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Switzerland (Geneva) 77

WORLD HEALTH STATISTICS QUARTERLY

1993 - VOLUME 46, NUMBER 2
CARDIOVASCULAR DISEASE MORTALITY IN THE DEVELOPING COUNTRIES

94.77.01 - English - Alan D. LOPEZ, Tobacco or Health Programmes, WHO, Geneva (Switzerland)

Assessing the Burden of Mortality from Cardiovascular Diseases (p. 91-96)

The present estimate of global mortality caused by cardiovascular diseases is accompanied by a considerable degree of uncertainty, which, in so far as monitoring their emergence in developing countries is concerned, undoubtedly represents one of the major obstacles to effective public health interventions for their control. In much of the developing world, vital registration data are lacking and it would be unreasonable to expect rapid progress in the recording of causes of death because resources are so limited. The most promising avenue is that of the progressive implementation of clearly defined mortality surveillance systems that cover all deaths and permit the attribution of probable causes via lay reporting. The reliability of the data largely depends on the specificity and clarity of the verbal autopsy algorithm employed and on the availability of medically trained personnel to validate the returns. (DEVELOPING COUNTRIES, EPIDEMIOLOGY, MORTALITY MEASUREMENT, CAUSES OF DEATH, CARDIOVASCULAR DISEASES)

94.77.02 - English - Ala'din A.S. ALWAN, Noncommunicable Diseases, WHO Regional Office for the Eastern Mediterranean, Alexandria (Egypt)

Cardiovascular Diseases in the Eastern Mediterranean Region (p. 97-100)

Rapid socioeconomic development, urbanization and improved survival have given rise to a progressive increase in the occurrence of noncommunicable diseases in the Eastern Mediterranean Region. Cardiovascular diseases have emerged as a leading cause of morbidity and mortality in many countries. The prevalence of hypertension is already high in many countries of the region and the number of hypertensives is likely to increase further in the coming years. Although the influence of geographical, ethnic and socioeconomic factors has not been studied adequately, it seems that the epidemiological and clinical patterns of hypertension do not differ markedly from those in developed countries. The growing impact of cardiovascular disease is already understood in most countries. The human and economic costs are enormous, there is a growing demand for medical services, and the need to take action is increasingly acknowledged. Most countries have either initiated or indicated the need to establish programmes in collaboration with WHO on the prevention and control of cardiovascular disease during 1992 and 1993. In view of the scarcity of precise epidemiological information, data collection and the assessment of risk factors for coronary heart disease are expected to form the basis of preliminary activities. (MEDITERRANEAN COUNTRIES, DISEASE PREVALENCE, CARDIOVASCULAR DISEASES)

94.77.03 - English - K.S. REDDY, Department of Cardiology, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi 110 029 (India)

Cardiovascular Diseases in India (p. 101-107)

India is undergoing an epidemiological transition and is on the threshold of an epidemic of cardiovascular disease. Cause specific mortality data indicate that cardiovascular disease is already an important contributor to mortality. Demographic projections suggest a major increase in cardiovascular disease mortality as life expectancy increases and the age structure of the growing population changes. Surveys in urban areas suggest that coronary risk factors are already widespread and that urgent action is needed to prevent a further rise as socioeconomic development proceeds. It is vital to obtain epidemiological data from several regions in order to plan, initiate and monitor public health action. (INDIA, EPIDEMIOLOGY, CARDIOVASCULAR DISEASES)

94.77.04 - English - Philippe HUNGERBUHLER, Conrad SHAMLAYE, Ministry of Health, Victoria (Seychelles), and Pascal BOVET, Institute for Social and Preventive Medicine, University of Lausanne, Lausanne (Switzerland)

The Cardiovascular Disease Situation in Seychelles (p. 108-112)

A rising frequency of cardiovascular diseases and related risk factors has been documented in Seychelles. This epidemiological transition to chronic diseases is believed to result from the aging of the population and from changes in lifestyle associated with a rapidly improving standard of living. Since 1990 a long-term national collaborative programme has been established for the prevention and control of cardiovascular diseases. It has been designed with a view to implementing a combination of population-based and specific, high-risk target-group strategies. Objectives have been formulated, and culturally acceptable multisectoral activities have been devised, along with plans for the monitoring of cardiovascular diseases and risk factors and for the evaluation of the programme as it proceeds. (SEYCHELLES, EPIDEMIOLOGY, CARDIOVASCULAR DISEASES)

94.77.05 - English - YAO Chonghua, Department of Community Health, WU Zhaosu, Department of Epidemiology and Prevention, and WU Yingkai, Beijing Hearth, Lung and Blood Vessel Medical Centre, Beijing (China)

The Changing Pattern of Cardiovascular Diseases in China (p. 113-118)

