BASIC
SANITATION: PERCENT OF POPULATION WITH ADEQUATE EXCRETA DISPOSAL
FACILITIES |
Social |
Chapter 6 |
State |
1. Indicator
(a) Name: Basic sanitation: percent of
population with adequate excreta disposal facilities.
(b) Brief Definition: Proportion of population with access to a
sanitary facility for human excreta disposal in the dwelling or immediate
vicinity.
(c) Unit of Measurement: %.
2. Placement in the Framework
(a) Agenda 21: Chapter 6: Protecting and
Promoting Health.
(b) Type of Indicator: State.
3. Significance (Policy Relevance)
(a) Purpose: To monitor progress in the
accessibility of the population to sanitation facilities.
(b) Relevance to Sustainable/Unsustainable
Development: This represents a basic indicator useful for assessing
sustainable development, especially human health. Accessibility to
adequate excreta disposal facilities is fundamental to decrease the faecal
risk and the frequency of associated diseases. Its association with other
socioeconomic characteristics (education, income) and its contribution to
general hygiene and quality of life also make it a good universal
indicator of human development. When broken down by geographic (such as
rural/urban zones) or social or economic criteria, it also provides
tangible evidence of inequities.
(c) Linkages to Other Indicators: The
indicator is closely associated with other socioeconomic indicators (see
section 3b above), particularly the proportion of population with access
to adequate and safe drinking water. These indicators represent two of the
eight elements of primary health care.
(d) Targets: International targets for this
indicator have been established under the auspices of the World Health
Organization (WHO). The Global Strategy for Health and the more regent
Ninth General Programme provide targets of 100% by the year 2000 and 75%
by the year 2001 respectively. In addition, many countries have
established national targets.
(e) International Conventions and Agreements:
The International Drinking Water Supply and Sanitation Decade (IDWSSD)
1980-1990 is an international agreement relevant to this indicator. It
represents a component of the WHO Global Strategy for Health for All by
the year 2000.
4. Methodological Description and Underlying
Definitions
(a) Underlying Definitions and Concepts: Definitions
for sanitary facility and population covered are required.
i) Sanitary facility: "A sanitary facility is
a unit for disposal of human excreta which isolates faeces from contact
with people, animals, crops and water sources. Suitable facilities range
from simple but protected pit latrines to flush toilets with sewerage. All
facilities, to be effective, must be correctly constructed and properly
maintained".
ii) Population covered: This includes the urban
population served by connections to public sewers; the urban population
served by household systems (pit privies, pour-flush latrines, septic
tank, etc); the urban population served by communal toilets; and the rural
population with adequate excreta disposal such as pit privies, pour-flush
latrines, etc.
(b) Measurement Methods: This indicator may
be calculated as follows: The numerator is the number of people with
adequate excreta-disposal facilities available multiplied by 100. The
denominator is the total population.
(c) The Indicator in the DSR Framework: Basic
sanitation is a fundamental factor in the human health component of
sustainable development. This indicator reflects the State of access to
sanitary facilities with in the DSR Framework.
(d) Limitations of the Indicator: The
availability of facilities does not always translate into their
utilization.
(e) Alternative Definitions: This indicator
could also be expressed as the percent of people without access to
adequate sanitation. The population that must be used in the numerator is
the number of people without access to adequate sanitation. If the data
available are in terms of proportion of households for which sanitation is
available, it should be possible to convert this into a percentage of
population, using average figures for household size. Also see section 4d
above.
5. Assessment of the Availability of Data from
International and National Sources
(a) Data Needed to Compile the Indicator: The
number of people with access to adequate sanitation, and the total
population.
(b) Data Availability: Routinely collected
at the national and sub-national levels in most countries using censuses
and surveys.
(c) Data Sources: In order to arrive at more
robust estimates of sanitation coverage, two main data source types are
required. First, administrative or infrastructure data which report on new
and existing facilities. Second, population-based data derived from some
form of national household survey.
6. Agencies Involved in the Development of the
Indicator
The lead agency is the World Health
Organization (WHO). The contact point is the Director, Office of Global
and Integrated Environmental Health, WHO; fax no. (41 22) 791 4123.
7. Further Information
(a) Further Readings:
WHO, Development of Indicators for Monitoring
Progress Towards Health for All by the Year 2000. Geneva, WHO, 1981, p.
29.
WHO, Global Strategy for Health for All by the Year
2000. Geneva, WHO, 1981.
WHO, Ninth General Programme of Work Covering the
Period 1996-2001. Geneva, WHO, 1994.
World Health Organization, Division of Operational
Support in Environmental Health, October 1995.
(b) Other References:
World Health Organization. National and Global
Monitoring of Water Supply and Sanitation. CWS Series of Cooperative
Action for the Decade, No. 2, 1982.
World Health Organization. Water Supply and
Sanitation Sector Monitoring Report (WSSSMR), 1990.
ACCESS TO SAFE
DRINKING WATER |
Social |
Chapter 6 |
State |
1. Indicator
(a) Name: Percent of people with safe
drinking water available in the home or with reasonable access.
(b) Brief Definition: Proportion of population with access to an
adequate amount of safe drinking water in a dwelling or located within a
convenient distance from the user's dwelling.
(c) Unit of Measurement: %.
2. Placement in the Framework
(a) Agenda 21: Chapter 6: Protecting and
Promoting Health.
(b) Type of Indicator: State.
3. Significance (Policy Relevance)
(a) Purpose: To monitor progress in the
accessibility of the population to safe drinking water.
(b) Relevance to Sustainable/Unsustainable
Development: Accessibility to safe drinking water is of fundamental
significance to lowering the faecal risk and frequency of associated
diseases. Its association with other socioeconomic characteristics,
including education and income, also makes it a good universal indicator
of human development. When broken down by geographic (such as rural/urban
zones), or social or economic criteria, it provides useful information on
inequity.
(c) Linkages to Other Indicators: This
indicator is closely associated with other socioeconomic indicators on the
proportion of people covered by adequate sanitation. These indicators are
among the eight elements of primary health care. It also has close links
to other water indicators such as withdrawals, reserves, consumption, or
quality. (See section 3b above.)
(d) Targets: International targets for this
indicator have been established under the auspices of the World Health
Organization (WHO). The Global Strategy for Health and the more regent
Ninth General Programme provide targets of 100% by the year 2000, and more
than 85% by the year 2001 respectively. In addition, many countries have
established national targets.
(e) International Conventions and Agreements:
The International Drinking Water Supply and Sanitation Decade (IDWSSD)
1980-1990 is an international agreement relevant to this indicator. It is
a component of the WHO Global Strategy for Health for All by the Year
2000.
4. Methodological Description and Underlying
Definitions
(a) Underlying Definitions and Concepts: This
indicator requires definitions for several elements.
i) Population covered: This includes urban
population served by house connections, urban population without house
connections but with reasonable access to public stand posts, and rural
population with reasonable access to safe water.
ii) Reasonable access to water: This is defined as
water supply in the home or within 15 minutes walking distance. Actually a
proper definition should be adopted taking the local conditions into
account; in urban areas, a distance of not more than 200 metres from a
house to a public stand post may be considered reasonable access. In rural
areas, reasonable access implies that anyone does not have to spend a
disproportionate part of the day fetching water for the family's needs.
iii) Convenient distance: Convenient distance and
access are distinct in a sense that there may be access to water but it is
not necessarily convenient to fetch the water due to distance. The water
should be within a reasonable distance from the home that is 200 metres.
iv) Adequate amount of water: The amount of water
needed to satisfy metabolic, hygienic, and domestic requirements. This is
usually defined as twenty litres of safe water per person per day.
v) Safe water: The water does not contain
biological or chemical agents at concentration levels directly detrimental
to health. "Safe water" includes treated surface waters and
untreated but uncontaminated water such as that from protected boreholes,
springs, and sanitary wells. Untreated surface waters, such as streams and
lakes, should be considered safe only if the water quality is regularly
monitored and considered acceptable by public health officials.
(b) Measurement Methods: This indicator may
be calculated as follows: The numerator is the number of persons with
access to an adequate amount of safe drinking water in a dwelling or
located within a convenient distance from the user's dwelling multiplied
by 100. The denominator is the total population.
(c) The Indicator in the DSR Framework:
Access to water is a crucial influence on human health and sustainable
development. The conditions related to water accessibility are contained
within this State indicator of the DSR Framework.
(d) Limitations of the Indicator: The
existence of a water outlet within reasonable distance is often used as a
proxy for availability of safe water. The existence of a water outlet,
however, is no guarantee in itself that water will always be available or
safe, or that people always use such sources.
