Longer lives and unfinished agendas on child survival
Authors: Kevin Watkins
Journal: The Lancet (2016)

The Global Burden of Disease Study 2015 (GBD 2015) is a landmark event.1GBD 2015 Mortality and Causes of Death CollaboratorsGlobal, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1459-1544Summary Full Text Full Text PDF PubMed Scopus (4142) Google Scholar, 2GBD 2015 Disease and Injury Incidence and Prevalence CollaboratorsGlobal, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1545-1602Summary Full Text Full Text PDF PubMed Scopus (4556) Google Scholar, 3GBD 2015 DALYs and HALE CollaboratorsGlobal, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1603-1658Summary Full Text Full Text PDF PubMed Scopus (1440) Google Scholar, 4GBD 2015 Risk Factors CollaboratorsGlobal, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1659-1724Summary Full Text Full Text PDF PubMed Scopus (2875) Google Scholar, 5GBD 2015 Child Mortality CollaboratorsGlobal, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1725-1774Summary Full Text Full Text PDF PubMed Scopus (471) Google Scholar, 6GBD 2015 Maternal Mortality CollaboratorsGlobal, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1775-1812Summary Full Text Full Text PDF PubMed Scopus (620) Google Scholar, 7GBD 2015 SDG CollaboratorsMeasuring the health-related Sustainable Development Goals in 188 countries: a baseline analysis from the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1813-1850Summary Full Text Full Text PDF PubMed Scopus (331) Google Scholar 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 1980.1GBD 2015 Mortality and Causes of Death CollaboratorsGlobal, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1459-1544Summary Full Text Full Text PDF PubMed Scopus (4142) Google Scholar 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.1GBD 2015 Mortality and Causes of Death CollaboratorsGlobal, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1459-1544Summary Full Text Full Text PDF PubMed Scopus (4142) Google Scholar 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 figure more prominently in years lived with disability (YLD).2GBD 2015 Disease and Injury Incidence and Prevalence CollaboratorsGlobal, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1545-1602Summary Full Text Full Text PDF PubMed Scopus (4556) Google Scholar 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 financing and service delivery, but also for economic growth and wellbeing. GBD 2015 also provides a salutary reminder of the human costs of conflict. In just a decade, the war in Syria has reduced male life expectancy by 11·3 years.1GBD 2015 Mortality and Causes of Death CollaboratorsGlobal, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1459-1544Summary Full Text Full Text PDF PubMed Scopus (4142) Google Scholar What GBD 2015 does not capture is the burden associated with conflict-related trauma—and this may be an area for refinement in future studies. Children account for a large share of that burden. In 2015 the number of people displaced by armed conflict and disasters, a proxy for exposure to conflict-related traumatic events, reached record levels of over 65 million.8United Nations High Commissioner for RefugeesGlobal trends forced displacement in 2015. United Nations High Commissioner for Refugees, New York2016https://s3.amazonaws.com/unhcrsharedmedia/2016/2016-06-20-global-trends/2016-06-14-Global-Trends-2015.pdfGoogle Scholar 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.9UNICEFUprooted: the growing crisis for refugee and migrant children. United Nations Children's Fund, New York2016http://www.unicef.org.uk/Documents/Media/UPROOTED%20Report.pdfGoogle Scholar More than half of them have fled violence and insecurity.9UNICEFUprooted: the growing crisis for refugee and migrant children. United Nations Children's Fund, New York2016http://www.unicef.org.uk/Documents/Media/UPROOTED%20Report.pdfGoogle Scholar 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 conflict-affected countries and neighbouring states receiving refugees are ill equipped to finance and deliver support on the required scale.10Jordans MJD Pigott H Tol WA Interventions for children affected by armed conflict: a systematic review of mental health and psychosocial support in low- and middle-income countries.Curr Psychiatry Rep. 2016; 18: 9Crossref PubMed Scopus (110) Google Scholar, 11Hassan G Ventevogel P Jefee-Bahloul H Barkil-Oteo A Kirmayer LJ Mental health and psychosocial wellbeing of Syrians affected by armed conflict.Epidemiol Psychiatr Sci. 2016; 25: 129-141Crossref PubMed Scopus (210) Google Scholar Yet the international aid system is failing to respond.12Watkins K No lost generation—holding to the promise of education for all Syrian refugees.http://b.3cdn.net/awas/304cdd77bee3dc886c_9zm6bswbi.pdfDate: 