Stagnant neonatal mortality and persistent health inequality in middle-income countries: a case study of the Philippines

Abstract

Background: The probability of survival through childhood continues to be unequal in middle-income countries. This study uses data from the Philippines to assess trends in the prevalence and distribution of child mortality and to evaluate the country's socioeconomic-related child health inequality.

Methodology: Using data from four Demographic and Health Surveys we estimated levels and trends of neonatal, infant, and under-five mortality from 1990 to 2007. Mortality estimates at national and subnational levels were produced using both direct and indirect methods. Concentration indices were computed to measure child health inequality by wealth status. Multivariate regression analyses were used to assess the contribution of interventions and socioeconomic factors to wealth-related inequality.

Findings: Despite substantial reductions in national under-five and infant mortality rates in the early 1990s, the rates of declines have slowed in recent years and neonatal mortality rates remain stubbornly high. Substantial variations across urban-rural, regional, and wealth equity-markers are evident, and suggest that the gaps between the best and worst performing sub-populations will either be maintained or widen in the future. Of the variables tested, recent wealth-related inequalities are found to be strongly associated with social factors (e.g. maternal education), regional location, and access to health services, such as facility-based delivery.

Conclusion: The Philippines has achieved substantial progress towards Millennium Development Goal 4, but this success masks substantial inequalities and stagnating neonatal mortality trends. This analysis supports a focus on health interventions of high quality--that is, not just facility-based delivery, but delivery by trained staff at well-functioning facilities and supported by a strong referral system--to re-start the long term decline in neonatal mortality and to reduce persistent within-country inequalities in child health.

Figure 1. Biennial estimates of under-five, infant, and neonatal mortality rates (per 1,000 live births), with trends between 1990 and 2007 and projections towards 2015 in the Philippines.

Notes: Data are from Demographic Health Surveys 1993, 1998, 2003, and 2008. Biennial estimates by source and using the pooled data are represented. The solid line represents the mortality estimates calculated using direct methods on the pooled data, while the shaded area signifies the corresponding 95% confidence intervals. DHS, Demographic Health Survey.

Figure 2. Under-five, infant, and neonatal mortality rates (per 1,000 live births) by rural and urban location: actual 1990–2007; projected to 2015.

Notes: Data are from Demographic Health Surveys 1993, 1998, 2003, and 2008. The solid and semi-broken lines represent the mortality estimates calculated using direct methods, while the shaded area signifies the corresponding 95% confidence intervals. DHS, Demographic Health Survey.

Figure 3. Under-five, infant, and neonatal mortality rates (per 1,000 live births) between 1990 and 2007 and projections towards 2015 in the Philippines by wealth groups.

Notes: Data are from Demographic Health Surveys 1993, 1998, 2003, and 2008. The solid lines represent the mortality estimates calculated using direct methods. DHS, Demographic Health Survey.

Figure 4. Under-five, infant, and neonatal mortality rates (per 1,000 live births) for selected years and 2015 projections in the Philippines by regions.

Notes: Data are from Demographic Health Surveys 2008. AM, Autonomous Region in Muslim Mindanao; CR, Cordillera Administrative Region; IL, Ilocoos Region; CY, Cagayan Valley; CL, Central Luzon; CZ, CALABARZON (Cavite, Laguna, Batangas, Rizal, and Quezon); BI, Bicol Region; MI, MIMAROPA (Occidental Mindoro, Oriental Mindoro, Marinduque, Romblon and Palawan); NC, National Capital Region; WV, Western Visayas; CV, Central Visayas; EV, Eastern Visayas; WM, Zamboanga Peninsula (Western Mindanao); NM, Northern Mindanao; SM, Davao Peninsula (Southern Mindanao); CM, SOCCSKSARGEN (South Cotabato, Cotabato, Sultan Kudarat, Sarangani and General Santos City); CA, Caraga Region. The projected increases in mortality rates in the Ilocoos region are driven by estimated upward trends since 2004. Accordingly, the projected trends are driven by a small number of recent estimates, and thus, should be treated with some caution.

Figure 5. Annual rates of reduction in under-five vs. neonatal mortality rates over the periods 1990–1994, 1995–1999, 2000–2007, and 1990–2007 in the Philippines by regions.

Notes: Data are from Demographic Health Surveys 2008. AM, Autonomous Region in Muslim Mindanao; CR, Cordillera Administrative Region; IL, Ilocoos Region; CY, Cagayan Valley; CL, Central Luzon; CZ, CALABARZON (Cavite, Laguna, Batangas, Rizal, and Quezon); BI, Bicol Region; MI, MIMAROPA (Occidental Mindoro, Oriental Mindoro, Marinduque, Romblon and Palawan); NC, National Capital Region; WV, Western Visayas; CV, Central Visayas; EV, Eastern Visayas; WM, Zamboanga Peninsula (Western Mindanao); NM, Northern Mindanao; SM, Davao Peninsula (Southern Mindanao); CM, SOCCSKSARGEN (South Cotabato, Cotabato, Sultan Kudarat, Sarangani and General Santos City); CA, Caraga Region; NMR, neonatal mortality rate; U5MR, under-five mortality rate.