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Availability of data in CIS countries on the health-related indicators of the Millennium Development Goals

By:

Adilet-Sultan Meimanaliev

Remigijus Prochorskas

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Summary

Monitoring the progress made towards achieving health-related Millennium Development Goals (MDGs) depends on the availability of data on the associated indicators and on the quality of that data. This report provides an assessment of the current situation regarding the availability of data required to produce the health-related MDG indicators in the Commonwealth of Independent States (CIS). It also discusses common and country-specific problems of the national health information systems as related to their capacities to produce the data required for the MDG indicators. The report was prepared for and presented as a background paper at the Meeting on MDG-related and other health indicators in the Commonwealth of Independent States, Almaty, Kazakhstan, 28-30 September 2005, organized by the WHO Regional Office for Europe within the framework of the CARINFONET Project.

Keywords

HEALTH STATUS INDICATORS DATA COLLECTION – standarts

DELIVERY OF HEALTH CARE – organization and administration GOALS

STATISTICS

COMMONWEALTH OF INDEPENDENT STATES EUROPE

EUR/05/5059667 E89350

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© World Health Organization 2006

All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full.

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation “country or area” appears in the headings of tables, it covers countries, territories, cities, or areas.

Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. The views expressed by authors or editors do not necessarily represent the decisions or the stated policy of the World Health Organization.

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CONTENTS

Page

Acknowledgements . . . . 1

Executive Summary . . . . 2

Introduction . . . . 3

Purpose and methodology. . . . 4

Results . . . . 5

Health information systems and MDGs. . . . 5

Completeness of birth and death registration . . . .7

Live birth definitions . . . .9

Review of data availability . . . 10

Conclusions and recommendations . . . 16

References . . . . 18

Annex . . . . 19

Table 1: Prevalence of underweight children under-five years of age . . . 20

Table 2: Under-five mortality rate. . . 22

Table 3: Infant mortality rate . . . . 24

Table 4: Proportion of one-year-old children immunized against measles . . . 26

Table 5: Maternal mortality ratio . . . 28

Table 6: Proportion of births attended by skilled health personnel. . . 30

Table 7: Condom use rate of the contraceptive prevalence rate . . . . 32

Table 8: Prevalence and death rates associated with malaria . . . . 34

Table 9: Prevalence and death rates associated with tuberculosis . . . . 36

Table 10: Proportion of tuberculosis cases detected and cured under DOTS. . . 38

Table 11: Proportion of population with sustainable access to an improved water source, urban and rural . . . . 40

Table 12: Proportion of population with access to improved sanitation, urban and rural . . . . 42

Table 13: Proportion of population with access to affordable essential drugs on a sustainable basis . . . . 44

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Abbreviations

CARINFONET: CAR Information Network – WHO Project “Information Network of the Central Asian Republics”

CIS: Commonwealth of Independent States CSO: Country Statistics Office

DHS: Demographic and health survey DOTS: Directly observed treatment strategy HIS: Health information system

ILBD: International live birth definition

MDG: Millennium Development Goals of the United Nations Organization MICS: Multiple-indicator cluster survey

MOH: Ministry of Health

RHS: Reproductive health survey

RR: Routine reporting

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Acknowledgements

This paper was initially prepared for and presented at the 10th CARINFONET meeting on MDG‑related and other health indicators in countries of the Commonwealth of Independent States (CIS) in Almaty, Kazakhstan, September 2005. It is based on contributions from countries represented at the meeting.

We should like to express our appreciation to the WHO counterparts in the Ministries of Health and Country Statistics Offices (Goskomstats) of Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, the Republic of Moldova, the Russian Federation, Tajikistan, Ukraine and Uzbekistan for providing data for the report and for their comments on the draft report.

Particular thanks go to Marat Bozgunchiev, Head of the former Information Centre on Health for the Central Asian Republics and Kazakhstan, and to Elmira Subanbaeva, Statistician/

Epidemiologist, WHO Country Office, Kyrgyzstan, for their contributions in collecting information for the report and commenting on the manuscript, as well as for their support in the publishing process.

We should also like to thank Vladimir Verbitski and Anna Müller for their editorial support and useful suggestions and Elisabeth Huybens Hald for her administrative support.

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Executive Summary

This report was prepared as a background paper for the extended 10th CARINFONET meeting on MDG‑related and other health indicators organized by the WHO Regional Office for Europe in Almaty, Kazakhstan, on 28‑30 September 2005. It presents a review of the current situation in the CIS countries as regards the availability and quality of data required for the health‑

related MDG indicators. It highlights some related problems that are common to the national health information systems in the CIS countries.

In 2005, the WHO Information Centre on Health for the Central Asian Republics and Kazakhstan conducted a survey of the CIS health statistics agencies. Information on the available sources of health data, existing data, and the national MDG methodologies was collected by means of a questionnaire, which was distributed to the heads of the national health information centres or departments. A review of the responses and the reported national data on MDG indicators is provided in the Annex.

