THE ISSUE OF HETEROGENEITY

Throughout this volume, statements are made about female moridity and mortality in Sub-Saharan Africa for the purpose of comparing those indexes with the rest of the world. It cannot be emphasized enough, however, that the continent is neither homogeneous nor uniform. There are many economic, political, and sociocultural differences among East, West, central, and southern Africa; among large nations and small; highly stratified states and the more egalitarian; countries suffering wars, ethnic tensions, or other civil disturbances, and countries more serene; the economically richer and the poorer; those suffering drought and famine, and those who are not; and nations with refugees, and those without. There are also variations in religion, tribal affiliation, kinship structure, residence and household formation, language, and educational heritage.

Current statistics on economic performance, population, fertility, and education also reflect the continent's heterogeneous experience and circumstance. Gross National Product (GNP) per capita in 1987 dollars ranged from $130 in Ethiopia to Gabon's $2,700; annual average change in GNP per capita since 1965 ranged from -2.7 percent in Uganda to +8.9 percent in Botswana. Land mass varies from Sudan's 967,494 square miles to Swaziland's 6,705, and national population size from 0.7 million in Swaziland to over 100 million in Nigeria. Annual population growth rates over the past 23 years range from 1.5 percent in Mauritius to 4.2 percent in Côte d'Ivoire. Although total fertility rates are uniformly high throughout Sub-Saharan Africa, there are still major differences in absolute numbers and trends among regions and individual countries, as well as within them (Blanc, 1991; Cohen, 1993). Adult literacy in Burkina Faso is 18 percent; in Botswana it is 74 percent. Secondary school enrollment ranges from 3 percent in Rwanda and Tanzania to 51 percent in Mauritius (Feachem and Jamison, 1991; UNDP, 1993; World Bank, 1993).

Dealing with diversity is a fundamental difficulty for any study that pretends to deal with the continent as a whole. This report recognizes diversity as a fundamental fact and deals with it through the use of case material that illustrates commonalities or significant divergence in a given subject area.

THE SOCIOECONOMICS OF LIFE AND DEATH

The Variables

In its 1990 Human Development Report (HDR), the United Nations Development Programme (UNDP) defined human development as the process of enlarging people's options. Of those, the most critical were the options to: (1) lead a long and healthy life; (2) acquire knowledge; and (3) have access to the resources needed for a decent standard of living. This holistic view of "human health in context" is the point of departure for this study.

It was also in the 1990 Human Development Report that the UNDP introduced the "Human Development Index" (HDI) as a more realistic and informative statistical measure of human development than per capita gross national product (GNP) alone. The HDI merges national income with two social indicators—adult literacy/mean years of schooling and life expectancy at birth—to yield a composite measure that makes it possible to rank the progress of nations in relation to one another. The HDI also permits measurement of how females are doing compared with males (Anand and Sen, 1992).

A great deal of analytic energy has been invested in seeking consistent patterns of causality between human mortality, and the worldwide trend of decline in that mortality, and one of the major socioeconomic factors, including income growth, education, provision of health services, ecology, and geography (cf. Feachem and Jamison, 1991). In spite of these efforts, there is still no clear picture of which of these matters most, in part because of inadequacies in the basic data and the manner of their application, and in part because of the sheer complexity in the way human health is embedded in those factors. Taking combined mortality as its lead indicator, the World Bank's World Development Report 1993 (WDR) finds four factors to be unremittingly important in mortality reduction: income growth, improvements in appropriate medical technology, basic education, and access to public health services and knowledge. These are not simple indicators, and there are important synergies among them. In all regions of the world, however, the main effect of income growth on health status lies in equity



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