Emmanuela Gakidou

Publications of Emmanuela Gakidou

• Effectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: a nationally representative observational study.

  Authors: Farshad Farzadfar, Christopher J L Murray, Emmanuela Gakidou, Thomas Bossert, Hengameh Namdaritabar, Siamak Alikhani, Ghobad Moradi, Alireza Delavari, Hamidreza Jamshidi, Majid Ezzati

  Lancet. 12/2011; 379(9810):47-54.

  Non-communicable diseases and their risk factors are leading causes of disease burden in Iran and other middle-income countries. Little evidence exists for whether the primary health-care system canNon-communicable diseases and their risk factors are leading causes of disease burden in Iran and other middle-income countries. Little evidence exists for whether the primary health-care system can effectively manage non-communicable diseases and risk factors at the population level. Our aim was to examine the effectiveness of the Iranian rural primary health-care system (the Behvarz system) in the management of diabetes and hypertension, and to assess whether the effects depend on the number of health-care workers in the community. We used individual-level data from the 2005 Non-Communicable Disease Surveillance Survey (NCDSS) for fasting plasma glucose (FPG) and systolic blood pressure (SBP), body-mass index, medication use, and sociodemographic variables. Data for Behvarz-worker and physician densities were from the 2006 Population and Housing Census and the 2005 Outpatient Care Centre Mapping Survey. We assessed the effectiveness of treatment on FPG and SBP, and associations between FPG or SBP and Behvarz-worker density with two statistical approaches: a mixed-effects regression analysis of the full NCDSS sample adjusting for individual-level and community-level covariates and an analysis that estimated average treatment effect on data balanced with propensity score matching. NCDSS had data for 65,619 individuals aged 25 years or older (11,686 of whom in rural areas); of these, 64,694 (11,521 in rural areas) had data for SBP and 50,202 (9337 in rural areas) had data for FPG. Nationally, 39·2% (95% CI 37·7 to 40·7) of individuals with diabetes and 35·7% (34·9 to 36·5) of those with hypertension received treatment, with higher treatment coverage in women than in men and in urban areas than in rural areas. Treatment lowered mean FPG by an estimated 1·34 mmol/L (0·58 to 2·10) in rural areas and 0·21 mmol/L (-0·15 to 0·56) in urban areas. Individuals in urban areas with hypertension who received treatment had 3·8 mm Hg (3·1 to 4·5) lower SBP than they would have had if they had not received treatment; the treatment effect was 2·5 mm Hg (1·1 to 3·9) lower FPG in rural areas. Each additional Behvarz worker per 1000 adults was associated with a 0·09 mmol/L (0·01 to 0·18) lower district-level average FPG (p=0·02); for SBP this effect was 0·53 mm Hg (-0·44 to 1·50; p=0·28). Our findings were not sensitive to the choice of statistical method. Primary care systems with trained community health-care workers and well established guidelines can be effective in non-communicable disease prevention and management. Iran's primary care system should expand the number and scope of its primary health-care worker programmes to also address blood pressure and to improve performance in areas with few primary care personnel. None.

• Assessment of population-level effect of Avahan, an HIV-prevention initiative in India.

  Authors: Marie Ng, Emmanuela Gakidou, Alison Levin-Rector, Ajay Khera, Christopher J L Murray, Lalit Dandona

  Lancet. 11/2011; 378(9803):1643-52.

  The aim of Avahan, the India AIDS Initiative, was to reduce HIV transmission in the general population through large-scale prevention interventions focused on high-risk groups. It was launched inThe aim of Avahan, the India AIDS Initiative, was to reduce HIV transmission in the general population through large-scale prevention interventions focused on high-risk groups. It was launched in 2003 in six states with a total population of 300 million and a high HIV burden. We assessed the population-level effect of the first phase of Avahan (2003-08). Population prevalence was estimated by use of adjustment factors from the national HIV sentinel surveillance data obtained annually from antenatal clinics. A mixed-effects multilevel regression model was developed to estimate the association between intervention intensity and population HIV prevalence trends, taking into account differences in the underlying epidemic trends in states and other potential confounders, and to estimate the number of HIV infections averted with Avahan. 80 (61%) of 131 districts in the six Avahan states received funding from Avahan for HIV prevention, as the only or shared source. Greater intensity of Avahan, measured as amount of grant per HIV population (medians US$24-432 in the six states), was significantly associated with lower HIV prevalence in Andhra Pradesh (p=0·004), Karnataka (p=0·004), and Maharashtra (p=0·008) states; this association was not significant in Tamil Nadu (p=0·06), Manipur (p=0·62), and Nagaland (p=0·67). Overall, we estimated that 100,178 HIV infections (95% CI 25,897-207,713) were averted at the population level from 2003 up to 2008 as a result of Avahan. The results of our analysis suggest that Avahan had a beneficial effect in reducing HIV prevalence at the population level over 5 years of programme implementation in some of the states. With stagnating funding for HIV prevention globally, our findings support investment in well planned and managed HIV prevention programmes in low-income and middle-income countries. Bill & Melinda Gates Foundation.