(e) Alternative Definitions: This indicator
may be also expressed as the percent of population without access to
sufficient and safe drinking water. Thus the population indicated in the
numerator would be those who do not have access to adequate and safe
drinking water. If these data are available in terms of the proportion of
households, it should be possible to convert this into a percentage of the
population, using average figures for household size.
5. Assessment of the Availability of Data from
International and National Sources
(a) Data Needed to Compile the Indicator:
The number of people with access to adequate and safe water, and the total
population. Data on the source of water, for example, house tap or yard
pipe, would provide additional meaning to this indicator.
(b) Data Availability: Routinely collected
at the national and sub-national levels in most countries using censuses
and surveys.
(c) Data Sources: Two sources are common:
administrative data that report on new and existing facilities, and
population data derived from some form of household survey or census.
6. Agencies Involved in the Development of the
Indicator
The lead agency is the World Health Organization
(WHO). The contact point is the Director, Office of Global and Integrated
Environmental Health, WHO; fax no. (41 22) 791 4123.
7. Further Information
(a) Further Readings:
WHO, Global Strategy for Health for All by the Year
2000. Geneva, WHO, 1981.
WHO, Ninth General Programme of Work Covering the
Period 1996-2001. Geneva, WHO, 1994.
WHO, Development of Indicators for Monitoring
Progress Towards Health for All by the Year 2000. Geneva, WHO, 1981, p.
40.
(b) Other References:
World Health Organization. National and Global
Monitoring of Water Supply and Sanitation. CWS Series of Cooperative
Action for the Decade, No. 2, 1982.
World Health Organization. Water Supply and
Sanitation Sector Monitoring Report (WSSSMR), 1990.
Program of Action of the Ministerial Drinking Water
Conference, 1994.
LIFE EXPECTANCY
AT BIRTH
|
Social |
Chapter 6 |
State |
1. Indicator
(a) Name: Life expectancy at birth.
(b) Brief Definition: The average number of years that a newborn
could expect to live, if he or she were to pass through life subject to
the age-specific death rates of a given period.
(c) Unit of Measurement: Life expectancy at birth as expressed in
years.
2. Placement in the Framework
(a) Agenda 21: Chapter 6: Protecting and
Promoting Human Health.
(b) Type of Indicator: State.
3. Significance (Policy Relevance)
(a) Purpose: Measures how many years on
average a new-born baby is expected to live, given current age-specific
mortality risks. Life expectancy at birth is an indicator of mortality
conditions and, by proxy, of health conditions. It is also one of the most
favoured indicators of social development, and is used as one of the
components of United Nations Development Programme's (UNDP) Human
Development Index.
(b) Relevance to Sustainable/Unsustainable
Development: Mortality, with fertility and migration, determines the
size of human populations, their composition by age, sex, and ethnicity,
and their potential for future growth. Life expectancy, a basic indicator,
is closely connected with health conditions, which are in turn an integral
part of development. The ICPD Programme of Action notes that the
unprecedented increase in human longevity reflects gains in public health
and in access to primary health-care services (paragraphs 8.1 and 8.2),
which Agenda 21 recognizes as an integral part of sustainable development
and primary environmental care (paragraph 6.1). The ICPD Programme of
Action highlights the need to reduce disparities in mortality and
morbidity among countries and between socioeconomic and ethnic groups. It
identifies the health effects of environmental degradation and exposure to
hazardous substances in the work-place as an issue of increasing concern.
(c) Linkages to Other Indicators: This
indicator reflects many social, economic, and environmental influences. It
is closely related to other demographic variables, particularly the
population growth rate. It also has linkages with indicators of human
health and the environment as well as economic indicators. Examples of
closely linked indicators would include infant mortality, and water and
air quality.
(d) Targets: The Declaration of Alma Ata
(1978) set a target of life expectancy greater than 60 years by the year
2000, and the ICPD Programme of Action revised the target: life expectancy
should be greater than 65 years by 2005 and 70 years by 2015 for countries
that currently have the highest levels of mortality; and 70 years and 75
years, respectively, for the other countries (ICPD Programme of Action,
paragraph 8.5).
(e) International Conventions and Agreements:
See section 3d above.
4. Methodological Description and Underlying
Definitions
Calculation of life expectancy at birth is based on
age-specific death rates, which may be calculated separately for males and
females, or for both sexes combined. The death rates are commonly
tabulated for ages 0 to 1 years, 1 to 5 years, and for 5-year age groups
for ages 5 and above. Where data on deaths by age are of good quality, or
adjustments for age mis-statement and incompleteness can be made, the life
expectancy at birth can be calculated directly from registered deaths and
population counts, which are usually based on census enumerations,
evaluated and, if necessary, adjusted. Several steps are needed to derive
life expectancy from age-specific death rates; the details can be found in
demographic or actuarial references that describe construction of life
tables, for example, Pressat (1972) or Shryock and Siegel (1980). For a
description of the methodology that is linked to computer routines to aid
in the calculation, see MORTPAK-LITE (item 7, below).
When data on deaths by age are unavailable from
registration systems or sample surveys, the life expectancy at birth can
be calculated through "indirect" methods based on special
questions asked in censuses or demographic surveys. For information on
these indirect estimates, see Manual X and MORTPAK-LITE (section 7,
below).
5. Assessment of the Availability of Data from
National and International Sources
Data is collected by the United Nations on a
regular basis and available for most countries from vital registration
systems or surveys. For all countries, census and registration data are
evaluated and, if necessary, adjusted for incompleteness by the Population
Division, United Nations Department of Economics and Social Information
and Policy Analysis (DESIPA) as part of its preparations of the official
United Nations population estimates and projections. Past, current and
projected estimates of life expectancy at birth are prepared for all
countries by the Population Division, DESIPA and appear in the United
Nations publication, World Population Prospects: The 1994 Revision (see
section 7, below).
Most countries tabulate data from death
registration systems at the sub-national level. The infant mortality rate
and the crude death rate (annual number of deaths per thousand population)
is more readily available for sub-national units than is life expectancy
at birth.
6. Agencies Involved in the Development of the
Indicator
The lead organization is the United Nations DESIPA.
The contact point is the Director, Population Division, DESIPA; fax no. (1
212) 963 2147. At the World Health Organization, the contact person is the
Director, Office of Global and Integrated Environmental Health; fax no.
(41 22) 791 4123.
7. Further Information
DESIPA. World Population Prospects: The 1994
Revision. Population Division. United Nations Sales No. E.95.XIII.16, New
York, 1995.
DESIPA. Manual X: Indirect Techniques for
Demographic Estimation. Population Division United Nations Sales No.
E.83.XIII.2, New York, 1983.
DESIPA. MORTPAK-LITE - The United Nations Software
Package for Mortality Measurement. Population Division. United Nations,
New York, 1988.
DESIPA. Demographic Yearbook. Statistical Division.
United Nations Sales No.E/F.95.XIII.1,1995. 1993.
Pressat, R. Demographic Analysis: Methods, Results,
Applications. London, Edward Arnold; Chicago, Aldine Atherton. 1972.
United Nations. Report of the International
Conference on Population and Development. Programme of Action of the
International Conference on Population and Development. United Nations
Document A/CONF. 171/13. Cairo, Egypt, September 5-13, 1994.
Shryock, H.S, and J.S.Siegel. The Methods and
Materials of Demography. U.S. Government Printing Office, Washington, D.C.
1980.
ADEQUATE BIRTH
WEIGHT |
Social |
Chapter 6 |
State |
1. Indicator
(a) Name: Adequate birth weight.
(b) Brief Definition: Adequate birth weight is defined as equal or
greater than 2500 grams, the measurement being taken preferably within the
first hours of life, before significant postnatal weight loss has
occurred.
(c) Unit of Measurement: The indicator is expressed as the number
of children per 1000 live births whose birth weight is equal or greater
than 2500 grams.
2. Placement in the Framework
(a) Agenda 21: Chapter 6: Adequate birth
weight.
(b) Type of Indicator: State.
3. Significance (Policy Relevance)
(a) Purpose: To monitor the percentage of
underweight newborns in a community.
(b) Relevance to Sustainable/Unsustainable
Development: Birth weight can be an important indicator of community
nutrition. Low birth weights signal insufficient access to adequate food
supply. It may also be related to certain diseases such as malaria, and to
specific nutritional deficiencies such as endemic goitre.
(c) Linkages to Other Indicators: This
indicator is closely associated with nutrition related indicators such as
measure of weight-for-age and height-for-age for infants and children.
