52797 Tajik Child Health: All Hands on Deck Anne Bakilana and Wezi Msisha Key Messages · Tajikistan is unlikely to meet its Millennium Child Health in Tajikistan Development Goals (MDGs) for infant and child mortality. The MDG 4 target of a two- Promoting and protecting the health of their families is thirds reduction in child mortality calls for a high priority of households in Tajikistan--half of all Tajikistan to decrease its current under-five households identify health as the aspect of life that is of mortality rate (U5MR) of 79 deaths per greatest concern to them. Thirty five percent, or 2.5 1000 live births to less than 30 per 1000, and million of the total estimated population of 7.2 million the current Infant Mortality Rate (IMR) of people in the country, are under 15 years of age. The 65 deaths per 1000 to under 25 per 1000. median age of the population is just 21.6 years (UN, 2008). Although fertility has fallen in recent years, the · The determinants of child mortality are total fertility rate remains above three. Thus, policies to complex and involve both direct factors improve maternal and child health (MCH) outcomes (such as, duration of breastfeeding, are central to improving the health of the nation. vaccinations, prenatal care, micronutrient Tajikistan faces considerable challenges in its quest to deficiencies, etc.) as well as indirect achieving the Millennium Development Goals (MDGs) determinants (such as, household poverty, for MCH over the next six years. low levels of maternal education, food insecurity, unsafe drinking water, limited The MDG 4 target of a two-thirds reduction in child access to health care services, etc.). mortality calls for Tajikistan to decrease its current under-five mortality rate (U5MR) of 79 deaths per 1000 live births to less than 30 per 1000, and the · The challenges of decreasing mortality current Infant Mortality Rate (IMR) of 65 deaths per among Tajik children are beyond the 1000 to under 25 per 1000. Countries with GDP levels control of just the Ministry of Health (MoH) similar to Tajikistan have made significantly better and health sector. In its stewardship role, progress towards reaching their MDG targets. For the MoH must collaborate with other non- instance, IMRs in the Lao People's Democratic health sector stakeholders--like the food Republic and Cambodia stand at 52 and 59 deaths per and agriculture, water and sanitation 1000 live births, respectively, compared to 65 per 1000 sectors -- to use their combined and in Tajikistan. IMRs in neighboring Uzbekistan and the coordinated efforts in focusing on common Kyrgyz Republic are 38 and 36 per 1000 live births, objectives over the medium to long-term respectively. Similarly, with child mortality rates of 69 horizon. and 41 per 1000 live births respectively, Lao and the Kyrgyz Republic are in a better position than · Targeting interventions and resources to Tajikistan. geographic areas and socio-economic groups with the poorest child health outcomes will have the greatest impact on reducing child mortality in Tajikistan. Why do so Many Children still die in broader structural factors beyond the control of the Tajikistan? individual. Until now, little was known about how these factors affect the health of children in Tajikistan. The bulk of child mortality in Tajikistan still takes However, the 2009 study--Multisectoral Determinants place largely due to preventable causes (Table A). A of Child Mortality in Tajikistan--provides concrete significant proportion of neonatal deaths are a result of evidence of the multi-sectoral constraints preventing premature delivery and low birth weight, while the achievement of lower child mortality rates and also diarrhea and meningitis are the leading causes of points to the various actions that can be initiated to deaths in the post-neonatal period. address them. Analysis of Tajikistan's most recent national level household data--the 2003 and 2007 Tajikistan Living Standards Surveys (TLSS) and the Main Determinants of Child Morbidity and 2005 Multiple Indicator Cluster Survey (MICS)--also Mortality revealed several significant indirect and direct determinants of child mortality (Table A). Health outcomes across the life course of any individual are influenced by a complex inter-play of Table A. Determinants of Child Mortality in Tajikistan Direct Determinants Indirect Determinants Short breastfeeding duration Household poverty Late vaccinations Low maternal education Low use of ORT for diarrheal diseases Household food insecurity Low antenatal care visits Rural households Micronutrient deficiencies Region of residence High number of miscarriages/stillbirths Use of unsafe drinking water and poor sanitation facilities Low contraceptive use Long distance to a health facility Direct Determinants In Tajikistan, U5MR and IMR differ by region, with 43 percent in the Khatlon region. The variations in the lowest rates for both observed in the