A Population-Based Study Comparing Child (0-4) and Adult (55-74) Mortality, GDP-Expenditure-on-Health and Relative Poverty in the UK and Developed Countries 1989-2014. Some Challenging Outcomes

Purpose: To compare the UK Child (0-4) and Adult (55-74) Mortality with twenty developed countries 
1989-2014 to explore whether the UK has lower priorities for children?


Introduction
Parents failing to meet the needs of their children are often categorized as `neglecting' parents so can this this be applied to nations? If so one criteria would be found in the UNICEF statement " that in the fi nal analysis Child Mortality Rates (CMR) are an indicator of how well a nation meets the needs of its children" [1]. Therefore to assess how well the UK and This hypothesis stimulating study, utilizing the latest available WHO data [3] and examines a perspective that is seldom acknowledged -the tacit competing demands between child and health care, as all Western countries grapple with the impact of increased longevity and its demands on health services [4,5].
Consequently, we examine Adult-Mortality Rates (AMR) of people aged 55-74year, which is below the life-expectancy of all countries under-review [3] to compare them with changes in CMR.
Child and Adult mortality rates between the baseline years of 1989-91 are compared with the latest index years 2012-14 to determine whether there is any indication of possible different priorities between child and adult health care in the UK and the other twenty developed countries? An earlier study of child mortality found the highest CMR amongst the twenty-one developed nations were all the English-speaking-countries, raising the question of whether this pattern will occur in the case of adult mortality (55-74) [6,7].
Socio-Economic Context: The mortality rates are examined within the context of socio-economic factors that are likely to infl uence clinical outcomes. Firstly in regard to a nation's percentage of its Gross-Domestic-Product-Expenditure-on-Health (%GDPHE) which is the `economic input' into health care, and, relative poverty measured by the World Bank's Income Inequality ratios [8,9].
The `economic input' into health is a country's total % GDPEH. It is recognised that this will be differently confi gured in the various countries and with varied fi scal value [8,9].
Moreover, there are two broad categories of sources of %GDPEH, monies coming from predominately `Public' sources such as State / Federal and the proportion of %GDPEH coming from `Private' sources, mainly insurance or work-related benefi ts [8,9]. Hence the need to report `Public' and `Private' sources as well as the total %GDPEH of each nation which includes both `Public' and `Private' sources. Taken together it is the total %GDPEH of a nation that is a practical indication of a country's economic commitment to health and social care, which is the fi scal context in which all health and social care services operate. Each nation acts as their own control over the years and from which ratios of change can be calculated. [10,] is a measure of relative poverty, known to be associated with poorer child health outcomes [11][12][13][14][15][16][17] and is the other major socio-economic context in which all health services operate.

Income Inequality
Clinical Outcomes are the latest WHO mortality data [5], with which to compare any changes between CMR (0-4 years) and AMR (55-74 years) in the UK and the Other Developed Countries (ODC) between 1989-91 and 2012-14.
There are two working null hypotheses. There will be:-1) no statistical association between the child and adult mortalities and %GDPEH and Income Inequality, and, 2) no signifi cant differences between UK child and adult mortalities and the Other Developed Countries (ODC).

Socio-economic context-input
The economic input is the total percentage of GDP Expenditure to Health (%GDPEH), which is the combined public and private sources devoted to health and social services [8,9], illustrating the fi scal degree to which countries prioritise health. We do not know the differential proportion of %GDPEH going to child or adult services but it is suggested are any differences might be a refl ection of signifi cant different priorities between CMR and AMR outcomes over the period. Each country's %GDPHE can be tracked and an over-all average rate for the period 1989-2014 can be calculated. The time under review period covers twenty-seven separate recorded years of %GDPEH however, some countries missed reporting the occasional year that is noted in table 1.
Self-evidently, there are differences in the ways the countries confi gure their services. The biggest variation regards any differences between private and public sources of funding that goes to the total %GDPEH. We examine this in table 1 separately for the index years 2012-14 in column 6 and 7, and calculate a private to public funding ratio in column 8. The bigger the ratio, the higher the proportion of funding comes from public (State / Federal/ Direct Taxation) sources.
There was no Public/Private data available for Belgium, which is noted in the table.
The USA has always had a substantially higher %GDPEH than every country, especially the UK [8,9] Relative Poverty: There are different ways of measuring relative poverty, but all countries apply a measure of how far a child or its family are below that country's average income, usually a third below the national average household income is considered to be in a state of relative poverty [19,20]. We use the World Bank Income Inequalities, which is the gap between the top and bottom 10% of incomes, which is a countryspecifi c measure [20] and highlights relative differences in society. Some studies use Gross National Income (GNI) but this blurs signifi cant variations as it is essentially average based. This is exemplifi ed by the UK average income 2015/16 that was £26,300 but 60% received less than £20,000, whilst the top fi fth averaged £85,000 and the bottom fi fth averaged £7,000 [21]. It is acknowledged that CMR (0-4years) are not only infl uenced by poverty but by various other separate cultural, socio-economic and social policy factors but such issues are also often associated with relative poverty [22][23][24][25][26][27].

