Editor — In 1990, Bosnia and Herzegovina enjoyed the economy, health status and health care of a middle-income country. The war from 1992 to 1995 left the country's resources devastated and, from a population of 4.5 million, an estimated 250 000 people (including 16 000 children) are believed to have died in the conflict or are missing (1). Health services, especially those supporting women and children, were severely disrupted, with over 35% of facilities destroyed or heavily damaged. To assess the impact of the conflict on the health status of women and children, we compared the following traditional indicators with information from the previous decade.

Data on women of reproductive age (15–49 years) and children (0–15 years) in Bosnia and Herzegovina were collected from two main sources: routine official reporting systems and a nationally representative survey of households, women and children carried out in mid-2000 (2). Numerator data from the official reporting systems were extracted for the year 1991 and the most recent year for which complete information was available. Denominator data were available from the 1991 census; best available state estimates were used for the most recent year.

The national survey covered 10 772 households, with a response rate of >98%; it was carried out using standardized United Nations Children's Fund (UNICEF) methodology, described elsewhere (3). The results suggest that the health of women and children in Bosnia and Herzegovina has not worsened in the last decade — in fact several indicators, including infant mortality rate and maternal mortality ratio, show improvement. These findings are extremely surprising, given four years of war and its consequences. Although the second half of the decade has seen rebuilding of essential services, the economic situation and health and other services remain far below pre-war standards (1).

Underlying factors suggest that the data quality may be poor. Official data collection systems are under considerable pressure and there is little systematic effort to assess or improve data quality. The unclarity is compounded by significant concerns about the denominator population data used to calculate rates, with uncertainty surrounding true figures for deaths and refugee and migrant populations. Despite being widely used, we also question the appropriateness of relying solely on traditional indicators such as infant and maternal mortality rates to assess the impact of the war — selective primary care can improve these indicators even when the general health status of the population deteriorates (4). The limitations of relying on such indicators, tested under "developing country paradigms", in responding to complex emergencies in more-developed countries has already been highlighted (5).

If our results indeed reflect a true stability in the health of this population, possible explanations include a good pre-war health status, resilience of the socialist primary health care, education and other basic systems that continued to function, and significant levels of external aid for postwar reconstruction (US$ 5.1 billion during the period 1995– 99) (1).

These results are important because they suggest the possibility that good primary health care systems and adequate, targeted external assistance can protect the health of vulnerable populations such as women and children against the adverse effects of war. However, credence cannot be given to these claims as it may take many years for the impact of a conflict to be visible in traditional indicators, or it may be masked by an overall deterioration in the data collection systems. More research is needed to produce indicators that can adequately evaluate population health status, the resilience of local communities, and the protective effects of humanitarian assistance in conflict situations. This is especially relevant as these indicators routinely form the basis for international assistance.

Sanjay Kinra,¹ Mary E. Black,² Sanja Mandic,² & Nora Selimovic³

Conflicts of interest: none declared.

1. Independent Bureau for Humanitarian Issues. Human development report: Bosnia and Herzegovina 1998. Sarajevo: United Nations Development Programme; 1999.

2. United Nations Children's Fund Bosnia and Herzegovina. Bosnia and Herzegovina multiple indicator cluster survey 2000. Sarajevo: United Nations Children's Fund; 2001 (in press).

3. Division of Evaluation, Policy and Planning. End-decade multiple indicator survey manual. New York: United Nations Children's Fund; 2000.

4. Ugalde A, Selva-Sutter E, Castillo C, Paz C, Canas S. Conflict and health. The health costs of war: can they be measured? Lessons from El Salvador. BMJ 2000;321:169-72.

5. Spiegel PB, Salama P. Emergencies in developed countries: are aid organisations ready to adapt? The Lancet 2001;357:714.

¹ Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, England (email: Sanjay.Kinra@bristol.ac.uk). Correspondence should be addressed to this author.

² UNICEF, Sarajevo, Bosnia and Herzegovina.

³ Agency for Statistics, Sarajevo, Bosnia and Herzegovina.