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Measuring the health-related Sustainable Development
Goals in 188 countries: a baseline analysis from the Global
Burden of Disease Study 2015
GBD 2015 SDG Collaborators*
Summary
Background
In September, 2015, the UN General Assembly established the Sustainable Development Goals (SDGs).
The SDGs specify 17 universal goals, 169 targets, and 230 indicators leading up to 2030. We provide an analysis of
33 health-related SDG indicators based on the Global Burden of Diseases, Injuries, and Risk F
actors Study 2015
(GBD 2015).
Methods
We applied statistical methods to systematically compiled data to estimate the performance of 33 health-
related SDG indicators for 188 countries from 1990 to 2015. We rescaled each indicator on a scale from 0 (worst
observed value between 1990 and 2015) to 100 (best observed). Indices representing all 33 health-related SDG
indicators (health-related SDG index), health-related SDG indicators included in the M
illennium Development G
oals
(MDG index), and health-related indicators not included in the MDGs (non-MDG index) were computed as the
geometric mean of the rescaled indicators by SDG target. We used spline regressions to examine the relations
between the Socio-demographic Index (SDI, a summary measure based on average income per person, educational
attainment, and total fertility rate) and each of the health-related SDG indicators and indices.
Findings
In 2015, the median health-related SDG index was 59∙3 (95% uncertainty interval 56∙8–61∙8) and varied
widely by country
, ranging from 85∙5 (84∙2–86∙5) in Iceland to 20∙4 (15∙4–24∙9) in Central African R
epublic. SDI was
a good predictor of the health-related SDG index (
r
²=0∙88) and the MDG index (
r
²=0∙92), whereas the non-MDG index
had a weaker relation with SDI (
r
²=0∙79). Between 2000 and 2015, the health-related SDG index improved by a median
of 7∙9 (IQR 5∙0–10∙4), and gains on the MDG index (a median change of 10∙0 [6∙7–13∙1]) exceeded that of the non-
MDG index (a median change of 5∙5 [2∙1–8∙9]). Since 2000, pronounced progress occurred for indicators such as met
need with modern contraception, under-5 mortality, and neonatal mortality, as well as the indicator for universal health
coverage tracer interventions. Moderate improvements were found for indicators such as HIV and tuberculosis
incidence, minimal changes for hepatitis B incidence took place, and childhood overweight considerably worsened.
Interpretation
GBD 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 suffi
cient.
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 eff
ectively address the expanded scope of
the health-related SDGs.
Funding
Bill & Melinda Gates Foundation.
Copyright
The Authors(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license.
Background
In September, 2015, the UN General Assembly adopted
“Transforming our World: The 2030 Agenda for
Sustainable Development”, a resolution outlining a new
framework to form the cornerstone of the sustainable
development agenda for the period leading up to 2030.
1
This new framework replaced the Millennium
Development Goal (MDG) framework that expired in 2015,
establishing 17 universal goals and 169 targets referred to
as the Sustainable Development Goals (SDGs). The SDGs
substantially broaden the development agenda beyond the
MDGs and are expected to frame UN member state
policies over the next 15 years. To measure progress
towards achieving the goals, the UN Statistical Commission
created the Inter-Agency and Expert Group on Sustainable
Development Goal Indicators (IAEG-SDGs) with a
mandate to draft an indicator framework that aligns with
the targets. The IAEG-SDGs announced a total of
230 indicators to measure achievement of the 169 targets.
2
Health is a core dimension of the SDGs; goal 3 aims to
“ensure healthy lives and promote wellbeing for all at all
ages”. Health-related indicators—ie, indicators directly
pertaining to health services, health outcomes, and
environmental, occupational, behavioural, or metabolic
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*Collaborators listed at
the end
of the Article
Correspondence to:
Prof
Christopher J L Murray,
University of Washington,
Institute for Health Metrics and
Evaluation, 2301 5th Avenue,
Suite 600, Seattle, WA 98121,
USA
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risks with well established causal connections to health—
are also present in ten of the other 16 goals.
3,4
Across these
11 goals, there are 28 health-related targets with a total of
47 health-related indicators.
The SDGs were developed through a highly
consultative and iterative process that included multiple
meetings with expert groups, civil society, and
governments. However, the process of developing the
SDGs and the accompanying goals, targets, and
indicators has not been without its critics. In both
scientifi
c settings and the news media, the common
refrain has been that the SDGs are a long list of vague
goals that lack clear, realistic, and measurable targets
and indicators,
5–11
and that they are not accompanied by a
clear theory of change
12
articulating how the pieces fi
t
together.
3
In view of the potential importance of the
SDGs in directing national policies and donor
investments, there has also been intense debate about
the selection of targets and indicators;
12
despite the
lengthy list, some think that the SDGs are missing key
areas of development, ranging from prohibition of
forced labour
13
to improvement of mental health.
14–16
Concerns have also been expressed about the feasibility
of measuring the 230 proposed indicators.
5,6,17
Indeed,
measurement of countries’ current status and progress
towards meeting the SDG targets will be an enormous
task and will require collective action across a range
of national and international organisations, both
governmental and non-governmental. The diffi
culties of
measurement are also further compounded by persistent
problems of data availability, quality, and comparability
across a host of indicators.
