The Persistence of Rural-Urban Health Gap Among Under-Five Children in Sub-Saharan Africa

Jacob Adetunji, U.S. Agency for International Development (USAID)

Background: Sub-Saharan African region has participated in the rapid rate of urbanization currently ongoing in the less developed regions of the world. For virtually all countries studied, the rate of urban growth exceed that of the total population growth. For example, in Zimbabwe, the rate of population growth is about half the rate urban growth. Consequently, it is estimated that the proportion of urban population will exceed that of rural areas in the future, and attention is beginning to shift to the welfare of urban residents, particularly the urban poor. However, this paper hopes to call attention to the fact that health of the rural dwellers, who still make up the majority of these countries, is still poor and should not be overlooked. In the West, a transition seems to have occurred in the health benefits of urban living over the past two centuries. Up to the early parts of the 20th century, rural areas seemed to be healthier places to live than urban centers. Then came the advances in medical technology and the urban-bias in distribution both of these facilities as well as in the location of the economically well-to-do in urban areas. The rural advantage then seemed to disappear. However, rural areas particularly those peri-urban localities seem to be regaining their health advantages, especially with the rise in urban pollution, crime, and poverty. In almost all sub-Saharan African countries, no data exist on rural-urban mortality differences up to recent decades. In these countries, most urban centers were inventions of the colonial era, and the location of superior facilities tended to be in such urban centers. Thus, unlike in the West, it appears that urban Africa have always had health advantages over rural areas. A study based on Cameroon Fertility Survey (Kuate-Defo, 1996) found a large urban advantage in childhood mortality. Objectives: The first objective of this paper is to assess the rural-urban trends and differentials in the health of under-five children in selected Sub-Saharan African countries and to investigate the extent of urban advantages/disadvantages that exist. The paper then aims to assess the contributions of specific factors to the rural-urban child health gap in the region. Data and Methods: Data for the analysis are from sixteen sub-Saharan African countries that have participated at least twice in the Demographic and Health Surveys (DHS) program from 1990. The main indicators chosen to represent health are infant and child mortality and nutritional status (proportion with low height for age or stunted and the proportion with low weight for height or wasted). Rural and urban categories are country-specific and defined according to a country’s definition of an urban place. Preliminary Results The results show that a large rural-urban gap exists in the risk of under-five deaths in sub-Saharan African countries. Children born in rural areas have higher risks of death. The gap was narrower in Kenya (1.3) and Zimbabwe (1.4) than in other countries. The widest gap was observed in Senegal where rural childhood mortality was almost double (1.9) that of urban areas. The rural urban gap does not seem to be closing over time in all countries except Kenya. An analysis of immunization against common childhood killer diseases, which is one of the possible determinants of the rural urban gap, shows that rural children were less likely to be fully immunized. The ratio of rural children aged 12-23 months that were not immunized ranged from 1.7 in Madagascar to 13.3 in Tanzania. Similarly, the proportion that have received all immunization is higher in urban areas. Variations exist across countries differ in the proportion of children that were fully immunized: the proportion of rural kids that were fully immunized in some countries is even higher that the proportion of urban kids immunized in other countries. For example in Zambia, 75% of rural kids were fully immunized compare with 17% of urban kids in Gabon – the country with the lowest proportion of fully immunized children in the table. (Note: children age 12-23 months are considered fully vaccinated if they have received BCG, measles, and three doses of DPT and polio excluding polio 0). Ethiopia had the largest rural urban gap in the proportion children that were fully immunized – 4 times as large in urban compared to rural areas. Next to this is Gabon (3.1) and Nigeria (2.8). In the next phase of this analysis, the author will investigate the contributions of such variables as mother’s level of education and reproductive behavior (age at childbearing, birth spacing, breastfeeding practices, etc.) to the rural-urban gap in childhood mortality in Africa.