Measuring the burden of disease and the cost-effectiveness of health interventions : a case study in Guinea

WORLD SANK TECHNICAL PAPER NO s33 WVf 333 Work In progress 'l t 9 for public discussion i Measuring the Burden of Disease and the Cost-Effectiveness of Health Interventions ,A Case Study in Guinea _ -, A01, , 4 Puzabhatjba Kent Ranson Josd Luis Bobadilla  RECENT WORLD BANK TECHNICAL PAPERS No. 256 Campbell, Design andt Operation of Smalllholder Irrigation in Souith Asia No. 258 De Geyndt, Managing the Quality of Health Care in Developing Colunitries No. 259 Chaudry, Reid, and Malik, editors, Civil Service Reform in Latin America and the Caribbean: Proceedings of a Conference No. 260 Humphrey, Paymenit Systems: Principles, Practice, and Improvements No. 261 Lynch, Provisionifor Chiildrenz wvitlh Special Eduz cational Needs in the Asia Region No. 262 Lee and Bobadilla, Health Statistics for the Americas No. 263 Le Moigne, Subramanian, Xie, and Giltner, editors, A Guide to the Fornmu lation of Water Resources Strategy No. 264 Miller and Jones, Organic and Compost-Based Growing Media for Tree Seedling Nurseries No. 265 Viswanath, Bu ilding Partnerslhipsfor Poverty Reduction: The Participatori Project Planniing Approaclh of the Women's Enterprise Management Training Ouitreaclh Program (WEMTOP) No. 266 Hill and Bender, Developing tlhe Reguilatory Enivironmentfor Competitive Agrictultural Markets No. 267 Valdes and Schaeffer, Surveillance of Agricuiltu ral Prices and Trade: A Handbook for the Dominic an Republic No. 268 Valdes and Schaeffer, Suirveillance of Agricultural Prices and Trade: A Hlndbookfor Colomnbia No. 269 Scheierling, Overcominig Agricuiltuiral Polluition of Water: The Clhallenge of Integrating Agricultural and Environniental Policies in the European Union No. 270 Banerjee, Rehabilitation of Degradtedi Forests in Asita No. 271 Ahmed, Technological Development antd Polluition Abatement: A Stu dy of HoL7w Enterprises Are Finding Alternatives to Chllorofluorocarbonis No. 272 Greaney and Kellaghan, Equiity Iss,ues in Pu blic Exanlinations in Developing Countries No. 273 Grimshaw and Helfer, editors, Vetiver Grassfor Soil andi Water Conservation, Lanid Rehlabilitation, and EmbankAment Stabilization: A Collection of Papers atnd Newsletters Comipiled by the Vetiver Network No. 274 Govindaraj, Murray, and Chellaraj, Healtht Expendituires in Latin Anmerica No. 275 Heggie, Managemenit and Financing of Roads: An Agenda for RefoLrm No. 276 Johnson, Quality Review Sch)emes.for Auditors: Their Potenitallfor Sub-SahUran Africa No. 277 Convery, Applying Environmental Economnics in Africa No. 278 Wijetilleke and Karunaratne, Air Quality Mvlanagemnent: Consider7tions for Developing COUntries No. 279 Anderson and Ahmed, The Case for Solar E nergtj Investments No. 280 Rowat, Malik, and Dakolias, Judiiciazl Refornm in Latin Amnerica and the Caribbean: Proceedings of a World Bank Conference No. 281 Shen and Contreras-Hermosilla, Environnmental and Economonic Issues in Forestry: Selecte d Case Studies in Asia No. 282 Kim and Benton, Cost-Benefit AnaltYsis of the Oniclhocercinsis Control Progranm (OCP) No. 283 Jacobsen, Scobie and Duncan, Statuitory Intervention in AgricUltuiral Marketing: A New 2 Zeailtand Perspective No. 284 Valdes and Schaeffer in collaboration with Roldos and Chiara, Survneillance of Agricultural Price and Trade Policies: A Handbookfor Ulruguai! 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C.  Copyright @ 1996 The International Bank for Reconstruction and Development/THE WORLD BANK 1818 H Street, N.W. Washington, D.C. 20433, U.S.A. All rights reserved Manufactured in the United States of America First printing September 1996 Technical Papers are published to communicate the results of the Bank's work to the development community with the least possible delay. The typescript of this paper therefore has not been prepared in accordance with the procedures appropriate to formal printed texts, and the World Bank accepts no responsibility for errors. Some sources cited in this paper may be informal documents that are not readily available. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations, or to members of its Board of Executive Directors or the countries they represent. 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The complete backlist of publications from the World Bank is shown in the annual Index of Publications, which contains an alphabetical title list (with full ordering information) and indexes of subjects, authors, and countries and regions. The latest edition is available free of charge from the Distribution Unit, Office of the Publisher, The World Bank, 1818 H Street, N.W., Washington, D.C. 20433, U.S.A., or from Publica- tions, The World Bank, 66, avenue d'Ina, 75116 Paris, France. ISSN: 0253-7494 Cover photo: Health worker and baby. Credit: World Bank/Curt Carnemark. Prabhat Jha is a public health specialist and Kent Ranson, a consultant in the World Bank's Human Development Department. Jose Luis Bobadilla is a senior public health specialist in the Inter-American Development Bank and was formerly a senior public health specialist in the World Bank. Library of Congress Cataloging-in-Publication Data Jha, Prabhat, 1965- Measuring the burden of disease and the cost-effectiveness of health interventions : a case study in Guinea / Prabhat Jha, Kent Ranson, and Jose Luis Bobadilla. p. cm. - (World Bank technical paper ; no. 333) Includes bibliographical references. ISBN 0-8213-3727-0 1. Medical economics-Guinea. 2. Medical care-Guinea-Cost effectiveness. I. Ranson, Kent, 1970- . II. Bobadilla, Jose Luis. 1I. Title. IV. Series. RA410.55.G92J48 1996 338.4'33621'096652-dc2O 96-31866 CIP  TABLE OF CONTENTS Foreword . . . . . . . . v Abstract . . . . . . . . . . vii Acknowledgments . . . . . . . . ix PURPOSE OF STUDY . . . . . 1 DEMOGRAPHIC AND HEALTH SYSTEM PROFILE OF GUINEA. . . 3 MEASURING MORTALITY AND DISABILITY IN GUINEA . 7 DATA SOURCES . . . . . . . 7 METHOD FOR DERIVING MORTALITY AND MORBIDITY ESTIMATES . 8 RESULTS FOR BURDEN OF DISEASE . . . . . . 10 CONCLUSIONS AND POLICY IMPLICATIONS OF DISEASE BURDEN . 18 COST-EFFECTIVENESS OF HEALTH INTERVENTIONS IN GUINEA . 21 METHODOLOGY FOR COST-EFFECTIVENESS ANALYSIS . . . 21 RESULTS OF COST-EFFECTIVENESS ANALYSES OF INTERVENTIONS . 23 A MINIMUM PACKAGE OF HEALTH SERVICES . 25 POLICY IMPLICATIONS OF COST-EFFECTIVENESS ANALYSIS . . 29 BIBLIOGRAPHY . . . . . . . . . 33 . .  TABLES Table Number Page 1 Health expenditures in Guinea from 1988 to 1994 (in millions of Guinean francs), and by level of care (as a percentage of total health expenditures) 6 2 Distribution of population and number of deaths, in Guinea by sex and age, 1992 . . . . . 