changes in - world...

CHANGES IN

UNDER-FIVE

MORTALITY

RATE IN

TURKEY

Dr. Sema ÖZBAŞ

General Directorate of

Mother and Child Health

and Family Planning

A CASE STUDY

Decrease in Under-5

Mortality Rate in Turkey

(U5MR)

Unite for

Children

December

2010

• 4th Millennium Development Goal proposes to Reduce

by two-thirds, between 1990 and 2015, the under-five

mortality rate.

• Until today, all the regions in the world and the world in

total have fallen behind the schedule for realizing this

goal by the year 2015.

• Turkey, on the other hand, has realized MDG4, which

means U5MR has been reduced by two-thirds and is

now one of the few countries that may go beyond this.

Table 3.1: Comparative State of U5MR in Turkey

World Region/Classification Decrease in % of U5MR (90-07)

Industrialized Countries 40.0%

Developing Countries 28.2%

Least Developed Countries 27.4%

Middle East and North Africa 41.8%

Middle/Eastern Europe,

Commonwealth of Independent Countries 52.8%

WORLD 26.9%

Turkish Republic 72.0%

(Source: UNICEF State Of The World’s Children Report 2009)

U5MR ANALYTICAL FRAME

CONTEXT

Demographic

factors in population

Economic factors

Rural-urban

migration

Mother's education

INPUTS

Policies

Health Planning

Health Reform

Preventive Efforts

Prevention of

Infectious Diseases

Family Planning

Child Care

and Child Survial

OUTPUTS

Antenatal Care

Perinatal Care

Systems

Maternity Wards

of Hospitals

Neonatal Care

Post-neonatal

Care

Personnel in

Mother and Child

are

RESULTS

Infant mortality

Neonatal deaths

Post-neonatal

deaths

Child mortality

EFFECT

Decrease in

U5MR

DEMOGRAPHIC CHANGE

• While the Yearly Population Growth Rate was 2.3% in

Turkey between the years 1970 and 1990, this rate

decreased to 1.6% in 1990-2007 period. And in 2007, it

decreased to 1.2%.

• In 2000-2006, Turkey's urban population grew

approximately by 14% and reached 49.5 millions. Rural

population, on the other hand, decreased by 1.4 percent to

23.4 millions. As a matter of fact, Turkey has become a

country with a mainly urban population in which 68% of the

population live in cities in the last decades.

• In the previous decades, while urban population was

increasing, family size dropped from 5.3 in 1980 down to

3.9 in 2003. Sources: OECD, Turkey Statistics Profile, 2009., UNICEF, State of World's Children, 2009.

The Relationship between population

and under 5 mortality rate

0

0,5

1

1,5

2

2,5

3

3,5

4

Low income group Middle income group High income group World Turkey

0

20

40

60

80

100

120

Total Fertility Rate

Population Growth Rate

U5MR

HDI 2009

ECONOMIC FACTORS

Turkey's economy annually grew by 1.9% during the period 1970-

1990 and GDP Per Person increased by 2.2% between the years

1990 and 2007.

Table 5.2 GDP Per Capita ($), Turkey 2000-2007

Year GDP Per Capita ($)

Source: OECD, Turkey Statistics Profile, 2009

THE RELATIONSHIP BETWEEN GNP PER

CAPITA AND UNDER FIVE

MORTALITY RATE

HDI 2009

0

5000

10000

15000

20000

25000

30000

35000

Low Income

Group

Middle Income

Group

High Income

Group

World Turkey

0

20

40

60

80

100

120

GNP

U5MR

2008 TNSA (TURKEY Demographic and Health Survey)

EDUCATION LEVEL OF FEMALE

POPULATION (%)

