HCH 201: MEDICAL DEMOGRAPHY

Lecturer: Dr Gaudencia Okumbe

COURSE OBJECTIVE
Demographic events have significance in health. The course is therefore designed to introduce students
of Medicine to Medical Demography. This will enhance student’s knowledge on the basic concepts in
demography, demographic processes and their consequences on health.

COURSE OUTLINE
1. Concepts of Population
- Definition of Population
- Definition of Demography
- Sources of population data

2. Rates, ratios and proportions

- Rates
- Census growth rates
- Factors for growth rates.
- Effects/ implications of growth
- Ratios
- Dependency ratios
- Proportions
3. Population composition
- Age
- Measurement of age
- Age structure
- Population pyramids
4. Fertility
- Meaning
- Measurement
- Analysis
5. Mortality
- Meaning
- Measurement
- Analysis
6. Migration
- Meaning
- Analysis
- Migration and Health
7. Population change
- Implications on health at the community level
9. Demographic transition theory
- Application to health
8. Population policies and implementation

COURSE DURATION: 35 HOURS

 Mode of assessment: Continuous assessment tests and end of semester examinations.

REFERENCES
1. Coward, D. J 1969: Civil Registration in Kenya.

2. Kpedekpo, G.M.K (- ) Essentials of Demographic analysis for Africa

HEINEMANN,
3. Kenya National Bureau of Statistics, Ministry of Planning, Kenya; 2009 Population Census Analytical
Reports

4. United Nations (1973). “The Determinants and Consequences of Population Trends “

New Summary of findings on Interaction of Demographic, Economic and Social Factors. Vol 1

5. United Nations: I984 Data Bases for Mortality Measurement, New York

6. William Brass et al (Eds) 1968: The Demography of Tropical Africa: Princeton University press, Princeton ,
New Jersey, 1968.
Definition of Terms

Population
Population is the total number of people in a designated area or territory.

Demography
Demography, as understood today, is the scientific study of human population and its dynamics. It is derived
from two Greek Words:
• Demos means population
• Graphics means to draw
Demography can be defined as the study of human populations including their composition, distributions,
densities, growth and other characteristics as well as the causes and consequences of changes in these
factors.
Demography focuses its attention on three readily available human phenomena:
• Changes in population size (growth or decline)
• The composition of the population and
• The distribution of population in space.

Demography also deals with analysis of three major “demographic processes” namely fertility, mortality and
migration. These processes are continually at work within a population determining its size, composition
and distribution.
Sources of Demographic Data
The sources of statistics on population include published reports, unpublished worksheets, tally tapes,
statistics produced by central statistics office, Censuses, Surveys, Registration data, Population registers.
These fall into two categories;
i) Primary Sources
ii) Secondary Sources
Primary Sources
These are the responsibility of the analyst. They are generated for a specific purpose, this is expensive
and time consuming. The advantage they have is that they are timely and meet specific data needs.
 Secondary Sources
These result from further analysis of statistics that have been already generated. They are regarded as
data disseminated via published reports, the internet, worksheets, and professional papers. The data
saves time and costs. The disadvantage is that the data is collected for a specific purpose in mind
sometimes creating a bias. Secondary data are also old data .Secondary sources can be official or
unofficial. They include text books, demographic year book, periodical journals, research reports,
gazettes and atlases. The United Nations is the chief producer of Secondary demographic statistics for
the world countries. Its publications include the demographic year book since 1948, monthly bulletin of
statistics since 1947, statistical papers, Epidemiological and vital statistics report. International
population statistics reports and Population Index.
International Data
There are many data sources at International level.
The Index to International Statistics published by the US, Congressional Information service since 1983.
Have publications on economics, industry, demography and social statistics by intergovernmental
organizations such as UN, Organization for Economic Cooperation and Development, the European Union,
the Organization of American States, commodity organizations, development banks and other organization
The Directory of International Statistics (DIS)
Published by the UN and provides statistics by subject matter and an inventory of readable data bases of
economic and social statistics by subject and by organization.
Demographic Year Book
This has been published since 1948
This provides data on world economy, , its structure, major trends, current performance and information on
issues such as world population, employment, inflation, production of energy and environmental pollution
and management among others.
World Population Prospects
The World Population prospects provides population estimates and projections. This has been published
since 1951.
The US Census Bureau conducts demographic and socio-economic studies and provides technical
assistance to countries through training, and production of soft ware products.

The major sources of demographic data include:

Census
Registration of vital events (Records)
Sample surveys
Population registers
Ad-hoc Demographic studies

Census
Census is defined as the total process of collecting, compiling, evaluating, analysing and publishing /
disseminating demographic, economic and social data pertaining, at a specific time or times, to all persons
in a country or delimited territory (UN Definition). Or others define it as an enumeration or complete
population count at a point in time within a specified geographical area. A census provides more reliable and
accurate data if properly enumerated. Modern censuses are associated with housing census as well. This is
defined as the total process of collecting, compiling, evaluating, analysing and publishing / disseminating
demographic, economic and social data pertaining, at a specific time or times, to all living quarters and
occupants there of persons in a country or delimited territory (UN Definition)

The scope of a census is the size, distribution and characteristics of the population. A census may also
include questions about births or deaths of household members in the period. It may also include questions
on fertility, e.g. children ever born; children still living, date of birth of every child.

History of Census taking.

The conducting of censuses has a long history. Egypt had a census in 2500 BC. The first record of census
taking is mentioned in the Bible in the book of Exodus. This was about 1491 BC. King David gave an order
for a census in 1017 BC. The Romans took a census quinquennially where citizens and their property were
inventoried for fiscal and military purposes. By 5 BC, The enumeration was extended to the entire Roman
Empire. It is mentioned in Luke’s gospel.
The doomsday inquest ordered by William of England in 1086 A.D covered land owners and their holdings.
Modern censuses were first held in the 17th century. By the end of
eighteenth and beginning of the nineteenth century many countries had held their first censuses. In Europe,
Sweden had a census 1749, The United States in 1790, While England and France had census in 1801.
Kenya had its first census in 1948.Some countries including Ethiopia and Zaire held their first censuses in
1984.

Uses of Census
A census is useful for:
• Planning
• Calculating health indicators and vital indices.
• Is the main source of demographic statistics.
•It provides information on size, distribution, and other characteristics of the population at fixed intervals
•Used in distribution of proceeds of economic growth/resources
•The data obtained in a census helps the government facilitate the development potential of its people
•Development plans are drawn using data from census
Steps in Conducting Census
The major steps to be followed in a census include.

1. Planning and preparation

Census requires advance planning, effective supervision, adequate resources and training of enumerators. A
census is a government responsibility and therefore the government decides on the department to handle the
process, the questions to be asked, and the interval for census taking.
The basic unit of a census is the individual and the individual household.
For ease of collection and enumeration, it is usual to combine a specified number of individuals into groups
to form enumeration areas or enumeration districts. House hold listing is essential in planning. The size of
the enumeration areas depends on the method used, the geographic nature of the area and the literacy of the
people.
In formation to be collected is determined by the needs of the government or country and needs for
International comparisons. Confidentiality ought to be exercised. Questions asked should be clear and easy
to answer. These questions should be pre tested and people must understand them. The format of the
questionnaire must be easy to fill and also easy to process.
Paid enumerators are selected and trained and each is assigned a given collection area.
Heads of households are usually the respondents to the questionnaire. In some rural areas, it is difficult to
find persons to use as enumerators.
a) The instruments
The census questionnaire has three sets
a) The individual questionnaire which contains information for only one person
b) The household questionnaire, which contains questions for all the members of the household
c) The multi household questionnaire which contains information for as many persons as can be
entered on the form, including members of other households
b) Census content
The subject to be included in a census is determined by the national and local needs as well as availability of
resources. Some consideration for achieving international comparison is also considered. Programmatic
subjects are used for planning, implementation, and evaluation and also provide legal evidence• Collecting
information
2. Recruitment and training of staff
It is important to plan and train competent staff to map out, enumerate, coding, data entry, analysis,
publication, supervision.
3. Pretesting
Pretesting of census content and methods has been found to be very useful in providing a basis for decisions
that must be made during the advance planning of the census. This is useful in revision of wording, revision
of questionnaire, enumeration procedures, suitability of topics. Some countries use a sample survey to
pretest census questions and procedure.
4. Enumeration
Types of Census
There are two techniques of conducting census, dejure and defacto.
a. Dejure
This technique is the counting of people according to the permanent place of location or residence. These
are people who usually reside in a given place. This is more suitable for administration and planning for
taxation, education, housing, military recruitment.
Advantages
• It gives permanent picture of a community.
• It provides more realistic and useful statistics.
• The procedure is easy to administer
Disadvantages
• Some persons may be omitted from the count. A household member who is temporarily away from home
may be missed from being counted unless the enumerator makes sure that nobody is missing.
• Some may be counted twice.
• Information collected regarding persons away from home is often incomplete or incorrect.
• It is difficult to enumerate the floating population.
B. Defacto
This technique of conducting census refers to counting persons where they are present at the time of the
census period.
Advantages
• There is less chance for the omission of persons from the count.
• It is simple and unambiguous. The enumerator only records only persons who spend the night at a given
place.
• It gives a complete coverage, reduces error of duplication or omission of entries.
Disadvantages
• Difficult to obtain information regarding persons in transit. These are persons who are, for example
traveling and have left their area of permanent residence but haven’t reached the area of destination during
the census day. These people are referred to as the floating population. Some may be in lodgings, or
displaced persons.
• It provides incorrect picture of the population in a community.
• Another difficult is application of retrospective questioning in reference to the census date. Some people
forget who spend the night in their home or lodgings.
A number of countries including Kenya apply both defector and dejure enumeration approaches. The needs
of a country dictate which scheme to use.

Errors in Census
There are two types of errors
i) Coverage errors
ii) Classification errors
Coverage errors result from failure to count all people or counting some people twice. The failure to
enumerate, results from difficulties in making contact with every household in the census area. This may
result from poor motivation of enumerators or the household being elusive. It can also result from failure to
enumerate household correctly, women and babies may be forgotten or omitted due tiredness of both
informant and enumerator.
5. Processing Data
Processing data is very important for data quality and its usefulness. Computer programmes have made
processing faster and easier than it was some years back.
6. Editing
Content and coverage errors are carefully checked during editing. Field officers do some editing in the field
to check for errors. The editorial staff are given guidelines on editing.
7. Coding
Coding is done and data processed by computers, where calculations, tables and results are printed out. Then
these are checked and edited for publications. Pre coding is common practice in modern census. This makes
analysis faster
8. Data Review
Several steps are taken to ensure accuracy and validity of results. The supervisors review samples of each
enumerator and also accompany enumerators to some house holds. Then there is progress reporting, hand
tallies of enumerated areas are compared with projections, re interviewing is common technique for quality
control, verification is done to test systematic errors, detect unsatisfactory performance of a work and to
determine whether the general rate of error is within tolerance.
The statistical tables produced by the tabulation equipment are are usually subjected to editorial and
statistical review before publication.
9. Evaluation
Evaluation of a census is important in production of good results. Evaluation is done for various reasons;
 To identify errors and the sources of error. This is done through re enumeration of a sample, comparison
of census results with aggregate data from independent sources such as administrative sources, matching
census documents with other documents for the same person, undertaking a demographic analysis by
comparing with earlier census data, analysis of census accuracy in comparison with estimates of births,
deaths and migrations and analysis of census data for internal consistency.
 Uses of census data which includes improvement in future census, assisting census users in interpreting
results. Evaluation can identify problems in enumeration. Can demonstrate the usefulness and
limitations of census data. It can also alert the users to errors in the data and the magnitude of the errors.
Evaluation may be used to adjust census results

Techniques for evaluation

1) Post enumeration surveys: These may be conducted to test census coverage and content errors
2) Demographic analysis: These are used to evaluate the quality of the results and to provide measures
of error, and the results used to estimate the coverage or under coverage and the basis of adjustment
to the official census population statistics.
10. Publication of Results
Tables or written reports are produced from the analysis.
11. Dissemination
Electronic dissemination is currently the trend. The internet has many methods for dissemination.

Problems of census as source of demographic data

•Only limited number of questions are asked

•Census conducted after long periods 5-10 years. This is too long to satisfy data requirements
•Time taken to process results is too long to assess current events and for urgent planning.
•Subjects become more complex with each census.
•It is too expensive, some countries cannot afford it
• It requires stable and peaceful countries to administer a census

Qualities of a Census
A census must have the following qualities
• It should include every individual in the area (no omission or duplication).
• Information should relate to a well – defined point in time.
• It should be taken at regular intervals (preferably every 10 years).
• It should refer to people inhabiting a well defined territory.
• Information be obtained from personal contact.

Vital Registration
According to the hand book of Vital Statistics Methods ( united Nations), Vital statistics system can be
defined as including the legal registration , statistical recording and reporting of the occurrence of , and the
collection , the compilation, analysis , presentation , and distribution of statistics pertaining to ‘vital events’,
which include live births, deaths, foetal deaths, marriages, divorces, adoptions, legitimations, recognitions,
annulments, and legal separations( United Nations , 1985). Demographers use the vital events and not legal
issues in the document. This can also de defined as a regular and continuous registration of vital events as
they occur. Most governments have this as a civil registration system, which records births, deaths,
marriages, etc. (vital statistics), enables rates of population growth to be calculated; but are much less
adequate than national censuses.
Vital registration systems are non existent in a number of developing countries. In countries where they
exist, not all vital events are recorded. Some events such as migration and naturalization are not considered
as vital statistics by demographers since they are not usually recorded by civil registration and these events
are not considered vital events. In some other countries with vital registration systems, the data are defective
and hardly meet the data requirements for planning purposes. The data obtained can hardly measure
mortality and fertility rates. Some vital events such as, marriage and divorce are not registered. In some
countries, registration documents are not forwarded to the central office for processing. Most data is not
analysed because of lack of manpower. In developing countries where illiteracy rates are high and
communications are poor, the problems of recording births and deaths are immense not only in rural
populations but also in urban areas.

Vital registration is fairly sophisticated and requires a well trained, well motivated staff and reliable if
completeness, accuracy and reliability are to be obtained.
Items on Vital registration certificate vary and some may be of demographic value, others of legal value
while others may be of legal value. Demographers value date of occurrence, age, sex, marital status,
occupation, order of birth or marriage, date of marriage or divorce etc. Medical and legal fraternity value the
hour of birth, name of physician in attendance, name of person certifying the report, and date of registration.
Some items such as birth weight, period of gestation, and place of occurrence (instead of usual place of
residence) may be of interest to demographers in specialized studies.
It is recommended that vital statistics be published annually (UN, 1985).

A lot of resources both human and monetary are required to have a reliable vital registration system. This
also requires an educated population or an education of the population on the need to report these events as
they occur. If this is not done, under coverage and miss allocation of the events may occur. Infant deaths
may not be recorded, births may be left out, migration both in and out may not be recorded and divorce and
marriages ignored. However, efforts are being made to improve the collection of these data in many
countries.
The purpose and importance of vital registration
•Vital registration measure change in the population in the period between the censuses.
•It enables trends in population dynamics to be computed
•Where well developed, it provides information on size of population
The World Health Report annually presents detailed country- specific statistical data on mortality rates,
causes of death, and other indicators of health trends at national and global levels.
World Health Statistics is a quarterly by WHO presenting inter-country comparisons together with
information based on the assessment of the trends over time. Changes in morbidity and mortality, resource
utilization, and the effectiveness of specific programmes or interventions are also reported.

Sample Surveys
A sample survey is another source of demographic data carried out in a scientifically selected area which
covers only a section or portion (sample) of the population under
consideration. A survey may be defined as collection of standardized information from a specific population
or from a sample usually but not necessarily by means of a questionnaire. The purpose of a survey is to
collect statistics about some aspects or characteristics of a study population.
Surveys generally may be for academic research, government official statistics, and commercial /advertising
research. This brings a unique perspective on approach, methods, errors, analysis and conclusions.The data
requirements for International comparisons resulted in World fertility surveys which became precursors of
Demographic surveys that have become important in obtaining information on demographic events. It was
recognized that the quality of demographic data available for the developing world was poor and the need
for better data both for scientific study and for policy application was needed.
Information obtained in sample surveys include demographic characteristics such as size, distribution,
mortality, fertility and migration.

