Latest information on the state of the world’s health released by WHO

In mid-May, WHO released World Health Statistics 2018: Monitoring health for the SDGs  (WHS2018). This WHO flagship publication compiles data from the organization’s 194 Member States on 36 health-related Sustainable Development Goals (SDG) indicators, providing a snapshot of both gains and threats to the health of the world’s people. While the quality of health data has improved significantly in recent years, many countries still do not routinely collect high-quality data to monitor more than 50 health-related SDG indicators. Nine of the SDG health indicators reported in the WHS2018 are mortality indicators drawn from the latest update of the WHO Global Health Estimates released in April this year.

This update of estimates of death by cause, age and sex for years 2000 to 2016 for 187 countries and for 236 causes and cause groups is available at www.who.int/evidence/bod.  Finalizing this update was a major focus of my work during my last months at WHO before retirement, and indeed, I continued to do some work after retirement to finalize numbers and documentation. So the 2018 World Health Statistics will be the last to which I have made substantial contributions. I have to recognize the huge efforts by my former team to produce and publish this report, in particular Annet Mahanani who was the overall project manager and editor, and Gretchen Stevens who played an important role both in the update of the Global Health Estimates and in the preparation of material and text for the WHS2018.

Since 2016 the World Health Statistics series has served as WHO’s annual report on the health-related Sustainable Development Goals (SDGs) and the 2018 report includes a section summarizing the current status of the health SDGs.

Making sense of the often complex available data on health indicators can be highly challenging. Health data derived from health information systems, including health-facility records, surveys or vital statistics, may not be representative of the entire population of a country and in some cases may not even be accurate. Comparisons between populations or over time can also be complicated by differences in data definitions and/or measurement methods. Although some countries may have multiple sources of data for the same year, it is more usual for data not to be available for every population or year. For example, measurement frequency for data collected through household surveys is typically every 3–5 years. This means that the years for which data are available differ by country. To overcome these and other issues and allow for comparisons to be made across countries and over time, WHO and collaborators have developed mathematical and statistical models with the aim of producing unbiased estimates that are representative and comparable.

As well as reporting on SDG health indicators, the WHS2018 includes several stories focusing on particular topics. One of these is the coverage of essential health services (which was discussed in an earlier blog entry on Universal Health Coverage) and a story on the rising tide of obesity in the young.

The world has seen a more than ten-fold increase in the number of obese children and adolescents aged 5¬19 years in the past four decades ¬ from just 11 million in 1975 to 124 million in 2016. An additional 213 million were overweight in 2016 but fell below the threshold for obesity. Taken together this means that in 2016 almost 340 million children and adolescents aged 5-19 years – or almost one in every five (18.4%) – were overweight or obese globally.

Analysis of these trends has shown that although population growth has played a role in the increase in numbers of obese children and adolescents, the primary driver has been an increase in the prevalence of obesity. Globally, the prevalence of obesity among children and adolescents aged 5-19 years increased from 0.8% in 1975 to 6.8% in 2016. Although high-income countries continue to have the highest prevalence, the rate at which obesity among children and adolescents aged 5-19 years is increasing is much faster in LMIC (see the following figure).

One of the six core functions of WHO is monitoring of the health situation, trends and determinants in the world. Over the years that I have worked for WHO (2000-2018) it has cooperated closely with other UN partner agencies like UNICEF, UNAIDS, UNFPA and the UN Population Division to collect and compile global health statistics. There are a number of established UN multi-agency expert group mechanisms for  cross cutting topics such as child mortality (the UN-IGME including UNICEF/WHO/UN Population Division/World Bank), and specific diseases such as HIV/AIDS (UNAIDS Reference Group), maternal mortality (MMEIG including WHO/UNICEF/UNFPA/World Bank), tuberculosis (WHO STAG), malaria (Malaria Reference Group and Roll Back Malaria- Malaria Monitoring and Evaluation Reference Group). Additionally, WHO collaborates with a network of academics (MCEE) to estimate child causes of death. This collaboration succeeds the former Child Health Epidemiology Reference Group (CHERG) of WHO and UNICEF.

