J Urban Health https://doi.org/10.1007/s11524-018-0270-6 Is the Urban Child Health Advantage Declining in Malawi?: Evidence from Demographic and Health Surveys and Multiple Indicator Cluster Surveys Edgar Arnold Lungu & Regien Biesma & Maureen Chirwa & Catherine Darker The Author(s) 2018 Abstract In many developing countries including Cluster Surveys. Rate differences between urban and Malawi, health indicators are on average better in rural values for selected child health indicators were urban than in rural areas. This phenomenon has large- calculated to denote whether urban-rural differentials ly prompted Governments to prioritize rural areas in showed a trend of declining urban advantage in Ma- programs to improve access to health services. How- lawi. The results show that all forms of child mortal- ever, considerable evidence has emerged that some ity have significantly declined between 1992 and population groups in urban areas may be facing worse 2015/2016 reflecting successes in child health inter- health than rural areas and that the urban advantage ventions. Rural-urban comparisons, using rate differ- may be waning in some contexts. We used a descrip- ences, largely indicate a picture of the narrowing gap tive study undertaking a comparative analysis of 13 between urban and rural areas albeit the extent and child health indicators between urban and rural areas pattern vary among child health indicators. Of the 13 using seven data points provided by nationally repre- child health indicators, eight (neonatal mortality, in- sentative population based surveys—the Malawi De- fant mortality, under-five mortality rates, stunting mographic and Health Surveys and Multiple Indicator rate, proportion of children treated for diarrhea and fever, proportion of children sleeping under insecticide-treated nets, and children fully immu- E. A. Lungu (*) nized at 12 months) show clear patterns of a declining HIV Section, UNICEF Malawi, P.O Box 30375, Lilongwe, urban advantage particularly up to 2014. However, Malawi U-5MR shows reversal to a significant urban advan- e-mail: firstname.lastname@example.org tage in 2015/2016, and slight increases in urban ad- R. Biesma vantage are noted for infant mortality rate, under- Department of Epidemiology and Public Health Medicine, Royal weight, full childhood immunization, and stunting College of Surgeons in Ireland, Lower Mercer Street, Dublin 2, rate in 2015/2016. Our findings suggest the need to Ireland e-mail: email@example.com rethink the policy viewpoint of a disadvantaged rural and much better-off urban in child health program- M. Chirwa ming. Efforts should be dedicated towards addressing Prime Health Services and Consultancy, Area 47 Sector 4, determinants of child health in both urban and rural Lilongwe, Malawi e-mail: firstname.lastname@example.org areas. C. Darker Department of Public Health & Primary Care, Trinity College . . . . Keywords Child health Urban Urban slum Malawi Dublin, Tallaght Hospital, Dublin 24, Ireland e-mail: email@example.com Urban advantage Lungu et al. Background the extent that they became better than in rural areas. This health transition has gone on for a few decades, and Globally, there has been tremendous progress in reduc- the urban areas have enjoyed a health advantage over ing child mortality. A recent report by the United Na- the rural areas leading to a phenomenon that has been tions Inter-agency Group for Child Mortality Estimation termed the urban advantage [8, 14, 15]. (UN-IGME) indicates that the total number of under- Nonetheless, for about three decades now, since the five child deaths dropped from 12.6 million in 1990 to urban health discourse has received some prominence in 5.6 million in 2016, with the under-five child mortality global health, some authors have argued that aggregate rate having declined by 56%, from 93 to 41 deaths per urban-rural comparisons suggesting an urban advantage 1000 live births . Nonetheless, wide differentials exist are misleading considering that the urban population is in child mortality between and within countries. Reduc- not homogeneous [6, 12, 14–17]. Moreover, literature ing inequities and reaching the most vulnerable children discourse has suggested that some population groups in (and their mothers) are important priorities to achieve urban areas, particularly those residing in urban slums, the Sustainable Development Goals targets on ending face similar levels of health disadvantage or in some preventable child deaths by 2030 . cases actually face worse health outcomes than the rural Health indicators are on average better in urban than areas [6, 12, 15–19]. In essence, poor health indicators rural areas [3–6]. In Malawi, for example, under-five in urban slums have been cited among reasons for the child mortality rate was 130 compared to 113 deaths per stagnating improvements in aggregate urban health in- 1000 live births for rural and urban residents, respec- dicators in some countries. tively, in 2010 , and 77 and 60 deaths per 1000 live In recent decades, the world population has increas- births for rural and urban residents in 2015 . Other ingly become urban based. The United Nations estimat- child health indicators generally reflect this trend of an ed that in 2016, about 