2000 Trends Analysis2000 Trends Analysis

Population, Health and Nutrition Team

Bureau for Latin America & the CaribbeanUS Agency for International DevelopmentJune 30, 2000

2

Inputs Utilized for the Analysis

Health and Economic Indicators Sources: DHS, CDC, WB/WDI, WHO, LAC Economic &

Social Data (mid-1980’s to the present)

Budget Data Sources: USAID/M/B Obligations FY89-99 and 1999

R4s for FY00-02; cross-checked w/ CPs

Country Profiles Sources: 1999 R4, G/PHN/OFPS

Special Studies conducted by NEPs

3

Outline for 7 PHN Sub-sectors

Empirical Data Impact Indicators a k a “Long term Performance

Indicators” measure the overall health status in the population

Intervention Indicators a k a “Performance Measurement Indicators” measure the efficiency and effectiveness of USAID programs

Critical Assumption--USAID programs target Intervention Indicators which will influence the pop-based Impact Indicators. An improvement in the Impact Indicators reflects the improved health status of a nation

Budget Data (FY89-02)

Country success story; best practices Recommendations

POPULATIONPOPULATION

Impact Indicator: Total Fertility Rate

Intervention Indicator: Contraceptive Prevalence Rate

June 2000 Source: DHS/RHS - 1995-1998

5

Total Fertility Ratebirths per 1,000 women 15-45 or 15-49 years

0

1

2

3

4

5

6

Guatem

ala

Honduras

Haiti

Parag

uay

Bolivia

Nicar

agua

El Sal

vador

Peru

Ecuad

or

Domin

ican

Rep

ublic

Colom

bia

Jam

aica

Brazi

l

Guyana

Mex

ico

Panam

a

DHS/CDC

BUCEN

USAID LAC Average = 2.9

June 2000 Source: DHS/RHS - 1995-1998

6

Contraceptive Prevalence Rate% of women in union using modern methods of

contraception

66

59

59

58

57

57

54

51

41

41

31

25

13

0 10 20 30 40 50 60 70

Jamaica

Colombia

DR

Brazil

Paraguay

Nicaragua

El Salvador

Ecuador

Peru

Honduras

Guatemala

Bolivia

Haiti USAID LAC Average = 54.6

Source: USAID/M/B Archives 7

Average Population Obligations FY93-99

Bol ivia

16%

DR

6%

Ecuador

6%

El Salvador

10%

Guatemala

15%

Hai ti

12%

Honduras

7%

Per u

13%

Par aguay

1%Panama

5%

Nicar agua

6%J amaica

3%

Source: FY99 R4s 8

Planned Pop Obligations

0%

5%

10%

15%

20%

25%

30%

FY00 FY01 FY02

PERU

BOLIVIA

HAITI

GUATEMALA

HONDURASEL SALVADOR

NICARAGUA

PARAGUAY

DR

JAMAICA

ECUADOR

9

POP Success Stories & Best Practices

Several countries have had rapid decreases in total fertility: Nicaragua 4.6 (1993) to 3.9 (1999)

El Salvador 3.85 (1993) to 3.54 (1998)

In Brazil, ProQuali represents useful model to improve quality through certification and accreditation

10

Recommendations for POP As countries succeed, we must plan for

phase out and recognize that more funds may be needed in the short run for responsible leave taking.

As controversy around informed consent has been a big issue in several countries (Peru, D.R., Mexico) more support for fine tuning quality is needed.

Adjustments should be made to budgets in relation to their country and population.

