[Guidelines for Accurate and Transparent Health Estimates Reporting: the GATHER Statement]. / Diretrizes para o relato preciso e transparente de estimativas de saúde: a Declaração GATHER.

Measurements of health indicators are rarely available for every population and period of interest, and available data may not be comparable. The Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) define best reporting practices for studies that calculate health estimates for multiple populations (in time or space) using multiple information sources. Health estimates that fall within the scope of GATHER include all quantitative population-level estimates (including global, regional, national, or subnational estimates) of health indicators, including indicators of health status, incidence and prevalence of diseases, injuries, and disability and functioning; and indicators of health determinants, including health behaviours and health exposures. GATHER comprises a checklist of 18 items that are essential for best reporting practice. A more detailed explanation and elaboration document, describing the interpretation and rationale of each reporting item along with examples of good reporting, is available on the GATHER website (http://gather-statement.org).

Correction: Guidelines for Accurate and Transparent Health Estimates Reporting: the GATHER statement.

[This corrects the article DOI: 10.1371/journal.pmed.1002056.].

Guidelines for Accurate and Transparent Health Estimates Reporting: the GATHER statement.

Measurements of health indicators are rarely available for every population and period of interest, and available data may not be comparable. The Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) define best reporting practices for studies that calculate health estimates for multiple populations (in time or space) using multiple information sources. Health estimates that fall within the scope of GATHER include all quantitative population-level estimates (including global, regional, national, or subnational estimates) of health indicators, including indicators of health status, incidence and prevalence of diseases, injuries, and disability and functioning; and indicators of health determinants, including health behaviours and health exposures. GATHER comprises a checklist of 18 items that are essential for best reporting practice. A more detailed explanation and elaboration document, describing the interpretation and rationale of each reporting item along with examples of good reporting, is available on the GATHER website.

Guidelines for Accurate and Transparent Health Estimates Reporting: the GATHER statement.

Gretchen Stevens and colleagues present the GATHER statement, which seeks to promote good practice in the reporting of global health estimates.

How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys.

BACKGROUND: Achievement of global health goals will require assessment of progress not only nationally but also for population subgroups. We aimed to assess how the magnitude of socioeconomic inequalities in health changes in relation to different rates of national progress in coverage of interventions for the health of mothers and children. METHODS: We assessed coverage in low-income and middle-income countries for which two Demographic Health Surveys or Multiple Indicator Cluster Surveys were available. We calculated changes in overall coverage of skilled birth attendants, measles vaccination, and a composite coverage index, and examined coverage of a newly introduced intervention, use of insecticide-treated bednets by children. We stratified coverage data according to asset-based wealth quintiles, and calculated relative and absolute indices of inequality. We adjusted correlation analyses for time between surveys and baseline coverage levels. FINDINGS: We included 35 countries with surveys done an average of 9·1 years apart. Pro-rich inequalities were very prevalent. We noted increased coverage of skilled birth attendants, measles vaccination, and the composite index in most countries from the first to the second survey, while inequalities were reduced. Rapid changes in overall coverage were associated with improved equity. These findings were not due to a capping effect associated with limited scope for improvement in rich households. For use of insecticide-treated bednets, coverage was high for the richest households, but countries making rapid progress did almost as well in reaching the poorest groups. National increases in coverage were primarily driven by how rapidly coverage increased in the poorest quintiles. INTERPRETATION: Equity should be accounted for when planning the scaling up of interventions and assessing national progress. FUNDING: Bill & Melinda Gates Foundation; World Bank; Governments of Australia, Brazil, Canada, Norway, Sweden, and UK.

Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries.

BACKGROUND: Countdown to 2015 tracks progress towards achievement of Millennium Development Goals (MDGs) 4 and 5, with particular emphasis on within-country inequalities. We assessed how inequalities in maternal, newborn, and child health interventions vary by intervention and country. METHODS: We reanalysed data for 12 maternal, newborn, and child health interventions from national surveys done in 54 Countdown countries between Jan 1, 2000, and Dec 31, 2008. We calculated coverage indicators for interventions according to standard definitions, and stratified them by wealth quintiles on the basis of asset indices. We assessed inequalities with two summary indices for absolute inequality and two for relative inequality. FINDINGS: Skilled birth attendant coverage was the least equitable intervention, according to all four summary indices, followed by four or more antenatal care visits. The most equitable intervention was early initation of breastfeeding. Chad, Nigeria, Somalia, Ethiopia, Laos, and Niger were the most inequitable countries for the interventions examined, followed by Madagascar, Pakistan, and India. The most equitable countries were Uzbekistan and Kyrgyzstan. Community-based interventions were more equally distributed than those delivered in health facilities. For all interventions, variability in coverage between countries was larger for the poorest than for the richest individuals. INTERPRETATION: We noted substantial variations in coverage levels between interventions and countries. The most inequitable interventions should receive attention to ensure that all social groups are reached. Interventions delivered in health facilities need specific strategies to enable the countries' poorest individuals to be reached. The most inequitable countries need additional efforts to reduce the gap between the poorest individuals and those who are more affluent. FUNDING: Bill & Melinda Gates Foundation, Norad, The World Bank.