• Net benefits: a multicountry analysis of observational data examining associations between insecticide-treated mosquito nets and health outcomes.

  Authors: Stephen S Lim, Nancy Fullman, Andrew Stokes, Nirmala Ravishankar, Felix Masiye, Christopher J L Murray, Emmanuela Gakidou

  PLoS medicine. 09/2011; 8(9):e1001091.

  Several sub-Saharan African countries have rapidly scaled up the number of households that own insecticide-treated mosquito nets (ITNs). Although the efficacy of ITNs in trials has been shown,Several sub-Saharan African countries have rapidly scaled up the number of households that own insecticide-treated mosquito nets (ITNs). Although the efficacy of ITNs in trials has been shown, evidence on their impact under routine conditions is limited to a few countries and the extent to which the scale-up of ITNs has improved population health remains uncertain. We used matched logistic regression to assess the individual-level association between household ITN ownership or use in children under 5 years of age and the prevalence of parasitemia among children using six malaria indicator surveys (MIS) and one demographic and health survey. We used Cox proportional hazards models to assess the relationship between ITN household ownership and child mortality using 29 demographic and health surveys. The pooled relative reduction in parasitemia prevalence from random effects meta-analysis associated with household ownership of at least one ITN was 20% (95% confidence interval [CI] 3%-35%; I² = 73.5%, p<0.01 for I² value). Sleeping under an ITN was associated with a pooled relative reduction in parasitemia prevalence in children of 24% (95% CI 1%-42%; I² = 79.5%, p<0.001 for I² value). Ownership of at least one ITN was associated with a pooled relative reduction in mortality between 1 month and 5 years of age of 23% (95% CI 13-31%; I² = 25.6%, p>0.05 for I² value). Our findings across a number of sub-Saharan African countries were highly consistent with results from previous clinical trials. These findings suggest that the recent scale-up in ITN coverage has likely been accompanied by significant reductions in child mortality and that additional health gains could be achieved with further increases in ITN coverage in populations at risk of malaria. Please see later in the article for the Editors' Summary.

• Management of diabetes and associated cardiovascular risk factors in seven countries: a comparison of data from national health examination surveys.

  Authors: Emmanuela Gakidou, Leslie Mallinger, Jesse Abbott-Klafter, Ramiro Guerrero, Salvador Villalpando, Ruy Lopez Ridaura, Wichai Aekplakorn, Mohsen Naghavi, Stephen Lim, Rafael Lozano, Christopher J L Murray

  Bulletin of the World Health Organization. 03/2011; 89(3):172-83.

  To examine the effectiveness of the health system response to the challenge of diabetes across different settings and explore the inequalities in diabetes care that are attributable to socioeconomicTo examine the effectiveness of the health system response to the challenge of diabetes across different settings and explore the inequalities in diabetes care that are attributable to socioeconomic factors. We used nationally representative health examination surveys from Colombia, England, the Islamic Republic of Iran, Mexico, Scotland, Thailand and the United States of America to obtain data on diagnosis, treatment and control of hyperglycaemia, arterial hypertension and hypercholesterolaemia among individuals with diabetes. Using logistic regression, we explored the socioeconomic determinants of diagnosis and effective case management. A substantial proportion of individuals with diabetes remain undiagnosed and untreated, both in developed and developing countries. The figures range from 24% of the women in Scotland and the USA to 62% of the men in Thailand. The proportion of individuals with diabetes reaching treatment targets for blood glucose, arterial blood pressure and serum cholesterol was very low, ranging from 1% of male patients in Mexico to about 12% in the United States. Income and education were not found to be significantly related to the rates of diagnosis and treatment anywhere except in Thailand, but in the three countries with available data insurance status was a strong predictor of diagnosis and effective management, especially in the United States. There are many missed opportunities to reduce the burden of diabetes through improved control of blood glucose levels and improved diagnosis and treatment of arterial hypertension and hypercholesterolaemia. While no large socioeconomic inequalities were noted in the management of individuals with diabetes, financial access to care was a strong predictor of diagnosis and management.

• Improving the public health utility of global cardiovascular mortality data: the rise of ischemic heart disease.

  Authors: Ryan M Ahern, Rafael Lozano, Mohsen Naghavi, Kyle Foreman, Emmanuela Gakidou, Christopher Jl Murray

  Population health metrics. 03/2011; 9:8.