In China, morbidity and mortality attributable to cardiovascular disease increased rapidly from the 1950s to the 1980s due to an increased life expectancy and changes in lifestyle. Cardiovascular disease has become the leading cause of death in the country. There is a high incidence of stroke, which is the commonest or second commonest cause of death. Hypertension, the main risk factor for stroke and an important risk factor for coronary heart disease, is the most prevalent cardiovascular disease, and should be given first priority in control programmes. Smoking, a common habit in males, is to be a principal focus of preventive activities over the next few years. Between 1970 and 1990, several community programmes for the prevention and control of cardiovascular diseases were established. The WHO MONICA Project has developed standardized methodologies that are used to establish systems for monitoring and evaluating control programmes. There is an urgent need to develop a long-term national strategy for the management and control of cardiovascular diseases. (CHINA, EPIDEMIOLOGY, CARDIOVASCULAR DISEASES, HEALTH POLICY)

94.77.06 - English - R. BOEDHI-DARMOJO, Research Institute, Diponegoro University, Semarang (Indonesia)

The Pattern of Cardiovascular Diseases in Indonesia (p. 119-124)

As its socioeconomic situation is improving, Indonesia is now in epidemiological transition, having the double burden of infectious diseases and emerging non-communicable, especially cardiovascular diseases. A review of the data from recent community surveys indicates an increase in cardiovascular diseases, particularly ischaemic heart disease and hypertension and its sequelae, as causes of morbidity and mortality, most markedly among the elderly, while rheumatic heart disease and congenital heart disease continue to have much lower incidences. In response to this situation, Indonesia has joined the WHO MONICA Project as an associate member. The first population screening, completed in 1988 on 2.073 randomly selected subjects, disclosed important risk factors including hypertension, smoking and physical inactivity. Lipid values are low compared with Western figures but higher than Japanese values. The prevalence of hypertension ranged from 5 to 15% in all adults but reached over 20% in those aged 50 years and over. Primary and primordial prevention programmes are to receive higher priority, and health education is to be given special attention at all levels. It will be necessary for the government to work closely with nongovernmental organizations in order to accomplish the tasks in hand. (INDONESIA, EPIDEMIOLOGY, CARDIOVASCULAR DISEASES, HEALTH SURVEYS)

94.77.07 - English - Walinjom F.T. MUNA, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaoundé (Cameroon)

Cardiovascular Diseases in Africa (p. 125-132)

The availability of basic and reliable data on cardiovascullar problem in Africa is limited and this hinders the presentation of a comprehensive review of the subject. Nervertheless, there is a strong suggestion that the spectrum and pattern of cardiovascular disorders in Africa is rapidly becoming indistinguishable from that observed in developed countries. The classic risk factors appear to be on the rise and smoking may attain levels equal to or exceeding those in many developed countries. Infectious and inflammatory cardiovascular conditions may still be the most common, although limitations in the technology available for accurate diagnosis make this difficult to verify. Rheumatic fever and rheumatic heart disease remain common, and the potential for education and other preventive strategies is being realized in many countries. Hypertension at frequencies exceeding 5-10% in most rural areas and 12% in most urban areas, together with complications such as stroke, heart failure and renal failure, are leading causes of morbidity and mortality. Hypertension is the major public health problem in most African countries. The cardiomyopathies are a common problem, and the limited availability of specific diagnostic procedures is matched by limited therapeutic options for most Africans. The prevalence of atherosclerosis and coronary artery disease and its complications, such as myocardial infarction and other degenerative disorders, remains low, but the situation is rapidly changing, especially in urban areas where appropriate diagnostic capabilities exist. It is thought that changes or modifications in lifestyle, risk-prone behaviour, diet, cultural attitudes and certain other consequences of rapid urbanization and demographic tendencies largely explain the observed trends. Our knowledge of risk factors and related conditions such as dyslipidaemias, diabetes, obesity, pulmonary embolism and thromboembolism remains fragmentary and incomplete. Both preventive and therapeutic strategies applicable to cardiovascular disorders are expensive. This is true not only of direct costs but also of indirect costs related to compliance, accessibility, applicability and so forth. The required budgets are currently beyond the reach of many sub-Saharan countries. There is a need for specific, multidisciplinary and collaborative research on a wide range of cardiovascular disorders in Africa. Taking the critical initial stemps should carry us beyond expressing the need for basic data. Such research should provide at least a data base that the countries can use in order to make rational decisions about health priorities. (AFRICA, EPIDEMIOLOGY, CARDIOVASCULAR DISEASES)

94.77.08 - English - Eric S. NICHOLLS, Armando PERUGA and Helena E. RESTREPO, Pan American Health Organization (PAHO/WHO), Washington, DC (U.S.A.)