Types of surveys
i) Single round surveys
ii) Multi round surveys

Single round surveys

This seeks to collect information from a fraction of the population usually 10%. The population is
enumerated once. It is simple, flexible and easy to administer.

Disadvantages
•High rates of error particularly non sampling errors
•Has serious under reporting of births and deaths

Multi- round surveys

This entails repeated visits to households in selected sample areas to ascertain what events have occurred
during the intervals between the visits . This have come into prominence partly in response to the
limitations of single round surveys and partly for their self checking nature.
These surveys provide information for checking and correcting data collected during earlier surveys.

Disadvantages
•They are expensive to administer
•Sampling and administrative problems are encountered
•Information obtained is difficult to process
•Data fro this source cannot meet heavy demands for various population statistics
•It is boring and leads to fatigue for enumerators and respondents
•Households withhold information due to fatigue
•Needs proper explanation to households
Demographic and Health Surveys: These are nationally representative household surveys carried out in
about fifty developing nations by Macro International Inc. The objective of the surveys is to provide data
concerning fertility, family planning and maternal and child health that can be used by program managers,
policymakers and researchers. In the household questionnaire there are questions on household composition,
education and occupation of the wife and husband, household facilities, and household possessions, etc.
Women of reproductive age in the households are identified and interviewed. The woman’s questionnaire
includes sections on background characteristics, a birth history, knowledge and use of family planning,
breastfeeding, immunization and health of children under age five, marriage, and fertility preferences, etc.
Advantages and uses of sample surveys
 Surveys not so large
 Not so expensive.
 They do not need the legal mandate
 Useful in studying relationships between variables(investigational)
 Surveys are also useful in assessment of characteristics of the population.
 The survey questions are flexible, one can experiment with new questions
 New features can be introduced in a continuing survey in questions or instructions, the coding, the
editing and the tabulations
 Surveys allow a particular topic of interest to be investigated in depth with related questions at a
relatively additional cost.
 Data from some surveys may be superior in some respects to those from census.
 Staff used is small and select and is used from year to year where possible hence easy to monitor and
control procedures.
 The shorter time for surveys make them ideal for studies of household formation, fertility,
employment status.
Population registers

Population registers entail maintenance of a regularly updated list of persons resident in a country with
details of their demographic and socio-economic characteristics. Population registers are built from a base
inventory of the population and its characteristics in an area, continuously updated by data on births, deaths,
adoptions, legitimations, marriages, divorces and changes of occupation, name or address. Population
registers are mostly found in developed countries.
Maintenance of population registers requires that the population have an accurate address system or e mail,
and the population also must be literate. A lot of resources are required to maintain them. When compared
with census data in some countries, the data from population registers are found to be inaccurate.
Partial Registers
These may include;
 Social insurance and welfare- such as social security, Hospital insurance schemes,
 Military Service
 Voter registration, School enrolment
 Judicial system
Advantages
Provide accurate and current information on demographic events

2. 2. Rates, ratios and proportions

Ratios
A ratio is any numerator /denominator relationship between two numbers. It results from dividing
one quantity by another. In demography, a ratio summarises the arithmetic relationship between two
characteristics that can be counted in a population.

When a number of occurrences are for example, A and B, then the ratio r is defined as r = ‘a’ or “b”
‘b’ ‘a’

Mathematically, these are represented as r = a: b or, r = b: a

The calculation of ratios in population is common. E.g., sex ratios, age ratios, dependency ratios,
child- woman ratios.

Sex Ratios
Sex ratios relates to the number of males to females in the same population. This could be in a
county, a class, place of work, nation or location. In demography, there are three types of sex ratios:
 Sex ratio at birth
 The general sex ratio
 The age sex ratios

a) Sex ratio at birth

Sex ratios at birth in a population are derived from census, sample surveys and vital registration
data. The sex ratio at birth relates male births to female births in a given population ( a district,
county or country).
Usually a sex ratio of 105 males: 100 females is common, but varies from 102-107 male births per
female births. A sex ratio at birth with a value of more than 100 indicates an excess of male over
female births, A value less than 100 indicates an excess of female over male.
The sex ratio at birth has a number of uses in demography;
1. Needed to calculate number of male and female births when only total number of births are
known. For example, if total births are 32, 503, the sex ratio is 103: 100, to get the total number
of females and males, we calculate

Number of male births = 103 x 32, 503

203 = 16, 517.

Number of female births = 100 x 32, 503

203 = 15, 986

The denominator is 203 which is the sex ratio at birth for males plus the sex ratio at birth for
females.
2. Secondly, the sex ratio at birth can be used for approximate evaluation of the quality of
registration data, census and survey data. The sex ratio at birth ranges 102-107 male births per
female births. If we assume that the sex ratio at birth has a fixed value of 105 male to 100 female
births, then this assumption can be used as a simple demographic model for analytical purposes.
Any wide variation from this generally accepted figure could lead to the suspicion that the
enumeration or registration may have been defective.

A comparison of trends in sex ratios at birth in countries may reveal errors or suggest complete
enumeration or registration or under registration that may affect both males and females.
The trends may also reflect changes in reported cases of male and female births. The variations
in sex ratios at birth may be mainly due to reporting errors, through erroneous classification of
still births and babies who die soon after birth. Where births are small, the influence of random
variation may affect the sex ratio drastically.

The General Sex Ratio

The general sex ratio is the ratio of males to females in a give population. This ratio can be obtained
from a census enumeration of the total population or from sample surveys.
The general sex ratio = all males x 100
all females
e.g 5, 482, 381 x100
5, 460, 324 = 104 males per 100 females

Bondo 1999, 113, 583 x 100

125, 197 = 90.7 males per 100 females.

National general sex ratios usually vary in the range 95-100 males per females. Real variations at the
national level from this range may occur in exceptional cases such as losses from wars, epidemics
and migration.

Dependency Ratios
The dependency ratio is defined as the ratio of depended population ( children under 15 years of
age+ adults aged above 65 years and above ) to adults aged 15-64 years. The ratio reflects the
number of persons dependent on those in the productive years.

The burden of dependency in Africa ranges from 80-100 per hundred productive persons. The
dependency ratio in developing countries is heavily youth based. This is because, in such countries,
over 40% of the population are children under 15 years of age. In developed countries where fertility
is lower, 20% of total population is under 15 years of age. The dependency index is usually
employed to stress the economic implications of the age distribution.

The Proportion

This is a special type of ratio in which the numerator is part of the denominator.

Example, the proportion of female population in a given population =

P= a+ b,
Where p= total population’
a = total number of males
b= total number of females

To find proportion of females,

P= a
a+ b

If population = 23, 000,000

Females = 13,000,000
Males = 10, 000
 Proportion of females = 13,000,000
13,000,000 + 10, 000’000

In large populations, proportions may determine the probability of certain events

Foetal Deaths = Number of foetal deaths
Number of foetal deaths +Number of live births
This may give the probability of foetal deaths in a population.
Percentages are proportion or fraction per 100 units.

Ratios and proportions are useful statistical summary measure of phenomena that occurred under
certain conditions.

Rates
Rates are special cases of ratios. Rates imply a concept of change either increase or decrease. The concept is
associated with the dynamics of a certain phenomena such as growth, birth, death, and spread of epidemics
such as malaria or HIV/AIDS.

Generally, a rate can be defined as a measure of change in one quantity per a unit of
another quantity on which that particular quantity depends.
A rate can also be defined as the relative frequency of occurrence of an event in a given time and place over
the group at risk. In demography, the term rate applies to the number of demographic events in a given
period of time divided by the population at risk during the period .

Death rate= number of deaths

Total population

The population at risk is only estimated usually at mid year. The period is usually a year, and the rate
is often expressed per 100, 1000, 10,000 or 100,000 depending on frequency of occurrence of
events.
However, in occurrence of events, not all people are at risk, in the case of crude birth rate or crude
death rate, the term crude is appropriate because not every body is at risk of occurrence of the event.

In the case of birth rate, the men and children and old people are not at risk of having a baby.

Various refinements are employed to obtain a more meaningful rate. Refinements may omit the part
of the population for which the risk is zero, and may also take into account the fact that the risk is
greatest for some population sub groups.
Specific rates are therefore refined where the numerator is restricted so as to correspond to the age
restriction in the age group.
Eg., age specific birth rate 20-24= births to women 20-24
Total number of women aged 20-24

Concepts Used in calculation of rates

i) Exposed to the risk of – this is used to refer to the population exposed to the risk of
occurrence of an event- e.g., women exposed to the risk of conception are those who are
capable, sexually active and not young or old women who cannot be pregnant.
ii) Mid year Population
This is the population as at 30th June or 1st July of the year in question. The estimate of mid
year population( mean population) is suitable as standard of comp ratability with regard to
time reference. This is used to approximate population in a given year, useful to compute
annual rates e.g. birth, death and marriage rates.
Mid year population may differ from mean population only in cases where population is
subject to seasonal fluctuations, otherwise the difference between mean and mid year
population is negligible.
The mid year population is obtained by the arithmetic mean of the population for the 1st
January dates that bound the year in question( 1st January 2013 and 1st January 2014) are
often used as approximation of the mean population or mid year population.

Crude Rates
Crude rates are obtained by relating the number of events of a specified type occurring within an
interval, usually one year to the size of the population within which the events occur. He mid year
population is taken as the best estimate.
Examples are crude birth rates and crude death rates.

Specific Rates

Specific rates relate events of occurrence to a particular sub group or groups at risk of occurrence of
the event.
Examples are age specific birth rates, age specific death rates, age specific marriage rates, and
divorce or remarriage rates. In the specific rates, the numerator in the specific age group is related to
the population from which the events occur within the same age group. The rates can be calculated
for either single years of age or for group intervals, usually five year age groups.

Census Growth Rates

i) Rates of Natural Increase

The rate of Natural Increase of a population over a specified period of time is usually measured as
the difference between Crude birth rate and crude death rates.

Crude birth rate is the total number of live births per 1000 population per given period usually one
year.

Crude death rate is the number of deaths per 1000 population over a specified period –usually over 1
year.

The Natural Increase is the difference between crude birth rate and crude death rate. Where CBR=50
and CDR= 20, then
NI= 50- 20
1000 = 30
 1000 = 0.03 , in % 3%.
The value is affected by interaction of population processes as well as the accuracy with which each
component is measured.

Census Growth Rates

Rates of population growth are defined as the rates of natural increase adjusted for Net migration.
CBR- CDR + Net Migration.
Where information on all the three components is available, it is easy to calculate population growth.

PT= PO+ B-D+I – O,

Where PO is population at base year,
B= Births
D= Deaths
I= Immigrants
O= out Migrants
In most African Countries, it is difficult to obtain data on Net Migration.
In this case, other methods that take migration into account are resorted to.

For example geometrical growth methods

Example , acountry had a population of 20 million in 1969, after a census ten years later, it had a
population of 31.5 million people. What was the annual growth rate?
growth rate = (present figure / past figure)1/n - 1

For example, suppose you are given present figure of 310, and past figure of 205, and a time period
of 10 years, then the annual growth rate is simply (310/205)1/10 - 1 = 4.22 percent.

31.5/20 log 10
10 = 0.04641 x100= 4.6
The method assumes that the rate of growth is constant but the changes which occur are periodic.

Exponential Growth Rate

Pt= Poern which assumes that growth is a continuous process rather than a set of period changes as
assumed by the geometric growth method. To calculate the growth rates, natural logarithms are used
‘ e’ where the initial poplation at base year Po is being raised to the power of rn where r is the
growth rate and n the number of years.

Factors for Growth Rate

Population growth rates are determined by the dynamics of fertility, mortality and migration. These
depend largely on the total number of births, the amount of reduction by mortality and the amount of
migration movements. The levels of fertility, mortality and migrations occurring in the past have a
significant influence in determining the age structure. These events however affect the age distribution
in different ways and to different extents. Changes in the level of fertility will at first, affect just the
youngest age groups and only over many years will it affect the older age groups working all through.
 A decline in fertility initially has the effect of narrowing the bars of the pyramid as the number of births
falls. Variation in the level of infant mortality tends to produce an effect very similar to that caused by
change in fertility. This first affects the youngest ages and only gradually working through to the whole
age range.

A change in adult mortality has little impact since it is spread through all adult age groups. Mortality is
also inherently less variable than fertility. However, in developing countries, high mortality due to
famines, epidemics or wars which affect particular age groups disproportionately can have a big impact
on age structure which is noticeable in the age structure for many years. Mortality caused by war will
deplete young males over all.

Migrations can cause big distortions in the age distribution because it is normally concentrated among
young adults and is mostly sex selective. Migrant communities will show small proportions of young
adults and a high proportion in older age groups and a few children. Where immigrants settle, it will
have a young age structure, with many children and a few elderly people.
An age distribution is determined primarily by fertility and modified by mortality and migration.

Effects/ implications of growth

Rapid population growth in less developed countries is linked to many problems, including poverty, hunger,
high infant mortality and inadequate social services and infrastructure (transportation, communication etc.)

Rapid population growth may intensify the hunger problem in the most rapidly growing countries.
Population growth can reduce or eliminate food production gains resulting from modernization of farming.

Population pressures may also encourage practices such as over irrigation and overuse of crop lands, which
undermine the capacity to feed larger numbers.

In some cases population growth is quite directly related to social problems because it increases the absolute
numbers whose needs must be met. For example some less developed countries have made enormous
progress in increasing the percentage of children enrolled in school. However, because of population growth
during the same period, the number of children who are not enrolled in school also increases because of
insufficient resources to meet the growing demand for schools and to meet basic needs.

Similar observations could be made about jobs and employment, housing, sanitation and other human needs
such as water supply, transportation, energy requirement etc. These problem are compounded when large
numbers migrate from rural to urban areas and increase the burden placed on already inadequate supplies
and services.

High growth rates are manifested in early marriages, high parity leading to increased incidences of
complications of pregnancy and maternal deaths.
Childhood diseases increased infant mortality and need for health facilities to cater for these needs. Many
developing countries do not have adequate finances to provide services hence poor health care delivery.

Land degradation: Erosion, desertification, Stalinization and loss of land is contributing to food shortage.
Overgrazing is a big problem in Africa and is growing much faster. This accelerates drought leading to
desertification. This is a major problem in Africa.

Deforestation: This depletes one of the world most valuable resources, driving up the cost of fuel and
housing. Land is cleared for agriculture and forests cut for fuel and timber. This contributes to low
agricultural production, since trees help keep the soil and keep it moist.

Housing: Provision of descent housing in developing regions is quite a problem. Housing construction
requires space, building materials, capital and machinery. Population increase results in increasing demand
for housing and hence an increase in the costs of land, timber, cement, fuel and all building materials.
Provision of housing is particularly acute in the fast growing cities of the world. The poor in the urban are
pushed to squatter camps and shanty dwellings where they have little or no access to water and proper
sanitation. Garbage accumulation increase the likelihood of fire, spread of diseases and stench in the
crowded and unhygienic conditions. Shortage of water increases the incidence of diseases.

Public services: National budgets are used to provide public services. When population is growing very fast,
the government is not able to meet the growing demands of various sectors and hence little chance to
improve their quality.
Education is adversely affected with poor quality services and high drop out rate due to lack of fees and
other necessities. The situation is compounded by high poverty levels.
Health services are similarly affected. They are inadequate, poorly distributed and lacking drugs and
necessary equipment. The rural population in most developing countries is lacking health services hence
have no access to health care.

3. Population Composition

Age
Age is an important demographic variable. It is the primary basis of demographic classification in vital
statistics, census and survey work.

Many life events are expressed in terms of the age at which these occur e.g. when an individual stars
schooling, stars working, marries or dies.

Age data are useful in studies of a nations man power potential, its requirement for schools, housing,
food and various other kinds of goods and services.

