ArticlesReductions in child mortality levels and inequalities in Thailand: analysis of two censuses
Introduction
Over the past five decades there have been substantial improvements in the health of Thai children, with reductions in the under-five mortality rate (U5MR) from above 160 per thousand in the 1950s and 60s to below 40 per thousand by 1990.1, 2 A further 24% reduction from 1990 to 20002 puts Thailand well on track to achieve the Millennium Development Goal (MDG) of a two-thirds reduction in U5MR between 1990 and 2015.3 This is in stark contrast to many other countries, particularly those in sub-Saharan Africa and southern Asia where varied progress towards this target has led to much doubt as to whether the goal can be achieved.4, 5, 6
As the MDGs focus on average levels, one unanswered question is whether the success in reducing the average U5MR has been accompanied by a reduction in the disparity in child health between subgroups of the Thai population. This notion is in line with global calls for routine monitoring of equity in health outcomes.7, 8, 9 Many other countries provide examples of increasing life expectancy and decreasing child mortality while inequalities between the rich and the poor remain10 or worsen.11 Although Thailand has experienced substantial economic growth over the past two decades (with some interruption due to the 1997 economic crisis), income inequality persists at a relatively high level.12 A critical question is how this has affected the distribution of child mortality. Although Thailand might be, on average, set to meet the MDGs for child health, relatively deprived segments of the population might be lagging behind.
We aimed to measure changes in child mortality inequalities by household-level socioeconomic strata of the Thai population using data from the 1990 and 2000 population censuses obtained from the National Statistics Office, Thailand.
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Population data
The 1990 and 2000 Thai population censuses were full enumerations of the Thai population. For both censuses, a random 20% sample of households completed a more detailed questionnaire on household characteristics and the analysis conducted here was limited to this sample (table 1).
The data from the Thai census have been used in other studies;2, 13 completeness is very high and quality is regarded to be good.14 The housing and population censuses can be linked through the use of several
Results
Economic status at the provincial level was highly correlated with gross provincial product; Spearman's rank correlation coefficient was 0·87 (p<0·0001) in 1990 and 0·78 (p<0·0001) in 2000. Mean economic status in Thailand increased from 1990 to 2000 and was accompanied by a narrowing of the distribution at the household level (coefficient of variation 0·40 in 1990 to 0·29 in 2000), as shown in figure 1.
Average U5MR was 27·4 (95% CI 26·8 to 28·0) per 1000 livebirths in the 1990 census and 18·7
Discussion
Between 1990 and 2000, in addition to successfully reducing the average level of under-five mortality by about 30%, Thailand approximately halved inequality between the poorest and the richest populations. This remarkable reduction in child-mortality inequality across economic strata is shown by all three measures used in this analysis—the rate ratio, the absolute difference, and the concentration index. The 55% reduction in the excess child-mortality risk between the poorest and richest
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