The Place and Role of Official Statistics within the National System of Health Monitoring

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Statistics, Development and Human Rights

Session I-Pa 7b

The Place and Role of Official Statistics within the National System of Health Monitoring

Alejandro AGUIRRE

The Place and Role of Official Statistics within the National System of Health Monitoring

Alejandro AGUIRRE

El Colegio de México

Camino al Ajusco 20, col. Pedregal de Sta. Teresa

10740 México. D.F., Mexico

T. + 52 5 449 3000 F. + 52 5 645 0464


The Place and Role of Official Statistics within the National System of Health Monitoring

Economic indicators are usually available with better quality and oportunity than social indicators. This drawback seems to be exacerbated in developing countries. However, in an intermediate developing setting it is possible to obtain realtively good social statistics with some imaginative ideas and taking full advantage of modern technology, especially the new informatic technology.

In this paper some experiences in the health area developed in Mexico are reviewed. These include the implementation of the Nominal Census for Vaccination, that allowed a considerable increase in immunisation coverage, and the utilisation of incomplete statistics on infant mortality within the theoretical framework of the epimiologic transition of infant mortality.


La place et le rôle de la statistique publique dans le suivi du système national de santé

Habituellement, nous disposons d’indicateurs économiques de meilleure qualité et pertinence que les indicateurs sociaux. Cet inconvénient semble être exacerbé dans les pays en développement. Néanmoins, un cadre de développement intermédiaire permet d’obtenir des statistiques relativement bonnes au prix de quelques idées imaginatives et en tirant le plein avantage de la technologie moderne, notamment au niveau de la nouvelle technologie informatique.

Cet exposé passe en revue certaines expériences développées au Mexique dans le domaine de la santé. Celles-ci incluent la mise en œuvre du recensement nominal pour la vaccination, qui a permis une augmentation considérable de la couverture d’immunisation, et l’utilisation de statistiques incomplètes sur la mortalité infantile dans le cadre théorique de la transition épidémiologique de la mortalité infantile.


Economic policy seems to have occupied a more relevant position compared to social policy in most countries. Macro economic indicators usually concern politicians more than demographic education or health indicators. This has been reflected in the kind of statistics produced in each area.

The particular situation of each country in relation to the kind of statistics produced, their quality and opportunity is different. However countries could be classified in three broad groups. Developed countries in general have good registration systems that allow the production of good statistics in both the economic and the social area. Countries with the lowest degree of development lack the infrastructure to produce reliable statistics in both fields. It is perhaps in countries with intermediate development where the contrast of quality between economic and social statistics is more notorious.

Countries with intermediate development like most of Latin American countries present a peculiar panorama in relation to economic and social statistics. In general economic statistics are opportune, and efficient, and they have been so for a period of time. Also they have been more linked to the decision-taking process. Social statistics in contrast are processed more slowly, the coverage of them is often incomplete, and sometimes they are dissociated from the planning activities. For instance, statistics on inflation, imports and exports, currency exchange, and stock exchange statistics to mention just a few are published on a monthly basis with only a few weeks or days ellapsing from the period they refer to and the moment they are available. On the other hand, mortality statistics in Mexico for example, are published two to three years later, have the pitfall of incomplete coverage, especially in rural areas, and in child mortality.

It can be argued that is easier to work with economic statistics. Nevertheless, it remains the image of considering more important to record stock exchange operations or price rises than counting people who die, get sick, have access or not to education or health facilities, or their human rights are not preserved.

Although in some cases social statistics can entail more difficulty in their generation and process it can be noticed some neglect in their importance. This situation has led to some unreliablity that can be real or just perceived. The percepcion that statistics are not reliable provokes that potential or actual user are discouraged to take full advantage of them.

In this special setting of intermediate development it is possible to obtain relatively good social statistics particularly health statistics. In this paper some imaginative experiences will be reviewed illustrated with examples of the Mexican case.

