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IHME Impact Institute for health metrics and evaluation

Issue 5 / MAY 2012

beneath the surface Inside this issue

2 The Director’s View Dr. Christopher Murray describes IHME’s progress as the Institute approaches its fifth anniversary

4 Deep Dive IHME’s Global Health Data Exchange, the GHDx, eases the “search” burden on researchers

5 Connections IHME shares groundbreaking research with international partners, wins academic and community awards

7 Innovations Research by IHME reveals the latest trends in countries’ health financing, malaria deaths, and impact of noncommunicable diseases

8 Ripple Effect IHME joins a major initiative to improve access to high-quality health care in Latin America

IHME consults with countries around the world as Global Burden of Disease study nears conclusion They were a roomful of experts and not easily impressed. Researchers and policymakers at the oldest public health organization in the world – the Pan American Health Organization (PAHO) in Washington, DC – gathered in January 2012 to hear Dr. Christopher Murray. The Director of the Institute for Health Metrics and Evaluation (IHME) was there to discuss the Global Burden of Diseases, Injuries, and Risk Factors 2010 Study (GBD 2010 Study). The reaction was immediate and effusive. “Two words. Impressive and exquisite. Really state of the art,” one senior PAHO official said. “This was a splendid presentation. You really have made a lot of improvements in the methods,” said a researcher who had been following GBD since the first iteration in 1996. They were amazed at the rigor of the science behind the GBD and energized by the possibilities for making the study even stronger. For hours after the presentation, Dr. Murray talked with PAHO leaders and staff about new data sources, new factors to consider in the analysis, and the need for ongoing collaboration.

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Discussions like this have been happening around the world as the GBD 2010 Study reaches its conclusion. IHME and its collaborators at Harvard University, the World Health Organization (WHO), the University of Queensland, and Johns Hopkins University are meeting with government officials and

Photo courtesy of PAHO

Christopher Murray, IHME Director, visited PAHO headquarters in January 2012 in Washington, DC, in consultation about the GBD 2010 Study.

researchers to test the work against prior assumptions and to engage in discussions about the GBD’s implications. Launched in the spring of 2007, the GBD 2010 Study is the most comprehensive effort since the GBD 1990 Study to produce comparable estimates of the burden of diseases, injuries, and risk factors. It is generating new estimates for the years 1990, 2005, and 2010. The GBD 2010 Study is significantly broader in scope than previous versions, including: • More than 220 conditions and injuries • More than 40 risk factors • More than 230 sequelae (nonfatal health consequences) • 800 collaborators worldwide

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The Director’s View

Research published on mortality trends in malaria has focused new attention on adult deaths, and our research on breast and cervical cancer trends has highlighted the increasing burden on the developing world.

Since opening our doors in 2007, IHME has grown from a handful of people into an organization with more than 100 researchers and staff. We published peer-reviewed research articles on subjects such as mortality and cause of death trends, rates of vaccination and bed net coverage, the connection between increased years of education and reducing child deaths, global health financing, and innovative methods that improve the measurement and estimates of all these areas. This July, IHME celebrates its fifth anniversary. We’ve come a long way in five years and I want to take this time to highlight some of our achievements and thank the people and organizations that helped us carry out our goal to improve people’s health through better information. Hundreds of researchers, health experts, and policymakers around the world work with us to improve population health measurement. Without their support we wouldn’t be where we are today. Some of the best examples of our impact are the innovations in measuring mortality. With improved measurement in the area of maternal mortality, for instance, IHME changed the conversation about the progress in reducing the deaths of women due to complications from pregnancy and childbirth. It was widely believed there had been no progress, and that a halfmillion women were dying annually from maternal deaths. Our analysis found fewer than 300,000 deaths due to maternal causes, and since publishing our research other organizations have adopted some of our analytical methods and are now reporting similar trends.

