- Email: [email protected]
Improving health statistics in Africa
Comment
Improving health statistics in Africa
www.thelancet.com Vol 370 November 3, 2007
officials who allocate resources for health budgets in such countries are essentially working in the dark. The low quality of statistics results in adverse outcomes, such as underfunding and poor monitoring of many development programmes. This Series highlights the importance of improving health statistics with an emphasis on civil registration systems, which provide records of births, deaths, and the causes of death. We agree with the Series authors that many developing countries and donor agencies have not adequately made a priority of collecting health or social data, compared with other statistical systems for gathering economic data. Data on gross domestic product and inflation in most developing countries are probably better estimated than for maternal mortality rates. In our experience, the quality of social statistics (compiled by both governmental and international agencies) in countries such as Nigeria is wanting. For example, we question data for the low life-expectancy (at birth) in Nigeria of about 47 years,6 which in our view underestimates the empirical reality. Casual empiricism based on our observations in various parts of Nigeria suggests that life expectancy tends to be a few years higher, particularly given Nigeria’s low and declining HIV/AIDS prevalence rates compared with other African countries. Strengthening statistical capacity in developing countries will need a concerted effort from governments
See Comment page 1526 See Perspectives page 1537 See Series page 1569
The printed journal includes an image merely for illustration Panos Pictures
The Lancet’s Who Counts? Series1–4 raises important issues about the relevance of statistics for effective health-care delivery in developing countries. The availability of statistics is crucial in the fight against poverty, and is a necessary starting point to quantify outcomes needed to monitor and measure progress towards the Millennium Development Goals. The lack of reliable and good-quality statistics is a major obstacle to assessment of changes in development indicators in many African countries. In particular, health indicators remain of major concern: many African countries with inadequate statistical capacity and measurement systems are also some of the countries worst hit by deadly diseases such as HIV/AIDS and malaria. The lack of health statistics ranges from poor systems for civil registration to poor data on immunisation and child mortality rates. A World Bank review of 125 middle-income and low-income countries with populations greater than 1 million illustrates this point.5 The countries were assessed for adherence to key international statistical methods and standards of good practices. About 60 countries in the survey—most in sub-Saharan Africa, except for Afghanistan—did not reach the midpoint score. Additionally, the World Bank noted that half the population of African countries had not recently been included in a census. The absence of statistics in many African countries is both a symptom and a cause of underdevelopment. Improvement of statistical systems is crucial in developing countries for three main reasons. First, without adequate capacity for obtaining statistics, assessment of the magnitude of the development problems to be faced is often impossible. Second, if we get the numbers wrong, tackling development problems effectively is difficult. Scaling up of interventions becomes difficult and resources might be allocated away from more pressing issues. Thus, in this case, we risk solving the wrong problem or solving a problem in the wrong way. Third, without adequate statistics, assessment of the effectiveness of various programmes after implementation becomes difficult. The absence of statistics has immediate implications for policymakers. In many African countries, evidence about the prevalence of child and maternal mortality and about the lack of access to health services is anecdotal. Yet without reliable information, government
Birth registration in Agadez, Niger
1527
Comment
there, from donors, and from multilateral institutions. Governments and donors must view reliable data as an important tool in the development process, and must invest both financial and human resources in strengthening their statistical systems. The Who Counts? Series is therefore most welcome, especially if it can spark a broader debate about the importance of statistics in development.
1
*Ngozi Okonjo-Iweala, Philip Osafo-Kwaako
6
Brookings Institution, Washington, DC 20036, USA [email protected]
2
3
4 5
Setel PW, Macfarlane SB, Szretzer S, on behalf of the Monitoring of Vital Events (MoVE) writing group. A scandal of invisibility: making everyone count by counting everyone. Lancet 2007; 370: 1569–77. Mahapatra P, Shibuya K, Lopez AD, et al. Civil registration systems and vital statistics: successes and missed opportunities. Lancet 2007; published online Oct 29, 2007. DOI 10.1016/S0140-6736(07)61308-7. Hill K, Lopez AD, Shibuya, et al. Interim measures for meeting needs for health sector data: births, deaths, and causes of death. Lancet 2007; published online Oct 29, 2007. DOI 10.1016/S0140-6736(07)61309-9. AbouZahr C, Cleland, J, Coullare F, et al. The way forward. Lancet 2007; published online Oct 29, 2007. DOI 10.1016/S0140-6736(07)61310-5. World Bank. Building statistical capacity to monitor development progress. 2002. http://siteresources.worldbank.org/SCBINTRANET/Resources/ 239410-1113334813340/board-paper-feb4.pdf (accessed Oct 29, 2007). World Bank. World development indicators database. 2007. http://web. worldbank.org/WBSITE/EXTERNAL/DATASTATISTICS/0,,contentMDK: 21298138~pagePK:64133150~piPK:64133175~theSitePK:239419,00.html (accessed Oct 29, 2007).
