Comment
Everyone counts—so count everyone
www.thelancet.com Vol 386 October 3, 2015
most critical failure of development over the past 30 years”.3 Today, as we stand on the cusp of this newly defined era of sustainable development, Alan Lopez, Carla AbouZahr, and colleagues present a new Lancet Series of four papers: Counting Births and Deaths.4–7 This Series answers the question of what has been achieved in the past 8 years, and reports, using new methods of analysis, that CRVS systems not only contribute to better health outcomes in the long term, but are also a necessary component of sustainable development. To achieve UHC and sustainable development for all, we need to know who the so-called “all” are, and measure the risks to their health. Yet as Lene Mikkelsen and colleagues6 report in the third Series paper, worldwide about 60% of deaths and causes of deaths and 35% of births go unaccounted for in registration. AbouZahr and colleagues4 highlight in the first Series paper that some progress has been made. Births are still more likely to be registered than deaths, but some countries have started their own CRVS improvement initiatives. India, for example, has increased birth registration coverage from 60% in 2001 to more than 80% in 2010, and has also introduced the requisite legislative and administration reforms to improve civil registration. New international initiatives to support countries in building strong CRVS systems, such as the work of the Commission on Information and Accountability for Women’s and Children’s Health, are welcome but global collective action is slow—and
Published Online May 11, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60305-1 See Editorial page 1312 See Comment page e14 See Series pages 1373, 1386, 1395, and 1407 See Online/Comment http://dx.doi.org/10.1016/ S0140-6736(15)00400-6
Andrew Aitchison/In Pictures/Corbis
The year is 2015. Remarkable achievement has been made in reducing preventable childhood mortality and morbidity through collective global action by governments, civil society, and private and public sector foundations. People in high-income and middleincome countries are healthier and living longer than in the past.1 National economies in low-income and middle-income countries are projected to rise,2 with the emergence of new middle classes expectant of their rights to education, health care, and employment. Yet there is also unacceptable inequality within countries. Links between health and the effects of human consumption and activity on the environment are yet to be fully defined. The Sustainable Development Goals (SDGs) were conceived to be more inclusive of development issues in every sector. Universal health coverage (UHC) and the environment are both identified target goals of the SDGs. In this newly defined world, everyone should count but too many still don’t. Many factors contribute to poor health outcomes and inequality, including social and political determinants of health, poverty, displacement, and natural disasters. But all sectors rely on simple acts that national health and legal systems should provide: the recognition and accurate reporting of the vital events of an individual’s life. By formally reporting birth, death, cause of death, marriage, and divorce, well functioning civil registration and vital statistics (CRVS) systems grant an individual identity, nationality, and begin the process of claiming rights to property, education, and access to health services. Although CRVS systems have been misused at times in history leading to genocide or persecution, used as they should be—to improve population health— they allow governments and the research community to design responsive health systems and generate research questions on the basis of quality national data rather than alternative models of mortality estimates. Although estimation methods have greatly improved, they are no substitute for the broader benefits of functional CRVS systems, in particular an individual’s legal right to claim national and legal identity with all that it encompasses throughout a lifespan of interacting with national administrative systems. In 2007, the Lancet Series Who Counts? described the neglect of global CRVS systems as “the single
1313
Comment
not reflective of CRVS systems as a critical component of human security and development, as described in a Comment by Kenji Shibuya and Stuart Gilmour.8 In the second Series paper, David Phillips and colleagues5 discuss whether countries that invest in improving their CRVS systems would see better health outcomes, and argue that strong CRVS systems should be seen as a driver, not merely the result, of development efforts. In the Series call to action, AbouZahr and colleagues7 underline how alternative global disease estimate and mortality statistical methods, from data sources as varied as household surveys to mortality surveillance in sentinel or sample sites, are no substitute for CRVS systems which can contribute to non-communicable disease control and injury prevention. The authors’ concluding call for CRVS to be recognised as a core component of sustainable development is both an opportunity—and warning—that should be heeded.
We thank Alan Lopez and Carla AbouZahr for leading this Series and the thoughtful contribution of the peer reviewers to the process. We also thank the University of Melbourne, Melbourne, and the University of Queensland, Brisbane, Australia, for their financial support to the Series. 1
2 3 4
5
6
7
8
Selina Lo, Richard Horton The Lancet, London EC2Y 5AS, UK
GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015; 385: 117–71. Jamieson DJ, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898–955. Setel PW, Macfarlane SB, Szreter S, et al. A scandal of invisibility: making everyone count by counting everyone. Lancet 2007; 370: 1569–77. AbouZahr C, de Savigny D, Mikkelsen L, et al. Civil registration and vital statistics: progress in the data revolution for counting and accountability. Lancet 2015; published online May 11. http://dx.doi.org/10.1016/S01406736(15)60173-8. Phillips DE, AbouZahr C, Lopez AD, et al. Are well functioning civil registration and vital statistics systems associated with better health outcomes? Lancet 2015; published online May 11. http://dx.doi. org/10.1016/S0140-6736(15)60172-6. Mikkelsen L, Phillips DE, AbouZahr C, et al. A global assessment of civil registration and vital statistics systems: monitoring data quality and progress. Lancet 2015; published online May 11. http://dx.doi.org/10.1016/ S0140-6736(15)60171-4. AbouZahr C, de Savigny D, Mikkelsen L, Setel PW, Lozano R, Lopez AD. Towards universal civil registration and vital statistics systems: the time is now. Lancet 2015; published online May 11. http://dx.doi.org/10.1016/ S0140-6736(15)60170-2. Shibuya K, Gilmour S. Civil registration as a means to promote human security. Lancet 2015; published online May 11. http://dx.doi.org/10.1016/ S0140-6736(15)60765-6.
