-from Epidemiological Bulletin, Vol. 20 No. 2, June 1999-

Preparatory Meeting of the PAHO/WHO Regional Advisory Committee on Health Statistics (CRAES)

  1. Introduction
  2. Situation of Vital and Health Statistics
  3. Situational Diagnosis of Vital, Health, and Population Statistics
  4. International Classification of Diseases
  5. Human Resources Education
  6. Proposed Work Areas for the Plan of Action 1999-2002


I. Introduction

With the object of reorganizing and coordinating support for the improvement of vital, health, and population statistics within the framework of the technical cooperation of the Pan American Health Organization, the Preparatory Meeting of the Regional Advisory Committee on Health Statistics (CRAES) was held at PAHO Headquarters in Washington, D.C. from 25 to 29 January 1999.

The objectives of the Committee will include advising PAHO activities aimed at: (1) reviewing the situation regarding vital and health statistics and providing support for their improvement and consolidation; (2) supporting lines of research in health situation analysis to orient programs designed to reduce inequities in health; (3) recommending the use of indicators that make it possible to measure the relationship between health and inequity; (4) supporting the preparation of guidelines for the implementation of the Tenth Revision of the International Classification of Diseases (ICD-10) and its updates; and (5) promoting the creation of a working group within the Committee to carry out these activities.


II. Situation of Vital and Health Statistics

The participants noted the effort that their countries had made to introduce various data collection methodologies and improve the coverage, timeliness, and quality of the core data in health. There are still problems, however, such as the lack of coordination among the institutions that generate the statistics; low coverage; the lack of timely information and the poor quality of the core data; and the use of different data collection forms to obtain the same type of information.

Even where there has been a general improvement in the quality of the registries, problems related to the composition by groups by age and sex persist. The conversion to automated systems in the countries has not been uniform, and where it has occurred, the emphasis is frequently more on the technology than on the quality of the data and the information processed. Moreover, with the decentralization of the health services, information is generated at the local level without the proper methodological preparation.

Other problems have also been identified: human resources lack training in data processing and data analysis; the Tenth Revision of the International Classification of Diseases (ICD-10) has not been implemented in some countries, or has only been partially implemented, without evaluating the quality of the coding; the dissemination of health information in some countries is inappropriate and is not part of an ongoing program; and, finally, demographic surveys are conducted to gather information in countries where population censuses and permanent vital statistics registries already exist.


III. Situational Diagnosis of Vital, Health, and Population Statistics

The observations of the Meeting’s participants reflected the situation in their own countries and not necessarily the reality of the Region as a whole, which will require a systematic diagnosis for all the countries.

In the early 1990s the United Nations Statistics Division conducted a situational diagnosis in 11 countries as part of an international program to improve vital statistics and civil registries. This study included workshops with the personnel responsible for civil registries and vital statistics and covered the preparation of manuals on legal aspects, administrative procedures, the use of computers and computer applications, the confidentiality of data, and the training of human resources.

With a view to developing a similar situational diagnosis for health and vital statistics in the Region, the participants discussed the preparation of a modular questionnaire for subsequent review in the countries. This questionnaire would serve as the foundation for the Committee’s plan of action for 1999-2002, within the framework of interagency cooperation, and would include indicators for aspects such as the overlapping of the work of different agencies, the heterogeneity of conceptual definitions and classifications, and deficiencies in the training provided to human resources in the collection, preparation, and use of the data.


IV. International Classification of Diseases

The International Classification of Diseases (ICD) is not only an instrument for the statistical description of mortality and morbidity but a mechanism for the improvement of health statistics. PAHO made a significant contribution to the implementation of the classification with the preparation of the Spanish version through its Collaborating Center in Venezuela.

Some of the more important activities in connection with the ICD were the workshops for coders and physicians; the preparation of a list presenting the causes of death, with consistency tables, and a proposal for two bridge studies between the ICD-9 and the ICD-10. Other noteworthy activities were the publication of one version of the ICD-10 for Mexico and another for the other countries of the Region, the preparation of an electronic version of volumes 1 and 3 of the ICD-10, and the creation of the Latin American Discussion Forum on the ICD and other members of the family of classifications via e-mail.