Something that has been immensely satisfying to me over the last two decades is the efforts from all the UN agencies involved in health statistics, as well as the World Bank, and some academic collaborators, to work towards consistent and coherent health statistics used by all the UN agencies and based in a common demographic statistical framework of births, population numbers and deaths prepared by the UN Population Division in their biennial World Population Prospects datasets. When I started working for WHO in 2000, the UN Population Division, the World Bank, UNICEF and WHO all independently produced statistics for child mortality which were not entirely consistent. This was just one example of the lack of coherence across agencies, which has been drastically reduced during the time I have been involved with UN statistics.

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Disease Control Priorities, Edition 3

The third edition of Disease Control Priorities was launched by the WHO Director General, Dr Tedros Adhanom, in London earlier this month. These nine volumes provide up-to-date evidence on priorities that countries should consider in order to reach Universal Health Coverage. The 9th and last volume includes a chapter from my team that summarizes global and regional patterns of causes of death for 2015 and trends for 2000–15 (chapter-deaths-cause-2000-and-2015). Further information available on the DCP3 website at http://dcp-3.org/

Launch of the DCP3 nine volumes in London on 6th December. At this end of the front row is Dr Ala Alwan, former WHO Regional Director for the Eastern Mediterranean Region and next to him is the new Director General of WHO, Dr Tedros Adhanom.

The chapter colleagues and I contributed to Volume 9 summarizes global and regional patterns of causes of death for 2015 and trends for 2000–15 using the 2015 Global Health Estimates (GHE 2015) released by WHO in early 2017. This period marks the end point for the Millennium Development Goals (MDG) and the starting point for the Sustainable Development Goals (SDGs) for the year 2030. This chapter documents major changes during the MDG era. Progress toward the MDGs, on the whole, has been remarkable, including, for instance, poverty reduction, improved education, and increased access to safe drinking water. Progress on the three health goals and targets has also been considerable. Globally, the HIV/AIDS, tuberculosis, and malaria epidemics have been “turned around,” and child mortality and maternal mortality have decreased greatly (53 percent and 44 percent, respectively, since 1990), despite falling short of the MDG targets. Large reductions in mortality have occurred in Sub-Saharan Africa since the early 2000s, coinciding with increased coverage of HIV/AIDS treatment, methods of malaria control, and scale-up of vaccination coverage. Despite this progress, major challenges remain in achieving further progress on child and maternal mortality and on infectious diseases such as HIV/AIDS, tuberculosis, malaria, neglected tropical diseases, and hepatitis.

The rate of increase in life expectancy in LICs over the past 15 years has exceeded the rate of growth observed for life expectancy in the countries with the highest life expectancies. Longer life expectancies and population aging have resulted in an increased focus on NCDs and their risk factors in LMICs and in HICs. Three-quarters of NCD-related deaths occurred in LMICs in 2015.

The SDGs expand the focus of health targets from the unfinished Millennium Development Goals (MDG) agenda for child and maternal mortality and priority infectious diseases to a broader agenda including noncommunicable diseases (NCDs), injuries, health emergencies, and health risk factors as well as a strong focus on universal health care. The GHE 2015 estimates of trends and levels of mortality by cause will contribute to WHO and UN monitoring and reporting of progress toward the SDG health goals and targets.

Overall, the nine volumes identify 21 essential packages of health interventions across five delivery platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines essential universal health coverage in terms of 218 cost-effective interventions that provides a starting point for country-specific analysis of priorities. In the Foreword to Volume 9, Bill and Melinda Gates describe DCP3 as innovately addressing the different needs of countries at different stages in the development of their health systems. DCP3 maps out pathways—essential packages of related, cost-effective interventions—that countries can follow to accelerate progress toward universal health coverage.

