WHO Library Cataloguing-in-Publication Data. World health statistics 2015.

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4 WHO Library Cataloguing-in-Publication Data World health statistics Health status indicators. 2.World health. 3.Health services - statistics. 4.Mortality. 5.Morbidity. 6.Life expectancy. 7.Demography. 9.Statistics. I.World Health Organization. ISBN (NLM classification: WA 900.1) ISBN (PDF) World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: ; fax: ; Requests for permission to reproduce or translate WHO publications whether for sale or for non-commercial distribution should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Luxembourg Original cover by WHO Graphics Layout by designisgood.info 2

5 2015 Table of Contents Abbreviations 7 Introduction 8 Part I. Health-related Millennium Development Goals 11 Summary of status and trends 13 Summary of progress at country level 25 Part II. Global health indicators 39 General notes 41 Table 1. Life expectancy and mortality 43 Life expectancy at birth (years) Life expectancy at age 60 (years) Healthy life expectancy at birth (years) Neonatal mortality rate (per 1000 live births) Infant mortality rate (probability of dying by age 1 per 1000 live births) Under-five mortality rate (probability of dying by age 5 per 1000 live births) Adult mortality rate (probability of dying between 15 and 60 years of age per 1000 population) Table 2. Cause-specific mortality and morbidity 55 Mortality Age-standardized mortality rates by cause (per population) Years of life lost (per population) Number of deaths among children aged < 5 years (000s) Distribution of causes of death among children aged < 5 years Maternal mortality ratio (per live births) Cause-specific mortality rate (per population) Morbidity Incidence rate (per population per year) Prevalence (per population) Table 3. Selected infectious diseases 77 Cholera Diphtheria Human African trypanosomiasis Japanese encephalitis Leishmaniasis Leprosy Malaria Measles Meningitis Mumps Pertussis Poliomyelitis Congenital rubella syndrome Rubella 3

6 Neonatal tetanus Total tetanus Tuberculosis Yellow fever Table 4. Health service coverage 89 Unmet need for family planning Contraceptive prevalence Antenatal care coverage Births attended by skilled health personnel Births by caesarean section Neonates protected at birth against neonatal tetanus Immunization coverage among 1-year-olds Children aged 6 59 months who received vitamin A supplementation Children aged < 5 years with ARI symptoms taken to a health facility Children aged < 5 years with suspected pneumonia receiving antibiotics Children aged < 5 years with diarrhoea receiving ORT (ORS and/or RHF) Children aged < 5 years sleeping under insecticide-treated nets Children aged < 5 years with fever who received treatment with any antimalarial Pregnant women with HIV receiving antiretrovirals to prevent MTCT Antiretroviral therapy coverage among people eligible for treatment Case-detection rate for all forms of tuberculosis Treatment-success rate for new tuberculosis cases Table 5. Risk factors 101 Population using improved drinking-water sources Population using improved sanitation Population using solid fuels Infants exclusively breastfed for the first 6 months of life Children aged < 5 years who are wasted Children aged < 5 years who are stunted Children aged < 5 years who are underweight Children aged < 5 years who are overweight Prevalence of anaemia among women aged years Prevalence of raised fasting blood glucose among adults aged 18 years Prevalence of raised blood pressure among adults aged 18 years Adults aged 18 years who are obese Alcohol per capita consumption ( 15 years) (litres of pure alcohol) Prevalence of smoking any tobacco product among adults aged 15 years Prevalence of current tobacco use among adolescents aged years Prevalence of condom use by adults aged years during higher-risk sex Population aged years with comprehensive correct knowledge of HIV/AIDS Table 6. Health systems 112 Health workforce Density of physicians per population Density of nursing and midwifery personnel per population Density of dentistry personnel per population Density of pharmaceutical personnel per population Density of psychiatrists per population Infrastructure and technologies Hospitals (per population) Psychiatric beds (per million population) Computed tomography units (per million population) Radiotherapy units (per million population) Mammography units (per million females aged years) 4