Child SurvivalChild Survival

Impact Indicators: Infant Mortality RateUnder 5 Mortality Rate

Intervention Indicator: Vaccination Coverage

June 2000 Source: DHS/RHS and BUCEN: 1987-1999

12

Infant Mortality Ratedeaths < 1 year per 1,000 live births

0

15

30

45

60

75

90

105

DHS/CDC

BUCEN

USAID LAC Average = 36.7

June 2000 Source: DHS/RHS and BUCEN: 1987-1999

13

Under-5 Mortality Ratedeaths < 5 years per 1,000 live births

0

20

40

60

80

100

120

140

160

180

Parag

uay

Colom

bia

Ecuad

or

El Sal

vador

Brazi

l

Nicar

agua

Honduras

Domin

ican

Rep

ublic

Guatem

ala

Peru

Mex

ico

Bolivia

Haiti

DHS/RHS

BUCENLAC Average = 47.7

June 2000 Source: DHS/RHS: 1987-1998

14

Vaccination Coverage Ratefully vaccinated children

78

78

78

69

64

60

53

48

47

38

37

21

15

0 10 20 30 40 50 60 70 80 90

Honduras

Ecuador

Brazil

Colombia

Peru

Guatemala

El Salvador

Paraguay

Nicaragua

Dom Rep

Haiti

Mexico

Bolivia

percent

USAID LAC Average = 54.8

Source: USAID/M/B Archives 15

Average Child Survival Obligations FY93-99

Brazil2%

DR3%

Ecuador4%

El Salvador9%

Guatemala13%Haiti

20%

Honduras4%

Nicaragua14%

Peru16%

Bolivia15%

Jamaica.01%

Source: FY99 R4s 16

Planned Child Survival Obligations

0%

5%

10%

15%

20%

25%

30%

FY00 FY01 FY02

PERU

BOLIVIA

HAITI

GUATEMALA

HONDURASEL SALVADOR

NICARAGUA

PARAGUAY

DR

JAMAICA

ECUADOR

17

Child Best Practices

IMCI is becoming institutionalized in several countries. In Honduras, IMCI was incorporated into the MOH operational plans; in Bolivia, IMCI is incorporated into the MOH’s Seguro Basico; in Peru, it was incorporated into the MOH operational plan.

AIN is a model for preventive intervention developed by USAID in Honduras and is being picked up by the World Bank for Bolivia and Nicaragua. USAID DR will also replicate this model.

18

Recommendations for Child Survival

Because ARIs and dehydration from diarrheal disease remain leading causes of death, IMCI should be supported.

As infant mortality rates decline, perinatal causes become greater % of deaths. Need to explore programming in rural areas and countries where institutional births are still low e.g. WHO/BASICS community mother/baby package.

Slight and moderate malnutrition account for 57% of all child deaths, therefore we need programming models like AIN.

Maternal HealthMaternal Health

Impact Indicator: Maternal Mortality Ratio

Intervention Indicator: Trained Attendants at Birth

Source: DHS/RHS 1994-1999 20

Maternal Mortality Ratiodeaths per 100,000 live births

120

159

161

190

192

229

265

390

1000

0 200 400 600 800 1000 1200

El Salvador

Ecuador

Brazil

Guatemala

Paraguay

Dom Rep

Peru

Bolivia

Haiti

USA MMR = 8.4

Source: DHS/RHS 1996-1999 (Jam '89)

21

% Trained Attendants at Birthphysician, nurse or nurse-midwife

95.3

93

91.7

84.6

69.2

64.6

58

56.7

56.4

56.3

54.5

46.3

40.6

0 20 40 60 80 100 120

Dom Rep

Brazil

Jamaica

Colombia

Ecuador

Nicaragua

El Salvador

Bolivia

Peru

Paraguay

Honduras

Haiti

Guatemala

USAID LAC Average = 76.2

Source: USAID/M/B Archives 22

Average Maternal Health Obligations FY93-99

Guatemala12%

Haiti24%

Honduras21%

Nicaragua12%

Peru14%

DR2%

El Salvador11%

Ecuador.01%

Bolivia4%

23

Maternal Health Success Story

Through the support of the RSD Regional Initiative to Reduce Maternal Mortality, an 8 member team formed the Rosario Health Committee in Honduras. The members include a nurse, doctor, teachers, local gov’t and NGO leaders. In 6 months they were able to meet the demand for obstetric services and to reduce maternal mortality by:

1. Receiving training and, in turn, training 40 volunteers and teens to recognize the danger signs of pregnancy

2. Negotiating MD coverage in the health center

3. Developing a network of car owners committed to drive pregnant women to the regional hospital at a reduced cost

4. Organizing an agreement to use a municipal car to transport low income women for free

Last August, a woman’s life was saved when one of the trainees noticed the woman’s sudden swelling (toxemia) and rushed her to a regional hospital 90 minutes away.

