Advancement of global health: key messages from the Disease Control Priorities Project.

The Disease Control Priorities Project (DCPP), a joint project of the Fogarty International Center of the US National Institutes of Health, the WHO, and The World Bank, was launched in 2001 to identify policy changes and intervention strategies for the health problems of low-income and middle-income countries. Nearly 500 experts worldwide compiled and reviewed the scientific research on a broad range of diseases and conditions, the results of which are published this week. A major product of DCPP, Disease Control Priorities in Developing Countries, 2nd edition (DCP2), focuses on the assessment of the cost-effectiveness of health-improving strategies (or interventions) for the conditions responsible for the greatest burden of disease. DCP2 also examines crosscutting issues crucial to the delivery of quality health services, including the organisation, financial support, and capacity of health systems. Here, we summarise the key messages of the project.

Malnutrition and dietary protein: evidence from China and from international comparisons.

Malnutrition, as measured by anthropometric status, is a powerful risk factor for illness and elevated death rates throughout life. Understanding the relative importance of disease, dietary quantity, and dietary quality in causing malnutrition is therefore of major importance in the design of public policy. This paper contributes to the understanding of the relative importance of quantity and quality of diet by utilizing aggregate data to complement previously reported individual-level studies. Three compilations of anthropometric data--one involving subjects from 13 provinces in China, another involving subjects from 64 counties in China, and a third involving 41 populations in 40 countries--are used to examine the relative importance for human growth of inadequacies of dietary energy and protein. The analysis involves regressing average adult heights and weights against estimates of average energy and protein availability (by province, county, or country) and per capita incomes. We use protein availability in part as a marker for overall quality of the diet, while recognizing that protein is far from perfectly correlated with dietary fat or micronutrient availability. The paper discusses issues of both data quality and statistical methodology, and points to relevant resulting caveats to our conclusions. Subject to these limitations, all three analyses suggest that, at the levels of dietary intake in these populations, lower protein intake is related to growth failure whereas lower levels of energy availability are not. The protein effect appears stronger for males than for females.

The perils of adding up: a cautionary tale about modeling and regression analysis.

To turn incomplete or imperfectly reliable information into estimates useful for policy, some modeling is often necessary or helpful. It does not follow that every statistical relation constitutes a model. There has to be an underlying theory, and the numerical estimates must respect any definitional or accounting identities that constrain the results. Ad hoc relations that do not meet these criteria can lead to uninterpretable or meaningless values, especially when different partial values, separately estimated, are added together. The imputed values of "responsiveness" in the WHO World Health Report 2000 illustrate this danger.

Turning neglected tropical diseases into forgotten maladies.

Because they afflict mostly poor people in poor countries, killing relatively few compared to the many who suffer from severe chronic disabilities, a large cluster of infections deserve the label of neglected tropical diseases (NTDs). That is changing as these diseases' enormous health, educational, and economic toll is better understood, including how they interact with HIV/AIDS, malaria, and other illnesses. Several NTDs could be controlled or even eliminated within a decade, using integrated, highly cost-effective mass drug administration programs together with nondrug interventions. Research is needed to provide additional means of control for these conditions and make elimination feasible for still others.

Protecting households from catastrophic health spending.

Many countries rely heavily on patients' out-of-pocket payments to providers to finance their health care systems. This prevents some people from seeking care and results in financial catastrophe and impoverishment for others who do obtain care. Surveys in eighty-nine countries covering 89 percent of the world's population suggest that 150 million people globally suffer financial catastrophe annually because they pay for health services. Prepayment mechanisms protect people from financial catastrophe, but there is no strong evidence that social health insurance systems offer better or worse protection than tax-based systems do.

Basic patterns in national health expenditure.

Analysed in this paper are national health accounts estimates for 191 WHO Member States for 1997, using simple comparisons and linear regressions to describe spending on health and how it is financed. The data cover all sources - out-of-pocket spending, social insurance contributions, financing from government general revenues and voluntary and employment-related private insurance - classified according to their completeness and reliability. Total health spending rises from around 2-3% of gross domestic product (GDP) at low incomes (< 1000 US dollars per capita) to typically 8-9% at high incomes (> 7000 US dollars). Surprisingly, there is as much relative variation in the share for poor countries as for rich ones, and even more relative variation in amounts in US dollars. Poor countries and poor people that most need protection from financial catastrophe are the least protected by any form of prepayment or risk-sharing. At low incomes, out-of-pocket spending is high on average and varies from 20-80% of the total; at high incomes that share drops sharply and the variation narrows. Absolute out-of-pocket expenditure nonetheless increases with income. Public financing increases faster, and as a share of GDP, and converges at high incomes. Health takes an increasing share of total public expenditure as income rises, from 5-6% to around 10%. This is arguably the opposite of the relation between total health needs and need for public spending, for any given combination of services. Within public spending, there is no convergence in the type of finance - general revenue versus social insurance. Private insurance is usually insignificant except in some rich countries.