Linkages to other health and socioeconomic indicators are also pertinent.
(d) Targets: An international target for
this indicator has been established by the World Health Organization
(WHO). Its Global Strategy for Health establishes a target of at least 90%
of newborn infants with a birth weight of at least 2500 grams. National
standards are also significant and relevant to countries and sub-national
areas.
(e) International Conventions and Agreements:
WHO's Global Strategy for Health for All by the Year 2000 is an
international agreement relevant to this indicator.
4. Methodological Description and Underlying
Definitions
(a) Underlying Definitions and Concepts: Not
available.
(b) Measurement Methods: In practice the
percentage of low birth weight is first calculated as follows: the
numerator is represented by live born babies with birth weight less than
2500 grams multiplied by 100. The denominator is the total number of live
born babies weighed. This percentage is then subtracted from 100 to give
the percentage of newborns weighing at least 2500 grams.
(c) The Indicator in the DSR Framework: This
proxy measure may be considered as a State indicator of human health and
nutrition.
(d) Limitations of the Indicator: It may be
difficult to obtain data on birth weight. This would apply, for example,
where coverage of supervised births by trained personnel is low.
(e) Alternative Definitions: Not available.
5. Assessment of the Availability of Data from
International and National Sources
(a) Data Needed to Compile the Indicator:
Number of newborns with a birth weight less than 2500g. Number of newborns
weighed.
(b) Data Availability: In principle,
routinely collected by ministries of health at the national and
sub-national levels in most countries.
(c) Data Sources: Sources of data would
include ministries of health, health centres, hospital records, sample
surveys and/or special studies.
6. Agencies Involved in the Development of the
Indicator
The lead agency is the World Health
Organization (WHO). The contact point is the Director, Office of Global
and Integrated Environmental Health, WHO; fax no. (41 22) 791 4123.
7. Further Information
Not available.
INFANT MORTALITY
RATE |
Social |
Chapter 6 |
State |
1. Indicator
(a) Name: Infant mortality rate (IMR).
(b) Brief Definition: The number of deaths
under 1 year of age during a period of time per 1000 live-births during
the same period.
(c) Unit of Measurement: Rate per thousand
live born.
2. Placement in the Framework
(a) Agenda 21: Chapter 6: Protecting and
Promoting Human Health.
(b) Type of Indicator: State.
3. Significance (Policy Relevance)
(a) Purpose: The purpose of this indicator
is to estimate the proportion of newborn who die during the first year of
life.
(b) Relevance to Sustainable/Unsustainable
Development: Beyond its obvious relevance to policy making for healthy
children, the IMR is sensitive indicator of availability, utilization and
quality of health care, particularly perinatal care. Moreover, given its
association with GNP per capita, family income, family size, mothers'
education, and nutrition, it is also considered one of the best indicators
of overall socioeconomic development of a community.
(c) Linkages to Other Indicators: This
indicator, associated with access to perinatal health services, is closely
linked with life expectancy at birth. It is more generally linked to many
other social and economic indicators, including those listed in section 3b
above.
(d) Targets: The Declaration of Alma Ata
(1978) set a target for the IMR to be less than 50 per 1000 live-births by
the year 2000. The Global Strategy for Health for All by the Year 2000
(WHO, 1981) aimed to achieve IMR in all identifiable subgroups below 50
per 1000 live-births by the year 2000. The 1990 World Summit for Children
Programme of Action adopted a target of reducing the 1990 infant mortality
rates by one third, or to 50 per 1000 live births, whichever is less, by
the year 2000. The Programme of Action of the International Conference on
Population and Development further encouraged countries with intermediate
mortality levels to achieve an infant mortality rate below 50 deaths per
1000 births by the year 2005, and all countries to achieve an infant
mortality rate below 35 per 1000 live births by 2015.
4. Methodological Description and Underlying
Definitions
(a) Underlying Definitions and Concepts: Not
available.
(b) Measurement Methods: Infant mortality
rate is calculated by dividing the number of deaths under one year of age
in a given period of time x 1000 by the number of live-births in the same
period of time.
(c) The Indicator in the DSR Framework: IMR
provides a basic reflection of the overall socioeconomic development in a
country. It is a State indicator within the DSR Framework..
(d) Limitations of the Indicator: There are
often problems in collecting the information required for calculating the
IMR in many less developed countries where routine data collection in the
health services omits many infant deaths. In countries where civil
registration of deaths is incomplete, especially in rural areas, many
infants dying during the first weeks of life have not even been registered
as having been born. For this reason, rates based on civil registration in
these countries, or hospital data covering mainly urban areas, are biased
to reflect the more privileged in the population. To compound these
problems, definitions of live birth differ among countries.
Where data on infant deaths and births are
complete, or adjustments for age mis-statement and incompleteness can be
made, the infant mortality rate can be calculated directly. When such data
are unavailable from registration systems or maternity history data in
sample surveys, the infant mortality rate can be calculated through
indirect or modelling methods based on special questions asked in censuses
or demographic surveys. For information on these estimates, see the Manual
X and MORTPAK-LITE (5) references listed in section 7 below.
(e) Alternative Definitions: Not available.
5. Assessment of the Availability of Data from
International and National Sources
(a) Data Needed to Compile the Indicator:
Number of live births during a given period and number of infant deaths
during the same period. Disaggregated data by ethnicity or urban/rural
zones support the interpretation of this indicator.
(b) Data Availability: Data are now
available for most countries thanks to special surveys of representative
samples of the population whenever vital registration systems are not
available. Surveys that rely on maternity histories, in which women are
asked to give the date of birth and age of death (if applicable) of each
live-born child, are used in many household surveys, but care must be
taken to avoid age mis-reporting and to ensure that there is a complete
report of infant deaths. The preceding birth technique, used in antenatal
clinics, maternity clinics, and at the time of immunization, can provide a
useful recent estimate of the probability of dying by age 2, for children
of health service users at the local level. Retrospective questions about
the survival of all children born included in censuses and surveys, and
analyses using indirect estimation procedures, are also considered to be
reliable sources.
(c) Data Sources: Original data sources
include: vital registrations, sample registration systems, surveillance
systems, censuses, and demographic surveys. Information needed for this
indicator is collected by the United Nations on a regular basis. For all
countries, survey and registration data are evaluated and, if necessary,
adjusted for incompleteness by the Population Division, Department of
Economics and Social Information and Policy Analysis (DESIPA) as part of
its preparations of the official United Nations population estimates and
projections. Past, current and projected estimates of infant mortality are
prepared for all countries by the Population Division; DESIPA and appear
in the United Nations publication, World Population Prospects: The 1994
Revision. Demographic monitoring done by government statistical offices
often allows desegregation of information to show differences within
countries. Surveys are generally designed to provide estimates for major
regions within countries as well as at the national level.
6. Agencies Involved in the Development of the
Indicator
(a) Lead Agency: The lead agencies for this
indicator are: the United Nations Department of Economics and Social
Information and Policy Analysis with the contact point being the Director,
Population Division, fax no. (1 212) 963 2147; and the World Health
Organization (WHO) with the contact point being the Director, Office of
Global and Integrated Environmental Health, fax no. (41 22) 791 4123.
(b) Other Organizations: Other contributing
organizations include: the United Nations Statistics Division; and the
United Nations Childrens Fund (UNICEF).
7. Further Information
(a) Further Readings:
WHO. Development of Indicators for Monitoring
Progress Towards Health for All by the Year 2000. Geneva, 1981, p. 67.
WHO. Global Health for All Data Base. Geneva, 1994.
WHO. Global Strategy for Health for All by the Year
2000. Geneva, 1981.
DESIPA. Manual X: Indirect Techniques for
Demographic Estimation. Population Division. United Nations Sales No. E.
83.XIII.2, New York, 1983.
DESIPA. MORTPAK-LITE - The United Nations Software
Package for Mortality Measurement. Population Division. United Nations,
New York, 1988.
DESIPA. World Population Prospects: The 1994
Revision. Population Division. United Nations Sales No. E.95.XIII.16, New
York, 1995.
United Nations. Report of the International
Conference on Population and Development, Programme of Action of the
International Conference on Population and Development, Cairo, Egypt,
September 5-13, 1994. United Nations Document A/CONF. 171/13.
UNICEF. State of the World Children. 1994.
(b) Other References:
Hill K. Approaches to the measurement of
childhood mortality: A comparative review. Population Index 57(3):368-382,
Fall, 1991.
