The ICIDH: evolution, status, and prospects.

The assessment of disability prevalence in populations is a long-standing concern. In the mid-1970s the World Health Organization (WHO) introduced a scheme for the measurement of the consequences of disease. The classification of the long-term non-fatal consequences of disease is structured on three axes, corresponding roughly to experiences at the level of organ or function (impairment--1009 items), individual action (disability--338 items) and societal interaction (handicap/disadvantage--72 items). The International Classification of Impairments, Disabilities, and Handicaps (ICIDH) is now well established. This paper describes developments in the use of the ICIDH since 1980, in assessing the prevalence of disability in populations, in formulating policy decisions, in management at institution level, and in the care of individuals. It lists problems identified in the use of the ICIDH, such as the need to clarify the role and interrelationship of environmental factors in the definition and development of the different planes addressed by the ICIDH, problems of overlap between disabilities and handicaps, and between impairments and disabilities. Suggestions for improvement include a greater emphasis on presenting handicap as a description of the interrelation between impairments or disabilities and their physical and social environment. It is anticipated that a revised proposal will be finalized for 1998 and formally issued in 1999.

Rapid evaluation methods (REM) of health services performance: methodological observations.

The rapid evaluation method (REM) was developed by WHO in order to assess the performance and quality of health care services, identify operational problems, and assist in taking managerial action. It was tested in five developing countries (Botswana, Madagascar, Papua New Guinea, Uganda and Zambia) between 1988 and 1991. REM consists of a set of observation- and survey-based diagnostic activities, carried out mainly in health care facilities. The article describes the various steps of REM, methodological issues such as setting objectives and using an issue-information matrix, preparation of survey instruments, use of computer software (Epi Info), data quality control, fieldwork, and the use of data to produce useful information for decision-makers. REM aims at bringing prompt and relevant information to planners and decision-makers who need it for a specific purpose. In the present examples, REM provided information for preparing a programme proposal for external funding, for establishing baseline data for a situation analysis, and for assessing staff performance after extensive training in order to improve the curriculum.

PIP: The rapid evaluation method (REM) is a health management tool aimed at bringing prompt an relevant information to planners and decision makers. The method was developed by WHO's Family Health Division and was field tested in mother and child health care and family planning facilities in Botswana, Madagascar, Papua New Guinea, Uganda, and Zambia between 1988 and 1991. The purpose of this paper is to acquaint the reader with the basic components of the method and methodological problems that arise. Each of the data collection instruments employed is described: clinic exit interviews, health staff interviews, observation of task performance, community and staff focus group discussions, review of clinical records, checking of facilities and equipment and supplies, and household interviews. REM was developed because of the apparent problems of too much paperwork and insufficient time for useful analysis and fears of the expense of surveys. There was a need for a quick, accurate, and economical method of evaluation of facilities and client satisfaction. Reference is made to other REM approaches and a review of REM methods. A basic requirement is the involvement of national program managers in the control, implementation, and application of the design; outside consultants furnish information on methods, formats, and analytical techniques as a complement to national efforts. THe first action taken is to define the objectives and specify the topics and issues of concern. A core group is assigned responsibility for REM. The action plan involves the objectives, information desired, sources for information, schedule of activities, logistical arrangements, and budget preparation. The level of detail of the information desired is defined by the core group and its objectives. A matrix of information is developed which includes information requested and sources; an example is provided. The results of the 5-county evaluation revealed methodological concern about the identification of issues and pretesting of instruments, data quality control, advance notice and planning of fieldwork, the need for analysts familiar with Epi Info Software, analysis of quantitative data first and training of leaders for focus groups, and the need for basic results in 7-10 days and a draft report in several weeks.

