WHO Library Cataloguing-in-Publication Data. World health statistics 2014.

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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 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website ( or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: ; fax: ; bookorders@who.int). Requests for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to WHO Press through the WHO website ( 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 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. Original cover by WHO Graphics Layout by designisgood.info Printed in Italy. 2

5 2014 Table of Contents Abbreviations 7 Introduction 8 Part I. Health-related Millennium Development Goals 11 Summary of status and trends 13 Regional and country charts AARD in under-five mortality rate, Measles immunization coverage among 1-year-olds AARD in maternal mortality ratio, Births attended by skilled health personnel Antenatal care coverage : at least one visit and at least four visits Unmet need for family planning AARD in HIV prevalence, Antiretroviral therapy coverage among people eligible for treatment Children aged < 5 years sleeping under insecticide-treated nets Children aged < 5 years with fever who received treatment with any antimalarial AARD in tuberculosis mortality rate, AARD in proportion of population without access to improved drinking-water sources AARD in proportion of population without access to improved sanitation 34 Part II. Highlighted topics 35 Putting an ending to preventable maternal mortality the next steps 37 Rising childhood obesity time to act 40 Life expectancy in the world in Years of life lost due to premature mortality trends and causes 45 Civil registration and vital statistics the key to national and global advancement 50 Part III. Global health indicators 55 General notes Life expectancy and mortality 59 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) 3

6 2. Cause-specific mortality and morbidity 71 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) Prevalence (per population) 3. Selected infectious diseases 93 Cholera Diphtheria Human African trypanosomiasis Japanese encephalitis Leishmaniasis Leprosy Malaria Measles Meningitis Mumps Pertussis Poliomyelitis Congenital rubella syndrome Rubella Neonatal tetanus Total tetanus Tuberculosis Yellow fever 4. Health service coverage 104 Unmet need for family planning Contraceptive prevalence Antenatal care coverage Births attended by skilled health personnel Births by caesarean section Postnatal care visit within two days of childbirth 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 smear-positive tuberculosis 4

7 Risk factors 116 Population using improved drinking-water sources Population using improved sanitation Population using solid fuels Preterm birth rate (per 100 live births) 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 raised fasting blood glucose among adults aged 25 years Prevalence of raised blood pressure among adults aged 25 years Adults aged 20 years who are obese Alcohol consumption among adults aged 15 years (litres of pure alcohol per person per year) 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 6. Health systems 128 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) Hospital beds (per population) Psychiatric beds (per population) Computed tomography units (per million population) Radiotherapy units (per million population) Mammography units (per million females aged years) 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 7. Health expenditure 141 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. $) 5

8 8. Health inequities 153 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) 9. Demographic and socioeconomic statistics 165 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 causes 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 176 WHO regional groupings 176 Income groupings 177 6

9 2014 Abbreviations AARD AFR AIDS AMR ARI ART CRS CRVS DAC DHS DTP3 EML EMR EUR GDP GHO HAI HALE HepB3 Hib3 HIV ICD ICPD+5 IGME ITU MCV MDG MDR-TB MICS MSH MTCT average annual rate of decline WHO African Region acquired immunodeficiency syndrome WHO Region of the Americas acute respiratory infection antiretroviral therapy Creditor Reporting System civil registration and vital statistics Development Assistance Committee, OECD Demographic and Health Survey 3 doses of diphtheria-tetanuspertussis vaccine essential medicines list WHO Eastern Mediterranean Region WHO European Region gross domestic product Global Health Observatory Health Action International healthy life expectancy 3 doses of hepatitis B vaccine 3 doses of Haemophilus influenzae type B vaccine human immunodeficiency virus International Classification of Diseases International Conference on Population and Development, five-year follow-up Inter-agency Group for Child Mortality Estimation United Nations International Telecommunication Union measles-containing vaccine Millennium Development Goal multi-drug resistant tuberculosis Multiple Indicator Cluster Survey Management Sciences for Health mother-to-child transmission NCD NGO NHA NTD OECD ORS ORT PPP RHF SAVVY SD SEAR UNAIDS UNDESA noncommunicable disease nongovernmental organization national health account neglected tropical disease Organisation for Economic Cooperation and Development oral rehydration salts oral rehydration therapy Purchasing Power Parity recommended home fluids Sample Registration with Verbal Autopsy standard deviation WHO South-East Asia Region Joint United Nations Programme on HIV/AIDS United Nations Department of Economic and Social Affairs UNESCAP United Nations Economic and Social Commission for Asia and the Pacific UNESCO UNICEF WPR YLL United Nations Educational, Scientific and Cultural Organization United Nations Children s Fund WHO Western Pacific Region years of life lost 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. This year, it also includes highlight summaries on the ongoing commitment to end preventable maternal deaths; on the need to act now to combat rising levels of childhood obesity; on recent trends in both life expectancy and premature deaths; and on the crucial role of civil registration and vital statistics systems in national and global advancement. 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 2014 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 databases maintained by a range of other organizations. These include the United Nations International Telecommunication Union (ITU), the United Nations Department of Economic and Social Affairs (UNDESA), the United Nations Educational, Scientific and Cultural Organization (UNESCO), the United Nations Children s Fund (UNICEF) and the World Bank. Indicators have been included on the basis of their relevance to global public health; the availability and quality of the data; and 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. The estimates given in this report are 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, 1. The Global Health Observatory (GHO) is WHO s portal providing access to data and analyses for monitoring the global health situation. See: accessed 22 March