The report is based on responses from ten countries, as well as on information from other sources.

From the findings, it is possible to conclude that over half of the 18 health‑related MDG indicators can be produced in full or in part based on data routinely collected by the national health information systems of the CIS countries. These are mainly indicators related to mortality and morbidity. Potentially, routine statistics available in the CIS countries can be used to calculate some of the indicators that are usually estimated through special surveys in other countries. For several indicators no data are available due to their limited relevance in the CIS region.

More focused effort is needed on the part of the national providers of health statistics to obtain and process the corresponding primary data required to calculate MDG indicators and to present them in a user‑friendly format. This is important with respect to providing the necessary data to the national institutions and international organizations that are monitoring progress made in the countries towards achieving the MDGs.

The Centre was closed in 2005.

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Introduction

The UN Millennium Declaration, adopted by 189 nations on 8 September 2000, provides a framework for planning and streamlining development activities up to 2015. The signatory countries are committed to reducing poverty and hunger and to addressing ill‑health, lack of education, gender inequality, lack of access to basic amenities and environmental protection.

In September 2001, eight MDGs were presented in the report of the Secretary‑General, “Road map towards the implementation of the UN Millennium Declaration” (1). These specified 18 targets and 48 indicators for monitoring progress towards reaching them. Three MDGs, six MDG targets and 18 MDG indicators relate directly to health.

Since the adoption of the UN Millennium Declaration, many countries have produced national MDG progress reports (2), while major international development agencies have prepared similar reports at global and regional levels. In most of these documents, the importance of availability and quality of data are emphasized as a key factor in monitoring progress within and across countries and regions.

Some of the 18 health‑related MDG indicators can be measured using routine registration data collected through the countries’ health information systems (HIS), for example, mortality‑

based data. The main problems with these indicators relate to accuracy and international comparability. The other indicators are more specific and often require special epidemiological surveys that are carried out at irregular intervals, if at all, or by external agencies. For these indicators the main problem is the availability of data as such.

Within the context of the WHO European Region, MDGs are monitored mostly in the central, eastern and southern parts, in particular in the countries of the Commonwealth of Independent States (CIS) – 12 former Soviet Union republics.

Most of the infrastructure and methodology of the statistical system used in the CIS originates from the former soviet system, the characteristics of which included high centralization, wide scope and disaggregation of statistical reporting. While efforts have been made within the CIS framework to retain single standards (e.g. the Interstate Statistical Committee of the CIS developed model statistical definitions and methodologies to transit from the statistics of the former Soviet Union to international standards (3)), it has not been possible to prevent wide divergencies resulting from differences from country to country.

In this regard, it is useful to explore to what extent the existing health information systems in the CIS are able to produce the comparable data necessary for calculating health‑related MDG indicators.

This report was prepared as a background paper for the extended 10th CARINFONET meeting on MDG‑related and other health indicators in the CIS countries that took place in Almaty, Kazakhstan, on 28‑30 September 2005. The meeting gathered leading experts on health statistics and demography from all 12 countries of the CIS.

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Purpose and methodology

The purpose of the study was to investigate the availability and quality of data on health‑

related MDG indicators in the CIS countries, focusing on the capacity of the existing systems of regular (routine) collection of statistical health information. Available survey data were taken into account as well. The international comparability and disaggregation of the data were also assessed.

In summer 2005, the WHO Information Centre on Health for the Central Asian Republics and Kazakhstan distributed a survey questionnaire to the heads of the health statistics departments in the ministries of health. The questionnaire comprised three parts: 1) information on available sources of health‑related MDG indicators; 2) a detailed description of the national methodologies used to produce these indicators; and 3) information on data available on these indicators since 1990, including data disaggregated by region, where possible.

Fully completed questionnaires were received from Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, the Republic of Moldova and Ukraine. Partially completed questionnaires were received from the Russian Federation, Tajikistan and Uzbekistan. No information was received from Belarus and Turkmenistan.

The responses were summarized and analysed. The methodology published by the UN Millennium Development Group was used as the reference methodology for calculation of the MDG indicators (4).

As the responses vary in completeness and accuracy from country to country, the conclusions reached are not necessarily exhaustive. This report also uses results from earlier studies on the completeness and quality of vital registration conducted in some of the countries.