24

Recommendations for Maternal Health

Additional technical assistance needed to some missions to assess situations and identify most promising program directions

Attention needed to budget coding of maternal health activities

New RSD program should continue to include maternal health with an emphasis on increasing the number of trained attendants at delivery & post-partum

NutritionNutrition

Impact Indicator: Under-nutritionChildren < 5 yr underweight-for- age

Intervention Indicator:Stunting

Children < 5 yr below height- for- age

Source: World Bank/WDI 2000 26

Undernutrition% children under 5 below weight-for-age

5.7

5.9

6.1

7.6

7.8

8.4

10.2

11.2

12.2

16.5

16.9

18.3

25.4

26.6

27.5

3.7

0 5 10 15 20 25 30

Paraguay

Brazil

Dom Rep

Panama

Bolivia

Peru

Colombia

Jamaica

El Salvador

Nicaragua

Ecuador

Mexico

Guyana

Honduras

Guatemala

Haiti

percent

USAID LAC Average = 11.2

Source: World Bank/WDI 2000 27

Chronic Malnutrition: Stunting

% children under 5 below height-for-age

9.9

10.5

10.7

15.0

17.0

22.0

23.1

24.9

25.8

26.8

31.9

34.0

38.9

49.7

0 10 20 30 40 50

Jamaica

Panama

Brazil

Dom Rep

Colombia

Paraguay

Mexico

El Salvador

Nicaragua

Peru

Bolivia

Haiti

Ecuador

Honduras

Guatemala

percent

USAID LAC Average = 22.1

Source: USAID/M/B Archives 28

Average Nutrition Obligations FY93-99

Haiti61%

Honduras1%

Nicaragua9%

Peru15%

El Salvador5%

Ecuador2%

Guatemala2%

Bolivia5%

29

Nutrition Survival Success Story

AIN is a community based, preventive health and nutrition program that engages families of children < 2 yr and the community in maintaining adequate growth. AIN focuses on health care seeking & household practices such as breastfeeding, increased feeding, home care of illness, and health referrals. The emphasis is on adequate monthly weight gain--a shift from the traditional focus on nutritional status which is a more static measure of attained growth. The great success in Honduras has led other missions to adopt this intervention. Results in the first year of implementation included:

almost universal participation (98% of < 2 yr) more children gaining weight in communities with increased levels of malnutrition at

baseline there was a decrease from 39% to 8%; in communities with medium levels of malnutrition--decrease from 25% to 10%, and in communities with low levels at baseline, all children improved

30

Recommendations for Nutrition

Emphasize complementary feeding practices for children 6-36 months.

Develop standard nutrition messages about exclusive breastfeeding, frequency, quality and quantity of food for children 6-24 months adapted to local food sources

Support micronutritient supplementation of iron and Vitamin A for pregnant & post-partum women and children < 5 years

Better coordination of Title II and DA activities Regional program could focus on quality assurance

of fortified foods particularly vis-à-vis trade in Central America. Need regional agreement on standards and regulation

Infectious DiseaseInfectious Disease

Impact Indicators: Tuberculosis and Malaria

Prevalence RatesIntervention Indicator:

% Countries Adopting DOTS(Direct Observation Treatment Strategy)

