TIME SERIES ANALYSIS OF UNDER-FIVE MORTALITY IN MULAGO HOSPITAL (1990-2010)

BY

OKUDA BONIFACE 09/U/3224/PS 209004160

A DISSERTATION SUBMITTED TO THE SCHOOL OF STATISTICS AND APLLIED ECONOMICS IN PARTIAL FULFILLMENTOF THE REQUIREMENTS FOR THE AWARD OF BACHELOR OF STATISTICS AT MAKERERE UNIVERSITY.

JUNE 2012

DECLARATION

I Okuda Boniface affirm that this proposal is entirely my original work and has not been presented for any award of a degree in any institution of higher learning unless otherwise cited.

Signature

..,. Date

This proposal has been submitted with my approval as a University Supervisor.

Mr. Odur Benard Lecturer SSAE, Makerere University Kampala

. Date

DEDICATION

This work is dedicated to my father Mr. Ogira Simon Peter, my mother Mrs. Akongo Sidonia, brothers Ochen Benjamin and Ogira Gabriel, my sisters Akello Brenda and Achieng Mercy and my friends for the support.

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ACKNOWLEDGEMENT

Special thanks to the almighty God for the special help and guidance. I am deeply indebted to some individuals whose contributions made it possible to reach a successful completion of this dissertation.

My utmost gratitude goes to my supervisor, Mr. Odur Bernard for his tireless effort in reading and providing relevant comments and corrections that have enabled me produce this research project.

Finaly special thanks goes to my father, mother and friends for all invaluable contributions both financially and morally especially during this time.

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TABLEOFCONTENTS
DECLARATION ............................................................................................................................ i DEDICATION ............................................................................................................................... ii ACKNOWLEDGEMENT ........................................................................................................... iii LIST OF TABLES ....................................................................................................................... vii LIST OF FIGURES ................................................................................................................... viii ACCRONYMS ............................................................................................................................. ix DEFINITIONS AND CONCEPTS .............................................................................................. x ABSTRACT ................................................................................................................................. xii CHAPTER ONE: BACKGROUND ............................................................................................ 1 1.1 Introduction ............................................................................................................................... 1 1.2 Previous trends of child mortality ............................................................................................. 2 1.3 Problem statement ..................................................................................................................... 3 1.4 Objectives ................................................................................................................................. 4 1.5 Hypotheses ................................................................................................................................ 4 1.6 Significance of the study ........................................................................................................... 5 1.7 Scope of the Study .................................................................................................................... 5 1.8 Limitation of the study .............................................................................................................. 5 CHAPTER TWO: LITERATURE REVIEWS .......................................................................... 6 2.1 Introduction ............................................................................................................................... 6 2.2 demographic factors .................................................................................................................. 6 2.2.1 Sex of the child ...................................................................................................................... 6 2.2.2 Season .................................................................................................................................... 7 2.3 Infectious diseases and under-five mortality ............................................................................ 7 iv

2.3.1 Malaria and under-five mortality ........................................................................................... 7 2.3.2 Tuberculosis and under-five mortality ................................................................................... 8 2.3.3 Tetanus and under-five mortality ........................................................................................... 9 2.3.4 Measles and under-five mortality ........................................................................................ 10 2.3.5 Pneumonia and under-five mortality.................................................................................... 10 2.3.6 HIV/ AIDS and under-five mortality ....................................................................................11 2.4 Forecasting model ................................................................................................................... 12 CHAPTER THREE: METHODOLOGY ................................................................................. 14 3.1 Introduction ............................................................................................................................. 14 3.2 Sources and nature of data to be used ..................................................................................... 14 3.3 Techniques of data collection .................................................................................................. 14 3.4 Analysis software .................................................................................................................... 14 3.5 Data processing and analysis .................................................................................................. 14 3.5.1 Time series analysis ............................................................................................................. 14 3.5.2 Data exploration techniques................................................................................................. 15 3.5.3 Autoregressive Integrated Moving Average (ARIMA) ........................................................ 19 3.6 Ethical considerations ............................................................................................................. 20 CHAPTER FOUR: DATA PRESENTATION AND ANALYSIS OF RESULTS ................... 21 4.1 Introduction ............................................................................................................................. 21 4.2. Graphical presentation of findings ......................................................................................... 21 4.3 Testing for stationarity in the mortality series ........................................................................ 27 4.4 Estimation of the model .......................................................................................................... 29 4.5 Diagnostic test ......................................................................................................................... 29 4.6: Forecasts of under-five mortality (2011Q1-2015Q4) ............................................................ 31

4.7 Test of hypotheses ................................................................................................................... 31 4.7.1 Testing for death differentials by gender ............................................................................. 31 4.7.2 Testing for death differentials by year ................................................................................. 32 4.7.3 Testing for death differentials by disease ............................................................................. 33 4.7.4 Trend analysis of mortality series ........................................................................................ 33 4.7.5 Trend analysis of mortality series by gender ....................................................................... 34 4.7.6 Test for seasonality............................................................................................................... 34 4.8 Discussion ............................................................................................................................... 35 4.8.1 Child sex and under-five mortality ...................................................................................... 35 4.8.2 Seasonality and Under-five mortality .................................................................................. 36 4.8.3 Trend in under-five mortality ............................................................................................... 36 4.8.4 Infectious Diseases and Under-five mortality...................................................................... 37 CHAPTER FIVE: SUMMARY OF FINDINGS, CONCLUSIONS AND RECOMMENDATIONS ........................................................................... 38 5.1 Introduction ............................................................................................................................. 38 5.2 Summary of the findings ......................................................................................................... 38 5.3 Conclusions ............................................................................................................................. 39 5.4 Recommendations ................................................................................................................... 39 5.5 Areas for further studies .......................................................................................................... 40 REFFERENCES ......................................................................................................................... 41 APPENDICES ............................................................................................................................. 44

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LIST OF TABLES Table 4. 1: Unit Root Test ............................................................................................................. 27 Table 4. 2: Correlogram of Mortality Series ................................................................................. 28 Table 4. 3: Autoregressive Moving Average Model (9, 0, 0) ........................................................ 29 Table 4. 4: Model Description ...................................................................................................... 31 Table 4. 5: Forecasted Mortality Values ........................................................................................ 31 Table 4. 6: Death Differential by Gender ...................................................................................... 32 Table 4. 7: Death Differential by Year (Period) ............................................................................ 32 Table 4. 8: Death Differential by Disease ..................................................................................... 33 Table 4. 9: Runs Test on Mortality Series ..................................................................................... 33 Table 4. 10: Runs Test on Mortality Series by Gender ................................................................. 34 Table 4. 11: Kruskal-Wallis Test for Seasonality .......................................................................... 35

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LIST OF FIGURES Figure 4. 1: Trend in Under-Five Mortality by Gender from 1990-2010 ..................................... 21 Figure 4. 2: Percentage Distribution of Under-Five Mortality by Disease (1990-2010) .............. 22 Figure 4. 3: Percentage Distribution of Under-Five Mortality for Each Month 1990-2010 ........ 23 Figure 4. 4: General Trend in Mortality Series ............................................................................. 24 Figure 4. 5: Variations in Mortality Series 2005-2010 by Quarters .............................................. 25 Figure 4. 6: Causes of Under-Five Mortality for the Period 1990-2010 ...................................... 26 Figure 4. 7: Bartletts Test for White Noise for Under-five mortality .......................................... 30

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ACCRONYMS

UDHS WHO UNICEF UN CHERG MDGs PEAP HIV AIDS NGOs MOH

Uganda Demographic Health Survey World Health Organisation United Nations International Childrens Emergency Fund United Nations Child Health Epidemiology Reference Group Millenium Development Goals Poverty Eradication Action Plan Human Immune Virus Acquired Immune Deficiency Syndrome Non Government Organisations Ministry Of Health

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DEFINITIONS AND CONCEPTS

Adequate compilation and measurement of vital events requires that the concepts used be given formal definitions even though the meaning of these concepts may appear as obvious to most people.

Hospital: This is a residential establishment which provides short and long term medical care consisting of observational and rehabilitative service to persons suffering from diseases or suspected to be suffering from an injury. Health: The World Health Organisation (WHO) defined health in 1948 as a state of complete physical, mental and social wellbeing not merely the absence of disease or infirmity.

Live birth: This is the complete expulsion from the womb of its mother, the product of conception irrespective of the duration of the pregnancy, after which it shows evidence of life such as breathing, crying, etc.

Premature baby: Babies born before 37 completed weeks of pregnancy are called premature. Injury: This is usually defined as physical harm to a persons body.

Disease: This is any disturbance or anomaly in the normal functioning of the body that probably has a specific cause and identifiable symptoms.

Types of diseases Diseases are classified according to the following, though a great deal of overlapping may be found in the different classes: 1. Infectious diseases. These are communicable and capable of infecting a large number of persons within relatively short time intervals. This kind of disease has the following different causes; a. Parasitic x

b. Bacterial c. Viral d. Fungal 2. Environmental diseases. in epidemiology, environmental disease is disease caused by environmental factors that are not transmitted genetically or by infection. It can be classified as follows; a. Nutritional b. Diseases due to unfavorable environmental factors 3. Other diseases a. Diseases connected with eggs and fry b. Tumors, genetic disorders Mortality: This is the risk of dying in a given year, measured by the death rate which is the number of deaths occurring per 100,000 people in a population.

