Prospects for tobacco control in Zimbabwe: a historical perspective.

Using a historical and political economy perspective, this paper explores the prospects for tobacco control in Zimbabwe, the world's sixth largest producer and third largest tobacco exporter. Tobacco production, which first began in the former Rhodesia in the early 1900s, is closely associated with colonial history and land occupation by white settlers. The Zimbabwe (formerly Rhodesia) Tobacco Association was formed in 1928 and soon became a powerful political force. Although land redistribution has always been a central issue, it was not adequately addressed after independence in 1980, largely due to the need for Zimbabwe to gain foreign currency and safeguard employment. However, by the mid-1990s political pressures forced the government to confront the mainly white, commercial farmers with a new land acquisition policy, but intense national and international lobbying prevented its implementation. With advent of global economic changes, and following the start of a structural adjustment programme in 1991, manufacturing began to decline and the government relied even more on the earnings from tobacco exports. Thus strengthening tobacco control policies has always had a low national and public health priority. Recent illegal occupation of predominantly white owned farms, under the guise of implementing the former land redistribution policy, was politically motivated as the government faced its first major challenge at the general elections in June 2000. It remains unclear whether this will lead to long term reductions in tobacco production, although future global declines in demand could weaken the tobacco lobby. However, since Zimbabwe is only a minor consumer of tobacco, a unique opportunity does exist to develop controls on domestic cigarette consumption. To achieve this the isolated ministry of health would need considerable support from international agencies, such as the World Health Organisation and World Bank.

The epidemiological transition in maternal and child health in a Brazilian city, 1982-93: a comparison of two population-based cohorts.

Two studies carried out in 1982 and 1993 in the city of Pelotas, Southern Brazil, provide a unique opportunity for assessing the impact on maternal and child health of the economic and health care changes, which took place in Brazil in this period. The cohorts of mothers and infants of 1982 and 1993 were studied from the time of delivery. In both years, all mothers identified in the city's maternity hospitals answered a standardised questionnaire and their infants were examined. Over 99% of all children born in the city in each of the 2 years were included in the cohorts. Deaths occurring among these children were monitored prospectively, as well as all hospital admissions in the 1993 cohort. In the 1982 study, attempts were made to locate a 25% sample of the children at the mean age of 12 months using the addresses collected at the hospital (82% of the children were located), and all of the cohort children at the mean age of 20 months and 42 months, through a city census (87% were located in both follow-ups). In the 1993 study, 20% of all children plus all low birthweight infants were sought at 12 months of age, using the addresses collected at the hospital, and 95% were successfully traced. There was a 12% fall in the number of births occurring in 1993 (5,304 births), in comparison with 1982 (6,011 births), in spite of the increase in the population of reproductive age in the city during the decade. There was a marked difference in maternal height and weight at the beginning of pregnancy, with women giving birth in 1993 being, on average, 3.4 cm taller and 2.5 kg heavier than those who gave birth in 1982. The proportion of preterm babies (<37 weeks), measured by the date of last menstrual period, increased from 5.6% in 1982 to 7.5% in 1993. The median duration of breast feeding increased from 3.1 months in 1982 to 4.0 months in 1993. At 12 months of age, the prevalence of deficit of weight for age decreased from 5.4% in 1982 to 3.7% in 1993. The prevalence of deficit of height for age, however, increased from 5.3% to 6.1%. The perinatal mortality rate dropped 31%, from 32.2 per 1,000 births in 1982 to 22.1 deaths per 1,000 births in 1993. There was also a marked reduction in the infant mortality rate, from 36.4 per 1,000 livebirths in 1982 to 21.1 per 1,000 livebirths in 1993. The findings of the study indicate that there were improvements in the decade for most of the indicators evaluated, with the exception of birthweight and gestational age. It appears that improvements in perinatal and infant mortality rates are largely due to improvements in the health care sector.

Explaining trends in inequities: evidence from Brazilian child health studies.

There is considerable international concern that child-health inequities seem to be getting worse between and within richer and poorer countries. The "inverse equity hypothesis" is proposed to explain how such health inequities may get worse, remain the same, or improve over time. We postulate that as new public-health interventions and programmes initially reach those of higher socioeconomic status and only later affect the poor, there are early increases in inequity ratios for coverage, morbidity, and mortality indicators. Inequities only improve later when the rich have achieved new minimum achievable levels for morbidity and mortality and the poor gain greater access to the interventions. The hypothesis was examined using three epidemiological data sets for time trends in child-health inequities within Brazil. Time trends for inequity ratios for morbidity and mortality, which were consistent with the hypothesis, showed both improvements and deterioration over time, despite the indicators showing absolute improvements in health status between rich and poor.

