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Levels of anchorage
to local data and NBD Results
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Addition of local health
state valuations highlights the
disability component to various extents.
The two HSV anchored estimates blur
general mortality level in Andhra Pradesh
and the age pattern of mortality. The
HSV- anchored estimates highlight
disability as the major source of disease
burden, almost to the exclusion of
premature mortality. If disability is the
major source of burden, the life
expectancy in Andhra Pradesh would have
been higher and the infant mortality
rate, lower. It is doubtful whether the
people in Andhra Pradesh are ready to
ignore premature mortality and focus on
the disability component of the burden to
the extent the HSV estimate would
recommend. Since we have not presented
this estimate to people in Andhra Pradesh
for serious consideration by policy
makers, there is no evidence to support
the above conjecture. But some insights
are available from a somewhat similar
situation elsewhere in the world. In
1989, the Oregon state in US set up the
Oregon Health Services Commission and
charged it with the responsibility of
preparing a list of health services
ranked by priority from the most
important to the least important,
representing comparative benefits of each
service to the entire population (OHSC
Website, 2000; Brown, 1991, Tengs and
others, 1996). The commission produced a
priority list in 1990. There was a lot of
criticism and popular outrage about the
ordering of various condition treatment
pairs. One of the contrasts chosen by
some people was to point out that routine
dental care had received priority over
life- saving procedures like appendectomy
(Hadorn, 1991). OHSC responded to the
popular outrage and revised the priority
list altogether. Now let's compare the
life expectancy at birth in Oregon and
Andhra Pradesh. In 1990, Oregon had a
life expectancy at birth of 76.6 years
(males = 73.4 and females = 79.8). My
estimate of life expectancy in Andhra
Pradesh around the same time (1991) is
between 56 to 60 years. Oregon was
already experiencing a much lower level
of mortality at the time of these
developments. |
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How do we then account for
the difference between the priority
implicit in the community valuation of
health states and popular support for
public health interventions to reduce
mortality? One reason could be the
difference in states of the world
visualised by persons while valuing
health states as an individual and while
considering priorities for public health
intervention by the community. For
example, valuers may give higher
importance to their own suffering while
valuing a health state. They may be able
to take a more detached view in the
context of public policy. Another reason
could be measurement error in health
state valuation. While it is clear that
further research on health state
valuation is required, the lesson for NBD
estimation is that investments on health
state valuation may not give immediate
returns to inform policy. Instead, NBD
estimates seeking to inform current
policy should invest in cause of death,
and descriptive epidemiological studies.
However, research on health state
valuation in different settings will be
important for methodological advancement
of summary measures of population health. |
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Finally what is the
information value of a National Burden of
Disease estimate? Anchoring NBD estimates
to local data on cause of death,
incidence and prevalence of diseases
gives added confidence to the validity of
those estimates and encourages policy
makers to give more weightage to the
evidence produced by NBD estimates.
Policy maker's confidence and reliance on
NBD estimates will depend on the quality
of local data to which the estimates are
anchored. Another important contribution
of NBD estimates is usually in allowing
for disaggregated analysis for different
population groups within the national or
sub-national entity. For example,
differences in needs and organisation of
health care for rural and urban areas is
an important issue. The Andhra Pradesh
Disease Burden estimates, prepared for
the rural and urban populations
separately, allowed for rural - urban
analyses, wherever necessary. |
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