Chapter One Global Health today's challenges Reviewing the latest global health trends, this chapter finds disturbing evidence of widening gaps in health worldwide. In 2002, while life expectancy at birth reached 78 years for women in developed countries, it fell back to less than 46 years for men in sub-Saharan Africa, largely because of the HIVIAIDS epidemic For millions of children today, particularly in Africa, the biggest health challenge is to survive until their fifth birthday, and their chances of doing so are less than they vere a decade ago. This is a result of the continuing impact of communicable diseases. However, a global increase in noncommunicable diseases is simultaneously occurring. adding to the daunting challenges already facing many developing countries 血GN
Global Health: today’s challenges 1 Chapter One Global Health: today’s challenges Reviewing the latest global health trends, this chapter finds disturbing evidence of widening gaps in health worldwide. In 2002, while life expectancy at birth reached 78 years for women in developed countries, it fell back to less than 46 years for men in sub-Saharan Africa, largely because of the HIV/AIDS epidemic. For millions of children today, particularly in Africa, the biggest health challenge is to survive until their fifth birthday, and their chances of doing so are less than they were a decade ago. This is a result of the continuing impact of communicable diseases. However, a global increase in noncommunicable diseases is simultaneously occurring, adding to the daunting challenges already facing many developing countries
Global health today's challenges Although this report is global in scope, the findings irresistibly draw the main focus to the increasingly fragile health of sub-Saharan Africa. It is here, where scores of millions of people scrape a living from the dust of poverty, that the price of being poor can be most starkly seen Almost an entire continent is being left behind Overall, 35% of Africa's children are at higher risk of death than they were 10 years ago. Every hour. more than 500 African mothers lose a small child. In 2002. more than four million African children died. Those who do make it past childhood are confronted with adult death rates that exceed those of 30 years ago. Life expectancy, always shorter here than almost anywhere else, is shrinking. In some African countries, it has been cut by 20 years and life expectancy for men is less than 46 years. Mostly, death comes in familiar garb. The main causes among children are depressingly rec- ognizable: the perinatal conditions closely associated with poverty; diarrhoeal diseases; pneu monia and other lower respiratory tract conditions; and malaria. Becoming more familiar by the day, HIV/AIDS, now the world,'s leading cause of death in adults aged 15-59 years, is killing almost 5000 men and women in this age group, and almost 1000 of their children very 24 hours in sub-Saharan Africa. The main components of Africa's tragedy are shared by many of the poorest people every where and include the agonizingly slow progress towards the Millennium Development Goals of reduced maternal and child mortality; the HIV/AIDS pandemic; and the double burden of communicable diseases plus noncommunicable diseases, including the tobacco epidemic and the avoidable deaths from road traffic crashes. Subsequent chapters of this report will exam- ne each of these components and show how they can and must be reshaped for a better future The global picture Life expectancy improves-but not for all Over the past 50 years, average life expectancy at birth has increased globally by almost 20 years, from 46.5 years in 1950-1955 to 65. 2 years in 2002. This represents a global average increase in life expectancy of 4 months per year across this period. On average, the gain in life expectancy was 9 years in developed countries(including Australia, European countries Japan, New Zealand and North America), 17 years in the high-mortality developing coun tries(with high child and adult mortality levels), including most African countries and poorer
Global Health: today’s challenges 3 1 Global Health: today’s challenges Although this report is global in scope, the findings irresistibly draw the main focus to the increasingly fragile health of sub-Saharan Africa. It is here, where scores of millions of people scrape a living from the dust of poverty, that the price of being poor can be most starkly seen. Almost an entire continent is being left behind. Overall, 35% of Africa’s children are at higher risk of death than they were 10 years ago. Every hour, more than 500 African mothers lose a small child. In 2002, more than four million African children died. Those who do make it past childhood are confronted with adult death rates that exceed those of 30 years ago. Life expectancy, always shorter here than almost anywhere else, is shrinking. In some African countries, it has been