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Results

Health information systems and MDGs

All of the CIS countries have similar health information systems. The following three information components are relevant to the calculation of MDG indicators:

i Vital registration that takes into account cause of death, based on the civil registration system. Usually, this system is under the country statistics office (CSO), called Goskomstat in most of the countries. Vital registration data can be used to calculate key MDG indicators on infant, child and maternal mortality, as well as on mortality from tuberculosis and malaria.

ii Routine statistical reporting by health care facilities subordinate to the Ministry of Health (MOH). This routine data can be used to calculate some MDG indicators related to incidence/prevalence of diseases or other health factors.

iii Various periodic and semi‑periodic population‑based surveys. Some household surveys are carried out by the CSO. The surveys most relevant to MDGs (e.g. the multi‑indicator cluster survey (MICS) and the demography and health survey (DHS)) are usually those initiated and supported by external agencies. Data from these surveys can be used to calculate “difficult” MDG indicators that cannot be obtained from routine data.

The health information systems of the MOH have wide networks of units at district and regional levels. Data collection within these networks is based on statistical reporting, the forms for which are developed and approved by the CSO and MOH.

There are two levels of reporting: 1) state level: all legal entities and individuals rendering health services, irrespective of ownership and administrative subordination, are required to report to health bodies; and 2) MOH level – all ministry of health system health providers report. Statistical reporting is carried out monthly, quarterly, semi‑annually and annually and for each reporting period there is a are different reporting form. In recent years, paper forms have gradually been replaced throughout the CIS region by electronic documents, depending on the availability of resources for implementation and maintenance of the information technologies and systems.

As mentioned above, the health information systems in the CIS countries are characterized by wide‑scale routine reporting encompassing various aspects of the health care services. The main weaknesses connected to routine reporting include:

• passive mode of data collection: data are based on referrals; vital statistics are often also effected by incomplete registration of births and deaths;

• partial duplication of data;

• incomplete use of the collected information;

• inadequate technological equipment.

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Referral‑based data collection does not capture the whole health picture of the country. The higher the proportion of people with ill health who do not seek care within the health system, the less accurate the estimation of the situation will be.

Since the different information components are administered by different agencies, the health information systems are not fully integrated. This is especially noticeable in vital registration statistics for which information is collected by different agencies. Parallel information flows and multiple sources of data result in different estimates of the same indicators. Studies conducted in some of the CIS countries on the completeness and quality of vital registration have evidenced this.

The limited capacity of the health information system, e.g. insufficient staff, poor technological equipment, often precludes the optimal use of the existing data. Large amounts of detailed data collected by the primary source are usually lost in the process of data aggregation.

Table 1: Implemented and planned health-related surveys (as per mid 2005) Country Demography and

health survey (DHS) Multi-indicator cluster survey (MICS)

Other

Armenia 2000

2005 (MEASURE DHS+) (planned)

2001: Study of completeness and quality of death registration for 1998–2001

Azerbaijan 2000 (MICS 2) 2001: Reproductive Health Survey

Georgia 1999

2005 (planned)

1999: Reproductive Health Survey (2005–planned)

2000: Medical Service Survey 2002: World Health Survey

2002: Global Youth Tobacco Survey Kazakhstan 1995

1999 2005 (planned) 2002: World Health Survey

Kyrgyzstan 1997 2006 – (started) 2001: Health Module of the Family Budget Survey

Republic of

Moldova 2005 (MEASURE DHS+)

(planned) 2000 1997: Reproductive Health Survey

Russian Federation

1996: Reproductive Health Survey 1999: Global Youth Tobacco Survey 2002: World Health Survey

Tajikistan 2000 2001

2005 (planned) Turkmenistan 2000

Ukraine 2000, 2005–planned 1999: Reproductive Health Survey

2002: World Health Survey Uzbekistan 1996 (DHS–III)

2002 (MEASURE DHS+) 2000 (MICS 2) 2006 (planned)

Sources: Websites of the WHO and UNICEF; data from countries.

Internationally recognized population surveys, like MICS and DHS, have been conducted in most of the CIS countries (Table 1). The results of thesesurveys are presumably comparable as they usually use the same methodology. Although they are not always carried out on a regular basis, their methodology and some of their modules are being incorporated into the national population-based surveys. In addition, countries conduct their own surveys, such as those

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for standard of living, household budget, labour force, time budget, energy consumption and others, which can provide certain MDG-relevant data.

MDG monitoring activities are coordinated at the national level in some countries. In Georgia and Kyrgyzstan, for instance, national MDG databases are maintained by the respective CSOs.

Donor agencies, particularly, the UN system organizations largely support these efforts to assist countries in the preparation of common country assessments and MDG progress reports (Table 2).

Table 2: MDG-related reports

Country Common country

assessment MDG progress report

Armenia 2002 2001

Azerbaijan 2001 2003

Georgia 2001, 2004 2003

Kazakhstan 1999, 2003 2002

Kyrgyzstan 1999, 2003 2003

Republic of Moldova 1997 2003

Russian Federation 2002

Tajikistan 2004 2003

Turkmenistan 2000, 2004

Ukraine 2002, 2004 2003

Uzbekistan 2001, 2003

Source: (2).

Some of the health‑related MDG indicators are quite specific and relevant only to developing countries; many CIS countries have modified these and added national MDG indicators that reflect the country‑specific health needs.