TURKEY CITY COUNTRY

2003 2008 2003 2008 2003 2008

UNEDUCATED/NO

PRIMARY SCHOOL

DEGREE38.6 33.4 33.8 28.1 48.8 47.6

PRIMARY

EDUCATION 1ST

STAGE37.6 35.8 36.4 35.2 40.1 37.4

PRIMARY

EDUCATION 2ND

STAGE9.5 12.3 10.8 13.7 6.6 8.8

HIGH SCHOOL 14.2 18.2 18.8 22.7 4.4 5.9

INPUTS: PROGRAMS, POLICIES AND

INCLINATIONS IN RESOURCES

11

Marriage and Pre-pregnancy Consultation Program

Family Planning Program

Antenatal Care Program

Urgent Obstetrical Care Program

Delivery and C-section Program

Postnatal Care Program

Maternal Mortality Monitoring Program

MOTHER AND CHILD HEALTH

PROGRAMS

12

Neonatal Resuscitation Program

Infant and Child Monitoring Program

Neonatal Intensive Care Program

Neonatal Scanning Program

Mother and Child Nutrition Program

Child Infection Prevention Program

Infant Mortality Monitoring Program


PROGRAMS

13

Youth Health Program

Older Age Reproductive Health Program

Sexual Health Program

Program for the Involvement of Males in MCHP

Services

International Education Program


PROGRAMS

14

MAIN FACTORS THAT AFFECT THE

PROGRAMS

Political Commitment

Scientific Support

Support of Vocational NGOs

Support of NGOs

Monitoring and Evaluation

Personnel Motivation

15

POLITICAL COMMITMENT

• Why does mother and child health matter?

• What political good does it bring to politicians?

• How does it affect the economic policy?

• What benefits does it have for prompting an

economic boon in medium and long term?

• What would be the costs if we did not provide

these services?

16

• We talked to universities

• We talked to the Ministry of Finance

• We talked to the Private Sector

• We talked to members of the parliament

• We talked to the NGOs

We ensured consensus,

We prepared the Women's Health Strategic

Plan,

Then we talked about it to decision makers

together and ensured political support.

POLITICAL COMMITMENT

17

SCIENTIFIC SUPPORT

It was necessary to have some strong scientific

support for the programs to be internalized

across the country.

We created scientific committees for each

program consisting of scientists from;

• Universities

• Hospitals of the Ministry of Health

• Hospitals of the Private Sector

18

All the programs were prepared and followed in

corporation with these scientific committees.

In order to ensure standardization across

the country, clinic application guides and

work flow schemes were prepared for each

program.

Therefore, it was ensured that all the institutions

in service could internalize the programs.

SCIENTIFIC SUPPORT

19

SUPPORT OF VOCATIONAL NGOs

In order for the programs to be internalized

by the implementing health personnel, we

ensured cooperation with specialized

associations.

20

SUPPORT OF NON

GOVERNMENTAL ORGANIZATIONS

There were two respects that made the

support of NGOs important;

• Ensuring Political Commitment

• Creating demand for health services

21

MONITORING AND EVALUATION

•Monitoring and evaluation indicators were

prepared for each program.

•A data glossary was prepared, indicators

were described, personnel responsible for

registry and notification were determined.

•Computer programs were created for

monitoring the data in digital media.

22

There were 3 stages to Monitoring and

Evaluation:The process was monitored by

•Directorates of Health on Province Level

•General Directorates on Ministry Level

•Besides, there was constant monitoring by field

coordinators that were not connected to routine

bureaucratic ranks but directly connected to the

Minister.


23

The evaluations of those who utilized the

Health Service were also taken.

•The data was checked with the demographic

and Health Surveys (TNSA).

•User opinions were taken through

satisfaction surveys.


24

PERSONNEL MOTIVATION

• People keep struggling as far as they know and they

believe; they do not struggle for what they don't know or

don’t believe; they determine their goals and expectations

within these limits.

• First, we made ourselves believe that we were going

to accomplish these goals. Then, we organized a set

of meetings to make our personnel believe that too.

• We rewarded success also in financial terms. We

brought about the performance system. We counted

Pregnancy and infant monitoring and other indicators

among performance criteria.

OUTCOMES: STRENGTHENED

MOTHER-CHILD HEALTH

SYSTEMS

DEVELOPMENTS IN PREGNANT CARE

AND DELIVERY

26

Prenatal Care Helper of Delivery Place of Delivery

TDHS-1993 TDHS-1998 TDHS-2003 TDHS-2008

Table 7.3 Neonatal Intensive Care Systems and Resources, Turkey, 2002-2008

MoH2002

Source: Ministry of Health, 2009

MoH2008

Other2008

Turkey-Total2008

Turkey/Target

Neonatal Centers

Neonatal intensive care beds

Mobile incubator

Ventilator

Neonatal specialists

Nurses in Neonatal Service

DEVELOPMENTS IN DELIVERY (%)