Source: WHO Global TB Control: WHO Report 2000, 1998 data

32

Tuberculosis Prevalence rate per 100,000 people

5

8

22

26

28

36

37

51

52

53

54

75

80

124

127

176

0 50 100 150 200

Jamaica

Mexico

Colombia

Guatemala

El Salvador

Paraguay

Guyana

Brazil

Dom Rep

Panama

Nicaragua

Ecuador

Honduras

Haiti

Bolivia

Peru

USAID LAC average = 48 TB cases per 100,000 people

Source: PAHO Basic Indicators 1999, 1998 Data

33

Malaria Prevalence rate per 100,000 people

7

14

19

37

39

256

271

301

307

324

457

526

614

706

4,546

0 250 500 750 1,000

Dom Rep

Mexico

El Salvador

Panama

Paraguay

Ecuador

Brazil

Guatemala

Colombia

Nicaragua

Haiti

Bolivia

Honduras

Peru

Guyana

USAID LAC average = 174 malaria cases per 100,000 people

not to scale

Source: USAID/M/B Archives 34

Average Infectious Disease Obligations FY93-99

Bolivia23%

DR1%

Ecuador2%

El Salvador13%

Guatemala2%

Honduras23%

Jamaica2%

Mexico3%

Nicaragua6%

Peru16%

Haiti9%

Source: FY99 R4s 35

Planned Infectious Disease Obligations

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

FY00 FY01 FY02

MEXICO

BOLIVIA

PERU

NICARAGUA

EL SALVADOR

JAMAICA

GUATEMALA

HONDURAS

36

Infectious Disease Best Practices

Brazil - DOTS & DOTS Plus programs initiated in one area of Rio de Janiero

Mexico - TB assessment completed, strategy developed & SOAG signed

Regional Anti-Microbial Resistance Surveillance and rational AM drug use

training workshops underway Book published by PAHO “Antimicrobial

Resistance in the Americas: Magnitude and Response”

37

Recommendations for Infectious Disease

TB - focus attention on countries with: High TB burden and/or incidence Multi-Drug Resistance High HIV/AIDS prevalence

Explore malaria activities in Amazon Basin

Increase attention to use of data for decision making as regional surveillance and rational drug use training activities are well underway

HIV/AIDSHIV/AIDS

Impact Indicator: Adult HIV Prevalence Rate

Intervention Indicator: Condom use with non-regularpartner (data forthcoming)

Source: UNAIDS, 1997 & 1999

39

HIV Adult Prevalence Rates rate per 1,000 adults 15-49 years

0

1

2

3

4

5

619971999

Source: UNAIDS 1997 & 1999 40

Estimated Number of HIV Infected Adults and Children

0

100,000

200,000

300,000

400,000

500,000

600,000

Brazil

Haiti

Mexico

Dom R

epPer

u

Guatem

ala

Hondu

ras

El Salv

ador

Ecuad

or

Guyana

Jam

aica

Nicara

gua

Bolivi

a

Parag

uay

1997

1999

Source: USAID/M/B Archives 41

Average HIV/AIDS Obligations FY93-99

Bolivia11%

Brazil9%

DR23%

Haiti20%

Honduras12%

Jamaica15%

Mexico5%

Nicaragua1%

Guatemala.01%

Peru2%

El Salvador2%

Source: FY99 R4s 42

Planned HIV/AIDS Obligations

0%

5%

10%

15%

20%

25%

30%

FY00 FY01 FY02

PERU

BOLIVIA

HAITI

GUATEMALA

HONDURASEL SALVADOR

NICARAGUA

PARAGUAY

DR

JAMAICA

ECUADOR

43

HIV/AIDS Best Practices

Formal ratification of National HIV/AIDS Strategic Plans in Guatemala, El Salvador, Honduras, Nicaragua, and Panama. No other region can match this accomplishment.

Jamaica has reduced syphilis rates through its intervention of prevention, detection and treatment. HIV/AIDS prevalence rates have declined from .99 to .71 from 1997-99

44

Recommendations for HIV/AIDS

Review the needs in the Caribbean and increase funding to address the problem.