Completeness of birth and death registration

Incomplete registration of births and deaths, especially infant deaths, is found in many CIS countries. Incomplete primary data result in considerably distorted vital registration indicators and inaccuracies in several key MGD indicators.

The problem of incomplete registration of births and deaths is relevant mostly to the countries of Central Asia and Transcaucasia. The problem is well known and recognized at the international level. It is usually demonstrated by comparing infant and child mortality rates, estimated on the basis of survey results, with the official statistics data. Survey‑based estimates show much higher rates than the official data. Even though survey‑based estimates have their own inherent methodological and precision problems, they allow an assessment of the extent to which mortality is understated in the official data as a result of incomplete registration of births and deaths.

Recently, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) have developed harmonized estimates of child mortality using special methodologies and data from different sources. At present, these estimates are widely used at the international level.

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As far as possible, the WHO Regional Office for Europe assists countries in taking action to improve the completeness and quality of vital registration. These efforts are aimed mainly at:

• raising the awareness of health authorities and practitioners by estimating the inaccuracy of the official statistical data on mortality as a result of incomplete registration of deaths. In the simplest case, the estimation is made by comparing the births and deaths registered separately by the MOH and CSO;

• reaching agreement on merging MOH and CSO data in order to improve the completeness of registration data in general;

• implementation of the international live birth definition (ILBD) to ensure completeness and international comparability of the data.

Studies on the completeness and quality of vital registration were conducted in Armenia (2003), Azerbaijan (2003 and 2004), Georgia (2000, 2003 and 2005), and Kyrgyzstan (2000).

In the Republic of Moldova, the completeness of vital registration was assessed within the frameworks of the MICS (2000) and DHS (2005) studies, while infant and child mortality registration was assessed under DHS (2005).

The key findings of these studies follow.

In all countries, vitality data are available from two health information systems (MOH and CSO) working in parallel. The CSO is deemed the official data source. Births and deaths are testified by medical birth and death certificates issued by health personnel to relatives of the newborn or deceased. The relatives are required to register births or deaths with the civil registration authorities who issue an official birth/death certificates and report the events to the regional CSO The regional CSO codes and records the data, which are then passed on, in aggregated form, to the national CSO for inclusion in the official published data. Copies of the medical birth and death certificates are retained by the health facilities that report corresponding data through the MOH information system. Since this system has primary vitality data, it has proven to present more complete data.

Nonetheless, there are exceptions. In the Republic of Moldova, for instance, under the joint Order of the Ministry of Health and Social Protection, the National Statistics Bureau and the Ministry of Information Development, the vitality registration data are collected through a unified information system that ensures the completeness and identity of the demographic data used by the different agencies.

In a number of other countries, studies have confirmed significant discrepancies between the MOH data and the CSO data. They show an understatement of births ranging from 8% in Kyrgyzstan to 22% in Georgia, and to 27% in Armenia. The understatement of infant deaths ranges from 18% in Georgia to 47% in Armenia and to 55% in Azerbaijan (5,6,7,8,9).

In general, such discrepancies are more prevalent in rural areas, one of the determining factors being the relatively high fee for registration of documents. Such fees are gradually being abolished or the amount lowered. Difficulties in accessing the registration departments, no immediate practical need for birth or death certificates, and citizen status are also important factors. In rural areas, it is not necessary to produce a death certificate in connection with a burial as cemetery space is ‘unlimited’. In comparison, cemetery space in cities is strictly limited and a death certificate is required for a burial. With regards to citizen status, in Kyrgyzstan, for example, births of foreign citizens (including refugees) are not registered.

Residence is also an important factor, particularly in rural areas, where maternity clinics only

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register births when mothers are included in the district register and do not register births when they are from outside the area.

Incorrect coding of cause of death is also a serious problem in the countries. Discrepancies between data on treatment protocols and those on official cause of death amount to about 34% in Georgia and 20% in Kyrgyzstan. Wrong coding is based on two factors: 1) health personnel do not have enough training in the correct completion of medical death certificates and the coding of deaths (ICD‑10 codes); 2) health personnel use non‑standard forms for death certificates that complicate coding.

The situation is however beginning to improve, at least in some of the countries. For example, the work that has been ongoing in Kyrgyzstan since 2000 on coding of deaths according to the ICD‑10 has resulted in a more complete register. In 2004, the situation also began to improve in Georgia.

Live birth definitions

Another important factor leading to understatement of infant and child mortality rates in some countries is the use of the live birth definition of the former Soviet Union rather than the international live birth definition.

International WHO definition: Live birth is the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached. Each product of such a birth is considered liveborn.

Definition of the Former Soviet Union: Live birth is the complete expulsion or extraction from its mother of a fetus at the 28th or more week of pregnancy (i.e. fetus 35 cm and more long, and with mass of 1000 g and more), which, after such separation, has taken at least one breath independently.

