3.3 Premature mortality - focusing on would have been due to infectious diseases. malnutrition deaths among those under 70 years of and child and maternal mortality(the MDG causes),with age further 5 million and o9 million due to ncds and i espectively. Fig. 3.6 shows the regional and global rates Also warranting consideration is a proposal for a measure of premature deaths(under 70 years of age) per 1000 of premature mortality with a target of reducing the number population in 2015, together with estimates of the deaths of deaths before age 70 by 40% by 2030 globally and that would have been averted by achievement of the in every country Numbers of deaths before age 70 is a Sdg mortality targets in 2015. It is worth noting that the more readily measurable indicator than life expectancy, achievement of Sdg mortality targets dramatically narrows and can decrease more rapidly than life expectancy can regional variations in the premature death rate increase as it is more sensitive to interventions. Countries at different stages of development could, depending on their epidemiological priorities, achieve this kind of gain by 3.4 Data gaps- most deaths not registered bringing down mortality due to HIv, malaria, tuberculosi or child mortality or to ncd deaths between ages 30 and As noted, many countries still lack adequate death 70. Concerted action to reduce nod deaths before age registration capacity. An estimated 53% of deaths go 70 would also reduce NCD death rates for people age 70 unregistered worldwide, and progress in improving and over death registration in developing countries has been slow. Nevertheless. a number of countries have made The impact of attaining the sdg health-related considerable progress in recent years, with notable on numbers of deaths under age 70 can be approxi examples including Brazil, China, the Islamic Republic of by applying the sdg target impact on mortality rates to Iran, South Africa and turkey. there are also indications provisional estimates of deaths in 2015 by cause, age and of a new momentum to improve civil registration and vital sex. There were an estimated 30 million deaths under statistics(CRVS) systems, backed by significant political age 70 in 2015, and if the SDg mortality targets had interest in Asia and africa and supported by global and been achieved in 2015, this would have been reduced regional agencies. One of the two indicators for SDG Target to 19 million deaths. This represents a 36% reduction 17.19: " By 2030, build on existing initiatives to develop (almost 11 million averted premature deaths)-close to the measurements of progress on sustainable development roposed 40% target Of these averted deaths, 5 million that complement gross domestic product, and support statistical capacity-building in developing countries"is the ional and global premature deaths and deaths that would have been averted by proportion of countries that have: (a) conducted at least achievement of SDG mortality targets, 2015 one population and housing census in the last 10 years Remaining deaths MDG prevented NCD prevented Injury prevented and(b)have achieved 100% birth registration and 80% For countries with inadequate death-registration capacity, mortality data from the population census and household surveys are used to obtain mortality estimates. A substantial amount of survey information is available for mortality for children aged under 5 years, usually based on the collection of birth histories, while adult mortality levels can be estimated from census and survey data on deaths in households, orphanhood and sibling survival histories However, there are considerable probl assessing the AFR AMR SEAR EUR EMR WPR Global reporting completeness and biases of such data, and the availability of consistent data sources over time is an issue for many countries. Information on older child and older age ends to help quantify the UN Sustainable Development Goal for health. Lancet. mortality is also less often available from survey sources Model life tables and other statistical models are used to 73670281492961591-9/fulltext, accessed 9 Apnl 2016 2 Provisional estimates based ause mortality from WHO life tables for 2015 ll data gaps( Table 3.2) istration data reported to WHO; and analyses from the ancer, diabetes, cardiovascular disease and chronic respiratory disease; 50% actions are conservative and do not include the mortality pacts of suicide, pollution and drug and alcohol targets(beyond their contribution to the NCD mortality target). WORLD HEALTH STATISTS: 2016