Population events are estimated in reference to age e.g. age specific fertility and mortality rates,
reproduction rates and life table functions. Age is the starting point for population projections
 The age structure of a population is considered basis to the study of population problems.

Methods of Measuring Age in Africa

Measurement of age in developing countries does not present a problem at all. This is because of advanced
statistical knowledge and increased universal education.

In developing countries in general and in most African countries in particular, accurate estimation of age is a
problem. This is because of illiteracy and ignorance of age in the orthodox sense of completed number of
years.
A number of techniques have therefore been developed to improve the quality of age reporting in censuses
and surveys.

1. The Historical Calendar Method

In this method, enumerators are provided with calendars of historical events of national or local importance.
This helps place life events of an individual on the standard time scale. The technique must be applied in a
systematic way where the interviewer is instructed to go through the list of historical events with each
respondent in order to identify events the respondent recalls.

Limitations of this method

a) In most cases, only national events mainly of political nature are used in the calendars, tough
disastrous events that cut across the nation can be used e.g. famine, drought, earth quakes or
epidemics. The use of national events may mean very little to the local people.
b) While it may be possible to prepare historical calendars specific to local regions, the task can be time
consuming.
c) Unless the interviewer is given specific instructions on how to use the calendars, as well as sufficient
motivation and time to carry out this procedure, properly, the results obtained can be highly
questionable even if an effort has been made to develop an adequate calendar.
d) The effective use of the calendars is a complex operation which cannot be applied blindly. The
method must be varied according to the nature of the respondents e.g. parents responding for the
children or on information obtained by proxy such as when husbands are responding for wives vice
varsa, and adults who are not able to respond themselves and those adults who are responding for
themselves.

2. Cohort Identification Method

This method involves the identification of age cohorts in the population and linking them to some specific
event or events in the standard time scale. In the actual interview, the respondents are asked about
membership to the age cohort. The age set system in some African communities is a good example. Those
circumcised together among the Maasai belong to the same cohort. Among the Kalenjins, the age sets are
cyclic and are given a name. Age can be dated according to which age set was performing which role.
Closely related is a procedure that involves obtaining from each respondent , the name of persons from the
same local area, considered to be of the same age . Age cohorts are then formed of all those reporting
themselves as contemporaries. Age is then determined and assigned to each member.

Limitations in the use of Cohorts

a) The usefulness of age cohorts is limited due to wide variations between different communities in
such culturally generated age cohorts
b) Migration of people into an area from backgrounds of different cultural traditions may make the
procedure difficult to apply

Advantages
a) No elaborate materials, event calendars or conversion tables need to be prepared in advance.
b) The method can be applied in populations lacking widely known historical events or without
culturally derived age cohorts. It makes use of the fact that relatively accurate age information may
be known for some persons in a community
c) The procedure is time consuming and expensive

Causes of error in age data

 Ignorance of correct age
 Carelessness in reporting age and or in recording
 A general tendency to exaggerate length of life at advanced ages
 A general tendency to state age in figures ending in certain preferred digits e.g. ‘0’ or ‘5’
 A possibly subconscious aversion to certain numbers e.g. 13 among whites
 Misstatements arising from motives of an economic, social, political or purely personal character.

Misstatements of Age

There are two types of age misstatements.

1 Gross age misstatements

2 Net age misstatements

1. The gross age misstatements can best be understood for example through examining people who report to
be 20 years. Among them, some are above 20; others are exactly 20 and others below 20. All these people
will be included in the 20 age group. However, the problem is therefore counter balanced by persons who
are aged 20 reporting themselves at other ages (Net age misstatement)

2. Net age misstatement is the number of persons reported at a particular age, minus the true number of
persons at that age. It can be distinguished from gross age misstatement by the fact that some of the persons
reporting themselves as age x who are not actually age x are counter balanced by persons aged age x
reporting themselves at other ages. A net shift occurs when there is a systematic tendency for persons in a
particular age range to report themselves as either younger or older than the true age which is not
counterbalanced by errors in the opposite direction.
Age heaping errors are unbiased errors i.e the errors cancel in either direction. Age shifting or net shift
errors are biased errors.

The causes of age misstatements are many and are reinforced by the fact that in most African cultures,
assigning a numerical value to age has no significance over the years. This is the main cause of errors in age
data in censuses and surveys in Africa.

Characteristics of age and sex distributions in many African Countries

i) Deficiency in the number of infants and young children

ii) Heaping at ages ending in 0 and 5 and therefore relatively large concentrations of persons
are enumerated at ages ending with 0 and 5
iii) A preference for even ages over odd ages , relatively large concentrations of persons
enumerated with even numbered ages
iv) Unexpected large differences between the frequency of males and females at certain ages
v) Unaccountably large differences between the frequencies in adjacent age groups
vi) Non stated or unknown ages

These factors give an indication that generally, reliability of age data obtained from census and
surveys in countries of tropical Africa is generally poor.
However, with education and literacy levels increasing, the quality of age data has improved.
However, there is need for continuous appraisal of the quality of data generated through systematic
analysis of age distribution.

Methods of Detecting Errors in age data

There have been great advances in development of techniques for examining the reliability of age data
obtained from censuses and surveys. The need to devise new techniques to meet new problems has led to a
multiplicity of of techniques. There are two main approaches in identifying errors in age data

1 Case by case checking techniques

This method is useful before the data is published. It involves case by case checking techniques, using data
from interviews and checking against independent lists or administrative records.

2 The second involves the use of demographic techniques.

Almost all techniques succeed in detecting some errors in the age data. Afew of them suggest methods of
correcting such errors when detected.

The use of Age Ratios and Sex Ratios

Age ratios and sex ratios can be used either separately or jointly to evaluate the quality of data from census
or survey returns by age groups.
Age ratio is defined as the ratio of the population in the given age group to one half the population in the
two adjacent age groups.

Mathematically, this can be defined as follows:

Let 5Px be the age group from age x to age x+5, 5Px -5 and 5PX+5 be the preceding and the following
age groups respectively, then ;
Age Ratio= 5Px
1
2 (5Px-5 +5Px +5)

5-9
1 x100
2(0-4+10-14)

NB, the age 0-4 and the last age group are not calculated because there is no age group preceding
and succeeding respectively.

The result of each age ratio obtained must be compared with expected value of 100. The discrepancy
at each age is a measure of the net age misreporting. An age ratio under 100 suggests an over
enumeration of the age group or misclassification or both, or errors in the age reporting resulted
misclassification of persons who belonged to the age group.
An age ratio more than 100 suggests an over enumeration of the age group of the age group, or
misclassification or both.
Generally, age ratios should be studied for a series of age groups , preferably for the entire span of
age for which they can be calculated.
An over all measure of the accuracy of an age distribution, is the age accuracy index. This is
obtained by taking the average deviation (regardless of sign) from 100 of the age ratios and summing
over all age groups. The lower this index, the more accurate the census data on age.
Age ratios are usually calculated for males and females separately. These are calculated for all age
groups except for 0-4 and the last age group.

Age Specific Sex Ratios

The age specific sex ratios (number of males per 100 females in each age group) can also be used to
evaluate census age data.
The United Nations proposed an age/ sex accuracy index. This employs the age ratios and the sex
ratios simultaneously . Age ratios and sex ratios are computed for five year age groups for ages upto
70.
In the case of sex ratios, successive differences between one age group and the next are noted and
the average taken, irrespective of the sign.
The index is computed as 3 x(SRA)+(ARAGM) +(ARAGF)
This is three times the average of sex ratio differences ( added to the average of sex ratio differences
is then added to the two averages of deviations of age ratios from 100) The result is not accuracy
index but usually regarded as an ‘order of magnitude’ rather than a precise measurement.

Disadvantages of the methods

The two methods suffer from one serious disadvantage. Fluctuations in age ratios and sex ratios can
be due to irregular demographic events (epidemics, military actions and etc) even when the
population is closed to migration. Unless the history of the population is well documented, there is a
likelihood of misinterpretation of irregular age or sex ratios.

Whipples index

This method is used in detecting errors in age data. It is based on assumption that certain digits are
preferred than others. To test this hypothesis, whipples drew age graphs of age distributions of
various countries and realized that some digits were preferred over others. He realised that most
people prefer to round off their ages. There was preference for age digits ending in ‘0’ and ‘5’.
Whipples index is applied where age is reported in single years.

The index is obtained by summing the age returns between age 23 and 62 years inclusive, and
finding what percentage is borne by the sum of the return of years ending in ‘10’ and ‘5’ to one fifth
of the total sum or to one tenth of the total sum if separate for ages ending in 5 or 10.
From this difference, whipples index can only measure the extent of age heaping at the digits of’’0’
and ‘5’s. It is not an efficient method since other ages are preferred too and other digits do have
cases of heaping. .ge distri

In addition, age data do have other errors a part from heaping. Only ages 23-62 are used because
outside of this range, shifting and other problems tend to confuse the pattern of heaping.
The results vary between a minimum of 100, representing no concentration at all and a maximum of
500 if no returns are recorded with any other digits other than 0 or 5. The scale for estimating the
reliability of the data can be

Whipples index for ages ending in ‘0’= (P30+P40+P50+P60)

1( P23 - p62)
10
Whipples index for ages ending in ‘5’= (P25+P35+P45+P55)
1 (P23- P62)
10
Whipples index for both ‘0’ and ‘5’ divide by 1
5

Index Quality of data

Less than 100 = Highly accurate

105-109.9 = Fairly accurate
110- 124.9 = Approximate
125 -174. 9 = Rough
175 + = Very rough
.
 Myers Index

Myers Index is used to reflect preference or dislike for each of the ten digits 0-10. It is applicable
where age is given in single years. The method derives a blended population which is essentially a
weighted sum of the number of persons reporting ages ending in each of the 10 terminal digits 0, 1,
2, 3, 4, 5, 6, 7, 8, 9, . The underlying assumption of this method is that if there are no systematic
irregularities, in the reporting of age, the blended sum at each terminal digit should be approximately
equal to 10% of the total blended population. If the sum at any given digit exceeds 10% of the total
blended population, it indicates over selection of ages ending in that digit(digit preference)
Conversely, a negative deviation (or a sum that is less than 10% of the total blended population
indicates under selection of ages ending in that digit( digit avoidance)

An overall measure of the extent to which there is digit preference and / avoidance in a census age
distribution is the index of preference, which is obtained as the absolute sum of deviations for each
of the ten terminal digits( or half the total of the absolute differences. It does not really matter for
comparative purposes which of these methods of computing the index are used. The method
facilitates comparison among different populations. Myers index can vary from 0-180, representing
respectively, the situation where ages are reported accurately and where all ages were reported with
the same terminal digit.

The age at which calculation starts or ends in the estimation of the index may vary and different
results can be expected by choosing different starting points , usually an inspection of the data will
suggest where to start and end because the incidence of heaping will become apparent from
inspection of data given in single years of age. It is usually advisable not to go far into age + years
because the incidence of age heaping may be confounded with the incidence of age shifting in this
part of the age span.

Calculation of Myers the Index.

Eight columns are necessary

Age range chosen is between 10 and 79

Column 1- has Digits 0-9

Column 2 -Population ending 10- 69
Column 3 – Population ending 20-79
Column 4 – Weights 10-69 ( 1-10)
Column 5 - Weights 20-79 (10-1)
Column 6 – sum of column 6 x 10%
Total column 6
The Myers index equals sum of column 8 regardless of the sign.

Population Composition by Age and Sex Structure

A normal age structure derived from a complete and relatively accurate census enumeration follows a
typical pattern. It begins with a large proportion in the first age group (0-4) of each sex. This gradually
diminishes in the subsequent age groups until the final group at around 100 years when the number
becomes negligible or nil because eventually every body dies off. Within the two sexes, males
predominate in the first few quinquennial age groups and then fall below the numbers of females, the
difference gradually widening at the advanced ages.

Determinants of Age Structure

Age and sex distribution is determined by the dynamics of fertility, mortality and migration. These
depend largely on the total number of births, the amount of reduction by mortality and the amount of
migration movements. The levels of fertility, mortality and migrations occurring in the past have a
significant influence in determining the age structure. These events however affect the age distribution
in different ways and to different extents. Changes in the level of fertility will at first, affect just the
youngest age groups and only over many years will it affect the older age groups working all through.

A decline in fertility initially has the effect of narrowing the bars of the pyramid as the number of births
falls. Variation in the level of infant mortality tends to produce an effect very similar to that caused by
change in fertility. This first affects the youngest ages and only gradually working through to the whole
age range.

A change in adult mortality has little impact since it is spread through all adult age groups. Mortality is
also inherently less variable than fertility. However, in developing countries, high mortality due to
famines, epidemics or wars which affect particular age groups disproportionately can have a big impact
on age structure which is noticeable in the age structure for many years. Mortality caused by war will
deplete young males over all.

Migrations can cause big distortions in the age distribution because it is normally concentrated among
young adults and is mostly sex selective. Migrant communities will show small proportions of young
adults and a high proportion in older age groups and a few children. Where immigrants settle, it will
have a young age structure, with many children and a few elderly people.
An age distribution is determined primarily by fertility and modified by mortality and migration.
Population Structure - Developing Countries

This population pyramid is wide at the base, which means there are a large proportion
of young people in the country. It tapers very quickly as you go up into the older age
groups, and is narrow at the top. This shows that a very small proportion of people are
elderly.

This shape of pyramid is typical of a developing country, such as Kenya or Vietnam.

Population Structure - Developed Countries

This shape is typical of a developed country. It is narrow at the base, wider in the
middle, and stays quite wide until the very top, as there is a sizable percentage of
older people. Note that there are more old women than men. Italy and Japan have
population structures that are of this shape.

Population Pyramids
A population pyramid shows the total picture of a population by age and sex.
Pyramids are useful in illustrating or depicting the age structure of a population.

Construction of a Pyramid
i) Absolute numbers in each age group are represented by a rectangle
ii) Ages are located on the vertical axis
iii) The total at each age group are shown on the horizontal axis
iv) The rectangles are placed on top of each other the younger age groups at the bottom, and the
oldest age group at the top
v) The rectangles for males are shown on the left side of the axis and the females on the right
side of the axis.
vi) The open ended age groups can be represented approximately e.g age 85+ can be shown as
85-80 age group and a rectangle drawn to represent the group at the top
vii) The need for comparison requires judicious choice of height and width relationship in
constructing the pyramid
 viii) The total in each age group for males and females has to be used as the numerator in each
age group, and the denominator is the combined total of all males and females.
ix) The percentages are shown on the horizontal axis and the age on the vertical axis.

Young and Old Populations

To describe and distinguish population is useful in demography. Population is therefore described as young
or as old.
Young Population
A young population contains a relatively large proportion of children(persons under 15 years). In most
African countries this ranges between 43 and 48 percent. The proportion of old people aged 65 and above
ranges between 2 and 6 percent. It also tends to have a low median age( the age which divides total
population into two halves, the age at which 50% of the population are above and 50% are below. It varies
between 17 and 19 years
Old Population
Old population tends to have a large number of its people age 65 and above ranges 11 -20 percent. It has a
high median age this could be in the range 33-40 years.
This patterns of age structure have different implications for population growth in the different parts of the
world.

MORTALITY.
Mortality refers to death as a component of Population change. Mortality is the first process to affect change
in population. Any change in mortality level has a significant impact on overall population. The incidence of
death can reveal much about the living standard, the health status of a population and the availability of
health services.
Historical background

Throughout 17th and 18th Century, European history attests to the presence of epidemics and diseases that
wiped out populations and disrupted trade and life in general. The life expectancy was very low
approximately 30 years as evident from burial sites. Wars claimed very many lives. The consequences of
high mortality were lack of labour and increased migration as survivors moved to other places including
America and Africa.

In the 18th century, life expectancy at birth was 37.5 in France, 30 in Northermptom, and 25 in Philadelphia.
By then, urban mortality was higher than rural mortality. Women lived longer than men.