55% of the world population were urban advantage in many developing countries [3–6]. in urban settlements, and projected that this will increase An analysis of under-five child mortality data in to 60% by 2030. It is projected that most of the urban resource-poor settings noted a declining trend of child population growth will be occurring in least developed mortality in many countries, mostly with an urban ad- countries and that urban population will grow by 63% vantage. Evidently, in the period between 1950 and between 2015 and 2030 . Four main reasons are 2000, under-five child mortality is said to have declined cited as global determinants of increasing urbanization by 57% in both urban and rural areas . However, over rates. These include (i) natural growth, whereby the the same period, urban mortality patterns in Africa, existing urban population grows as a result of a high Asia, and Latin America were reported to be 25% lower rate of natural increase (i.e., the difference between than rural mortality albeit acknowledging country vari- crude death rate and crude birth rate), (ii) internal ations in the urban-rural divide [9, 10]. rural-to-urban migration, (iii) international urban migra- Historically, prior to and in the early stages of indus- tion which relates to people moving from urban areas trialization, health indicators in urban areas of many from one country to the other, and (iv) reclassification of countries in Europe were worse off than in rural areas. urban boundaries encompassing formerly rural areas For example, evidence suggests that in the nineteenth thereby increasing the urban population count by new century, infant mortality in urban areas in England and geographical demarcations . Wales were 2.2 times higher than in rural areas [9, 10]. Malawi’s population of about 17.3 million in 2017 is With prevailing circumstances as these at the time, some predominantly rural based with only about 15% of the authors have argued that the urban population could population residing in urban areas . Different figures easily have been wiped out if it were not for high levels have been provided for Malawi’surbanization ratefrom of in-migration . 4%  to as high as 6.2% which makes it among the The term urban penalty was prompted due to the highest in the world . In Malawi, natural growth and phenomenon of worse health status of urban residents rural to urban migration are arguably two main reasons [11–13]. However, over the years, the public health attributable to the high urbanization rate. Evidently, revolution characterized by improved sanitation, access there is a high total fertility rate of 4 among urban to safe water, vaccinations, and improved housing con- women in Malawi  and rural to urban migration ditions led to improvements in urban health indicators to accounts for 54% of total migration . People migrate Is the Urban Child Health Advantage Declining in Malawi?: Evidence from Demographic and Health Surveys and... from rural to urban areas due to, inter alia, limited health and is not worse than some preferred measures in cultivable land in rural areas, lack of rural off-farm recent times, such as the Disability-Adjusted Life Ex- economic activities, environmental degradation pectancy (DALE) . Secondly, under-five child resulting in inability to perform some of the convention- health is a policy priority for the Ministry of Health in al livelihood activities, and escaping rural poverty and Malawi and many countries and hence essential to ex- the perception of a better life in the cities . plore as a policy imperative in urban health discourse. Poverty levels remain high with 74% of households Rate changes over time for both urban and rural areas in Malawi considering themselves poor . In urban as independent geographical entities and rate differences areas, this has led to emergence of urban slums charac- for respective indicators between urban and rural areas terized by inadequate access to clean water, sanitation, are described to ascertain whether the urban advantage overcrowding, insecurity of housing tenure, and inade- for child health is declining or widening or has remained quate access to health and other social services [24, 28, static over the years in Malawi. 29], all of which are critical determinants of health. Indeed, the UN-HABITAT estimates that 61% of the Study Setting: Brief Country Profile urban population in Lilongwe, Malawi’s capital city, resides in slum conditions . Our study uses national data for Malawi as the study In view of the aforementioned evidence and context, setting. Malawi is a low-income country with an esti- the key question for public health in the urban setting, mated per capita gross domestic product (GDP) of therefore, is whether there is any evidence of a declining US$332 for 2016 . Using the United Nations De- urban advantage. This paper seeks to contribute to this velopment Programme’s (UNDP) Human Development area of urban health discourse, using under-five child Index (HDI) for 2016, Malawi is classified as a low human development country and is ranked 170 of the health indicators as reported in five Demographic and Health Surveys (DHS) and two Multiple Indicator Clus- 187 countries . Evidently, 50% of the population ter Surveys (MICS) in Malawi. lives below the national poverty line of MK-101 (about US$0.3 according to prevailing exchange rates) per capita per day and 25% are considered to be ultra-poor Methods (meaning they cannot afford to meet the minimum stan- dard for recommended daily food requirement) . Study Design Malawi’s epidemiological profile is characterized by a high burden of communicable diseases including ma- We used a descriptive study undertaking a comparative laria, acute respiratory infections (ARI), tuberculosis, analysis of 13 child health indicators between urban and and HIV and AIDS, albeit the burden of non- rural areas using seven data points provided by nation- communicable diseases has recently been increasing. ally representative population-based surveys—the DHS Pneumonia, diarrhea, HIV and AIDS, malaria and neo- and MICS. The use of under-five child health indicators natal causes are the highest causes of morbidity and for our focus is warranted on two premises. mortality for children under 5 years of age . Despite Firstly, it is common consent that the health of chil- a significant reduction in infant and under-five mortality, dren is sensitive to socioeconomic and environmental to an extent that Malawi achieved MDG 4 to reduce determinants such as economic development, general child mortality by two thirds between 1990 and 2015 living conditions, social well-being, rates of illness, , the rates are still high. The critical shortage of and the quality of the environment, all of which may health system resources represents a challenge to effec- reflect distinct differences between urban and rural geo- tively address the health problems of adults and partic- graphic entities. Intuitively, using under-five child ularly children. Evidently, per capita expenditure on health indicators may closely reflect general health than health for 2012/2013 through 2014/2015 fiscal years other age groups. Indeed, infant mortality rate (IMR), was only at US$40 which falls far below the US$86 for example, has long been regarded as a good proxy of that the WHO Commission on Macroeconomics and population health albeit acknowledging arguments that Health recommends for delivery of basic health services contest this viewpoint . However, some authors for countries like Malawi . Inadequate health work- have argued that IMR is a safe indicator of population force and inconsistent supply of essential medicines at Lungu et al. the point of healthcare use also represent critical chal- under 5 years of age; treatment seeking from a biomed- lenges . ical health provider for children with ARI, fever, and diarrhea; low birth weight; use of insecticide-treated Data Sources nets (ITNs), and full immunization coverage. We used secondary data from five Malawi Demographic Data Extraction and Health Surveys (DHS) and two Multiple Indicator Cluster Surveys (MICS). The DHS are nationally rep- Data for the urban and rural were extracted from respec- resentative household surveys usually conducted qua- tive DHS and MICS reports into a data abstraction drennially by the ICF International in collaboration with matrix. The extraction of selected standard child health governments in about 90 countries and provide data on a indicators applying the DHS and MICS definition and wide range of health and demographic indicators includ- geographical entity of our interest—rural and urban— ing mortality, sexual and reproductive health, HIV, allowed for direct comparison of the indicator values health status and health seeking, and child nutrition and direct computation of the rate differences. . The MICS surveys are conducted by various coun- tries with support from UNICEF with an aim of provid- Data Synthesis and Analysis ing internationally comparable data on the health status of children and women . We calculated rate differences between urban and rural In Malawi, the DHS have been conducted in 1992, areas by subtracting the value of the child health indi- 2000, 2004, 2010, and 2015 [7, 8, 40–42], whereas the cator in a rural area from that reported for the urban area MICS have been conducted in 1995, 2006, and 2014 [43, in the case of child health service utilization indicators 44]. The 1995 MICS report is not included because it did (such as immunization coverage) and vice versa in the not provide information on some indicators used in this case of child morbidity and mortality indicators. This descriptive study. The 2014 MICS was used as an end- was intended to maintain the premise of an urban ad- line survey to measure the country’sprogresstowards vantage for all indicators whereby a low value was achieving the Millennium Development Goals. Both the subtracting from a larger value (thus expected low mor- DHS and MICS use nationally representative sample tality in urban was subtracting from expected higher sizes and have used similar methodological approaches mortality in rural whereas expected low health service in measuring the indicators selected for this study; hence, utilization in rural was subtracting from expected higher their findings are highly comparable. In essence, the utilization levels in urban). We then plotted trends using technical teams developing and supporting the DHS rate differences to observe changes over time