cut by 20 years and life expectancy for men is less than 46 years. Mostly, death comes in familiar garb. The main causes among children are depressingly recognizable: the perinatal conditions closely associated with poverty; diarrhoeal diseases; pneumonia and other lower respiratory tract conditions; and malaria. Becoming more familiar by the day, HIV/AIDS, now the world’s leading cause of death in adults aged 15–59 years, is killing almost 5000 men and women in this age group, and almost 1000 of their children, every 24 hours in sub-Saharan Africa. The main components of Africa’s tragedy are shared by many of the poorest people everywhere and include the agonizingly slow progress towards the Millennium Development Goals of reduced maternal and child mortality; the HIV/AIDS pandemic; and the double burden of communicable diseases plus noncommunicable diseases, including the tobacco epidemic and the avoidable deaths from road traffic crashes. Subsequent chapters of this report will examine each of these components and show how they can and must be reshaped for a better future. The global picture Life expectancy improves – but not for all Over the past 50 years, average life expectancy at birth has increased globally by almost 20 years, from 46.5 years in 1950–1955 to 65.2 years in 2002. This represents a global average increase in life expectancy of 4 months per year across this period. On average, the gain in life expectancy was 9 years in developed countries (including Australia, European countries, Japan, New Zealand and North America), 17 years in the high-mortality developing countries (with high child and adult mortality levels), including most African countries and poorer
The World Health Report 2003 countries in Asia, the Eastern Mediterranean Region and Latin America; and 26 years in the low-mortality developing countries. As shown in Figure 1.1, the large life expectancy gap between the developed and developing countries in the 1950s has changed to a large gap between the high-mortality developing countries and others Life expectancy at birth in 2002 ranged from 78 years for women in developed countries to less than 46 years for men in sub-Saharan Africa, a 1.7-fold difference in total life expectancy. Exceptions to the life expectancy increases in most regions of the world in the last 50 years are Africa and countries of eastern Europe formerly in the Soviet Union. In the latter case, male and female life expectancies at birth declined, by 2.9 years and I year, respectively, over the period 1990 to 2000. Estimated life expectancies for males and females for 2002 are given in Annex Table I for all Member States of the World Health Organization(WHO) The increases in life expectancy that occurred in the first half of the 20th century in devel oped countries were the result of rapid declines in mortality, particularly infant and maternal mortality, and that caused by infectious diseases in childhood and early adulthood. Access to better housing, sanitation and education, a trend to smaller families, growing incomes, and public health measures such as immunization against infectious diseases all contributed greatly to this epidemiological transition. In many developed countries, this shift started approxi- mately 100 to 150 years ago. In a number of countries, such as Japan, the transition started later but proceeded much more quickly. In many developing countries, the transition started even later and has not yet been completed. In developed countries, improvements in life xpectancy now come mainly from reductions in death rates among adults. Global mortality patterns Almost 57 million people died in 2002, 10.5 million(or nearly 20%)of whom were children of less than 5 years of age(see Figure 1. 2). Of these child deaths, 98% occurred in developing Figure 1.1 Life expectancy at birth: developed and developing countries, 1955-2002 ≌ g 20 Developing- low mortality Developing-high mortality 940 1960 020 Note: The term developed countries indudes Australia, Canada, European es. former Soviet Japan, New Zealand and the developing countries indude those in sub-Saharan Africa, and countries with I Central and South America and the Eastern Mediterranean. Other developing countries are refered to as'developing-low mortality
