Failed to meet Millennium target of reducing CMR by 2% p.a. (UN [39, 7]).

**Table 2.** West child mortality rates (0–4 years) per million (pm) and % of change (1988–1990 v 2008–2010) [Source WHO, [40]].

The USA, New Zealand and Canada merit a relative *reproach* as their CMR are 1 SD above the Western mean; Canada and the USA also failed to meet the UN millennium target of reducing CMR by 2% per annum. Conversely Sweden, Finland, Japan and Norway merit a *commendation* as their CMR is 1 SD below the Western mean. Portugal and Greece previously had the highest CMR but, at the index years, achieved the largest reductions (74%) over the period. Eleven other countries had falls in their CMR of 50% or more; the UK's rate fell by 42%, lower than the average Western reduction of 51% over the period.

*CMR—poverty, health and military associations:* There is a positive significant correlation between higher CMR and GNI (Rho = +0.6416; *p* < 0.005) confirming that at national lev‐ els there is an association between relative poverty and child mortality. Whilst there was no significant correlation between CMR and health and military expenditures, there was a significant correlation between higher military expenditure and worse relative poverty as measured by income inequality (Rho = +0.4758; *p* < 0.025).

### **3.2. ASIA**

Military: Health ratios are narrowest in Australia 1:4.5, the UK 1:1.4.8 and the USA 1:5.2, the West's average being 1:7.5; ratios are widest in Ireland 1:22.3, Switzerland 1:16.0 and the Netherlands 1:10.3; reflecting different political priorities, which according to Nye Bevan is

*Child-mortality-rates:* **Table 2** shows the top‐six highest CMR (0–4 years) are from English‐ speaking nations led by the USA at 1503 per million (pm), New Zealand at 1308 pm, Canada at 1189 pm, UK at 1113 pm, Australia at 1030 pm and Ireland at 947 pm. Nations with the lowest CMR, apart from Japan at 663 pm, are from Europe: Sweden at 624 pm, Finland at 632

> **CMR index pm (2008–2010 unless stated) [20]**

**% of change**

**(1988–1990) [20]**

*1. USA 2420 1503 −38*# 2. New Zealand (2007–2009) *2361 1308 −45 3.* Canada (2007–2009) *1740 1189 −32*# 4. UK 1929 1113 *−*42 5. Australia 1886 1030 *−*45 6. Ireland 1659 947 *−*43 7. Switzerland 1783 944 *−*47 8. Austria 1944 939 *−*52 9. Netherlands 1729 906 *−*48 10. Belgium 2013 886 *−*56 11. France 1740 876 *−*50 12. Germany 1611 838 *−*48 13. Italy 1895 822 *−*57 14. Spain 1790 820 *−*54 15. Denmark 1993 813 *−*59 16. Greece 2039 792 *−*61 17. Portugal 3019 782 *−*74 *18. Norway* 2005 691 *−*64 *19. Japan 1218 663 −46* 20. Finland *1463 632 −57 21. Sweden 1520 624 −59* **Mean average** *1893 910 −51*

the essence of politics (Foot, 1978)

70 International Development

pm and Norway at 691 pm.

1 SD = 216 pm.

Failed to meet Millennium target of reducing CMR by 2% p.a. (UN [39, 7]).

**Table 2.** West child mortality rates (0–4 years) per million (pm) and % of change (1988–1990 v 2008–2010) [Source WHO, [40]].

#

**Country by CMR rank (latest years) CMR baseline pm** 

*Socio-economic data:* **Table 3** shows Singapore's and Hong Kong's GNI at \$49780 and \$44540, respectively; they hold the second and fifth highest GNI figures within the three regions, well above the average of the industrialised Asian countries at \$38,750 and the West's average of \$35,662. Conversely, GNI in non‐industrialised Asian countries runs from \$1180 in Nepal, to \$1559 in Bangladesh and \$6890 in China. So, the Western GNI average, based upon the US dol‐ lar's PPP, is nearly eight times higher than the non‐industrialised Asian country average of \$4460.

