health system responsiveness
(ie. what does a health system need to be responsive?)
1) data
2) descriptive statistics
3) measurement tools and surveillance systems
descriptive statistics
mean, median, range, standard deviation of data set, etc.
- prevalence of conditions / risk factors
- incidence of new cases
- outcomes
infant mortality rate
number of deaths of infants (<12 months) per 1,000 live births, measured annually
life expectancy at birth
average number of years a new baby can expect to live if current mortality trends continue
neonatal mortality rate
number of deaths of neonates (<28 days) per 1,000 live births, measured annually
neonate mortality rate statistics
~4 per 1,000 in high-income countries
~40 per 1,000 LMICs
under-5 mortality rate (child mortality rate)
number of deaths of children under 5 per 1,000 live births, measured annually
under-5 mortality rate (child mortality rate) statistics
~3-5 per 1,000 in high-income countries
~200 per 1,000 LMICs
captures deaths among children aged 0-59 months
maternal mortality ratio
measure of the risk of death associated with childbirth
number of women who die each year as a result of pregnancy, labor, delivery, or within 42 days after delivery, per 100,000 women who deliver a live child
2023 maternal mortality ratio data
CA - 4/100,000
MA - 8.4/100,000
LA - 58.1/100,000
global MMR
declined from 341 to 211 / 100,000 deaths between 2000 & 2017
which region has the largest percent reduction of MMR of any region (59%)
South Asia
also - SSA (39%) was large
which region has the highest MMR in the world? (2017)
South Sudan
1,150 / 100,000
why is MMR measured per 100,000 but neonatal morality and under-5 mortality are measured per 1,000?
it's relatively rare compared to child mortality / neonatal mortality rates
produces a more meaningful, less fractional number
fertility rate
number of births per woman
global average fertility rate
~2.3
highest fertility rate? (2024)
Niger
6.6
lowest fertility rate? (2024)
Hong Kong
0.8
morbidity
sickness
mortality
death
mortality rate
annual number of deaths per 100,000 population
disability
long-term or short-term reduction in functional capacity
prevalence
number of people with condition X at any given time
cross-sectional in nature
incidence rate
number of new cases over time per a given population that's at risk
disability-adjusted life year (DALY)
a measure of losses due to illness, disabilities, and premature death
- accounts for loss due to death and disability
- requires data about prevalence and incidence
Mortality + Morbidity
goal of health policy
avert DALYs in the most cost-effective way
health-adjusted life expectancy (HALE)
the number of years one can expect to live in good health
risk factor
an entity (characteristic, environment, behavior, etc.) that is known to be associated with a health issue
health professionals seek to ______ risk factors
minimize
_______ is the lead risk factor for death and disability in high-income countries
Smoking
malnutrition
a leading risk factor worldwide (too much, not enough, not the right kind of nutrition)
categories covered in global burden of disease study (GBD project)
- infections and perinatal and maternal conditions
- NCDs
- injuries and accidents
(grouped into 8 global regions - established market economies)
findings: global burden of disease study
- high premature mortality in impoverished regions
- lack of good data
- NCDs and injuries play a major role (infectious diseases also critical component)
- inequities among regions are enormous
- findings can be very different for mortality versus for DALYs
epidemiologic transition "ages"
1) age of pestilence and famine
2) age of receding pandemics
3) age of degenerative and manmade diseases
4) age of delayed chronic diseases
limitations of the epidemiologic transition model
1) diseases do not occur in a stepwise fashion (in contrast to what the model states)
2) disease burden is diverse in all countries
3) health systems in all countries are needed that can address a variety of health issues
4) treatment often is prevention, so healthcare systems need to be able to provide treatment
cost-effectiveness
1) formula proposed in '77 by Weinstein and Stason
2) for intervention to be cost-effective, its cost should be no more than 3x the per capita health costs
3) limited impoverished countries to interventions $5-15 per patient per year
limitations of cost-effectiveness
1) cheap interventions fail to address the actual burden of disease, out-of-pocket costs, & other costs the patient experiences (also - doesn't address other factors that negatively impact health)
2) fixed costs in cost-effectiveness models that are planned for 5-10 years out fail to account for cost changes
