UNICEF : Questions and Answers for the Iraq child mortality surveys

On 16 August 1999 a document was posted to ReliefWeb, a website for relief agencies. On 20 August 1999 that document was then circulated on the electronic discussion list of the Campaign Against Sanctions on Iraq (CASI). When CASI later went to consult the original document on ReliefWeb, it was no longer there. Subsequent conversations have confirmed that the document does exist but suggest that it was intended primarily for internal use. The document below is CASI's HTML conversion of the version that was circulated to its discussion list. It has not been checked against the original.

Source: UNICEF
Date: 16 Aug 1999

BAGHDAD, 16 August 1999 (UNICEF)

Survey Methodology/credibility

Why were two household surveys of child mortality carried out in Iraq at the same time?

In any country UNICEF nearly always undertakes major surveys in partnership with the Government. The current administrative arrangements in Iraq made it necessary to undertake two surveys in order to cover the whole of Iraq. One survey covered the 15 governorates in the center and south of Iraq. This was carried out in partnership with the Government of Iraq. The second survey covered the three autonomous northern governorates of Erbil, Dohouk and Al-Suleimaniyah. In these UNICEF undertook the survey in partnership with the local authorities.

How can UNICEF be sure that the results are accurate/reliable?

The large sample sizes - nearly 24,000 households randomly selected from all fifteen governorates in the south and center and 16,000 from the three autonomous northern governorates - helps to ensure that the margin of error for child mortality in both surveys is low. Another important factor was that in the south and center of Iraq the survey interviewers were all women and all were medical doctors. In the northern governorates 80% of interviewers were female - each team had at least one female interviewer - and all interviewers were trained health workers. UNICEF was also involved in all aspects of both surveys - from survey design through to data analysis. Specifically:

What checks have been made on the data?

Each questionnaire was first checked at the local level and then at the governorate level by staff of the local statistical offices. This check was primarily to determine whether the randomly sampled households were correctly identified, visited and interviewed. Final editing and checking was done at the central level for completeness and consistency. A number of internal checks normally carried out for Demographic and Health Surveys (DHS) were also completed for both surveys. The surveys and findings were also reviewed by a panel of experts in early July. This panel included senior personnel from DHS, Macro International, WHO and senior UNICEF officials from the Regional Office in Amman and New York Headquarters.

Could the Government of Iraq have manipulated the data to give higher mortality figures?

If the Government had attempted to manipulate the data by influencing the survey interviewers to over-record the number of deaths or by directly manipulating the survey data on the computer, this would have been detected by analyzing the spread of births and deaths. The panel of experts who reviewed the survey methodology and results looked for this, but it was not found.

How can UNICEF be sure that the survey interviewers didn't manipulate the results?

Internal cross checking of data has not detected any manipulation of the results of this survey. UNICEF is satisfied that the interviewers were properly trained on how to administer the questionnaire. Answers in the questionnaires were entered in ballpoint pen to avoid unwarranted changes in the answers. Any alterations made had to be signed by the survey collectors and their supervisors. Local supervisors and supervisors from Baghdad oversaw the fieldwork.

What problems were encountered in collecting the data?

There were several minor problems such as flooding which disrupted access to some households for several days. In several areas security problems also temporarily inhibited access. By meeting the survey interviewers during the course of the fieldwork UNICEF was also able to resolve any technical questions that arose.

Why were "household surveys" chosen to assess child mortality in Iraq?

A Household Survey is the best way to measure child mortality. This is the first time in ten years that household surveys have been undertaken in Iraq to assess the levels of child mortality. During this time "routine reporting" has been used to estimate child mortality. Because of the uncertainties of the mortality situation, the Ministry of Health, in partnership with UNICEF and WHO, decided to conduct a household survey to provide a more reliable current estimate of the mortality of young children and mothers in Iraq. In consultation with the local authorities, UNICEF subsequently carried out a similar survey in the three autonomous northern governorates.

Why also survey maternal mortality?