*Health and military expenditure:* The average expenditure on health as a percentage of GDP is 7.4% for industrialised and 4.4% for non‐industrialised Asian countries (see **Table 3**). Figures range from 10.5% in Japan, followed by 7.5% in Cambodia, 6% in Nepal and Vietnam, down to 3.1% in Indonesia, 2.8% in Pakistan and 1.8% in Myanmar.

The average expenditure on the military is 2.6% for Asian countries. Figures range from 3.6% in Pakistan, followed by 3.4% in Myanmar and 3.2% in Singapore, down to 1% in Japan and 0.9% in Indonesia. The narrowest military to health ratios are in Myanmar (1:0.5) and Pakistan (1:08), as they spent more on their military than health expenditure.

*Child mortality rates:* Pakistan has the highest CMR of *non-industrialised* Asian nations at 87,000 pm and alongside Myanmar and India merit a *reproach* as their CMR are 1 SD above the regional non‐industrialised mean (see **Table 4**).

China's (WHO) data from 1994, based upon urban and rural 10% samples, averaged CMR of 9394 pm. Yet, UNICEF data estimate a total mortality rate of 48,000 pm in 1990 reducing by 62% to 18,000 pm by 2010. CMR in Thailand is 1 SD below the non‐industrialised Asian mean of 39,000 pm and merits a *commendation* alongside Singapore*.* Sri Lanka and China narrowly missed a *commendation* with current CMR of 17,000 and 18,000 pm respectively. Malaysia, with CMR *estimated* at 6000 pm, achieved a remarkable 67% reduction over the period. CMR in non‐industrialised Asian countries are more than 40 times higher than the Western average. All industrialised Asian countries' CMR are lower than the Western average (910 pm) with remarkable lows of 522 pm in Singapore and 663 pm in Japan [20]. South Korea is likely to have suffered from the problem of diminishing returns [41] and also merits a *reproach* because its rate of 842 pm is above 1 SD above the industrialised mean; it also failed to meet the UN target.


**Table 3.** Asian countries: gross national income (GNI) by purchasing power parity (PPP) and % GDP expenditure on health (GDPEH) % GDP military (source World Bank) and health to military ratio [Source World Bank [37]] .

*CMR—poverty, health and military associations*: The correlation between CMR and GNI is highly statistically significant (Rho = +0.9323; *p* < 0.001) again confirming the statistical link between relative poverty and child mortality. There is no correlation between CMR and military and health expenditures. However, mention must be made about Myanmar and Pakistan, whose disproportionate high military to health expenditure proved to be the biggest distortion of all 71 countries reviewed.

Comparing GDP Health and Military Expenditure, Poverty and Child Mortality of 71 Countries from Different Regions http://dx.doi.org/10.5772/67120 73


Failed to meet Millennium target of reducing CMR by 2% p.a. (UN [39, 7]).

**Table 4.** Industrial and non‐industrialised Asian countries CMR (0–4 years) per million (pm) and % of change (1988–1990 v 2008–2010) [Sources WHO [40]].

#### **3.3. Sub‐Saharan Africa**

remarkable lows of 522 pm in Singapore and 663 pm in Japan [20]. South Korea is likely to have suffered from the problem of diminishing returns [41] and also merits a *reproach* because its rate of 842 pm is above 1 SD above the industrialised mean; it also failed to meet the UN

1. Singapore 49,780 4.6 3.2 1:1.4 2. Hong Kong 44,540 n/a n/a n/a 3. Japan 33,440 10.5 1.0 1:10.5 4. Korea South 27,240 7.2 2.6 1:2.8 **Industrialised average 38,750 7.4 2.7 1:2.7** 5. Malaysia 13,710 4.0 1.5 1:2.7 6. Thailand 7640 4.6 1.5 1:3.1 7. China 6890 5.6 n/a n/a 8. Sri Lanka 4720 3.2 2.2 1:1.5 9. Indonesia 3720 3.1 0.9 1:3.4 10. Philippines 3540 4.4 1.3 1:3.4 11. India 3280 4.0 2.4 1:1.7 12. Vietnam 2790 6.0 2.4 1:2.5 13. Pakistan **27** 2680 2.8 3.6 1:0.8 14. Cambodia 1820 7.5 n/a n/a 15. Bangladesh 1550 3.7 n/a n/a 16. Nepal 1180 6.0 1.5 1:4.0 17. Myanmar n/a 1.8 3.4 1:0.5

