Angola - Multiple Indicator Cluster Survey - 2000

Publication date: 2000

:';.'~.f~::: \ Republic of Angola Government of Unity and National Reconciliation National Institute of Statistics MICS Multiple Indicator Cluster Survey Assessing the Situation of Angolan Children and Women at the Beginning of the Millennium Analytical Report Permission to reproduce any part of this publication is not required, except for commercial purposes. Acknowledgement of source requested. © INE/UNICEF. Luanda, Angola, 2003. The points of view expressed in this publication are the responsibility of the authors and do not . necessarily reflect the opinion of the National Institute of Statistics. Acknowledgements INSTITUTION RESPONSIBLE FOR THE SURVEY National Institute of Statistics (INE) TECHNICAL SUPPORT United Nations Children's Fund (UNICEF) FINANCIAL SUPPORT United States Agency for International Development (USAID} Office for Foreign Disaster Assistance (OFDA) National Institute of Statistics (INE) United Nations Children's Fund (UNICEF) TECHNICAL AND NATIONAL CO-ORDINATION TEAM Kodi Samba- National Co-ordinator- INE Ana Paula Machado -INE Walter Cavero - UNICEF Jean Dupraz - UNICEF ANALYSIS OF SURVEY RESULTS AND REPORT ELABORATION Jean Dupraz (Co-ordinator) - UNICEF Ndola Prata- Consultant, Berkeley University Kodi Samba- INE Ana Paula Machado -INE Lisa Chapman- Action Against Hunger Claudia Plock -Action Against Hunger Mary Daly - Christian Children's Funds Alan Cain - Development Workshop Oscar Castillo - UNICEF Abubacar Sultan- UNICEF Jorge Mariscal - UNICEF Patricia Fernandes - UNICEF EDITORS James Elder- UNICEF Patricia Fernandes - UNICEF REPORT DESIGN AND PHOTOGRAPHY Giacomo Pirozzi Table of Content Foreword 13 ii Summary Table of Main Indicators 14 iii International Goals and Targets for Children and Women 17 iv The Millennium Development Goals 18 1 Survey Scope 21 2 Assessing Vulnerabilities 23 3 Demographic and Household Characteristics 26 4 Infant and Under-Five Mortality 34 5 Malnutrition 40 6 Breast-feeding 49 7 Salt lodisation 54 8 Vitamin A 58 9 Malaria 63 10 Diarrhoeal Diseases 67 11 Water, Sanitation and Hygiene 70 12 Acute Respiratory Infections 77 13 Maternal Care 80 14 Immunisation 87 15 Poliomyelitis 93 16 Measles 96 17 Maternal and Neonatal Tetanus 99 18 HIV and AIDS 101 19 Youth and HIV/AIDS 114 20 Contraception 117 21 Basic Education 120 22 Literacy 127 23 Orphaned and Separated Children 131 24 Birth Registration 135 25 Child Labour 139 Annex - Methodology 143 Bibliography 148 List of Tables, Graphs, Maps and Boxes 1. Survey Scope Table 1.1 Map 1.1 Survey sample and response rate The six MICS regions 2. Assessing Vulnerabilities Graph 2.1 Graph 2.2 Graph 2.3 Chronic malnutrition prevalence in children according to wealth index quintile Mortality among under-five children according to mothers' education levels Percentage of children attending the second level of basic education per socio- economic quintile 3. Demographic and Household Characteristics Table 3.1 Table 3.2 Table 3.3 Graph 3.1 Graph 3.2 Graph 3.3 Graph 3.4 Graph 3.5 Map3.1 Map 3.2 Population distribution by age, area of residence and masculinity index Household size according to area of residence Distribution of households according to their means of transportation Total population by sex and age group, Angola 2001 Masculinity index among the population between 0 and 50 years of age Masculinity index per region Percentage of households with access to electricity by region Percentage of households with access to electricity by wealth index quintile Percentage of households owning a radio Percentage of households owning a television 4. Infant and Under-Five Mortality Table 4.1 Graph 4.1 Graph 4.2 Graph 4.3 Graph 44 Map 4.1 Map 4.2 5. Malnutrition Table 5.1 Graph 5.1 Graph 5.2 Graph 5.3 Graph 5.4 Graph 5.5 Map 5.1 Infant and under-five mortality rates, Angola, 2001 Differentials in mortality by mothers' education level Differentials in mortality by wealth index quintile Differentials in mortality by sex Differentials in mortality by area of residence Under-five mortality rate in the world in 2001 Under-five mortality rate in Africa in 2001 Stunting, wasting, and underweight malnutrition prevalence among under-five children, Angola, 2001 Stunting prevalence by age group Wasting prevalence by age group Wasting prevalence per region Underweight prevalence by age group Underweight prevalence according to mothers' education level Chronic malnutrition prevalence among under-five children 6. Breast-feeding Table 6.1 Graph 6.1 Graph 6.2 Summary table of breast-feeding indicators, Angola, 2001 Percentage of infants exclusively breast-fed by age group Selected breast-feeding indicators by region 7. Salt lodisation Table 7.1 Map 7.1 8. Vitamin A Table 8.1 Table 8.2 Graph 8.1 9. Malaria Graph 9.1 Graph 9.2 Percentage of households consuming adequately iodised salt, Angola, 2001 Percentage of households consuming adequately iodised salt Percentage of children who ever received vitamin A supplementation by age group and method of delivery High-dose vitamin A supplementation among children 6 to 59 months and mothers 15 to 49 years Percentage of mothers receiving vitamin A according to level of households' wealth Fever prevalence among children by age groups Percentage of children under five years of age using mosquito nets (treated or not) by wealth index quintile International Goals and Targets for Children and Women Through a series of world summits, conferences and UN General Assembly special sessions, the international community has set a series of goals and targets to promote the well-being of children and women. The first such event was the World Summit for Children held in 1990, when world leaders committed to achieve a series of 27 goals aiming to improve the lives of children and women. At the beginning of the millennium, the Secretary General of the United Nations reported to the General Assembly on the progress made towards these goals in a report entitled "We the Children". This report was mainly based on information gathered by countries around the world through household surveys such as MICS. In his report, the Secretary General stated to the children of the world: "We, the grown- ups, have failed you deplorably". During the Millennium Summit held in New York in September 2000, attended by 189 countries, the international community and the Government of Angola adopted a declaration that reiterated the goals and targets of the World Summit for Children and set additional goals to be achieved by 2015 to reflect emerging issues, such as HIV and AIDS. This set of eight goals and 18 targets, which were unanimously approved, are known as the Millennium Development Goals (MDGs). Most recently Angola and the international community reaffirmed their commitments to children and women at the May 2002 Special Session of the UN General Assembly on Children. During the Special Session, Nations reaffirmed their obligation to take action to promote and protect the rights of each child, as defined in the Convention on the Rights of the Child. Nations also reiterated their commitment to complete the unfinished agenda of the World Summit for Children and build a strong foundation for attaining the 2015 MDGs. The outcome document of the Special Session, "A World Fit for Children", outlined this decade's promises from world leaders and governments to children around four priority areas: namely promoting healthy lives, providing quality education, protecting children against abuse, exploitation and violence, and combating HIV/AIDS. For each of these areas a set of specific goals and targets were established in line with the MDGs. The Millennium Development Goals Goals and targets to be achieved by 2015 Goal1 Target 1 Target 2 Goal2 Target 3 Goal3 Target 4 Goal4 Target 5 GoalS Target 6 Goal6 Target 7 Target 8 Goal7 Target 9 Eradicate extreme poverty and hunger Reduce by half the proportion of people living on less than a dollar a day Reduce by half the proportion of people who suffer from hunger Achieve universal primary education Ensure that all boys and girls complete a full course of primary schooling Promote gender equality and empower women Eliminate gender disparity in primary and secondary education preferably by 2005, and at all levels by 2015 Reduce child mortality Reduce by two thirds the mortality rate among children under five Improve maternal health Reduce by three quarters the maternal mortal ity ratio Combat HIVIAIDS, malaria and other diseases Halt and begin to reverse the spread of HIV/AIDS Halt and begin to reverse the incidence of malaria and other major diseases Ensure environmental sustainability Integrate the principles of sustainable development into country policies and programmes; reverse loss of environmental resources Target 10 Reduce by half the proportion of people without sustainable access to safe drinking water Target 11 Achieve significant improvement in lives of at least 100 mil lion slum dwellers, by 2020 Goal 8 Develop a global partnership for development Target 12 Further develop an open trading and financial system that is rule-based, predictable and non-discriminatory. Includes a commitment to good governance, development and poverty reduction - nationally and internationally Target 13 Address the special needs of the least developed countries . This includes tariff and quota-free access for their exports, enhanced debt relief for heavily indebted poor countries, cancellation of official bilateral debt and more generous official development assistance for countries committed to poverty reduction Target 14 Address the special needs of landlocked and small island developing states Target 15 Deal comprehensively with developing countries' debt problems through national and international measures to make debt sustainable in the long term Target 16 In co-operation with the developing countries, develop decent and productive work for youth Target 17 In co-operation with pharmaceutical companies, provide access to affordable essential drugs in developing countries Target 18 In co-operation with the private sector, make available the benefits of new technologies - especially information and communications Goals of the World Fit for Children Promoting healthy lives Promoting quality education Combating HIV/AIDS Protecting against abuse, exploitation and violence Congruence between the World Fit for Children Goals and the Millennium Development Goals Millennium Development Goals Goal 1: Poverty and hunger Goal 4: Child mortality Goal 5: Maternal health Goal 6: HIV/AIDS, malaria and other diseases Goal 7: Environmental sustainability Goal 2: Universal primary education Goal 3: Gender equality and empowerment of women Goal 6: HIV/AIDS, malaria and other diseases Goal 3: Gender equality and empowerment of women Millennium Summit Declaration Section 6- Protecting the Vulnerable The Millennium Development Goals and the MICS results, Angola 2001 Target: Halve, between 1990 and 2015, the proportion of people who suffer from hunger Underweight prevalence Stunting prevalence Wasting prevalence Goal 2: Achieve universal primary education Target: Ensure that, by 2015, children everywhere - boys and girls alike - will be able to complete a full course of primary schooling Net primary school attendance rate Children reaching Grade Five Literacy rate of 15 to 24 year olds Goal 3: Promote gender equality and empower women Target: Eliminate gender disparity in primary and secondary education preferably by 2005 and to all levels of education no later than 2015 Target: Between 1990 and 2015, reduce by two-thirds the under-five mortality rate Target: Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio Literacy rate among 15 to 24 year olds: male/female Net primary school attendance rate: male/female Goal 4: Reduce child mortality Under-five mortality rate Infant mortality rate OPT immunisation coverage Measles immunisation coverage Polio immunisation coverage Tuberculosis immunisation coverage Children protected against neonatal tetanus Home management of diarrhoea Goal 5: Improve maternal health Antenatal care Childbirth care Mothers receiving vitamin A supplementation Goal6: Combat HIVIAIDS, malaria and other diseases Target: Halt and begin to reverse the spread of HIV/AIDS by 2015 Target: Have halted by 2015, and begun to reverse, the incidence of malaria and other major diseases Knowledge of preventing HIV/AIDS (total population) Knowledge of misconceptions of HIV/AIDS (total population) Knowledge of mother-to-child transmission (total population) Attitude to people with HIV/AIDS (total population) Proportion of population 15 to 49 years who have been tested for H IV Proportion of population 15 to 49 years who know where to get a HIV test Contraceptive prevalence rate (total population) Bed nets Malaria treatment Goal 7: Ensure environmental sustainability Target: Halve, by 2015, the proportion of people without sustainable access to safe drinking water Target: By 2020, to have achieved a significant improvement in the lives of at least 100 million slum dwellers Use of safe drinking water Use of sanitary means of excreta disposal 31 percent 45 percent 6 percent 56 percent 76 percent 71 percent 83 percent/63 percent 55 percent/56 percent 250 per 1 ,000 live births 150 per 1 ,000 live births 34 percent 53 percent 63 percent 69 percent 62 percent 7 percent 66 percent 45 percent 29 percent 20 percent 18 percent 29 percent 45 percent 2 percent 26 percent 6 percent 2 percent 61 percent 62 percent 59 percent Survey Scope Carried out in all 18 provinces of the country, the MICS covers 6,252 households or a total of 29,811 people in urban and rural areas. About two-thirds of the population was surveyed in urban areas (66%) and one-third in rural areas (34%). A total of 5,663 children under five years of age and 7,089 women aged 15 to 49 years were interviewed with an overall good response rate of 94%. Data collection in the field was conducted during a six-month period, from April to October 2001 '. Table 1.1: Survey sample and response rate Households Number of households selected Number of households found Number of households surveyed Response rate Women (15 to 49 years) Total number of women found in households Total number of women interviewed Response rate Children (below five years of age) Total number of children found in households Total number of children interviewed Response rate Map 1.1: The Six MICS Regions ' See Methodology in Annex. Areas of residence Urban Rural Total 4,080 2,580 6,660 4,056 2,568 6,624 3,852 2,400 6,252 95 93.5 94.4 4,750 2,350 7,100 4,745 2,344 7,089 99.9 99 7 99.8 3,693 1,974 5,667 3,689 1,974 5,663 99.9 100 99.9 The survey provides socio-economic indicators desegregated by region and area of residence (urban and rural). The country is divided into six regions, each of which represents two, three or four provinces: • Capital Region: Luanda, Bengo, Kwanza Norte and Cabinda provinces e North Region: Zaire, Uige and Malanje provinces e East Region: Lunda Norte, Lunda Sui, and Moxico provinces • West Region: Benguela and Kwanza Sui provinces • Centre South Region: Huambo, Bie and Kuando Kubango provinces e South Region: Namibe, Cunene and Huila provinces The survey uses two indicators to measure vulnerabilities among households. 1. Wealth index quintile As it is assumed that similar assets are common among households of similar wealth and that wealthy households have more assets than poor households, the survey ranks Angolan households according to an asset or wealth index. Households are divided into five equal groups of 20% each, and are ranked according to socio-economic criteria1. The first group or first quintile refers to those 20% of households with the worst socio-economic conditions (with the least assets) while the fifth group or fifth quintile refers to those 20% of households with the best socio-economic conditions (with the most assets). The first quintile is usually referred to as the most vulnerable or the "poorest", while the fifth quintile is referred to as the least vulnerable or the "richest". Graph 2.1: Chronic malnutrition prevalence in children according to wealth index quintile 60 50 40 30 20 10 0 1st quintile 2nd quintile 3rd quintile 4th quintile 5th quintile The survey indicates that households from the fifth quintile systematically present better conditions than households from the first quintile, indicating that poverty plays a determinant role in people's vulnerability. For example, ch ildren from the poorest households are almost 60% more likely to be chronically malnourished than children from better off households. However, one should note that even among the fifth quintile, socio- economic indicators drawn by the MICS remain worrying. This probably reflects the fact that in Angola the rich are so few that they are statistically irrelevant in the analysis by quintile. For example, even among the "wealthiest" households a third of children , The asset or "wealth" index was constructed using the following socio-economic criteria: whether any member owns a radio, television, refrigerator, bicycle, motorcycle or car, whether electricity is used, the source of drinking water, the type of sanitation, how many rooms, and the type of materials used in dwelling construction. For detailed methodology, see Filmer D. and Pritchett L. , 1 ggs, Estimating wealth effects without expenditure data- or tears: An application to educational enrolments in States of India, World Bank Policy Research Working Paper No. 1994, Washington. under five years of age suffer from chronic malnutrition. In this sense, the use of the expression "rich" can be misleading. In the present analysis the fifth quintile is therefore preferably referred to as the "better off" or the "least vulnerable" rather than the "richest". 2. Level of education e surveyed population is divided into hree groups according to their education level: those who never went to school and are presumably illiterate, those who received primary education only, and those who received secondary or higher education . The survey consistently shows that children whose mothers received secondary or higher education are less vulnerable than children whose mothers are illiterate. For example, a child whose mother is illiterate is 60% more likely to die before reaching the age of five than a child whose mother received secondary or higher education. Graph 2.2: Mortality among under-five children according to mothers' education levels 300 250 200 150 100 50 No education Primary education The survey shows that households' economic vulnerability strongly affects the capacity of their members to access education . For example, children from the first quintile are 16 times less likely than better off children to attend the second level of basic (per 1 , 000 live births) Secondary/ higher education education . The correlation seen, throughout the survey, between better results for the MICS indicators for wealthier and more educated people is probably a reflection of the fact that better off people are in fact the most educated. Graph 2.3: Percentage of children attending the second level of basic education per socio-economic quintile 1st quintile 2nd quintile 3rd quintile 4th quintile 5th quintile phic and • Chara Demography: main characteristics • The Angolan population is very young: almost 50% of Angolans are under 15 years of age and 60% are under 18 years of age. • 93% of the population is below 50 years of age. • The fertility rate is very high: on average there are seven live births per woman. • The analysis of the population structure by age and sex reveals a significant deficit of males which is especially pronounced in the age group 20 to 29 years. • The masculinity index is 91%: for every 100 Angolan women there are on average 91 Angolan men. • The proportion of urban population is 66% and rural population is 34%. It was almost the opposite in the mid-1990s. • At 18 years of age a third of Angolan girls have already given birth and at 20 years of age more than two-thirds are already mothers. • The average age at first marriage is 21.4 for women and 24. 7 for men. • Only 6% of the population use contraceptives. I n Angola the lack of accurate population data poses enormous difficulties in terms of planning, monitoring, evaluation and management of socio-economic policies. It also hinders the functioning of national information systems. Because the latest population census was conducted in Angola in 1970, population figures should be regarded with caution. At national level, current population estimates are projections from the 1970's national census and from partial provincial censuses carried out in 1983. Based on this data, the National Institute of Statistics (INE) projected a population of 13.8 million in 2001. Since the latest census, however, about four million people were internally displaced and more than half a million took refuge in neighbouring countries. In addition, the war and AIDS probably impacted on mortality rates thus affecting overall population figures. In this context, the MICS data provides a refreshed picture of the demographic characteristics of the Angolan population. With almost 60% of the population under 18 years of age and a very high fertility rate (seven children per woman on average), the survey indicates that Angola is a demographically booming country that has not yet started a demographic transition. The 1.{) C\1 0 C\1 I I extremely low levels of contraception (6%) and the high adolescent fertility rates recorded (before 18 years of age a third of Angolan women are already mothers) are also two important indicators confirming a demographically pre-transitional society. Table 3.1: Population distribution by age, area of residence and masculinity index Percentage of total population Masculinity index (ratio male/female) Age group (years) 0 to 4 19 5 to 9 16 10 to 14 14 15 to 19 11 20 to 24 7 25 to 29 7 30 to 34 6 35 to 39 6 40 to 44 4 45 to 49 3 50 and above 7 Urban 66 Rural 34 Total 100 The population pyramid reveals a demographic profile typical of a young population with a broad base ind icative of a high fertility rate, . as well as a reduced number of people aged 40 years and over. 98 100 98 89 64 72 81 91 103 117 98 92 90 91 In fact, 85% of the population is below 40 years of age. The structure of the population pyramid also indicates a marked deficit of men in the age group 20 to 29 years. Graph 3.1: Total population by sex and age group, Angola 2001 Male II I I I 0 ~ I 0 Age 70+ 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 0 I I I I I 0 Female I I I 0 C\1 1.{) C\1 Percentage Percentage e masculinity index, which expresses he ratio of men per hundred women, ndicates a pronounced lack of men. At national level there are on average 91 men for 100 women. This male to female ratio is characteristic of countries that have experienced high levels of migration or suffered a war. In Angola, the lack of men is likely to be associated with selective mortality caused by the war and by male migration. The masculinity index varies greatly by age group and is particularly pronounced in the age groups 20 to 24 and 25 to 29 years In these age groups, there are on average only 68 men for 100 women. The acute male deficit noticed in the age groups 20 to 29 may also be related to errors in age declarations by young men, who feared that the survey results might be used for mi litary conscription purposes. Although less acute, there is also an important male deficit in the age groups 30 to 39. The very same patterns were observed during the 1 996 MICS exercise. Graph 3.2: Masculinity index among the population between 0 and 50 years of age - .- ~ ~ ""' ~ e pattern whereby there is an excess of men in older age group categories, which was also observed in 1996, is likely to be due to inaccuracies of the information provided on age by older women and men, whereby men would tend to overestimate their age and women to underestimate it. The MICS indicates that in 2001 , 66% of households were in urban areas and 34% in rural areas. Residency patterns have significantly changed from those observed by the MICS in 1 996 when 42% of the surveyed population was urban and 58% rural. This undoubtedly reflects the large population movements towards urban areas that occurred between 1 996 and 2001 . The masculinity index is slightly higher in urban areas (92%) than in rural areas (90%), which probably reflects more intense male migration towards urban areas for economic reasons and a greater impact of the war in rural areas. The population structure observed nationally ~ / / / ~ is replicated in all six regions. There are however regional variations in terms of male deficit. While the Capital Region registers the highest index of masculinity with an almost equal proportion of men and women (99%), in other regions the masculinity index varies from 86% in the West to 93% in the North . Variations are particularly accentuated for the age group 20 to 24. In this age group, the highest variation is noted in the Centre South Region where there are on average only 55 young Graph 3.3: Masculinity index per region Capital North East men aged 20 to 24 years for every 100 young women of the same age. In comparison, in the Capital Region the masculinity index in this age group is 83%. This finding is probably related to a greater impact of the war in the Centre South Region, which in fact includes the more war- affected provinces (Huambo, Bie, and Kuando Kubango). The relatively higher proportion of men in the Capital Region might be related to male economic migration towards the capital, Luanda. South Centre South West Households: main characteristics · • Angolan households average 4.8 people. • Urban households tend to be larger than rural households with an average of 5. 