1. Ayaga Bawah, PhD Principal Research Associate INDEPTH Network Accra, Ghana Using Demographic Surveillance Systems to Monitor Progress in MDGs 4 and 5 Presented at African Science Academies Development Initiative meeting in Accra, Ghana, Nov 9-11, 2009.

2. Introduction All African countries aim to reduce both childhood and maternal mortality by two thirds over the 25-year period ending in 2015 from 1990. Yet, with only a decade remaining in the MDG framework, maternal and child mortality remains unacceptably high in Africa The 2007 UN MDG progress report expressed concerned about the low pace in childhood mortality decline in SSA Similarly, maternal mortality remains high The UN report described the lack of progress with MDG5 (maternal mortality) as a “Global Scandal” One critical issue that most African countries face is how to monitor progress of the MDGs

3. Measurement is critical “A Millennium Development Goal which cannot be monitored cannot be met or missed.” Johansson and Stewart, UNDP, 2002

4. This presentation seeks to highlight the importance of longitudinal health and demographic surveillance systems (HDSS) in monitoring MDGs 4 and 5.

5. How do we measure progress? Process indicators… Infant and child mortality rates Maternal Mortality Rate

6. What options exists for measuring outcomes? Censuses  Poor in capturing events…periodicity too long Civil Registration Systems  Poorly developed Periodic Surveys  Large sample size  Estimate events several years before survey  Wide confidence intervals Sample registration with vital events registration Health records, etc Health and Demographic Surveillance Systems  Cover entire districts  Verbal Autopsy

7. What is HDSS and how does it operate? INDEPTH Network Process of defining risk in a population and corresponding demographic events: birth rates, death rates, and migration events, over time For surveillance to exist, certain basic operations must exist A census must define the population under study Periodic follow up to monitor changes over time.

8. Core elements of a HDSS Key events monitored:  Births  Deaths  Migrations in-and-out of the area. Other characteristics of individuals are recorded -- relationships, ages, immunization, educational attainments and other socio-economic attributes.

9. Prospective monitoring of demographic and health events Verbal autopsy for cause of death Capturing episodes of disease and hospital admission Measure characteristics of environment or household members (e.g. SES, vaccines, HIV, nutrition) Intervention trials (randomised)

10. Data permit the longitudinal observation of individuals because… Each individual has a unique identifier for linking events, individuals, and groups. The system of recording births registers exact dates of birth and maternal relationships. Mothers not experiencing birth are defined. The system records deaths with dates of deaths and links to individuals at risk. Individuals surviving at a point in time are also defined. The registration of migration in and out of the area permits precise individual level definition of censoring. Attributes

11. The Millennium Development Goals (MDGs) : Measurable Indicators involving individuals, families, or relationships 1. Eradicate extreme poverty and hunger 2. Achieve universal primary education 3. Promote gender equality and empower women 4. Reduce child mortality (“Core” output) 5. Improve maternal health (“Core” output) 6. Combat HIV/AIDS, malaria and other diseases 7. Ensure environmental sustainability 8. Global Partnership

13. 0.0000 0.0025 0.0050 0.0075 0.0100 0.0125 m(x) 01224364860 age(months) children aged 0-59, months Infant and Child Mortality

15. District level demonstration Source: de Savigny D et al. 2004

16. 0.00 0.25 0.50 0.75 1.00 Survival 0246 Analysis time in years NonePartial Full Kaplan-Meier Cumulative Probabilities of Survival, by immunization status of under five children Source: Bawah et al. 2008

17. SOURCE: Ghana health service, reproductive and child health unit, annual report, 1994-2004 Institutional MMR in Ghana

19. Concluding remarks… Longitudinal demographic data allows for continuous monitoring of demographic and health events over time Provides process indicators for measuring progress Platform intervention studies and to monitor progress of those interventions HDSS sites can be constituted into national sentinel sites for measuring progress of the MDGS. INDEPTH Network provides a great opportunity to contribute to monitoring the MGGs in Africa

20. Currently 35 sites in 18 countries 24 sites in Africa 10 sites in Asia 1 site in Oceania Close to 3 million people under surveillance

21. INDEPTH Network West Africa Oubritenga, Burkina Faso (150,000) Nouna, Burkina Faso (76,847) Navrongo, Ghana (140,000) Kintampo, Ghana (145,000) Dodowa, Ghana ( 96,921) Farafenni, The Gambia (16,883) Bandim, Guinea Bissau (101,000) Niakhar, Senegal (35,000) Mlomp, Senegal (7,500) Bandafassi, Senegal (11,200) East Africa Butajira, Ethiopia (40,000) Rakai, Uganda (12,000) Iganga, Uganda (62,000) Nairobi, Kenya (68,598) Kisumu, Kenya (135,000) Kilifi, Kenya (220,000) Ifakara, Tanzania (67,000) Rufiji, Tanzania (90,000) Magu, Tanzania (28,000) Southern Africa Manhica, Mozambigue (80,000) Dikgale, South Africa (8,000) Agincourt, South Africa (70,000) Africa Centre, South Africa (90,000) Karonga, Malawi ( 40,000) 1 2 3 4 5 6 7 1- Ethiopia 2-Kenya 3- Uganda 4-Tanzania 5-Malawi 6- Mozambique 7- South Africa 8 - Senegal 9 - The Gambia 10-Guinea Bissau 11-Burkina Faso 12- Ghana 8 9 10 11 12 Total Population 1,815,349 INDEPTH Demographic Surveillance Sites in Africa

22. Thank you!