In an era of economic growth, is inequity holding back reductions in child malnutrition in Vietnam?

In the past decade of economic growth, Vietnam has achieved an impressive rate of socioeconomic development. However, the rate of improvement in child malnutrition lags far behind that of most other health indicators. This study examines factors other than income that might affect this inability to reduce rapidly child malnutrition by exploring the socioeconomic factors that explain the high rates of stunting and underweight status of many Vietnamese children. A nationally representative survey of Vietnamese households, the 1997-98 Vietnam Living Standards Survey (VLSS) is used. Multivariate logit is used for regression analysis. The key parameters are household poverty status, total expenditure level, rural residence, and minority status with controls for many key socio-demographic measures. Children from rural households, poor households, and ethnic minority backgrounds are significantly more likely to be malnourished (with a 17.6%, 10.9%, and 14.1%, respectively, greater prevalence of malnutrition) than are urban residents, non-poor households, and the majority Kinh population. These results suggest that economic improvements in Vietnam have, for the most part, bypassed the rural poor and minorities and that targeting economic resources towards these groups will be most critical for reducing undernutrition in Vietnam.     

Patterns of food consumption in Vietnam: effects on socioeconomic groups during an era of economic growth

OBJECTIVE: To identify if the nutritional status and improvements in Vietnam during the 1990s applied equally to the key vulnerable population groups (poor, rural, and ethnic minority) as it did to the nonpoor-largely in the urban areas. DESIGN: This study used cross-sectional analyses in the context of inequalities occurring in the diets of the poor and nonpoor that accompanied economic improvements during the Vietnam Doi Moi period. SETTING: During the Doi Moi period in Vietnam. SUBJECTS: A cross-sectional analysis was conducted on data using 23,839 individuals (4800 households) from the Vietnam Living Standard Survey (VLSS) in 1992-1993 and 28,509 individuals (6,002 households) from the Vietnam Living Standard Survey in 1997-1998. Analysis for changes in food consumption was conducted on 17,763 individuals (4,305 households) that were included in both surveys. INTERVENTION: None. RESULTS: After initiation of Doi Moi in 1986, the average Vietnamese person reached the dietary adequacy of 2,100 kcal per day per capita in the early 1990s, but this did not improve during the next decade. The structure of diet shifted to less starchy staples while proteins and lipids (meat, fish, other protein-rich higher fat foods) increased significantly. Although the gap in nutrient intake between the poor and the nonpoor decreased, the proportion of calories from protein- and lipid-rich food for the poor is lower than for the nonpoor. The VLSS data showed that the increase of protein and lipid foods in total energy structure over the 5 y between the VLSS studies for poor households was 0.43% (CI=0.33, 0.53) and 0.47% (CI=0.41, 0.54) lower, respectively, than for nonpoor households (P<0.0001). Inequalities compared to the nonpoor were also found in both quantity and quality of food consumption. For example, poor households consumed (quantity) 127 kcal/day (CI=119, 135) less from meat, and 32 kcal/day (CI=27, 38) less from fats than nonpoor households (P<0.0001), and the proportion of calories consumed (quality) by poor households was 5.8% (CI=5.4, 6.1) less from meat and 0.96% (CI=1.2, 0.7) less from fats than by nonpoor households (P<0.0001). CONCLUSIONS: Although the key vulnerable groups-rural, poor, and minority populations-showed improvements in diet, there still remains an inequity between these groups and the nonpoor of the population. In particular, the vulnerable groups consumed less of their daily consumption from the desirable high-quality proteins of animal foods and fats, and more from cereals and other starches-lagging the better-off populations in desired composition.     

Childhood malnutrition during the Bosnian conflict: Four linked cross-sectional studies

In the first years of the Bosnia conflict (1992–1995), a number of small local studies failed to confirm the expected widespread malnutrition that was the basis of humanitarian appeals. At the request of relief agencies, four population surveys from 1994 to 1997 measured childhood malnutrition during and immediately after the conflict as well as potential risk factors. The four surveys visited a random sample of clusters from population registers in Bosnia and Herzegovina (BiH) and the Republica Srpska (RS). All surveys measured mid-upper arm circumference (MUAC) in children 6–59 months old in 31 BiH clusters and in 10 RS clusters (last three surveys). An administered questionnaire documented potential risk factors, including breastfeeding, receipt of food aid and socio-economic variables. Analysis relied on a cluster-adjusted multivariate Mantel–Haenszel procedure. In BiH, the proportion of children with MUAC less than 125 mm increased between 1994 and 1997: 5.5%, 6.8%, 14.2% and 8.6% (χ²?=?23.2; 2 d.f.); using z-scores (>?2SD), the increase was 2.8%, 5.6%, 7.5% and 5.7% (χ²?=?11.9; 2 d.f.). In the third year of life, the risk of malnutrition was significantly higher in children from households receiving food aid (OR_a?=?2.38, 95% CI_ca?=?1.36–4.15), whereas in the fourth year of life the risk of malnutrition was higher among children in male-absent households (OR_a?=?4.42, 95% CI_ca?=?1.99–9.83). The risk of malnutrition was not related to ethnicity, sex of the child or urban/rural residence. The increased childhood malnutrition between 1994 and 1997 confirms increased vulnerability of some segments of the Bosnian population over the last years of the war, despite the humanitarian aid programme.     