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Our work tracking health financing has similarly attracted attention from policymakers and governments eager to make connections between money spent and progress made. Launched in 2009, our annual Financing Global Health report tracks public and private contributions to development assistance for health worldwide. IHME shares this work with NGOs, international agencies, and national policymakers each year when the new numbers are released. In the US, research showing that progress in women’s life expectancy is lagging behind the progress men are making has caught the attention of journalists, county health officials, and the general public. Becoming a premier training ground for future global health researchers and leaders was another goal. We have had a total of 55 Post-Bachelor Fellows and 23 Post-Graduate Fellows at the Institute. Our master’s program, the only health metrics and evaluation track in the country, has produced eight graduates. This fall we will kick off a new PhD program that will complete our educational offerings in metrics. The combination of our innovative research and quality training is helping to create a stronger foundation for health metrics and fundamentally strategic decision-making in population health. Today we look forward to projects just getting underway. In Latin America, for example, the InterAmerican Development Bank has hired IHME to evaluate the effectiveness of its ambitious health reform program in eight countries, a project you will read more about in this issue. And the Kingdom of Saudi Arabia signed an agreement this month with IHME that will result in a detailed analysis of population health trends in that country.

We are discussing similar projects with other countries around the world. In this issue of IHME Impact: 1. Beneath the Surface looks at the Global Burden of Disease 2010 Study. As the estimates are being finalized and readied for peer review, IHME researchers travel the world, consulting with researchers and country governments about the preliminary findings. 2. In Connections, we look at how IHME fellows and faculty are spreading the word about the world’s latest health trends to journalists and the community. 3. In Deep Dive, we take a closer look at IHME’s Global Health Data Exchange (GHDx) and the challenges to finding all the data that are out there. 4. The research highlighted in Innovations is a roundup of IHME’s latest published work, including studies on diabetes management in Iran, the slowing of global health financing due to the global financial crisis, innovative causes of death modeling, and global malaria mortality trends. 5. In Ripple Effect, read how IHME is providing technical assistance to the Salud Mesoamérica 2015 Initiative, monitoring progress and generating insight and evidence on how results are achieved in the areas of reproductive health and maternal and child health, including immunization and nutrition. Thanks again for your support over the last five years. We look forward to continuing to make a measurable difference over the next five to come.

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

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BENEATH THE SURFACE (continued)

For four years, IHME and its collaborators met regularly and discussed the data being gathered and the methods being used to analyze the data. These meetings included dozens of expert groups in about 100 countries. “This is the first time we have a study with the involvement of scientists from every region of the world focused on this broad range of diseases and risk factors,” said Dr. Mohsen Naghavi, the head of IHME’s Burden of Disease research team. Dr. Naghavi said that with one expert group alone – the researchers involved in cardiovascular diseases – IHME and its collaborators discussed the work over email, by phone, or in person with the expert groups at least 1,000 times. “This project is too important to miss a step,” Dr. Naghavi said. “We have to focus on even the smallest details and work hard to get them right.” Consultations about the GBD started last year with a round of meetings in Geneva, Switzerland, including discussions with WHO and the GAVI Alliance. IHME met with disease-specific organizations for some of the biggest causes of child and adult mortality, including the Joint United Nations Programme on HIV/AIDS, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the International Agency for Research on Cancer. To better understand how policymakers might make use of the new GBD, and to learn more about national assessments of health status, IHME met with top officials at several national agencies, including the US Centers for Disease Control and Prevention, the Ministry of Health of Brazil, the Ministry of Health of Zambia, and the Chinese Center for Disease Control and Prevention. “Over the years, the burden of disease has driven health reforms and important new public health initiatives in a wide range of countries,” said Dr. Rafael Lozano, the head of IHME’s Causes of Death research team and one of the principal researchers

