We thus turn our attention to what makes health estimates useable, and useful. We believe that health data and estimates at any level are only useful if they are demonstrably used to improve the health of individuals other than those (including ourselves) who make a comfortable living out of the health estimates industry. However most of the debate so far has centred on the interests of institutions and individuals who work at a supranational level, as though ‘global health’ were in some way independent of the health of billions of individuals living in specific local and national settings, as though global health estimates were independent of data collected by people and institutions in very concrete contexts. Who designates the experts? Which methods are considered robust? Which forums confer legitimacy to communicated data? Whose funding decisions are influenced?Ī few authors have argued that the political legitimacy and technical validity of global health estimates would be improved if estimation processes worked from the bottom up. But there has been less discussion of how these constructions come about. Who is making the estimates, and by what right? How ‘robust’ are they, and how ‘legitimate’ ? Several contributors to this debate recognised that data and concepts in global health are institutionally and politically constructed: a health issue rises up the international agenda because people deemed to be experts have used accepted methods to demonstrate its importance, and have communicated that in forums which entrench that importance (and which influence funding decisions). The second wave of responses focused mostly on social issues, such as the role of health estimates in shaping the global health agenda. Rumbling under both of these areas of concern was a larger discomfort, which built into a second wave of responses, questioning power relationships in global health. Experts working globally on specific disease areas questioned methods, complaining that they could not see the workings inside the ‘black box’ of IHME models. Academics and health officials from several countries were confronted with estimates they found hard to reconcile with the facts as they saw them this led to many questions about data sources. The first wave focused largely on technical issues. The publication by the Institute for Health Metrics and Evaluation (IHME) of estimates for the burden of very many diseases in very many countries drew sharp responses, in two waves. The validity and legitimacy of global health estimates have been a topic of debate for at least two decades, but it was the Global Burden of Disease estimates of 2010 that really set the discussions alight. Local capacities to use knowledge to improve health must be supported. Besides strengthening national information systems, this requires ongoing interaction, building trust and establishing a communicative infrastructure. We suggest that greater engagement of local actors (and local data) in the formulation, communication and interpretation of health estimates would increase the likelihood that these data will be used by those most able to translate them into health gains for the longer term. In other words, data that are both technically and socially robust for those who make key decisions about health. Internationally standardised indicators are necessary, but they are no substitute for data that meet local needs, and that fit with local ideas of what is credible and useful. This paper draws on country case studies and personal experience to support our opinion that the production and use of estimates are deeply embedded in specific social, economic, political and ideational contexts, which differ at different levels of the global health architecture.īroadly, most global health estimates tend to be made far from the local contexts in which the data upon which they are based are collected, and where the results of estimation processes must ultimately be used if they are to make a difference to the health of individuals. These changes have rekindled debates about the validity and legitimacy of global health estimates. A plethora of new development goals and funding institutions have greatly increased the demand for internationally comparable health estimates in recent years, and have brought important new players into the field of health estimate production.
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