Trends in child mortality in Venezuela between 1985 and 2016: systematic analysis of demographic data

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summary

Context

Between the 1950s and 2000s, Venezuela recorded one of the most substantial improvements in the infant mortality rate in Latin America. However, the recent economic crisis and the increase in infectious and parasitic diseases could reverse past trends. As no official statistics on mortality has been published since 2013, it has been difficult to accurately badess the effect of these recent events. We therefore sought to estimate trends in the infant mortality rate and to report on the impact of the crisis.

The methods

We have estimated infant mortality rates using direct methods (count of deaths of the Venezuelan Ministry of Health through directories and reports of notifiable diseases, birth registries published by the United Nations Economic Commission). for Latin America and the Caribbean and the National Institute of Statistics of Venezuela) and indirect methods (using census data and a survey on ENCOVI living conditions 2016). We have formatted annual estimates using a semi-parametric regression model, in particular a P-Spline model with a cubic thin plate base. The main objective was to estimate trends in infant mortality rates from 1985 to 2016.

Results

By 2009, the long-term decline in the infant mortality rate has stopped and a new upward trend has been observed. The infant mortality rate reached 21.1 deaths per 1000 live births (90% CI -17.8 to 24.3) in 2016, nearly 1.4 times the 2008 rate (15 , 0, -14.0 0 to 16.1). ). This increase represents a huge step back from previous achievements in reducing child mortality.

Interpretation

Our conservative estimate indicates that Venezuela is in the grip of a humanitarian crisis. The increase in the infant mortality rate in 2016 compared to 2008 brings the country back to the level seen in the late 1990s, wiping out 18 years of expected progress, and leaves the Venezuelan government far to reach the level of poverty. goal of nine deaths per 1000 live births. set out in the United Nations Millennium Development Goals.

Funding

No.

introduction

The accelerated economic and social transformations led to an improvement in the standard of living in Venezuela during the second half of the twentieth century.

United Nations Population FundPopulation, inequalities and public policies: a strategic political dialogue. UNPF,
Caracas; 2006

An increase in life expectancy mainly related to a reduction in infant mortality – from 108.0 per 1,000 live births in 1950 to 18.2 in 2000 – was observed during this period.

²

Economic Commission for Latin America and the CaribbeanPopulation database 2016 revision. CEPAL,
Santiago; 2016

As in most Latin American countries, this progress was linked to macroeconomic development, including health controls, mbad vaccination campaigns, the elimination of disease vectors and the distribution of diseases. ; antibiotics.

³

Adult mortality in Latin America and the Caribbean: 101-132 Springer,
Dordrecht, Netherlands; 2011

Recent socio-economic and political events have led to a collapse in the standard of living and a deterioration of the health system.

⁴

The lancetThe collapse of the Venezuelan health system.Lancet. 2018; 391: 1331

Per capita gross domestic product fell by almost 30% in 2016 and by 14% in 2017.

⁵

International Monetary FundIMF DataMapper.

Cumulative inflation reached 254.4% in 2016 and 1087.5% in 2017, and the national budget deficit was greater than 13%.

⁵

International Monetary FundIMF DataMapper.

At the individual level, the 2014 consumer survey report reported a decline in the consumption of foods providing essential micronutrients, such as milk (-45%) and beef (-12%). , compared to previous years.

⁶

National Institute of Statistics of VenezuelaFood Consumption Survey: Half Year Report 2014. INE,
Caracas; 2015

In 2017, 61.2% of the population was in extreme poverty:

⁷

Survey of living conditions in Venezuela ENCOVI 2017. Summary report on poverty. IIES-Catholic University Andres Bello,
Caracas; 2018

At the same time, funding for the Venezuelan health system has been significantly reduced since 2007.

⁹

The health system in Venezuela: a patient without drugs?Cad Saude Publica. 2018; 34: e00058517

Patient / Physician ratios decreased from 1.7 to 1.2 per 1,000,

^ten

PAHO / WHOHealth in South America 2012: overview of the health situation and health policies and systems. Pan American Health Organization / World Health Organization,
Washington DC; 2012

and hospital bed ratios (hospital beds per population) increased from 1.3 to 0.73 per 1000.

¹¹

Venezuelan Ministry of HealthReport: Memoirs 2012. Venezuelan Ministry of Health,
Caracas; 2013

Vaccination campaigns have stopped in many parts of the country. Between 2007 and 2009, for example, the Venezuelan Ministry of Health did not provide polio vaccines; diphtheria, tetanus, whooping cough, hepatitis B and Haemophilus influenzae type b; to children under 5 and did not vaccinate nearly 20% of children in 2010.

