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U5MR DECEMBER 2009 U5MR / TURKEY DECLINE IN THE UNDER-5 MORTALITY RATE (U5MR) in TURKEY: A CASE STUDY March 2010 Dr Lilia Jelamschi, UNICEF Turkey Prof. Dr. Timothy De Ver Dye, Epidemiologist U5MR DECEMBER 2009 U5MR / TURKEY Decline in the Under-5 Mortality Rate (U5MR) in Turkey: A Case Study Page (1) Executive Summary 3 (2) Introduction 5 (3) Turkish U5MR in Global Context 6 (4) U5MR Analytic Framework and Data Sources 7 (5) The Context: Social, Economic, and Demographic 9 Change in Turkey (6) The Inputs: Trends in Programs, Policies, and Resources 12 (7) The Outputs: Strengthened Maternal and Child Health 19 Systems (8) The Outcomes: Neonatal, Post-neonatal, Infant, and 27 Child Mortality (9) The Impact: Reduction in U5MR in Turkey 35 (10) Implications of Observations: Achievements and Op- portunities for Maternal and Child Health System Strength- 37 ening in Turkey Appendix A: Turkey Demographic and Health Survey 2008: 41 Infant and Child Mortality Reference Tables table of contents U5MR / TURKEY DECEMBER 2009 (1) Executive Summary Several notable points from this assessment • Despite these achievements, some populations include: remain at elevated risk for infant and under-5 mortality, namely: residents of the Eastern • Turkey has observed a rapid decline in the region, in rural areas, with no/ incomplete Under-5 Mortality Rate (U5MR) since 1990, primary education, in the lowest quintile of largely due to the rapid decline in both wealth, and for infants born to women who components (neonatal and post-neonatal) already have several other children (higher birth of the infant mortality rate. Since both order). There has been an impressive expansion components of the infant mortality rate of public health programs and strengthened declined significantly, these declines were health systems in Turkey; though a gap remains likely systemically-induced, the result of broad in health disparities between high- and low-risk comprehensive improvements in the public groups, this gap is narrowing. health and health services systems in Turkey. • While exhibiting a precipitous decline, the • This decline occurred in the context of a infant mortality rate in Turkey could decrease similarly rapid population shift from rural to further with attention to the major causes of urban areas, a corresponding large increase infant death, which are largely preventable with in GDP/capita, decreased family size, and scale-up of and access to existing technology increased education achievement for women. and intervention: low birthweight/ prematurity, • Sustained focus on health strategy and congenital anomalies, and sepsis, among planning, and implementation of widespread, others. effective public health campaigns namely As a result of Turkey’s investments in public focused around family planning, vaccination, health programs and health systems, in the child survival, and neonatal resuscitation have context of a generally stronger socioeconomic contributed significantly to the decline in the status of its population, the U5MR decline since IMR and subsequently in the U5MR. 1990 is one of the highest in the world, likely • The resulting strengthening of components of a decline of more than 70 percent from 1990 maternal and child health systems in Turkey to 2007. The Turkey Demographic and Health – namely, a rapid increase in antenatal care Survey (TDHS) is an invaluable resource in attendance, large increases in the proportion assessing risk, progress, and opportunities; a of women delivering in health institutions and population-based perinatal data system would in the proportion of women whose deliveries enhance the utility of TDHS and provide more were attended by health providers, and the real-time monitoring, evaluation, and research rapid development of neonatal intensive care, opportunities for targeting further declines in all directly contributed to increased survival of U5MR. newborns and children. DECEMBER 2009 U5MR / TURKEY (2) Introduction The Republic of Turkey is a country that has the examination of U5MR in Turkey, a framework undergone rapid social, economic, and health that may help other countries similarly examine change in the past two decades. Since the their declines in U5MR over time in the context 1980s and before, the economy of Turkey of other country changes. has grown rapidly, with occasional setbacks and recoveries, and large portions of the rural The purpose of this report is to present a population have migrated to several rapidly description and analysis of U5MR mortality growing cities, creating challenges facing the decline in Turkey, with a particular focus on Turkish health care system. In the historical policy, programmatic, and epidemiological context of these