11 2014 population coverage and estimation methods used. More-detailed information on indicator metadata is available in the WHO Indicator and Measurement Registry. 1 WHO presents World Health Statistics 2014 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. 1. See: accessed 22 March

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13 Part I Health-related Millennium Development Goals

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15 2014 Summary of status and trends With one year to go until the 2015 target date for achieving the MDGs, substantial progress can be reported on many health-related goals. The global target of halving the proportion of people without access to improved sources of drinking water was met in 2010, with remarkable progress also having been made in reducing child mortality, improving nutrition, and combating HIV, tuberculosis and malaria. Between 1990 and 2012, mortality in children under 5 years of age declined by 47%, from an estimated rate of 90 deaths per 1000 live births to 48 deaths per 1000 live births. This translates into fewer children dying every day in 2012 than in The risk of a child dying before their fifth birthday is still highest in the WHO African Region (95 per 1000 live births) eight times higher than that in the WHO European Region (12 per 1000 live births). There are, however, signs of progress in the region as the pace of decline in the under-five mortality rate has accelerated over time; increasing from 0.6% per year between 1990 and 1995 to 4.2% per year between 2005 and The global rate of decline during the same two periods was 1.2% per year and 3.8% per year, respectively. Nevertheless, nearly children worldwide died every day in 2012, and the global speed of decline in mortality rate remains insufficient to reach the target of a two-thirds reduction in the 1990 levels of mortality by the year Table 1 shows the number of countries that have achieved this target; those that are on track to meet the target by 2015 if the current rate of progress is maintained; those that 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 those that are less than halfway to meeting the target. Less than one-third of all countries have achieved or are on track to meet the MDG target by Inequities in child mortality between high-income and low-income countries remain large. In 2012, the under-five mortality rate in low-income countries was 82 deaths per 1000 live births more than 13 times the average rate in high-income countries (Fig. 1). Reducing these inequities across countries and saving the lives of more children by ending preventable child deaths are key priorities. Table 1. Number of countries according to MDG Target 4.A achievement status, by WHO region, 2012 MDG Target 4.A achievement status WHO region Achieved On track Halfway or more 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 (19%) (12%) (54%) (15%) (100%) Calculated using unrounded under-five mortality rates, 1990 and