Dean Jamison

The Disease Control Priorities projects provide fitting book-ends to my career in international health statistics.  The first Disease Control Priorities project stimulated the original Global Burden of Disease Study for the year 1990 at a time when I was just getting involved in the international work on healthy life expectancy and summary measures of population health. I was experimenting with a form of disability-adjusted life years when the World Development Report 1993, edited by Dean Jamison, published the first global and regional DALY results. I applied the DALY and burden of disease methodology to Australian data to produce the first Australian Burden of Disease study in 1996 and a few years later moved to the World Health Organization to work on updating the Global Burden of Disease Study  with Chris Murray and Alan Lopez.  I joined Dean Jamison, Alan Lopez, Chris Murray and Majid Ezzati in producing the second volume of the Disease Control Priorities (Edition 2): Global Burden of Disease and Risk Factors in 2006.  And now with the third edition, I have contributed another chapter on the latest WHO assessment of global and regional causes of death in 2015, the end of the MDG period and the start of the SDG period.

The nine volumes of DCP3

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Universal health coverage

A WHO report monitoring progress towards Universal Health Coverage (UHC) was released yesterday. It reports the proportion of the population that can access essential health services, and the proportion that are pushed into poverty by healthcare expenses, for 183 countries. Staff of my unit were responsible for the service coverage measurement, and estimated that at least half the world’s population do not have full coverage of essential services. The report is available at http://www.who.int/healthinfo/universal_health_coverage/en/

The report uses 16 essential health services as indicators of the level and equity of coverage in countries. More details on the service coverage index have been published simultaneously in the Lancet Global Health:

http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30472-2/fulltext

Currently, 800 million people spend at least 10 percent of their household budgets on health expenses for themselves, a sick child or other family member. For almost 100 million people these expenses are high enough to push them into extreme poverty, forcing them to survive on just $1.90 or less a day.

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Child mortality continues to decline, but large disparities remain

The United Nations Inter-agency Group for Child Mortality Estimation (UN-IGME) released new data last week showing that the world has made substantial progress in reducing child mortality in the last several decades. The total number of child deaths has dropped to 5.6 million in 2016 from 12.6 million in 1990. Under-five mortality rates per 1,000 live births have dropped by 56% between 1990 and 2016. If all countries achieved the average mortality of high-income countries, 87 per cent of under-five deaths could have been averted and almost 5 million lives could have been saved in 2016. The report and country-level data are available at www.childmortality.org

At current trends, 60 million children will die before their fifth birthday between 2017 and 2030, half of them newborns, according to the report released by UNICEF, the World Health Organization, the World Bank and the Population Division of UNDESA which make up the Inter-agency Group for Child Mortality Estimation (IGME).

Most newborn deaths occurred in two regions: Southern Asia (39 per cent) and sub-Saharan Africa (38 per cent). Five countries accounted for half of all new-born deaths: India (24 per cent), Pakistan (10 per cent), Nigeria (9 per cent), the Democratic Republic of the Congo (4 per cent) and Ethiopia (3 per cent).

                                                                                                                 Source: UN-IGME 2017 report

The report notes that many lives can be saved if global inequalities are  reduced. If all countries achieved the average mortality of high-income countries, 87 per cent of under-five deaths could have been averted and almost 5 million lives could have been saved in 2016.

                                                                                          Source: UN-IGME 2017 report

The United Nations Inter-agency Group for Child Mortality Estimation or UN IGME was formed in 2004 to share data on child mortality, harmonize estimates within the UN system, improve methods for child mortality estimation report on progress towards child survival goals and enhance country capacity to produce timely and properly assessed estimates of child mortality. At that time, the UN Population Division, WHO and UNICEF were all producing their own estimates of child mortality, and I was instrumental in bringing UNICEF and WHO together to share data, information and to harmonize statistics.

