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Global Health in Transition: A Synthesis: Perspectives from International Organizations Global Comparative Assessments in the Health Sector Murray, CJL, and AD Lopez. 1994. Global Comparative Assessments in the Health Sector: Disease Burden, Health Expenditures, and Intervention Packages. Geneva: World Health Organization. Underlying the conclusions of the 1993 World Development Report is a series of comparative economic, epidemiologic, demographic, and institutional analyses undertaken collaboratively by the World Bank and the World Health Organization. Many of these analyses present original data and interpretations, and most are lengthy and somewhat technical. To make these analyses more widely and readily available to the policy and scholarly communities, the authors summarized their results in a series of eight papers, reprinted in this volume. The first four papers present details on methods and assumptions used to quantify the global burden of disease and the findings from that quantification. The remaining four papers present the methodology used for comparative assessment of the financial resources available to the global health sector, the results of that assessment, the range of intervention options that can be purchased with these resources, and a method for using information on the burdens of different diseases and cost-effectiveness analysis to identify packages of cost-effective health care. Because this compilation has two parts, our analysis is slightly longer than most of the others in this report. OBJECTIVES To provide the conceptual and empirical underpinnings for the 1993 World Development Report and to make the best possible use of available data by assessing information from a common perspective. To develop a methodology for measuring the global burden of disease that would account for morbidity as well as mortality. To quantify public, private, and total expenditures on health for
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Global Health in Transition: A Synthesis: Perspectives from International Organizations all countries and to analyze trends in volumes and allocations to specific activities. To consider alternative allocations of resources on the basis of the burden of disease, health resource availability, and intervention cost-effectiveness. CONCLUSIONS the global burden of disediscase Despite an uneven and sometimes flawed database, there are clear and profound differences in cause-of-death structures between developed and developing regions. Of the 50 million deaths worldwide each year, 39 million (78 percent) are in developing countries. Communicable, maternal, and perinatal causes account for 40 percent of those deaths, whereas these causes account for only 5 percent of deaths in developed regions. Injuries cause roughly equal proportions of deaths in both developed and developing countries and are invariably more common in males than in females. Their relative importance in cause-of-death structures varies, from greater importance in Eastern Europe, Latin America, and China to lesser importance in developed countries. Major challenges in the developing world are inherent in the disease burden on children ages 0 to 14 and are well known: perinatal conditions, diarrhea, acute respiratory infections, measles, malaria, tetanus, and pertussis. Other diseases, notably tuberculosis, syphilis, and meningitis, produce large disease burdens throughout the life span but are underappreciated as causes of mortality. Still, the noncommunicable diseases are already the leading causes of death in the developing world, where they account for one in two deaths, and where the risk of death from those diseases is much higher than in the developed world. There is more disability from noncommunicable causes in India alone than in the entire group of established market economies. Only in the Middle Eastern Crescent and sub-Saharan Africa are communicable, maternal, and perinatal diseases more important than noncommunicable diseases. There are some startling mismatches between the burden of disease by cause and international efforts in research and health policy analysis: many of the causes of disease burden in developing countries receive grossly disproportionate attention in international public health forums.