Trends in access to health services and financial protection in China between 2003 and 2011: a cross-sectional study.

BACKGROUND: In the past decade, the Government of China initiated health-care reforms to achieve universal access to health care by 2020. We assessed trends in health-care access and financial protection between 2003, and 2011, nationwide. METHODS: We used data from the 2003, 2008, and 2011 National Health Services Survey (NHSS), which used multistage stratified cluster sampling to select 94 of 2859 counties from China's 31 provinces and municipalities. The 2011 survey was done with a subset of the NHSS sampling frame to monitor key indicators after the national health-care reforms were announced in 2009. Three sets of indicators were chosen to measure trends in access to coverage, health-care activities, and financial protection. Data were disaggregated by urban or rural residence and by three geographical regions: east, central, and west, and by household income. We examined change in equity across and within regions. FINDINGS: The number of households interviewed was 57,023 in 2003, 56,456 in 2008, and 18,822 in 2011. Response rates were 98·3%, 95·0%, and 95·5%, respectively. The number of individuals interviewed was 193,689 in 2003, 177,501 in 2008, and 59,835 in 2011. Between 2003 and 2011, insurance coverage increased from 29·7% (57,526 of 193,689) to 95·7% (57,262 of 59,835, p<0·0001). The average share of inpatient costs reimbursed from insurance increased from 14·4 (13·7-15·1) in 2003 to 46·9 (44·7-49·1) in 2011 (p<0·0001). Hospital delivery rates averaged 95·8% (1219 of 1272) in 2011. Hospital admissions increased 2·5 times to 8·8% (5288 of 59,835, p<0·0001) in 2011 from 3·6% (6981 of 193,689) in 2003. 12·9% of households (2425 of 18,800) had catastrophic health expenses in 2011. Caesarean section rates increased from 19·2% (736 of 3835) to 36·3% (443 of 1221, p<0·0001) between 2003 and 2011. INTERPRETATION: Remarkable increases in insurance coverage and inpatient reimbursement were accompanied by increased use and coverage of health care. Important advances have been made in achieving equal access to services and insurance coverage across and within regions. However, these increases have not been accompanied by reductions in catastrophic health expenses. With the achievement of basic health-services coverage, future challenges include stronger risk protection, and greater efficiency and quality of care. FUNDING: None.

Data resource profile: the World Health Organization Study on global AGEing and adult health (SAGE).

Population ageing is rapidly becoming a global issue and will have a major impact on health policies and programmes. The World Health Organization's Study on global AGEing and adult health (SAGE) aims to address the gap in reliable data and scientific knowledge on ageing and health in low- and middle-income countries. SAGE is a longitudinal study with nationally representative samples of persons aged 50+ years in China, Ghana, India, Mexico, Russia and South Africa, with a smaller sample of adults aged 18-49 years in each country for comparisons. Instruments are compatible with other large high-income country longitudinal ageing studies. Wave 1 was conducted during 2007-2010 and included a total of 34 124 respondents aged 50+ and 8340 aged 18-49. In four countries, a subsample consisting of 8160 respondents participated in Wave 1 and the 2002/04 World Health Survey (referred to as SAGE Wave 0). Wave 2 data collection will start in 2012/13, following up all Wave 1 respondents. Wave 3 is planned for 2014/15. SAGE is committed to the public release of study instruments, protocols and meta- and micro-data: access is provided upon completion of a Users Agreement available through WHO's SAGE website (www.who.int/healthinfo/systems/sage) and WHO's archive using the National Data Archive application (http://apps.who.int/healthinfo/systems/surveydata).

Measuring impact in the Millennium Development Goal era and beyond: a new approach to large-scale effectiveness evaluations.