Rapid evaluation methods (REM) of health services performance: methodological observations

The rapid evaluation method (REM) was developed by WHO in order to assess the performance and quality of health care services, identify operational problems, and assist in taking managerial action. It was tested in five developing countries (Botswana, Madagascar, Papua New Guinea, Uganda and Zambia) between 1988 and 1991. REM consists of a set of observation- and survey-based diagnostic activities, carried out mainly in health care facilities. The article describes the various steps of REM, methodological issues such as setting objectives and using an issue-information matrix, preparation of survey instruments, use of computer software (Epi Info), data quality control, fieldwork, and the use of data to produce useful information for decision-makers. REM aims at bringing prompt and relevant information to planners and decision-makers who need it for a specific purpose. In the present examples, REM provided information for preparing a programme proposal for external funding, for establishing baseline data for a situation analysis, and for assessing staff performance after extensive training in order to improve the curriculum

[Monitoring progress towards health for all in the European region of WHO IV. Changes in health systems]. / Vers la santé pour tous dans la région européenne de l'OMS surveillance des progrès accomplis IV. Réponses des systèmes de santé.

This review deals with recent changes in health services development and support among the Member States of the European Region in response to changes in health indicators in the framework of the Regional targets for Health for all. Developments in research, in health legislation and in training which take into account the targets of Health for all represent long-term actions; several countries mention efforts to increase community participation in the development and evaluation of health programmes, efforts which must be actively pursued. Changes are perforce slow, and economic pressure represents both a challenge and a constraint.

[Monitoring progress towards health for all in the European region of WHO. III. Life style and physical environment]. / Vers la Santé pour tous dans la région européenne de l'OMS surveillance des progrès accomplis. III. Modes de vie et milieu physique.

A review of recent progress towards the Regional targets set for Health for all in the European Region of WHO, as regards lifestyle and environmental factors. Tobacco consumption (in most countries), and alcohol drinking (mainly in countries with previous high consumption) show some improvement. Illicit drug use is emerging in new countries, although it appears to stabilise in previously affected areas. Despite considerable efforts on environmental factors, there remains a serious problem of communication with the public, and action is poorly coordinated; indicators for environmental health show little progress.

[Toward health for all in the European region of the WHO. Survey of progress accomplished. II. Preliminary conditions: demographic and health status]. / Vers la santé pour tous dans la région européenne de l'OMS. Surveillance des progrès accomplis. II. Conditions préalables: bilan démographique et sanitaire.

A review of recent progress towards the regional targets set for health for all by the Member States of the European Region of WHO, as regards preliminary conditions for health, and for indicators of mortality, morbidity and disability. Life expectancy, infant and maternal mortality, and mortality from ischaemic heart disease and from traffic accidents show an improvement, as does the incidence of several infectious diseases, but the situation has worsened or stagnated as regards suicide and cancer, and there is a lack of information on disability and chronic morbidity. Despite some progress, the goal of equity in health is still very far from being attained.

[Consequences of disease and their measurement: introduction]. / Les conséquences de la maladie et leur mesure: introduction.

The measurement of the long-term consequences of disease, which are said to affect 7-10% of the world population in both developing and developed areas, presents both technical and conceptual problems. The development of classification schemes, foremost among which is the International Classification of Impairments, Disabilities, and Handicaps (ICIDH), has considerably changed our perception of these consequences, and has influenced the areas of rehabilitation, social insurance and legislation, disability surveys and health planning. More indirect applications have been the use of classifications in identifying, at local level, disadvantages in everyday life and ways to mitigate these disadvantages; at the macroplanning level, the concept of disability-free life expectancy is gaining increasing recognition. There is an increasing call for revising and updating ICIDH, particularly in the area of handicap, where societal and environmental factors have to be more explicitly taken into account. The operationalization of proposed modifications will require considerable thought and discussion in which persons with disabilities and their representatives will have an important role to play.

Maternal mortality in developing countries.

PIP: The author stresses that uncritical reliance on the institutional maternal mortality rates in developing countries will provide spurious indications of improvement in this area. There appears to bean an important, although imprecisely known, differential in coverage between deliveries and maternal deaths. In 1 area, the institutional maternal mortality rate was 10 times higher among unbooked than among booked deliveries. Moreover, caution should be used in transposing maternal mortality estimates based on life table data from Europe and North America from the early 20th century to present-day Africa. Health statistics should be used to monitor health status; analyzed reduction in maternal mortality should be analyzed carefully to ensure they are valid.^ieng

Maternal mortality in developing countries.

