Ayaga Bawah, PhDPrincipal Research Associate

INDEPTH Network Accra, Ghana

Using Demographic Surveillance Systems to Monitor Progress in

MDGs 4 and 5

Presented at African Science Academies Development Initiative meeting in Accra, Ghana, Nov 9-11, 2009.

Introduction

All African countries aim to reduce both childhood and maternal mortality by two thirds over the 25-year period ending in 2015 from 1990.

Yet, with only a decade remaining in the MDG framework, maternal and child mortality remains unacceptably high in Africa

The 2007 UN MDG progress report expressed concerned about the low pace in childhood mortality decline in SSA

Similarly, maternal mortality remains highThe UN report described the lack of progress with MDG5

(maternal mortality) as a “Global Scandal”One critical issue that most African countries face is how to

monitor progress of the MDGs

Measurement is critical

“A Millennium Development Goal which cannot be monitored cannot be met or missed.”

Johansson and Stewart, UNDP, 2002

This presentation seeks to highlight the importance of longitudinal health and demographic surveillance systems (HDSS) in monitoring MDGs 4 and 5.

How do we measure progress?

Process indicators…Infant and child mortality ratesMaternal Mortality Rate

What options exists for measuring outcomes?

Censuses Poor in capturing events…periodicity too long

Civil Registration Systems Poorly developed

Periodic Surveys Large sample size Estimate events several years before survey Wide confidence intervals

Sample registration with vital events registration

Health records, etcHealth and Demographic Surveillance Systems

Cover entire districts Verbal Autopsy

What is HDSS and how does it operate?

INDEPTH Network

Process of defining risk in a population and corresponding demographic events: birth rates, death rates, and migration events, over time

For surveillance to exist, certain basic operations must exist

A census must define the population under study

Periodic follow up to monitor changes over time.

Core elements of a HDSS

Key events monitored:

Births Deaths Migrations in-and-out of the area.

Other characteristics of individuals are recorded -- relationships, ages, immunization, educational attainments and other socio-economic attributes.

Prospective monitoring of demographic and health events

Verbal autopsy for cause of

death

Capturing episodes of disease and hospital

admission

Measure characteristics of environment or household

members (e.g. SES, vaccines, HIV, nutrition)

Intervention trials

(randomised)

Data permit the longitudinal observation of individuals because…

• Each individual has a unique identifier for linking events, individuals, and groups.

• The system of recording births registers exact dates of birth and maternal relationships. Mothers not experiencing birth are defined.

• The system records deaths with dates of deaths and links to individuals at risk. Individuals surviving at a point in time are also defined.

• The registration of migration in and out of the area permits precise individual level definition of censoring.

Attributes

The Millennium Development Goals(MDGs) : Measurable Indicators involving

individuals, families, or relationships

1. Eradicate extreme poverty and hunger

2. Achieve universal primary education

3. Promote gender equality and empower women

4. Reduce child mortality (“Core” output)5. Improve maternal health (“Core” output)6. Combat HIV/AIDS, malaria and other diseases

7. Ensure environmental sustainability

8. Global Partnership

Trends in Infant Mortality Rates KND (July 1994-June 2003)

0

20

40

60

80

100

120

140

July 94-June95

July 96-June97

July 98-June99

July 00-June01

July 01-June02

July 02-June03

Period

Rat

e pe

r 10

00

0.0

00

00

.00

25

0.0

05

00

.00

75

0.0

10

00

.01

25

m(x

)

0 12 24 36 48 60age(months)

children aged 0-59, months

Infant and Child Mortality

Trends in under five mortality in Ghana and the MDG Targets

0

20

40

60

80

100

120

140

160

180

200

1985 1990 1995 2000 2005 2010 2015 2020

Year

Ind

icat

ors

Underfive mortality_NavrongoUnderfive mortality_Ghana DHSLinear (Official MDGTrajectory)

District level demonstration

Source: de Savigny D et al. 2004

0.0

00

.25

0.5

00

.75

1.0

0S

urv

iva

l

0 2 4 6Analysis time in years

None Partial

Full

Kaplan-Meier Cumulative Probabilities of Survival, by immunization status of under five children

Source: Bawah et al. 2008

SOURCE: Ghana health service, reproductive and child health unit, annual report, 1994-2004

Institutional MMR in Ghana

Maternal Mortality Ratio (institutional) by year for Ghana from 1994 to 2004 with a projected trend up to 2015

0

50

100

150

200

250

300

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Year

MM

R

MMR Linear trendline modeling maternal mortality ratio up to 2015

Concluding remarks…

Longitudinal demographic data allows for continuous monitoring of demographic and health events over time

Provides process indicators for measuring progressPlatform intervention studies and to monitor progress

of those interventionsHDSS sites can be constituted into national sentinel

sites for measuring progress of the MDGS.INDEPTH Network provides a great opportunity to

contribute to monitoring the MGGs in Africa

Currently 35 sites in 18 countries24 sites in Africa10 sites in Asia1 site in Oceania

Close to 3 million people under surveillance

INDEPTH Network

West AfricaOubritenga, Burkina Faso (150,000)Nouna, Burkina Faso (76,847)Navrongo, Ghana (140,000)Kintampo, Ghana (145,000)Dodowa, Ghana ( 96,921) Farafenni, The Gambia (16,883)Bandim, Guinea Bissau (101,000) Niakhar, Senegal (35,000)Mlomp, Senegal (7,500)Bandafassi, Senegal (11,200)

East AfricaButajira, Ethiopia (40,000)Rakai, Uganda (12,000)Iganga, Uganda (62,000)Nairobi, Kenya (68,598)Kisumu, Kenya (135,000)Kilifi, Kenya (220,000)Ifakara, Tanzania (67,000)

Rufiji, Tanzania (90,000)

Magu, Tanzania (28,000)

Southern AfricaManhica, Mozambigue (80,000)Dikgale, South Africa (8,000)Agincourt, South Africa (70,000)Africa Centre, South Africa (90,000)Karonga, Malawi ( 40,000)

1

23

4

5

6

7

1- Ethiopia

2-Kenya

3- Uganda

4-Tanzania

5-Malawi

6- Mozambique

7- South Africa

8 - Senegal

9 - The Gambia

10-Guinea Bissau

11-Burkina Faso

12- Ghana

8910

11

12

Total Population

1,815,349

INDEPTH Demographic Surveillance Sites in Africa

Thank you!