1 members against 4.3 in rural areas. • 82% of households have at least one child below 15 years of age. • 60% of households have at least one child below five years of age. • 27% of Angolan households are headed by women. • Over half of women heads of households are illiterate. • 71% of Angolan dwellings have floors made of "terra batida" (dirt floor). • 57% of dwellings have only one bedroom or none at all. • 80% of households do not have electricity. • Only 38% of households own a radio and 14% a television. • The main sources of energy used by households for cooking are firewood (42%), charcoal (41%) and gas (14%). The survey indicates that there are on average 4.8 members per household and that urban households are of slightly bigger size than rural households. About 8% of Angolan households have 1 member only, 26% have 2 or 3 members, 31% have 4 or 5 members, 21% have 6 or 7 members, and 14% have 8 or more members. The MICS Table 3.2: Household size according to area of residence (%) Urban Rural Total 1 Member 7 2 - 3 Members 23 4 - 5 Members 31 6 - 7 Members 22 8 and more Members 1 7 10 31 31 19 8 8 26 31 21 14 indicates a high level of promiscuity with 57% of all households having no or only one bedroom. Most dwellings (71 %) have dirt floors ("terra batida"), while floors made of wood or cement are found in less than 30% of households. The MICS indicates that only 20% of Angolan households have electricity. The percentage of households connected to electricity varies between about 33% in the Capital and South Regions to 6% in the North Region. Graph 3.4: Percentage of households with access to electricity by region South Capital West There are significant variations by wealth index quintile, with none of the households among the two lowest quintiles benefiting from electricity. Even among the third and fourth quintiles the proportion of households connected to electricity is very limited (7% East Centre South North and 21% respectively). One also notes that even among better off households, 15% do not have access to electricity. Electricity supply is almost exclusively restricted to urban areas where 30% of households have electricity compared to only 4% in rural areas . Graph 3.5: Percentage of households with access to electricity by wealth index quintile 1st quintile 2nd quintile 3rd quintile 4th quintile 5th quintile In terms of energy source used by households for cooking, the survey indicates that the vast majority of households use firewood and charcoal (83%) . The use of gas is limited (14 %) while the use of electricity and fuel is marginal (less than 3%). In the North, East and Centre South Regions the use of gas is negligible with households using firewood and charcoal almost exclusively. Although in the Capital Region more than half of households use charcoal and firewood (54%), gas is an important source of energy with 40% of households using gas for cooking. The use of gas is also important in the South and West Regions (27% and 23% respectively) . In terms of household assets, the MICS establishes that 18% of households own the means of transportation. The most frequently owned are bicycles (50%) followed by cars and motorcycles (33%). Table 3.3: Distribution of households according to their means of transportation Households that own a means of transport Bicycle Region Capital 16 45 North 13 66 East 17 72 West 15 20 South 21 29 Centre South 30 70 Area of residence Urban 18 50 Rural 17 51 Total 18 50 With regard to information means, 38% of households own a radio and 14% a television set. There are important variations by region and wealth index quintile. The higher proportion of households that own a radio and/or television set is found in urban households in the Capital, West and South Map 3.1: Percentage of households owning a radio Less than 30% Between 30% and 50% Above 50% Type of transport Horse/ Motorbike Automobile Wagon Donkey 15 37 0 19 12 1 15 12 1 22 15 5 10 10 16 17 7 3 23 23 2 7 3 13 17 16 6 Regions. Ownership of radios varies between 25% in the East Region and 52% in the Capital Region. The same patterns are observed with regard to television sets, with the highest proportion of households owning a 1V found in the Capital Region (28%) and the lowest in the North Region (3%). Map 3.2: Percentage of households owning a television Region South 24% Less than 1 0% Between 10% and 20% Above20% 0 0 0 0 6 0 4 2 (%) Other 3 2 0 39 29 3 2 22 9 Indicators Infant mortality rate: Probability of dying between birth and one year of age, per 1, 000 live births - 150 Under-five mortality rate: Probability of dying between birth and five years of age, per 1000 live births - 250 e under-five mortality rate (U5MR) is he principal indicator used to measure the level of child wel t-being and its rate of change . This indicator is the result of a wide variety of inputs: the nutritional health and the health knowledge of mothers, the availabi lity and quality of maternal and child health services, incorne and food availability in the family, the availability of clean water and safe sanitation, and the overall safety of the child's environment. It also measures an end result of the development process rather than an "input" such as school enrolment level, which is a means to an end. It therefore presents a good overall picture of the health status of Angolan children and of Angolan society as a whole. The MICS indicates alarming levels of mortality among children . In fact, the survey shows that Angola records one of the highest levels of child mortality in the world. Infant mortality is estimated nationally at 150 deaths per 1 ,000 live births and under-five mortality at 250 deaths per 1 ,000 live births. This means that in Angola today one in four children wi ll die before reaching the age of five. Of an estimated 600,000 newborn babies every year, the mortality rate recorded also means that 90,000 will die before their first birthday and an additional 60,000 wilt not reach their fifth birthday. The main causes of mortality in Angola among children are related to rnataria, diarrhoeal diseases, acute respiratory infections and vaccine preventable diseases, particularly measles' . Malnutrition is also implicated in about half of all deaths. A large majority of these deaths could be avoided as they are essentially related to diseases for which practical and tow cost interventions exist. When comparing the 1 996 MICS and 2001 MICS mortality results, the under-five mortality rate decreased from 271 to 250 and the infant mortality rate decreased from 166 to 150. These variations do not show significant change in the probability of death among children. The tack of substantive progress in reducing mortality reflects the serious humanitarian problems that much of the Angolan population has suffered, the tack of impact of health interventions, and the insufficient public investment in social sectors2 . ' Although there are no accurate data on the main causes of child mortality in Angola, data from the Ministry of Health showed that among the causes of mortality recorded in national health seNices in 2000, malaria was by far the largest killer (76%) followed by acute respiratory infections (7%) and diarrhoeal diseases (7%). 2 According to the 2002 study on Public Financing of the Social Sectors in Angola, jointly conducted by the Ministry of Finance and the United Nations, Angola spends the lowest amount on education and health of any Southern African Development Community (SADC) country. The share of resources spent on primary health care, primary education and water and basic sanitation averaged 3.2% of total Government expenditure between 1997 and 2001, peaking in 2001 at 6%. On average, 4.7% of national expenditures between 1997 and 2001 were spent on education compared to 16.7% in the 14 SADC countries. During the same period, 3.3% was spent on health, compared with 7.2% among SADC members. Methodological note Women of childbearing age (15 to 99 years) were asked about the number of children they had given birth to, and the number of surviving children. From these statements, infant and under-five mortality rates were indirectly estimated. To calculate these estimates, the technique of Brass, as modified by Coale and Demeny, was used (Southern model). The most consistent data for estimating mortality among children are obtained from the declarations of women aged 20 to 34, which implies that the estimates of mortality from the 1996 MICS corresponded to 1991, and those from 2001 MICS correspond to 1996. Statements from younger women, aged 15 to 19, which approximate to mortality estimates for the year 2000, are not used in this analysis since this age group has a lower birth rate and greater risks which might distort the results. As with other demographic variables, the mortality estimates are subject to mistakes made in the statements of the women surveyed. Thus the reliability of the estimates of mortality depend on the levels of omission of children who died shortly after birth, particularly when the death occurred a long time before the survey. In order to avoid these omissions, the methodology used incorporated additional questions verifying the statements of the mothers and increasing the reliability of the data. Map 4.1: Under-five mortality rate in the world in 2001 Below 50 Betvyeen 50 and 149 r-. ""'i Between 150 and 249 250 and above legend (per 1,000 live births) .___ _ ___. Missing data Source: State of the World's Children 2003, UNICEF Map 4.2: Under-five mortality rate in Africa in 2001 ~Verde Legend (per 1 ,000 live births} Below 50 Between 50 and 149 Between 150 and 249 250 and above Missing data Source: State of the World's Children 2003, UNICEF The level of education attained by the mother is the characteristic that provides the greatest differential in risk of infant and under-five mortality. The children of mothers with secondary and Comoros 0 higher education are 62% less likely to die before their fifth birthday and 40% less likely to die in their first year of life than the children of mothers without education. Graph 4.1: Differentials in mortality by mothers' education level IMR U5MR • None Primary Secondary and over Q Seychelles Mauritius 0 Households' socio-economic status also appears as an important factor impacting on mortality among Angolan children . One notes a gradually descending mortality gradient, fall ing as poverty declines. Children in the poorest households (first quintile) are 40% more likely to die before reaching the age of five than children from the better off households (fifth quintile). Differentials in mortality by wealth index quintile 350 288 ._____ 261 _ 260 - 300 - -.-,23_0 250 1 ?0~ ._167 - 155 155 141 - - - 200 150 - - 129 . 100 50 0 I I First Second Third Fourth Fifth ---- IMR --- U5MR Boys have an 8% higher chance of dying in their first year of life than girls. This situation is similar to that observed in other countries; however boys are still at greater risk of death between the ages of one and four, which is not a usual pattern. Graph 4.3: Differentials in mortality by sex 300 250 200 150 100 50 IMR • Male One notes that rural areas show only slightly higher mortality than urban areas . This difference is very small when compared with that observed in other countries. This probably reflects the massive displacement of the rural population towards urban areas and the poor living and overcrowded U5MR Female conditions for a great part of the population in urban areas . The lowest risk in terms of under-five mortality is in the Southern Region, where it is 30% lower than the national average. The risk of under-five mortality is the greatest in Graph 4.4: Differentials in mortality by area of residence IMR U5MR • urban Rural the Western Region, which shows a risk 64% risk of dying in the Eastern Region than would higher than the Southern Region and 26% have been expected there. The Capital and higher than the national average. The Centre Northern Regions have intermediate figures South Region also has a greater risk than the when compared with the national average national average. One notes a relatively lower and the other regions. Table 4.1: Infant and under-five mortality rates, Angola, 2001 Infant mortality Under-five mortality Wealth index quintile First 167 288 Second 155 261 Third 155 260 Fourth 141 230 Fifth 129 205 Sex Male 157 265 Female 143 234 Mothers' level of education None 162 275 Primary 148 245 Secondary and higher 116 170 Region Capital 150 250 North 156 262 East 135 217 West 181 315 South 123 192 Centre South 162 277 Area of residence Urban 148 245 Rural 155 260 Total 150 250 Indicators Stunting prevalence: Also referred to as chronic malnutrition. This indicator manifests a retardation in growth as a result of poor diet over a prolonged period of time. It is the proportion of under-fives who fall below minus 2 and below minus 3 standard deviations from median height for age of NCHSIWHO reference population - 45% Wasting prevalence: Also referred to as acute malnutrition. This indicator manifests a recent loss of weight as a result of severe illness or lack of food. It is mainly used in emergency settings as it reflects the present nutritional situation of the child. It is the proportion of under-fives who fall below minus 2 and below minus 3 standard deviations from median weight for height of NCHSIWHO reference population - 6% Underweight prevalence: This indicator is a combination of the two previous indices (height/age and weight/height) and reflects the global nutritional status of a child without taking into account that the child might be short or thin. It is mainly a reflection of stunting with a relatively small contribution from wasting and is used in national health programmes, such as Mother and Child Clinics. It is the proportion of under-fives who fall below minus 2 and below minus 3 standard deviations from median weight for age of NCHS/WHO reference population- 31% e risk of mortality for children under five ears of age due to infections is 2.5 fold n the case of mild malnutrition, 4.5 fold in the case of moderate malnutrition, and 8 fold in the case of severe malnutrition. Malnutrition is implicated in half of all under-five deaths' . Among children, the causes of malnutrition are interrelated and complex. There is a strong synergetic relationship between malnutrition and poor health. The interaction between inadequate dietary intake and disease leads to increased morbidity and mortality. Inadequate dietary intake and diseases in tum are caused by insufficient access to food, inadequate maternal and child care practices, and insufficient access to safe water and sanitation, as well as poor health care. These underlying causes are the consequences of the availability, use and control of various resources. On an individual level malnutrition places the child at risk of entering the downward spiral of malnutrition/infection. Insufficient dietary intake leads to an immuno-incompetency similar to that of HIV and hence 'an increased susceptibility to infections. Infections lead to a further reduction in nutrient intake. As a consequence, the child suffers from frequent infections that become progressively more severe and longer lasting. The child fails to regain weight lost during one infection before the onset of the next, therefore increasing the child's chances of dying. Three different anthropometric indicators have been used in the MICS: stunting prevalence (height for age), wasting prevalence (weight for height), and underweight prevalence (weight for age). ' Pelletier, D. and Jonsson, U., 1994. Methodological note All children aged between 0 and 59 months encountered in households were included in the sample. A total of 5,127 children under five years of age were measured and weighed, i.e. over 90% of the total survey sample size. The distribution of children surveyed in different age groups corres- ponds to the distribution generally found in populations in developing countries. The anthropometric variables were obtained as follows: Age: Whenever possible available docu- mentation such as birth certificates or vaccination cards were used as reference. If no documentation was available a Calendar of Events was used to estimate the age. Weight: The UNICEF Electronic Scale 890 was used to obtain the weight of the children. The caretaker and the child were weighed together, then the mother alone. Her weight was deducted from the total weight to obtain the child's weight. Height: A standard UNICEF measuring board was used to measure height. Children less than 85 em were measurec lying down, and those of 85 em or more were measurec standing. The presence of oedema among children was not recorded. This fact might compromise the analysis of the anthropometric data. Bilateral oedema is an indicator of Kwashiorkor. Children presenting bilateral oedema are regarded as severely malnourished independently of their anthropometric indices. The oedema is caused by the retention of water and sodium in the extra-cellular spaces and may account for between 5% to 15% of body weight. The presence of oedema is closely associated with an increased risk of mortality. Because the weight of children with bilateral oedema might be biased, the indicators' weight for height and weight for age might not reflect their actual nutritional status. The indicators using age (stunting and underweight) might be compromised in cases where it was difficult to verify the age of a child due to absence of documentation. To estimate the nutritional status of Angolan children, the MICS anthropometrical data were compared to an international reference population using the National Centre for Health Statistics I Centre for Disease Control I World Health Organisation International Growth References (NCHS, 1977). These growth references indicate the height a child should have reached at a certain age, the weight it should have at certain age, and the weight it should present for a certain height thus offering a comparison. The expression in z~scores (i.e. the exact number of standard deviations from the median) is used in the analysis as it takes into account both the median weight and the standard deviation from the distribution of the reference population. This expression provides a more exact estimation of the nutritional status than other expressions, such as percentage of the median and percentiles, and possesses statistical properties that allow for comparison of nutritional data. Five levels of malnutrition are defined for the three indicators used in the MICS (i.e. stunting, wasting, and underweight prevalence): • Absence of malnutrition: :::- -1 z-score • Slight malnutrition: :::- -2 z-score a< -1 z-score • Moderate malnutrition: :::- -3 z-score a< -2 z-score • Severe malnutrition: < -3 z-score • Global malnutrition: < -2 z-score The combination of moderate malnutrition and severe malnutrition is generally referred to as global malnutrition (i.e. children whose z- scores fall 2 or more standard deviations below the median of the reference population). This analysis focuses on global, moderate, and severe malnutrition, as slight malnutrition is of lesser importance and pertinence to the study. The anthropometric data was analysed using the SPSS and EPIINFOIEPINUT software. Severity level of malnutrition among Angolan children I n order to determine the severity of malnutrition within a population, WHO has established international threshold levels expressed in percentage of malnutrition prevalence. The severity of malnutrition has been classified in four levels, from low to very high. When using this classification as a reference, one notes that no substantial improvement in malnutrition prevalence among Angolan children occurred between 1 996 and 2001 . Stunting and underweight malnutrition prevalence is still at a very high level whereas wasting malnutrition prevalence remains at a medium level. This high prevalence has enormous social and economic implications and constitutes one of the main challenges for public health interventions in Angola. WHO classification by level of malnutrition prevalence(%) Low Medium High Very high Stunting prevalence <20 20-30 30-40 >40 Wasting prevalence <5 5-10 10-15 >15 Underweight prevalence <10 10-20 20-30 >30 Comparison of malnutrition prevalence in Angola between 1996 and 2001 Stunting prevalence Wasting prevalence Underweight prevalence Angola 2001 45% 6% 31% Angola 1996 53% 6% 42% Stunting prevalence (chronic malnutrition} 0 efined on the basis of the height to age ratio, stunting or chronic malnutrition refers to malnutrition resulting from accumulated distortions in the child's nutritional status. The stunting process can start in utero and continue post-natally during the first three years of life. It is assumed that children are stunted because of environmental reasons. Many children become stunted because of inappropriate weaning practices, repeated infections, and poor diet. Stunting is a good indicator for the general well-being of a population as it reflects the structural context surrounding malnutrition. Despite the fact that some catch up growth is possible, total recovery is generally very difficult as it can only occur with a very substantial improvement of the child's quality of life. In addition, stunting is closely linked to impaired mental development. With 45% stunting prevalence, the MICS reveals that almost one in two Angolan children suffer from chronic malnutrition. Stunting prevalence in Angola is higher than the average stunting prevalence recorded among children in sub-Saharan Africa countries, which was estimated in 2001 at 40%. When using the WHO classification as a reference, Angola in 2001 was among the eleven African countries with very high stunting prevalence (above 40%)2. Stunting, both for global and severe chronic malnutrition rates, increases with age up to 12 to 23 months. From the 24th month 'See State of The World's Children 2003, UNICEF. onwards it remains at stable levels. This is because during the first months of life the nutritional demands of the child can still be met with breast milk. With increasing age poor quality traditional weaning practices are introduced which lead directly to impaired growth. In the absence of adequate feeding, the accumulation of deficits over an extended period of time will result in children with lower height than required for their age. Graph 5.1: Stunting prevalence by age group 60,-----------------------------------------------------. 