16 Figure 1. Neonatal and under-five mortality rates globally and by country income group, 1990 and 2012 Probability of dying per 1000 live births months 0 27 days (neonatal) 0 Global Low-income countries Lower-middle-income countries Upper-middle-income countries High-income countries Each bar indicates the total under-five mortality rate as the sum of the neonatal mortality rate (0 27 days; lighter-shaded bars) plus the combined mortality rate for infants aged 1 11 months and children aged 1-4 years (darker-shaded bars). The first 28 days of life the neonatal period represent the most vulnerable time for a child s survival. In 2012, around 44% of under-five deaths occurred during this period, up from 37% in 1990 (Fig. 1). As overall underfive mortality rates decline the proportion of such deaths occurring during the neonatal period is increasing. This highlights the crucial need for health interventions that specifically address the major causes of neonatal deaths, particularly as these typically differ from the interventions needed to address other under-five deaths. Current evidence indicates that undernutrition 1 is the underlying cause of death in an estimated 45% of all deaths among children under 5 years of age. 2 The number of underweight children globally declined from 160 million in 1990 to 99 million in 2012, representing a decline in the proportion of underweight children from 25% to 15%. This rate of progress is close to that required to meet the 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 ( lancet/article/piis %2813% x/abstract, accessed 12 March 2014). relevant MDG target, but varies between regions (Fig. 2). Beyond the MDGs, a new global target was recently set for a 40% reduction in the number of stunted children by 2025 against the 2010 baseline, along with five other targets on maternal, infant and young-child nutrition. 3 Between 1990 and 2012, the number of children affected by stunting declined from 257 million to 162 million, representing a global decrease of 37%. In 2012, global measles immunization coverage reached 84% among children aged months. More countries are now achieving high levels of vaccination coverage, with 66% of WHO Member States reaching at least 90% coverage in 2012, up from only 43% in Between 2000 and 2012, the estimated number of total measles deaths worldwide decreased by 78% from to MDG 5 Improve maternal health sets out the targets of reducing the maternal mortality ratio from its 1990 level by three quarters and achieving universal access to reproductive-health services by the year The 3. Comprehensive implementation plan on maternal, infant and young child nutrition. Sixty-fifth World Health Assembly, WHA resolution 65.6 and Annex 2. Geneva: World Health Organization; (WHA65/2012/REC/1; int/gb/ebwha/pdf_files/wha65-rec1/a65_rec1-en.pdf, accessed 7 April 2014). 14

17 2014 Figure 2. Prevalence of underweight children under 5 years of age globally and by WHO region, Children aged < 5 years underweight AFR AMR SEAR EUR EMR WPR Global number of women dying due to complications during pregnancy and childbirth decreased by nearly 50% from an estimated in 1990 to in While such progress is notable, the average annual rate of decline (AARD) is far below that needed to achieve the MDG target (5.5%), and the number of deaths remains unacceptably high. In 2013, nearly 800 women died every day from maternal causes. Almost all of these deaths (99%) occur in developing countries, and most can be avoided as the necessary medical interventions exist and are well known. The key obstacle is the lack of access to quality care by pregnant women before, during and after childbirth. In many countries, programmes have been implemented to eliminate or reduce the barriers that prevent access to effective reproductive-health interventions. Despite increasing overall levels of contraceptive use, there still remain significant gaps between the desire of women to delay or avoid having children and their actual use of contraception. Globally in 2011, around one in every eight women aged years who were married or in a union had an unmet need for family planning. In the WHO African Region, the figure was around one in four. Although the proportion of women receiving antenatal care at least once during pregnancy was 81% globally for the period , the figure dropped to around 56% for the recommended minimum of four visits or more. Around seven in every 10 births globally are attended by skilled health personnel. However, coverage varies sharply across country-income level from almost all births (99%) in high-income countries to less than half of births (46%) in low-income countries. Despite progress in reducing the birth rate among adolescents, more than 15 million of the estimated 135 million live births worldwide are to girls aged years. Pregnant adolescents are more likely than adults to have unsafe abortions, and early childbearing increases risks for both mothers and their newborns. Complications from pregnancy and childbirth are a major cause of death among girls aged in lowand middle-income countries. Globally, an estimated 2.3 million people were newly infected with HIV in 2012 representing a 33% decline compared with the 3.4 million new infections estimated for People living in sub-saharan Africa accounted for 70% of all new infections. As access to antiretroviral therapy (ART) improves, the population living with HIV increases as fewer people die from AIDS-related causes. In 2012, an estimated 35.3 million people were living with HIV with 9.7 million people in low- and middle-income countries receiving ART. It has been estimated that during the 15