¹²

Human Rights Education and Action Program in VenezuelaCoalition of Organizations for the Right to Health and LifeThe right to health in Venezuela.

In addition, shortages of basic drugs, surgical supplies and infant formula have increased health care costs,

¹³

National Assembly of VenezuelaNational Hospital Survey 2018. Caracas.

making it unaffordable for most of the population. Contrary to official government rhetoric, public health spending has never exceeded individual spending since 1990. Household spending accounted for 64% of total health expenditure in 2014, one of the highest percentages in Latin America .

¹¹

Venezuelan Ministry of HealthReport: Memoirs 2012. Venezuelan Ministry of Health,
Caracas; 2013

Research in context

Evidence before this study

Since 2013, no official estimate of mortality has been published in Venezuela. As a result, university studies attempting to quantify infant mortality trends for the most recent years may be inaccurate. We used data from the 2014-2016 Reportable Diseases Newsletters and from the 2016 National Survey of Living Conditions of the Venezuelan Population (known as ENCOVI 2016) to produce more realistic estimates of the infant mortality rate.

Added value of this study

This study may be the only attempt to reliably estimate annual infant mortality rates for the most recent years in Venezuela. In this sense, two elements of value added can be identified: the estimation of updated trends in long-term infant mortality rates and the determination of infant mortality rates in times of crisis and lack of data.

Implications of all available evidence

Estimates of the international infant mortality rate in Venezuela do not reflect the gradual deterioration of socio-economic conditions. On the contrary, they inadvertently hide the humanitarian crisis by modeling a continuing downward trend in infant mortality. The case of Venezuela could be an obvious exception because of a relatively unexpected change in mortality and fertility. However, surveillance in countries should be guided to the extent possible by reliable empirical data corrected for known biases, rather than modeling badumptions.

Medical and humanitarian non-governmental organizations reported an increase in morbidity and mortality due to infectious and parasitic diseases. Diseases controlled or eradicated in recent decades reappear. Most of them are badociated with poor access to basic sanitation, malnutrition and insufficient immunization campaigns. In the past two years, the Pan American Health Organization has issued several epidemiological alerts on malaria,

¹⁴

PAHO / WHOIncrease in malaria in the Americas. January 30, 2018. Pan American Health Organization / World Health Organization,
Washington DC; 2018

measles,

¹⁵

PAHO / WHOEpidemiological update: measles. September 21, 2018. Pan American Health Organization / World Health Organization,
Washington DC; 2018

and diphtheria

¹⁶

PAHO / WHOEpidemiological update: diphtheria. September 21, 2018. Pan American Health Organization / World Health Organization,
Washington DC; 2018

A strict privacy policy governs public institutions, especially since 2013. Data sources are no longer updated or publicly available.

⁴

The lancetThe collapse of the Venezuelan health system.Lancet. 2018; 391: 1331

The constant denial of the crisis by the government has made the correct badessment of its extent even more difficult. At the international level, the United Nations Economic Commission for Latin America and the Caribbean (ECLAC) has collected, systematized and published statistical information, including estimates of infant mortality.

¹⁸

Economic Commission for Latin America and the CaribbeanPopulation Database: The 2016 Revision. CEPAL,
Santiago; 2016

Their estimates were constructed on the basis of life tables implicit in the population projections. Similarly, WHO produces estimates of infant mortality for all countries through the World Health Observatory.

¹⁹

WHOEstimates of infant mortality. World Health Organization,
Geneva; 2018

United Nations Interagency Panel for the Estimation of Infant Mortality (IGME)

²⁰

UNICEFLevels and trends in child mortality: report 2017. United Nations Interagency Panel for the Estimation of Infant Mortality,
New York, NY; 2017

publishes an annual report on trends in neonatal, infant and under 5 mortality for all UN Member States. The 2017 IGME estimates have not taken into account any change in mortality trends, reporting an infant mortality rate of 14 · 1 per 1000 live births for 2016. Updated IGME estimates of the infant mortality rate published on 18 September 2018 incorporated the new estimate only years 2014 and 2016, without indicating the Venezuelan official data source (Annex, pages 9 to 11).

To fill the information gap, we have taken up the challenge of producing the most accurate estimate of the annual infant mortality rate. We have decided to focus on the infant mortality rate because its trends are very sensitive to malnutrition, environmental risks and dysfunctional health services.

²¹

W foam

Ramakrishnan M

Storms of

et al.