4 The World Health Report 2003 countries in Asia, the Eastern Mediterranean Region and Latin America; and 26 years in the low-mortality developing countries. As shown in Figure 1.1, the large life expectancy gap between the developed and developing countries in the 1950s has changed to a large gap between the high-mortality developing countries and others. Life expectancy at birth in 2002 ranged from 78 years for women in developed countries to less than 46 years for men in sub-Saharan Africa, a 1.7-fold difference in total life expectancy. Exceptions to the life expectancy increases in most regions of the world in the last 50 years are Africa and countries of eastern Europe formerly in the Soviet Union. In the latter case, male and female life expectancies at birth declined, by 2.9 years and 1 year, respectively, over the period 1990 to 2000. Estimated life expectancies for males and females for 2002 are given in Annex Table 1 for all Member States of the World Health Organization (WHO). The increases in life expectancy that occurred in the first half of the 20th century in developed countries were the result of rapid declines in mortality, particularly infant and maternal mortality, and that caused by infectious diseases in childhood and early adulthood. Access to better housing, sanitation and education, a trend to smaller families, growing incomes, and public health measures such as immunization against infectious diseases all contributed greatly to this epidemiological transition. In many developed countries, this shift started approximately 100 to 150 years ago. In a number of countries, such as Japan, the transition started later but proceeded much more quickly. In many developing countries, the transition started even later and has not yet been completed. In developed countries, improvements in life expectancy now come mainly from reductions in death rates among adults. Global mortality patterns Almost 57 million people died in 2002, 10.5 million (or nearly 20%) of whom were children of less than 5 years of age (see Figure 1.2). Of these child deaths, 98% occurred in developing 0 10 20 30 40 50 60 70 80 1940 1960 1980 2000 2020 Year Life expectancy at birth (years) Note: The term developed countries includes Australia, Canada, European countries, former Soviet countries, Japan, New Zealand and the USA. High-mortality developing countries include those in sub-Saharan Africa, and countries with high child and adult mortality in Asia, Central and South America and the Eastern Mediterranean. Other developing countries are referred to as “developing – low mortality”. Developed Developing – low mortality Developing – high mortality Figure 1.1 Life expectancy at birth: developed and developing countries, 1955–2002
Global Health: todays challenges igure 1.2 Age distribution of global mortality: developed and developing countries. 2002 50 40000 s20000 10000 eveloped W-mortality High-mortality World countries. Over 60% of deaths in developed countries occur beyond age 70, compared with about 30% in developing countries. A key point is the comparatively high number of deaths in developing countries at younger adult ages(15-59 years). Just over 30% of all deaths in developing countries occur at these ages, compared with 20% in richer regions. This vast premature adult mortality in developing countries is a major public health concern Developing countries themselves are a very heterogeneous group in terms of mortality (Fig ure 1.1). A contrast between low-mortality developing countries such as China(with more than one-sixth of the world s population)and high-mortality countries in Africa(with one tenth of the global population) illustrates the extreme diversity in health conditions among developing countries. Less than 10% of deaths in China occur below 5 years of age compared with 40% in Africa. Conversely, 48% of deaths in China occur beyond age 70, compared with Although risk of death is the simplest comparable measure of health status for populations, there has been increasing interest in describing, measuring and comparing health states of populations. Mortality statistics, in particular, substantially underestimate the burden from noncommunicable adult disease because they exclude non-fatal health outcomes such as de- pression and visual impairment. A useful method of formulating a composite summary of isease burden is to calculate disability-adjusted life years(DALYs), which combine years of DALY can be thought of as one lost year of " healthy " life and the measured disease burden is the gap between a population,s health status and that of a normative global reference popula tion with high life expectancy lived in full health. In terms of DALYs, 36% of total lost years of healthy life for the world in 2002 were a result of disease and injury in children aged less than 15 years, and almost 50% as a result of disease and injury in adults aged 15-59 years(see Fis I Estimated deaths by cause, age group and sex for 2002 are available on the WHO web site for the six WHo regionsandforthe14epidemiologicalsubregions(www.who.int/evidence/bod) LYs by cause, age group and sex for 2002 are available on the WHO web site for the six wHO regionsandforthe14epidemiologicalsubregions(www.who.int/evidence/bod)