Evaluation of large-scale programmes and initiatives aimed at improvement of health in countries of low and middle income needs a new approach. Traditional designs, which compare areas with and without a given programme, are no longer relevant at a time when many programmes are being scaled up in virtually every district in the world. We propose an evolution in evaluation design, a national platform approach that: uses the district as the unit of design and analysis; is based on continuous monitoring of different levels of indicators; gathers additional data before, during, and after the period to be assessed by multiple methods; uses several analytical techniques to deal with various data gaps and biases; and includes interim and summative evaluation analyses. This new approach will promote country ownership, transparency, and donor coordination while providing a rigorous comparison of the cost-effectiveness of different scale-up approaches.

Estimating incidence from prevalence in generalised HIV epidemics: methods and validation.

BACKGROUND: HIV surveillance of generalised epidemics in Africa primarily relies on prevalence at antenatal clinics, but estimates of incidence in the general population would be more useful. Repeated cross-sectional measures of HIV prevalence are now becoming available for general populations in many countries, and we aim to develop and validate methods that use these data to estimate HIV incidence. METHODS AND FINDINGS: Two methods were developed that decompose observed changes in prevalence between two serosurveys into the contributions of new infections and mortality. Method 1 uses cohort mortality rates, and method 2 uses information on survival after infection. The performance of these two methods was assessed using simulated data from a mathematical model and actual data from three community-based cohort studies in Africa. Comparison with simulated data indicated that these methods can accurately estimates incidence rates and changes in incidence in a variety of epidemic conditions. Method 1 is simple to implement but relies on locally appropriate mortality data, whilst method 2 can make use of the same survival distribution in a wide range of scenarios. The estimates from both methods are within the 95% confidence intervals of almost all actual measurements of HIV incidence in adults and young people, and the patterns of incidence over age are correctly captured. CONCLUSIONS: It is possible to estimate incidence from cross-sectional prevalence data with sufficient accuracy to monitor the HIV epidemic. Although these methods will theoretically work in any context, we have able to test them only in southern and eastern Africa, where HIV epidemics are mature and generalised. The choice of method will depend on the local availability of HIV mortality data.

Mind the gap: equity and trends in coverage of maternal, newborn, and child health services in 54 Countdown countries.

BACKGROUND: Increasing the coverage of key maternal, newborn, and child health interventions is essential if Millennium Development Goals (MDG) 4 and 5 are to be reached. We have assessed equity and trends in coverage rates of a key set of interventions through a summary index, to provide overall insight into past performance and progress perspectives. METHODS: Data from household surveys from 54 countries in the Countdown to 2015 for Maternal, Newborn and Child Survival initiative during 1990-2006 were used to compute an aggregate coverage index based on four intervention areas: family planning, maternal and newborn care, immunisation, and treatment of sick children. The four areas were given equal weight in the computation of the index. Standard measures were applied to assess current levels and trends in the coverage gap measure by wealth quintile. FINDINGS: The overall size of the coverage gap ranged from less than 20% in Tajikistan and Peru to over 70% in Ethiopia and Chad, with a mean of 43% for the most recent surveys in the 54 countries. Large intracountry differences were noted, with a country mean coverage gap of 54% for the poorest quintiles of the population and 29% for the wealthiest. Differences between the poorest and the wealthiest were largest for the maternal and newborn health intervention area and smallest for immunisation. In 40 countries with more than one survey, the coverage gap had decreased by an average of 0.9 percentage points per year since the early 1990s. Declines greater than 2 percentage points per year were seen in only three countries after 1995: Cambodia, Mozambique, and Nepal. Country inequity patterns were remarkably persistant over time, with only gradual changes from top inequity (disproportionately smaller gap for the wealthiest) in countries with coverage gaps exceeding 40%, to linear patterns and bottom inequity (disproportionately greater gap for the poorest) in surveys with gaps below 40%. INTERPRETATION: Despite most Countdown countries having made gradual progress since 1990, coverage gaps for key interventions remain wide and, in most such countries, the pace of decline needs to be more than doubled to reach levels of coverage of these and other interventions needed in the context of MDG 4 and 5. In general, in-country patterns of inequality are consistant and change only gradually if at all, which has implications for the targeting of interventions.

Violence-related mortality in Iraq from 2002 to 2006.