The dethronement of income as a cause of health: an essay / O destronamento da renda como causa da saúde: um ensaio

Income, whether of nations, groups or individuals, appears in many analyses to have a strong relation to health status and even to be the principal explanatory variable for health differences. Poor people tend to be sicker than average, and sick people tend also to be poorer than average. Of course, income is needed to buy the goods and services that contribute to protecting and improving health, but its importance has been overstated. Cross-sectional relations that ignore history exaggerate how much income matters for health. Income is dethroned as the king of explanations by four lines of evidence: (1) distribution matters more than totals or averages, and the distribution of financial protection through insurance, rather than the distribution of income, is particularly crucial; (2) historically, income growth by itself contributed little to health improvements; (3) it matters more, how rapidly and thoroughly people and nations adopt sound health interventions; and (4) some recent changes in lifestyle (diet and physical activity) that accompany income growth actually worsen health. These causes are especially relevant for infant and child health, somewhat less so for maternal health. The less important income is, the easier it is to improve health; so it is good news that countries and people need to escape from poverty, but they don't have to be rich to be healthy.

Renda, tanto de nações, grupos ou indivíduos, aparece em muitas análises como fortemente relacionada ao estado de saúde, além de ser a variável explanatória principal para a análise das diferenças em saúde. Pessoas pobres tendem a ser mais doentes que a média e pessoas doentes tendem a ser mais pobres do que a média. Certamente a renda é necessária para a compra de bens e serviços que contribuem para a promoção e melhoria da saúde, porém sua importância tem sido exagerada. Análises transversais que ignoram a história comentam exageros no quanto a renda é importante para a saúde. A renda é destronada como rainha das explicações em quatro linhas de evidências: (1) a distribuição da renda importa mais do que os totais ou médias e a distribuição da proteção financeira por meio da seguridade, melhor que a distribuição da renda, é particularmente crucial; (2) historicamente, o crescimento da própria renda contribui pouco para melhorias na saúde; (3) importa mais quão rápida e completamente populações e nações adotam intervenções de saúde adequadas e (4) algumas mudanças recentes do estilo de vida (dieta e atividade física) que acompanham o crescimento da renda realmente agravam a saúde. Essas causas são especialmente relevantes para a saúde infantil e da criança um pouco menos para a saúde materna. Quanto menos importante a renda é, mais fácil será a melhoria das condições de saúde. É uma boa notícia saber que países e povos necessitam fugir da pobreza, mas não necessitam ser ricos para serem saudáveis.

Indicadores de bienestar y salud: selección y empleo de indicadores socioeconómicos para monitoría y evaluación / Welfare indicators and health: the selection and use of socioeconomic indicators for monitoring and evaluation

El plan de acción de la OPS para alcanzar la meta de salud para todos en el año 2000 requiere la evaluación del progreso del bienestar mediante el empleo de por lo menos ocho indicadores. En este artículo se examinan esos ocho indicadores, se estima la utilidad para su evaluación y se indica cómo se podría organizar y desdoblar la información relacionada con cada uno de ellos (AU)

Indicadores de bienestar y salud: selección y empleo de indicadores socioeconómicos para monitoría y evaluación / Welfare indicators and health: the selection and use of socioeconomic indicators for monitoring and evaluation

El plan de acción de la OPS para alcanzar la meta de salud para todos en el año 2000 requiere la evaluación del progreso del bienestar mediante el empleo de por lo menos ocho indicadores. En este artículo se examinan esos ocho indicadores, se estima la utilidad para su evaluación y se indica cómo se podría organizar y desdoblar la información relacionada con cada uno de ellos (AU)

Se justifica economicamente la erradicacion de la poliomielitis en las Americas? / Is polio eradication in the Americas economically justified?