4,18
Furthermore, measurement
of development indicators is accompanied by a high
potential for political entanglement, which can lead to
distorted estimates.
19–22
Independent monitoring of the
SDG indicators will be crucial if they are to be used to
accurately evaluate progress to ensure accountability
and drive national and international development
agendas towards meeting the SDGs.
4,23–26
Despite these concerns, increasing work has been done
in the past decade to generate independent, comparable,
valid, and consistent measurements of development
indicators.
27–32
To measure progress on the SDGs, these
existing eff
orts will need to be leveraged, particularly
those that provide comparable assessments of health
outcomes and risks across countries and over time. The
Global Burden of Diseases, Injuries, and Risk Factors
Study (GBD) is a primary example of such an initiative.
GBD is an open, collaborative, independent study to
comprehensively measure epidemiological levels and
trends of disease and risk factor burden worldwide,
with more than 1870 individual collaborators from
124 countries and three territories across the full range
of development. GBD uses a highly standardised
approach to overcome challenges of inconsistent coding
and indicator defi
nitions across countries, missing and
confl
icting data, and time lags in measurement and
estimation. Of the 47 health-related indicators included
as part of the SDGs, estimates for 33 indicators are
presently included as part of GBD. The GBD study also
has several mechanisms to ensure independence,
including the GBD Scientifi c Council that meets
regularly to review all methods and major data changes,
and the Independent Advisory Committee that meets
twice yearly to review GBD progress and provide
recommendations for strengthening GBD estimates.
33
In this analysis, while acknowledging the continued
debate about the structure, selection, and construction
of SDG indicators, we used the GBD study to assess the
current status of these 33 health-related SDG indicators.
With this baseline assessment, we developed and
estimated a summary indicator for the health-related
SDG indicators and documented historical trends for
this summary indicator. With the GBD results, we
identifi
ed countries with the largest improvements
between 1990 and 2015 to inform roadmaps and provide
a basis for monitoring the health-related SDG
indicators.
Research in context
Evidence before this study
Since the adoption
of
the Sustainable Development Goals
(SDGs) in September, 2015, demand to establish independent,
robust avenues for monitoring progress for the SDGs has
escalated. However, substantial challenges exist in undertaking
comprehensive and comparable assessments of health-related
SDG indicators to monitor and guide development agendas and
health policy implementation.
Added value of this study
The Global Burden of Diseases, Injuries, and Risk Factors Study
(GBD) features more than 1870 collaborators from
124 countries and three territories and provides an independent
analytical platform through which levels of health-related SDG
indicators can be assessed across geographies and over time in a
comparable manner. Drawing from GBD, we provide the
measurement of 33 of the 47 health-related SDG indicators and
introduce an overall health-related SDG index for 188 countries
from 1990 to 2015.
Implications of all the available evidence
GBD and its analytical framework allow detailed analyses of
country-level performance across health-related SDG indicators
and over time. This information can be used to identify
high-performing and low-performing countries, inform policy
decisions, guide resource allocation, and monitor progress
towards the health-related SDGs. The varied historical progress
in improving a subset of health-related SDG indicators and
rising prevalence of risks such as child overweight underscores
the complex health landscape the world faces in the SDG era.
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Methods
Overview of GBD
GBD is an annual eff
ort to measure the health of
populations at regional, country, and selected subnational
levels.
33
GBD produces estimates of mortality and
morbidity by cause, age, sex, and country for the period
1990 to the most recent year, refl ecting all available data
sources adjusted for bias. GBD also measures many
health system characteristics, risk factor exposure, and
mortality and morbidity attributable to these risks. In
addition to providing highly detailed standardised
information for many outcomes and risks, various
summary measures are also computed, including
disability-adjusted life-years (DALYs) and healthy life
expectancy. For the present analysis, we used estimates
from GBD 2015 to provide a baseline assessment for
188 countries. Further details on GBD 2015, which covers
1990–2015, are available elsewhere.
34–39
Indicators, defi
nitions, and measurement approach
We defi ned health-related SDG indicators as indicators
for health services, health outcomes, and environmental,
occupational, behavioural, and metabolic risks with well
established causal connections to health. Many of the
47 health-related SDG indicators selected by the
IAEG-SDGs are produced as part of GBD. Table 1
outlines the ten goals, corresponding to 21 health-related
targets and 33 health-related indicators included in this
present iteration of GBD. This table also outlines the
defi
nition of the indicator used in this analysis; detailed
descriptions of the estimation methods and data sources
are given in the methods appendix pp 10–311. For the
14 health-related indicators that were not included in this
analysis, their prospects for measurement in future
iterations of GBD are described in table 2.
Direct outputs of GBD that are health-related SDG
indicators include mortality disaggregated by age
(under-5 and neonatal) and cause (maternal,
cardiovascular disease, cancer, diabetes, chronic
respiratory diseases, road injuries, self-harm, un inten-
tion al poisonings, exposure to forces of nature, inter-
personal violence, and collective violence and legal
inter vention [ie, deaths due to law enforcement actions,
irrespective of their legality]), as well as disease incidence
(HIV, malaria, tuberculosis, and hepatitis B) and
prevalence (neglected tropical diseases). The GBD
comparative risk assessment includes measurement of
exposure prevalence included as health-related SDG
indicators (under-5 stunting, wasting, and overweight;
tobacco smoking; harmful alcohol use; intimate partner
violence; unsafe water, sanitation, and hygiene;
household air pollution; and ambient particulate matter
pollution), as well as deaths or disease burden attributable
to risk factors selected as health-related SDG indicators
(unsafe water, sanitation, and hygiene; household air
pollution and ambient particulate matter pollution; and
occupational risks).
