Rajagopal Dhar Chakraborti

Recognition for the need to improve the status of a girl child and to promote their potential roles in development can no longer be seen only as an issue of human rights or social justice. Investment in girl children and particularly on their health is crucial for achieving sustainable development. Low levels of education and training, poor health and quality of nutritional standard and limited access to resources since early childhood depresses women’s quality of life, limits productivity and hinders economic growth and efficiency.

Investing in the health of girls not only results in positive returns to the girls themselves but returns to society are even larger and could last for generations. For girls, better health means less drop outs from schools and therefore more improved skill formation, enhanced earning capacity, increased access and opportunities in the labour market, reduced health risks associated with pregnancy and child birth and often greater control of their personal lives. Investment in a girl’s health has positive impacts on raising the general quality of life, reducing the country’s population growth rates, improving the health and welfare of children and families, reducing health costs and contributing to poverty reduction.

A perusal of the status of child health care in most developing countries in South- Central Asia indicates that the policy makers are yet to recognize the importance of non- discriminatory health care for children. The girls suffer, as parents by their narrow private cost benefit calculation prefer to invest less on girls than on boys in the family. Most governments in developing countries have failed to adopt suitable social intervention to induce families to move to more girl friendly approaches.

The Childhood Gender Gap In Health Care

There is a vicious circle of ill health in most developing countries. When a family’s breadwinner becomes ill, other members of the household may at first cope by working harder and by reducing consumption. Both adjustments can harm the health of the family. As health care costs are high and rising, many households get deeper into debt. Thus ill health may contribute to financial distress and further sickness in the house. The girl child is often forced to be in door and look after the sickly relatives. Moreover, their own iron and iodine deficiency, sexual abuse, non-conducive social atmosphere etc., bring further agony on their mental and physical health.

Despite significant improvements in medical sciences and health care, 23% of all deaths in developing countries are deaths to children under age 5. The infant mortality rate has declined during the last decade in virtually all countries of South and Southeast Asia, but it still remains high (60-100 per 1000 live births) in some places.

Child mortality rates show a similar pattern. Tables 1 and 2 summarize the sex differences in infant and child mortality data from the Demographic and Health Surveys (DHS) for six countries of the region: Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand.

Table 1: Infant mortality rate by sex in six selected South and Southeast Asian countries

Table 2: Child mortality rate by sex

Infant³ mortality

Genetically, on the first year after birth males are more susceptible to deaths than females because of greater incidence of pre-maturity and the fact that their lungs are less well developed and their immune system is weaker than that of females. Mortality in infancy and especially in the neonatal period is dominated by perinatal causes to which males are especially vulnerable. Higher female mortality is rare in infancy and even more so in the early neonatal period. ⁵

We see a similar pattern in developed countries during periods of high mortality in their history. Between 1800 and 1900 infant mortality rates (IMR) was within the range of 110 to 122 deaths in males per 100 deaths in females in today’s developed nations. Almost similar trends are seen in all these six countries of South and Southeast Asia (as shown in Table 1).

However, when infant mortality rates are disaggregated into neonatal and post-neonatal mortality rates (as in Table 3), a different picture appears. While neonatal mortality rates for males were higher than that for females in all countries, female post-neonatal mortality exceeded that for males in Bangladesh and India.

This vital statistics remain hidden if infant mortality data are not disaggregated into neonatal and post neonatal mortality. It is an unusual phenomenon which makes it obvious that insufficient and discriminatory family level health care in Bangladesh and India have nullified the inherent biological advantage of females over males.

Table 3: Infant, neonatal and post-neonatal mortality rates by sex in selected countries of the Region

Child⁷ mortality

As in the case of infant mortality, higher female child mortality is also relatively rare. Risks of dying are almost the same for girls and boys between age one and four. Higher girl’s mortality from measles (measles is known to have higher female mortality for all ages up to 50 years) is compensated by male mortality from violence and accidents. In the developed countries, the sex ratios in child mortality rates are close to one. Once again, south-central Asia and to a lesser extent Northern Africa and Western Asia stand out as regions with unexpectedly high female child mortality relative to male mortality.

Once again, south-central Asia and to a lesser extent Northern Africa and Western Asia stand out as regions with unexpectedly high female child mortality relative to male mortality. While in the latter two groups, there are signs of improvements; the trends in South Central Asia are not satisfactory. The most pronounced excess female mortality is found in Bangladesh, India and Nepal in the 1980’s. In these three countries, girls are 20 to 30% more likely to die in the childhood years than boys. As Table 4 shows, female child mortality rates (1-4 years) exceeded male child mortality rates in all countries except Sri Lanka and Thailand.

Higher female child mortality was evident in all countries except Indonesia in the 1970s. But here too, the situations turned worse for the females in later years. The situation in Thailand and Sri Lanka had changed for the better for girl children by 1985 and 1995, respectively. In Pakistan also the relative survival chances of girls in childhood appear to have improved in 1970’s and 1980’s.