3) too little money allocated for health in impoverished countries; failing to provide healthcare is a moral issue
the epidemiologists's bathtub
prevalence = water in bathtub
water leaking out = death
recovery = water evaporating from tub
incidence = faucet putting water into the tub
'90 burden of disease (measured in DALYs)
1) diarrhea and common infectious diseases (557.39 million)
2) neonatal disorders (277.79 million)
3) cardiovascular diseases (266.82 million)
(4. cancers, 5. other NCDs)
'00 burden of disease
1) diarrhea and common infectious diseases (418.8 million)
2) cardiovascular diseases(300.06 million)
3) neonatal disorders (253.16 million)
(4. cancers , 5. HIV/AIDS and TB)
'10 burden of disease
1) cardiovascular diseases (329.07 million)
2) diarrhea and common infectious diseases (295.21 million)
3) neonatal disorders (219.25 million)
(4. cancers , 5. HIV/AIDS and TB)
2019 burden of disease
1) cardiovascular disease (393.11 million)
2) cancers (251.39 million)
3) neonatal disorders (185.89 million)
(4. other NCDs, & 5. respiratory infections & TB)
on the decline over time ('90 - '19), global burden of disease
- neonatal disorders
- respiratory infections and TB
- enteric infections
- malaria & neglected tropical diseases
- HIV/AIDS and STIs
- other infectious diseases
- nutritional deficiencies
- maternal disorders
on the rise over time ('90 - '19), global burden of disease
- cardiovascular disease
- cancers
- musculoskeletal disorders
- diabetes and kidney disease
- mental disorders
- respiratory diseases
- neurological disorders
- digestive diseases
- skin diseases
- substance use disorders
- conflict and terrorism
staying about the same, global burden of disease
- unintentional injuries
- transport injuries
- self-harm
- interpersonal violence
- natural disasters
burden of disease
quantity of diseases and conditions and their impact on a population
- assessing this = attempting to build systems of care to achieve targets in SDGs
Global Burden of Disease project ('90)
quantifies the impact of diseases worldwide on a regular basis
epidemiological transition
observed shift in the types of diseases that affect populations as economic conditions improve
- used disease burden to help countries of differing economic strata to assign health priorities
Disease Control Priorities (DCP) project
burden of disease in impoverished countries impede economic development -- need to address this
prioritize interventions with greatest impact on burden of disease impoverished communities
(uses cost-effectiveness analyses to help policymakers set priorities in national health systems)
health system responsiveness x burden of disease
the health of a population must be measured and understood if the health system is to appropriately respond
reasons to quantify the burden of disease
planning, policymaking, design of delivery systems, and program evaluation
disease
refers to conditions, illnesses, and injuries
burden
refers to the impact of disease on a population
disease surveillance
measurement of conditions
why insufficient data to estimate burden of disease early on?
1) never reach medical care (get sick and die at home)
2) facilities don't have adequate diagnostic capabilities (causes of illnesses remain unknown)
3) record keepers in short supply (insufficient data to estimate BOD)
'92, World Bank commissions WHO to quantify global burden of disease
published a series of papers in the Lancet
sequelae
consequences of diseases
- GBD sought to characterize this
leading causes of death (wealthy versus impoverished countries) - 2021
wealthiest quartile
1) cardiovascular disease
2) cancer
3) chronic respiratory diseases
impoverished quartile
1) cardiovascular disease
2) respiratory infections and TB
3) maternal and neonatal
age of pestilence and famine
- high mortality rate in population
- caused by infectious diseases and starvation
low life expectancies
age of receding pandemics
reductions in mortality (esp. young children and infants)
life expectancy increase w/ improved access to food, clean water, and infrastructure
age of degenerative and manmade diseases
total fertility rate declines as infant mortality continues to fall
major causes of death = NCDs (cancer, diabetes)
age of delayed chronic diseases
reductions in mortality, old age, and primary prevention of chronic diseases (promotion of exercise and healthy diets)
three dependent inputs for prioritization (GBD project)
1) understanding types of diseases and overall burden within a country
2) design of health system to respond to need of population
3) ability of govt to set priorities, ability to use instruments at their disposal
*choosing interventions that could be supported within the confines of their health budgets*