12 WORLD HEALTH STATISTICS: 2016 3.3 Premature mortality – focusing on deaths among those under 70 years of age Also warranting consideration is a proposal for a measure of premature mortality with a target of reducing the number of deaths before age 70 by 40% by 2030 globally and in every country.1 Numbers of deaths before age 70 is a more readily measurable indicator than life expectancy, and can decrease more rapidly than life expectancy can increase as it is more sensitive to interventions. Countries at different stages of development could, depending on their epidemiological priorities, achieve this kind of gain by bringing down mortality due to HIV, malaria, tuberculosis or child mortality, or to NCD deaths between ages 30 and 70. Concerted action to reduce NCD deaths before age 70 would also reduce NCD death rates for people age 70 and over. The impact of attaining the SDG health-related targets on numbers of deaths under age 70 can be approximated by applying the SDG target impact on mortality rates to provisional estimates of deaths in 2015 by cause, age and sex.2 There were an estimated 30 million deaths under age 70 in 2015, and if the SDG mortality targets had been achieved in 2015,3 this would have been reduced to 19 million deaths. This represents a 36% reduction (almost 11 million averted premature deaths) – close to the proposed 40% target. Of these averted deaths, 5 million 1 Norheim OF, Jha P, Admasu K, Godal T, Hum RJ, Kruk ME et al. Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health. Lancet. 2015;385(9964):239–52 (http://www.thelancet.com/journals/lancet/article/PIIS0140- 6736%2814%2961591-9/fulltext, accessed 9 April 2016). 2 Provisional estimates based on all-cause mortality from WHO life tables for 2015; WHO estimates for MDG causes, cancers, child causes of death, road injury, homicide, disasters and conflict; death-registration data reported to WHO; and analyses from the Global Burden of Disease 2013 study. 3 Targets for maternal mortality ratio, neonatal and under-five mortality rates; 90% reduction in HIV, TB, malaria and NTD death rates, one third reduction in hepatitis, cancer, diabetes, cardiovascular disease and chronic respiratory disease; 50% reduction in road injury deaths; 50% reduction in diarrhoea deaths (through achievement of WASH target); and one third reductions (arbitrary interpretation of the SDG target of substantial reduction) in deaths due to homicide, conflict and disasters. These estimated mortality reductions are conservative and do not include the mortality impacts of suicide, pollution and drug and alcohol targets (beyond their contribution to the NCD mortality target). would have been due to infectious diseases, malnutrition, and child and maternal mortality (the MDG causes), with a further 5 million and 0.9 million due to NCDs and injuries respectively. Fig. 3.6 shows the regional and global rates of premature deaths (under 70 years of age) per 1000 population in 2015, together with estimates of the deaths that would have been averted by achievement of the SDG mortality targets in 2015. It is worth noting that the achievement of SDG mortality targets dramatically narrows regional variations in the premature death rate. 3.4 Data gaps – most deaths not registered As noted, many countries still lack adequate deathregistration capacity. An estimated 53% of deaths go unregistered worldwide, and progress in improving death registration in developing countries has been slow. Nevertheless, a number of countries have made considerable progress in recent years, with notable examples including Brazil, China, the Islamic Republic of Iran, South Africa and Turkey. There are also indications of a new momentum to improve civil registration and vital statistics (CRVS) systems, backed by significant political interest in Asia and Africa and supported by global and regional agencies. One of the two indicators for SDG Target 17.19: “By 2030, build on existing initiatives to develop measurements of progress on sustainable development that complement gross domestic product, and support statistical capacity-building in developing countries” is the proportion of countries that have: (a) conducted at least one population and housing census in the last 10 years; and (b) have achieved 100% birth registration and 80% death registration. For countries with inadequate death-registration capacity, mortality data from the population census and household surveys are used to obtain mortality estimates. A substantial amount of survey information is available for mortality for children aged under 5 years, usually based on the collection of birth histories,4 while adult mortality levels can be estimated from census and survey data on deaths in households, orphanhood and sibling survival histories. However, there are considerable problems in assessing the reporting completeness and biases of such data, and the availability of consistent data sources over time is an issue for many countries. Information on older child and older age mortality is also less often available from survey sources. Model life tables and other statistical models are used to fill data gaps (Table 3.2). 4 Levels & Trends in Child Mortality: Report 2015. UNICEF, WHO, the World Bank, United Nations Population Division. New York: UNICEF on behalf of the UN Inter-agency Group for Child Mortality Estimation; 2015 (http://www.childmortality.org/files_v20/download/ IGME%20report%202015%20child%20mortality%20final.pdf, accessed 9 April 2016). Figure 3.6 Regional and global premature deaths and deaths that would have been averted by achievement of SDG mortality targets, 2015 Remaining deaths MDG prevented NCD prevented Injury prevented 5 3 2 1 4 6 8 7 Deaths under age 70 (per 1000 population) AFR AMR SEAR EUR EMR WPR Global 0
