—from the Epidemiological Bulletin, Vol. 20 No. 1, March 1999—

Assessment of the 1980-1998 Health Situation and Trends in the Americas, by subregion

The Pan American Health Organization (PAHO), Regional Office of the World Health Organization (WHO) for the Americas, is responsible for disseminating information on the health situation and its trends. Since 1956, when its first assessment of the health situation in the Americas was published (1), PAHO periodically provides these health situation assessments. Since then, the Organization produces and distributes publications containing data and information of the health situation in the countries of the Region, among them Health in the Americas, Health Statistics from the Americas, Basic Health Indicators, the Epidemiological Bulletin and other reports. This article contains an analytical summary of the health situation and trends in the Americas for the 1980-1998 period using some basic indicators, included in the above publications. Its aim is to underscore some important inequalities occurring in various subregions of the Americas over that period.

Data

A total of 38 indicators pertaining to four categories, namely demographic, socioeconomic, morbidity and mortality and resources and coverage of health services, were included. Further detail on their definition and calculation is shown in the technical notes at the end. Data have been updated and validated from various sources. Demographic indicators were obtained from the United Nations World Population Prospects 1996 Revision (2), the United Nations World Urbanization Prospects 1996 Revision (3), from the U. S. Census Bureau International Data Base (4) and from the World Health Organization Demographic Data for Health Situation Assessment and Projections (5). Socioeconomic indicators were obtained from the UNESCO Statistical Yearbook 1996 (6) and from the PAHO Mid-Decade Evaluation of Water Supply and Sanitation in Latin America and the Caribbean (7). Morbidity and mortality indicators were obtained from Technical Reports from PAHO/WHO Country Representatives in the Region of the Americas, from Technical reports from PAHO/WHO Regional Programs and from the PAHO Technical Information System Regional Mortality Database (8). Health services indicators were obtained from Technical reports from PAHO/WHO Regional Programs and from PAHO’s Health in the Americas 1998 (1) publication.

Because of their large number and geopolitical nature of Member States, the Region of the Americas was divided into subregions to allow comparisons of country groups instead of individual countries. Regionalization was defined according to geographic location, population size and socioeconomic criteria, including the following subregions: North America; Latin America, comprising the Andean Area, Brazil, Central American Isthmus, Latin Caribbean, Mexico, and Southern Cone; and the Non-Latin Caribbean. Additional detail of their composition by country and territories is given in the footnote for Table 1.

To highlight disparities and inequities in health and their secular trends, data are compared by subregion, indicator and year period. Aggregate subregional figures were estimated by averaging the country values and weighting for population size when required.

Demographic situation and trends

The overall population in the Region was estimated at nearly 800 million in 1998, that is, nearly 14% of the total population in the world. It is estimated that by the year 2000 the population in the Region of the Americas will be 823,255 millions, an increase of 25% compared to 1980 (Table 1). Around 37% of the population resides in North America, while another third can be found in two other countries: Brazil and Mexico. The remaining is scattered among the other 43 countries and territories in the Region.

The Region of the Americas is going through the denominated demographic transition, with marked changes in total fertility, infant mortality and life expectancy, with their consequent impact in population structure.

Birth rates have decreased in the Region of the Americas by an average of 19%, between 1980-1985 and 1995-2000. Although birth rates in the Southern Cone, the Latin and the Non-Latin Caribbean are twice as high as that of North America, they showed a similar trend of decrease (13%). The rest of the subregions experienced decreases of 20% or more. Also showing a decreasing trend, the overall total fertility rate in the Americas in the 1980-1985 period was 3.0 children born alive per woman compared to 2.4 in 1995-2000. Except in North America, where there was a slight increase, total fertility decreased in all the other subregions. Reductions over 1 child per women occurred in Mexico, Brazil, Central America and the Andean Area. In spite of the overall decrease in birth rates and total fertility, the number of births has not changed dramatically in the Americas between 1980-1985 and 1995-2000. This will have important implications for health care planners.

