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POPULATION DYNAMICS OF SUB-SAHARAN AFRICA
DEMOGRAPHIC CHANGE
IN SUB-SAHARAN AFRICA
DEMOGRAPHIC EFFECTS OF ECONOMIC REVERSALS
IN SUB-SAHARAN AFRICA
EFFECTS OF HEALTH PROGRAMS ON CHILD MORTALITY
IN SUB-SAHARAN AFRICA
FACTORS EFFECTING CONTRACEPTIVE USE
IN SUB-SAHARAN AFRICA
POPULATION DYNAMICS OF KENYA
POPULATION DYNAMICS OF SENEGAL
SOCIAL DYNAMICS OF ADOLESCENT FERTILITY
IN SUB-SAHARAN AFRICA
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NOTE: This map which has been prepared solely for the convenience of the readers, does not purport to express political boundaries or relationships. The scale is a composite of several forms of projection.
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POPULATION DYNAMICS OF SUB-SAHARAN AFRICA
Effects Of Health Programs on Child Mortality in Sub-Saharan Africa
Douglas C. Ewbank and James N. Gribble, Editors
Working Group on the Effects of Child Survival and General Health Programs on Mortality
Panel on the Population Dynamics of Sub-Saharan Africa
Committee on Population
Commission on Behavioral and Social Sciences and Education
National Research Council
NATIONAL ACADEMY PRESS
Washington, D.C.
1993
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NATIONAL ACADEMY PRESS
2101 Constitution Avenue, N.W. Washington, D.C. 20418
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Robert M. White is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Robert M. White are chairman and vice chairman, respectively, of the National Research Council.
Library of Congress Catalog Card No. 93-84761
International Standard Book Number 0-309-04941-5
Additional copies of this report are available from:
National Academy Press,
2101 Constitution Avenue, N. W., Box 285, Washington, D.C. 20418. Call 800-624-6242 or 202-334-3313 (in the Washington Metropolitan Area).
B165
Copyright 1993 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
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WORKING GROUP ON EFFECTS OF CHILD SURVIVAL AND GENERAL HEALTH PROGRAMS ON MORTALITY
DOUGLAS C. EWBANK (Chair),
Population Studies Center, University of Pennsylvania
ROBERT E. BLACK,
Department of International Health, Johns Hopkins University
MICHEL GARENNE,
Center for Population and Development Studies, Harvard University
ALLAN G. HILL,
Center for Population and Development Studies, Harvard University
PATRICK O. OHADIKE,
Regional Institute for Population Studies, Accra, Ghana
JAMES N. GRIBBLE, Staff Officer
JOAN MONTGOMERY HALFORD, Senior Project Assistant*
PAULA J. MELVILLE, Senior Project Assistant
*
through July 1992
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PANEL ON THE POPULATION DYNAMICS OF SUB-SAHARAN AFRICA
KENNETH H. HILL (Chair),
Department of Population Dynamics, Johns Hopkins University
ADERANTI ADEPOJU,
Institut de Dévelopment Economique et de la Planification (IDEP), Dakar, Senegal
JANE T. BERTRAND,
School of Public Health and Tropical Medicine, Tulane University
CAROLINE H. BLEDSOE,
Department of Anthropology, Northwestern University
WILLIAM BRASS,
Centre for Population Studies, London School of Hygiene and Tropical Medicine, England
DOUGLAS C. EWBANK,
Population Studies Center, University of Pennsylvania
PHILIPPE FARGUES,
Centre d'Etudes et de Documentation Economique, Sociale et Juridique (CEDEJ), Cairo, Egypt
RON J. LESTHAEGHE,
Faculteit van de Economische, Sociale en Politieke Wetenschappen, Vrije Universiteit, Brussels, Belgium
PATRICK O. OHADIKE,
Regional Institute for Population Studies (RIPS), Accra, Ghana
ANNE R. PEBLEY,
The RAND Corporation, Santa Monica, California
DANIEL M. SALA-DIAKANDA,
Institut de Formation et de Recherche Démographiques (IFORD), Yaoundé, Cameroon
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COMMITTEE ON POPULATION
SAMUEL H. PRESTON (Chair),
Population Studies Center, University of Pennsylvania
JOSE-LUIS BOBADILLA,
World Bank, Washington, D.C.