  High-quality, cause-specific mortality data are critical for effective health policy. Yet vague cause of death codes, such as heart failure, are highly prevalent in global mortality data. We proposeHigh-quality, cause-specific mortality data are critical for effective health policy. Yet vague cause of death codes, such as heart failure, are highly prevalent in global mortality data. We propose an empirical method correcting mortality data for the use of heart failure as an underlying cause of death. We performed a regression analysis stratified by sex, age, and country development status on all available ICD-10 mortality data, consisting of 142 million deaths across 838 country-years. The analysis yielded predicted fractions with which to redistribute heart failure-attributed deaths to the appropriate underlying causes of death. Age-adjusted death rates and rank causes of death before and after correction were calculated. Heart failure accounts for 3.1% of all deaths in the dataset. Ischemic heart disease has the highest redistribution proportion for ages 15-49 and 50+ in both sexes and country development levels, causing gains in age-adjusted death rates in both developed and developing countries. COPD and hypertensive heart disease also make significant rank gains. Reproductive-aged women in developing country-years yield the most diverse range of heart failure causes. Ischemic heart disease becomes the No. 1 cause of death in several developed countries, including France and Japan, underscoring the cardiovascular epidemic in high-income countries. Age-adjusted death rate increases for ischemic heart disease in low- and middle-income countries, such as Argentina and South Africa, highlight the rise of the cardiovascular epidemic in regions where public health efforts have historically focused on infectious diseases. This method maximizes the use of available data, providing better evidence on major causes of death to inform policymakers in allocating finite resources.

• What do children die from in India today?

  Authors: Emmanuela Gakidou, Alan D Lopez

  Lancet. 11/2010; 376(9755):1810-1.

• Increased educational attainment and its effect on child mortality in 175 countries between 1970 and 2009: a systematic analysis.

  Authors: Emmanuela Gakidou, Krycia Cowling, Rafael Lozano, Christopher J L Murray

  Lancet. 09/2010; 376(9745):959-74.

  In addition to the inherent importance of education and its essential role in economic growth, education and health are strongly related. We updated previous systematic assessments of educationalIn addition to the inherent importance of education and its essential role in economic growth, education and health are strongly related. We updated previous systematic assessments of educational attainment, and estimated the contribution of improvements in women's education to reductions in child mortality in the past 40 years. We compiled 915 censuses and nationally representative surveys, and estimated mean number of years of education by age and sex. By use of a first-differences model, we investigated the association between child mortality and women's educational attainment, controlling for income per person and HIV seroprevalence. We then computed counterfactual estimates of child mortality for every country year between 1970 and 2009. The global mean number of years of education increased from 4·7 years (95% uncertainty interval 4·4-5·1) to 8·3 years (8·0-8·6) for men (aged ≥25 years) and from 3·5 years (3·2-3·9) to 7·1 years (6·7 -7·5) for women (aged ≥25 years). For women of reproductive age (15-44 years) in developing countries, the years of schooling increased from 2·2 years (2·0-2·4) to 7·2 years (6·8-7·6). By 2009, in 87 countries, women (aged 25-34 years) had higher educational attainment than had men (aged 25-34 years). Of 8·2 million fewer deaths in children younger than 5 years between 1970 and 2009, we estimated that 4·2 million (51·2%) could be attributed to increased educational attainment in women of reproductive age. The substantial increase in education, especially of women, and the reversal of the gender gap have important implications not only for health but also for the status and roles of women in society. The continued increase in educational attainment even in some of the poorest countries suggests that rapid progress in terms of Millennium Development Goal 4 might be possible. Bill & Melinda Gates Foundation.

• India's Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation.

  Authors: Stephen S Lim, Lalit Dandona, Joseph A Hoisington, Spencer L James, Margaret C Hogan, Emmanuela Gakidou

  Lancet. 06/2010; 375(9730):2009-23.

  In 2005, with the goal of reducing the numbers of maternal and neonatal deaths, the Government of India launched Janani Suraksha Yojana (JSY), a conditional cash transfer scheme, to incentivise womenIn 2005, with the goal of reducing the numbers of maternal and neonatal deaths, the Government of India launched Janani Suraksha Yojana (JSY), a conditional cash transfer scheme, to incentivise women to give birth in a health facility. We independently assessed the effect of JSY on intervention coverage and health outcomes. We used data from the nationwide district-level household surveys done in 2002-04 and 2007-09 to assess receipt of financial assistance from JSY as a function of socioeconomic and demographic characteristics; and used three analytical approaches (matching, with-versus-without comparison, and differences in differences) to assess the effect of JSY on antenatal care, in-facility births, and perinatal, neonatal, and maternal deaths. Implementation of JSY in 2007-08 was highly variable by state-from less than 5% to 44% of women giving birth receiving cash payments from JSY. The poorest and least educated women did not always have the highest odds of receiving JSY payments. JSY had a significant effect on increasing antenatal care and in-facility births. In the matching analysis, JSY payment was associated with a reduction of 3.7 (95% CI 2.2-5.2) perinatal deaths per 1000 pregnancies and 2.3 (0.9-3.7) neonatal deaths per 1000 livebirths. In the with-versus-without comparison, the reductions were 4.1 (2.5-5.7) perinatal deaths per 1000 pregnancies and 2.4 (0.7-4.1) neonatal deaths per 1000 livebirths. The findings of this assessment are encouraging, but they also emphasise the need for improved targeting of the poorest women and attention to quality of obstetric care in health facilities. Continued independent monitoring and evaluations are important to measure the effect of JSY as financial and political commitment to the programme intensifies. Bill & Melinda Gates Foundation.

