Health Policy
A custom publication of the Disease Control Priorities Project
©2006 The International Bank for Reconstruction and Development / The World Bank
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The chapters in this publication were originally published in the following two books, and any
citations should include the complete information provided:
1) Dean T. Jamison, Joel G. Breman, Anthony R. Measham, George Alleyne, Mariam Claeson,
David B. Evans, Prabhat Jha, Anne Mills, and Philip Musgrove, eds. 2006. Disease Control
Priorities in Developing Countries, 2nd ed. New York: Oxford University Press.
2) Alan D. Lopez, Colin D. Mathers, Majid Ezzati, Dean T. Jamison, and Christopher J. L.
Murray, eds. 2006. Global Burden of Disease and Risk Factors. New York: Oxford University
Press.
Contents
1
Millennium Development Goals for Health: What Will It Take to Accelerate Progress? ...............................................
1
Disease Control Priorities in Developing Countries
Adam Wagstaff, Mariam Claeson, Robert M. Hecht, Pablo Gottret, and Qiu Fang
2
Fiscal Policies for Health Promotion and Disease Prevention .........................................................................................
15
Disease Control Priorities in Developing Countries
Rachel Nugent and Felicia Knaul
3
Indoor Air Pollution .........................................................................................................................................................
29
Disease Control Priorities in Developing Countries
Nigel Bruce, Eva Rehfuess, Sumi Mehta, Guy Hutton, and Kirk Smith
4
Prevention of Chronic Disease by Means of Diet and Lifestyle Changes .......................................................................
53
Disease Control Priorities in Developing Countries
Walter C. Willett, Jeffrey P. Koplan, Rachel Nugent, Courtenay Dusenbury, Pekka Puska, and Thomas A. Gaziano
5
Tobacco Addiction ...........................................................................................................................................................
71
Disease Control Priorities in Developing Countries
Prabhat Jha, Frank J. Chaloupka, James Moore, Vendhan Gajalakshmi, Prakash C. Gupta, Richard Peck, Samira Asma, and Witold
Zatonski
6
Alcohol .............................................................................................................................................................................
89
Disease Control Priorities in Developing Countries
Jürgen Rehm, Dan Chisholm, Robin Room, and Alan Lopez
7
Illicit Opiate Abuse ..........................................................................................................................................................
109
Disease Control Priorities in Developing Countries
Wayne Hall, Chris Doran, Louisa Degenhardt, and Donald Shepard
8
Public Health Surveillance: A Tool for Targeting and Monitoring Interventions ...........................................................
135
Disease Control Priorities in Developing Countries
Peter Nsubuga, Mark E. White, Stephen B. Thacker, and others
9
Information to Improve Decision Making for Health ......................................................................................................
157
Disease Control Priorities in Developing Countries
Sally K. Stansfield, Julia Walsh, Ndola Prata, and others
10
School-Based Health and Nutrition Programs .................................................................................................................
171
Disease Control Priorities in Developing Countries
Donald Bundy, Sheldon Shaeffer, Matthew Jukes, and others
11
Natural Disaster Mitigation and Relief ............................................................................................................................
189
Disease Control Priorities in Developing Countries
Claude de Ville de Goyet, Ricardo Zapata Marti, and Claudio Osorio
12
Control and Eradication ...................................................................................................................................................
205
Disease Control Priorities in Developing Countries
Mark Miller, Scott Barrett, and D. A. Henderson
13
Improving the Quality of Care in Developing Countries .................................................................................................
219
Disease Control Priorities in Developing Countries
John W. Peabody, Mario M. Taguiwalo, David A. Robalino, and others
14
Health Workers: Building and Motivating the Workforce ..............................................................................................
235
Disease Control Priorities in Developing Countries
Charles Hongoro and Charles Normand
15
Strategic Management of Clinical Services .....................................................................................................................
249
Disease Control Priorities in Developing Countries
Alexander S. Preker, Martin McKee, Andrew Mitchell, and others
16
Measuring the Global Burden of Disease and Risk Factors,19902001 ............................................................................
Global Burden of Disease and Risk Factors
Alan D. Lopez, Colin D. Mathers, Majid Ezzati, Dean T. Jamison, and Christopher J. L. Murray
263
Chapter 9
Millennium Development Goals for Health:
What Will It Take to Accelerate Progress?