JOHN B. CASTERLINE,
Department of Sociology, Brown University
KENNETH H. HILL,
Department of Population Dynamics, Johns Hopkins University
DEAN T. JAMISON,
School of Public Health, University of California, Los Angeles
ANNE R. PEBLEY,
The RAND Corporation, Santa Monica, California
RONALD R. RINDFUSS,
Department of Sociology, University of North Carolina, Chapel Hill
T. PAUL SCHULTZ,
Department of Economics, Yale University
SUSAN C.M. SCRIMSHAW,
School of Public Health, University of California, Los Angeles
BETH J. SOLDO,
Department of Demography, Georgetown University
MARTA TIENDA,
Population Research Center, University of Chicago
BARBARA BOYLE TORREY,
Population Reference Bureau, Washington, D.C.
JAMES TRUSSELL,
Office of Population Research, Princeton University
AMY O. TSUI,
Carolina Population Center, University of North Carolina, Chapel Hill
LINDA G. MARTIN, Director
BARNEY COHEN, Research Associate
SUSAN M. COKE, Senior Project Assistant
KAREN A. FOOTE, Research Associate
DIANE L. GOLDMAN, Administrative Assistant*
JAMES N. GRIBBLE, Program Officer
JOAN MONTGOMERY HALFORD, Senior Project Assistant**
CAROLE L. JOLLY, Program Officer
DOMINIQUE MEEKERS, Research Associate*
PAULA J. MELVILLE, Senior Project Assistant
*
through December 1991
**
through July 1992
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Preface
This report is one in a series of studies that have been carried out under the auspices of the Panel on the Population Dynamics of Sub-Saharan Africa of the National Research Council (NRC) Committee on Population. The Research Council has a long history of examining population issues in developing countries. In 1971 it issued the report Rapid Population Growth: Consequences and Policy Implications . In 1977, the predecessor Committee on Population and Demography began a major study of levels and trends of fertility and mortality in the developing world that resulted in 13 country reports and 6 reports on demographic methods. Then, in the early 1980s, it undertook a study of the determinants of fertility in the developing world, which resulted in 10 reports. In the mid- and late-1980s, the Committee on Population assessed the economic consequences of population growth and the health consequences of contraceptive use and controlled fertility, among many other activities.
No publication on the demography of sub-Saharan Africa emerged from the early work of the committee, largely because of the paucity of data and the poor quality of what was available. However, censuses, ethnographic studies, and surveys of recent years, such as those under the auspices of the World Fertility Survey and the Demographic and Health Survey programs, have made available data on the demography of sub-Saharan Africa. The data collection has no doubt been stimulated by the increasing interest of both scholars and policymakers in the demographic development of Africa and the relations between demographic change and socioeconomic developments.
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In response to this interest, the Committee on Population held a meeting in 1989 to ascertain the feasibility and desirability of a major study of the demography of Africa, and decided to set up a Panel on the Population Dynamics of Sub-Saharan Africa.
The panel, which is chaired by Kenneth Hill and includes members from Africa, Europe, and the United States, met for the first time in February 1990 in Washington, D.C. At that meeting the panel decided to set up six working groups, composed of its own members and other experts on the demography of Africa, to carry out specific studies. Four working groups focused on cross-national studies of substantive issues: the social dynamics of adolescent fertility, factors affecting contraceptive use, the effects on mortality of child survival and general health programs, and the demographic effects of economic reversals. The two other working groups were charged with in-depth studies of Kenya and Senegal, with the objective of studying linkages between demographic variables and between those variables and socioeconomic changes. The panel also decided to publish a volume of papers reviewing levels and trends of fertility, nuptiality, the proximate determinants of fertility, child mortality, adult mortality, internal migration, and international migration, as well as the demographic consequences of the AIDS epidemic.
This volume, one of the four cross-national studies, attempts to document the effects of general health and child survival programs on mortality. Although progress has been made, infant and child mortality levels in parts of sub-Saharan Africa remain among the highest in the world. The disease-specific orientation of this report draws attention to a variety of strategies and interventions that have been developed in an effort to reduce the mortality effects of many of the most important diseases. It also examines the effects of general health programs that have been implemented in various settings of sub-Saharan Africa.
