摘要：In most countries, rates of mortality and malnutrition among children continue to decline, but large inequalities between poor and better-off children exist, both between and within countries. These inequalities, which appear to be widening, call into question the strategies for child mortality reduction relied upon to date. We review (1) what is known about the causes of socioeconomic inequalities in child health and where programs aimed at reducing inequalities may be most effectively focused and (2) what is known about the success of actual programs in narrowing these inequalities. We end with lessons learned: the need for better evidence, but most of all for a new approach to improving the health of all children that is evidence based, broad, and multifaceted. Substantial progress has been and continues to be made in child health. A child born in 1960 in Latin America or the Caribbean had a 105 in 1000 risk of dying before her first birthday; by 1999, this figure had fallen to 30 in 1000. 1 But progress has been uneven. In the statistics on child health, one common theme emerges: poor children lag behind their better-off peers. Mortality among children aged younger than 5 years (under-5 mortality) currently averages 6 per 1000 live births in the industrialized countries but is as high as 91 per 1000 in the developing world. 2 Child health also tends to be worse among the poor within countries. In southeast and northeast Brazil, for example, over the period 1987 to 1992, among children in the poorest third of the population the under-5 mortality rate was 6 times that among the richest 10% of children (113 vs 19). 3 In addition, socioeconomic inequalities in child health appear to be widening. Reductions in infant and under-5 mortality have been fastest among the rich countries, 4 and there is growing evidence that rates of child mortality and malnutrition have fallen faster among the better-off. 5– 9 There is broad acceptance that these inequalities are ethically indefensible—they are inequities , not simply inequalities 10 —and that programs and policies in the future ought to improve the health of all children. 11– 14 In this spirit, we review in this article what is known about the causes of socioeconomic inequalities in child health. These provide the entry points for programs aimed at narrowing child health inequalities. We also review what is known about the success of actual programs in narrowing socioeconomic inequalities in child health. Our search strategy for the review of evidence was as follows. On inequalities in proximate determinants, we aimed to reflect the medical and social scientific literature on (a) the proximate determinants and (b) their socioeconomic distribution. We also aimed to reflect the medical and social scientific literature on (a) the underlying determinants of child health outcomes, (b) their socioeconomic distribution, and (c) the impact and socioeconomic aspects of child health and related programs (e.g., maternal and child health programs, health insurance for children, etc.). We started by pooling our knowledge of these areas, based on research and programmatic work at a variety of institutions. We then undertook targeted searches in Medline, EconLit, and the World Bank’s catalog of bank documents and reports (see http://www-wds.worldbank.org ). We then circulated the document for comment among specialists in child health and equity issues in academia, the World Bank, the World Health Organization, other international agencies, and bilateral donors. This process added to the literature reviewed. We have tried to focus on journal articles in peer-reviewed journals. However, much of the literature on programs and program evaluation has been produced by agencies such as development banks, and we decided that excluding this material would significantly limit the depth and scope of the paper. Where possible, we have tried to cite only documents in the public domain and with a reference number (which typically implies an element of peer review and quality control).