Adam Wagstaff, Mariam Claeson, Robert M. Hecht, Pablo Gottret,
and Qiu Fang
The scale of the diseases and conditions that the Millennium
Development Goals (MDGs) address is staggering:
• Almost 11 million children died before their fifth birthday
in 2000 (UNICEF 2001). Less than 1 percent of these 11 million deaths (79,000) occurred in high-income countries,
compared with 42 percent in Sub-Saharan Africa, 35 percent
in South Asia, and 13 percent in East Asia.
• In 1998, an estimated 843 million people were considered
undernourished on the basis of their food intake (FAO
2000). Of the estimated 140 million children under the age
of five who were underweight, almost half (65 million) were
in South Asia.
• Of the 3.1 million people who died from HIV/AIDS in
2003, almost all (99 percent) were in the developing
world—74 percent in Sub-Saharan Africa alone (UNAIDS
2004). Tuberculosis and malaria together killed an equal
number; most of these deaths were among the poor.
• In 1995, 515,000 women died during pregnancy or childbirth: 1,000 in the industrial world, contrasted with 252,000
in Sub-Saharan Africa (UNICEF 2001).
This burden of death and suffering is heavily concentrated in
the world’s poorest countries (Wagstaff and Claeson 2004).
Death and disease matter in their own right, but they also act as a
brake on poverty reduction. Nobel laureate Amartya Sen (2002)
has described health as one of “the most important conditions
of human life and a critically significant constituent of human
capabilities which we have reason to value.” Health also matters
because it influences the living standards of both households
and countries. Health expenses can easily become burdensome
for households. In Vietnam, they are estimated to have pushed
3 million people into poverty in 1993 (Wagstaff and van
Doorslaer 2003).
Beyond the direct impact of ill health on households’ living
standards through out-of-pocket expenditures, it indirectly
affects labor income through productivity and the number of
hours that people can work. The effects of illness on income,
which may take time to appear, are often long lasting. Malnourished children are less likely to attend school and less likely
to learn when they do attend, reducing their productivity in
later life. The devastating economic consequences of illness and
death are evident at the macroeconomic level as well. The AIDS
epidemic alone has been estimated to reduce rates of economic growth by 0.3 to 1.5 percentage points annually (Bell,
Devarajan, and Gersbach 2003).
In the 1990s, the international community recognized the
importance of health in development. In a period when overall
official development assistance declined, development assistance to health rose in real terms. World Bank lending for
health increased, with a doubling of the share of International
Development Association disbursements going to health
(OECD Development Assistance Committee 2000). The 1990s
saw an increased global concern over the debt in the developing world, fueled in part by a perception that interest payments
were constraining government health expenditures in
developing countries. The enhanced Highly Indebted Poor
Country Initiative, spearheaded by the International Monetary
Fund and World Bank in response to the unsustainable debt
burden of the poorest countries, was explicitly geared to channel freed resources into the health and other social sectors. The
181
©2006 The International Bank for Reconstruction and Development / The World Bank
1
Poverty Reduction Strategy Papers submitted by governments
of developing countries seek debt relief or concessional
(low-interest) International Development Association loans to
set out their plans for fighting poverty on all fronts, including
health.
The 1990s also saw the development of major new global
health initiatives and partnerships, including the Joint United
Nations Programme on HIV/AIDS (UNAIDS); the Global
Alliance for Vaccines and Immunization; the Stop TB
Partnership; the Roll Back Malaria Partnership; the Global
Fund to Fight AIDS, Tuberculosis, and Malaria; and the Global
Alliance for Improved Nutrition. A range of new not-for-profit
organizations were set up to spur the accelerated discovery and
uptake in developing countries of low-cost health technologies
to address the diseases of the poor; these organizations
included the International AIDS Vaccine Initiative, the
Medicines for Malaria Venture, the Global Alliance for
Tuberculosis, and the International Trachoma Initiative. In
addition, the scale of philanthropic involvement in international health increased, with the launch of the Bill & Melinda
Gates Foundation and the Packard Foundation and the continued attention to global health issues by such established entities
as the Rockefeller Foundation. These initiatives brought not
only new resources—funds, ideas, energy, and mechanisms—
but also new challenges to harmonization in the attempt to coordinate and link global goals with local actions in the fight against
disease, death, and malnutrition in the developing world.
