IHME Impact Summer 2010

IHME Impact Institute for health metrics and evaluation

Inside this issue

2 The director’s view Dr. Christopher Murray discusses IHME’s maternal and child mortality research

3 Deep dive IHME studies cash payment program for Indian mothers

4 Connections New fellows join IHME; recent outreach events

5 Innovations IHME’s recently published work examines global mortality, risk factors, health aid, and more

7 Ripple effect IHME research inspires new dialogue, action on maternal and child health

For more information, please visit IHME’s Web site: www.healthmetricsandevaluation.org or contact us at comms@healthmetricsandevaluation.org or +1-206-897-2800 ©Copyright IHME 2010

Issue 2 / summer 2010

beneath the surface

New approach generates more accurate estimates of child mortality The breakthrough moment came last summer.

IHME researchers had embarked on a full assessment of child mortality levels and trends over time, gathering data from around the world. But they were struggling to find a way to track and analyze all the information they were collecting. The model they were trying to use wasn’t flexible enough to accommodate the varying amounts and quality of data they were finding.

“The problem was how to fit it together,” said Post-Bachelor Fellow Jake Marcus. “In some places, we had multiple measurements with drastically different estimates in mortality. In some countries, the data are really good, and you trust them. It’s a puzzle that you have to put together to make all the pieces fit.”

Then Dr. Abraham Flaxman, a Post-Graduate Fellow at the time, saw a way to make those pieces fit using a different method: the Gaussian process regression (GPR) model.

Flaxman, now an Assistant Professor of Global Health, had been introduced to GPR through a software package by a team of programmers, including Anand Patil at the University of Oxford. They were using it in a public health setting to study the spread of malaria. Flaxman thought it just might work for the child mortality project.

After Flaxman suggested GPR, Marcus spent a weekend toying with it to see if it would really work.

“It was an interesting problem,” Marcus said.

“How to think of one model that will work in the United States, work in Zambia, and work

Photo by Scott Phillips

Dr. Abraham Flaxman illustrates the GPR model while Jake Marcus looks on.

with so many different types of data from so many different sources.”

After spending time trying it out, Marcus was hopeful: “It was definitely promising. It did what we needed it to do.”

The GPR method gives researchers a way to classify data quality in different countries.

In the United States, for instance, the data are reliable because they come from a vital registration system. But other countries may use several surveys that estimate mortality, and each of those surveys may report drastically different numbers. In that situation, GPR can adjust its analysis based on the differences among the surveys and the proven accuracy and reliability of each. The GPR method is flexible enough to accommodate varying amounts of data and levels of data quality.

Finding the best and most accurate way to measure the data was vital to see how much Continued on page 2

1

The Director’s View

BENEATH THE SURFACE (continued)

There are valuable lessons to be learned from countries that have seen remarkable declines in mortality, particularly those that have achieved accelerated declines in a short time span. We hope that our research spawns further study so that programs that have achieved rapid improvements can be replicated elsewhere where people continue to die from preventable causes.

Each year, hundreds of thousands of women worldwide die during childbirth or from birth-related causes, and millions of children die before reaching age 5. Improving the odds of survival for mothers and children has been propelled to the forefront of global health issues in the past decade, with reduction of mortality in both areas prioritized as part of the Millennium Development Goals (MDGs) set to be achieved by 2015.

With the goal of measuring progress toward those goals, the Institute for Health Metrics and Evaluation (IHME) set out in 2007 to thoroughly and accurately assess adult, maternal, and child mortality worldwide.

We gathered all available data, building the largest dataset currently available, and created new methods and tools to analyze the information, assessing mortality from an array of vantage points. What we found was promising: Deaths of mothers and children have been declining at a steady pace worldwide for the last three decades.

It wasn’t all good news, however.

Several countries continue to see annual increases in maternal and child mortality.

The majority of deaths worldwide are still clustered in a small group of countries. In addition, IHME published research this spring that showed the gap in adult mortality widening between the countries with the lowest death rates and those with the highest. To see how far we still have to go in improving health worldwide, consider that young adults in southern Africa now die at a higher rate than adults in Sweden did in 1751.

www.healthmetricsandevaluation.org

In this issue of Impact, we highlight how IHME research and outreach are both advancing the science of population health measurement and guiding the policy discussions around global health interventions.

1. In Beneath the Surface, we look at a breakthrough method that enabled IHME researchers to complete a full assessment of worldwide child mortality levels and trends over time.

2. In Deep Dive, we take a closer look at a study that measured the effectiveness of a conditional cash transfer program in India.