Cardiovascular Disease Mortality in the Americas (p. 134-150)

Despite subregional differences, mortality profiles have undergone major changes in most countries of the Americas. While the proportion of deaths caused by noncommunicable diseases, particularly cardiovascular diseases, has increased, overall age-adjusted mortality rates attributable to all cardiovascular disease are declining in 13 of the 15 countries selected for the present study. About half the countries showed decreasing mortality rates for ischaemic heart disease; the other half had increasing rates. The mortality rates for cerebrovascular disease and hypertensive disease declined in all but four countries. The ischaemic heart disease/cerebrovascular disease mortality ratio increased as a consequence of a greater decline in deaths due to cerebrovascular disease, except in two countries that exhibited a greater decline for ischaemic heart disease. With few exceptions the maleto-female mortality ratios increased for all cardiovascular disease, ischaemic heart disease and cerebrovascular disease, reflecting a greater decline in female mortality. In general there was a decline in all cardiovascular disease mortality for almost every age group in the North American, Southern Cone, English-speaking Caribbean, and Andean subregions, while there were increases in the Central American and Latin Caribbean subregions. The magnitude of the changes was related to the initial level of mortality and the date of onset of the decline. Change began earlier and the declines were largest in the countries with the highest initial mortality levels, whereas in the countries that initially had comparatively low values the mortality rates are still increasing. lnsufficient information is available to permit elucidation of the determinants of the changes reported. There has been speculation about the possible role of factors such as demographic and sociocultural changes, changes in lifestyle and subsequently in the prevalence of risk factors for cardiovascular disease, and the increased utilization of advanced diagnostic and therapeutic technologies. (LATIN AMERICA, NORTHERN AMERICA, EPIDEMIOLOGY, CARDIOVASCULAR DISEASES)

1993 - VOLUME 46, NUMBER 3
THE HEALTH TRANSITION IN THE COUNTRIES OF CENTRAL AND
EASTERN EUROPE AND THE NEWLY INDEPENDENT STATES OF THE FORMER USSR

94.77.09 - English - Arun NANDA, Anatoly NOSSIKOV, Remigijus PROKHORSKAS and Mirvet H. Abou SHABANAH

Health in the Central and Eastern Countries of the WHO European Region: An Overview (p. 158-165)

The enormous social, political and economic changes that began in the CCEE/NIS in the late 1980s included the revelation and public discussion of a widening health gap between these countries and the other Member States of the European Region. The continuing economic problems and their effects on health increase the urgency of the need for assistance from the international community. Diverging trends in life expectancy became evident in the mid-1970s, and the gap continued to widen in the 1980s for all major causes of death, particularly cardiovascular diseases. The situation is worse in the NIS than in the CCEE, and worst in the central Asian countries. In 1990, the worst infant mortality rate in these countries was eight times the best rate elsewhere in the region. Non-mortality data, while patchy, confirm the indications given by mortality data. There is no single reason for the health gap, but contributory factors include the increasing prevalence of major risk factors in lifestyles and the environment, and the low efficiency and effectiveness of health care systems. The current situation and short-term prospects are mixed, but the negative trends in mortality and morbidity patterns are likely to continue for some time. While the worst health problems of the transition period in the CCEE/NIS could largely have been avoided, there is no doubt that economizing on health today will exact large costs tomorrow. (EASTERN EUROPE, COMMONWEALTH OF INDEPENDENT STATES, HEALTH CONDITIONS, LIFE EXPECTANCY, CAUSES OF DEATH)

94.77.10 - English - Mikko A. VIENONEN, Health Services Management, and W. Cezary WLODARCZYK, Health Economics, WHO Regional Office for Europe

Health Care Reforms on the European Scene: Evolution, Revolution or Seesaw? (p. 166-169)

In rough terms a tripartite picture characterized the European health care delivery map until the late 1980s. The Beveridge model has its roots in the British National Health Service, the Bismarck model for sickness insurance arose in Germany, and the centrally controlled Semashko model was developed in the USSR. All three models are undergoing reforms with similar aims expressed in similar language. Differences in the content and speed of reforms stem from the different circumstances and models of health care organization and financing in the countries. Practically all of the CCEE/NIS have declared their determination to change their health services financing from a centrally run system into a health insurance based structure, meaning a switch from the Semashko to the Bismarck models. Hungary, the Czech Republic, Slovakia and some other CCEE have already passed and implemented health insurance legislation, but considerable problems have arisen in the form of budget deficit, which has had to be filled by state budgets. The NIS are following behind, but no practical change has so far has come in sight. Going beyond the popular slogans of privatization and market economy is difficult during a situation of political instability, when the real transition will inevitably mean readjustment in the form of cuts and constraints, and painful reorganization in the priorities of health services. (EASTERN EUROPE, COMMONWEALTH OF INDEPENDENT STATES, HEALTH POLICY)

94.77.11 - English - Jane SALVAGE, Nursing and Midwifery, WHO Regional Officer for Europe, Copenhagen (Denmark)