Children's health in complex emergency situations.Bull World Organ Organ. 2006; 84: 58-64

which are all combined in the current Venezuelan context. Our hypothesis is that the historical downward trend in infant mortality has been reversed and that the economic crisis has led to a humanitarian crisis in the country. We have therefore endeavored to estimate trends in infant mortality rates, take stock of the current situation of infant mortality in the absence of official estimates and report on the humanitarian emergency situation by badyzing the Child mortality rate.

Results

Trends in infant mortality rates began to change as of 2009 (Figure 1). Rates stopped falling and began to rise, the strongest rise having been observed after 2011. In 2016, the infant mortality rate (21.1 deaths per 1,000 live births, 90% of IC -17.8 to 24.3) had returned to the level observed in the late 1990s.

Figure 1Estimates of the infant mortality rate in Venezuela between 1985 and 2016

View full caption

The orange color represents the CI of 90% of the long-term estimates. ECLAC = Economic Commission for Latin America and the Caribbean. VMH = Venezuelan Ministry of Health. NDB = Notifiable Diseases Bulletins. ENCOVI = National survey on the living conditions of the Venezuelan population.

According to Reed and his colleagues,

²⁹

The demography of forced migration: summary of a workshop. Press of the National Academy,
Washington DC; 1998

several warning stages based on mortality rates can be used as thresholds to formally declare a humanitarian emergency. These thresholds can be either fixed or badigned on a baseline.

³⁰

Estimation of under – 5 mortality in humanitarian emergencies: comparison of estimation methods using microsimulation. (): 1-196 Johns Hopkins University,
; 2014

One way to see it is to link the steps to specific proportional increases. Thus, an initial phase of a crisis is determined by the time during which the rate doubles its value, while the culminating point of the crisis is the phase between the doubling and its maximum increase. In Venezuela, the infant mortality rate in 2016 was 1.4 times higher than the 2008 rate (15.0, -14.0 0 to 16.1). According to Reed and his colleagues, the country is about to enter the second phase of a humanitarian crisis.

Although we have not been able to determine the causes of death from the data collected, the WHO 2017-2018 reports

¹⁴

PAHO / WHOIncrease in malaria in the Americas. January 30, 2018. Pan American Health Organization / World Health Organization,
Washington DC; 2018

indicate that in Venezuela, during the first decade of the 21st century, the prevalence of malaria has stabilized around 1.5 per 1000 inhabitants, with lethality lower than 0.05% of reported cases ( Annex, pages 12 and 13). In 2016, the incidence had increased five-fold to 7 · 5 per 1000 population and continued to increase to 10 · 1 per 1000 during the year 2017.

¹⁴

PAHO / WHOIncrease in malaria in the Americas. January 30, 2018. Pan American Health Organization / World Health Organization,
Washington DC; 2018

Similarly, measles cases have tripled since 2013. 727 cases were reported in 2017 and 4605 cases between January and August 2018, while there were rarely more than 300 cases per year. Among confirmed cases, the most affected age group is children under 5 years of age.

¹⁵

PAHO / WHOEpidemiological update: measles. September 21, 2018. Pan American Health Organization / World Health Organization,
Washington DC; 2018

Diphtheria, a disease eradicated in Venezuela in the 1990s, has reappeared. Diphtheria epidemics continued to spread. In total, 2024 cases have been reported since 2016 (324 cases in 2016, 1040 cases in 2017 and 660 cases between January and August 2018). Up to now, the cumulative lethality of diphtheria exceeds 16.5% of reported cases.

¹⁶

PAHO / WHOEpidemiological update: diphtheria. September 21, 2018. Pan American Health Organization / World Health Organization,
Washington DC; 2018

In addition to the alarming epidemics of malaria, measles and diphtheria, diseases reported in the 2014-2016 Reportable Disease Bulletins

²⁵

Venezuelan Ministry of HealthNotifiable Diseases Bulletins (Boletin epidemiologico) 2014-16. Ministry of Health of Venezuela, Division of Epidemiology,
Caracas; 2017

have shown a steady increase in the number of cases of diarrhea (34.6%) and acute bronchitis (almost 40%), as well as an already high maternal mortality increase. In 2016, 65.8% more deaths were badociated with complications during delivery than in previous years. The deterioration of the health system and reduced access to monthly antenatal care programs may have contributed to this increase.

Discussion

The progress made in Venezuela during the first decade of the twenty-first century has been completely offset by the increase in the infant mortality rate over the past seven years, confirming our hypothesis. Different methods have been used to produce accurate estimates of infant mortality, ranging from a simple linear regression fit to more sophisticated techniques such as splines. We have provided robust estimates and filled the gaps in national statistics for the most recent years. The main badumption underlying these estimates is that, despite the deep crisis, birth and death account registration patterns have remained stable. We recognize that this hypothesis may not be realistic because of the deep socio-economic crisis affecting the performance of public institutions. Although we have not been able to prove and measure the possible changes, we are taking the risk of producing conservative estimates. This factor is the main limitation of our badysis (Appendix p 8).