11 3 Distribution of deaths by cause in Guinea, by sex 1992 . . 11 4 Top ten causes of death in Guinea, by age, 1992 (ranked in order and percentage except as noted) . . . 13 5 Distribution of years of life lost in Guinea, by sex and cause, 1992 . . 14 6 Top ten causes of years of life lost in Guinea, by age, 1992 (ranked in order and percentage except as noted) . . . . 14 7 Distribution of years of life lived with a disability in Guinea, 1992 by cause and sex . . . . . . 15 8 Relative importance of causes of death in Guinea and Ghana. . . 20 9 Summary of population, coverage, and cost-effectiveness for forty health interventions in Guinea, 1994 . . . 24 10 Health interventions in Guinea, ranked by cost-effectiveness . . 26 11 Cost-effectiveness of health services in Guinea, by level of care and future costs from expanded coverage of health services (assuming no improvement in quality of care) . . . 27 12 Total and per capita costs of a minimum package of health services in Guinea (assuming no improvement in quality of care) . . 28 13 Contributions of burden of disease and cost-effectiveness analyses to evaluation of health sector performance . . . . . 31 FIGURES Figure . . . . . . . . . Page 1 Rapid method to calculate mortality data for Guinea . . . 9 2 Distribution of deaths, by major cause and age in Guinea, 1992 . 13 3 Relative importance of causes of death in Guinea, sub-Saharan Africa, developing and developed countries . . . . . 16 4 Projections of number of deaths in Guinea, by cause . . . 17 5 Distribution of deaths by age group in Guinea, 1992, 2000, and 2010 . 18 iv  FOREWORD Health care investments in low-income countries such as Guinea are crucial to development. The choice of allocating spending to various health interventions is a complex one. This report draws upon the methodology of the 1993 World Development Report: Investing in Health to offer a set of guidelines for the rational allocation of scarce health resources. Analytic efforts, such as this one, can help guide policy choices towards viable and cost-effective health care interventions. This study draws upon local data from Guinea, and represents a useful addition to our knowledge of disease burden and cost-effectiveness in low-income African countries. As a fully collaborative effort with the Ministry of Health in Guinea, this study represents an important aspect of the non-lending policy development work of the World Bank. David de Ferranti Director Human Development Department v   ABSTRACT This study draws upon the methodology of the 1993 World Development Report. Investing in Health to provide analyses of the burden of disease and cost-effectiveness of health interventions. The analysis aims to provide a common framework for the activities of the government of Guinea in prioritizing health care services. The burden of disease analysis presents detailed estimates of mortality in Guinea, by cause of death in 1992, using a new, rapid methodology. The cost-effectiveness analysis compares the costs of forty interventions selected from treatment protocols at health centers, health posts and first referral hospitals' health care intervention with their health impact. These two methodologies complement other methods to measure health system performance. The results of the burden of disease study underscore the need for national health care planners and international donors to focus on diseases that cause the most premature deaths. In 1992, the largely avoidable or treatable communicable disease, maternal, and malnutrition diseases together accounted for 86,400 deaths or seventy percent of all deaths and, with perinatal disease, account for nine in ten deaths before age five. Injuries caused 9,000 deaths (seven percent) and non communicable diseases caused 28,700 deaths (twenty-three percent). Many deaths among the economically-productive adult age group could be also avoided. Detailed data on years of life lost, simplified estimates of years lived with a disability, a comparison to other regions, and estimates of the impact of population growth on burden of disease support these findings. The cost-effectiveness analysis suggests that several affordable interventions already exist for the major causes of death in Guinea. Communicable, maternal, and perinatal diseases, the largest causes of death in Guinea, are subject to several highly cost-effective curative interventions. Those costing less than about one hundred dollars per year of life saved include treatment of childhood pneumonia, rehydration therapy for diarrhea at health centers and at health posts, treatnent of childhood malaria at health centers, childhood vaccination at health centers, short- course tuberculosis treatment at health centers, treatment of sexually-transmitted diseases at health centers, and impregnated bed nets against malaria. Maternal and perinatal diseases have slightly less cost-effective interventions, involving prenatal and delivery care at health centers or programs using out reach trained birth attendants. The report concludes with one possible minimum package of health services that includes outreach preventive programs and a package of curative treatments at health center and hospital levels. The total package of services would cost about thirteen dollars per capita and would address about sixty percent of total years of life lost. The analysis confirms that provision of a basic package of health services will require substantial increases in funding from the government of Guinea and donors. The minimum package is about three times the public per capita expenditure of four dollars. The core set of interventions at the outreach, health center, and first referral hospital level, should be the priority for the government of Guinea as it plans further health system reforms. vii  I  ACKNOWVLEDGMENTS The authors thank the many individuals whose input helped complete this study. Sergiu Luculescu was chiefly responsible for the initiation of the work, and supervised its early stages. Numerous officials in the Ministry of Health, Republic of Guinea, provided data for the study, notably Dr. Ousmame Bangoura, Secretary-General, and Dr. Robert Tolno. The Ministry of Health held two review meetings for the study in Guinea. Dr. Alan Lefevre was the consultant for the study. Marisol Ravicz provided the templates for the cost-effectiveness analysis. Pascale Kervyn provided useful information from the public expenditure review. Mariari Claeson, Peter Cowley, Ed Elmendorf, Yves Genevier, Salim Habayeb, Dean Jamison, Varsha