Children of Kenya face serious survival challenges.

PIP: Survey findings pointing to the worsening health situation for children in Kenya that were highlighted during the National Dissemination Seminar for the 1998 Kenya Demographic and Health Survey (KDHS). The survey indicates that currently, 1 in 9 Kenyan children does not live to his or her 5th birthday. Under-five mortality stands at 112 deaths per 1000 live births, a 24% increase over the last decade. The high prevalence of childhood mortality is associated with a short preceding birth interval, a low level of maternal education, and rural location (under-five mortality is 23% higher in rural than in urban areas). Moreover, the risk of children dying varies greatly across provinces. A comparison between the results of the 1993 and 1998 KDHS also indicates recent setbacks in the fight against vaccine preventable diseases. Full vaccination coverage has fallen from 79% in 1993 to 65% in 1998. One of the more positive findings is the continuing decline in total fertility rate from 8.1 children per woman in the mid-1970s to current levels of 4.7 children per woman. In addition, knowledge and use of family planning has continued to rise in Kenya. Lastly, participants in the seminar also discussed the need for further dissemination of findings and further analysis of projects.^ieng

Update: Hib vaccination in the Americas.

PIP: Both Colombia and Brazil have introduced vaccination programs against Haemophilus influenzae type b (Hib). In 1998, Colombia added free Hib vaccination to the country's routine vaccination program. To date, 600,000 children (60% of the target population) have been reached with the vaccine and this effort has stimulated coverage with all vaccines. Initial coverage rates were hindered by civil unrest, rains, and a hospital strike a week prior to the campaign. In Brazil's Curitiba municipality (Parana State), routine Hib vaccination of all children 2-24 months of age was introduced in 1996, in part because Hib was implicated in 16% of bacterial meningitis cases. Hib incidence among children under 5 years of age dropped from 35.5/100,000 in 1996 to 9.7/100,000 in 1997 and there have been no further cases of bacterial meningitis among vaccinated children. The Pan American Health Organization is establishing a regional epidemiologic surveillance system for Hib-associated meningitis and pneumonia in children under 5 years and standardizing laboratory methodologies in the region.^ieng

Spotlight: Costa Rica.

PIP: 3.5 million people lived in Costa Rica as of mid-1997. There were 24 births and 4 deaths per 1000 population, respectively, contributing to the annual natural increase rate of 2.0%. Each woman in Costa Rica bears an average of 2.8 children during her reproductive lifespan and men and women were expected to live for 73 and 78 years, respectively. Costa Rica's low infant mortality rate and high literacy and life expectancy rates set it apart from the rest of Central America. Costa Rica is also the only country in the region which maintains no standing army. About 96% of the population is White or Mestizo, 3% is Black, and 1% is indigenous Indian. More than half of the country lives in San Jose and its metropolitan area, 6% of the country's total land area. Unemployment has run near 5% over the past 2 years, but much of the labor force is underemployed. Costa Rica's economy depends upon tourism and agricultural exports such as coffee, beef, and bananas. A large Intel factory opened in 1997. The government and Costa Rican environmentalists are planning a joint campaign to reconvert 80% of Costa Rica's pasture back to forest and tree crops. About 20% of the government's budget is spent upon education and the 93% literacy rate is the highest in the region. Government health services provide low-cost contraceptives to more than 75% of users and 75% of women use some form of family planning.^ieng

Spotlight: El Salvador.