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on the GBD 2010 Study. “We want to make sure that policymakers understand how to use GBD as a benchmark and the need to go even further with the analysis to the subnational level. That’s where you can truly make a difference in the quality of people’s health.” IHME also met with large funding organizations, where the decisions are made about how to balance the broad needs for population health improvement against the limited resources available. These include meetings with the World Bank, which commissioned the original Global Burden of Disease Study in the early 1990s, and the United Kingdom Department for International Development. IHME also hosted smaller groups of researchers from the Child Health Epidemiology Reference Group and WHO in Seattle as part of these final consultations before starting the process of submitting the research papers to peer-reviewed journals for publication. The papers will be the core of the work produced by the GBD 2010 Study. “These consultations have been enormously productive and enlightening,” Dr. Murray said. “We have been meeting with researchers and governments from around the world and listening to their thoughts on what is happening on the ground. It has given us a new window into what we are seeing in the data and helped shape the project as it enters the final stage.” IHME expects the GBD results to be published later this year and then to begin holding meetings and training sessions around the world to put these new findings into action.

William Heisel, IHME Communications

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DEEP DIVE

Quest for data In the world of open data and cloud-based data repositories, data for research should be increasingly easy to access. Pretty much every ministry and health organization has a website. There are huge online catalogs such as WorldCat. More and more countries have open data sites. The number of organizations involved in data collection and dissemination grows and grows. And there is Google. However, the road to data isn’t very straight. In fact, it’s bumpy and twisted, and sometimes giant crevasses suddenly open beneath your feet. Why is it so hard? For starters, there are translation and terminology issues. Websites change and go down. Organizations, inexplicably, take down all mention of last year’s health statistics report. And often, the biggest issue is that search engines are a popularity contest that health and demographic data simply don’t win. The search algorithms that make it so easy to find what movies are playing close to your house make it nearly impossible to find websites that get under 100 hits a day and don’t have a lot of links. Enter the GHDx, IHME’s Global Health Data Exchange. Our shiny online catalog provides information about health and demographic data, including the name of the data provider. It doesn’t eliminate all of our data quests, but once we find a

Peter Speyer and Eden Stork of the Data Development team discuss new health data cataloged on the GHDx.

dataset and have it cataloged, it doesn’t get lost again. And as we catalog more and more, the GHDx becomes the best place to start a search for health-related data. Google also makes sure that with more data being cataloged, our site, and thus the information about the data, gets easier for others to find. The ephemeral nature of some websites means that sometimes our links to the sources won’t be current, but we provide enough information that you

should be able to establish 1) it existed, 2) what it covered, and 3) who is most likely to have it. We also catalog what we find in libraries and bookstores, bringing the online and print worlds together in one place. We use a standard terminology for topics and translate everything into English so that one search will find all similar datasets, even if the datasets themselves didn’t use the same terms. We use keywords in specific ways relevant to health research to help provide the context for a topic. We still have a long way to go to get all relevant health and demographic data cataloged, and the work will never be finished. There is always a new dataset just published. But with each new batch of records, we make your quest for healthrelated data that much easier.

Peter Speyer, IHME Data Development

The GHDx home page on the IHME website welcomes users to the world’s most complete catalog of health and demographic data.

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CONNECTIONS

IHME presents research abroad and at home, wins academic and community awards IHME shares its innovative research in global health at international conferences and events. Since the beginning of the year, IHME researchers have presented to diverse audiences and won awards for our academic and community work. Here is a roundup of some of the events in which we participated.

Dr. Christopher Murray delivers keynote speech at World Malaria Day 2012 hosted by PATH On April 25, IHME Director Christopher Murray was the featured speaker at the commemoration of World Malaria Day 2012 held by PATH, a Seattle-based nonprofit organization delivering global health programs. Dr. Murray discussed recent advances in the fight against the disease as well as challenges and opportunities for the future, if progress in fighting malaria is to be sustained.

New county life expectancy results released at health journalism conference At the 14th Annual Conference of the Association of Health Care Journalists, IHME Professor Ali Mokdad released results from the only county-by-county assessment of life spans in the United States. IHME cosponsored the conference, held in April in Atlanta, GA. Receiving a resounding nationwide response, the county life expectancy estimates resulted in more than 500 media mentions in more than 30 states.