As the 1990s closed, the international community decided
that even more needed to be done. At the United Nations
Millennium Summit in September 2001, heads of 147 states
endorsed the MDGs, nearly half of which concern different
aspects of health—directly or indirectly (box 9.1). Several other
goals are indirectly related to health—for example, the goals on
education and gender. Gender equality is considered important
to promoting good health among children. Other health outcomes than those included in the MDGs measure progress on
health—for example, targets related to noncommunicable
diseases. These targets are referred to as the MDG plus and
are included in national priority setting, especially in many
middle-income countries.
THE MILLENNIUM DEVELOPMENT GOALS
FOR HEALTH: PROGRESS AND PROSPECTS
Of the MDGs for which trend data are available or estimated,
the fastest progress has been on malnutrition, whereas overall
progress on under-five mortality and maternal mortality has
been slower.
A Mixed Score at Halftime
In-depth analysis of the health-related MDGs shows a mixed
score at halftime (Wagstaff and Claeson 2004):
• The number of people living in on-track countries (countries that will reach the MDGs if they maintain the rate of
progress they have already achieved during the period from
1990 to the present) matters. For the malnutrition target,
77 percent of the developing world’s people live in an ontrack country, but in Sub-Saharan Africa only 15 percent of
the people live in an on-track country.
• Different indicators show different levels of improvement.
For under-five mortality, the developing world was reduced
by an average of only a 2.5 percent in the 1990s, well short
of the target of 4.3 percent.
Box 9.1
The Health-Related Millennium Development Goals
Goal 1—eradicating extreme poverty and hunger. This goal
includes as a target the halving between 1990 and 2015 of
the proportion of people who suffer from hunger, with
progress to be measured in terms of the prevalence of
underweight children under five years of age. The target
implies an average annual rate of reduction of 2.7 percent.
Goal 4—reducing child mortality. The target is to reduce by
two-thirds between 1990 and 2015 the under-five mortality
rate, equivalent to an annual rate of reduction of 4.3 percent.
Goal 5—improving maternal health. The target is to reduce
by three-quarters between 1990 and 2015 the maternal
mortality ratio, equivalent to an annual rate of reduction of
5.4 percent.
Goal 6—combating HIV/AIDS, malaria, and other diseases.
The target is to halt and begin to reverse the spread of these
diseases by 2015.
Goal 7—ensuring environmental sustainability. This goal
includes as a target the halving by 2015 of the proportion
of people without sustainable access to safe drinking water.
Goal 8—developing a global partnership for development.
This goal includes as a target the provision of access to
affordable essential drugs in developing countries.
Source: United Nations Millennium Declaration, the United Nations Millennium Summit 2000.
182 | Disease Control Priorities in Developing Countries | Adam Wagstaff, Mariam Claeson, Robert M. Hecht, and others
©2006 The International Bank for Reconstruction and Development / The World Bank
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• Regional differences are also pronounced, with Sub-Saharan
Africa faring worse than other regions. In Africa, trends in
reducing under-five mortality and underweight in children
were barely above zero during the 1990s, and maternal mortality fell on average by just 1.6 percent a year compared
with the annual target rate of 5.4 percent.
• Evidence on how the poor are faring within countries is
mixed. For malnutrition, the poorest 20 percent of the population within countries appears, on average, to have been
experiencing broadly similar rates of reduction to the population as a whole. However, for under-five mortality, the
rate has been falling more slowly among the poor, while
better-off families are seeing faster rates of progress.
Will the Second Half Go Better?
As a comparison of the child mortality experiences in the 1980s
and 1990s demonstrates, past performance is not necessarily a
good predictor of future performance. The fact that a country
is on track on the basis of its performance in the 1990s does not
guarantee that it will maintain the required annual rate of
reduction of malnutrition or mortality during the second half
of the MDG “window” from 2000 to 2015. Countries currently
off track may possibly get on track in the second half if they can
combine good policies with expanded funding for programs
that address both the direct and the underlying determinants
of the health-related goals.