Maternal, Infant and Child Mortality Rates are closely linked as maternal mortality has an impact on the Infant Mortality Rate. An even more obvious link is that each mother that dies in childbirth leaves behind motherless children who are then often even more vulnerable. UNICEF and the Government of Iraq agreed this would be a good opportunity to collect data on the maternal mortality and establish a baseline for assessing future trends in maternal mortality.

UNICEF's role

What is UNICEF's role in Iraq?

  1. Since 1983 UNICEF has been working with the Government of Iraq to promote the survival, protection and development of children. We have programs in the areas of education, health and nutrition and water and sanitation and children in need of special protection. UNICEF's current country program of cooperation with the Government has two main roles:
    1. To provide technical and financial support to assess the situation of children in Iraq, to track changes over time and to advocate for more to be done to help the situation of children in Iraq;
    2. To use the resources of the Country Program to supplement the Oil-for-Food Program through the provision of cash to support activities such as training, capacity building, rehabilitation and facilitating distribution.
    UNICEF is planning to spend US$25 million through its current Country Program in Iraq before the end of the year 2000, providing funds from donors are available.
  2. Since the implementation of Security Council Resolution 986 in 1996 - commonly called the Oil-for-Food Program - UNICEF, in partnership with other UN agencies and programs, is responsible for the implementation and monitoring of programs for Water and Sanitation, Primary Education, Nutrition, Primary Health Care and Programs for Children in Need of Special Protection in the three northern governorates. In the south and center of Iraq UNICEF is responsible for observing and reporting on the arrival in country, the adequacy of, and equitable distribution to end users of supplies for Water and Sanitation, Child Health and Nutrition, and Primary Education procured under the Oil-for-Food Program.

What is UNICEF doing about child mortality in Iraq?

UNICEF works with the Government to implement the child immunization program, a community based nutrition program, a targeted nutrition rehabilitation program, child health programs dealing with Acute Respiratory Infections and diarrhoea, as well as supporting the provision of clean water and safe sanitation and the rehabilitation of schools. All of these programs have an impact on child mortality.

UNICEF is also documenting the situation of children in Iraq and using this information to advocate for improvements benefiting children. The Child Mortality Surveys are specific examples of this.

Given the link between rising malnutrition and rising child mortality what specifically is UNICEF doing to address child malnutrition?

UNICEF and the Ministry of Health agreed to setup Community Child Care Units to bring basic nutritional services closer to the community. In partnership with local authorities and local communities, volunteers have been identified and trained to manage these units.

The main functions of the Community Child Care Units are to screen children for malnutrition and refer malnourished children to the local Public Health Centers. At the Public Health Center their nutritional status is again assessed and if a child is found to be severely malnourished they are sent to a Nutrition Rehabilitation Center for specialized treatment.

The Community Child Care Unit workers are also trained to advise the child caretakers on nutrition and dietary practices that will prevent child malnutrition. High protein biscuits and therapeutic milk - made available through the Oil-for-Food Program are also distributed to severely and moderately malnourished children and to pregnant and lactating mothers.

To date more than 1900 Community Child Care Units have been established. UNICEF is committed to supporting the Government of Iraq establish more than 3000 of these units. It is planned that through the Community Child Care Units, 75% of all children in Iraq will be regularly screened for malnutrition.

Given the impact of mothers' education on child mortality rates what specifically is UNICEF doing to help improve education services?

UNICEF is working with the Government to improve access to education for all children by rehabilitating schools in urban areas and fully reconstructing schools in rural areas. So far more than 300 schools have been covered. But with more than 50% of schools in the 15 governorates of the south and center of Iraq deemed unfit for teaching and learning, further substantial resources are required.

UNICEF is also assisting the Government to improve the quality of education through the resumption of in-service teachers' training - focusing on improving teaching methodologies.

UNICEF and the Government are also working together on improving planning and management in the education sector through improving systems of data collection at both the central and local levels.UNICEF is also assisting the Government in the preparation of the Education For All review report.