Two Post-Graduate Fellows present at conference on population health research methods In April, Post-Graduate Fellow Lahn Straney and former fellow Casey Olives traveled to Birmingham, United Kingdom, to speak at the Population Health – Methods and Challenges Conference. They highlighted the strengths of small area estimation models and stressed the need for localized research to assist policymakers in their health promotion efforts.

Post-Bachelor Fellow K. Ellicott Colson explains IHME’s life expectancy map to children at Paws-on-Science.

IHME introduces children to global health research at Paws-on-Science family event Over a weekend at the end of March, IHME hosted an exhibit for Paws-on-Science, a family-oriented event held at the Seattle Pacific Science Center. Twenty Post-Bachelor Fellows (PBFs) and IHME staff engaged children in visualizations and maps that demonstrated who lives longest in the US. After learning about what IHME researchers do, one 7-year-old girl told her father, “I want to be a PBF when I grow up. I really do.” Photo courtesy of PAHO

Left to right: IHME Professor Rafael Lozano; Mirta Roses Periago, Director of PAHO; Fátima Marinho, Project Coordinator for Health Information and Analysis, PAHO.

IHME encourages improving cause of death research at health statistics meeting for the Americas In March, IHME Professor Rafael Lozano chaired the 2012 meeting of the Regional Advisory Committee on Health Statistics, Comité Regional Asesor sobre Estadísticas de Salud (CRAES), in Havana, Cuba. Dr. Lozano led a discussion on assessing the quality of mortality information, drawing upon IHME’s work in identifying and redistributing cause of death codes.

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AIDS talk spurs interest at conference on retroviruses and opportunistic infections At a March conference in Seattle, the 19th Conference on Retroviruses and Opportunistic Infections, Dr. Murray highlighted preliminary findings for HIV/AIDS from the GBD 2010 Study. Dr. Murray’s presentation generated a sharing of ideas and suggestions for collaboration among global health researchers.

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CONNECTIONS (continued)

IHME reaches new audiences at Seattle Asian Art Museum lecture In February, Dr. Murray spoke on health developments in Asia as part of the Seattle Asian Art Museum’s Saturday University lecture series on the global implications of Asia’s explosive growth. Dr. Murray’s talk, “Health trends in Asia during three decades of growth, 1980-2010,” shared preliminary findings from the GBD 2010 Study with an audience of art followers, broadening the reach of IHME beyond the arena of scientific research.

Panel examines global health financing trends Dr. Murray and Lecturer Michael Hanlon discussed significant developments in global health financing in a community meeting held in January in Washington, DC. The panel “What’s happening to development assistance for health as the MDG deadline approaches?” drew upon IHME’s policy report Financing Global Health 2011: Continued Growth as MDG Deadline Approaches, which shows that development assistance for health continues to rise, albeit at a slower rate than before the recession.

Left to right: William Heisel, Kelsey Pierce, Katherine Leach-Kemon, Hannah Peterson, Emily Carnahan, Dane Boog.

IHME wins awards for innovative community fundraising In fall 2011, IHME devised a creative plan for gathering food and financial donations for the Combined Fund Drive (CFD) of King County, Washington. IHME raised over $1,000 for the Refugee Women’s Alliance through a cookie bake-off and trivia night, while also competing to gather the most healthy food donations for the food bank Northwest Harvest. In March, IHME accepted three awards at the CFD Volunteer Appreciation Night for spirit of service, innovative fundraising, and outstanding team work. The fundraising team members were Dane Boog, Emily Carnahan, Abraham Flaxman, Emily Hall, William Heisel, Katherine Leach-Kemon, Kelsey Moore, Kate Muller, Hannah Peterson, and Kelsey Pierce. Team leader Dane Boog said, “Our fundraising team has a member from every arm of the organization, bringing vibrant energy that helps motivate all of IHME to give back to the community.”

IHME and the Kingdom of Saudi Arabia collaborate on health tracking Dr. Abraham Flaxman wins award for research paper on mobile data collection.