for all-cause mortality Available recent data 2015 Complete death-registration 59 28 Observed death rates registration data Adjusted death rates Other populatio 18(3 Estimated death rates and age-specific mortality and adult (15-59 years) 30(18) timated death rates and mortality only model life table systems I Data on child mortality only 37(22) 10 Model life table systems No recent data Projected from data for years before 2005 Only indudes 183 Member States with population ab b Percentage of global deaths that occur in the countries included in each category -not the percentage registered Numbers in parenthesis show the number of high H prevalence countries for which multistate epidemilogical modelling for HIV mortality was also carried ou MONITORING HEALTH FOR THE SDGs
MONITORING HEALTH FOR THE SDGs 13 Available recent data (since 2005) Number of WHO Member Statesa Percentage of global deaths in 2015 b Methods Complete death-registration datac 59 28 Observed death rates Incomplete deathregistration data 38 25 Adjusted death rates Other populationrepresentative data on age-specific mortalityd 18 (3) 25 Estimated death rates and model life table systems Data on child (under 5 years) and adult (15–59 years) mortality onlyd 30 (18) 12 Estimated death rates and model life table systems Data on child mortality onlyd 37 (22) 10 Model life table systems No recent data 1 <1 Projected from data for years before 2005 Table 3.2 Data availability for all-cause mortality a Only includes 183 Member States with population above 90 000 in 2015. b Percentage of global deaths that occur in the countries included in each category – not the percentage registered or included in datasets. c Completeness of 90% or greater for de facto resident population; as assessed by WHO and the United Nations Population Division, 2016. d Numbers in parenthesis show the number of high HIV prevalence countries for which multistate epidemiological modelling for HIV mortality was also carried out
UNIVERSAL HEALTH COVERAGE-AT THE CENTRE OF THE HEALTH GOAL The main text of the sdg declaration endorsed by heads of reviews, and on consultations and discussions with country government in February 2015 puts UHC at the centre of the representatives, technical experts and global health and overall health goal, and makes progress towards the UHc development partners. The framework focuses on the target a prerequisite for the achievement of all the others. two core components of UHC: coverage of the population Under SDG 3, UHC is also assigned the specific Target with quality, essential health services; and coverage of the 3. 8: " Achieve universal health coverage(UHC), including population with financial protection, the key to which is financial risk protection, access to quality essential health reducing dependence on payment for health services out care services, and access to safe, effective, quality and of-pocket(ooP)at the time of use. The proposed indicators affordable essential medicines and vaccines for all". The goal are a"coverage index "of essential services, disaggregated of UHC (all people and communities receiving the needed by key stratifiers where possible, and a measure of the lack quality services, including health protection, promotion, of financial protection against the costs of health services financial hardship)is relevant to all countries and offers an assess the state of UHC, both nationally and globally o prevention, treatment, rehabilitation and palliation without These two indicators need to be interpreted together to unprecedented opportunity to increase coherence in health related actions and initiatives 4.1 UHC coverage index of essential health Accountability -defined as a cyclical process of monitoring, services-a new summary measure review and remedial action?-will be critically important in ensuring progress towards UHC WHO and the World The proposed SDG indicator for services is a UHC coverage Bank have developed a UHC monitoring framework index of essential health services. While recognizing that based on a series of country case studies and technical countries may have different health priorities, and will develop their own indicators accordingly it is possible to 的s world. the 2030 Agenda for Sustainable Development. Resolution Seventiethsessionagendaitems15and116;paragraph26(http://3WorldHealthOrganizationand ww.un.org/ga/search/view_ doc. asp? symbol=ARES/70/1&Lang=E, accessed 10 April k of the Commission on Information and Accountability fo 10 April out/coia/en/index5. html, accessed 10 April 2016). MONITORING HEALTH FOR THE SDGs
