I

The Documents Reviewed: An Analysis



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 7
Global Health in Transition: A Synthesis: Perspectives from International Organizations I The Documents Reviewed: An Analysis

OCR for page 7
Global Health in Transition: A Synthesis: Perspectives from International Organizations This page in the original is blank.

OCR for page 7
Global Health in Transition: A Synthesis: Perspectives from International Organizations Disease Control Priorities in Developing Countries Jamison, DT, WH Mosley, AR Measham, and JL Bobadilla, eds. 1993. Disease Control Priorities in Developing Countries. New York: Oxford University Press. The core of this collection is a set of analyses undertaken for the World Bank's Health Sector Priorities Review. Its impetus was recognition of the lack of analytic approaches developing countries might take in dealing with the implications of the health transition and the emergence of behavioral risk factors and noncommunicable diseases as significant problems. Each chapter assesses the current and probable future public health significance of over 100 individual diseases or related clusters of diseases in the developing world. It then assesses the cost and effectiveness of alternative interventions for preventing each condition and managing it clinically in different contexts by using the Disability-Adjusted Life Year as a measure. Each chapter also includes an extensive bibliography. The authorship of the collection reflects a balance among economists, epidemiologists, clinicians, and biomedical scientistsover 80 in alldrawn from the international academic and technical communities. OBJECTIVES To assess the current and probable future public health significance of the burden of disease in developing countries as those countries experience demographic and epidemiologic transitions. To take stock, in a systematic disease-by-disease manner, of the cost-effectiveness of alternative responses to those conditions in various socioeconomic, demographic, and epidemiologic contexts. CONCLUSIONS The net effects of demographic and epidemiologic transition and

OCR for page 7
Global Health in Transition: A Synthesis: Perspectives from International Organizations socioeconomic change will be unprecedented increases in the volume, diversity, range, and complexity of problems developing country health systems will face in the next decades. The “unfinished agenda” of communicable disease, malnutrition, and unwanted fertility among the most vulnerable groups will persist, along with an “emerging agenda” of new health risks, noncommunicable diseases, injury, and disability in an ever-greater proportion of the population. The total burden of disease, measured by days lost to acute disease episodes, chronic disabilities, and premature death (Disability-Adjusted Life Years), will grow. Demand for health services, especially by more urbanized, educated, affluent, and vocal populations, will also grow, at the same time that access to health resources for the most vulnerable populations will need to be strengthened and preserved. This means that the range of health services will have to expand correspondingly, since new provider skills, technologies, and organizational arrangements will be required for even minimum standards of care. The needs of these new sectors, as well as the higher health maintenance costs for older cohorts, will require rising percentages of gross national product, at the same time that austerity will continue to dominate the economies of most countries. Health systems will be challenged to mount a broader range of preventive measures and to develop very low cost protocols for managing increasing numbers of cases. Though marginal cost-effectiveness varies widely, many interventions are attractive by any reasonable economic standard. A major challenge will be to use them, optimally grouped into efficient basic packages of prevention and essential clinical services. Although core sets of preventive and clinical interventions would seem appropriate to the needs of most countries, they will have to be defined and targeted to account for local epidemiologic variability and financial capacities. Primary prevention or public health interventions are not inherently more cost-effective than the clinical strategies that are suggested, none of which requires more specialized facilities than those available at a reasonably well-equipped, well-organized district hospital. Although some components of an individual package are simple technologies, their recombination, reassignment to different delivery levels, and proper functioning will require new standards of care and provider skills. This will be especially crucial for those diseases that carry particularly large burdens of death and disability. The full range of policy tools available to governmentsfor example, regulatory interventions or taxes to promote public health and