Global Health: today’s challenges 5 countries. Over 60% of deaths in developed countries occur beyond age 70, compared with about 30% in developing countries. A key point is the comparatively high number of deaths in developing countries at younger adult ages (15–59 years). Just over 30% of all deaths in developing countries occur at these ages, compared with 20% in richer regions. This vast premature adult mortality in developing countries is a major public health concern. Developing countries themselves are a very heterogeneous group in terms of mortality (Figure 1.1). A contrast between low-mortality developing countries such as China (with more than one-sixth of the world’s population) and high-mortality countries in Africa (with onetenth of the global population) illustrates the extreme diversity in health conditions among developing countries. Less than 10% of deaths in China occur below 5 years of age compared with 40% in Africa. Conversely, 48% of deaths in China occur beyond age 70, compared with only 10% in Africa.1 Although risk of death is the simplest comparable measure of health status for populations, there has been increasing interest in describing, measuring and comparing health states of populations. Mortality statistics, in particular, substantially underestimate the burden from noncommunicable adult disease because they exclude non-fatal health outcomes such as depression and visual impairment. A useful method of formulating a composite summary of disease burden is to calculate disability-adjusted life years (DALYs), which combine years of life lost (YLLs) through premature death with years lived with disability (YLDs) (1). One DALY can be thought of as one lost year of “healthy” life and the measured disease burden is the gap between a population’s health status and that of a normative global reference population with high life expectancy lived in full health. In terms of DALYs, 36% of total lost years of healthy life for the world in 2002 were a result of disease and injury in children aged less than 15 years, and almost 50% as a result of disease and injury in adults aged 15–59 years (see Figure 1.3).2 1 Estimated deaths by cause, age group and sex for 2002 are available on the WHO web site for the six WHO regions and for the 14 epidemiological subregions (www.who.int/evidence/bod). 2 Estimated DALYs by cause, age group and sex for 2002 are available on the WHO web site for the six WHO regions and for the 14 epidemiological subregions (www.who.int/evidence/bod). 0 10 000 20 000 30 000 40 000 50 000 60 000 Developed Low-mortality developing High-mortality developing World Number of deaths (000) 0–4 5–14 15–59 60+ Figure 1.2 Age distribution of global mortality: developed and developing countries, 2002
The World Health Report 2003 gure 1.3 Distribution of disease burden(DALYs) by age group and region, 2002 rld loped regio 60+ 5-14 15% 33% 5-14 15-59 15-59 49% Low-mortality developing regions High-mortality developing regions 18% 5-14 57% 15-59 43% 5-14 9% As Figure 1.3 illustrates, child survival continues to be a major focus of the international health agenda for developing countries(2 ). Because nearly 90% of global deaths under age 15 occur before the age of 5, the following sections focus on child deaths under 5 years In con trast, the international effort to understand the magnitude of challenges to adult health in developing countries is still in its early stages. Even at present, there remains a perception that adult health is of great concern only in wealthy countries, where premature mortality among children has been substantially reduced. However, Figures 1. 2 and 1.3 also illustrate the high proportion of burden of disease and injury suffered by adults in developing countries, a grov ing burden that requires urgent action by the global public health community. This chapte therefore first examines trends and issues in child health, focusing on ages 0-4, then among dults aged 15-59 years and among adults aged 60 years and over. Unfortunately, complete cause-specific death registration data are routinely available for only a minority of the world s countries(see Chapter 7 and the Explanatory Notes in the Statisti al Annex). However, complete or incomplete vital registration data(see Box 1.1)together
6 The World Health Report 2003 As Figure 1.3 illustrates, child survival continues to be a major focus of the international health agenda for developing countries (2). Because nearly 90% of global deaths under age 15 occur before the age of 5, the following sections focus on child deaths under 5 years. In contrast, the international effort to understand the magnitude of challenges to adult health in developing countries is still in its early stages. Even at present, there remains a perception that adult health is of great concern only in wealthy countries, where premature mortality among children has been substantially reduced. However, Figures 1.2 and 1.3 also illustrate the high proportion of burden of disease and injury suffered by adults in developing countries, a growing burden that requires urgent action by the global public health community. This chapter therefore first examines trends and issues in child health, focusing on ages 0–4, then among adults aged 15–59 years and among adults aged 60 years and over. Unfortunately, complete cause-specific death registration data are routinely available for only a minority of the world’s countries (see Chapter 7 and the Explanatory Notes in the Statistical Annex). However, complete or incomplete vital registration data (see Box 1.1) together 0–4 29% 5–14 15–59 7% 49% 60+ 15% 0–4 6% 5–14 4% 15–59 57% 60+ 33% 0–4 40% 5–14 9% 15–59 43% 60+ 8% 0–4 18% 5–14 6% 15–59 57% 60+ 19% World Developed regions Low-mortality developing regions High-mortality developing regions Figure 1.3 Distribution of disease burden (DALYs) by age group and region, 2002