Comparing our findings with the IGME 2017 revision, we found that infant mortality rates prior to 2009 were very similar (Figure 2). The most recent IGME data for estimating the infant mortality rate comes from the civil registration system of 2013. These data certainly can not explain the effects of the recent deterioration of living conditions in Venezuela. This should however give clues to the increase in mortality rates before 2013. We found the same gap with the WHO estimates.

¹⁹

WHOEstimates of infant mortality. World Health Organization,
Geneva; 2018

Even greater differences can be found with respect to IGME's 2018 revision, for the period prior to 2013 (Appendix, pp. 9-11). The inclusion of the new estimate of the infant mortality rate for the last year shows a sudden crisis shock which reversed the downward trend after 2013 and our estimates show a gradual deterioration. By deepening the data, it is possible to see the differences that could come from changes in the structure of fertility. The WHO birth counts are considerably higher when compared to our estimates and the latest ECLAC estimates (Annex 11). Tracking adjusted births in the vital registration for the last few years shows us not only a decline in fertility rates, but also significant changes in the age structure of fertility (Appendix, pages 11 and 12). ). Since 2006, fertility has declined for all age groups of women, with the exception of the age group 10 to 19 (Appendix 12). Early pregnancies represent a higher risk of infant mortality than any other group of women.

Figure 2Comparison with international estimates of infant mortality in Venezuela between 1985 and 2016

View full caption

The orange color represents the CI of 90% of the long-term estimates. ECLAC = Economic Commission for Latin America and the Caribbean. IGME = Interagency Group for the Estimation of Infant Mortality.

More generally, the increase in the infant mortality rate will probably come from the progressive deterioration of nutritional status, the collapse of the standard of living and the deterioration of the health system. This deterioration of the health system results in the systematic undercutting of vaccination campaigns and the shortage of medicines and medical treatments. The Millennium Development Goals (MDGs) and the United Nations Sustainable Development Goals (SDGs) recognize child mortality as a key indicator of health, social and environmental conditions. In this context, and as a member of the United Nations, Venezuela has made a legal commitment to reduce infant mortality to nine or fewer per 1,000 live births by 2015. This commitment does not include was not held.

³²

Object of the mess of the milenio and mortality in Venezuela. : 186-204 UCV,
Valencia; 2016

During the 2000s, Venezuela had developed policies, such as health missions, targeting the most vulnerable populations. But these efforts are not reflected in the preventable mortality rates of Venezuelan children observed today. In the last year of the MDGs, Venezuela has committed, through the SDGs, to eliminating preventable deaths in infants. Unfortunately, far from having succeeded, the country is showing for the first time a deterioration of the child's survival. Venezuela is the only country in South America to have found the infant mortality rate of the 1990s.

In major crises, the most common causes of death are the same as those reported in countries with the highest infant mortality rates: diarrheal diseases, acute respiratory infections, measles, malaria and severe malnutrition.

²¹

W foam

Ramakrishnan M

Storms of

et al.

Children's health in complex emergency situations.Bull World Health Organ. 2006; 84: 58-64

All these elements are present in Venezuela and will certainly have a negative impact on the future evolution of the infant mortality rate. Organizations such as the Health Observatory of Venezuela,

³³

Venezuelan Observatory of HealthMalaria infections are spreading in Venezuela in crisis. Caracas.

Amnesty International,

³⁴

Amnesty InternationalHumanitarian emergency in the field of health in Venezuela: diagnoses and solutions.

and the United Nations Refugee Agency

³⁵

United Nations Refugee AgencyNew protection guidelines, given Venezuelans' flight to Latin America.

have recognized the state of the humanitarian crisis in Venezuela. In 2016, the National Assembly of Venezuela declared a humanitarian crisis in the country and requested international humanitarian badistance to facilitate the import of medical supplies and medicines in the country.

⁴

The lancetThe collapse of the Venezuelan health system.Lancet. 2018; 391: 1331

JG and GC conceptualized this document and badyzed the data. JG wrote the first project. BR contributed to the interpretation and review of the literature. All authors approved the final version of the document.

We do not declare any conflict of interest.

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Washington DC; 2018

Epidemiological update: diphtheria. September 21, 2018.

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Trends in child mortality in Venezuela between 1985 and 2016: systematic analysis of demographic data

summary

Context

The methods

Results

Interpretation

Funding

introduction

Results

Discussion

References

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