Some years later, the Bill and Melinda Gates Foundation funded the Institute for Health Metrics and Evaluation (IHME) at the University of Washington in Seattle, and they started to release independent estimates of child mortality. This stimulated methods improvements in both UN IGME and IHME, as well as closer examination of available data and assumptions.  While initial IHME estimates of child mortality published in 2007 concluded that child mortality was declining faster than assessed by UN-IGME (Lancet 2007, estimates from both groups have tended to converge in subsequent revisions, until this year.

According to the Global Burden of Disease (GBD) 2016 update, published in September this year (Lancet 2017 ), IHME’s most recently published estimate of child mortality for the year 2016 is just under 5 million, 642,000 deaths lower than the UN-IGME estimate.  This is a dramatic change in their assessment of global child mortality.  What is the reason for the change?

HME GBD 2016 and UN IGME estimates of the global under-five mortality rate in 2016 are actually quite similar at 38.4 deaths per 1000 live births and 40.8 respectively, as are most country estimates. The main reason in the discrepancies in the number of deaths is that different sets of estimates of live births are used by the UN IGME and IHME. UN IGME used the live birth estimates from the UN Population Division (UNPD), while IHME used its own live birth estimates. In the IHME estimates there were 128.8 million live births in 2016, 12.2 million lower than the 141 million estimated by UNPD. Previously they had also used the UNPD birth estimates, but starting from this round they have developed their own estimates.  The consequence is that the IHME number of deaths in this round (5 million) is much lower than its last round estimate. Last year IHME estimated 5.8 million under-five deaths in 2015, which is very close to the UN IGME estimate of 5.9 million.

UN IGME estimates of under-five and neonatal deaths are based on UN IGME mortality rates and UNPD estimates of the annual number of live births in each country from the World Population Prospects: the 2017 revision.  UNPD estimates of live births (like UN IGME estimates of under-five mortality) are based on a comprehensive analysis of the population dynamics and fertility levels and trends in each country taking into account all sources of data available (https://esa.un.org/unpd/wpp/DataSources/).

IHME relies on UNPD estimates of female population and age pattern of fertility for each country, but IHME estimates lower fertility levels and trends for many countries. While the information published by IHME is insufficient to fully understand all the differences, a cursory comparison suggests that about 85% of the differences in the number of live births estimates by IHME is concentrated in 25 countries (mostly in Asia and Africa) with nearly half in China and India. IHME estimates there were 11.2 million births in China in 2016, 44% lower than the 16.9 million estimated by the UN Population Division, which is quite similar to the number reported by the national Burea of Statistics of China.

Despite a very large reduction in estimated numbers of child deaths, IHME has not increased its uncertainty ranges to take into account the additional uncertainty in estimates of births.  The uncertainty range for the most recent estimate (4.8-5.2 million) is similar width to the previous IHME estimate (5.7 -6.0 million) despite the fact that there is a very substantial non-overlap between these successive revisions.

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Tenfold increase in childhood and adolescent obesity in four decades

The number of obese children and adolescents (aged five to 19 years) worldwide has risen tenfold in the past four decades. If current trends continue, more children and adolescents will be obese than moderately or severely underweight by 2022, according to a new study led by Imperial College London and WHO.

Trends in childhood obesity and underweight. Source: The Lancet

The paper is available at

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32129-3/fulltext#sec1

More than 1000 contributors participated in the study, which looked at body mass index (BMI) and how obesity has changed worldwide from 1975 to 2016. The study analysed weight and height measurements from nearly 130 million people aged over five years.  It provides a complete picture of trends in mean BMI and prevalence of BMI categories that cover the underweight to obese range among children and adolescents aged 5–19 years, for all countries in the world with the longest observation period, and compares trends with those of adults.