However, in Bangladesh, India, Indonesia and Nepal, the situation for girls relative to boys has been progressively worsening since the 1970s. The result for India is particularly striking and important because of its large population. In the 1970’s, excess female mortality in childhood was estimated at 11% but by 1980’s the excess had grown to 28%. Studies indicate that gender discrimination contribute significantly to this excess female mortality.⁹

Nutritional deficiency at the extreme may cause death but in between some of its effects such as Low height for age (stunting), Low weight for height (wasting) and Low weight for age (stunting and wasting) are equally dangerous. Luckily for us, Demographic and Health Survey data for 35 developing countries between 1986 and1994 on nutritional status does not indicate much sex differences on the access to nutrition. While India was not a part of the surveys, two countries of South Central Asia: Pakistan and Sri Lanka were part of those surveys. Girls in Pakistan received better nutritional status than boys while girls in Sri Lanka are slightly stunted and underweight for age.

Sex differences in the health caring of children

Sex-specific data from demographic and health surveys are available for some countries of the South and Southeast Asia on family health caring on children. This includes vaccination coverage of children and of treatment of diarrhoeal diseases, acute respiratory infections and fever. In almost all countries, there is a noticeable difference by sex of the child in both vaccination coverage and in treatment sought in case of illness.

Further, a smaller proportion of girls than boys were taken to a health facility or provider in many countries. Table 5 sums up the findings from different national level surveys on health care discrimination in the childhood. In Bangladesh and Nepal, the overall levels of treatment seeking are very low but even then families manage to show less care to the girl children. In contrast, in India and Indonesia, over 60% of children are taken to health service providers for cough and cold. Here too, the boys are more favoured than girls.

Not seeking medical treatment need not necessarily mean that no treatment was given to the children, as most Asian countries abounds in home remedies and traditional healthcare practices. However, some surveys have managed to secure data to prove that there exist a large proportion of children for which no treatment was sought for diarrhoea.

This confirmed that more girls than boys went without any treatment for diarrhoea in all countries except Sri Lanka. In Pakistan, sex differences in the curative health care are almost negligible. In India, boys have been more favoured than girls with respect to diarrhoea, fever and respiratory health care, though bias was more pronounced in the North than in the South. In Bangladesh, northern India and Pakistan boys are significantly more likely than girls to have received any vaccination and to have received measles vaccination. Table 5: Gender differentials in vaccination coverage and treatment sought for diarrhoe and cough in selected countries of the Region

Family formation

In a society where a boy is preferred to a girl, the birth of a daughter will be followed more swiftly by another birth than the other way around. Conversely, parents to whom a son has been born may discontinue childbearing altogether or to delay the next birth. Such a pattern of family formation may put girls at a disadvantage because children who experience a short interval to the birth of a younger sibling are known to be at a higher rate of death than other children. In Egypt such factors contribute to 5% of overall excess female mortality. In Bangladesh, birth spacing is little longer than Egypt but even then this type of family formation disadvantageously places girls.

Gender gaps in education

The Population Action International has classified the developing countries into gender gaps on the basis of school enrolment. Gender gap scores average the difference between gross enrolment rates for boys and girls at the primary and secondary levels. The higher the gap score, the more disadvantaged girls are relative to boys. There are four broad groups according to gender gaps: (a) Large gap: This group includes India, Nepal, Afghanistan (b) Moderate gap: Bangladesh, China, Indonesia etc; (c) No gap: The Philippines, South Korea, Singapore etc (d) Reverse gap: Sri Lanka, Lebanon etc. Most developed countries are included in the No Gap category.

The Factors responsible for childhood gender gap in health care

i. Maximization of Productivity of family income: There is a perception that future income flows from sons are greater than those of the daughters. Such perceptions are boosted by the fact that:

   . Job market particularly in the informal sector is gender bias;

   . Technology in the informal / rural sector is male bias;

   . Migration is male specific;

   . Boys support during old age;

   . Girls leave the natal home after marriage while boys normally do not leave the home unless required for
      income generations;

   . For the marriage of girls, often dowry is to be paid while reverse flows from the sons’ marriage;

   . Girls require protection both indoor and outdoor.

Most low income families are subject to these economic realities and are therefore keener to protect the health of male children rather than female children. There is widespread son preference in most of these countries. The problem is further compounded by the wrong understanding of the potential of the girls in family’s upbringing and growth. This arises through lack of education on the part of mothers. Studies indicate that in households with an educated mother, girls get more nutritional advantage or curative health care.

ii. Extreme poverty forces a family to prioritise their budgetary allocation. Limited resources are allocated disproportionately to sons. Studies show that girls with brothers have been neglected while girls without any brother face no such problems.

iii. 3. Girls who have one or more older sisters often find themselves undervalued and often consciously or unconsciously withdraw from various activities and become a victim of their own wrong decisions.

