Inequalities in Immunisation

Save the Children Report CoverGlobal inequalities in health find their expression in a wide range of issues that start in the very early ages of a person’s life. Children are most at risk, as health-related problems can have implications on the rest of their life – if they survive childhood at all. Finding the Final Fifth: Inequalities in Immunisation is the title of a new report published by Save the Children in partnership with ACTION and endorsed by the World Health Organisation.
The report takes a closer look at health inequalities related to immunisation coverage. With children being highly vulnerable, no access to immunisation is one of the preventable causes of death. Further efforts such as the Global Vaccine Action Plan (pdf) are needed to tackle the problem. “Reaching the hard-to-reach must be a priority for all countries“, concludes Save the Children in a statement prior to the 65th World Health Assembly where these issues were on the agenda.
The Worldmapper project contributed a cartogram series to the report, looking at some of the data that Save the Children used in its findings. The data shows how access to health and immunisation compares to mortality rates of children and how this data gives an indication of the prevailing global inequalities. We created four maps, of which three were included in the report (the following maps are modified version of these maps). All of the maps show the countries resized according to the total number of people for each topic that is visualised (i.e. these images work like a cartographic version of a pie chart). The original data sources are given in the report (download link see below). The first map shows the mortality of under-five year old children:

Cartogram / Map of Child Mortality under the Age of Five in the World
(click for larger version)

Describing the occurring trends behind this map, the WHO states that “the number of children who die before their fifth birthday has been reduced by 35%, from 12.4 million estimated in 1990 to 8.1 million in 2009“, but that the “countries with worsened urban under-five mortality rates were all located in sub-Saharan Africa“. (WHO Global Health Observatory).
While Africa and South/South-East Asia dominate the mortality map, the report finds that basic health interventions such as immunisation are one important factor in the underlying causes. As an example, Somalia and Chad as the countries with the lowest measles vaccination coverage (less then half of the children are immunised there) are also among the top five countries with a high child mortality rate (180 and 173 under-five year olds per thousand live births). The report states that Africa and South/South-East Asia are home to 80% of the world’s unimmunised children, as shown in the following map:

Cartogram / Map of Unimmunised Children in the World
(click for larger version)

Child mortality and no access to immunisation are a result of poverty. Low-income countries dominate these statistics shown above, and the lack of access to health services such as immunisation for large parts of the population is an expression of a weak health system. The report uses health workers as a proxy to characterise the quality of the health system, not least because there is no immunisation without a health worker (and a health worker costs money, money that isn’t spent where there is a shortage of health workers). Visualising a shortage of health workers (based on the WHO recommendation of 23 doctors, nurses and midwives per 10,000 people) in a map demonstrates the injust distribution of access to health even more than the previous two maps. In the following map of health worker shortages the two regions (Africa and South/South-East Asia) are almost solitary on the world map, while unimmunised children also occur (although in much smaller numbers) in most parts of the world (for various reasons that go beyond the mere access to health services):

Cartogram / Map of Health Worker Shortages in the World
(click for larger version)

All three maps shown above outline a clear trend of the manifestation of global inequalities in health. To visualise the full dimension of this unequality one can also look at the opposite picture that demonstrates where the health systems are not as weak as shown before. Such a complementary picture is given when looking into the numbers of health worker surpluses based on the WHO recommendation. The following map shows the countries of the world according to a surplus of health workers:

Cartogram / Map of health worker surpluses in the World
(click for larger version)

One has to keep in mind that health inequalities are existing in varying scales. The global picture as shown above is one part of injustices in health systems, which does not show that there are also health inequalities within countries – not only of the poor countries, but similarly in the wealthier parts of the world (see here or here). But while trying to find solutions for problems ‘at home’, one should equally tackle the prevailing global disparities to create a fairer planet for everyone.
The report looks into these inequalities in the poorer parts of the world in much more detail than the global level and tries to find explanations and to propose solutions:

Addressing inequalities is the right thing to do from both a moral and an economic perspective.
Reducing inequalities is cost-effective, produces more sustainable outcomes, and increases the impact of every dollar invested, accelerating progress towards global and national development goals.
In just twelve countries, Save the Children’s analysis suggests that overcoming wealth inequalities in immunisation coverage in just 12 countries could prevent 370,000 child deaths each year.

Finding the Final Fifth: Inequalities in Immunisation was published in May 2012 by Save the Children and can be downloaded as a PDF document on the organisation’s website.

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