WHO and UNICEF. Measurement of overall and
cause-specific mortality in infants and children. Report of a Joint
WHO/UNICEF Consultation, 15-17 December 1992. Unpublished document WHO/ESM/UNICEF/CONS/92.5.
DESIPA. 1993 Demographic Yearbook. Statistical
Division. United Nations Sales No. E/F.95.XIII.1, 1995.
MATERNAL
MORTALITY RATE |
Social |
Chapter 6 |
State |
1. Indicator
(a) Name: Maternal mortality rate (MMR).
(b) Brief Definition: Number of maternal deaths per 1 000 (or per
10 000 or per 100 000) live births.
(c) Unit of Measurement: Ratio. Due to the considerable decrease of
MMR in many countries, this ratio is now increasingly expressed per 10 000
or more often per 100 000 live-births, which is acceptable if preferred
and indicated by the country.
2. Placement in the Framework
(a) Agenda 21: Chapter 6: Protecting and
Promoting Human Health.
(b) Type of Indicator: State.
3. Significance (Policy Relevance)
(a) Purpose: This indicator estimates the
proportion of pregnant women who die from causes related to or aggravated
by the pregnancy or its management.
(b) Relevance to Sustainable/Unsustainable
Development: The MMR reflects the risk to mothers during pregnancy and
childbirth and is influenced by the following factors: general
socioeconomic conditions; unsatisfactory health conditions preceding the
pregnancy; incidence of the various complications of pregnancy and
childbirth; availability and utilization of health care facilities,
including prenatal and obstetric care.
Monitoring MMRs is particularly useful for policy
making and decisions regarding the accessibility to and the quality of
prenatal and obstetric care.
(c) Linkages to Other Indicators: This
indicator is closely linked with infant mortality rate, contraceptive
prevalence, and health care expenditures.
(d) Targets: The Ninth General Programme of
Work Covering the Period 1996-2001 calls for a reduction of MMR by half in
all countries between 1990 and the year 2000.
(e) International Conventions and Agreements:
See section 3d above.
4. Methodological Description and Underlying
Definitions
(a) Underlying Definitions and Concepts:
Maternal death: The death of a woman while pregnant or within 42 days of
termination of pregnancy, irrespective of the duration and the site of
pregnancy, from any cause related to or aggravated by the pregnancy or its
management, but not from accidental or incidental cause. Maternal deaths
should be divided into two groups: (i) direct obstetric deaths are those
resulting from obstetric complications of the pregnant state (pregnancy,
labour, and puerperium), from interventions, omissions, incorrect
treatment, or from a chain of events resulting from the above; and (ii)
indirect obstetric deaths are those resulting from previous existing
disease or disease that developed during pregnancy and which was not due
to direct obstetric causes, but was aggravated by physiologic effects of
pregnancy.
The ICD-10 includes two further definitions of
maternal mortality: (i) late maternal death: the death of a woman from
direct or indirect obstetric causes more than 42 days but less than one
year after termination of pregnancy; and (ii) pregnancy-related death: the
death of a woman while pregnant or within 42 days of termination of
pregnancy, irrespective of the cause of death (includes deaths from
accidents).
(b) Measurement Methods: The maternal
mortality ratio is expressed as follows:
Maternal
deaths (direct and indirect) x K
live-births
k = 1 000, 10
000, or 100 000
For the purpose of international reporting of
maternal mortality, only those maternal deaths occurring before the end of
the 42-day reference period should be included in the calculation of the
rate, although the recording of later maternal deaths is useful for
national analytical purposes (see section 4e below).
Published maternal mortality rates should always
specify the numerator (number of recorded maternal deaths), which can be
given as: (i) the number of recorded direct obstetric deaths; or the
number of recorded obstetric deaths (direct plus indirect). It should be
noted that maternal deaths from HIV disease and obstetrical tetanus are to
be included in the MMR.
(c) The Indicator in the DSR Framework: The
MMR provides an indication of the State of health care and general
socioeconomic conditions in a country.
(d) Limitations of the Indicator: The
computation of the MMR implies a well-developed registration system of
births and deaths, as well as of causes of death. In order to improve the
quality of maternal mortality data and provide alternative methods of
collecting data on deaths during pregnancy or related to it, as well as to
encourage the recording of deaths from obstetric causes occurring more
than 42 days following termination of pregnancy, the Forty-third World
Health Assembly in 1990 adopted the recommendation that countries consider
the inclusion on death certificates of questions regarding current
pregnancy and pregnancy within one year preceding death. In the absence of
a reliable registration system, a proxy measurement may be used based on a
count of deaths among women soon after childbirth. To be used as a health
indicator, the rate should preferably be based on observations of at least
50 maternal deaths.
In countries with a small population (for example,
less than half a million), and also in some larger countries with very low
maternal mortality, the rate should be considered with great caution, as
annual rates are subject to considerable random variation.
(e) Alternative Definitions: Recording
"late maternal death" and monitoring its rate become more
important the more developed the country is. In either cases, it is
essential to state which definition is used. The definition of
"pregnancy-related death" (see section 4a above) is irrespective
of cause of death and therefore includes incidental and accidental causes.
This avoids the determination of pathogenic causes of death, and strong
clinical inputs during data collection. In countries where maternal
mortality is high, the bias introduced by the inclusion of external causes
is usually low and simplifies data collection.
5. Assessment of the Availability of Data from
International and National Sources
(a) Data Needed to Compile the Indicator:
Number of live births; number of maternal deaths.
(b) Data Availability: Data are routinely
collected at national and sub-national levels in most countries.
(c) Data Sources: The primary sources of
data are: vital statistics registration; and community-based information
(reproductive age mortality survey, case finding, sisterhood method).
Hospital maternal mortality ratios should not be interpreted as it is
impossible to know the direction of the bias.
6. Agencies Involved in the Development of the
Indicator
The lead agency is the World Health Organization
(WHO). The contact point is the Director, Office of Global and Integrated
Environmental Health, WHO; fax no. (41 22) 791 4123.
7. Further Information
(a) Further Readings:
Abouzahr, C. and Royston, E. Maternal Mortality: A
Global Factbook. Geneva, WHO, 1991.
WHO. Maternal mortality, Rates and Ratios. A
Tabulation of Available Information. 3rd ed. Geneva, WHO/MCH/MSM/91.6,
1991.
WHO. Indicators to Monitor Maternal Health Goals.
Report of a Technical Working Group. Geneva, WHO, 1994.
(b) Other References:
WHO. Development of Indicators for Monitoring
Progress Towards Health for All by the Year 2000. Geneva, WHO, 1981.
WHO. International Statistical Classification of
Diseases and Related Health Problems, 10th rev. Geneva, WHO, 1992.
WHO. Ninth General Programme of Work Covering the
Period 1996-2001. Geneva, WHO, 1994.
WHO. Global Health for All Database. Geneva, WHO,
1994.
NUTRITIONAL
STATUS OF CHILDREN |
Social |
Chapter 6 |
State |
1. Indicator
(a) Name: The nutritional status of children
in relation to national standards.
(b) Brief Definition: Children under age five whose weight-for-age
and height-for-age is between either 80% and 120% of the reference value
of the country, or within two standard deviations of this value.
(c) Unit of Measurement: %.
2. Placement in the Framework
(a) Agenda 21: Protecting and Promoting
Human Health.
(b) Type of Indicator: State.
3. Significance (Policy Relevance)
(a) Purpose: The purpose of this indicator
is to measure long term nutritional imbalance and malnutrition, as well as
current under-nutrition.
(b) Relevance to Sustainable/Unsustainable
Development: Health and development are intimately interconnected.
Meeting primary health care needs and the nutritional requirement of
children are fundamental to the achievement of sustainable development.
Anthropometric measurements to assess growth and development, particularly
in young children, are the most widely used indicators of nutritional
status in a community. The percentage of low height-for-age reflects the
cumulative effects of under-nutrition and infections since birth, and even
before birth. This measure, therefore, should be interpreted as an
indication of poor environmental conditions and/or early malnutrition. The
percentage of low weight-for-age reflects both the cumulative effects of
episodes of malnutrition or chronic under-nutrition since birth and
current under-nutrition. Thus, it is a composite indicator which is more
difficult to interpret.
(c) Linkages to Other Indicators: This
indicator is closely linked with adequate birth weight. It is also
associated with such socioeconomic and environmental indicators as squared
poverty gap index, access to safe drinking water, infant mortality rate,
life expectancy at birth, national health expenditure devoted to local
health care, Gross Domestic Product (GDP) per capita, environmental
protection expenditures as a percent of GDP, and waste water treatment
coverage.