Fetuses born before the 28th week of pregnancy (i.e. with length less than 35 cm and body mass less than 1000 g), and having lived over 7 days (i.e. after the end of perinatal period) are considered liveborn in pre-term deliveries.

The ILBD has been used in Azerbaijan since 2002, in Georgia since 1995, in Kyrgyzstan since 2004, in the Russian Federation since 1993, and in Ukraine since 1996 (only within the MOH system). In Armenia it has been used partially since 1995. Other countries are preparing to shift to the ILBD in the near future.

A formal declaration on the introduction of the ILBD, for instance in the form of a MOH decree/order, does not necessarily mean that the new definition is being used by all health facilities and that it is reflected in the national statistics data. The actual introduction of the ILBD may require changes and amendments in the national legislation, as well as additional resources, effort and time. In Ukraine, for example, the ILBD was adopted by the MOH in 1996; however, the CSO continued to use the old definition until 2004.

Usually, the introduction of the ILBD is followed by a sharp growth of registered infant mortality due to an increase in the registration of neonatal mortality. Such an increase was observed in Kyrgyzstan in 2004.

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0 Review of data availability

The conclusion reached on the basis of the responses received is that the majority of the countries have the capacity to produce the data necessary for estimating health‑related MDG indicators on the basis of routine reporting or surveys. However, for a number of the indicators, the national methodologies differ from the internationally‑adopted methodology. For example, different live birth definitions are being used. A rough assessment of the availability and comparability of data based on responses from countries is presented in Table 3.

Tables 1‑13 of the Annex summarize the information obtained from the countries, showing the mode of data collection, available time series, level of data disaggregation, and differences between the international and national methodologies.

As already noted above, the data presented are only an illustration of the potential availability of MDG data. To be used practically, the data should be verified and supplemented by additional data.

Indicator 4: Prevalence of underweight children under five years of age The routine reporting systems of Armenia, Kazakhstan, the Republic of Moldova and Uzbekistan can produce such indicators as: the proportion of children under one year of age with low body mass (I, II and III degrees hypotrophy); the number of children aged 0‑5 years with hypotrophy per 1000; and the proportion of underweight children aged 1‑4 years (Annex – Table 1).

Kyrgyzstan has modified Indicator 4 to calculate the proportion of underweight children aged 1‑6 years; this calculation is based on household panel data. No data on this indicator were reported in the Russian Federation. In the Republic of Moldova, under DHS in 2005, nutritional status indicators (age/weight, height/age and weight/height coefficients) were estimated for children under‑5 years and women aged 15‑49 years.

In terms of the survey‑based data, whereas the MICS methodology is fully compliant with international MDG definitions and methodology, the DHS methodology differs in that undernourishment in children aged 0‑35 months is measured. However, both surveys produce such indicators as age/weight, height/age and weight/height deficiency that allow a more comprehensive and univocal interpretation of the data on underweight.

In general, data comparability for this indicator across countries is limited.

Indicator 5: Proportion of population below minimum level of dietary energy consumption

No routine reporting data exists in the CIS countries to estimate this indicator since, historically, adult undernourishment has not been common in these countries. A number of countries, however, have survey data on the basis of which the average daily calorie intake is estimated.

These data may potentially be used to estimate the MDG indicator given the national minimum dietary energy consumption thresholds.

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Table 3: Availability and comparability of data on health-related MDG indicators in the CIS

MDG indicators

Armenia Azerbaijan Georgia Kazakhstan Kyrgyzstan Republic of Moldova Russian Federation Tajikistan Ukraine Uzbekistan

4. Prevalence of underweight children (under- five years of age)

5. Proportion of population below minimum level of dietary energy consumption

13. Under-five mortality rate

14. Infant mortality rate

15. Proportion of 1 year old children immunized against measles

16. Maternal mortality ratio

17. Proportion of births attended by skilled health personnel

18. HIV prevalence among 15-24 year old pregnant women

19. Condom use rate of the contraceptive prevalence rate

20. Number of children orphaned by HIV/AIDS 21. Prevalence and death rates associated with malaria

22. Proportion of population in malaria risk areas using effective malaria prevention and treatment measures

23. Prevalence and death rates associated with tuberculosis

24. Proportion of TB cases detected and cured under DOTS (Directly Observed Treatment Short Course)

30. Proportion of population with sustainable access to an improved water source, urban and rural

31. Proportion of people with access to improved sanitation

46. Proportion of population with access to affordable essential drugs on a sustainable basis

– Data not available or it’s availability unknown – Data available, national definition

– Data available, international definition

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Indicator 13: Under-five mortality rate

In all the CIS countries, data for this indicator is collected through routine MOH and/or the CSO reporting (Annex – Table 2). Disaggregated data are available by region and rural/urban areas. Some countries can also produce data disaggregated by other factors, such as ethnicity.