OCR for page 7
Global Health in Transition: A Synthesis: Perspectives from International Organizations raise revenue;is underused. The economics of investment in research, its transportability, and the existence of substantial research capacity in donor countries make research a most viable domain for foreign aid, yet the current volume of resources going into research is quite limited and virtually ignores issues that will dominate the policy agenda in years to come. Vaccine development, which offers the means of preventing a broader range of conditions with greater cost-effectiveness and less logistical complexity than many other preventive interventions, receives relatively little support. RECOMMENDATIONS FOR POLICY AND ACTION As their central task, national governments should explore, develop, and apply the following: A full range of policy instruments;legislation, regulation, taxes, subsidies, investment research; Goal-oriented, comprehensive, integrated strategies mixing preventive and clinical interventions, continuing education for providers, and technology assessment and control; and Analytic skills in demographic and economic analysis, epidemiologic surveillance, health technology assessment, and input-output-outcome interactions. The central tasks for countries providing development assistance are to help do the following: Improve health services delivery by continuing emphasis on immunization and family planning and increasing selectivity in delivery of oral rehydration therapy and tuberculosis vaccine (BCG) in low-risk environments; enhancing emphasis on measles immunization, case management of acute respiratory infection, control of vitamin A deficiency, tuberculosis chemotherapy, anti-helminthic prophylaxis, control of sexually transmitted diseases, and control of cancer pain; strengthening capacity for drug logistics to support system priorities, provider training to manage priority procedures, and delivery of inexpensive rehabilitative services; and reducing support for hospital facilities and shifting emphasis away from general institutional development and toward strengthening specific capacities.

OCR for page 7
Global Health in Transition: A Synthesis: Perspectives from International Organizations Improve the policy environment by applying a full range of mechanisms to limit tobacco use; tracking and reducing use of procedures that are of low cost-effectiveness; reducing occupational and transport injuries, including control of alcohol use; strengthening the capacity to develop policy instruments for sustainable allocations to the health sector; and formulating and implementing policies involving taxation, regulation, and communication. Increase allocation of resources to research for exemplary programs of essential national health research; epidemiologic and operational research on cardiovascular and other noncommunicable diseases, sexually transmitted diseases, mental and chronic obstructive pulmonary disorders, and injury; assessment of intervention cost-effectiveness in different environments; vaccine development; strengthening national and international capacities to address these research emphases; and monitoring epidemiologic trends and the efficacy of intervention in well-documented populations. COMMENTARY This comprehensive collection of concepts, methods, and strategies for addressing the major health problems of the developing world advances the global capacity for management or control of those problems in two crucial ways. Its methods for measuring disease burdens and intervention cost-effectiveness provide a basis for priority setting, and thereby support policy formulation and resource allocation, as well as epidemiologic and health care guidance for managing these diseases. A major question remains: how to facilitate the absorption and application of these important findings and strategies into developing country settings. Stated somewhat differently, although each disease problem is well analyzed, with appropriate advice for disease control and case management, there is still the substantial challenge of how to develop health systems that can encompass interventions for large clusters of such problems. In the 1960s and 1970s, the search was on for models

OCR for page 7
Global Health in Transition: A Synthesis: Perspectives from International Organizations of primary health care that were effective and affordable in settings of poverty and remoteness in developing countries. Some were found and served as the basis for strengthening health systems in a variety of settings. Now, new models are needed that, first, go beyond primary health care, to more comprehensive approaches in which primary and secondary care are effectively and efficiently joined to address emerging epidemiologic diversity, and, second, can act as policy generators for system development and change. In material that follows, we will call attention to the usefulness of models and their limitations as universal solutions on the basis of the fact that each country is unique. Modeling remains important, but in a context in which each country is helped to build capacity to assess its own needs, reform its own policies, and adapt models to its own situation. Thus, the new capacities required to advance health would build on the methods and strategies presented in this volume and would include construction of health care prototypes at the district level to handle changing epidemiology, relevant health research, human resources development, and related policy making and implementation. The metric described here and in the World Development Report for determining burdens of disease and the cost-effectiveness of interventions provides a basis for priority setting and related policy formulation, assuming that capacities exist at the country level for their adaptation and application.