geographic, sociodemographic, changes observed since 1990 that may and health status challenges, Turkey’s help explain Turkey’s rapid progress toward achievements in reducing mortality among reducing U5MR, and indeed underscoring infants and children since 1990 are quite Turkey’s experience in achieving the remarkable. In fact, Turkey’s Infant Mortality Millennium Development Goal 4 (to reduce Rate (IMR) and Under-5 Mortality Rate (U5MR)* by two-thirds between 1990 and 2015 the are among the most rapidly declining rates under-five mortality rate). Further, this report worldwide. provides interpretation of trends in Turkey and summarizes the Turkish experience in improving As many countries are undergoing similar rapid maternal and child health status. The analysis social and economic changes, Turkey provides adopts a logic model approach, examining an interesting case study in U5MR mortality context, system inputs, system outputs and decline. This report provides a framework for outcomes, impacts. * U5MR: Under-5 Mortality Rate is defined as “the probability (expressed as a rate per 1,000 live births) of a child born in a specified year dying before reaching the age of five if subject to current age-specific mortality rates” (http://www.childinfo.org/mortality_ methodology.html). 5 U5MR / TURKEY DECEMBER 2009 (3) Turkish U5MR in Global Context The Fourth Millennium Development Goal the MDG4 goal and have reduced their U5MR (MDG4) is by 2015 to reduce the under-five by more than two-thirds: in fact, according to mortality rate (U5MR) by two-thirds from the UNICEF’s State of the World’s Children Report 1990 level. To date, all regions of the world (2009), Turkey’s U5MR in 2007 has reduced by and the world in aggregate fall well-below this 72% over 1990 levels. This substantial decline goal, and well-below where one might expect is only slightly less than the decline observed by them to have achieved if the goal is to be met Portugal during the same period, the only other by 2015. Turkey, however, is one country among European or OECD country to have achieved a only a few that have likely already surpassed greater decline than Turkey. Figure 3.1: Comparison of Turkey Under-5 Mortality (U5MR) World Region/ Classification Percent Change in U5MR (90-07) Industrialized Countries - 40.0% Developing Countries - 28.2% Least Developed Countries - 27.4% Middle East and North Africa - 41.8% Central/ Eastern Europe, Commonwealth of - 52.8% Independent States WORLD - 26.9% Republic of Turkey - 72.0% (Source: UNICEF State of the World’s Children 2009) The U5MR in Turkey declined an average of 7.5% per year during this timeframe as well (1990-2007), with only five countries worldwide with a higher annual decline. U5MR declined much faster than expected in Turkey during this period when compared with similar countries throughout the world. 6 DECEMBER 2009 U5MR / TURKEY (4) U5MR Analytic Framework and Data Sources The analytic framework adopted to examine outcomes, and impacts as shown in the model U5MR is the logic model approach, which below. delineates systems inputs and outputs, Figure 4.1: Logic Model Framework for U5MR Reduction o Turkey Underlying this framework is the assumption policies, health reforms, and implementation that direct attribution of a single cause (or, of effective intervention programs surrounding input) that creates the impact desired (in this family planning, childhood immunization, instance, decreased U5MR) is not possible, nor breastfeeding and child nutrition, and oral is appropriate. In fact, U5MR is a multifactoral rehydration/ child survival, all combine to create construct that results from the combined well-functioning MCH systems of care. These effects of health policies and reforms, and well- MCH systems of care (the “outputs”) include functioning maternal and child health (MCH) direct maternal and neonatal care contexts systems and interventions, in the context of (including antenatal, delivery, neonatal, and particular social, demographic, and economic post-neonatal clinical and preventive care), contexts. In this model, we examine the which subsequently directly and indirectly contexts of population and economic change, impact infant mortality, comprised of both and educational change and gender, as these neonatal and post-neonatal death, and child often relate directly and indirectly to under-5 death. These components combined form the mortality. Systems inputs, particularly health U5MR, which is expected to decline as the logic 7 U5MR / TURKEY DECEMBER 2009 model functions, i.e., as the inputs create the from sources from within Turkey that allow for outputs desired, which subsequently impact comparable assessment with other countries’ the outcomes and impacts anticipated. Data data, particularly core UNICEF monitoring data sources