• Measuring adult mortality using sibling survival: a new analytical method and new results for 44 countries, 1974-2006.

  Authors: Ziad Obermeyer, Julie Knoll Rajaratnam, Chang H Park, Emmanuela Gakidou, Margaret C Hogan, Alan D Lopez, Christopher J L Murray

  PLoS medicine. 04/2010; 7(4):e1000260.

  For several decades, global public health efforts have focused on the development and application of disease control programs to improve child survival in developing populations. The need to reliablyFor several decades, global public health efforts have focused on the development and application of disease control programs to improve child survival in developing populations. The need to reliably monitor the impact of such intervention programs in countries has led to significant advances in demographic methods and data sources, particularly with large-scale, cross-national survey programs such as the Demographic and Health Surveys (DHS). Although no comparable effort has been undertaken for adult mortality, the availability of large datasets with information on adult survival from censuses and household surveys offers an important opportunity to dramatically improve our knowledge about levels and trends in adult mortality in countries without good vital registration. To date, attempts to measure adult mortality from questions in censuses and surveys have generally led to implausibly low levels of adult mortality owing to biases inherent in survey data such as survival and recall bias. Recent methodological developments and the increasing availability of large surveys with information on sibling survival suggest that it may well be timely to reassess the pessimism that has prevailed around the use of sibling histories to measure adult mortality. We present the Corrected Sibling Survival (CSS) method, which addresses both the survival and recall biases that have plagued the use of survey data to estimate adult mortality. Using logistic regression, our method directly estimates the probability of dying in a given country, by age, sex, and time period from sibling history data. The logistic regression framework borrows strength across surveys and time periods for the estimation of the age patterns of mortality, and facilitates the implementation of solutions for the underrepresentation of high-mortality families and recall bias. We apply the method to generate estimates of and trends in adult mortality, using the summary measure (45)q(15)-the probability of a 15-y old dying before his or her 60th birthday-for 44 countries with DHS sibling survival data. Our findings suggest that levels of adult mortality prevailing in many developing countries are substantially higher than previously suggested by other analyses of sibling history data. Generally, our estimates show the risk of adult death between ages 15 and 60 y to be about 20%-35% for females and 25%-45% for males in sub-Saharan African populations largely unaffected by HIV. In countries of Southern Africa, where the HIV epidemic has been most pronounced, as many as eight out of ten men alive at age 15 y will be dead by age 60, as will six out of ten women. Adult mortality levels in populations of Asia and Latin America are generally lower than in Africa, particularly for women. The exceptions are Haiti and Cambodia, where mortality risks are comparable to many countries in Africa. In all other countries with data, the probability of dying between ages 15 and 60 y was typically around 10% for women and 20% for men, not much higher than the levels prevailing in several more developed countries. Our results represent an expansion of direct knowledge of levels and trends in adult mortality in the developing world. The CSS method provides grounds for renewed optimism in collecting sibling survival data. We suggest that all nationally representative survey programs with adequate sample size ought to implement this critical module for tracking adult mortality in order to more reliably understand the levels and patterns of adult mortality, and how they are changing. Please see later in the article for the Editors' Summary.

• Exploring the determinants of unsafe abortion: improving the evidence base in Mexico.

  Authors: Angelica Sousa, Rafael Lozano, Emmanuela Gakidou

  Health policy and planning. 12/2009;

  BACKGROUND Despite the realized importance of unsafe abortion as a global health problem, reliable data are difficult to obtain, especially in countries where abortion is illegal. Estimates for mostBACKGROUND Despite the realized importance of unsafe abortion as a global health problem, reliable data are difficult to obtain, especially in countries where abortion is illegal. Estimates for most developing countries are based on limited and incomplete sources of data. In Mexico, studies have been undertaken to improve estimates of induced abortion but the determinants of unsafe abortion have not been explored. METHODS We analysed data from the 2006 Mexican National Demographic Survey. The sample comprises 14 859 reported pregnancies in women between 15 and 55 years old, of which 966 report having had an abortion in the 5 years preceding the survey. We use logistic regression to explore the relationship between unsafe abortion and various socio-economic and demographic characteristics. Findings We estimate that 44% of abortions have been induced and 16.5% of those were unsafe. We find three variables to be positively and significantly associated with the probability of having an induced abortion: (1) whether the woman reported that the pregnancy was mistimed (OR = 4.5, 95% CI = 1.95-10.95); (2) whether the woman reported that the pregnancy was unwanted (OR = 2.86, 95% CI = -1.40-5.88); and (3) if the woman had three or more children at the time of the abortion (OR = 3.73, 95% CI = 1.20-11.65). There is a steep socio-economic gradient in the probability of having an unsafe abortion: poorer women are more likely to have an unsafe abortion than richer women (OR = 2.48, 95% CI = 1.09-5.63); women with 6-9 years of education (OR = 0.30, 95% CI = 0.11-0.81) and with more than 13 years of education are less likely to have an unsafe abortion (OR = 0.065, 95% CI = 0.01-0.43), and women with indigenous origin are more likely to have an unsafe abortion (OR = 5.44, 95% CI = 1.91-15.51). Thus, the probability for poor women with less than 5 years of education and indigenous origin is nine times higher compared with rich, educated and not indigenous women. We also find marked geographical inequities as women living in the poorest states have a higher risk of having an unsafe abortion. Interpretation This analysis has explored the determinants of unsafe abortion and has demonstrated that there are large socio-economic and geographical inequities in unsafe abortions in Mexico. Further efforts are required to improve the measurement and monitoring of trends in unsafe abortions in developing countries.