Neonatal mortality:

the probability of dying within the first month of life

Infant mortality: the probability of dying between birth and the first birthday

Post neonatal mortality: the arithmetic difference between infant and neonatal mortality

Child mortality:

the probability of dying between exact age one and the fifth birth

Under-five mortality:

the probability of dying between birth and the fifth birthday.

Cause specific mortality: mortality classified by cause.

Death: This is the permanent disappearance of all evidence of life after a life birth has occurred.

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ABSTRACT

The purpose of the current study was to carry out a time series analysis of under-five mortality in Mulago hospital for the period of 1990-2010 with specific objectives of; establishing whether there is trend in the mortality series over the time period, investigating the occurrence of seasonality in the mortality series, to analyse mortality differences in terms of sex, cause and period and lastly to make predictions of under-five mortality for the period of 2011-2015. Secondary data obtained from the records department of Mulago hospital was used for this study.

Descriptive statistics showed that malaria accounted for most of the deaths (19.41%) followed by Pneumonia and Diarrhoea with 12.68% and 10.80% respectively. Genital infection and oral disease accounted for the least number of deaths recorded with 0.68% and 0.77% respectively. Augmented Dickey-Fuller Test also revealed that the mortality series was stationary for the recorded period of 1990-2010. Under-five mortality was also found to vary by gender, period and sex, where the male deaths were higher than the female deaths. Runs test also revealed that the mortality series did not exhibit any trend over the period of study. Whereas the mortality series of the male did not exhibit trend, that of the female exhibited trend over the period of study. Seasonality was also found to exist in the mortality series where most of the deaths were recorded in the month of June, February, December, July and August and the least in January and October. There was also a general reduction in mortality causes where causes due to measles and tetanus had the least deaths in 2010.

The study therefore recommended political awareness, commitment and leadership that are needed to ensure that child health receives the attention and resources needed to accelerate progress towards MDG4, consistent use of treated mosquito nets for malaria prevention and enhancing workers skills through workshops. This would increase survival rates of children who visit health units.

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CHAPTER ONE BACKGROUND

1.1 Introduction Infant and child mortality levels in Sub-Saharan Africa are the highest in the world. In the median African country, more than 15 of 100 children die before their fifth birthday (Jameson et al., 2006). This compares to less than 25 out of 1,000 in the richer parts of the world. Not only are under-five mortality levels very high; in addition, progress in reducing child mortality is very slow. Hence, Sub-Saharan Africa as a whole is seriously off track in terms of reaching MDG4. In 2010, the world average under-five mortality was 57 (5.7%), down from 88 (8.8%) in 1990 and in 2006, the average in developing countries was 79 (down from 103 in 1990), whereas the average in industrialized countries was 6 (down from 10 in 1990) (UNICEF press release, 2011). A child in Sierra Leone, which has the world's highest child mortality rate 262 in 2007 (UNICEF press release September, 12, 2010) is about 87 times more likely to die than one born in Sweden with a rate of 3 (UNICEF Sweden statistics, 2010).

According to the World Health Organization, 2008 questions and answer archives, the main causes of child death are pneumonia, diarrhea, malaria, measles, and HIV. Malnutrition is estimated to contribute to more than one third of all child deaths in that 1 child dies every 5 seconds as a result of hunger ,700 every hour, 16 000 each day, 6 million each year (2002-2008 estimates Jacques Diouf). One in eight children in Sub-Saharan Africa dies before their fifth birthday (UNICEF 2010). The biggest improvement between 1990 and 2006 was in Latin America and the Caribbean, which cut their child mortality rates by 50% (UNICEF state of the worlds children report, 2008).

Child mortality was an important indicator of the successful implementation of the Poverty Eradication Action Plan (PEAP) in Uganda, and for good reasons, the level of child mortality is a consequence of a broad range of Government intervention areas in terms of access to education, safe water, basic health care and provision of security and stability. Other determinants of child mortality include household incomes, HIV/AIDS, gender disparities, cultural practices and nutrition, all of which can be influenced by Government. Child mortality is therefore an 1

important health issue, but it must be stressed from the beginning that the health sector is not the only sector responsible for the child mortality outcome.

Statistics from the Uganda Demographic and Health Survey (UDHS, 2006) reveal declining trends in the levels of infant, under-five and maternal mortality. Between 2000 and 2005 infant mortality decreased from 98 to 76 deaths per 1,000 births. This means that one in every 13 newborn Ugandan die within the first year of life. During the same period, under-five mortality increased from 162 to 137 deaths per 1,000 births.

According to the world population data sheet of population reference bureau Washington (2009), the average infant mortality rate was 46 deaths per 1000 live births in the world, 6 deaths per 1000 in the more developed world, 50 deaths per 1000 in the developing world and 76 deaths per 1000 in Uganda.

The World Bank policy study 2010 indicates that the highest rates of child mortality continue to be in the Sub-Saharan Africa, where 1 child in 8 dies before age five that is nearly 20 times the average of 1 in 167 for developed regions. Southern Asia has the second highest rates, with about 1 child in 14 children dying before age five.

1.2 Previous trends of child mortality The global under-five mortality rate has declined by a third, from 89 deaths per 1,000 live births in 1990 to 60 in 2009 (World Bank policy statement report, 2010). This report also highlights that all regions except Asia and Oceania have seen reductions of at least 50 percent.

At regional levels, in 2009, the highest rates of under-five mortality continue to be in SubSaharan Africa, where 1 child in 8 died before age of five (129 deaths per 1,000 live births) that is nearly double the average in developing regions (66 deaths per 1,000 live births) and nearly 20 times the average in developed regions (6 deaths per 1,000 live births). For sub-Saharan Africa as a whole there has been a decline in U5MR concentrated largely in the period between 1965 and 1990, during which the median U5MR dropped from 232 t o 170 per 1000. Since 1990, the trend seems to have stalled. The pattern of this overall trend also characterizes each region, 2

though at different levels and speeds. The countries of the West region had the highest U5MR in 1960, with a median value around 290 per 1000 live births. This level fell Below 200 per 1000 by 1985, a level similar to that of the Middle region, which had a median around 260 per 1000 in 1960. The East region median oscillated around 200 per 1,000 prior to 1975 before declining to 170 per 1000 in 1990. The Southern Region had the lowest median U5MR in 1960 (around 200 per 1000) and experienced the sharpest decline to about 60 per 1000 by 1990. Declines appear to have stalled in all regions in the 1990s. The West and Southern regions thus experienced the fastest declines from 1960 t o 1990, with the countries of t he Middle and East regions showing the slowest improvement.

In Uganda, Child mortality fell significantly between 1948 and 1970 as a result of political stability, high economic growth, and increased access to health care and scientific progress which, amongst others, increased access to vaccines against immunizable diseases. Ugandas health sector was considered to be one of the best in Africa during this period (Hutchinson, 2001). The period from the early 1970s and mid-1980s was characterized by political turmoil and conflict, severely limited access to health services, and a consequent stagnation in infant mortality was observed. The recovery period of 1986-1995 with high economic growth, political stability and poverty reduction under the NRM Government, produced a reduction in child mortality (MFPED, 2002).

1.3 Problem statement 7.6 million Children under age five died in 2010, representing an under-five mortality rate of 57/1000 live births (WHO, 2011). Unlike in the developed countries where death rarely occurs among infants and children, in developing countries like Uganda, it is estimated that on average 50% of the deaths occur to children aged 15 and below (UN, 2008).

According to various studies carried out, a small number of diseases and conditions are the biggest killers of young children today. Pneumonia, measles, diarrhea, malaria, HIV and AIDS and complications during pregnancy and after birth to mention but a few cause more than 90% of deaths in children under five (WHO, 2010). Children who are malnourished are at far greater risk of dying from these causes because they have low immunity. 3

The increasing focus on the reduction of child mortality arising from the Millennium Declaration and from the Millennium Development Goal (MDG) 4 of reducing by two-thirds, between 1990 and 2015, the under-five mortality rate, has generated renewed interest in the development of more accurate assessments of the number of deaths in children aged less than 5 years by cause. Moreover, the monitoring of the coverage of interventions to control these deaths has become crucial if MDG 4 is to be achieved; thus a more accurate establishment of the causes of deaths in children aged less than 5 years becomes crucial.

Although various studies have been conducted about under-five mortality in the country, not much has been done in Mulago concerning the documentation of trends, seasonality and mortality by sex and cause of death hence the research would like to find out the behavior of mortality rates over time and the specific causes of these deaths.

1.4 Objectives The chief purpose of this study is to carry out a time series analysis of under-five mortality in Mulago Hospital for the period 1990-2010.