  1. The Nominal Census for Immunisation

Within the framework of the World Summit for Children (WSC), Mexico established some goals to be achieved within this decade. At the September 1990 meeting in New York the international community set these goals related to diseases preventable through immunisation

  1. Eradication of polimielitis by the year 2000

  2. Elimination of neonatal tetanus by 1995

  3. Reduction of 95% of measles mortality and 90% of measles cases by 1995

  4. Keeping a coverage of immunisation of at least 90% in children under one against diftheria, whooping cough, tetanus, measles, polio, and tuberculosis.

As part of the process to reach these goals the Mexican authorities were particularly interested in eliminating polio and achieving Universal Vaccination of children under by October 12 1992, namely, half a millenium after the arrival of some of the diseases to the Western Hemisphere.

Some strategies were implemented in order to reach the latest goals. Apart from rutinary vaccination in the over 10 000 medical facilities in the country, combing operations were conducted during National Immunisation Weeks. During these weeks all children under 5 contacted were vaccinated regarldess of their vaccination status to make sure that an opportunity in which the contact had been established would not be missed. I.e., some children already with complete shcemes of immunisation were re-vaccinated in these occasions. The number of doses applied in both rutinary and brooming operations gave the impression that there was a higher coverage than the one actually achieved. This occurred because while some children had not been reached some others in more accesible areas had been over-vaccinated.

An ambitious proposal to tackle this problem was brought up: to create a Census of children under 5 in which the every dose of any of the EPI shots had to be recorded. For a developing country like Mexico this seemed at first sight an impossible task. Moreover the census needed to have some characteristics:

  1. The census had to be nominal; i.e. every child hat to be identified by name (and address)

  2. The census had to be dynamic. It should incorporate the childern being born, and eliminate those reaching age 5.

  3. In the census every particular dose applied to each child and the date of application had to be recorded. For instance, the second Sabin dose was applied to Ernesto Juárez on July 3, 1992.

  4. It had to constantly updated.

For a country with some economic limitations, where even the Population Census presents some coverage problems, the idea of the Nominal Census for Vaccination appeared something less than Science Fiction. A standard population census just intends to gathered the stock of people at a particular moment. At the beggining there were many skeptical people about the feasibility of the NCV. However, the NCV was a success story due to several reasons.


No staff was taken on for the purpose of ellaborating and updating the census at the grassroot level. A member of the vaccination brigade was in charge of doing that. Rahter than complaints for the extra work that entailed the census it brought more motivation to the teams that knew better the advance they had achieved.


The census improved dramatically the logistics. When going to the field each team knew not only how many children they were going to visit but who they were visiting, what particular dose were going to apply and remind the mother of the next visit. The certainty of the task to be completed each day allowed the brigades to take enough doses of vaccine preventing them from having to return other day to complete the work on one hand, and on the other, from taking an excess of doses that may be wasted if the cold chain colud not be kept. All this resulted in the first case in saving time and petrol, and in the second situation not wasting vaccines. In both cases the optimization of the logistics meant considerable savings as well as greater efficiency in the goal of applying the whole EPI scheme to every child.

Modern technology played a key role in the implementation of the NCV. Full advantage was taken of the informatic facilities available. Ten years earlier such an operation would have not been possible. The informatic advances allwoed the implementation of this information system that required medium level skills of the staff involved.

Before the implementation of the NCV despite the huge number of applied doses, coverage surveys indicated that the goal of universal vaccination was distant. The NCV represented a breakthrough in the challenge of reaching more children. By 1992 over 95% of children under five had been vaccinated.

The moral of this story is that with some skills, taking full advantage of modern technology and with imaginative proposals it is possible to undertake apparantly “titanic” challenges successfully.