PIP: As of mid-1998, El Salvador had a population of 5.8 million people residing in a land area of 8000 sq. miles. There were 29 births and 4 deaths per 1000 population, as well as 41 infant deaths for every 1000 live births, and a population growing in size at 2.5% annually. The average woman has 3.9 births during her reproductive lifetime and life expectancy is 65 years for men and 72 years for female. With 39% of El Salvador's population under age 15 years, it will continue to grow rapidly even as birth rates decline. The proportion of urban residents in El Salvador is expected to grow beyond the 1994 level of 45%. Population growth has intensified competition for farmland and jobs, with extreme poverty forcing Salvadoran farmers and laborers to make choices which are beneficial in the short term, but which may cause long-term environmental damage. Human and chemical wastes, often untreated and unregulated, pollute 90% of the rivers and almost all topsoil and drinking water in heavily populated areas. 66% of farmland in the mountainous area is eroded, and the resulting pollution and agricultural runoff threaten shellfish and seafood businesses close to the coast. While forests once covered 85% of El Salvador, now only less than 5% is forest, and much of the cleared land is so degraded that there is little hope of restoring endangered plant and animal species. Most of the country's workers are employed in agriculture, but industrial parks are helping the country's economic growth. 74% of Salvadoran men and 70% of women are literate, school enrollment levels are low, and about 4% of the country's gross national product comes from official development assistance. The El Salvador Environment Fund was created in 1994 to support small projects for environmental protection and child development.^ieng

Human development index as a predictor of infant and maternal mortality rates.

OBJECTIVE: The United Nations Human Development Index (HDI) is a composite index of life expectancy, literacy, and per capita gross domestic product that measures the socioeconomic development of a country. We estimated infant and maternal mortality rates in the world and assessed how well the HDI and its individual components predicted infant and maternal mortality rates for individual countries. MATERIALS: Data on mortality rates and values for HDI components were obtained from the United Nations and the World Bank. RESULTS: For the 1987 to 1990 period, approximately 9 million infant deaths and 349,000 maternal deaths occurred in the world annually, yielding global infant and maternal mortality rates of 67 per 1000 and 250 per 100,000 live births, respectively. HDI is a powerful predictor of both infant and maternal mortality rates. It accounts for 85% to 92% of the variation in infant mortality rates, and 82% to 85% of the variation in maternal mortality rates among countries. Each component of HDI is also strongly correlated with both infant and maternal mortality rates (significance of all values for r, p < 0.001), and eliminating life expectancy from HDI does not decrease significantly the predictive power of HDI for infant or maternal mortality rates. CONCLUSION: HDI is not only a useful measure for socioeconomic development, but also a powerful predictor of infant and maternal mortality rates for individual countries.

PIP: The UN Human Development Index (HDI), a composite index of life expectancy, literacy, and per capita gross domestic product, provides a measure of a country's level of socioeconomic development. An analysis of mortality data obtained from the United Nations and the World Bank indicated that the HDI is, in addition, a powerful predictor of infant and maternal mortality rates. The 1990 infant mortality rate in the 78 countries for which data were available ranged from 5/1000 live births in Japan to 143/1000 live births in Bhutan and Gambia; the maternal mortality rate ranged from 3/100,000 live births in Finland to 1500/100,000 live births in Nepal. The HDI accounted for 85-92% of the variance in infant mortality rates and 82-85% of that in maternal mortality. Although life expectancy tended to be the HDI component with the strongest predictive power, especially for infant mortality, the explanatory power of the index did not decrease significantly even when this component was excluded. If infant and mortality rates in developed countries in 1987-90 had prevailed worldwide, 8 million infant and 340,000 maternal deaths would have been averted each year.

A nested frailty model for survival data, with an application to the study of child survival in northeast Brazil.

"This article presents a multivariate hazard model for survival data that are clustered at two hierarchical levels.... We apply the model to an analysis of the covariates of child survival using survey data from northeast Brazil collected via a hierarchically clustered sampling scheme. We find that family and community frailty effects are fairly small in magnitude but are of importance because they alter the results in a systematic pattern."

Spotlight: Bolivia.

PIP: Bolivia is one of the poorest and least developed countries in South America. As of mid-1997, the country's population was comprised of 7.8 million individuals spread across 418,680 square miles. Bolivia's population size is growing through natural increase at the rate of 2.6% per year, with 36 births and 10 deaths per 1000 population. Bolivia's total population size is projected to reach 13.2 million by 2025. The total fertility rate is 4.8 births per woman even though the 1994 Demographic and Health Survey found that only 45% of pregnancies were wanted and the average woman has reported wanting only 2.5 children. 42% of women at risk of pregnancy use some form of contraception, with 18% using a modern method. There are 71 infant deaths per 1000 live births, child mortality is especially high between ages 1 and 3 years due to widespread child malnutrition after weaning, 650 women die for every 100,000 births, and life expectancy is 59 and 62 years for men and women, respectively. Concern over the high infant and child mortality rates has led to increased interest in family planning in recent years and the government of Bolivia now provides some support for the distribution of contraceptives.^ieng

[The estimation of years lived in disability: a global initiative]. / La estimacion de los anos vividos con discapacidad: una iniciativa universal.

