Ergebnisse der internationalen Vergleichsstudie »State of the World‘s Mothers 2015« der Kinderschutzorganisation Save the Children, 4.5.2015 (engl. Originalfassung)
Executive Summary: Key Findings and Recommendations
Increasing numbers of mothers are rasing their children in urban areas. Over half the world’s population now lives in cities and a growing proportion of child deaths occur in these areas. While cities are home to the wealthiest and healthiest people in a country, they are also home to some of the poorest and most marginalized families on earth.
In much of the world, the odds of children surviving to celebrate their fifth birthday have improved considerably in recent years. Today, 17,000 fewer children die every day than in 1990 and the global under-5 mortality rate has been cut nearly in half, from 90 to 46 deaths per 1,000 live births, between 1990 and 2013. But beneath remarkable improvements in national averages, inequality is worsening in far too many places. Some groups of children are falling behind their more fortunate peers, and these disparities tend to be more pronounced in cities.
Earlier this year, Save the Children’s Lottery of Birth report called attention to those childrenwho have been left behind and demonstrated how a more equitable path is needed in order to accelerate progress in reducing global and national under-5 deaths. State of the World’s Mothers 2015 focuses on one vulnerable groupof children that urgently needs more attention– those living in urban poverty. It also focuses on the people who feel the loss of a child most keenly and who have tremendous potential to make a positive difference in children’s lives – their mothers.
This report presents a first-ever global assessment of health disparities between rich and poor in cities. It analyzes data for dozens of cities in developing countries and 25 cities in industrialized countries to see where child health and survival gaps are largest and where they are smallest. It also looks at progress over time to see where gaps have narrowed and where they have grown wider. While preventable deaths of young children are tragic, unacceptable and reason enough to focus more attention on health care for the most vulnerable, it is important to note that child mortality rates are also an impor-tant indicator of the overall health of a city. The young children dying in city slums today – even where lifesaving care may be a stone’s throw away – represent perhaps the saddest expression of urban health system failure, and they also represent the everyday misery faced by millions of others. While there are multiple determinants of health in urban settings, this report focuses primarily on health-related interventions and approaches that we know can have a significant impact on the health and survival of mothers and children.
Key Findings
1. While great progress has been made in reducing urban under-5 mortality around the world, inequality is worsening in too many cities. Many countries have made importantprogress in reducing child death rates overall, including among the poorest urban children. But progress often does not eliminate disparities, and sometimes it exacerbates them. In almost half of the countries with available trend data (19 out of 40), urban survival gaps have grown. In relative terms, survival gaps have roughly doubled in urban areas of Kenya, Rwanda and Malawi despite these countries’ overall success in saving more children’s lives in cities.
2. The poorest children in almost every city face alarmingly high risks of death. In all but one of the 36 developing countries surveyed, there are significant gaps between rich and poor urban children. Save the Children’s Urban Child Survival Gap Scorecard examines childdeath rates for the richest and poorest urban children and finds that in most countries the poorest urban children are at least twice as likely to die as the richest urban children before they reach their fifth birthday. The Scorecard finds urban child survival gaps are largest in Bangladesh, Cambodia, Ghana, India, Kenya, Madagascar, Nigeria, Peru, Rwanda, Vietnam and Zimbabwe. In these countries, poor urban children are 3 to 5 times as likely to die as their most affluent peers. In contrast, cities in Egypt and the Philippines have been able to achieve relatively low child mortality rates with com-paratively smaller urban child survival gaps.
3. The poorest urban mothers and children are often deprived of lifesaving health care. Savethe Children’s City Health Care Equity Ranking looks at how access to, and use of, health care differs among the poorest and wealthiest mothers and children within 22 cities. It also includes a comparison of child malnutrition (stunting) rates between rich and poor in these same cities. The ranking finds huge dispari-ties in access to prenatal care and skilled birth attendance. The largest coverage gaps between rich and poor were found in Delhi (India), Dhaka (Bangladesh), Port au Prince (Haiti) and Dili (Timor-Leste). Child malnutrition gaps are greatest in Dhaka, Delhi, Distrito Central (Honduras), Addis Ababa (Ethiopia) and Kigali (Rwanda). In these cities, stunting rates are 29 to 39 percentage points higher among the poor-est compared to the richest.
4. High child death rates in slums are rooted in disadvantage, deprivation and discrimination. High rates of child mortalityin urban slums are fueled by a range of factors, including social and economic inequalities. While high-quality private sector health facilities are more plentiful in urban areas, the urban poor often lack the ability to pay for this care – and may face discrimination or even abuse when seeking care. Public sector health systems are typically under-funded, and often fail to reach those most in need with basic health services. In many instances, the poor resort to seeking care from unqualified health practitioners, often paying for care that is poor quality, or in some cases, harmful. Overcrowding, poor sanitation and food insecurity make poor mothers and children even more vulnerable to disease and ill health. And fear of attack, sexual assault or robbery limit their options when a health crisis strikes.