50 40 30 20 10 0 18% Less than 6 months 30% 6-11 months 12-23 months 24-35 months 36-47 months 48-59 months Boys are slightly more stunted than girls (48% versus 43%), which can be partly accounted for by the fact that boys have a higher requirement for certain micronutrients such as zinc and are, therefore, more susceptible to zinc deficiency. This finding also reveals the lack of discriminatory practices against girls in terms of access to food. Children living in rural areas show a higher prevalence of stunting than those living in urban areas, largely explained by differences in food availability (43% versus 50%). In addition, monotonous feeds and lesser access to services might also play a role . The highest stunting prevalence is found in the Centre South Region (55%), which includes the provinces most affected by the war. Stunting prevalence in the Southern Region is also very elevated with 53% recorded. The lowest stunting prevalence is found in the Capital Region (35%), whereas all other regions record a prevalence rate of between 39% and 45%. Map 5.1: Chronic malnutrition prevalence among under-five children Region North 45% Less than 36% Between 36% and 50% Above 50% As expected the prevalence of stunting declines with increasing social status and level of schooling. One notes however that only among the better off households (fifth quintile) is stunting prevalence significantly lower than among all other households. While stunting prevalence is only 13% lower in the fourth quintile than in the first quintile, it is 37% lower in the fifth quintile than in the first quintile. This refiects poor nutrition in the overwhelming majority of Angolan households Regarding education levels, the same patterns are observed, with stunting prevalence varying from 50% among children whose mothers are illiterate to 33% among children whose mothers received secondary or higher education. Wasting prevalence {acute marnutrition) 0 efined on the basis of weight to height, wasting or acute malnutrition refers to malnutrition resulting from excessive loss of weight that occurred in a recent period due to severe illness or lack of food. This indicator is particularly dynamic as it is very sensitive to seasonal variations and changes in the child's environment With 6% prevalence, the severity of wasting among Angolan children can be considered medium according to WHO threshold levels. No improvement occurred since 1996, when the MICS also recorded 6% wasting prevalence nationally. The prevalence of wasting does not reach the proportions of stunting and underweight, but is elevated enough to be a public health concern given its close association with morbidity and mortality. For example, acutely malnourished children are 20 to 40 times more likely to die during an episode of persistent diarrhoea, and 4 to 1 0 times more likely to die during an episode of acute diarrhoea. The prevalence of acute malnutrition increases steadily during the first two years of life and only decreases after 35 months of age, which is explained by poor breast- feeding and feeding practices in Angola. Breast milk is complemented or even replaced by foods of inadequate nutrient content, usually at a far too early age. With early weaning, passively acquired immunity declines earlier while children come increasingly into contact with each other and start to consume foods prepared under poor hygienic circumstances. At the same time their dietary requirements relative to body size are higher than in adults and they require frequent feeding with adequate and hygienically prepared foods. Graph 5.2: Wasting prevalence by age group 14 12 12% 10 9% 8 6 6% 4 2 0 Less than 6-11 12-23 6 months months months When reading the results pertaining to the prevalence of acute malnutrition one should keep in mind the following facts. First, the survey did not reach those children in areas of difficult access and does not reflect the nutritional emergencies that occurred throughout 2001 in the most war-affected areas, where wasting prevalence rates of over 20% were commonly recorded among chi ldren attending Therapeutic Feeding Centres . Second, anthropometric MICS data were gathered in the periods covering the harvest and post -harvest periods (April-October 2001 ), when there was a higher availability of foods in most provinces. Graph 5.3: Wasting prevalence per region West Capital South East 6% 3% 24-35 36-47 48-59 months months months There are no significant differences between wasting prevalence in boys and girls, or by area of residence. The prevalence of wasting declines proportionally to increasing social status and level of schooling. However, even among those with the highest wealth index or the highest level of schooling, rates of acute malnutrition remain relatively high (5%) which reflects overall poor nutritional habits. In terms of geographical distribution the West Region presents the highest rates of wasting. Unfortunately an analysis by region according to the agricultural calendar is not possible, as the survey in the different provinces that constitute one region took place at different periods. North Centre South Underweight reflects, similarly to stunting, the past nutritional or health deficits experienced by the population. This index represents body mass relative to age and is a composite of stunting and wasting. With 31% prevalence, the severity of underweight among Angolan children is, according to WHO threshold levels, very high. It is slightly higher than the average underweight prevalence recorded among children in sub-Saharan Africa countries, which Underweight prevalence was estimated in 2001 at 29%3 . Similarly to stunting and wasting, underweight levels by age group are higher at ages 12 to 23 months, decreasing slowly after that to what can still be considered to be high levels of malnutrition. Boys are also slightly more underweight than girls. Children living in rural areas show a slightly higher prevalence of underweight than those living in urban areas (32% against 30%). Graph 5.4: Underweight prevalence by age group 50 ,-------------------------------------------------~ 42% 40 30 29% 20 10 9% 0 Less than 6-11 12-23 6 months months months As for stunting and wasting prevalence, underweight prevalence declines propor- tionally to increasing educational levels of children's mothers. The MICS shows that children whose mothers are not educated are 70% more likely to be underweight, 53% more likely to be stunted, and 40% more likely 24-35 months 29% 36-47 months 48-59 months to be wasted. In developing countries, women's education contributes to 43% of the underlying factors of malnutrition'. This is particularly important, considering that 35% of women surveyed in the MICS have no education and 52% received only primary education. Graph 5.5: Underweight prevalence according to mothers' education level No education Primary education Secondary/higher education 3 State of the World's Children 2003, UNICEF. ' Smith, L. C. and Haddad. L. , 2000. Table 5.1: Stunting, wasting, and underweight malnutrition prevalence among under-five children, Angola, 2001 Wealth index quintile First Second Third Fourth Fifth Sex Male Female Region Capital North East West South Centre South Area of residence Urban Rural Age group < 6 months 6 to 11 months 12 to 23 months 24 to 35 months 36 to 4 7 months 48 to 59 months Mothers' education level None Primary Secondary and higher Total2001 Comparison Sub-Saharan Africa 2001 Stunting prevalence (%) (Height for age) Global Severe (percent (percent below below -2 z-score) -3 z-score) 52 28 51 27 48 24 45 21 33 13 48 23 43 21 35 18 45 22 39 17 41 21 53 26 55 29 43 21 50 26 18 7 30 12 52 24 49 24 51 27 52 28 50 25 45 22 33 15 45 22 40 Wasting prevalence (%) (Weight for height) Global Severe (percent (percent below below -2 z-score) -3 z-score) 8 2 7 2 7 6 5 7 6 7 2 5 6 1 10 2 6 5 7 6 6 2 g 2 12 3 6 1 3 0 3 0 7 6 5 6 1 10 ' Underweight prevalence (%) (Weight for age) Global Severe (percent (percent below below -2 z-score) -3 z-score) 35 10 34 11 34 10 30 8 22 4 32 g 29 8 23 6 31 7 27 7 32 10 40 12 31 8 30 8 32 g g 2 29 8 42 13 34 11 29 6 30 7 34 11 30 8 20 5 31 8 29 Indicators Exclusive breast-feeding rate Proportion of infants under 4 months who are exclusively breast-fed- 14% Timely complementary feeding rate Proportion of infants aged 6 to 9 months who are receiving breast milk and complementary food - 77% Continued breast-feeding rate Proportion of children aged 12 to 15 months and 20 to 23 months who are still receiving breast milk in addition to family foods - 89% and 37% respectively e MICS reveals poor breast-feeding practices among Angolan women. At one month of age, the vast majority of infants are no longer exclusively breast-fed. In addition, almost two-thirds of children aged 20 to 23 months are not breast-feeding at all. Best practices recommend that children exclusively breast-feed until six months of age' , start complementary feeding at six months while still breast-feeding, and continue to breast-feed up to two years of age. Although in most cases Angolan mothers initiate breast-feeding, the rate of abandoning it is very high. At three months of age, only 14% of infants are exclusively breast-fed. Solid/mushy food is introduced far too early in the Angolan child's life, which given poor dietary habits, food availability and insufficient hygienic preparation of foods, can be extremely harmful. At one month of age, 42% of infants are already given water. The survey Breast milk provides a complete source of nutrition during the first six months of life, fulfils half of the child's nutritional requirements during the second six months of life, and one- third of requirements in the second year of life. further indicates that nearly one-fourth of all chi ldren under one year of age are given the feeding bottle. All of which only increases the child's vulnerability to infections and places the child at risk of entering the vicious malnutrition-infection cycle. The two most important breast-feeding indicators - exclusive breast-feeding and complementary breast-feeding at 20 to 23 months - are in Angola well below the sub- Saharan African countries' average, estimated in 2001 at 33% and 51% respectiveli. Only in the field of complementary breast-feeding at 1 2 to 15 months is Angola performing adequately. No major changes have occurred in breast-feeding patterns since the last MICS survey carried out in 1996. Nevertheless, some smaller improvements can be noted in the field of exclusive and complementary breast-feeding, whereas practising of continued breast-feeding at 20 to 23 months deteriorated. Despite being a risk factor of HIV transmission from the sero-positive mother to the child, overall, the benefits of breast- feeding, both for the child as well as for the mother, are well known and widely documented. Among the most important benefits of breast -feeding for infants in developing countries are the reduction of the incidence and severity of diarrhoeal diseases during the first year, reduction of the risk of respiratory infections and improved neurological development, as well as an improved protection against a number of chronic diseases in later life. Infants not breast-fed at all are at a much higher risk of dying, particularly due to diarrhoea, than breast-fed children3 . In the second year of life, breast milk remains an important source of fats, calcium, quality protein and vitamin A. Absence of frequent and sustained breast-feeding is a significant risk factor for Vitamin A Deficiency (VAD). Children who are still breast-fed in their second year of life are 65% to 95% less likely to develop deficiency signs when mothers' ' Although international recornrnendations for exclusive breast-feeding is up to six rnonths of age, the MICS focuses on exclusive breast-feeding only up to four months of age. 2 See State of the World's Children 2003, UNICEF. ' Feachem, R.G. and Jarnison, D.T., 1991. 4 Somrnerfelt, A E., and Stewart, K., 1994. milk has sufficient levels of vitamin N. The MICS found that breast-feeding is stopped rather early, between 16 months and 1 9 months. At the age of 20 to 23 months only 37% of the children stil l receive breast milk, which might result in depleted vitamin A stores. This is a worrying factor considering the low coverage of vitamin A supple- mentation in Angola. Breast-feeding also greatly benefits mothers. Initiation of breast-feeding within one hour of delivery prevents post-partum haemorrhage and promotes uterine involution. Breast- feeding mothers have a decreased risk of developing diabetes and osteoporosis, as well as reproductive cancers. In addition, breast-feeding can act as a powerful contraceptive that is highly effective for six months after delivery if the mother is fu lly or nearly fu lly breast -feeding (Lactation Amenorrhoeal Method). This benefits the health of mother and child through child spacing. This contraceptive method is hardly practised at all by Angolan women. The MICS found that only 0.2% of women aged 15 to 49 years old were using it. When analysing the curve that characterises the frequency of exclusive breast-feeding by age, one notes that although the majority of children start breast-feeding at birth (96%), the rate of abandoning exclusive breast-feeding is extremely high in the first month of life, with only 17% of children from 0 to 1 month of age being exclusively breast-fed. Further, exclusive . breast-feeding declines significantly with age, with only 6% of infants aged 4 to 5 months exclusively depending on mother's milk. It should also be noted that nearly half of the surveyed children under four months of age receive additional fluids such as water and other liquids and 34% of them already receive a solid/mushy food component in addition to breast milk, which highly increases their vulnerability to infections. Graph 6.1: Percentage of infants exclusively breast-fed by age group 18 16 14 Q) 12 Ol ell 10 -c Q) ~ 8 Q) 0. 6 4 2 0 0 to 1 2 to 3 4 to 5 6 to 7 8 to 9 Age of infants in months Te area of mothers' residence, urban or rural, does not have a major nfluence on breast-feeding patterns in Angola. Only complementary feeding and continued breast-feeding at 20 to 23 months register as a slightly higher percentage of breast-fed children in rural areas. This can partly be explained by the fact that women in urban areas have better access to jobs, which might oblige them to stop breast-feeding for convenience. Another contributing factor might be the higher availability of milk substitutes in urban areas4 . The highest percentage of exclusive breast- feeding is practised in the South Region (32%), and the lowest in the East Region (2%) . Continued breast-feeding at 20 to 23 months is most practised in the Centre South Region (54%) and is least practised in the Capital Region (18%). Graph 6.2: Selected breast-feeding indicators by region Capital North East Exclusive breastfeeding (0 to 3 months) Mothers with a higher educational level are more likely to breast-feed exclusively, though at the same time they are also more likely to abandon breast-feeding earlier. This West South Centre South • Continued breastfeeding (20 to 23 months) may partly be explained by the better job opportunities these women have access to , which might lead them to choose more convenient feeding methods. Mothers with ' Implementation of the International Code of Marketing of Breast Milk SLJbstitutes is still under study in Angola. no or low education levels are those least likely to breast-feed exclusively, but they are also more likely to breast-feed for longer. This probably reflects the fact that the least educated women are also economically more vulnerable and might, therefore, have the least access to milk substitutes. Use of bottle feeding The use of the feeding bottle is a dangerous practice taking into account that the hygienic requirements necessary for the preparation of safe foods in Angola can often not be met. In addition, a bottle-fed child might not receive all nutrients offered by powdered milk, as mothers tend to over- dilute powdered milk in order to stretch the supply. Bottle-feeding is extensively practised all over Angola but in the South Region nearly half of all children of under one year of age received the feeding bottle. It is possible that the provinces located close to the border with Namibia have more access to feeding bottles and breast milk substitutes than the other provinces and regions. Similarly infants of mothers with higher levels of education are more often bottle-fed than infants of mothers with lower levels of education or no education at all. This can be explained by the higher purchasing power of this group of women and greater job opportunities, which might oblige them to stop breast-feeding and turn to bottle-feeding. Finally, more children in urban than in rural areas (29% versus 18%) receive the feeding bottle, which can be explained by the higher availability of breast milk substitutes in urban areas. Table 6.1: Summary table of breast-feeding indicators, Angola, 2001 Exclusive Timely Continued breast-feeding complementary breast-feeding rate (less than feeding rate (12 to 4 months) rate 15 months) Sex Male 12 79 89 Female 15 76 90 Region Capital 21 63 86 North 3 76 90 East 2 78 89 West 18 83 94 South 32 82 85 Centre South 18 79 91 Area of residence Urban 14 75 89 Rural 13 83 89 Mothers' education level None 11 78 88 Primary 15 78 91 Secondary and higher 19 70 86 Total 14 77 89 Comparison Sub-Saharan Africa 2001 33 63 n.a. Comparison Total Angola 1996 12 70 90 Continued breast-feeding rate (20 to 23 months) 37 37 18 40 33 41 37 54 35 43 43 37 21 37 51 48 I odine deficiency remains the single greatest cause of preventable brain damage and mental retardation world-wide. Iodine Deficiency Disorders (IDDs) can lead to increased rates of stillbirths, congenital abnormalities, cretinism, psychomotor defects and neonatal mortality. In the child and adolescent the effects are manifested as goitre, hypothyroidism, impaired mental function, and retarded mental and physical development. In addition, it can lead to diminished school function, as milder IDD in a community means that many children without outward disabilities will be condemned to suffer learning problems and do poorly in school. The most cost -effective and efficient way to prevent IDDs among the population is to ensure that salt consumed contains enough iodine. This means reaching the vast majority of the population , as salt is encountered in most households. Globally, progress towards the elimination of IDD through universal salt iodisation appears to be one of the most significant successes in the field of non- communicable diseases. In August 1996 Angola adopted the Universal Salt lodisation policy as a way to control IDDs. That same year, the government's decree of Exclusive Distribution of lodised Salt recommended that all salt for human and anirnal consumption should be iodised . Angola has a large and potentially self- sufficient salt production capacity. In 2001, there were 1 7 salt production plants located in Namibe, Benguela, Kwanza Sui, Luanda and Zaire provinces, with ten plants having the capacity to produce iodised salt. The national production of salt in 2000 was estimated at 32,600 metric tons, of which only 30% was iodised (9,800 metric tons). The plants in Benguela and Kwanza Sui were accountable for 70% of the salt production and 86% of the iodised salt production . In 2001, the trends were similar. The criterion used for the adequacy of prevention of IDD is the proportion of households (> 90%) consuming adequately iodised salt. In 2001, the MICS reveals that 87% of Angolan households use salt. Among Indicator lodised salt consumption1 Proportion of households consuming adequately iodised salt - 35% households with salt, only 35% are using salt that is adequately iodised, with wide regional disparities, from 11% in the West Region to 62% in the East Region . In other words, at national level 65% of households have salt that if iodised adequately could prevent the occurrence of iodine deficiencies. This level places Angola well below the average iodised salt consumption recorded in sub-Saharan Africa in the same period at 67%2 . There are some variations by area of residence. Rural households have relatively less salt available, and for those that have, the salt is less adequately iodised than in the urban population. The availability of salt can be related to reduced product diversity and distribution as well as market accessibility in rural settings. The MICS findings highlight that the poorest groups are the least likely to afford and thus ' Salt is considered adequately iodised when it contains at least 15 parts of iodine per million. 'see State of the World's Children 2003, UNICEF. consume salt on a regular basis. This is an important factor when targeting salt iodisation programmes. Alternative or additional strategies may be required in such situations where groups at risk of IDD do not purchase iodised salt through normal commercial channels. Whereas the availability of salt in households is significantly related to the households' wealth, the adequacy of iodised salt is not. While one in five of the most vulnerable households do not have salt compared to one in 20 among those which are better off, the proportion of adequately iodised salt consumed is the same in each group. The probability of encountering adequately iodised salt is actually slightly higher among the most vulnerable (34%) than the least vulnerable (33%). This finding should be highlighted in the sense that market prices for iodised and non-iodised salt vary, the latter being less expensive. This situation reflects the fact that a large proportion of vulnerable people were receiving in 2001 monthly food baskets provided by the World Food Programme, that included iodised salt. These findings also reflect the overall poor availability of iodised salt in Angola and the lack of knowledge about its benefits . If educated about the importance of iodine in salt, it would not be surprising to see women from better off households purchasing more expensive iodised salt. Household salt availability has a clear correlation with the areas of salt production and the regions surveyed in relation to their proximity. The Western Region (Benguela and Kwanza Sui provinces) accounts for approximately 70% of all salt produced annually in Angola. It is in the same region that the highest number of households with salt is encountered (93%) . The same trend is observed in other regions where salt is produced, namely the Southern, Capital and Northern Regions, which all present significantly lower numbers of households with no salt in comparison to the non-littoral East and Centre South Regions . However, the households with salt testing adequate for iodisation show no correlation to proximity of localities where salt is iodised. In fact there is a marked reverse trend between availability of salt, consumption of adequately iodised salt, and regions of production. It is in the West Region that the salt consumed by households is the least adequately iodised (only 11 %), an area that is seen to produce the vast majority of the iodised salt in Angola and where salt is most frequently available to households. Map 7.1: Percentage of households consuming adequately iodised salt Above 50% Less than 30% Region North 46% Region South 33% Region East 62% Table 7.1: Percentage of households consuming adequately iodised salt, Angola, 2001 Test results Percentage Percentage of Salt not of households households in which adequately with no salt salt was tested iodised Wealth index quintile First 20 78 66 Second 16 82 66 Third 14 84 60 Fourth 9 89 67 Fifth 5 93 68 Region Capital 8 90 72 North 12 86 54 East 20 78 38 West 7 92 89 South 9 91 67 Centre South 19 74 70 Area of residence Urban 11 86 64 Rural 15 83 67 Total 13 85 65 Salt adequately iodised 34 35 40 33 33 28 46 62 11 33 30 36 33 35 Vtamin A is an essential micronutrient for the normal functioning of the visual system, development, maintenance of epithelial cellular integrity, immune function and reproduction. Deficiency in vitamin A initially compromises the integrity of the epithelial barriers and the immune system, which is then followed by impairment of the visual system and increased infection. Consequently, there is an increased risk of death, especially among children. In Angola, Vitamin A Deficiency (VAD) is a major public health problem. In 1998, the Ministry of Health National Nutrition Programme conducted a study to determine the VAD prevalence among children' . Low vitamin A prevalence (i.e. proportion of children aged 6 to 59 months with serum retinol below 20 (g/1 00 ml) was established at 64%, which is well above the WHO threshold of severe public health importance (;;:::. 