PIP: The authors of this letter respond to earlier letters prepared in response to their article on maternal mortality in developing countries. It is conceded that maternal mortality is high in India and Bangladesh; however, statistics from Gambia are based on small populations and are therefore inconclusive. It is noted that a 7-year survey of 4000 households in Machakos, Kenya, where 73% of deliveries occurred at home, yielded a maternal mortality rate of only 0.8/1000 deliveries. Finally, it is asserted that the measurement traditionally used in estimating maternal mortality for many African countries (ratio of recorded maternal deaths to recorded deliveries) is misleading. Maternal deaths are more likely than deliveries to be recorded. In Niger, the number of maternal deaths increased from 1980 (374) to 1982 (484). The ratio of maternal deaths to expected live births also increased from 135 to 166/100,000, whereas the traditionally calculated maternal mortality rate decreased from 519 to 420/100,000 due to changes in the denominators. It is recommended that health authorities of African countries such as Niger consider setting an absolute number of maternal deaths below which they would try to bring the current toll.^ieng

[Survey on the prevalence of sequelae of poliomyelitis of the lower limbs in school-age children in rural areas of the Department of Niamey, Niger]. / Enquête sur la prévalence des séquelles de poliomyélite au niveau des membres inférieurs chez les enfants d'âge scolaire dans les zones rurales du Departement de Niamey, Niger.

An investigation of lower limb motor disorders among school age children in three rural areas of Niger has demonstrated a prevalence rate of approximately seven per thousand in the 5-9 and 10-14 years age-groups, with no significant difference in rates for boys and girls. Although severe (bilateral) paralysis is encountered only among non-attenders, no significant difference in overall prevalence is found with regard to school attendance status. Eight per cent of affected children are unable to walk and a further eight per cent need crutches or other aids. Patient histories indicate that over 90 per cent of cases occur before the child's fourth birthday; there is no indication of a modification in incidence over the past nine years. Extrapolation from the observed data indicates an annual incidence rate for paralytic poliomyelitis of the order of 45 per hundred thousand population, i.e. about 2,500 cases a year for the whole of Niger, approximately 2,000 of whom survive with a permanent disability. These rates and figures are similar to those calculated for several other african countries and are seven to ten times higher than the figures gathered from routine reports of poliomyelitis in Niger. The total number of children unable to walk unaided among the 5-14 years age-group can be estimated in 1981 at 1,600, half of whom are paralysed in such a way that they are unable to walk at all. Other preventable causes of paralysis of the lower limbs encountered include i.a. tuberculosis of the spine, sequelae of cerebrospinal meningitis and, second only to paralytic poliomyelitis in importance, trauma to peripheral nerves through faulty injection technique.

A prevalence survey of lower limb motor disorders in school-age children in Niger and an estimation of poliomyelitis incidence.

An investigation of lower limb motor disorders among school-age children in Niger has shown a prevalence rate of seven per thousand in this age group. Sequelae of poliomyelitis, the major group among these disorders, show no significant difference according to sex or to school attendance status. Eight per cent of children suffering from poliomyelitis sequelae are unable to work and a further eight per cent need crutches or other aids. Patient histories indicate that over 90% of cases occurred before the child's fourth birthday. Extrapolation from the observed data indicate a tentative annual incidence rate for paralytic poliomyelitis in the order of 45 per 100,000, a figure seven to ten times higher than the figures gathered from routine notifications of poliomyelitis in Niger. The total number of those unable to walk unaided among children under 15 can be estimated in 1981 at 1600, half of whom are unable to walk at all. Trauma to peripheral nerves after intramuscular injections, usually of quinine salts, is second only to poliomyelitis as a cause of lower limb motor disorders.