3. In Connections, we introduce our new cohort of Post-Graduate Fellows and look at how IHME fellows and faculty are spreading the word about metrics to journalists and the community.

4. The research highlighted in Innovations is a roundup of IHME’s latest published work, including studies on preventable risk factors, public spending on health in developing countries, and our recent mortality research.

5. In Ripple Effect, read how IHME is helping to shape the conversation about MDGs 4 and 5 with a recent symposium on maternal and child mortality in Washington, D.C., presence at maternal and child health conferences throughout the summer, and a widely distributed policy report to inform maternal and child health policy.

I hope you enjoy this issue.

Christopher J.L. Murray Institute Director and Professor of Global Health

progress was being made toward Millennium Development Goal 4, which calls for a two-thirds reduction in mortality for children under age 5 worldwide between 1990 and 2015. Past studies have focused on cross-sections of the child population or compared levels of mortality at different times. This study was a comprehensive look at how child mortality is changing over time and by country.

“We feel like now we’re getting a more accurate and realistic picture of what we know about mortality and what we don’t know,” said Dr. Julie Knoll Rajaratnam, who led the study and is an Assistant Professor of Global Health at IHME. “GPR predicts mortality better than any of the other mortality methods used to date.”

“We feel like now we’re getting a more accurate and realistic picture of what we know about mortality and what we don’t know.”

Dr. Julie Knoll Rajaratnam The picture of child mortality that the researchers uncovered in their study includes some very good news: The number of deaths of children under 5 has dropped from 11.9 million in 1990 to 7.7 million in 2010.

“I’m really excited about putting the picture together to determine what’s driving those declines,” Rajaratnam said. “The next step is to generate estimates of different interventions, such as skilled birth attendance, immunization coverage, and others targeted at improving child health.

Once we have those, we’ll be able to do an analysis looking at which factors are the most relevant in which countries.”

Leah L. Culler, IHME Communications Office

IHME Impact / Summer 2010 2

DEEP DIVE

‘Cash on delivery’ appears to reduce newborn deaths in India In 2010, IHME undertook the first independent assessment of an innovative program in India that pays women to give birth in a health facility, concluding that the program appears to be saving newborns’ lives and lowering the number of stillbirths.

The conditional cash transfer program is called Janani Suraksha Yojana (JSY).

Translated, the name means “Safe Motherhood Scheme.” It was launched in April 2005 as a government response to high rates of maternal and neonatal deaths in India. The program aims to encourage low-income women to deliver their children in a government or accredited private health facility by paying them to do so.

IHME’s research found that women who took part in JSY had 4 fewer stillbirths and deaths in the first week of life for every 1,000 pregnancies and 2 fewer neonatal deaths per 1,000 live births.

But the study, conducted in partnership with the Public Health Foundation of India, also found wide variations from state to state, both in the implementation and in the effects of the program. The largest increases in the proportion of women delivering in a health facility happened in the same states where more women participated in JSY. Cash payments from JSY were also associated with a significantly higher proportion of women receiving prenatal care.

The state of Madhya Pradesh stands out for its high level of implementation, with nearly 45% of births reporting JSY payments. Levels were also high in other states, such as Orissa, Rajasthan, and Assam, but several other states fall at the other end of the spectrum, with less than 5% participation.

At the same time, the researchers found that the program may not be consistently reaching those who need it most. The poorest and least educated women

www.healthmetricsandevaluation.org

appeared to be participating in JSY to a lesser extent than women with moderate levels of education and income.

One of the study authors, Post-Bachelor Fellow Spencer James, said the variation among states in out-of-facility births is likely due to lack of access to clinics for

women in rural areas. Another factor could be that the difference in cash benefit may not be as significant for some women, so they choose to have a child at home and take the smaller payment.

Leah L. Culler, IHME Communications Office

IHME Impact / Summer 2010 3

CONNECTIONS

IHME welcomes new fellows, shares research and expertise IHME welcomes new PGFs

IHME Fellows get kids excited about health metrics

IHME researchers help journalists understand population health data

A group of IHME’s Post-Bachelor and PostGraduate Fellows reached out to young future scientists in April at the University of Washington’s Paws-on Science event at the Pacific Science Center. IHME’s station was called “Do Shots & Nets Save Lives?” and focused on the effectiveness of immunizations and bed nets.

Photo by Corwyn Ellison

Three new Post-Graduate Fellows joined IHME in February 2010 (pictured above, left to right): Tom Achoki was born in Kisii, Kenya, and received his MD from Nairobi University and his MPH from the University of Pretoria.

He is in the Evaluations Work Group.