Underlying GBD outputs are a range of additional
health determinants that contribute to the estimation of
morbidity and mortality, for which data are
systematically compiled and estimates are produced.
For example, GBD comprehensively analyses data from
household surveys on vaccine coverage and combines
survey estimates with reported administrative data to
produce time series of vaccine coverage for all countries
from 1990 to 2015. Estimates of vaccine coverage are
then included as predictors of vaccine-preventable
morbidity and mortality in GBD. Additional health
indicators produced as part of GBD and included as
health-related SDG indicators in this analysis are: met
need with modern contraception among women of
reproductive age, adolescent birth rate, skilled birth
attendance coverage, and universal health coverage
(UHC) tracer interventions. For UHC tracer
interventions, we developed an index based on the
geometric mean of the coverage of a set of UHC tracer
interventions: met need with modern contraception;
antenatal care (one or more visits and four or more
visits); skilled birth attendance coverage; in-facility
delivery rates; vaccination coverage (three doses of
diphtheria–pertussis–tetanus, measles vaccine, and
three doses of oral polio vaccine or inactivated polio
vaccine); tuberculosis case detection rate; coverage of
antiretroviral therapy for populations living with HIV,
and coverage of insecticide-treated nets for malaria-
endemic countries.
For selected indicators proposed by the IAEG-SDGs,
we made modifi cations to the defi nition for clarity or on
the basis of the defi nition used in GBD (table 1). For
example, Indicator 2.2.2 proposes a measure of
malnutrition that combined prevalence of wasting and
overweight among children under age 5 years. As
childhood wasting and overweight have very diff
erent
determinants, we opted to report them separately. For
childhood overweight, we report prevalence in children
aged 2–4 years, the defi nition used in GBD based on
thresholds set by the International Obesity Task Force.
40
Further details on the estimation and data sources
used for all indicators, compliant with Guidelines for
Accurate and Transparent Health Estimates Reporting
(GATHER),
41,42
are included in the methods appendix
pp 10–311.
Health-related SDG, health-related MDG, and health-
related non-MDG indices
To identify broad patterns and more easily track general
progress, we developed an overall health-related SDG index
that is a function of the 33 health-related SDG indicators
(referred to as the health-related SDG index). We also
constructed two related indices: one refl ecting the SDG
health-related indicators previously included in the MDG
monitoring framework (referred to as the MDG index) and
one refl ecting SDG health-related indicators not included
in the MDGs (referred to as the non-MDG index).
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Health-related SDG
indicator
Defi
nition used in this
analysis
Further details
Inclusion in
MDG or
non-MDG index
Goal 1: End poverty in all its forms everywhere
Target 1.5: By 2030, build the resilience of the poor and those
in vulnerable situations and reduce their exposure and
vulnerability to climate-related extreme events and other
economic, social and environmental shocks, and disasters
Disaster (1.5.1; same
as Indicators 11.5.1
and 13.1.2)
Age-standardised death rate
due to exposure to forces of
nature, per 100 000 population
Existing datasets do not comprehensively measure
missing people and people aff ected by natural
disasters. We revised this indicator to exposure to
forces of nature and reported in age-standardised
rates
Non-MDG
Goal 2: End hunger, achieve food security and improved nutrition, and promote sustainable agriculture
Target 2.2: By 2030, end all forms of malnutrition, including
achieving, by 2025, the internationally agreed targets on
stunting and wasting in children under 5 years of age, and
address the nutritional needs of adolescent girls, pregnant and
lactating women, and older persons
Stunting (2.2.1)
Prevalence of stunting in
children under age 5 years, %
Stunting is defi
ned as below –2 SDs from the median
height-for-age of the reference population.
No indicator modifi
cations required
MDG
Target 2.2 (as above)
Wasting (2.2.2a)
Prevalence of wasting in
children under age 5 years, %
Wasting is defi ned as below –2 SDs from the median
weight-for-height of the reference population.
We separated reporting for indicator 2.2.2 into
wasting (2.2.2a) and overweight (2.2.2b)
MDG
Target 2.2 (as above)
Overweight (2.2.2b)
Prevalence of overweight in
children aged 2–4 years, %
We used the IOTF thresholds because the WHO cutoff
at age 5 years can lead to an artifi cial shift in prevalence
estimates when the analysis covers more age groups.
