WORLD HEALTH STATISTICS 2008 2008 W ORLD H EALTH S TATISTICS WHO Library Cataloguing-in-Publication Data World health statistics 2008. 1.Health status indicators. 2.World health. 3.Health services - statistics. 4.Mortality. 5.Life expectancy. 6.Demography. 7.Statistics. I.World Health Organization. ISBN 978 92 4 156359 8 (NLM classi cation: WA 900.1) ISBN 978 92 4 0682740 (electronic version) © World Health Organization 2008 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). 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. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of speci c 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. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. This publication was produced by the Department of Measurement and Health Information Systems of the Information, Evidence and Research Cluster, under the direction of Ties Boerma, Carla Abou-Zahr and Yohannes Kinfu, in collaboration with WHO technical programmes and regional of ces, and assisted by Mie Inoue and Jessica Ho. Valuable inputs to the statistical highlights in Part 1 were received from Carla Abou-Zahr, Maru Aregawi, Eric Bertherat, Ties Boerma, Somnath Chatterji, David Evans, Daniel Ferrante, Christopher Fitzpatrick, Marta Gacic Dobo, Yohannes Kinfu, Doris Ma Fat, Colin Mathers, Richard Cibulskis, Katya Fernandez-Vegas, Lale Say, Maria Cecilia Sepulveda Bermedo, Andreas Ullrich, and Ke Xu. Contributors to the statistical tables in Part 2 were: Michel Beusenberg, Monika Bloessner, Cynthia Boschi Pinto, Anthony Burton, Claudia Cappa, Somnath Chatterji, Claire Chauvin, Mercedes de Onis, Daniel Ferrante, Christopher Fitzpatrick, Alexandra Fleischmann, Marta Gacic Dobo, Jesus Maria Garcia Calleja, Charu Garg, Sandra Garnier, Neeru Gupta, Regina Guthold, Chika Hayashi, Jessica Ho, Rifat Hossain, Mehran Hosseini, Ahmadreza Hosseinpoor, Chandika Indikadahena, Mie Inoue, Yohannes Kinfu, Teena Kunjumen, Edilberto Loaiza, Doris Ma Fat, Colin Mathers, Chizuru Nishida, Vladimir Poznyak, Eva Rehfuess, Dag Rekve, Leanne Riley, Lale Say, Jonathan Siekmann, Jacqueline Sims, William Soumbey-Alley, Yves Souteyrand, Khin Win Thin, Tessa Tan-Torres, Emese Verdes, Tessa Waldraw, Catherine Watt, Jelka Zupan, and many staff in WHO country of ces, governmental departments and agencies and international institutions. Additional help and advice were kindly provided by regional of ces and members of their staff. Ahmadreza Hosseinpoor, Kacem Iaych, Veronique Joseph and Maya Mascarenhas have kindly assisted in checking tables for accuracy. The publication was edited and proofread by Frank Theakston. Support for mapping and the online database was provided by Kathryn O’Neill, Liliana Pievaroli, John Rawlinson, Florence Rusciano and Philippe Veltsos. Production support was provided by the Departmentof Knowledge Management and Sharing, including Caroline Allsopp, Ian Coltart, Laragh Gollogly, Maryvonne Grisetti, Sophie Guetaneh Aguettant and Peter McCarey. The web site version and other electronic media were provided by the Digital Publishing Solution, Ltd. We also thank Petra Schuster for her administrative support. Printed in France 2008 W ORLD H EALTH S TATISTICS 1 Introduction 5 Part 1. Ten highlights in health statistics 7 Progress towards MDG 5: maternal mortality 8 Coverage gap and inequity in maternal, neonatal and child health interventions 10 HIV/AIDS estimates are revised downwards 13 Progress in the fi ght against malaria 15 Reducing deaths from tobacco 18 Breast cancer: mortality and screening 21 Divergent trends in mortality slow down improvements in life expectancy in Europe 24 Monitoring disease outbreaks: meningococcal meningitis in Africa 27 Future trends in global mortality: major shifts in cause of death patterns 29 Reducing impoverishment caused by catastrophic health care spending 32 References 34 Part 2. Global health indicators 35 Mortality and burden of disease 36 Mortality 36 Life expectancy at birth (years) Healthy life expectancy (HALE) at birth (years) Neonatal mortality rate per 1000 live births Infant mortality rate per 1000 live births Under-5 mortality rate (probability of dying by age 5 per 1000 live births) Adult mortality rate (probability of dying between 15 to 60 years per 1000 population) Maternal mortality ratio per 100 000 live births Cause-specifi c mortality rate per 100 000 population Age-standardized mortality rate by cause per 100 000 population Distribution of years of life lost by broader causes (%) Distribution of causes of death among children aged <5 years (%) Morbidity 47 Prevalence of tuberculosis per 100 000 population Incidence of tuberculosis per 100 000 population per year Prevalence of HIV among adults aged ≥15 years per 100 