Showing papers by "Christopher J L Murray published in 2001"

Burden of disease--implications for future research.

Abstract: One overall challenge for public health and medicine in the future is to allocate available resources effectively to reduce major causes of disease burden globally and to decrease health disparities between poor and affluent populations The major risk factors for death and disability worldwide are malnutrition; poor water supply, sanitation, and personal and domestic hygiene; unsafe sexual behavior; tobacco use; alcohol use; occupational hazards; hypertension; physical inactivity; illicit drugs; and air pollution The challenge for research in the 21st century is to maintain and improve life expectancy and the quality of life that was achieved for most of the world's population during the 20th century

Rethinking Human Security

Abstract: In the 1990s, the two dominant strands of foreign policy-economic development and military security-became intertwined. The development and security establishments have also each undergone a period of conceptual turmoil with the end of the cold war, the recognition of highly uneven patterns of change in different components of development, and the technological and political changes often labeled globalization. One consequence has been the emergence of the concept of human security. As fostered by the United Nations Development Program, this term usually means "freedom from fear and want."' Human security has rapidly moved to occupy center stage in discussions of foreign policy; for example, the Group of Eight (G8) foreign ministers declared in June of 1999 that they are "determined to fight the underlying causes of multiple threats to human security... ."2 Despite articulated links to both the development and security fields, alternative definitions abound for human security, and the research and policy agenda for human security remains unclear. In this article, we propose a simple, rigorous, and measurable definition of human security: the number of years of future life spent outside a state of "generalized poverty." Generalized poverty occurs when an individual falls below the threshold of any key domain of human well-being. An agenda for research

Comparative efficiency of national health systems: cross national econometric analysis

Abstract: Objective: To improve the evidence base for health policy by devising a method to measure and monitor the performance of health systems. Design: Estimation of the relation between levels of population health and the inputs used to produce health. Setting: 191 countries. Main outcome measure: Health system efficiency (performance). Results: Estimated efficiency varied from nearly fully efficient to nearly fully inefficient. Countries with a history of civil conflict or high prevalence of HIV and AIDS were less efficient. Performance increased with health expenditure per capita. Conclusions: Increasing the resources for health systems is critical to improving health in poor countries, but important gains can be made in most countries by using existing resources more efficiently. What is already known on this topic Evidence on the effectiveness of health system reforms is scarce Studies have not used a consistent framework for specifying goals or measuring outcomes What this study adds Countries with the best levels of health do not always have efficient health systems Efficiency is related to expenditure on health per capita, especially at low expenditure The methods of measuring performance provide a basis for identifying policies that improve health and for monitoring reforms

Measuring quality: from the system to the provider.

Abstract: The literature on quality has often focused on process indicators. In this paper we outline a framework for describing and measuring the quality of health systems in terms of a set of desirable outcomes. We illustrate how it can be measured using data collected from a recent evaluation of health system performance conducted by the World Health Organization (WHO). We then explore the extent to which this framework can be used to measure quality for all components of the system; for example, regions, districts, hospitals, and providers. There are advantages and disadvantages to defining quality in terms of outcomes rather than process indicators. The advantage is that it focuses the attention of policy makers on whether systems are achieving the desired goals. In fact, without the ability to measure outcomes it is not possible to be sure that process changes actually improve attainment of socially desired goals. The disadvantage is that measuring outcomes at all levels of the system poses some problems particularly related to the sample sizes necessary to measure outcomes. WHO is exploring this, initially in relation to hospitals. The paper discusses two major challenges. The first is the question of attribution, deciding what part of the outcome is due to the component of the system under discussion. The second is the question of timing, including all the effects of current health actions now and in the future.

Modelling HIV / AIDS epidemics in sub-Saharan Africa using seroprevalence data from antenatal clinics.

Abstract: OBJECTIVE: To improve the methodological basis for modelling the HIV/AIDS epidemics in adults in sub-Saharan Africa, with examples from Botswana, Central African Republic, Ethiopia, and Zimbabwe. Understanding the magnitude and trajectory of the HIV/AIDS epidemic is essential for planning and evaluating control strategies. METHODS: Previous mathematical models were developed to estimate epidemic trends based on sentinel surveillance data from pregnant women. In this project, we have extended these models in order to take full advantage of the available data. We developed a maximum likelihood approach for the estimation of model parameters and used numerical simulation methods to compute uncertainty intervals around the estimates. FINDINGS: In the four countries analysed, there were an estimated half a million new adult HIV infections in 1999 (range: 260 to 960 thousand), 4.7 million prevalent infections (range: 3.0 to 6.6 million), and 370 thousand adult deaths from AIDS (range: 266 to 492 thousand). CONCLUSION: While this project addresses some of the limitations of previous modelling efforts, an important research agenda remains, including the need to clarify the relationship between sentinel data from pregnant women and the epidemiology of HIV and AIDS in the general population.

Measuring health inequality: challenges and new directions.