Furthermore, considerably more studies use IOTF
cutoff
s than WHO cutoff
s, which allowed us to build a
larger database for estimating child overweight. We
separated reporting for indicator 2.2.2 into wasting
(2.2.2a) and overweight (2.2.2b)
Non-MDG
Goal 3: Ensure healthy lives and promote wellbeing for all at all ages
Target 3.1: By 2030, reduce the global maternal mortality ratio
to less than 70 per 100 000 livebirths
Maternal mortality
ratio (3.1.1)
Maternal deaths per
100 000 livebirths
No indicator modifi
cations required
MDG
Target 3.1 (as above)
Skilled birth
attendance (3.1.2)
Proportion of births attended
by skilled health personnel
(doctors, nurses, midwives, or
country-specifi c medical staff
[eg, clinical offi
cers]), %
No indicator modifi
cations required
MDG
Target 3.2: By 2030, end preventable deaths of newborns and
children under 5 years of age, with all countries aiming to
reduce neonatal mortality to at least as low as 12 per
1000 livebirths and under-5 mortality to at least as low as
25 per 1000 livebirths
Under-5 mortality
(3.2.1)
Probability of dying before
age 5 years per 1000 livebirths
No indicator modifi
cations required
MDG
Target 3.2 (as above)
Neonatal mortality
(3.2.2)
Probability of dying during
the fi rst 28 days of life per
1000 livebirths
No indicator modifi
cations required
MDG
Target 3.3: By 2030, end the epidemics of AIDS, tuberculosis,
malaria, and neglected tropical diseases and combat hepatitis,
water-borne diseases, and other communicable diseases
HIV (3.3.1)
Age-standardised rate of new
HIV infections, per
1000 population
We revised this indicator to HIV incidence of all
populations and reported in age-standardised rates
MDG
Target 3.3 (as above)
Tuberculosis (3.3.2)
Age-standardised rate of new
and relapsed tuberculosis
cases, per 1000 population
No indicator modifi
cations required
MDG
Target 3.3 (as above)
Malaria (3.3.3)
Age-standardised rate of
malaria cases, per
1000 population
No indicator modifi
cations required
MDG
Target 3.3 (as above)
Hepatitis B (3.3.4)
Age-standardised rate of
hepatitis B incidence, per
100 000 population
No indicator modifi
cations required
Non-MDG
Target 3.3 (as above)
Neglected tropical
diseases (3.3.5)
Age-standardised prevalence
of neglected
tropical
diseases,
per 100 000 population
People requiring interventions against
neglected
tropical diseases
are not well defi
ned; thus, we
revised this indicator to the sum of the prevalence of
14 neglected tropical diseases currently measured in
GBD: African trypanosomiasis, Chagas disease, cystic
echinococcosis, cysticerosis, dengue, food-borne
trematodiases, intestinal nematode infections,
leishmaniasis, leprosy, lymphatic fi
lariasis,
onchocerciasis, rabies, schistosomiasis, and
trachoma
Non-MDG
(Table 1 continues on next page)
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5
Health-related SDG
indicator
Defi
nition used in this
analysis
Further details
Inclusion in
MDG or
non-MDG index
(Continued from previous page)
Target 3.4: By 2030, reduce by one-third premature mortality
from NCDs through prevention and treatment, and promote
mental health and wellbeing
NCDs (3.4.1)
Age-standardised death rate
due to cardiovascular disease,
cancer, diabetes, and chronic
respiratory disease in
populations aged 30–70 years,
per 100 000 population
No indicator modifi
cations required
Non-MDG
Target 3.4 (as above)
Suicide (3.4.2)
Age-standardised death rate
due to self-harm, per
100 000 population
No indicator modifi
cations required
Non-MDG
Target 3.5: Strengthen the prevention and treatment of
substance abuse, including narcotic drug abuse and harmful
use of alcohol
Alcohol (3.5.2)
Risk-weighted prevalence of
alcohol consumption, as
measured by the SEV for
alcohol use, %
We revised this indicator to include six categories of
alcohol consumption because national alcohol
consumption per person does not capture the
distribution of use. The SEV for alcohol use is based
on two primary dimensions and subcategories of
each: individual-level drinking (current drinkers,
lifetime drinkers, lifetime abstainers, and alcohol
consumption by current drinkers) and drinking
patterns (binge drinkers and frequency of binge
drinks). The SEV then weights these categories with
their corresponding relative risks, which translates
to a risk-weighted prevalence on a scale of 0%
(no risk in the population) to 100% (the entire
population experiences maximum risk associated
with alcohol consumption)
Non-MDG
Target 3.6: By 2020, halve the number of global deaths and
injuries from road traffi
c accidents
Road injuries (3.6.1)
Age-standardised death rate
due to road traffi
c injuries, per
100 000 population
No indicator modifi
cations required
Non-MDG
Target 3.7: By 2030, ensure universal access to sexual and
reproductive health-care services, including for family
planning, information and education, and the integration of
reproductive health into national strategies and programmes
Family planning need
met, modern
contraception (3.7.1)
Proportion of women of
reproductive age (15–49 years)
who have their need for family
planning satisfi
ed with
modern methods, % women
aged 15–49 years
No indicator modifi
cations required
MDG
Target 3.7 (as above)
Adolescent birth rate
(3.7.2)
Birth rates for women aged
10–14 years and women aged
15–19 years, number of
livebirths per 1000 women
aged 10–14 years and women
aged 15–19 years
No indicator modifi
cations required
MDG
Target 3.8: Achieve universal health coverage, including
fi nancial risk protection, access to quality essential health-care
services and access to safe, eff ective, quality, and aff
ordable
essential medicines and vaccines for all
Universal health
coverage tracer
(3.8.1)
Coverage of universal health
coverage tracer interventions
for prevention and treatment
services, %
Tracer interventions included immunisation coverage
(ie, coverage of three doses of diphtheria–pertussis–
tetanus, measles vaccine, and three doses of oral polio
vaccine or inactivated polio vaccine), met need with
modern contraception, antenatal care coverage (one
or more visits and four or more visits), skilled birth
attendance, in-facility delivery rates, coverage of
antiretroviral therapy for people living with HIV,