(d) Targets: At least 90% of children within
a population should have a weight-for-age that corresponds to the
reference values given in section 1b above by the year 2000. This target
has been established by the World Health Organization's (WHO) Global
Strategy for Health for All by the Year 2000.
(e) International Conventions and Agreements:
The WHO Global Strategy for Health for All by the Year 2000 and its Ninth
General Programme of Work, together with the United Nations World Summit
for Children represent international agreements relevant to this
indicator.
4. Methodological Description and Underlying
Definitions
(a) Underlying Definitions and Concepts: A
national or international reference population is used to calculate the
indicators for weight-for-age and height-for-age. A WHO Working Group has
recommended that the best available data for this has been established by
the United States National Center for Health Statistics (see references in
section 7 below). This data may be used for children up to five years of
age, since the influence of ethnic or genetic factors on young children is
considered insignificant.
Low weight and low height are defined as less than
the value corresponding to two standard deviations below the median of the
respective frequency distributions for healthy children (see WHO, 1981 in
section 7 below).
(b) Measurement Methods: The proportion of
children under five with acceptable weight-for-age (or height-for-age) can
be calculated by using the following formula:
Numerator: number of
children under five with weight-for-age (or height-for-age)
acceptable
x 100.
Denominator: total number
of children under five weighed.
For height, supine length is measured in children
under two, and stature height in older children.
(c) The Indicator in the DSR Framework: This
indicator, as a proxy measure for access to adequate food supply, is a
State indicator within the DSR Framework.
(d) Limitations of the Indicator: Available
data may be outdated, site-specific, and lack a time series perspective.
In some countries, the age of children is difficult to determine. It is
also difficult to measure the height of children under two with accuracy
and consistency.
(e) Alternative Definitions: Not available.
5. Assessment of the Availability of Data from
International and National Sources
(a) Data Needed to Compile the Indicator: The
data needed to compile this indicator are the number of children under
five weighed; and the number of children under five with weight-for-age or
height-for-age within the national reference values.
(b) Data Availability: The data are
routinely collected by ministries of health at the national and
subnational levels for most countries.
(c) Data Sources: The primary national
sources of data are the ministries of health.
6. Agencies Involved in the Development of the
Indicator
The lead agency for the development of this
indicator is the World Health Organization (WHO). At WHO, the contact
point is the Director, Office of Global and Integrated Environmental
Health; fax no. (41 22) 791 4123.
7. Further Information
United States Department of Health, Education, and
Welfare. Growth Charts. National Center for Health Statistics, Public
Health Service, Health Resources Administration. Rockville, Maryland.
1976.
Waterlow, J.C. et al. The Presentation and Use of
Height and Weight Data for Comparing the Nutritional Status of Groups of
Children under the Age of Ten Years. Bulletin of the World Health
Organization, Volume 55: 489-498. 1977.
WHO. Global Strategy for Health for All by the Year
2000. Geneva. 1981.
WHO. Development of Indicators for Monitoring
Progress Towards Health for All by the Year 2000. Geneva. 1981.
WHO. Ninth General Programme of Work Covering the
Period 1996-2001. Geneva. 1994.
IMMUNIZATION
AGAINST INFECTIOUS CHILDHOOD DISEASES |
Social |
Chapter 6 |
Response |
1. Indicator
(a) Name: The percent of the eligible
population that have been immunized according to national immunization
policies.
(b) Brief Definition: The definition includes three components: (i)
the proportion of children immunized against diphtheria, pertussis,
tetanus, measles, poliomyelitis, tuberculosis and hepatitis B before their
first birthday; (ii) the proportion of children immunized against yellow
fever in affected countries of Africa; and (iii) the proportion of women
of child-bearing age immunized against tetanus.
(c) Unit of Measurement: %.
2. Placement in the Framework
(a) Agenda 21: Chapter 6: Immunization
against infections childhood diseases.
(b) Type of Indicator: Response.
3. Significance (Policy Relevance)
(a) Purpose: This indicator monitors the
implementation of immunization programs.
(b) Relevance to Sustainable/Unsustainable
Development: Health and sustainable development are intimately
interconnected. Both insufficient and inappropriate development can lead
to severe health problems in both developing and developed countries.
Addressing primary health needs is integral to the achievement of
sustainable development. Particularly relevant is the provision of
preventative programmes aimed at controlling communicable diseases and
protecting vulnerable groups. Good management of immunization programmes,
essential to the reduction of morbidity and mortality from major childhood
infectious diseases, is a basic measure of government commitment to
preventative health services.
(c) Linkages to Other Indicators: This
indicator is linked to other health indicators, particularly those
associated with the young, such as infant mortality and life expectancy.
It is influenced by such indicators as health expenditure and the
proportion of population in urban areas.
(d) Targets: Several international targets
have been established for this indicator. In the Global Strategy for
Health and the Ninth General Programme at Work, all children and 90% of
children respectively, should be immunized against diphtheria, pertussis,
tetanus, measles, poliomyelitis, and tuberculosis (see section 7 below).
The 1992 World Health Assembly agreed that all children should be
immunized against hepatitis B as part of expanded national programmes of
immunization. In addition, all children in affected countries of Africa
should be immunized against yellow fever. At the World Summit for Children
it was resolved that all pregnant women should be immunized against
tetanus.
(e) International Conventions and Agreements:
See sections 3d and 7.
4. Methodological Description and Underlying
Definitions
(a) Underlying Definitions and Concepts: A
child is considered adequately immunized against a disease when he or she
has received the following number of doses: tuberculosis (1 dose);
diphtheria, pertussis, and tetanus (DPT) (2 or 3 doses according to the
immunization scheme adopted in the country); poliomyelitis (3 doses of
live or killed vaccine); measles (1 dose); hepatitis B (3 doses); and
yellow fever (1 dose). A pregnant woman is considered adequately immunized
against tetanus if she has received at least 2 doses of tetanus toxoid
during pregnancy or was already previously immunized.
(b) Measurement Methods:
i) Infant population: The numerator is the number
of infants fully immunized with the specified vaccines x 100, while the
denominator is the number of infants surviving to age one. If the national
schedule provides for immunization in a different age group, such as
measles in the second year of age, the value should be the percentage of
children immunized in the target age group. For the proper management of
immunization programmes, it is however essential to be able to break down
the data in such a way as to show the percentage covered in the first year
of life (or second year for measles immunization).
ii) Women of child-bearing age: The numerator is
the number of women immunized with two or more doses of tetanus toxoid
during pregnancy x 100, while the denominator is the number of live
births.
(c) The Indicator in the DSR Framework: This
indicator focuses on a fundamental aspect of preventative health care. As
such, it represents a Response indicator influencing the State indicators
of health in the DSR Framework.
(d) Limitations of the Indicator: It is
useful to have a composite indicator of adequate coverage by immunization.
However, it is easier to collect data on the global coverage of a
population against one disease than on the immunization of each child
against all target diseases at the same time. This is why in most
countries only the former data are easily available and collected.
The percent of pregnant women immunized with two or
more doses of tetanus toxoid during pregnancy is rather easy to monitor
through routine data collection in the health services. However, it
underestimates the percent of pregnant women actually immunized against
tetanus. It does not tale into account women who are already adequately
immunized when becoming pregnant and therefore do not require new doses of
tetanus toxoid during pregnancy. Women in this category are not numerous
in countries where neonatal tetanus is still an issue and where,
accordingly, this indicator is mainly used. But in some countries in
transition, with long-standing child immunization programmes, the percent
of pregnant women receiving tetanus toxoid is misleading as a significant
number of them may be already immunized at the moment of pregnancy.
The indicator does not reflect other health
preventative measures, such as education, diet, and pollution prevention.
The international targets are not very meaningful for many countries.
(e) Alternative Definitions: Not available.
5. Assessment of the Availability of Data from
International and National Sources
(a) Data Needed to Compile the Indicator:
The number of infants fully immunized against: DPT; poliomyelitis;
measles; tuberculosis; the number of infants surviving to age one year;
the number of infants living in African countries exposed to yellow fever;
the number of pregnant women immunized against tetanus; and the number of
live births.
(b) Data Availability: Data is readily
available from national immunization programmes of most countries, at
least at the national level.
(c) Data Sources: Reporting of vaccinations
performed annually or nationwide surveys are the most common data sources.
6. Agencies Involved in the Development of the
Indicator
(a) Lead Agency: The lead agency is the
World Health Organization (WHO). The contact point is the Director, Office
of Global and Integrated Environmental Health, WHO; fax no. (41 22) 791
4123.