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
Global Health: todays challenges Figure 1.5 Differences in child mortality in three developing countries according to socioeconomic status 0.40 80.30 0.25 0.15 0.10 angladesh Bolivia There are significant differences in child mortality risks by poverty status in all countries, although the size of the gap varies; the risk of dying in childhood is approximately 13 per centage points higher for the poor than for the non-poor in Niger but less than 3 percentage points higher in Bangladesh Child mortality rates among the poor are much higher in Africa than in any other region despite the same level of income used to define poverty. The probability of poor children in Africa dying is almost twice that of poor children in the Americas. Likewise, better-off chil- dren in Africa have double the probability of dying than their counterparts in the Americas. Moreover, better-off children in Africa have a higher mortality risk(16%)than poor children in the Americas, whose risk of death is 14% Child survival: improvements for some The last three decades have witnessed considerable gains in child survival worldwide(shown by WHO region in Figure 1.6). Global child mortality decreased from 147 per 1000 live births in 1970 to about 80 per 1000 live births in 2002. The reduction in child mortality has been particularly compelling in certain countries of the Eastern Mediterranean and South-East Asia Regions and Latin America, while that of African countries was more modest Gains in child survival have also occurred in rich industrialized nations, where levels of mortality were already low. Although child mortality has fallen in most regions of the world, the gains were not consist ent across time and regions. The greatest reductions in child mortality across the world oc- curred 20-30 years ago, though not in the African or the Western Pacific Regions, where the decline slowed down during the 1980s, nor in some eastern European countries, where mor tality actually increased in the 1970s. Over the past decade, only countries of the South-East Asia Region and the higher mortality countries in Latin America have further accelerated their reduction in child mortality
Global Health: today’s challenges 9 There are significant differences in child mortality risks by poverty status in all countries, although the size of the gap varies; the risk of dying in childhood is approximately 13 percentage points higher for the poor than for the non-poor in Niger but less than 3 percentage points higher in Bangladesh. Child mortality rates among the poor are much higher in Africa than in any other region despite the same level of income used to define poverty. The probability of poor children in Africa dying is almost twice that of poor children in the Americas. Likewise, better-off children in Africa have double the probability of dying than their counterparts in the Americas. Moreover, better-off children in Africa have a higher mortality risk (16%) than poor children in the Americas, whose risk of death is 14%. Child survival: improvements for some The last three decades have witnessed considerable gains in child survival worldwide (shown by WHO region in Figure 1.6). Global child mortality decreased from 147 per 1000 live births in 1970 to about 80 per 1000 live births in 2002. The reduction in child mortality has been particularly compelling in certain countries of the Eastern Mediterranean and South-East Asia Regions and Latin America, while that of African countries was more modest. Gains in child survival have also occurred in rich industrialized nations, where levels of mortality were already low. Although child mortality has fallen in most regions of the world, the gains were not consistent across time and regions. The greatest reductions in child mortality across the world occurred 20–30 years ago, though not in the African or the Western Pacific Regions, where the decline slowed down during the 1980s, nor in some eastern European countries, where mortality actually increased in the 1970s. Over the past decade, only countries of the South-East Asia Region and the higher mortality countries in Latin America have further accelerated their reduction in child mortality. Figure 1.5 Differences in child mortality in three developing countries according to socioeconomic status 0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40 Poor Non-poor Poor Non-poor Poor Non-poor Probability of dying before 5 years of age Niger Bolivia Bangladesh
