General comment on the principles of the CRC and child and maternal health in Sub Saharan
Africa (SSA) - a child rights-based accountability framework for the implementation of article 24
O’Hare B.A.
Preamble
Article 24.2(a). Mandates States to decrease infant and child mortality both within their own borders and also outside their borders. Children have the right to survival and all states or individuals making decisions on behalf of states have a duty to ensure that children enjoy the right to survival and that they make decisions which will reduce child mortality. It is an urgent priority to identify the underlying determinants of child and maternal health in order to develop a child rights based framework which will identify states that have taken policy decisions which violate these rights and demand redress within the principles of the CRC.
Background
We already know that some upstream socioeconomic determinants of health is associated with reduced child mortality. We also know that some of these upstream determinants of health are susceptible to policy changes and some are not. What we do not know, is the relative influence that each of these factors has and how much this influence varies between countries or regions. In clinical medicine, evidence based practice has come to play an important role in assisting physicians to make decisions when providing individual patient care. Given the scale of the impact of the outcomes which result from upstream policy decisions, it is important that policy makers make decisions on the best available evidence. It is a priority to produce a policy analysis tool which quantifies the proportion of child and maternal mortality in any one country which can be ascribed to a given policy or the proportion by which mortality might be reduced by introducing or abandoning a given policy.
Background - African poverty
After independence most African countries witnessed growth in their economies and sharp decreases in child mortality. However both economic growth and the gains in under 5 mortality slowed dramatically in
the 1980s and 1990s (Cornia and Mwabu 1997). In the 1970s many SSA countries took out large loans at
a time of high inflation and low interest rates. In the 1980s there was an increase in oil prices and an increase in interest rates. At the same time there was a decrease in the price countries were receiving for their main exports, primary commodities. The interest rate on these loans spiraled and a debt crisis ensued. Commercial banks stopped lending money and financial rescue was offered by the international community provided the conditions of the IMF had been reached. This gave the IMF huge leverage over indebted countries, in an era when there were strong neoliberal influences on international organizations.
The resulting conditions dictated that countries opened their markets, decreased spending on welfare and
oriented their produce towards export in order to earn foreign currency to repay the debts (O'Hare,
Venables et al. 2005). Few African countries had joined the WTO at the time of the Uruguay Round, but
as a result of the conditions of loans, many had already liberalized their economies much more than required for accession. However accession to the WTO made the liberalization they had agreed to almost irreversible. The main instrument which countries have at their disposal when there are breaches of the international trade rules are sanctions but these are of limited usefulness to African countries given the small role they play on the international market stage, plus the cost of bringing a case before the WTO is prohibitively expensive for most African countries. Using loopholes, developed countries subsidize agricultural products’ and set their tariffs at high levels thus limiting the import of agricultural products and processed goods, which negatively affects exporting African countries. Voting power within organizations
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responsible for economic governance, the IMF and the World Bank, is weighted towards economically powerful countries, which use this power to influence policy in their own commercial, financial and geopolitical interests. These interests may often be aligned with the interests of powerful groups within those countries, with lobbying muscle power. The WTO is supposedly one country one vote but in reality
the vote of African countries is often influenced using the tool of aid (Aileen Kwa 2004). The Uruguay
round also extended trade rules into such domains such as trade in services and to intellectual property rights, these issues directly affects the cost of medication and seeds which greatly impacts the lives of the poor.
Background -Poverty and child health
Child mortality may be caused by proximate, intermediate or distal determinants of health (Schell, Reilly et al. 2007). Socioeconomic factors which have been shown to be important at the distal and intermediate level include income and maternal education (Pritchett 1996; Filmer and Pritchett 1999), the latter is influenced by the former (Houweling and Kunst 2010), There is abundant research which shows the
inverse relationship between income and child mortality. This relationship is often reported as the elasticity. Elasticity reports the percentage change in one variable if there is a 1% change in the other variable. The elasticity between income and child mortality is generally reported somewhere between -0.2 to -0.8, which means that for a 1% increase in income there is a fall in mortality of between 0.2-0.8%, see table 1. Infant or under 5 mortality rates, are generally measured in the number of deaths per 1000 live births so an increase in income of 1% would mean a fall in mortality of 2-8 per 1000 live births. (Child and infant mortality are highly correlated in datasets from African countries). An increase in income of 10% would mean a fall in mortality of 20-80 per 1000 live births.