000 population Number of confi rmed cases of poliomyelitis Table of contents 2008 W ORLD H EALTH S TATISTICS 2 Health service coverage 56 Antenatal care coverage (%) Births attended by skilled health personnel (%) Births by caesarean section (%) Neonates protected at birth against neonatal tetanus (PAB) (%) Immunization coverage among one-year-olds (%) Children aged 6–59 months who received vitamin A supplementation (%) Children aged <5 years sleeping under insecticide-treated bednets (%) Children aged <5 years who received any antimalarial treatment for fever (%) Children aged <5 years with ARI symptoms taken to facility (%) Children aged <5 years with diarrhoea receiving ORT (%) Contraceptive prevalence (%) Women who have had PAP smear (%) Women who have had mammography (%) Antiretroviral therapy coverage among HIV-infected pregnant women for PMTCT (%) Antiretroviral therapy coverage among people with advanced HIV infection (%) Tuberculosis detection rate under DOTS (%) Tuberculosis treatment success under DOTS (%) Risk factors 66 Access to improved drinking-water sources (%) Access to improved sanitation (%) Population using solid fuels (%) Low birth weight newborns (%) Children aged <5 years stunted for age (%) Children aged <5 years underweight for age (%) Children aged <5 years overweight for age (%) Adults aged ≥15 years who are obese (%) Per capita recorded alcohol consumption (litres of pure alcohol) among adults (≥15 years) Prevalence of current tobacco use among adults (≥15 years) (%) Prevalence of current tobacco use among adolescents (13–15 years) (%) Prevalence of condom use by young people (15–24 years) at higher risk sex (%) Health systems resources 76 Health workforce and hospital beds 76 Number of physicians and density per 10 000 population Number of nursing and midwifery personnel and density per 10 000 population Number of dentistry personnel and density per 10 000 population Number of pharmaceutical personnel and density per 10 000 population Number of environment and public health workers and density per 10 000 population Number of community and traditional health workers and density per 10 000 population Number of laboratory health workers and density per 10 000 population 2008 W ORLD H EALTH S TATISTICS 2008 W ORLD H EALTH S TATISTICS 3 Number of other health service providers and density per 10 000 population Ratio of nurses and midwives to physicians Ratio of health management and support workers to health service providers Hospital beds per 10 000 population Health expenditure 84 Total expenditure on health as a percentage of gross domestic product General government expenditure on health as a percentage of total expenditure on health Private expenditure on health as a percentage of total expenditure on health General government expenditure on health as a percentage of total government expenditure External resources for health as a percentage of total expenditure on health Social security expenditure on health as a percentage of general government expenditure on health Out-of-pocket expenditure as a percentage of private expenditure on health Private prepaid plans as a percentage of private expenditure on health Per capita total expenditure on health at average exchange rate (US$) Per capita total expenditure on health (PPP int. $) Per capita government expenditure on health at average exchange rate (US$) Per capita government expenditure on health (PPP int. $) Inequities in health care and health outcome 92 Inequalities in skilled birth attendance Inequalities in measles immunization coverage Inequalities in under-5 mortality (probability of dying by age 5 per 1000 live births) Demographic and socioeconomic statistics 96 Population: total (‘000s) Population: median age (years) Population: under 15 (%) Population: over 60 (%) Annual population growth rate (%) Population in urban areas (%) Registration coverage (%): births and deaths Total fertility rate (per woman) Adolescent fertility rate (per 1000 women) Adult literacy rate (%) Net primary school enrolment ratio (%) Gross national income per capita (PPP int. $) Population living on <$1 a day (%, PPP int. $) Footnotes and explanatory notes 104 2008 W ORLD H EALTH S TATISTICS The publisher has intentionally left this page blank. 