7 2015 Essential medicines Median availability of selected generic medicines in public and private sectors Median consumer price ratio of selected generic medicines in public and private sectors Table 7. Health expenditure 125 Health expenditure ratios Total expenditure on health as a percentage of gross domestic product General government expenditure on health as a percentage of total expenditure on health Private expenditure on health as a percentage of total expenditure on health General government expenditure on health as a percentage of total government expenditure External resources for health as a percentage of total expenditure on health Social security expenditure on health as a percentage of general government expenditure on health Out-of-pocket expenditure as a percentage of private expenditure on health Private prepaid plans as a percentage of private expenditure on health Per capita health expenditures Per capita total expenditure on health at average exchange rate (US$) Per capita total expenditure on health (PPP int. $) Per capita government expenditure on health at average exchange rate (US$) Per capita government expenditure on health (PPP int. $) Table 8. Health inequities 137 Contraceptive prevalence: modern methods Antenatal care coverage: at least four visits Births attended by skilled health personnel DTP3 immunization coverage among 1-year-olds Children aged < 5 years who are stunted Under-five mortality rate (probability of dying by age 5 per 1000 live births) Table 9. Demographic and socioeconomic statistics 149 Total population (000s) Median age of population (years) Population aged < 15 years Population aged > 60 years Annual population growth rate Population living in urban areas Civil registration coverage of births and cause of death Crude birth rate (per 1000 population) Crude death rate (per 1000 population) Total fertility rate (per woman) Adolescent fertility rate (per 1000 girls aged years) Literacy rate among adults aged 15 years Net primary school enrolment rate Gross national income per capita (PPP int. $) Population living on < $1 (PPP int. $) a day Cellular phone subscribers (per 100 population) Annex 1. Regional and income groupings 160 WHO regional groupings 160 Income groupings 161 5

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9 2015 Abbreviations AIDS acquired immunodeficiency syndrome ORS oral rehydration salts AFR WHO African Region ORT oral rehydration therapy AMR WHO Region of the Americas PPP Purchasing Power Parity ARI acute respiratory infection RHF recommended home fluids ART antiretroviral therapy SEAR WHO South-East Asia Region CRS Creditor Reporting System SHA System of Health Accounts cvdpv circulating vaccine derived poliovirus SNA System of National Accounts DAC Development Assistance Committee, OECD UNAIDS Joint United Nations Programme on HIV/AIDS DHS DTP3 EML EMR EUR GDP Demographic and Health Survey 3 doses of diphtheria-tetanuspertussis vaccine essential medicines list WHO Eastern Mediterranean Region WHO European Region gross domestic product UNDESA UNESCO UNICEF WPR YLL United Nations Department of Economic and Social Affairs United Nations Educational, Scientific and Cultural Organization United Nations Children s Fund WHO Western Pacific Region years of life lost GHO Global Health Observatory HAI Health Action International HALE healthy life expectancy HepB3 3 doses of hepatitis B vaccine Hib3 3 doses of Haemophilus influenzae type B vaccine HIV human immunodeficiency virus IGME Inter-agency Group for Child Mortality Estimation ITN insecticide-treated net ITU United Nations International Telecommunication Union LGU local government unit MCV measles-containing vaccine MDG Millennium Development Goal MICS Multiple Indicator Cluster Survey MSH Management Sciences for Health MTCT mother-to-child transmission NHA national health account OECD Organisation for Economic Co-operation and Development 7

