Global Health: todays challenges Box 1.1 Sentinel vital registration in the United Republic of Tanzania Accurate statistics on basic demographic events are an important foun- ment and research bodies began to provide essential indicators to the dation of rational health and public policy. Unfortunately, reliable vital National Poverty Monitoring Master Plan. In the context of all informa registration is lacking for the vast majority of the world's poorest coun- tion systems in the United Republic of Tanzania that produce demo. tries. Some new approaches to meeting the need for mortality and mor. graphic, health and poverty indicators, sentinel demographic surveillance 1992, the Ministry of Health established the Adult Morbidity and Mor. people, at a per capita recurrent cost of USS 0.02 per year. These costs tality Project (AMMP) in partnership with the University of Newcastle are considerably less than for many other systems. upon Tyne, England, and with funding from the United Kingdom Depart. At the local level, AMMP has helped districts to feed sentinel sur- ment for International Development. veillance information about the prevailing burden of disease back to AMMP developed a demographic surveillance system and verbal community members who have, in turn, actively participated in setting autopsy tools for measuring levels and causes of death, and a validated priorities for district health. One local council was prompted by data on tool for estimating household consumption expenditure to monitor in- health-seeking for children dying at home from acute febrile illness to ome poverty. One of the initial project aims was to establish baseline increase the resources allocated to fight malaria and to promote the use levels of adult mortality by cause in three selected districts (3-5). In of treated bednets. At the national level, these same data provided an 1997, the Ministry of Health elected to expand data collection to a larger evidence base for a policy change in first-line malaria drug use, and the sample of districts and to establish a national sentinel system for health overall cause-specific mortality burden measured in years of life lost and poverty monitoring. In addition, the contributions of other demo- was a key input to the design of the first national package of essential graphic surveillance sites were coordinated to produce annual health health interventions. Drawing on the poverty data from sentinel sites, it statistics abstracts and public health sector performance profiles has also been possible to provide government with solid evidence about In 2002, sentinel vital registration, cause of death, and poverty how health intervention priorities among the poorest citizens differ from monitoring figures flowing from five sites managed by the Ministry of those of others Health and local councils and three sites managed by health develop with sample registration systems now capture one-third of deaths globally and provide infor- mation on 74% of global mortality, and these have been used to analyse adult mortality patterns and trends here Surviving the first five years of life Although approximately 10.5 million children under 5 years of age still die every year in the world, progress has been made since 1970, when the figure was more than 17 million. These reductions did not take place uniformly across time and regions, but the success stories in developing countries demonstrate clearly that low mortality levels are attainable in those settings. The effects of such achievements are not to be underestimated. If the whole world were able to share the current child mortality experience of Iceland (the lowest in the world in 2002), over 10 million child deaths could be prevented each year. Today nearly all child deaths occur in developing countries, almost half of them in Africa While some African countries have made considerable strides in reducing child mortality, the majority of African children live in countries where the survival gains of the past have been wiped out, largely as a result of the HIVIAIDS epidemic Across the world, children are at higher risk of dying if they are poor. The most impressive declines in child mortality have occurred in developed countries, and in low-mortality devel oping countries whose economic situation has improved. In contrast, the declines observed in countries with higher mortality have occurred at a slower rate, stagnated or even reversed Owing to the overall gains in developing regions, the mortality gap between the developing and developed world has narrowed since 1970. However, because the better-off countries in developing regions are improving at a fast rate, and many of the poorer populations are los- ing ground, the disparity between the different developing regions is widening
Global Health: today’s challenges 7 with sample registration systems now capture one-third of deaths globally and provide information on 74% of global mortality, and these have been used to analyse adult mortality patterns and trends here. Surviving the first five years of life Although approximately 10.5 million children under 5 years of age still die every year in the world, progress has been made since 1970, when the figure was more than 17 million. These reductions did not take place uniformly across time and regions, but the success stories in developing countries demonstrate clearly that low mortality levels are attainable in those settings. The effects of such achievements are not to be underestimated. If the whole world were able to share the current child mortality experience of Iceland (the lowest in the world in 2002), over 10 million child deaths could be prevented each year. Today nearly all child deaths occur in developing countries, almost half of them in Africa. While some African countries have made considerable strides in reducing child mortality, the majority of African children live in countries where the survival gains of the past have been wiped out, largely as a result of the HIV/AIDS epidemic. Across the world, children are at higher risk of dying if they are poor. The most impressive declines in child mortality have occurred in developed countries, and in low-mortality developing countries whose economic situation has improved. In contrast, the declines observed in countries with higher mortality have occurred at a slower rate, stagnated or even reversed. Owing to the overall gains in developing regions, the mortality gap between the developing and developed world has narrowed since 1970. However, because the better-off countries in developing regions are improving at a fast rate, and many of the poorer populations are losing ground, the disparity between the different developing regions is widening. Box 1.1 Sentinel vital registration in the United Republic of Tanzania Accurate statistics on basic demographic events are an important foundation of rational health and public policy. Unfortunately, reliable vital registration is lacking for the vast majority of the world’s poorest countries. Some new approaches to meeting the need for mortality and morbidity data have been pioneered in the United Republic of Tanzania. In 1992, the Ministry of Health established the Adult Morbidity and Mortality Project (AMMP) in partnership with the University of Newcastle upon Tyne, England, and with funding from the United Kingdom Department for International