MONITORING HEALTH FOR THE SDGs 15 The main text of the SDG declaration endorsed by heads of government in February 2015 puts UHC at the centre of the overall health goal, and makes progress towards the UHC target a prerequisite for the achievement of all the others.1 Under SDG 3, UHC is also assigned the specific Target 3.8: “Achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all”. The goal of UHC (all people and communities receiving the needed quality services, including health protection, promotion, prevention, treatment, rehabilitation and palliation without financial hardship) is relevant to all countries and offers an unprecedented opportunity to increase coherence in healthrelated actions and initiatives. Accountability – defined as a cyclical process of monitoring, review and remedial action2 – will be critically important in ensuring progress towards UHC. WHO and the World Bank have developed a UHC monitoring framework based on a series of country case studies and technical 1 Transforming our world: the 2030 Agenda for Sustainable Development. Resolution adopted by the General Assembly on 25 September 2015. A/RES/70/1. United Nations General Assembly, Seventieth session, agenda items 15 and 116; paragraph 26 (http:// www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E, accessed 10 April 2016). 2 As per the framework of the Commission on Information and Accountability for Women’s and Children’s Health (http://www.who.int/woman_child_accountability/ about/coia/en/index5.html, accessed 10 April 2016). reviews, and on consultations and discussions with country representatives, technical experts and global health and development partners.3 The framework focuses on the two core components of UHC: coverage of the population with quality, essential health services; and coverage of the population with financial protection, the key to which is reducing dependence on payment for health services outof-pocket (OOP) at the time of use. The proposed indicators are a “coverage index” of essential services, disaggregated by key stratifiers where possible, and a measure of the lack of financial protection against the costs of health services. These two indicators need to be interpreted together to assess the state of UHC, both nationally and globally. 4.1 UHC coverage index of essential health services – a new summary measure The proposed SDG indicator for services is a UHC coverage index of essential health services. While recognizing that countries may have different health priorities, and will develop their own indicators accordingly, it is possible to 3 World Health Organization and World Bank Group. Monitoring progress towards universal health coverage at country and global levels. Framework measures and targets. Geneva: World Health Organization and International Bank for Reconstruction and Development/World Bank; 2014 (http://apps.who.int/iris/ bitstream/10665/112824/1/WHO_HIS_HIA_14.1_eng.pdf?ua=1, accessed 10 April 2016). 4 UNIVERSAL HEALTH COVERAGE – AT THE CENTRE OF THE HEALTH GOAL
identify a set of tracer indicators that can be combined into Table 4.1 an index suitable for the purposes of regional and global Tracer indicators for UHC service coverage, with data availability UHC monitoring. The set of tracer indicators for service coverage was selected following extensive review and discussion of potential indicators These are grouped into four main categories, each with four indicators(Table 4.1) dicator (1)reproductive, maternal, newborn and child health; (2)Reproductive, maternal, newborn and child healt infectious diseases; (3)NCDs; and (4)service capacity and Family planning W,ER, (A access, and health security. Statistics for the tracer indicators coverage are then combined into a UHc service coverage index 2 Antenatal and delivery Surveys W,ER, (A) ull child immunization Surveys, W ER, S The resulting 16 tracer indicators spread across the four Admin ealth-seeking 72 W, E.R. S categories are then used to track health service coverage. All indicators are defined so that they range between 0% pneumonia and 100%, with 100% implying full coverage Data for Infectious diseases Tuberculosis effective Admin these indicators come from a mix of household surveys treatment and administrative data. Ten of the 16 tracer indicators HIV antiretroviral Admin, treatment of health service coverage are supported by recent Surveillance comparable