10 Introduction The World Health Statistics series is WHO s annual compilation of health-related data for its 194 Member States, and includes a summary of the progress made towards achieving the health-related Millennium Development Goals (MDGs) and associated targets. The series is produced by the WHO Department of Health Statistics and Information Systems of the Health Systems and Innovation Cluster. As in previous years, World Health Statistics 2015 has been compiled using publications and databases produced and maintained by WHO technical programmes and regional offices. A number of demographic and socioeconomic statistics have also been derived from data produced and maintained by a range of national and international organizations. The latter include the United Nations Children s Fund (UNICEF), the United Nations Department of Economic and Social Affairs (UNDESA) and its Population Division, the United Nations Educational, Scientific and Cultural Organization (UNESCO), the United Nations International Telecommunication Union (ITU) and the World Bank. The indicators used in this report have been included on the basis of their relevance to global public health, on data availability and quality, and on the reliability and comparability of the resulting estimates. Taken together, these indicators provide a comprehensive summary of the current status of national health and health systems in the following nine areas: life expectancy and mortality cause-specific mortality and morbidity selected infectious diseases health service coverage risk factors health systems health expenditure health inequities demographic and socioeconomic statistics. Where necessary the estimates provided have been derived from multiple sources, depending on each indicator and on the availability and quality of data. In many countries, statistical and health information systems are weak and the underlying empirical data may not be available or may be of poor quality. Every effort has been made to ensure the best use of country-reported data adjusted where necessary to deal with missing values, to correct for known biases, and to maximize the comparability of the statistics across countries and over time. In addition, statistical modelling and other techniques have been used to fill data gaps. Because of the weakness of the underlying empirical data in many countries, a number of the indicators presented here are associated with significant uncertainty. It is WHO policy to ensure statistical transparency and to make available to users the methods of estimation and the margins of uncertainty for relevant indicators. However, to ensure readability while covering such a comprehensive range of health topics, printed versions of the World Health Statistics series do not include the margins of uncertainty which are instead made available through online WHO databases such as the Global Health Observatory. 1 While every effort has been made to maximize the comparability of the statistics across countries and over time, users are advised that country data may differ in terms of the definitions, data-collection methods, population coverage and estimation methods used. More-detailed information on indicator metadata is available in the WHO Indicator and Measurement Registry The Global Health Observatory (GHO) is WHO s portal providing access to data and analyses for monitoring the global health situation. See: accessed 16 March See: accessed 16 March

11 2015 WHO presents World Health Statistics 2015 as an integral part of its ongoing efforts to provide enhanced access to comparable high-quality statistics on core measures of population health and national health systems. Unless otherwise stated, all estimates have been cleared following consultation with Member States and are published here as official WHO figures. However, these best estimates have been derived using standard categories and methods to enhance their cross-national comparability. As a result, they should not be regarded as the nationally endorsed statistics of Member States which may have been derived using alternative methodologies. 9

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13 2015 Part I Health-related Millennium Development Goals

14 Table 1. Global and regional progress towards the achievement of the health-related MDGs Target Global AFR AMR SEAR EUR EMR WPR Target 1.C: Halve, between 1990 and 2015, the proportion of people who suffer from hunger Percent reduction in proportion of underweight children under five years of age, Target 4.A: Reduce by two thirds, between 1990 and 2015, the under-five mortality rate Percent reduction in under-five mortality rate, Measles immunization coverage among 1-year-olds a, Target 5.A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio Percent reduction in maternal mortality ratio, Births attended by skilled health personnel b, Target 5.B: Achieve, by 2015, universal access to reproductive health Antenatal care coverage : at least one visit, Unmet need for family planning, Target 6.A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS Percent reduction in HIV incidence, > < Target 6.C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases Percent reduction in incidence of malaria a, Percent reduction in mortality rate of tuberculosis (among HIV-negative people) a, Target 7.C: Halve, by 2015, the proportion of the population without sustainable access to safe drinking-water and basic sanitation Percent reduction in proportion of population without access to improved drinking-water sources, Percent reduction in proportion of population without access to improved sanitation, a Target etablished via resolutions of the World Health Assembly or agreed upon by WHO multilateral partnerships. b Target set by the International Conference on Population and Development. Met or on track Substantial progress No or limited progress Data not available or not applicable 12