Malhotra, David Peters, Alexander Preker and Helen Saxenian gave constructive comments. Alberto Harth chaired a review meeting for the study within the World Bank. Mendy Woodly and Lauren Ptito helped edit the report. The authors extend their special thanks to Ok Pannenborg, Technical Manager, Africa Technical Human Development 2, Western Africa Population and Human Resources, and to Richard Feachem, Senior Adviser, Human Development Departrnent, for their enthusiastic and continuous support for the study. ix   PURPOSE OF STUDY Like most other developing countries, the Republic of Guinea faces difficult choices in allocating limited financial resources to its people's health needs. Making these choices depends on accurate information about the country's health status and on the effectiveness of various interventions the country might undertake to improve health status. The 1993 World Development Report of the World Bank, which focused upon investments in health (World Bank, 1993b), outlined two analytic steps to guide allocation of scarce health care resources in low and middle income countries. The first was the application of burden of disease measures to obtain estimates of deaths and disability from various diseases. The second was cost-effectiveness analysis to identify health interventions that make best use of money in reducing mortality and morbidity. The report suggested that addressing diseases with a high burden with the most cost-effective interventions could do much to reduce disease in the population. To yield meaningful results, burden of disease and cost-effectiveness studies should be made at a country or sub-country level. This is because large variation exists in epidemiological conditions, health services, and unit costs across countries. This report presents the results of studies in Guinea based on the World Development Report's methodology, the outcome of discussion between Guinea's Ministry of Health and staff in the World Bank. While these analyses offer technical information to guide policy, actual choices must also take into account other factors: the feasibility of the interventions; institutional capacity; political support; and the results of macroeconomic, financial, and operational research. As well, consumer preferences for various interventions are important. Moreover, policy choices are influenced by the way the existing system of health care delivery works, including the allocation of investment and recurrent spending. The analyses had five objectives: (a) to provide a common framework for the government of Guinea in prioritizing health care services. Prioritization includes both current health expenditures and planned external aid from the World Bank and other international donors; (b) to provide a framework for similar analyses at regional levels within Guinea; (c) to permit a review of current health programs in the context of disease burdens and cost-effectiveness; (d) to create a set of baseline data and methods that could become a template for similar analyses in other low-income African countries; and (e) to create a data base that would permit selected inputs into economic analyses of projects in low-income African countries. I  To achieve these objectives, the Population and Human Resources Division of the Western Africa Department, and the Human Development Department of the World Bank in conjunction with the Ministry of Health of Guinea undertook a study of the burden of disease and cost-effectiveness of various interventions. The study began with preliminary discussions in March 1994, followed by a mission by Bank staff in November 1994 to collect detailed data. Preliminary estimates were completed in March 1995 and shared with counterparts in Guinea. A second mission in July 1995 validated detailed assumptions. It also included a consultant who verified data sources and numbers for the cost-effectiveness analysis.' ' The results we present here for burden of disease, and cost-effectiveness analyses are the major results only. To obtain an annex containing more detailed data, or computer files of the analyses, please contact Prabhat lha in the Human Development Department of the World Bank. 2  DEMOGRAPHIC AND HEALTH SYSTEM PROFILE OF GUTINEA Guinea is located in West Africa, north of the Ivory Coast. It is one of the poorest nations in Africa with a gross domestic product of $460 (US dollars2) per person per year (World Bank, 1993b). Moreover, Guineans suffer among the worst health indicators in the world. Life expectancy at birth is only forty-four years and newborns face a one in four chance of dying before age five. In 1993, according to government surveys, infant mortality was about one- hundred thirty-three deaths per thousand live births and maternal mortality was eight-hundred per hundred thousand live births. Both these measures are among the worst in Africa. The population of Guinea was 6.6 million in 1995 and was 6.1 million in 1992, the year upon which we base the burden of disease analysis (World Bank, 1993a). Guinea's population is young: forty-seven percent of its people are under fifteen and only four percent are sixty or older. World Bank projections suggest children under fifteen will constitute over forty percent of the population until the year 2025. Life expectancy will increase only slightly, to forty-six years by 2005. Women constitute fifty-one percent of the population, because of a slightly higher mortality among male children. The sex ratio is generally constant over different age groups. Approximately seventy-two percent of Guinea's population live in rural areas (DNSI, 1994). Apart from having less access to health services than urban inhabitants, only half of those in rural areas have access to drinkable water compared with almost three-quarters of urban residents; and only one percent have access to basic sanitation facilities compared with nearly a fifth of urban residents. About twenty-eight percent of the population live in Maritime Guinea and one million in Conakry, the capital city. Middle Guinea, Upper Guinea, and Forest Guinea constitute thirty-two, twenty-one, and twenty percent, respectively of the total population. International migration is responsible for 0.3 percent to 0.6 percent net migration out of the country. The Ministry of Health is responsible for organization and delivery of health services in Guinea. An informal system of private and traditional practitioners receives about half of per capita health spending in Guinea. However, the major infrastructure of health facilities is in the public system. The public system relies upon thirty-three