In 1985 the Pan American Health Organization launched a five-year campaign to eradicate poliomyelitis from the Americas. Through a cost/benefit analysis, this article seeks to answer the question: do savings in treatment and rehabilitation costs justify the cost of eradication? Although this question should never come up if the private market for vaccination functioned properly, its answer is a categorical yes. This analysis covers only economic savings, without considering savings in pain, suffering, and loss of productivity. Two different situations are analyzed: one where treatment covers all victims, and a second where it covers only a portion of them. In the first case, the article concludes that current levels of control of the disease have yet to absorb all potential benefits, and consequently, additional eradication efforts are justifiable. In the second, the analysis also finds that eradication is a justifiable investment, even when the only benefits considered are efective reduction in treatment cost- the cost of treating even a small portion of the affected individuals offsets the overal costs of prevention. Finally, the article compares strategies adopted by two hypothetical regions with equal incidence of paralytic poliomyelitis. In region A, the patients are treated but vaccination is only begun five years later because initially the treatment costs are not high enough

La eficacia en funcion de los costos y la reforma del sector salud / Cost-effectiveness and the health sector reform

La eficacia en función del costo de una intervención de salud es una estimación de la relación entre lo que cuesta proveer una intervención, y el mejoramiento en salud que se produce como consecuencia. La salud puede mejorar porque se reduce la incidencia de la enfermedad o lesión, porque se evita o demora la muerte, o porque se reduce el intervalo o la severidad de una incapacidad. El cálculo de este beneficio combina factores objetivos, como son la edad de incidencia y si resulta o no en muerte, con factores subjetivos, como son la evaluación del grado de incapacidad no-mortal, la ponderación del valor de la vida sana según la edad, y la tasa de descuento que se aplica al futuro. Se explica cómo se construye el estimado y cómo se debería interpretarlo. Luego, se examina el grado en que el concepto es consistente con normas éticas y de equidad, concluyéndose que no están en conflicto. Finalmente, se discute la incorporación de la eficacia en función de los costos como elemento de una reforma de salud, y las posibles medidas para implementarla.

The cost-effectiveness of a health intervention is an estimate of the relation between what it costs to be provided, and the improvement in health which results from such intervention. Health may improve because the incidence of illness or injury is reduced, because death is avoided or delayed, or because the duration or severity of disability is limited. The calculation of this health benefit combines objective factors, such as the age at incidence and whether or not the outcome is death, with subjective factors such as the severity of disability, the judgement as to the value of life lived at different ages, and the rate at which the future is discounted. The construction and interpretation of the estimate are explained. Also, the paper examines whether the concept of cost-effectiveness is consistent with ethical norms such as equity, and concludes that they are not in conflict. Finally, it addresses the question of how to incorporate cost-effectiveness into a health sector reform, and possible ways to implement it.

Diseño, contenido y financiamiento de un paquete nacional de servicios de salud esenciales / Design content and financing of an essential national package of health services

En los países de bajos ingresos se podría ofrecer un paquete mínimo de intervenciones clínicas y de salud pública, muy efectivas en función del costo, destinadas a aliviar la carga ocasionada por las principales enfermedades, por unos US$ 12 anuales por persona, y en los de medianos ingresos, por cerca de $ 22. Al prestarse debidamente, este paquete permitiría eliminar de 21 a 38 por ciento de la carga de mortalidad prematura y discapacidad en niños menores de 15 años y de 10 a 18 por ciento de la que recae en los adultos. El costo excedería lo que los gobiernos gastan en salud en los países más pobres, pero estaría al alcance de los de medianos ingresos. Los gobiernos deberían asegurarse de que por lo menos la población pobre tenga acceso a esos servicios. El gasto público adicional debería destinarse entonces a ampliar la cobertura de la población solvente o a llevarla más allá de los servicios mínimos, para prestar un paquete nacional de servicios de salud esenciales, que incluya intervenciones algo menos efectivas en función del costo para tratar más enfermedades y trastornos

Se pública en inglés en el Bull. WHO. Vol. 72(4), 1994

Diseño, contenido y financiamiento de un paquete nacional de servicios de salud esenciales / Design content and financing of an essential national package of health services

En los países de bajos ingresos se podría ofrecer un paquete mínimo de intervenciones clínicas y de salud pública, muy efectivas en función del costo, destinadas a aliviar la carga ocasionada por las principales enfermedades, por unos US$ 12 anuales por persona, y en los de medianos ingresos, por cerca de $ 22. Al prestarse debidamente, este paquete permitiría eliminar de 21 a 38 por ciento de la carga de mortalidad prematura y discapacidad en niños menores de 15 años y de 10 a 18 por ciento de la que recae en los adultos. El costo excedería lo que los gobiernos gastan en salud en los países más pobres, pero estaría al alcance de los de medianos ingresos. Los gobiernos deberían asegurarse de que por lo menos la población pobre tenga acceso a esos servicios. El gasto público adicional debería destinarse entonces a ampliar la cobertura de la población solvente o a llevarla más allá de los servicios mínimos, para prestar un paquete nacional de servicios de salud esenciales, que incluya intervenciones algo menos efectivas en función del costo para tratar más enfermedades y trastornos