As mentioned earlier, the accuracy and comparability of data may be limited for some countries owing to incomplete vital registration and the use of the live birth definition of the former Soviet Union. The same applies to infant mortality.

Indicator 14: Infant mortality rate

Infant mortality data exist in all countries with the same breakdown as the under‑five mortality data (Annex –  Table  3). As well as the differences in the live birth definition used by the countries, the formulas used also vary. Until 2003 Kazakhstan used the RATS formula, which includes the denominators: one third of live births in the previous year, and two thirds of live births in the reference year. The Russian Federation, Ukraine and Uzbekistan use another formula that calculates infant mortality as the sum of infant deaths/live births ratios in the previous year and the reference year. Other countries use the international formula, the denominator of which includes live births in the reference year.

Indicator 15: Proportion of one-year-old children immunized against measles

Data on this indicator are available through routine reporting in all countries (Annex – Table  4). All countries have data disaggregated by region; most of them have data also disaggregated by urban/rural areas and can potentially produce data disaggregated by sex and ethnicity.

It should be noted that Kazakhstan and the Republic of Moldova calculate this indicator for vaccinated children below two years of age, while other countries produce estimates for children under one year of age. In the Republic of Moldova, this is because immunization against measles is carried out at the age of 12 months; hence, children under one year of age are not subject to vaccination. This situation must be inherent to countries where the age for immunization against measles is above one year. Nonetheless, both methodologies fall under the international definition and are comparable.

Indicator 16: Maternal mortality ratio

Maternal mortality data (Annex –  Table  5) are collected through routine reporting in all countries and are available by region. As for other mortality indicators, there are two data sources (MOH and CSO) that can give significantly different results.

These data are disaggregated by urban/rural area in six countries, by ethnicity in two countries and by socio‑economic status also in two countries. Four countries can potentially produce disaggregated data by ethnicity.

The prevalence of anemia in pregnant women is included as a national MDG indicator in six countries. Data for this indicator are collected through routine reporting in all six countries where identical methodology is used to estimate the indicator. Data are disaggregated by

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region in all the countries; in Kazakhstan they are also disaggregated by urban/rural areas.

Kyrgyzstan, Ukraine and Uzbekistan can potentially produce them by urban/rural areas, ethnicity and age.

Indicator 17: Proportion of births attended by skilled personnel

In most countries data on this indicator are collected through routine reporting as a proportion of births in health facilities (Annex –  Table  6) and disaggregated by region. A number of countries can potentially produce the data by urban/rural areas, by ethnicity and age.

Data on this indicator are comparable across countries.

Indicator 18: HIV-prevalence among pregnant women aged 15-24

Responses show that some data on this indicator are available in Armenia, Kazakhstan and possibly in some other countries; however, their informational value is not high due to the very low frequency of cases. In the response from Armenia, for example, only one case of HIV in a pregnant woman in this age group was reported in 2003. Most countries responded that they have data on the total number of registered HIV‑infected people and that these data can be disaggregated by sex and age.

Indicator 19: Condom use rate of the contraceptive prevalence rate

Five countries collect data on this indicator through routine reporting or surveys (Annex –  Table 7). In the Republic of Moldova, collection of these data was introduced in 2005. Data on the proportion of the population using any type of contraceptive are likely to be available in most of the countries.

Indicator 20: Ratio of school attendance of orphans to school attendance of non-orphans aged 0- years

Only Azerbaijan, Georgia and Ukraine have some data or estimates on this indicator. In Azerbaijan, for instance, the cumulative number of AIDS orphans for 1990‑2004 is 140. The other countries have no readily available data but can potentially produce them, even though they would be insignificant within the context of the CIS countries.

It is worthwhile to note that the last three‑mentioned MDG indicators are intended to reflect the situation surrounding the HIV/AIDS pandemic. In this regard, given the fast spread of the infection among injecting drug users, some CIS countries use their national MDG indicators, such as the number of registered HIV/AIDS cases and the number of registered drug addicts.

All countries collect these data through routine reporting carried out by their national AIDS and narcology agencies. All countries have data by region and can potentially produce more disaggregated data. Data on these national MDG indicators are likely to be comparable across countries.

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Indicator 21: Prevalence and death rates associated with malaria

Data on malaria prevalence and death rates is available in all countries through routine reporting by the epidemiological surveillance services (Annex – Table 8). These data comply with the international methodology and are comparable across countries. The general system of registering death by cause (CSO) is the main source of data for malaria mortality. All countries have disaggregated data.

Indicator 22: Proportion of population in malaria-risk areas using effective malaria prevention and treatment measures

Only Armenia reported having some data on this indicator. In some countries at high risk for the spread of malaria (Azerbaijan, Kyrgyzstan and Uzbekistan) zoning was carried out to grade the territories as low, moderate or high risk malaria potential. National malaria programmes define effective treatment measures, i.e. anti‑malarial drugs. This indicator can be estimated provided that additional studies are carried out.