We declare that we have no conflict of interest.
Crown Copyright
Obesity plan lacks foresight
See Editorial page 1521
1528
If words were eaten and not read, the UK Government would have developed the perfect tool for fighting the world’s escalating obesity epidemic. The Tackling obesities—future choices report,1 issued on Oct 17, 2007, by its Foresight programme (part of the Office for Science), is so indigestible that readers will need strong stomachs to get beyond the first page. Try this convoluted example, from the executive summary, and more worthy of a New Age management consultant than a modern governmental department: “The central dynamic of the obesity system is a positive feedback cycle that locks us into a pattern of positive energy balance as individuals and at a societal level.” The convoluted centrepiece graphic (map 27) of weighted causal linkages, described by a colleague as resembling rhinoceros’ intestines, seems to have no practical value. In a very complex way, the graphic simply makes the banal point that the many factors that contribute to obesity all influence each other. The main 162-page report, and several accompanying publications, are a triumph of vapid political style and flabby prose over meaningful substance. That does not bode well for a new approach to policy generally—not to mention public health—under Prime Minister Gordon Brown’s fledgling administration, after the spin-led style of his predecessor, Tony Blair. This state of affairs is pitiful, because there is no doubt about the urgency of the need to reverse obesity, and hidden away in the document and its supporting references is the collective work of 250 scientists over the past 2 years, which
summarises current understanding and highlights the challenges ahead. Yet, the launch of the report was a lesson in poor communication, and of packaging for political expediency. At the press conference to release the report, Dawn Primarolo, the Minister for Public Health, became the latest official to spout the triumphalist governmental claim that the UK is “leading the world” in its work on obesity. That claim is both questionable and unnecessary, just as much as others made in recent months on issues as diverse as hospital-acquired meticillin-resistant Staphylococcus aureus and preparations for pandemic influenza. The trumpeting of redoubled governmental commitment also sat uneasily with the news, which slipped out discreetly a few days before Tackling obesities was released (and later reported2), that the UK had backtracked on a previous target unveiled in 2004 to reduce the proportion of obese and overweight children by 2010 to 2000 levels. The deadline for that goal is now 2020. Health and science correspondents from leading UK media who attended the Foresight press conference left no better enlightened about or equipped for efforts to tackle obesity than the additional physical exercise offered to them by walking away with the bulky briefing documents. Health correspondents are not a particularly cynical group, but several were exasperated in their efforts to find a fresh angle to report. One reason was that the www.thelancet.com Vol 370 November 3, 2007
Improving health statistics in Africa
www.thelancet.com Vol 370 November 3, 2007
officials who allocate resources for health budgets in such countries are essentially working in the dark. The low quality of statistics results in adverse outcomes, such as underfunding and poor monitoring of many development programmes. This Series highlights the importance of improving health statistics with an emphasis on civil registration systems, which provide records of births, deaths, and the causes of death. We agree with the Series authors that many developing countries and donor agencies have not adequately made a priority of collecting health or social data, compared with other statistical systems for gathering economic data. Data on gross domestic product and inflation in most developing countries are probably better estimated than for maternal mortality rates. In our experience, the quality of social statistics (compiled by both governmental and international agencies) in countries such as Nigeria is wanting. For example, we question data for the low life-expectancy (at birth) in Nigeria of about 47 years,6 which in our view underestimates the empirical reality. Casual empiricism based on our observations in various parts of Nigeria suggests that life expectancy tends to be a few years higher, particularly given Nigeria’s low and declining HIV/AIDS prevalence rates compared with other African countries. Strengthening statistical capacity in developing countries will need a concerted effort from governments
See Comment page 1526 See Perspectives page 1537 See Series page 1569
The printed journal includes an image merely for illustration Panos Pictures
The Lancet’s Who Counts? Series1–4 raises important issues about the relevance of statistics for effective health-care delivery in developing countries. The availability of statistics is crucial in the fight against poverty, and is a necessary starting point to quantify outcomes needed to monitor and measure progress towards the Millennium Development Goals. The lack of reliable and good-quality statistics is a major obstacle to assessment of changes in development indicators in many African countries. In particular, health indicators remain of major concern: many African countries with inadequate statistical capacity and measurement systems are also some of the countries worst hit by deadly diseases such as HIV/AIDS and malaria. The lack of health statistics ranges from poor systems for civil registration to poor data on immunisation and child mortality rates. A World Bank review of 125 middle-income and low-income countries with populations greater than 1 million illustrates this point.5 The countries were assessed for adherence to key international statistical methods and standards of good practices. About 60 countries in the survey—most in sub-Saharan Africa, except for Afghanistan—did not reach the midpoint score. Additionally, the World Bank noted that half the population of African countries had not recently been included in a census. The absence of statistics in many African countries is both a symptom and a cause of underdevelopment. Improvement of statistical systems is crucial in developing countries for three main reasons. First, without adequate capacity for obtaining statistics, assessment of the magnitude of the development problems to be faced is often impossible. Second, if we get the numbers wrong, tackling development problems effectively is difficult. Scaling up of interventions becomes difficult and resources might be allocated away from more pressing issues. Thus, in this case, we risk solving the wrong problem or solving a problem in the wrong way. Third, without adequate statistics, assessment of the effectiveness of various programmes after implementation becomes difficult. The absence of statistics has immediate implications for policymakers. In many African countries, evidence about the prevalence of child and maternal mortality and about the lack of access to health services is anecdotal. Yet without reliable information, government
Birth registration in Agadez, Niger
1527
Comment
there, from donors, and from multilateral institutions. Governments and donors must view reliable data as an important tool in the development process, and must invest both financial and human resources in strengthening their statistical systems. The Who Counts? Series is therefore most welcome, especially if it can spark a broader debate about the importance of statistics in development.
