There is growing international agreement that a new approach is needed for this task. Following a 2003 resolution of the WHO Regional Committee for Europe (14), the WHO Regional Office for Europe is developing a European strategy for child and adolescent health and development (15). Its aim is to assist Member States in formulating their own policies and programmes, not to act as a straitjacket for the Region. The strategy identifies the main challenges to child and adolescent health and, most important, provides options that are based on evidence and the experience gleaned by WHO over recent years. The strategy and an associated toolkit will help Member States identify any gaps in their plans and clarify their priorities for future investment.
Because circumstances vary, each country in the Region must decide its own priorities.
Countries will remain free to set their own targets for achievement, in the light of their particular circumstances and resources. While the principles and approaches that underpin child and adolescent health and development are universal, their application may vary from country to country in this complex and diverse Region.
All these approaches share basic features: they must be evidence based, broad and better aimed at underprivileged groups in the population (see pp. 78–81 for further discussion of factors in success). While more effort and, naturally, resources are needed for the successful implementation of the interventions known to be effective, one thing is clear: delays in action on children’s health and development are not primarily a question of evidence but one of the ambition required to pursue substantial improvements. In particular, the recent economic growth in most eastern countries in the Region is an opportunity to scale up services for child health and development that will pay off in the future.
The aim is to ensure full coverage of children of all social and ethnic groups by the best achievable public health services. This must be supplemented by access to high-quality health services, which can deliver indispensable results. This short report does not include health care services in its scope, but aims to focus on population-level indicators of interest to public health.
The process of preparing this report uncovered many limitations in the availability of adequate information on children’s health, as discussed below. In general, all countries need better information on and monitoring systems for children’s health, particularly in relation to social inequalities.
Information on children’s health
In general, good data on children’s health are still surprisingly difficult to obtain. Regrettably, existing data are often inaccurate, incomplete or inconsistent. The methods used to access and present data vary considerably between countries, adding to the complexities of analysis. The lack of data on the total population of children (that is, all those aged 0–17 years) is a particular problem. A more standardized approach will not only help build the evidence base for children’s health and development but also improve the confidence of policy-makers in the information available to support policy.
In particular, neonatal, infant and child mortality is underreported in several countries, mainly in the Caucasus and central Asia, which have only recently started to use the international definition of live birth. Underreporting is also a problem in some countries in the Balkans. Household surveys carried out in some of these countries in the 1990s produced estimates of mortality that are much higher than the official figures, which are based on
registration. Similarly, the children’s immunization rates given by official sources are sometimes at variance with those derived from household surveys (16).
Owing to these differences, in May 2004, WHO, the United Nations Children’s Fund (UNICEF), the United Nations Population Division and the World Bank agreed to carry out regular, joint activities to improve the estimation of mortality. Accordingly, WHO and UNICEF produced a consistent set of mortality rates for children aged under 5 years by country for the period 1990–2003; these may not be directly derived from reported data and should be interpreted as the best estimates of WHO, rather than the official views of Member States.
WHO published these data with uncertainty intervals, to communicate the plausible range between the high and low estimates for each country (8). Fig. 5 shows the uncertainty intervals in relation to the officially reported data. In a number of countries in the Eur-B and -C groups, mainly in the Caucasus and central Asia, even the low WHO estimate is considerably higher than the official figures (see Annex Table 2 for the WHO estimates of the midpoints of the uncertainty intervals). While the rates in Eur-A are around 5 deaths per 1000 live births, those for some central Asian republics are estimated at over 100 per 1000.
Unfortunately, health data for socioeconomic subgroups are mainly available through research studies or population surveys. For this reason, the country averages usually conceal the differences between such groups, such as the health experience of subgroups with a mobile lifestyle, including homeless people and refugees; or the impact of disability on access to services, such as education.
Another major concern is the lack of sufficient information at the population level on the positive aspects of children’s health and development.
The WHO Regional Office for Europe carried out a special data collection exercise to support the move to a more child-centred approach to compiling and presenting data on children’s health. The Regional Office sent the data specifications – based on the
recommendations of the Child Health Indicators of Life and Development (CHILD) project (18,19) – to all 52 Member States in the Region and invited them to nominate focal points; the focal points submitted the data available to them by September 2004. These were added to the data already available in the Regional Office. The analyses for this report have used all data selectively (see Annex Table 6).
The overall conclusion of the exercise is that the required data are not readily available in a single central database in any country, and compiling them requires special effort and resources. Thus, the existing data on children’s health are most likely underused.
4
The development of this report was an interactive exercise, involving divisions and programmes in the Regional Office, WHO headquarters, selected other organizations and individual experts. In particular, WHO headquarters databases – the Global Burden of Disease Database (20) and the WHO Global InfoBase (21) – have provided estimates of the burden of disease in children for each Member State in the WHO European Region.
a The former Yugoslav Republic of Macedonia.
b NA = not available.
Source: official estimates from the European health for all database (17); WHO estimates from The world health report 2005 – Make every mother and child count (8).
Fig. 5. Official figures and WHO estimates of deaths in children under 5 in the WHO European Region, 2003
Iceland Sweden Czech Republic Finland Germany Monaco Norway San Marino Spain Andorra Austria Belgium Cyprus Denmark France Greece Italy Luxembourg Netherlands Slovenia Switzerland Ireland Israel Malta Portugal United Kingdom
Croatia Estonia Poland Slovakia Hungary Lithuania Belarus TFYR Macedoniaa
Latvia Serbia and Montenegro Bulgaria Russian Federation Bosnia and Herzegovina Romania Ukraine Albania Armenia Republic of Moldova Turkey Georgia Uzbekistan Kyrgyzstan Kazakhstan Azerbaijan Turkmenistan Tajikistan
0 10 20 0 20 40 60 80 100 120 140
Deaths per 1000 live births
Official figures WHO estimate (low) WHO estimate (high)
Overview
In general, the health status of children in the 52 countries in the WHO European Region reflects the widening east–west gap seen in adults, with health worsening as one moves from Eur-A to -B and then -C. In contrast to this pattern, however, high rates of respiratory and infectious diseases in Eur-B mean that overall child mortality is higher in this group than in Eur-C. In Eur-A, mortality from such causes is already very low, which means a smaller disease burden overall, but the disease patterns include proportionately more NCDs, originating from
Major causes of the burden of disease
The causes and rates of deaths and loss of health in children vary widely across the Region. In general, eastern countries have higher morbidity and mortality from respiratory and infectious diseases, and injuries and poisoning. Asthma and obesity rates are rising sharply in the western countries, which have lower mortality. Vaccine-preventable diseases remain a worry across the Region. The different patterns of child and adult health underline the need for countries to design complementary health strategies for the two.
complex interactions of genetics, behaviour and the environment, such as asthma and allergies, diabetes, obesity and neuropsychiatric disorders.
Overall, the countries in the Region have made substantial progress in reducing mortality and morbidity from acute conditions, although considerable problems remain in many countries in Eur-B and -C, particularly Turkey and the countries in the Caucasus and central Asia.
Unintentional and intentional injuries remain much too frequent in all countries. In addition, evidence is accumulating of growing inequalities in health in many countries.
This section of Part 3 begins by analysing mortality in the group aged 0–14 years, which provides one very important view on children’s health. An analysis of the DALY estimates for this age group follows, and provides useful additional insights. The section concludes by examining two additional types of indicators of child health: largely preventable conditions and very complex conditions.