SITUA liON ANALYSIS FOR POLICY REPORT SAP/TRlWPROI001102 PACIFIC ISLAND MORTALITY EVALUATION Strengthening capability for collection, evaluation, analysis, project and reporting of mortality data from Pacific Island countries Regional Office for the Western Pacific Manila, Philippines June 2002 TABLE OF CONTENTS 1. INTRODUCTION AND BACKGROUND ................................................................................. 1 2. METHODS ............................................................................................................................. 2 2.1 Survey of existing mortality data ................................................................................ 2 2.2 Evaluation of Validity of mortality data ....................................................................... 2 3. RESULTS 3.1 Problems with currently available Pacific Island mortality data .................................. 3 3.2 Best estimates of current Pacific Island mortality ...................................................... 4 3.3 Priority countries requiring assistance ....................................................................... 4 3.4 Summary table .......................................................................................................... 5 4. CONCLUSiONS ..................................................................................................................... 7 ANNEXES: ANNEX 1 - MELANESIA SUMMARY, GRAPHS AND TABLES ..................................... 9 ANNEX 2 - MICRONESIA SUMMARY, GRAPHS AND TABLES ................................. 21 ANNEX 3 - POLYNESIA SUMMARY, GRAPHS AND TABLES ................................... 39 ANNEX 4 - FORM FOR SURVEY OF PACIFIC ISLAND MORTALITY INFORMATION AND NOTE ON RESPONSE ............................................ 67 ANNEX 5 - INTERNET SEARCH ................................................................................. 73 ANNEX 6 - CANBERRA VISIT ..................................................................................... 77 ANNEX 7 - SPC VISIT.. ................................................................................................ 79 REFERENCES ................................................................................................................... 81 1. INTRODUCTION The Pacific Island countries are at different stages of the demographic transition, with some populations still experiencing relatively high mortality and fertility, while others manifest lower mortality and declining fertility. Many of these countries are also passing through the epidemiological transition, which is associated with complex changes in causes of mortality by age and sex over time and between countries. The availability of accurate and current mortality data and trends is of vital importance for comparison purposes between countries to assist in the generation of the political will necessary to channel public and private resources into health-related activities. The consequences of inaccurate (low) mortality data are an under-estimate of the gravity and urgency of the health situation, and can result in under-investment in health development. Many international and aid agencies use infant and childhood mortality rates and life expectancy as part of the process of decision making for allocation of funds. Trends in mortality can also provide an overall assessment of the results of investment in social and economic development and health services. In the mortality data from Pacific Island countries presently available, considerable contradictions are evident, especially with regard to implausible increases in life expectancy in several countries during the 1990's, and variation in data supposedly for the same period reported by different agencies. The objectives of this project are to: (1) identify and obtain recent empirically derived mortality data for Pacific Island countries, examine for validity, and report accurate mortality by sex; (2) assist countries with assessment and analysis of their mortality data, including identification of important gaps; and (3) assist countries with filling important gaps in mortality data and provide opportunities for group and individual training. Phase 1 (2001) of the project involved: a detailed examination of material already obtained, searches of web sites and databases; telephone, email and fax contact with key informants in international agencies, universities and Pacific Island countries; visits to the Australian National University (ANU) in Canberra and the Secretariat for the Pacific Community (SPC) in Noumea; and a survey of mortality information held by Ministries/Departments of Health and Statistics in Pacific Island countries through the World Health Organization. Mortality data were evaluated from information on: source and methods, plausibility, and accuracy and consistency. It is envisaged that Phase 2 (2002) would involve country visits to priority countries identified by the Phase 1 assessment. The purpose of the visits would be to obtain further mortality data and provide countries with assistance in evaluation and analysis of their own data, as well as identification of important gaps in mortality information collection and analysis. Phase 3 - 2 - would involve: projects to rectify gaps in mortality information, detailed regional mortality analysis, and training activities including fellowships. 2. METHODS 2.1 Survey of existing mortality data A systematic survey was undertaken of international and regional agencies, and universities and research institutes, known to be involved in the production and dissemination of mortality data in the Pacific Island region. The primary source of mortality data was traced through references in secondary material, and by interviews with authors of reports and key informants as far as possible. Relevant web sites were searched as well as electronic health and demographic databases. During Phase 1 information was gathered from institutions and a survey of countries with visits to ANU (Canberra) and SPC (Noumea). A data collection instrument was sent to the Health and Statistics Ministries/Departments of the Pacific Island countries through WHO offices and representatives requesting published and un-published mortality data from 1990. Follow-up of this survey instrument by telephone and email was undertaken. 2.2 Evaluation of validity of mortality data Mortality data was evaluated with respect to its: source and methods; plausibility; and accuracy and consistency. Sources and methods: The source of mortality data was identified, and the methods used for computation and projections were ascertained as far as possible. These were evaluated with respect to known strengths and weakness of sources and methods. Some countries are known to have relatively good vital registration by the civil system or death recording by health departments. However, completeness of death recording is suspect in many Pacific Island countries. Use of model life tables for imputation of adult mortality from child mortality, or as part of indirect methods, were examined in relation to the appropriateness of the model life tables used. Projections were examined in relation to methodology and assumptions, when these were available. Plausibility: Infant and childhood mortality and life expectancy figures were evaluated with respect to plausibility compared with other similar countries, the cause-structure of mortality, and reported changes in relation to previous estimates of greater validity. Accuracy and consistency: If mortality estimates derived by independent methods requiring different assumptions provide approximately the same estimates, then confidence in such figures is enhanced. For example, concurrence of death recording corrected for under-enumeration and indirect methods from demographic analysis of censuses. - 3 - 3. RESULTS 3.1 Problems with currently available Pacific Island mortality data The problems encountered with assessment of Pacific Island mortality data are set out below. 3.1.1 Death or vital registration data There is considerable use of under-enumerated death recording or vital registration data, especially within countries, without any attempt to estimate and correct for under-enumeration using sample surveys or the Brass Growth Balance method. Both infant and adult mortality data are underestimated using these calculations. (1) In some small island countries, especially with populations below 50 000, vital registration or death recording data are used to produce annual mortality estimates. The small number of deaths produces significant fluctuations from year to year with some estimates implausibly high and others implausibly low. Averages over three to five years, or in some cases seven to ten years, are required. (2) Possibly inappropriate life tables are used in some countries to adjust and smooth empirical death recording or vital registration data. Depending on the locations of the countries in the demographic and health transitions, some model life tables may be inappropriate. (3) In some small island countries with extensive connections with more developed metropolitan countries, out-migration of seriously ill persons for treatment may lead to under­ enumeration of deaths of these people (especially the French associates of New Zealand and the United States of America). Furthermore, sailors or expatriate workers may die overseas and not be registered although they were counted in the census. This usually causes greater under­ enumeration of male