(b) Other Organizations: The United Nations
Chilren's Fund is a cooperating agency.
7. Further Information
WHO. Global Strategy for Health for All by the Year
2000. Geneva, WHO, 1981.
WHO. Ninth General Programme of Work Covering the
Period 1996-2001. Geneva, WHO, 1994.
WHO. World Health Assembly Resolution. WHO45.19,
1992.
WHO. Expanded Programme on Immunization Data Base.
Geneva, WHO.
WHO. World Summit for Children. Paris, UNICEF,
1990.
CONTRACEPTIVE
PREVALENCE |
Social |
Chapter 6 |
Response |
1. Indicator
(a) Name: Contraceptive prevalence.
(b) Brief Definition: This indicator is generally defined as the
percent of women or reproductive age using any method of contraception. It
is usually calculated for married women of reproductive age, but sometimes
for other base population, such as all women of reproductive age, or for
men of a specified age group.
(c) Unit of Measurement: %.
2. Placement in the Framework
(a) Agenda 21: Chapter 6: Protecting and
Promoting Human Health.
(b) Type of Indicator: Response.
3. Significance (Policy Relevance)
(a) Purpose: The measure indicates the
extent of people's conscious efforts to control their fertility. It does
not capture all actions taken to control fertility, since induced abortion
is common in many countries.
(b) Relevance to Sustainable/Unsustainable
Development: Increased contraceptive prevalence, is, in general, the
single most important proximate determinant of inter-country differences
in fertility, and of ongoing fertility declines in developing countries.
Contraceptive prevalence can also be regarded as an indirect indicator of
progress in providing access to reproductive health services including
family planning, one of the eight elements of primary health care.
Agenda 21 discusses reproductive health programmes,
which include family planning, as among the programmes that promote
changes in demographic trends and factors towards sustainability. Family
planning is discussed in the broader context of reproductive, sexual
health, and reproductive rights by Chapter VII of the Programme of Action,
International Conference on Population and Development (ICPD); and
Strategic Objective C of the Platform for Action adopted at the Fourth
World Conference on Women. Health benefits include the ability to prevent
pregnancies that are too early, too closely spaced, too late, or too many.
Current contraceptive practice depends not only on
people's fertility desires, but also on availability and quality of family
planning services; social traditions that affect the acceptability of
contraceptive use; and other factors, such as marriage patterns and
traditional birth-spacing practices, that independently influence the
supply of children.
(c) Linkages to Other Indicators: The level
of contraceptive use has a strong, direct effect on the total fertility
rate (TFR) and, through the TFR, on the rate of population growth. Use of
contraception to prevent pregnancies that are too early, too closely
spaced, too late, or too many has benefits for maternal and child health.
This indicator is also closely linked to access to primary health care
services particularly those pertaining to reproductive health care.
Furthermore, it has broader and predictive implications for many other
sustainable development indicators and issues, such as rate of change of
school-age population, woman's participation in the labour force, and
natural resource use.
(d) Targets: International agreements do not
establish specific national or global targets for contraceptive
prevalence. Recent international conferences have strongly affirmed the
right of couples and individuals to chose the number, spacing and timing
of their children, and to have access to the information and means to do
so. The ICPD Programme of Action states that "Governmental goals for
family planning should be defined in terms of unmet needs for information
and services. Demographic goals, while legitimately the subject of
government development strategies, should not be imposed on
family-planning providers in the form of targets or quotas for the
recruitment of clients" (paragraph 7.12).
4. Methodological Description and Underlying
Definitions
(a) Underlying Definitions and Concepts: The
standard indicator is the percentage currently using any method of
contraception among married women aged 15-49 or 15-44. In this context,
the married group usually includes those in consensual or common-law
unions in societies where such unions are common. Contraceptive prevalence
is also frequently reported for all women of reproductive age, and
statistics are sometimes presented for men instead of, or in addition to,
women.
Users of contraception are defined as women who are
practising, or whose male partners are practising, any form of
contraception. These include female and male sterilization, injectable and
oral contraceptives, intrauterine devices, diaphragms, spermicide,
condoms, rhythm, withdrawal and abstinence, among others.
For this indicator, too early is defined as under
age 15. Such adolescents are 5 to 7 times more likely to die in pregnancy
and childbirth than women in the lowest risk group of 20-24 years. Too
closely spaced means women who become pregnant less than two years after a
previous birth. Greater adverse consequences to women and their children
are experienced under such circumstances. Women who have had five or more
pregnancies (too many) or who are over 35 (too late), also face a
substantially higher risk than the 20-24 year old group.
When presenting information about contraceptive
use, it is useful to show the data according to specific type of
contraception; by social characteristics such as rural/urban or region of
residence, education, marital status; by 5-year age group, including
specific attention to adolescents aged under 18 years; and by family size.
(b) Measurement Methods: Measurements of
contraceptive prevalence come almost entirely from representative sample
surveys of women or men of reproductive age. Current use of contraception
is usually assessed through a series of questions about knowledge and use
of particular methods.
(c) The Indicator in the DSR Framework: This
indicator focuses on individual preventative action to control fertility
through family planning. It is a Response indicator with wide implications
for many elements of the DSR Framework.
(d) Limitations of the Indicator: For
surveys, under-reporting can occur when specific methods are not mentioned
by the interviewer. This can be the case with the use of traditional
methods such as rhythm and withdrawal, and use of contraceptive surgical
sterilization. The list of specific methods is not completely uniform in
practice, but in most cases is sufficiently consistent to permit
meaningful comparison. "Current" use is often specified in
surveys to mean "within the last month", but sometimes the time
reference is left vague, and occasionally longer reference periods are
specified. With statistics from family planning programmes, the accuracy
of the assumptions is often difficult to assess. The derived estimates
obviously omit contraceptive users who do not use the programme's
services, and thus tend to underestimate the overall level of use.
Service statistics maintained by family planning
programmes are also sometimes used to derive estimates of contraceptive
prevalence. In such cases it is necessary to apply assumptions in order to
derive estimates of numbers of current users from the records of numbers
of family planning clients. Base population statistics (numbers of women
or of married women) are in this case usually derived from census counts,
adjusted to the reference date by the Population Division of the
Department of Economics and Social Information and Policy Analysis (DESIPA),
as part of its preparations of the official United Nations population
estimates and projections.
(e) Alternative Definitions: Not available.
5. Assessment of the Availability of Data from
International and National Sources
(a) Data Needed to Compile the Indicator:
Number of women of childbearing age using family planning methods. Number
of women of childbearing age. Both data sets are frequently limited to
married women.
(b) Data Availability: The most recent
United Nations review of contraceptive prevalence includes statistics for
119 countries and areas with information dating from 1975 or later. These
countries include 90 per cent of world population. This review includes
contraceptive prevalence measures for all women of reproductive age in 64
countries and areas and for samples of men in 27 countries and areas.
Contraceptive prevalence is one of the few topics
for which data coverage is more complete and more current for developing
than for developed countries. Most surveys provide estimates for major
regions within countries as well as at the national level. Less frequently
the sample design permits examining prevalence at the state, provincial,
or lower administrative levels. In addition to those with national or
near-national coverage, surveys covering this topic are sometimes
available for particular geographic areas. Data are much less widely
available for population groups other than married women, although such
information has increased in recent years.
(c) Data Sources: Executing agencies for
surveys covering this topic vary. National statistical offices and
ministries of health are the most common source, but other governmental
offices, non-governmental voluntary or commercial organizations are
frequently involved. Many surveys are conducted in collaboration with
international survey programmes. The Population Division, DESIPA regularly
compiles information about contraceptive prevalence and publishes it in
the annual World Population Monitoring report.
6. Agencies Involved in the Development of the
Indicator
The lead agencies are: the United Nations
Department of Economics and Social Information and Policy Analysis (DESIPA),
with the contact point as the Director, Population Division, fax no. (1
212) 963 2147; and the World Health Organization (WHO), with the contact
point as the Director, Office of Global and Integrated Environmental
Health, fax no. (41 22) 791 4123.
7. Further Information
Levels and Trends of Contraceptive Use as Assessed
in 1988 (United Nations, Sales No. E.89.XIII.4).
Levels and Trends of Contraceptive Use as Assessed
in 1994 (United Nations, ST/ESA/SER.A/146, forthcoming).
Programme of Action of the International Conference
on Population and Development, Report of the International Conference on
Population and Development, Cairo, Egypt, September 5-13, 1994. (United
Nations Document - A/CONF. 171/13).
World Population Monitoring, 1993 (Sales No.
