Longer lives and unfinished agendas on child survival

1450 www.thelancet.com Vol 388 October 8, 2016 The Global Burden of Disease Study 2015 (GBD 2015) is a landmark event. Building on the earlier GBD studies it provides a detailed snapshot of the state of global health and an analytic approach to tracking this dynamic picture. As the international community embarks on the transition from the Millennium Development Goals (MDGs) to the Sustainable Development Goals (SDGs), GBD 2015 is a critical part of the toolkit for measuring progress and— critically—holding governments to account. So what are the big themes in GBD 2015? Perhaps the biggest revolves around global demography. Our generation is living longer—a full decade longer—than in 1980. The profound demographic shifts associated with increased life expectancy and falling child mortality are generating new challenges for health systems. As we live longer the burden of non-communicable disease is rising, along with the attendant costs of treatment. The demographic transition now underway in developing countries comes with the transition to a disease burden in which the ailments of ageing—cancers, ischaemic heart disease, cirrhosis, and Alzheimer’s disease—and injuries fi gure more prominently in years lived with disability (YLD). The paradox of our era, powerfully captured in GBD 2015, is that as health indicators have improved globally, more people are spending more time with functional health loss, and morbidity is increasing in absolute terms. This has far-reaching implications not just for health-system fi nancing and service delivery, but also for economic growth and wellbeing. GBD 2015 also provides a salutary reminder of the human costs of confl ict. In just a decade, the war in Syria has reduced male life expectancy by 11·3 years. What GBD 2015 does not capture is the burden associated with confl ict-related trauma—and this may be an area for refi nement in future studies. Children account for a large share of that burden. In 2015 the number of people displaced by armed confl ict and disasters, a proxy for exposure to confl ict-related traumatic events, reached record levels of over 65 million. Distressingly, children accounted for over half of the world’s refugees and there are now some 50 million children living either as refugees or as internally displaced people. More than half of them have fl ed violence and insecurity. Failure to invest in psychosocial support and opportunities for education is robbing these children of a chance to rebuild their lives, with damaging consequences for their future prospects. The health systems of many confl ict-aff ected countries and neighbouring states receiving refugees are ill equipped to fi nance and deliver support on the required scale. Yet the international aid system is failing to respond. Another central, if understated, theme in GBD 2015 is that in celebrating the very real achievement of the MDG era, governments have failed to recognise the scale of the shortfalls from the targets that were set. Maternal health is a case in point. Only ten countries achieved the MDG target of reducing maternal mortality by three-quarters. There were 24 countries, many of them aff ected by confl ict and state fragility, that had a maternal mortality ratio greater than 400 in 2015. Disparities between countries are widening. This is refl ected in the sharp increase, from about 68% in 1990 to more than 80% in 2015, in the share of maternal deaths accounted for by haemorrhage—the main cause of maternal death in the poorest countries. Changing this picture will require governments and aid donors to focus on the development of health systems equipped to deliver universal antenatal care and skilled birth attendance. More than that, GBD 2015 provides governments around the world with a salutary reminder that far greater emphasis must be placed on maternal health care if the more ambitious 2030 goals are to be achieved. Child survival is another area marked by unfi nished MDG business. GBD 2015 highlights the good news that child death rates are falling at an accelerating pace since Longer lives and unfi nished agendas on child survival