What else does UNICEF think should be done to bring down the high Child Mortality Rates in Iraq?

There are a number of specific recommendations made in Secretary General's reports and the Security Councils Humanitarian Review Panel which UNICEF would like to see implemented immediately. These include:

Also, given the dramatic increase in bottle-feeding and its contribution to malnutrition and child mortality, UNICEF urges the Government of Iraq to remove breastmilk substitutes from its food ration and to replace them with additional food for pregnant and lactating women. UNICEF also urges the Government of Iraq to promote exclusive breastfeeding as its national policy.

Urgent action must also be taken to bring about the full rehabilitation of the education sector. This is critically important given the impact of mothers' education on Child Mortality Rates.

What is UNICEF doing to encourage the Iraqi government to comply with its commitments under the Convention on the Rights of the Child?

Government of Iraq's Child Welfare Commission is responsible for overseeing the implementation of the Convention on the Rights of the Child in Iraq. UNICEF is working closely with the Commission:

  1. to review the outcome of the plenary session of Committee on the Rights of the Child and the Government of Iraq that was held in late 1998;
  2. to analyze the current situation of children in Iraq; and
  3. to revise the National Plan of Action for children.

The Child Mortality Surveys are important contributions to the analysis of the current situation of children in Iraq.


What is UNICEF's position on sanctions?

UNICEF as a member of the UN family recognizes that sanctions are an instrument used by the international community to promote peace and security.

UNICEF's concern is that whenever sanctions are imposed they should be designed and implemented in such a way as to avoid a negative impact on children. UNICEF believes there must be a child impact assessment at the point at which any set of sanctions are applied and most importantly constant monitoring thereafter to gauge the humanitarian impact. The Child Mortality Surveys in Iraq are an important contribution to the ongoing monitoring of the humanitarian situation in Iraq.

Does UNICEF think the type of sanctions imposed on Iraq are responsible for the rise in child mortality?

It is certainly one factor. The Security Council Panel on Humanitarian Issues summarized the situation well when it said in March - "Even if not all suffering in Iraq can be imputed to external factors, especially sanctions, the Iraqi people would not be undergoing such deprivations in the absence of the prolonged measures imposed by the Security Council and the effects of war".

How does UNICEF explain the differences in the current levels of child mortality between the autonomous northern governorates and the rest of Iraq?

This is an area that needs further investigation. The Child Mortality Surveys describe the child mortality situation - but they do not explain why the levels are as they are.

What we do know is that the difference in the current rate cannot be attributed to the differing ways the Oil-for-Food Program is implemented in the two parts of Iraq. The Oil-for-Food Program is two and a half years old. Therefore it is too soon to measure any significant impact of the Oil-for-Food Program on child mortality over the five year period of 1994 - 1999 as is reported in these surveys.

We need to look at longer-term trends and factors including the fact that since 1991 the north has received far more support per capita from the international community than the south and center of Iraq. Another factor maybe that the sanctions themselves have not been able to be so rigorously enforced in the north as the border is more "porous" than in the south and center of Iraq.

Given the results of this survey - does UNICEF think the sanctions should be lifted?

The imposition and lifting of sanctions is a matter for the Security Council. As an agency of the United Nations, UNICEF is bound by article 48 of the United Nations Charter to implement the decisions of the Security Council.

UNICEF has voiced its concern repeatedly that if sanctions are to be implemented they should be implemented in such a way as to not have a negative impact on children. This is not the case in Iraq.

UNICEF has also recommended that a child impact assessment is undertaken at the time any set of sanctions are applied, and that the impact of sanctions be constantly and reliably monitored. These Child Mortality Surveys are a contribution to the monitoring process.

How many children have died as a result of the sanctions?

These surveys were never intended to provide an absolute figure of how many children have died in Iraq as a result of sanctions. Given the difficulty of accurately and specifically attributing the cause of death of a child to sanctions, any such figure that may be derived would certainly be questionable.

What is of real importance is the trends - which are clear. Children under 5 years of age are dying at more than twice the rate they were ten years ago.