2016Google Scholar 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.6GBD 2015 Maternal Mortality CollaboratorsGlobal, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1775-1812Summary Full Text Full Text PDF PubMed Scopus (620) Google Scholar There were 24 countries, many of them affected by conflict and state fragility, that had a maternal mortality ratio greater than 400 in 2015.6GBD 2015 Maternal Mortality CollaboratorsGlobal, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1775-1812Summary Full Text Full Text PDF PubMed Scopus (620) Google Scholar Disparities between countries are widening. This is reflected in the sharp increase, from about 68% in 1990 to more than 80% in 2015,6GBD 2015 Maternal Mortality CollaboratorsGlobal, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1775-1812Summary Full Text Full Text PDF PubMed Scopus (620) Google Scholar 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 unfinished MDG business. GBD 2015 highlights the good news that child death rates are falling at an accelerating pace since 2000—5·8 million children younger than 5 years died in 2015, which represents a 52·0% decrease in the number of under-5 deaths since 1990.5GBD 2015 Child Mortality CollaboratorsGlobal, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1725-1774Summary Full Text Full Text PDF PubMed Scopus (471) Google Scholar The divergence highlighted in GBD 20155GBD 2015 Child Mortality CollaboratorsGlobal, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1725-1774Summary Full Text Full Text PDF PubMed Scopus (471) Google Scholar between the gains expected on the basis of wider improvements in social and economic indicators and the progress achieved reflects the extraordinary impact of national policies and international cooperation. The scaling up of multiple health interventions, including insecticide-treated bednets, prevention of mother-to-child HIV transmission, introduction of new vaccines, and integrated community-based health interventions on maternal and child health have delivered tangible results in terms of lives saved. The bad news is that the world fell far short of the MDG4 target of a two-thirds reduction in the under-5 mortality rate between 1990 and 2015. Under-5 mortality fell at an annual average rate of 3% between 1990 and 2015, compared with the 4·4% rate required to achieve the MDG target.5GBD 2015 Child Mortality CollaboratorsGlobal, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1725-1774Summary Full Text Full Text PDF PubMed Scopus (471) Google Scholar Another 14 million children would have survived had the target been met.13UNICEFCommitting to child survival: a promise renewed progress report 2015. United Nations Children's Fund, New York2015http://www.unicef.org/publications/files/APR_2015_9_Sep_15.pdfGoogle Scholar GBD 2015 reinforces wider concerns over prospects for achieving the 2030 targets set for child survival. Admittedly, these targets are not well framed. The SDG ambition is to end "preventable" deaths among newborns and children younger than 5 years, with all countries aiming to fall below quantitative threshold indicators (respectively, 12 and 25 deaths for every 1000 livebirths). Unfortunately, while the thresholds have been set at a level that constitutes a high level of ambition for many countries in sub-Saharan Africa, for most countries in south Asia, east Asia, and Latin America they represent a softer target than the two-thirds reduction goal specified under the MDGs. If the aim is to end "preventable deaths", the thresholds should have been set far lower—and there is a danger of governments viewing the SDGs on child survival with some complacency. That would be unjustified. Projections by UNICEF indicate that there are 47 countries which need to increase the pace of progress on child mortality to achieve the 2030 goal of 25 or fewer deaths per 1000 livebirths.14UN Interagency Group for Child Mortality EstimationLevels and trends in child mortality report 2015: estimates developed by the UN Interagency Group for Child Mortality Estimation. United Nations Children's Fund, New York2015http://www.unicef.org/publications/files/Child_Mortality_Report_2015_Web_9_Sept_15.pdfGoogle Scholar Within this group, 30 will have to at least double the current rate of reduction.14UN Interagency Group for Child Mortality EstimationLevels and trends in child mortality report 2015: estimates developed by the UN Interagency Group for Child Mortality Estimation. United Nations Children's Fund, New York2015http://www.unicef.org/publications/files/Child_Mortality_Report_2015_Web_9_Sept_15.pdfGoogle Scholar GBD 2015 turns the spotlight on some of the underlying challenges. Three major themes stand out. First, neonatal mortality is falling more slowly than child mortality—neonatal