2008 W ORLD H EALTH S TATISTICS 5 Introduction World Health Statistics 2008 presents the most recent available health statistics for WHO’s 193 Member States. This fourth edition includes 10 highlights of health statistics as well as data on an expanded set of over 70 key health indicators. The indicators were selected on the basis of their relevance to global health monitoring and c onsiderations of data availability, accuracy and comparability among Member States. This publication is in two parts. Part 1 presents 10 topical highlights based on recent publications or results of new analyses of existing data. Part 2 presents key health indicators in the form of six tables for all WHO M ember States: mortality and burden of disease; health service coverage; risk factors; health systems resources; inequities in health care coverage and health outcome; and basic demographic and socioeconomic statistics. This edition i ncludes, for the rst time, data on trends where the statistics are available and of acceptable quality. World Health Statistics 2008 has been collated from publications and databases produced by WHO’s technical p rogrammes and regional of ces, as well as from publicly accessible databases. The data on inequalities in health care coverage and health outcome are primarily derived from analyses of household surveys and are available only for a limited number of countries. It is anticipated that the number of countries reporting disaggregated data will increase during the next few years. Nevertheless, even in their current limited form, the data will be useful for the global public health community. In estimating country indicators based on different data sources, regional of ces and technical programmes a pply peer-reviewed methods and consult with experts around the world. To maximize the accessibility, a ccuracy, c omparability and transparency of health statistics, the technical programmes and regional of ces also work c losely with Member States through an interactive process of data collection, compilation, quality assessment and e stimation. All statistics presented in this publication have, unless otherwise stated, been cleared as WHO’s of cial gures in consultation with Member States. Nevertheless, the estimates published here should still be regarded as best estimates made by WHO rather than the of cial statistics of Member States, which may use alternative r igorous procedures. More detailed information, including a compendium of statistics and an online version of this publication, is a vailable data become available. The web site, which has now been revised with new features and a new look to better meet users’ needs, will allow data to be displayed in different formats such as tables, maps and graphs. It also provides, wherever possible, metadata describing the sources of data, estimation methods and quality a ssessment. Careful scrutiny and use of the statistics presented in this report should contribute to progressively better m easurement of relevant indicators of population health and health systems. 2008 W ORLD H EALTH S TATISTICS from WHO’s Statistical Information System (http://www.who.int/statistics). This will be regularly u pdated as new The publisher has intentionally left this page blank. 2008 W ORLD H EALTH S TATISTICS 7 Part 1 Ten highlights in health statistics 2008 W ORLD H EALTH S TATISTICS 8 PROGRESS TOWARDS MDG 5: maternal mortality The target for monitoring progress towards Millennium Development Goal 5 (MDG 5) (improve maternal health) is to reduce the maternal mortality ratio in all countries so that by 2015 it is one quarter of its 1990 level. This indicator is often described as the most seriously “off track” of all the health-related MDG indicators. The most recent interagency estimates developed by technical experts from academic institutions and international agencies (WHO, UNICEF, UNFPA and the World Bank) provide updated data on maternal mortality, while acknowledging the large uncertainty in these estimates because there are few or no data available for most high-mortality countries. 1 The latest estimate is that 536 000 women died in 2005 as a result of complications of pregnancy and childbirth, and that 400 mothers died for every 100 000 live births (this is the “maternal mortality ratio”, the main indicator of the safety of pregnancy and childbirth). The maternal mortality ratio was 9 in developed countries, 450 in developing countries and 900 in sub-Saharan Africa. This means that 99% of the women who died in pregnancy and childbirth were from developing countries. Slightly more than half of these deaths occurred in sub-Saharan Africa and about a third in southern Asia: together these regions accounted for over 85% of maternal deaths worldwide. MATERNAL MORTALITY RATIO PER 100 000 LIVE BIRTHS, 2005 Pregnancy and childbirth are still dangerous for most women Meeting the MDG target for maternal mortality requires a decline in the maternal mortality ratio of around 5.5% each year. No region in the world has achieved this result. Globally, the maternal mortality ratio showed a total fall of 5.4% in the 15 years between 1990 and 2005, an average reduction of 0.4% each year. Maternal mortality is declining too slowly < 15 15 – 199 200 – 499 500 – 999 ≥ 1000 Data not available [...]