UNICEF has called attention to this and set out a series of recommendations which the international community and Government of Iraq needs to implement.

Does UNICEF believe that the international community is doing all it can to minimize the impact of sanctions on children?

The international community has responded to the humanitarian situation in Iraq through the establishment of the Oil-for-Food Program, which has enabled Iraq to export oil and use its own resources to fund humanitarian relief. Since the introduction of Oil-for-Food there has been virtually no humanitarian aid to Iraq outside the framework of this program.

UNICEF endorses both the Secretary General's call for, and the Security Council Humanitarian Panel Report recommendation that the international community should be encouraged to provide funding for humanitarian efforts in Iraq."

Does UNICEF believe that the Government of Iraq is doing all it can to minimize the impact of sanctions on children?

UNICEF recognizes that there are limitations in the Oil-for-Food Program and that there are limitations on the Government's ability to implement this program. But UNICEF believes there is more that the Government can do within the Oil-for-Food Program that would help improve the situation of children in Iraq. We would like the Government of Iraq to remove breastmilk substitutes from the food ration and replace these with an additional ration for pregnant and lactating women.

We would also urge the Government to introduce a breastfeeding promotion campaign to counteract the current high levels of bottle-feeding.

In the event that sanctions continue we would urge the Government to negotiate a cash component for the program in the south and center of Iraq to support distribution of supplies, installation of equipment and the updat ing of technical and managerial skills and systems.

What about the stories of bottlenecks in the supply chain and warehouses overflowing with life saving supplies?

There have been delays in the distribution of some humanitarian supplies and these have been reported by the UN as part of its ongoing observation of the Oil-for-Food Program. These delays are due in part to shortages of transportation to deliver the supplies to the end-users; lack of qualified people to carry out the installation of equipment, and a lack of cash that would allow the purchase of materials that make these supplies usable - such as cement to install water pumps.

In the case of undistributed medicines and medical supplies as noted in the recent Security Council Report, the responsibility for their distribution lies with the Government. As well as some of the factors already mentioned, further reasons for non-distribution are that these supplies may not have met specifications or passed Iraq's own quality control checks, or that effective deployment is dependant on complementary supplies that have not yet arrived in the country.

The Secretary General has also recommended that the Sanctions Committee acknowledge that a humanitarian program of such magnitude requires a commensurate level of transport, communications and material-handling equipment and to be ready to act favorably on requests for essential logistic support.

Impact of the Oil-for-Food Program

Why are there still high levels of child mortality now that the Oil-for-Food Program is being implemented?

In the last ten years Iraq has experienced a dramatic shift from relative prosperity to increasing levels of poverty. Child mortality must be seen in the context of an acute deterioration of living conditions and severe strains on the social fabric of Iraq.

It is widely agreed that the Oil-for-Food Program was neither designed to, or is sufficient to meet the basic needs of the Iraqi people. It is also widely agreed that the implementation of the Oil-for-Food Program in 1996/7 averted what would have been an even greater crisis for the Iraqi people.

While the Oil-for-Food Program is helping to meet some of the basic immediate needs of the people of Iraq in terms of food, medicine, water, sanitation and education, it is a short-term response to what is now a long-term crisis. It was not designed to address the many deeper problems facing the children of Iraq that are contributing to the current levels of child mortality, such as increasing poverty, declining access to services, deteriorating infrastructure, and the quality of care and treatment.

Does UNICEF believe that this survey indicates that the Oil-for-Food Program is failing?

The data from the Child Mortality Surveys does not allow us to draw any conclusions about the impact of the Oil-for-Food Program on child mortality levels in Iraq because the most current information covers the period 1994 - 1999. The Oil-for-Food Program is just two and a half years old. Therefore it is too soon to measure a significant impact of the Oil-for-Food Program on child mortality.

What we do know is that since the Oil-for-Food Program has been implemented, one of the key indicators of the health and well being of children - the level of malnutrition - has stabilized in the south and center and improved considerably in the three northern governorates.