—from Epidemiological Bulletin, Vol. 23 No. 2, June 2002—
Situation Analysis of Mortality in Bolivia
Introduction
The latest report on mortality in Bolivia was issued in 1990. The three leading
causes of death were infectious and parasitic diseases (23.9%), diseases of
the circulatory system (19.5%), and diseases of the respiratory tract (14%),
followed by accidents and violence (9.8%), disorders of the digestive system
(8.6%), affections originating in the perinatal period (7.4%), and tumors (4%).(1)
Bolivia lacks a national vital statistics information system and the process of automation and modernization of the national civil registration system, which is dependent on the National Electoral Court (Corte Nacional Electoral, CNE), is slow in coming. A recent inter-institutional coordination effort by the Ministry of Health and Social Welfare (MHSW), the National Directorate of Civil Registration (Dirección Nacional de Registro Civil, DNRC), and the National Institute of Statistics (Instituto Nacional de Estadísticas, INE) is trying to solve this problem. In 2002, a collection system for medically certified deaths has been put in place in all the hospitals of the national health system, using a standard death certificate.
As part of the technical cooperation that PAHO provides to the Ministry of Health to strengthen the health information system, epidemiological surveillance, and health situation analysis in the country, a plan for the study of mortality was implemented, covering the years 2000 and 2001. This study was carried out using registries of medically certified deaths from 9 cemeteries located in departmental capital cities, representing about 43% of the Bolivian population.
Current situation
For 2000-2005, INE and the Latin American Demography Center (CELADE for its
Spanish name) estimates Bolivia’s crude death rate to be 8.2 per 1,000 population
and life expectancy 63.6 years for the same period. Table 1 presents the crude
mortality rates and life expectancy at birth for Latin America, Bolivia, and
the 9 departments of Bolivia in the periods 1990-1995 and 2000-2005.(2)
The most recent survey on demography and health, implemented in 1998, estimated the infant mortality rate in Bolivia at 67 per 1,000 live births and the under five mortality rate at 92 per 1,000 live births for the period 1993-1997.(3) For the year 2002, MHSW and PAHO estimated those rates at 50 and 72 per 1,000 live births, respectively.(4) Figure 1 presents the proportional distribution of mortality in the under 5 by registered cause.(4)
|
Table 1: Crude mortality rate and life expectancy
at birth for Latin America and Bolivia and its departments, 1990-1995
and 2000-2005
|
|
Crude mortality rate
(both sexes) |
Life expectancy at birth (both
sexes)
|
||||
|
1990-1995
|
2000-2005
|
1990-1995
|
2000-2005
|
||
| Latin America |
8.3
|
7.7
|
65.4
|
68.1
|
|
| Bolivia |
10.2
|
8.2
|
59.3
|
63.6
|
|
|
La Paz |
9.8
|
8.6
|
60.5
|
61.7
|
|
| Santa Cruz |
7.2
|
5.9
|
63.7
|
67.7
|
|
| Cochabamba |
10.5
|
8.3
|
59.1
|
63.2
|
|
| Tarija |
8.1
|
6.6
|
63.1
|
67.3
|
|
| Potosi |
14.7
|
11.1
|
53.0
|
58.9
|
|
| Beni |
10.5
|
8.0
|
57.4
|
61.9
|
|
| Pando |
9.7
|
7.8
|
58.0
|
62.6
|
|
| Chuquisaca |
11.8
|
8.9
|
57.8
|
62.2
|
|
| Oruro |
13.3
|
10.8
|
53.7
|
59.3
|
|
| Source: INE/CELADE | |||||
Under-registration of mortality was estimated at 63% in 1999, with variations in the departments ranging between 47% in Beni and 89% in Pando. Table 2 presents estimates provided by the DNRC of mortality under-registration by department for this same year, calculated from estimated population data, crude mortality rates, and expected and registered deaths. In the case of the Department of La Paz, the information is also presented for the capital city, called “Sala Murillo”, and for the remainder of the Department.