Reduction in childhood malnutrition in Vietnam from 1990 to 2004

Reduction in childhood malnutrition in Vietnam between 1990 and 2004 was assessed using data from 5 national surveys. The prevalence of malnutrition, including stunting, declined significantly for underweight from 45% in 1990 to 26.6% in 2004. While the average reduction was 1.3% per year in the period from 1990 to 2000, it was 1.8% per year in the period from 2000 to 2004. The prevalence of stunting declined from 56.5% in 1990 to 30.7% in 2004, with an average reduction of 2% per year in the period from 1990 to 2000 and 1.5% per year in the period from 2000 to 2004. There were clear differences in the decrease in malnutrition prevalence between urban, rural and mountainous areas, the reduction being highest in the urban regions and lowest in the mountainous areas. Regression analysis showed that the nutrition status of the child is positively related to better household living conditions and to the educational level of the father, but not the mother. Stunting is higher in children whose parents are farmers and higher in households with more children. Stunting prevalence is lower in households with safe water access and hygienic toilets. In future , the dramatic reduction is childhood malnutrition as seen in the period 1990 to 2004 might not continue. More comprehensive apptoaches will be needed to lower childhood malnutrition in Vietnam further.     

Does economic inequality affect child malnutrition? The case of Ecuador

Economic inequality has been hypothesized to be a determinant of population health, independent of poverty and household income. We examined the association between economic inequality and child malnutrition in Ecuador. Economic inequality was measured by the Gini coefficient of household per capita consumption, estimated from the 1990 Census. Childhood stunting, assessed from height-for-age z scores, was obtained from the 1998 Living Standards Measurement Survey (LSMS). We controlled for a range of individual and household covariates, including per capita food consumption, education, housing, ethnicity, fertility, access to health services, diarrhea morbidity, child care, mother's age and diet composition. Stunting still affects 26% of children under five in Ecuador, with higher prevalence in the rural Highlands and among indigenous peoples. Maternal education, basic housing conditions, access to health services, ethnicity, fertility, maternal age and diet composition were independently associated with stunting. However, after controlling for relevant covariates, economic inequality at the provincial scale had a statistically significant deleterious effect on stunting. At municipal or local levels, inequality was not associated with stunting.     

Tobacco expenditures and child health and nutritional outcomes in rural Bangladesh

This study examined the relationship between tobacco prices and child health outcomes so as to assess the potential of improved child health outcomes resulting from less tobacco expenditure. In part, this paper was motivated by a study by. Efroymson et al. [(2001). Hungry for tobacco: An analysis of the economic impact of tobacco consumption on the poor in Bangladesh. Tobacco Control, 10, 212–217] suggesting that for the poorest households in Bangladesh, amongst whom malnutrition is widespread, shifting tobacco expenditures to expenditures on food would significantly improve the nutritional status of the household. We used data from a survey of 956 households conducted in rural Bangladesh between June 1996 and September 1997. The households were surveyed four times at approximately 4-month intervals during the 16-month period. We restricted our sample to households with children aged 2–10, and 600 households satisfied this criterion. The primary dependent variables for this study are three anthropometric indicators of child health and nutritional status: a standardized measure of height for age, a standardized measure of weight for height, and a standardized measure of weight for age. We also used measures of self-reported morbidity, including the incidence and duration of respiratory illness. We used regression methods on data averaged across survey rounds to estimate the relationship between tobacco prices and the outcome variables. Tobacco prices were found to be a significant determinant of height for age and weight for height for both boys and girls. Furthermore, the price of tobacco products is a significant predictor of weight for age for girls and the pooled sample. Our results suggest that higher tobacco prices would, for the most part, improve child health.     

Understanding wealth-based inequalities in child health in India: A decomposition approach

India experienced tremendous economic growth since the mid-1980s but this growth was paralleled by sharp rises in economic inequality. Urban areas experienced greater economic growth as well as greater increases in economic inequality than rural areas. During the same period, child health improved on average but socioeconomic differentials in child health persisted. This paper attempts to explain wealth-based inequalities in child mortality and malnutrition using a regression-based decomposition approach. Data for the analysis come from the 1992/93, 1998/99, and 2005/06 Indian National Family Health Surveys. Inequalities in child health are measured using the concentration index. The concentration index for each outcome is then decomposed into the contributions of wealth-based inequality in the observed determinants of child health. Results indicate that mortality inequality declined in urban areas but remained unchanged or increased in rural areas. Malnutrition inequality increased dramatically both in urban and rural areas. The two largest individual/household-level sources of disparities in child health are (i) inequality in the distribution of wealth itself, and (ii) inequality in maternal education. The contributions of observed determinants (i) to neonatal mortality inequality remained unchanged, (ii) to child mortality inequality increased, and (ii) to malnutrition inequality increased. It is possible that the increases in child health inequality reflect urban biases in economic growth, and the mixed performance of public programs that could have otherwise offset the impacts of unequal growth.     