• Public policy for the poor? A randomised assessment of the Mexican universal health insurance programme.

  Authors: Gary King, Emmanuela Gakidou, Kosuke Imai, Jason Lakin, Ryan T Moore, Clayton Nall, Nirmala Ravishankar, Manett Vargas, Martha María Téllez-Rojo, Juan Eugenio Hernández Avila, Mauricio Hernández-Avila, Héctor Hernández Llamas

  Lancet. 05/2009;

  BACKGROUND: We assessed aspects of Seguro Popular, a programme aimed to deliver health insurance, regular and preventive medical care, medicines, and health facilities to 50 million uninsuredBACKGROUND: We assessed aspects of Seguro Popular, a programme aimed to deliver health insurance, regular and preventive medical care, medicines, and health facilities to 50 million uninsured Mexicans. METHODS: We randomly assigned treatment within 74 matched pairs of health clusters-ie, health facility catchment areas-representing 118 569 households in seven Mexican states, and measured outcomes in a 2005 baseline survey (August, 2005, to September, 2005) and follow-up survey 10 months later (July, 2006, to August, 2006) in 50 pairs (n=32 515). The treatment consisted of encouragement to enrol in a health-insurance programme and upgraded medical facilities. Participant states also received funds to improve health facilities and to provide medications for services in treated clusters. We estimated intention to treat and complier average causal effects non-parametrically. FINDINGS: Intention-to-treat estimates indicated a 23% reduction from baseline in catastrophic expenditures (1.9% points; 95% CI 0.14-3.66). The effect in poor households was 3.0% points (0.46-5.54) and in experimental compliers was 6.5% points (1.65-11.28), 30% and 59% reductions, respectively. The intention-to-treat effect on health spending in poor households was 426 pesos (39-812), and the complier average causal effect was 915 pesos (147-1684). Contrary to expectations and previous observational research, we found no effects on medication spending, health outcomes, or utilisation. INTERPRETATION: Programme resources reached the poor. However, the programme did not show some other effects, possibly due to the short duration of treatment (10 months). Although Seguro Popular seems to be successful at this early stage, further experiments and follow-up studies, with longer assessment periods, are needed to ascertain the long-term effects of the programme. FUNDING: Mexican Ministry of Health, the National Institute of Public Health of Mexico, and Harvard University Institute for Quantitative Social Science.

• Understanding the decline of mean systolic blood pressure in Japan: an analysis of pooled data from the National Nutrition Survey, 1986-2002.

  Authors: Nayu Ikeda, Emmanuela Gakidou, Toshihiko Hasegawa, Christopher Jl Murray

  Bulletin of the World Health Organization. 01/2009; 86(12):978-88.

  OBJECTIVE: To assess the relationships between the observed drop in mean systolic blood pressure (SBP) in Japan in 1986-2002 and the use of antihypertensive treatment and lifestyle factors. METHODS:OBJECTIVE: To assess the relationships between the observed drop in mean systolic blood pressure (SBP) in Japan in 1986-2002 and the use of antihypertensive treatment and lifestyle factors. METHODS: A nationally representative sample of 90 554 men and 101 903 women aged 20 years and over was obtained from pooled data of annual cross-sectional surveys in Japan during 1986-2002. Using two-stage least squares with an instrumental variable, we examined the association between SBP and antihypertensive medication and lifestyle factors, including body mass index (BMI), physical activity, alcohol consumption, cigarette smoking and dietary salt intake. In the surveys, regular exercise was defined as exercise for more than 30 minutes at a time more than twice a week for over 1 year. Current smoking was defined as either daily or occasional cigarette use. Current drinking was defined as an intake of more than one standard cup of Japanese sake, one large bottle of regular beer, or one double measure of whisky at a time more than three times a week. Changes in mean predicted SBP in each sex and age group between 1986 and 2002 were decomposed into the respective contributions of these explanatory variables. FINDINGS: Age-specific means of predicted SBP declined during this period by 1.8 (95% confidence interval, CI: 1.2-2.5) to 3.0 (95% CI: 2.4-3.6) mmHg in men and 3.7 (95% CI: 3.4-4.1) to 5.1 (95% CI: 4.5-5.7) mmHg in women. These reductions were partly explained by the increased use of medications across all sex and age groups and decreased mean BMI in women in their 30s and 40s. The contributions of treatment effects increased with age. Elevated mean BMI in men and elderly women offset part of the decline of their mean SBP. CONCLUSION: Declining mean SBP in Japan between 1986 and 2002 was partly attributable to the increased use of antihypertensive medications, especially in the older population, and lowered mean BMI in young women. However, a substantial part of the decline was left unexplained and needs to be investigated further. A still greater decline in SBP would be expected through improvements in body weight management, salt and alcohol intake, and treatment and control of hypertension.