Choosing indicators for the health-related SDG targets In the era of the Millennium Development Goals (MDGs), regular reporting of specific health indicators drew public and policy attention, and ultimately resources, to causes such as maternal and child health. On Sept 25–27, 2015, the UN Sustainable Development Summit was held in New York, NY, USA, leading to the adoption of the Sustainable Development Goals (SDGs) by the UN General Assembly. On the basis of the lessons learned from the MDGs, the indicators chosen for each SDG target will probably determine the amount of action and attention each target receives.1 Multiple efforts have been underway to develop indicator candidates;2–4 for example, the Sustainable Development Solutions Network report proposes 84 indicators for health-related targets.2 UN member states have not yet selected indicators and have directed the UN Statistical Commission to develop them by early 2016. Further, given the 169 SDG targets, there is a strong interest in parsimony. Consequently, the operating instructions for the UN Statistical Commission are to select one indicator per target, and, in some cases, to have indicators that monitor more than one target 1314
so the overall set is less than 169. Shortening the long lists of proposed indicators for various targets will be a challenging task; for good reasons, advocacy groups will want their component of the target reflected in the selected indicator. Given some heterogeneous targets, it is likely that two indicators will emerge for a few targets. What basic properties should be fulfilled by the highlevel indicators for the health-related SDGs? First, the indicators should not only measure the intended effect of a target but should also be important for population health. The danger of diverting resources and managerial attention to an outcome that is only tangentially related to the target is too great. Second, any indicator should be easily interpreted and communicated. A higher value of an indicator should be unequivocally bad or good, ruling out indicators for which the ideal value for a country is somewhere in the middle. The meaning and value of the indicator should also be clear to the public, decision makers, and the scientific community. Third, it should be affordable to produce valid, timely, local, and comparable measurements of an indicator. Fourth, wherever possible and relevant indicators should be disaggregated by age, www.thelancet.com Vol 386 October 3, 2015
Everyone counts—so count everyone
www.thelancet.com Vol 386 October 3, 2015
most critical failure of development over the past 30 years”.3 Today, as we stand on the cusp of this newly defined era of sustainable development, Alan Lopez, Carla AbouZahr, and colleagues present a new Lancet Series of four papers: Counting Births and Deaths.4–7 This Series answers the question of what has been achieved in the past 8 years, and reports, using new methods of analysis, that CRVS systems not only contribute to better health outcomes in the long term, but are also a necessary component of sustainable development. To achieve UHC and sustainable development for all, we need to know who the so-called “all” are, and measure the risks to their health. Yet as Lene Mikkelsen and colleagues6 report in the third Series paper, worldwide about 60% of deaths and causes of deaths and 35% of births go unaccounted for in registration. AbouZahr and colleagues4 highlight in the first Series paper that some progress has been made. Births are still more likely to be registered than deaths, but some countries have started their own CRVS improvement initiatives. India, for example, has increased birth registration coverage from 60% in 2001 to more than 80% in 2010, and has also introduced the requisite legislative and administration reforms to improve civil registration. New international initiatives to support countries in building strong CRVS systems, such as the work of the Commission on Information and Accountability for Women’s and Children’s Health, are welcome but global collective action is slow—and
Published Online May 11, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60305-1 See Editorial page 1312 See Comment page e14 See Series pages 1373, 1386, 1395, and 1407 See Online/Comment http://dx.doi.org/10.1016/ S0140-6736(15)00400-6
Andrew Aitchison/In Pictures/Corbis
The year is 2015. Remarkable achievement has been made in reducing preventable childhood mortality and morbidity through collective global action by governments, civil society, and private and public sector foundations. People in high-income and middleincome countries are healthier and living longer than in the past.1 National economies in low-income and middle-income countries are projected to rise,2 with the emergence of new middle classes expectant of their rights to education, health care, and employment. Yet there is also unacceptable inequality within countries. Links between health and the effects of human consumption and activity on the environment are yet to be fully defined. The Sustainable Development Goals (SDGs) were conceived to be more inclusive of development issues in every sector. Universal health coverage (UHC) and the environment are both identified target goals of the SDGs. In this newly defined world, everyone should count but too many still don’t. Many factors contribute to poor health outcomes and inequality, including social and political determinants of health, poverty, displacement, and natural disasters. But all sectors rely on simple acts that national health and legal systems should provide: the recognition and accurate reporting of the vital events of an individual’s life. By formally reporting birth, death, cause of death, marriage, and divorce, well functioning civil registration and vital statistics (CRVS) systems grant an individual identity, nationality, and begin the process of claiming rights to property, education, and access to health services. Although CRVS systems have been misused at times in history leading to genocide or persecution, used as they should be—to improve population health— they allow governments and the research community to design responsive health systems and generate research questions on the basis of quality national data rather than alternative models of mortality estimates. Although estimation methods have greatly improved, they are no substitute for the broader benefits of functional CRVS systems, in particular an individual’s legal right to claim national and legal identity with all that it encompasses throughout a lifespan of interacting with national administrative systems. In 2007, the Lancet Series Who Counts? described the neglect of global CRVS systems as “the single
1313
Comment
not reflective of CRVS systems as a critical component of human security and development, as described in a Comment by Kenji Shibuya and Stuart Gilmour.8 In the second Series paper, David Phillips and colleagues5 discuss whether countries that invest in improving their CRVS systems would see better health outcomes, and argue that strong CRVS systems should be seen as a driver, not merely the result, of development efforts. In the Series call to action, AbouZahr and colleagues7 underline how alternative global disease estimate and mortality statistical methods, from data sources as varied as household surveys to mortality surveillance in sentinel or sample sites, are no substitute for CRVS systems which can contribute to non-communicable disease control and injury prevention. The authors’ concluding call for CRVS to be recognised as a core component of sustainable development is both an opportunity—and warning—that should be heeded.