Other objectives may include the following; 1. To establish if there is trend in under five mortality from 1990-2010 2. To investigate whether there is seasonality in the recorded figures from 1990-2010 3. To analyze death differentials by sex, year & diagnosis 4. To make predictions for under five mortality 5. To assess Cause reductions of under-five mortality overtime

1.5 Hypotheses there is no trend in child mortality there is no seasonality in child deaths more male children die than female children death differentials by sex, year & diagnosis is the same

1.6 Significance of the study This study is an important addition to the mortality research already done by scholars in Uganda The study will also be helpful to facilitate the improvement of the understanding of the specific causes of death in infants on the basis of which proper policy measures for prevention of diseases and reducing mortality can be developed. The analysis of child mortality data will present the demographic status of the population as well as its potential growth, which will be of great importance to policy makers and planners.

1.7 Scope of the Study Under-five mortality data from the records department of Mulago hospital for the period 19902010 will be used for the study. The data set will consider children less than 5 years of age. The variables that will be used include gender, period of occurrence and the cause of death.

1.8 Limitation of the study There was a problem of extracting huge amount of data from the record files since Mulago hospital does not have a Hospital information management system. This took a lot of time for the researcher.

CHAPTER TWO LITERATURE REVIEWS

2.1 Introduction In Uganda, according to UNICEF (2009), the causes of childhood morbidity and mortality like elsewhere in Sub-Saharan Africa were malaria, diarrhoea, measles and acute respiratory infections. In most recent years Acquired Immune Deficiency Syndrome (AIDS) has also joined in as a major risk to women and children.

Despite droughts, natural disasters and famine, mortality appears to have fallen in all parts of Africa though the rates of decline have shown substantial variation from one region to another. The percentage of children dying before celebrating their fifth birth day almost halved in Ghana over 30 years in the late 1930s and 1960s (from 37%-20%); in Congo over 20 years between the 1940s and the 1960s(from 29%-15%) and in Kenya over the 25 years between late 1940s and early 1970s from 26-15% (UNICEF statistics-Ghana, 2010).

According to several studies conducted, age, sex and infectious disease have been found to be major factors affecting mortality. But also season of the year play a role in determining mortality levels (Kenneth Hill, 1988) hence mortality factors can be broken down into demographic factors and infectious disease factors.

2.2 demographic factors 2.2.1 Sex of the child In the reviewed micro-econometric studies, child characteristics typically show the expected influence on mortality. Boys are often found to be significantly more likely to die than girls and the same holds for first born children ( Lavy et al, 2000; Ssewanyana and Younger, 2007).

In terms of maternal proximate determinants, the studies in general confirm the important influence in particular of mothers age and birth intervals (for example Mturi and Curtis, 1995; Brockerhoff and Derose, 2000; Lavy et al, 2002; Lalou and Le Grand, 2000).

Overall, for the world as a whole, under-five mortality rates are the same for boys and girls. However, the rate varies by income group and region. In general, under-five mortality is higher for boys than it is for girls among low income countries and upper middle and high income countries. The pattern seems reversed for lower middle income countries. Similarly, under-five mortality is higher among boys for most regions of the world except the South East Asia region where it is reversed, and there is little difference among boys and girls in the Eastern Mediterranean region (WHO, 2010).

2.2.2 Season According to the study by Nyombi in 2000, child deaths have a seasonal pattern occurring more frequently during certain months of the year. There may exist seasonality in death level among children, that is there are more deaths occurring in a particular time of the year or day due to specific diseases being rampant in certain months of the year e.g. cases of death due to anemia, are predominant in dry seasons when there is little vegetables, and also when malaria cases are rampant causing break down of red blood cells. Cases due to malaria are most predominant in months of April, June, July, September, and December, when there is stagnant water, which are used by mosquitoes as breeding places.

2.3 Infectious diseases and under-five mortality Preventable infectious diseases cause two-thirds of child deaths, according to a study published by The Lancet in 2011. Experts from the World Health Organization (WHO) and UNICEFs Child Health Epidemiology Reference Group (CHERG) assessed data from 193 countries to produce estimates by country, region and the world. While the number of deaths has declined globally over the last decade, the analysis reveals how millions of children under five die every year from preventable causes. These causes include;

2.3.1 Malaria and under-five mortality Malaria is a life-threatening disease caused by parasites that are transmitted to people through the bites of infected mosquitoes. In 2010, malaria caused an estimated 655,000 deaths, mostly among African children (WHO, 2011). According to the World Health Organization (WHO 2011) Malaria is responsible for 10 per cent of all under-five deaths in developing countries. 7

According to the world health report (2002), in 1970, there were 3.7 million deaths annually and 170 million cases, 88 percent of them in tropical Africa and the disease is endemic in 100 countries. The aim of the current global malaria strategy was to reduce mortality at least by 20 percent compared to 1995 in at least 75 percent of the countries that would have been affected by the year 2000 in WHO accelerated malaria control activities in 24 endemic countries in Africa.

Africa still remains the region that has the greatest burden of malaria cases and deaths in the world. In 2000, malaria was the principal cause of around 18% that is 803 000 (uncertainty range 710,000 - 896,000) of deaths of children under 5 years of age in Africa south of the Sahara as by Rowe AK et al (2005).

During the 1980s and the early 1990s, malaria mortality in rural Africa increased considerably, probably as a result of increasing resistance to chloroquine as by Korenromp EL et al (2003). According to Ter Kuile FO et al (2004) Malaria is also a significant indirect cause of death: malaria-related maternal anemia in pregnancy, low birth weight and premature delivery are estimated to cause 75 000200 000 infant deaths per year in Africa south of the Sahara.

2.3.2 Tuberculosis and under-five mortality There has been a perception, particularly in the industrialized world, that TB is a disease of the old. Fifty years ago, however, hospital services for children today dedicate entire wards for infants and children with TB. In developing countries where a large proportion of the population is under the age of 15 years, as many as 40 per cent of tuberculosis notifications may be children; tuberculosis may be responsible for 10 per cent or more of childhood hospital admissions, and 10 per cent or more of hospital deaths.

According to the WHO (2008), complacency towards tuberculosis in the three decades led control programs to be run down in many countries. The result has been a powerful resurgence of the disease, now estimated to kill three million people a year, with 7.3 million new cases annually. The WHO declared tuberculosis a global emergency in 1993. About 3 million cases a year occur in south East Asia and nearly two million in sub Saharan Africa, with 340000 in Europe. One third of the incidence in the last five years can be attributed to HIV infection which 8

weakens the immune system and makes the person infected with tubercle bacillus 30 times more likely to become ill with tuberculosis strains of bacillus resistant to one or more drugs may have infected up to 50 million people.

Tuberculosis may be responsible for more death worldwide than any other disease caused by any pathogen, Sundre et al, 2000. The incidence of Tuberculosis among children will therefore increase in the areas where HIV prevalence is high because HIV negative individuals could increase in the areas where HIV prevalence is high because HIV negative individuals could increase by 13-14 percent in African countries, depending on the prevalence of tuberculosis and AIDS.

2.3.3 Tetanus and under-five mortality Tetanus is a potentially deadly infection that can occur if a babys umbilical cord is cut with an unclean tool or if a harmful substance such as ash or cow dung is applied to the cord, as is traditional practice in some African countries. When tetanus develops, child death rates are extremely high, especially in countries where health systems are not strong and access to more advanced medical treatment can be difficult.

Tetanus is a major cause of neo- natal death in African as well as among other age groups. Tetanus mortality rates in Africa are probably among the highest in the world. The few available studies in Uganda suggest that the rates of 10 to 20 neo-natal tetanus deaths per 1000 live birth are not usual (Kawuma et al., MOH 2000). According to the world health report (2008), tetanus of the newborn is the third killer of children after measles and pertusis among the six EPI vaccine preventable disease and is concern in all WHO regions except Europe. Between 800,000 and 1 million newborn a year died from tetanus in the early 1980s. An estimated 730,000 such deaths are now preventable every year, particularly by targeting the elimination efforts to high risk areas. In 1997, there was an estimated 275000 deaths WHO Estimated than 1995, about 90 percent of neonatal tetanus cases occurred in only 25 countries of which Uganda was not part.

2.3.4 Measles and under-five mortality Measles, an acute viral respiratory illness associated with high fever, rashes and vomiting, is considered one of the most deadly vaccine-preventable diseases, accounting for an estimated 777,000 childhood deaths per year worldwide, with more than half occurring in Africa, according to the United Nations Children's Fund (UNICEF, 2011).

Measles is caused by paramyxovirus called morbili. It is highly infectious and transmitted from person to person via droplets spread (sneezes, coughs). Cough nasal congestion and conjunctivitis follow the incubation period of approximately 10 to 12 hours. The characteristic rash appears about 2 to 4 days after the onset of other symptoms. Measles is one of the major causes of death among children in Africa. Its contributing factor is about 8 to 10% of deaths among African children. (Ofosu- Amaah, 2003; Rodriguez).

Apart from death, children who are affected by measles may suffer from life-long disability including brain damage, blindness and deafness. In Uganda, Measles deaths reduced from 6,000 to 300 between 1996 and 2006 and to none according to the New Vision Uganda (Oct 19, 2011). Sabiiti and WHO officials attributed the achievement to aggressive immunisation of children against killer diseases, measles inclusive. Babies are vaccinated against Measles at the age of nine months.