PIP: "This paper [translated from the original French] sets out the main information brought by the calculations of health expectancies at a global level: sex differences, national geographical comparisons, socio-economic differences; causes of disability and handicap; time trends; and nature of the years lived with disabilities. The study illustrates the policy relevance of health expectancies to (i) appraise the quality of the years lived, (ii) supervise health inequalities, (iii) allocate resources to different programmes, or (iv) assess health policies. It also illustrates the large diversity of potential indicators of the quality of years lived." (EXCERPT)^ieng

Sex ratio at birth deviations in modern Venezuela: the Trivers-Willard effect.

This study evaluates the impact of the Trivers-Willard (T-W) effect on human populations, using demographic data collected from vital registration data in Venezuela. The evaluation of the sex ratio at birth (SRB) and of fetal and infant deaths supports the existence of T-W effect in the Venezuelan population in extreme conditions. This T-W effect was observable in the SRB but not at later ages and is related to the marital status of the mother. The results indicate that the investment in females associated with environmental adversity is greater than the investment in males associated with good environmental conditions.

PIP: This study relies on stepwise discriminant analysis to evaluate the influence of socioeconomic status (SES) factors according to marital status on the probability of the child being born a male or a female. Data were obtained from the 1988 and 1990 Venezuelan death and birth registers in the Central Office of Statistics and Information. Fetal and infant deaths numbered 87,229. Births numbered 577,976 and were reported for a variety of demographic/socioeconomic variables. The study evaluates the Trivers and Willard (1973) hypothesis that the sex ratio at birth is correlated with socioeconomic status. The focus is on the deviations in the sex ratio at birth (SRB) in Venezuela. The authors refer to studies confirming sex biases in mortality and sex biases in allocating resources and care and refuting the Trivers-Willard (T-W) effect. Findings indicate that the SRB was 0.5124 and confirms other estimates. The SRB for married and cohabiting couples was 0.512 and 0.514, respectively. The SRB was lower for single women (0.508). Differences were all statistically significant. Findings suggest that the T-W effect may be stronger in women who do not live with a male partner. Sex ratio deviations varied by SES. Higher educational status was associated with a higher SRB. Extreme poverty was associated with lower SRB and had a stronger impact on SRB than high SES. The T-W effect appeared stronger prior to conception. The T-W effect varied by maternal marital status. Females were more advantaged when mothers were unmarried. The sex ratio of neonatal deaths was 0.562; that for infant deaths was 0.574. The sex ratios for mortality did not differ for any of the SES indicators. There were differences by type of births and gestation time. Single births and early gestational times had higher male mortality. Infant deaths among mothers aged 30-34 years showed a higher sex ratio.

[The relationship between years of life lost and life expectancy: applications to the analysis of mortality]. / La relacion entre los anos de vida perdidos y la esperanza de vida: aplicaciones para el analisis de la mortalidad.

"This paper presents a new, continuous, version of the index of years of life lost (YLL) in the population, distinguishing different causes of death. Also, it shows the mathematical relationship between the YLL and temporary life expectancies in the discrete and continuous cases....The model is applied to the analysis of mortality of the province of Cordoba, Argentina, during 1947-1991." (SUMMARY IN ENG)

[The use of years of life lost for measuring the level and change of mortality]. / Los anos de vida perdidos: su utilizacion para medir el nivel y cambio de la mortalidad.

