IV. ENGLISH SUMMARY } THE ENVIRONMENTAL REASONS OF INFANT MORTALITY METROPOLITAN ANKARA: 1989 The qualitative differences in community health parameters always took the attention of social scientists in terms of analyzing and understanding the reasons lying behind the social indicators. Such an inequality exists between the developed and the developing Third World nations within the mother and child çare concerns which specifically points out the welfare of individuals: less than half of the World's population is under a satisfactory health umbrella; a great proportion of the women in the Third World is stili giving birth without any assistance of community health worker ör official; more than öne tenth of the World's inhabitants is malnourished and more than half of the World's population do not have any safe access to potable water. The natural outcome of such conditions is quiet discrete: rising level of infant mortality rate and decreasing level of community health status. The overall aim of this study is to analyze and to investigate the infant mortality rate as a manageraental planning tool. Consequently, the objective of the study is to search the environmental reasons which cause the infant mortality in urban areas. The infant mortality rate (IMR) is generally accepted as a very reliable social development indicator. Indeed, the IMR has observed to be changing considerably betvreen the rich and the poor nations. For instance, IMR has been measured to be 15.5 and 17.6 per thousand in Canada and the USA vrhereas the GNP as 5672 and 5949 US â in 1975. in the same year the parameters have been measured as 77.3 and 723 US e in Brasil and 78 and 647 US e in Chile. in the same year, parameters were 140 and 600 US e in Turkey. 141The study declined to provide a prototype health system on purpose. Instead, the overriding principles and objectives are developed to shed the light on how to get re-organised. The proposed approach is management oriented and three objectives are determined: to increase the organizational effectiveness, to increase the managemental efficiency and to develop resource management and planning capacity. Organisational re-structuring should be based on the idea of functionality and the determination of optimum area sizes of health services through cost-benefit analysis. However multi- sectoral characteristics of health services and the importance of primary health care services vis-a-vis secondary services should always bare priority. Managemental development should base on the idea of management-by-objectives and accountable management understanding. Complementary job descriptions, workload and workforce analysis and training manuals should be made available. Additionally, financial management capacity based on cost centers and management accounts should be further utilized. Finally, appropriate resource management and planning techniques should be established. 148The research methodology is comprised of two essential segments: data, inventory and registry analysis of all the deaths occurred in 1989 in Ankara (around 40.000) and interviewing of 103 families having infant mortality experience in the same year. The data obtained from both studies are processed by D-Base III canned computer program. In order to facilitate the detailed analysis of physical conditions of the neighborhoods. Two reliable maps have been obtained in this regard: a map based on aerial photographs indicating the boundaries of developed, underdeveloped and mixed regions of the Ankara metropolitan area and a map indicating the boundaries of wards in the same area. These two maps were superposed to each other and a single map was produced indicating both characteristics. The data on live births is obtained from the Provincial Governorate based on the official registries within the same period. The population of wards is obtained from the State Institute of Statistics based on 1985 Census. Consequently, rather unique information has been gathered for the first time for any urban conurbation in Turkey, i.e., Ankara metropolitan region. The data has been disaggregated at the ward (mahalle), the neighborhood (semt) and the district (ilce) level. The IMRs based upon the registry analysis are given below by districts: IMRs In Ankara, 1989 The above table reveals, for the first time, the IMR values at the district level in an urban settlement which indicates rather interesting resul tes: the IMR changes radically amongst the districts of the same metropolitan area. Çankaya and Keçiören represents the best and the worst cases whereas the rate is almost more than twice. The remaining three districts have rather close values. The same pattern also prevails for perinatal and neonatal deaths. As far as the post-neonatal deaths are concerned the relative superiority of Çankaya becomes more obvious. 143The study declined to provide a prototype health system on purpose. Instead, the overriding principles and objectives are developed to shed the light on how to get re-organised. The proposed approach is management oriented and three objectives are determined: to increase the organizational effectiveness, to increase the managemental efficiency and to develop resource management and planning capacity. Organisational re-structuring should be based on the idea of functionality and the determination of optimum area sizes of health services through cost-benefit analysis. However multi- sectoral characteristics of health services and the importance of primary health care services vis-a-vis secondary services should always bare priority. Managemental development should base on the idea of management-by-objectives and accountable management understanding. Complementary job descriptions, workload and workforce analysis and training manuals should be made available. Additionally, financial management capacity based on cost centers and management accounts should be further utilized. Finally, appropriate resource management and planning techniques should be established. 148As far as the educational status of the family is concerned, it is found that mothers educational status is extremely important. The higher the level of the educational status of the women the lower the IMR. in terms of economical characteristics, the study has proven that the IMR is relatively higher amongst the house-wife type mothers. The IMR is also higher if father's occupation is self-employed. The IMR is a direct result of income level. Although the ratio of families having less than 500.000 TL/month is 15 per cent, the ratio of infant mortality in these families is 43 per cent. The IMR is also related to the house expenses such as monthly rents and house utility. The higher the level of these expenses the lower the rate of the IMR. The same is also true för the type of the families' social security systems. Among the possible three alternatives the worst is determined to be the blue-collars' social security system of SSK comparing to the white-collars' and self-employeds' systems. As far as the characteristics of the shelter in which the baby has died are