The World Health Report 2003 Figure 1. 6 Changes in child mortality rates by WHO region, 1970-2002 5%8 Africa World The most impressive gains in child survival over the past 30 years occurred in developing countries where child mortality was already relatively low, whereas countries with the highes rates had a less pronounced decline. Despite an overall decline in global child mortality over the past three decades, the gap between and within developing regions has widened. Although the chances of child survival among less developed regions of the world are becom ing increasingly disparate, the gaps in child mortality among affluent nations have been clos ing over the past 30 years, largely as a result of medico-technological advances, particularly in the area of neonatal survival In 16 countries(14 of which are in Africa) current levels of under-5 mortality are higher than those observed in 1990. In nine countries(eight of which are in Africa) current levels exceed even those observed over two decades ago. hiviaidS has played a large part in these Analyses from the demographic and health surveys show that, while child mortality has in reased in many of the African countries surveyed, the gap between poor and non-poor populations has remained constant over time in this setting. In contrast, there has been a widening of the mortality gap between poor and better-off groups in the Americas, where overall child mortality rates have fallen. This indicates that survival gains in many regions have benefited the better-off. The reduction in child mortality has been much slower in rural reas,where poor people are concentrated, than in urban areas(6). These analyses suggest that health interventions implemented in the past decade have not been effective in reaching Losses in child survival in the countries described above are at odds with impressive gains ir some African countries. Despite the ravages of the HIV/AIDS epidemic in Africa, eight coun tries in the region have reduced child mortality by more than 50% since 1970. Among these are Gabon, the Gambia and ghana Overall, at least 169 countries, 112 of them developing countries, have shown a decline child mortality since 1970. Some of these are presented in Figure 1.7. Oman has had the most
10 The World Health Report 2003 The most impressive gains in child survival over the past 30 years occurred in developing countries where child mortality was already relatively low, whereas countries with the highest rates had a less pronounced decline. Despite an overall decline in global child mortality over the past three decades, the gap between and within developing regions has widened. Although the chances of child survival among less developed regions of the world are becoming increasingly disparate, the gaps in child mortality among affluent nations have been closing over the past 30 years, largely as a result of medico-technological advances, particularly in the area of neonatal survival. In 16 countries (14 of which are in Africa) current levels of under-5 mortality are higher than those observed in 1990. In nine countries (eight of which are in Africa) current levels exceed even those observed over two decades ago. HIV/AIDS has played a large part in these reversals. Analyses from the demographic and health surveys show that, while child mortality has increased in many of the African countries surveyed, the gap between poor and non-poor populations has remained constant over time in this setting. In contrast, there has been a widening of the mortality gap between poor and better-off groups in the Americas, where overall child mortality rates have fallen. This indicates that survival gains in many regions have benefited the better-off. The reduction in child mortality has been much slower in rural areas, where poor people are concentrated, than in urban areas (6). These analyses suggest that health interventions implemented in the past decade have not been effective in reaching poor people. Losses in child survival in the countries described above are at odds with impressive gains in some African countries. Despite the ravages of the HIV/AIDS epidemic in Africa, eight countries in the region have reduced child mortality by more than 50% since 1970. Among these are Gabon, the Gambia and Ghana. Overall, at least 169 countries, 112 of them developing countries, have shown a decline in child mortality since 1970. Some of these are presented in Figure 1.7. Oman has had the most Figure 1.6 Changes in child mortality rates by WHO region, 1970–2002 -80 -70 -60 -50 -40 -30 -20 -10 0 % change in child mortality Africa Americas Eastern Mediterranean South-East Europe World Asia Western Pacific