2. The use of incomplete statistics on infant mortality

Mortality statistics do not have full coverage in developing countries. This problem is exacerbated in rural areas and is particuraly important in what refers to infant mortality. In Mexico, for instance according to a survey conducted in 1992, 25% of infant deaths go unrecorded. However allthough not all th deaths are known the knowledge of the Epidemiologic transition has helped reducing infant mortality

Associated with the demographic transition, the epidemiologic transition has been taking place around the world. In a nutshell, the epidemiologic transition consists on the passage from a situation in which infectious and parasitic diseases are the main causes of death in a high mortality setting to a situation in which chronic and degenerative ailments such as heart disease, cancer or diabetes mellitus, become the main causes of death. This change in the order of importance of the causes of death. runs parallel to mortality decline .

The epidemiologic transition is currently at different stages in various countries. As expected is in the most advanced stages in developed countries; in intermediate stages in countries with some degree of development such as the Latin American nations, and in the earlier period in most African countries.

The epidemiologic transition of infant mortality

Infant mortality has been considered an index that reflects the conditions of life. However, most developing countries lack efficient registration systems that lead to the underestimation of mortality, particularly infant mortality. A methodology to obtain better estimates of infant mortality has been developed since the 1960s (Brass). These indirect techniques utilise data from censuses or surveys

When not even the indirect estimation techniques can be applied due to the lack of recent censuses or surveys, the incomplete information from vital statistics can be used both to derive an epidemilogic profile, and from this a rough estimate of the level of infant mortality.

While infectious diseases are among the leading causes of infant mortality in pretransitional stages, the epidemiological transition of infant mortality is a different process: one year is a short period of time to develop a chronic or degenerative condition (ailment). Nevertheless, dramatic changes in the epidemiologic pattern take place as infant mortality declines.

For the analysis of the epidemiologic transition of infant mortality the causes of death can be grouped according to how easy or difficult is to prevent them as follows:

  1. Diseases preventable through immunization (DPI).

  2. Diarrhoeal diseases (DD).

  3. Acute respiratory infections (ARI).

  4. Perinatal conditions.(PC).

  5. Congenital anomalies (CA).

The groups of causes of death are ranked from the easiest to the most difficult to control. In most populations these groups of causes account for over two-thirds of infant deaths, regardless of the stage of the epidemiologic transition.

The stage of the epidemiologic transition of infant mortality in which a population is , is determined by the order of importance of the cause of death. Table 1 shows six identified stages:

Table 1. Stages of the Epidemiologic Transition of Infant Mortality

Stage First Second Third Fourth







Although some deaths go unrecorded in a setting with deficient vital statistics and the deaths not recorded may have a different distribution by causes, in most cases, there is not distortion in the order of causes. Therefore the order and the corresponding stage in the transition will give an indication of the level of infant mortality, and also will reflect the most important health needs to be attended.

All this theoretical background help in the orientation of the programmmes. In particular in 1992 the Programme of control of diarrhoeal diseases was strengthened. As a result of this, deaths due to diarrhoeal diseases in children under one (those recorded) droped dramatically from some 10 thousand in 1990 to less than 3 thousand by 1997.

Other “experiments” are underway in Mexico. On one hand the Programme IMSS-Solidaridad that attends about ten million people (10% of the Mexican population) mainly in rural areas is conducting a census of the target population with special emphasis in women of reproductive ages. In this census information on health and demographic matters is gathered. As to the latter, data that allows the application of indirect estimation of infant and maternal mortality are now being collected.

Apart from that the implementation of the Unique Code of Population Identification is being implemented. Once this task is completed it will be possible to incorporate infromation on health that can be very useful in the revision and evaluation of prioritary programmes.


Aguirre, A. "Epidemiologic Transition of Infant Mortality" XXIII General Population Conference. International Union for the Scientific Study of Population. Beijing, 1997.

Brass, W. et. al. The Demography of Tropical Africa. Princewton, 1968.

Omran, A. "The Epidemiologic Transition. A Theory of the Epidemiology of Population Change". Milbak Memorial Fund Quarterly. Vol. XLIX, No. 4, 1981

Montreux, 4. – 8. 9. 2000


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