|
Table 2: Estimation of mortality under-registration
in the National Vital Statistics System, based on civil registration,
Bolivia and departments, 1999
|
| Department |
Population (1)
|
Crude Mortality Rate
(p. 1,000) (2) |
Expected deaths
|
Registered deaths
(3) |
% registered
|
Under-registration (%)
|
| La Paz |
2,359,724
|
9.3
|
21,899
|
9,901
|
45
|
55
|
|
Sala Murillo
|
786,812
|
9.3
|
7,302
|
6,807
|
93
|
7
|
|
Rest of the Department
|
1,572,912
|
9.3
|
14,597
|
3,094
|
21
|
79
|
| Santa Cruz |
1,757,409
|
6.5
|
11,458
|
2,789
|
24
|
76
|
| Cochabamba |
1,484,867
|
9.4
|
13,913
|
6,056
|
44
|
56
|
| Tarija |
391,225
|
7.3
|
2,844
|
1,441
|
51
|
49
|
| Potosi |
765,254
|
12.5
|
9,566
|
3,040
|
32
|
68
|
| Beni |
355,983
|
8.9
|
3,186
|
1,700
|
53
|
47
|
| Pando |
55,885
|
8.6
|
479
|
54
|
11
|
89
|
| Chuquisaca |
576,287
|
10.1
|
5,838
|
811
|
14
|
86
|
| Oruro |
390,478
|
11.9
|
4,627
|
1,724
|
37
|
63
|
| Total |
8,137,112
|
9.1
|
73,966
|
27,516
|
37
|
63
|
| (1) INE Projection, 1999 (2) INE estimation, PRODEM 2.0, CELADE, INE, 1996 (3) National Civil Registration Directorate, National Electoral Court, 1999 |
||||||
Aside from under-registration, another problem in mortality data is the quality of death certification. A study of the quality of death registration in the La Paz general cemetery (S. Murillo), found that “cardio-respiratory arrest” was used in 57% of the certificates, which only indicates that the person died, without providing any information on the cause of death.(5)
The limitations in the mortality registration, whether related to coverage (under-registration) or data quality, are also encountered in the birth registry system. In 1999, under-registration of births was estimated at 34%, with values ranging between 0% in Tarija and Pando and 63% in Santa Cruz (table 3). Reported under-registration of 0% in the departments of Tarija and Pando may be attributed to the use of demographic estimators that do not take into account recent substantial migratory movements to these departments recorded in other demographic reports.(6) To reduce the natality under-registration, a proposal is in place to cancel the present fees for the registration of newborns in civil registration offices.
|
Table 3: Estimation of natality under-registration
in the National Vital Statistics System, based on civil registration,
Bolivia and departments, 1999
|
| Department |
Population
(1) |
Crude Birth Rate
(p. 1,000) (2) |
Expected births
|
Registered births(3)
|
% registered
|
Under-registration(%)
|
| La Paz |
2,359,724
|
31.4
|
74,095
|
51,626
|
70
|
30
|
|
Sala Murillo
|
786,812
|
31.4
|
24,706
|
22,124
|
90
|
10
|
|
Resto del Depto.