20%). VAD among lactating women was also worryingly high at 77% (breast milk retinol below 8 (~g/1 00 ml). High-dose vitamin A supplementation is one method of improving the vitamin A status of children and women. Since 1999, the national Expanded Programme of Immunisation (EPI) has included the administration of high-dose vitamin A for all children aged 6 to 59 months vaccinated against polio during the annual National Immunisation Days (NIDs) . The Angolan national protocol of high-dose vitamin A supplementation recommends that children from 6 to 59 months receive supplementation of vitamin A every six months and women post-partum receive one dose of vitamin A within six weeks of delivery. The MICS, which reviewed vitamin A supplementation coverage for these two population groups, reveals very low coverage and compliance practices with the national protocol. Only 31% of children received timely vitamin A supplementation. Just 7% reported to have received the supplement after the six- month period and 13% were unable to specify the timeframe in which they had Indicators Children receiving vitamin A supplements Proportion of children aged 6 to 59 months who received a high-dose vitamin A supplement in the last six months- 31% Mothers receiving vitamin A supplements Proportion of mothers who received a high-dose vitamin A supplement before the infant was eight weeks old - 26% received the supplementation. There is no variation in the coverage according to gender. The most common method of delivering vitamin A supplementation are the NIDs (83%), followed by routine clinic services (12%), and curative clinic consultations (5%). There is no significant variation between rural and urban areas, which could be explained by the fact that the NIDs covered both urban and rural areas. The m'ain limitation of NIDs however is that they provide the opportunity for only one dose of vitamin A per year. One of the underlying causes of vitamin A deficiency is poor maternal awareness, education and literacy. Studies also suggest that VAD has strong socio-economic Improving the vitamin A status in young child populations leads to an average reduction of 23 % in mortality rates in children with VAD. Improving the vitamin status of pregnant women may reduce their risk of dying during pregnancy and childbirth. Vitamin A improves their resistance to infection such as HIV and malaria. ' Study on vitamin A deficiency in Angola, Ministry of Health and UNICEF, 1998. associations 2 . In Angola, the significant variations observed between the coverage of vitamin A supplementation according to households' wealth and mothers' level of education highlight that those most at risk have the lowest coverage rates. For example, a child whose mother is not educated is 60% less likely to receive vitamin A supplementation than a child whose mother received secondary or higher education. Poorest children are 40% less likely to receive timely supplementation than children from better off households. Considering that the main way of administering vitamin A to children is the NIOs, the variations by wealth index quintile indicate that, contrarily to polio immunisation, the NIOs did not yet result in reduced vulnerabilities among the poorest population. This reflects the fact that the NIDs did not reach all children in terms of vitamin A distribution. Among children and mothers the middle wealth index has a higher coverage than the fourth quintile, and even the fifth quintile in the case of mothers. This might reflect the fact that socio-economically better off households more frequently use private sector services that may not follow the national health guidelines regarding vitamin A administration. In this sense, the middle socio-economic group seems to be the one that more frequently takes advantage of implemented national programmes. Graph 8.1: Percentage of mothers receiving vitamin A according to level of households' wealth 1st quintile 2nd quintile 3rd quintile 4th quintile 5th quintile Regional results of vitamin A supplementation among children should be interpreted with caution . Indeed, the third round of the 2001 NIDs during which high-dose vitamin A was distributed was carried out in August 2001 , i.e. during the period of MICS data collection. As data were collected in the regions over different periods of time, vitamin A coverage wil l be higher in those regions where MICS ' ACC/SCN, 2000. data were collected during August, September and October 2001 . This is particularly true in the case of the Southern Region, which was surveyed prior to the NIOs and presents the lowest coverage. An interesting trend is the reduction in the number of children who receive vitamin A in routine clinic services as their age increases, in comparison with those receiving vitamin A through the NIDs, which number increases with age. This can be related to the distribution of vitamin A in routine immunisation services, which primarily target children under one year of age. Thereafter, as the age of children increases, supple- mentation is progressively more reliant on the NIDs. Table 8.1: Percentage of children who ever received vitamin A supplementation by age group and method of delivery Age in months 6 to 11 12 to 23 24 to 35 36 to 47 48 to 59 Total Percentage of children who ever received vitamin A 41 50 54 54 52 51 With regard to supplementation among women, only 26% received vitamin A before their infant was eight weeks old. There was no significant variation between rural or urban residence. Breast-feeding is critical for vitamin A status of infants and therefore giving vitamin A to new, breast-feeding mothers helps protect the infant during the first months of life . The MICS indicates that those mothers from the lower wealth index quintiles who are most likely to have low vitamin A stores are those who have the least coverage of supplementation. Assistance during delivery with post-partum follow-up, and/or place of delivery are certainly factors that can be related to the low coverage of vitamin A among women. Indeed, in Angola most of the deliveries take Received in routine clinic services 21 12 11 10 9 12 Received during curative consultation 4 7 5 3 4 5 place outside the health facilities, or they take place without skilled assistance. Integrating vitamin A supplementation alongside routine immunisation services and NIDs continues to function as an important method of delivery. However, as the causes of Vitamin A Deficiency are diverse (e.g. immediate causal factors are low vitamin A levels in mothers' breast milk, low birth weight, breast-feeding of short duration and non exclusive breast-feeding in the first six months) interventions should also be targeted through other channels. For example, food based approaches such as food fortification with vitamin A and nutrition education are the logical preferred long-term strategies to improve the vitamin A status of children and women. Received during the NIDs 75 80 84 86 87 83 Table 8.2: High-dose vitamin A supplementation among children 6 to 59 months and mothers 15 to 49 years Wealth index quintile First Second Third Fourth Fifth Sex Male Female Region Capital North East West South Centre South Area of residence Urban Rural Mothers' education level None Primary Secondary and higher Total Children receiving vitamin A supplements * 26 29 33 29 36 31 31 51 37 33 24 9 35 31 30 25 33 40 31 Mothers receiving vitamin A supplements 19 23 31 28 26 n.a. ** n .a. 34 30 22 24 31 16 26 25 22 27 32 26 * This indicator only takes into account children who received timely supplementation within the six-month period. The other groups who received vitamin A after six months or an unknown period have been excluded from the analysis as the date of vitamin A administration could have ranged far beyond the positive effect of the vitamin A on the child's status. ** n.a. = not applicable J ,. . • Indicators Use of bed nets Proportion of children aged 0 to 59 months who slept under a mosquito net (treated or not treated with insecticide) during the previous night - 10% Use of treated bed nets Proportion of children aged 0 to 59 months who slept under an insecticide treated mosquito net (/TN) during the previous night - 2% Use of untreated bed nets Proportion of children aged 0 to 59 months who slept under a non-treated mosquito net during the previous night-8% Fever prevalence Proportion of children aged 0 to 59 months who were ill with fever in the last two weeks - 25% Malaria treatment Proportion of children aged 0 to 59 months who were ill with fever in the last two weeks and received anti- malarial drugs - 63% n Angola, malaria is by far the largest cause of mortality and morbidity among children . In 2000, the Ministry of Health reported that over 75% of all illnesses and deaths in national health services were related to malaria'. Malaria also has extensive effects on economic productivity and households income. The disease is the first cause of absenteeism among Angolans at school and at work. According to the National Malaria Control Programme, every Angolan typically experiences three to five malaria episodes per year. In April 2000, during the Roll Back Malaria Summit held in Abuja, Nigeria, African heads of state adopted a comprehensive action plan for the prevention, diagnosis and treatment of the disease. Preventive measures, especially the use of mosquito nets treated with insecticide, were put forward as a way to reduce malaria mortality rates among children2 • The MICS looks into the use of treated and untreated mosquito nets and the prevalence and treatment of fever among children under five years of age. In general, the survey indicates a very high prevalence of fever, with 25% of all chi ldren reporting to have had fever in the two weeks prior to the survey. Although the majority of children with fever are treated with some anti-malarial medicine (63%) and take some antipyreti<;; agent such as paracetamol and aspirin (77%), prevention of malaria through the use of mosquito nets is very low, with only 8% and 2% of children using untreated and treated mosquito nets respectively. At the national level, only 10% of children use mosquito nets, of which 23% are treated with insecticide. This means that overall, only 2% of children use bed nets treated with insecticide. Occurrence of fever is about the same among children surveyed, with no major variations between socio-economic groups, areas of residence and sex, indicating that fever suggestive of malaria affects children from all segments of the Angolan population. Fever prevalence among children also remains steady among regions (between 21% and 27%), with the exception of the West Region where prevalence peaks at 35%, i.e. 40% above the national average. Considering that the survey took place over a six-month period, th is finding probably reflects a distortion due to the fact that malaria prevalence is seasonal. Fever prevalence by age group shows the same pattern as observed with diarrhoea prevalence. It reaches a peak at 6 to 11 ' See "Angola the post war challenges" United Nations System 2002 Common Country Assessment. In view of the poor national health information system in Angola, these data should be regarded as only indicative of the determinant role played by malaria in morbidity and mortality. ' Within the framework of the Roll Back Malaria Initiative, the National Malaria Control Programme launched with UNICEF support in 1998 a large project to promote the use of insecticide treated mosquito nets. At the beginning of 2003, the prOJect was operating in 14 provincial capitals where 500,000 nets were distributed at a subsidised price and 47 1nsecticide Treatment Units for the impregnation of mosquito nets with insecticide were established. months and declines gradually thereafter until 48 to 59 months. The increased vulnerability among children aged 6 to 11 months reflects the immunology status at this age whereby the antibodies provided by the mother no · longer efficiently protect the child. Graph 9.1: Fever prevalence among children by age groups 10+-----------------------------------------------------~ 0 +--------,--~----.--------,,-------,--------.-------~ Less than 6 months 6-11 months 12-23 months 34-35 months 36-37 months 48-59 months In areas where malaria is common (such as Angola) it is recommended to treat any fever in children as if it were malaria and give the child a full course of anti-malarial tablets. Overall, 63% of children with fever received anti-malarial drugs. The most frequently used drug is chloroquine (57%), while the use of other anti-malarial drugs such as quinine, Alofantrin and Sulfadoxin+Pyrimetamin (commercial brands known as Alfan and Fansidar) remains marginal (6%) . This reflects the fact that chloroquine is the most accessible anti-malarial drug in terms of market supply and price in Angola. One should note however that in Angola 50% of malaria cases are resistant to chloroquine. In general, a relatively high percentage of children with fever (20%) were given some other medicine. The important use of antipyretic agents, such as paracetamol and aspirin, and chloroquine and "other medicine" reveals positive action taken by the child caretaker in case of fever. However, this also expresses a self- medication attitude among the population, probably as a result of the overall poor availability of health services in Angola. It can indeed be assumed that, as in the case of respiratory infections, a large proportion of children with fever were not taken to a qualified health provider for proper consultation and treatment. There are important disparities in terms of households' socio-economic status, with children from the most vulnerable households three times less likely to use mosquito nets (treated or untreated) than children from better off households. It is really mainly among the fifth quintile that mosquito nets are more available (although quite low at 20%), while in all other quintiles their use varies between 5% and 11%. Similar vulnerability among the poorest is observed regarding the use of treated nets, which varies from 11% among the most disadvantaged households to 23% among the better off households. The MICS shows here that economic constraint remains an important factor as to whether a household will appropriately protect itself against malaria or noP. By far, the largest percentage of children using nets (treated or not) is in the Capital Region (23%), a finding probably reflecting higher availabi lity of mosquito nets in the country's capital, Luanda. In all other regions, untreated mosquito net use varies between 4% in the Centre South Region to 3 This finding should be highlighted as, although distributed at a very low subsided price, mosquito nets provided within the framework of the Roll Back Malaria initiative are sold. 14% in the West Region . It is not however in the Capital Region where the use of treated mosquito nets is the highest but in the North Region where 51% of all children who sleep under a mosquito net use a treated one. The higher use of treated nets in the North may be related to the fact that the promotion of Insecticide Treated Nets through the Roll Back Malaria Initiative first started in the northern provinces and Luanda in 2000 before being expanded to the South in 2002. While there are no significant variations in the use of untreated nets between urban and rural households {11% versus 9%), the use of treated nets is much more pronounced in urban areas . Graph 9.2: Percentage of children under five years of age using mosquito nets (treated or not) by wealth index quintile 1 st;quintile 2nd quinti le 3rd quintile 4th quintile 5th quintile Indicators Diarrhoea prevalence Proportion of children aged 0 to 59 months who had diarrhoea in the last two weeks - 23% Home management of diarrhoea Proportion of children aged 0 to 59 months who had diarrhoea in the last two weeks and received increased fluids and continued feeding during the episode- 7% D iarrhoeal disease in Angola stands out as one of the most important causes of mortality among children ' . Children are more likely to die from diarrhoea than adults because they become dehydrated more quickly. Diarrhoea, which is caused by germs that are swallowed (especially germs from faeces), kills children through dehydration and malnutrition. The survey found a high prevalence of diarrhoea among Angolan children reflecting poor hygiene practices, unsafe disposal of faeces, lack of clean drinking water and poor breast-feeding practices. With regard to fever prevalence, the MICS assesses the prevalence of diarrhoea among children for a reference period of two weeks prior to the survey. Diarrhoea is defined as all situations where children have three or more liquid evacuations per day. The survey reveals overall high diarrhoea prevalence, with 23% of children under five years of age having suffered diarrhoea in the two weeks prior to the survey. Apart from age group variations, there are no significant variations in diarrhoea prevalence among households' characteristics. Prevalence varies between 20% and 28% for all indicators, namely wealth index quintile, sex, region and area of residence, indicating that diarrhoea affects all Angolan children similarly. Like what was observed for fever suggestive of malaria, the prevalence of diarrhoea increases with the age of the child, reaching its peak at 6 to 11 months (44%) and then declines with age. This reflects the fact that at six months of age Angolan children in general are not exclusively breast-fed anymore and are given complementary foods. Breast milk indeed reduces the severity and frequency of diarrhoea in children. It is also between 6 and 1·1 months that children, for reasons linked to their development, are most exposed to pathogens. Graph 10.1: Diarrhoea prevalence among children by age group 50 45 40 35 30 25 20 15 10 5 0 / 19%/ • less than 6 months 44% ~ / ~ 34% / ~ ~ 24% ~ ~ 14% - . 12% I I I 6-11 months 12-23 months 24-35 months 36-47 months 48-59 months ' Although there are no accurate data on the main causes of mortality in Angola, data from the Ministry of Health indicate that among the causes of mortality recorded in national health services in 2CXJO, malaria was by far the largest killer (76%) followed by acute respiratory infections (7%) and diarrhoeal diseases (7%). Diarrhoea mostly kills children by draining liquid from the body, thus dehydrating the child. As soon as diarrhoea starts, it is essential that the child be given extra fluids as well as regular food and fluids. Although the vast majority of children (98%) were given fluids defined as acceptable during the diarrhoea episode2 the MICS indicates poor care practice in terms of diarrhoea episode management as only 14% of all children with diarrhoea were given extra fluids by their caretakers. Furthermore, only 7% of Angolan children with diarrhoea received more liquid and continued to eat. There is a trend showing slightly better management of diarrhoea among urban, better off and more educated households. The survey also indicates that older children are more likely to be administered proper care than younger children (4% proper management among children less than six months old versus 11 % among children aged three years). . As for the type of liquid given by caretakers to children with diarrhoea, the most frequently given is water. In a context where water used by Angolan households is rarely safe for drinking without treatment, one should consider the very low proportion of the population treating water before drinking (19%). The use of Oral Rehydration Salts (ORS) is limited, with only 40% of children being given ORS. Children in the better off households are twice more likely to receive ORS (50%) than children from the most vulnerable households (24%). The same pattern is observed according to mothers' education levels. Breast milk, which is known to reduce the severity and frequency of diarrhoea, is only given to half of children with diarrhoea (51%). As the survey does not assess the severity of the diarrhoea episode in the child, these findings should be seen as indicative of the general state of the children's health and the measures taken by the caregivers during the diarrhoea episode . ' Acceptable fluids received by children during diarrhoea include oral rehydration salt, breast milk, milk or infant formula, water, and locally acceptable home fluids. M ore than half the world's illnesses and deaths among young children are caused by germs that enter their mouths through food, water or dirty hands. Many illnesses, especially diarrhoea and water-borne diseases, can be prevented by good hygiene practices, such as putting all faeces in a toilet or latrine, but also by exclusively drinking water that is from a clean and safe water source, or is purified. The single most important action to prevent the spread of germs is to dispose of all faeces safely by using sanitary means of excreta disposal. The suNey shows that 81% of the Angolan population does not treat water before drinking, 41% of households do not use sanitary means of excreta disposal and almost 40% do not extract the water they drink from safe water sources. Further, there are very important disparities between areas of residence, with rural households being three times less likely to use sanitary means of excreta disposal or to treat water before drinking than urban households. Rural households are also twice less likely to extract water from safe sources than urban households. In Angola, under the Ministry of Energy and Water, the National Directorate of Water has the overall responsibility for the management of water supply and sanitation systems, with a high level of decentralisation at provincial level through the Provincial Delegations of Water. The state of the water supply system in Angola has been affected both by the significant destruction of infrastructure during the 27- year war and the increased demand on urban water supply caused by the massive population displacement towards provincial and municipal capitals There are few provincial capitals to which water is supplied on a continuous basis. Among the Indicators Use of safe drinking water Proportion of population who use any of the following types of water supply for drinking: piped water; public tap; borehole/pump; well (protected/ covered); protected spring; rainwater - 62% Use of sanitary means of excreta disposal Proportion of population who have, within their dwelling or compound: toilet connected to sewage system; any other flush toilet (private or public); improved pit latrine; traditional pit latrine - 59% Water treatment Proportion of population that treat water before drinking - 19% main constraints are the poor quality of the water supply systems and the lack of appropriate sources of energy to sustain these water supply systems. The situation is considerably more precarious in rural areas where, when safe water is supplied, it is only done so through wells and boreholes equipped with manual pumps. Communities are not well equipped to independently manage their water supply and there is little operational support from provincial water delegations in terms of spare parts and equipment maintenance. This constitutes a constraint to the implementation of the New Water Law, passed in 2002, which stipulates that the development and utilisation of water resources be developed with the participation of communities ' . ' Approved by the Angolan Parliament on 21st June 2002, it set out the main principles that guide the administration and usage of water resources in Angola. Among the most significant elements set out in the legislation is the active promotion of the participation of the private sector in water management. The Water Law also determines that the general framework of development and utilisation of water resources be developed with the participation of communities and foresees the creation of voluntary associations of consumers stipulating that it is the responsibility of the State to promote the participation of these associations in matters pertaining to the rational utilisation of water resources. Note During the war, the massive population displacement towards urban and peri- urban areas was accompanied by significant efforts by the humanitarian community to provide both displaced and resident populations with safe water and sanitation. The results of these efforts are reflected in the MICS coverage figures. Populations inaccessible at the time of the survey benefited from no water and sanitation interventions. Humanitarian Rapid Assessment of Critical Needs conducted by the Government during 2002 in areas that were previously inaccessible revealed that the overwhelming majority of the population in these areas did not have access to safe drinking water and sanitary means of excreta disposal. The disproportionate destruction of the water and sanitation infrastructure in areas outside State control in 2001 and the concentration of rehabilitation efforts by the humanitarian community in urban and peri-urban areas contributed to the creation of major discrepancies between coverage rates in urban and rural areas. The MICS findings illustrate those discrepancies and show that in rural areas only 40% of the population has access to protected water sources and 25% use sanitary means of excreta disposal (compared to 71% and 74% respectively in urban areas). The situation in rural areas is however considered to be much worse by the Ministry of Energy and Water, which in its 2002 report on national water and sanitation coverage indicated that adequate water supply and sanitation coverage in rural areas was 15% and 20% respectively. Safe water source: type of water source Khough the MICS indicates whether he water used for drinking by the opulation is extracted from a safe water source or not, it does not ultimately indicate whether the water is safe for consumption. This is of particular importance when reading the MICS findings2 . Almost 40% of Angolans drink water extracted from an unsafe water source (21% from lakes, rivers and streams and 1 7% from other unprotected water sources). The findings concerning the use of water extracted from safe sources shows that 33% of Angolans use piped water (directly in dwellings or yards, neighbours' taps or public fountains), while 29% use water extracted from other safe sources such as boreholes, protected wells and springs as well as rain water. The source of water used by households varies greatly among urban and rural areas. While in urban areas the most important source of drinking water is piped water (42%), lakes, rivers and streams are the main sources of drinking water in rural areas (42%). The relatively high proportion of households using water extracted from safe water sources at national level (62%) certainly reflects rapid urbanisation, with an increasing number of Angolans moving into urban centres where they have better access to safe water sources. The survey, however, does not touch upon the quality of the water supply. As noted, there are very few provincial and municipal capitals where water is provided on a continuous basis. 