tuberculosis case detection rate, and coverage of
insecticide-treated nets in malaria-endemic countries
MDG
Target 3.9: By 2030, substantially reduce the number of
deaths and illnesses from hazardous chemicals and air, water,
and soil pollution and contamination
Air pollution
mortality (3.9.1)
Age-standardised death rate
attributable to household air
pollution and ambient air
pollution, per
100 000 population
No indicator modifi
cations required
Non-MDG
Target 3.9 (as above)
WaSH mortality
(3.9.2)
Age-standardised death rate
attributable to unsafe WaSH,
per 100 000 population
No indicator modifi
cations required
Non-MDG
Target 3.9 (as above)
Poisons (3.9.3)
Age-standardised death rate
due to unintentional
poisonings, per
100 000 population
No indicator modifi
cations required
Non-MDG
(Table 1 continues on next page)
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Health-related SDG
indicator
Defi
nition used in this
analysis
Further details
Inclusion in
MDG or
non-MDG index
(Continued from previous page)
Target 3.a: Strengthen the implementation of the World
Health Organization Framework Convention on Tobacco
Control in all countries, as appropriate
Smoking (3.a.1)
Age-standardised prevalence
of daily smoking in
populations aged 10 years
and older, % population aged
10 years and older
We revised this indicator to daily smoking because
of data limitations regarding the systematic
measurement of current smoking and to refl
ect
populations aged 10 years and older
Non-MDG
Goal 5: Achieve gender equality and empower all women and girls
Target 5.2: Eliminate all forms of violence against all women
and girls in the public and private spheres, including traffi
cking
and sexual and other types of exploitation
Intimate partner
violence (5.2.1)
Age-standardised prevalence
of women aged 15 years and
older who experienced
intimate partner violence, %
women aged 15 years and
older
Existing datasets do not comprehensively measure
the status of ever-partnered women relative to
never-partnered women; therefore, the
denominator was revised to all women aged
15 years and older. Data on exposure to subtypes of
violence are not systematically available across
geographies and over time
Non-MDG
Goal 6: Ensure availability and sustainable management of water and sanitation for all
Target 6.1: By 2030, achieve universal and equitable access to
safe and aff
ordable drinking water for all
Water (6.1.1)
Risk-weighted prevalence of
populations using unsafe or
unimproved water sources, as
measured by the SEV for
unsafe water, %
Diff
erent types of unsafe water sources have
diff erent relative risks associated with poor health
outcomes; thus, we revised this indicator to SEV for
water, which captures the relative risk of diff
erent
types of unsafe water sources and then combines
them into a risk-weighted prevalence on a scale of
0% (no risk in the population) to 100% (the entire
population experiences maximum risk associated
with unsafe water)
MDG
Target 6.2: By 2030, achieve access to adequate and equitable
sanitation and hygiene for all and end open defecation, paying
special attention to the needs of women and girls and those in
vulnerable situations
Sanitation (6.2.1a)
Risk-weighted prevalence of
populations using unsafe or
unimproved sanitation, as
measured by the SEV for
unsafe sanitation, %
We separated reporting for indicator 6.2.1 into
sanitation (6.2.1a) and hygiene (6.2.1b). We had
three mutually exclusive, collectively exhaustive
categories for sanitation at the household level:
households with piped sanitation (with a sewer
connection); households with improved sanitation
without a sewer connection (pit latrine, ventilated
improved latrine, pit latrine with slab, or
composting toilet), as defi
ned by the JMP; and
households without improved sanitation (fl
ush
toilet that is not piped to sewer or septic tank, pit
latrine without a slab or open pit, bucket, hanging
toilet or hanging latrine, shared facilities, or no
facilities), as defi ned by the JMP
MDG
Target 6.2 (as above)
Hygiene (6.2.1b)
Risk-weighted prevalence of
populations with unsafe
hygiene (no handwashing
with soap), as measured by
the SEV for unsafe hygiene, %
Safe hygiene practices were defi ned as handwashing
with soap and water following toilet use or contact
with excreta. We separated reporting for indicator
6.2.1 into sanitation (6.2.1a) and hygiene (6.2.1b)
Non-MDG
Goal 7: Ensure access to aff ordable, reliable, sustainable, and modern energy for all
Target 7.1: By 2030, ensure universal access to aff
ordable,
reliable, and modern energy services
Household air
pollution (7.1.2)
Risk-weighted prevalence of
household air pollution, as
measured by the SEV for
household air pollution, %
Existing datasets do not comprehensively measure
population use of clean fuels and technology for
heating and lighting across geographies; thus, we
revised this indicator to focus on exposure to clean
(or unclean) fuels used for cooking
Non-MDG
Goal 8: Promote sustained, inclusive, and sustainable economic growth, full and productive employment, and decent work for all
Target 8.8: Protect labour rights and promote safe and secure
working environments for all workers, including migrant
workers, in particular women migrants, and those in
precarious employment
Occupational risk
burden (8.8.1)
Age-standardised all-cause
DALY rate attributable to
occupational risks, per
100 000 population
We revised this indicator to the DALY rate
attributable to occupational risks because DALYs
combine measures of mortality and non-fatal
outcomes into a singular summary measure, and
occupational risks represent the full range of safety
hazards that could be encountered in working
environment
Non-MDG
(Table 1 continues on next page)
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7
Three broad approaches can be used to create
composite measures: normative, preference weighted,
and statistical. Normative approaches combine each
indicator based on fi
rst principles or an over-riding
construct such as the contribution of each indicator to
overall health. Preference-weighted approaches weight
each indicator by expressed or elicited social preferences
for the relative importance of diff
erent indicators.