Best paper award at Dev 2012 symposium IHME Assistant Professor Abraham Flaxman won the best paper award at the Dev 2012 symposium on computing for global development. The paper titled “Automated quality control for mobile data collection” was co-authored by Benjamin Birnbaum, Brian DeRenzi, and Neal Lesh. Held in March, the symposium presented original and innovative work on the applications, technologies, architectures, and protocols for computing in developing regions.

In May, the Kingdom of Saudi Arabia and IHME launched an innovative, multiyear collaboration to create an integrated tracking system to monitor the health status of Saudi citizens and to inform health policy priorities. Dr. Murray and Dr. Mokdad formalized the collaboration at a ceremony in Riyadh, Saudi Arabia, with Saudi ministers of health and development. The Saudi government is funding the work through a $9.7 million grant. The Ministry of Health in Saudi Arabia is modernizing the country’s health information system to deliver integrated and comprehensive health care services. IHME will create a tracking system that would give policymakers both real-time snapshots of the country’s health status and long-term trend lines showing where the country is heading. This five-year initiative will allow the Ministry of Health to pinpoint what is working and what is not working and then take the necessary steps to raise the level of health for all its people. Patricia Kiyono, IHME Communications

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Innovations

IHME’s recently published work Novel analysis shows effectiveness of primary health care on diabetes and hypertension management in Iran Research by IHME suggests that the Behvarz workers of the Iranian primary health care system, if provided with enough training and well-defined guidelines, can effectively reduce chronic disorders such as diabetes and hypertension, particularly in rural areas. This study, the first to use individual-level data to analyze the effects of health care workers on risk factors for cardiovascular disease, shows that the approach of using Behvarz workers could provide a model for how primary care can manage chronic diseases. Innovation: This study is a novel analysis of the association between primary health care and noncommunicable diseases and risk factors. The researchers used a nationally representative sampling from the 2005 Non-Communicable Disease Surveillance Survey in Iran for nearly 66,000 participants to measure the coverage of treatment for diabetes and hypertension and to estimate the effectiveness of treatment. Censuses provided socioeconomic information and the number of Behvarz workers by areas. Farzadfar F, Murray CJL, Gakidou E, Bossert T, Namdaritabar H, Alikhani S, Moradi G, Delavari A, Jamshidi H, Ezzati M. Effectiveness of diabetes and hypertension management by rural primary healthcare workers (Behvarz workers) in Iran: a nationally representative observational study. The Lancet, December 2011

Yearly update of research shows global financial crisis has slowed growth of development assistance for health While development assistance for health (DAH) continued to increase in 2011, IHME researchers showed that the rate of growth was slow, following the global financial crisis. This research supports the necessity for continued measurement of DAH, especially given the persistent economic hardship in donor countries and the international community’s focus

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on meeting the Millennium Development Goals by their 2015 deadline. Innovation: In addition to the sources of DAH that IHME researchers have studied in previous years, this publication incorporated new data and refined methodological approaches to improve the quality of these estimates. They collected new data on health expenditure from some of the largest non-governmental organizations in the United States, resulting in better estimates of DAH flowing through these channels. Additional data from the World Bank were incorporated, leading to a better understanding of how this channel invests its money. Finally, researchers began tracking efforts by the Bloomberg Family Foundation to fight tobacco use, resulting in more complete estimates of DAH for noncommunicable diseases. Leach-Kemon K, Chou DP, Schneider MT, Tardif A, Dieleman JL, Brooks BPC, Hanlon M, Murray CJL. The global financial crisis has led to a slowdown in growth of funding to improve health in many developing countries. Health Affairs, December 2011

New method to estimate cause of death trends performs better than previously used methods IHME researchers created a new analytic tool, the Cause of Death Ensemble model (CODEm), to estimate trends in causes of death. Accurate assessment of these trends is essential for global health policymakers, advocates, and planners to understand the current magnitude of health problems and trends in these problems in order to best help populations in need. Innovation: While researchers have made many efforts in the past to model causes of death, there has been a lack of accepted standards for good modeling practice. This study includes the authors’ principles for cause of death model development, validation, and reporting. CODEm follows all of these principles. To demonstrate CODEm’s performance compared to other single component models, the authors

used a covariate selection algorithm on 1,984 possible models for maternal mortality. CODEm outperformed all other plausible models. Foreman KJ, Lozano R, Lopez AD, Murray CJL. Modeling causes of death: an integrated approach using CODEm. Population Health Metrics, January 2012

