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   Chapter 6: Protecting and Promoting Human Health

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 ), endosulfan sulfate, endrin, hexachlorocyclohexane
( and 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 ), endosulfan sulfate, endrin, hexachlorocyclohexane
( and 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 ), endosulfan sulfate, endrin, hexachlorocyclohexane ( and 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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15 December 2004