Statistical approaches seek to reduce a long set of
variables or indicators into common components of
variance using methods such as principal component
analysis or factor analysis. In this case, because the SDGs
refl
ect the collective vision of UN member states, we
used a preference-weighted approach, assuming that
each SDG target should be treated equally.
To combine indicators, we adopted methods used to
construct the Human Development Index,
43
which
include rescaling each indicator on a scale from 0 to 100
and then combining indicators using the geometric
mean. The geometric mean allows indicators with very
high values to partly compensate for low values on other
indicators (referred to as partial substitutability). In the
methods appendix pp 312–13, we describe results from
alternative index construction methods (ie, principal
component analysis; the arithmetic mean across targets
referred to as complete substitutability; and the minimum
value across targets referred to as zero substitutability).
Quantitative targets for each of the health-related SDG
indicators are not universally specifi
ed. As a result, we
rescaled each health-related SDG indicator on a scale
from 0 to 100, with 0 being the lowest (worst) value
observed and 100 being the highest (best) value observed
over the time period 1990–2015. We log-transformed
mortality and morbidity before rescaling. We then
estimated the health-related SDG index by fi
rst computing
the geometric mean of each rescaled health-related SDG
indicator for a given target, followed by the geometric
mean of resulting values across all SDG targets. To avoid
problems with indicator values close to 0, when
computing indices we applied a fl
oor of one to all
indicators. This analytic approach weights each of the
health-related SDG targets equally. In addition to the
health-related SDG index, we also used the same methods
to construct an index that represents 14 health-related
SDG indicators that were previously MDG indicators and
an index representing 19 non-MDG indicators (table 1).
Uncertainty in the indicator and indices values was
computed using a simulation analysis.
Health-related SDG
indicator
Defi
nition used in this
analysis
Further details
Inclusion in
MDG or
non-MDG index
(Continued from previous page)
Goal 11: Make cities and human settlements inclusive, safe, resilient, and sustainable
Target 11.5: By 2030, signifi cantly reduce the number of
deaths and the number of people aff ected and substantially
decrease the direct economic losses relative to global gross
domestic product caused by disasters, including water-related
disasters, with a focus on protecting the poor and people in
vulnerable situations
Disaster (11.5.1; same
as Indicators 1.5.1
and 13.1.2)
Age-standardised death rate
due to exposure to forces
of nature, per
100 000 population
Existing datasets do not comprehensively measure
missing people and people aff ected by natural
disasters; we revised this indicator to exposure to
forces of nature and reported in age-standardised
rates
Non-MDG
Target 11.6: By 2030, reduce the adverse per-capita
environmental impact of cities, including by paying special
attention to air quality and municipal and other waste
management
Mean PM2·5 (11.6.2)
Population-weighted mean
levels of PM2·5, μg/m³
No indicator modifi
cations required
Non-MDG
Goal 13: Take urgent action to combat climate change and its impacts
Target 13.1: Strengthen resilience and adaptive capacity to
climate-related hazards and natural disasters in all countries
Disaster (13.1.2; same
as Indicators 1.5.1
and 11.5.1)
Age-standardised death rate
due to exposure to forces
of nature, per
100 000 population
Existing datasets do not comprehensively measure
missing people and people aff ected by natural
disasters; we revised this indicator to exposure to
forces of nature and reported in age-standardised
rates
Non-MDG
Goal 16: Promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build eff
ective, accountable and inclusive institutions at all levels
Target 16.1: Signifi cantly reduce all forms of violence and
related death rates everywhere
Violence (16.1.1)
Age-standardised death rate
due to interpersonal violence,
per 100 000 population
Existing datasets do not comprehensively measure
displacement and migratory status of victims of
intentional homicide; we revised this indicator to
deaths due to interpersonal violence (ie, homicide)
Non-MDG
Target 16.1 (as above)
War (16.1.2)
Age-standardised death rate
due to collective violence and
legal intervention, per
100 000 population
Existing datasets do not comprehensively measure
the displacement status of deaths due to confl
ict; we
revised this indicator to deaths due to collective
violence and legal intervention (ie, war)
Non-MDG
Detailed descriptions of the data sources and methods used to estimate each health-related SDG indicator are in the methods appendix pp 10–311. SDG=Sustainable Development Goal. MDG=Millennium
Development Goal. IOTF=International Obesity Task Force. GBD=Global Burden of Disease Study. NCDs=non-communicable diseases. SEV=summary exposure value. WaSH=water, sanitation, and hygiene.
JMP=Joint Monitoring Program. DALY=disability-adjusted life-year. PM2·5=fi ne particulate matter smaller than 2·5 μm.