2.3.5 Pneumonia and under-five mortality Pneumonia is a form of acute respiratory infection that affects the lungs. The lungs are made up of small sacs called alveoli, which fill with air when a healthy person breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid, which makes breathing painful and limits oxygen intake.

Pneumonia is the single largest cause of death in children worldwide. Every year, it kills an estimated 1.4 million children under the age of five years, accounting for 18% of all deaths of children under five years old worldwide. Pneumonia affects children and families everywhere, but is most prevalent in South Asia and sub-Saharan Africa (WHO, 2011).

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In the early 1970s Cockburn & Assaad generated one of the earliest estimates of the worldwide burden of communicable diseases. In a subsequent review, Bulla & Hitze described the substantial burden of acute respiratory infections and, in the following decade, with data from 39 countries, Leowski estimated that acute respiratory infections caused 4 million child deaths each year 2.6 million in infants (01 years) and 1.4 million in children aged 14 years. In the 1990s, also making use of available international data, Garenne et al. further refined these estimates by modeling the association between all-cause mortality in children aged less than 5 years and the proportion of deaths attributable to acute respiratory infection. Results revealed that between one-fifth and one-third of deaths in preschool children was due to or associated with acute respiratory infection. The 1993 World Development Report produced figures showing that acute respiratory infection caused 30% of all childhood deaths.

2.3.6 HIV/ AIDS and under-five mortality More than 1,000 children are newly infected with HIV every day, and of these more than half will die as a result of AIDS because of a lack of access to HIV treatment (UNICEF, 2011). In addition, over 7.4 million children every year are indirectly affected by the epidemic as a result of the death and suffering caused in their families and communities.

Nine out of ten children infected with HIV were infected through their mother either during pregnancy, labor and delivery or breastfeeding (UNAIDS, 2010). Without treatment, around 1530 percent of babies born to HIV positive women will become infected with HIV during pregnancy and delivery and a further 5-20 percent will become infected through breastfeeding (WHO, 2006). In high-income countries, preventive measures ensure that the transmission of HIV from mother-to-child is relatively rare, and in those cases where it does occur a range of treatment options mean that the child can survive - often into adulthood. This shows that with funding, trained staff and resources, the infections and deaths of many thousands of children could be avoided.

HIV has caused adult mortality rates to increase in many countries of sub-Saharan Africa (Timaeus IM, 2000/2002), and there is some indication that child mortality rates are also rising due to vertical transmission. Since HIV prevalence levels are high and still increasing in many 11

countries, the effect of AIDS on child mortality is likely to persist for several decades. However, for a variety of reasons, direct evidence for the impact of HIV on child mortality is relatively weak.

2.4 Forecasting model a) The ARIMA procedure The ARIMA procedure analyzes and forecasts equally spaced univariate time series data, transfer function data, and intervention data using the autoregressive Integrated Moving Average (ARIMA) or autoregressive moving-average (ARMA) model. An ARIMA model predicts a value in a response time series as a linear combination of its own past values, past errors (also called shocks or innovations), and current and past values of other time series. The ARIMA approach was first popularized by Box and Jenkins, and ARIMA models are often referred to as BoxJenkins models. The general transfer function model employed by the ARIMA procedure was discussed by Box and Tiao (1975). When an ARIMA model includes other time series as input variables, the model is sometimes referred to as an ARIMAX model. Pankratz (2001) refers to the ARIMAX model as dynamic regression. The ARIMA procedure provides a comprehensive set of tools for univariate time series model identification, parameter estimation, and forecasting, and it offers great flexibility in the kinds of ARIMA or ARIMAX models that can be analyzed. The ARIMA procedure supports seasonal, subset, and factored ARIMA models; intervention or interrupted time series models; multiple regression analysis with ARMA errors; and rational transfer function models of any complexity.

Meyler (1998) states that the main advantage of ARIMA forecasting is that it require data on the time series in question only. This feature is advantageous if one is forecasting a large set of time series data. This also avoids a problem that occurs in multivariate models since timeliness can be a problem. ARIMA models are unable to capture non linear relationships in time series and this makes the process of forecasting limited.

b) Lee-carter forecasting model The method proposed in Lee and Carter (1992) has become the leading statistical model of mortality forecasting in the demographic literature (Deaton and Paxson, 2004). It was used as a 12

benchmark for recent Census Bureau population forecasts (Hollmann, Mulder and Kallan, 2000), and two U.S. Social Security Technical Advisory Panels recommended its use, or the use of a method consistent with it (Lee and Miller, 2001). Lee-Carter approach makes strong assumptions about the functional form of the mortality surface. In the last decade, scholars have rallied (White, 2002) to this and closely related approaches, and policy analysts forecasting all-cause and cause-specific mortality in countries around the world have followed suit (Booth, Maindonald and Smith, 2002; Deaton and Paxson, 2004; Haberland and Bergmann, 1995; Lee, Carter and Tuljapurkar, 1995; Lee and Rofman, 2000; Lee and Skinner, 2002; Miller, 2001; NIPSSR, 2002; Perls et al., 2002; Preston, 2004; Tuljapurkar and Boe, 2003; Tuljapurkar, Li and Boe, 2000; Wilmoth, 1996, 2000). Lee-carter was able to capture non linear relationships in the time series data whereas ARIMA models were not able to capture non linear relationships.

13

CHAPTER THREE METHODOLOGY

3.1 Introduction This chapter presents the data collection methods, sources of data, and methods of data analysis. The selected variables used in this study are sex of the deceased, cause of death, and the period of the occurrence of the death.

3.2 Sources and nature of data to be used The data used is secondary data that was obtained from Mulago referral hospitals records department office. The data was extracted from the mortuary register.

3.3 Techniques of data collection The technique used was mainly by observation of the summaries made in the mortuary register kept in the records department of the hospital.

3.4 Analysis software Data entry was by use of the computer package, Microsoft Excel, and then exported to statistical packages like SPSS, STATA, and E-Views for analysis.

3.5 Data processing and analysis 3.5.1 Time series analysis A time series is a collection of observations of well-defined data items obtained through repeated measurements over time. A basic assumption in any time series analysis is that some aspects of the past pattern will continue to remain in the future.

Chatfield (1989) observed that time series methods are based on studying past behavior of the series to make forecasts.

14

As an important step in analyzing time series data, the types of data patterns were considered so that the models most appropriate to the patterns can be utilized. Four components of time series can hence be distinguished.

i. Trend: This refers to the general direction, either upward or downward in which a series have been moving.

ii. Cycle: This where the data exhibits a wave like pattern (rises and falls) that are not of fixed periods.

iii. Seasonality: This is concerned with periodic fluctuations that recur on a regular periodic basis.

iv. Irregular term: This is the movement left when Trend, Seasonality and Cyclic components have been accounted for.

The analysis however concentrated on Trend and Seasonality. Assuming a multiplicative model, then = Where is the mortality series, is Trend and is the seasons.

3.5.2 Data exploration techniques a. Graphical presentation This involved plotting the series against time t.

b. Statistical tests Unit root test

The unit root test was used to establish if the mortality series is stationary. Stationarity has to be established because;

15

The stationarity or otherwise of a series can strongly influence its behavior and properties -e .g. persistence of shocks will be infinite for non stationary series Spurious regressions. If two variables are trending over time, a regression of one on the other could have a high R2 even if the two are totally unrelated. If the variables in the regression model are not stationary, then it can be proved that the standard assumptions for asymptotic analysis will not be valid. In other words, the usual t -ratios will not follow a t-distribution, so we cannot validly undertake hypothesis tests about the regression parameters.

The early and pioneering work on testing for a unit root in time series was done by Dickey and Fuller (Dickey and Fuller 1979, Fuller 1976). The basic objective of the test is to test the null hypothesis that =1 in: Yt = yt-1+ ut Against the one-sided alternative <1. So in general we have;

Ho: the series is stationary Ha: the series is trended or has seasonality We usually use the regression: yt = yt-1+ ut So that a test of =1 is equivalent to a test of =0 (since -1= ).

Conclusions Reject Ho: this means there is sufficient evidence at a given level of confidence that the series is trended or has seasonality. Fail to reject Ho: this means that there is no sufficient evidence at a given level of significance that the series is trended or has seasonality.

c. Non parametric tests for trend Runs test: The runs test (Bradley, 1968) can be used to decide if a data set is from a random process. 16

A run is defined as a series of increasing values or a series of decreasing values. The number of increasing, or decreasing, values is the length of the run. In a random data set, the probability that the (i+1)th value is larger or smaller than the i th value follows a binomial distribution, which forms the basis of the runs test. Testing procedure Ho: the mortality series is stationary Ha: the mortality series is non-stationary

Test statistic

= Z=

( 1) 2 1

Where m=number of pluses Decision rule is at =0.05 The researcher would reject Ho if Z>
2

i.e. if the computed Z statistic is greater than

the notable value and then conclude with (1-)*100% confidence, the series has trend.

d. Test for seasonality Several scholars have come up with different ways of assessing seasonality in a series such as graphical methods, non parametric methods, correlation analysis, analysis of variance method, etc.