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Global Health in Transition: A Synthesis: Perspectives from International Organizations resource allocation and development assistance In 1990, the world spent $1.7 trillion on health, or 8 percent of global gross domestic product (GDP). The established market economies accounted for more than 87 percent of that amount, with the United States alone accounting for 41 percent; the developing countries accounted for 10 percent. Of global health spending, 60 percent is from the public sector, and 40 percent is from the private sector. There is a virtual dichotomy between per capita health spending in the established market economies and the rest of the world, ranging from $1,859 in the United States to $11 in India. All external assistance (overseas development assistance [ODA], multilateral loans, and nongovernmental flows) to health sectors in developing countries in 1990 amounted to $4,800 million, 82 percent of which came from public coffers in developed countries and 18 percent of which came from private households of those countries. Of those resources 40 percent flowed through bilateral agencies, 33 percent through United Nations agencies, 8 percent through the World Bank and regional development banks, 17 percent through nongovernmental organizations, 1.5 percent through foundations. The share of external assistance from the bilateral agencies began to decline in the mid-1980s, whereas the multilateral contribution (especially that from the World Bank) has more than quadrupled. In 1990, 9 percent of all external assistance was allocated to the health sector. That assistance was most important for Africa, which got the largest share of donor support and the highest per capita allocation. In 1990, 20 percent of all health expenditure in sub-Saharan Africa (excluding South Africa) came from external assistance. Yet, for all developing countries, external assistance represented only 2.8 percent of total health expenditures. In no region outside Africa did ODA surpass 1.6 percent of total regional health expenditures. Total external assistance for population activities was $936 million, about 20 percent of all health sector assistance. Sixty percent of that amount flowed from bilateral agencies, and although in absolute terms the United States has been the largest single bilateral donor, its share fell from 88 percent in 1972, to 55 percent in 1980, and to 32 percent in 1990. Trends in overall ODA over the last two decades are clear. Between 1972 and 1980, there were steady annual increases; in the next 5-year period, levels remained constant in real terms. Although the
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Global Health in Transition: A Synthesis: Perspectives from International Organizations years between 1986 and 1990 again brought steady annual increases, the rates of increase were half those of the 1970s. Of the 18 member countries of the Organization for Economic Cooperation and Development, the biggest contributors of ODA to the health sector relative to their own national GDPs in 1990 were Norway (0.159 percent), Sweden, Denmark, Finland, and The Netherlands. Germany, Japan, Austria, and New Zealand (0.006 percent) provided the least. The United States ranked 13th among the 18 countries, with its 0.02 percent of GDP close to the percentages contributed by Italy and the United Kingdom. Countries vary greatly in the way that they channel external assistance funds. The United States, Italy, France, and Belgium disburse the majority of funds through direct bilateral channels; most others channel about two-thirds through multilateral agencies and one-third through direct bilateral projects. relationships between resource allocation and disease burdens Measures of health status do not inevitably correspond with aid volumes. Half of health assistance goes for infrastructure development via grants for health services and hospitals, and half goes for specific health programs19 percent to specific health problems, 9 percent to nutrition programs, and 20 percent to population activities. There are some striking disproportions in funding for specific health problems in terms of the burdens that they produce. Using the Disability-Adjusted Life Year (DALY) as a metric, the best funded leprosy, onchocerciasis, other tropical diseases, sexually transmitted diseases and human immunodeficiency virus infection, and blinding conditionsget around $4 per DALY; the immunizable diseases, malaria, and trachoma get a little over $1. Acute respiratory infections, which produce by far the largest DALY burden in the developing world, get $0.015 per DALY and noncommunicable diseases and injuries, which produce 50 percent of the disease burden in developing countries, get less than $0.05 per DALY. A minimum package of highly cost-effective public health and clinical interventions that address the main sources of disease could be provided in low-income countries for about $12 per person per year (more than is now spent in the poorest countries) and for about $22 in middle-income countries (where it is affordable at current expenditure
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Global Health in Transition: A Synthesis: Perspectives from International Organizations levels). Properly delivered, this package could eliminate 21 to 38 percent of the burden of premature mortality and disability in children under age 15 and 10 to 18 percent of the burden in adults. RECOMMENDATIONS FOR POLICY AND ACTION The mismatch between international efforts in research and policy analysis and the individual causes of the burden of disease suggest that it is time to review the international health research system, attending carefully to the relationships between disease burden and the current availability of cost-effective interventions. For the global burden of disease and DALY to be better tools for policy and program determination, more research and methodologic development are needed in the following areas: increasing the number of conditions included in the global burden of disease; studying those conditions that cause many years of disability and designing methods for prospective monitoring of disability on a sample or a general basis; developing simple methods to account for comorbidity; improving the mapping from disease to impairment to disability and better quantifying the cost-effectiveness of health interventions for preventing or treating disability; and extending the burden-of-disease approach to assessments of contributions from environmental factors and individual behaviors in the causation of disease and injury. Regional disability patterns should be seen as highlighting foci for health protection interventions by age, sex, and cause. Despite data limitations (which should be neither over-nor underestimated), the numbers are large enough even at this early methodologic stage to identify some clear priorities. If information on the burden of disease is found to be useful as a baseline for health policy makers, the logical next step is to assess the overall performance of the health sector in terms of trends in that burden.