Reasons for high mortality in 18th century

1. Acute chronic food shortage leading to famine and malnutrition

2. Outbreak of epidemics such as bubonic plaque and cholera,

3. Poor public health conditions especially in urban areas. This resulted from lack of knowledge on
basic hygiene, sanitation and low standards of living.. Rubbish and carbage were thrown and
remained uncollected for long.

4. Disposal of untreated waste in large water bodies thus laeding to watrborne diseases. Water and
sewage systems had not been developed.

5. Overcrowding in slums of urban areas was common.

6. Oubreak of smallpox, cholera and typhoid. There was no immunisation against these
diseases.

7. Typhus and cholera killed very many people . Cholera killed millions of people in London in 1924,
while Typhus fever 700,000 people in Ireland in 1819. This was spread mainly through voyages of
exploration and wars. Lice, fleas and rats are hosts for typhus fever.

Mortality decline

Mortality began to decline in Europe following improved production of food after the agrarian revolution.
Incidents of famine and malnutrition declined.

The industial revolution resulted in increased mortality due to poor working and living production of goods .
Initially, the industrial revolution came with changes that resulted in increased conditions.

Improvements in public sanitation especially in urban areas reversed mortality trends. Piped water, water
purification and treatment, and proper methods of sewage disposal led to decline in mortality.

Changes in personal hygiene made significanft contribution to mortality decline. The use of cheap cotton
clothing and cotton bed sheets facilitated cleanliness. The availability and use of soap to wash hands and
clothes improved cleanliness.
The rising standards of living such as better working conditions and living conditions and increased number
of people being more careful about contracting diseases.

The ability to control temperature and humidity at will in homes and place of work may have contributed to
a decline in respiratory infections.

Changes in mode of transport facilitated distribution of agricultural and industrial products.

The development of ascepsis( the precautionary exclusion of pathogenic microrganisms) and

antisepsis(killing or inhibiting the growth of micro-organisms) helped reduce deaths due to bacteria
infections.

Development of immunology was able to control some diseases. Small pox was controlled through
vaccination . The vaccine was developed by Edward Jenner. Man developed immunity or resistance to
some diseases.

Advanced medical care and develoment of drugs to treat some illnesses was significant in reduction of
mortality. Notable was the development of Penicillin to treat bacterial diseases. This drastically reduced
deaths from bacterial infections.

Measures of Mortality )

The analysis of mortality is generally considered under two main headings.

i) infant mortality
ii) child and adult mortality
This division is necessary in view of the special problems of measurement inherent in each. The
calculation and the estimation for the different parts of the mortality schedule are slightly different in
each case.
Mortality (Death) rates have three essential elements:
• A population group exposed to the risk of death (denominator)
• The number of deaths occurring in that population group (numerator)
• A time period.
There a number of measures of mortality include crude and age specific mortality rates, the proportionate
mortality indices, life table functions such as the expectation of life , probabilities of dying and living and
infant mortality rates.:

Crude Death Rate (CDR)

The crude death rate is the number of deaths per 1000 population in a given year.
CDR = Total number of deaths in a year X 1000
Mid-year population.
As its name implies the CDR is a crude measure of death in a population not a sensitive measure (indicator)
of health status of a population. It is affected by particularly the age structure of the population. Crude Death
Rate also varies between populations of the world. According to the “World Population Data Sheet of the
population Reference Bureau the crude Death Rate during 2003 was.
• World = 9 deaths per 1000 population
• More developed countries =10 deaths per 1000 population
• Less Developed countries = 8 deaths per 1000 population
• Less Developed countries (Excluding China) = 9 deaths per 1000
population
• Africa =14 deaths per 1000 population
• Sub – Saharan Africa =16 deaths per 1000 population
• Eastern Africa = 17 deaths per 1000 population ( check for current estimates)
The crude death rate has many advantages and limitations.
Advantages
It shows the level of mortality in an entire population.
It is a simple measure whose meaning can be communicated or explained to the general public without
much difficulty.
It is easy to estimate and requires minimum amount of data to calculate.
It is a key determinant of population growth.
It is used in calculating the rate of natural increase.

Weaknesses
It is not a good index for comparing mortality levels because of a number of reasons;
 The crude death rate can be misleading because the influences of age structure override the impact
of levels of mortality. A population with an old age structure is likely to have a higher crude death
rate than a population with a younger age structure, if levels of mortality do not differ very much.
 Even with quite different mortality levels, the CDR can be misleading if the age structures differ
significantly. In countries with similar age structures, differences of the mortality level are
adequately reflected in the CDR.

Age specific Death Rates

Death Rates can be calculated for specific age groups, in order to compare mortality at different ages. E.g.
for infants (< one year of age) , children 1-4 yeas of age, children under five years, and for adults. This can
be worked out separately for males and females.
ASMR = Number of deaths in a specific age group X 1000
Mid-year population of the same age group

The age specific death rates contribute enormously to the study of mortality because differences in risks of
death are related to age and therefore calculating the rates by age is the most efficient means of reducing the
effects of this diversity in the death rate.
The age specific death rates form a good basis for making comparisons about mortality levels, as they are
not affected by age and sex composition of the population. It is advantageous to prepare the rates separately
for males and females.
A weighted average of a set of ASDR (the weights being the proportion of the total population at each age)
will be equal to CDR.
A change in CDR may be attributed to changes in ASDR or change in age composition of a population.
An examination of patterns of death shows that mortality varies considerably with age and sex. Death rate is
high in infancy, slows during childhood the increases through adolescence and middle life and increase
rapidly in old age.
The data for male and female death rates shows higher death rates for males than for females.
Sharpe differences exist between mortality patterns of developing and developed countries. In developed
countries, mortality occurs primarily among the elderly and rarely among children and infants. In the
developing countries, nearly half the deaths occur to those under age 15 and frequently more deaths occur in
the first year of life.

Expectation of life at birth

Expectation of life at birth is a more concise way of summarising mortality for all ages of a population.
Expectation of life at birth is defined as the average number of years a new born infant can be expected to
live if he or she is subjected to the schedule of age specific mortality currently in effect. It is also called the
mean length of life.

Proportionate mortality indicators

A fall in mortality has an effect of shifting deaths to the later years of life and increasing expectation of life
at birth. Deaths at the younger ages become less frequent and are shifted to the later stages of life. Thus
within a particular cohort, the proportions of deaths taking place at say age 50 or 60 is directly correlated to
the life expectancy at birth.This therefore provides an index of mortality known as the proportionate
mortality index PMI).
The index is defined as the proportion of deaths at age 50 or above to the to all deaths
Advantages
 If deaths are under reported uniformly throughout the age span, it does not affect the reliability of the
indicator
 It can be calculated on the basis of rough breakdown of deaths

Disadvantages
 The index is not age standardized and therefore will be affected by age structure of the population
 The index may in fact reflect past history of the population rather than present conditions
 If infant deaths are under reported, to a greater degree than other deaths, the proportionate indicator
will be over estimated.

As mortality falls, the proportionate mortality index rises.

The differences in the age structure of the populations are also reflected in the magnitude of the indices

Infant Mortality Rate (IMR)

Infant mortality rate is high in developing countries warranting serious attention. The developing countries
have made efforts to bring down rates of infant mortality.

Why infant mortality is of concern.

1. The contribution of infant mortality to the total loss of human life is substantial
2. The leel of ifant mortality is relatively high particularly in developing countries
3. The level of infant mortality is a useful indicator of the state of health and standard of living of a
society.
Because of these reasons, health authorities are working hard to prevent infant mortality. Various
interventions programmes are therefore in place to improve the situation. The success of these programmes
are reflected in declines in infant mortality rates.

Calender Year Rates and Cohort Rates of infant mortality

Calender Year Infant Mortality Rates

Infant Mortality Rate is the number of deaths of infants under one year of age (0-12 months of age) per 1000
live births in a given year. Infant (children under one year of age) are at highest risk of death than any other
age group.

IMR = Number of death of children < 1 year of age in a year X 1000

Total live births during that year

The data for calculation of the rate is derived from vital registration. The record of deaths and the record of
live births in the same period are required.
The numerator consists of deaths under one year of age derived from death records. The denominator
consists of life births derived from live birth records. These records limit studies to characteristics that
appear on the death and birth records. Such as sex, place of residence, age. The method conforms to the
practice of measuring mortality on the basis of deaths recorded in a specified calendar year. This is the
method commonly used in health statistics.

Disadvantages of the method

1. Under conditions of complete registration of life births and infant deaths, the rates can provide only
estimates of the risks of infant deaths, yet in any given year, some infants who die were born in the previous
year, while others born in the year will die the following year. However when we use this method, we
assume that deficiencies in one will be offset by excesses in the other. This assumption may be true when
live births are fairly constant but when numbers of live births increase and decrease rapidly, then it becomes
less acceptable.
2. Another limitation is that it limits analysis on the items that appear on the birth and death registers. For
example, place of residence may vary from time to time at time of birth and at time of death. The same
infant may appear in different geographic ares as infant birth, and infant death.

The total calendar year mortality rate for all infants can be separated according to age at death yielding the
neonatal mortality and post neonatal mortality rates..

Neonatal Mortality Rate (NNMR)

Neonatal period is the first month of age of an infant.
Neonatal mortality rate is the the death of infants under one month (<4 weeks). Per 1000 live births.
Neonatal Mortality Rate = Number of deaths of infants < 1 month in a year X 1000
Total number of live births in the same year
Neonatal mortality rate reflects mortality due to maternal factors during pregnancy and birth such as birth
injuries, and neonatal infections among others..
It is an indicator of the level of prenatal and obstetric components of maternal and child health care (MCH).
Post-Neonatal Mortality Rate (PNNMR)
The post neonatal age is the period of time from one month up to one year.
Post – Neonatal mortality (death) is deaths of infants one month (four weeks) of age up to one year (1 – 11
months age ) per 1000 live births.

PNNMR = Number of deaths of infants 1 month to 1 year of age in a year X1000

Total Number of live births during the same year
The post-neonatal mortality rate reflects deaths due to factors related to;
• Environmental sanitation
• Infections (communicable diseases)
• Nutritional problems
• Child care etc.
It can be used as an indicator to evaluate Maternal and Child Health Care services and socio-economic
development of a community or country.

The neonatal plus the post natal mortality rates equals infant mortality.

Perinatal mortality rate

The Perinatal mortality rates is measured as late foetal deaths (still births) plus early neonatal deaths over
live births in year per thousand.

The infant mortality rate is considered to be a sensitive indicator of the health status of a community,
because it reflects the socio-economic condition of the population; i.e. the
level of education, environmental sanitation, adequate and safe water supply, communicable diseases,
provision of health services etc. These factors mostly affect infants and children under five years of age.
Hence, IMR widely varies between countries in the world.

Child Mortality Rate (CMR)

It is the number of deaths of children 1-4 years of age per 1000 children 1-4 years of age. It is a sensitive
indicator of the health status of a community.
CMR = Number of deaths of children 1-4 year of age in a year X 000
Total number of children 1-4 years of age

Under Five Mortality Rate (<5MR)

It is the number of deaths of children under five years of age in a year (0-4 years of age) per 1000 children
under five years of age (0-4 year). It is also a very good indicator of the health states of a community. It can
also be calculated as the number of deaths of children
under five years of age in a year per 1000 live births.

<5MR = Number of deaths of children <5 yrs in a year X 1000

Total number of children < 5 years of age

Maternal Mortality (Death) Rate (MMR)

Maternal mortality rate is the number of maternal deaths related to pregnancy, child birth and post natal
(puerperium) complications per 1000 live births (usually per 100,000 L.B).

MMR = No of deaths of women related to pregnancy child birth and puerperium in a year
X 100,000
Total number of live births in the same year

It is a sensitive indicator of health status of a population. It reflects the socio- economic status of a
community.

Determinants of Mortality

1. Biology and Genetic Endowment - In some circumstances inherited predispositions appears to

predispose certain individuals to particular diseases or health problems. Inherited traits and the way the
human body functions have an impact on an individual’s state of health and wellness. An individual’s
genetic make up may include inherited disorders such as sickle cell anaemia, or chromosomal abnormalities
such as Down syndrome. Both these may ultimately affect an individuals quality of life and levels of health.
Human biology affects health because normal body functioning prevents some illnesses and makes us more
susceptible to others. Many of these effects are produced by the female and male hormones, estrogen and
testosterone respectively.

2. Environmental influences.

This may be natural or manmade and may vary according to geographical locations and living conditions.
Physical Environments - Factors in our natural environment (e.g. air, water quality) and human-built
environment (e.g. housing, workplace safety and road design) play a role in individual and public health.
The quality of physical environment promotes health while poor environment increase disease incidence.
Employment and working conditions – people in employment are healthier, particularly those who have
more control over their working conditions

/Exposure to hazardous chemicals such as lead, asbestos, ivy and mercury can cause disease or death.
Prolonged exposure to solar radiation can cause death. Natural disasters such as hurricanes, floods, volcanic
eruptions, drought and heat waves and other extreme weather conditions pose health risks. Man made
environmental crises such as wars bombings, pollution and over population affect health and can lead to
death.

3. Social Environments - The array of values and norms of a society influence in varying ways the health
and well being of individuals and populations. Social stability, recognition of diversity, safety, good working
relationships, and cohesive communities provide a supportive society that reduces or avoids many potential
risks to good health. Exposure to crime, violence, and social disorder, such as the presence of trash,
exposure to mass media and emerging technologies, such as the Internet or cell phones can promote or
impact negatively on health.
4. Income and Social Status - Health status improves with prosperity and social standing. High income
determines living conditions such as safe housing and ability to buy sufficient good food and availability of
resources to meet daily needs, such as educational and job opportunities, living wages, or healthful
foods. . Income is a determinant of health in itself, but it is also a determinant of the quality of early life,
education, employment and working conditions, and food security. Income also is a determinant of the
quality of housing, need for a social safety net, the experience of social exclusion, and the experience of
unemployment and employment insecurity across the life span.

5. Employment / Working Conditions - Unemployment, underemployment, stressful or unsafe work are

associated with poorer health. People who have more control over their work circumstances and fewer stress
related demands of the job are healthier and often live longer than those in more stressful or riskier work
and activities. Unemployment, underemployment, stressful or unsafe work are associated with poorer
health. People with good job are healthier and often live longer than those in more stressful or riskier work
and activities.

6. Education and Literacy - Education contributes to health and prosperity by equipping people with
knowledge and skills for problem solving, and helps provide a sense of control and mastery over life
circumstances. It increases opportunities for job and income security, and job satisfaction. And it improves
people's ability to access and understand information to help keep them healthy. Low education levels are
linked with poor health, more stress and lower self-confidence.

7. Social Support Networks - Support from families, friends and communities is associated with better
health. The caring and respect that occurs in social relationships, and the resulting sense of satisfaction and
well-being, seem to act as a buffer against health problems.
.
8. Personal Health Practices and Coping Skills –
Learning how and what individuals can do to prevent diseases and promote self-care, cope with challenges,
develop self-reliance, and solve problems will help people make choices that enhance health.

9. Culture – People’s customs, traditions and the beliefs and values of their family and community all affect
their health. These factors influence what people think, feel, do and believe in.
10. Personal behaviour
Healthy eating habits are essential for health. Integrating physical activity in daily life promotes health.
Personal hygiene is necessary for health. Having healthy sexual relationships, the level of stress, tobacco
and alcohol abuse, drug and substance abuse affect health. The relationship between lifestyle and health is
clear, but adopting healthy lifestyle habits has been difficult for many people.
Exercise improves muscle strength, blood circulation, lowers blood pressure thus reduce chances of heart
attack, osteoporosis and stroke. Regular exercises make one look healthier and feel better.
11. Residence- in most cases, the place of residence may account for variations in health status. It could be
rural or urban. Residential isolation/segregation has negative impact on health. Such prevent access to health
care as well as information.

12. Gender differences

Women have lower socioeconomic position than men. They are vulnerable to health problems.
There are general differences in labour force participation and in the structure and quality of occupations
themselves. This may play a role in explaining gender differences in the relationship between socio –
economic position and health.