Catherine Wetmore, originally from Branford, CT, received her MPH and PhD, both in Epidemiology, from the University of Washington. She is in the Costing and National Health Information Systems work groups.

Casey Olives, originally from Albuquerque, NM, received his PhD in Biostatistics from the Harvard School of Public Health. He is in the National Health Information Systems and Models work groups.

Children and their parents were drawn in by the furry models of parasites and a hanging bed net. IHME fellows asked visitors how much they knew about malaria and mosquitoes, showed them what it was like to be under a bed net, and talked about why children in other countries need protection from mosquitoes.

Post-Bachelor Fellow Nancy Fullman said the children already knew a lot about malaria and other diseases. They were also very interested in a special computer visualization explaining IHME’s research.

They asked questions about why there were certain countries that had seen increases in immunization coverage or mortality.

“It was amazing how engaged the kids were with our research,” Fullman said.

Data can be intimidating to many people, journalists included. But during recent presentations at the Health Journalism 2010 conference in Chicago, IHME faculty members aimed to demystify data and educate journalists on how to evaluate data quality.

Dr. Emmanuela Gakidou, IHME Associate Professor of Global Health, led two sessions intended to encourage journalists to examine and understand the data behind the stories they report.

“The goal was to help them understand what’s reliable and when they should be questioning the data,” Gakidou said. “It was also to show them that they need to demand better data and better evidence for their stories, and not think that we know things with certainty just because people make claims.”

The Institute’s Post-Graduate and PostBachelor Fellowship programs strengthen the field of health metrics and evaluation by cultivating and training tomorrow’s leaders in global health, developing the fellows’ research and analytical skills as well as their understanding of the global health landscape.

Gakidou said there was a lot of interest from the approximately 60 journalists who attended the two sessions. She and other IHME faculty hope to continue to improve the quality of reporting on health data through future outreach.

For more information: PGF program: http://www. healthmetricsandevaluation.org/what/ training/fellowships/pgfs/pgf.html PBF program: http://www. healthmetricsandevaluation.org/what/ training/fellowships/pbfs/pbf.html

Photo by Corwyn Ellison

Dr. Emmanuela Gakidou speaks at a recent journalism conference.

Photo by Jolayne Houtz

IHME Fellows Nancy Fullman, Kyle Foreman, and Leslie Mallinger at the University of Washington’s Paws-on Science event at the Pacific Science Center.

www.healthmetricsandevaluation.org

IHME Impact / Summer 2010 4

Innovations

IHME’s recently published work Preventable risk factors shorten US lives, drive health disparities

Life expectancy in the US is cut short by 4.9 years in men and 4.1 years in women because of smoking, high blood pressure, high blood glucose, and being overweight – all preventable risk factors. Southern rural blacks had the largest loss of life expectancy at 6.7 years for men and 5.7 years for women. Asians had the smallest drop in life expectancy – 4.1 years for men and 3.6 years for women.

Innovation: Researchers married preventable risk factors to eight subgroups of the US population – known as the Eight Americas – and found that the risk factors account for 20% of disparities in health outcomes overall. Researchers also found that ethnicity and where people live are predictors of life expectancy and of specific risk factors for disease.

Danaei G, Rimm EB, Oza S, Kulkarni C, Murray CJL, Ezzati M. The Promise of Prevention: The Effects of Four Preventable Risk Factors on National Life Expectancy and Life Expectancy Disparities by Race and County in the United States. PLoS Medicine, March 2010

Injuries threaten survival of Iranian children More than 44,000 Iranian children under the age of 15 died due to injuries between 2001 and 2006, making injuries the leading cause of death among children in Iran. Road transport injuries were responsible for the most deaths. Falls and burns resulted in the most cases of hospitalization and outpatient care. Overall death rates were higher in rural areas.

www.healthmetricsandevaluation.org

Innovation: Child injuries are recognized as a global health problem, but precise numbers for countries have been elusive.

IHME researchers, in collaboration with Harvard University, the Ministry of Health and Medical Education in Iran, and Tehran University of Medical Sciences, broke child deaths down into a range of categories, finding that there were 3,000 to 4,000 transport injury deaths annually. They also found that the increase in the proportion of child injury deaths grew from a true rise in injury deaths and a decline in other competing causes of death.

health spending as source and spending in other health-related sectors.

Lu C, Schneider MT, Gubbins P, Leach-Kemon K, Jamison D, Murray CJL. Public financing of health in developing countries: a cross-national systematic analysis. The Lancet, April 2010

Global maternal deaths fall by 35%

Naghavi M, Pourmalek F, Shahraz S, Jafari N, Delavar B, Motlagh ME. The burden of injuries in Iranian children in 2005. Population Health Metrics.