2 The intemationally recommended indicator to monitor the goal of universal access to safe drinking water is the "Use of Safe Drinking Water". This indicator only looks into whether the water source used by households is protected, but not at the cleanliness of the water used by households for drinking. Therefore, the MICS does not indicate whether the water used by Angolan households is safe for drinking. Table 11.1: Main source of drinking water used by households (%), Angola, 2001 Piped water Other safe sources Unprotected Other unprotected (in dwellings or yards, (borehole, protected water sources water sources neighbours' taps, well and spring, (lake, river (unprotected well public fountain) rain water) Regions Capital 57 6 North 13 56 East 21 19 West 57 9 South 35 25 Centre South 19 54 Area of residence Urban 42 29 Rural 13 27 Total 33 29 The use of piped water for drinking is highest in the Capital Region (57%) and lowest in the North and Centre South Regions (13% and 19% respectively). In the two latter regions, the majority of households extract water from boreholes and protected wells and springs (about 55%) . The worst situation in terms of safe water source is found in the East Region where 60% of households use drinking water extracted from unsafe water sources, the main one being river, lake or stream (43%). The highest proportion of households getting water delivered by water truck is also found in and stream) and spring, water truck) 16 21 17 14 43 17 18 15 19 21 12 14 12 17 42 18 21 17 the East Region (16%), providing a clear indication of increased difficulties in accessing water there. In urban areas, the main source of water is piped water extracted from public or neighbours' taps (31 %) , followed by boreholes and protected wells and springs (29%), rivE;rS, lakes or streams (12%), and piped water within the dwelling (11 %) . The very low proportion of households with water facilities within their dwellings indicates the precarious state of the water supply in urban areas. Graph 11.1: Type of water source used by urban households unprotected well or spring river, lake, stream 12% 7% borehole, protected well and spring 29% other 5% piped water 11% water truck 5% public or neighbours' tap 31% Percentage of households extracting water from a safe water source 63 69 40 67 60 74 71 40 62 The majority of rural households extract water for drinking from unsafe sources. Rural households are in fact over three times more likely to procure drinking water from lakes, rivers or streams than urban households and twice as likely to get water from unprotected wells. Access to piped water is extremely limited in rural areas. Rural households are 30 times less likely than urban households to have direct access to a piped water system, nine times less likely to have access to piped water in their residential compound and 35 times less likely to have access to a neighbour's tap. The most significant source of piped water in rural areas is public fountains, which provide access to drinking water to only 12% of rural households. Water treatment Adequately treating water before drinking is fundamental to prevent water borne diseases such as diarrhoea, which is an important cause of mortality and morbidity among children. MICS results indicate that only 1 9% of the population treats water before drinking, with important variations between regions and areas of residence. Treatment of water is least practised in the East Region (9%) and most practised in the Capital Region (29%). Worryingly, the East Region also has the worst record for availability of safe drinking water sources. In urban areas, households are three times more likely to treat water than in rural areas. Treatment rates are above the national average in the South Region (25%) and remain slightly below the national average in the North, West and Centre South Regions. The vast majority of Angolan households who provide treatment for drinking water do so by boiling the water they consume (72%). This method is over three times more popular than the next most commonly used method , i.e. the use of bleach (22%). The use of chlorine remains negligible at national level (6%). Households' members who fetch water As seen above, the overwhelming majority of households do not have access to drinking water within their dwellings and therefore need to walk to fetch water. MICS results indicate that the task of fetching water for cooking, cleaning and drinking falls squarely to women and girls. At national level, in 80% of the cases water is fetched by women and girls aged 12 years old and over (15% by girls aged 12 to 17 years and 65% by women 18 years and over). The lack of adequate access to water has a disproportionate impact on the workload of women and girls . This pattern is observed both in rural and urban areas and across all regions, where the proportion of women and girls collecting water fluctuates between 73% in the Capital Region to 85% in the East Region. Women are on average 13 times more likely than men and boys to fetch water, followed by girls aged 12 to 17 years, who are again three times more likely to carry out this domestic chore than either adult men or boys. The proportion of children fetching water is also important with 5% of children aged 5 to 11 years carrying out this task. The survey indicates that an important proportion of women and girls fetching water walk long distances to reach the water source . The MICS measures the distance of the water source from the household. When women and girls reach the water source, they have to travel a similar distance to return to their households carrying a heavy weight When the MICS therefore indicates, for example, that 9% of households' water sources are located between 500 meters and one kilometre away from the dwellings, one should understand that households' members travel between one and two kilometres to fetch water. At national level, 16% of Angolans walk more than one kilometre to collect water, 31% walk between 200 meters and one kilometre, and 53% less than 200 meters. The distance travelled by households' members confirms the trend whereby rural areas suffer from the worst conditions in terms of access to water supply. While the majority of water sources in urban Graph 11.2: Distance of water source from dwelling in urban areas between 100 and 500 metres 29% between 500 metres and 1 km 8% over 1km 5% less than 100 metres 58% areas are located less than 1 00 meters away from the dwelling (58%), the majority of water sources in rural areas are located more than 100 meters away (60%) . Nearly a quarter of the rural population has to walk over one kilometre to fetch water. Furthermore, over one in ten urban Angolans walk more than two kilometres to fetch water. The situation for girls and women is particularly precarious in the East Region where a third of them walk more than one kilometre to fetch water. It is in the Capital Region that households' members walk the least to fetch water, with 65% of households with drinking water sources located less than 1 00 meters from the dwellings. Graph 11.3: Distance of water source from dwelling in rural areas over 1km 11 % and 500 metres 35% less than 100 metres 41 % Use of sanitary means of excreta disposal Overall, the MICS indicates that a high proportion of Angola's population does not use sanitary means of excreta disposal (41 %) , with very high variations across regions and areas of residence. The situation is the most precarious in the West and Centre South Regions where two-thirds of the population does not have access to sanitary means of excreta disposal (62%). Better access is found in the South Region where 82% of households dispose of excreta by safe sanitary means, mainly through the use of traditional pit latrines (62%) . At national level, the main way used to dispose of excreta is in the open air (39%), followed by the use of traditional pit latrines (30%) and sewage systems (14%). Overall the proportion of the population benefiting from a connection to a sewage network is very low, varying from 28% in the Capital Region to only 6% in the East Region . It is worth noting here that only five cities in Angola benefit from the partial coverage of a sewage network (Luanda, Huambo, Namibe, Lob ito and Benguela). Households in rural areas are three times less likely to have access to appropriate sanitation than those in urban areas (26% against 7 4 %) . In rural areas, almost three in four people dispose of excreta in the open air compared to 24% in urban areas. Furthermore, rural households are nine times less likely to be connected to a sewage system and eleven times less likely to possess a toilet with a connection to a septic tank. Graph 11.4: Households' ways of disposing of excreta open air 39% other 1% traditional pit latrine 30% Improved pit latrine 8% Indicators Acute respiratory infections (ARI) prevalence Proportion of children aged 0 to 59 months who had acute respiratory infections in the last two weeks - 8% hospital and the other half to health centres and posts (28%). There are important variations in the likelihood of children receiving appropriate treatment by wealth index quintiles, with the most vulnerable children almost twice less likely to be taken to an appropriate health provider than children from better off households. The use of hospitals is more pronounced among the better off (34%) than among the socio- economically more vulnerable (18%), with the same pattern observed regarding the use of health centres and posts . Care seeking for acute respiratory infections Proportion of children aged 0 to 59 months who had ARI in the last two weeks and were taken to an appropriate health provider - 58% with diarrhoeal diseases, acute espiratory infections (ARI) stand out s one of the most important causes of mortality among Angolan children 1 . A child who is breathing rapidly or with difficulty might have pneumonia, which is a life- threatening disease that requires immediate treatment. In the survey, ARI in children are defined as all situations where children suffered in the two weeks prior to the interview from coughing, accompanied by rapid or difficult breathing, with or without colds. The MICS indicates that 8% of children under five years of age suffered from such illnesses in the two weeks prior to the survey2 . Furthermore, a large proportion of children (42%) with signs of ARI did not see an appropriate health provider3 . The group most affected with ARI are those chi ldren aged between 12 and 23 months (11 %) . Acute respiratory infections seem to affect boys and girls with the same intensity and no significant differences are noted according to area of residence, households' socio-economic level or region. In total, 58% of chi ldren with ARI were taken to an appropriate health provider. Of those chi ldren, about half (28%) were taken to a One notes that it is mostly among the fifth socio-economic quintile that health centres and posts are the most used. The variations in the use of health centres and posts among the first four quintiles are of limited 'Although there are no accurate data on the main causes of child mortality in Angola, data from the Ministry of Health showed that among the causes of mortal ity recorded in national health services in 2000, malaria was by far the largest killer (76%) followed by acute respiratory infections (7%) and diarrhoeal diseases (7%). ' Simi larly to fever suggestive of malaria and diarrhoeal diseases, the MICS findings on ARI should be regarded only as indicative of the general state of the children's health and the measures taken by the caregivers during the infections. The diagnosis is made by the caretaker and is therefore subject to its interpretation. In addition the survey does not assess the severity of the infections. 3 Appropriate health providers include those who see children in hospitals, health centres, health posts and dispensaries. significance. These findings show that socio- economic conditions play a determinant role in whether a child will be seen by an appropriate health provider or not. They also reveal the extent to which the vast majority of the population is vulnerable. Finally, they reflect the overall availability of health services and the fact that the better off population is more likely to be urban and, therefore, have better access to health facilities. Graph 12.1: Proportion of children with ARI taken to health centres and posts according to socio-economic quintile 1st quintile 2nd quintile 3rd quintile 4th quintile 5th quintile In terms of regional disparities, children are more likely to be taken to an appropriate health provider in the Capital Region (65%) and the least likely in the North and East Regions {51% and 54% respectively), reflecting the overall availability of health services in the country. Maternal Care S killed health personnel should check pregnant women at least four times during every pregnancy and assist women during delivery at every birth' . Regular contact with skilled health personnel2 during pregnancy allows women to identify and possibly correct potential health problems in addition to receiving general health advice on tetanus immunisation, good nutrition, HIV/AIDS, malaria and hygiene. It is also necessary that doctors, midwives or nurses, who have the skills to safely handle normal deliveries and to recognise the onset of complications requiring emergency care, supervise labour and delivery This is particularly important to tackle maternal mortality, which in Angola is thought to be extremely high3 . In Angola the MICS indicates that qualified health personnel assist less than half of all deliveries and that a third of women are not attended even once during pregnancy. This situation is similar to that in sub-Saharan Indicators Antenatal care Proportion of women aged 15 to 49 years attended at /east once during pregnancy by skilled health personnel (doctors, nurses, and midwives) - 66% Childbirth care Proportion of births attended by skilled health personnel (doctors, nurses, and midwives) - 45% Africa, where in 2001 antenatal care was estimated at 66% and childbirth care at 41%. Although no improvement in antenatal care was recorded since 1996, with actually a decline in urban areas, the number of women attended by skilled health personnel almost doubled between 1996 and 2001. Antenatal care e MICS indicates that 66% of women are provided antenatal care by skilled personnel, 16% by Traditional Birth Attendants4 (TBAs), and 19% are not provided care at all. Among skilled personnel providing care, the overwhelming majority are nurses and midwives (7 4%), followed by doctors (18%) and auxiliary midwives (8%) . There are important variations in coverage according to areas of residence, region, socio-economic quintile, and level of education. At national level, the situation is similar to that in 1996, when the MICS indicated that 64% of women received antenatal care. However coverage decreased in urban areas from 80% in 1996 to 71% in 2001, probably reflecting increased hardship for women in accessing health services in urban areas. ' See Facts for Life: The MICS gathered data on the proportion of women attended once during pregnancy. ~ is internationally recommended, however, that women should be attended by skilled personnel at least four times during each pregnancy ' Skilled health personnel include doctors, nurses and midwives. Not included are traditional birth attendants, whether trained or not ' There are no accurate estimates of maternal mortality in Angola. In 2001 , the Ministry of Health estimated the maternal mortality rate at 1 ,500 per 100,000. ' TBAs are considered to be unskilled perscnnel, as the MICS does not identify whether TBAs have been trained or not, or determine the quality of the training provided. The survey points out serious .disparities among women in terms of access and capacity to pay for health care . The greater the level of schooling and wealth, the higher the antenatal coverage rate (about double) . Regardless of schooling or wealth, a nurse or midwife attends most women. What differentiates the better off women from the rest of the women surveyed is that following attendance by a nurse or midwife, most of them receive pre-natal consultations from doctors, while illiterate women and women from the lowest four quintiles are seen by traditional midwives. Graph 13.1: Type of personnel providing antenatal care by wealth index quintile Nurse/midwife TBAs • 1st quintile The use of TBA drastically decreases by socio- economic groups and mothers' level of education. Poorest women use TBAs ten times more during prenatal consultation than better off women. TBAs are also more largely seen in Doctor Auxi liary Not attended 5th quintile rural areas (23%) than in urban areas (13%) . Furthermore, the proportion of unqualified personnel attending pregnant women varies significantly by region, from 29% in the East, to 20% in the North, and 7% in the South. Graph 13.2: Percentage of women provided with antenatal care by traditional birth attendants per socio-economic quintile 1st quintile 2nd quintile 3rd quintile 4th quintile 5th quintile In rural areas, only half of the women are attended at least once during pregnancy, compared to more than two-thirds in urban areas. In general, women in rural areas either receive no antenatal care (24%), or receive it from less qualified staff. Antenatal coverage also varies according to the country's regions. The South has higher antenatal coverage than the other regions (76%), while the Centre South has the lowest coverage (59%). Similarly to what is observed at national level, the midwife nurse is the person who provides most antenatal care in all regions of the country. However the Capital, West and South Regions stand out where, unlike the other regions, the person most frequented (after the midwife nurse) is the medical doctor. In the other regions, the second most frequented person is the TBA. Table 13.1: Percentage of women 15 to 49 years old with a birth in the last year by type of personnel delivering antenatal care, Angola, 2001 Person delivering antenatal care Total assisted Nurse/ Auxiliary Traditional No care by skilled Doctor midwife midwife birth attendant received personnel Wealth index quintile First 10 35 3 29 24 47 Second 12 43 6 22 17 61 Third 10 43 6 18 23 59 Fourth 10 55 6 11 18 71 Fifth 18 64 5 3 11 86 Region Capital 12 51 8 9 20 71 North 12 48 9 20 12 69 East 14 39 2 29 15 56 West 17 50 2 15 17 69 South 13 58 4 7 17 76 Centre South 3 50 6 10 31 59 Area of residence Urban 14 52 5 13 16 71 Rural 7 41 5 23 24 53 Mothers' education level None 7 36 6 26 24 49 Primary 12 54 5 12 17 72 Secondary and higher 23 63 3 . 3 9 89 Total Angola 12 49 5 16 19 66 Care at childbirth e MICS reveals a completely different picture in terms of childbirth care and type of personnel delivering care than in 1996. At national level, the coverage increased from 26% to 45%. While in 1 996 the majority of births were assisted by parents or friends (55%) followed by nurse/midwife/auxiliary (21 %) and TBAs (12%), in 2001 the majority were assisted by nurse/midwife/auxiliary (39%), followed by TBAs (26%) , and then parents or friends (24%). The number of births not assisted also decreased from 9% to 3%. Table 13.2: Type of personnel assisting at birth: comparison between 1996 and 2001 in urban areas 1996 2001 Doctor 3 7 Nurse/midwife/ auxiliary 32 45 TBAs 8 20 These findings might be partly accounted for by better awareness and behaviour of women who increasingly demand more assistance for delivery outside the family circle. They also show a significant increase in the demand for health services, certainly as a result of the rapid urbanisation. Finally, they indicate that the increase in demand has not been adequately met by the offer of appropriate health services . For example the number of births attended by TBAs in urban areas increased by 150% between 1 996 Parents/ friends 49 23 No assistance 7 2 (%) Other 2 and 2001 while the number of births attended by qualified personnel increased by only 40% over the same period. In short, women increasingly resort to basic level health professionals as a matter of convenience and due to problems in access to health services, and possibly lack of capacity to pay. In rural areas only 25% of women have their births assisted by skilled health personnel. This coverage is less than half of that in urban areas and reflects a lack of knowledge and lack of access to health services. For example, while nurses or midwives more frequently assist women in urban areas, it is TBAs in rural areas who most frequently assist women during delivery. The importance of friends or relatives in childbirth care is also far from negligible in rural areas where they assist a quarter of all births. Although the survey does not indicate the place of birth, it can be assumed that those births assisted by relatives or friends, plus those that were not assisted at all, plus those assisted by traditional midwives, are home deliveries. This would mean that the majority of women in Angola are still delivering at home. As a reference, the MICS in 1996 established that 83% of all births were taking place at home. Women among the lowest three wealth index quintiles predominantly use traditional midwives. Only from the fourth quintile upwards (the less poor) did women more frequently use nurses or midwives to assist at birth. The same patterns are observed according to women's level of schooling. While the majority of women with higher education use nurses or midwives, women with the least education mainly use TBAs and relatives or friends to assist at delivery. Education about the critical benefits of · childbirth care appears as the determinant factor in whether a woman will seek assistance at birth or not. The childbirth coverage is three times higher among women with secondary and higher education than among illiterate women5 . Graph 13.3: Type of personnel assisting women at delivery according to women's level of education Nurse/midwife TBAs Parents/friends Doctor Not attended • No education Analysis of assistance at delivery by regions reflects the overall availability of health services in Angola. The highest childbirth care coverage is found in the Capital and West Regions,. and the lowest in the East Region. Coverage is similar to the national average in the North, South and Centre South Regions. The use of doctors is twice higher in the Capital than the national average. In the Capital, care at birth is essentially provided by nurses or midwives and relatives or friends. In the North, West, Centre South and South Regions, nurses or midwives more frequently assist births, although in the South assistance from relatives or friends accounts for more than a third of all deliveries. The highest percentage of women receiving no assistance at delivery at all is found in the Secondary and higher Centre South Region, where the percentage is three times higher than the national average. In this region, almost one in ten women never receive assistance at delivery. Of note is the relatively high percentage of women in the Capital that receive no assistance, where the rate is almost double the national average. The MICS indicates that a large proportion of women in the Capital (over a third) have their deliveries either assisted by relatives/friends or not assisted at al l. Only in the Eastern Region are most of the births assisted by traditional midwives. Paradoxically, it is in the East that friends or relatives assist least deliveries and where unassisted births are the lowest. The great majority of maternal care pro- vided is undertaken by mid-level and basic professionals. Taking