In addition, the Spanish version of the second edition of the International Classification of Diseases for Oncology (ICD-O-2) has been prepared with the collaboration of the Escuela Andaluza de Salud Pública (Andalusian School of Public Health) in Spain and the Centro Colaborador para la Clasificación de Enfermedades en Español, CEVECE, (Latin American Center for the Classification of Diseases). In December 1998, the International Agency for Research on Cancer (IARC) approved changes in the morphology coding for lymphomas and leukemias that will be incorporated in the third edition of the ICD-O-3, soon to be published in Spanish.

The participants discussed the mechanisms for updating the ICD-10, focusing on the implementation, frequency, and dissemination of proposals for corrections or new codes, as well as the mechanisms for disseminating the updates. No plans are afoot to prepare an international classification of medical procedures parallel to the ICD-10 in the coming years, since some members of the family of classifications are linked to the ICD and others are not.

The participants also proposed the promotion of research on the use of the definitions contained in the ICD (for example, an exploration of the cost-benefit of using different members of the family of classifications, among other potential areas of cooperation), recommending, moreover, the formation of a subgroup for the ICD that would include the three Collaborating Centers (Venezuela, Brazil, and the United States).


V. Human Resources Education

One reason for the lack of training in the collection, processing, and analysis of health information is that the courses for statistical personnel have ceased to be offered. Decentralization of the health services has generated a local demand for health statisticians at the professional and technical level, creating the need for human resources education in health statistics at the upper and middle levels.

The experience of PAHO in promoting distance learning through e-mail and the Internet was described, and the possibilities for cooperation with the Universidad Abierta de Cataluña (Open University of Catalonia) and other academic institutions were discussed.

The participants also agreed to make an inventory of the available teaching materials and courses, obtaining information on the curriculum, the length of the courses, and the target population. They requested interagency coordination to create funds for training fellowships, since the lack of opportunities of this type is one of the greatest obstacles to the training of personnel.


VI. Proposed Work Areas for the Plan of Action 1999-2002

Eight work areas were considered, with recommendations for each of them requested from the participants:

  1. Situational diagnosis of vital, health, and population statistics in the Region, through the questionnaire mentioned above.
  2. International Classification of Diseases, support mechanisms for the ICD-10, dissemination of its updates, adoption of new definitions, research agenda (for example, the demand, use, and cost-benefit of implementing other members of the family of classifications), and the model for the registry of hospital morbidity.
  3. Human resources education in the production, analysis, and use of applied health statistics, conducting inventories of the available training materials and courses on vital and health statistics and promoting distance learning on vital and health statistics through the Internet.
  4. Core data project in health to promote the initiative in the countries, including the subnational levels; validation and processing of the data; mechanisms for disseminating and communicating core data among the countries.
  5. Support for the organization of national health information systems, based on a methodological-conceptual document with recommendations on data collection, validation criteria, variables and basic indicators, articulation among entities and institutions, access to and confidentiality of the data, dissemination of information, and user support mechanisms.
  6. Validation of the health information, including the definition of validation and consistency criteria; national case studies on validation and guidelines for their review; methodologies for adjusting the data and health indicators; guidelines for consistency and data clean-up methods.
  7. Dissemination of information, which includes presentation of the data in accordance with the recommendations of international organizations; standards for developing the information, including those for electronic media; guidelines for the creation and operation of nodes for the dissemination of information, including "gray literature" (texts of articles that do not appear in publications for lack of space but are considered valuable or useful).
  8. Legislation on vital and health statistics, through a comparative analysis of the legal framework governing vital statistics, to strengthen vital and health statistics.

The Core Data Initiative in Health was finally presented as a project to respond to the need to monitor and evaluate the national and international commitments of PAHO. This initiative permits the standardization of a basic set of health indicators to facilitate health situation analysis. At least 18 countries have produced their own pamphlets of basic indicators, even at the provincial level. The initiative is spreading to other parts of the world--for example, the European Region and the Middle East. PAHO is working with other agencies to develop criteria for the validation of these indicators, with a view to improving the system. Geographic information systems are also being developed as support for health information analysis.

After establishing the eight work areas described above, the participants agreed to divide them among the following four working groups and to circulate the conclusions among all the groups: (1) diagnosis and evaluation of health information systems; (2) development of statistical methodologies and technologies in health; (3) promotion of training, research, and dissemination of information; and (4) the International Classification of Diseases.

Dr. George Alleyne, Director of PAHO, will approve the reactivation of this important Committee in 1999, selecting outstanding professionals in the fields of statistics and public health in the Region to serve on it.

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Epidemiological Bulletin , Vol. 20 No. 2, June 1999