18 Figure 3. Impact of ART use on the estimated number of deaths due to HIV/AIDS (millions) that would otherwise have occurred in low- and middle-income countries, Number of deaths (millions) With ART Without ART period , ART cumulatively averted 5.5 million deaths in such countries (Fig. 3). Globally, an estimated 1.6 million people died of HIV/AIDS in 2012; down from the peak of 2.3 million in In 2012, an estimated 8.6 million people developed tuberculosis and 1.3 million died from the disease (including deaths among HIV-positive people). 2 The rate of new tuberculosis cases worldwide has been falling for about a decade, thus achieving MDG target 6.C to reverse the spread of the disease by In addition, two WHO regions the WHO Region of the Americas and the WHO Western Pacific Region have also achieved related 2015 targets 3 to reduce tuberculosis incidence, prevalence and mortality rates (Fig. 4). Globally, the tuberculosis mortality rate has fallen by 45% since 1990 and the target of a 1. Global report: UNAIDS report on the global AIDS epidemic Geneva: Joint United Nations Programme on HIV/AIDS (UNAIDS); Table 2 in Part III presents data on mortality due to tuberculosis among HIV-negative people. Tuberculosis-related deaths among HIV-positive people are included in the mortality data for HIV/AIDS. 3. Stop TB Partnership targets linked to the MDG target 6.C of halting and beginning to reverse the incidence of major diseases such as tuberculosis by 2015, include reducing tuberculosis prevalence and deaths by 50% by 2015 compared with the 1990 baseline. 50% reduction by 2015 is within reach. Nevertheless, despite this decline in mortality rate, the number of tuberculosis deaths remains unacceptably high given that most are preventable. Between 1995 and 2012, 56 million people were successfully treated for tuberculosis and 22 million lives were saved. However, multi-drug resistant tuberculosis (MDR-TB), which emerged primarily as a result of inadequate treatment, continues to pose problems. In 2012, an estimated people worldwide developed MDR-TB, but only were newly detected. Treatment options for MDR-TB are often limited and expensive, and recommended medicines are not always available or may cause numerous adverse side-effects. Infection with HIV is the strongest risk factor for developing active tuberculosis disease. Many countries have made considerable progress in addressing the tuberculosis and HIV co-epidemic. However, less than half of notified tuberculosis patients had a documented HIV test result in 2012, with only 57% of those who tested positive being on ART or started on ART. In 2012, almost half of the world s population 3.4 billion people was estimated to be at risk of malaria. Of these, 1.2 billion people were considered to be at high risk, with more than one case of malaria occur- 16

19 2014 Figure 4. Reductions in tuberculosis incidence, prevalence and mortality, by WHO region, % 50% 40% 30% 20% 10% 0% 10% 70% 60% 50% 40% 30% 20% 10% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% Figure 5. Estimated number of deaths due to malaria, Global AFR AMR SEAR EUR EMR WPR Global AFR AMR SEAR EUR EMR WPR Global AFR AMR SEAR EUR EMR WPR Decline in incidence per population Decline in prevalence per population Decline in mortality per population ring per 1000 population. The WHO African Region bears the highest burden of malaria, with 80% of the estimated 207 million cases and 90% of the estimated malaria deaths worldwide occurring in this region in More than three quarters (77%) of all malaria deaths occur in children under 5 years of age (Fig. 5). During the period , malaria incidence rates among populations at risk 1 are estimated to have fallen by 25% globally and by 31% in the WHO African Region. Over the same period, estimated malaria mortality rates 1 decreased by 42% globally, by 49% in the WHO African Region and by 48% in children under 5 years of age globally. An estimated 3.3 million lives were saved as a result of scaling-up malaria interventions during the same period. If the annual rate of decrease is maintained, malaria mortality rates are projected to decrease by 52% globally, and by 62% in the WHO African Region and by 60% in children under 5 years of age, by Of 103 countries that had ongoing malaria transmission in 2000, 62 have produced reliable trend data indicating that 59 are meeting the MDG target of reversing its incidence. In the other 41 countries accounting for 80% of estimated cases of malaria it is not possible to reliably assess national malaria trends using the data reported to WHO. Neglected tropical diseases (NTDs) 2 are endemic in 149 countries, often cause multiple infections in a single individual, and can lead to severe pain, permanent disability and death. Many of these diseases can be prevented, eliminated or even eradicated with improved access to existing safe and cost-effective tools. The reported number of cases of human African trypanosomiasis dropped to less than in 2009 the lowest level in 50 years. In 2013, the number of cases of dracunculiasis worldwide WHO African Region, < 5 years WHO African Region, 5 years and older Rest of the world, 5 years and older Rest of the world, < 5 years The percentage changes shown in this paragraph are based upon malaria incidence rates defined as cases per 1000 population at risk, and mortality rates as deaths per population at risk. Elsewhere in this report, malaria incidence and mortality rates are calculated per population. 2. The diseases concerned are: Buruli ulcer; Chagas disease; cysticercosis; dengue; dracunculiasis; echinococcosis; endemic treponematoses; foodborne trematode infections; human African trypanosomiasis; leishmaniasis; leprosy; lymphatic filariasis, onchocerciasis; rabies; schistosomiasis; soil-transmitted helminthiases; and trachoma. 17