points of and MICS are in greater collaboration in recent times the population-based surveys, with a view of ascertain- . Granted that we used indicators as published in the ing whether the urban advantage was declining, increas- DHS and MICS survey reports, the definitions of urban ing, or remaining constant. or rural areas as eligibility for our study were adopted from the two surveys. Both the DHS and MICS use robust data quality control measures throughout the data management process to the extent that their findings, Results including in both rural and urban settings, are highly regarded and utilized by researchers and policymakers. Trends in Child Mortality: Aggregate Improvements and Declining Urban Advantage Selected Child Health Indicators for Analysis The results show that there is an overall significant Based on availability and comparability in all data decline in neonatal mortality rate (NMR), infant mortal- sources, we selected and extracted 13 child health indi- ity rate (IMR), and under-five mortality rate (U-5MR) cators, namely, neonatal mortality rate (NMR); infant from 1992 to 2015 in Malawi, as reflected in Fig. 1.The mortality rate (IMR); under-five child mortality rate NMR declined from 41 to 27 deaths per 1000 live births; (U-5MR); stunting rate, prevalence of acute respiratory IMR declined from 135 to 42 and U-5MR from 234 to infections (ARI), fever, and diarrhea among children 63 deaths per 1000 live births. Is the Urban Child Health Advantage Declining in Malawi?: Evidence from Demographic and Health Surveys and... Fig. 1 Trends in aggregate child mortality (NMR, IMR, and 234 U-5MR) from 1992 to 2015/2016 in Malawi 41 42 42 27 27 MDHS 1992 MDHS 2000 MDHS 2004 MDHS 2010 MDHS2015/16 Neonatal Mortality Rate Infant Mortality Rate Under-5 Mortality Rate Table 1 shows that whereas U-5MR has shown a 2015/2016 DHS reflects wide differentials between ur- consistent decline in both urban and rural geographical ban and rural with an urban advantage in U-5MR as settings, for NMR and IMR, this pattern is only ob- shown by a rate difference of 17 increasing from 6 in served for rural areas where there is a consistent decline 2014 and similar to the rate difference (17) noted in in all forms of child mortality. In urban areas, NMR and 2010. IMR show declining trends from 1992 DHS to the 2004 DHS but both increase in the 2006 MICS and 2010 Child Morbidity Indicators by Urban–Rural Place DHS reports and for the NMR even in the 2014 MICS of Residence report. However, both NMR and IMR show a signifi- cant decline in the 2015/2016 DHS (Fig. 2). Acomparison of urban–rural differentials for child mor- Correspondingly, a comparison of urban–rural differ- bidity and nutrition (underweight) indicators show an entials shows that the rate difference between urban and unstable pattern. As shown in Table 2 and Fig. 3, the rate rural child mortality rates has been declining up to 2014 differences for prevalence of ARI show a slight rural and thereafter increasing in 2015/2016, as shown in a advantage (less burden in rural compared to urban) in trend of rate differences of NMR, IMR, and U-5MR and 1992 but shift to a wide urban advantage in 2000 before astunting rate in Fig. 1. This suggests a declining urban following a significant decline in urban advantage to the advantage relative to rural settings with regard to all extent of an almost equal burden in 2006 (RD = − 0.2) forms of child mortality and stunting rates only up to andin2010(RD=0.2)beforemovingtoanurban 2014 and an increase reflected in the latest DHS but one advantage in 2014 and 2015/2016. Prevalence of fever which is not worse than that noticed in 2010 for NMR indicates a slight urban advantage in 1992 but follows and U-5MR. an increase in urban advantage in 2000 before following The urban advantage increased between 1992 and a declining urban advantage until 2014 when the urban 2000 for stunting rate and IMR and U-5MR but after- advantage greatly increased to reaching the highest rate wards showed a trend of a declining urban advantage difference (RD = 13) of the review period. Both rate reaching the same levels of IMR between rural and differences for prevalence of ARI and fever decline in urban in 2010 (73 in both) and a reversal to a rural the 2015/2016 DHS from the 2014 MICS levels. advantage in IMR in 2014 (52 vs 61; RD = − 9%). On Rate differences for prevalence of diarrhea have remained low across the surveys albeit showing a pat- the other hand, NMR started on a rural advantage in the 1992 DHS but reversed to an urban advantage in 2000, tern of increase in urban advantage from 1992 to 2004 but thereafter the urban advantage has been declining to reports and like other child morbidity indicators show- an extent that the rural setting retained its advantage as ing a declining urban advantage through 2010 DHS NMR was worse in urban than rural areas (as reflected which reflected a rural advantage followed by a slight by a rate difference below 0). However, a recent urban advantage (rate difference of less than 2%) in the Lungu et al. Table 1 Child mortality (NMR, IMR, U-5MR) and stunting rates for urban and rural areas and rate differences between urban and rural levels Child mortality indicators and Geographical DHS and MICS