Gorno- these critical factors within the country contribute to Badakhshan Autonomous Oblast (GBAO) region (54 the increased risks in some regions for poorer child and 46 deaths per 1000, respectively), and the highest health outcomes. Of course, these factors alone do not in the Khatlon region (102 and 81 deaths per 1000, entirely account for the observed child mortality levels, respectively, according to the 2005 MICS). Not but are worsened or indirectly caused by other broader surprisingly, proximate factors that increase the risk of environmental factors. child mortality also vary by region, maternal education and household poverty. For instance, contraceptive use Socioeconomic Determinants was highest in GBAO (55 percent) and lowest in Khatlon (33 percent). Similarly, immunization rates Certain socioeconomic factors play a crucial role in were lowest in Khatlon and the Rayons of Republican child health in Tajikistan. These are: region of Subordination (RRS) region, and highest in the Sogd residence, the educational attainment level of the region. Notably, 41 percent of children in the RRS had mother and household head, household head's been vaccinated against measles, compared to 77 employment sector, access to clean water, household percent in Sogd. Also, the proportion of exclusively floor type and toilet type, and distance to a health breastfed infants (aged 0 to 3 months) was 23 percent facility. Compared to other regions, children living in in Dushanbe and 33 percent in Khatlon, compared to Khatlon were at the greatest risk of dying before the 61 percent in GBAO (TLSS 2007). The practice of age of five; at the lowest risk were children residing in early weaning, combined with food shortages faced by Dushanbe. Similarly, factors such as residing in rural many households--particularly the poor ones, areas and household poverty carried a greater risk of contributes to the relatively high levels of stunting mortality. More often than not, household poverty observed in Tajik children and is also reflected in the levels were related to educational attainment and high incidence of low birth weight babies. The occupation type. prevalence of moderate to severe stunting among children under the age of five was 30 percent in Dushanbe, 38 percent in Sogd, RRS and GBAO, and Child mortality risks are higher when the mothers or Although significant non-health sector action is the heads of the households have no education or only required in order to reverse the current child mortality primary level education. Higher maternal education is trends in Tajikistan, equally concerted efforts are associated with increased utilization of health services required by the health sector. Several interventions do and the provision of a quality lifestyle for children exist that have proven to be effective for the types of (Hobcraft, 1993). Children's household environments health problems responsible for the greatest burden of also pose various threats to their survival--for example, illness among Tajik children (Table B). Effective the availability of safe drinking water is an important implementation is the key to reaping the benefits of factor for decreased incidence of diarrheal diseases. these interventions. Mortality risk is also clearly decreased by the presence of a ventilated pit latrine or a latrine connected to a As Tajikistan continues to work towards meeting its septic tank which enables the safe disposal of human MDG targets, the greatest impact will be realized from waste. Finally, a clay or earth floor is a hazard for child targeting interventions and resources to those survival, whilst improved floors diminish child geographic areas with the poorest child health mortality risk. outcomes. What can be done to reduce the Number of Tajikistan's MoH should also focus on implementing Children Dying in Tajikistan? the complementary interventions to support these broader areas which are the mainstay of other sectors- -such as, nutrition, education of women and families The findings on the determinants of child mortality in on appropriate child feeding practices, and good Tajikistan confirm the general thinking on how to sanitation. Global evidence from countries that have address pressing health problems that have remained achieved successes in child health and mortality shows unresolved for many years in several regions around that implementing results-oriented child health the world. It is obvious that most of the identified programs, and coordinated implementation of high problems are beyond the control of the health sector as impact interventions by multiple sectors, can be useful we know it; they are rooted in areas outside health. for countries like Tajikistan. However, their effects manifest more visibly as poor health outcomes. The health sector, then, has to lead Multi-sectoral approaches have been shown to be combined efforts, along with other stakeholders, to critical in accessing