1
*Ngozi Okonjo-Iweala, Philip Osafo-Kwaako
6
Brookings Institution, Washington, DC 20036, USA [email protected]
2
3
4 5
Setel PW, Macfarlane SB, Szretzer S, on behalf of the Monitoring of Vital Events (MoVE) writing group. A scandal of invisibility: making everyone count by counting everyone. Lancet 2007; 370: 1569–77. Mahapatra P, Shibuya K, Lopez AD, et al. Civil registration systems and vital statistics: successes and missed opportunities. Lancet 2007; published online Oct 29, 2007. DOI 10.1016/S0140-6736(07)61308-7. Hill K, Lopez AD, Shibuya, et al. Interim measures for meeting needs for health sector data: births, deaths, and causes of death. Lancet 2007; published online Oct 29, 2007. DOI 10.1016/S0140-6736(07)61309-9. AbouZahr C, Cleland, J, Coullare F, et al. The way forward. Lancet 2007; published online Oct 29, 2007. DOI 10.1016/S0140-6736(07)61310-5. World Bank. Building statistical capacity to monitor development progress. 2002. http://siteresources.worldbank.org/SCBINTRANET/Resources/ 239410-1113334813340/board-paper-feb4.pdf (accessed Oct 29, 2007). World Bank. World development indicators database. 2007. http://web. worldbank.org/WBSITE/EXTERNAL/DATASTATISTICS/0,,contentMDK: 21298138~pagePK:64133150~piPK:64133175~theSitePK:239419,00.html (accessed Oct 29, 2007).
We declare that we have no conflict of interest.
Crown Copyright
Obesity plan lacks foresight
See Editorial page 1521
1528
If words were eaten and not read, the UK Government would have developed the perfect tool for fighting the world’s escalating obesity epidemic. The Tackling obesities—future choices report,1 issued on Oct 17, 2007, by its Foresight programme (part of the Office for Science), is so indigestible that readers will need strong stomachs to get beyond the first page. Try this convoluted example, from the executive summary, and more worthy of a New Age management consultant than a modern governmental department: “The central dynamic of the obesity system is a positive feedback cycle that locks us into a pattern of positive energy balance as individuals and at a societal level.” The convoluted centrepiece graphic (map 27) of weighted causal linkages, described by a colleague as resembling rhinoceros’ intestines, seems to have no practical value. In a very complex way, the graphic simply makes the banal point that the many factors that contribute to obesity all influence each other. The main 162-page report, and several accompanying publications, are a triumph of vapid political style and flabby prose over meaningful substance. That does not bode well for a new approach to policy generally—not to mention public health—under Prime Minister Gordon Brown’s fledgling administration, after the spin-led style of his predecessor, Tony Blair. This state of affairs is pitiful, because there is no doubt about the urgency of the need to reverse obesity, and hidden away in the document and its supporting references is the collective work of 250 scientists over the past 2 years, which
summarises current understanding and highlights the challenges ahead. Yet, the launch of the report was a lesson in poor communication, and of packaging for political expediency. At the press conference to release the report, Dawn Primarolo, the Minister for Public Health, became the latest official to spout the triumphalist governmental claim that the UK is “leading the world” in its work on obesity. That claim is both questionable and unnecessary, just as much as others made in recent months on issues as diverse as hospital-acquired meticillin-resistant Staphylococcus aureus and preparations for pandemic influenza. The trumpeting of redoubled governmental commitment also sat uneasily with the news, which slipped out discreetly a few days before Tackling obesities was released (and later reported2), that the UK had backtracked on a previous target unveiled in 2004 to reduce the proportion of obese and overweight children by 2010 to 2000 levels. The deadline for that goal is now 2020. Health and science correspondents from leading UK media who attended the Foresight press conference left no better enlightened about or equipped for efforts to tackle obesity than the additional physical exercise offered to them by walking away with the bulky briefing documents. Health correspondents are not a particularly cynical group, but several were exasperated in their efforts to find a fresh angle to report. One reason was that the www.thelancet.com Vol 370 November 3, 2007