15 2015 Summary of status and trends 2015 represents the target year for the Millennium Development Goals (MDGs). By assessing the progress made based upon data available up to 2014 this report provides a clear indication of whether the regional and global targets set for 2015 are likely to be met. It should be noted, however, that the progress assessments reported below may change for some countries once the 2015 data have been taken into account in upcoming final analyses. Table 1 summarizes the current estimates of global and regional progress made towards the achievement of health-related MDG indicators with set targets 1 for which data are available. For relative target reductions the numbers indicate the overall percent reduction, while for absolute targets (% coverage) the numbers indicate the latest available figure. For each of the indicators shown in Table 1 the extent of global and regional progress has been classified into one of three categories based upon the following arbitrarily defined criteria: Met or on track indicates that the relative target reduction has already been met or will be achieved by 2015 should the trends observed since 1990 continue. In the case of absolute targets, the criterion used is that the latest observed data are within 5 percentage points of the target value. Substantial progress indicates that for relative target reductions the latest observed data are at least halfway to achieving the target. For the absolute coverage targets, indicates that the difference between the latest observed data and the target is no more than half the gap between the target and the global 1. The targets shown for measles immunization coverage, percent reduction in malaria incidence and percent reduction in mortality due to tuberculosis were established via resolutions of the World Health Assembly or agreed upon by WHO multilateral partnerships. The target shown for births attended by skilled health personnel was set by the International Conference on Population and Development (ICPD+5). baseline 2 but greater than 5 percentage points. No or limited progress indicates that latest observed data are not yet halfway to achieving the relative target reduction. For the absolute coverage targets, indicates that the difference between the latest observed data and the target is more than half of the gap between the target and the global baseline. Table 1 clearly shows that significant strides have been taken at the global level towards achieving many of the health-related MDGs, with the corresponding targets for HIV and drinking-water having been met. Although not shown in Table 1 the MDG targets for both malaria and tuberculosis were also met. In addition, it can be seen that substantial progress has been made in terms of the proportion of the target achieved in reducing child undernutrition (four fifths), child mortality (two thirds) and maternal mortality (three fifths), and in increasing access to improved sanitation (three fifths). Substantial progress was also made towards achieving the Stop TB Partnership target of halving the tuberculosis mortality rate. However, it is also clear from Table 1 that the gains made in different regions of the world have been uneven and renewed efforts are now needed if progress is to be made in all countries. In order to sustain and build upon the gains already made new global action plans have therefore emerged or are being prepared with even more ambitious goals set for This unfinished agenda will need to incorporate new challenges such as the growing impact of noncommunicable diseases, and changing social and environmental determinants. Such an ambitious agenda and its goals will need to be firmly embedded within a sustainable development and implementation framework, and be driven by the crucially important concept of universal health coverage. 2. After rounding to the nearest 5% this leads to the following cutoff values: (a) measles immunization coverage among 1-yearolds 80%; (b) births attended by skilled health personnel 75%; (c) antenatal care coverage: at least one visit 80%; and (d) unmet need for family planning 10%. 13

16 Figure 1. Proportion of children under 5 years of age who are underweight globally and by WHO region, Proportion of children aged < 5 years who are underweight target 0 Global African Region Region of the Americas South-East Asia Region European Region Eastern Mediterranean Region Western Pacific Region Goal 1, Target 1.C: Halve, between 1990 and 2015, the proportion of people who suffer from hunger Undernutrition 1 is the underlying cause of death in an estimated 45% of all deaths among children under 5 years of age. 2 Between 1990 and 2013 the proportion of underweight children in developing countries declined from 28% to 17%, and if past trends continue will reach 16% in This rate of progress is close to, but does not meet, the MDG target for this indicator. As shown in Fig. 1, the proportion of underweight children declined globally from 25% in 1990 to 15% in At regional level, the MDG target for this indica- tor was met in the WHO Region of the Americas, the WHO European Region and the WHO Western Pacific Region. Of the remaining regions, some are more likely to reach the target than others (Fig. 1). Between 1990 and 2013, the number of children affected by stunting declined globally from 257 million to 161 million, representing a decrease of 37%. 1. Including fetal growth restriction, stunting, wasting, and deficiencies of vitamin A and zinc, along with suboptimal breastfeeding. 2. Black RE, Victora CG, Walker SP, Bhutta ZA Christian P, de Onis M et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 3 August 2013;382(9890): doi: / S (13)60937-X (http://www.sciencedirect.com/ science/article/pii/s x, accessed 25 March 2015). 14