Death rates exhibit a similar distribution pattern as fertility, the differences arising from the population’s size, age structure and specific mortality of each age group. In the Region of the Americas, the crude death rates decreased from an estimated 8.1 deaths per 1,000 population in 1980-1985 to 7.2 in 1995-2000. There was a slight increase in North America (8.5 to 8.6) while the most dramatic decrease was observed in Central America (9.1 to 5.8). Over the past decades, infant mortality in the Americas has decreased around one third, from an estimated 36.9 deaths per 1,000 live births in 1980-1985 to 24.8 per 1,000 in 1995-2000. Although their infant mortality rates are still higher than the 1980-1985 average, the largest gains occurred in Central America (45% reduction), Brazil (34%) and the Latin Caribbean (30%).

The annual population growth also decreased in the Americas from an estimated average of 1.6% in the 1980-1985 period to 1.3% in 1995-2000. The subregions with slowest population increase were North America (0.8%) and the Non-Latin Caribbean (1.0%). Brazil, Mexico and the Andean Area had an important decrease of their population growth of between 22 and 27%. In contrast with other subregions, Central America saw its growth rate slightly increased from 2.4 to 2.5% in the same period.

As a consequence of decreased mortality, in particular among infants, life expectancy at birth has increased in the Americas an average of 3.2 years from an estimated 69.2 years in 1980-1985 to 72.4 in 1995-2000. North America reached the highest levels of life expectancy at birth with 76.9 years in the 1995-2000 period. In contrast, Brazil, the Latin Caribbean, Central America and the Andean Area are still lagging the other subregions by several years, although they have experienced increases between 3 to 8 years.

Urbanization of the population of the Americas increased in the 1980-2000 period, as a result of both natural growth and rural-urban migration. This form of migration, where people move in search for jobs and better living conditions, has had a major impact by creating additional pressure over the resources in the urban areas. It is estimated that the rural population in the Americas will shrink from nearly 31% of the total population in 1980 to 24% in 2000. The smallest changes will occur in Central America decreasing from 58% to 52%, respectively, followed by the Non-Latin Caribbean, while the most dramatic changes will take place in Brazil (from 36 to 19%), the Andean Area (36 to 25%) and Mexico (34 to 26%).

Socioeconomic situation and trends

The Region of the Americas has been characterized as one with most dramatic and unequal socioeconomic change, as reflected in some human development indicators: literacy, access to public services and health expenditure (Table 2).

For example, population literacy has increased from 88 to 92% in the period 1980-1997. The highest levels were achieved in the North America (99%) and the Southern Cone (96%) subregions. Yet, at the other extreme, two subregions, the Central American Isthmus (75%) and the Latin Caribbean (79%), are reaching literacy levels that were attained by others more than 15 years ago.

The availability and access of public services of drinking water and basic sanitation are essential for maintaining a healthy environment. On average, the population in the Americas covered by drinking water services increased from 76% in 1980 to 80% in 1997. In spite of having increased over that period, coverage in Central America, Brazil and the Southern Cone is still below 70% and between 70 and 75% in the Latin Caribbean and the Andean Area. The overall situation of basic sanitation in the Americas followed a similar trend of increased coverage.

Average national health expenditure, expressed as a percentage of the Gross Domestic Product (GDP), was chosen as an indicator of the effort devoted to health promotion, prevention and care. There was an increase in health expenditure in the Region of the Americas, from 6.8% in 1984 to 9.5% in 1995. Although Mexico had a modest increase, its health expenditure was the lowest (4.8%) in the Region. The Central American Isthmus subregion was the only one that experienced a marked reduction of health expenditure, from 9.5% to 6.7%. Since these percentages are higher than the rate of population growth, the trends suggest real growth in absolute terms of per capita resources of health.

Mortality and morbidity situation and trends

Mortality and morbidity are important indicators of the health situation, providing an insight of the magnitude and patterns of ill-health in the population. The age-adjusted risk of dying from four broad groups of causes, communicable diseases, malignant neoplasms, diseases of the circulatory system and external causes, according to sex, is presented in Table 3.