prefectures containing three-hundred and seventy-six centre de sante or health centers and three-hundred and forty-seven poste-de sante or health posts. There are thirty-three prefectoral and four regional hospitals and two teaching hospitals in Conakry. A 1993 inventory study by a consulting firm found two-hundred and sixty- nine health centers were part of the Extended Program of Immunization, Basic Care and Essential Medicines, (known as Programme Extendee Vaccination, here referred to as the extended program). Twenty-one health centers were not active due to construction or renovation, and eighty- six were not integrated into the extended program. This study also found one-hundred and fourteen of the health posts were not active and only thirty-five were part of extended program. The activities of the health centers are primary care, infant health (immunization, growth monitoring and nutrition), normal maternal labor (in rural areas; in urban areas, hospitals largely perform 2 All dollar figures in this report are in 1994 US dollars. The conversion rate used in the report is 976 Guinean francs for every US dollar. 3  maternal care), family planning, minor surgery, simple diagnostic tests, sale of essential medications, dental care (in certain urban centers), and provision of information. Health posts promote health education, monitor the growth of infants and progress of pregnant women, offer limited primary care, sell essential medications, and make referrals to the health centers. Both health centers and health posts follow written protocols for presentations of common causes of illness (SEATS/JSI, 1994). According to the government and the World Bank, most of Guinea's health centers and hospitals lack drugs and operating facilities, good management and trained staff, so that even where health services are available, they are inadequate and poorly utilized (World Bank, 1986 and 1993a; SEATS/JSI, 1994). Two other key problems include weak sector organization and institutional capacity and financial constraints and inefficient use of resources (World Bank, 1993a). In keeping with the international declaration of Alma-Ata in 1978, the government aims to make health services accessible to the largest number of people consistent with reasonable costs to the country. The focus is on the implementation of primary health care, particularly through the expanded delivery of immunization and essential drugs, and rehabilitation of physical structures and equipment at health centers and hospitals. The government has set a goal of activating all health centers by the end of 1996. The average public spending on health in Guinea from 1991 to 1994 was slightly under four dollars per capita in real terms in 1994 US dollars (table 1). A 1991 household survey conducted by an international aid agency suggested private expenditures were about double this amount per capita. Of the private spending, the public system realized a cost-recovery of only ten to twenty percent. Thus, the actual total per capita spending of about eight dollars falls below the level of twelve dollars suggested by the 1993 World Development Report for a minimum package of health services (World Bank, 1993b). A recent review of public expenditures in Guinea showed health expenditures declined in real terms from 1988 to 1994 (World Bank, 1996). On a per capita basis, the drop was significant: from seven dollars in 1988 to under two dollars in 1994. Similarly, expenditures dropped from 1.3 percent of gross domestic product in 1988 to 1.0 percent in 1994 -- a performance that compares poorly with similar low-income countries. However, as a share of total public expenditures, health expenditures remained fairly constant at about 4.5 percent. In 1995, the government increased the health recurrent budget from 3.9 percent of the total public budget in 1994 to 5.4 percent in 1995. Despite this increase, the recurrent budget for the sector remains inadequate, exasperated by the large proportion of funds spent on salaries (which reached over ninety percent of the recurrent budget in 1994), and low budget implementation, especially for non-salary expenditures. During the years 1991, 1992 and 19943, expenditures for primary care represented an average of twenty-eight percent of total expenditures on health. Secondary-care and tertiary-care facilities captured twenty-four and twenty-seven percent, respectively, and administration captured twenty-one percent. Three factors are noteworthy in this expenditure pattern. First, 3Data for 1993 budget expencitures were incomplete at the time for this analyses, and thus are excluded. 4  about three-quarters of expenditures at the secondary-care level went to prefecture hospitals that also deliver primary health services. Second, the increase in expenditures for tertiary care in 1994 was only temporary, largely for rehabilitation works performed at the two large hospitals in the capital. Lastly, hospitals included in the tertiary care category performed largely secondary- care tasks. Recurrent non-salary expenditures for primary health care facilities are inadequate. Public expenditures for medicines increased in 1994 to about sixty-four percent of recurrent non- salary expenditures. However, this amounted to less than twenty-five cents per capita, and compares poorly with the average expenditure of two dollars in other sub-Saharan countries (World Bank, 1994). The share remaining for other recurrent expenditures such as the maintenance of infrastructure and vehicles is insufficient. This creates deficiencies in supervision, patient referral, and vehicle operation. Finally, the expenditure on administration in Guinea is higher than the average for sub-Saharan Africa (World Bank, 1994). 