Raising the Nursing Profile: The Case of the Invisible Nurse (p. 170-176)

The reform of nursing and midwifery is a key concern of health services in the CCEE/NIS. This major change will be impossible without accurate and up-to-date information made readily available to nursing leaders and to people helping them with the reforms. At present, however, such information is hard to come by and nurses remain statistically neglected - the case of the Invisible Nurse. The WHO Regional Office for Europe has launched a project to tackle this through the development of nursing and midwifery profiles. Such profiles were created for each of these countries, and they have proved useful to nursing leaders, WHO staff and consultants and other agencies and researchers. Despite the problems arising from limited WHO resources, the quality of the data collected and differences in terminology, the success of the profiles has laid the foundation for future work: completing the profiles for the central and eastern countries and answering the demands for profiles for other Member States of the European Region. The data thus compiled would enable a comparative analysis of nursing in the Region to be made, with the tracking of trends and perhaps the design of indicators of nursing development in countries. (EASTERN EUROPE, COMMONWEALTH OF INDEPENDENT STATES, NURSES, WHO, PERSONNEL MANAGEMENT)

94.77.12 - English - Colette ROURE and George OBLAPENKO, WHO Regional Office for Europe, Copenhagen (Denmark)

Communicable Diseases in the CCEE/NIS (p. 177-187)

The European Region is passing through a period of rapid transition with the most dramatic changes in the CCEE and NIS. The provision of adequate vaccine supplies has become a priority for many Member States in their efforts to sustain immunization activities. The Regional Office has therefore launched a special programme on vaccines for CCEE/NIS. New operational targets for the Expanded Programme on Immunization (EPI) in Europe in the 1990s were established by the European Advisory Group in 1993. These operational targets highlight the steps countries need to follow to achieve the European target 5. Immunization coverage generally remains high and stable in the Region. In 1990-1992, pockets of non-immunized individuals in different countries led to outbreaks of disease. Currently, the low coverage with DPT/DT vaccines in many provinces of the Russian Federation is one of the reasons for the epidemic of diphtheria that has affected the country since 1990. Despite the difficulties experienced by many CCEE and NIS, progress has been observed. Morbidity from poliomyelitis declined during 1990-1993. There remain only a few hot spots with endemic transmission of wild poliovirus: the Balkans, trans-Caucasus and central Asia. The diphtheria situation deteriorated in 1990, becoming increasingly dramatic in 1992 and 1993. Almost all cases have been reported from the Russian Federation and the Ukraine. Increasing diphtheria morbidity has been observed in Belarus, Kazakhstan and Uzbekistan. (EASTERN EUROPE, COMMONWEALTH OF INDEPENDENT STATES, COMMUNICABLE DISEASES, WHO, VACCINATION)

94.77.13 - English - Tapani PIHA, Eefje BESSELINK, WHO Regional Office for Europe, Copenhagen (Denmark), and Alan D. LOPEZ, Tobacco or Health Programmes, WHO, Geneva (Switzerland)

Tobacco or Health (p. 188-194)

Tobacco smoking is the major cause of premature death among men in the CCEE/NIS. Reliable information on smoking prevalence and tobacco use is scarce, but the overall evidence points to two different patterns: a traditional and a high prevalence pattern. The traditional pattern dominates in the NIS and some of the CCEE, and is characterized by a high smoking rate in men (about 50%) and a low rate in women (10%). Smoking by women, however, is increasing, starting with the younger age groups. The high prevalence pattern found in the Czech Republic, Hungary and Poland, for example, shows a high smoking prevalence in women (about 25%) in addition to a high prevalence in men. Predictions made in 1990 indicated further increases or stable tobacco consumption in the CCEE/NIS by the year 2000, in contrast with the steady decrease in Western European countries. When smoking is combined with other types of harmful health behaviour and environmental influences, the result is some of the highest mortality rates from lung cancer and other diseases in the world. This situation has caused severe concern in public health professionals in many of the affected countries, but not in the public and policy-makers. The fundamental changes in social and economic structures have both improved and decreased opportunities to promote nonsmoking. In the short term, the negative influences seem to dominate, although some countries, such as Lithuania and Poland, are now introducing their first realistic policies on tobacco. In most countries, however, tobacco control has to compete with other issues for priority on a crowded public health agenda. Most of the CCEE/NIS import large amounts of tobacco leaf and cigarettes. In particular, the dislocation of domestic production, with the dissolution of the USSR, and worsening economic conditions have caused a shortage of domestic brands in the NIS, and thus vast increases in legal and illegal imports. Multinational tobacco companies have been quick to take advantage of such situations. Most of the CCEE/NIS have no systematic policy to organize health education and health promotion activities on tobacco. While many of these countries have laws or policies banning or restricting tobacco advertising, these are often not enforced. A number of countries also have legislation on smoke-free environments, health warnings and the tar and nicotine content of cigarettes. In addition, many of the CCEE/NIS promote nonsmoking, particularly for young people, and take part in the annual celebration of the World No-Tobacco Day. (EASTERN EUROPE, COMMONWEALTH OF INDEPENDENT STATES, SMOKING, GOVERNMENT POLICY)