Allocate funding according to need (prevalence) and magnitude (population)

Health Sector ReformHealth Sector Reform

Impact Indicator: Health Expenditures as a % GDP

Intervention Indicators: Number of countries with

routine National Health Accounts tracking

June 2000 Source: World Bank WDI 2000 1990-1998 data

46

Total Health Expenditures as a % of GDP

9.7

9.4

8.3

7.7

7.4

7.3

7

5.6

5.4

5.2

4.9

4.7

4.7

3.4

2.6

2.4

0 2 4 6 8 10 12

Nicaragua

Colombia

Honduras

Panama

Paraguay

Brazil

El Salvador

Peru

Guyana

Dom Rep

Ecuador

Mexico

Jamaica

Haiti

Bolivia

Guatemala

USAID LAC average = 6.6%

June 2000 Source: World Bank 1998 ($PPP); Jamaica 1994, Ecuador 1993

47

Total Health Spending per capita

$0

$100

$200

$300

$400

$500

$600

$700

Haiti

Bolivia

Guat

emal

a

Ecuad

or

Guya

na

Jam

aica

Honduras

Nicar

agua

Domin

ican

Rep

ublicPer

u

El Sal

vador

Parag

uay

Mex

ico

Panam

a

Brazi

l

Colom

bia

USAID LAC Average = $402

Source: USAID/M/B Archives 48

Average Health Sector Reform Obligations FY93-99

Bolivia9%

DR4%

Ecuador9%

El Salvador31%Guatemala

9%

Haiti8%

Honduras16%

Jamaica2%

Peru12%

49

Health Sector Reform Best Practices

MOH now uses USAID-supported NGO certification process as basis for funding in DR

3.5 million more rural Guatemalans served by NGOs contracted by MOH

9 countries have implemented National Health Accounts (NHAs), 5 have routine NHA tracking

USAID-supported NHAs contributed to World Health Report inclusion of health spending table for the first time

50

Recommendations for Health Sector Reform

Monitor coverage of basic services

Expand information synthesis and tools dissemination

Implement pilots and reforms

Focus on policy

Foster South to South exchanges

Strengthen decentralization

Consider addressing HSR in Brazil

Source: FY99 R4s 51

Planned Other Health Obligations

0%

5%

10%

15%

20%

25%

30%

FY00 FY01 FY02

BOLIVIA

PERU

HAITI

GUATEMALA

ECUADORBRAZIL

JAMAICA

DRELSALVADORHONDURAS

NICARAGUA

MEXICO

PARAGUAY

52

Highlights of AnalysisPopulation

Phase-out needs include:Consistent Graduation StandardsCareful planning for sustainabilityAdequate funding (may need increase)

Child SurvivalDiarrhea and pneumonia, exacerbated

by malnutrition, are the primary killers of infants and children in AID countries

Perinatal and accidental causes of death are increasing in importance

53

Highlights (continued)

Maternal MortalityMissions need to increase internal

technical expertise to provide appropriate programmatic direction

Results Frameworks need a specific focus on maternal health programs

NutritionConsiderably more attention and

funding needed; USAID not a major player among international donors

54

Highlights (continued)

Infectious DiseasesFocus TB programs on countries with:

high disease burden, multi-drug resistant strains, or high HIV prevalencei.e. Haiti, Brazil, Dominican Republic

HIV/AIDS A full-blown epidemic can still be

prevented in LAC by applying the lessons learned to date.

55

Highlights (continued)

Health Sector ReformFocus efforts on USAID’s comparative

advantages at the regional level:

information/tools dissemination South-to-South exchanges monitoring reform impact

at the country level: policy development strengthening decentralization financing mechanisms

Source: USAID/M/B Archives 56

Average PHN Obligations FY93-99

Bolivia13%

Brazil1%

DR6%

Ecuador4%

El Salvador11%

Guatemala10%Haiti

19%

Honduras9%

Jamaica3%

Mexico1%

Nicaragua7%

Panama2%

Paraguay1%

Peru13%

Source: FY99 R4s 57

% of Total PHN Planned Obligations by Country

0%

5%

10%

15%

20%

25%

30%

FY00 FY01 FY02

PERU

BOLIVIA

HAITI

GUATEMALA

HONDURASEL SALVADOR

NICARAGUA

PARAGUAY

DR

JAMAICA

ECUADOR