We thank Alan Lopez and Carla AbouZahr for leading this Series and the thoughtful contribution of the peer reviewers to the process. We also thank the University of Melbourne, Melbourne, and the University of Queensland, Brisbane, Australia, for their financial support to the Series. 1
2 3 4
5
6
7
8
Selina Lo, Richard Horton The Lancet, London EC2Y 5AS, UK
GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015; 385: 117–71. Jamieson DJ, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898–955. Setel PW, Macfarlane SB, Szreter S, et al. A scandal of invisibility: making everyone count by counting everyone. Lancet 2007; 370: 1569–77. AbouZahr C, de Savigny D, Mikkelsen L, et al. Civil registration and vital statistics: progress in the data revolution for counting and accountability. Lancet 2015; published online May 11. http://dx.doi.org/10.1016/S01406736(15)60173-8. Phillips DE, AbouZahr C, Lopez AD, et al. Are well functioning civil registration and vital statistics systems associated with better health outcomes? Lancet 2015; published online May 11. http://dx.doi. org/10.1016/S0140-6736(15)60172-6. Mikkelsen L, Phillips DE, AbouZahr C, et al. A global assessment of civil registration and vital statistics systems: monitoring data quality and progress. Lancet 2015; published online May 11. http://dx.doi.org/10.1016/ S0140-6736(15)60171-4. AbouZahr C, de Savigny D, Mikkelsen L, Setel PW, Lozano R, Lopez AD. Towards universal civil registration and vital statistics systems: the time is now. Lancet 2015; published online May 11. http://dx.doi.org/10.1016/ S0140-6736(15)60170-2. Shibuya K, Gilmour S. Civil registration as a means to promote human security. Lancet 2015; published online May 11. http://dx.doi.org/10.1016/ S0140-6736(15)60765-6.
Choosing indicators for the health-related SDG targets In the era of the Millennium Development Goals (MDGs), regular reporting of specific health indicators drew public and policy attention, and ultimately resources, to causes such as maternal and child health. On Sept 25–27, 2015, the UN Sustainable Development Summit was held in New York, NY, USA, leading to the adoption of the Sustainable Development Goals (SDGs) by the UN General Assembly. On the basis of the lessons learned from the MDGs, the indicators chosen for each SDG target will probably determine the amount of action and attention each target receives.1 Multiple efforts have been underway to develop indicator candidates;2–4 for example, the Sustainable Development Solutions Network report proposes 84 indicators for health-related targets.2 UN member states have not yet selected indicators and have directed the UN Statistical Commission to develop them by early 2016. Further, given the 169 SDG targets, there is a strong interest in parsimony. Consequently, the operating instructions for the UN Statistical Commission are to select one indicator per target, and, in some cases, to have indicators that monitor more than one target 1314
so the overall set is less than 169. Shortening the long lists of proposed indicators for various targets will be a challenging task; for good reasons, advocacy groups will want their component of the target reflected in the selected indicator. Given some heterogeneous targets, it is likely that two indicators will emerge for a few targets. What basic properties should be fulfilled by the highlevel indicators for the health-related SDGs? First, the indicators should not only measure the intended effect of a target but should also be important for population health. The danger of diverting resources and managerial attention to an outcome that is only tangentially related to the target is too great. Second, any indicator should be easily interpreted and communicated. A higher value of an indicator should be unequivocally bad or good, ruling out indicators for which the ideal value for a country is somewhere in the middle. The meaning and value of the indicator should also be clear to the public, decision makers, and the scientific community. Third, it should be affordable to produce valid, timely, local, and comparable measurements of an indicator. Fourth, wherever possible and relevant indicators should be disaggregated by age, www.thelancet.com Vol 386 October 3, 2015
