever, policy may focus on improving levels of, and reducing inequality in, access to facility deliveries, maternal nutrition (which may be related to maternal weight and height), complementary feeding (for breastfed children), wealth, maternal education, and child care (related to birth order effects). Improving overall levels of these determinants contribute to the persistence of inequality if these determinants are unequally concentrated on the well off to begin with.

Partial Text

Socioeconomic inequalities in childhood health have persisted, with children from poor households experiencing a disproportionately larger burden [1, 2]. This also implies that they may bear a larger share of later life consequences of childhood ill-health. Apart from increasing under-5 mortality rates, childhood ill-health negatively affects cognitive abilities, education attainment, later life income, and adult health [3–6]. This study focusses on two key measures of childhood ill-health, namely, stunting and fever.

Data were obtained from the 2007 and the 2014 Demographic and Health Survey (DHS). For children under the age of 5 years, our final dataset consisted of 5,616 observations in 2007 and 12,714 in 2014. The large difference in the number of observations between the two periods was due to the fact that the sample size for the 2014 DHS was more than doubled in order to provide reliable estimates for rural and urban areas within provinces [24].

We investigated determinants of, and socioeconomic inequality in, stunting and fever in Zambia between 2007 and 2014, a period when child health interventions were rapidly scaled up to meet the 2015 MDG target on child health. We find that although stunting prevalence reduced, inequality increased. On the other hand, fever incidence did not fall but inequality still increased. The increase in inequality of stunting and fever implies that the rapid scale up of child health interventions may not have been successful in reducing childhood disease burden among the most vulnerable, suggesting the need for policy reform if the goal of reducing inequality, as captured by the Sustainable Development Goals (SDGs), is to be achieved.

Childhood ill-health has serious consequences. Apart from increasing under-5 mortality rates, it negatively affects cognitive abilities, education attainment, later life income, and adult health. However, children in low socioeconomic background bear a significantly larger share of childhood ill-health implying that they will continue to shoulder a larger share of these adverse consequences. This raises ethical issues. Why should children from poor backgrounds experience more ill-health when the determinants of ill-health are beyond their control, and to a large extent beyond the control of their parents. How can such inequalities be justified when they are hugely generated by inequality of opportunities to determinants of good health, such as education and health care? Against this backdrop, reducing inequality constitutes one of the most important development goals and is now part of the post 2015 development agenda, the Sustainable Development Goals (SDG), the successor to the Millennium Development Goals (MDG). To derive lessons for the post 2015 agenda of designing interventions that are effective in improving overall child health and reducing inequality, it is important go beyond asking whether or not inequalities increased by undertaking an in-depth analysis of the forces that drive inequality.




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