reports stunting area MDHS MDHS MDHS MICS MDHS MICS MDHS 1992 2000 2004 2006 2010 2014 2015/2016 Neonatal mortality rate Urban 50.9 29.8 22 30 31 31 26 Rural 48.6 47.9 39 34 34 29 27 RD − 2.3 18.1 17 4 3 −21 Infant mortality rate Urban 118.1 82.5 60 70 73 61 44 Rural 138 116.7 98 73 73 52 47 RD 19.9 34.2 38 3 0 −93 Under-5 mortality rate Urban 205.4 147.9 116 113 113 80 60 Rural 243.9 210.4 164 123 130 86 77 RD 38.5 62.5 48 10 17 6 17 Stunting (%) Urban 35 34.2 37.8 37.5 40.7 36.2 25 Rural 50.3 51.2 49.2 47.5 48.2 43.2 38.9 RD 15.3 17 11.4 10 7.5 7 13.9 Rate differences were calculated by subtracting urban values from rural values. This arrangement reflected the expected direction of health advantage RD rate difference 2014 MICS report and a reversal to rural advantage largely moved from a rural to an urban advantage, the (lesser diarrhea burden in rural by 4 percentage points) rate differences for the rest of child morbidity indicators in 2015/2016 DHS. The pattern of urban–rural differen- in 2015/2016 reflect lower levels than those of preced- tials with regard to children classified as underweight ing 15 years (2000 DHS levels). shows a rural advantage (greater burden of underweight children in urban areas) from 1992 through to 2004 Child Health Service Utilization Indicators when there was a reversal to an urban advantage (greater by Urban–Rural Place of Residence burden of underweight children in rural areas) in 2006, to equal burden and an urban advantage in 2014 MICS Table 3 shows utilization rates and rate differences for and 2015/2016. Except for underweight which has child health services in urban and rural areas, and Figs. 4 Fig. 2 Rate differences in child 70 mortality and stunting between urban and rural areas 40 Stunng Rate (%) Neonatal Mortality Rate Infant Mortality Rate -10 Under-5 Mortality Rate -20 Is the Urban Child Health Advantage Declining in Malawi?: Evidence from Demographic and Health Surveys and... Table 2 Child morbidity (ARI, fever, and diarrhea) and underweight for urban and rural areas and rate differences between urban and rural levels Child morbidity indicators and Geographical DHS and MICS reports underweight area MDHS MDHS MDHS MICS MDHS MICS MDHS 1992 2000 2004 2006 2010 2014 2015/2016 Prevalence of ARI (%) Urban 14.9 15.7 11.3 8.7 6.6 5.6 3.6 Rural 14.5 28.3 20 8.5 6.8 8.1 5.7 RD − 0.4 12.6 8.7 − 0.2 0.2 2.5 2.1 Prevalence of diarrhea (%) Urban 19.3 14.3 17.5 22 18.2 22.7 25.5 Rural 22.3 18.1 23 24.4 17.4 24.2 21.1 RD 3 3.8 5.5 2.4 − 0.8 1.5 − 4.4 Prevalence of fever (%) Urban 37 31.9 25.9 29.5 30.7 25.8 22.1 Rural 41 43 34.6 35.6 35.1 38.7 29.9 RD 4 11.1 8.7 6.1 4.4 12.9 7.8 Underweight (%) Urban NA 7.3 6.1 11.2 12.2 7.6 7.9 Rural NA 4.6 5.2 13.9 12.3 8.8 12.3 RD NA − 2.7 − 0.9 2.7 0.1 1.2 4.4 Rate differences were calculated by subtracting urban values from rural values. This arrangement reflected the expected direction of health advantage. Data for children that were underweight was not available in the 1992 DHS RD rate difference and 5 show trends of urban–rural differentials with direction reflecting a rural advantage with regard to regard to utilization of essential child health inter- access to treatment for the two common childhood mor- ventions: biomedical treatment for ARI, fever, and diar- bidities in the 2006, 2010, 2014, and 2015/2016 survey rhea; use of insecticide-treated nets (ITNs), and full child reports. immunization at 1 year of age. ARI treatment shows a Data for use of ITNs was available from 2000 and rapidly fluctuating pattern of rate differences across the reflects an urban advantage which continued an increas- surveys. Utilization of diarrhea and fever treatment ser- ing pattern until 2006 when it rapidly declined up to vices clearly show a trend of declining urban advantage 2014 although increased again in the 2015/2016 DHS. to an extent that rate differences are in the negative Full immunization coverage for children at 12 months Fig. 3 Rate differences in ARI, 14 fever, diarrhea child morbidity, and underweight (prevalence) between urban and rural Prevalence of ARI 6 (%) Prevalence of diarrhoea (%) Prevalence of fever (%) -2 -4 Under weight (%) -6 Lungu et al. Table 3 Healthcare seeking for children with ARI, fever, and diarrhea for urban and rural areas and rate differences between urban and rural levels Child health service utilization Geographical DHS and MICS reports indicators area MDHS MDHS MDHS MICS MDHS MICS MDHS 1992 2000 2004 2006 2010 2014 2015/2016 ARI treatment (%) Urban 54.8 48.3 22.6 74.5 67 32.6 83.5 Rural 48.2 24.9 19.3 47.8 70.8 18.9 77 RD 6.6 23.4 3.3 26.7 − 3.8 13.7 6.5 Diarrhea treatment (%) Urban 49.3 34.9 38.7 NA 55.2 60.5 59.6 Rural 45 27.6 36.2 NA 63.3 67.9 67 RD 4.3 7.3 2.5 NA − 8.1 − 7.4 − 7.4 Fever treatment (%) Urban 54.5 45.8 42.6 20.2 42.6 65.8 59.1 Rural 45.2 34 28.9 27.3 43.5 75.7 67.7 RD 9.3 11.8 13.7 − 7.1 − 0.9 − 9.9 − 8.6 Children fully immunized at Urban 87.2 78.6 70.7 76.8 75.8 54.6 12.2 12 months (%) Rural 81.1 68.7 63.5 69.3 81.8 54 10 RD 6.1 9.9 7.2 7.5 − 6 0.6 2.2 Use of insecticide-treated nets (%) Urban 19 30.2 42.3 85.9 72.8 52.4 Rural 5 12.4 21.6 71 67.9 41.3 RD 14 17.8 20.7 14.9 4.9 11.1 Rate differences were calculated by subtracting rural values from urban values. This arrangement