5  Table 1. Health expenditures in Guinea from 1988 to 1994 (in millions of Guinean francs), and by level of care (as a percentage of total health expenditures) Year Averagefor 1988 to 1994, excluding 1993 In nominal terms Recurrent 7,600 Investment 8.300 Total health expenditure 15,900 In real terms (1994 values) Total health expenditure 23,300 Percent of total govermment expenditures 4.5 Percent of gross domestic product 0.78 Per capita in constant US dollars 3.9 By level of care, as percentage of total health expenditures Average for 1991-1994, excluding 1993 Primary 28 Recurrent 13 Non-salary 1 Drugs 1 Investment 15 Secondary 24 Recurrent 17 Non-salary 8 Drugs 1 Investment 8 Tertiary 27 Recurrent 9 Non-salary 2 Drugs 1 Investment 18 Administration 21 Recurrent 7 Non-salary 1 Investment 13 Total 100 Recurrent 47 Non-salary 13 Drugs 3 Investment 53 6  MEASURING MORTALITY AND DISABILITY IN GUINEA This section presents detailed estimates of mortality in Guinea, by cause of death in 1992. The methodology relies upon data specific to Guinea and on an external database for sub- Saharan Africa and uses a rapid methodology. Figure 1 shows the various steps in the rapid methodology. The sources of data are given below. DATA SOURCES A) Data on population and mortality for Guinea We obtained numbers of age and sex-specific data on population and mortality in Guinea for 1992 from the World Bank demography database. These population projections are derived from data collected in Guinea in a full census in 1955 and a partial census in 1983. A demographic household survey conducted in 1992 showed a population and age distribution similar to the World Bank estimates (Chi square p value =0.39 and 0.92 for men and women, respectively; DNSI, 1994). B) Data on all possible causes of death We used estimates of the specific causes of death for sub-Saharan Africa from the Global Burden of Disease Project organized by the World Health Organization and the World Bank (known as Version 4 of the GBD; Murray and Lopez, 19944). This consisted of age and sex- specific estimates for disease groupings based on the International Classification of Disease-9th version (ICD-9). The ICD-9 system covers nearly 100 percent of all causes of deaths, classified into three major categories: (1) communicable, matemal and perinatal; (2) injuries; and (3) non- communicable. We maintained the ICD-9 classification for specific diseases as utilized by the Global Burden of Disease Project. We combined all diarrhea diseases into one category, all maternal causes of death into one category, and all trypanosomiasis, schistosomiasis, and onchocerciasis into one category. We separated injuries into unintentional and intentional injuries. We also established four categories consisting of the following: (1) all neoplasms; (2) all nutritional and endocrine diseases; (3) epilepsy, psychosis, alcoholism, dementia, Parkinson's disease, and multiple sclerosis; and (4) rheumatic, ischemic and inflammatory heart disease, and cerebrovascular disease. Finally, we placed components of the respiratory, digestive, and genito-urinary diseases into three broader categories. The details of the methodology for the GBD are described elsewhere (Murray, 1994). C) Local studies of childhood and maternal deaths, HiIV infection, injuries and malnutrition Given the high mortality and high fertility rates in Guinea, we adjusted estimates so as to optimize the quality of data for early childhood (age zero to four) and for maternal deaths. These relied upon: (1) local unpublished surveys of childhood mortality done in 1986 by the U. S. Agency for International Development in rural parts of Kindia province in Guinea; (2) studies of childhood 4These data are consistent with newer Version 6 estimates for mortality in sub-Saharan Africa, although injuries are a higher percentage of deaths in the latter. The rank order and percentage of deaths from the top five causes of death are similar. 7  mortality in Conakry conducted by Cornell University; and (3) maternal mortality estimates in Guinea (data on file, Ministry of Health, Guinea 1994). These data permitted adjustments for deaths from malaria, respiratory illness, malnutrition and diarrhea. Attributing deaths to malnutrition among children is controversial (Pelletier et al., 1993) because the direction of causation may be unclear: malnourished children are at increased risk of acquiring and dying from an infection; conversely, certain infections may lead to malnutrition. Using results from a similar study in Eastern Africa, we assumed that malnutrition was the direct cause in only eighteen percent of all deaths attributed to malnutrition in the AID and Cornell studies (World Bank, 1995). This avoided double-counting of causes of deaths. We used two additional pieces of data to adjust the estimates of deaths. First, we reduced deaths from human immunodeficiency virus (HIV) infection by half to reflect a 1993 finding that, among patients at a sexually-transmitted disease clinic in Conakry, only 2.7 percent were seropositive for the HIV (data on File, Ministry of Health, 1994). This prevalence is significantly lower than that among other high-risk populations in sub-Saharan Africa (US Bureau of the Census, 1994). Second, we reduced estimates of deaths from war by an arbitrary one-quarter because Guinea has been at peace in recent history. METHOD FOR DERIVING MORTALITY AND MORBIDITY ESTIMATES After deriving final estimates for children aged zero to four, we used these to provide estimates for deaths at older ages, with a separate analysis for males and females. Figure 1 shows the details of this approach. Our method ensured that each death had only one cause and those total deaths in any age group did not exceed the data based upon the census information for Guinea. We explicitly assumed that the pattern of deaths across age groups was similar for the populations covered by the estimates. To validate our approach, we also calculated deaths at older ages based upon the cause-of-death structure taken as that within age groups for the Global Burden Disease Project for sub-Saharan Africa. These two approaches yielded virtually identical results (Chi square P value =0.99) in the final distribution of major causes of deaths. A) Discounting of life years To calculate the discounted years of life lost, we derived the average age of death for each age and sex group for the various diseases using a study in Ghana (Ghana Health Assessment Project Team, 1981). We subtracted the mean age of death from the maximum time lived in developed countries: eighty for women and seventy-eight for men (Ansley et al., 1982). We discounted years of life lost from death at a rate of three percent to take into account that society has a preference for consumption now rather than later (World Bank, 1993b). The higher the discount rate, the more years of life in the present are valued relative to those in the future. 