76 73

8391

60

7378

90

0

10

20

30

40

50

60

70

80

90

100

TDHS 1993 TDHS 1998 TDHS 2003 TDHS 2008

DELIVERIES BY MEDICAL PERSONNEL HOSPITAL DELIVERIES28

29 29

92,1

79,8

0

9688,8

94,1 95,4

70,5

88,9

0

20

40

60

80

100

120

POST-NATAL INFANT CHECK

2008 TNSA (TURKEY Demographic and Health Survey)

RESULTS: NEONATAL AND

POSTNEONATAL

INFANT AND CHILD

MORTALITY

CHANGES IN PERINATAL, NEONATAL,

POSTNEONATAL INFANT AND UNDER FIVE

MORTALITY RATE

TNSA

43

29

,2

23

,4

53

39

25,8

16,9

43

24

17

12

29

19

13

4

17

0

10

20

30

40

50

60

Prenatal

Mortality

Rate

Neonatal

Mortality

Rate

Postnatal

Mortality

Rate

Infant

Mortality

Rate

1993

1998

2003

2008

INFANT MORTALITY

ACCORDING TO

THE REASONS IN 2008

INFANT MORTALITY

ACCORDING TO

THE REASONS IN 2007

5%

1%

15%

6%

28%

6%

5%

11%

2%1%

1%

1%

19% Bilinmiyor

dogum travması

konjenital anomali

KKH

prematürite

perinatal asfiksi

özel durumlar

sepsis

ASYE

menejit

İVH

ishal

neonatal tetanos

malignite

kaza

diger

32

Reason of death

unknown

birth trauma

congenital anomaly

CHD

Prematurity

Perinatal asphyxia

Special cases

Sepsis

LRTI

meningitis

intra-ventricular hemorrhage

diarrhea

neonatal tetanus

malignancy

accident

other

Unknown

birth trauma

congenital anomaly

CHD

Prematurity

Perinatal asphyxia

Special cases

Sepsis

LRTI

Meningitis

intra-ventricular

hemorrhage

Diarrhea

neonatal tetanus

Malignancy

Accident

other

1%

16%

5%

30%

5%

29%

9%

2%

1%1%

dogum travması konjenital anomali KKH

prematürite perinatal asfiksi diğer

sepsis ASYE menejit

İVH ishal neonatal tetanos

malignite kaza

1%

4%2% 2%

11%

1%

5%

1%

7%

1%

3%1%

1%2%

1%1%

1%

1%2%

1%1%

6%

42%

postmatürite hidrosefali NEKIU enfeksiyon hepatit ensefalitdiger enfeksiyon RDS pnömotoraksMAS PHT diger sol.sis.prob.sok diger kalp hast. nöromusk.hast.genetik hast. metabolik hast. metabolik bzk.nöro.prob. imm.yetm. endok.prob.bobrek yetm. diger renal prob. kanama bzk.HF anemi malnutrisyonpostop.nedenler ABO ihmal-ist.ayrışmamış

INFANT MORTALITY

ACCORDING TO THE REASONS IN 2009

birth trauma

prematurity

sepsis

IVH

malignancy

Congenital anomaly

Perinatal asphyxia

LRTI

diarrhea

accident

CHD

other

meningitis

Neonatal

tetanus

Postmaturity

IU infection

Other infection

MAS

Shock

Genetic diseases

Neuro. Prob.

Renal Failure

HF

Post-op. Reasons

Unclassified

Hydrocephalia

Hepatitis

RDS

PHT

Other heart dis.

Metabolical dis.

İmm. Fail.

Other renal prob.

Anemia

ABO

NEK

Encephalitis

Pneumothorax

Other resp.sys.prob.

Neuromusc.dis.

Metabolic mal.

Endok. Prob.

Bleeding prob.

Malnutrition

Negligence/abuse

EFFECT: DECREASE IN

U5MR IN TURKEY

COMPONENTS OF UNDER FIVE

MORTALITY RATE

Table 9.1 Under Five Mortality Rate (U5MR) in Turkey according to various sources, 1998-2008

Research Year

Resources: TDHS: Demographic and Health Survey of Turkey, 2008; TURKSTATEstimates: Health at a Glance 2007; UNICEF State of World's Children 2009

TDHS - 1998

U5MR

TDHS - 1993

TDHS - 1998

TDHS - 2003

TURKSTAT Estimates 2004



UNICEF/TURKSTAT Estimates 2007

TDHS - 2008

UNICEF/TURKSTAT Estimates 1990

37

Marriage and Pre-pregnancy Consultation Program

Postnatal Care Program

Neonatal Resuscitation Program

Infant and Child Monitoring Program

Neonatal Intensive Care Program

Neonatal Scanning Program

Mother and Child Nutrition Program

Child Infection Prevention Program

Child Emergency and Intensive Care Education

Program


PROGRAMS

THANK YOU

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