Obesity rates in the world’s children and adolescents increased from less than 1% (equivalent to five million girls and six million boys) in 1975 to nearly 6% in girls (50 million) and nearly 8% in boys (74 million) in 2016. Combined, the number of obese five to 19 year olds rose more than tenfold globally, from 11 million in 1975 to 124 million in 2016. An additional 213 million were overweight in 2016 but fell below the threshold for obesity.

Children and adolescents have rapidly transitioned from mostly underweight to mostly overweight in many middle-income countries, including in East Asia, Latin America and the Caribbean. More recently, overweight and obesity levels have plateaued in higher income countries, although obesity levels remain unacceptably high. Among high-income countries, the United States of America had the highest obesity rates for girls and boys.

The number of obese adults increased from 100 million in 1975 (69 million women, 31 million men) to 671 million in 2016 (390 million women, 281 million men). Another 1.3 billion adults were overweight, but fell below the threshold for obesity. Here are maps of adult obesity levels in 2016 from the NCD-Risc website (see link below).

Prevalence of obesity in adult males in 2016. Source: NCD-RisC

Prevalence of obesity in adult females in 2016. Source: NCD-RisC

Detailed results can be explored using dynamic visualisations and downloaded from the NCD-RisC website at

http://www.ncdrisc.org/

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Monitoring trends in causes of death – India and the Million Death Study

The United Nations Sustainable Development Goals for 2030 include around 15 targets for mortality-related indicators.  The “gold” standard method for monitoring mortality and causes of death is a well-functioning civil registration system in which every death certificate has a medically certified cause of death. Unfortunately, in almost all low-income countries, and some middle income ones, death registration systems do not function well enough to produce data for reliable mortality statistics.  The graph below from our 2017 WHO World Health Statistics report (http://www.who.int/gho/publications/world_health_statistics/en/) shows that around half  of deaths worldwide are registered in a national system with medical certification of cause of death. Not all of these deaths are reported to WHO: about 40 % of global deaths are currently reported to the WHO Mortality database, which collects information on registered deaths and their causes from Member States which have them. Even fewer deaths have a meaningful cause of death code (ICD code), with many in some countries coded to ill-defined causes, symptoms, or non-informative immediate causes such as respiratory failure or heart failure.

The main gaps  in terms of reporting to WHO are China and India, who report only data from their sample registration systems. China has very substantially expanded its sample registration system over the last decade and the per cent of deaths registered with cause of death has increased from 9% in 2005 to over 60% in 2015.

India has a death registration system with medically certified cause of death which essentially captures mostly deaths in urban hospitals, a relatively small proportion of the more than 1 million deaths annually in India. Over the last 10 years, the Indian Registrar General has collaborated since 2001 with the Centre for Global Health Research in Toronto, Canada,  headed by Professor Prabhat Jha, to implement the Million Death Study (MDS) to obtain nationally representative data on causes of death in India. The MDS surveys a national sample of 1.3 million homes within the Sample Registration System (SRS), a continuous demographic surveillance system in operation since 1971.

https://en.wikipedia.org/wiki/Million_Death_Study

The MDS uses a modified version of the 2011 WHO verbal autopsy (VA) questionnaire to obtain information on deaths from household members or close associates of people who have died. This questionnaire  uses structured checklist questions about key symptoms and a half-page local language narrative that captures events and their chronology.  Each verbal autopsy is assigned to two of 404 trained physicians, and they classify the underlying cause of death according to the WHO International Classification of Diseases 10th revision (ICD-10) using strict coding guidelines. Differences in diagnosis are reviewed and if agreement is not reached, a senior physician makes the decision (in about 10% of VAs).

Clearly, recall of relevant symptoms may be poor, and some causes of death are much more difficult to distinguish by events and symptoms than others. So VA-based diagnoses tend to have variable and higher uncertainty at the individual level. But in the absence of better data at population level, they do provide useful results for monitoring mortality trends and major causes of death of public health importance.