estimates of national coverage. For another four IN coverage for (pregnancy care, care seeking for suspected pneumonia in children, hospital inpatient admission rates and health and adequate sanitation worker density) well-maintained databases of country Noncommunicable diseases data points from either survey or administrative data are valence of raised Surveys (E, (R),S, A vailable, with comprehensive estimates for pregnancy Prevalence of rised surveys (E, (R), SA care expected within the next year. For the remaining two blood glucose indicators(cervical cancer screening and access to essential Cervical cancer edicines)there are currently no comprehensive databases Tobacco (non-use) surveys (), E), R)S(A) or comparable estimates available. As a result, these two Service capacity and access indicators are for now, left out of the calculation of the Basic hospital access Facility data 10 index in this report Access to essential To provide a summary measure of coverage of essential health services, an index of national service coverage i Health security IHR 191 omputed for each country by averaging service-coverage values across the 16 tracer indicators This is performed in a wa househol weath quintle r in educational tainment t a p ue ef residen e typically utane y, two steps: first, computing the average coverage in each of theales实却A的 indicated dimension but that more analytical work is needed to prepare disaggregated estimates. these four category-level scores. Geometric means are used therefore l时如如的如邮m购 the four categories; and second, computing the average of surveys standardized rently a lck consistent data sources to characterize equity for service coverage in many to increase sensitivity to very low coverage levels for any t Only pertains to countries with highly malria. cator an nd to reduce the impact of on the rankings implied by the index. These computations observed in OECD countries. Additionally, as comparable are simple and straightforward. antiretroviral therapy (art) coverage estimates are currently not available for high-income countries, this However, a small but necessary series of adjustments are input is set at the average value of 44% for these countrie made for a few indicators. To obtain greater spread in values country-level estimates of ART coverage for high-income cross countries, the NCD indicators for hypertension, countries are expected in 201 diabetes and tobacco are re-scaled based on minimum values observed across countries. Hospital inpatient The distribution of countries by coverage index in quintiles admission rates and health-worker density values are is presented in Fig. 4. 1. The UHC index values based capped at a threshold, as ov erase a nd oversupply can be national coverage levels show substantial differences across an issue in high-income countries. These two indicators WHO regions. The WHO European Region, WHO Region are capped at 100% once rates reach minimum values of the Americas and Who Western Pacific Region all have more than 30% of their countries in the upper quintile of 1 Boerma T, AbouZahr C, Evans D, Evans T Monitoring int UHC index values globally, whereas the WHO Eastern text of universal health coverage. PLoS Med. 2014; 11: e1001 Mediterranean Region and WHO African Region have no 2 Hogan D, Hosseinpoor AR, Boerma T. Developing an index for the cover countries in the upper quintile. The WHo African Region ealth services. Technical Note. Geneva: World Health Organization accounts for 30 of the 37 countries in the lowest quintile WORLD HEALTH STATISTS: 2016
16 WORLD HEALTH STATISTICS: 2016 identify a set of tracer indicators that can be combined into an index suitable for the purposes of regional and global UHC monitoring. The set of tracer indicators for service coverage was selected following extensive review and discussion of potential indicators.1 These are grouped into four main categories, each with four indicators (Table 4.1): (1) reproductive, maternal, newborn and child health; (2) infectious diseases; (3) NCDs; and (4) service capacity and access, and health security. Statistics for the tracer indicators are then combined into a UHC service coverage index.2 The resulting 16 tracer indicators spread across the four categories are then used to track health service coverage. All indicators are defined so that they range between 0% and 100%, with 100% implying full coverage. Data for these indicators come from a mix of household surveys and administrative data. Ten of the 16 tracer indicators of health service coverage are supported by recent, comparable estimates of national coverage. For another four (pregnancy care, care seeking for suspected pneumonia in children, hospital inpatient admission rates and health worker density) well-maintained databases of country data points from either survey or