Indicator 23: Prevalence and death rates associated with tuberculosis Data on tuberculosis are available in all countries (Annex – Table 9). They are collected through routine reporting and are very detailed given the traditionally strong vertical tuberculosis control programmes. National methodologies generally comply with the international one, therefore the data are likely to be comparable across countries.

It should be noted, that there is a certain amount of confusion in the meaning of the term

“prevalence” in Russian language. Most responses contained data on TB incidence, i.e. new cases detected in the reference year. The MDG indicator (prevalence) implies both the new and treated cases registered in the reference year.

Indicator 24: Proportion of tuberculosis cases detected and cured under DOTS

All countries that introduced DOTS have data on this indicator (Annex – Table 10). This data is available in different breakdowns, compliant with international methodology and comparable across countries.

Given the growing prevalence of brucellosis, a number of countries also have prevalence and death rates associated with brucellosis as a national MDG indicator.

Indicator 30: Proportion of population with sustainable access to an improved water source, urban and rural

Most countries reported the availability of survey‑based data on this indicator (Annex –  Table 11). Disaggregated data are available by region and by urban/rural areas.

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In their national definitions, Kazakhstan and the Republic of Moldova use only water provided through a water supply system. Other countries use all water sources in their definitions, except unprotected reservoirs, and they do not specify distance from water source.

Indicator 31: Proportion of population with access to improved sanitation, urban and rural

In their national definitions, most of the countries include only access to a centralized sewer system (Annex – Table 12).

Indicator 46: Proportion of population with access to affordable essential drugs on a sustainable basis

Azerbaijan is the only country in the study that has estimates of this indicator (aggregated for 1990‑2000) (Annex –  Table 13). In Kazakhstan, people enjoy the right to free health care within a defined benefit package, including free drugs. In other countries, within the framework of drug provision to vulnerable populations (based on social status and disease), there are public schemes for the exempt provision of drugs (full exemption (free drugs) and partial exemption). However, these do not provide a clear picture of which essential drugs are provided and whether they are available to all those eligible to receive them.

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Conclusions and recommendations

1) Health information systems in the CIS countries have a wide network of units working together in a hierarchical reporting system using detailed reporting forms. They can potentially produce routinely collected data on most of the MDG indicators, including some that, in other countries, are estimated only on the basis of surveys. There are also CSO‑conducted periodic household surveys, but these focus on non‑health dimensions, such as household expenditure or living conditions. In some cases, they may serve as a data source.

2) Recently, with support from external agencies (e.g., USAID for DHS; UNICEF for MICS), semi‑periodic or ad hoc population surveys were conducted in most of the CIS countries. These surveys focus on mother and child health and are used as alternatives to or the only data source for relevant MDG indicators.

3) National vital registration routine reporting systems generate mortality data by cause, age and sex. These data are needed for the calculation of health‑related MDG indicators on infant, child and maternal mortality, and mortality from malaria and tuberculosis and are available in all countries. This data source should be supplemented by data collected through the MOH system in order to improve completeness and accuracy.

Mortality data can be disaggregated by region and, in some cases, by other factors.

4) There are two problems that compromise the accuracy and hence the value of the statistical data on mortality: (1) incomplete registration of births and deaths; and (2) the use of the live birth definition of the former Soviet Union, which differs from the international standard. These problems are inherent mainly to the CAR and the Caucasus countries. Therefore, for these countries, survey‑based estimates are usually used as an alternative source. To this end, WHO and UNICEF have developed harmonized estimates of child and infant mortality using various data sources.

There is evidence that, at least in some countries (e.g., Georgia and Kyrgyzstan), efforts made to improve the completeness of the official births and deaths register are starting to show results.

5) In addition to mortality‑based indicators, MOH routine reporting systems in the CIS can usually produce referral‑based data on the following MDG indicators: incidence and prevalence of malaria and tuberculosis, immunization against measles, number of tuberculosis cases detected under DOTS (in countries where DOTS has been introduced), and the proportion of births attended by skilled health personnel (estimated on the share of home deliveries). Also, there are data on modified indicators of the prevalence of underweight children, the prevalence of the use of contraceptives and the prevalence of HIV in women. These indicators differ however from the international MDG indicator definition.

6) Data on the accessibility of safe, potable water and improved sanitation are based mainly on household surveys. However, it is possible that some estimates may also be obtained using data from the national housing registers.

7) As they are of little relevance in the CIS countries, there are basically no routinely reported data on the following four MDG indicators: proportion of population below

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the minimum level of dietary energy consumption; number of children orphaned by HIV/AIDS; proportion of the population in malaria risk areas using effective malaria prevention and treatment measures; and sustainable access to affordable essential drugs.