13. Age differences

The socio-economic relationship with health varies by age. There are socioeconomic differences in prenatal,
neonatal, and infant health and maternal mortality. There are however diminished differences by
adolescence. Socioeconomic inequalities in adult health are generally small in early adulthood, increasingly
larger through middle and early old age, and then smaller in later old age. The explanation for the little
variation may be due to immunity of the hardiest and healthiest people of low socioeconomic position who
survive infancy and into older ages, making them resistant to most health problems.

14. Importance of Medical Care

Most research suggests that access to medical care plays a relatively minor role in explaining socioeconomic
inequalities in health. Evidence from developed countries that have come up with national programmes that
equalize health care indicates persistence of, or even increased socioeconomic inequalities in health.
Countries that have more equal access to health care have found that differential access to and quality of
care still exists. Medical care plays only a minor role in the overall health of populations in more developed
countries.

16. Psycho-social Factors-People in lower socioeconomic strata tend to be disadvantaged in a broad array
of biomedical, environmental, behavioural and psychosocial risk factors for health, which mediates the
relationship between socioeconomic position and health. Central among these are health behaviours, chronic
and acute stress in life and work, hostility and depression, lack of social relationships and supports, and lack
of control, efficacy or mastery.

17. Policies at the State or County level affect individual and population health. Increasing taxes on
tobacco sales, or on sales on alcohol for example, can improve population health by reducing the number of
people using tobacco products. Highway Safety Act and the National Traffic and Motor Vehicle Safety Act

18 Poverty- The gap between the richest and poorest people, make greater differences in health.
Concentrated poverty has adverse impact on health. Much of this has to do with the lack of the basic
necessities of life (food, water, sanitation, primary health care, etc.) common to developing nations. The
material conditions under which people live their lives which include availability of resources to access the
amenities of life, working conditions, and quality of available food and housing among others are important
factors in health status of individuals and groups.

19 Policies- The availability of quality, regulated childcare is an especially important policy option in
support of early life. These are not issues that usually come under individual control. It is the responsibility
of the government to modify their adverse living conditions.

20.Security and good neighborliness is linked to better health .

22Poverty - increase in stress and isolation, social exclusion arising out of poverty, discrimination and other
health hazards , conflicts and tensions are other mechanisms and the adoption of health threatening
behaviours as means of coping with these difficult circumstances.[29]
23 Education
Educational level is probably one of the better predictors of health behaviour and the utilization of health
services. Education is related to the levels of service utilization , the types of services used and the
circumstances under which they are received.

24 Unemployment- The unemployed are likely to be characterized by informal health behaviour that
contributes to poor health status. They are less likely to eat and sleep properly, to exercise, and to abstain
from risky behaviour such as smoking and drinking.

25 Residence- in most cases, the place of residence may account for variations in health status. It could be
rural or urban.
26 Age differences
The socio-economic relationship with health varies by age. There are socioeconomic differences in prenatal,
neonatal, and infant health and maternal mortality. The explanation for the little variation may be due to
immunity of the hardiest and healthiest people of low socioeconomic position who survive infancy and into
older ages, making them resistant to most health problems.

27 Psychosocial risk Factors

Research indicates that people in lower socioeconomic strata tend to be disadvantaged in a broad array of
biomedical, environmental, behavioural and psychosocial risk factors for health, which mediates the
relationship between socioeconomic position and health. Central among these are health behaviours,
chronic and acute stress in life and work, hostility and depression, lack of social relationships and supports,
and lack of control, efficacy or mastery.

MORTALITY DIFFERENTIALS

Differences in mortaliity between countries of the world are attributed to the following factors

a) Rural –Urban differentials

Generally, there is higher mortality in rural han in urban areas. There is however, lower mortality in rural
areas of developed regions while in urban areas, the leess developed urban suburbs such as slums or
informal setttlements may have high mortality.

b) Geographical differentials in mortality are mainly due to diffferentials in social and economic conditions.
There is lower mortality in areas of higher social and economic development. Cological factors also account
for variations in diseases prevalence and hence mortality. High temperatures and low altitude are ideal for
vector survival unlike high altitude and low temperature zones where vector survival is difficult.

c) Occupation, income education, diet, houusing conditions and good living conditions promote lower
mortality.

d)Ethnicity differences have been observed in mortality perhaps due to genetic and cultural practices.
e)The distribution and availability of medical services, and socio-economic factors whish affect utilization
of medical services and the personal motivation to achieve a state of positive health matter in mortality
decline.

f)There asre also age and sexx differentials in mortality. There is high infant moratality among oys than girls
and among men than women. Children and olde people have higher icidences of mortality.

Factors crucial in mortality decline.

Sustained changes in mortality require the following:

 Economic development and rising income levels leading to improvement in the standard of living
 Improved environmental conditions.

 Improved food supply and nutritional status

 Improvement in sanitary conditions and puplic health measures

 Social reforms such as disease control measures

 Improved working conditions such as reduced working hours, introduction of pension schemes,

 Medical and nonmedical interventions to control disease. This results from advances in medicine in
areas such as vaccination, surgery,

FACTORS IN PERSISTENCE OF HIGH MORTALITY IN SOME REGIONS OF THE WORLD

In some developing regions of the world such as South East Asia and Sub Saharan Africa, there is
persistence of high mortality. The following are some of the factors that sustain high mortality

1. Infectious and parastic diseases have not been brought under control
2. Sanitary conditions are still poor especially in rural areas and in urban informal settlements

3. Food shoratages due to persistent droughts, poor food plocies and poor governance. This has
affected nutritional status thus leading to higmortality

4. Poor housing conditions with no ventilation, lighting, piped water and toilet facilities.

5. Social and cultural factors that are repugnant to the practice of positive health. Superstitions, taboos
and certain belives and practices that affect health and mortality.

6. Poor health conditions and lack of adequate health facilities, lack of access to medical care and
inadequate health personnel

7. Poor communication systems which makes it difficult or impossible to access health facilities in case
of emergency or even to deliver food and emrgency supplies to some areas.
 8. Natural disasters such as floods, droughts, earthquakes and other disasters that kill somany people.
The situation is aggravated by lack of disaster management.

9. Political upheavals and wars and riots kill very many people

10. Road accidents are killing many people in these regions.

LEVELS AND TRENDS OF MORTALITY

Improvement in mortality has been achived throughout the world since world war 11. By 2005-2010 period,
the global average life expectancy at birth was estimated to be 68 years.

The crude death rate declined from 20 per 1000 in 1950-1955 period to 9 per 1000 in the 1990-1995 period
and to 8.5 in 2005-2010..

The number of deaths has been increasing slowly due to HIV/AIDS pandemic which is reversing the trends
gained in the 1990-1995 period. The reversal in the trends is also attributable to ageing population and the
increased popuation of the world.

The distribution of deaths by age in the more developed regions and the less developed regions in the 2005-
2010 period reveal unequal distribution of deaths across the ages.

At the global level, most deaths occur at the youngest age group(under 5) or in the older age groups(75+)

In the developed countries, 51% of deaths occur in the older age groups 75+ and less than 2% of deaths
occur under age 5group. This is because o the old age structure and low mortality levels. In the less
developed regions, 285 of all deaths are of children under the age of five and 185 of deaths are of adults
above age 75. This is attributed to ayoung age structure and and high infant and child mortality levels.

Trends of mortality in more developed regions

In the 2005-2010 period, mortality levels continued to decline and thus resulted in incresed life expectancy

Region/Country Life Expectancy(1990-1995) Life epectancy(2005-2010)

Southern Europe - 76 greatest gain of 12.7 years in 4 decades 80

Western Europe 76.7 80

Ausralia and Newzealand 77.4 81

Northern America 76.2 79

Eastern Europe 68.2 69

Japan 79.5 83

Iceland 78.8 82

Sweeden 78.1 81

Russia 70- lowest 66

Trends of mortality in less developed regions

In these regions, life expectancy increased to 62.1 in the 1990- 1995 period and to 66 in the 2005-2010
period.

Progress has been uneven with variations between regions and countries.

Region/Country Life Expectancy(1990-1995) (2005-2010)

Asia 64.5 69

Israel 77 81

Cyprus and Macao 76.8 80

Singapore 76.3 80

Afghanistan 43.5(lowest in the region 44

Latin America and Carribean 68.5 73

Bolivia 59.4 66

Haiti 59.4 61

Costa Rica 76.3 79

Africa 51.8 54
Trends of mortality in Africa

Country Life Expectancy in Africa (1990-1995) (2005-2010)

Algeria 62.1 72

Tunisia 67.8 74

Mauritius 70.2 72

Re- Union 74 76

It was expected that by 2005, a life expectancy of 70 years would be achieved and a life expectancy of 75
years by 2015. Some countries have surpassed the targets for 2015.

Levels and Trends in Mortality in Sub-Saharan Africa

One of the major achievements of the twentieth century in Sub-Saharan Africa is the unprecedented decline
in mortality and the corresponding increase in the expectation of life at birth. At the dawn of the twentieth
century, Sub-Saharan Africa was characterized by extremely high under-five mortality levels and by low life
expectancy at birth. By the end of the century, however, mortality among children under five had decreased
from about 500 per 1,000 live births to about 150 (World Bank 2005). Similarly, the average length of life,
which was less than 30 years about 100 years ago, had increased to more than 50 years by the early 1990s.
Much of the mortality decline happened in the second half of the twentieth century, the fastest rate of
decline occurring in the first decades after World War II. In the 1990s, mortality decline stalled for the
region overall, with many countries experiencing reversals in the upward trend in life expectancy largely
because of AIDS mortality.

This overview focuses on the period between 1960 and 2005. This period roughly corresponds to the
postcolonial era in many countries in the region, in which large economic and social changes occurred.
Some of these changes were beneficial to the health of the population (such as economic growth and
increasing access to health interventions), whereas others are associated with increasing exposure to risk
factors that lead to increased morbidity and mortality (such as increasing exposure to risks for
noncommunicable diseases or the spread of new and reemerging communicable diseases). Therefore,
monitoring mortality levels and trends in the Sub-Saharan region provides not only a direct reflection of the
health status of populations but also an indirect gauge of the effects of economic, political, and
epidemiological turbulence that faced the region.

Indicators of Mortality Levels and Trends

In this overviewr, two indicators of mortality are used to assess levels and trends for Sub-Saharan Africa, its
subregions, and countries. The infant mortality rate, calculated as the proportion of newborns in a given
period that do not survive to their first birthday, is a standard measure not affected by age structure and
therefore suitable to use for comparisons over time and across regions. Life expectancy at birth, calculated
as the average number of years a newborn would live if subject to the mortality rates for a given year, is
used to compare the force of mortality across the entire age spectrum. The dearth of reliable data is one of
the main problems confronting the study of mortality levels and trends in Sub-Saharan Africa. Although
vital registration systems exist in most countries in the region, they usually do not produce reliable data. In
the absence of reliable vital registration systems and good quality census data that are needed for direct
calculation of infant and child mortality rates, demographers have developed indirect methods for obtaining
these vital statistics from incomplete and often defective data. However, over the past 30 years, information
available for the study of mortality patterns, particularly among children under age five, has improved
dramatically. The improvement in information is largely due to the implementation of large-scale household
survey programs, such as the World Fertility Surveys (WFS) program of 1972–84, the Demographic and
Health Surveys (DHS), and UNICEF's Multiple Indicator Cluster Surveys (MICS). Of all these survey
programs, the DHS has had the largest impact on data availability, analysis, and report dissemination. About
70 DHS surveys have been conducted in 33 of the 46 major countries in Sub-Saharan Africa.

Apart from the DHS-type surveys, Sub-Saharan Africa has an extensive network of longitudinal study sites.
At least 19 such study sites exist in the region and their data have been invaluable in deriving mortality
estimates by age as well as model life tables that show how the age pattern of African mortality differs from
the model life tables constructed by Coale and Demeny (1983) and United Nations model life tables. The
main problem with this source is that most of these longitudinal study sites are based in rural settings and
are scattered throughout the whole region and therefore provide estimates of unknown generalizability. The
locations of the sites are neither systematically planned to represent the Sub-Saharan Africa region nor do
they adequately represent the countries in which they are located.

The estimates for countries and sub regions are those issued most recently by the United Nations Population
Division; the estimates are based on a variety of sources, including surveys, censuses, and demographic
modeling. The delineation of geographic sub regions used are those defined by the United Nations.

Mortality Levels and Trends

The following section will provide a comparison of indicators of mortality trends discussed above, first
comparing trends in life expectancy and infant mortality in Sub-Saharan Africa and other regions, followed
by a comparison of these mortality indicators for sub regions within Sub-Saharan Africa.

Sub-Saharan Africa Relative to Other, Less Developed Regions

Sub-Saharan Africa is, by far, the region of the world with the highest level of mortality. Overall life
expectancy at birth is 51 years, whereas in Asia, the region with the second lowest life expectancy, it is 61 a
drop from 67.3 in 2000- 2004.
Life Expectancy at Birth for World and UN Regions, (more...)

Table 2.1

Life Expectancy at Birth for World and UN Regions, 1960–2010

Region 1960–69 1970–79 1980–89 1990–99 2000–04 2005-2010
World 52.5 58.1 61.4 63.7 65.4 68
Sub-Saharan Africa 42.4 46.3 49.0 47.6 45.9 51
Asia 48.5 56.4 60.4 64.0 67.3 61
Europe 69.6 71.0 72.0 72.6 73.7 75
Latin America and Caribbean 56.8 60.9 64.9 68.3 71.5 73
Northern America 70.1 71.6 74.3 75.5 77.6 79
Oceania 63.7 65.8 69.3 71.5 74.0 76

Source: United Nations 2005.

As shown in table 2.1, the disparity between Sub-Saharan Africa and other regions of the world has widened
since the 1960s. In that decade the difference in life expectancy with the Asian region was only 6 years, but
this has grown to almost 21 years now. And, whereas all other regions have experienced uninterrupted
increases in life expectancy, in Sub-Saharan Africa life expectancy peaked in the early 1990s at 50 years,
and has since fallen back by almost 4 years and then has picked to 51 in the 2005-2010.

Table 2.2

Infant Mortality Rates for World and UN Regions, 1960–2010

(per 1,000 live births)
Region 1960–69 1970–79 1980–89 1990–99 2000–04 2005-2010
World 119 93 78 66 57 47
Sub-Saharan Africa 149 130 115 107 101 89
Asia 123 96 77 63 54 42
Europe 33 23 17 11 9 7
Latin America and Caribbean 96 75 52 35 26 22
Northern America 24 16 9 7 7 6
Oceania 49 43 36 32 29 23

Source: United Nations 2005.

Declines in infant mortality rates in Sub-Saharan Africa started to slow down considerably in the 1990s.
These slow declines have meant that Sub-Saharan Africa has lagged more and more behind other regions
and hence the mortality gap has widened (table 2.2).

Subregional Differences in Mortality

In Sub-Saharan Africa as a whole, infant mortality rates declined from 149 per 1,000 live births in the 1960s
to about 101 in 2005—a 32 percent decline over a period of 35 years. Toward the end of the last decade of
the twentieth century, the decline in infant mortality rates leveled off, decreasing only slightly for the region
as a whole. However, the decline over 2005-2010 has been substantial.

Table 2.3

Infant Mortality Rates for Sub-Saharan Africa and UN Sub regions, 1960–2010
(per 1,000 live births)
Region, subregion 1960–69 1970–79 1980–89 1990–99 2000–04 2005-2010
Sub-Saharan Africa 149 130 115 107 101 89
Eastern Africa 144 124 112 101 93 76
Middle Africa 156 131 121 122 116 112
Southern Africa 90 78 58 47 45 49
Western Africa 165 145 128 119 114 98

Source: United Nations 2005.

In regard to sub regional disparities, infant mortality rates are highest in West Africa and in Middle Africa
and have consistently been so from 1960 (table 2.3). The infant mortality rate declined somewhat faster in
West Africa, and as a result, Middle Africa is currently the sub region with the highest rate. Of all sub
regions of Sub-Saharan Africa, countries in Southern Africa have had the lowest infant mortality rates. For
example, in 1960 the rate was 42 percent lower than in other sub regions, and even with increasing overall
mortality in the 1990s, the infant mortality rate in Southern Africa was still less than half the average for
Sub-Saharan Africa in 2000. The rate has since 2004 increased to 49 in 2005-2010 period.
Life Expectancy at Birth for Sub-Saharan Africa and (more...)