5. We know what works to save poor urban children. Save the Children profiles six citiesthat have made good progress in saving poor children’s lives despite significant population growth. The cities are: Addis Ababa (Ethiopia), Cairo (Egypt), Manila (Philippines), Kampala (Uganda), Guatemala City (Guatemala) and Phnom Penh (Cambodia). These cities have achieved success through a variety of strategies to extend access to high impact services, strengthen health systems, lower costs, increase health awareness and make care more accessible to the poorest urban residents. The city profiles provide a diverse set of examples, but the most consistently employed success strategies included: 1) Better care for mothers and babies before, during and after childbirth; 2) Increased use of modern contraception to prevent or postpone pregnancy; and 3) Effective strategies to provide free or subsidized quality health services for the poor
6. Among capital cities in high-income countries, Washington, DC has the highest infant death risk and great inequality. Save theChildren examined infant mortality rates in 25 capital cities of wealthy countries and found that Washington, DC had the highest infant mortality rate at 6.6 deaths per 1,000 live births in 2013. While this rate is an all-time low for the District of Columbia, it is still 3 times the rates found in Tokyo and Stockholm. There are also huge gaps between rich and poor in Washington. Babies in Ward 8, where over half of all children live in poverty, are about 10 times as likely as babies in Ward 3, the richest part of the city, to die before their first birthday.
Recommendations
Cities on fast and more equitable pathways to reducing child mortality have made concerted efforts to ensure that hard-to-reach groups have access to essential, cost-effective and high-impact health services that address the leading causes of child mortality. Malnutrition is now an underlying cause of nearly half of all under-5 deaths worldwide, and an increasing proportion of all child deaths occur in the first month of life (the newborn period). These facts point to an urgent need to strengthen efforts to improve maternal and child nutrition, provide prenatal care, safe childbirth and essential newborn care. A range of policies make equitable progress more likely for the urban poor, including steps toward the pro-gressive realization of universal health coverage to ensure that poor and marginalized groups have access to quality services that meet their needs.
1. The final post-2015 framework should include an explicit commitment to equitably ending preventable child and maternal deaths with measurable targets. 2015 is a pivotalyear for maternal, newborn and child survival. September 2015 will mark the launch of the post-2015 framework (Sustainable Development Goals) and the end of the Millennium Development Goals (in December 2015). This framework will determine the future of mothers’ and children’s lives around the world. Given the rapid growth of urban populations, and the increasing portion of under-5 deaths occurring among the urban poor, the post-2015 framework needs to highlight investments needed for basic health services, water and sanitation, and improved nutrition for this under-served, and often neglected, population.
2. Commit to leaving no one behind by embedding equity in the final post-2015 framework. The post-2015 framework mustmake a commitment that no target will be considered to have been met unless it has been met for all social and economic groups. While we have made tremendous progress in reducing maternal and child deaths over the last two decades, not all mothers and children have benefited from this progress. This is especially true for the urban poor. Within the context of the post-2015 framework for addressing inequities, explicit attention should be given to advancing strategies to addressing the inequities that exist within urban populations.
3. Improve the health of the urban poor by ensuring universal health coverage. Endingpreventable maternal, newborn and child deaths will require that everyone, starting with the most vulnerable, has access to high quality basic health and nutrition services, and is protected from the impoverishing effects of out-of-pocket costs of care. To achieve this, quality basic preventive and curative health services must be made more accessible and affordable. This will require investing in strengthened and expanded urban health systems designed to reach the poor, ensuring access to health workers able to provide quality care in slums and informal settlements, and removing financial barriers to accessing quality health services.
4. All governments must follow through on Nutrition for Growth commitments and ensure that the World Health Assembly nutrition targets are met. Malnutrition isthe underlying cause of 45 percent of deaths of children under 5, leading to over 3 million deaths each year, 800,000 of which occur among newborn babies. The locus of poverty and malnutrition among children appears to be gradually shifting from rural to urban areas, as the number of the poor and undernourished increases more quickly in urban than in rural areas. Child stunting is equally prevalent in poor urban settings as in rural settings. Stunting, which is caused by chronic malnutrition, can start during pregnancy as a result of poor maternal nutrition, poor feeding practices, low food quality and frequent infections. Attention must also be given to supporting and promoting exclusive breastfeeding for the first 6 months of life. Breastfeeding in some poor urban settings is lower than in rural areas due to lack of knowledge and education. Country-costed plans must include ways to address malnutrition in urban areas, including an emphasis on wasting, exclusive breastfeeding and stunting.
5. Develop comprehensive and cross-sectoral urban plans. National governments should develop and invest in integrated, cross-sectoral urban policies, strategies and plans that include maternal, newborn and child health (MNCH) and nutrition, as well as investments in improved access to clean water, sanitation and primary education. Donors should support these plans with funding critical to the achievement of the post-2015 goal of ending preventable maternal and child deaths.
6. Invest in data collection. National governments and donors should invest in strengthening data collection to better identify disadvantaged groups, track quality and use of services and monitor progress against agreed-upon plans and targets. Disaggregated data to identify residents of slums, informal settlements and street dwellers is needed to ensure that the urban poor are recognized and brought into the health system.
7. Mobilize resources to end preventable child deaths in poor urban areas. All governments must meet their funding commitments for maternal, newborn and child health and nutrition. Country governments must increase their own health budgets.
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