17 2015 Table 2. Number of countries according to MDG Target 4.A achievement status, by WHO region, 2013 MDG Target 4.A achievement status WHO region Achieved On track At least halfway Less than halfway Total African Region (AFR) Region of the Americas (AMR) South-East Asia Region (SEAR) European Region (EUR) Eastern Mediterranean Region (EMR) Western Pacific Region (WPR) Global (25%) (7%) (56%) (12%) (100%) Goal 4, Target 4.A: Reduce by two thirds, between 1990 and 2015, the under-five mortality rate Progress in child survival worldwide has been described as one of the greatest success stories of international development, with child deaths being almost halved over the last two decades compared to the 1990 MDG baseline. Between 1990 and 2013 under-five mortality rates declined by 49%, falling from an estimated 90 deaths per 1000 live births to 46 deaths per 1000 live births. More than half of this reduction has taken place in the past decade with the global rate of decline accelerating greatly from 1.2% per annum between 1990 and 1995 to 4.0% per annum between 2005 and As a result, an estimated fewer children died every day in 2013 than in Nevertheless, such a rate of decline remains insufficient to reach the target of a two thirds reduction in the 1990 mortality levels by the year Worldwide, the total number of neonatal deaths decreased from 4.7 million in 1990 to 2.8 million in Neonatal mortality rates per 1000 live births declined from 33 to 20 over the same period a reduction of 39%. This rate of decline is slower than that for child mortality overall with the proportion of deaths in children aged < 5 years that occurred in the neonatal period increasing from 37% in 1990 to 44% in Despite remarkable progress at the global level, the MDG Target 4.A will not be achieved in most countries by Table 2 shows the number of countries that: (a) have achieved this target; (b) are on track to meet the target by 2015 if the current rate of progress is maintained; (c) are at least halfway to achieving a two thirds reduction in the 1990 level of mortality but are unlikely to achieve it by 2015 at the current rate of progress; and (d) are less than halfway to meeting the target. As shown in Table 2, less than one third of all countries have either achieved or are on track to meet the MDG target by Improved understanding of cause-specific trends will now be an essential element in accelerating further 15

18 Figure 2. Global trends in cause-specific mortality rates among children under 5 years of age, Deaths per 1000 live births > 30% decline from 2000 to % decline from 2000 to 2013 < 20% decline from 2000 to // Pneumonia 6 Diarrhoea 3 Measles 3 Malaria Intrapartum related complications Prematurity Other postneonatal conditions Meningitis Neonatal sepsis & other infections Injuries HIV/AIDS Tetanus Congenital Other neonatal conditions change. As the MDG era draws to a close, analysis indicates that preterm birth complications are now the leading cause of under-five deaths globally, accounting for 17% of all such deaths, not just deaths in the neonatal period. This finding underlines the major transition which has taken place in the patterns of child survival. Pneumonia is now the second leading cause of death among the under-fives (15%) with birth asphyxia third (11%), diarrhoea (which was the third leading cause in 2010) fourth (9%) followed by malaria (7%), congenital anomalies (7%) and neonatal infections (7%). Despite an increase in the global number of live births from million in 2000 to million in 2013, the total number of deaths in children aged < 5 years decreased from 9.9 million to 6.3 million respectively, with under-five mortality rates falling from 77 to 46 per 1000 live births over the same period. In absolute terms, deaths from pneumonia, diarrhoeal diseases, measles and malaria were associated with the largest reductions (Fig. 2). Taken together, these reductions accounted for more than half (58%) of the gains made in under-five survival rates between 2000 and The first 28 days of life the neonatal period represent the most vulnerable time for a child s survival. In 2013, around 44% of under-five deaths occurred during this period, up from 37% in In 2010 the World Health Assembly established the following three milestones for 2015: (a) at least 90% routine coverage with the first dose of measles-containing vaccine for children aged 1 year; (b) a reduced and maintained global annual measles incidence of less than 5 cases per million; and (c) a 95% reduction in the 2000 global measles mortality estimate. a. During the period , estimated measles immunization coverage increased globally from 73% to 83% and remained at 83 84% through As of 2013, 66% of WHO Member States had reached 16