deaths fell from 4·6 million in 1990 to 2·6 million in 2015, decreasing by 42·4% (compared with 52% for under-5 deaths).5GBD 2015 Child Mortality CollaboratorsGlobal, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1725-1774Summary Full Text Full Text PDF PubMed Scopus (471) Google Scholar Preterm birth complications and neonatal encephalopathy were the two leading causes of under-5 deaths in 2015.5GBD 2015 Child Mortality CollaboratorsGlobal, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1725-1774Summary Full Text Full Text PDF PubMed Scopus (471) Google Scholar In south Asia, neonatal mortality rates are now more than double post-neonatal mortality rates.5GBD 2015 Child Mortality CollaboratorsGlobal, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1725-1774Summary Full Text Full Text PDF PubMed Scopus (471) Google Scholar With 45% of all child deaths occurring in the first day, week, and month of life, there is an urgent need to gear the health-system response towards effective provision of antenatal care, obstetric provision, skilled birth attendance, and postnatal care.14UN Interagency Group for Child Mortality EstimationLevels and trends in child mortality report 2015: estimates developed by the UN Interagency Group for Child Mortality Estimation. United Nations Children's Fund, New York2015http://www.unicef.org/publications/files/Child_Mortality_Report_2015_Web_9_Sept_15.pdfGoogle Scholar Second, GBD 2015 helps to turn the spotlight on cause-specific death rates. Lower respiratory infections are the main cause of post-neonatal under-5 deaths and the third leading cause of child deaths overall.1GBD 2015 Mortality and Causes of Death CollaboratorsGlobal, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1459-1544Summary Full Text Full Text PDF PubMed Scopus (4142) Google Scholar, 5GBD 2015 Child Mortality CollaboratorsGlobal, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1725-1774Summary Full Text Full Text PDF PubMed Scopus (471) Google Scholar These infections account for around 16% of mortality, with diarrhoeal diseases (the fourth leading cause of death in 2015) accounting for another 9%.14UN Interagency Group for Child Mortality EstimationLevels and trends in child mortality report 2015: estimates developed by the UN Interagency Group for Child Mortality Estimation. United Nations Children's Fund, New York2015http://www.unicef.org/publications/files/Child_Mortality_Report_2015_Web_9_Sept_15.pdfGoogle Scholar Pathogen counterfactual analyses in GBD 2015 identify pneumococcal pneumonia and rotavirus as the leading causes of deaths from the two infections in 2015.1GBD 2015 Mortality and Causes of Death CollaboratorsGlobal, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1459-1544Summary Full Text Full Text PDF PubMed Scopus (4142) Google Scholar In both cases, effective vaccines are available, in part as a result of private–public partnerships developed under multilateral initiatives. The development and provision of the pneumococcal vaccine through the Advance Market Commitment of GAVI, the Vaccine Alliance15GaviThe Vaccine AllianceGAVI advance market commitment for pneumococcal vaccines annual report 1 January–31 December 2015 prepared by AMC Secretariat of Gavi, The Vaccine Alliance.http://www.gavi.org/funding/pneumococcal-amc/Date: 2015Google Scholar is one of the success stories of the MDG era— and a potential catalyst for accelerated progress to 2030. An important challenge for international cooperation is to increase funding and accelerate programmes to roll out the vaccines now available. However, vaccines are not a substitute for efficient and equitable health systems. Indeed, their effectiveness and reach depends on the presence of skilled health workers, cold storage chains, and well governed procurement and delivery systems. More generally, sustained progress in combating both the major infectious disease killers like pneumonia and diarrhoea and neonatal deaths will require a strengthened focus on the development of health systems rather than disease-specific and cause-specific interventions. The third big theme to emerge from GBD 2015 is that policy makers have to climb out of their sector silos. Cause-specific analysis of under-5 deaths can obscure the critical importance of background risk factors, including nutritional status, inadequate access to clean water and sanitation, and poverty. As countries progress towards the SDG targets, disparities in these areas are likely to become more important. For example, undernutrition is implicated in around half of child deaths.1GBD 2015 Mortality and Causes of Death CollaboratorsGlobal, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1459-1544Summary Full Text Full Text PDF PubMed Scopus (4142) Google Scholar, 5GBD 2015 Child Mortality