**GDPEH % 2014 % GDP military Health:military ratio**

*CMR—poverty, health and military associations*: The correlation between CMR and GNI is highly statistically significant (Rho = +0.9323; *p* < 0.001) again confirming the statistical link between relative poverty and child mortality. There is no correlation between CMR and military and health expenditures. However, mention must be made about Myanmar and Pakistan, whose disproportionate high military to health expenditure proved to be the biggest distortion of all

**Table 3.** Asian countries: gross national income (GNI) by purchasing power parity (PPP) and % GDP expenditure on

health (GDPEH) % GDP military (source World Bank) and health to military ratio [Source World Bank [37]] .

**4460 4.4 2.5 1:1.8**

target.

72 International Development

**Country and GNI rank \$ GNI average per** 

**person**

71 countries reviewed.

**Non‐industrialised** 

n/a, not available.

**average**

*Socio-economic data:* GNI data are available from World Bank [29] for 30 of the 33 SSA countries, as shown in **Table 5**. Gabon (\$16,350), Botswana (\$15,110) and South Africa (\$12,350) hold the high‐ est GNI figures in this region. The Democratic Republic of Congo, Liberia and Malawi and Niger have the lowest figures ranging from \$630 to \$880. Bearing in mind these figures denote average income per person, this means that a considerable proportion of SSA populations must be living in *absolute poverty* on less than \$1 or \$2 per day [25]. Although the SSA GNI average of \$3,833 is similar to the non‐industrialised Asian countries average of \$4,460, the Western (\$35,662) and industrialised Asian (\$38,750) averages are around 10 times higher.

*Health and military expenditure:* No data were available for six SSA countries (see **Table 5**). The average expenditure on health as a percentage of GDP is 6.6%, well below the West's figure (10.5%) but above Asia's average (4.6%). There are marked variations led by Lesotho at 11.5%, Rwanda 11.1% and Liberia 10%, down to 5% in Zambia, 4.2% in Madagascar and 3.6% in Chad.

The average military expenditure in SSA countries is 1.5% of GDP. Again, there are marked variations ranging from 4.8% in Namibia and 3.5% in the Democratic Republic of Congo to 0.5% in Ghana and 0.4% in Nigeria. The average military to health ratio is 1:4.4. The narrow‐ est is a 1:1 ratio in the Democratic Republic of Congo; Lesotho has the highest ratio of 1:16.

*Child mortality rates:* **Table 6** lists CMR for SSA nations. Only South Africa has WHO [20] data; UNICEF estimates are used for the remaining countries. Highest CMR are in Somalia at 188,000 pm, followed by Burkina Faso 176,000 pm, Sierra Leone 174,000 pm, Chad 173,000 pm, Democratic Republic of Congo 170,000 pm and 161,000 pm in Angola. These six countries are classed as a relative *reproach* as their figures are 1 SD above the regional mean; they also failed to meet the UN millennium goal target of reducing CMR by 2% per annum. Somalia, Zimbabwe and South Africa increased their rates over the period.

Countries with the lowest regional CMR include Namibia at 40,000 pm, Botswana at 48,000 pm and Madagascar at 62,000 pm, all of whom are 1 SD below the mean meriting a relative *commendation*. Botswana's commendation is tempered by the fact that they had a 19% reduc‐ tion in CMR over the period thereby failing to achieve the UN target of a 2% reduction per annum and with a GNI by PPP figure four times the regional mean.

The average reduction in CMR was 33% and 16 SSA countries reduced their CMR by more than 35%; 12 achieving the millennium goal. Therefore, 21 (including South Africa) SSA countries failed to meet the UN target of a 2% reduction in CMR per annum, though five countries came close with falls of more than 30%. Fourteen SSA countries have been in civil conflict situations in the last 20 years; paradoxically Ethiopia, Liberia, Madagascar, Rwanda and Yemen managed to reduce their CMR by more than 40% over the review period. Compared to Nigeria who had the sixth highest income and equal seventh highest CMR, surely meriting a reproach.

Out of the 33 SSA counties, 21 (including South Africa) failed to meet the UN target of a 2% per annum reduction in CMR, although 5 came close with falls of more than 30%.