... up less than 15% of total spending on health 32 care, fewer households tend to face financial catastrophe due to the cost of health care Other factors, such as the availability of health services and income inequality, do play a role but OOPs for health care are the main factor WORLD HEALTH STATISTICS 2008 Percentage of houheholds with catastrophic expenditure on health care (logarithmic scale) THE... regional levels 9 WORLD HEALTH STATISTICS 2008 C O V E RA GE GA P AN D IN EQU ITY IN MAT E RN A L, N EON ATAL A N D C HILD HEALTH IN TERVEN TIONS Coverage, defined as the percentage of people receiving a specific intervention among those who need it, is a key health system output and an essential indicator for monitoring health service performance.2 Using data available from Demographic and Health Surveys... of catastrophic health care spending because only actual OOPs for health care were included Costs incurred by those who need services but cannot afford them, transport costs and loss of income due to illness were not considered 33 WORLD HEALTH STATISTICS 2008 REF EREN C E S 1 2 Bryce J et al Reducing child mortality: can public health deliver? Lancet, 2003, 362:159–164 3 Countdown 2008 Equity Analysis... March 2008) 20 Financial resources required to achieve universal access to HIV prevention, treatment, care and support Methodological Annex II Revised projections of the number of people in need of ART Geneva, UNAIDS, 2007 21 Global economic prospects 2008 Washington, DC, World Bank, 2008 22 Xu K et al Designing health financing systems to reduce catastrophic health expenditure Geneva, World Health. .. International Health, 2008, 13:218–228 12 Impact of long-lasting insecticidal-treated nets (LLINs) and artemisinin-based combination therapies (ACTs) measured using surveillance data, in four African countries: Preliminary report based on four country visits Geneva, World Health Organization, 2007 13 WHO report on the global tobacco epidemic, 2008: the MPOWER package Geneva, World Health Organization, 2008 14 Breast... 5 Cessation programmes Health warnings 4 Advertising bans Taxation * Note that for taxation, “No policy” implies an exise tax rate 25% or less For smoke-free policy, “No policy” means no smoke-free legislation or no smoke-free legislation covering either health care or educational facilities 19 WORLD HEALTH STATISTICS 2008 Efforts to control tobacco use reach only 5% of the world s population WHO recommends... The impact of population ageing is generally much more important than that of population growth 31 WORLD HEALTH STATISTICS 2008 RE D U C I N G IMP O VERIS HMEN T AND CATA S T R O P H IC HEALTH C A RE S P EN DING Many countries rely heavily on out-of-pocket payments (OOPs) by patients to finance their health care systems OOPs include fees for services levied by public and/or private providers (officially... as more people benefit from treatment and live longer with HIV infection, this will increasingly affect the number of people in the world living with HIV/AIDS WORLD HEALTH STATISTICS 2008 P RO G RE S S IN THE F IGHT AG A INST MA LAR IA Malaria is endemic in many of the world s poorest countries The MDG target aims to have halted and begun to reverse the incidence of the disease by 2015 Indicators for... reported data for possible confounders and biases before they are used for the purpose of MDG monitoring.6 17 WORLD HEALTH STATISTICS 2008 RE D U C I N G DEATHS F ROM TO BAC CO Tobacco use is the single largest cause of preventable death in the world today The WHO report on the global tobacco epidemic, 20081 3 provides a comprehensive analysis, based on data from 135 countries, of patterns of tobacco use,... Treatment of sick children 100 Coverage gap (%) (A) (B) 11 WORLD HEALTH STATISTICS 2008 Understanding the data and estimates The coverage gap index is a summary measure of the difference between maximum and actual coverage for key interventions It has been constructed to reflect a range of essential public health interventions that draw on different health system delivery strategies Such a summary measure . WORLD HEALTH STATISTICS 2008 2008 W ORLD H EALTH S TATISTICS WHO Library Cataloguing-in-Publication Data World health statistics 2008. 1 .Health status indicators. 2 .World health. 3 .Health. 0682740 (electronic version) © World Health Organization 2008 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue. S TATISTICS 5 Introduction World Health Statistics 2008 presents the most recent available health statistics for WHO’s 193 Member States. This fourth edition includes 10 highlights of health statistics as well as