Clinical outputs
Clinical Outputs are the combined boy and girl 0-4 years CMR rates per million (pm) of population, compared with Adult (55-74)-Mortality-Rates (AMR) of both sexes of people aged 55-74 per million, which is below the life-expectancy of all the countries under review and is the age-band in which reducing adult deaths might be feasible [3]. In this total populationbased study it was not possible to examine what if any factors that might have infl uenced the child and adult rates, which would require a country-specifi c study. On the other hand, these 21 Western countries are amongst the very richest in the world [8], though this is not to deny there are differences between them. For example based upon US Census Bureau data, who report mortality by ethnicity, African American children die at virtually double the rate of White 0-4 year olds and such feature occurs in other Western countries but here we are reviewing the nation's mortality rates in their entirety [6,9,[11][12][13][14][15][16][17].
The countries reviewed are the twenty-one liberal democratic countries which have broadly similar socioeconomic situations and it is acknowledged that this hypothesis stimulating paper can only provide a broad over-view and it is acknowledged that explanations for any differences between countries would require country-specifi c research

Statistics
Confi dence Intervals (95%) are used to determine any signifi cant differences between UK child and adult mortalities with each of the Other Developed Countries (OCD) over the period. Actual odds ratios are calculated and included in the normal binominal based confi dence intervals.
Spearman Rank Order correlations (Rho) test any statistical association between %GDPHE, the mortalities and Income Inequality and odds ratios are calculated for the average European to UK for child and adult mortalities.

Socio-economic context
(a) Input %GDPEH: Table 1 presents the countries' %GDPEH, ranked by the highest average GDP spending on   indicating only a slight a degree of consistency in CMR over the period reviewed confi rming some countries made different progress in reducing CMR. The was a strong positive correlation between Income Inequality and CMR (Rho=+0.6175 p<0.005) indicating the statistical association of CMR and relative poverty in the developed world. There was no signifi cant correlation between lowest CMR and average %GDPHE Rho= -0.1646 n.sig. However there was a signifi cant correlation between the lowest Private: Pubic %GDPEH and the highest child mortality rate (Rho=+0.3805 p<0.05) but not with adult mortality rate (Rho= -0.1323 n.sig). Mortality Rates (55-74): Table 4 shows the highest AMR was the USA 12284pm, Denmark 12,056pm and Germany 11,740; the UK were seventh highest at 10,754pm.

(b) Adult
The lowest were in Australia 80812pm, Switzerland 8,460pm and Japan 8563pm.
The European average fell from 16,107pm to 9,545pm, a 41% reduction, the UK reduction of 48% was third biggest reduction, and over the period. UK adult death rates relatively improved from being 3 rd highest to now being 7 th out the 21 countries.
European current average was 9545pm, giving a European to UK odds ratio of 1:1.13 compared to the child mortality European to UK odds ratio of 1:1.33.
There was a signifi cant correlation between AMR baseline and index years (Rho=+0.68701 p <0.001), indicative of a degree of continuity over time in respect to adults. There were no signifi cant correlations between AMR and Income Inequality (Rho= +0.0091 n.sig) or between lowest AMR and GDPHE (Rho= -0.1432 n. sig). It is noteworthy that there was no correlation between the latest CMR and AMR (Rho-=+0.1506 n.sig) again suggesting differing priorities in some countries.

Comparing Other Countries with UK Child and Adult
Mortality Outcomes: Table 5 shows the Confi dence Intervals results of comparing the other countries CMR and AMR outcomes with those of the UK over the period.
The UK had signifi cantly bigger child mortality reductions than Canada and the USA but eleven other countries had signifi cantly greater falls in CMR than the UK.
The converse was the case in regard to reducing AMR as whilst Ireland had a signifi cantly bigger reduction than the UK, Britain's adult death rates fell signifi cantly more than seventeen other countries, including France, Germany and the USA, possibly suggesting greater priority had been given to adult health care?

Study limitations
The study cannot explain the differences found between the countries, such as the UK's comparative excess of child mortality; nor why the UK outcomes on reducing adult deaths were so much better. This might have been infl uenced by the law of diminishing returns, as previously the UK had the third highest AMR so in countries with initially high baseline rates it is easier to make proportionately bigger reductions following new investment, whereas those with initially lower rates is harder to achieve comparable reductions over the same time [28][29][30]. Only country-specifi c research can explain these individual results.
Despite these limitations, the study provides a perspective of how twenty-one developed nations 'meet the needs of its children' compared with its outcomes for adults and provides a baseline for future comparative research.

Conclusions
These results appear to indicate that in practice the UK has given greater priority to adult than child health. It not being suggested that there should be any reduction in adult health resources but if the UK is to `meet the needs of its children' [1] then relative poverty will need to be reduced and probably greater resources devoted to child health will be require in an attempt to off-set the accumulative impact of relative poverty upon children. This study gives support to the case that only a prolonged effort to reduce income inequalities, will improve CMR for disadvantaged children even in the Western world [35,36].
Summarizing the UK situation. It has the third widest income inequality, the lowest average (1980-2014) %GDPHE, the fourth highest CMR, which is the highest in Western Europe and a third higher than the other European countries. This is a matter of some concern especially as the reverse is true for UK achievements in reducing adult deaths.
Paradoxically, notwithstanding the UK children's results, the AMR outcomes confi rms that the NHS is one of the most effective and effi cient in the world, achieving more with proportionately less. Indeed, this study is not a criticism of the UK children's services, but rather shows the socio-economic context in which they operate and perhaps achieve more than we have a right to expect. However, with a comparatively chronic under-resourced NHS [37] and the long-standing structural relative poverty the UK is unlikely to be unable to match other countries' achievements and therefore the UK, along with the USA can be said to relatively neglect `to meet the needs of its children' [1].