Assessing the burden of sexual and reproductive ill-health: questions regarding the use of disability-adjusted life years.

The use of the disability-adjusted life year (DALY) as the unit in which to calculate the burden of disease associated with reproductive ill-health has given rise to considerable debate. Criticisms include the failure to address the problem of missing and inadequate epidemiological data, inability to deal adequately with co-morbidities, and lack of transparency in the process of ascribing disability weights to sexual and reproductive health conditions. Many of these criticisms could be addressed within the current DALY framework and a number of suggestions to do so are made. These suggestions include: (1) developing an international research strategy to determine the incidence and prevalence of reproductive ill-health and diseases, including the risk of long-term complications; (2) undertaking a research strategy using case studies, population-based surveillance data and longitudinal studies to identify, evaluate and utilize more of the existing national data sources on sexual and reproductive health; (3) comprehensively mapping the natural history of sexual and reproductive health conditions--in males and in females--and their sequelae, whether physical or psychological; (4) developing valuation instruments that are adaptable for both chronic and acute health states, that reflect a range of severity for each health state and can be modified to reflect prognosis; (5) undertaking a full review of the DALY methodology to determine what changes may be made to reduce sources of methodological and gender bias. Despite the many criticisms of the DALY as a measurement unit, it represents a major conceptual advance since it permits the combination of life expectancy and levels of dysfunction into a single measure. Measuring reproductive ill-health by counting deaths alone is inadequate for a proper understanding of the dimensions of the problem because of the young age of many of the deaths associated with reproductive ill-health and the large component of years lived with disability from many of the associated conditions.

Evaluation designs for adequacy, plausibility and probability of public health programme performance and impact.

The question of why to evaluate a programme is seldom discussed in the literature. The present paper argues that the answer to this question is essential for choosing an appropriate evaluation design. The discussion is centered on summative evaluations of large-scale programme effectiveness, drawing upon examples from the fields of health and nutrition but the findings may be applicable to other subject areas. The main objective of an evaluation is to influence decisions. How complex and precise the evaluation must be depends on who the decision maker is and on what types of decisions will be taken as a consequence of the findings. Different decision makers demand not only different types of information but also vary in their requirements of how informative and precise the findings must be. Both complex and simple evaluations, however, should be equally rigorous in relating the design to the decisions. Based on the types of decisions that may be taken, a framework is proposed for deciding upon appropriate evaluation designs. Its first axis concerns the indicators of interest, whether these refer to provision or utilization of services, coverage or impact measures. The second axis refers to the type of inference to be made, whether this is a statement of adequacy, plausibility or probability. In addition to the above framework, other factors affect the choice of an evaluation design, including the efficacy of the intervention, the field of knowledge, timing and costs. Regarding the latter, decision makers should be made aware that evaluation costs increase rapidly with complexity so that often a compromise must be reached. Examples are given of how to use the two classification axes, as well as these additional factors, for helping decision makers and evaluators translate the need for evaluation--the why--into the appropriate design--the how.

Epidemiologia para municípios: manual para gerenciamento dos distritos sanitários / Epidemiology for municipalities: manual for management of sanitary districts

Guia sobre epidemiologia e sua relaçäo com o planejamento, gerenciamento e avaliaçäo, enfatizando o uso de informaçöes epidemiológicas no planejamento ao nível municipal e distrital.

Control of tuberculosis by community health workers in Bangladesh.

BACKGROUND: Tuberculosis remains a major public-health problem in Bangladesh, despite national efforts to improve case identification and treatment compliance. In 1984, BRAC (formerly the Bangladesh Rural Advancement Committee), a national, non-governmental organisation, began an experimental tuberculosis-control programme in one thana (subdistrict). Community health workers screened villagers for chronic cough and collected sputum samples for acid-fast bacillus (AFB) microscopy (phase one). Positive patients received 12 months of directly observed therapy. Phase two (1992-94) included another nine thanas and, in phase three (1995), eight more thanas were included. From 1995, the treatment was an 8-month oral regimen. METHODS: In 1995-96, we analysed all programme data from 1992 to 1995. First we analysed phases two (12-month therapy) and three (8-month therapy) separately for proportion cured, died, treatment, failed, defaulted, migrated, and referred. Second, we did a cross-sectional survey of tuberculosis cases in more than 9000 randomly selected households in two phase-two thanas and one non-programme thana, and analysed the follow-up of all patients treated in the programme thanas. FINDINGS: In the phase-two analysis, 3497 (90%) of 3886 cases identified had accepted 12-month treatment. In phase three, all of 1741 identified cases accepted the 8-month regimen. 2833 (81.0%) and 1496 (85.9%) in phases two and three, respectively, were cured; 336 (9.6%) and 133 (7.6%) died. The relapse rate 2 or more years after treatment was discontinued was higher than the early relapse rate. The drop-out rate was 3.1%. In the cross-sectional survey, the prevalence of tuberculosis in the two programme thanas was half of that in the comparison thana, where only government services were available (0.07 vs 0.15 per 100 [corrected]). INTERPRETATION: The BRAC tuberculosis-control programme has successfully achieved high rates of case detection and treatment compliance, with a cure rate of at least 85% and a drop-out rate of 3.1%. The prevalence survey suggested that at least half of all existing cases had been detected by the programme.