E.95.XIII.8, New York).
World Population Monitoring, 1996 (ESA/P/WP.131).
PROPORTION OF
POTENTIALLY HAZARDOUS CHEMICALS MONITORED IN FOOD |
Social |
Chapter 6 |
Response |
1. Indicator
(a) Name: Proportion of potentially
hazardous chemicals monitored in food.
(b) Brief Definition: Proportion of potentially hazardous chemicals
monitored in food which are appropriate for the country's stage of
development.
(c) Unit of Measurement: %.
2. Placement in the Framework
(a) Agenda 21: Chapter 6: Protecting and
Promoting Human Health.
(b) Type of Indicator: Response.
3. Significance (Policy Relevance)
(a) Purpose: The purpose of this indicator
is to assess national capacities to monitor, through population-based
sampling and analysis, the presence of potentially hazardous chemicals in
various food commodities, based on lists of priority chemicals and foods
in which they occur, appropriate for the country's stage of development.
(b) Relevance to Sustainable/Unsustainable
Development: Human health care is integral to the achievement of the
goals of sustainable development. Food contamination is a major route of
human exposure to a range of chemicals potentially hazardous to health.
Food contamination monitoring is essential to protect public health and
maintain confidence in the food supply. Taken together with information on
food consumption, monitoring provides an assessment of whether human
exposure to chemicals in food exceeds established acceptable or tolerable
levels. In this way, monitoring provides information to identify problems,
establish priorities, and select appropriate interventions. Monitoring can
also detect sporadic contamination which is often associated with chemical
misuse or accidents. Food contamination monitoring serves to confirm the
adequacy of source directed (environmental) measures and other
interventions to reduce or prevent the contamination of food.
(c) Linkages to Other Indicators: This
indicator is closely linked with other measures associated with human
exposure to chemicals, such as use of agricultural pesticides, ambient air
pollution, unintentional chemically induced acute poisonings, and
generation of hazardous waste. It is also linked to other health response
indicators, such as total national health care expenditure related to
Gross National Product (GNP).
(d) Targets: It is generally accepted that
at least 90% of the contaminant/food commodity combinations should be
monitored.
(e) International Conventions and Agreements:
The Food Contamination Monitoring and Assessment Programme (GEMS/Food) of
the Global Environment Monitoring System is of relevance to this
indicator.
4. Methodological Description and Underlying
Definitions
(a) Underlying Definitions and Concepts: The
definitions and concepts for this indicator are well know and readily
available. Monitoring is the representative (random) sampling and analysis
of selected food commodities, including drinking water, to assess the
dietary exposure of the population to a potentially hazardous contaminant
for comparison with the acceptable or tolerable levels of human exposure
established by national and international bodies. Such monitoring should
not be confused with compliance monitoring which is performed for
regulatory purposes.
(b) Measurement Methods: This indicator may
be calculated by using: the number of combinations of contaminants and
foods which are monitored as the numerator; and the number of combinations
of contaminants and foods which should be monitored by the country at its
stage of development as the denominator.
Based on over twenty years of GEMS/Food experience,
three separate standard lists of contaminant/food combinations have been
prepared based on knowledge of potentially hazardous chemicals and the
foods in which they are known to occur. The core list for lesser developed
countries contains 153 combinations of contaminants and foods which offer
basic protection of the consumer from known chemical hazards. The
intermediate list for developing countries contains 358 combinations of
contaminants and foods which offer improved protection of the consumer,
especially as development increases the number and amount of potentially
hazardous chemicals used in the country. The comprehensive list for
industrialized countries includes 394 combinations which provide assurance
that the full range of potentially toxic chemicals are being monitored in
the food supply. For guidance on which list to select, countries with per
capita GNP under US$3 500 should use the core list. For counties with per
capita GNP between US$3 500 and US$7 500, the intermediate list should be
used. For countries with per capita GNP over US$7 500, the comprehensive
list should be used. The lists are attached in Annex 1 below.
(c) The Indicator in the DSR Framework: This
indicator represents a societal Response to human exposure to potentially
hazardous chemicals.
(d) Limitations of the Indicator: Frequency
of monitoring, which is based on the importance of the food in the diet
and to total exposure, is not addressed by this indicator.
(e) Alternative Definitions: Not available.
5. Assessment of the Availability of Data from
International and National Sources
(a) Data Needed to Compile the Indicator:
The number of contaminant/commodity combinations monitored are required
(see section 4b above).
(b) Data Availability: The information is
available for most countries through the ministries of health,
agriculture, and/or environment.
(c) Data Sources: The information may be
obtained directly from the laboratories with the mandate to collect it.
Most countries undertaking monitoring usually publish annual reports,
often in professional journals. In over seventy countries, the GEMS/Food
Programme maintains a network of Participating Institutions which are
involved in this type of monitoring.
6. Agencies Involved in the Development of the
Indicator
(a) Lead Agency: The lead agency is the
World Health organization (WHO). The contact point is the Director, Office
of Global and Integrated Environmental Health, WHO; fax no. (41 22) 791
4123.
(b) Other Organizations: The Food and
Agriculure Organization (FAO) and the United Nations Environment Programme
(UNEP) are partners with WHO in the GEMS/Food Programme.
7. Further Information
World Health Organization. Guidelines for
Establishing or Strengthening National Food Contamination Monitoring
Programmes. Unpublished Document WHO/HCS/FCM/78.1. GEMS/Food, Geneva.
World Health Organization. Guidelines for
Predicting Dietary Intake of Pesticide Residues. GEMS/Food, Geneva. 1990.
World Health Organization. Guidelines for the Study
of Dietary Intake of Chemical Contaminants. WHO Offset Publication No 87.
GEMS/Food, Geneva. 1985.
ANNEX 1
CORE LIST |
Contaminant |
Food |
aldrin, dieldrin, DDT (p,p'-
and o,p'-), TDE (p,p'-), TDE (p,p'-), DDE (p,p'-) endosulfan ( and
ß), endosulfan sulfate, endrin, hexachlorocyclohexane
( and ß and ), hexachlorobenzene, heptachlor, heptachlor epoxide
and polychlorinated biphenyls |
whole milk, butter, animal fats and oils,
fish, cereals*, human milk
|
lead
|
milk, canned/fresh meat,
kidney, cereals*, canned/fresh fruit, fruit juice, spices, infant
food, canned beverages, wine, drinking water |
cadmium |
kidney, mollusks, crustaceans,
cereals* |
mercury |
fish |
aflatoxins |
milk, maize, groundnuts, other
nuts, dried figs |
diazinon, fenitrothion,
malathion, parathion, methyl parathion, methyl pirimiphos |
cereals*, vegetables, drinking
water |
* Or other staple foods
INTERMEDIATE
LIST |
Contaminant |
Food |
aldrin, dieldrin, DDT (p,p'-
and o,p'-), TDE (p,p'-), TDE (p,p'-), DDE (p,p'-) endosulfan ( and
ß), endosulfan sulfate, endrin, hexachlorocyclohexane
( and ß and ), hexachlorobenzene, heptachlor, heptachlor epoxide
and polychlorinated biphenyls (congeners No. 28, 52, 101, 118,
138, 153 and 180) |
whole milk, dried milk, butter, eggs, animal
fats and oils, fish, cereals*, vegetable fats and oils, human
milk, total diet, drinking water
|
lead
|
milk, canned/fresh meat,
kidney, fish, molluscs, crustaceans, cereals*, pulses, legumes,
canned/fresh fruit, fruit juice, spices, infant food, canned
beverages, wine, total diet, drinking water |
cadmium
|
kidney, molluscs, crustaceans,
cereals* flour, vegetables, total diet |
mercury |
fish, fish products, total diet |
aflatoxins
|
milk, milk products, maize,
cereals*, groundnuts, other nuts, spices, dried figs, total diet |
diazinon, fenitrothion,
malathion, parathion, methyl parathion, methyl pirimiphos,
chlorpyrifos |
cereals*, vegetables, fruit, total diet,
drinking water
|
radionuclides (Cs-137, Sr-90,
I-131, Pu-239) |
cereals*, vegetables, milk,
drinking water |
nitrate/nitrite |
vegetables, drink water |
* Or other staple foods
COMPREHENSIVE
LIST |
Contaminant |
Food |
aldrin, dieldrin, DDT (p,p'-
and o,p'-), TDE (p,p'-), TDE (p,p'-), DDE (p,p'-) endosulfan ( and
ß), endosulfan sulfate, endrin, hexachlorocyclohexane ( and ß
and ), hexachlorobenzene, heptachlor, heptachlor epoxide and
polychlorinated biphenyls (congeners No. 28, 52, 101, 118, 138,
153 and 180), dioxins (PCDDs and PCDFs) |
whole milk, dried milk, butter, eggs, animal
fats and oils, fish, cereals*, vegetable fats and oils, human
milk, total diet, drinking water
|
lead
|
milk, canned/fresh meat,
kidney, fish, molluscs, crustaceans, cereals*, pulses, legumes,
canned/fresh fruit, fruit juice, spices, infant food, total diet,
drinking water |
cadmium |
kidney, molluscs, crustaceans,
cereals*, vegetables, total diet |
mercury |
fish, fish products, mushrooms,
total diet |
aflatoxins |
milk, milk products, eggs, maize, cereals*,
groundnuts, other nuts, spices, dried figs, total diet
|
ochratoxin A |
wheat, cereals, meat (pork) |
patulin |
apples, apple juice, other pome fruit and
juice
|
fumonisins |
maize |
diazinon, fenitrothion,
malathion, parathion, methyl parathion, methyl pirimiphos,
chlorpyrifos |
cereals*, vegetables, fruit,
total diet, drinking water |
dithiocarbamates |
cereals*, vegetables, fruit,
total diet, drinking water |
radionuclides (Cs-137, Sr-90,
I-131, Pu-239) |
cereals*, vegetables, milk,
drink water |
nitrate/nitrite |
vegetables, drinking water |
* Or other staple foods
NATIONAL HEALTH
EXPENDITURE DEVOTED TO LOCAL HEALTH CARE |
Social |
Chapter 6 |
Response |
1. Indicator
(a) Name: National health expenditure
devoted to local health care.
