Tim EvansI, 1; Sally StansfieldII
IAssistant Director-General, World Health Organization, Geneva, Switzerland (email: email@example.com)
IIBill and Melinda Gates Foundation, Washington, USA
Health information is the foundation of public health. In the early 19th century, pioneering work by Edwin Chadwick and William Farr was instrumental in developing public health as a legitimate discipline in England and Wales. New civil registration systems identified the plight of poor urban populations and led to an unprecedented liaison between public health and financial accounting systems. The evolution of evidence-based medicine over the last 30 years, in which quantitative metrics are used to inform health care practice, has recently extended into public health. This influence can explain the current prominence of "epidemonomics"; the combined efforts of the disciplines of epidemiology, demography and economics (1).
Despite acknowledging the importance of counts and measures in health systems for the past 150 years, we can identify many instances of woeful ignorance on critical fronts, even in 2003. We are still unable to count the dead in the vast majority of the world's poorest countries, and these are the countries where disease burden is greatest (2). In sub-Saharan Africa, for example, fewer than ten countries have vital registration systems that produce usable data. We still have very limited measures of health systems performance, and major reforms, such as decentralization, are often done in the absence of adequate data on either needs or consequences.
Ironically, this picture of lamentable gaps does not reflect the hard work put into information gathering. Countries and donors invest heavily in attempts to measure effects and deficiencies of their particular health systems, but unfortunately many of these measurements are made in such a way that their benefit is negligible. Duplication abounds when health information systems are developed for each special health programme; inefficiency and opportunity costs rise when the same person has to fill in the forms for all programmes separately. Information collected has an unfortunate tendency to go up but never come down; or the data are simply never used. In a headlong rush to get information on project performance, little thought is given to constructing a solid platform from which specific information might flow in a more sustainable way. As Peter Piot, Executive Director of UNAIDS, stated recently, "In AIDS as elsewhere, programme managers are often little more than data processors for donors, spending obscene amounts of time trying to satisfy dozens of duplicative reporting requirements, and hosting repetitive review missions month after month."
The current global preoccupation with outcomes-based development may inadvertently aggravate this precarious situation. Outcome measures are priority tasks for the Millennium Development Goals (MDGs), Poverty Reduction Strategy Plans, the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), and the Global Alliance for Vaccines and Immunization, among others. As these policies and programmes begin to land in countries, the demand for information accelerates rapidly. In many low-income countries, the storm is brewing, as a massive influx of monitoring programmes threatens to flatten the unsteady pillars of local health information systems. Instead of flattening everything in its path, the current focus on outcomes should be used as an opportunity to reform and strengthen existing health information systems. To do so requires balancing the powerful demands of donors and special programmes with tenuous capacities to supply information according to priority needs of information for the health system as whole.
Strengthening these systems requires a collaborative effort similar to the sector-wide approaches (SWAP) advocated for the health sector but tailored to the needs of health information systems. The Health Metrics Network, to be launched in 2004, will focus on improving the availability and utilization of sound health information for policy-making and planning, programme monitoring and evaluation, monitoring of international goals, and measuring equity in health. The Network aims to strengthen the capacity of health information systems to provide high-quality, timely information in a form that is useful for public health work at the global, national, and subnational levels. It is a multi-disciplinary, multi-sectoral partnership that includes multilateral agencies such as the UN Statistics Division, UNICEF, UNAIDS, World Bank and WHO, the Global Fund, bilateral agencies, and foundations, such as the Bill and Melinda Gates and Rockefeller Foundations, ministries of health, statistical organizations, academic institutions, and organizations representing civil society. The Network will also support innovation in the monitoring and evaluation of health status and health programmes. Improved, standardized methods to assess the quality of health information will make it possible to measure progress towards global goals such as the MDGs. Reformed and robust health information systems should be able to harness the gathering storm to inform and accelerate the achievement of our shared health goals.
1. Szreter S. Health and security in historical perspective. In Chen L, Leaning J and Narasimhan V, editors. Global health challenges for human security; Cambridge, MA: Harvard University Press; 2003. p. 31-52.
2. Mathers CD, Begg S, Bernard C, Iburg K, Inoue M, Ma Fat D, et al. The Global Burden of Disease in 2002: data sources, methods and results. Geneva: World Health Organization: 2003 (GPE Discussion Paper No. 54 available from: http://www.who.int/evidence).
1 Correspondence should be sent to this author.