19 2015 Figure 3. Maternal mortality ratio globally and by WHO region, Maternal mortality ratio (per live births) Global AFR AMR SEAR EUR EMR WPR Goal 5, Target 5.A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio at least 90% coverage, compared with only 44% in b. During the period , the incidence of measles decreased by 72%, from 146 to 40 cases per million population. However, following outbreaks in a number of countries, the figure for 2013 was an increase on the figure for c. Between 2000 and 2013, the estimated global number of measles deaths in children aged < 5 years decreased by 74% from to This decrease was one of three main contributors to the observed decline in overall under-five mortality. The maternal mortality ratio the number of maternal deaths per live births decreased globally by around 45% between 1990 and 2013, with reductions observed in all WHO regions (Fig. 3). Although large, this rate of decrease is unlikely to lead to the achievement of the targeted 75% reduction by In addition, of the 89 countries with the highest maternal mortality ratio in 1990 (100 or more maternal deaths per live births) 13 have made insufficient or no progress at all, with an average annual decline of less than 2% between 1990 and The absolute number of women dying due to complications during pregnancy and childbirth has decreased by 45% from an estimated in 1990 to in Direct obstetric causes, notably haemorrhage (27%), hypertensive diseases of pregnancy (14%) and sepsis (11%), continue to be the leading causes of maternal deaths. Increasingly, however, deaths during pregnancy are attributed to other medical conditions. 17

20 Figure 4. Contraceptive prevalence, unmet need and total demand for family planning globally and by WHO region, 2012 Demand for family planning among women aged who are married or in union Global African Region Region of the Americas South-East Asia Region European Region The sum of contraceptive prevalence and unmet need represents total demand for family planning. Eastern Mediterranean Region Western Pacific Region Unmet need for family planning Contraceptive prevalence (any method) Goal 5, Target 5.B: Achieve, by 2015, universal access to reproductive health In order to reduce maternal mortality rates and improve maternal health women need access to effective interventions and high-quality reproductive health care. Many countries have implemented programmes to expand access to interventions in order to reduce the level of unmet need for contraception, provide antenatal care during pregnancy and ensure delivery by a skilled birth attendant. The prevalence of contraceptive use among women aged years who were married or in a consensual union increased globally from 55% in 1990 to 64% in Unmet need defined as the proportion of women who are married or in a union who want to stop or postpone childbearing but are not using contraception declined from 15% in 1990 to 12% in Although the WHO African Region had the lowest total demand for family planning in 2012 it also had the highest level of unmet need at 24% (Fig. 4). Worldwide, the proportion of women receiving antenatal care at least once during pregnancy was 83% for the period However, only 64% of pregnant women received the recommended minimum of four antenatal care visits or more, suggesting that large expansions in antenatal care coverage are still needed. In addition, despite increasing coverage of delivery by a skilled birth attendant both globally and in several regions, coverage is still only 51% in the WHO African Region and in low-income countries. 18

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