CollaboratorsGlobal, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1725-1774Summary Full Text Full Text PDF PubMed Scopus (471) Google Scholar As highlighted in GBD 20151GBD 2015 Mortality and Causes of Death CollaboratorsGlobal, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1459-1544Summary Full Text Full Text PDF PubMed Scopus (4142) Google Scholar, 5GBD 2015 Child Mortality CollaboratorsGlobal, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1725-1774Summary Full Text Full Text PDF PubMed Scopus (471) Google Scholar progress in reducing nutritional deficiencies is slower than in other areas and this represents an obstacle to the 2030 goals. So, too, does the rapidly increasing share of global poverty accounted for by Africa's children—a by-product of demography, high levels of inequality, and slow economic growth. Recent projections suggest that about 148 million African children will be living below the US$1·90 international poverty threshold in 2030, representing 43% of all global poverty.16Watkins K Quattri M Child poverty, inequality and demography: why sub-Saharan Africa matters for the Sustainable Development Goals. Overseas Development Institute, London2016https://www.odi.org/sites/odi.org.uk/files/resource-documents/10794.pdfGoogle Scholar Much of the unfinished business associated with the MDGs can be traced to failures of equity, an issue that is present but understated in GBD 2015. The poorest and most disadvantaged children and mothers face increased health risks. Yet they are the least likely to be diagnosed, treated, or supported through health services. Some of the greatest health disparities are to be found in precisely those areas—antenatal care, skilled birth attendance, and postnatal care—needed to accelerate progress on child survival and maternal health.17UNICEFThe state of the world's children 2016: a fair chance for every child. United Nations Children's Fund, New York2016http://www.unicef.org/publications/files/UNICEF_SOWC_2016.pdfCrossref Google Scholar Future GBD studies could usefully provide data on DALYs and years of life lost (YLL) disaggregated by socioeconomic status and location. The Socio-demographic Index (SDI) is a useful way to measure disparities between countries, but it could be supplemented to a comparable method for capturing disparities within countries. Perhaps the greatest failing of the MDG era was a tendency to focus reporting on national averages, rather than on what was happening to inequality and the progress achieved by the most disadvantaged. The underlying assumption was that the benefits of expanded health provision would automatically trickle down through all social strata. That assumption was fatally flawed. Under the SDGs governments have now committed to "leave no one behind" and to ensure that the most marginalised achieve the most rapid progress. In the case of child survival, the 2030 goal of ending preventable deaths by 2030 cannot be achieved unless death rates among the poor fall more rapidly than the average. That is why the idea of universal health coverage has to be reinforced by the principle of what the Lancet Commission on Investing in Health's Global Health 2035 report described as progressive universalism, or progress that improves national average indicators while delivering higher-than-average gains for the poor.18Jamison DT Summers LH Alleyne G et al.Global health 2035: a world converging within a generation.Lancet. 2013; 382: 1898-1955Summary Full Text Full Text PDF PubMed Scopus (790) Google Scholar And it is why we need GBD 2017 to provide a data window on who is getting left behind and by how far. I declare no competing interests. GBD 2015: from big data to meaningful changeThe Global Burden of Diseases, Injuries, and Risk Factors Study 2015 ( GBD 2015 ) brings together the most recent epidemiological data according to year, age, and sex from 195 countries and territories. In a continuation of the partnership between The Lancet and the Institute for Health Metrics and Evaluation ( IHME ), this year marks the first of an annual commitment to publish the four capstone GBD papers—on global mortality, years lived with disability, disability-adjusted life-years, and risk factors—in a single issue. Full-Text PDF Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015At the global scale, age-specific mortality has steadily improved over the past 35 years; this pattern of general progress continued in the past decade. Progress has been faster in most countries than expected on the basis of development measured by the SDI. Against this background of progress, some countries have seen falls in life expectancy, and age-standardised death rates for some causes are increasing. Despite progress in reducing age-standardised death rates, population growth and ageing mean that the number