March 2010

Developing countries devoting more money to health

Overall domestic government spending on health doubled in low-income countries over 12 years to reach $18 billion in 2006. But in sub-Saharan Africa, health aid appears in part to be replacing domestic health spending rather than supplementing it.

Innovation: Missing data and contradictions in data from different agencies have prevented a complete tally of how much money governments in the developing world spend on health.

Researchers analyzed spending data from developing countries and health aid data from agencies, multilateral institutions, and hundreds of nonprofit groups and charities. By using these data, they were able to generate the best estimates to date of public health financing. They also recommended the adoption of a clear set of reporting standards for government

The number of women dying annually from pregnancy-related causes declined from a half-million in 1980 to about 343,000 in 2008 – a 35% decrease that runs contrary to the perception that improvements in maternal mortality had stagnated. Developing countries, in particular, have made substantial progress toward the Millennium Development Goal set in 2000 of reducing the number of women dying from maternal causes by 75% between 1990 and 2015.

Innovation: Researchers constructed a dataset three times the size of datasets used in earlier efforts to track maternal mortality. They assessed vital registration data, censuses, surveys, and verbal autopsy data for 181 countries for a 28year period, applying newly developed analytical methods to generate estimates of maternal deaths. By separating HIVrelated maternal deaths, they were also able to estimate that 20% of all maternal deaths are linked to HIV. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez AD, Lozano R, Murray CJL. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. The Lancet, April 2010

IHME Impact / Summer 2010 5

innovations, (continued)

Adult mortality trends reveal rise in inequalities

Health disparities among countries and between men and women are widening worldwide. An adult male in Swaziland, the country with the world’s highest mortality rate, is nine times more likely to die prematurely than an adult male in Cyprus, which has the world’s lowest mortality rate. AIDS, the collapse of the Soviet Union, and the rising prevalence of smoking, high blood pressure, and obesity in developing countries all appear to be having effects on mortality.

Innovation: Adult mortality research has focused on a subset of the global population and has often relied on estimates derived from child deaths.

IHME calculated mortality rates using vital registration data, censuses, surveys on household deaths, and sibling survival histories. Researchers developed new methods to estimate the probability that a 15-year-old will die a premature death before reaching age 60. They then calculated mortality rates for 187 countries for a 40-year period.

Rajaratnam JK, Marcus JR, Levin-Rector A, Wang H, Dwyer L, Costa M, Murray CJL. Worldwide mortality in men and women aged 15–59 years from 1970 to 2010: a systematic analysis. The Lancet, April 2010

New methods offer more accurate estimates of mortality Newly developed analytical methods will help countries see a clearer picture of adult and child mortality measures and trends in their populations and make population health measurement in low-resource settings faster, more accurate, and less costly.

Innovation: In three separate studies, researchers increased the effectiveness www.healthmetricsandevaluation.org

of mortality estimates in low-income countries by using the Corrected Sibling Survival method to compensate for recall bias and survival bias; created five new methods for calculating child mortality from summary birth histories in lowincome countries; and evaluated the performance of 234 death distribution methods, used in low-resource settings to estimate deaths.

countries for a 40-year period and found that 31 developing countries are on pace to meet Millennium Development Goal 4 by reducing child deaths by 66% between 1990 and 2015.

Rajaratnam JK, Marcus JR, Flaxman AD, Wang H, Levin-Rector A, Dwyer L, Costa M, Lopez AD, Murray CJL. Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970–2010: a systematic analysis of progress towards Millennium Development Goal 4. The Lancet, May 2010

Cash payments appear to help reduce newborn deaths

Obermeyer Z, Rajaratnam JK, Park CH, Gakidou E, Hogan MC, Lopez AD, Murray CJL. Measuring Adult Mortality Using Sibling Survival: A New Analytical Method and New Results for 44 Countries, 1974–2006. PLoS Medicine, April 2010

Child deaths fall below 8 million

An Indian government program that pays women to give birth in a health facility appears to be saving newborns’ lives and lowering the number of stillbirths, though it may not be reaching the poorest and least educated women at the highest rates. Janani Suraksha Yojana (JSY), the largest maternal health program in the world, is now reaching an estimated 10 million women annually in India.

Worldwide mortality in children younger than 5 years has dropped from 11.9 million deaths in 1990 to 7.7 million deaths in 2010, with under-5 mortality rates falling in every region of the world. Under-5 mortality has fallen 35% in that period, and neonatal mortality has declined much faster than expected, at an annual rate of 2.1%.

