Facts relating to global health can be elusive. Even when they are known, they are rarely put to use in improving health outcomes. So what can be done to fix the problem?
Which country has the highest child mortality, Thailand or South Africa? Poland or South Korea?* The late Hans Rosling, Professor of International Health at Sweden’s Karolinksa Institute, tested his students with those questions as part of his quest to try to construct a real picture of global health. Faced with five pairs of countries, the students make a significantly worse job of picking the right answers than a chimpanzee picking randomly. “They would have scored half right,” he said in a famous TED talk, thus neatly illustrating a serious problem of global health perception. The fact is that, ironically, we really don’t know some critically important facts about the state of the global population and its health.
Through Gapminder, the foundation he started in 2005, Rosling wanted to pioneer a new way of thinking – called “Factfulness” – based on solid facts. Only then, he argued, could we provide the right resources at the right cost to the right people – not just healthcare but everything from social aid and education to affordable and effective insurance.
But just how much difference does knowledge really make? In a 2013 interview with the Guardian, Rosling conceded that he had been surprised by how little impact he had made on public knowledge or behaviour, a trend echoed by many of the world’s leading authorities on health data. “The belief that providing facts alone will encourage people to do the right thing is immensely naïve,” says Desmond Chavasse, senior vice president and chief evidence officer at Population Services International (PSI), a non-profit organisation that aims to gather and share health data more effectively across developing countries.
“The belief that providing facts alone will encourage people to do the right thing is immensely naïve.”
Chavasse cites a 1995 World Health Organization (WHO) report on the impact of treated mosquito nets on malaria infections, which demonstrated that high levels of usage could lead to a 20 per cent decline in child mortality. Yet despite this very strong case made by a very powerful voice, there was no significant change in national policies or availability of funding until the start of the so-called malaria decade at the turn of the century. “Now we have high treated net usage and a 50 per cent reduction in malaria mortality, but at no point did anyone look in the mirror and ask why we’d lost those five years,” he says. “It took an awful lot of advocacy from people like Bono, Bill Gates and economists like Jeffrey Sachs who went way beyond the facts, which had been sitting there all that time.”
Joining the dots on healthcare provision
Getting basic facts straight on issues such as death rates is hard enough, but things can get even tougher when dealing with complex health systems, according to one expert at Milliman
“If you can’t measure healthcare problems, you have no chance of working out how to solve them,” says Joanne Buckle, principal and consulting actuary at Milliman. “If you don’t know what the baseline is, it’s hard to do any kind of robust modelling and make change – even in the UK’s National Health Service (NHS), one of the most joined-up healthcare services in the world.”
Milliman has worked with several organisations to try to help understand the data gaps in the NHS and find ways to deploy true population health analytics to predict and manage future medical interventions. Sharing data, Buckle says, remains a huge obstacle.
“We know what the total NHS budget is, but we can’t trace costs for a particular patient or see the costs of treating particular cohorts,” she says – a result of the fact that data is still stored in silos, with little internal incentive or resource to change that. “Everything in health is very, very slow, especially when you have legacy data and IT systems as we do in developed countries.”
Better healthcare data will eventually lead to great improvements across the board, she thinks – in diagnosis, treatment, payment and insurance. The question is how we share that data effectively around the people who need it.
According to Buckle, some of the most innovative approaches are coming from the developing world, largely because they’re not tied to legacy systems. And not all of this relies on the latest technology; she cites the role of data in helping to develop low-cost checklist-based approaches to improving surgery outcomes and productivity in India and elsewhere. “They’re forced to solve problems in other ways,” she adds. “If you have a blank sheet of paper, you can develop something more fit for purpose.”
What hope, then, for health issues with a lower profile or less convincing data? “Generally you don’t have such good data in global health,” says Chavasse, a fact that he thinks is likely to have an even more deleterious effect on less well-publicised health trends.
One particular area of concern is data on global death rates, which clearly has an enormous impact on the understanding of everything from infectious disease to lifestyle risk factors. Death registration data is a valuable source of health information in the West, according to Colin Mathers, coordinator for mortality and burden of disease at the WHO, but he says such information is incomplete in many parts of the developing world and “almost totally lacking in Africa and many parts of Asia”.
“Information is incomplete in many parts of the developing world and almost totally lacking in Africa and Asia.”
Despite such challenges, many global health programmes have been extremely successful. The eradication of smallpox is perhaps the best-known example, and diseases such as polio and measles are now close on its heels. Although one consequence of such success is that life expectancy has increased significantly, leaving health services facing the challenge of caring for ageing populations. “We’ve been successful in reducing the burden of infectious disease,” says Mathers, “but now cardiovascular disease and cancer are gaining more prominence as people live longer. It doesn’t mean we’re failing – it means that priorities are shifting and there’s a need to focus on prevention.”
Technology, of course, is giving scientists and doctors powerful new tools for improving healthcare provision, often by sharing data. According to PSI’s Chavasse, about half of all healthcare in developing countries is delivered by private providers who are mostly unregulated and without government accreditation. His organisation has created a web-based app that assesses and improves over time the quality of health services delivered by the private providers and shares that information with national governments.
“By making this information available to ministries of health they get “a window” into the quality of service provision in the private sector,” says Chavasse. “This means they can see how good or bad it is, but perhaps most usefully they can then use the information to accredit the best providers so they can operate legally.”
“In some cases the village chief himself will phone the data in.”
Smartphones can also play a part in gathering data. The WHO has been involved in programmes to collect death registration data via smartphones from remote areas. “In some cases the village chief himself will phone the data in,” says Mathers. “But I don’t think there’s a magic bullet. You still need to invest in people, resources and infrastructure. Services aren’t going to suddenly appear on their own.”
Chavasse adds that smartphones are having an enormous impact on the ability to connect with patients and consumers who might be otherwise difficult to reach. PSI’s archetypal consumer – “we call her Sarah, although she could be anyone from a young mother to an injecting drug user or anyone else we are trying to reach” – is now directly contactable, giving practitioners fresh options for delivering healthcare. This includes alerting patients to the availability of new drugs or treatments, directing them to sexual-health clinics or providing advice on modern contraception, for example.
Overall, says Chavasse, data is helping us make progress towards longer, healthier lives – and, perhaps, towards Prof Rosling’s vision of a “Factful” world. The trick is to keep thinking ahead, instead of relying on old assumptions. “The primary metrics are all moving in the right direction, but if we show up with the same ideas and toolsets as we did yesterday we’re going nowhere,” he says. And facts are still right at the heart of the solution to many of our health problems. “Without data we’re all just shouting at each other,” he adds.
*The answer is South Africa and Poland, respectively.
This content was produced by FT², the advertising department of the Financial Times, in collaboration with Milliman.