Despite the knowledge of seasonal effects on diseases for two millennia, the definition and the measurement of seasonality has not been the center of attention until Edwards (1961) developed a test based on a geometrical framework which was specially designed for seasonality. It turned out to become the most cited and the benchmark against which other tests are evaluated (Wallenstein et al, 2000, p. 817). In his article, Edwards explicitly also mentions the possibility to estimate cyclic trends by considering the ranking order of the events which are above or below the median number. This idea has 17

been taken up by Hewitt et al (2002). They did not use a binary indicator as suggested by Edwards but all the ranking information. Rogerson (2000) made a first step to generalize this test, relaxing the relatively strict assumption of Hewitt et al.(2000) that seasonality is only present if a six-month peak period is followed by a six-month trough period. Rogerson allowed that the peak period can also last three, four, or five months.

In this research, the researcher will use the Kruskal-Wallis test which is an alternative for the parametric one-way analysis of variance test, if there are two or more independent groups to compare (Siegel & Castellan 1988). Barker et al. (2006), for example, found with the Kruskal-Wallis test that significant seasonal and monthly variations in mean daily frequency of suicide attempts were observed in women, but not in men. In addition, significant relationships (as assessed with the Mann-Whitney U-test) were found between female parasuicides and hot, still, still/hot days as well as between male parasuicides and windy days.

The test is described as below;

Ho: the series has no seasonality Ha: the series has seasonality
2 Test statistics, H to compare with (Chi square)

H=(+1)

12

=1

3( + 1)

ni is the number of observations in the ith season N is the total number of specific seasons Ri= ( ) Yi is the specific season for time t. Critical region
2 Reject Ho if H>(1)

18

3.5.3 Autoregressive Integrated Moving Average (ARIMA) This is also known as the Box-Jenkins model. This methodology will be used to forecast the under-five mortality rates. The model is based on the assumption that the time series involved are stationary. Stationarity will first be checked and if not found, the series will be differenced d times to make it stationary and then the Autoregressive Moving Average (ARMA) (p, q) will be applied.

The ARIMA procedure provides a comprehensive set of tools for univariate time series model identification, parameter estimation, and forecasting, and it offers great flexibility in the kinds of ARIMA models that can be analyzed. The ARIMA procedure supports seasonal, subset, and factored ARIMA models; intervention or interrupted time series models; multiple regression analysis with ARMA errors; and rational transfer function models of any complexity.

The Box-Jenkins methodology has four steps that will be followed when forecasting the mortality rates as stipulated below; i. Identification. This involves finding out the values of p, d, and q where; p is the number of autoregressive terms d is the number of times the series is differenced q is the number of moving average terms

The identification here will be done basing on the correlogram plot obtained. Where both autocorrelation and partial correlation cuts of at a certain point, we conclude that the data follows an autoregressive model. The order p, of the ARIMA model is obtained by identifying the number of lags moving in the same direction. In case the series was non stationary, the number of times we difference the series to obtain stationarity is the value of d.

ii. Estimation. This involves estimation of the parameters of the Autoregressive and Moving average terms in the model. The non linear estimation will be used.

iii. Diagnostic checking. Having chosen a particular ARIMA model, and having estimated its parameters, we now examine whether the chosen model fits the data reasonably well. The simple 19

test of the chosen model will be done to see if the residuals estimated from this model are white noise. If they are, we can accept the particular fit and if not, the model will have to be started over.

iv. Forecasting. Exponential smoothing methods will be used for making forecasts. While exponential smoothing methods do not make any assumptions about correlations between successive values of the time series, in some cases you can make a better predictive model by taking correlations in the data into account. Autoregressive Integrated Moving Average (ARIMA) models include an explicit statistical model for the irregular component of a time series that allows for non-zero autocorrelations in the irregular component.

3.6 Ethical considerations Ethics in research refer to considerations taken to protect and respect the rights and well fare of participants and other parties associated with the activity (Reynolds 2001). The rights of parties involved at every stage of this study were treated with utmost care. The following considerations were made to promote and protect the rights and interests of participants at the different stages of the study.

During Data collection: steps taken to protect the rights of participants during actual data collection included securing informed written consent by the head of department notifying the management of Mulago hospital about my study and to grant me permission to collect data from the hospital.

During analysis and reporting of findings: the investigation made sure to report modestly and exactly what the findings were, without exaggerations that would create false impressions. In the same respect, the database was created honestly using SPSS programme without any distortions.

20

CHAPTER FOUR DATA PRESENTATION AND ANALYSIS OF RESULTS

4.1 Introduction This chapter presents key findings on the trend of under-five mortality. It presents both descriptive and inferential analysis of the relationship between variables. The choice of the different test statistic used depended on the hypothesis to be tested. The data was obtained from the records department of Mulago hospital and directly entered into Microsoft Excel from which it was exported to SPSS, STATA and E-VIEWS for analysis

4.2. Graphical presentation of findings Figure 4. 1: A Line Graph Showing the Trend of Under-Five Mortality by Gender from 1990-2010
1200

total number of deaths

1000 800 600 400 200 male female

0 1991 1999
1990 1992 1993 1994 1995 1996 1997 1998 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

year

From the Figure 4.1 above, the mortality series of both male and female showed a downward trend between 1990 and 1995. However, the rate of decline for the female is greater than that of the male. For the male under-five the rate of decline is about 30.6% whereas for the female under-five, the rate is 38.1%. However between 1995 and 2010, the series exhibited stationarity with a rate of decline of only 6.7% and 8.8% for the female and male under-five respectively. 21

Variations in deaths by gender can also be observed in that the number of male deaths recorded remained higher than that of female children except in 2003 where a total of 701 female deaths were recorded against 633male deaths.

Figure 4. 2: A Bar Graph Showing Percentage Distribution of Under-Five Mortality by Disease (1990-2010) percenatage of deaths
25.00 20.00 15.00
10.80% 19.41%

12.68%

10.00 5.00 0.00

2.88% 1.10% 2.78% 3.85% 2.06% 0.68% 4.17% 1.25% 1.28% 4.81% 3.32% 1.41% 0.77% 2.32% 5.48% 3.68% 3.37% 2.98% 4.73%4.19%

Nervous system disorder

Cardiovascular disease

Resoiratory infection

Genital infection

Diabetes Mellitus

Tuberculosis

Oral Disease

Pneumonia

Kwashiorkor

Dehydration

Septicaemia

Meningitis

Diarrhoea

Dysentry

Marasmus

Measles

Tetanus

Malaria

Anaemia

DISEASES

From Figure 4.2 above, Malaria accounted for most of the deaths (19.41%) for the period 1990 to 2010 followed by Pneumonia and Diarrhoea with 12.68% and 10.80% respectively. Genital infection and oral disease accounted for the least number of deaths recorded with 0.68% and 0.77% respectively. The high number of deaths due to malaria can be attributed to the rainy season that cause a lot of stagnant water which acts as breeding places for mosquitoes since most deaths were recorded in June, February, December, July and august of which these months are faced with heavy rains at times.

22

Asthma

Injuries

Aids

Figure 4. 3: A Bar Graph Showing Percentage of Under-Five Mortality Recorded for Each Month for the Period 1990-2010
12.00 10.71% 10.00 8.85% 8.00 7.70% 7.50% 9.13% 9.03% 7.76% 6.34% 6.00 5.36% 10.73% 9.36%

percentage deaths

7.48%

4.00

2.00

0.00 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

months

Figure 4.3 above shows that most deaths were recorded in June, February, December, July and August of which each accounted for 10.73%, 10.71%, 9.36%, 9.13% and 9.03% of the total deaths respectively. The least number of deaths were recorded in the months of January and October accounting for only 5.36% and 6.34% of the total number of deaths recorded for the period 1990 to 2010.

23

Figure 4. 4: General Trend in Under-five Mortality (1990-2010)

2500 2000

deaths total number of

1500 1000 500 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

year

From Figure 4.4 above, Mulago Hospital recorded the highest number of child deaths in 1990 with 2062 deaths and the lowest in 2009 with 1172 deaths. The mortality series exhibited a downward trend between 1990 and 1995 but after wards the series remained almost constant over the remaining years. The down ward trend between 1990 and 1995 can be attributed to the government constant effort to improve child health care over the years through provision of better health facilities and increased number of health workers. The period of 1990-1995 according to (MFPED, 2002) was characterized with high economic growth, political stability and poverty reduction under the NRM Government. Between 1996 and 2007, the series was stationary and this can be attributed to the non improving health facility standards and inadequate budget provisions for the health sector.

24

Figure 4. 5: Line Graph showing Variations in Mortality Series 2005-2010 by Quarters

500 450 400 350 300

total number of deaths

250 200 150 100 50 0 Q1 2005 Q2 2005 Q3 2005 Q4 2005 Q1 2006 Q2 2006 Q3 2006 Q4 2006 Q1 2007 Q2 2007 Q3 2007 Q4 2007 Q1 2008 Q2 2008 Q3 2008 Q4 2008 Q1 2009 Q2 2009 Q3 2009 Q4 2009 Q1 2010 Q2 2010 Q3 2010 Q4 2010 deaths

year

From figure 4.5 above, the mortality series varied between different months of the year. The series indicated consistently high number of deaths for the second quarter and first quarter of the year as seen above. This can be attributed to the rainy season in the first and second quarter of the year that cause a lot of stagnant water which acts as breeding places for mosquitoes which cause malaria and lead to death of children with weak immune systems.