As is the case for all of the panel's work, this report would not have been possible without the cooperation and assistance of the Demographic and Health Survey (DHS) Program of the Institute for Resource Development/Macro Systems. We are grateful to the DHS staff for responding to our inquiries and facilitating our early access to the survey data.
We are also grateful to the organizations that provided financial support for the work of the panel: the Office of Health, the Office of Population, and the Africa Bureau of the U.S. Agency for International Development; the Andrew W. Mellon Foundation; the William and Flora Hewlett Foundation; and the Rockefeller Foundation. Besides providing funding, the representatives of these organizations were a source of information and advice in the development of the panel's overall work plan.
This report results from the joint efforts of the working group members and staff and represents a consensus of the members' views on the issues
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addressed. The Committee on Population and the Panel on the Population Dynamics of Sub-Saharan Africa appreciate the time and energy that all the working group members devoted to the study.
The working group was assisted in its efforts by several commissioned background papers. Charles Katende authored a paper on infant and child mortality and the proximity of health facilities in Liberia and Zimbabwe. Margaret Luck wrote a paper on mortality trends in Senegal.
Special thanks are also due Joan Montgomery Halford and Paula Melville for providing superb administrative and logistical support to the working group and to Florence Poillon for her skillful editing of the report. Eugenia Grohman and Elaine McGarraugh were instrumental in guiding the report through the report review and production processes.
SAMUEL H. PRESTON, Chair
Committee on Population
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Contents
EXECUTIVE SUMMARY
1
1
INTRODUCTION
5
2
TRENDS IN MORTALITY AND CAUSES OF DEATH IN AFRICA
11
Trends in Child Mortality
11
Causes of Death Among African Children
17
Summary
25
3
IMMUNIZATION PROGRAMS
26
MEASLES
29
Epidemiology
29
Vaccine Efficacy
30
Why Africa Might Be Different
32
Evidence of Mortality and Morbidity Effects from Africa
33
Nonlinearities in Relationship Between Coverage and Effect
39
Program History, Coverage, and Quality
44
Treatment of Measles (Including Vitamin A)
47
Summary
48
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PERTUSSIS (WHOOPING COUGH)
49
Pertussis in Developed Countries
50
Pertussis in Africa
52
Program Effort
53
Summary
56
TUBERCULOSIS AND LEPROSY
56
Epidemiology of Tuberculosis
56
Prevention and Treatment of Tuberculosis
57
Efficacy of Bacille Calmette-Guérin (BCG) Vaccination
59
Epidemiology of Leprosy
60
Program Coverage
62
Summary
64
TETANUS
64
Epidemiology
64
Programs to Reduce the Incidence of Neonatal Tetanus
65
Program Coverage
69
Programs to Reduce Nonneonatal Tetanus Mortality
70
Summary
70
CONCLUSION
72
4
OTHER INTERVENTIONS TARGETED AT SINGLE DISEASES
74
DIARRHEAL DISEASE CONTROL PROGRAMS
75
Epidemiology
75
Treatment
77
Summary
81
MALARIA CONTROL PROGRAMS
82
Epidemiology
82
Malaria Mortality in Sub-Saharan Africa
84
Program Options
85
Studies of the Effects of Malaria Eradication on Mortality
86
Presumptive Treatment of Fevers with Antimalarial Drugs
89
Programs Based on Chemoprophylaxis Among Pregnant Women
96
Programs Based on Vector Control
100
Summary
101
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ACUTE RESPIRATORY INFECTIONS
104
Epidemiology
104
Interventions
105
Summary
107
5
NUTRITION AND NUTRITION PROGRAMS
108
Introduction
108
Protein-Energy Malnutrition (PEM)
109
Low Birthweight
123
Vitamin A Deficiency
128
Summary
131
6
INTEGRATED AND GENERAL HEALTH PROGRAMS
132
Introduction
132
Case Studies of Long-Term Mortality Trends
134
Hospitals and Health Centers
137
Primary Health Care Programs
138
Child Survival and Expanded Programs on Immunization
141
Summary
144
7
CONCLUSIONS AND RECOMMENDATIONS
146
Disease- and Intervention-Specific Conclusions
147
General Observations about the Evaluation of Health Programs in Africa
149
APPENDIX A
CASE STUDIES OF CHILD MORTALITY:
155
APPENDIX B
DEMOGRAPHIC AND HEALTH SURVEY (DHS) REPORTS:
164
REFERENCES
166
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