Perhaps the biggest surprise relates to figures from South Africa. Under the apartheid regime in 1990, WHO data yielded CMR of 6431 pm, but this might be a serious underestimation as child mortality in rural areas could have gone unreported. The first available WHO data for the post‐apartheid regime (2002–2004) records a rate of 10,410 pm, equivalent to a 62% increase. Taking only post‐apartheid WHO data, the latest index years 2007–2009 figure of 11,245 pm points to a rise in CMR of 8% over 7 years. However, South Africa's annual figures vary widely from year to year, for example, in 2009, the WHO reported rate fell to 9158 pm. This variation is also reflected in the UN Statistics Division data where for the baseline years (1988–1990) CMR is estimated at 61,000 pm, 59,600 pm and 58,500 pm, respectively, averaging 59,700 pm. For the years 2008–2010, CMR estimates went from 69,300 pm, down to 53,200 pm and 47,500 pm, averaging 56,700 pm—a 5% reduction, yet well below the millennium target.

income per person, this means that a considerable proportion of SSA populations must be living in *absolute poverty* on less than \$1 or \$2 per day [25]. Although the SSA GNI average of \$3,833 is similar to the non‐industrialised Asian countries average of \$4,460, the Western (\$35,662) and

*Health and military expenditure:* No data were available for six SSA countries (see **Table 5**). The average expenditure on health as a percentage of GDP is 6.6%, well below the West's figure (10.5%) but above Asia's average (4.6%). There are marked variations led by Lesotho at 11.5%, Rwanda 11.1% and Liberia 10%, down to 5% in Zambia, 4.2% in Madagascar and 3.6% in Chad. The average military expenditure in SSA countries is 1.5% of GDP. Again, there are marked variations ranging from 4.8% in Namibia and 3.5% in the Democratic Republic of Congo to 0.5% in Ghana and 0.4% in Nigeria. The average military to health ratio is 1:4.4. The narrow‐ est is a 1:1 ratio in the Democratic Republic of Congo; Lesotho has the highest ratio of 1:16.

*Child mortality rates:* **Table 6** lists CMR for SSA nations. Only South Africa has WHO [20] data; UNICEF estimates are used for the remaining countries. Highest CMR are in Somalia at 188,000 pm, followed by Burkina Faso 176,000 pm, Sierra Leone 174,000 pm, Chad 173,000 pm, Democratic Republic of Congo 170,000 pm and 161,000 pm in Angola. These six countries are classed as a relative *reproach* as their figures are 1 SD above the regional mean; they also failed to meet the UN millennium goal target of reducing CMR by 2% per annum. Somalia,

Countries with the lowest regional CMR include Namibia at 40,000 pm, Botswana at 48,000 pm and Madagascar at 62,000 pm, all of whom are 1 SD below the mean meriting a relative *commendation*. Botswana's commendation is tempered by the fact that they had a 19% reduc‐ tion in CMR over the period thereby failing to achieve the UN target of a 2% reduction per

The average reduction in CMR was 33% and 16 SSA countries reduced their CMR by more than 35%; 12 achieving the millennium goal. Therefore, 21 (including South Africa) SSA countries failed to meet the UN target of a 2% reduction in CMR per annum, though five countries came close with falls of more than 30%. Fourteen SSA countries have been in civil conflict situations in the last 20 years; paradoxically Ethiopia, Liberia, Madagascar, Rwanda and Yemen managed to reduce their CMR by more than 40% over the review period. Compared to Nigeria who had

Out of the 33 SSA counties, 21 (including South Africa) failed to meet the UN target of a 2%

Perhaps the biggest surprise relates to figures from South Africa. Under the apartheid regime in 1990, WHO data yielded CMR of 6431 pm, but this might be a serious underestimation as child mortality in rural areas could have gone unreported. The first available WHO data for the post‐apartheid regime (2002–2004) records a rate of 10,410 pm, equivalent to a 62% increase. Taking only post‐apartheid WHO data, the latest index years 2007–2009 figure of 11,245 pm points to a rise in CMR of 8% over 7 years. However, South Africa's annual figures vary widely from year to year, for example, in 2009, the WHO reported rate fell to 9158 pm.

the sixth highest income and equal seventh highest CMR, surely meriting a reproach.

per annum reduction in CMR, although 5 came close with falls of more than 30%.

industrialised Asian (\$38,750) averages are around 10 times higher.