25

Figure 4. 6: A Line Graph Showing Various Causes of Under-Five Mortality for the Period 1990-2010
450 400

350
300 250 200 150 100 50 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 MEASLES TETANUS AIDS MALARIA PNEUMONIA ANAEMIA

deaths

year

From Figure 4.6 above, there has been a down ward trend in mortality by the selected causes; malaria, tetanus, Aids, measles, pneumonia and anaemia for the period of 1990-2010. Tetanus and measles according to WHO report 2011 was declared nonexistent in Uganda although malaria still remains a big challenge. The general downward trend for the period of 1990-2010 can be attributed to improved health facilities and the government effort to achieve the MDG 4.

26

4.3 Testing for stationarity in the mortality series Before fitting a particular model to time series data, the series must be made stationary. Stationary occurs in a series when statistical properties in the series tend to remain the same over a given period of time. The test hypotheses are stated below; Ho: mortality series is stationary Ha: mortality series is not stationary

Table 4. 1: Unit Root Test for Under-five mortality

Null Hypothesis: TOTAL has a unit root Exogenous: Constant Lag Length: 0 (Automatic based on SIC, MAXLAG=4) t-Statistic Augmented Dickey-Fuller test statistic Test critical values: 1% level 5% level 10% level *MacKinnon (1996) one-sided p-values. -5.287243 -3.808546 -3.020686 -2.650413 Prob.* 0.0004

Augmented Dickey-Fuller Test Equation Dependent Variable: D(TOTAL) Method: Least Squares Date: 04/27/12 Time: 08:49 Sample (adjusted): 1991 2010 Included observations: 20 after adjustments Variable TOTAL(-1) C R-squared Adjusted R-squared S.E. of regression Sum squared resid Log likelihood F-statistic Prob (F-statistic) Coefficient -0.323773 412.2893 0.608312 0.586551 57.93498 60416.32 -108.5116 27.95493 0.000050 Std. Error 0.061237 87.07992 t-Statistic -5.287243 4.734608 Prob. 0.0001 0.0002 -43.00000 90.10111 11.05116 11.15073 11.07060 2.407887

Mean dependent var S.D. dependent var Akaike info criterion Schwarz criterion Hannan-Quinn criter. Durbin-Watson stat

According to Table 4.1 above, the Dickey-Fuller Unit root test on the original series shows that the series is stationary since the absolute value for the combined test statistics (5.287243) is greater than the three test statistics at 1%, 5%, and 10% critical values 3.808546, 3.020686, 27

2.650413 respectively. Since the series is stationary, we now obtain the Autoregressive Moving Average (p, q). Here the chief tools of model identification are the autocorrelation function (ACF) and the Partial Autocorrelation Function (PAF) and there corresponding correlogram plots.

Table 4. 2: Correlogram Plot for Mortality (1990-2010)

From the above captured correlogram in Table 4.2, we observe that Both AC and PAC cuts off after a certain point hence we can say that the data follows an autoregressive model. The order of the ARIMA model is now obtained by identifying the number of lags moving in the same direction. By counting the lags moving in the same direction, we obtain 9 lags. Hence its AR (9).

28

4.4 Estimation of the model Table 4. 3: Autoregressive Moving Average Model (9, 0, 0)

According to Table 4.3 above, the probability value of (0.000) is less than 0.05. This means that the deaths in the previous quarter can significantly determine the deaths in the current quarter.

4.5 Diagnostic test In order to check whether the model was good for the data, Bartletts white noise test was carried out. The residuals generated were plotted using a cumulative periodogram white Noise test.

29

Figure 4. 7: Bartletts Test for White Noise

As presented in Figure 4.7, using the periodogram white noise test for goodness of fit of the model to the data, the researcher found that the model best fits the data since almost all values appeared within the confidence bands thus the model is good for this data. After carrying out the white noise test, the mortality series were predicted within the range of the original series. This is done in order to find out whether the model is good for the data.

30

4.6: Forecasts of under-five mortality (2011Q1-2015Q4) Table 4. 4: Model Description

Model Type Model ID Mortality forecast Model_1 ARIMA(9,0,0)

Table 4. 5: Forecasted Mortality Values year 2011 2011 2011 2011 2012 2012 2012 2012 2013 2013 2013 2013 2014 2014 2014 2014 2015 2015 2015 2015 quarter Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Forecast values 303 327 281 225 294 317 272 218 284 306 263 211 274 296 254 203 265 285 245 196

4.7 Test of hypotheses 4.7.1 Testing for death differentials by gender A paired sample t-test was conducted to find out whether on average the male deaths and female deaths are significantly different and the output is displayed below. Ho: more male children die than female children Ha: the number of deaths is the same between the sexes 31

Table 4. 6: Death Differential by Gender

Paired Differences 95% Confidence Interval of the Difference Mean Pair 1 male female 58.000 Std. Std. Error Deviation Mean Lower 50.444 11.008 35.038 Upper 80.962 t df Sig. 0.000

5.269 20

From Table 4.6 above, it is revealed that the means of the male and female death figures have a probability value of 0.000 which is less than 0.05. This implies that if 100 similar studies were carried out under the same conditions, all of them would show that there is a significant difference between the male mortality and female mortality. The null hypothesis is therefore rejected and its concluded that on average, more male children died than female children.

4.7.2 Testing for death differentials by year Ho: mortality in the different years studied differ Ha: mortality in the different years studied is the same

Table 4. 7: Death Differential by Year (Period)

Test Value = 0 (one sample t-test) 95% Confidence Interval of the Difference t total 29.601 df 20 Sig. 0.000 Mean Difference Lower 1396.476 1298.07 Upper 1494.89

It is revealed from Table 4.7 above that the mean deaths of the years 1990-2010 are significantly different with a probability value of 0.000 which is less than 0.05. This implies that if 100 similar studies were carried out under the same conditions, all of them would show that there is a significant difference in the deaths over the period of 1990-2010. This leads to the rejection of the null hypothesis and a conclusion is made that on average the mean deaths in the years considered are significantly different.

32

4.7.3 Testing for death differentials by disease Ho: under-five deaths due to the different diseases differ Ha: under-five deaths due to the different diseases is the same Table 4. 8: Death Differential by Disease
One sample test Mean Difference 1271.304 95% Confidence Interval of the Difference Lower 717.16 Upper 1825.45

t deaths 4.758

df 22

Sig. 0.000

From Table 4.8 above, it is established that means between figures of disease give a combined significance value of 0.000 which is less than 0.05. This implies that if 100 similar studies were carried out under the same conditions, all of them would show that there is a significant difference in the number of deaths due to the different diseases. The null hypothesis is thus rejected and a conclusion is made with 95% confidence that on average, deaths due to the different diseases vary.

4.7.4 Trend analysis of mortality series Runs test was used to establish whether there was a trend in the series of observations recorded. Summary statistics generated are presented in the table below. Ho: the mortality series is not trended Ha: the mortality series is trended

Table 4. 9: Runs Test forUnder-five Mortality ( 1990-2010)

DEATHS Test Value Cases < Test Value Cases >= Test Value Total Cases Number of Runs Z Asymp. Sig.
a

334 42 42 84 34 -1.976 0.055

a. Median

33

From Table 4.9 above, the probability value (0.055) is greater than 0.05. This implies that if 100 similar studies were carried out under the same conditions, about 95 of them would show that the series exhibited trend. Thus the null hypothesis is not rejected and it is concluded at 95% level of confidence that the series did not significantly exhibited trend for the years observed (19902010).

4.7.5 Trend analysis of mortality series by gender Ho: the mortality series of male children is not trended Ha: the mortality series of male children is trended Ho: the mortality series of female children is not trended Ha: the mortality series of female children is trended

Table 4. 10: Runs Test for Under-five Mortality by Gender

male Test Valuea Cases < Test Value Cases >= Test Value Total Cases Number of Runs Z Asymp. Sig. (2-tailed) a. Median 693 10 11 21 8 -1.336 0.82 female 644 10 11 21 6 -2.234 0.026

According to Table 4.10 above, the probability value of the male mortality series is 0.82 which is greater than 0.05 and that of female is 0.026 which is less than 0.05. This implies that if 100 similar studies were carried out under the same conditions, only 18 of them would show that trend significantly exists in the male mortality series and 97 of them would show that trend significantly exists in the female mortality series.

4.7.6 Test for seasonality The Kruskal-Wallis test also known as the H-test was used to investigate whether there was seasonality in the recorded figures from 1990-2010.

34

Table 4. 11: Kruskal-Wallis Test for Seasonality quarter Number of Rank sum observations 1 2 3 4 20 20 21 20 606.50 1182.50 1030.00 502.00 27.580 with 3 d.f. 0.0001

chi-squared = probability =

It is established that the probability value =0.0001 which is less than 0.05 (5% level of significance). The null hypothesis is thus rejected and it is concluded that the series exhibited seasonality for the periods recorded. This also implies that if 100 similar studies were carried out under the same conditions, all of them would show that seasonality significantly exists in the mortality series. As observed in figure 4.3, most deaths were recorded in June, February, December, July and August of which each accounted for 10.73%, 10.71%, 9.36%, 9.13% and 9.03% of the total deaths respectively. The least number of deaths were recorded in the months of January and October accounting for only 5.36% and 6.34% of the total number of deaths recorded for the period 1990 to 2010.