"The use of the new index of years of life lost allows us to relate mortality by age and causes of death to the change of the life expectancy, at birth or between any given ages. This index replaces the use of the multiple decrement life tables for analyzing the impact of the change in mortality by age and cause of death on the life expectancies....The article presents the theoretical derivation of the index, some examples of its use, and a detailed calculation." Examples provided include Mexico, Chile, and Argentina. (SUMMARY IN ENG)

Variations in familial neonatal mortality risks in four countries.

This paper investigates variations in the strength and structure of familial association in neonatal mortality risks in four populations; Bolivia, Kenya, Peru, and Tanzania. Exploratory analyses of the structure of the familial association are presented for each population. Random effects logistic models are then used to estimate the strength of familial association in neonatal mortality risks using a standard set of control variables. The results suggest that the strength of familial association in neonatal mortality risks is quite similar in these four populations which would be consistent with a biological explanation for the association. However, some differences were found, particularly in the form of the association in Peru, which may suggest at least a small role of other factors.

Using lot quality assurance sampling to assess measurements for growth monitoring in a developing country's primary health care system.

BACKGROUND: Local supervisors used lot quality assurance sampling (LQAS) during routine household visits to assess the technical quality of Costa Rican community-based health workers (CHW): measuring and recording weights of children, interpreting their growth trend and providing nutrition education to mothers. METHOD: Supervisors sampled 10 households in each of 12 Health Areas (4-8 hours per area). No more than two performance errors were allowed for each CHW. This LQAS decision rule resulted in judgments with a sensitivity and specificity of about 95 percent. RESULTS: Three categories of results are reported: (1) CHW adequately weighed children, calculated ages, identified children requiring nutritional services, and used the growth chart. (2) They needed to improve referral, education, and documentation skills. (3) The lack of system support to regularly provide growth cards, supplementary feeding to identified malnourished children, and other essential materials may have discouraged some CHW resulting in them not applying their skills. CONCLUSIONS: Supervisors regularly using LQAS should, by the sixth round of supervision, identify at least 90 percent of inadequately performing CHW. This paper demonstrates the strength of LQAS, namely, to be used easily by low level local health workers to identify poorly functioning components of growth monitoring and promotion.

PIP: Nurses and rural health supervisors used the Lot Quality Assurance Sampling (LQAS) technique to assess the quality of growth monitoring and promotion (GMP) conducted by community health workers (CHWs) in 12 health areas in Costa Rica. Each supervisor made 10 routine household visits and spent 4-8 hours in each area. The study allowed no more than two performance errors per CHW. CHWs could correctly identify children in need of the nutritional services of the primary health care (PHC) system. Yet they were weak in their referral, education, and documentation skills. The supply system and the documentation system that support growth monitoring did not work well. Perhaps the inadequate support system may have contributed to the CHWs' inferior use of their skills. The finding that there were inadequate supplies and poor documentation of required GMP data suggest that CHWs did not regularly conduct growth monitoring, perhaps due to a lack of scales and growth charts. The PHC system did not follow children with nutritional deficiencies, suggesting that health facilities did not keep a register and refer these children systematically. This would explain why CHWs did not refer malnourished children to health facilities. CHWs had significant time constraints that influenced their ability to perform regular growth monitoring. The evaluation team required 4-8 hours to observe growth monitoring in 10 households. The PHC system expects each CHW to conduct about 10 complete household visits/day, which includes growth monitoring, vaccinations, pre- and post-natal care, oral rehydration therapy training, and monitoring blood pressure. With each subsequent supervision visit, the misclassification error of substandard CHW (i.e., the probability of identifying an inadequate performer) decreases. By the sixth visit, supervisors could identify almost all CHWs with a performance quality of 80% or less. These findings suggest that supervisors use LQAS methods to regularly identify GMP problems.

Epidemiological transition in Latin America: the case of Chile.