|
1,572,912
|
31.4
|
49,389
|
29,502
|
60
|
40
|
| Santa Cruz |
1,757,409
|
33.7
|
59,277
|
21,830
|
37
|
63
|
| Cochabamba |
1,484,867
|
34.3
|
50,886
|
44,340
|
87
|
13
|
| Tarija |
391,225
|
33.3
|
13,016
|
13,006
|
100
|
0
|
| Potosi |
765,254
|
33.6
|
25,713
|
23,143
|
90
|
10
|
| Beni |
355,983
|
36.7
|
13,061
|
7,.250
|
56
|
44
|
| Pando |
55,885
|
32.4
|
1,808
|
1,802
|
100
|
0
|
| Chuquisaca |
576,287
|
36.2
|
20,844
|
9,355
|
45
|
55
|
| Oruro |
390,478
|
30.4
|
11,851
|
7,.462
|
63
|
37
|
| Total |
8,137,112
|
33.2
|
270,478
|
179,814
|
66
|
34
|
| (1) INE Projection, 1999 (2) INE estimation, PRODEM 2.0, CELADE, INE, 1996 (3) National Civil Registration Directorate, National Electoral Court, 1999 |
||||||
Study of Mortality 2000
The study included 10,744 medically certified death records in 21 cemeteries
in the 9 departmental capitals (1 by city, except Santa Cruz, where 13 cemeteries
were used). Cemeteries were selected for their geographic location, whether
they belonged to the municipal or public system, and the availability of mortality
records and data from the year 2000.(7)
Information was collected from death certificates in the civil registry from the year 2000. When the medical death certification was issued on a document that did not correspond to the official death certificate, the information was collected through a specially-designed, validated instrument. This process was followed in less than 5% of the cases. Duplicate certificates, certificates issued for persons who had died outside of the country, and incomplete certificates (without age, sex, or diagnosis) were excluded. These corresponded to 2.4% of all registries. The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, was used to code the data. PAHO’s 6/67 list (6 groups, 67 subgroups) was used to group mortality causes.(8)
Estimated numbers of deaths were based on the registered deaths collected for the study, using procedures recommended by PAHO to adjust for under-registration and ill-defined deaths.(9) Table 4 presents the number of collected certificates and estimated deaths by capital city, as well as the reference population. The reference population was defined as the fraction of the departmental population proportional to the “collection coverage” for each cemetery. The “collection coverage” was defined in each cemetery as the proportion of certificates collected, with respect to the total of deaths in the civil registry in each department in 1999.
|
Table 4: Collected deaths, estimated deaths and reference
population used in the study, Bolivia, 2000
|
|
Deaths
|
Reference population
|
||
|
Collected
|
Estimated
|
||
| La Paz (S. Murillo) |
3,563
|
3,871
|
411,842
|
| Santa Cruz |
1,499
|
6,280
|
944,552
|
| Cochabamba |
2,047
|
4,791
|
501,903
|
| Tarija |
564
|
1,110
|
153,123
|
| Potosi |
687
|
2,188
|
172,937
|
| Trinidad (1) |
343
|
652
|
71,825
|
| Cobija (2) |
78
|
726
|
55,885
|
| Sucre (3) |
882
|
6,326
|
576,.287
|
| Oruro |
1,081
|
2,938
|
244,841
|
| TOTAL |
10,744
|
28,882
|
3,133,196
|
| Departments of (1) Beni, (2) Pando, (3) Chuquisaca | |||
The proportional distribution of mortality by major cause of death groups is presented in table 5. This table shows that 4 out of 10 deaths registered in the capital cities of the country were attributed to causes related to the circulatory system. This proportion is slightly higher for women. The high proportion of deaths from this cause may be biased by the frequent use of the term “cardio-pulmonary arrest” as the underlying cause of death. On the other hand, also worthy of note is the high proportion of external causes of death among males and of neoplastic causes of death among women.
The estimated general mortality rates show clear differences between departmental capitals and are consistently higher in men (table 6). According to this study, the absolute risk of dying is highest in Pando and Potosi and lowest in Santa Cruz. At the country level, the estimated total mortality rate was 9.2 per 1,000 population, consistent with the INE/CELADE estimate.