into account the existing ' This is also related to the fact that in the MICS, women with secondary or higher education belong in their vast majority to the richest segment of the population (i.e. the fifth wealth index quintile). high levels of maternal mortality, with deaths occurring during pregnancy, childbirth and post-childbirth, the data on maternal care suggest the importance of training for mid- level and basic staff in order to maintain acceptable levels of maternal services. Table 13.3: Percentage of women 15 to 49 years old with a birth in the last year by type of personnel assisting at delivery, Angola, 2001 Person assisting at delivery Total Nurse/ Auxilliary Traditional Parents/ Not Other/ assisted Doctor midwife midwife birth friends assisted missing by skilled assistant personnel Wealth index quintile First 3 16 4 41 29 3 4 23 Second 4 25 8 32 27 3 2 36 Third 3 25 9 32 26 3 2 37 Fourth 7 39 8 20 23 2 2 54 Fifth 11 53 6 9 17 2 2 67 Region Capital 10 32 8 10 30 5 5 50 North 3 31 12 28 23 2 2 46 East 4 29 4 50 11 0 37 West 9 35' 5 26 24 0 49 South 7 37 3 12 35 3 4 47 Centre South 3 32 9 20 26 9 2 43 Area of residence Urban 7 38 7 20 23 2 2 53 Rural 19 6 40 26 5 4 25 Mothers' education level None 3 19 7 35 30 4 2 29 Primary 6 35 7 24 23 2 2 48 Secondary and higher 12 63 6 3 10 4 2 82 Total Angola 6 32 7 26 24 3 2 45 Indicators Seven of the main childhood illnesses can be prevented through vaccination. Three doses of DPT vaccine protect the child against diphtheria, pertussis and tetanus. Three or more doses of polio vaccine protect the child against poliomyelitis. One dose of BCG vaccine protects the child against severe cases of tuberculosis (TB), one dose of measles vaccine protects the chi ld against measles, and one dose of yellow fever vaccine protects the child against yellow fever' . TB immunisation coverage Proportion of one-year-old children immunised against tuberculosis - 69% Polio immunisation coverage Proportion of one-year-old children immunised against poliomyelitis (Polio 3) - 63% Measles immunisation coverage Proportion of one-year-old children immunised against measles - 53% DPT immunisation coverage Proportion of one-year-bid children immunised against diphtheria, pertussis and tetanus (DPT3) - 34% Children fully immunised Proportion of one-year-old children immunised against OPT, polio, measles, and tuberculosis - 27% In Angola, the national Expanded Programme of Immunisation (EPI) recommends that all children be fu lly vaccinated against DPT, tuberculosis, measles, yellow fever and polio before reaching one year of age. Therefore, the most appropriate age group to estimate vaccination coverage is among children 12 to 23 months old, as all the compulsory vaccination doses should have been administered to the child by 12 months of age. Recommended vaccination calendar in Angola Age of child at which vaccine should be administered Type of vaccine 0 months 2 months BCG and initial dose of polio (Polio 0) First dose of DPT (DPT1) and first dose of polio (Polio 1) 4 months Second dose of DPT (DPT2) and second dose of polio (Polio 2) 6 months Third dose of DPT (DPT3) and third dose of polio (Polio 3) 9 months Measles and yellow fever Overall, the MICS indicates that only 27% of one-year-old children are ful ly immunised against six of the seven preventable diseases2 . Children are least immunised against DPT (34%) and more immunised against tuberculosis ' Immunisation against yellow fever is not covered in the MICS. ' Diphtheria, pertussis, tetanus, polio, measles and TB. ' See State of the World's Children 2003, UNICEF. (69%) . This coverage places Angola among the ten countries in the world with the lowest immunisation coverage, and well below the average coverage in sub-Saharan Africa, which in 2001 was estimated at 46%3 . Only in terms of polio immunisation is Angola performing significantly well compared to sub-Saharan African countries. This positive achievement is due to the major efforts deployed by the EPI to interrupt wild poliovirus transmission in Angola through the implementation of National Immunisation Days (NIOs). Since 1996 these national campaigns have been repeatedly conducted throughout the country. As a result, the number of children immunised against polio more than doubled since 1 996 (from 28% to 63%) Relatively adequate coverage against tuberculosis (69%) is also another feature of immunisation in Angola, which might reveal a higher awareness of mothers about TB than other diseases such as OPT and measles and the fact that BCG vaccine is given at birth. Immunisation levels against TB, measles and OPT increased by about 10% since 1996, whereas polio stands out as the vaccine that recorded a more than 100% increase. The two main ways of administering vaccines in Angola are through routine immunisation services and supplementary immunisation activities, such as campaign- type interventions. The MICS has confirmed that routine immunisation services function poorly. For example, the percentage of children receiving the third dose of OPT is usually used as a good indicator of how well countries provide routine immunisation. It is a particularly relevant indicator in the Angolan context, as OPT is solely ad- ministered through routine service channels. The MICS shows that nationally only a third of one-year-old children are immunised against OPT3. In 2001, of 164 munici- palities in the country, the routine EPI was operating in only 91 of them and functioning routine immunisation services were mainly concentrated in and around provincial and municipal capitals. This was highlighted in that children in urban areas were twice as likely to be more immunised against OPT than children in rural areas. These findings highlight a considerable challenge for the public health sector in Angola. Until routine immunisation services are revitalised at community level, targeted vaccination campaigns will remain the most effective way to reach an increased number of children, particularly among the most vulnerable. These campaigns however are unsustainable, as they only provide short- term and non cost-effective solutions. Nonetheless, without the war constraint, the campaign approach can now be used in Angola as a mean, and not only a pallia- tive solution, to help rebuilding routine immunisation services, increasing mothers' awareness, and reducing disparities among socio-economic groups. The MICS illustrates how the campaign-type approach in general and the NIOs in particular have been powerful instruments in eliminating socio-economic disparities and disparities between the urban and rural populations. Among the most vulnerable children, immunisation levels against poliomyelitis are similar to those among the more privileged children. In comparison, immunisation levels against OPT are twice lower among the poorest. The same pattern is observed for immunisation against measles and tuberculosis. Of concern is the very low OPT immunisation coverage, even among the wealthiest population (less than 50%). This not only reveals the poor access to routine immunisation services, but also the inadequate awareness about diphtheria, pertussis and tetanus among the Angolan population. Graph 14.1: Immunisation coverage among one-year-old children by wealth index quintile Polio Tuberculosis • 1st quintile The education level of mothers is the most determinant factor impacting on whether a child is vaccinated or not. Overal l, an Angolan child whose mother has attained secondary or higher education is 2.5 times more likely to be fully immunised than a child whose mother never attended school . More than 75% of all children whose mothers enjoyed secondary education are immunised against polio, measles, and tuberculosis. Similarly to what Measles OPT 5th quintile is observed among wealth iest households, immunisation coverage against OPT is the lowest among educated mothers (61 %), but still significantly higher than OPT cover- age among children whose mothers are illiterate, where it does not even reach 25%. Immunisation coverage for polio shows the smallest variations in terms of education , which probably reflects the positive effects of the NIOs. Graph 14.2: Immunisation coverage among one-year-old children by mothers' level of education Polio Tuberculosis • No education Children are most protected against tuberculosis and polio in the Capital Region. The coverage against measles and OPT is also higher in the Capital than in the West, East, South, and Centre South Regions. Measles OPT Secondary and higher education Surprisingly, it is not, however, where full immunisation coverage is the highest. This is due to the fact that OPT3 coverage in the Capital is very low (37%) when compared to OPT3 coverage in the North Region (57%). For all preventable diseases, the North Region consistently presents a coverage superior to 50%. Consequently, one-year- old children in this region are two times more fully immunised than children in any other region . It is also only in the North Region that more than 50% of children possess a vaccination card . This fact might indicate higher access to routine immunisation services . The least variations in immuni- sation level across regions are recorded for tuberculosis (between 64% and 78% coverage across regions), whereas the highest variations are recorded for OPT {between 17% and 57% coverage across regions) . Map 14.1: Full immunisation coverage among one-year-old children Above 40% Between 20% and 40% Less than 20% Region North 54% Although immunisation coverage varies greatly according to households' wealth, area of residence, regions, and mothers' education level, there are no significant variations by sex. Boys and girls are vaccinated alike, which reveals no gender discrimination. Finally, the MICS shows that 70% of all Angolan children under five years of age do not have a vaccination card. Even among the least vulnerable , less than 40% own a card . Urban areas indicate a higher number of children with vaccination cards than rural areas (32% versus 24%) . This low level of possession of vaccination cards is due to their unavailability in vaccination posts, their loss, and the fact that they are not distributed during national immunisation campaigns. Table 14.1: Immunisation coverage among children aged 12 to 23 months, Angola, 2001 (by vaccination card and mothers' history)• TB Polio3 Measles DPT3 Full immunisation immunisation immunisation immunisation immunisation coverage coverage coverage coverage coverage Socio-economic quintile First 54 63 38 23 20 Second 57 57 44 23 18 Third 73 62 56 34 28 Fourth 70 68 55 36 28 Fifth 84 65 68 47 35 Sex Male 68 61 54 34 26 Female 69 65 53 34 27 Region Capital 78 72 65 37 28 North 73 69 69 57 54 East 64 60 44 24 17 West 65 64 53 33 28 South 64 53 52 27 19 Centre South 69 63 42 27 17 Area of residence Urban 74 64 58 39 31 Rural 57 61 42 22 18 Mothers' education level None 57 59 41 23 20 Primary 73 63 55 35 26 Secondary and higher 85 78 82 61 49 Total 69 63 53 34 27 Comparison 73 52 54 46 Total Sub-Saharan Africa 2001 ' In the MICS, mothers were asked if they had a vaccination card for their children . If th is was the case, the interviewer extracted from the vaccination card information about the child's immunisation status. When children did not possess a vaccination card or when it was incomplete, mothers supplied information on the children's vaccination history through conversation with the interviewer. Poliomyelitis 0 ne of the most remarkable achievements in Angola's recent public health history has been the progress made towards the eradication of polio . As a result of the massive investment made since 1996 to eradicate the disease through the implementation of repeated National Immunisation Days (NIDs), polio immunisation coverage among one-year-old Angolan children more than doubled between 1996 and 2001 , from 28% to 63%. Polio eradication Eradication of polio involves both halting the incidence (the number of new cases) of the disease and the world-wide eradication of poliovirus, the virus that causes it. The world will be certified polio-free after at least three years of no new cases reported due to indigenous wild poliovirus. Polio is a highly infectious disease that has paralysed thousands of Angolan children. The poliovirus spreads silently and rapidly, and only the fi rst cases of paralysis trigger awareness of an outbreak. Polio cannot be cured but can be prevented by immunisation. World-wide, polio cases have declined by UNICEF special reprensentative, Mrs Mia Farrow, gives a dose of polio vaccine to a baby. 99% since the launch of the global polio eradication initiative. Much attention was given to Angola, as in 2000 it was among the 20 countries in the world where pol io was stil l endemic. This was largely because of the difficulties in reaching all children due to the war and massive internal displacement. In 2002, polio was no longer considered to be endemic in Angola. From 1,103 polio cases reported in 1999, the numbers of confirmed cases decreased to 55 in 2000, only one in 2001, and none in 2002. Table 15.1: Evolution in the number of confirmed wild poliovirus cases among countries that recorded the highest number of cases in 1999 1999 2000 2001 2002 India 2817 265 268 1458 Angola 1103 55 0 Nigeria 981 28 56 159 Pakistan 558 199 119 89 Bangladesh 393 0 0 Afghanistan 150 27 11 9 Ethiopia 131 3 0 Sudan 60 4 0 DRC 45 28 0 0 Somalia 19 46 7 3 Source: WHO, January 2003. The trend observed in Angola is similar to that observed in Bangladesh and other African countries such as Ethiopia, Sudan and ORC where the number of polio cases consistently decreased since 1999 and fell to zero in 2002 . However, the example of Nigeria and India, where confirmed polio cases first drastically decreased and then increased again, shows how critical it is in the coming years to sustain the NIOs and the coverage already attained. If the virus is to be globally eradicated, those countries where polio cases have not been reported for several years cannot afford to diminish their efforts towards polio immunisation and surveillance. For example, in 2000 polio was not con- sidered to be endemic in Zambia with zero confirmed polio cases. It recorded however three polio cases in 2001 and two polio cases in 2002. Large movements of population from Zambia to Angola are expected in 2003, with the return of Angolan refugees. Costly immunisation campaigns will therefore remain necessary until at least 2005. In Angola, all regions register immunisation levels above 50%, with the highest coverage in the Capital Region (72%) and the lowest in the South Region (53%). In the Southern Region however, results should be interpreted with caution, as this region was surveyed prior to the 2001 NIOs, which were conducted in June, July and August 2001. Therefore, it is not surprising that this region registers the lowest coverage. This phenomenon was also observed in vitamin A supplementation among children. As noted, immunisation levels are harmonised throughout urban and rural areas, socio-economic groups and sex, although mothers' education level remains a determinant factor. M easles is a highly contagious, yet avertable viral infection that kills more Angolan children than any other vaccine-preventable disease. In Angola it is probably responsible for 5% to 10% of all deaths among under-five children. Analysis of available epidemiological data shows that 95% of measles cases occur in children below 15 years of age, the majority of which occur in children under five years of age. Measles-related mortality usually occurs among young infants. The virus weakens the immune system and renders children very susceptible to fatal complications from diarrhoea, pneumonia, and encephalitis. Children that survive measles can have permanent disabilities, including brain damage, blindness and deafness. Due to the weak national surveillance information system for the collection and analysis of health data, it is difficult to provide an accurate picture of measles incidence in Angola. There is massive under-reporting about measles cases, particularly in rural areas. In 2001, the Ministry of Health reported 9,000 cases of measles nation- wide, but this is thought to represent less than 30% of the real number. The measles virus is transmitted via droplets released into the air when an infected person coughs or sneezes. Because it is highly contagious, vaccination coverage levels need to be maintained at least at 90%. The MICS shows that on average 53% of one-year-old children are vaccinated against the disease. Analysis of immunisation levels by age groups reveals that only 42% of Angolan children are vaccinated at the recommended age (i.e. between 9 and 12 months). Immunisation levels increase slightly with age, reaching 54% among one-year-olds, 56% among two- year-aids, and 60% among three-year-olds. At four years of age they decrease to 56%. Double the number of children whose mothers are most educated are vaccinated than children whose mothers are illiterate. The same pattern occurs according to households' wealth. Children are the most vaccinated in the Capital and North Regions, and the least vaccinated in the East and Centre South Regions. The overall low measles coverage is linked to the weak health care system, logistical difficulties in reaching children, lack of awareness about the disease, and the high level of missed opportunities. Typically, a sick Angolan child attending health facilities will generally not be checked for his/her immunisation status, therefore missing the opportunity to be vaccinated against measles. With polio eradication almost within reach, it is now possible to focus on measles mortality reduction in Angola. The under-five mortality rate could decrease by up to 10% if all children were immunised against measles. This means that over 7,000 Angolan children could be saved every year. The implementation in April-May 2003 of the first ever nation-wide measles campaign conducted in Angola, targeting all children 9 months to 14 years old, was the first significant step in that direction. The campaign also allowed the development of better measles epidemiological surveillance . However, similarly to what was observed in polio, the campaign-type approach is inherently difficult to sustain and is costly. In the present context, it is nevertheless a powerful instrument, not only to reach an increased number of children and protect the most vulnerable, but also to equip and reactivate the network of routine vaccination centres throughout the country. Map 16.1: Measles immunisation coverage among one-year-old children Above 60% Between 50% and 60% Less than 50% Region North 69% Region South 52% M aternal and neonatal tetanus is a preventable, often fatal condition resulting from unhygienic birth practices which expose the umbilical cord to tetanus bacteria. When mothers give birth under unhygienic conditions, both mother and chi ld are at risk of getting tetanus, a major killer of new-born infants. In Angola, tetanus is one of the main causes of neo- natal mortality. Tetanus Toxoid (TT) is given to women of childbearing age, or who are already pregnant, in order to protect both women and new-born chi ldren against tetanus. The national Expanded Programme of Immunisation (EPI) recommends that women of childbearing age receive five doses of n vaccine according to the following calendar: First dose: as soon as the woman knows she is pregnant Second dose: one month after the first dose Third dose: six months after the second dose Fourth dose: one year after the third dose or during a subsequent pregnancy Fifth dose: one year after the fourth dose or during a subsequent pregnancy. If a girl or a woman has been vaccinated with five properly spaced doses of Toxoid Tetanus, she is protected for her lifetime. Her children are also protected for the first few weeks of life. During pregnancy two doses of n will give mother and new-born baby adequate protection but, given that protection only lasts for three years, will fall short of providing lifetime protection covering all other pregnancies. In the MICS, all women between 15 and 49 years of age who had a child in the 12 months prior to the survey were asked about anti-tetanus vaccination. Women were regarded as protected if they had received at least two doses in the last three years; if they had received at least three doses in the last ten years ; and if they had received at least five doses at any time in their life. Overall, 62% of women who had a child in the 1 2 months prior to the survey received two doses of n vaccine in the last three years, indicating that a relatively adequate number of Angolan women were protected during their last pregnancy. However, their protection level was not sufficient to protect them and their children during further pregnancies. It is worth noting that only 0.1% of women received three doses of n vaccine in the last ten years, and none received five doses in their entire lifetime. These striking findings mean that no Angolan woman of childbearing age is protected for life against tetanus. It also indicates that Angolan women rnight not be fully aware of the risk of neonatal tetanus and do not comply with the recommended national vaccination calendar. Women in urban areas are more protected than women in rural areas. Similarly to what was observed in child immunisation patterns, it is in the North Region that women are most protected {71 %) and in the Centre South Region that they are the least protected (50%). The level of poverty is directly associated with anti-tetanus coverage, with coverage increasing from 4 7% among the poorest women to 71 % among the better off women. Mothers' level of education has the highest impact on whether mother and child are protected. Coverage among the rnost educated worn en reaches 82% compared to 51 % among women who are illiterate. BY the end of 2001 HIVIAIDS was being transmitted to about four million people annually in sub-Saharan Africa. With the death toll doubling every four years, it seems increasingly likely that less affected countries, such as Angola, are merely at an earlier phase of the pandemic' . By the end of 2001, the proportion of adults (ages 15 to 49 years) infected with HIV I AIDS was more than 20% in seven sub-Saharan African countries, two of which border Angola. In Namibia, South Africa, Swaziland, Lesotho, Botswana, Zambia and Zimbabwe2 the pandemic already promises to kill more than one in five adults . One third of children have already lost one parent and their chances of losing the other one ar.e high. The demo-graphic consequences of the epidemic are unprecedented, with the expected population deficit surpassing that of any war ever known. By the end of 2001, in sub-Saharan Africa alone, 28 million people were infected and 11 million children were orphaned with one or both parents lost to the disease. If the pandemic continues unabated, the fabric of African society may start to . disintegrate under its demographic, social and economic onslaughr. Controlling the spread of HIV I AIDS is without doubt the biggest public health challenge of modern times, both at global and regional levels. African leaders' commitment to halting the spread of HIV was reaffirmed during the April 2001 Abuja Conference on HIV and AIDS. In addition to their personal commitment to fight HIV, African leaders were to allocate 15% of the government budget to the health sector. The United Nations General Assembly Special Session (UNGASS) on HIV/AIDS, held in June 2001, also represented an extraordinary effort by the global political leadership to act upon the HIV/ AIDS pandemic in a concerted and meaningful way. The UNGASS Declaration of Commitment, which Angola signed, set clear targets to reduce the spread and impact of HIV and AIDS. In Angola this has been taken up at the highest level of decision-making through the creation of a National Aids Commission, including all ministerial representatives and chaired by the President of the Republic. Despite the general lack of information on the scope of the epidemic in Angola, there are indications that HIVIAIDS is spreading rapidly. The large number of internally displaced persons together with increased contact with military personnel, the high percentage of the population under 24 years of age, low levels of education, and a high poverty index further indicate that Angola has almost all of the risk factors associated with the rapid increase of the epidemic. '·' "UNICEF and UNAIDS evaluation of HIV!AIDS programme in sub-Saharan Africa", introduction by Mahesh Patel, Karen B. Allen, Robert Keatley and Urban Jonsson, in Evaluation and Programme Planning, volume 25, Number 4, November 2002. 