94.77.14 - English - Juhani LEHTO, WHO Regional Office for Europe, Copenhagen (Denmark)

Alcohol Consumption and Related Problems (p. 195-198)

The CCEE/NIS have different alcohol traditions. Some countries favour wine, and others, beer or vodka, while the impact of Islamic culture in some of the central Asian countries has kept alcohol consumption very low. Although alcohol-related health problems in these countries vary with their alcohol traditions, the CCEE/NIS have shown many important similarities in alcohol consumption and problems, and in alcohol policies, in both previous decades and the current, transition period. Official statistics showed that alcohol consumption in the CCEE/NIS rose from the 1960s to the mid-l980s, and then remained stable or fell in most countries. There are no reliable statistics on consumption in the 1990s, as no new systems have been created to replace the former systems based on data on state-controlled sales. Further, efforts in Poland and the USSR in the 1980s showed that political and economic transition do not automatically lead to increased alcohol consumption and problems. Nevertheless, many observers think that consumption in the CCEE/NIS has increased, because the available information shows increases in alcohol-related problems. This is the result of three factors: the loosening of state controls, the relatively low price of alcohol and the underdevelopment of methods of decreasing harmful consumption that do not involve the state. The WHO Regional Office for Europe gives priority to helping the CCEE/NIS to develop new policies and action on alcohol as part of the European Action Plan. (EASTERN EUROPE, COMMONWEALTH OF INDEPENDENT STATES, ALCOHOLISM, GOVERNMENT POLICY)

94.77.15 - English - Xavier LEUS, Coordination and Resource Mobilization, WHO Regional Office for Europe, Copenhagen (Denmark)

Humanitarian Assistance: Technical Assessment and Public Health Support for Coordinated Relief in the Former Yugoslavia (p. 199-203)

Since July 1992, the WHO Regional Office for Europe has been using epidemiological and public health assessment techniques to guide its interventions in the crisis in the former Yugoslavia. WHO field operations have evolved into the largest emergency relief operation ever undertaken in the European Region. The WHO Programme of humanitarian assistance focuses on five major areas: public health, equipment, supplies and logistic support, support to war victims, primary health care for refugees and rehabilitation of the health care system. The main thrust of the programme is to implement the public health measures required for survival. The first step is to provide health intelligence for international humanitarian assitance programmes through health and nutrition monitoring. This leads to targeted intervention. While involved in all aspects of relief, WHO clearly justifies its presence by its technical focus, bringing its network of expertise and experience to bear on the assessment of need and the coordination of intervention. Three examples of this approach are given: the nutrition programme, which includes emergency food aid and health and nutrition monitoring, the winter protection programme in Bosnia and Herzegovina, and the medical kit programme, involving the design and use of special kits to cover basic emergency needs for medical supplies to the maximum number of people. In the former Yugoslavia, the WHO Regional Office for Europe has concentrated on technical situation analysis and sound public health grounding to guide and direct interventions. (YUGOSLAVIA, WHO, AID PROGRAMMES, PUBLIC HEALTH)

94.77.16 - English - K.F. BAVERSTOCK, WHO European Centre for Environment and Health, Rome (Italy)

Thyroid Cancer in Children in Belarus after Chernobyl (p. 204-208)

The accident to the nuclear reactor at Chernobyl in the Ukraine in April 1986 led to the exposure of substantial populations in northern Ukraine and southern Belarus to radioactive fallout. Recently, increases in the incidence of childhood thyroid cancer have been reported from these areas. The possible causal association between exposure to the isotopes of iodine in the fallout and the increased thyroid cancer is examined, with a view to predicting the public health consequences of this aspect of the accident. The reported increases are shown to be consistent with a causal association and, if this is established, then a substantial increase in thyroid cancer can be expected over the next 50 years in the exposed populations. This conclusion underlines the urgent need for research to establish beyond doubt the origin of the reported increases and to formulate an appropriate public health response, including exploration of possible mitigating measures for the future. (BELARUS, UKRAINE, CANCER, THYROID GLAND, EPIDEMIOLOGY)

1993 - VOLUME 46, NUMBER 4
HEALTH AND THE FAMILY

94.77.17 - English - Judith EVANS, Consultative Group on Early Childhood Care and Development, Haydenvilla (U.S.A.), and P.M. SHAH, Child Health and Development, Division of Family Health, WHO, Geneva (Switzerland)

Child-care Programmes for Health and Family Support (p. 214-221)