Table 2.4

Life Expectancy at Birth for Sub-Saharan Africa and UN Subregions, 1960–2010

Region, subregion 1960–69 1970–79 1980–89 1990–99 2000–04 2005-2010
Sub-Saharan Africa 42.4 46.3 49.0 47.6 45.9 51
Eastern Africa 43.4 47.3 49.4 46.7 45.7 53
Middle Africa 41.0 45.3 47.0 44.3 43.4 48
Southern Africa 50.7 54.4 59.6 59.6 47.7 52
Western Africa 40.3 43.9 47.1 47.2 46.3 51

Source: United Nations 2005.

Life expectancy at birth has increased 3.5 years for the continent as a whole since 1960, but it is now lower
in Southern Africa than in the 1960s (table 2.4). All the subregions reached peak levels of life expectancy
about 1990, but they have since shown a decline, largely due to AIDS mortality. Nowhere has the decrease
in life expectancy been steeper and greater than in Southern Africa, where 40 years of increases in life
expectancy were reversed in a period of 10 years. Interventions to reduce HIV has resulted in increased life
expectancy to 52 in 2005-2010 period

RECENT REVERSALS OF MORTALITY DECLINE

HIV infection has reversed gains in mortality declone . The impact of HIV/AIDS is devastating in sub
Sharan Africa , where widesread transmission of the virus began in te 1980s. In the 1985-1995 period, the
epidemic killed 4.2 million people in Africa. AIDS increases the number of deaths in each period. But the
largest impact is in the robust years of life. HIV/AIDS, interventions have resulted in improvements in life
expectancy in the region.

War has had an impact on mortality . Since world war 11, there has been morethan 150 local wars in Africa ,
Asia, Europe and Latin America. In Rwanda life expectancy decreased by 50% from 46.7 to 22.6 in 1990-
1995 period. Liberia also experienced a decline in life expectancy due to civil strife. In Sierra Leon, civil
strife led to a decline in life expectancy.

Similarly, in Iraq, life expectancy decreased from 64.9 t0 58.8 in 1990-1995 period, then increased to 67 in
2005-2010.

MIGRATION
Interest in the subject of migration stems from;
i) The consequences of migration particularly rural-urban migration both in developing and developed
countries. Rural urban migration is a necessary component of Industrialization and modernization. The
major problem is that urban economic growth usually lags behind population growth in urban centres. This
creates a problem of a congregation of unemployed migrants in cities. This has social and economic
consequences.

ii) Migration is a component of population change together with fertility and mortality. Migration is one of
the most complex of demographic processes. Migration can occur at any age. Migration can affect the
growth and decline of a population by influencing fertility and mortality of areas of origin and destination. It
can influence birth rate by altering the proportions of women of child bearing ages in the population.
Migration can also affect the characteristics of the labour force of the areas of origin and destination.

iii) Migration data is necessary for analysis of changes in the structure of population of an area and for
assessment of other basic characteristics. Modifications in the structure of population may result from
migration and changes in the pattern of natural increase.

iv) Migration together with natural increase form the two components of population growth and distribution.
Each of the components has a separate and additive effect. The contribution of migration to growth can
either be positive or negative.

The spectrum of human mobility is broad, ranging from permanent emigration to a foreign country, to a
nearby city, to a daily commute to work.

MIGRATION CONCEPTS

Migrant
A migrant is defined as a person who changes his usual place of residence. If the change involves crossing
an international boundary, then this type of a movement becomes an International migration.

Internal migration is a term usually employed to refer to changes of residence within a nation and defined in
terms of residential moves across boundaries e.g. of locations, divisions, districts, or regions of the country.
In other words, a person has to move across administrative boundaries to be considered a migrant.

Demographers distinguish migration from other kinds of mobility on the basis of actual or intended length
of stay. Minimum ranges from 24 hours to one year or more.
Migrants may be classified as permanent, temporary or circulatory (making repeated short trips from home).

In migration and out migration are terms used to refer to internal migration. A person moving from one part
of the country to another part of the same country is said to be an out-migrant from his place of origin, while
he becomes an in-migrant in his place of destination.

There are two basic types of migration studied by demographers:

 1. Internal migration. This refers to a change of residence within national boundaries, such as between
states, provinces, cities, or municipalities. An internal migrant is someone who moves to a different
administrative territory.

There are four types of internal migration

 Rural to urban
 Rural to rural
 Urban to urban and
 Urban to rural

2. International migration. This refers to change of residence over national boundaries. An

international migrant is someone who moves to a different country. International migrants are further
classified as legal immigrants, illegal immigrants, and refugees. Legal immigrants are those who
moved with the legal permission of the receiver nation, illegal immigrants are those who moved
without legal permission, and refugees are those crossed an international boundary to escape
persecution.

With internal migration, there is the problem of distance. Below a certain distance, people are only movers,
not migrants. This is more so when people are moving for houses rather than job related moves.

Migration therefore can be internal or international. Migration in developing countries is predominantly

from rural to urban areas while in the developed countries, migration can be either urban to rural or urban to
urban.

Immigration and emigration describe international migration.

Return Migrants
A return migrant is a person who moved from his original country to another country and then decides to
return permanently to his country of origin. Return migration is common since wherever a flow of migrants
developes, it is inevitable that they will also develop a smaller counter-flow of return migrants.

Life time migrants

A life time migrant is one who has spend many years a way from his place of birth.
The information on this is usually derived from a census, from a question on place of birth. The place of
birth is compared with the place of enumeration to produce a measure of life time migration.

Sources of data on migration

Censuses are the most common source of migration data. Many censuses include some questions on
migration. The direct questions are;
i) Place of birth
ii) Place of last birth
 iii) duration of current residence in the place of enumeration
iv) Place of residence on a specific date before the census/ residence at a certain time in the past.
Each question captures slightly different information and yields different estimates of
migration.
On the basis of information obtained from these questions, the population can be classified into migrants
and non migrants. Comparisons can be made depending on individual characteristics such as age, sex,
marital status, residence, occupation, etc. In general, censuses underestimate migration because they collect
data on only two or three places of residence for each individual and may miss illegal immigrants.
If censuses don’t include direct question on migration, net migration between censuses can be calculated
from the differences between population growth and natural increase.

Population registers, which record all changes in residence as they occur, are in theory the best source of
migration data. Few countries maintain accurate registers, and even fewer tabulate and publish migration
statistics based on them.

Immigration Statistics provide important information on international migration, since most governments
routinely collect some information on foreigners crossing their boarders. These statistics may miss out on
would be immigrants who pose as tourists or students or who cross the boarder surreptitiously. Also where
workers cross boarders more often, they may be counted more than once.

Surveys or general enquiries can gather the most detailed information about individual migration histories
and socio-economic characteristics. Surveys however gather data for specific purposes such as studying
fertility or housing. Very few surveys gather complete data on migrants before and after the move, and, for
comparison, on non migrants in places of origin and destination.

Determinants of migration
People move to find jobs and higher wages
 Employers locate n cities to access raw materials, communication and transportation and consumer
markets. Thus many new jobs are created in cities, thus making workers move from the country side
to fill them.
 Technological advances change what people buy and so change the demand for workers in different
jobs.
 Technological advances in agriculture reduce labour needs. Agriculture expands more slowly than
industry, and as income rises, people spend more money on manufactured goods than on food.
 The rural increase of population is higher than in urban. Migration from rural to urban results from
more rapid growth of rural population and demand for labour in urban areas.
 Women move due to marriage and other family considerations
 Distance deters migration. People are more likely to move over shorter distances. This is mainly true
of low-income and less well educated migrants. In addition, long distance travel is more difficult for
the traveler, and far –away places differ more from home. However, modern means of
communication has reduced the costs of migration and weakened the deterrent effect of distance.
 International migration has legal barriers. It also requires assistance and this makes it more difficult
 Information is important because would be migrants base the decisions to move on information
concerning the costs and returns of moving. People rely on their relatives and friends living in other
places for information about possible destinations. Gifts and visits from migrants demonstrate
 prospects of migration. People are unlikely o move to places they know little about. Migrants from
same origin tend to move to same destination. This is termed chain migration
 The mass media may make migration easier and more appealing. They make villagers aware that
conditions in cities and the developed world are better.

Migration can occur as result of push and pull factors.

Push Factors

Push factors are those which force a person to move. This can include drought, famine, lack of jobs, over
population and civil war.

 Not enough jobs

 Few opportunities
 Inadequate conditions
 Desertification
 Famine or drought
 Political fear or persecution
 Slavery or forced labour
 Poor medical care
 Loss of wealth
 Natural disasters
 Death threats
 Desire for more political or religious freedom
 Pollution
 Poor housing
 Landlord/tenant issues
 Bullying
 Discrimination
 Poor chances of marrying
 Condemned housing (radon gas, etc.)
 War

Pull Factors

Pull factors are those which encourage a person to move. These include a chance of a better job, better
education, a better standard of living.

 Job opportunities
 Better living conditions
 The feeling of having more political and/or religious freedom
 Enjoyment
 Education
 Better medical care
  Attractive climates
 Security
 Family links
 Industry
 Better chances of marrying

Characteristics of migrants
The tendency to migrate is related to age, sex, education, and ethnic group.
Age: Young adults age 15-35 are more likely to migrate because they have fewer personal ties or
responsibilities and more years to enjoy the returns from migration.

Sex: In most developed countries, men predominate in both rural to urban and international migrations,
while women marrying often form the majority of short-distance, rural to rural migrants. Currently, more
and more women are joining their husbands in town or independently migrating to cities to look for jobs. By
contrast, in Latin America and some East Asia countries, such as the Phillipines, the majority of rural –to –
urban migrants are women. These are responding to opportunities for jobs such as domestic service and
factory work

Education: International migrants tend to be better educated, higher income, older, with valuable job
skills than internal migrants. Rural to urban migrants in most cases are better educated than those who
stay behind. Better educated people are more aware of outside opportunities and may have learned urban
values. They are also likely o benefit more from moving. Schools teach skills that are useful in obtaining
urban jobs and the difference between rural and urban wages is greatest for the better educated.

Ethnicity: Members of some ethnic groups are more likely to migrate than others. The Kikuyu in Kenya
are more likely to migrate than others. In some cultures, migration is a normal and mandatory part of a
young person’s life. In contrast, traditional authorities in other groups such as the maasai, discourage
movement outside the tribe and consider urban material wealth irrelevant to success.

Methods of estimating internal Migration

Internal migrations are not usually recorded as they occur, and hence migration rates and other measures
of population mobility are estimated on the basis census or survey data on place of birth, place of previous
residence, or place of residence at some fixed point in time. Migration like other components of population
growth is measured by a series of indices, rates or ratios.
The methods are not standardized and well developed.

Basic Measures

Rates
i) The in-migration rate = I
P
ii) The out-migration rate = O
 P
iii) The gross migration rate = I+O
P
iv) The net migration rate = I- O
P
Where I, is the number of in migrants during a specified time to an area, O, the number of out migrants
during a specified time from a given area, and P, the population of the given area at the beginning, mid
point or end of the migration interval. The common practice is to use the mid-point of the migration
interval.
On the other hand, the out migration is regarded as a probability rate and therefore the population at the
beginning of the interval can be used as the denominator. The use and availability of data determines
choice of denominator.

Effectiveness of migration can be measured by relating net migration to gross turn over. This ratio
measure the relative difference between effective addition or loss through migration, and overall gross
movement. It varies from 0-1, and the higher the ratio, the fewer the moves required to produce a given
net gain or loss in the population of an area.

The Balancing Equation Method

In a given area, the number of net migrants during an interval between two censuses can be estimated by
a method of a balancing equation.

Net migration = P t+n _ pt _ nBt +nDt

Where n is the intercensal interval, Pt+n is the population of the area at time t+n, Pt is the population of
the area at time t, nBt is the number of births during the interval t to t+n, and nDt, the number of deaths
occurring during the interval t to t+n,

Methods Using the Life Table or Census Survival Ratios

There are two types of survival ratios. The life table survival ratios , and the census survival ratios. Both
can be used to estimate migration

Net migration = Pt +n, t+n _ Pi,1( Lx+n

Lx
Where, Lx and Lx +n are life table survival ratios calculated as Lx +n/ Lx. derived by dividing population aged x+n at the later census by the population aged x at the earlier
census for the nation as a whole.

Estimates of Internal Migration through the use of data on Place of Birth by Place of Enumeration

The place of birth by place of enumeration statistics are important sources of data for measuring internal
migration in most developing countries. From this two way classification, estimates of in-migration, out-
 migration, net and gross migration rates and inter- regional migration rates can be made for the country
and compared with other estimates.
The major problem is indefinite time periods a since no idea is given about date of arrival or length of
stay or previous migratory movements. The data is also in gross geographic units. There also
uncertainties about geographic boundaries at the time of birth and about reporting of birth place for
babies who were not born at the usual place of residence of their parents. The factor of return migration
makes the use of place of birth and place of enumeration data difficult in distinguishing a migrant and a
non migrant.

Inter regional migration may be estimated as =  nij -  ni = j x 100

N
=  Mij x 100
N
Where, N is the total population, subscript i region of enumeration, j the region of birth, nij is the
number of persons living in the region i and born in the region j.

Impact of migration and health

High fertility rates can predispose a population to high morbidity as a result of competition over scarce
resources. This may trigger migration to other destinations in search of other resources such as land for
settlement or for business or employment. Both migrants and movers can be exposed to diseases in the
process of moving.
Prothero (1989) identified three categories in the relationship between migration and morbidity.

a) Exposure to diseases from movement through different ecological zones or environment. Sleeping
sickness affected a number of migrants and movers this way in the 19th and 20th centuries in East and
Central Africa. In the Busoga region of Uganda, people deserted the area due to tsetse fly. In south
Kigezi of Uganda, it is estimated that between 1949 and 1975, over 24, 000 people were forced to move
to other areas of Uganda due to presence of tsetse fly. The Lambwe valley of South Nyanza in Kenya
was similarly deserted.

Mosquito presence in some regions prevented settlement of large populations. Suna Migori for long
remained unpopulated due to mosquito abundance. It is said that the rural movements in search of
firewood, hunting, or collection of fruits in the forests exposes these people to direct mosquito bites and
hence malaria. Movers and migrants from malaria endemic areas have led to introduction of malaria to
areas which were originally free from it. This way, highland malaria has been introduced from South
Nyanza, Western region and other place.

b) Exposure to diseases from movements including contacts between different groups of people.
Studies in Africa and elsewhere, suggest that mobility has been a key factor in the spread of HIV/AIDS,
and related sexually transmitted diseases. There are a number of reasons why migration is a matter of
concern in relation HIV/AIDS. This is because population movements allow the virus to disseminate, and
because of the possible risky behaviours of those who are mobile. The spread of AIDS originally, spread
through movement of people especially along the highways. A survey by in Uganda found that 30% of truck
drivers were infected with HIV/AIDS along the Busia Kasese Highway(UN,1994).

Yet it is not easy to quantify the impact of migration on the spread of these diseases, nor is it simple to
isolate the overall effect of migration on the likelihood of reducing disease incidence. Migrants not only
transmit and/or suffer from disease, but may also move into areas of economic or cultural circumstances in
which it is easier to combat disease.
Although Small pox has been eradicated, from the world since 1980s when WHO declared it eradicted, the
disease was spread mainly through movement and contact with different persons. Diseases like jiggers,
measles, plague and influenza reached East Africa through contact with Europeans, Asians who brought the
disease from their countries of origin.
In Thailand, opium smugglers and other traders across regions of Burma, Laos and Kampuchea have spread
malaria from endemic regions to areas that were originally non endemic.
In Nigeria, it was found that women who travel long distance to fetch water were more prone to contracting
guinea worm disease. Prothero also found that during religious festivals, pilgrimage and marketing and
trading, the use of contaminated water spread the guinea worm further (prothero, 1989)

Rural-Urban Migration and Health

Migrants’ health-seeking behaviour may be different to that of non-migrants.