reflected the expected direction of health advantage. For the MICS 2006, diarrhea treatment was classified differently (ORT and fluids) which was not directly comparable with other surveys thus indicated NA (not applicable) RD rate difference also reflects a declining urban advantage over the years, The results further show that across all health service moving to a rural advantage (RD = − 6) in 2010 albeit indicators, even where there is evidence of an urban there is an almost equal utilization in 2014 (RD = 0.6) advantage, the rate differences remain low, typically and a reversal to a slight urban advantage in 2015/2016 below five percentage points for most of the recent (RD = 2.2). survey reports with the exception of ARI treatment Fig. 4 Rate differences in care- seeking for ARI, fever, and diarrhea between urban and rural areas 5 ARI treatment (%) Diarrhoea treatment (%) -5 Fever treatment (%) -10 -15 Is the Urban Child Health Advantage Declining in Malawi?: Evidence from Demographic and Health Surveys and... Fig. 5 Rate differences in full immunization coverage and use of insecticide treated between urban and rural areas Children fully immunised at 12 months (%) Use of Inseccide Treated Nets (%) -5 -10 and use of ITN where rate differences exceed 15% in from 2000, 2004, to 2010 data points before another most survey reports. increase in 2014, except for ARI treatment which shows an unstable trend across all data points. Prevalence of underweight is the exception as it starts from a rural Discussion advantage when the data was first available in 2000 before a reversal to a slight urban advantage in 2006 MICS moving to almost equal levels in 2010 and a This study sought to explore whether the urban advan- tage in child health indicators is declining in Malawi. slight urban advantage in the 2015/2016 survey report. A notably consistent decline in urban advantage with The results show that all forms of child mortality have significantly declined between 1992 and 2015/2016 regard to all forms of childhood mortality is mainly due to a more rapid absolute decline in childhood mortality reflecting successes in child health interventions. Ru- ral–urban comparisons, using rate differences, largely in rural areas. For health service-related indicators that show a declining urban advantage as aforementioned, it indicate a picture of the narrowing gap between the two geographical areas albeit the extent and pattern are is seemingly due to two main reasons: (i) higher abso- lute increase in utilization of child health services in the different at the levels of child mortality, morbidity, and health service use. rural areas, and (ii) lower absolute decrease in the rate of utilization of child health services in rural areas where Of the 13 child health indicators used in this study, the pattern in both urban and rural showed low utiliza- eight (NMR, IMR, U-5MR, stunting rate, proportion of children treated for diarrhea and fever, proportion of tion relative to the preceding survey. In some few cases, the narrowing gap between urban and rural is due to children sleeping under ITN, and children fully immu- nized at 12 months) show clear patterns of a declining worsening of the indicator between one data point and another in the urban while there is an improvement urban advantage particularly up to 2014. However, U- 5MR shows a reversal to a significant urban advantage between the same data points in the rural area. For example, while IMR increased in urban areas from 60 in 2015/2016, and slight increases in urban advantage are noticed for IMR, underweight, full childhood immu- deaths per 1000 live births in 2004 to 70, 73, and 61 in the 2006, 2010, and 2014 reports, respectively, it largely nization, and stunting rate in 2015/2016. Furthermore, of the eight, five (NMR, IMR, diarrhea reduced in rural areas over the same period from 98 to treatment, fever treatment, and full immunization cov- 73, 73, and 52 deaths per 1000 live births. Conversely, the increasing urban advantage typically noticed for erage) reach a point of reversal where one or more data points show a move from an urban to a rural advantage some indicators in 2015/2016 is because of a faster improvement of respective child health indicators in position. Four indicators (prevalence of fever, ARI, diarrhea, and treatment of ARI) have shown fluctuating urban areas and not necessarily worsening of indicators in rural areas. trends with a declining urban advantage largely moving Lungu et al. Our findings suggest that for most indicators, a clear We postulate that the three salient factors proposed trend of declining urban advantage emerged for a large by Garenne and to some extent supported by other part of the years under review. This is consistent with authors [14–19] as being responsible for the narrowing other studies in Africa which have largely demonstrated urban–rural gaps in health are applicable in Malawi. the narrowing urban–rural gap with regard to child These factors, in aggregate terms, relate to determinants mortality and other determinants of childhood morbidity of urban health, and they include extreme urban poverty and mortality. Evidently, Garenne investigated trends in in some areas of the urban such as the urban slums often