Demographic, social and economic factors have affected the types of health and social service support that the people require. For many, child care is a necessity, not an option. Child care refers to group care of children in creche, child minding, family day care, kindergarten and day care in different settings. Maternal and child health services are often seen as sources of curative rather than preventive care. Planning by the health and social sectors has failed to incorporate many of the perceived needs of the communities. As a result, the services that are available have neither attracted the attention, nor inspired the confidence of the people. One possible strategy is to integrate health care into the rapidly expanding systems of child care that are developing out of family and community needs. These health services can be developed and delivered by adequately trained child-care as well as health-care personnel. With appropriate and simple back-up technologies and skills and referral mechanism, the childcare personnel can undertake some of the MCH care activities in childcare centres. When needed, either a primary health worker or nurse-midwife from health sector should deliver services. Early-childhood care programmes are in increasing demand. Such programmes have potential to reach more than half of the population consisting of the children under-five years of age and their parents. Childcare and development programmes have a social attractiveness and acceptability that invites participation from families that might not avail themselves of primary health-care services. Thus, support for and the utilization of early-childhood care and development programmes in many settings may be more regular than is often the case with health-care and family-planning services. Primary health care is a logical extension of the current services being provided within early-childhood care and development programmes. Moreover, child care offers parents and the community the possibility of participating in the health care of their own children through the monitoring of physical growth and development, the early detection of physical and psychosocial handicaps, nutrition surveillance, immunization, prevention and treatment of common diseases and health education. Some constraints are likely to be encountered. However, the experience indicates that positive factors supporting the introduction of health-care elements into child-care programmes largely outweigh the constraints. Where access to the health-care system is inadequate there is now a clear need to recognize the full dimension of child-care systems to integrate basic health care and developmental stimulation, complementing existing primary health-care structures and activities. (DAY CARE CENTRES, MATERNAL AND CHILD HEALTH, PRIMARY HEALTH CARE)

94.77.18 - English - J. Ties BOERMA, TANESA Project, Mwanza (Tanzania), and A. Elisabeth SOMMERFELT, DHS, Columbia, MD (U.S.A.)

Demographic and Health Surveys (DHS): Contributions and Limitations (p. 222-226)

Surveys conducted in the context of the Demographic and Health Surveys (DHS) programme are an important source of data on health of families in developing countries. Both at the national and international level, DHS surveys provide much-needed data on fertility and family planning, on mortality and nutrition, and on health services utilization. The use of uniform survey instruments allows detailed international and subnational comparisons of health status and health care. Limitations of the DHS surveys are also discussed. (DEMOGRAPHIC AND HEALTH SURVEYS)

94.77.19 - English - Debarati G. SAPIR, Université Catholique de Louvain, 30.34, Clos Chapelle aux Champs, 21200 Brussels (Belgium)

Natural and Man-made Disasters: The Vulnerability of Women-headed Households and Children without Families (p. 227-233)

Since 1980, over 2 million people have died as an immediate result of natural and man-made disasters and by 1992, the refugee population registered nearly 16 million people. This article reviews the human impact of disasters as a composite of two elements: the catastrophic event itself and the vulnerability of people. It also examines the specific case of women and children in the current world emergency context. It identifies four broad policy areas that affect women and children in disaster situations and discusses them with examples and field evidence. The first policy area addresses humanitarian assistance and armed conflicts, and armed conflict and international humanitarian law, the use of food as instrument of war, mines and civilian disability, and rape and sexual violence are discussed within this context. The second problem discussed is the issue of unaccompanied and abandoned children in terms of its magnitude and implications for relief response. Thirdly, the article examines the differential risks in emergencies for mortality and morbidity, specifically for women and children. Finally, it addresses certain policies and approaches to disaster rehabilitation which effectively mirror and reinforce inherent inequities in the affected society. The article notes that: (i) the largest proportion of disaster victims today arise from civil strife and food crises and that the majority of those killed, wounded and permanently disabled are women and children; and (ii) the ability of any country to respond effectively to disasters depends on the strength of its health and social infrastructure, and its overall developmental status. It concludes by identifying seven areas where concrete measures could be taken to improve the current situation. (DISASTERS, MATERNAL AND CHILD HEALTH, AID PROGRAMMES)

94.77.20 - English - Lorraine DENNERSTEIN, Key Centre for Women's Health in Society, Victoria (Australia)

Psychosocial and Mental Health Aspects of Women's Health (p. 234-236)

Both community-based studies and studies of treatment seekers indicate that women are disproportionately affected by mental health problems and that their vulnerability is closely associated with marital status, employment and roles in society. Women's mental health cannot be considered in isolation from social, political and economic issues. When women's position in society is examined, it is clear that there are sufficient causes in current social arrangements to account for the surfeit of depression and anxiety experienced by women. WOMEN'S STATUS, MENTAL HEALTH, SOCIAL PROBLEMS)