Development. AMMP developed a demographic surveillance system and verbal autopsy tools for measuring levels and causes of death, and a validated tool for estimating household consumption expenditure to monitor income poverty. One of the initial project aims was to establish baseline levels of adult mortality by cause in three selected districts (3–5). In 1997, the Ministry of Health elected to expand data collection to a larger sample of districts and to establish a national sentinel system for health and poverty monitoring. In addition, the contributions of other demographic surveillance sites were coordinated to produce annual health statistics abstracts and public health sector performance profiles. In 2002, sentinel vital registration, cause of death, and poverty monitoring figures flowing from five sites managed by the Ministry of Health and local councils and three sites managed by health development and research bodies began to provide essential indicators to the National Poverty Monitoring Master Plan. In the context of all information systems in the United Republic of Tanzania that produce demographic, health and poverty indicators, sentinel demographic surveillance generates a large number of indicators from a sample of over 500 000 people, at a per capita recurrent cost of US$ 0.02 per year. These costs are considerably less than for many other systems. At the local level, AMMP has helped districts to feed sentinel surveillance information about the prevailing burden of disease back to community members who have, in turn, actively participated in setting priorities for district health. One local council was prompted by data on health-seeking for children dying at home from acute febrile illness to increase the resources allocated to fight malaria and to promote the use of treated bednets. At the national level, these same data provided an evidence base for a policy change in first-line malaria drug use, and the overall cause-specific mortality burden measured in years of life lost was a key input to the design of the first national package of essential health interventions. Drawing on the poverty data from sentinel sites, it has also been possible to provide government with solid evidence about how health intervention priorities among the poorest citizens differ from those of others
The World Health Report 2003 Figure 1. 4 Child mortality in the six WHO regions, 2002 g 0008040 Africa Americas South-East World Asia Mediterranean Pacific Child mortality: global contrasts Regional child mortality levels are indicated in Figure 1.4. Of the 20 countries in the world with the highest child mortality(probability of death under 5 years of age), 19 are in Africa, the exception being Afghanistan. a baby born in Sierra Leone is three and a half times more likely to die before its fifth birth day than a child born in India, and more than a hundred times more likely to die than a child born in Iceland or Singapore. Fifteen countries, mainly European but including Japan and Singapore, had child mortality rates in 2002 of less than 5 per 1000 live births. Estimated hild mortality rates for 2002 are given for all WHO Member States in Annex Table 1 Child mortality: gender and socioeconomic differences Throughout the world, child mortality is higher in males than in females, with only a few exceptions. In China, India, Nepal and Pakistan, mortality in girls exceeds that of boys. This disparity is particularly noticeable in China, where girls have a 33% higher risk of dying than their male counterparts. These inequities are thought to arise from the preferential treatment of boys in family health care-seeking behaviour and in nutrition There is considerable variability in child mortality across different income groups within countries. Data collected by 106 demographic and health surveys in more than 60 countries show that children from poor households have a significantly higher risk of dying before the age of 5 years than the children of richer households. This is illustrated in Figure 1.5, using the results for three countries from different regions. The vertical axis represents the prob ability of dying in childhood (on a zero to one scale). The horizontal axis shows the informa tion by"poor and"non-poor. The identification of poor and non-poor populations uses a global scale based on an estimate of permanent income constructed from information ownership of assets, availability of services and household characteristics. This approach has the advantage of allowing comparison of socioeconomic levels across countries. It implies that the individuals defined as poor in Bangladesh have the same economic status as the population defined as poor in Bolivia or Niger I The"poor"are individuals from the lowest quintile of income, while the"non-poor"are the remainder
8 The World Health Report 2003 Child mortality: global contrasts Regional child mortality levels are indicated in Figure 1.4. Of the 20 countries in the world with the highest child mortality (probability of death under 5 years of age), 19 are in Africa, the exception being Afghanistan. A baby born in Sierra Leone is three and a half times more likely to die before its fifth birthday than a child born in India, and more than a hundred times more likely to die than a child born in Iceland or Singapore. Fifteen countries, mainly European but including Japan and Singapore, had child mortality rates in 2002 of less than 5 per 1000 live births. Estimated child mortality rates for 2002 are given for all WHO Member States in Annex Table 1. Child mortality: gender and socioeconomic differences Throughout the world, child mortality is higher in males than in females, with only a few exceptions. In China, India, Nepal and Pakistan, mortality in girls exceeds that of boys. This disparity is particularly noticeable in China, where girls have a 33% higher risk of dying than their male counterparts. These inequities are thought to arise from the preferential treatment of boys in family health care-seeking behaviour and in nutrition. There is considerable variability in child mortality across different income groups within countries. Data collected by 106 demographic and health surveys in more than 60 countries show that children from poor households have a significantly higher risk of dying before the age of 5 years than the children of richer households. This is illustrated in Figure 1.5, using the results for three countries from different regions. The vertical axis represents the probability of dying in childhood (on a zero to one scale). The horizontal axis shows the information by “poor” and “non-poor”.1 The identification of poor and non-poor populations uses a global scale based on an estimate of permanent income constructed from information on ownership of assets, availability of services and household characteristics. This approach has the advantage of allowing comparison of socioeconomic levels across countries. It implies that the individuals defined as poor in Bangladesh have the same economic status as the population defined as poor in Bolivia or Niger. 1 The “poor” are individuals from the lowest quintile of income, while the “non-poor” are the remainder. 0 20 40 60 80 100 120 140 160 180 Africa Americas Eastern Mediterranean South-East Europe Asia Western Pacific World Deaths per 1000 live births Figure 1.4 Child mortality in the six WHO regions, 2002