of deaths from most non-communicable causes are increasing in most countries, putting increased demands on health systems. Full-Text PDF Open AccessGlobal, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015Ageing of the world's population is increasing the number of people living with sequelae of diseases and injuries. Shifts in the epidemiological profile driven by socioeconomic change also contribute to the continued increase in years lived with disability (YLDs) as well as the rate of increase in YLDs. Despite limitations imposed by gaps in data availability and the variable quality of the data available, the standardised and comprehensive approach of the GBD study provides opportunities to examine broad trends, compare those trends between countries or subnational geographies, benchmark against locations at similar stages of development, and gauge the strength or weakness of the estimates available. Full-Text PDF Open AccessGlobal, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015Health is improving globally, but this means more populations are spending more time with functional health loss, an absolute expansion of morbidity. The proportion of life spent in ill health decreases somewhat with increasing SDI, a relative compression of morbidity, which supports continued efforts to elevate personal income, improve education, and limit fertility. Our analysis of DALYs and HALE and their relationship to SDI represents a robust framework on which to benchmark geography-specific health performance and SDG progress. Full-Text PDF Open AccessGlobal, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015Declines in some key environmental risks have contributed to declines in critical infectious diseases. Some risks appear to be invariant to SDI. Increasing risks, including high BMI, high fasting plasma glucose, drug use, and some occupational exposures, contribute to rising burden from some conditions, but also provide opportunities for intervention. Some highly preventable risks, such as smoking, remain major causes of attributable DALYs, even as exposure is declining. Public policy makers need to pay attention to the risks that are increasingly major contributors to global burden. Full-Text PDF Open AccessGlobal, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015Gains in child survival have been large, widespread, and in many places in the world, faster than what was anticipated based on improving levels of development. Yet some countries, particularly in sub-Saharan Africa, still had high rates of under-5 mortality in 2015. Unless these countries are able to accelerate reductions in child deaths at an extraordinary pace, their achievement of proposed SDG targets is unlikely. Improving the evidence base on drivers that might hasten the pace of progress for child survival, ranging from cost-effective intervention packages to innovative financing mechanisms, is vital to charting the pathways for ultimately ending preventable child deaths by 2030. Full-Text PDF Open AccessGlobal, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015Several challenges to improving reproductive health lie ahead in the SDG era. Countries should establish or renew systems for collection and timely dissemination of health data; expand coverage and improve quality of family planning services, including access to contraception and safe abortion to address high adolescent fertility; invest in improving health system capacity, including coverage of routine reproductive health care and of more advanced obstetric care—including EmOC; adapt health systems and data collection systems to monitor and reverse the increase in indirect, other direct, and late maternal deaths, especially in high SDI locations; and examine their own performance with respect to their SDI level, using that information to formulate strategies to improve performance and ensure optimum reproductive health of their population. Full-Text PDF Open AccessMeasuring the health-related Sustainable Development Goals in 188 countries: a baseline analysis from the Global Burden of Disease Study 2015GBD provides an independent, comparable avenue for monitoring progress towards the health-related SDGs. Our analysis not only highlights the importance of income, education, and fertility as drivers of health improvement but also emphasises that investments in these areas alone will not be sufficient. Although considerable progress on the health-related MDG indicators has been made, these gains will need to be sustained and, in many cases, accelerated to achieve the ambitious SDG targets. The minimal improvement in or worsening of health-related indicators beyond the MDGs highlight the need for additional resources to effectively address the expanded scope of the health-related SDGs. Full-Text PDF Open Access