• Coverage of cervical cancer screening in 57 countries: low average levels and large inequalities.

  Authors: Emmanuela Gakidou, Stella Nordhagen, Ziad Obermeyer

  PLoS medicine. 07/2008; 5(6):e132.

• Fifty years of violent war deaths from Vietnam to Bosnia: analysis of data from the world health survey programme.

  Authors: Ziad Obermeyer, Christopher J L Murray, Emmanuela Gakidou

  BMJ (Clinical research ed.). 07/2008; 336(7659):1482-6.

  OBJECTIVE: To provide an accurate estimate of violent war deaths. DESIGN: Analysis of survey data on mortality, adjusted for sampling bias and censoring, from nationally representative surveysOBJECTIVE: To provide an accurate estimate of violent war deaths. DESIGN: Analysis of survey data on mortality, adjusted for sampling bias and censoring, from nationally representative surveys designed to measure population health. Estimated deaths compared with estimates in database of passive reports. SETTING: 2002-3 World health surveys, in which information was collected from one respondent per household about sibling deaths, including whether such deaths resulted from war injuries. MAIN OUTCOME MEASURE: Estimated deaths from war injuries in 13 countries over 50 years. RESULTS: From 1955 to 2002, data from the surveys indicated an estimated 5.4 million violent war deaths (95% confidence interval 3.0 to 8.7 million) in 13 countries, ranging from 7000 in the Democratic Republic of Congo to 3.8 million in Vietnam. From 1995 to 2002 survey data indicate 36,000 war deaths annually (16,000 to 71,000) in the 13 countries studied. Data from passive surveillance, however, indicated a figure of only a third of this. On the basis of the relation between world health survey data and passive reports, we estimate 378,000 globalwar deaths annually from 1985-94, the last years for which complete passive surveillance data were available. CONCLUSIONS: The use of data on sibling history from peacetime population surveys can retrospectively estimate mortality from war. War causes more deaths than previously estimated, and there is no evidence to support a recent decline in war deaths.

• Prevention of cardiovascular disease in high-risk individuals in low-income and middle-income countries: health effects and costs.

  Authors: Stephen S Lim, Thomas A Gaziano, Emmanuela Gakidou, K Srinath Reddy, Farshad Farzadfar, Rafael Lozano, Anthony Rodgers

  Lancet. 01/2008; 370(9604):2054-62.

  In 2005, a global goal of reducing chronic disease death rates by an additional 2% per year was established. Scaling up coverage of evidence-based interventions to prevent cardiovascular disease inIn 2005, a global goal of reducing chronic disease death rates by an additional 2% per year was established. Scaling up coverage of evidence-based interventions to prevent cardiovascular disease in high-risk individuals in low-income and middle-income countries could play a major part in reaching this goal. We aimed to estimate the number of deaths that could be averted and the financial cost of scaling up, above current coverage levels, a multidrug regimen for prevention of cardiovascular disease (a statin, aspirin, and two blood-pressure-lowering medicines) in 23 such countries. Identification of individuals was limited to those already accessing health services, and treatment eligibility was based on the presence of existing cardiovascular disease or absolute risk of cardiovascular disease by use of easily measurable risk factors. Over a 10-year period, scaling up this multidrug regimen could avert 17.9 million deaths from cardiovascular disease (95% uncertainty interval 7.4 million-25.7 million). 56% of deaths averted would be in those younger than 70 years, with more deaths averted in women than in men owing to larger absolute numbers of women at older ages. The 10-year financial cost would be US$47 billion ($33 billion-$61 billion) or an average yearly cost per head of $1.08 ($0.75-1.40), ranging from $0.43 to $0.90 across low-income countries and from $0.54 to $2.93 across middle-income countries. This package could effectively meet three-quarters of the proposed global goal with a moderate increase in health expenditure.

• Improving child survival through environmental and nutritional interventions: the importance of targeting interventions toward the poor.

