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Vladimir M. Shkolnikov

Material for panel discussion at the European Population Forum 2004 for the session “Morbidity, Mortality and Reproductive Health: Facing Challenges in Transition Countries”, 12-14 January, 2004, Geneva Mortality in post-Soviet countries beyond statistical reports:

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Vladimir M. Shkolnikov

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  1. Material for panel discussion at the European Population Forum 2004 for the session “Morbidity, Mortality and Reproductive Health: Facing Challenges in Transition Countries”, 12-14 January, 2004, Geneva Mortality in post-Soviet countries beyond statistical reports: Challenges in monitoring true mortality levels and increasing inequalities in the face of death. Vladimir M. Shkolnikov

  2. This presentation aims at drawing attention to three important challenges related to monitoring the health situations in the region: 1. Growing difficulties in the estimation of mortality in southern and eastern parts of the region. 2. Lack of information for monitoring and analyzing the increase in inequalities in mortality and its very high levels in disadvantaged population groups. 3. Lack of international collaboration in this area. 2

  3. Growing difficulties in the estimation of mortality in Southern and Eastern parts of the region. - There are serious reasons to suspect a deterioration of the quality of mortality data in countries of the Caucasus and Central Asia since the beginning of transition. - Substantial part of temporal changes in officially reported mortality indicators could be due to growing problems in registration of vital events and estimating the current populations. 3

  4. Estimates of life expectancy at birth (LEB) in Armenia and Georgia by the WHO-Euro (HFA database), by the WHO-International (Life tables for 191 countries) and by the international INTAS project group with participants from France (INED), Russia (CDHE), Georgia and Armenia (GCPR), and Germany (MPIDR) HFA/WHO-Euro http://www.who.dk/hfadbLT191/WHO-Int http://www3.who.int/whosis/menu.cfm?path=whosis,burden_statistics,life&language=englishINED-CDHE-GCPR-MPIDR http://www.demographic-research.org/Volumes/Vol5/7/ 4

  5. The three variants of LEBs are calculated in three different ways. 1. The WHO-Euro estimates are based on: - original data on deaths and populations by age and sex reported by the national health ministries. Mortality under-estimation. 2. The WHO-International estimates are based on: - UN estimates of current populations;- modification of the original age-specific death rates by using a logit system of life tables;- recalculation of deaths from the new death rates and the UN population estimates and estimation of the coverage of deaths (73% in Armenia and 56% in Georgia in 2000). Distorted age pattern of mortality is attributed to a death undercount only and mortality is over-estimated. 5

  6. 3. The INED-CDHE-GCPR-MPIDR estimates are based on: - identification of nature of possible biases in the data with the help of local experts; - quantitative estimation of biases in the numerator and denominator data;- re-estimation of populations by using official populations, additional sources of information, indirect estimates and the expertise of local researchers;- corrections for under-registration of deaths at young and old ages using additional sources of information and model life tables;- calculation of life tables from re-estimated deaths and populations. 6

  7. In 1999 official estimates of the current populations of Armenia and Georgia are very much biased upwards (by about 1/4 and 1/3, respectively), due to huge non-registered out-migration and de-facto territorial changes in the late-1980s and the 1990s caused by natural disasters, wars, and economic hardships. Estimates of out-migration are taken from household surveys conducted by the UNDP, the World Bank, and the national Statistical Offices. The estimates were validated by comparison with the Russian statistics of deaths by ethnic group. Official and estimated populations of Georgia in 1989-2000  UN estimate Source: Yeganyan et al., 2001 7

  8. The fallen quality of the vital registration - Since the late 1980s due to lack of funds and several other circumstances - In Georgia the situation is particularly bad due to a newly established system for collecting fees for the registration of vital events. Death under-reporting is significant at old ages especially in rural areas. Levels of under-reporting at old ages were estimated by comparison with model life tables. - The system for registration has problems. Comparisons of official IMRs with those calculated from the infant death registers by national Ministries of Health reveal a 33% and a 15% undercount in Georgia and Armenia, respectively. 8

  9. The fallen quality of the vital registration - After corrections of denominator and numerator, Armenian and Georgian LEBs drop substantially and LEB trends are less favorable. There is no improvement between 1989-90 and 2000. - However, the corrected LEB values remain higher than those in other post-Soviet countries, with exception for females in Lithuania. - This makes a difference from low LEB estimates by the WHO-International and high LEB estimates by the WHO-Euro. 9

  10. Lack of data for monitoring and analyzing the increase in social differentials in mortality- Very high and rising levels of mortality in disadvantaged population groups. - Market transformations result in growing differentials in wealth and life chances. However, there is still very little data documenting the widening inter-group gaps in health. (The Czech case presented by Rychtariková, 2002) - In Russia the general mortality increase in the 1990s was mostly due to mortality of the worse-off groups. 10