User fees and health service utilization in Vietnam: how to protect the poor?

OBJECTIVES: Vietnam started its health reform process two decades ago, initiated by economic reform in 1986. Economic reform has rapidly changed the socio-economic environment with the transition from a centrally planned economy to a market-oriented economy. Health reform in Vietnam has been associated with the introduction of user fees, the legalization of private medical practices, and the commercialization of the pharmaceutical industry. This paper presents the user fees and health service utilization in Vietnam during a critical period of economic transition in the 1990s. STUDY DESIGN: The study is based on two national household surveys: the Vietnam Living Standard Survey 1992-1993 and 1997-1998. METHODS: The concentration index and related concentration curve were used to measure differences in health service utilization as indicators of health outcomes of income quintiles, ranking from the poorest to the richest. RESULTS: User fees contribute to health resources and have helped to relieve the financial burden on the Government. However, comparisons of concentration indices for hospital stays and community health centre visits show that user fees can drive people deeper into poverty, widen the gap between the rich and the poor, and increase inequality in health outcomes. CONCLUSIONS: An effective social protection and targeting system is proposed to protect the poor from the impact of user fees, to increase equity and improve the quality of healthcare services. This cannot be done without taking measures to improve the quality of care and promote ethical standards in health care, including the elimination of unofficial payments.     

Changes in out-of-pocket payments for healthcare in Vietnam and its impact on equity in payments, 1992-2002

BACKGROUND: Economic reforms in Vietnam initiated in the late 1980s included deregulation of the health system resulting in extensive changes in health care delivery, access, and financing. One aspect of the health sector reform was the introduction of user fees at both public and private health facilities, which was in stark contrast to the former socialized system of free medical care. Subsequently, health insurance and free health care cards for the poor were introduced to mitigate the barriers to seeking care and financial burden imposed by out-of-pocket (OOP) health payments as a result of the user fees. OBJECTIVE: To examine the determinants of seeking care and OOP payments as well as the relationship between individual out-of-pocket (OOP) health expenditures and household ability to pay (ATP) during 1992-2002. DATA: The data are drawn from 1992-93 and 1997-98 Vietnam Living Standard Surveys (VLSS) and 2002 Vietnam Household and Living Standards Survey (VHLSS). METHODS: We use a two-part model where the first part is a probit model that estimates the probability that an individual will seek treatment. The second part is a truncated non-linear regression model that uses ordinary least-squares and fixed effects methods to estimate the determinants of OOP payments that are measured both as absolute as well as relative expenditures. Based on the analysis, we examine the relationship between the predicted shares of individual OOP health payments and household's ATP as well as selected socioeconomic characteristics. RESULTS: Our results indicate that payments increased with increasing ATP, but the consequent financial burden (payment share) decreased with increasing ATP, indicating a regressive system during the first two periods. However, share of payments increased with ATP, indicating a progressive system by 2002. When comparing across years, we find horizontal inequities in all the years that worsened between 1992 and 1998 but improved by 2002. CONCLUSION: The regressivity in payments noted during 1992 and 1998 might be because the rich could avail of health insurance more than those at lower incomes and as a consequence, were able to use the healthcare system more effectively without paying a high OOP payment. In contrast, the poor either incurred higher OOP payments or were discouraged from seeking treatments until their ailment became serious. This inequality becomes exacerbated in 1998 when insurance take-up rates were not high, but the impact of privatization and deregulation was already occurring. By 2002, insurance take-up rates were much higher, and poverty alleviation policies (e.g., free health insurance and health fund membership targeted for the poor) were instituted, which may have resulted in a less regressive system.     

Determinants of child morbidity in Latin America: a pooled analysis of interactions between parental education and economic status

Diarrhea and respiratory infections account for more than two-fifths of all deaths among children under five. Parental education and economic status are well-known risk factors for child morbidity, but little is known about whether education and economic status operate synergistically or independently to influence children's health. Confirming the presence and direction of such interactions is important to better target education and development policies. Our objective is to test for interactions between parental education and economic status in predicting the risk of diarrhea and respiratory illness among children under five, before and after adjusting for key proximate risk factors. We pool 12 Demographic and Health Surveys (DHS) and nine Living Standards Measurement Surveys (LSMS) from Latin America, creating two large databases. Quintiles of economic status are constructed from principal components asset indices. We use logistic regression to analyze episodes of diarrhea and respiratory illness, and interactions between economic quintile and maternal and paternal education are evaluated via likelihood ratio tests. We find that mother's education and quintile interact synergistically in the DHS data, while results are inconclusive in the LSMS data. The effect of increasing maternal education appears to be more protective for children in wealthy families than for children in poor families. Conversely, improvements in economic status reduce health risks more for children whose mothers are better educated. Father's education is protective and operates independently of economic status. Our findings imply that poverty alleviation efforts occurring in concert with programs to educate women and girls will be more effective for improving children's health than either approach alone.