  Authors: Emmanuela Gakidou, Shefali Oza, Cecilia Vidal Fuertes, Amy Y Li, Diana K Lee, Angelica Sousa, Margaret C Hogan, Stephen Vander Hoorn, Majid Ezzati

  JAMA : the journal of the American Medical Association. 11/2007; 298(16):1876-87.

  CONTEXT: The United Nations Millennium Development Goals (MDGs) set targets related to important global poverty, health, and sustainability issues. A critical but underinvestigated question forCONTEXT: The United Nations Millennium Development Goals (MDGs) set targets related to important global poverty, health, and sustainability issues. A critical but underinvestigated question for planning and allocating resources toward the MDGs is how interventions related to one MDG might affect progress toward other goals. OBJECTIVES: To estimate the reduction in child mortality as a result of interventions related to the environmental and nutritional MDGs (improving child nutrition and providing clean water, sanitation, and fuels) and to estimate how the magnitude and distribution of the effects of interventions vary based on the economic status of intervention recipients. DESIGN, SETTING, AND POPULATION: Population-level comparative risk assessment modeling the mortality effects of interventions on child nutrition and environmental risk factors, stratified by economic status. Data on economic status, child underweight, water and sanitation, and household fuels were from the nationally representative Demographic and Health Surveys for 42 countries in Latin America and the Caribbean, South Asia, and sub-Saharan Africa. Data on disease-specific child mortality were from the World Health Organization. Data on the hazardous effects of each MDG-related risk factor were from systematic reviews and meta-analyses of epidemiological studies. MAIN OUTCOME MEASURE: Child mortality, stratified by comparable international quintiles of economic status. RESULTS: Implementing interventions that improve child nutrition and provide clean water and sanitation and clean household fuels to all children younger than 5 years would result in an estimated annual reduction in child deaths of 49,700 (14%) in Latin America and the Caribbean, 0.80 million (24%) in South Asia, and 1.47 million (31%) in sub-Saharan Africa. These benefits are equivalent to 30% to 48% of the current regional gaps toward the MDG target on reducing child mortality. Fifty percent coverage of the same environmental and nutritional interventions, as envisioned by the MDGs, would reduce child mortality by 26,900, 0.51 million, and 1.02 million in the 3 regions, respectively, if the interventions are implemented among the poor first. These reductions are 30% to 75% larger than those expected if the same 50% coverage first reached the wealthier households, who nonetheless are in need of similar interventions. CONCLUSIONS: Interventions related to nutritional and environmental MDGs can also provide substantial gains toward the MDG of reducing child mortality. To maximize the reduction in childhood mortality, such integrated management of interventions should prioritize the poor.

• Reductions in child mortality levels and inequalities in Thailand: analysis of two censuses.

  Authors: Patama Vapattanawong, Margaret C Hogan, Piya Hanvoravongchai, Emmanuela Gakidou, Theo Vos, Alan D Lopez, Stephen S Lim

  Lancet. 04/2007; 369(9564):850-5.

  BACKGROUND: Thailand's progress in reducing the under-five mortality rate (U5MR) puts the country on track to achieve the fourth Millennium Development Goal (MDG). Whether this success has beenBACKGROUND: Thailand's progress in reducing the under-five mortality rate (U5MR) puts the country on track to achieve the fourth Millennium Development Goal (MDG). Whether this success has been accompanied by a widening or narrowing of the child mortality gap between the poorest and richest populations is unknown. We aimed to measure changes in child-mortality inequalities by household-level socioeconomic strata of the Thai population between 1990 and 2000. METHODS: We measured changes in the distribution of the U5MR by economic strata using data from the 1990 and 2000 censuses. Economic status was measured using household assets and characteristics. The U5MR was estimated using the Trussell version of the Brass indirect method. FINDINGS: Average household economic status improved and inequalities declined between the two censuses. There were substantially larger reductions in U5MR in the poorer segments of the population. Excess child mortality risk between the poorest and richest quintile decreased by 55% (95% CI 39% to 68%). The concentration index, measured using percentiles of economic status, in 1990 was -0.20 (-0.23 to -0.18), whereas in 2000 it had dropped to -0.12 (-0.15 to -0.08), a 43% (22% to 63%) reduction. INTERPRETATION: These findings draw attention to the feasibility of incorporating equity measurement into census data. Thailand has achieved both an impressive average decrease in U5MR and substantial reductions in U5MR inequality over a 10 year period. Contributing factors include overall economic growth and poverty reduction, improved insurance coverage, and a scaling-up and more equitable distribution of primary health-care infrastructure and intervention coverage. Understanding the factors that have led to Thailand's success could help inform countries struggling to meet the fourth MDG and reduce inequality.

• Use of modern contraception by the poor is falling behind.

  Authors: Emmanuela Gakidou, Effy Vayena

  PLoS medicine. 03/2007; 4(2):e31.