Stimuli External to the Health Sector. The World Bank estimates that economic growth will fall somewhat in East Asia
and the Pacific in 2000–15, turn from negative to positive in
Europe and Central Asia as well as Sub-Saharan Africa, and
increase somewhat in Latin America and the Caribbean, the
Middle East and North Africa, and South Asia (Jones and others 2003). Primary education completion rates will probably
grow faster in the new millennium as a result of the global education initiatives and partnerships on Education for All and
the Fast-Track Initiative. However, higher rates of educational
attainment among women of childbearing age will not be
achieved until 2005 or so, and even then the first full round of
effects on under-five mortality will not be felt until 2010.
More relevant is the fact that gender gaps in secondary education may well narrow faster in the new millennium than in
the 1990s as a result of the gender MDG (Goal 3: Eliminate
gender disparity in primary and secondary education by 2005
and in all levels of education no later than 2015). To achieve
parity with boys by 2015 in the proportion of the population
who are age 15 and have completed secondary education, girls
will have to achieve a faster growth in completion rates in the
new millennium than in the 1990s in most regions, especially
in South Asia and in East Asia and the Pacific. If the water
MDG (ensuring that households have access to safe drinking
water) is to be reached, access rates will need to grow much
faster in 2000–15, especially in Sub-Saharan Africa (Wagstaff
and Claeson 2004). Gender equality in school and access to
clean water will have a positive effect on progress toward the
health MDGs. Even with economic growth and faster progress
on these nonhealth goals, however, many regions will still miss
many of the health targets. The picture is bleakest for underfive mortality—and for Sub-Saharan Africa.
The Goals Matter for All Countries. These goals need to be
taken seriously for three main reasons:
• Faster progress is important even if targets are missed. A key
message of this chapter is that progress can be accelerated
in all countries through a judicious mix of spending and policy and institutional reform.
• The goals facilitate benchmarking and monitoring of results.
Because the goals focus on a limited set of outcomes, monitoring and evaluating progress toward the MDGs can show
what is achievable and where faster progress can be made.
• Focusing attention on national progress, as measured by
distributional analysis of the MDGs, forces countries to consider how the benefits of progress are distributed among the
rich and poor within each country—the poor risk being left
behind even in countries making progress overall. One limitation of the MDGs and targets is that they are national averages. However, distributional analysis of MDG trends
(Wagstaff and Claeson 2004) reminds us that progress needs
to be for everyone, not just the better off. Progress has been
uneven, with the poorer countries lagging behind the rest,
and for under-five mortality, the poor within countries are
lagging behind the rest of the population.
SCALING UP: DEFINING INTERVENTIONS
AND REMOVING CONSTRAINTS
A lack of interventions is not the primary obstacle to faster
progress toward the goals, although new interventions that can
be delivered by weak health systems could greatly improve
progress—for example, malaria or HIV vaccines and effective
vaginal microbicides to block the spread of HIV and other
sexually transmitted infections. The main obstacle is the low
levels of use—especially among the poor—of existing effective
interventions. For example, if use of all the proven effective
preventive and treatment interventions for childhood illness
were to rise from current levels to reach all, the number of
under-five deaths worldwide could fall by as much as 63 percent (World Bank 2003b).
Array of Interventions, Programs, and Service Modalities
The available interventions constitute a powerful arsenal for
preventing and treating the main causes of malnutrition and
death (table 9.1).1 The major diseases and conditions that the
MDGs aim to prevent and control are discussed in several
Millennium Development Goals for Health: What Will It Take to Accelerate Progress? | 183
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Table 9.1 Effective Interventions to Reduce Illness, Deaths, and Malnutrition
MDG
Preventive interventions
Treatment interventions
Child mortality
Breastfeeding; hand washing; safe disposal of stool; latrine use; safe preparation of weaning foods; use of insecticide-treated bednets; complementary feeding; immunization; micronutrient supplementation (zinc and vitamin A); prenatal
care, including steroids and tetanus toxoid; antimalarial intermittent preventive
treatment in pregnancy; newborn temperature management; nevirapine and
replacement feeding; antibiotics for premature rupture of membranes; clean
delivery
Case management with oral rehydration therapy
for diarrhea; antibiotics for dysentery, pneumonia, and sepsis; antimalarials for malaria;
newborn resuscitation; breastfeeding; complementary feeding during illness; micronutrient
supplementation (zinc and vitamin A)
