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A new way to measure progress in global health

Rich and poor in Sao Paulo, Brazil. An increasingly common sight worldwide are slums next to wealthy enclaves. Researchers focused on tracking global health progress say measures must include social and economic factors. (Credit: Wikimedia Commons)

The world has made tremendous progress in global health during the past 25 years, reducing the impact of some major killers like HIV or, well, childbirth, and greatly expanding access to drugs or vaccines to prevent and treat many millions of the poorest people on the planet.

But sustaining that rate of progress is likely to get a lot harder. And measuring success, or failure for that matter, is likely to get more important.

According to the latest results from a massive worldwide research collaboration called the Global Burden of Disease Study, one new way of measuring progress that compares health indicators with a country’s economic development status, the United States is still doing quite poorly.

Figure 1: Actual health outcomes compared to those expected due to development level. Countries in blue have worse outcomes than expected; countries in orange and red, better

Figure 1: Actual health outcomes compared to those expected due to development level. Countries in blue have worse outcomes than expected; countries in orange and red, better

“Development drives, but does not determine, health,” said Dr. Christopher Murray, director of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington in Seattle, the coordinating center for the GBD enterprise.

“We see countries that have improved far faster than can be explained by income, education, or fertility,” Murray said in a statement announcing the publication of the new findings in The Lancet. “And we also continue to see countries – including the United States – that are far less healthy than they should be given their resources.”

Funding for global health has flattened, or even declined, over the last few years just as some of the most challenging work has begun. As humanitarian organizations, development agencies and donors shift to tackling more complex, chronic and systemic problems in health, some believe we will also need much more rigorous assessments of what works and what doesn’t.

Yesterday, the GBD team of researchers announced the creation of a new way of classifying development that they believe improves upon other metrics for evaluating the impact of health interventions.

The new measure, called the Socio-Demographic Index (SDI), was revealed along with the results of the 2015 Global Burden of Disease (GBD) study.

The SDI is intended to avoid the outdated labeling of nations as “developed” (i.e., comparatively rich) or “developing” (not so rich) and instead use a fine-grained yardstick of development. That yardstick can be used to evaluate progress (or not) of countries since, as the US statistics unfortunately make clear, a country’s wealth status as a whole does not accurately reflect what is happening in its more disenfranchised communities.

By pairing this new analysis of development – the Socio-Demographic Index – with analyses of overall health and disease burden, the study’s authors hope that the metric will help identify the most successful efforts to improve health around the world.

As Humanosphere has reported, there is a much broader effort already underway aimed at creating better yardsticks for evaluating how we’re doing in the fight to reduce poverty and inequity worldwide.

This new one, the Socio-Demographic Index, adds to a growing arsenal of indexes that researchers are using to describe and gauge how we’re doing at making the world a healthier, safer and more equitable place.

Researchers have created indexes to classify specific problems (such as poverty, captured in the United Nations Multidimensional Poverty Index) and holistic concepts (such as the Legatum Institute’s Prosperity Index). Generally, they break down into indexes that combine previously published data, such as the venerable Human Development Index, which combines life expectancy, education, and income data, or those that depend on researchers’ assessments of local conditions, such as the Social Progress Index.

Despite the abundance of these other tools for measuring the impact of aid and development, GBD researchers found that none of the existing indexes met their needs.

“Many of the indexes used to describe development or wellbeing – such as the Human Development Index – are calculated using a measure of overall health,” said Dr. Theo Vos, Professor of Global Health at IHME. “That makes using them problematic when measuring how development influences health, since you would not want to mix the outcome you want to measure – health – into your index of development.”

The researchers working on the GBD study settled, over the course of several years, on a methodology similar to that behind the Human Development Index, but dependent on different indicators in its calculation. They used a set of indicators – income per capita, average educational attainment, and fertility rate – that each correlated with better health outcomes, but gained in correlative power when combined into a composite index.

Since people around the world have been collecting data on income, educational attainment, and fertility for many years, the researchers were able to calculate Socio-Demographic Index for 195 countries – and in some cases districts within countries – for each of the past 35 years. That allows for analyses of how health has changed over time.

As far as the GBD team is concerned, the Socio-Demographic Index provides a more accurate development benchmark against which health outcomes can be measured.

Armed with historical information on the health outcomes of countries with different Socio-Demographic Index values, GBD researchers could predict how healthy countries ought to be given their Socio-Demographic Index value. They then compared that picture with how countries actually performed in health.

There were countries at all levels of development that over- and underperformed in health outcomes. Some high SDI countries with worse-than-expected health outcomes were Russia and the previously mentioned United States of America. High SDI countries with better-than-expected outcomes were clustered in Western Europe and East Asia. Several low SDI countries underperformed their SDI level (Afghanistan, the Central African Republic, and Cote D’Ivoire, for example), but many low SDI countries outperformed their SDI, among them Niger, Ethiopia, Mauritania, Burkina Faso, and Senegal. Some middle SDI countries, such as China, did better than expected while others, such as Guyana, did worse.

Figure 2: The GBD Study tracks the causes of health problems and how they have changed between 1990 and 2015. It uses the most comprehensive database of illness and injury in the world.

Figure 2: The GBD Study tracks the causes of health problems and how they have changed between 1990 and 2015. It uses the most comprehensive database of illness and injury in the world.

As the world’s health policymakers work to reduce the burden of disease, examining places with higher-and lower-than-expected disease burdens may prove a useful tool for determining which techniques should be embraced and which mistakes may be avoided.

“Many nations face significant health challenges despite the benefits of income, education, and low birth rates, while other countries farther behind in terms of development are seeing strong progress,” said Dr. Charles Shey Wiysonge, a GBD collaborator from South Africa who serves as a professor of clinical epidemiology at the Faculty of Medicine and Health Sciences, Stellenbosch University, in Cape Town. “Policymakers in all nations – from Afghanistan to Zimbabwe – can use this study to align spending to target the things that will make their communities healthier faster.


About Author

Sean McKee

Sean McKee is a policy translation specialist at the Institute for Health Metrics and Evaluation (IHME) in Seattle. Having worked extensively outside health-related professions, Sean’s objective is to connect policymakers, legislators, and other nonacademic audiences to the work of the Global Burden of Diseases, Injuries and Risks Study. Contact him at