Table 1:
Health-related SDG goals and targets proposed by the Inter-Agency and Expert Group on SDG Indicators, and health-related SDG indicators used in this analysis
Articles
8
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Relations between health-related SDG indicators and the
Socio-demographic Index and healthy life expectancy
As part of GBD 2015, we assessed cause-specifi
c disease
burden and risk exposure along the development
spectrum, providing context on expected changes as
countries progress to higher levels of income per person,
higher educational attainment, and lower fertility.
34,37–39
We conducted a similar analysis by examining the
relations of the overall health-related SDG index and
each of the individual health-related SDG indicators
Health-related SDG indicator
Measurement needs and strategy
Goal 3: Ensure healthy lives and promote wellbeing for all at all ages
Target 3.5: Strengthen the prevention and treatment of
substance abuse, including narcotic drug abuse and harmful
use of alcohol
3.5.1: Coverage of treatment interventions (pharmacological,
psychosocial and rehabilitation and aftercare services) for
substance use disorders
Prevalence of specifi c substance use disorders (opioid use
disorders, cocaine use disorders, amphetamine use disorders,
and cannabis use disorders), as well as alcohol use disorders,
are presently estimated as part of GBD. Systematic reviews on
coverage of specifi
c interventions (eg, opioid substitution
therapy) are in progress by GBD collaborators
Target 3.8: Achieve universal health coverage, including
fi nancial risk protection, access to quality essential health-care
services and access to safe, eff ective, quality and aff
ordable
essential medicines and vaccines for all
3.8.2: Number of people covered by health insurance or a
public health system per 1000 population
Omission of information on insurance depth and status of user
fees within the public health system might limit the
applications of this indicator. Construction of proxy measures
of health-care use, for both outpatient and hospital care, by
country and over time is feasible as part of future iterations of
GBD and is likely to be an improved measurement strategy
Target 3.b: Support the research and development of vaccines
and medicines for the communicable and non-communicable
diseases that primarily aff
ect developing countries, provide
access to aff
ordable essential medicines and vaccines, in
accordance with the Doha Declaration on the TRIPS Agreement
and Public Health, which affi
rms the right of developing
countries to use to the full the provisions in TRIPS regarding
fl exibilities to protect public health, and, in particular, provide
access to medicines for all
3.b.1: Proportion of the population with access to aff
ordable
medicines and vaccines on a sustainable basis. The
recommended measure is percentage of health facilities with
essential medicines and life-saving commodities in stock
Across all geographies and over time, comparable data on
the stocking and stock-out rates of essential medicines and
vaccines for all facility types (hospitals, primary care
facilities, pharmacies, and other health-care outlets) and
facility ownership (public, private, informal) are not
available at present. In the absence of robust measures of
stock-outs in both the public and private sectors across
countries and over time, the measurement strategy for
producing comparable results for this indicator is unclear.
Furthermore, the proposed indicator stipulates
measurement of not only access to medicines and vaccines,
but also access to affordable medicines and vaccines. No
comprehensive and comparable datasets on the status of
essential medicine and vaccine affordability, in addition to
their stocks, presently exist
Target 3.b (as above)
3.b.2: Total net offi
cial development assistance to the medical
research and basic health sectors
DAH is currently assessed within a comprehensive, comparable
analytical framework by source, channel, recipient country,
and health focus area from 1990 to 2015; however, funding
specifi cally for medical research (eg, research and development
of vaccines and medicines, as described in Target 3.b) is not
systematically available across source and recipient countries.
Additionally, the appropriate assessment of country-level
performance remains unclear (eg, whether countries that
receive high levels of DAH for medical research are equivalent,
in terms of indicator performance, to countries that disperse
high levels of DAH for medical research)
Target 3.c: Substantially increase health fi
nancing and the
recruitment, development, training and retention of the
health workforce in developing countries, especially in least
developed countries and small island developing States
3.c.1: Health worker density and distribution, as measured by
number of health workers per 1000 population by cadre.
Cadres include generalist medical practitioners, specialist
medical practitioners (surgeons, anaesthetists,
obstetricians, emergency medicine specialists, cardiologists,
paediatricians, psychiatrists, ophthalmologists,
gynaecologists, etc), nursing and midwifery professionals,
and traditional and complementary medicine professionals,
among others
A systematic analysis of population census data and Labour
Force Surveys is possible as part of future iterations of GBD.
The total quantity of individual health worker cadres that
could be comparably assessed by geography by year will be a
function of the availability of detailed International Labour
Organization occupational codes across geographies and
survey iteration
Target 3.d: Strengthen the capacity of all countries, in
particular developing countries, for early warning, risk
reduction and management of national and global health risks
3.d.1: International Health Regulations (IHR) capacity and
health emergency preparedness. The WHO-recommended
measure is the percentage of 13 core capacities that have
been attained at a specifi c time (IHR core capacity index).