Abstract: Inequalities in health both across and within populations are a major public concern and have become the focus of attention for both researchers and policy makers. This book chapter discusses two topics related to health inequalities: 1) measurement of health inequality; and 2) social inequalities as determinants of health status. First it reviews three current approaches to measure health inequality the most prominent of which focuses on social group differences such as education income or class. Then an alternative framework or complementary approach to studying health inequality is suggested along with a discussion of why doing so is important. Two families of measures are proposed: individual- mean differences and inter-individual differences. The quantity of interest for measuring health inequity is the distribution of period health expectancy which can be calculated from the risks of death or ill-health that individuals are exposed to at each age. The paper concludes that continued research can lead to better evidence on the magnitude and determinants of health inequality. Moreover addressing this problem of health inequality will no doubt be a major item on the analytical and policy agenda of the 21st century.

Science or marketing at WHO? A response to Williams.

Abstract: The World Health Report 2000 [1] sought tooutline, for the first time, a consistent frameworkfor assessing the performance of health systemsthat could be used by countries to monitor theirown progress over time, and which would helpcountries learn from each other. It was motivatedby the need to have the debate about appropriatehealth sector policies and reforms guided by thebest available evidence on outcomes. ProfessorWilliams describes Dr Gro Harlem Brundtland’sambition in undertaking this exercise as ‘a worthyone’ and calls the task undertaken by the Report‘ambitious, and potentially very rewarding’. Hismain criticisms focus on the quality of the dataused to measure outcomes. Yet his solution is notto seek better data or to develop better outcomeindicators, but to advocate that further attemptsto measure outcomes should cease forthwith.Moreover, he concludes his piece by impugningthe very integrity of the Organization in seekingto provide evidence for health policy.There is something inconsistent and disquietingin this. It is particularly disquieting whenWilliams claims (based on no evidence at all) that‘internal dissent is stifled’ in WHO and that theOrganization would benefit from more academicdebate. It is inconsistent to argue on the one handthat more academic debate should be stimulatedwithin the Organization while at the same timearguing that WHO’s attempts to focus healthpolicy on outcomes, and to measure these out-comes using the best evidence possible, should becensored. To stifle the search for evidence on thegrounds that current data are weak is totallyinconsistent with the scientific ethos which WHOis trying to pursue and which we believe is thehallmark of academia.Because of Williams’ attack on the integrity ofthe Organization and its management, it is impor-tant to respond to the individual technical pointsmade. They are dealt with in turn.OVERALL ATTAINMENTWilliams takes exception to producing an overallscore rather than confronting people with thetrade-offs between competing objectives. This issimply not relevant. The World Health Report(WHR) provides tables showing attainment on allof the individual components as well as the over-all score. We should not underestimate the intelli-gence of policy makers who, if they wish toexamine the trade-offs, can look at the individualtables as well as the overall scores.It is true that there are some statistically signif-icant differences between respondents from devel-oped countries and those from developingcountries in the weights assigned to health andto inequalities in responsiveness in constructionof the overall index. The difference between

A reply to Rosén

Abstract: In his commentary on the World Health Report 2000, Professor Rose n has raised some extremely important issues. We strongly agree with him that policies to improve the performance of health systems need to be more ® rmly based on evidence than has been the case in the past, and that work to measure the extent to which systems are achieving the desired outcomes should continue and progress. This will require continued debate about the goals to which health systems contribute, indicators to measure them, and data collection strategies and methods to evaluate how well resources invested in health systems are contributing to these critical social goals. It is our fervent hope that this debate will lead to better indicators and data sources, and encourage countries to routinely collect and report data relating to their own performance. This will be invaluable for indicating which policies work and which do not through international comparison, but also will help countries monitor their own progress over time. In the WHO Framework for assessment of the performance of health systems ( 1) , we start with the essential question: what are the social goals to which health systems contribute that are important enough to include in annual monitoring? We believe that the three key social goals to which health systems contribute are: ( a) to improve population health; ( b) to be responsive to people’ s legitimate expectations; and ( c) to ensure that the ® nancial burden of paying for the health system is distributed fairly. For health and responsiveness, we should be concerned with both the average level and the distribution in the population. Most of Professor Rose n’s concerns are related to the indicators used to measure these outcomes and the data, rather than to the proposed framework. However, he does have concerns about identifying the contribution of the health system alone to these social goals. In the WHO Framework, we use the concept of performance to discuss the contribution of the health system. The level of attainment of health, responsiveness, and fairness in ® nancial contribution achieved in a society is compared with what would be possible, given the resources invested in the health system and the key non-health system determinants, if the resources were spent most wisely. Conceptually, comparing each national health system with what it could achieve, taking into consideration all other nonhealth system factors, isolates the ef® ciency of the system itself in contributing to the three social goals. The debate must then turn to the methods available to evaluate what each system can achieve. Micro approaches use a wealth of information on the costs and effects of all major interventions to assess what is possible ( 2) ; WHO is investing in such work by creating regional databases on the costs and effects of interventions. Presently, however, there is insuf® cient information on interventions to implement the micro approach for a large number of countries. Macro approaches use statistical analysis of the experience across countries to give information on what is possible. For the WHO Health Report ( WHR) 2000 we used stochastic frontier production analysis to estimate what each country could achieve given investments in the health system and levels of key non-health system factors. WHO is actively engaging econometricians in efforts to improve the application of frontier production analysis to health systems. Professor Rose n raises important points about some of the indicators used to measure the goals to which health systems contribute. We try to address these in order. First, he criticizes the use of healthy life expectancy ( DALE) as the indicator of the average health of the population partly because the overall level of health in a population is in ̄ uenced by factors outside the control of the health system. Clearly we