The social determinants of childhood mortality in Sri Lanka: timetrends & comparisons across South Asia.

BACKGROUND & OBJECTIVE Sri Lanka has been able to achieve low childhood mortality levels at low cost. However, this achievement may have been at the expense of increasing mortality inequalities between socio-economic groups. This study addresses the question whether socio-economic mortality inequalities rise as overall mortality falls by describing socio-economic inequalities in under 5 mortality in Sri Lanka and comparing the magnitude of these inequalities over time and with other South Asian countries. Further, the role of female autonomy, fertility, malnutrition, and health care use in explaining the observed patterns in mortality inequality were also examined. METHODS Time-trends in inequality in under 5 mortality by maternal education were described using data from the 1987, 1993 and 2000 Sri Lanka Demographic and Health Surveys (DHS). Using DHS data, the magnitude of these inequalities was compared across 50 low and middle income countries, and with three South Asian countries in particular. Socio-economic inequalities in determinants of under 5 mortality were estimated for Sri Lanka over time, and compared with such inequalities in the other South Asian countries. RESULTS Absolute inequalities in under 5 mortality in Sri Lanka were very low internationally, while relative mortality inequalities were high. The decline in under 5 mortality between the 1987 and 2000 survey in Sri Lanka had been accompanied by rising relative mortality inequalities across educational groups. High and improving levels of health care use and declining levels of malnutrition in Sri Lanka ran parallel with high and increasing relative inequalities in undercoverage of health care and malnutrition. INTERPRETATION & CONCLUSION Despite the low overall under 5 mortality levels and absolute mortality inequalities, Sri Lanka exhibited a clear mortality gradient across educational groups. Further, the high and rising relative inequalities in under 5 mortality in Sri Lanka showed that the achievement of low mortality might be at the expense of increasing relative mortality inequalities between socioeconomic groups. Increasing inequalities in malnutrition and undercoverage of health care, perhaps related to a strong gradient in female autonomy across educational groups, may have contributed to the rising relative under 5 mortality inequalities in this country.