8  Figure 1. Rapid method to calculate mortality data for Guinea DATA SOURCES METHOD, BY STEPS Global Burden of Step 1: Abstract the age-, sex-specific population values and age-, sex-, cause- Disease estimates > specific numbers of deaths for sub-Saharan Africa. These data are presented in seven age categories; 0 to 4, 5 to 14, 15 to 29, 30 to 44, 45 to 59, 60 to 69 and 70 or more. v Step 2: In place of zero (published) values, assume the number of deaths due to most diseases to be 500 for each age and sex-category in the entire sub-Saharan population. V Step 3: Adjust proportionally the number of age and sex-specific causes of death such that their sum matches the total number of deaths in sub-Saharan Africa. e Step 4: As described in the text, collapse the data into twenty-five disease categories, based upon the Intemational Classification of Diseases system. v Step 5: Calculate mortality rates for each age and sex-stratum. v Step 6: For each stratum, calculate the ratios of the mortality rates among older age groups to the corresponding mortality rate among 0 to 4 year-olds. For "maternal causes" calculate the ratios of mortality rates among older age groups to the mortality rate among 5-14 year-olds. e Guinean studies of Step 7: Adjust the mortality rates for the group aged 0 to 4 years to reflect data childhood mortality > available from Guinea, using local studies with data on deaths in early childhood, and data on HIV studies of HIV prevalence and injuries. infection and injuries e Guinean data, derived Step 8: Multiply the sex-specific mortality rates generated in Step 7 for each disease from censuses, for > by the corresponding population of 0 to 4 year-olds. Sum the resulting values to yield population and the total predicted number of deaths among 0 to 4 year-olds. Adjust proportionally mortality the sex-specific mortality rates such that the predicted number of deaths matches the actual number of deaths among 0 to 4 year-olds. V Step 9: Calculate mortality rates for the older age categories by multiplying the sex- specific mortality rates for each disease for 0 to 4 year-olds by the ratios calculated in Step 6. e Guinean studies of Step 10: Divide the total number of maternal deaths in Guinea into the 5 age maternal mortality > categories 5 to 14, 15 to 29, 30 to 44, 45 to 59, and 60 to 69 years of age such that the ratios of maternal mortality rates among older groups to the rate among 5 to 14 year- olds is the same as the ratios calculated in Step 6. V Guinean data, derived Step 11: Multiply the age and sex-specific disease mortality rates by the populations from censuses, for > of the appropriate age-and sex-specific groups in Guinea. Sum the resulting values population and to yield the total predicted number of deaths for each age category. Adjust mortality proportionally the sex and age-specific disease mortality rates (except maternal mortality rates) such that the predicted number of deaths for each age group matches the actual number of deaths. 9  B) Estimates of burden of disability Unlike for deaths, there was no feasible method to estimate years of disability by age and sex group. Thus, we used a simplified methodology adjusting the Global Burden of Disease Project estimates of years lived with a disability in sub-Sahara Africa among age groups' 0-4, 5-14, 15-44, 45-59 and 60+ for each sex to the relative population size for Guinea. As with mortality estimates, we combined certain categories of diseases. These estimates are discounted at three percent per year and have been age-weighted with a maximum social age preference of twenty-four years (Murray, 1994). In contrast, the estimates for mortality are not discounted and are not age- weighted; the estimates for years of life lost are discounted but not age-weighted. Thus the three measures are not directly comparable, but as reported by Murray et al. (1994a), these different weighting schemes do not greatly alter the relations among the major causes of death -- communicable, maternal, and perinatal disease, injuries, and non-communicable diseases. RESULTS FOR BURDEN OF DISEASE Among a Guinean population estimated at 6.09 million, 124,078 people died in 1992 or 20.4 deaths per thousand population. As table 2 shows, the mortality rates among females and males were very similar--20.2 deaths and 20.5 deaths per thousand female and male population, respectively. A child born in Guinea faces a nearly one in four chance of dying before age five and has a life expectancy at birth of only forty-four years. A child reaching age five has about a one in fourteen chance of death before age fifteen. A child at age fifteen has a twenty-four percent chance of dying before age forty-five and adults who reach age forty-five have about a twenty-three percent chance of dying before age sixty. The table also reveals that mortality rates are higher for males than for females at younger ages but lower at older ages. Background annex 1, tables 1 to 4 provide detailed data for the results of the burden of disease analysis. Causes of death, Overall, communicable, maternal, and perinatal diseases caused 86,400 deaths (seventy percent), injuries caused 9,000 deaths (seven percent) and non-communicable diseases caused 28,700 deaths (twenty-three percent). The proportions in the first category are similar for females and males. Deaths from injuries are more common among males, and deaths from non-comrnmunicable diseases are more common among females. As table 3 shows, the top seven causes of death are the same for both sexes, ranging down from respiratory infections, malaria, diarrhea, childhood infections, cardiovascular diseases, tuberculosis, and perinatal causes. Of those diseases shared by males and females, the gap between the percentages for the two sexes is widest --being more common in women -- for cardiovascular diseases, and -- being more common in men -- for unintentional injuries. Results for Age Groups. Figure 2 illustrates the relative importance of the major categories of cause of death in Guinea by age group. Table 4 lists, in decreasing order, the top ten causes of death by age group in Guinea. The mortality rate among children aged zero to four is 54.1 deaths per thousand population. Among this age group, ninety-one percent of deaths are due to communicable, maternal, and perinatal diseases, led by diarrhea, respiratory infections, malaria, 10  Table 2. Distribution of population and number of deaths in Guinea, by sex and age, 1992 Sex and age Percent of total Number of Deaths per Probability of group population deaths thousand dying in this population age group Females 0-4 9.7 29,624 50.4 23.7 5-14 13.9 7,103 8.4 7.6 15-44 20.8 11,716 9.3 24.4 45-59 4.1 4,788 18.9 22.8 60+ 2.3 9,328 66.7 100.0 Total 50.8 62,559 20.2 ... Males 0-4 9.5 33,639 58.0 23.0 5-14 13.7 6,885 8.3 6.7 15-44 20.3 9,689 7.8 24.8 45-59 3.8 4,147 18.1 25.9 60+ 1.9 7,159 60.3 100.0 Total 49.2 61,519 20.5 ... Total males and females 100.0 124,078 20.4 ... Table 3. Distribution of deaths by cause in Guinea, by sex 1992 Botb sexes Females Males Ranked cause Percentage Ranked cause Percentage Ranked cause Percentage of death of death of death Respiratory infections 13.3 Respiratory