PIP: In 1984 the Bangladesh Rural Advancement Committee (BRAC), a national nongovernmental organization, began an experimental tuberculosis control program in 1 thana (subdistrict). In phase 1 community health workers screened villagers for chronic cough and collected sputum samples for acid-fast bacillus (AFB) microscopy. Positive patients underwent a 12-month therapy. Phase 2 during 1992-94 included 9 other thanas, and in phase 3 in 1995 8 more thanas were included. Between 1984 and 1994 the treatment regimen consisted of 30 streptomycin injections on alternate days for 2 months and 300 mg of isoniazid and 150 mg of thiacetazone daily for 12 months. From 1985 the treatment was an 8-month oral regimen of isoniazid, pyrazinamide, ethambutol, and rifampicin daily for 2 months, then isoniazid and thiacetazone daily for 6 months. During 1995-96 program data were analyzed from 1992-95. First the 12-month therapy of phase 2 and the 8-month therapy of phase 3 were analyzed separately for proportion cured, deceased, treatment failed, defaulted, migrated, and referred. Then a cross-sectional survey of TB cases was carried out in more than 9000 randomly selected household in 2 phase-2 thanas and 1 nonprogram thana. The follow-up of all patients in the program thanas was analyzed. In the phase-2 analysis 3497 (90%) of 3886 cases identified had accepted the 12-month treatment. In phase 3 all of 1741 identified cases accepted the 8-month treatment regimen. 2833 (81%) and 1496 (85.9%) in phases 2 and 3, respectively, were cured; 336 (9.6%) and 133 (7.6%) died. 2 or more years after treatment was concluded, the relapse rate was higher than the early relapse rate. The drop-out rate was 3.1%. In the cross-sectional survey the prevalence of TB in the 2 program thanas was half of that in the comparison thana, where only government services were available: 0.07 vs. 0.15 per 1000. High rates of case detection and treatment compliance were achieved, with a cure rate of at least 85% and a low drop-out rate. At least half of all existing cases had been detected by the program.

Land tenure and child health in Rio Grande do Sul: the relationship between agricultural production, malnutrition and mortality.

"Four different approaches were applied to test the hypothesis that patterns of land tenure and agricultural production in Rio Grande do Sul [Brazil] are important infant mortality determinants. These studies have employed various data sources on distinct analytical levels.... The results...provide reliable evidence of there being a strong relationship between the degree of concentration of land tenure and agricultural production on the one hand, and malnutrition and infant mortality on the other."

Financing the World Health Organisation: global importance of extrabudgetary funds.

From 1948, when WHO was established, the Organisation has relied on the assessed contributions of its member states for its regular budget. However, since the early 1980s the WHO World Health Assembly has had a policy of zero real growth for the regular budget and has had to rely increasingly, therefore, on attracting additional voluntary contributions, called extrabudgetary funds (EBFs). Between 1984-85 and 1992-93 the real value of the EBFs apparently increased by more than 60% and in the 1990-91 biennium expenditure of extrabudgetary funds exceeded the regular budget for the first time. All WHO programmes, except the Assembly and the Executive Board, receive some EBFs. However, three cosponsored and six large regular programmes account for about 70% of these EBFs, mainly for vertically managed programmes in the areas of disease control, health promotion and human reproduction. Eighty percent of all EBFs received by WHO for assisted activities have been contributed by donor governments, with the top 10 countries (in Europe, North America and Japan) contributing about 90% of this total, whereas the UN funds and the World Bank have donated only about 6% of the total to date. By contrast, about 70% of the regular budget expenditure has been for organisational expenses and for the support of programmes in the area of health systems. Despite the fact that the more successful programmes are heavily reliant on EBFs, there are strong indications that donors, particularly donor governments, are reluctant to maintain the current level of funding without major reforms in the leadership and management of the Organisation. This has major implications for WHO's international role as the leading UN specialised agency for health.