To describe Chile's stage of epidemiological transition, a descriptive study of the changes to the demographic and economic profile of this country during the last 20 years is presented. The decline in the total fertility rate from 3.4 in 1970 to 2.6 in 1992 and the important decrease in general and infant mortality rate has led to an increase of life expectancy of 8 years for men and 9 years for women. This has resulted in changes to the age structure and causes of mortality and morbidity of the population. A reduction of 82% in the proportion of deaths among children < 1 year and a 73% increase of mortality amongst those 65 years and older can be observed. In line with these changes non-communicable diseases have increased from 53.7% of all deaths in 1970 to 74.9% in 1991. In the same period mortality rates from cardiovascular causes have decreased from 189.6 to 161.1 per 100,000 population, whilst their relative proportion of all causes has increased from 22.3% to 29%. High prevalence of risk factors should lead to a significant increase of chronic diseases in future years. Regarding morbidity, a high incidence rate for tuberculosis persists together with an increase of infections of the digestive system and of sexually transmitted diseases. A decrease in the rates of diseases preventable by immunisation has been noted. It is concluded that, as defined by population mortality statistics, Chile is in a post-transition stage but with a persistence of some infectious diseases corresponding to a transitional stage of development.

The Cuban health care system and factors currently undermining it.

This paper explores the dynamics of health and health care in Cuba during a period of severe crisis by placing it within its economic, social, and political context using a comparative historical approach. It outlines Cuban achievements in health care as a consequence of the socialist transformations since 1959, noting the full commitment by the Cuban state, the planned economy, mass participation, and a self-critical, working class perspective as crucial factors. The roles of two external factors, the U.S. economic embargo and the Council of Mutual Economic Cooperation (CMEA), are explored in shaping the Cuban society and economy, including its health care system. It is argued that the former has hindered health efforts in Cuba. The role of the latter is more complex. While the CMEA was an important source for economic growth, Cuban relations with the Soviet bloc had a damaging effect on the development of socialism in Cuba. The adoption of the Soviet model of economic development fostered bureaucracy and demoralization of Cuban workers. As such, it contributed to two internal factors that have undermined further social progress including in health care: low productivity of labor and the growth of bureaucracy. While the health care system is still consistently supported by public policy and its structure is sound, economic crisis undermines its material and moral foundations and threatens its achievements. The future of the current Cuban health care system is intertwined with the potentials for its socialist development.

PIP: The dynamics of health care in Cuba during a period of severe crisis was explored within an economic, social, and political context. Cuban achievements in health care since 1959 were a consequence of the full commitment to health care by the state, the planned economy, and mass participation. In 1959 the infant mortality rate was 60/1000 live births and life expectancy was 65.1 years. By the period of 1983-88 Cuba had attained an infant mortality rate of 15/1000 and female life expectancy of 76 years compared to the figures of 27/1000 and 73 years, respectively, in South Korea. In response to problems that arose in the 1960s an improved health care model stressing the involvement of health care workers in the community was proposed in 1974. In the early 1980s 20,000 family physicians were trained to provide primary care services in the communities. Two external factors, the US economic embargo and the Council of Mutual Economic Cooperation (CMEA), shaped the Cuban society and economy, including its health care system. The U.S. embargo forced Cuba to pay higher transportation costs to import medical supplies from Soviet-bloc countries. Once the Soviet bloc collapsed, Washington further tightened the embargo through the Torricelli Bill of 1992, which bars U.S. subsidiaries in other countries from trading with Cuba and forbids US portage for 6 months to any ship that has docked in Cuba. As a result, in 1993 Cuba's imports for public health cost an extra $45 million. The CMEA was an important source for economic growth; however, the adoption of the Soviet model of economic development contributed to two internal factors that have undermined health care: low productivity of labor and the growth of bureaucracy. Social expenditures declined from 70% of the GNP in 1970 to 36% in 1995. Meanwhile, administrative personnel grew from 90,000 persons in 1973 to 240,000 persons in 1984. In 1995 some 50,000 physicians were serving a population of 11 million. Since 1986 a total of 1042 individuals have been found to be HIV positive. The policy of forced isolation of HIV-positive persons and AIDS patients was relaxed recently. While the health care system and its structure is sound, the economic crisis undermines its material and moral foundations and threatens its achievements.

[The future population of Latin America]. / La poblacion futura de America Latina.