infections 13.4 Respiratory infections 13.2 Malaria 12.3 Cardiovascular 12.2 Malaria 12.6 Diarrhea diseases 11.8 Malaria 12.1 Diarrhea diseases 12.1 Childhood infections 10.5 Diarrhea diseases 11.6 Childhood infections 10.9 Cardiovascular 10.2 Childhood infections 10.2 Cardiovascular 8.2 Tuberculosis 7.1 Tuberculosis 6.9 Perinatal causes 7.6 Perinatal causes 6.3 Perinatal causes 5.2 Tuberculosis 7.3 Unintentional injuries 4.4 Maternal causes 4.6 Unintentional injuries 6.2 Malignant neoplasms 3.5 Malignant neoplasms 3.7 Intentional injuries 3.7 Intentional injuries 2.9 Nutritional/endocrine 2.7 Malignant neoplasms 3.4 Nutritional/endocrine 2.4 Unintentional injuries 2.6 Nutritional/endocrine 2.1 Maternal causes 2.3 Syphilis 2.2 Digestive 2.0 Syphilis 2.1 Intentional injuries 2.0 Syphilis 2.0 Digestive 2.0 Digestive 1.9 Tropical diseases 1.5 Tropical diseases 1.6 HIV 1.8 Congenital 1.4 HIV 1.5 Tropical diseases 1.6 HIV 1.3 Note: total deaths 124,078 62,559 61,519 11  childhood infections, and perinatal diseases. Among non-communicable diseases, congenital diseases are the largest causes of death. The mortality rate among children aged five to fourteen is much lower, 8.3 deaths per thousand population. Among this age group, communicable, maternal, and perinatal diseases continue to predominate, constituting seventy-three percent of deaths; these are led by malaria, childhood infections, diarrhea, respiratory infections, and tuberculosis. Unintentional injuries constitute nine percent of deaths in this age group. Neuro-psychiatric disease is the leading non- communicable cause of death. The mortality rate during young adulthood and early middle age (ages' fifteen to forty-four) is 8.6 deaths per thousand population. Three in five deaths in this group are caused by communicable, matemal, and perinatal diseases, led by tuberculosis and maternal causes (one in four of all deaths among women in this age group). Intentional and unintentional injuries together account for more than twenty-two percent of deaths. Non-communicable diseases are not yet prominent. The mortality rate among people aged forty-five to fifty-nine years of age is 18.5 deaths per thousand population. The leading causes of death in this age group are non-communicable diseases (sixty-four percent), led by cardiovascular diseases and cancer. However, even in this age group, one in five deaths are due to tuberculosis. Finally, as expected, people over sixty years have the highest mortality rate of 63.7 deaths per thousand population; three in four succumb to non-communicable diseases, mainly cardiovascular disease and malignant neoplasms. Even in this older age group, respiratory infections and tuberculosis cause substantial numbers of deaths. YearL of life lost Table 5 presents years of life lost discounted at a rate of three percent. These show a pattern similar to that for deaths, with communicable, maternal, and perinatal diseases accounting for more than three-quarters of years lost. Non-communicable diseases account for sixteen percent, and injuries cause seven percent. Diseases of childhood obviously are responsible for the most lost years: diarrhea, malaria, respiratory infections, injuries, childhood cluster, and tuberculosis (see table 6). Simple estimates of years lived with a disability. Table 7 provides estimates for years lived with a disability, discounted at three percent and with a maximum time preference of twenty-four years. This analysis shows that the group of communicable, maternal, and perinatal diseases account for about forty-three percent of these years lived with a disability. Non-communicable diseases account for a similar percentage. Injuries cause the most years lived with a disability, followed by neuro- psychiatric illness. Approximately thirty-five percent of all years lived with a disability begin at ages' fifteen to forty-four and another thirty-five percent in children under age five. Years lived with a disability from ages' five to fourteen contribute sixteen percent to the total. There are important sex differences: sexually transmitted diseases account for nearly six times more such years in females 12  Figure 2. Distribution of deaths, by major cause and age in Guinea, 1992 100% -1 90% 6%1 80% 70% 2 L 4;~~~~~~~~~~~~~~~~4 60% e~~~~~~~~~~~~g Gru\yas 0 o 4 \o1 St 44 o5 0 50%\ 40%\ \ 30%~ 9 20%~~~~~~~~~~~~~~~~2 20%~~~~~~~~~~~~~~0 10% 21% 0% OA4 (63,264 deaths) 5-14 (13.988 deaths) 15-44(21.405 deaths) 45-59 (8,935 deaths) 60+ (16,486 deaths) Age Group (years) *g Communicable, Maternal & Perinatal a Injuries [jNoncommunicable Table 4. Top ten causes of death in Guinea, by age, 1992 (ranked in order and percentage except as noted) 0 to 4 5 to 14 15 to 44 45 to 59 60+ Diarrhea diseases 20.3 Malaria 19.0 Tuberculosis 19.4 Cardiovascular 29.4 Cardiovascular 50.0 Respiratory 19.3 Childhood 14.8 Matemal causes 12.8 Tuberculosis 19.8 Malignant 12.6 infections infections neoplasms Malaria 17.6 Diarrhea diseases 10.5 Intentional injuries 11.4 Malignant 15.9 Respiratory 12.1 neoplasms infections Childhood infections 17.3 Respiratory 10.5 Unintentional 11.0 Digestive 6.5 Tuberculosis 7.4 infections injuries Perinatal causes 12.4 Tuberculosis 8.9 Syphilis 6.5 Unintentional 4.2 Respiratory 3.2 injuries Congenital 2.2 Unintentional 8.8 Malaria 6.1 Nutritional/endoc 3.4 Digestive 3.1 injuries Nutritional/endocrine 2.1 Tropical diseases 4.8 HIV 5.9 Tropical diseases 3.2 Genito-urinary 2.3 Unintentional injuries 2.0 Neuro-psychiatric 4.2 Cardiovascular 5.7 Respiratory 2.9 Nutritional/ 2.2 endocrine Syphilis 1.7 Meningitis 2.7 Tropical diseases 3.4 Intentional 2.6 Unintentional 1.5 injuries injuries Digestive 0.8 Nutritional/ 2.4 Nutritional/ 3.3 Genito-urinary 2.6 Diabetes mellitus endocrine endocrine Total Deaths 63,264 13,988 21,405 8,935 16,486 Probability of dying in this age group 23.4 7.1 24.6 24.3 100.0 13  Table 5. Distribution of years of life lost in Guinea, by sex and cause, 1992 Both sexes Females Males Ranked cause Percentage Ranked cause Percentage Ranked cause Percentage of years of life lost of years of life lost of years of life lost Malaria 14.2 Respiratory infections 14.2 Malaria 14.4 Respiratory infections 14.2 Malaria 14.1 Respiratory infections 14.1 Diarrhea diseases 13.9 Diarrhea diseases 13.7 Diarrhea diseases 14.0 Childhood Infections 12.3 Childhood Infections 12.1 Childhood Infections 12.6 Perinatal causes 7.5 Tuberculosis 6.6 Perinatal causes 8.8 Tuberculosis 6.3 Cardiovascular 6.3 Unintentional injuries 6.2 Cardiovascular 5.3 Perinatal causes 6.2 Tuberculosis 6.0 Unintentional injuries 4.5 Maternal causes 4.7 Cardiovascular 4.2 Intentional