One of the foremost impacts of improved living conditions and basic technology is a reduction on mortality due to communicable diseases. In the case of the Americas, the risk of dying from communicable diseases was reduced to almost one half between 1980-1985 and 1995-2000, from 112.4 deaths per 100,000 population to 67.4 among males and from 89.0 to 51.2 among females. This mortality pattern of significantly higher risk among males than females occurred in most subregions, except in the Southern Cone and the Non-Latin Caribbean where the excess of mortality risk among males tended to be smaller. In North America a slight increase of risk was observed among males and females, possibly resulting from an increase of emerging diseases such as AIDS and tuberculosis, among others. In spite of the overall reduction, communicable diseases still accounted for a large contribution of the risk of dying (nearly 10%) in Central America, Brazil, the Andean Area and Mexico.

Overall, mortality from malignant neoplasms has remained at relatively similar levels between 1980-1985 and 1995-2000 in the Americas, accounting between 9% of the mortality in Central America and nearly 25% in North America in the latter period. Mortality rates were higher in North America and the Southern Cone than among the other subregions, among both males and females. However, except in Mexico and Central America, where rates were the lowest, an excess of mortality risk was observed among males in the rest of the subregions, the largest differences (nearly 50%) occurring in North America and the Southern Cone.

Although there was a decreasing trend of 15-20% between 1980-1985 and 1995-2000, mortality from diseases of the circulatory system accounted for almost one third of the risk of dying in the Americas. The mortality pattern of these causes of death followed a similar distribution as that of malignant neoplasms, with an excess among males. The highest rates were observed in Brazil, North America, the Southern Cone and the Non-Latin Caribbean. Proportionally, these causes represented a major problem in North America, the Southern Cone and the Non-Latin Caribbean where they represented nearly 40% of the overall mortality.

Also, there was an overall trend towards reduction of mortality rates from external causes among males between 1980-1985 and 1995-2000. The most dramatic reduction of mortality occurred among males in Central America, possibly as a consequence of pacification in conflict areas. In contrast, Brazil and the Andean Area experienced an increase of mortality rates from these causes. Overall in the Americas, external causes of death tended to be more than three times more frequent among males than in females. Except in the Latin Caribbean, where mortality was only twice as frequent, this pattern was followed in all the other subregions.

Changes in mortality patterns tend to be more sensitive to variations among children. Also, the relative importance of some specific health problems was analyzed by using proportional mortality (Table 4). Mortality patterns varied significantly among the subregions of the Americas. Thanks to the availability and promotion of simple and low-cost technologies (i.e. oral re-hydration therapy, immunizations, and simplified protocols for managing of respiratory disease), major reductions in the proportion of deaths due to acute diarrheal diseases (ADD) and to acute respiratory infections (ARI) have been observed between 1980-1985 and 1995-2000.

As seen in Table 5, the effort to prevent and control communicable diseases has had mixed results. Some of the major notifiable diseases like tuberculosis, malaria and cholera have re-emerged in the Americas. Tuberculosis continued to be a public health problem, the overall number of cases of tuberculosis increasing by 13% between 1980 and 1997 to 255,581. Although the absolute number differed significantly, these figures were higher in Mexico (49%), the Andean Area (30%) and Brazil (23%). The endemic areas of malaria in the Americas have been reduced over the past decades; however, the number of cases sharply increased between 1980 and 1997, almost doubling its number to more than one million. The number of cholera cases decreased between 1992 and 1997, becoming an endemic problem in certain subregions, including the Andean Area, Brazil, Mexico and Central America. AIDS cases also continued to be a major concern in certain areas, particularly North America, Brazil and Mexico. Except for an important epidemic in Brazil, measles cases occurred less frequently in the Americas, contrasting with other infectious diseases.

Resources and coverage of health services situation and trends

Most of the countries in the Region of the Americas have gone through modernization of the state processes and health care reforms. Actions derived from them impacted the political, social and economic dynamics in general, and their health systems, in particular. Health systems structure and function had to be adjusted to respond accordingly. Health resources and coverage represent the response of the countries to cope with the health needs, including the human and structural resources and health programs. Table 6 summarizes the trends of some of these indicators.

In terms of human resources, the overall number of physicians in the Americas increased from 13.1 per 10,000 population to 19.6 between 1980 and 1997. Likewise, the number of nurses and dentists almost doubled in that period from 23.1 to 41.2 and from 2.6 to 5.3, respectively. Central America and the Non-Latin Caribbean continued to have the lowest figures in terms of physicians, while North America and the Southern Cone had the highest. In the case of nurses, Central America, Brazil and the Andean Area had the lowest numbers and North America and the Latin Caribbean the highest.