The Million Deaths Study data are used by my unit at WHO and our academic collaborators as a major input to the estimation of trends and distribution of causes of neonatal, infant and child deaths, as well as the overall age-specific causes of death for India for years 2000-2015, available on the WHO website as part of our Global Health Estimates 2015 (www.who.int/evidence/bod).

Last week, the Lancet published a detailed analysis of the MDS results for trends in cause-specific neonatal and 1–59-month child mortality in India from 2000 to 2015 prepared by Prabhat Jha and the Million Death Study Collaborators (who include myself and our key academic collaborators in preparing the WHO-MCEE  and GHE2015 child cause of death estimates). The paper is available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32162-1/fulltext

The Lancet, 380 (2017) . doi:10.1016/S0140-6736(17)32162-1

Among other findings, the study found that for children aged 1-59 months, mortality rates from pneumonia and diarrhoea have fallen by more than 60%. Improved female literacy rates, schemes paying women to deliver babies in hospitals and an increase in spending on public health by the Indian government have all contributed to the falling death rates. Mortality from vaccine-preventable diseases such as measles and tetanus have also fallen substantially. For babies under 1 month of age, mortality rates have fallen but at a slower rate (3.4% per year) than for the 1-59 month age group (5.9% per month). Mortality rates for prematurity or low birthweight have actually risen.

The U.N.’s Sustainable Development Goals seek to end the preventable deaths of newborns and children under five, with countries aiming to reduce infant mortality to at least as low as 25 per 1,000 live births by 2030. To meet the 2030 Sustainable Development Goals for child mortality, India will need to maintain the current trajectory of 1–59-month mortality and accelerate declines in neonatal mortality (to >5% annually) from 2015 onwards. Continued progress in reduction of child mortality due to pneumonia, diarrhoea, malaria, and measles at 1–59 months is feasible. Additional attention to prematurity and low birthweight is required.

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Sex and gender in reporting health indicators

I am writing a chapter for a US publication, which has tables of statistics for males and females (which I refer to as “sex”).  The editor contacted me to ask whether I should be calling this “gender”.  This reminded me of a Lancet editorial (December 10, 2016) http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32392-3/abstract which referred to sex and gender as basic variables in clinical scientific research and requires the reporting of “reporting of sex, gender or both where appropriate”.

Sex is defined in the policy explicitly as biological sex with three categories (male, female, intersex). Gender is explicitly defined as “Gender is a constellation of sociocultural processes that interact with and have the potential to influence human biology.”  In other words, gender is not a variable with a definable set of categories, but a complex web of interacting processes modifying a huge array of health and other personal and group outcomes.  The policy provides no guidance on how it may be possible for researchers to report results by gender.

Because of this confusion of a complex web of interacting processes with a categorical reporting variable, most researchers wanting to report on gender simply use the label “gender” for the biological sex variable collected in their data.

I am by no means dismissing the importance of sex and gender as key determinants of health progress. But the many voices calling for reporting of research by “gender” need to realize that gender is indeed a complex constellation of sociocultural processes, not a set of categories.

Population growth is a major issue for sustainable development, global climate change, etc.  High fertility levels drive population growth, particularly in Africa. The biggest factors impeding reductions in fertility levels relate to high levels of child mortality, lack of access to modern contraception, and gender inequality. In turn, a major determinant for reductions in child mortality is the education of mothers.

All of this relates back to gender inequality, and the inability of women in many societies to have full autonomy in areas relating to sex and reproduction.  We are used to thinking of this as an issue in Africa and the Middle East, associated with premodern cultural and religious traditions, and the Taliban and IS are extreme manifestations of these attitudes.  But similar attitudes exist and are growing in parts of the developed world.  The US right-wing war on women is the obvious example.  Along with strenuous efforts to block access to safe abortion, there are now growing efforts to block access to contraception.  It is very clear that this is not about moral views on the personhood of embryos, it is really about making sexual behavior highly risky as part of the efforts to control the sexuality of women.

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