74 International Development

Zimbabwe and South Africa increased their rates over the period.

annum and with a GNI by PPP figure four times the regional mean.



**Table 5.** Sub‐Saharan African countries: gross national income (GNI) by purchasing power parity (PPP) and health and military expenditure on health (GDPEH) 2014 [Source World Bank [37]] #indicates 2000 military GDP.


Comparing GDP Health and Military Expenditure, Poverty and Child Mortality of 71 Countries from Different Regions http://dx.doi.org/10.5772/67120 77


n/a, Not available.

**SSA country CMR Baseline pm CMR index pm % of change Lowest GNI: rank**

**Table 5.** Sub‐Saharan African countries: gross national income (GNI) by purchasing power parity (PPP) and health and

**% GDP on health % GDP military4 Military: health ratio**

*1.* Somalia C *180,000* 188,000 *+4 # n/a 2. Burkina Faso 205,000* 176,000 *−14 # 10 3. Sierra Leone C 276,000* 174,000 −*37 # 15= 4. Chad C 207,000* 173,000 −*16 # 14 5. Dem Republic Congo C 181,000* 170,000 −*6 # 1 6*. Angola *C 243,000* 161,000 −*34 # n/a* 7. Nigeria C 213,000 143,000 −33 # 25 8. Niger 311,000 143,000 −54 4 9. Cameroon 137,000 136,000 −1 # 17 10. Mozambique 219,000 135,000 −38 # 5 11. Guinea 229,000 130,000 −43 6 12. Cote d' Ivory C 151,000 123,000 −19 # 19 13. Zambia 183,000 111,000 −39 # 21 14. Ethiopia C 184,000 106,000 −42 7= 15. Sudan C 125,000 103,000 −18 # 23 16. Liberia C 227,000 103,000 −55 2 17. Uganda 175,000 99,000 −43 13 18. Gambia 165,000 98,000 −41 11 19. Congo (Kinshasa) C 116,000 93,000 −20 # n/a 20. Malawi 222,000 92,000 −59 3 21. Rwanda C 163,000 91,000 −44 9 22. Lesotho 89,000 85,000 −4 # 20

military expenditure on health (GDPEH) 2014 [Source World Bank [37]] #indicates 2000 military GDP.

*30. Dem Republic Congo 630 3.5 3.5 1:1.0* 31. Tanzania *n/a 7.3 1.1 1:6.6* 32. Angola *n/a n/a n/a n/a* 33. Somalia *n/a n/a n/a n/a* SSA average *3833 6.6 1.5 1:4.4*

**SSA country GNI by PPP \$average p.p**

n/a, Not available.

76 International Development

#Military expenditure from 2000. C, Civil conflict over the period.

#Failed to meet Millennium target of reducing CMR by 2% p.a. (UN [39, 7]).

C, Civil conflict over the period.

No GNI rank for Anglo, Congo (Kinshaha) and Somalia.

**Table 6.** Sub‐Saharan Africa CMR (0–4 years) per million (pm), % of change (1988–1990 v 2008–2010) and lowest GNI rank.

*CMR—poverty, health and military associations:* The rank order of the lowest GNI with the highest child mortality rates was significantly and positively correlated (Rho = +0.5204; *p* = 0.005), thus across the three regions, there are positive and significant statistical associations with CMR and 'poverty' however defined, reflecting the truism that poverty, even relative poverty, is linked to the deaths of children throughout the world.

When looking at SSA nations, those with the highest GNI figures such as Cameroon and Nigeria, against expectations, had higher CMR, whilst poorer countries such as Madagascar and Zimbabwe had lower CMR, suggesting major differences in policy in these societies in relation to child health. To explain this more fully would require country‐specific research. Remembering that GNI is adjusted for PPP in comparative terms, we in the West probably cannot conceive what such low levels of effective income mean for these societies. Again, perhaps counter intui‐ tively, there was no correlation between the health, military expenditures and CMR.