In contrast to human resources, health infrastructure, as measured by the number of hospital beds, dropped in the Americas from an overall of 4.2 per 1,000 population in 1980 to 3.6 in 1995, reflecting changes in the health system. Mexico, Central America and the Andean Area are the least equipped subregions, while North America, Brazil and the Southern Cone have most hospital beds per population.

There has been an overall increase of immunization coverage of children against childhood diseases. Interestingly, the coverage of immunization services of all four vaccines has increased dramatically over the 1980-1997 period, while the incidence of vaccine-preventable disease in childhood has decreased and even been eliminated. This is a unique example of what can be achieved when the financial resources, the political will and social mobilization are put together.

Conclusion

The situation of health in the Americas indicates a demographic re-shape and an overall improvement of health indicators over a 20-year period. Changes had also occurred in the health profile populations, shifting from the communicable diseases to the chronic ones. This double health burden is unique in the Americas.

From the analysis of subregional indicators it was apparent that there are subregions with health inequalities that have not reached the same levels of well-being as their counterparts. A first step towards the reduction of such unfair inequalities is their recognition and a more precise characterization. This knowledge is essential for assisting policy makers and health managers in the formulation of sound health and environment policies, the reorganization of basic health services, and of health promotion, disease prevention and control, programming and evaluation. PAHO supports countries to analyze their health situation at the subnational level, to improve targeting of health interventions in populations and areas with the largest basic unmet health needs.

Technical notes (additional details in quoted data sources).

Demographic indicators are the mid-year values; they are obtained by linear interpolation of the corresponding quinquennial projection (using the fertility medium variant).

Total fertility rate shows the average expected number of children born alive to a woman during her reproductive years, according to prevailing fertility rates for each age group.

Population with drinking water supply services and with sewerage refers to house connection and to easy access facilities.

Proportion of under-5 registered deaths due to ADD and to ARI uses the total number of registered deaths from defined causes in children under 5 years of age as the denominator.

Estimated age-adjusted mortality rates were computed on the basis of registered mortality data, applying a correction algorithm for mortality underregistration and a redistribution algorithm for deaths from ill-defined causes, following the methodology presented in Health Statistics from the Americas, 1992 edition (PAHO/WHO, Scientific Publication No. 542). These rates represent the average quinquennial figure, built with mortality data from, at least, three years within the same quinquennium. In order to remove the effect of age distribution differences and to make the rates comparable, adjustment was carried out using estimated age-specific mortality rates, applying the United Nations standard population (2,400 under 1 year; 9,600 from 1 to 4 years; 19,000 from 5 to 14 years; 43,000 from 15 to 44 years; 19,000 from 45 to 64 years; and 7,000 older than 64 years) (WHO. World Health Statistics Annual; Geneva, 1994).

AIDS basic indicators refer to year 1995; most recent figures, although available, could be distorted due to delayed notification effect.

References

1. Pan American Health Organization. Health in the Americas 1998. Washington, DC; 1998.

2. United Nations. World Population Prospects: The 1996 Revision. New York; 1996.

3. United Nations. World Urbanization Prospects: The 1996 Revision. New York; 1996.

4. U.S. Bureau of the Census. International Data Base. Washington, DC.

5. World Health Organization. Demographic Data for Health Situation Assessment and Projections – 1998. Geneva; 1998.

6. UNESCO. Statistical Yearbook 1996. UNESCO Publishing & Bernan Press; Paris/New York; 1996.

7. Pan American Health Organization. Mid-Decade Evaluation of Water Supply and Sanitation in Latin America and the Caribbean. Washington, DC; 1997.

8. Pan American Health Organization. PAHO Technical Information System: Regional Mortality Database. HDP/HDA; Washington, DC; 1998.

This article was originally published as: Castillo-Salgado C, Mujica O, Loyola E. A Subregional Assessment of Demographic and Health Trends in the Americas: 1980-1998, Statistical Bulletin, Metropolitan Life Insurance Company, Vol. 80, No. 2, Apr-Jun 1999, New York, USA.