concerned, it is determined that 68 per cent of the deaths occurred in the houses which could be described as gecekondu (illegally and unpermittedly built houses). Parallelly, the description of the surrounding spatial environment has been predominantly (56 %) gecekondu type of buildings. it is also calculated through the aerial photographs that only 38 per cent of inhabitants is living in these areas. in terms of house-hold utilities it is measured that the families living in centrally heated buildings have smaller chances of infant mortality compared to the houses heated by stove. Although, 14 per cent of dwellings do not have any sewage system no relation has been found between these parameters. However, certain relation has been detected between the presence of toilet in the shelter and the IMR. in terms of environmental pollution and nuisances, the interviewees complaining about water pollution was 18 per cent, air pollution was 93 per cent, indicating and insisting on domestic heating originated air pollution, domestic solid waste problem was 20 per cent, industrial solid waste problem was 7 per cent, and noise was 12 per cent. The last sub-system of health environment has revealed also rather important findings. The ratio of breast-feeding mothers was considerably less than the national urban average. Similarly the ratio of immunized babies is virtually non-existant among the interviewees.As a result of the above summarized findings the risk groups and factors are identified as follows: *spatial and physical development of the area in which the family is residing *the parents whose birth place are not Ankara *mothers less than 20 years old *fathers less than 30 years old *couples whose marriage age is less than 25 *families living less than five years in Ankara *in-laws marriages *educational status of parents (especially mothers) *father's employment type and status *level of family income *the quality of the house in which the family is living *type of family's social security system *the availability of household utilities *environmental pollution and nuisances *the sex of the infant *life span of the infant *infants not breast-fed '* low level of immunization *the type of illness affecting the baby As an overall judgement it could be stated that the infant mortality risk relatively and provenly higher in the families who are in the process, and, especially at the beginning of urbanization, för the younger parents to-be, för the families whose marriage age and residence in Ankara is less than 5 years, in smaller families,for the mothers experiencing infant mortality previously, for the mothers having lower level educational status, in non-white collar type of father employment cases, in low income families, in less quality houses, if the shelter does not have seperate kitchen, bath and toilet, in families living in the under-developed segments of the metropolitan area, in families belonging to the SSK social security system, where the environmental pollution and nuisances are wide-spread, for the infants who has not been immunized and for the infants who are not breast-fed. in Turkey, there are two types of public administration responsible for health services delivery systems: tnunicipalities and the field branch of the Ministry of Health under the management of the director and the coordination of the governor ör sub-governor,Hovrever, the division of responsibilities, powers and financial resources between the local government and the central governraent has not yet been effectively institutionalized. Systemmic deficiencies are dominant and, although the Alma Ata based UN Resolution for Health For Ali By 2000 and the Primary Health Çare approach have been accepted, lots have göt to be done in order to develop efficient and effective health service delivery system. Some rural successes have been obtained after the introduction of health socialization programmes. Unfortunately, such a similar system has not yet been tailored for urban areas although the majority of the population now lives in urban settlements. The above mentioned institutionally under-developed structure causes caotic conditions for the supply and demand mechanism of health services. The main reasons are: lack of information and data, insufficiency in research, insufficient planning endeavours, lack of performance objectives, inefficiencies in decision making procedures, limited availability of coordination, cooperation and communication, non-utilisation of data automation, lack of strategies, contradicting approaches, non- comprehensive approaches, insufficient registry and referral systems, insufficiency in managemetal abililities, lack of control and lack of performance monitoring and evaluation. Under these conditions it is quite obvious that any better performance in health system is virtually non-expectable. Consequently, an overhaul and re-structuring are indeed needed in the urban health services. Such an objective requires the development of an efficient planning mechanism based on dependable data and reliable indicators. in order to develop an indicator for health services delivery system an attempt has been made for the creation of the infants environmental quality indicator (IEQI). The IEQI is based upon the utility measurement technique and the analysis of the following critical quality parameters: IMR, deaths related to diarrhoea, tuberculosis, malnutrition, pneumonia, menengitis and tetanus. The data has been gathered at the district level and a subjective vreighing has been carried out. Then, a utility curve has been designed for critical elements indicating a utility value for the obtained data. Consequently, IEQIs are achieved at the district level pointing out that Çankaya is the best and Keçiören is the worst. However, the degree of relative superirority among the remaining three districts became more visible: Yenimahalle, Mamak and Altındağ in order.The study declined to provide a prototype health system on purpose. Instead, the overriding principles and objectives are developed to shed the light on how to get re-organised. The proposed approach is management oriented and three objectives are determined: to increase the organizational effectiveness, to increase the managemental efficiency and to develop resource management and planning capacity. Organisational re-structuring should be based on the idea of functionality and the determination of optimum area sizes of health services through cost-benefit analysis. However multi- sectoral characteristics of health services and the importance of primary health care services vis-a-vis secondary services should always bare priority. Managemental development should base on the idea of management-by-objectives and accountable management understanding. Complementary job descriptions, workload and workforce analysis and training manuals should be made available. Additionally, financial management capacity based on cost centers and management accounts should be further utilized. Finally, appropriate resource management and planning techniques should be established. 148