PIP: Latin America has a population of 471 million, which grows at a rate of around 2% per year; if this does not change, the population will double in a period of 35 years. Life expectancy at birth was 68 years in the period 1990-1995, it will be 73 years in the period 2020-2025, while the global birth rate of 3.1 in 1990-1995 will be reduced to 2.2 in 2020-2025. In the year 2000 the area will have a population of 510.9 millions and in 2025 it will increase to 686.4 millions; 23.9% will be under the age of 15 years, 67% will be aged between 15 and 64 years, and 9% will be aged 65 years or over. These figures show the quick process of aging in the area's population as a result of the decrease in births. The region will face two fundamental demographic problems at the beginning of the third millennium: the aging of the population and the rapid increase of the working-age members of this population. (author's modified)^ieng

[Causes of adult mortality in developing and developed countries with low mortality rates]. / Causas de defuncion de adultos en paises en desarrollo y desarrollados con bajas tasas de mortalidad.

"In a certain number of developing countries, life expectancy levels now approach those of the developed world. But, though life expectancies at birth may be similar, the infant mortality rate in developing countries remains higher, but is compensated by a lower rate of mortality for adults. Is it to be expected that as infant mortality rates continue to decline, the developing countries will maintain their advantageous adult mortality rates and that life expectancy will forge ahead of the level achieved in developed countries?... To answer this question, recent trends in adult cause-specific mortality rates in four developing countries (Chile, Hong Kong, Mexico, and Costa Rica) were compared with those in three industrialized countries (France, Germany and Japan). The results were inconclusive. Whilst life expectancies in some of these countries may be expected to forge ahead (Chile, Hong Kong), in others the margin between their life expectancies and those of developed countries have already narrowed." (SUMMARY IN ENG)

[Avoidable causes of death and their effects on life expectancy. A socio-demographic interpretation. The case of the northern frontier, 1980-1990]. / Causes de muerte evitables y su contribucion al incremento en la esperanza de vida. Una interpretacion sociodemografica. El caso de la frontera norte, 1980-1990.

"This study forms part of [a] research project on the health-disease-death process along the [Mexican] Northern Frontier--a by-product of the socio-economic structure of a specific social formation that determines disease and death--to support regional and sectorial design of policies and actions for the improvement of health conditions for its population.... An important finding is a 4.1 year increase of life expectancy due, among other causes, to a slight decrease in avoidable death causes, although these still produce about 50% of deaths." (SUMMARY IN ENG)

Vaccination efforts lauded in Brazil.

PIP: According to a United Nations Children's Fund (UNICEF) report, which evaluated progress toward fulfillment of the 29 recommendations of the Childhood Pact signed in 1993 by 22 of Brazil's 27 provincial governors, large-scale vaccination programs have been successful while attempts to improve education have not. The pact covered the rights of children and adolescents, the reduction of infant mortality, and improved health and education services. Massive vaccination efforts have eradicated polio from Brazil and reduced measles from 23,000 cases in 1992 to 124 cases in 1993 and 14 cases, to date, in 1994. However, 77% of primary school students are over the expected age for their educational level; plans to increase literacy among adolescents who lack primary education were frustrated, and teacher's strikes in many states cut into their time with students. In 1993, classes were suspended in 10 states to protest poor salaries and a lack of respect for teachers, another issue to be addressed by the pact. Provision of lunches for at least 180 days of the year in order to prevent malnutrition and boost school attendance in the poorest areas was also in the pact, but 17 of the 22 states which signed the pact have yet to do implement lunch programs. UNICEF, the executive secretary of the pact, has released a document, "Expectations for 1995-1998," suggesting renewal of the pact in combination with other measures to ensure the survival and development of Brazil's children.^ieng

[Infant and child mortality in Mexico, estimated using the 1980 and 1990 censuses and projections to 2000]. / La mortalidad infantil y en los primeros anos de vida en Mexico, estimada en los censos de 1980 y 1990 y su proyeccion al 2000.

PIP: Using indirect methods based on information about live births and surviving children, the author reviews estimates of infant and child mortality in Mexico. Data are from the 1980 and 1990 censuses.^ieng