The 13 core capacities are (1) national legislation, policy, and
fi nancing; (2) coordination and national focal point
communications; (3) surveillance; (4) response;
(5) preparedness; (6) risk communication; (7) human
resources; (8) laboratory; (9) points of entry; (10) zoonotic
events; (11) food safety; (12) chemical events; and
(13) radionuclear emergencies
Comprehensive and comparable data for all components of
the IHR core capacity index, for all geographies and over time,
are not available at present. Specifi c core capacities, such as
zoonotic events, could be assessed as part of future iterations
of GBD; other core capacities, such as coordination and
national focal point communications, have no clear
measurement strategy beyond self-report from country
representatives or secondary research on policy status and
types of surveillance systems available, among others
(Table 2 continues on next page)
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9
with the Socio-demographic Index (SDI), a summary
measure of development that uses lag-distributed
income per person, average educational attainment in
the population over age 15 years, and the total fertility
rate. The SDI was constructed using the same method
for the Human Development Index and the health-related
SDG index. Each of the three components was fi
rst
rescaled on a 0–1 scale, with 0 being the lowest (worst)
Health-related SDG indicator
Measurement needs and strategy
(Continued from previous page)
Goal 5: Achieve gender equality and empower all women and girls
Target 5.2: Eliminate all forms of violence against all women
and girls in the public and private spheres, including traffi
cking
and sexual and other types of exploitation
5.2.2: Proportion of women and girls aged 15 years and older
subjected to sexual violence by persons other than an intimate
partner in the previous 12 months, by age and place of
occurrence
Prevalence of intimate partner violence among women and
girls aged 15 years and older is currently estimated as part of
GBD. An updated systematic review of the literature, data
re-extraction, and analysis are needed to specifi
cally quantify
prevalence of sexual violence (separately or in addition to
physical violence, or both) and by persons other than an
intimate partner. Data availability by geography by year on the
latter, sexual violence by persons other than intimate partners,
might be limited
Target 5.6: Ensure universal access to sexual and reproductive
health and reproductive rights as agreed in accordance with
the Programme of Action of the International Conference on
Population and Development and the Beijing Platform for
Action and the outcome documents of their review
conferences
5.6.1: Proportion of women aged 15–49 years who make their
own informed decisions regarding sexual relations,
contraceptive use, and reproductive health care
The proportion of women who make their own informed
decisions regarding all three dimensions of this indicator—
sexual relations, contraceptive use, and reproductive health
care—are included in the Demographic and Health Survey
(DHS) series. Data availablility for non-DHS countries is
unclear. The feasibility of measuring this indicator as part of
future iterations of GBD is under review at present
Target 5.6 (as above)
5.6.2: Number of countries with laws and regulations that
guarantee women aged 15–49 access to sexual and
reproductive health care, information, and education
Across all geographies and over time, comprehensive and
comparable data documenting the status of laws and
regulations regarding access to sexual and reproductive health
care, information, and education do not exist at present.
Compiling the past and current status of such laws and
regulations might be possible; however, systematic
assessment of their depth or intensity, enforcement, and
eff ectiveness in guaranteeing access to reproductive health
care, information, and education might be challenging across
countries and over time
Goal 6: Ensure availability and sustainable management of water and sanitation for all
Target 6.3: By 2030, improve water quality by reducing
pollution, eliminating dumping and minimising release of
hazardous chemicals and materials, halving the proportion of
untreated waste water, and substantially increasing recycling
and safe reuse globally
6.3.1: Proportion of waste water safely treated.
UN Water defi
nes this indicator as the proportion of waste
water generated by both households (sewage and faecal
sludge), as well as economic activities (based on ISIC
categories) safely treated compared to total waste water
generated both through households and economic activities.
While the defi
nition conceptually includes waste water
generated from all economic activities, monitoring will focus
on waste water generated from hazardous industries (as
defi ned by relevant ISIC categories)
Across all geographies and over time, comprehensive and
comparable data containing information on total waste water,
as generated by both households and non-household entities
(however they are to be defi
ned), and waste water treatment
status do not exist at present. UN Water suggests there will be
suffi cient data to generate estimates of global and regional
levels of safely treated waste water by 2018; however, in the
absence of more country-level data, it is diffi
cult to determine
the representativeness of such global and regional estimates
Goal 16: Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build eff ective, accountable, and inclusive institutions at all levels
Target 16.1: Signifi cantly reduce all forms of violence and
related death rates everywhere
16.1.3: Proportion of population subjected to physical,
psychological, or sexual violence in the previous 12 months
Prevalence of intimate partner violence among women and
girls aged 15 years and older is currently estimated as part of
GBD, as are the incidence and prevalence of interpersonal
violence among all populations. An expanded systematic
review of the literature and available data sources for all types
of violence (physical, psychological, and sexual) for both men
and women of all ages would be required for inclusion in
future iterations of GBD
Target 16.1 (as above)
16.1.4: Proportion of people that feel safe walking alone
around the area they live
Comprehensive data on reported safety, in general or walking
alone near one’s residence (or both), do not currently exist
across geographies or over time. Substantive primary data
collection is likely to be required
Target 16.2: End abuse, exploitations, traffi cking and all forms
of violence against and torture of children
16.2.3: Proportion of young women and men aged
18–29 years who experienced sexual violence by age 18
Prevalence of intimate partner violence among women and
girls aged 15 years and older is estimated as part of GBD.
An expanded systematic review and analysis of the literature
and available data sources for both men and women, and for all
types of sexual violence (ie, not limited to intimate partners)
would be required. The feasibility of measuring this indicator as
part of future iterations of GBD is under review at present
(Table 2 continues on next page)