Global Health: todays challenges 11 Figure 1.7 Countries with large absolute reductions in child mortality since 1970 -+ Bangladesh Bolivia 50- 1980Year 1990 striking reduction, from 242 per 1000 live births in 1970 to its current rate of 15 per 1000 live births, which is lower than that of many countries in Europe. Overall, the lower mortality countries of the Eastern Mediterranean Region experienced an impressive decline in child mortality, which has been accompanied by a reduction in the gap between countries'child mortality levels since 1970 Child mortality has also declined substantially in the Americas. The most striking propor tional reductions in mortality have been seen in Chile, Costa Rica and Cuba, where child mortality has decreased by over 80%since 1970. There have also been large absolute reduc tions in child mortality in Bolivia, Nicaragua and Peru. In contrast, Haitian child mortality ates are still 133 per 1000: almost double the mortality rate of Bolivia, the next highest coun- try in the americas. An interesting pattern of child mortality trends has been observed in several eastern European countries. Here, child mortality initially increased or remained constant during the 1970s, only to decline after 1980(7). This may to some extent be attributed to a more complete registration of child and infant deaths during that period. Interestingly, while adult mortality levels increased in the early 1990s, child mortality continued to decline. There is no other region where this particular pattern of mortality has occurred in such a systematic manner, and the reasons for the trend remain poorly understood Causes of death in children Infectious and parasitic diseases remain the major killers of children in the developing world, partly as a result of the HIVIAIDS epidemic. Although notable success has been achieved in certain areas(for example, polio), communicable diseases still represent seven out of the top 10 causes of child deaths, and account for about 60% of all child deaths. Overall, the 10 leading causes represent 86% of all child deaths(see Table 1.1) Many countries of the Eastern Mediterranean Region and in Latin America and Asia have partly shifted towards the cause-of-death pattern observed in developed countries. Here, conditions arising in the perinatal period, including birth asphyxia, birth trauma and low birth weight, have replaced infectious diseases as the leading cause of death and are now
Global Health: today’s challenges 11 striking reduction, from 242 per 1000 live births in 1970 to its current rate of 15 per 1000 live births, which is lower than that of many countries in Europe. Overall, the lower mortality countries of the Eastern Mediterranean Region experienced an impressive decline in child mortality, which has been accompanied by a reduction in the gap between countries’ child mortality levels since 1970. Child mortality has also declined substantially in the Americas. The most striking proportional reductions in mortality have been seen in Chile, Costa Rica and Cuba, where child mortality has decreased by over 80% since 1970. There have also been large absolute reductions in child mortality in Bolivia, Nicaragua and Peru. In contrast, Haitian child mortality rates are still 133 per 1000: almost double the mortality rate of Bolivia, the next highest country in the Americas. An interesting pattern of child mortality trends has been observed in several eastern European countries. Here, child mortality initially increased or remained constant during the 1970s, only to decline after 1980 (7). This may to some extent be attributed to a more complete registration of child and infant deaths during that period. Interestingly, while adult mortality levels increased in the early 1990s, child mortality continued to decline. There is no other region where this particular pattern of mortality has occurred in such a systematic manner, and the reasons for the trend remain poorly understood. Causes of death in children Infectious and parasitic diseases remain the major killers of children in the developing world, partly as a result of the HIV/AIDS epidemic. Although notable success has been achieved in certain areas (for example, polio), communicable diseases still represent seven out of the top 10 causes of child deaths, and account for about 60% of all child deaths. Overall, the 10 leading causes represent 86% of all child deaths (see Table 1.1). Many countries of the Eastern Mediterranean Region and in Latin America and Asia have partly shifted towards the cause-of-death pattern observed in developed countries. Here, conditions arising in the perinatal period, including birth asphyxia, birth trauma and low birth weight, have replaced infectious diseases as the leading cause of death and are now Figure 1.7 Countries with large absolute reductions in child mortality since 1970 1970 1980 1990 2000 Year Oman Bolivia Bangladesh Gambia 0 50 100 150 200 250 Under-5 mortality per 1000 live births 300 350