urban and rural mortality by reconstructing yearly mor- due to lack of state interventions; emerging diseases tality estimates from Welfare Monitoring Surveys such as HIV and AIDS for which there is a greater (WMS) and DHS data from some sub-Saharan African disease burden in the urban than rural areas, especially countries which included Malawi in the periods from in the pre-ART (anti-retroviral therapy, including pre- early 1970s to the late 1990s. The results, while gener- vention of mother-to-child transmission) era; and ally affirming the declining trend in child mortality in heightening risk of some diseases such as respiratory both urban and rural settings, indicated that in some infections resulting from air and chemical pollution in countries such as Burkina Faso, Rwanda, Senegal, To- cities. go, and Uganda, mortality decline was faster in rural Indeed, while Malawi is one of the least urbanized areas effectively narrowing the rural–urban gap. In Be- countries, its rate of urbanization is high and the major- nin, urban mortality had stagnated while it continued ity (up to 61%) of people in Malawi’s capital city are declining in rural areas also reducing the rural–urban said to be residing in slum conditions which embody gap. In cases where the rural–urban gap had increased urban poverty that manifest in limited access to im- due to a faster mortality decline in urban areas such as proved water, appropriate sanitation, durable housing, sufficient living area, and insecurity of tenure . The Niger and Mozambique, the situation was reversed with data of the late 1990s . Likewise, Murage et al. found HIV factor is relevant granted that the HIV burden in that while there was an overall decline in childhood Malawi shows geographic disparities and the urban HIV mortality in Kenya, urban–rural gaps in mortality prevalence is almost twice as high (17.4%) as in rural narrowed and that mortality levels in urban slums areas (9%) . Moreover, AIDS-related mortality showed a declining trend but remained high . accounted for about 13% and was among the top three Furthermore, similar to our study, an analysis was causes of under-five mortality, and it can logically be conducted using DHS data to determine trends in ur- argued that this affected the urban more than the rural at ban–rural differentials of malnutrition among children some point. The tremendous progress of the prevention aged 1 to 35 months for 15 sub-Saharan African coun- of mother-to-child transmission (PMTCT) program in tries. The results indicate a general decline in urban Malawi in recent years is however noted having regis- advantage in 8 of the 15 countries albeit with statistical tered a 71% reduction in mother-to-child transmission significance in only two of these, no change in urban– rate between 2009 and 2015 . A successful PMTCT rural differentials in four countries, and an increasing program in Malawi may explain greater survival of urban–rural gap in three of the countries. An increase in infants in the urban areas (which is disproportionately urban malnutrition was attributable to the declining affected by HIV) and ultimately an increasing urban urban advantage in some countries whereas a faster advantage in IMR as reflected in the 2015/2016 DHS declining rate of urban malnutrition was responsible report. for the widening urban–rural gap in others . The heightened risk of respiratory infections due to On the basis of evidence from our descriptive study, air pollution cannot be backed by evidence from this it is clear that while there are some fluctuating patterns study. In essence, the trend of ARI prevalence in the in some indicators, a trend of declining urban health urban area seems to be that of a declining burden (see advantage in so far as child health indicators are con- Table 2) albeit the cross-sectional nature of the na- cerned in Malawi appears evident over the years. The tional surveys used in this study is not the most underlying factors for this phenomenon are not obvious appropriate to provide a true picture even when most from the current study, but various hypotheses can be surveys were undertaken over the same period of the put forward for further interrogation in the context of year. Indeed, all the surveys ask for child morbidity in Malawi but which have been highlighted in literature. the 2 weeks preceding day of interview and would not Is the Urban Child Health Advantage Declining in Malawi?: Evidence from Demographic and Health Surveys and... be as precise in measuring a comprehensive morbidity health inequities in Malawi and the effect of urban burden as would a prospective study ascertaining economic deprivation to overall urban health. incidence of ARI episodes over a given period. This Could the declining urban advantage noted especial- notwithstanding, some underlying causes of child ly up to 2014 in this study merely be a phenomenon of morbidityand mortalitysuchasstunting rates have the rural setting catching up with the urban? This is either stagnated, worsened, or dismally improved in unlikely to be the case granted that the levels of child urban areas over long periods and could play a critical mortality and morbidity in urban areas also remain high role. and health service use is suboptimal, hence