Background -Policy and poverty
There is evidence that policy decisions taken at the level of international organizations, including trade liberalization has resulted in changes to GDP per capita in many African countries in the last twenty years
(Kraev 2005). The ongoing use of agricultural subsidies in the US, EU and Japan impacts the GDP of many western and central African countries (3D 2004).Given the relationship between policies and GDP
and the elasticity of GDP per capita and child mortality, it is possible to produce a policy pathway to quantify policy decisions in terms of children’s lives. We can then use a child rights based framework which will identify states that have taken policy decisions which violate these rights and demand redress
Socioeconomic determinants of health influenced by policies taken at country and at international level
(see Figure 1 and 2) This is a difficult field of study but it is crucial that we know the relative impact of different upstream policies. For example, it has been estimated that liberalization introduced as part of the structural adjustment process, may have cost SSA countries on average 11% of their GDP over the last
20 years (Kraev 2005)
, in terms of children’s lives if we assume an elasticity of -0.2 to -0.8, this is equal to
20-80/1000 change in the under 5 mortality for a given country every year for 20 years.
Summary
The associations between policies and income and child mortality can be used to develop a policy analysis pathway (see Figure 1) in order to monitor policies taken by states which violate children’s rights and after quantification, compensation must be sought from the offending state. Others have suggested using tools such as international human rights agreements for this purpose for example in
the case of cotton subsidies (3D 2004).
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Table 1. Summary of results
L= longitudinal, CS = cross sectional U5M = under 5 mortality rates per 1000 live births, IMR = Infant mortality per 1000 live births. HIC = high income countries, MIC = middle income, LIC = low income countries
Reference Study type
Controlling for R2 Measure of child mortality
(Cornia and
Mwabu
1997)
Link
(Filmer and
Pritchett
1999)
Link
(Schell,
Reilly et al. 2007)
Link
(Pritchett
1996)
Link
(Bokhari
2007)
Link
(Amouzou
2004)
Link
(Anyanwu
2006)
Link
(Mogford
2004)
Link
African countries only,
CS/LS
Time, female literacy, daily calories, proportion immunized
47-
53%
IMR
U5M
CS, LS Time, GDP pc, public expenditure on health,
CS, HIC,
Female education, ethno linguistic difference, predominantly Muslim
Female literacy, GINI
MIC, LIC
Results for LIC &
MIC shown
CS, LS GDP pc
HIC,
MIC, LIC
HIC,
MIC.LIC
C/S
Literacy, paved roads, government expenditure on health
Africa only, C/S and LS
95%
55-
62%
87
%
U5M or IMR
IMR
40% IMR
U5M
Literacy, urbanization, 79% U5M
African only
African countries only,
CS, LS
Per capita health expenditure,
Female literacy, urbanization, no physicians
Female SS enrolment, log GNP pc,
Debt/export ratio
89-
91%
56-
61%
IMR
U5M
U5M
Measure of
Income
GDP pc USD
GDP pc PPP
GNI pc USD
Atlas method
GDP pc PPP
GDP pc
GNP pc constant
1995 USD
GDP pc
GNP pc in constant 1985
USD
Elasticity child mortality with income
-0.12
-0.18
-0.6
- 0.46 to
0.56
-0.43 to
0.76
-0.4
-0.14
NS
NS
NS
–
–
Year/s studied
1960-1995
1960-1985
2003
1960-1985
2000
1970-2000
2006
1997
& 1970-1997
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(Houwelin g, Caspar et al.
2005)
Link
(Cornia
2008)
LIC Female literacy, region,
GINI index
NK U5M GDP pc PPP -0.19
(Bhalotra
July 2006)
Link
(Garenne
2006)
Link
Female literacy, DTP immunization, HIV,
GINI
85% U5M GDP pc -0.21
Single country.
LS
Single country.
LS
State, GINI, health expenditure, poverty gap, gender, ethnicity, religion
Public health expenditure PPP, imports of medical products
U5M
U5M
GDP pc
GDP pc PPP
-0.50
-0.34
NS = not significant.
* These estimates are all partial elasticity’s because variables which were entered into the models were themselves a function of the GDP, e.g. infrastructure
1990-1998
1960-2005
1970-1998
1960-2000
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Figure 1 Pathway of socioeconomic influences on child mortality in SSA
Markets International Financial institutions
Household income=food & shelter
Debt
Conditions introduced as a result of debt restructuring – SAP,
Free market orientation liberalization/
↓import tariff ↓agricultural subsidies in SSA. Privatization
of parastatals
PRSP
Country resources
Infrastructure/governance/ ability to generate tax/ability to subsidize food or its production/ policies to avoid corruption
Expenditure on health/education/water & sanitation
Household: Maternal education, income, access to water & sanitation
International community liberalization leveraged by providing credit via IMF and by aid
Child: access to healthcare
WTO accession - liberalized orientation less reversible
Child mortality
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