4.8 Discussion The discussion of the key findings has been arranged in relation to the research hypotheses that were investigated. The findings are also discussed in reference to the findings from some relevant previous studies that were either similar or contrary to the findings in the present study.

4.8.1 Child sex and under-five mortality The study findings revealed that mortality of under-five male children remained higher than those of the female children. This study is in line with a study carried out by Lavy, 2000; Ssewanyana and Younger, 2007 who also found out that boys are often found to be significantly more likely to die than girls. Also according to (WHO, 2010), for the world as a whole, underfive mortality rates are the same for boys and girls. However, the rate varies by income group 35

and region. In general, under-five mortality is higher for boys than it is for girls among low income countries and upper middle and high income countries. The pattern seems reversed for lower middle income countries. Similarly, under-five mortality is higher among boys for most regions of the world except the South East Asia region where it is reversed, and there is little difference among boys and girls in the Eastern Mediterranean region.

4.8.2 Seasonality and Under-five mortality According to this study, the mortality series in Mulago varied between different months of the year. The series indicated consistently high number of deaths for the second quarter and first quarter of the year. According to the study by Nyombi in 2000, child deaths have a seasonal pattern occurring more frequently during certain months of the year. There may exist seasonality in death level among children, that is there are more deaths occurring in a particular time of the year or day due to specific diseases being rampant in certain months of the year e.g. cases of death due to anemia, are predominant in dry seasons when there is little vegetables, and also when malaria cases are rampant causing break down of red blood cells.

4.8.3 Trend in under-five mortality The study findings revealed that there is no trend in under-five mortality (0.055> 0.05). The mortality series exhibited a downward trend between 1990 and 1995 but after wards the series remained almost constant over the remaining years. The down ward trend between 1990 and 1995 can be attributed to the government constant effort to improve child health care over the years through provision of better health facilities and increased number of health workers. Child mortality fell significantly between 1948 and 1970 as a result of political stability, high economic growth, and increased access to health care and scientific progress which, amongst others, increased access to vaccines against immunizable diseases. Ugandas health sector was considered to be one of the best in Africa during this period (Hutchinson, 2001). The recovery period of 1986-1995 with high economic growth, political stability and poverty reduction under the NRM Government, produced a reduction in child mortality (MFPED, 2002).

36

4.8.4 Infectious Diseases and Under-five mortality According to this study,Malaria accounted for most of the deaths (19.41% ) for the period 1990 to 2010 followed by Pneumonia and Diarrhoea with 12.68% and 10.80% respectively. Genital infection and oral disease accounted for the least number of deaths recorded with 0.68% and 0.77% respectively. The high number of deaths due to malaria can be attributed to the rainy season that cause a lot of stagnant water which acts as breeding places for mosquitoes since most deaths were recorded in June, February, December, July and august of which these months are faced with heavy rains at times. This is in line with the study of (Nyombi 2000) who also found out that cases due to malaria is predominant in the months of April, June, July, September and December. According to the World Health Organization (WHO 2011) Malaria is responsible for 10 per cent of all under-five deaths in developing countries.

37

CHAPTER FIVE SUMMARY OF FINDINGS, CONCLUSIONS AND RECOMMENDATIONS

5.1 Introduction This chapter summarizes the findings, conclusions and recommendations in line with the objectives of the study. The major objective of the study was to carry out a time series analysis of under-five mortality in Mulago Hospital for the period 1990-2010.

5.2 Summary of the findings This study focused on the behavior of the mortality series for under-five children obtained from the records department of Mulago hospital. The study found out that mortality series in Mulago hospital recorded the highest number of child deaths in 1990 and the lowest in 2009. The mortality series exhibited a downward trend between 1990 and 1995 but after wards the series remained almost constant over the remaining years. Malaria accounted for most of the deaths for the period 1990 to 2010 followed by Pneumonia and Diarrhoea. Genital infection and oral disease accounted for the least number of deaths recorded.

The study also revealed seasonality in Under-five mortality (0.0001<0.05). Most deaths were recorded in June, February, December, July and August. The least number of deaths were recorded in the months of January and October for the period 1990 to 2010. . It was also revealed that under-five deaths varied by gender, year and disease (0.000<0.05) respectively.

The forecasted under-five mortality shows a decline in under-five mortality for the periods of 2011, 2012, 2013, 2014 and 2015. The study also revealed a general downward trend in underfive mortality causes. Tetanus and measles accounted for the least deaths by 2010 and in 2011 Uganda was declared free of measles according to the ministry of health report 2011 and WHO report 2011.

38

5.3 Conclusions Basing on the findings of this study, it was possible to draw a number of conclusions. It was inferred from the findings that the mortality series observed over the period 1990-2010 is stationary since the Augmented Dickey-Fuller Test (Unit root) revealed that the series had a unit root. Runs test also revealed that the mortality series did not exhibit trend for the period studied. However, the mortality series for the female exhibited trend whereas that of the male did not exhibit any trend for the period 1990-2010.

It was also found out that under-five mortality significantly differ by gender. It was found out that more male children die than the female children. Under-five mortality was also found to vary significantly over the period of study.

The study also found out that under-five mortality varies significantly for the different causes observed over the period 1990-2010. Malaria accounted for most of the deaths observed followed by pneumonia and diarrhoea.

The study also established that the mortality series exhibited seasonality for the periods recorded. As observed in figure 4.3, most deaths were recorded in June, February, December, July and August. The least number of deaths were recorded in the months of January and October.

5.4 Recommendations The study revealed that most under-five deaths are due to infectious diseases. By scaling up effective health services, the government will be able to ensure that most of the under-five mortality can be avoided with proven, low-cost preventive care and treatment. Preventive care includes: continuous breast-feeding, vaccination, adequate nutrition and, the use of insecticide treated bed nets. The major causes of under-five deaths need to be treated rapidly, for example, with salt solutions for diarrhoea or simple antibiotics for pneumonia and other infections. To reach the majority of children who today do not have access to this care, we need more and

39

better trained and equipped health workers. Families and communities need to know how best to bring up their children healthily and deal with sickness when it occurs.

The study also revealed stionarity in the mortality series hence political awareness, commitment and leadership are needed to ensure that child health receives the attention and resources needed to accelerate progress towards MDG4. Better information on the number and causes of underfive child deaths will help leaders to decide on the best course of action.

The results also revealed that Malaria accounted for the highest percentage of the deaths in the period covered. Therefore, consistency in usage of treated mosquito nets must be encouraged and presumptive malaria treatment of pregnant women must be done.

The researcher also found out that the doctor patient ratio in Mulago hospital is 1:40, this is a fair ratio but more effort such as providing attractive wage for health workers has to be done in order to increase the number of health workers in the health units. Lastly health ministries should embark on enhancing workers skills through workshops. This would increase survival rates of children who visit health units.

5.5 Areas for further studies The current study was done in Mulago hospital hence further studies should consider focusing on mortality differences basing on regions and location. For example studies that will be able to compare mortality in urban and rural areas. Further studies on under-five mortality should consider finding out why more male children die than female children as it was found in the present study and other studies carried out. Further studies should also consider using other forecast models apart from ARIMA models for the forecast of mortality figures in the future. Further studies on mortality should also consider focusing on identification of several determinants of under-five mortality in the country. 40

REFFERENCES Bulla. A, Hitze, KL (2000), Acute respiratory infections: a review. Bull World Health Organ; 56:481-98 pmid: 308414.

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Health sector strategic & investment plan (2010/2011), http//www.who.intlfeatures/qa/en/index http://www.un.org/millenniumgoals/.

Jacques .d (2004), The state of food insecurity in the world: monitoring progress towards the world food summit and millennium development goals

Korenromp, EL (2003), Measurement of trends in childhood malaria mortality in Africa: an assessment of progress toward targets based on verbal autopsy. Lancet Infectious Diseases, 3(6):349358.

Leowski. J (2000), Mortality from acute respiratory infections in children under 5 years of age: global estimates. World Health Stat Q; 39: 138-44 pmid: 3751104

MFPED (2002), The Complementarities of MDG Achievements: The Case of Child Mortality in Sub-Saharan Africa problems. Bull World Health Organ 1973; 49: 1-12 pmid: 4545151.

Rowe, AK (2005), The burden of malaria mortality among African children in the year 2000.

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Ter Kuile, FO (2004), The burden of co-infection with HIV-1 and malaria in pregnant women in sub-Saharan Africa. American Journal of Tropical Medicine and Hygiene, 2004, 71(Suppl. 2):4154.

The world development report (1993), Investing in health Washington, DC: World Bank.

Timaeus, I.M (2002), Adult Mortality in the era of AIDS. Third African Population Conference. Dakar, Senegal, Union fo r African Population Studies, 1999.

Timaeus, I.M (2003), Impact of the HIV epidemic on mo rtality in sub-Saharan Africa: evidence from national surveys and censuses. AIDS 1998;12 Suppl 1:S15-27.

