This is a joint post with Alexander Rosinski at the University of California, San Francisco.
A few days ago the World Health Statistics 2012 Report released its annual compendium of statistics. No doubt, it was a lot of work to compile—to verify every number in every cell, for each country and indicator. The WHO should be commended for providing this invaluable global public good. A sincere request: the Report would be more user-friendly and useful if the Report came with spreadsheets in downloadable tables (much like the World Malaria Report), and if the Report’s tables were consistent with their main database, the Global Health Observatory (GHO). For example, the coverage measures of oral rehydration therapy (ORT) which were included in the Report are absent from the GHO, as far as we can tell. (On an unrelated note, we did notice that the GHO recently added hand-washing as an indicator, perhaps in response to a recent blog—kudos to WHO!)
The Report also offers a glimpse into what is of current interest and priority among donors and countries. Global health donors generally have pet priorities and interests. These are reflected in part by how many countries report for a given indicator.
For example, if one turns to the chapter on “Health Service Coverage” (beginning on page 98), we see that “immunization coverage” for measles and for diphtheria, pertussis and tetanus is available for the reporting 193 Member States. This is not surprising given the recent occurrence of measles epidemics in high-income countries as well as GAVI’s success and use of coverage levels as conditions of both eligibility and future funding. Similarly, when we consider the “big three” of AIDS, tuberculosis, and malaria, we see relatively high coverage of the relevant indicators. For the indicator “antiretroviral therapy coverage among people with advanced HIV infection”, 44 of the 47 of sub-Saharan countries reported. When considering the “case-detection rate… of tuberculosis” indicator, 40 of the 47 countries reported the statistic. For the indicator on under-5 children with fever treated with anti-malarials, 38 of the 47 countries reported. These indicators seem to have higher-than-average coverage.
In contrast, when one considers the indicators for under-5 children (1) with diarrhea who received oral rehydration therapy (ORT), and (2) with pneumonia who receive antibiotics, the picture is bleaker. For the ORT indicator, 36 of the 47 reported. For the pneumonia indicator, less than half (23 of the 47) reported. Moreover, under-5 children with diarrhea or with pneumonia who take zinc does not appear in the Report (or the GHO), even though zinc is in the WHO’s Model List of Essential Medicines and is widely recognized as an important intervention for preventing child mortality.
What explains the differences in coverage of these indicators? The differences in reporting reflect in part different global health priorities and with it, the money disbursed by donors. Where there is interest and money, there is an indicator, and the coverage of indicators is higher (the correlation is not perfect). Not surprisingly, the single disease category with the highest development aid in 2009 was AIDS (see here), and the ART indicator in the Report also has fairly high coverage. Malaria and tuberculosis are the other two leading single disease categories for development assistance, with the associated malaria indicator having slightly worse coverage than the tuberculosis indicator. However, when considering diarrhea and pneumonia (which are not listed as separate diseases in the IHME report despite causing 10% and 18% of all under-five deaths), less international aid is devoted to these diseases and not surprisingly the coverage of these indicators is lower, at least compared to the big three. While some have noted the tremendous dearth and low coverage of cause-of-death statistics, the phenomenon of low coverage is also true for health service indicators which are arguably easier to measure than cause of death.
Do these indicators matter? In her first address as director of the WHO, Dr. Margaret Chan quoted the axiom, “What gets measured gets done.” If what is measured gets done, then better measurement and reporting is urgently needed. However, if only what is of interest is what is measured -- and only what is measured gets done -- the question remains: For diseases which are of less interest, can we (the global health community and perhaps the WHO in particular) create the incentives for better measurement and reporting for those diseases?