injuries 2.9 Unintentional injuries 2.7 Intentional injuries 3.6 Nutritional/endocrine 2.4 Nutritional/endocrine 2.6 Nutritional/endocrine 2.2 Maternal causes 2.4 Malignant neoplasms 2.4 Syphilis 2.1 Syphilis 2.2 Syphilis 2.3 Malignant neoplasms 1.9 Malignant neoplasms 2.2 Intentional injuries 2.1 Digestive 1.6 HIV 1.7 HIV 2.0 Congenital 1.6 Digestive 1.7 Digestive 1.7 Tropical diseases 1.5 Tropical diseases 1.5 Tropical diseases 1.6 HIV 1.4 Total years of life lost 3,157,636 1,579,520 1,578,117 Table 6. Top ten causes of years of life lost in Guinea, by age, 1992 (ranked in order and percentage except as noted) O to 4 5 to 14 15 to 44 45 to 59 60+ Diarrhea diseases 20.3 Malaria 19.2 Tuberculosis 19.8 Cardiovascular 29.5 Cardiovascular 47.9 Respiratory 19.3 Childhood Infections 14.9 Maternal causes 13.2 Tuberculosis 19.6 Malignant neoplasms 13.6 infections Malaria 17.6 Diarrhea diseases 10.6 Intentional injuries 11.5 Malignant neoplasms 15.9 Respiratory 12.3 infections Childhood Infections 17.3 Respiratory infections 10.6 Unintentional injuries 11.1 Digestive 6.5 Tuberculosis 8.6 Perinatal causes 12.4 Tuberculosis 9.0 HIV 6.7 Unintentional injuries 4.1 Digestive 3.3 Congenital 2.2 Unintentional injuries 8.8 Syphilis 6.6 Nutritional/endocrine 3.5 Respiratory 3.1 Nutritional/endocrine 2.1 Tropical diseases 4.8 Malaria 6.2 Tropical diseases 3.4 Genito-urinary 2.4 Unintentional 2.0 Neuro-psychiatric 4.2 Cardiovascular 5.4 Respiratory 2.9 Nutritional/endocrine 2.3 injuries Syphilis 1.7 Meningitis 2.7 Tropical diseases 3.6 Genito-urinary 2.6 Diabetes mellitus 1.7 Digestive 0.8 Nutritional/endocrine 2.4 Nutritional/endocrine 3.2 Intentional injuries 2.6 Tropical diseases 1.4 Note: total years of life lost, in thousands 1,902 406 539 161 148 14  Table 7. Distribution of years of life lived with a disability in Guinea, 1992, by cause and sex Both sexes Females Males Ranked cause Percentage Ranked Cause Percentage Ranked Cause Percentage Injuries 14.3 Maternal 11.6 Injuries 19.7 Neuro-psychiatric 11.4 Neuro-Psychiatric 9.8 Neuro-Psychiatric 13.1 Nutritional/endocrine 8.9 Injuries 9.0 Nutritional/endocrine 9.1 Malaria 7.3 Nutritional/endocrine 8.6 Malaria 7.4 Perinatal 7.1 Malaria 7.2 Perinatal 7.3 Maternal 5.9 STD's except HIV 7.0 Tropical cluster 7.2 Tropical cluster 5.5 Perinatal 7.0 Congenital 4.8 Congenital 4.8 Cardiovascular disease 4.7 Cardiovascular disease 4.3 Cardiovascular disease 4.5 Congenital 4.7 Respiratory-chronic 3.8 STD's except HIV 4.2 Respiratory-chronic 3.9 Digestive 3.6 Respiratory-chronic 3.8 Tropical cluster 3.8 Childhood cluster 2.6 Digestive 3.5 Digestive 3.4 Respiratory-acute 2.6 Respiratory-acute 2.6 Respiratory-acute 2.6 Tuberculosis 2.2 Childhood cluster 2.3 Sense organs 2.2 Genito-urinary 1.8 Tuberculosis 2.0 Trachoma 2.0 Sense organ 1.7 Sense organ 1.9 Childhood cluster 2.0 HIV 1.6 HIV 1.6 Tuberculosis 1.7 STD's except HIV 1.3 Genito-urinary 1.6 HIV 1.6 Intestinal worms 1.2 Note: total years lived with a disability 789,370 401,802 387,569 than in males, and men have more years than women from the tropical cluster of disease and from neuro-psychiatric illness. Comparison with other regions, The distribution of causes of death in Guinea is similar to that in sub-Saharan Africa, which is not surprising given the methodology (figure 3). In comparison with developing and developed countries, the overall burden of mortality in Guinea is much higher. The explanation exists partly in Guinea's younger age structure, and thus a higher probability of deaths from diseases associated with childhood and childbearing. However, even among children under age five, those in Guinea have a more than two-fold higher probability of death than do children in other developing countries. Among the middle aged (fifteen to fifty-nine), Guineans have a higher probability of death than people in other developing countries (forty percent versus twelve percent, respectively). These higher risks are largely due to a higher burden of communicable, maternal, and nutritional disease, that carry a high chance of death in the absence of available medical care. Thus, these higher risks also represent the relatively low access to medical care in Guinea. 15  Figure 3. Relative importance of causes of death in Guinea, sub-Saharan Africa, developing and developed countries 1000/; - 900/0 23 [13 O/o 26% 800/o 7% ~~~~~~~~~~50%/ 70D/o 8/- 600/o 88- a~500/o-- 400/o - 300% I100/0 7% 5% 0% Guinea SSA Developing Developed Countries Countries | Communicable, Maternal & Perinatal * Injuries j Non-communicable Item Guinea Sub-Saharan Developing Developed Africa countries countries Probability of dying before age 5, in percent 23.5 15.8 9.7 1.7 Probability of dying between ages 15 and 60, in percent 39.9 35.1 21.8 11.7 16  Impact of population growth on burden of disease. World Bank estimates suggest that population growth in Guinea was 2.8 percent per annum in 1992 and it is projected to increase to 2.9 percent by 2000. The growth rate in Conakry is about five percent per annum. The population of Guinea is expected to reach over 7.6 million by 2000 and 11.6 million by 2015. No major declines in the fertility rate are expected before 2010, and therefore the number of births is expected to increase annually by 2.5 percent (from 298,000 in 1992 to 446,000 in 2012). Figure 4 depicts future numbers of deaths based upon population growth and changes in death rates. Detailed estimates are in Background annex 1, table 4. These estimates assume that HIV-related deaths will increase at a net rate of one percent per year, that current levels of health service provision will be maintained, and that no major epidemics will occur. They suggest that the total number of deaths will increase by about 1.5 percent a year, despite a falling death rate. Given shifts in the age of the population (Figure 5), more deaths are likely to occur from tuberculosis and injuries, diseases that have a higher death rate in adolescents and young adults. These simple linear projections are not reliable for each specific disease, but they do suggest that the overall pattern of high mortality from communicable, maternal, perinatal, and nutritional diseases will continue among an ever-increasing absolute number of children born over the next decade. Figure 4. Projections of number of deaths in Guinea, by cause 180 -- 160 140 43 _________ ; 140 ,- 35 CNonconmnunicable 120 .0 r- 100 ~~~~~~~~~~~~~~~~~*Injuries 80- 0 _ * ] Comrnunicable, c) 60 106 Matemal & Perinatal z 40 86 20 0 1992 2000 2010 Year 17  Figure 5. Distribution of deaths by age group in Guinea, 1992, 2000, and 2010 90% 80% 70% 0o6+ < 60% -J45-59