[Longitudinal study of the mother and child population in an urban region of southern Brazil, 1993: methodological aspects and preliminary results]. / Estudo longitudinal da população materno-infantil da região urbana do Sul do Brasil, 1993: aspectos metodológicos e resultados preliminares.

All babies born in the hospitals of the city of Pelotas, Brazil, in 1982 were studied soon after delivery and followed up prospectively during the first years of their lives. In 1993, this study was repeated with a similar methodology, with the aim of assessing eventual changes in the level of maternal and child health. All five maternity hospitals in the city were visited daily and the 5,304 babies born included in the study. They were weighed and measured, and their gestational age was assessed using the Dubowitz method. Their mothers were examined and interviewed regarding a large number of risk factors. The mortality of these children was studied through the surveillance of all hospitals, cemeteries and death registries, and all hospital admissions were also recorded. Two nested case-control studies were carried out to assess risk factors for mortality and hospital morbidity. A systematic sample of 655 children were examined at home at one and three months of age, and these infants, as well as another sample of 805 children including all low-birthweight babies were also examined at the ages of six and twelve months. Their psychomotor development was also assessed. Losses to follow-up were only 6.6% at twelve months. Relative to the 1982 indicators, perinatal mortality fell by about 30% and infant mortality by almost 50%. The median duration of breastfeeding increased from 3.1 to 4.0 months. On the other hand, there was little change in the prevalences of low birthweight or of length for age at twelve months. The article that refers this abstract describes the methodology of the study and forthcoming publications will present detailed results.

PIP: All babies born in the hospitals of the city of Pelotas, Brazil, in 1982 were studied soon after delivery and followed up prospectively during the first years of their lives. In 1993 this study was repeated with a similar methodology, with the aim of assessing eventual changes in the level of maternal and child health. All five maternity hospitals in the city were visited daily and the 5304 babies born included in the study. They were weighed and measured, and their gestational age was assessed using the Dubowitz method. Their mothers were examined and interviewed regarding a large number of risk factors. The mortality of these children was studied through the surveillance of all hospitals, cemeteries, and death registries, and all hospital admissions were also recorded. Two nested case-control studies were carried out to assess risk factors for mortality and hospital morbidity. A systematic sample of 655 children was examined at home at 1 and 3 months of age, and these infants, as well as another sample of 805 children including all low-birth-weight babies, were also examined at the ages of 6 and 12 months. Their psychomotor development was also assessed. Losses to follow-up were only 6.6% at 12 months. Relative to the 1982 indicators, perinatal mortality fell by about 30% and infant mortality by almost 50%. The median duration of breast feeding increased from 3.1 to 4.0 months. On the other hand, there was little change in the prevalences of low birth weight or of length for age at 12 months. The methodology of the study is described, and forthcoming publications will present detailed results. (author's modified)

Early childhood mortality in a Brazilian cohort: the roles of birthweight and socioeconomic status.

The deaths of children aged 1-4 years were studied in a cohort of 5914 Brazilian liveborns. A total of 29 early childhood deaths were recorded (cumulative mortality risk of approximately 6 per 1000), 17 of which (59%) were due to infectious diseases. The death rate was highest in the second year. Deaths were highly concentrated in children from low income (< US $50/month) families, where the cumulative risk of early childhood death was about 10 per 1000; on the other hand, there were no deaths among the 616 children from families with a monthly income of US $300 or more. Birthweight was also associated with mortality: the cumulative risk of children weighing less than 2000 g at birth was 21 per 1000, compared to 4 per 1000 among those with birthweights of 3500 g or more. Simultaneous adjustment for income and birthweight did not substantially change these differentials. These findings confirm the strong association between early childhood mortality and socioeconomic conditions, but also make evident the long-term effects of low birthweight.

PIP: Mortality was studied among a cohort of 5914 Brazilian live-borns aged 1-4 years. 29 early childhood deaths were recorded, 17 of which were due to infectious diseases. The highest death rate was observed in the 2nd year. Deaths were highly concentrated among children of families with income US$50/month, with a 10/1000 cumulative risk of early childhood death. No deaths, however, occurred among the 616 children from families with monthly income or= US$300. As for birth weight, the cumulative risk of death among children weighing 2000 gm at birth was 21/1000, compared with 4/1000 among those with birth weights of 3500 gm or more. Simultaneous adjustments for both income and birth weight failed to substantially change mortality differentials. Study results therefore confirm the strong association between early childhood mortality, income, and low birth weight.