Duke 2008 | ASHE | Equity and Efficiency in Health and Healthcare

Objective: To evaluate cross-national inequalities in mortality rates of adults and children under age 5 employing a novel approach using clustering techniques to stratify countries into mortality groups (better-off, worse-off, mid-level) and to examine risk factors associated with inequality.

Design, Setting, Participants: Analysis of data from the World Development Indicators 2003 database, compiled by the World Bank.

Main Outcome Measures: Adult and child mortality among countries placed into distinct mortality categories by cluster analysis.

Results: 29 countries had a high adult mortality rate (mean 584/1,000; range 460/1000 to 725/1,000), and 23 had a high child mortality rate (mean 207/1,000, range 160/1,000 to 316/1,000). All these countries were in Western and Sub-Saharan Africa and Afghanistan. Bivariate analyses showed that, relative to countries with low child mortality, those with high child mortality had significantly higher rates of extreme poverty, population living in rural areas and female illiteracy and significantly lower per capita expenditure on health care, outpatient visits, hospital beds, and physicians and lower rates of access to improved water and sanitation and immunizations. In multivariate analyses, countries with high adult mortality had a higher prevalence of HIV infection (odds ratio [OR] per 1% increase, 18.6; 95% CI, 0.3-1135). Between 1960 and 2000, adult male mortality in high-mortality countries increased at more than 4 times the rate in low-mortality countries.

Conclusions: Inequalities in child and adult mortality are unacceptably large, are growing, and related to a number of economic, social, and heath sector variables. Global efforts to address this problem should focus on the worse-off countries, be concentrated geographically, and adopt a multi-dimensional and integrated approach to development.