Vigilancia de la salud de los trabajadores

In 2000, BiH was a post-conflict, middle-income country(48) in economic transition to a market-driven economy. Reference is made to middle-income countries,a as BiH was ranked in this group economically in 2000 (and remains so in 2010). The effects of conflict on population health are summarized, as are the consequences of economic transition, and how conflict and transition can be synergistic in their effects.

1.5.1 The effects of conflict on child health

Armed conflict and war are societal factors that directly cause death and injury. b They also lead to secondary causes of morbidity and mortality, including for example,

a _{The ranking in 2000 was based on data from 1998. A middle-income country had an annual gross}

national product (GNP) per capita equivalent to more than $760 but less than $9,360 in 1998. The standard of living is higher than in low-income countries, and people have access to more goods and services, but many people still cannot meet their basic needs. In 2000 there were about 65 middle- income countries with populations of one million or more. Their combined population was more than 1.5 billion.

b _{The difference in terminology being largely a semantic one; war is a state of usually open and declared}

armed hostile conflict between states or nations, and civil war is between parties within a state or nations. Armed conflict is a broader term.

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reducing health care access by the destruction of hospitals and clinics, limiting access to and the availability of basic supplies such as food, water and shelter, and impoverishing society in general and population sub-groups in particular.

War obviously has negative effects on child health, and this can persist through the post-conflict period. The pattern of mortality and morbidity in conflict has progressively altered over the past century towards a majority of civilian deaths. It is claimed that 80% or more of deaths and injuries in contemporary wars are civilian; however there is no objective evidence for this as little accurate information is available. Recent surveys suggest, however, a proportion of between 35 and 65%.(49) Children may be more deeply affected both directly and indirectly by conflict than adults.(50)

Recent approaches to the estimation of war-related mortality and morbidity confirm that the effects of war are widespread and persist for many years after the conflict has ended.(51) During the first five years of peace after a civil war, the average under-five mortality rate remains 11% higher than its corresponding level before the conflict.(52) Other indicators that may be impacted negatively during and after conflict are related to the use of health services, school attendance and nutrition. However, data collected during a war and in the period afterwards may vary in quality, with particular difficulties gaining a nationally representative picture.

The likely changes in patterns of health and health-seeking behaviour are multiple. Malnutrition may be more prevalent due to disruption of food supplies, increased poverty and migration away from farmland. The morbidity patterns may also have changed due to reduced immunisation coverage, overcrowding, a breakdown in preventive health measures and primary health care. Health-seeking behaviour may have changed post-conflict due to a decrease in health education, a reduction in available health services or a change in family priorities. There may be a reduction in school attendance, reduced access to clean drinking water and a breakdown in sanitation services.

Documenting such gaps and filling them is an important part of understanding the public health status of the population and tracking recovery during the rebuilding phase post-conflict. It is also never certain how quickly recovery will occur or how

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complete it will be; data is essential for tracking this. Rebuilding the national or regional HIS is has therefore great value to recovery and development after a conflict.

1.5.2 Measuring the effects of conflict

Earlier efforts to measure the cost of conflict focused on military expenditure and economic losses, but were later broadened into the wider development costs. Comprehensive analysis of the overall costs of human conflict were boosted by Michael Cranna’s 1994 analysis which extended the range of impacts that should be measured and the time over which effects should be considered.(51)

The Strategic Foresight Group,(53) a think tank based in India, has been developing the

Cost of Conflict tool, which attempts to calculate the cost of conflict to the human race.

The idea behind this tool is to examine this cost, not only in terms of the deaths and casualties and the economic costs borne by the people involved, but also to calculate the social, developmental, environmental and strategic costs of conflict. A key benefit of using this tool is to encourage people to look at conflict in new ways, to widen public discussion of the subject, and to bring new insights to the debate on global security. Civil registration systems that track deaths in peacetime typicallyfall apart during war, and many wars occur in places without a pre-existing surveillance infrastructure.(50) There is often a breakdown in routine data collection services and so there may be gaps in data. Therefore, during and following a conflict, countries usually have major gaps in population data on children. Pre-war demographic data may no longer be applicable due to population movement, changes in demographic structure due to migration outside national boundaries, conflict-related mortality and altered birth rates during and after the conflict. This means that projected data is no longer reliable and the determination of rates and ratios is a major challenge, as the population base is not stable and the denominators may not be known.

The analysis presented here so far has referred only to quantitative data. Qualitative data is also important in understanding the patterns, contributing factors and relevance of quantitative data. Qualitative data can be used to validate and confirm the relevance of quantitative data.(54) This study will discuss later the issue of how

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much the selected health indicators from the BiH MICS 2000 survey contributed to understanding the cost of the conflict and the pace of the recovery in BiH.

A more detailed discussion of the domains of child and maternal health and the indicators that will be examined in this study is given next.