|
Table 5: Proportional mortality calculated from the
data collected for the study, Bolivia, 2000
|
|
Causes
|
TOTAL
|
MALE
|
FEMALE
|
| communicable |
13.3
|
13.4
|
13.2
|
| neoplasms |
8.0
|
5.8
|
10.4
|
| circulatory |
40.1
|
36.4
|
44.5
|
| perinatal |
5.4
|
5.9
|
4.8
|
| external |
11.9
|
16.5
|
6.7
|
| other causes |
21.3
|
22.0
|
20.4
|
| TOTAL |
100.0
|
100.0
|
100.1
|
|
Table 6: Estimated general mortality rates (per 1,000
population), calculated from the data collected for the study, Bolivia,
2000
|
| Department |
TOTAL
|
MALE
|
FEMALE
|
| Bolivia |
9.2
|
9.8
|
8.6
|
| La Paz |
9.4
|
9.5
|
9.3
|
| Santa Cruz |
6.6
|
7.4
|
5.9
|
| Cochabamba |
9.5
|
10.3
|
8.8
|
| Tarija |
7.3
|
7.8
|
6.7
|
| Potosi |
12.6
|
12.9
|
12.3
|
| Trinidad (1) |
9.1
|
10.1
|
8.1
|
| Cobija (2) |
13.0
|
15.7
|
10.7
|
| Sucre (3) |
11.0
|
11.5
|
10.5
|
| Oruro |
12.0
|
12.6
|
11.4
|
| Department of (1) Beni, (2) Pando, (3) Chuquisaca | |||
Table 7 presents the estimated cause-specific mortality rates by major groups of causes of death, expressed per 100,000 population for the 9 capital cities studied and for both sexes. In the capital cities, mortality from circulatory diseases prevailed, especially among women, with the exception of Trinidad and Cobija, where the rates were higher for men. Men, in general, were exposed to higher risks of death due to communicable diseases, with the exception of Tarija. The risk of death from neoplasm was three times greater in the highland cities of La Paz and Oruro than in the Tarija valley and was consistently higher for women, except in Sucre. On the other hand, mortality from external causes was greater in men. The city of Cobija, with an important agroindustrial population (chestnuts, rubber, and gold) and the cities of La Paz, Oruro and Potosí, with intense industrial and mining activities, presented the highest rates of mortality from external causes.
|
Table 7: Mortality rates from communicable diseases,
malignant neoplasms, diseases of the circulatory system and external causes,
by capital city and by sex (per 100,000 population), calculated from data
collected for the study, Bolivia, 2000
|
|
Communicable
|
Neoplasms
|
Circulatory
|
External
|
|||||||||
|
Total
|
Male
|
Female
|
Total
|
Male
|
Female
|
Total
|
Male
|
Female
|
Total
|
Male
|
Female
|
|
| BOLIVIA |
122.6
|
132.0
|
113.3
|
73.5
|
57.4
|
89.7
|
370.3
|
358.2
|
382.6
|
109.7
|
161.8
|
58.1
|
| La Paz |
115.3
|
118.4
|
111.9
|
112.9
|
84.1
|
162.7
|
235.6
|
205.3
|
266.7
|
136.1
|
180.4
|
90.2
|
| Santa Cruz |
129.8
|
147.3
|
112.3
|
65.4
|
58.4
|
72.4
|
218.8
|
225.2
|
212.5
|
74.2
|
115.8
|
32.5
|
| Cochabamba |
108.1
|
124.2
|
92.5
|
75.6
|
57.8
|
92.5
|
399.2
|
376.4
|
420.2
|
112.3
|
158.7
|
67.9
|
| Tarija |
59.2
|
56.1
|
62.3
|
32.3
|
24.1
|
40.6
|
433.2
|
422.3
|
444.4
|
61.9
|
101.6
|
21.7
|
| Potosi |
197.6
|
199.4
|
194.6
|
70.9
|
36.6
|
108.6
|
455.3
|
398.8
|
515.8
|
148.2
|
227.9
|
58.8
|
| Trinidad (1) |
176.3
|
196.3
|
156.3
|
47.8
|
23.8
|
72.1
|
487.0
|
571.0
|
402.7
|
59.8
|
59.5
|
60.1
|
| Cobija (2) |
241.2
|
247.8
|
235.1
|
111.3
|
41.3
|
167.9
|
556.5
|
660.7
|
470.2
|
241.2
|
495.5
|
33.6
|
| Sucre (3) |
87.8
|
91.2
|
84.6
|
46.5
|
49.5
|
43.6
|
607.0
|
573.0
|
640.5
|
113.7
|
169.3
|
58.9