BACKGROUND: Estimates of the death toll in Iraq from the time of the U.S.-led invasion in March 2003 until June 2006 have ranged from 47,668 (from the Iraq Body Count) to 601,027 (from a national survey). Results from the Iraq Family Health Survey (IFHS), which was conducted in 2006 and 2007, provide new evidence on mortality in Iraq. METHODS: The IFHS is a nationally representative survey of 9345 households that collected information on deaths in the household since June 2001. We used multiple methods for estimating the level of underreporting and compared reported rates of death with those from other sources. RESULTS: Interviewers visited 89.4% of 1086 household clusters during the study period; the household response rate was 96.2%. From January 2002 through June 2006, there were 1325 reported deaths. After adjustment for missing clusters, the overall rate of death per 1000 person-years was 5.31 (95% confidence interval [CI], 4.89 to 5.77); the estimated rate of violence-related death was 1.09 (95% CI, 0.81 to 1.50). When underreporting was taken into account, the rate of violence-related death was estimated to be 1.67 (95% uncertainty range, 1.24 to 2.30). This rate translates into an estimated number of violent deaths of 151,000 (95% uncertainty range, 104,000 to 223,000) from March 2003 through June 2006. CONCLUSIONS: Violence is a leading cause of death for Iraqi adults and was the main cause of death in men between the ages of 15 and 59 years during the first 3 years after the 2003 invasion. Although the estimated range is substantially lower than a recent survey-based estimate, it nonetheless points to a massive death toll, only one of the many health and human consequences of an ongoing humanitarian crisis.

HIV infection does not disproportionately affect the poorer in sub-Saharan Africa.

BACKGROUND: Wealthier populations do better than poorer ones on most measures of health status, including nutrition, morbidity and mortality, and healthcare utilization. OBJECTIVES: This study examines the association between household wealth status and HIV serostatus to identify what characteristics and behaviours are associated with HIV infection, and the role of confounding factors such as place of residence and other risk factors. METHODS: Data are from eight national surveys in sub-Saharan Africa (Kenya, Ghana, Burkina Faso, Cameroon, Tanzania, Lesotho, Malawi, and Uganda) conducted during 2003-2005. Dried blood spot samples were collected and tested for HIV, following internationally accepted ethical standards and laboratory procedures. The association between household wealth (measured by an index based on household ownership of durable assets and other amenities) and HIV serostatus is examined using both descriptive and multivariate statistical methods. RESULTS: In all eight countries, adults in the wealthiest quintiles have a higher prevalence of HIV than those in the poorer quintiles. Prevalence increases monotonically with wealth in most cases. Similarly for cohabiting couples, the likelihood that one or both partners is HIV infected increases with wealth. The positive association between wealth and HIV prevalence is only partly explained by an association of wealth with other underlying factors, such as place of residence and education, and by differences in sexual behaviour, such as multiple sex partners, condom use, and male circumcision. CONCLUSION: In sub-Saharan Africa, HIV prevalence does not exhibit the same pattern of association with poverty as most other diseases. HIV programmes should also focus on the wealthier segments of the population.

Health statistics now: are we making the right investments?

Increases in international funding for health have been accompanied by accelerating demand for more and better statistics, which are needed to track performance and ensure accountability. Worldwide interest in the monitoring of development, as exemplified in the Millennium Development Goals (MDGs), generates pressure for high-quality and timely data for reporting on country progress. This rapid escalation of demand has exposed major gaps in the supply of health statistics for developing countries but also provides major opportunities to increase the supply and use of sound health statistics. First, the emphasis on monitoring and evaluation is leading to proliferation of indicators and excessive reporting requirements, and needs to be refocused on systematic investments in data generation and analysis. Second, the risk of inadequate or poorly targeted investments can be kept to a minimum by understanding the causes of poor availability of health statistics, including lack of accurate measurement instruments, application of suboptimum methods of data collection, and inadequate use of methods and analyses to produce comparable estimates. Third, the preoccupation with MDGs does not take into account the rapid health transition, which implies that health statistics should systematically include a much wider array of health issues from acute infectious diseases to chronic non-communicable diseases and injuries, disaggregated by socioeconomic position. Fourth, the growing number of national household surveys, which are the main source of most population health statistics, need to be streamlined into cohesive and comprehensive country health survey programmes. Now is the time to accelerate the production and use of accurate, complete, and timely health statistics for decision-making by investing in country health information systems that should be based on an efficient and effective mix of standardised methods of data collection and analysis that meet country and international needs.

HIV testing in national population-based surveys: experience from the Demographic and Health Surveys.