94.77.21 - English - Lee-Nah HSU, Programme on Substance Abuse, WHO, Geneva (Switzerland)

Family Health and the Use of Psychoactive Substances (p. 237-241)

Substance abuse is spreading to countries previously unaffected, to all age groups, including the elderly, and to women: the potential impact of drug abuse on the family is therefore increasing while at the same time, the family can play a crucial role in prevention, treatment and rehabilitation. The family is the arena for learning healthy behaviour, including ways of handling problems associated with psychoactive substance use. The ability of family members to cope with life events is influenced by the available behavioural role models, the quality of communications among family members and the options a family has within the community. Strengthening the social network and families' coping mechanisms may reduce the demand for and the consequences of substance abuse by family members. (DRUG ADDICTION, FAMILY ENVIRONMENT, HEALTH EDUCATION)

94.77.22 - English - Carl TAYLOR, Stella GOINGS, Johns Hopkins Institute of International Programs, The Johns Hopkins University, Baltimore, MD (U.S.A.), David SANDERS and Mary BASSETT, Department of Community Medicine, University of Zimbabwe School of Medicine, Harare (Zimbabwe)

Surveillance for Equity in Maternal Care in Zimbabwe (p. 242-247)

The great hope and promise of post-independence efforts to promote equitable health care in Zimbabwe started with three years of dramatic improvement. Commitment to correcting inequities which were as discriminatory as any country in the world produced rapid extension of health centre infrastructure and the improvement of district hospitals. The major constraint was the entrenched pattern of sophisticated, high-technology health care left by colonial administrators which continued to monopolize resources. In spite of the excellent beginning, development of services for the poor was thwarted by recession, prolonged drought and external military destabilization. The cutbacks in funding for health care have been particularly severe as a result of economic adjustment policies imposed by IMF. Political pressure moved the health system toward private entrepreneurship returning to earlier patterns of discrimination in favour of whites and urban residents. Efforts to promote high-risk monitoring have had little impact among the poor and those living in remote areas. Equity has become symbolic rather than real. The government of Zimbabwe maintains a continuing commitment to the original goals of equity through primary health care. International agencies also would like to find a way to help reallocate services. There seems to be recognition that little will be accomplished in improving health conditions unless services are provided to those in greatest need. Disparities in maternal care are especially severe and can be improved only by building infrastructure to provide antenatal and perinatal services. The timing seems right to try surveillance for equity as a means of using limited resources to reach the most needy mothers with targeted services. A system is proposed involving periodic surveys to identify groups among whom maternal care problems are concentrated and to tailor actions to the major causes of maternal mortality and morbidity. It would also establish a process of finding locally appropriate adaptations of cost-effective and sustainable solutions. The highest-priority interventions would be defined and implemented locally by strengthening the primary health care infrastructure and community participation. Health systems research in demonstration areas could lead to national extension. (ZIMBABWE, MATERNAL AND CHILD HEALTH, EQUAL OPPORTUNITY)

1994 - VOLUME 47, NUMBER 1
FAMILY PLANNING AND HEALTH

94.77.23 - English - Iqbal H. SHAH

The Advance of the Contraceptive Revolution (p. 9-15)

With over 50% of couples using a contraceptive method in 1990, contraception - a novelty two decades ago has become the norm in much of the world. Only in sub-Saharan Africa does the prevalence remain below 18% for most countries. However, it is expected to rise to 26% by the year 2000, corresponding to a projected TFR of 5.33 births per woman. Tubectomy, the IUD and the pill account for much of the contraceptive use in the world. The use of traditional methods (rhythm and withdrawal) is relatively higher in the more developed regions, which have a high prevalence of contraceptive use, and in sub-Saharan Africa, where prevalence is very low. A wide variety in method mix is found in the developing as well as in the developed countries, suggesting different pathways to increased contraceptive prevalence. These patterns of method mix also indicate the importance of local cultural norms regarding acceptability of different methods as well as the role of family planning programmes in the promotion and provision of different contraceptive methods. The available information suggests that future trends in family planning will be characterized by rapid growth in the number of contraceptive users in the developing world, from 381 million in 1990 to 567 million in the year 2000. The rate of increase in prevalence is compatible with the changes observed in recent years. However, to meet the existing potential requirements of 120 million women in developing countries and the anticipated demand of the increasing number of couples, the provision of services poses new challenges and will remain a priority issue for policy-makers and agencies concerned with improving the quality of life. (WORLD, CONTRACEPTIVE PREVALENCE, PROJECTIONS)

94.77.24 - English - John R. ROSS and W. Parker MAULDIN

Measuring the Effort Levels of Family Planning Programmes (Profile of 30 Programme Effort Scores, 1982 and 1989) (p. 16-25)