  BACKGROUND: The widespread increase in the use of contraception, due to multiple factors including improved access to modern contraception, is one of the most dramatic social transformations of theBACKGROUND: The widespread increase in the use of contraception, due to multiple factors including improved access to modern contraception, is one of the most dramatic social transformations of the past fifty years. This study explores whether the global progress in the use of modern contraceptives has also benefited the poorest. METHODS AND FINDINGS: Demographic and Health Surveys from 55 developing countries were analyzed using wealth indices that allow the identification of the absolute poor within each country. This article explores the macro level determinants of the differences in the use of modern contraceptives between the poor and the national averages of several countries. Despite increases in national averages, use of modern contraception by the absolute poor remains low. South and Southeast Asia have relatively high rates of modern contraception in the absolute poor, on average 17% higher than in Latin America. Over time the gaps in use persist and are increasing. Latin America exhibits significantly larger gaps in use between the poor and the averages, while gaps in sub-Saharan Africa are on average smaller by 15.8% and in Southeast Asia by 11.6%. CONCLUSIONS: The secular trend of increasing rates of modern contraceptive use has not resulted in a decrease of the gap in use for those living in absolute poverty. Countries with large economic inequalities also exhibit large inequalities in modern contraceptive use. In addition to macro level factors that influence contraceptive use, such as economic development and provision of reproductive health services, there are strong regional variations, with sub-Saharan Africa exhibiting the lowest national rates of use, South and Southeast Asia the highest use among the poor, and Latin America the largest inequalities in use.

• A "politically robust" experimental design for public policy evaluation, with application to the Mexican universal health insurance program.

  Authors: Gary King, Emmanuela Gakidou, Nirmala Ravishankar, Ryan T Moore, Jason Lakin, Manett Vargas, Martha Maria Tellez-Rojo, Juan Eugenio Hernandez Avila, Mauricio Hernandez-Avila, Hector Hernandez Llamas

  Journal of policy analysis and management : [the journal of the Association for Public Policy Analysis and Management]. 02/2007; 26(3):479-506.

  We develop an approach to conducting large-scale randomized public policy experiments intended to be more robust to the political interventions that have ruined some or all parts of many similarWe develop an approach to conducting large-scale randomized public policy experiments intended to be more robust to the political interventions that have ruined some or all parts of many similar previous efforts. Our proposed design is insulated from selection bias in some circumstances even if we lose observations; our inferences can still be unbiased even if politics disrupts any two of the three steps in our analytical procedures; and other empirical checks are available to validate the overall design. We illustrate with a design and empirical validation of an evaluation of the Mexican Seguro Popular de Salud (Universal Health Insurance)program we are conducting. Seguro Popular, which is intended to grow to provide medical care, drugs, preventative services, and financial health protection to the 50 million Mexicans without health insurance, is one of the largest health reforms of any country in the last two decades. The evaluation is also large scale, constituting one of the largest policy experiments to date and what may be the largest randomized health policy experiment ever.

• [Assessing the effect of the 2001-06 Mexican health reform: an interim report card]

  Authors: Emmanuela Gakidou, Rafael Lozano, Eduardo González-Pier, Jesse Abbott-Klafter, Jeremy T Barofsky, Chloe Bryson-Cahn, Dennis M Feehan, Diana K Lee, Héctor Hernández Llamas, Christopher J L Murray

  Salud pública de México. 02/2007; 49 Suppl 1:S88-109.

  Since 2001, Mexico has been designing, legislating, and implementing a major health-system reform. A key component was the creation of Seguro Popular, which is intended to expand insurance coverageSince 2001, Mexico has been designing, legislating, and implementing a major health-system reform. A key component was the creation of Seguro Popular, which is intended to expand insurance coverage over seven years to uninsured people, nearly half the total population at the start of 2001. The reform included five actions: legislation of entitlement per family affiliated which, with full implementation, will increase public spending on health by 0.8-1.0% of gross domestic product; creation of explicit benefits packages; allocation of monies to decentralised state ministries of health in proportion to number of families affiliated; division of federal resources flowing to states into separate funds for personal and non-personal health services; and creation of a fund to protect families against catastrophic health expenditures. Using the WHO health-systems framework, a wide range of datasets to assess the effect of this reform on different dimensions of the health system was used. Key findings include: affiliation is preferentially reaching the poor and the marginalised communities; federal non-social security expenditure in real per-head terms increased by 38% from 2000 to 2005; equity of public-health expenditure across states improved; Seguro Popular affilates used more inpatient and outpatient services than uninsured people; effective coverage of 11 interventions has improved between 2000 and 2005-06; inequalities in effective coverage across states and wealth deciles has decreased over this period; catastrophic expenditures for Seguro Popular affiliates are lower than for uninsured people even though use of services has increased. We present some lessons for Mexico based on this interim evaluation and explore implications for other countries considering health reforms.