The Agenda for Action

It may not be easy to alter the family level discriminations against girl children. It has been rooted in many cultural practices. Even in China and Korea despite reforms and pro-women measures including favourable education, employment, sex-selective abortion and high female mortality are very common. There is growing evidence that parents of smaller family size are able to spend more on health care and education than parents of large families. Small family norms help the girl child. Poor families are unwilling to spend on the curative health care of girls. The shift towards market system of health care will prove disastrous for the girl child.

Some system of compulsory health insurance for girl children with cross subsidy and the state buying the premiums of the girl child in the BPL (below the poverty line) families, may be effective. For that identification of BPL families is very important and must be completed in an impartial manner. Education of mothers should get some priority. Some system of providing information and education that emphasize the importance of equal treatment for boys and girls may be tried at maternity homes. Such education should continue thereafter. Many countries have been able to create awareness on breast feeding through educational campaigns. At the same time, policy and programme interventions that target morbidity and mortality of both boys and girls should continue to receive priority.

At the last but not the least, programmes that provide adequate food and nutrition to mothers and children should be implemented. Provision of adequate food and nutrition are essential for women to ensure optimal work capacity and normal reproductive performance, and to develop resistance to infections. Under nutrition increases susceptibility to infection and disease, and reduces work capacity and productivity. It stunts growth and impedes physiological maturity in the childhood. Poverty combined with cultural norms regarding food taboos, and food allocation within the household often causes nutritional deficiencies in women.

As a consequence, an estimated 20-45% of women of childbearing age in the developing world do not eat the WHO recommended 2250 calories a day. Women work no less than men both within and outside the home. In addition, menstruation, pregnancy and lactation further emphasize that they must have access to the required food intake providing the calories. Otherwise vicious circles of ill health from mothers to the children would continue unabated.

The World Summit for Children in 1990 recognized the magnitude of the problem of malnutrition and suggested several remedies to reduce severe and moderate malnutrition among children less than five years of age by half of the 1990 levels. It is also necessary to increase the percentage of newborns having an adequate birth weight (2500 grams or more) and to eliminate iodine deficiency disorders, and vitamin A deficiency and its consequences including blindness, and reduce iron deficiency anemia.

It is imperative that the countries come forward and work hard to ensure adequate food and nutrition for all our neglected sons and daughters. The task may not be difficult because presently we have the capability to produce more foods than what is consumed in the world require. Yet we falter and probably will continue to in the years to come. The political will to create a hunger free world for our children is simply not ready.

Data Sources

Bangladesh
Mitra SN, Al-Sabir A, Cross AR, Jamil K. Bangladesh demographic and health survey, 1996-97. Dhaka and Calverton, MD: National Institute of Population Research and Training (NIPORT), Mitra and Associates, and Macro International Inc.; 1997.

India
International Institute of Population Sciences. National family health survey, India 1992-93. Mumbai (Bombay): IIPS; 1995.

Indonesia
Central Bureau of Statistics, State Ministry of Population/National Family Planning Coordination Board, Macro International Inc. Indonesia demographic and health survey 1997. Calverton, MD: Central Bureau of Statistics and Macro International Inc.; 1998.

Nepal
Pradhan A, Aryal RH, Regmi G, Ban B, Govindasamy P. Nepal family health survey 1996. Kathmandu and Calverton, MD: Ministry of Health, New ERA, and Macro International Inc.; 1997.

Sri Lanka
Department of Census and Statistics, Ministry of Finance, Planning, Ethnic Affairs and National Integration in collaboration with Ministry of Health, Highways and Social Services. Sri Lanka demographic and health survey 1993. Colombo: Department of Census and Statistics; 1995.

Thailand
Chayovan N, Kamnuansilpa P, Knodel J. Thailand demographic and health survey 1987. Bangkok and Columbia, MD: Institute of Population Studies, Chulalongkorn University and Institute for Resource Development/Westinghouse; 1988.

NOTES & REFERENCES

¹ The number of infants, out of every 1,000 babies born in a given year, who die before reaching age 1. The lower the rate, the fewer the infant deaths, and generally the greater the level of health care available in a country.

² The number of infants, out of every 1,000 babies born in a given year, who die before reaching age 1. The lower the rate, the fewer the infant deaths, and generally the greater the level of health care available in a country.

³ Those who have not reached one year yet.

⁴ The period from 22 completed weeks (154 days) of gestation until seven completed days after birth.

⁵ The period from 22 completed weeks (154 days) of gestation until seven completed days after birth.

⁶ The number of deaths in infants under 28 days of age in a given period, usually a year, per 1000 live births in that period.

⁷ Children are defined as those who have completed 1 year but not completed 5 years.

⁸ Garenne M., Sex differences in measles mortality: a world review, Int J Epidemiol 1994; 23(3): 632-42.

Copyright ©2002 Rajagopal Dhar Chakraborti.   About The Author