2 UNAIDS, 2001 . Map 18.1: The HIVIAIDS Pandemic Speed at which the pandemic has developed and progressed in sub-Saharan Africa Estimated percentage of adults aged 15 to 49 years infected with HIV in sub-Saharan Africa between 1984 and 2001 1984 0 0 1994 0 0 A 250% increase in the sera-prevalence of women attending antenatal clinics in Luanda was recorded between 1999 and 2001 (from 3.4% to 8.6%)4. Of particular concern was the very high syphilis rate (1 9%), which often serves as a proxy indicator for HIV sera- prevalence. The same year, it was discovered that 33% of commercial sex workers in Luanda were infected with the HIV virus and 34.1% were infected with syphilis5 . In Lubango, 11 . 7% sera-prevalence was recorded among 1989 2001 20% and above Between 9% and 19% Between 2% and 8% Below 2% or no data or not in sub-Saharan Africa Source: UNAIDS blood donors in 2001 6 . 0 0 0 0 In spite of the rapid pace of the increase of the sera-prevalence rate by the end of 2001, UNAIDS still estimated sera-prevalence among the Angolan population at 5.5%7 , a rate four times lower than that recorded in neighbouring Zambia (21 .5%) and Namibia (22 .5%), indicating that there still might be a rare window of opportunity for Angola to avoid the disaster witnessed in neighbouring countries. Angola National Public Health Institute (INSP), National HIV/AIDS Program (PNLS), UNICEF, Italian Co-operation, WHO, 2001. The study also indicated sera-prevalence rates of 2.6% in Benguela and 4.4% in Huila, with syphilis rates of 13.9% and 18.5% respectively. 5 Population Action International, 2001 . ' Huila Provincial Public Health Delegation, 2001 . 7 This would mean that in 2001, there were about 330,000 Angolans aged between 15 and 49 infected. Projections from this data further indicate that there were in 2001 approximately 100,000 Angolan children between 0 and 14 years of age orphaned by AIDS. The MICS looks in detail at the knowledge of four simple, life-saving facts of HIV prevention among the Angolan population aged between 15 and 49: • Consistently use a condom when having sex. • Having only one faithful uninfected sexual partner. • Abstain from sex. • HIV can be transmitted from mother to child during pregnancy, childbirth and breast- feeding . The survey also examines the stigma that surrounds HIV and AIDS by looking into the understanding of the disease by the population. In particular it gauges the level of prejudice and the attitude of Angolans towards compatriots who have already been infected, by looking at three misconceptions and two discriminatory attitudes: Three misconceptions: • Healthy looking persons cannot be infected with HIV. • HIV can be transmitted by mosquito bites. • HIV can be transmitted by supernatural means. Two discriminatory attitudes: • Believe that a teacher with HIV or AIDS should not be allowed to work. • Would not buy food from a person with HIV or AIDS. When it comes to monitoring the impact of HIV/AIDS, the state of decay of Angola's public health infrastructure . puts the country at an enormous disadvantage. Functioning national health information systems have allowed Namibia and Zambia to determine that more than one in five adults were infected. In Angola, this capacity does not yet exist. In 2001, less than half of all provinces had laboratories capable of undertaking HIV tests. At the beginning of 2003, in Luanda there were only four locations where Angolans could be tested and counselled for HIV, although the city of Luanda has about 3.5 million inhabitants. No other provinces at the beginning of 2003 possessed facilities for Voluntary Counselling and Testing (VCT). In this context of uncertainty regarding sera- prevalence status among the Angolan population, the MICS provides information at national and regional levels on the attitude, knowledge, and to some extent practice, of the Angolan population towards HIV and AIDS. MICS data shows that, while time is running out if Angola is to avoid the disaster witnessed in neighbouring countries, the only existing way to avoid infection (i.e . possessing enough knowledge about it in order to change sexual behaviour) is still lacking among the population. Overall, the survey indicates that only one in ten Angolan people aged 15 to 49 years have sufficient knowledge about the disease. Disparities among men and women are dramatic, with women twice as likely not to possess sufficient knowledge on HIV prevention and transmission . The most important strategy for reducing the spread of the pandemic is to promote accurate knowledge of how HIV 1s spread and prevented, leading to behaviour changes. The future evolution of the pandemic will mostly depend on the success of actions - such as information, education and communication campaigns - to prevent HIV transmission among young people. This is particularly relevant in the Angolan context where 59% of the population is under 18. The MICS reveals that Angolan youth has very little knowledge about the disease. For example, only 21% of young people aged 15 to 1 9 years know the three main ways of preventing HIV transmission and a mere 1 8% are able to correctly identify three misconceptions about HIV The survey indicates great regional variations. Most knowledge of HIV trans- mission and prevention is consistently found among Angolans in the Capital Region, while the lowest proportion is found in the Centre South Region . In Huambo, Bie and Kuando Kubango provinces, only three percent of women and six percent of men have sufficient knowledge to protect themselves, revealing the extent to which war-affected provinces have been cut off from information, education and communication. The situation Indicators Knowledge of preventing HIV/AIDS is however not much better in the Capital Region where less than one in four people over 1 5 years of age has a sufficient level of knowledge about HIV transmission and prevention . Interestingly, it is in the Capital Region that the majority of people show discriminatory attitudes towards people living with HIV or AIDS and in the Centre South Region where people are the least discriminatory. The MICS here establishes a clear correlation between the level of knowledge and attitude of the population. People with basic knowledge about HIV transmission and prevention tend to be more discriminatory towards infected people. This correlation is also visib le according to households' level of wealth and education. Proportion of women who correctly state the three main ways of avoiding HIV infection - 17% Knowledge of misconceptions of HIV/AIDS Proportion of women who correctly identify three misconceptions about HIV/AIDS- 14% Knowledge of mother-to-child transmission of HIV Proportion of women who correctly identify means of HIV transmission from mother to child - 29% Attitude to people with HIV/AIDS Proportion of women expressing a discriminatory attitude towards people with HIV/AIDS- 44% Sufficient knowledge about HIVIAIDS Proportion of women who know the three main ways to prevent HIV transmission and who correctly identify three misconceptions about HIV transmission - 8% Women who know where to be tested for HIV Proportion of women who know where to get a HIV test - 23% Women who have been tested for HIV Proportion of women who have been tested for HIV- 2% Fear, silence and stigma The more wealthy and educated people are, the more they know about HIV transmission and prevention. Paradoxically, they are also more likely to have a discriminatory attitude towards people living with HIV or AIDS . For example , better off people are seven times more likely to have sufficient knowledge about HIV and AIDS than the poorest, but are also twice as likely to show discriminatory attitudes. Similarly, people with secondary or higher education are twelve times more likely to have sufficient knowledge than illiterate people, but are three times more likely to have discriminatory attitudes towards infected people. This finding reveals the importance of the "culture of silence" and "social stigma" that exists around the disease, a factor that greatly contributes to the rapid spread of HIV/AIDS. The fact that increased knowledge does not dispel misconceptions about the disease is indicative of the significant progress that remains to be made to provide the Angolan population with comprehensive knowledge about HIV and AIDS . The prevalence of discriminatory attitudes reveals that knowledge of transmission and pre- vention remains partial and confused even among those groups which can demonstrate a sufficient level of basic knowledge of prevention and transmission. It also reveals the urgent need to find ways to break the silence and end the stigma in order to fight the epidemic . Women who have heard of HIV and AIDS Among Angolan women aged 15 to 49 years, one third have not even heard of HIV/AIDS (32%), with a much higher proportion in rural areas (47%) than urban areas (26%) . The highest number of women who have heard of HIV/AIDS is found in the Capital Region (90%) and the lowest in the East and Centre South Regions (60% and 50% respectively) . The West, North, and South Regions are close to the national average. Almost all women who have received secondary or higher education have heard of HIV/AIDS (96%), against less than half of illiterate women (45%) . Although less pronounced, the same pattern is observed when looking at households' level of wealth, with 51 % of women among poorest households who have never heard of the disease against 11 % among the better off women. Map 18.2: Percentage of women 15 to 49 years who have never heard of HIV/AIDS Region North 28% Less than 20% Between 20% and 39% 40% and above Region South 27% Knowledge of preventing HIV/AIDS On~ 17% of women aged 15 to 49 years know the three main ways to prevent transmission, namely the consistent use of a condom when having sex, having on~ one faithful uninfected partner, and abstaining from sex. The nrst two ways are known to 27% of Angolan women, whereas the latter is known by on~ 21%. There are colossal variations according to households' wealth levels, regions, areas of residence, age group and education levels. Knowledge of the three main ways of preventing HIV transmission is eight times higher among women with secondary or higher education than among illiterate women, with the same pattern observed according to wealth index quintiles. Among the most vulnerable Angolan women, only 6% know the three main ways to protect themselves from being infected. Graph 18.1: Percentage of women 15 to 49 years who know the three main ways of preventing HIV according to wealth index quintile 1st quintile 2nd quintile 3rd quintile Prevention knowledge is higher than the national average among younger women than among older women. For example, while 19% of 15 to 19-year-old women know the three main ways of avoiding HIV, only 8% of women aged 45 to 49 years do. With almost 70% of the Angolan population under 24 years of age, it is extremely worrying that two-thirds of women aged between 15 and 2 4 do not know any ways that HIV can be prevented. In the Capital Region, women are four times more likely to know the main ways of transmission than in the North and Centre South Regions. The other regions are close to the national average. 4th quintile 5th quintile The same patterns are observed when looking at the knowledge about each individual way of preventing HIV For example, while 51% of women in the Capital Region know that the consistent use of a condom during sexual relationships can prevent infection, only 13% and 16% of women in the Centre South and North Regions respectively know this fact. Women with secondary or higher education are almost seven times more likely to identify condom use as a prevention method than those with no education (63% against 9%) , and women aged 15 to 1 9 years are twice as likely to know about condom use than women aged between 45 and 49. Knowledge of misconceptions of HIV/AIDS 0 nly 14% of women aged between 15 and 49 could correctly identify three misconceptions about HIV/ AIDS. The same patterns as those observed in the knowledge of preventing HIV are noted. Poorest women are six times less likely to correctly identify these three beliefs as misconceptions than better off women (6% versus 33%). More-over, illiterate women are ten times less likely to correctly identify these misconceptions than more educated women (4% versus 42%). Only 10% of women in the Centre South Region know that HIV cannot be transmitted by mosquito bites, against 44% in the Capital Region. It is striking to note that although higher levels of misconceptions are recorded among older Angolan women, a staggering 84% of young Angolan women aged 15 to 1 9 years cannot correctly identify the above-mentioned beliefs as miscon-ceptions. Almost 80% of young women believe that HIV can be transmitted by mosquito bites and 70% that it can be transmitted by supernatural means. Graph 18.2: Percentage of women 15 to 49 years who correctly identify three misconceptions about HIV/AIDS according to education level No education Primary education Secondary/higher education T:e MICS gauged women's discriminatory attitudes towards people living with HIV/AIDS by asking women whether they believe that a teacher who has HIV or AIDS should be allowed to continue teaching and whether they would buy food from an infected person. More than one in four Angolan women believe that a teacher with HIV or AIDS should not be allowed to work (28%) . The same proportion would not buy food from an infected person. In general, 44% of women agree with at least one discriminatory statement. Urban women and those with secondary or higher education are more likely to express discriminatory attitudes than rural women and those with no education or only a primary school education. As noted, there is a striking correlation between the level of women's knowledge of HIV I AIDS and their attitude towards infected people. The more women are better off, educated and able to demonstrate basic knowledge about HIV transmission, the more they tend to have discriminatory attitudes, indicating the alarming level of prejudice surrounding HIV and AIDS. This finding also reflects the fact that the more people know about HIV and AIDS, the more they tend to isolate themselves from the problem. Attitude to people with H IV or AIDS Map 18.3: Percentage of women aged between 15 and 49 years who demonstrate a discriminatory attitude towards people living with HIVI AIDS Region North 45% Less than 40% Between 40% and 50% Above 50% Region East 39% Region South 46% Knowledge of mother-to-child transmission of HIV M ore than half of Angolan women do not know that HIV can be transmitted from mother to child. When looking at the specific mechanisms through which mother-to-child transmission can take place, 55% of women do not know that HIV can be transmitted during preg- nancy, 38% do not know that HIV can be transmitted during childbirth, and 34% do not know that it can be transmitted through breast-feeding. Similar patterns are observed to those noted in knowledge of prevention and prevalence of misconceptions, with a higher proportion of women knowing about mother-to-child transmission among the better off, rnore educated, younger and urban women, and women living in the Capital Region. Women who know where to be tested for HIV Voluntary testing for HIV, best when accompanied by counselling, allows those infected to seek health care and to prevent the infection of others. Testing is particularly important for pregnant women who can then take steps to prevent infecting their babies. The MICS measures whether women are aware of places to get an HIV test, the extent to which they have been tested, and the extent to which those tested have been told the result of the test. As a result of the fear, "culture of silence" and stigma that surround HIV/AIDS, in some places a relatively large proportion of people who are tested do not return to get their results due to fear of having the disease, fear that their privacy will be violated, or other reasons. In other cases, health care professionals, mainly due to lack of training, do not inform the patients of their sero-positivity but rather indicate a more socially acceptable diagnosis such as malaria or TB. Outside Luanda, there are very few places where people can be tested for HIV. This factor has allowed the epidemic to go unchecked in Angola. Overall , less than one in four women know a place to get tested for HIV (23%), with wide disparities among regions, households' wealth, women's education levels, age groups and areas of residence. For example, better off women and women in the Capital Region are four times more likely to know a place to get tested than poorest women and women in the Centre South Region. Women who have been tested for HIV and have been told the results Overall, only two percent of Angolan women have been tested for HIV, a percentage that varies from one percent among illiterate women to six percent among women who received secondary or higher education. It is in the Capital Region that the highest percentage of women has been tested (4%). In all other regions, the percentage varies between one and two percent. Although the majority of women who have been tested were told the result, one in four were not. There are also worrying variations across regions, age groups, and education levels. Surprisingly, it is not in the Capital Region that most women tested were told the results of the test but in the East where 96% of women tested had knowledge of the test results. Of particular note is the situation in the West Region, where nine in ten women who were tested were not told the results of the test. In all other regions, the percentage of women who were informed of the test results is 70% or over. Despite the importance of targeting youth to fight the epidemic, it is adolescent Angolan women (aged 15 to 1 9) who are the least likely of any age group to have been tested (only 1 %). They are also the least likely to know the result of their test with only 56% of the adolescents tested ever being told the test results. Source of information about HIV and AIDS Although only 14% of Angolan households own a television, com~ pared to 38% that own a radio, the survey reveals that at national level most women received information on HIV/AIOS through television (42%) with only 4% being informed through radio. The second most important channels through which women received information on HIV I AIDS are parents, relatives and friends (36%), with the third main source of information being the Church and meetings within the communities (23%) . There are imp~rtant variations between regions regarding the source of information. While TV is the main channel through which informatio1 on HIV/AIOS is circulated to women i1 the Capital Region, parents, relatives, friends, communities and Church appear as the main source of information in all other regions. Box 1: United Nations General Assembly Special Session (UNGASS} on HIV/AIDS of June 2001 Selected UNGASS Targets Prevention targets By 2003, establish time bound national targets to achieve the internationally agreed global prevention goal to reduce by 2005 HIV prevalence among young men and women aged 15 to 24 in the most affected countries by 25% and by 25% globally by 2010. By 2005, ensure that at least 90% and by 2010 at least 95% of young men and women aged 15 to 24 have access to the information, education, including peer education and youth specific HIV education and services necessary to develop the life skills required to reduce their vulnerability to HIV infection; in full partnership with youth, parents, families, educators and health care providers: By 2005 reduce the proportion of infants infected by HIV by 20% and 50% by 2010, by: • ensuring that 80% of pregnant women accessing antenatal care have information, counselling and other HIV prevention services available to them; • increasing the availability of and providing access for HIV~infected women and babies to effective treatment to reduce mother to child transmission of HIV; and • providing effective interventions for HIV~infected women, including voluntary and confidential counselling and testing, access to treatment, especially retro~viral therapy and, where appropriate, breast milk substitutes and the provision of a continuum of care . Care, support and treatment target By 2003, ensure that national strategies are developed in order to provide psychosocial care for individuals, . families and communities affected by HIV/AIDS. Children orphaned by HIV/AIDS targets By 2003, develop and by 2005 implement national policies and strategies to build and strengthen governmental, family and community capacities to provide a supportive environment for orphans and girls and boys infected and affected by HIV/AIDS. Ensure non-discrimination and full and equal enjoyment of human rights through the promotion of an active and visible policy of de-stigmatisation of children orphaned and made vulnerable by HIV/AIDS. Table 18.1: Summary table of HIV/AIDS indicators Have heard of . Know three main Correctly Have sufficient HIV/AIDS ways to identify three knowledge prevent HIV misconceptions transmission about HIV transmission Female Male Female Male Female Male Female Male Wealth index quintile First 49 60 6 11 6 9 3 6 Second 57 72 9 20 7 17 4 11 Third 63 76 11 24 8 18 5 10 Fourth 71 81 16 30 11 25 6 15 Fifth 89 92 36 44 33 43 19 26 Region Capital 90 95 36 44 37 46 21 28 North 72 80 9 20 9 23 4 12 East 60 72 15 26 10 19 6 13 West 65 85 17 35 12 24 7 18 South 73 77 18 25 13 24 7 13 Centre South 50 62 9 17 5 11 3 6 Area of residence Urban 74 84 21 33 17 29 10 18 Rural 53 66 8 16 7 14 4 8 Age group 15 to 1 9 years 68 71 19 23 16 19 8 11 20 to 2 4 years 72 81 21 30 18 29 11 16 25 to 29 years 71 81 18 32 14 27 8 17 30 to 34 years 70 83 16 31 14 28 8 17 35 to 39 years 67 83 15 31 12 27 7 18 40 to 44 years 59 81 13 29 10 26 6 16 45 to 49 years 56 77 8 25 8 22 4 13 Education level None 45 42 5 7 4 5 2 3 Primary 76 78 19 24 14 20 8 12 Secondary and higher 96 94 42 45 42 44 22 27 Total 68 79 17 28 14 25 8 15 I n sub-Saharan Africa, the majority of new HIV infections are among young people aged 15 to 24. In areas where the spread of HIV/AIDS is subsiding or even declining, it is primarily because young men and women are being given the tools and the incentives to adopt safe sexual behaviours. For example, in Lusaka, Zambia, HIV prevalence among adolescents aged 15 to 1 9 declined from 28% in 1993 to 15% in 1998. This decrease was attributed to increased condom use and fewer sexual partners, thanks to a vigorous national programme providing life-skills education and health services for young people1 . In Angola, more than two decades into the epidemic, the overwhelming majority of young men and women remain uninformed about HIV and AIDS. This is particularly worrying in a context where the youth is sexually active (by 20 years of age, almost 70% of Angolan women have already given birth). The vast majority of the Angolan youth have no idea how HIV/AIDS is transmitted or how to protect themselves from the disease. More than nine in ten young people (15 to 19 years) do not have sufficient knowledge about the disease. What young people have the right to know: • To know about sex and their sexuality • To know the basic facts on HIV/AIDS and have the necessary life skills to protect themselves from HIV and other ST/s • To know their HIV status • To know how to protect themselves if they are living with HIV/AIDS • To know where to get medical, emotional and psychological support if they are living with HIV/AIDS • To know how to protect those in their communities who are living with HIV/AIDS • To know about and participate in HIV education programmes tailored for youth • To know their rights and entitlements, and the commitments that governments have made to them • To know how to protect, claim and realise these rights 1 Young people and HIV/AIDS: Opportunity in crisis, UNAIDS, UNICEF, WHO, 2002. Although a majority have heard of AIDS, many do not know how HIV is spread and do not believe they are at risk. More than two-thirds (68%) do not know that the consistent use of a condom can prevent infection. Further, those young people who do know about HIV often do not protect themselves because they lack the ski lls, the support or the means to adopt safe behaviours. This was strikingly illustrated by the fact that only 0.6% of young men and women reported use of either feminine or masculine condoms. The youth is more likely to have less knowledge about HIV/AIDS than other age grou[i)s. For example, young Angolan men have the lowest knowledge about HIV/AIDS than any other age group among the male population 15 to 49 years of age. Young women aged 15 to 19 years also demonstrate less knowledge about HIV transmission than women aged 20 to 24 years, although their knowledge is higher than women aged 35 to 49 years. Graph 19.1: Proportion of the population aged 15 to 49 years with sufficient knowledge about HIV/AIDS: disparities between men and women by age group 20 18 16 14 12 10 8 6 4 2 0 _ 1a% ~6~ - 17% ~ -~16% - - / ~ / ~13% .