Highlights of 2014 related to health sector

Health headlines have recently been dominated by the Ebola outbreak in West Africa and humanitarian emergencies in many other countries. 2014 also saw major public health successes, and a clearer understanding of a number of public health threats. WHO produced reports on a range of critical health issues and provided new advice to help countries improve their people's health. Here are a few highlights:

1.Record every birth and death, make every life count

Health Ministers and policy makers from the 11 Member States of WHO's South-East Asia Region deliberated on how to ensure strong Civil Registration and Vital Statistics (CRVS) systems at the Sixty-seventh Session of the Regional Committee in Dhaka on10 September 2014

An estimated 7.6 million children under age 5 died globally in 2010, but fewer than 2.7% of those deaths were medically certified, assigned a cause of death by a health worker, or recorded in an official database. Lack of reliable data has been a long-standing constraint for effective health planning and management.

Civil Registration—the public recording of key life events, such as births, deaths, cause of death, and marriages—and Vital Statistics—the data that comes from such records—go hand in hand and are essential for evaluating national progress and taking steps forward. The best way for countries to ensure that this data is consistently and continuously recorded is through a national CRVS system—governed by legal mandate and run by the national government with a network of key stakeholders, including government agencies, the national statistics office, the police department and the health sector.

"We must make every life count by recording every birth and death. When each birth is not counted, then the denominator for nearly all health indicators is incorrect. CRVS systems are the only way to obtain continuous, compulsory, and cost effective data on births, deaths, and cause of death,” said Dr Poonam Khetrapal Singh, Regional Director for WHO South-East Asia Region. "A strong and reliable CRVS system is an essential tool for national planning across multiple sectors, especially in the health sector", she added. It is key to achieving time-bound health targets, such as the Millennium Development Goals (MDGs). Reliable vital statistics from civil registration systems can provide essential inputs to 42 of the 60 Millennium Development Goal (MDG) indicators and help countries to achieve their 2015 goals.

WHO and the World Bank, with input from several agencies and countries, have developed the Global CRVS Scaling Up Investment Plan 2015-2024, with a goal of universal civil registration and access to legal proof of registration for all individuals.

To achieve this goal, the WHO South-East Asia Region has developed the “Regional Strategy to Strengthen the Role of the Health Sector in Improving CRVS Systems”, which is expected to be endorsed by the Regional Committee. Given the multisectoral nature of CRVS systems, the Regional Strategy is a multi-dimensional approach, with focus on such key strategic areas as strengthening the organizational framework of CRVS systems, reinforcing intersectoral collaboration, and employing the help of community health workers to boost completeness of already existing registries. Aligned with other regional initiatives such as the UNESCAP Regional Action Framework, it offers a systematic basis for how the health sector in each country can contribute to achieving universal civil registration of births and deaths and generating accurate, complete and timely vital statistics.

While in general, civil registration of births and deaths is conducted to some degree in all countries of the Region, greater efforts are needed to ensure completeness of these registers, with particular emphasis on including accurate causes of death. The WHO South- East Asia Region with its 11 Member States has considerable diversity in terms of population size, geographical distribution, and socio-economic status. The Regional Strategy articulates common principles in the development of a CRVS system, but countries will need to develop country-specific National Investment Plans based on their nations’ individual needs.

2.Improved data reveals higher global burden of tuberculosis

Recent intensive efforts to improve collection and reporting of data on tuberculosis (TB) are shedding new light on the epidemic, revealing that there are almost half a million more cases of the disease than previously estimated. WHO’s "Global Tuberculosis Report 2014", published today, shows that 9 million people developed TB in 2013, and 1.5 million died, including 360 000 people who were HIV positive.

The report stresses, however, that the mortality rate from TB is still falling and has dropped by 45% since 1990, while the number of people developing the disease is declining by an average 1.5% a year. An estimated 37 million lives have been saved through effective diagnosis and treatment of TB since 2000.

“Following a concerted effort by countries, by WHO and by multiple partners, investment in national surveys and routine surveillance efforts has substantially increased. This is providing us with much more and better data, bringing us closer and closer to understanding the true burden of tuberculosis,” says Dr Mario Raviglione, Director of the Global TB Programme, WHO.

Although higher, these revised figures fall within the upper limit of previous WHO estimates. The report, however, underlines that a staggering number of lives are being lost to a curable disease and confirms that TB is the second biggest killer disease from a single infectious agent. In addition, around 3 million people who fall ill from TB are still being ‘missed’ by health systems each year either because they are not diagnosed, or because they are diagnosed but not reported.

Insufficient funding is hampering efforts to combat the global epidemic. An estimated US$ 8 billion is needed each year for a full response, but there is currently an annual shortfall of US$ 2 billion, which must be addressed.

Diagnostic capacity for MDR-TB increasing faster than treatment capacity

The multidrug-resistant TB (MDR-TB) crisis continues, with an estimated 480 000 new cases in 2013. Worldwide, about 3.5% of all people who developed TB in 2013 had this form of the disease, which is much harder to treat and has significantly poorer cure rates. While the estimated percentage of new TB cases that have MDR-TB globally remains unchanged, there are severe epidemics in some regions, particularly in Eastern Europe and Central Asia. In many settings around the world, the treatment success rate is alarmingly low. Furthermore, extensively drug-resistant TB (XDR-TB), which is even more expensive and difficult to treat than MDR-TB, has now been reported in 100 countries.

Since 2009, with more laboratories rolling out rapid tests, there has been a tripling of MDR-TB cases being diagnosed. In 2013, 136 000 MDR-TB cases were detected and 97 000 people were started on treatment. Although the number of patients treated has increased three-fold since 2009, at least 39 000 patients, diagnosed with this form of TB, were not being treated last year and globally only 48% of patients were cured.