(b) Brief Definition: Proportion of national health expenditure
devoted to local primary health care. This is the first-level contact and
includes community health care, health centre care, dispensary care, etc.,
but excludes hospital care.
(c) Unit of Measurement: %.
2. Placement in the Framework
(a) Agenda 21: Chapter 6: Protecting and
Promoting Human Health.
(b) Type of Indicator: Response.
3. Significance (Policy Relevance)
(a) Purpose: This indicator measures the
proportion of resources devoted to primary health care.
(b) Relevance to Sustainable/Unsustainable
Development: Everybody now agrees that significant health progress
worldwide can only be achieved through universal access to primary health
care, that is essential health care made accessible to all at an
affordable cost. The proportion of the national health expenditure devoted
to local health care is an indicator of the effort made by a society to
finance essential and easily accessible health care.
(c) Linkages to Other Indicators: This
indicator is closely linked to other health care indicators, such as total
national healthcare as a percent of Gross National Product, immunization
against infectious childhood diseases, and infant and maternal mortality
rates.
(d) Targets: Not available.
(e) International Conventions and Agreements:
Not available.
4. Methodological Description and Underlying
Definitions
(a) Underlying Definitions and Concepts:
Local Health Care: first-level contact, including community health care,
health centre care, dispensary care and the like, excluding hospital care.
National health expenditure includes: Public: current and capital
expenditure of ministries of health and other ministries with
responsibilities in the health sector, and social security expenditure,
including external aid for the health sector; Private: out-of-pocket
health expenditure, patient co-payments, private health insurance
premiums, and health expenditures by non-government organizations (NGOs).
(b) Measurement Methods: Numerator: national
health expenditure on local health care; Denominator: total national
health expenditure.
(c) The Indicator in the DSR Framework: In
reflecting the proportion of total health care expenditures devoted to
local health care, this is a Response indicator in the DSR Framework.
(d) Limitations of the Indicator: The
definition does not take into account primary health care activities which
are delivered in hospitals, nor the cost of central and regional
activities needed to support and guide local health care. Furthermore,
each country will have to define what is "local health care"
with respect to its own health system.
The indicator says nothing about the quality or
efficiency of health actions and services. Household surveys are required
to generate the information needed for this indicator which may pose a
significant burden for some countries.
(e) Alternative Definitions: Not available.
5. Assessment of the Availability of Data from
International and National Sources
(a) Data Needed to Compile the Indicator: A
large amount of financial data are needed from a wide variety of sources,
as can be seen from the definition.
(b) Data Availability: Data on out-of-pocket
health expenditures requires a household survey. All other data should
usually be available from responsible institutions at the national level
(public or private).
(c) Data Sources: The primary sources of
data are national ministries of health, finance, and regional development;
and NGOs.
6. Agencies Involved in the Development of the
Indicator
The lead agency is the World Health Organization
(WHO). The contact point is the Director, Office of Global and Integrated
Environmental Health, WHO; fax no. (41 22) 791 4123.
7. Further Information
WHO. Development of Indicators for Monitoring
Progress Towards Health for All by the Year 2000. Geneva, 1981.
WHO. Global Strategy for Health for All by the Year
2000. Geneva, 1981.
TOTAL NATIONAL
HEALTH EXPENDITURE RELATED TO GROSS NATIONAL PRODUCT |
Social |
Chapter 6 |
Response |
1. Indicator
(a) Name: Total national health expenditure
related to gross national product (GNP).
(b) Brief Definition: This indicator is defined as the share of GNP
devoted to health expenditure. It includes public and private expenditure.
(c) Unit of Measurement: %.
2. Placement in the Framework
(a) Agenda 21: Chapter 6: Protecting and
Promoting Human Health.
(b) Type of Indicator: Response.
3. Significance (Policy Relevance)
(a) Purpose: The purpose of the indicator is
to measure the proportion of national resources devoted to health.
(b) Relevance to Sustainable/Unsustainable
Development: Health and sustainable development are intimately
interconnected. This measure provides a first indication of the priorities
granted to health as compared to other sectors within the same country. It
allows comparisons of the priority given to health between countries.
(c) Linkages to Other Indicators: Health
expenditures is closely linked to other indicators measuring the fiscal
support for the provision of basic needs, such as GDP spent on education.
(d) Targets: The Global Strategy for Health
for All by the Year 2000 states that at least 5% of the Gross National
Product should be spent on health (see section 7 below).
(e) International Conventions and Agreements:
See section 3d above.
4. Methodological Description and Underlying
Definitions
(a) Underlying Definitions and Concepts: The
definitions for national health expenditure are well established and
include:
i) Public: The current and capital expenditure of
the Ministry of Health and other ministries with responsibilities in the
health sector; and social security expenditure. It also includes external
aid for the health sector.
ii) Private: This definition covers out-of-pocket
health expenditure, patient co-payments, private health insurance
premiums, and health expenditures by non-government organisations.
iii) Gross National Product: GNP consists of the
Gross Domestic Product (the total output of goods and services for final
use produced by residents) plus net factor income from abroad. This second
aspect is the income citizens receive from abroad for factor services,
less similar payments made to foreigners who contribute to the domestic
economy.
(b) Measurement Methods: The numerator is
the sum of public and private expenditures on health, while the
denominator is the GNP, both measured on a national basis.
(c) The Indicator in the DSR Framework: This
indicator deals with the share of GNP devoted to national health. It
provides a summary Response indicator within the DSR Framework.
(d) Limitations of the Indicator: The cost
of health care, the efficiency of the health care systems, and the quality
of the services provided affect the level of health expenditure. It is
sometimes difficult to identify all elements of public and private health
expenditure, for example military and traditional expenditures. The
assessment of out-of-pocket expenditure requires a household survey which
may prove to be a burden for some countries. Difficulties could arise with
respect to estimating private health expenditure. If estimated via
extrapolation of data from small-scale household surveys, mention should
be made of the survey scope.
(e) Alternative Definitions: Not available.
5. Assessment of the Availability of Data from
International and National Sources
(a) Data Needed to Compile the Indicator:
Public current and capital health expenditure (including external aid),
together with private health expenditure and GNP.
(b) Data Availability: Most are normally
available from the ministries of health, finance and/or planning, and any
other ministry engaged in health expenditures. Data may not be readily
available for private health expenditure.
(c) Data Sources: Primary sources of data
are the budget of the ministry of health and the national budget.
6. Agencies Involved in the Development of the
Indicator
(a) Lead Agency: The lead agency is the
World Health Organisation (WHO), with the contact point as the Director,
Office of Global and Integrated Environmental Health, WHO; fax no. (41 22
791 4123).
(b) Other Organizations: The World Bank and
the Organisation for Economic Co-operation and Development contributed to
the development of this indicator.
7. Further Information
WHO. Global Strategy for Health for all by the Year
2000. Geneva, WHO, 1981.
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