In relation to both child and maternal mortality, available evidence suggests that, for rural-urban migrants at
least, migration is associated with improvements in health outcomes, not least because of an increased
utilisation of services in urban relative to rural areas. For example, recent work on rural-urban migration in
Ghana suggests that infant mortality is lower amongst rural-urban migrants compared to rural non migrants,
and that this applies after controlling for socioeconomic characteristics. However, the health status of rural-
urban migrants still often falls short of that of urban residents. One way of considering whether migration
impacts levels of child and maternal mortality overall is to look at the policy interventions that aim at
reducing child and infant mortality, and whether migration helps or hinders such interventions. Key
interventions to reduce child mortality include immunisation against childhood diseases, action to reduce
malnutrition, oral rehydration therapy, HIV/AIDS Interventions, female education and family planning.
Attempts to improve maternal mortality have focused on institutional delivery and the potential for pre-natal
care to highlight risky deliveries. From this perspective, there is some evidence that migration is positively
associated with the spread of female education and family planning. The use of medical services in general
by migrants also appears to increase. However, a key question is whether migrants are already pre-disposed
to seek health services, or whether the act of migration makes them more likely to do so. Here, although
some studies of health-seeking behaviour by migrants are available, they do not provide conclusive
evidence one way or another. For example, a recent study of rural-urban migrants in Mumbai, India, found
migrant women more likely to take up opportunities for prenatal care, but making the same choices
regarding place as rural non-migrants.

However, when rural to urban migration occurs, exposure to and adoption of modern child rearing practices
may result from interaction with more modern segments of the populations as well as access to modern
means of communication such as T.V, Radio, Internet Newspapers and magazine among others. Exposure to
information result in adoption of positive child care practices such as clean food preparation, better storage
of food and health seeking behaviour and hygiene. These reduces incidence of disease.
Urban areas are perceived to have better health care services and facilities. This has resulted in improved
health conditions in urban areas.

Migrants affect health care in areas they migrate from. The more educated people move out of rural areas
leaving behind people of little education. The loss of manpower due to migration stream deprives rural areas
of trained health care personnel. Rural-Urban migration aggravates the disparity between the city and the
rural areas in terms of number of Doctors, nurse, teachers, extension workers and therefore this may lead to
higher morbidity and mortality in rural areas.

However, migrants can also try to improve health in home areas. Migrants send remittances to their
relatives. These remittances have been used to improve living conditions, and hence improved health.

Population growth in urban areas through natural increase and in movements promotes concentrations of
population at densities which favour transmission of some diseases. These movements may introduce in
urban areas diseases or infections common in rural areas.

Failure by governments to provide for expanding population in urban areas has led to growth of informal
settlements with lack of basic sanitary facilities and clean water supply. Nairobi, Lagos, Bombay have
almost 30% of their population living in informal settlements. Many diseases, such as dysentery, typhoid,
and cholera, thrive as a result lack of access to safe drinking water and proper sanitation and proper methods
of waste disposal.
In addition, urban areas attract young people who have just completed school in search of employment
opportunities. The migrants are single, often liberated from the mandates of familial roles and traditional
culture for the first time and they may therefore engage in sexual behaviour that may not have been tolerated
in rural areas. Such behaviour includes unprotected sex, multiple sexual partners, premarital sex, or extra
marital sex, casual sexual relations or sex with commercial sex workers. These practices have led to
increased incidents of HIV/AIDS and STI infections in the urban areas. The concentration of young
unmarried males attracts commercial sex workers in urban areas particularly when employment
opportunities for girls and women are scarce..

Urban areas have certain characteristic diseases, which may be selective of some but not all migrants.
Psychological and psychiatric illnesses due to changing lifestyles, increased pressure on those who are
unemployed or lacking family social and psychological support are common in urban areas. Some of these
pressures often lead to violent behaviour and crime, drug taking, and alcoholism.

The affluent also have a share of these diseases. Due to changes in lifestyle and , feeding habits, heart
diseases , high blood pressure, cardiac arrests, stress, ulcers, depression, diabetes and cancers among others
commonly afflict the well to do.
Migration and Family Planning

Migrants pose a special challenge to family planning programmes. Migrants are concentrated in the child
bearing ages and are generally from rural to urban and from developing to developed regions where
contraception may not be well known and less used than in the urban and developed regions. The migrant
needs for special services varies, depending on how different they are culturally and linguistically from the
usual family planning clients in their place of destination

Generally, the level of contraceptive knowledge and practice among rural to urban migrants falls below
urban levels but rises with duration of residence in the urban areas. This follows taking advantage of the
easy access to contraceptives in the urban areas.

Factors that deter migrants from use of family planning are same as those that deter other FP users. This
consists of high costs, long waits, rude treatment by health professionals, and dependence on rumours for
information.

Therefore, a strategy to extend and improve family planning among the poor, rather than one that that
singles out migrants, may be the most efficient way to reach rural- to- urban migrants. Such programmes
should concentrate on location and quality of the services. Services should be readily available in the
squatter settlements and slums where migrants live, more so that recent migrants may have trouble in
locating urban services.

Distributing contraceptives door-to door or through migrants’ social groups are good ways of reaching them.

Migrants to rural areas also need family planning services. This is important so that population growth
among the migrants will not overwhelm existing resources.

Government population distribution policies

Government policies on resettlement can force and create conditions conducive to spread of diseases.
Organized resettlement in Tanzania forced an otherwise sparsely populated population to concentrate in
villages (ujamaa) so that better social facilities especially schools and hospitals could be provided and living
conditions improved. In Ethiopia, The transfer of a group from highlands to the wetter south west exposed
the population to a range of health hazards to which they were not immune.
The creation of irrigation schemes creates conditions favourable t spread of water borne diseases.
Forced Migration, Mortality and Morbidity

Refugee movements are associated with political disruption and environmental catastrophe. Rapidly
accumulating refugee camps, with lack of sufficient water supply lack of clean water supply, lack of
sanitation and waste disposal facilities provide ideal environments for out break of diseases such as
dysentery typhoid cholera and others. Lack of adequate nutrition predisposes the refugee communities to
malnutrition and hence weak immunity and vulnerability to infections.

Whilst poor migrants in general may be vulnerable to disease, where migration is forced, the impact on
health can be much more severe. This is particularly true where refugees are contained in camps or
detention centres. For example, Physicians for Human Rights have recently raised concerns about how
asylum-seekers are treated when they arrive and are detained in industrialised countries. Their findings
indicate that the experience is often extremely stressful, and can contribute to ill health. There has also been
an impassioned debate on the ‘prison-like’ conditions in refugee camps , and their impact on health.
However, it is not always the case that refugee flight and settlement leads to negative outcomes for health.
For example, monitoring of the health status of Malian refugees in Mauritania during the 1990s shows an
improvement in health outcomes as a result of the provision of health care to a previously nomadic
population beyond the reach of modern medicine.

International Migrants and health.

In some countries, immigrants accompanied by their husbands form a large pool of potential clients for
family planning. Programmes include information, special programmes for immigrants. However, special
programmes can be politically sensitive; partly because international migration itself is a political issue and
partly because of suspicions that the motive for the programmes is eugenic rather than humanitarian.

International family planning programmes face certain challenges, among them; language barriers which
pose an immediate problem. The immigrants may find t difficult to make appointments and discuss their
needs with a Counsellor or doctor.
Family planning personnel have to understand how cultural differences affect their work. For example, they
may not appreciate the importance that their clients place on the male
In family planning decision making, they may not be able to judge when clients fully understand
instructions.
Family planning programmes may have to make special efforts to reach migrants, by making home visits or
by using migrant organizations and individuals to spread information about services
Illegal migrants may actively avoid contact with a family planning organization for fear of being deported.

Family planning programmes that serve temporal immigrants may indirectly reach sending countries as
well, since return migrants often take home positive attitudes and information about family planning.

Over all sympathetic , user oriented approaches that reach migrants enhance the quality of family planning
for no migrants including young people, men, ethnic communities and people with little education.
Improved services for family planning should be an integral part of population distribution policy.
Perhaps the key to achieving health is the provision of adequate and timely health interventions, yet this
may be compromised by the high levels of emigration of health professionals in some countries. A survey of
African countries in 1998, revealed vacancy levels of over 70 percent for medical specialists in Ghana, and
over 50 percent for nurses in Malawi. A number of countries around the world are affected by shortages of
medical personnel as a result of overseas recruitment. However, such high rates of emigration are not
universal. Indeed, migration of health professionals may represent as much a symptom as a cause of poor
health systems in many developing countries.

Codes of conduct to address ‘poaching’ of health professionals from developing countries have been
developed by, amongst others, the UK’s National Health Service and the Commonwealth, but these are not
always entirely effective. It is also important to allow for the professional development of health
professionals, in which a period spent abroad may be highly valuable. As a result, some migrant health
workers may return better equipped and more experienced to augment the provision of health services. This
opportunity is being exploited by some developing countries who are recruiting from the diaspora.

There remain a number of areas concerning the relationship between migration and health. The
Development Research Centre on Migration, Globalisation and Poverty is seeking to improve existing
knowledge on these areas through funding research. For example: There is potential to explore the causes of
change in health-seeking behaviour by migrants, particularly in relation to childbirth and child mortality.
This would help to inform policies that seek to engage with migrants to improve their health outcomes,
rather than treating immigrants as a health risk. There is some evidence of investment in health protection
for families and communities back home by migrants, but the extent of this investment remains un
quantified. The factors which promote health investment – and positive health outcomes – are also relatively
unexplored. Studies of the ‘brain drain’ of health professionals have tended to confine themselves to
analysis of the numbers leaving individual countries, rather than exploring the range of dynamic effects – on
training and labour markets, for example – that might result from such emigration. Ways to encourage the
sustainable return of developing country health professionals also deserves closer scrutiny.
Remittances from international migrants have been used to cater for health care back home.
Return migrants may bring back home health skills and knowledge acquired from te more developed
regions.
The Demographic Transition Theory
The demographic transition theory resulted from the study of trends in fertility and mortality. Need a rose to
formulate population theory in terms of its main components- fertility and mortality. The theory of demographic
transition enquires into the simultaneous behaviour of fertility and mortality through time. The theory derives
from actual historical experience of western countries.

Landry (1909) was the first to describe stages of the demographic transition. He identified three main regimes
of population; the primitive, the intermediate, and the modern.

The primitive regime is characteristic of all living things and is characterized by uncontrolled fertility, though
marital customs prevent fertility from reaching a physiological maximum. No economic factors such as
economic costs of children regulate fertility. Economic factors however, influence mortality through which it
regulates population growth. Population growth will tend to the maximum limit determined by the means of
existence and will reach that maximum when mortality, due to the depressing effect of a growing population on
levels of living will increase and reach and fluctuate around the level of natality.

In the intermediate regime (though not well defined), economic factors will affect fertility through
postponement or foregoing of marriage which results in the decline in birth rates. This is meant to maintain
certain levels of living. Population growth will be affected and will tend to a level below the maximum.

In the modern regime, caused by the demographic revolution, economic factors no longer play the role they had
in the earlier stages; instead, there is conscious family limitation as a result of change in the aspirations of man
concerning his conditions. The decrease in fertility is not indefinite or inevitable.

Thompson (1929), attempted to generalize the demographic experience of Europe into a theoretical framework
which could apply to other areas as well. He grouped the nations of the world into three groups according to the
level of their birth and death rates. Starting with the countries which were at a demographically more advanced
stage, he distinguished;
(a) Countries with very rapidly declining birth rates and death rates, with the former
declining more rapidly so that the growth rate is also declining
(b) Countries with declining birth rates and death rates for certain classes, but with death
rates declining as rapidly as or more rapidly than the birth rate, producing a stable or
even increasing growth rate.
(c) Countries where both birth and death rates are less controlled, but where there is
evidence that the death rates are coming under control faster than birth rates,
producing the likelihood of a very rapid increase in numbers in the future.
Blacker (1947) identified five stages of demographic evolution;
(a) The high stationary stage characterized by high birth rates and death rates;
 (b) The early expanding stage with high birth rates but high and decreasing mortality rates;
(c) The late expanding stage with falling birth rates but more rapidly decreasing mortality;
(d) The low stationary stage with low birth rates balanced by equally low mortality, and
(e) The declining stage with low mortality, lower natality and deaths exceeding births.

Notestein (1945) used experience of European countries to demonstrate the impact of modernization on
mortality and fertility.

Modernization has the effect of reducing death rates through:

 rising levels of living
 improvements in communication
 Improvement in productivity
 Improvement in sanitation
 Development of vaccines and other preventive medicines.

Fertility responded more slowly to modernization, but ultimately began a decline through the widespread
use of contraception under the impact of such factors as growing individualism and rising levels of
aspiration developed in urban industrial living. He distinguished three demographic types or stages of
evolution:
(a) Populations with incipient decline or “transition completed” (United States, Europe, Australia),
characterized by a declining fertility rate to or even below replacement level;
(b) A transitional type of population (Soviet Union, Japan, some countries in Latin America) with a rate of
growth which is still relatively rapid , but where a decline in the birth rate is well established; and
(c) Populations with high growth potentials or transitional growth not yet begun( most of the countries in
Africa, Asia and Latin America) where fertility remains high with no tendency to decline and where the
high , but declining death rate is the main growth factor

Coale and Hoover (1958) developed a comprehensive theory on demographic transition. This was based on
economic development and on the experiences of the industrialized countries.

According to this theory, agrarian society has high death and high birth rates, with death rates fluctuating as a
consequence of variations in crop production and varying incidences of epidemics, poor diets, primitive
sanitation and absence of effective preventive and curative medical practices. However, as the economy
progresses to become more interdependent specialized and market- dominated, the average death rate begins to
decline under the impact of better organization and improved medical knowledge and care.

Some what later, the birth rate begins to fall. The births and the death rates pursue a more or less parallel down
ward course with the decline in of birth rate lagging behind.

Finally as further decline of death rate become harder to attain, the birth rate again approaches equality with the
death rate and a more gradual rate of growth is established with low risks of mortality and small families as the
typical pattern. Mortality rates then become relatively stable from year to year and birth rates respond to
voluntary decisions rather than deeply embedded customs.

The idea of demographic transition has been widely adopted and is frequently applied in generalized
descriptions of population evolutions. Some writers have emphasized its limitation as a theory because it is
linked to the experiences of western European countries whose historical experiences were not uniform and
may not be replicated elsewhere. Social experiences and industrialization may produce different patterns of
demographic transition case of Russia. Other writers noted that the tempo of change in some countries is faster
than that in Europe, especially with regard to rapid decline of mortality. This is attributed to medical
interventions. In some European countries, fertility fell before major decline in mortality).
Other critics view demographic transition as a description of historical events that have occurred in some
western countries with irregularity and not so much of a theory.

Other critics of this theory, such as Lebenstein (1954) point out that mortality response to modernization may
vary according to levels of income, until a certain level beyond which it has little effect on mortality. Others
such as Nelson, argue that income, investment and population growth affect one another to the extent that
changes in population growth can only result from mortality, which is determined by the level of per capita
income. Lebenstein (1956) argues that mortality is negatively related to income because higher wages, better
food, shelter, medical care associated with an increase in income will lower mortality. The experience of
western countries clearly demonstrates mortality response to modernization.

The demographic transition theory has for long influenced programmes aimed at reduction of mortality levels
and in formulation of health policies and interventions in many parts of the world.. Most public health systems
are guided in principle by the theory of demographic transition. (See mortality and health policies).
On the contrary, the widespread poverty in Africa, particularly in rural areas or in urban slums with lack of
sanitation, pure water, food, education and health services is maintaining high levels of mortality and morbidity
in developing countries. In order to break this vicious cycle, one has to intervene in the physical and social
environment by provision of sanitation, pure water, immunization, sufficient food and health education..

