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*