|
| Oruro |
163.1
|
162.0
|
164.1
|
108.0
|
75.3
|
141.0
|
388.2
|
385.6
|
390.7
|
175.7
|
241.9
|
108.7
|
| Departments of(1) Beni, (2) Pando, (3) Chuquisaca | ||||||||||||
The 2000 mortality study presented here was an attempt to show an up-to-date mortality profile in Bolivia, to support the process of the development and implementation of the National Vital Statistics Information System. Vital statistics should present characteristics of continuity and stability, be compulsory, and provide for complete coverage. Within the organizational framework of the State’s institutions, data related to vital events (birth or death) are solely and officially registered in a single entity, the National Civil Registration System. From the Supreme Decree No. 24247 of the Bolivian National Coordination Committee for Information of Registered Vital Events, “the Civil Registry consists of the legal and compulsory registration of vital events, in a continuous and permanent way. Accordingly, the civil registry has a legal and statistical function in the collection of information.”10 Furthermore, this civil registry serves for the study of inequalities in mortality and for epidemiological analyses in public health. The diagram in figure 2 summarizes the ideal organization of a national vital statistics system based on the civil registration system, which has been chosen to be implemented in Bolivia in the near future.
References
(1) PAHO/WHO, Health Conditions in the Americas, 1990 Edition, Volume II,
Scientific Publication N°524, cited in: Calvo Alfredo, El Registro de la Mortalidad
en Bolivia, Ministerio de Salud y Previsión Social, Dirección General de Epidemiología,
Anuario Epidemiológico 2000. La Paz Bolivia, 2001.
(2) INE/CELADE 1996, LC/DEM/R.260 Serie OI, Nro. 113.
(3) INE, DHS, Macro International Inc., Encuesta Nacional de Demografía y Salud
1998, Bolivia.
(4) Ministerio de Salud y Previsión Social, Información Urgente, Situación de
Salud de la Niñez Boliviana frente al Nuevo Milenio, Bolivia 2000.
(5) Ministerio de Salud y Previsión Social, INIS, Pando R. Diagnóstico del registro
y notificación de la mortalidad y morbilidad. La Paz, 2000.
(6) Calvo Alfredo, Análisis de la Situación Demográfica, OPS/OMS Serie de Documentos
Técnicos Nº 2, 2001.
(7) Mejía Martha, Calvo Alfredo, Gonzales Oscar, Estudio Sobre Causas de Mortalidad
Hospitalaria en Menores de 5 años 1998 – 2000 y Estudio Sobre Causas de Mortalidad
General, 2000, OPS/OMS, AIEPI, SHA, La Paz, Bolivia, septiembre de 2001.
(8) PAHO/WHO, Epidemiological Bulletin, New PAHO/WHO 6/67 list for the tabulation
of ICD-10 mortality data, Vol. 20, N° 3, September 1999, Washington D.C.
(9) PAHO. Health Statistics from the Americas.1992 Edition. Scientific Publication
N° 542. Washington DC, 1992.
(10) Decreto Supremo N° 24247, cited in MSPS, INE, OPS, Propuesta técnica para
la conformación del Comité Nacional de Coordinación para la Información de Hechos
Vitales Sujetos a Registro, Mimeografiado, La Paz, 30 de octubre de 2000.
Source: Prepared by Dr. Alfredo Calvo Ayaviri from the Special Program for Health Analysis (SHA), PAHO/WHO Representation in Bolivia.
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Epidemiological Bulletin, Vol. 23 No. 2, June
2002