Population Policies

Definition of population policy

Policy in general is defined as a set of objectives a long with the measures and means to achieve them.

Population policy can be defined in a narrow sense as being concerned only with efforts to affect the size,
structure, distribution or characterristics of the population, or it may be conceived of in the much broader
sense of including efforts to regulate economic and social conditions which are likely to have demographic
consequences.
Spengler and Duncan define population policy as specific set of government objectives relative to the
population magnitude and or composition along with the instruments by which it may be possible to achieve
those objectives.

Eldridge(1954) defined population policies as legislative measures, administrative programmes, and other
government action intended to alter or modify existing poulation trends in the interest of national survival
and welfare.

Population polcicy is therefore understood in the more restricted sense , as positive deliberate action by
government taken expressely to facilitate achievement of adopted goals relative to population size, growth
and composition in the interest of national well-being(Eldridge, 1968).

Main purpose of population policy is to control population size and also its composition and geographic
distribution. In a country, before developing population policies, look at the demographic trends, then set
goals you need to achieve. The goals are placed in a kind of frammework . The dicide on the programmes to
achieve the goals. Population policies can be independent of economic goals. However, it is important to
think of socio-economic framework through which the goals are to be implemented.

Some population policies are responsive and these aim at qualitative improvements through general
development efforts and other policies are influencing and these attempt to influence one or more of the
demographic variables.

The contol of population size may be influenced through any of the three components of population change
fertility, mortality and migration. The reduction of mortality is a concern of all governments and therefore
mortality policies are generally viewed as health policies because their purpose is to improve health rather
than to affet the rate of population growth.

Legislation regulating international migration is almost universal among nations.

Evolution of Population Policy

Population matters became significant in the writing of social scientists and in the deliberations of
governments. In the later part of the 19th century, population in Europe declined, this became a concern.
After the Second World War, some countries in Europe realised increased population growth. In the
developing countries, the introduction of medical technology and public health measures, coupled with
improved social conditions, led to a decline in mortality. Declining mortality coupled with rising fertility led
to increase in population growth. Concern over growing population was raised at International for a Rome
1955, Mexico 1984, and ICPD 1994.

The year 1974 was declared by UN as World Population year. The third World Population Conference was
held at Bucharest in the same year. It brought together high ranking government officials and experts. The
agenda by the USA was to endorse Family Planning programmes. The Asian countries opposed the move
insisting that development was the best contraceptive.
The world population plan of action was adopted however. It was about development.
Population policies addressed mortality and migration in addition to fertility in terms of social programmes
that influence demographic variables other than family planning. In developing countries, it was noted that
rapid population growth constrained development. At Mexico 1984, attention focused on development as
ultimate contraceptive. The US advocated for free market economy as the only way to modify population
trends.

Evolution of Population Policy since 1984

By 1991, the world population was 5.4 billion people. The growth rate was 1.7 % per annum. These were 90
million additions per year yet resources are fixed. In 2011 the population reached 7 billion. Estimates are
that Africa has the highest population growth rate followed by Asia, ad Latin America. Some Countries in
Arabia have even shorter doubling time with TFR of 8 children.
The target of all population policies should be in those areas where effect is most. Health and education are
goals that are instrumental in achievement of fertility and mortality reduction. Weight should be given to
these specific areas. If the major issue in a country is economic setting, then these should be emphasized in
the policies. A good policy takes advantage of those issues that would give it the greatest impact.

The need to regulate Population growth

Reasons for the need to regulate population growth result from
 Mounting pressure on human needs and on non renewable and biological resources
 Environmental pollution and degradation
 Food crisis
 Pressure of migration within and between countries
 Unprecedented rates of urban growth
 High population growth rates contributed to persistent poverty
These factors have led to the need to modify population growth and also the need to stabilize population
growth in the shortest time possible.

Demographic goals
Most population policies set goals to reduce
 Population growth rates say from 2.8 to 1.7 % depending on the rate of growth
 Reduction in Total fertility rate (TFR)
 Increasing level of contraceptive prevalence
 Extending family planning information and services
 Family planning recognized as important in fertility reduction
 Improved levels of education and
 Rising standards of living especially for women
Demographic ageing
This was an issue in developed countries. Anticipated ageing by year 2150 and increase in median age to 42
years by 2150. More flexible retirement policies are used to address the issue. There are also attempts to
meet the needs of the elderly in some countries. The government has to meet this responsibility through
medical schemes, allowances and any other.
Fertility and Family Planning
Most governments have adopted policies to regulate fertility. In this regard, governments support
contraception. This is done by ensuring availability of family planning services. This includes ensuring
provision of quality services, availability of commodities, training of personnel and provision of counselling
and education services.

Contraceptive prevalence has increased in most countries. Several million births have been averted through
family planning use. The demand for family planning is on the rise. It surpasses supply. Unmet need is high.
In some countries however, knowledge of family planning is still limited.
Good quality FP services, political and administrative support and innovative public education efforts can
produce changes in reproductive behaviour.
There is a realization that FP services be offered alongside efforts to improve social and economic
conditions though primary health care, education, employment, housing, legal reforms to strengthen role
and status of women.
Family planning programmes are sophisticated involving community based distribution (CBDs)
contraceptive social marketing programmes, and active use of mass media, to promote ideas of birth spacing
and family limitation and also to provide information on specific methods.

Programmes have give attention to adolescents to address adolescent fertility and sexual health. The
involvement of men in this regard as partners, opinion leaders and major decision makers has been found to
be important in the success of FP programmes.
Governments have given equal protection under the law, the right to women to earn and inherit property,
raising legal age at marriage and eliminating such discriminatory customs against women.
Some countries have legalized abortion, but this remains a controversial issue though of public health
concern.

Mortality and Health

World wide, mortality has reduced, and health has improved. Life expectancy has improved though some
countries in the developing regions have life expectancy under 50. Infant mortality is reduced and
immunization coverage increasing.

In developing countries, there is concern over Cholera, respiratory diseases, T.B, Malaria, Schistosomiasis
and STIs. The region has shortage of medical and health care personnel. In addition, there is uneven
distribution of health services with most facilities concentrated in urban areas.
The growing elderly population and rising lifestyle diseases are another concern.
With regard to health care, there has been a shift since Alma Ata 1978 to preventive care( primary).
UNICEF is a lead agency in growth monitoring, ORS, Breast feeding, Immunization, food supplementation
and FP.

Policy Responses
1. Child health and survival
The strategy followed for reducing child mortality and morbidity has undergone major revisions.
Because of many challenges faced by developing countries in the provision of primary health care a
more selective approach to primary health care was used in these countries. Effective interventions
that were able to have a quick impact on mortality and morbidity were preferred.
The adoption by the forty second World Health Assembly in 1989 of an agenda for the Expanded
Programme on Immunization in the form of time-bound and measurable goals became focus for
 strategic development. This received political commitment, and increased resource mobilisation and
accountability. The developing countries found the approach practical since most of these countries
lacked capacity building systems in data collection so vital in tracking of child health or basic
programme monitoring. The goal approach was endorsed at the highest political level at the world
summit for children in 1990. The ICPD-1994 reaffirmed goals for children with emphasis on
reduction in infant, child and maternal mortality. The main focus of the goals are;
 The control or elimination of major childhood diseases,
 Immunization against six major childhood diseases(diphtheria, pertussis, tetanus,
measles, poliomyelitis and tuberculosis,
 Promotion of breast feeding
 Elimination of micronutrient deficiency disorders by means of salt iodization and
Vitamin A supplement
 Elimination of water and food-borne disease vectors through improved sanitation
and access to safe water
 Home management of diarrhoea by use of oral rehydration
 Case management and treatment of acute respiratory infections by use of
 antibiotics.

Women’s health and safe motherhood

Pregnancy and childbirth is a problem in developing countries especially sub-Saharan Africa. WHO
estimates that about half of the women in the developing countries still give birth without any trained
assistance and cannot reach medical help in case of an emergency. As part of the Global strategy for Health
for All, WHO is collaborating with countries to ensure that all women have community based maternity care
during pregnancy and delivery, and access to a hospital or clinic in the case of emergency obstetric
complications. WHO is at the forefront to improve the health of women, to reduce maternal mortality with
fourfold strategy.
a) Reducing social inequalities
b) Ensuring access to FP services and information
c) Developing community based maternity care
d) Providing back up for those women who require skilled obstetric care.

An increasing number of countries have taken initiatives to improve maternal mortality. These
include:
 implementation of Safe Motherhood Programme.
 Other countries have established maternity waiting homes near maternity near
maternity hospitals for women in later stages of pregnancy. These countries include
Ethiopia, Zimbabwe, Malawi, Bangladesh, Cuba, Indonesia, Mongolia, Nicaragua,
Mozambique;
 Kenya has a compulsory screening programme to detect anemia, rubella, diabetes
and other high risk diseases during pregnancy.
 The Philippines promoted the four pillars of Safe Motherhood by encouraging
family planning, quality prenatal care, clean safe deliveries and emergency obstetric
care.
 In Fiji, rural maternity services and 100% hospital births were promoted.
 In Canada, the government established five centres of excellence for women’s
health. Many federal institutions address issues concerning women’s health
 including reproductive health, breast cancer, women and AIDS , violence against
women, and inclusion of women in clinical trials.
 Australia has a National Women’s Health Policy which focuses on issues such as
reproductive health and sexuality; health of aging women; women’s emotional and
mental health; violence against women; occupational health and safety and health of
needs of women as care givers.
 In Israel, health insurance for women covers obstetrics, gynaecology, fertility
treatment and early detection of breast and uterine cancers.
HIV/AIDS

HIV/AIDS is of concern in both developed and developing countries. This is because the disease prevalence
is high and the pandemic so complex and diverse. The risk of exposure to the virus is very high. This has
diverted resources from other health and development issues. A lot of research has been devoted to it. The
epidemic is dynamic and increasing globally. Sub Saharan Africa is hard hit by the virus. Two thirds of
people living with the virus are in sub-Sahara Africa a region hard hit with inadequate resources to tackle
the problem. The virus is quickly spreading to all over the world including S.E Asia where it took time to
spread.

The Global AIDS strategy focuses on;

 Better treatment and prevention programmes for other sexually transmitted diseases
 Prevention of HIV infection through improvement of women’s health, education and status
 Greater support to prevention programmes.
Measures taken by governments to control spread of the virus are;
 Establishment of AIDS control and prevention programmes,
 Information, education and communication programmes
 Training of health-care workers
 Epidemiological surveillance of AIDS cases
 Sensitization and public awareness campaigns
 Systematic tasting of blood donors,
 Promotion of safe sex and the use of condoms as a preventive measure
 Screening of high risk groups.
 Prevention of mother to child transmission through the use of Zidovudine(AZT)
 Care and support of children orphaned by AIDS
 The use of disposable syringes
 Establishment of VCT centres
 Cuba has compulsory screening of entire population and the quarantine of all HIV
positive persons
 The participation of non governmental organisations and people living with HIV/AIDS in
designing and implementing HIV/AIDS related policies and programmes.
 Establishment of a health committee for gay people in Norway
 Organised support groups for people living with AIDS.
 Support for behavioural research and biomedical research
 Encouraging couples to practice safer sex
 Prevention of discrimination against HIV/infected personnel
 Activities to deal with complacency and denial
 Life style diseases
Voluntary health risks such as tobacco use and alcohol consumption, contribute to higher mortality
both in developed and developing countries. However, there is evidence of declining tobacco use in
developed countries but rising levels of use in the developing countries.
Policy responses include;
 Restrictions on the sale of tobacco products
 Health warnings on the cigarette packets
 Higher prices of cigarettes through additional taxes
 Ban on smoking in public places
 Anti smoking campaigns that target young people
 Access to counselling and support groups for people willing to stop smoking

There is evidence of reduction of deaths resulting from lung cancer in some countries. The United
Kingdom and Finland are some of these countries.
The mortality consequences of the use of Alcohol have also elicited a broad range of policy
measures
These policies include;
 Regulating the production and sale of Alcohol
 Increasing the probability of being arrested while drunk driving e.g. by use of Alco blow
 Training health workers to recognise alcoholism and to help rehabilitate alcoholics.
 Limiting hours of drinking and purchasing alcohol
 No sale of alcoholic drinks to minors
 No sale of alcohol to intoxicated persons in Canada, the United States, and the
Netherlands.
 Legal limit of blood alcohol concentration in many countries for drivers, pilots
 Use of educational programmes and dissemination through the mass media.

Economic Goals
1. Accelerated economic growth
 Countries want to develop and improve. The population policies must be supported by a dynamic
economic process.
 Increased per capita income and fair income distribution
 Agricultural development
 Rural development
2. Women in development
Formerly, governments paid little attention to women. Governments have however realized that
unless women are empowered economically the government cannot achieve set goals.
Some governments have developed gender policies aimed at equity in access to education and
employment. Creation of women representatives in the constitution of Kenya, access to financial facilities
and others. What women are expected to achieve must be stipulated.
3. Environmental goals
Population has a lot of destruction on the environment.
Policies for environmental protection must be developed
4. Poverty reduction
Poverty is linked to income distribution. Many countries do not achieve fair distribution of income.
Poverty can interfere with achievement of population policies. Poverty can bring all policies to a
standstill.

Policies to tackle poverty, inequality and social exclusion

 Tackling low income through minimum wage, taxation of high income earners, and financial support
to poor families
 Job creations and improvement of employment opportunities
 Community development initiatives
 Reducing crime rate
 Addressing housing needs of deprived groups through development of descent housing
 Reducing number of homeless people
 Drug and alcohol abuse prevention programmes
 Prevention of teenage pregnancy
 Tackling health inequalities through strategic planning, creation of health living centres, health
community collaboratives and development of national targets to reduce health inequalities.
International Migration
Few countries have adopted migration policies for demographic reasons. Many governments have
expressed satisfaction with levels and trends of immigration and emigration. Majority of countries have
no control beyond the visa and passport. Others have policies to attract migrants- e.g. the green card in
the USA. A number of countries prefer temporal rather than permanent workers.

European countries are concerned with problems related to the economic, social and cultural integration
of legal immigrants, the growing number of asylum seekers, and the possibility of large scale population
movements following the disintegration of Russia and Eastern Europe. There is also concern over
growing hostility to immigrants in many host countries. In addition, there are unknown consequences of
abolition of boarder controls at frontiers of European community

North Africa and West Africa had policies of importing workers in project packages. Some crisis in the
world have also focused attention on the plight of migrant worker should war arise as it did during the
gulf crisis or the war s in Afghanistan and Pakistan. The repatriation of foreign workers during the gulf
crisis led to a realization of the problems of return migrants in some of the poorest countries.
Other issues concern undocumented migration
The refugee problem is a major concern. Kenya has carried a heavy burden of hosting refugees from her
neighbouring countries owing to political instability in those neighbouring countries coupled with
persons fleeing from generalized oppression and poverty.

Population distribution and urbanization policies

Currently, world countries are experiencing concentrations of people in urban areas. The numbers keep
growing.

Policy responses
Most governments aim at population redistribution through
 Investment in rural infrastructure
 Attraction of urban residents to rural areas
 Rural development strategies are important for expanding food production and improvement of
agricultural productivity not because they offer solution to migration. It so happens that as most
areas develop, people continue to migrate. It is better to meet needs of urban areas.
 In many developing countries, population distribution policies are same as measures to control
growth of cities
 Some countries promote development of new towns, but usually very slow
 Others promote small towns and intermediary cities but how to go about it is an issue
 Others built new capitals , but many stall or cut back
 Regional development policies for areas lagging behind but the main issue a rises from politics
especially in allocation of resources.
 There are also issues of implementation of population distribution policies
 Lack of consistency in explicit population distribution policies.
 There are also macro policies and spatial policies that have harmful spatial impacts e.g. irrigation
schemes
With regard to urbanization policies, it is evident that most urbanization policies have very little to
do with size but failure to manage rapid urban population growth. Municipal revenue systems are
poor, there gaps in urban services and clear evidence of neglect, and failures of urban management.