Research shows malaria kills nearly twice as many people as previously thought IHME researchers found that malaria caused over 1.2 million deaths worldwide in 2010, twice the number found in the most recent comprehensive study of the disease. While substantial progress has been made in the fight against malaria over the past five years, these findings show substantially more deaths across all ages and regions than other assessments, especially in adults. The fact that malaria is a significant factor in adult mortality indicates that control strategies should shift to pay more attention to adults and underscores the dangers posed by the global economic crisis. Innovation: The researchers used a new approach to predict levels and trends over time in malaria mortality, previously used for other causes of mortality including breast and cervical cancer. Researchers used all available data for deaths due to malaria, correcting for known biases in the data, including misclassification of deaths to causes other than malaria. Data were also obtained from countries’ vital registration systems and verbal autopsy studies. The researchers tested many different models for analyzing the data, including ensemble models, which are weighted averages of individual component models. Murray CJL, Rosenfeld LC, Lim SS, Andrews KG, Foreman KJ, Haring D, Fullman N, Naghavi M, Lozano R, Lopez AD. Global malaria mortality between 1980 and 2010: a systematic analysis. The Lancet, February 2012

Kate Muller, IHME Communications

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ripple effect

IHME provides expertise, tools for ambitious Latin American health initiative IHME has been key to the success of the Salud Mesoamérica 2015 Initiative, a project poised to improve the health of millions of people throughout southern Mexico and Central America. Dr. Bernardo Hernández Prado helped lead a team of researchers that wrote the blueprint that would become one of the foundational elements of Salud Mesoamérica. They proposed as a regional goal to lower maternal and neonatal mortality and recommended a five-year plan for rolling out health interventions, including skilled birth attendance, family planning, and emergency care. The Inter-American Development Bank (IDB) liked the plan and adapted it for the Salud Mesoamérica 2015 Initiative. “We wanted to set goals that were ambitious but also realistic for countries with a lot of competing priorities,” Dr. Hernández Prado said. “It was very gratifying to see that our recommendations were adopted almost in their entirety and now are being put into action.” Funded by IDB, the Carlos Slim Health Institute, the Bill & Melinda Gates Foundation, and the government of Spain, the initiative supports efforts to improve health system performance and build capacity in eight countries: El Salvador, Guatemala, Honduras, Nicaragua, Belize, Costa Rica, Panama, and Chiapas, Mexico. IHME began developing household and health facility surveys in 2010 as part of the initiative. Researchers will use data from the surveys in combination with other sources to measure coverage of key interventions in nutrition, immunization, and maternal and child health. “One of our biggest challenges is finding the right way to capture all the necessary information in what are often resourcepoor settings,” said Dr. Gulnoza Usmanova, an IHME Post-Graduate Fellow who has been designing the surveys for the

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Dr. Ali Mokdad (right) conducted a fact-finding visit to Guatemala as part of IHME’s work on the Salud Mesoamérica 2015 Initiative.

initiative. “We are trying a combination of time-tested techniques and innovative tools to overcome that challenge.” Once IHME has established a health status baseline, researchers will begin measuring improvements in health over time. If the countries meet the targets set by the initiative, they will be rewarded with funding from the initiative. “We might say, for example, that a country’s immunization rate for children is at 60%, but all of the science tells us it should be at 75%. If a country can make that target, they will get a payment,” said Dr. Ali Mokdad, the head of IHME’s Integrated Surveillance Systems research team. “This is an incredible opportunity to improve the health of a very broad population.”

William Heisel, IHME Communications

IHME researchers visited Nicaragua to measure coverage of key interventions in maternal and child health.

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IHME Impact May 2012