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UNAIDS (2010), UNAIDS report on the global AIDS epidemic UNICEF (2008), state of the worlds children report UNICEF (2010), Sweden statistics UNICEF (2011), press release UNICEF (2011), Statistics Uganda

UNICEF 12, September (2010), press release September UNICEF September 17 (2010), press release. WHO (2006), Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants in resource-limited settings: towards universal access

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WHO (2010) Statistics Data tables retrieved 2/9/2011 WHO/UNAIDS/UNICEF (2011) Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access 2011

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APPENDICES APPENDIX 1: UNDER FIVE DEATHS BY SEX JAN 81 71 152 55 65 120 43 33 76 31 30 61 57 47 104 41 34 75 47 49 96 31 22 53 FEB 77 73 150 81 73 154 89 61 150 71 55 126 71 69 140 98 87 185 75 86 161 61 69 130 MAR 84 76 160 79 76 155 57 51 108 70 67 137 57 55 112 57 51 108 57 61 118 54 47 101 APR 75 79 154 89 78 167 67 55 122 66 55 121 71 75 146 65 59 124 61 49 110 63 52 115 MAY 81 88 169 77 73 150 78 62 140 76 59 135 47 50 97 66 60 126 58 60 118 37 32 69 JUN 88 86 174 71 76 147 81 71 152 67 63 130 75 79 154 80 67 147 72 67 139 71 69 140 44 JUL 73 79 152 79 87 166 61 69 130 71 69 140 68 69 137 64 59 123 61 65 126 66 67 133 AUG 112 102 214 81 76 157 67 71 138 72 73 145 63 57 120 66 44 110 64 55 119 54 66 120 SEPT 89 86 175 68 79 147 69 81 150 68 66 134 75 67 142 57 48 105 40 39 79 63 54 117 OCT 89 71 160 88 65 153 77 67 144 69 57 126 64 48 112 33 47 80 44 37 81 46 37 83 NOV 119 102 221 88 76 164 81 79 160 63 54 117 78 56 134 41 30 71 33 21 54 54 34 88 DEC 93 88 181 84 81 165 88 65 153 62 70 132 61 65 126 68 34 102 55 47 102 66 67 133 TOTAL 1061 1001 2062 940 905 1845 858 765 1623 786 718 1504 787 737 1524 736 620 1356 667 636 1303 666 616 1282

1990

1991

1992

1993

1994

1995

1996

1997

M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL M F TOTAL M

33 42 75 22 19 41 20 22 42 23 28 51 31 37 68 33 37 70 39 37 76 33 42 75 27 39 66 37 26 63 41

81 72 153 67 61 128 77 101 178 65 51 116 67 69 136 77 73 150 72 81 153 83 77 160 85 96 181 100 91 191 98

57 43 100 53 49 102 47 39 86 59 47 106 54 47 101 58 44 102 55 49 104 57 43 100 54 41 95 47 39 86 33

63 47 110 66 55 121 43 55 98 66 55 121 71 59 130 76 62 138 73 59 132 69 49 118 61 57 118 55 55 110 62

44 40 84 43 31 74 53 47 100 41 38 79 38 33 71 40 37 77 27 31 58 46 41 87 51 37 88 69 66 135 63

99 89 188 71 63 134 68 65 133 69 63 132 73 71 144 77 75 152 70 76 146 101 89 190 89 69 158 105 84 189 80 45

51 56 107 57 69 126 67 62 129 68 69 137 67 69 136 61 72 133 69 64 133 59 56 115 55 47 102 67 62 129 56

50 62 112 56 71 127 66 53 119 67 68 135 56 68 124 56 73 129 79 66 145 53 67 120 63 39 102 58 37 95 62

47 34 81 55 76 131 43 33 76 69 56 125 63 54 117 49 71 120 59 38 97 49 34 83 45 27 72 41 33 74 50

20 27 47 44 36 80 38 35 73 52 41 93 47 39 86 44 36 80 44 29 73 20 27 47 27 31 58 36 35 71 38

41 54 95 37 60 97 69 63 132 54 37 91 56 34 90 37 60 97 31 53 84 43 59 102 53 33 86 69 38 107 43

59 78 137 62 69 131 57 51 108 62 70 132 68 69 137 88 61 149 69 81 150 59 76 135 83 52 135 78 41 119 68

645 644 1289 633 659 1292 648 626 1274 695 623 1318 691 649 1340 696 701 1397 687 664 1351 672 660 1332 693 568 1261 762 607 1369 694

2009

2010

F TOTAL M F TOTAL M F TOTAL

19 60 33 37 70 41 33 74

87 185 71 61 132 72 86 158

44 77 49 38 87 45 61 106

57 119 62 57 119 53 41 94

55 118 61 49 110 57 51 108

51 131 66 66 132 72 53 125

44 100 51 44 95 58 62 120

41 103 67 44 111 63 51 114

44 94 35 41 76 38 37 75

33 71 33 37 70 28 37 65

27 70 44 28 72 33 21 54

34 102 61 37 98 62 47 109

536 1230 633 539 1172 622 580 1202

Data source: Mulago Hospital Records Department

46

APPENDIX 2: UNDER FIVE MORTALITY BY CAUSE 1990-2010

DYSENTRY MEASLES TETANUS AIDS DIARRHOEA GENITAL INFECTIONS MALARIA PNEUMONIA RESPIRATORY INFECTIONS SEPTICAEMIA TUBERCULOSIS MENINGITIS DEHYDRATION ANAEMIA ASTHMA ORAL DISEASE DIABETES MELLITUS ENDOCRINE AND METABOLIC DISORDER CARDIOVASCULAR DISEASES NERVOUS SYSTEM DISORDER KWASHIOKOR MARASMUS INJURIES TOTAL

1990 55 55 77 71 206 37 389 237 41 72 41 16 55 85 61 47 88 76 65 41 91 77 79 2062

1991 71 42 57 71 212 21 333 227 37 72 36 7 48 79 57 31 47 48 72 55 82 73 67 1845

1992 65 31 55 69 201 17 321 211 45 66 27 11 37 71 48 22 40 26 66 41 53 49 51 1623

1993 60 27 42 61 197 13 301 172 37 55 31 13 32 67 39 24 31 37 58 36 71 55 45 1504

1994 76 23 57 66 183 19 298 183 58 55 27 17 44 55 27 16 29 33 52 37 66 47 56 1524

1995 68 12 47 61 173 14 235 153 61 49 17 13 41 52 26 11 27 21 47 31 74 57 66 1356

1996 70 6 41 55 172 11 244 143 52 41 4 17 36 53 22 7 22 49 51 29 61 60 57 1303

1997 48 7 39 61 159 9 256 164 41 52 9 11 28 47 18 5 21 44 55 27 74 55 52 1282

1998 45 9 32 57 143 7 248 172 37 62 11 15 31 51 22 3 27 47 51 29 65 66 59 1289

1999 38 12 38 51 132 4 242 162 31 72 15 21 34 53 24 6 30 51 47 33 71 63 62 1292

2000 47 10 49 46 121 3 230 157 21 67 22 27 45 61 18 3 34 55 37 32 61 66 62 1274

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UNDER- FIVE MORTALITY BY CAUSE 2001-2010 continued

DYSENTRY MEASLES TETANUS AIDS DIARRHOEA GENITAL INFECTIONS MALARIA PNEUMONIA RESPIRATORY INFECTIONS SEPTICAEMIA TUBERCULOSIS MENINGITIS DEHYDRATION ANAEMIA ASTHMA ORAL DISEASE DIABETES MELLITUS ENDOCRINE AND METABOLIC DISORDER CARDIOVASCULAR DISEASES NERVOUS SYSTEM DISORDER KWASHIOKOR MARASMUS INJURIES TOTAL

2001 30 8 51 46 139 0 267 155 17 72 21 23 41 68 13 9 38 52 33 31 60 71 73 1318

2002 27 7 38 33 137 9 277 171 13 71 25 15 41 65 9 5 47 61 37 39 61 75 77 1340

2003 22 15 44 57 121 10 287 169 17 55 13 22 53 74 11 7 40 69 47 43 73 79 69 1397

2004 26 15 31 51 135 11 271 163 11 41 15 27 45 61 7 11 37 73 44 43 99 63 71 1351

2005 22 13 28 55 147 7 284 141 9 37 11 21 50 77 5 7 33 61 39 51 91 77 66 1332

2006 18 11 21 44 135 2 267 163 12 45 13 14 51 87 1 3 23 59 31 66 89 73 33 1261

2007 17 9 20 39 137 0 289 193 19 67 8 24 66 83 3 4 21 53 45 63 93 71 45 1369

2008 13 3 16 47 110 2 226 201 11 55 4 21 71 79 0 1 17 48 36 54 98 77 40 1230

2009 10 5 18 35 105 0 230 197 11 51 7 17 63 72 1 1 15 55 38 41 82 63 55 1172

2010 14 2 11 51 111 3 237 183 22 62 9 21 59 66 0 3 11 59 33 49 88 67 41 1202

Data source: Mulago Hospital Records Department 48