having more Our study has also shown that the urban advantage room for improvements at a rate similar to that in the with regard to child health service use has been waning. rural areas or even better. Moreover, an increasing urban In fact, when needed, some health service components advantage in some child health indicators in the recent such as diarrhea treatment, fever treatment, and child- 2015/2016 DHS in the context of faster absolute im- hood immunization have recently reversed from an ur- provements in urban relative to rural supports the asser- ban to a rural advantage. In this regard, it would be tion that there is still room for significant improvements argued that Malawi Ministry of Health policies of pro- in child health indicators in both settings. moting access to health services for the rural population We note some limitations to our study that should be such as using Service Level Agreements, increasing taken into consideration when interpreting our results. health infrastructure, and undertaking community out- We relied on already estimated values in DHS and reach clinics  may have yielded results. However, MICS; hence, the limitations of these surveys such as the findings also call into question the assumption that recall bias and reporting bias should be borne in mind. urban residents have adequate access to health services The rigor in undertaking both DHS and MICS surveys used in this study and the fact that they are the most by virtue of geographical proximity relative to rural areas and that they ultimately have much better child frequently used in shaping policy represent particular health outcomes. Moreover, studies have demonstrated strengths. that access to health services transcends physical access [5, 47–49]. It is therefore imperative for the Ministry of Health in Malawi to rethink the policy premised on Conclusion urban advantage pertaining to access to child healthcare services. Community health interventions such as child Using a total of 13 child health indicators reflecting immunization and community case management of impact level, morbidity, and health service use, the study common childhood conditions like diarrhea could be has demonstrated that the urban child health advantage considered especially in impoverished urban areas. Ar- has largely declined in the past two and a half decades. guably, implementing an integrated Community Case The findings suggest the need to rethink the policy Management (iCCM) component of IMCI in urban viewpoint of a disadvantaged rural and much better-off slums would be a form of differentiation of child urban in child health programming. In particular, efforts healthcare delivery in the urban setting, effectively should be dedicated towards addressing determinants of affording prompt access to essential child health child health and this would arguably entail targeted interventions. interventions in urban slums for which arguments abide Some authors have argued that a stagnation of urban that they contribute to stagnation in some child health health levels, due to, among other reasons, the pervasive indicators and slow pace of improvements in other child socioeconomic inequalities, has led to the narrowing of health indicators. the urban–rural health gap . Our study does not Further research is warranted to validate some of our provide any evidence to this effect. The national surveys findings, particularly using yearly estimates and to as- in this study do not report further socioeconomic quin- certain levels of intra-urban inequities which arguably tile analysis by rural and urban geographical areas albeit contribute to the declining urban advantage. It is worth- it is possible to undertake a secondary analysis of their while to note that the declining urban child health ad- primary data. This was beyond the scope of this study vantage itself is not a public health problem as rural but represents an area where further analysis is required progress is essentially a welcome development. Rather, granted the paucity of evidence of intra-urban child it points to the need to pay as much attention to urban Lungu et al. 3. Anyamele OD. Urban and rural differences across countries health to improve child health especially in the context in child mortality in sub-Saharan Africa. 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Acknowledgements We would like to acknowledge the support 2006;84(6):470–8. rendered by the Connecting Health Research in Africa and Ireland 11. Vlahov D, Freudenberg N, Proietti F, Ompad D, Quinn A, Consortium (CHRAIC) and the Health Research Capacity Nandi V, et al. Urban as a determinant of health. JUrban Strengthening Initiative for the financial support towards a larger Health. 2007;84:16–26. study for which this study was part of. 12. Harpham T. Urban health in developing countries: what do we know and where do we go? Health Place. 2009;15:107– Author Contributions EL conceived and designed the study, 13. Harpham T, Molyneux C. Urban health in developing coun- analyzed the data, prepared the initial manuscript, and approved tries: a review. Prog Dev Stud. 2001;1:24. the final version of the manuscript; CD participated in designing 14. Fotso JC. 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