Innovation: IHME, working with the Public Health Foundation of India, used data from India’s district-level household surveys conducted from 2002 to 2004 and from 2007 to 2008 to study the association of JSY with a reduction in stillbirths and newborn deaths. The researchers used three analytical approaches and found that those receiving this program had four fewer stillbirths and deaths in the first week of life for every 1,000 pregnancies after adjusting for potential confounding factors.

Innovation: Researchers created a database with more than 16,000 data points – twice as many as in previous estimates – and applied new analytical methods to improve the accuracy of their estimates. They created estimates for 187

Lim SS, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E. India’s Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation.

The Lancet, June 2010

Rajaratnam JK, Tran LN, Lopez AD, Murray CJL. Measuring Under-Five Mortality: Validation of New Low-Cost Methods. PLoS Medicine, April 2010 Murray CJL, Rajaratnam JK, Marcus J, Laakso T, Lopez AD. What Can We Conclude from Death Registration? Improved Methods for Evaluating Completeness. PLoS Medicine, April 2010

IHME Impact / Summer 2010 6

ripple effect

Maternal mortality research inspires optimism, debate on MDG progress In May, IHME co-hosted a symposium with The Lancet and the Kaiser Family Foundation to explain the new research and explore the policy implications. The event in Washington, D.C., attracted close to 300 maternal experts.

Photo by Corwyn Ellison

Dr. Christopher Murray discusses IHME’s new mortality research at a global health conference in June.

For years, it appeared there was little – if any – progress being made on improving the chance of survival for the world’s mothers. With only five years remaining to achieve the Millennium Development Goal of reducing maternal mortality by 75% between 1990 and 2015, many working in the field felt disheartened.

The research published in The Lancet, “Maternal mortality for 181 countries, 1980-2008: A systematic analysis of progress towards Millennium Development Goal 5,” drew from a larger dataset than previous studies and used new analytical methods to generate the most accurate estimates to date.

“I have been working as a midwife for more than a decade trying to improve the health and safety of women giving birth,” said Rachel Ibinga Koula, a Regional Midwife Adviser for the International Confederation of Midwives. “I found it very discouraging that the numbers always showed that these efforts made no difference.”

The research met with resistance from some researchers who had done similar studies and from maternal health advocates who feared a negative impact on funding. However, positive reactions quickly filled news reports and blogs.

For many, it was welcome news when IHME released new estimates in April showing a 35% reduction in maternal deaths between 1980 and 2008, from 500,000 annual deaths to about 343,000.

Dr. Flavia Bustreo, Director of the Partnership for Maternal, Newborn & Child Health, said evidence of progress is just what the movement needed. “It is clear that the new estimates offer hope at last that … our collective actions are starting to reduce this tragedy in the new millennium.”

www.healthmetricsandevaluation.org

“This research is fantastic news,” said Adam Musgrave, Health and Education Campaigner for Oxfam International, who worked in Malawi and saw the positive effects of targeted health policies there. “(It) shows what can be achieved when governments invest in their health systems and help mothers to access health care when they really need it.”

The research came just in time for a summer of events focused on maternal and newborn health, including an announcement by world leaders of a joint action plan to improve reproductive, maternal, and newborn health. IHME’s new research figured prominently in the announcement.

The dialogue continued at conferences such as Women Deliver 2010, where Melinda Gates, co-chair and trustee of the Bill & Melinda Gates Foundation, cited IHME statistics in announcing $1.5 billion in funding for maternal and child health over the next five years.

At the Global Health Council’s Goals & Metrics 2010, hundreds picked up IHME’s comprehensive policy report based on the mortality results. Many filled a ballroom to hear Institute Director Dr. Christopher Murray describe the most critical findings, such as the role HIV has played in slowing efforts to reduce maternal mortality in some African countries. Murray said HIV was responsible for more than 64,000 of the 343,000 maternal deaths in 2008.

Numerous mentions of IHME’s new estimates also were made at the Pacific Health Summit in London and the G8 Summit north of Toronto, where a final announcement referred to the IHME study and pledged $5 billion of additional funding over the next five years toward maternal and child health.

In August, IHME will continue the conversation on maternal mortality at the Global Maternal Health Conference 2010 in India.

“Although many countries have achieved substantial progress in reduction of maternal deaths, far too many have not,” Murray explained. “Progress needs to be accelerated in countries that have seen their maternal mortality trends stagnate or worsen. We hope our research helps to pinpoint strategies that are working so that other countries with less success can replicate them.”

Jill Oviatt Director of Communications, IHME

IHME Impact / Summer 2010 7