“The progress that has been made in combatting MDR-TB has been hard won and must be intensified. Containing and reversing the epidemic requires immediate and sustained efforts by all stakeholders,” says Dr Karin Weyer, WHO Coordinator for Laboratories, Diagnostics and Drug Resistance. “Improved diagnostic tools and access mean that we are detecting and treating more cases. But the gap between detecting and actually getting people started on treatment is widening and we urgently need increased commitment and funding to test and treat every case. In countries such as Estonia and Latvia, where there is universal access to rapid diagnostics and treatment, the number of MDR-TB cases has fallen significantly. This shows what can be achieved.”

A special supplement to this year’s WHO report marks 20 years of anti-TB drug-resistance surveillance. It outlines the MDR-TB response to-date and the priority actions that must now be taken from prevention to cure. Anti-TB drug-resistance surveillance has been a pathfinder in global efforts against antimicrobial resistance (AMR).

HIV-related TB deaths down by one third in last decade

Another key challenge is the co-epidemic of TB and HIV. An estimated 1.1 million (13%) of the 9 million people who developed TB in 2013 were HIV-positive, with 4 out of 5 cases and deaths occurring in the African Region. While the number of TB deaths among HIV-positive people has been falling for almost a decade, from 540 000 in 2004 to 360 000 in 2013, antiretroviral treatment, preventive therapy and other key interventions still need to be further scaled-up.

Research funding urgently required

Research has a crucial role to play in ending the global TB epidemic and efforts to develop new tools to combat the disease have intensified during the past decade. The research and development pipeline has produced several new diagnostics (such as Xpert MTB/RIF) and 2 new drugs to treat MDR-TB (bedaquiline and delamanid). Additional rapid tests, new drugs and drug regimens, and vaccines are in clinical trials. However, TB research and development is still severely underfunded.

“In addition to the serious underfunding for research, US$ 8 billion a year is required for TB and MDR-TB prevention, diagnosis and treatment. Domestic and international financing needs to step up to prevent millions of unnecessary deaths,” says Katherine Floyd, WHO Coordinator for TB Monitoring and Evaluation.

3.“Ageing well” must be a global priority

A major new Series on health and ageing, published in "The Lancet", warns that unless health systems find effective strategies to address the problems faced by an ageing world population, the growing burden of chronic disease will greatly affect the quality of life of older people. As people across the world live longer, soaring levels of chronic illness and diminished wellbeing are poised to become a major global public health challenge.

Effective health interventions increasing life expectancy

Worldwide, life expectancy of older people continues to rise. By 2020, for the first time in history, the number of people aged 60 years and older will outnumber children younger than 5 years. By 2050, the world’s population aged 60 years and older is expected to total 2 billion, up from 841 million today. Eighty per cent of these older people will be living in low-income and middle-income countries.

The increase in longevity, especially in high-income countries (HICs), has been largely due to the decline in deaths from cardiovascular disease (stroke and ischaemic heart disease), mainly because of simple, cost-effective strategies to reduce tobacco use and high blood pressure, and improved coverage and effectiveness of health interventions.

Challenge of ageing healthily

However, although people are living longer, they are not necessarily healthier than before – nearly a quarter (23%) of the overall global burden of death and illness is in people aged over 60, and much of this burden is attributable to long-term illness caused by diseases such as cancer, chronic respiratory diseases, heart disease, musculoskeletal diseases (such as arthritis and osteoporosis), and mental and neurological disorders.

This long-term burden of illness and diminished wellbeing affects patients, their families, health systems, and economies, and is forecast to accelerate. For example, latest estimates indicate that the number of people with dementia is expected to rise from 44 million now, to 135 million by 2050.

“Deep and fundamental reforms of health and social care systems will be required.”- Dr John Beard, Director of Ageing and Life Course, WHO

“Deep and fundamental reforms of health and social care systems will be required,” says Dr John Beard, Director of the Department of Ageing and Life Course at the WHO, and co-leader of the Series with Dr Ties Boerma and Dr Somnath Chatterji, also from WHO. “But we must be careful that these reforms do not reinforce the inequities that drive much of the poor health and functional limitation we see in older age.”

“While some interventions will be universally applicable, it will be important that countries monitor the health and functioning of their ageing populations to understand health trends and design programmes that meet the specific needs identified”, adds Dr Ties Boerma, Director of the Department of Health Statistics and Informatics at WHO. “Cross-national surveys such as the WHO Study on Global Ageing and Adult Health (SAGE), the Gallup World Poll, and other longitudinal cohorts studies of ageing in Brazil, China, India, and South Korea, are beginning to redress the balance and provide the evidence for policy, but much more remains to be done.”

Strategies must go beyond health sector

However, the responsibility for improving quality of life for the world’s older people goes far beyond the health sector, say the Series authors.

Strategies are needed that better prevent and manage chronic conditions by extending affordable health care to all older adults and take into consideration the physical and social environment. Examples include changing policies to encourage older adults to remain part of the workforce for longer (e.g., removing tax disincentives to work past retirement age), emphasising low-cost disease prevention and early detection rather than treatment (eg, reducing salt intake and increasing uptake of vaccines), making better use of technology (eg, mobile clinics for rural populations), and training health-care staff in the management of multiple chronic conditions.

According to Dr Chatterji, also from the Department of Health Statistics and Information Systems at WHO, “Collectively, we need to look beyond the costs commonly associated with ageing to think about the benefits that an older, healthier, happier, and more productive older population can bring to society as a whole.”