8) Although many data are collected through routine reporting, this does not mean that necessary primary data are easily obtainable or retrievable or that MDG indicators are easily calculated and accessible to potential users (except for a few of the most commonly‑used indicators, such as infant and maternal mortality).

In order to retrieve and process the appropriate primary data for the calculation of MDG indicators and present them in a user friendly format, more focused efforts are required by the producers of health statistics in the countries.

It is recommended that the national institutions responsible for the routine collection and dissemination of health data in the country (i.e. health information centres under the MOH) process – on a regular basis – all the available primary data related to MDGs, compute their values in a breakdown of regions and other possible factors, and make the results available to the public, together with information on methodology and sources.

This is an essential step in providing relevant national and international organizations interested in monitoring countries’ progress regarding MDGs with necessary data.

It is recommended that all possible MDG indicators, including national modifications, be included in the national databases on health indicators to ensure wide and easy access to available data.

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References

1. United Nations. Road map towards the implementation of the United Nations Millennium  Declaration. Report of the Secretary‑General. A/56/326. United Nations, 2001.

2. UNDP web site http://www.undp.org/mdg/countryreports.html.

3. Interstate Statistical Committee of the CIS web site: http://www.cisstat.com.

4. United Nations Development Group. Indicators  for  Monitoring  the  Millennium  Development Goals: Definitions, Rationale, Concepts and Sources. ST/ESA/STAT/SER.

F/95. United Nations: New York, 2005.

5. Center for Medical Statistics and Information, WHO Regional Office for Europe. Survey of completeness and quality of death, birth and fetal death registration by the civil acts registration bodies and health care in Georgia. Tbilisi, 2000.

6. Ministry of Health of Azerbaijan, WHO Regional Office for Europe. Assessment  of completeness  of  birth  and  death  registration  in  the  Republic  of  Azerbaijan. Baku, 2004.

7. Republic of Armenia Ministry of Health, State Statistical Service. Mortality-births underreporting study. Erevan, 2004.

8. Republican Medical Information Center. Survey study report on the completeness of registration and quality of medical documentation on births and deaths in civil registration bodies and health facilities in the Kyrgyz Republic in 2000. Bishkek, 2000.

9. Ministry of Labor, Health and Social Affairs of Georgia, Department for State Statistics, WHO Regional Office for Europe. Comparison of completeness of birth and death data collected by two systems: Quality assessment of death certificate information and coding of the main cause of death. Tbilisi, 2003.

10. Methodological note. DCD/DAC(98)6/ADD. (OECD document) http://www.oecd.org/

dataoecd/3/45/1896978.pdf.

11. United Nations Statistics Division – Millennium Indicators Database: http://unstats.

un.org/unsd/mi/mi_goals.asp.

All referenced web-sites were accessed in June-July 2005.

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Annex

Summary data Tables –

Notes:

Breakdown of data:

1 – by region 2 – by urban/rural 3 – by sex

4 – by ethnicity

5 – other factors (or factors measured during surveys)

√ – readily available

¤ – available but requiring additional work/research

International definitions are taken from references nos. (4), (10) and/or (11).

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0

Table 1:Prevalence of underweight children under-five years of age a) Methodology and data sources Definition Prevalence of (moderately or severely) underweight children is the percentage of children under five years old whose weight for age is less than minus two standard deviations from the median for the international reference population ages 0–59 months. Computation The weights of the under-five child population in a country are compared with the weights given in the NCHS/WHO table of child weights for each age group. The percentages of children in each age group whose weights are more than 2 standard deviations less than the median are then aggregated to form the total percentage of children under age 5 who are underweight. CountryMode of collectionNational methodologyDisaggregation ARMMOH RRProportion of children with low body mass (I, II and III degrees hypotrophy) under one year old AZECSO surveyComplianceBy income level and socioeconomic status GEOCSO surveys (1998–2001)Full compliance. All three indicators available: weight/age, height/age, weight/heightMICS KAZMOH RRNumber of children 0–5 years old with hypotrophy per 1000DHS KGZCSO panel surveys (1996–2002) Since 2005, survey with quarterly change of sample

1) Proportion of underweight children 1–6 years old 2) DHS 1997 children 0–35 months all three indicators available: weight/age, height/age, weight/height¤¤DHS MDAMOH RR; CSO survey; DHS 2005Weight/age, height/age, weight/height indicators for children 0–4 years oldDHS UKRCSO surveyCompliance UZBMOH RRProportion of underweight children 1–4 years old¤¤DHS

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b) Presented data Country0000000000000 ARM2.83.23.93.43.52.82.52.1 AZE4.24.8 GEO3.1 KAZ0.91.11.11.41.3 KGZ4.67.96.26.67.212.4 MDA0.50.50.80.91.21.21.31.31.51.61.21.31.24.3 (DHS) UKR6.4

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