OBJECTIVES: To describe the methods used in the Demographic and Health Surveys (DHS) to collect nationally representative data on the prevalence of human immunodeficiency virus (HIV) and assess the value of such data to country HIV surveillance systems. METHODS: During 2001-04, national samples of adult women and men in Burkina Faso, Cameroon, Dominican Republic, Ghana, Mali, Kenya, United Republic of Tanzania and Zambia were tested for HIV. Dried blood spot samples were collected for HIV testing, following internationally accepted ethical standards. The results for each country are presented by age, sex, and urban versus rural residence. To estimate the effects of non-response, HIV prevalence among non-responding males and females was predicted using multivariate statistical models for those who were tested, with a common set of predictor variables. RESULTS: Rates of HIV testing varied from 70% among Kenyan men to 92% among women in Burkina Faso and Cameroon. Despite large differences in HIV prevalence between the surveys (1-16%), fairly consistent patterns of HIV infection were observed by age, sex and urban versus rural residence, with considerably higher rates in urban areas and in women, especially at younger ages. Analysis of non-response bias indicates that although predicted HIV prevalence tended to be higher in non-tested males and females than in those tested, the overall effects of non-response on the observed national estimates of HIV prevalence are insignificant. CONCLUSIONS: Population-based surveys can provide reliable, direct estimates of national and regional HIV seroprevalence among men and women irrespective of pregnancy status. Survey data greatly enhance surveillance systems and the accuracy of national estimates in generalized epidemics.

Creating and validating an algorithm to measure AIDS mortality in the adult population using verbal autopsy.

BACKGROUND: Vital registration and cause of death reporting is incomplete in the countries in which the HIV epidemic is most severe. A reliable tool that is independent of HIV status is needed for measuring the frequency of AIDS deaths and ultimately the impact of antiretroviral therapy on mortality. METHODS AND FINDINGS: A verbal autopsy questionnaire was administered to caregivers of 381 adults of known HIV status who died between 1998 and 2003 in Manicaland, eastern Zimbabwe. Individuals who were HIV positive and did not die in an accident or during childbirth (74%; n = 282) were considered to have died of AIDS in the gold standard. Verbal autopsies were randomly allocated to a training dataset (n = 279) to generate classification criteria or a test dataset (n = 102) to verify criteria. A rule-based algorithm created to minimise false positives had a specificity of 66% and a sensitivity of 76%. Eight predictors (weight loss, wasting, jaundice, herpes zoster, presence of abscesses or sores, oral candidiasis, acute respiratory tract infections, and vaginal tumours) were included in the algorithm. In the test dataset of verbal autopsies, 69% of deaths were correctly classified as AIDS/non-AIDS, and it was not necessary to invoke a differential diagnosis of tuberculosis. Presence of any one of these criteria gave a post-test probability of AIDS death of 0.84. CONCLUSIONS: Analysis of verbal autopsy data in this rural Zimbabwean population revealed a distinct pattern of signs and symptoms associated with AIDS mortality. Using these signs and symptoms, demographic surveillance data on AIDS deaths may allow for the estimation of AIDS mortality and even HIV prevalence.

The global impact of scaling up HIV/AIDS prevention programs in low- and middle-income countries.

A strong, global commitment to expanded prevention programs targeted at sexual transmission and transmission among injecting drug users, started now, could avert 28 million new HIV infections between 2005 and 2015. This figure is more than half of the new infections that might otherwise occur during that period in 125 low- and middle-income countries. Although preventing these new infections would require investing about U.S.$122 billion over this period, it would reduce future needs for treatment and care. Our analysis suggests that it will cost about U.S.$3900 to prevent each new infection, but that this will produce a savings of U.S.$4700 in forgone treatment and care costs. Thus, greater spending on prevention now would not only prevent more than half the new infections that would occur from 2005 to 2015 but would actually produce a net financial saving as future costs for treatment and care are averted.

Monitoring the scale-up of antiretroviral therapy programmes: methods to estimate coverage.

This paper reviews the data sources and methods used to estimate the number of people on, and coverage of, antiretroviral therapy (ART) programmes in low- and middle-income countries and to monitor the progress towards the "3 by 5" target set by WHO and UNAIDS. We include a review of the data sources used to estimate the coverage of ART programmes as well as the efforts made to avoid double counting and over-reporting. The methods used to estimate the number of people in need of ART are described and expanded with estimates of treatment needs for children, both for ART and for cotrimoxazole prophylaxis. An estimated 6.5 million people were in need of treatment in low- and middle-income countries by the end of 2004, including 660,000 children under age 15 years. The mid-2005 estimate of 970,000 people receiving ART in low- and middle-income countries (with an uncertainty range 840,000-1,100,000) corresponds to a coverage of 15% of people in need of treatment.