hard-to-reach and poor address these issues if any appreciable gains are to be populations, tackling underlying causes of poor health made in child health. outcomes, and operationalizing effective child health interventions (CORE, 2004). Such approaches are even A significant reduction in high infant and child more critical in environments where there are mortality in the United States and other industrialized competing demands for limited resources, and help in nations during the 19th and early part of the 20th ensuring the optimal use of available resources. It is centuries was achieved through improvements in important for the MoH, in its stewardship role, to sanitation, hygiene, access to clean water, highlight the benefits of combined and coordinated immunizations, and antibiotics1. Most of the decline in collaboration between health and non-health sector infant mortality came about due to less post-neonatal stakeholders, and help them both focus on common deaths (1 month to 11 months) which are generally objectives over the medium- to long-term horizon. more amenable to non-health sector factors. The Collaborating with NGOs that may be better placed to greatest impact was on children from low effectively mount cross-sectoral interventions could socioeconomic backgrounds than on more affluent prove to be particularly beneficial. ones2. Therefore, it is important to ensure that interventions are distributed equitably so that the children most in need get the highest benefits. ____________________________________ 1 Sanders et al. `The Epidemiological Transition: the Current Status of Infectious Diseases in the Developed World versus the Developing World', Science Progress, March 2008 2 Burstrom, B. `Social Differentials in The Decline Of Infant Mortality In Sweden In The Twentieth Century: The Impact Of Politics And Policy', International Journal of Health Services, Volume 33, Number 4, Pages 723­741, 2003 CORE. (2004). Reaching communities for child health: Advancing health outcomes through multi-sectoral approaches. Washington DC: The CORE Group. Hobcraft, J., McDonald, J., & & Rutstein, S. (1985). Demographic determinants of infant and early child mortality: A comparative analysis. Population Studies 3 (1985), 363-385. Table B: Cost-Effective Priority Interventions for Child Mortality Reduction in Tajikistan Health Sector Interventions* Non-Health/Multi-Sectoral Actions Short-Term Preventive Treatment Increased breastfeeding Increased breastfeeding Hand washing campaigns (with water, local government, education sectors) Hand washing Increased use of ORT for Improve female education attainment, diarrheal diseases particularly secondary school completion rates Appropriate complementary Antibiotic use for Increase household access to and use of feeding dysentery, sepsis and clean water and sanitation facilities pneumonia Full immunization coverage Complementary feeding for Improve household food security sick children Micronutrient Better prevention and early Improved child nutrition through school supplementation treatment of infectious and feeding programs (education sector) parasitic diseases Increased contraceptive use Early detection and Better physical access to health facilities management of (roads and transportation sectors) malnutrition Quality antenatal care Better management of Anti-helminthic treatment for school age newborn complications and children (education sector) newborn resuscitation Antibiotics for premature rupture of membranes during labor Clean conditions during labor and delivery Anti-helminthic treatment for school age children (in conjunction with education sector) Medium- Better targeting of interventions to poor and vulnerable Economic growth and poverty reduction Term populations and regions Provision of quality essential neonatal and obstetric care Payment incentives for health providers (in conjunction with the health sector) Ensure availability of essential drugs and equipment in Possible use of social safety net health facilities (immunizations, antibiotics, resuscitative interventions, for example, cash vouchers equipment) for poor households to use preventive health services Improve health service provider skills at both the primary Improve household food security and secondary care levels Provision of provider incentives for improvements in child Better physical access to health facilities health outcomes (in collaboration with Ministry of Finance) (roads and transportation sectors) Increased engagement with families and communities in preventive and treatment activities Improve collaboration with other sectors on cross-sectoral health issues (education, agriculture, finance) Greater funding allocated to preventive services Improved monitoring and data collection on health outcomes * Adopted from: The Millennium Development Goals for Health: Rising to the Challenges, World Bank, 2004. 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