Jan 10, 2015 Volume 385 Number 9963 p89-200 e4
Beyond Ebola: a new agenda for resilient health systems
Marie Paule Kieny, Delanyo Dovlo
A resilient health system is one able to absorb the shock of an emergency like Ebola and at the same time continue to provide regular health services, leaving other sectors of the country fully functioning. In Guinea, Liberia, and Sierra Leone, the 2014 Ebola outbreak has claimed many lives and laid waste to economies, food provision, and development. The World Bank’s forecast1 of tens of billions of dollars lost for the three affected countries and the broader west Africa region points to the interdependence between health and countries’ wider socioeconomic landscape.
Offline: Solving WHO’s “persisting weaknesses” (part 1)
When the 34 members of WHO’s Executive Board gather in Geneva on Jan 25—first, for a special session on the response to the Ebola outbreak and, second, for its 136th meeting—countries will have an unprecedented opportunity to reflect on the future of the world’s only global health agency. Why unprecedented? Because, in WHO’s own words (from documents submitted to the Board and available on WHO’s website), Ebola has put “enormous strain” on the agency’s managerial structures and systems. The outbreak has had a “significant impact” on WHO’s non-Ebola work, with the result that “time-bound projects will be affected”.
Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013
GBD 2013 Mortality and Causes of Death Collaborators
Collaborators listed at the end of the Article
Published Online: 17 December 2014
Up-to-date evidence on levels and trends for age-sex-specific all-cause and cause-specific mortality is essential for the formation of global, regional, and national health policies. In the Global Burden of Disease Study 2013 (GBD 2013) we estimated yearly deaths for 188 countries between 1990, and 2013. We used the results to assess whether there is epidemiological convergence across countries.
We estimated age-sex-specific all-cause mortality using the GBD 2010 methods with some refinements to improve accuracy applied to an updated database of vital registration, survey, and census data. We generally estimated cause of death as in the GBD 2010. Key improvements included the addition of more recent vital registration data for 72 countries, an updated verbal autopsy literature review, two new and detailed data systems for China, and more detail for Mexico, UK, Turkey, and Russia. We improved statistical models for garbage code redistribution. We used six different modelling strategies across the 240 causes; cause of death ensemble modelling (CODEm) was the dominant strategy for causes with sufficient information. Trends for Alzheimer’s disease and other dementias were informed by meta-regression of prevalence studies. For pathogen-specific causes of diarrhoea and lower respiratory infections we used a counterfactual approach. We computed two measures of convergence (inequality) across countries: the average relative difference across all pairs of countries (Gini coefficient) and the average absolute difference across countries. To summarise broad findings, we used multiple decrement life-tables to decompose probabilities of death from birth to exact age 15 years, from exact age 15 years to exact age 50 years, and from exact age 50 years to exact age 75 years, and life expectancy at birth into major causes. For all quantities reported, we computed 95% uncertainty intervals (UIs). We constrained cause-specific fractions within each age-sex-country-year group to sum to all-cause mortality based on draws from the uncertainty distributions.
Global life expectancy for both sexes increased from 65•3 years (UI 65•0–65•6) in 1990, to 71•5 years (UI 71•0–71•9) in 2013, while the number of deaths increased from 47•5 million (UI 46•8–48•2) to 54•9 million (UI 53•6–56•3) over the same interval. Global progress masked variation by age and sex: for children, average absolute differences between countries decreased but relative differences increased. For women aged 25–39 years and older than 75 years and for men aged 20–49 years and 65 years and older, both absolute and relative differences increased. Decomposition of global and regional life expectancy showed the prominent role of reductions in age-standardised death rates for cardiovascular diseases and cancers in high-income regions, and reductions in child deaths from diarrhoea, lower respiratory infections, and neonatal causes in low-income regions. HIV/AIDS reduced life expectancy in southern sub-Saharan Africa. For most communicable causes of death both numbers of deaths and age-standardised death rates fell whereas for most non-communicable causes, demographic shifts have increased numbers of deaths but decreased age-standardised death rates. Global deaths from injury increased by 10•7%, from 4•3 million deaths in 1990 to 4•8 million in 2013; but age-standardised rates declined over the same period by 21%. For some causes of more than 100 000 deaths per year in 2013, age-standardised death rates increased between 1990 and 2013, including HIV/AIDS, pancreatic cancer, atrial fibrillation and flutter, drug use disorders, diabetes, chronic kidney disease, and sickle-cell anaemias. Diarrhoeal diseases, lower respiratory infections, neonatal causes, and malaria are still in the top five causes of death in children younger than 5 years. The most important pathogens are rotavirus for diarrhoea and pneumococcus for lower respiratory infections. Country-specific probabilities of death over three phases of life were substantially varied between and within regions.
For most countries, the general pattern of reductions in age-sex specific mortality has been associated with a progressive shift towards a larger share of the remaining deaths caused by non-communicable disease and injuries. Assessing epidemiological convergence across countries depends on whether an absolute or relative measure of inequality is used. Nevertheless, age-standardised death rates for seven substantial causes are increasing, suggesting the potential for reversals in some countries. Important gaps exist in the empirical data for cause of death estimates for some countries; for example, no national data for India are available for the past decade.
Bill & Melinda Gates Foundation.