-'11% ~1% ~ ~ - - a% - a% a%~--6% --------4% - 15-19 years 20-24 years 25-29 years 30-34 years 35-39 years 40-44 years 45-49 years ___._ Female ----- Male , Contraception Indicators Contraceptive prevalence Proportion of women aged 15 to 49 who are using (or whose partner is using) a contraceptive method (either modern or traditional) - 6% Contraceptive prevalence among married women and women in unions Proportion of married women or women in unions aged 15 to 49 who are using (or whose partner is using) a contraceptive method (either modern or traditional) - 6% At the beginning of the millennium, contraceptive prevalence in sub~ Saharan Africa was the lowest in the world. It was estimated in 2000 at 23%' . The MICS indicates a much lower prevalence in Angola, with only 6% of women aged 15 to 49 using (or whose partner is using) a modern or traditional method. The pattern of contraceptive use for married women (or women in unions) is identical. These findings ' State of the World's Children 2003, UNICEF. are directly related to the very high fertility rate recorded in Angola, with on average seven children per woman. At national level, the use of modern methods, such as pills, condoms, and intra~uterine devices (IOU) is more frequent than the use of traditional methods such as periodical abstinence and the lactation amenorrhoeal method (5% versus 1 %). Overall, contraception is more prevalent in urban areas, where women are nearly four times more likely to use contraceptives than women in rural areas. There are also important regional variations . The highest proportion of contraceptive use is found in the Capital Region (15%) and the lowest in the North Region (2%). Contraceptive use is highly variable according to the socio~economic status of households and women's education level. It is seven times more prevalent among better off Angolans than among those belonging to the lowest socio~economic quintile. Furthermore, the level of contraceptive use among the first four socio~economic quintiles is very similar, indicating that there are significant income barriers to the use of contraceptives. Women who have secondary education are ten times more likely to use con- traceptives than women with no education. This trend is also confirmed for married women and women in unions. Among this category, more educated women are 1 8 times more likely to use modern methods of contraception than women who have never attended school . This trend reveals the close link between higher levels of education and reduced fertility rate. In fact, the MICS has shown that women with secondary or higher education have on average two children less than women with no education or primary education only. Graph 20.1: Contraception prevalence according to women's education level None Primary Among the 6% of women that use contraception, the most commonly used method is the contraceptive pill (34%), followed by contraceptive injections (23%) Secondary and periodical abstinence (18%). Despite the threat of HIV and AIDS, the use of male and female condoms remains significantly low at 7%. Graph 20.2: Type of contraception methods used by married women (or in union) that use contraception methods Female sterilization Interrupted intercourse Female condom Others Amenorrhoeal method Male condom IUD Periodical abstinence Injection Pill 0 5 10 15 20 25 30 35 U ntil the recent reform of the Angolan educational system, only the first four years (Grade 1 to 4) of basic education, also referred to as primary education, were compulsory for Angolan children. With the Education Reform Law passed by the national Parliament in 2001 , this period has now been extended to six years (i .e. until Grade 6), effective as of 2003. The Education Reform Law also had the merit of simplifying the structure of the education system: primary education now consists of six mandatory years of schooling for all children aged 6 to 11 . Secondary education similarly consists of six years divided into two levels of three optional years each. Prior to 2003, basic education in Angola comprised eight years of schooling (or eight grades) divided into three levels . The first level consisted of four years and was referred to as primary education, while the second and third levels, which were referred to as basic intermediate education, comprised two years each. As for secondary education, it consisted of four years. The age of entry into the first year of primary education remained the same before and after the reform (six years of age). The MICS focuses on the first six years of schooling, looking into attendance rates in the mandatory first level and attendance rates in the second optional level of basic education . It also assesses the internal efficacy of the education system by focusing on completion rates and socio-economic and demographic characteristics of those attending the first six years of schooling . The survey reveals very low attendance rates, with 44% of children not attending the compulsory first four years of schooling and 94% not attending the second level of basic education. Of those children attending the first level of basic education, the survey indicates that 25% will not reach Grade 5. Furthermore, and as a result of late entry into school , the majority of children who attend school do not do so at the recommended age. For example, 70% of seven-year-old children in school do not attend the appropriate grade for their age (i.e . second class) . The MICS also reveals that due to the high repetition rates the education system has become overloaded and is presently unable to absorb new pupils. The findings of the survey indicate that children are attending Indicators Net primary school attendance rate - first level of . basic education Proportion of 6 to 9-year-old children attending the first level of basic education (Grade 1 to 4) - 56% Net primary school attendance rate - second level of basic education Proportion of 10 and 11-year-old children attending the second level of basic education (Grades 5 and 6) - 6% Completion rate - children reaching Grade 5 Proportion of children who enter the first grade of primary school and eventually reach Grade 5 - 76% basic education at a late age and are therefore occupying the places of younger pupils . For example, among 15-year-old Angolan teenagers attending school, the overwhelming majority (85%) are still attending the first six classes of basic education, which should normally have been completed at 11 years of age. Pre- and post-2003 education system in Angola School system prior to 2003 School system from 2003 onwards 1st level 2nd level 3rd level Grade/year 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 1Oth 11th 12th Normal age of attendance Primary education 6 years old 7 years old 8 years old 9 years old Intermediate basic education 10 years old 11 years old 12 years old 13 years old Secondary education 14 years old 15 years old 16 years old 17 years old 1st level 2nd level (Source: Ministry of Education) When looking at net attendance rates in the first level, there are serious disparities among areas of residence, regions and households' wealth . On a positive note, there are no disparities between boys and girls, who at national level attend school in equal numbers. This positive finding corroborates the 1996 MICS results, which registered minimal difference in attendance rate between boys and girls (only 4% difference). This does however hide disparities in terms of school completion rates, to the disadvantage of girls. At national level, 79% of boys who enter Grade 1 will eventually reach Grade 5 compared to only 73% of girls . In the East Region, while 70% of boys who enter Grade 1 will eventually reach Grade 5, only 56% of girls will, therefore indicating a higher dropout rate amongst girls. Grade/year 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th Normal age of attendance 6 years old 7 years old 8 years old 9 years old 10 years old 11 years old 12 years old 13 years old 14 years old 15 years old 16 years old 17 years old Graph 21.1: Proportion of children aged 6 to 18 years attending the first six years of basic education by age 6 7 8 9 10 11 12 13 14 15 16 17 18 Age of children Attending • Not attending Graph 21.2: Percentage of children attending the first six years of basic education at the recommended age 6 years old in 7 years old in 8 years old in 9 years old in 10 years old in 11 years old in 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade Attending • Not attending Seventy-nine percent of 11-year-olds attend school, the highest of any age group in Angola. At this age, children should normally be attending Grade 6. Strikingly however only 2% of 11-year-old children attend the 6th grade. The overwhelming majority of 11- year-old children (91 %) are still attending primary education (Grade 1 to 4), therefore occupying the place of younger pupils. This situation creates teaching difficulties as the same curriculum is taught to pupils of different ages. Adding to those difficulties, one notes that in 2001 the Ministry of Education reported that there were on average 64 pupils per classroom. This severe shortage of classrooms has thus led to the introduction of a system of two or three shifts of classes per day, which significantly reduces the contact time of pupils with their teachers. Graph 21.3: Grade attended by 11- year-old children 2nd grade 31 % Lack of school personnel and infrastructure, low system productivity, early entry into the labour market, low household incomes, and lack of school material limit the normal progression of children attending basic education. The ability to gain access to education is directly influenced by the level of households' wealth. For example, in primary education, the attendance rate of children from the better off households is double that of children from the most vulnerable households. In the second level, this rate is 16 times higher, revealing the extent to which the poorest children have been marginalized after just a few years of schooling . The very low level of attendance recorded among children from the most vulnerable households is directly linked to the early flight of these children to the labour market. For example, child labour is much more prevalent among poorest children than better off children (43% versus 17%). The close correlation between income and school attendance is also linked to the level of birth registration. The lack of documen- tation indeed deprives many children of enrolling in school especially in the second level of primary education as proof of identity is required for enrolment in schools. Specifical ly, the MICS shows that while 48% of children from the better off households are registered, only 17% of children from the poorest households have civil documentation. One can also assume that the cost of basic education explains this correlation. For example the shortage of school material implies that pupils' access to school material is dependent on the ability of households to buy that material on the market. Graph 21.4: Primary school attendance rate according to wealth index quintile 80 70 60 50 40 30 20 10 0 1st quintile 2nd quintile 3rd quintile 4th quintile 5th quintile While completion rates of children (i.e. the proportion of children reaching Grade 5) are also associated to households' wealth, with 56% of the poorest children eventually reaching Grade 5 compared to 89% among the better off children, disparities between lower and higher wealth index quintiles in completion rates are less significant than disparities in attendance rates. For example, a poor child is 60% less likely to reach Grade 5 than a child from a better off household, although he is 120% less likely to attend school. The vulnerability of children from better off households with regard to completion rate is probably linked to factors internal to the education system itself, such as the minimal amount of teaching time, the low qualifications of teachers, and the general lack of resources. The extent to which the system is not functioning is also revealed by the fact that even among the better off population, the overwhelming majority of children (84 %) are not attending the second level of basic education at the correct age. The Capital and South Regions show the highest primary education attendance rates (63%) and the East Region the lowest (44%). Attendance rates in the West, North and Centre South Regions are close to the national average. When looking at the proportion of children eventually reaching Grade 5, the same patterns are observed, with the highest percentage found in the Capital and the South Regions (82%) and the lowest in the East (61 %). Of interest is the fact that only in the Capital Region is the proportion of children reaching Grade 5 without repeating classes significantly higher than in all other regions, including the South. Similar patterns are further observed in the second level of basic education, where the Capital Region stands out as the region with the highest attendance (double the national average) and the East as the region with the lowest attendance rate (six times lower than the national average). Table 21.1: Proportion of children entering Grade 1 who reach Grade 5 Eventually reach Grade 5 (with repetition) Total Male Female Wealth index quintile First 56 56 54 Second 68 71 64 Third 70 77 63 Fourth 76 83 70 Fifth 89 90 88 Sex Male Female Region Capital 82 88 76 North 71 76 62 East 61 70 56 West 77 81 73 South 82 85 65 Centre South 75 78 87 Area of residence Urban 77 82 72 Rural 73 71 76 Total 76 79 73 (%) Reach Grade 5 without repetition Total 37 36 39 48 55 48 43 65 39 39 39 45 46 45 45 46 Table 21.2: Net primary school attendance rate, Angola, 2001 First level (class 1 to 4) Second level (class 5 to 6) Total Male Female Total Male Female Wealth index quintile First 35 36 34 0 1 0 Second 45 45 44 1 1 2 Third 51 52 60 3 5 1 Fourth 62 60 63 4 4 3 Fifth 77 77 77 16 16 17 Region Capital 63 66 60 14 12 17 North 55 52 58 2 2 2 East 44 43 45 1 3 0 West 53 54 52 8 9 6 South 63 62 64 6 8 4 Centre South 56 55 56 5 6 3 Area of residence Urban 61 60 61 8 9 7 Rural 44 41 44 2 Children's age 6 years 35 35 35 7 years 56 54 57 8 years 66 66 67 9 years 71 72 70 10 years 5 6 4 11 years 8 8 7 Total 56 55 56 6 7 5 Box 2: Public expenditure in the education sector In 2001, State Budget expenditures in the education sector represented just 4.7% of the total budgetary expenditure in Angola. This figure was the lowest of all the countries of the Southern African Development Community (SADC), which for the same period averaged 16.7%. Percentage of government expenditure dedicated to the education sector in SADC member countries, 1997-2001 1 Countries Angola Zambia Tanzania South Africa Zimbabwe Botswana Namibia SADC Average Percent of the education sector in governmental expenditure 4.7 9.6 13.6 22.1 23 23.1 24.3 16.7 Together with the low level of expenditure in the education sector, the nature of this expenditure indicates a low level of investment. Between 1997 and 2001, 60% of expenditure in the sector was on wages, while only 14% was spent on goods and services. The total investment in the sector was limited to 6% of total educational expenditure. It is also important to stress that in the period 1997-2001, only 39% of expenditure was on basic education. ' Ministry of Finance and United Nations System in Angola 2002, 0 Financiamento Publico dos Sectores Sociais em Angola. Indicators Total literacy rate Proportion of the population aged 15 years and older that is literate - 67%1 Female literacy rate Proportion of the women aged 15 years and older that is literate - 54% Illiteracy is directly correlated with the poor living conditions of the population. It is normally associated with low life expectancy, high rates of child mortality, unemployment and consequently with an income insufficient to guarantee the fundamental needs of households. The results of the MICS have shown that children whose mothers are educated are consistently less vulnerable than children whose mothers are illiterate. The survey indicates that a third of the population is illiterate, with very high disparities between men and women. Only 54% of women are literate compared to 82% of men, which means that men are on average 50% more likely to know how to read and write. The gender gap is further accentuated in older age groups, with men aged 65 years and above being 150% more likely to be literate than women aged 65 years and above. The concentration of educational resources in urban areas is reflected in a higher literacy rate for both male and female urban pop- ulations. Only half of the rural population report knowing how to read and write, a proportion 48% lower than that reported for urban areas, where 7 4% of the population is literate. Significantly the gender gap is two and a half times more accentuated in rural areas with a third of rural women reported to know how to read and write against 69% of men. The MICS reveals important regional variations, which follow those generally observed for the primary education indicators with the higher values being registered for the Capital Region (79%) and the lowest for the East Region (56%). While the South Region registers literacy rates above the national average (7 4 %) , the West, Centre South and North Regions register values closer to the national average (67%, 65% and 62% respectively). In terms of women literacy, the lowest rates are found in the East and North Regions (39% and 47% respectively), while the highest rates are found in the Capital and South Regions (69% and 66% respectively). ' The literate population includes those who are reported in the household to read and write easily or with difficulty. Map 22.1 : Female literacy rate .__ __ __,J Above 60% .__ __ __,J Between 50% and 60% The correlation between access to education and the level of households' socio-economic well-being observed for pre-school and primary education indicators is again confirmed here with the proportion of literate Angolans increasing progressively with levels of well-being . While only 1 0% of better off Angolans do not know how to read and write, among the poorest the illiteracy rate approaches 60%. The effect of poverty on women's ability to learn how to read and write is particularly striking with the poorest women being three times more likely to be illiterate than the better off women. While the same tendency is observed with male literacy rates, the effect of poverty is less intense with the poorest men being one and a half times less likely to be literate than those belonging to the highest socio-economic quintile. The effects of poverty on the gender gap seem to indicate that households place a greater value on male education. When resources are insufficient to provide education to all household members it would seem that girls tend to be the first to be pulled out of school. Graph 22.1: Male literacy rate according to wealth index quintile 1st quintile 2nd quintile 3rd quintile 4th quintile 5th quintile Graph 22.2: Female literacy rate according to wealth index quintile 1st quintile 2nd quintile 3rd quintile 4th quintile 5th quintile In spite of the high illiteracy rates, the MICS reveals a positive trend whereby there is a tendency for a greater proportion of younger Angolans to know how to read and write. While only a third of Angolans over 65 years of age are literate, over two-thirds of young Angolans 15 to 24 years of age are literate. Encouragingly there is also a reduction of the gender gap among younger Angolans revealing progressively more equitable access to education. Among Angolans aged between 15 and 24 years, women are 32% less likely than men to know how to read and write. Although still extremely significant, this disparity constitutes a marked improvement in relation to that observed among the oldest Angolans, with women being 150% less likely to be literate than men. Table 22.1: Proportion of the population aged 15 years and older that is literate, Angola, 2001 (%) Male Female Total Wealth index quintile First 62 27 42 Second 74 36 53 Third 83 50 65 Fourth 88 59 73 Fifth 95 86 90 Region Capital 90 69 79 North 81 47 62 East 74 39 56 West 85 53 67 South 82 66 74 Centre South 82 51 65 Area of residence Urban 88 63 74 Rural 69 34 50 Age group 15 to 24 years 83 63 71 25 to 34 years 88 62 73 35 to 44 years 89 53 71 45 to 54 years 78 30 54 55 to 64 years 64 20 43 65 years and older 47 19 33 Total 82 54 67 'and Sepa Indicators Children's living arrangements Proportion of children 0 to 14 years not living with a biological parent - 10% Orphans in households Number of children 0 to 14 years who are orphans of one or both biological parents - 11% I n 2001 , sub-Saharan Africa had the highest percentage of orphaned children of any region in the world with 12% of children having lost at least one parent. This is almost double the proportion of orphans in Asia (7%), and more than double that found in Latin America' . Such high numbers of orphans in sub-Saharan Africa is attributable to HIV/AIOS. The MICS indicates that the situation in Angola falls within the average values for sub-Saharan Africa with 11 % of Angolan children being orphans of one or both parents. Of these 1 .3% have lost both their mother and their father. In more concrete terms this means that in 2001, 730,000 Angolan children had lost at least one of their parents and 88,000 were orphaned of both2 . The survey seems to indicate that the high rate of orphans is also related to the impact of the war, with orphaned children being three times more likely to have lost their father than their mother. Although the MICS does not verify the cause of parents' death, estimates for this period project a growing impact of HIV and AIDS in the number of orphans in sub- Saharan Africa3 . The highest proportion of children who have lost one or both parents is found in the South Region (14%) and the lowest in the Capital and East Regions (9%) . In addition, the proportion of orphans is slightly higher in urban areas (11 %) than in rural areas (9%). The percentage of orphaned children decreases with age. The number of orphans is significantly higher among children aged 1 0 to 14 years (17%), and this group also comprises the majority of children placed with foster families. While 12% of children aged between 5 and 9 have lost at least one parent, that figure falls well below the national average for children aged between 0 and 4 (5%). The survey indicates that there is no correlation between the proportion of orphans observed and socio-economic quintile, with no variation in the percentage of orphans among the poorest and the better off households. Regarding children not living with their biological parents, the survey indicates that ' ' UNAIOS, UNICEF and USAID, 2002, Children on the Brink 2002- A joint report on orphan estimates and program strategies. ' Estimates based on a population of 13.8 million people in 2001. about a third (32%) of all children aged 0 to 14 years do not live with both parents. Children who do not live with both parents are six times more likely to live with their mother only, which is compatible with the significant percentage of female headed households found by the MICS (27%). The percentage of children not living with their biological family does not vary between rural and urban areas. Small variations are also recorded among regions, between 8% in the Capital Region and 11 % in the West and Centre South Regions. Interestingly children in the last age group (1 0 to 14) are overall 27% less likely to live with both their parents than children in the youngest category (0 to 4). The survey further indicates that 1 0% of children live with neither parent. Among those, more than half (6%) are children who live with foster families despite the fact that both of their parents are alive. This finding might be explained by poverty, with households not having the financial capacity to care for all children and also by the high level of separated rather than orphaned children due to the war. In fact, only 14% of all children in foster care have lost both their parents. Older children {1 0 to 14 years) are 58% more likely to live with foster families in spite of the fact that both their parents are still alive, than the youngest children (0 to 4 years). Although the MICS does not assess the relative weight of foster care in relation to the care of children in institutions, f

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