  11. In the 1990s socio-economic differentials among regions of the Russian Federation increased sharply. Former mechanisms of the centralized redistribution of funds from relatively rich to relatively poor regions and state support for regions of the North and East have been abandoned. Between 1989-90 and 2001 the absolute amount of inter-regional diversity in LEB increased in spite of a decrease in the overall LEB. Calculated by V.Shkolnikov and D.Jdanov from the Goskomstat’s data on populations and life expectancies by sex and region. *Population weights were modified according to Shkolnikov et al., 2001 11

  12. Mortality rate ratios by broad educational categories in Russia in 1988-89 and 1993-94. Mortality increase is highly concentrated among people with low levels of education. Source: Shkolnikov, Leon, et al., 1998 12

  13. Mortality in two epidemiological cohorts of men from St. Petersburg by level of education. No increase between 1975-85 and 1986-96 in people with university education and very substantial increases among those who have the least education. Source: Plavinsky, Plavinskaya, Klimov, 2003 13

  14. Mortality effects of calendar period by level of education in the Moscow-St. Petersburg male Lipid Research Clinics cohort: Poisson regression rate ratios. Increases are observed for low and middle levels of education, but not for the high level of education. Shkolnikov, Deev, Kravdal, Valkonen, 2003 14

  15. Age-stadardized death rates for the range of ages 40 to 74 by level of education in three male cohorts: LRC (Moscow-St.Petersburg), Helsinki and Oslo. (per 100,000 person-years). Extreme absolute mortality level in the Russian low education group. 15 Source: Shkolnikov, Deev, Kravdal, Valkonen, 2004

  16. Age- and sex-stadardized rates of homicide in Moscow in 1993-95. (Death rate for the whole population = 40/100,000).Extreme level of homicide victimisation in disadvantaged groups. Source: Pridemore and Shkolnikov, 2004 16

  17. Conclusion: 1. In-depth demographic studies using multiple sources of data and the local expertise suggest that for some countries of the region routine mortality data produced by national and international agencies do not correctly reflect true levels, trends and do not show growing health inequalities within the national populations and very bad situations of the disadvantaged population groups. 2. At the same time, in-depth studies conducted by various research teams are inconsistent and internationally incomparable due to differences in methods, definitions of categories, data shapesetc. 3. A co-ordinated effort involving a network of working groups from different parts of the European region under the umbrella of the UN, WHO or UNDP could improve the situation. 17

  18. References DHS. Demographic and Health Surveys. Measure DHS+. Country statistics. Available at http://www.measuredhs.com/countries/start.cfm last accessed on 9.01.2004 WHO-Euro HFA. Health for all. Downloadable database by the WHO Office for Europe. Available athttp://www.who.dk/hfadb last accessed on 9.01.2004 WHO-International. Life Tables for 191 countries. Available athttp://www3.who.int/whosis/life/life_tables/life_tables.cfm?path=whosis,burden_statistics,life,life_tables&language=english last accessed on 9.01.2004. WHO-International. Estimated coverage of mortality data for latest year. Available athttp://www3.who.int/whosis/mort/table4.cfm?path=whosis,mort,mort_table4&language=english last accessed on 9.01.2004Plavinski, S.L., Plavinskaya, S.I., Klimov, A.N. 2003. Social factors and increase in mortality in Russia in the 1990s: prospective cohort study. British Medical Journal, 326, pp. 1240-1242. Pridemore W.A., Shkolnikov V.M. 2004. Education and marriage as protective factors against homicide mortality: Methodological and substantive findings from Moscow. Quantitative Criminology (in press). Rychtařiková, J. 2004. The case of Czech Republic. Determinants of the recent favorable turnover in mortality. Demographic Research. (In press). A preliminary version is available at http://www.demogr.mpg.de/Papers/workshops/020619_paper35.pdf Shkolnikov, V.M., Deev, A.D., Kravdal, Ø., Valkonen, T. 2004. Educational differentials in male mortality in Russia and northern Europe. A comparison of an epidemiological cohort from Moscow and St. Petersburg with the male populations of Helsinki and Oslo. Demographic Research, vol. 10, article 1, http://www.demographic-research.org/Volumes/Vol10/1/. Shkolnikov, V., Leon, D., Adamets, S., Andreev, E., Deev, A. 1998. Educational level and adult mortality in Russia: an analysis of routine data 1979 to 1994. Social Science and Medicine, Vol. 47, No 3, pp. 357-369. Shkolnikov, V., Valkonen, T., Begun, A., Andreev, E. 2001. Measuring inter-group inequalities in length of life. Genus, Vol. LVII, No 3-4, pp. 33-62. Yeganyan, R., Badurashvili, I., Andreev, E., Meslé, F., Shkolnikov, V., Vallin, J. 2001. Life expectancy in two Caucasian countries. How much due to overestimated population? Demographic Research, Vol. 5, article 7, http://www.demographic-research.org/Volumes/Vol5/7/ 18

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