The family planning programmes which are considered to be the most dynamic are so from the point of view of all 30 variables taken into consideration. Scores are more homogeneous in those programmes which, overall, are the most dynamic rather than in those which are less dynamic. Scoring profiles did not change between 1982 and 1989. The countries which moved up from the less dynamic group to the dynamic one made this transition in a very progressive manner and at a varying rhythm depending on the variables taken into consideration. Contraceptive prevalence and the decline in the average number of children per woman are closely linked to the dynamics of the programme and this association is particularly strong with the variables which demonstrate access to contraceptive methods and the supply of services. (PROGRAMME DE PLANNING FAMILIAL, EVALUATION DE PROGRAMME, ANALYSE COMPARATIVE)

94.77.25 - English - Henry MOSLEY

Population Change, Health Planning and Human Resource Development in the Health Sector (p. 26-30)

As a result of the demographic and epidemiological transitions now occurring rapidly in many developed countries, a dramatic shift in the age structures of populations and the burden of disease towards the middle-aged and elderly is expected to take place over the next several decades. In the 1990s, however, there remains great diversity across countries in fertility levels and mortality patterns. The World Bank's 1993 World Development Report assessed the global burden of disease in order to define the minimum packages of public health measures and clinical interventions that would improve health conditions in low-income countries in a cost-effective and affordable way. Strategically implementing these programmes will require that government investments be directed toward a limited number of cost-effective health interventions, delivered equitably to the entire population. At the same time, steps must be taken to improve the efficiency and contain the costs of health care delivery in the public and private sectors. Such a population-based health strategy will require the development of a wide range of scientific, analytical and technical capacities, currently rare in most ministries of health. This will require the involvement of epidemiologists, demographers, sociologists, analysts, operations research specialists and environmental health scientists. Building up these capabilities in health ministries, universities or the private sector will be an essential ingredient of health system reform. (WORLD, HEALTH POLICY, EVALUATION, PROJECTIONS)

94.77.26 - English - Herbert L. FRIEDMAN

Reproductive Health in Adolescence (p. 31-35)

The health and well-being of adolescents is closely intertwined with their physical, psychological and social development, but this is put at risk by sexual and reproductive health hazards which are increasing in much of the world. Changes in population growth and distribution, the rise of telecommunications, the increase in travel and a decline in the family, as well as a generally earlier start of menarche and later age of marriage are contributing to an increase in unprotected sexual relations before marriage. This, combined with risks from early marriage, result in too early or unwanted pregnancy and childbirth, induced abortion in hazardous circumstances and sexually transmitted diseases, including HIV infection leading to AIDS. With more than half the world's population below the age of 25, and 4 out of 5 young people living in developing countries with inadequate access to prevention and care, there is an urgent need for action. Young women are particularly vulnerable. Mortality and morbidity from early pregnancy whether ending in childbirth or abortion, is much higher for the younger adolescent. Young women, especially those who have less formal education, are more vulnerable to pressures for marriage, or sexual relations before marriage, often with older men. Young people generally lack adequate knowledge about their own development and information on how to get help. Those who could help are rarely trained for working with adolescents, and services which are generally designed for adults or children often deter young people from getting help when they most need it. Policy and legislation relating to sexual and reproductive health issues are often contradictory, and unclear or unenforced. However, successful programmes have demonstrated the value of involving young people themselves, in partnership with adults, in planning, implementing and evaluating activities designed to promote their health. (ADOLESCENTS, ADOLESCENT PREGNANCY, HEALTH POLICY)

94.77.27 - English - Marie-Thérèse FEUERSTEIN

Family Planning in Viet Nam: A Vigorous Approach (p. 36-39)

Viet Nam, a country in transition, is vigorously implementing its population and family planning polices and plans, despite the fact that increased government expenditure for family planning only amounts to some US $0.15 per capita, far short of the minimum $0.60 required. An increased range of family planning methods will be offered to the population through a "cafeteria" approach. Genital tract infections will be reduced, as well as the incidence of abortion. Research continues on injectable and implanted contraceptives, and the use of quinacrine nonsurgical female sterilization. In the long term, a mix of imported and locally-produced contraceptives is envisaged to achieve greater sustainability. Family planning will be closely linked to economic development and poverty alleviation, with mass organizations developing family planning-linked credit, savings and income generating schemes. Pilot experience has indicated value if integrated approach linking family planning, nutrition, and parasite control. The health manpower and health services systems are being overhauled, with plans to appoint family planning focal points at commune level, linked to mobile district teams and grassroots motivators. Medical equipment, contraceptives and essential drugs for family planning and reproductive health services. are in short supply at an estimated 60% of commune health stations. Both the public sector and the growing private sector will need to face the challenge of providing the population with high quality reproductive health services and family planning options suited to individual needs and preferences. (VIET NAM, FAMILY PLANNING POLICY, EVALUATION). (VIET NAM, POLITIQUE DE PLANNING FAMILIAL, EVALUATION)

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