administrative data are available, with comprehensive estimates for pregnancy care expected within the next year. For the remaining two indicators (cervical cancer screening and access to essential medicines) there are currently no comprehensive databases or comparable estimates available. As a result, these two indicators are, for now, left out of the calculation of the index in this report. To provide a summary measure of coverage of essential health services, an index of national service coverage is computed for each country by averaging service-coverage values across the 16 tracer indicators. This is performed in two steps: first, computing the average coverage in each of the four categories; and second, computing the average of these four category-level scores. Geometric means are used to increase sensitivity to very low coverage levels for any indicator, and to reduce the impact of re-scaling indicators on the rankings implied by the index. These computations are simple and straightforward. However, a small but necessary series of adjustments are made for a few indicators. To obtain greater spread in values across countries, the NCD indicators for hypertension, diabetes and tobacco are re-scaled based on minimum values observed across countries. Hospital inpatient admission rates and health-worker density values are capped at a threshold, as overuse and oversupply can be an issue in high-income countries. These two indicators are capped at 100% once rates reach minimum values 1 Boerma T, AbouZahr C, Evans D, Evans T. Monitoring intervention coverage in the context of universal health coverage. PLoS Med. 2014;11:e1001728. Also see: http:// www.who.int/healthinfo/universal_health_coverage/en/, accessed 25 April 2016. 2 Hogan D, Hosseinpoor AR, Boerma T. Developing an index for the coverage of essential health services. Technical Note. Geneva: World Health Organization; 2016 (http:// www. who.int/healthinfo/universal_health_coverage/en/). observed in OECD countries. Additionally, as comparable antiretroviral therapy (ART) coverage estimates are currently not available for high-income countries, this input is set at the average value of 44% for these countries; country-level estimates of ART coverage for high-income countries are expected in 2017. The distribution of countries by coverage index in quintiles is presented in Fig. 4.1. The UHC index values based on national coverage levels show substantial differences across WHO regions. The WHO European Region, WHO Region of the Americas and WHO Western Pacific Region all have more than 30% of their countries in the upper quintile of UHC index values globally, whereas the WHO Eastern Mediterranean Region and WHO African Region have no countries in the upper quintile. The WHO African Region accounts for 30 of the 37 countries in the lowest quintile. Indicator Data sources Number of countries with national data since 2010 Number of countries with comparable estimates Measurability of key dimensions of inequalitya,b Reproductive, maternal, newborn and child health Family planning coverage Surveys 98 184 W,E,R,(A) Antenatal and delivery care Surveys 121 194 W,E,R,(A) Full child immunization Surveys, Admin 193 194 W,E,R,S Health-seeking behaviour for child pneumonia Surveys 72 None W,E,R,S Infectious diseases Tuberculosis effective treatment Admin 190 190 (R) HIV antiretroviral treatment Admin, Surveys, Surveillance 118 118 (R) ITN coverage for malaria prevention Surveys, Admin 40c 40c W,E,R,S Improved water source and adequate sanitation Surveys 156 192 W,R Noncommunicable diseases Prevalence of raised blood pressure Surveys 86 192 (E),(R),S,A Prevalence of raised blood glucose Surveys 76 192 (E),(R),S,A Cervical cancer screening Surveys <30 None — Tobacco (non-use) Surveys 146 123 (W),(E),(R),S,(A) Service capacity and access Basic hospital access Facility data 105 None (R) Health-worker density Administrative data 166 None (R) Access to essential medicines Facility surveys <30 None (R) Health security: IHR compliance Country reported 191 None — Table 4.1 Tracer indicators for UHC service coverage, with data availability a W = household wealth quintile; E = educational attainment; R = place of residence (typically urban vs. rural); S = sex; and A = age. Letters in parentheses indicate that data sources exist to estimate coverage by the indicated dimension but that more analytical work is needed to prepare disaggregated estimates. b Information to estimate coverage across key inequality dimensions typically comes from population-based surveys. Standardized population-based surveys are typically only conducted in developing countries, and therefore there is currently a lack consistent data sources to characterize equity for service coverage in many high-income countries. c Only pertains to countries with highly endemic malaria