key: cord-0806265-zjahhnfd authors: You, Danzhen; Beise, Jan; Lee, Sinae; Requejo, Jennifer; Strong, Kathleen title: Demographic challenges and opportunities for child health programming in Africa and Asia date: 2021-03-18 journal: BMJ DOI: 10.1136/bmj.n19 sha: 0ff5f6cdf15259eb72bcae95077ceb6c7667f4c0 doc_id: 806265 cord_uid: zjahhnfd Danzhen You and colleagues call for child health programming to take into consideration changing population sizes and dynamics Demographic challenges and opportunities for child health programming in Africa and Asia All population data (estimates and projections) in this paper are based on the World Population Prospect 2019 1 and the Revision of World Urbanization Prospects 2018 2 by the United Nations Population Division (UNPD). Possible implications of using alternative population projections published recently by the the Institute for Health Metrics and Evaluation (IHME) 3 are discussed further down together with other "limitations". Data on coverage of skilled birth attendant are produced by UNICEF and WHO 4 and data on the health work force (doctors, nurses and midwifes) are from WHO's Global Health Observatory. 5 Scenario based projections are made to show the impact of population growth on health services, using skilled birth attendant and health work force as examples as illustrated in figures 4 and 5. Detailed methods are described below. Figure 4 shows the implication of Africa's increasing numbers of births on the resources needed at the example of births attended by a skilled provider. The authors calculated the additional births to be assisted due to increasing numbers of births in 2020-2050 (based on UNPD's projection on births), if coverage of skilled birth attendant remains at the level of 2019. The additional number of births that need to be assisted each year was calculated by subtracting the number of births assisted in 2019 from the total number of births that need to be assisted if the coverage of skilled birth attendant remains at 2019 level (births multiplied with the coverage of skilled birth attendant in 2019). The calculations were done for each year at country level and aggregated to obtain the number for Africa as a whole. Figure 5 shows the number of health service providers (doctors, nurses and midwifes) in Africa for 2018 and its required change under different scenario. The calculation of the number of health service providers and their density was based on UNPD's population data and WHO's data on the number of medical doctors and of nursing and midwifery personnel (health work force -HWF) 6 and were done on the country level before aggregating to the regional level. Regional averages were used for countries without data or with outdated data. For each country the latest data point was used (separately for medical doctors, and nurses and midwifes) and only if both data points were not older than five years (valid range: 2014-2018). Out of 54 African countries, 49 countries had valid data according to the selection criteria (representing 95 per cent of the African population). The density for health service providers was calculated using population data for 2018. Calculations on health workers needed were done based on two scenarios: 1) keeping the density constant over time at the 2018 level. The total number of health workers needed was derived by multiplying the population in 2030 (or 2050) with the 2018 HWF density; 2) meeting the WHO minimum standard of density (44.5 doctors, nurses and midwives per 10,000 inhabitants). In this scenario, the total number of health works needed was calculated by multiplying the population in 2030 (or 2050) and the WHO minimum standard of density. In both scenarios, additional number of health workers needed was derived by subtracting the number of health works in 2018 from the total number of health workers needed in 2030 (or 2050). Calculations were done separately for 2030 and 2050. This publication uses the latest projections from UNPD 1 to illustrate population changes over the next 10 to 30 years. Projections published recently by IHME 7 differ overall only slightly from the one from UNPD when considering the time horizon applied here (2030 and 2050). For example, while UNPD projects the global population for 2030 to be 8.5 billion, IHME's estimation is 8.6 billion (0.5 per cent difference). For 2050 the respective projections are 9.7 billion (UNPD) and 9.5 billion (IHME) representing a difference of 2.2 per cent. Larger differences can be observed concerning fertility measures and specific regions such as Sub-Saharan Africa. 8 The value of any population projection is limited by the possibility of unforeseeable events, may it be conflicts, disasters or simply extreme or exceptional policy changes or interventions which influence population trajectories in an unexpected way. 9 Nevertheless, United Nations population projections proofed to be very reliable on relatively short time horizons as applied in this paper. Another limitation concerns the data on the health workforce, which was not available for all countries in Africa, were partially outdated, or in few cases could have been subject to recent drastic political processes. Data were included in the analysis when not older than five years before the latest available data point (2018) resulting in available data from 49 out of 55 countries covering 95 per cent of the continent's population. Libya is ranked second in Africa in terms of density of health work force with 86 doctors, nurses midwifes per 10,000 population and a reference year of the data of 2017. If this number still reflects the reality after years of ongoing and violent internal conflict is not sure. However, in the overall setting of the analyses the described limitations are not large enough to influence the results significantly or alter the main messages. The paper does not fully address heterogeneities in population size and changes, urbanization trends, current status of health services and outcomes for different subregions and countries, given the limited space. However, many subregions and countries in Africa also share similarity in population changes in the next 30 years and the potential gaps in health service provision (see Figure A6 for one example). The main messages in the paper hold validpopulation growth and unplanned urbanization will pose additional challenges to many countries in Africa to provide health services to children and for many countries in Asia, urbanization and urban inequity also pose challenges; and it is important for each region or country to take demographic changes into account in health programming. Figure Note: Analysis based on countries with available data on both doctors, and nurses and midwives not older than 2014. Regional aggregates were calculated using weighted averages. The WHO minimum threshold of density is 44.5 skilled health professionals per 10,000 population. Numbers are rounded to second significant digit. Source: UNICEF analysis based on WHO Global Health Observatory, http://apps.who.int/gho/data/node.main.SDG3C?lang=en, accessed on 26 October 2020. United Nations, Department of Economic and Social Affairs United Nations, Department of Economic and Social Affairs