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Global Health in Transition: A Synthesis: Perspectives from International Organizations Given its proportion, external assistance to the health sector must be seen realistically as functioning at the margin, not as the centerpiece of developing country economies. As such, its most powerful effects might be capital formation, policy formulation, and, in those connections, research and capacity building. Because no single database permits a comprehensive view of external assistance to the health sector, some international mechanism needs to be established that will provide such a view through regular, consistent monitoring of health expenditures at the national and international levels. COMMENTARY This compilation of interrelated analyses contains the only available comparative assessments of cause of death, disease burden, health expenditures, and international aid for health. It is therefore a unique resource for policy analysts and scholars. The processes preparatory to these analyses also served to identify and mobilize a broad network of national and international expertise. Finally, the methodology as a whole serves to level the playing field so that decisions about priorities are based on objective realities rather than personal or political vested interest. The preparation of these analyses also clarified what has long been the case: the existence of significant gaps, if not chasms, in international and national systems for gathering, analyzing, and distributing policy-relevant comparative data. Without information on how levels and trends in key indicators in their own countries compare with those in other countries, those intent on health sector reform will continue to lack any reasonable basis for policy determinations and planning strategies and programs, or any benchmarks for judging performance. Students of health systems will lack an empirical basis for making judgments on which policies work and which do not in developing and developed countries, including the United States. Reliable information on global and regional mortality and disability by cause are essential to managing health sector activities; determining financial and human resource allocations; balancing apportionments of all resources among different categories of disease; and deciding on the levels, types, and focus of research activities. The DALY indicator can be very helpful in assessing the combined burdens of disability and premature mortality, and doing so by age
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Global Health in Transition: A Synthesis: Perspectives from International Organizations and sex across a wide variety of disease categories and geographic regions. The DALY's development has beenand undoubtedly will continue to besomewhat embattled, as has every past effort to develop composite indicators that go beyond measuring mortality. The conceptualizers of the DALY have been at some pains to state that it is one more step in a process, not some ideal methodologic endpoint, and have invited critical comment as a way to enhance its utility. At the same time, the DALY advances the field by incorporating several new features. First, it explicitly incorporates some ethical dimensions and value choices by taking into account the meaning of loss of welfare and the implications of time lived with a disability, weighing the severity of the disability, treating health outcomes equitably, and measuring the value of human life at different ages by using an exponential function that reflects the dependence of the young and the elderly on adults. The inclusion of these value choices serves to make the indicator applicable across a wide range of environments, by age group and by gender. For comparable reasons, the indicator can also be used in conjunction with the literature on cost-effectiveness of health interventions. At the same time, it is primarily these value choices that are at the heart of the ongoing debate about the DALY approach. The analysis of changes in distributions of global health expenditures and flows of external assistance to the health sectors in developing countries raises large and challenging questions, especially when the relative volumes of those expenditures are poised against the structure of the global burden of disease. For example, given its small size relative to overall health expenditures in developing countries, what is the appropriate role for external assistance and how can that role be maximized realistically, respectfully, and usefully? What will be the effects of the de facto shift in the ODA portfolio away from bilateral dominance to dominance by multilateral banks? What might be said about the small proportion of GPD in the established market economies that is dedicated to ODA, recognizing that some of those countries have their own economic problems and that previous attempts to seek global formulas and standard funding commitments have been almost totally unsuccessful? What might be done about the lack of compatibility between the burden of certain diseases or conditions and the corresponding proportions of ODA and research dedicated to them?
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