Maternal mortality
Family planning (lifetime risk); intermittent malaria prophylaxis; use of
insecticide-treated bednets; micronutrient supplementation (iron, folic acid,
calcium for those who are deficient)
Antibiotics for preterm rupture of membranes,
skilled attendants (especially active management
of third stage of labor), basic and emergency
obstetric care
Nutrition
Exclusive breastfeeding for 6 months, appropriate complementary child feeding
for next 6–24 months, iron and folic acid supplementation for children, improved
hygiene and sanitation, improved dietary intake of pregnant and lactating
women, micronutrient supplementation for prevention of anemia and vitamin A
deficiency for mothers and children, anthelmintic treatment in school-age
children
Appropriate feeding of sick child and oral rehydration therapy, control and timely treatment of
infectious and parasitic diseases, treatment and
monitoring of severely malnourished children,
high-dose treatment of clinical signs of vitamin A
deficiency
HIV/AIDS
Safe sex, including condom use; unused needles for drug users; treatment of
sexually transmitted infections; safe, screened blood supplies; antiretrovirals
in pregnancy to prevent maternal to child transmission and after occupational
exposure
Treatment of opportunistic infections,
co-trimoxazole prophylaxis, highly active
antiretroviral therapy, palliative care
Tuberculosis
Directly observed treatment of infectious cases to prevent transmission and
emergence of drug-resistant strains and treatment of contacts, Bacillus
Calmette-Guérin immunization
Directly observed treatment to cure, including
early identification of tuberculosis symptomatic
cases
Malaria
Use of insecticide-treated bednets, indoor residual spraying (in epidemic-prone
areas), intermittent presumptive treatment of pregnant women
Rapid detection and early treatment of uncomplicated cases, treatment of complicated cases
(such as cerebral malaria and severe anemia)
Source: Authors.
chapters (for example, see chapters 15, 19, 21–24, 28–31, 44,
and 45). The most cost-effective interventions and programs
are also discussed in several chapters (see chapters 59–62 and
65). The chapters dealing with health systems and service
delivery issues and other constraints related to the health
MDGs are found in the latter part of the book (see chapters
66–68, and 73).
In the case of child mortality, for example, diarrheal diseases, pneumonia, and malaria account for 52 percent of deaths
worldwide (World Bank 2003b). For each of these major causes
of childhood mortality, at least one proven effective preventive
intervention and at least one proven effective treatment intervention exist, capable of being delivered in a low-income setting. In most cases, several proven effective interventions exist.
For diarrhea—the second-leading cause of child deaths—no
fewer than five proven preventive interventions and three
proven treatment interventions are available.
Effective Interventions Reaching Too Few People
The high rates of malnutrition and death in the developing
world have several causes. First, people do not receive the effec-
tive interventions that could save their lives or make them well
nourished. In middle- and high-income countries, 90 percent of
children are fully immunized, more than 90 percent of deliveries are assisted by a medically trained provider (that is, a doctor,
nurse, or trained midwife, excluding traditional birth attendants), and more than 90 percent of pregnant women have at
least one prenatal visit (UNICEF 2001). In South Asia, fewer
than 50 percent of pregnant women receive a prenatal checkup,
and only 20 percent of deliveries are assisted by a trained
provider.
The story is similar for other childhood interventions—
and for interventions for other goals. Condom use to prevent
transmission of HIV is low in much of Sub-Saharan Africa
and South Asia, and inexpensive one-time treatment with
antiretroviral medicine to prevent transmission from mother
to child covers only a small fraction of at-risk pregnant
women in most of the developing world. In Asia, where
more than 7 million people are living with HIV/AIDS, no
country has yet exceeded 5 percent antiretroviral therapy
coverage among those who could benefit from it (World Bank
2003c).
184 | Disease Control Priorities in Developing Countries | Adam Wagstaff, Mariam Claeson, Robert M. Hecht, and others
©2006 The International Bank for Reconstruction and Development / The World Bank
4
Just as shortfalls in coverage vary across countries, so do
they vary within countries, with the poor and other deprived
groups consistently lagging. These groups are less likely to
receive full basic immunization coverage, to have their deliveries attended by a trained provider, and to have at least one prenatal care visit to a medically trained provider. On the positive
side, the poor are often making fastest progress in coverage,
reflecting in part that the better off already have high coverage
rates for many interventions.
Underuse of Effective Interventions Costs Lives
The low use of effective interventions—in the developing
world in general and among the poor in particular—translates
into rates of mortality, morbidity, and malnutrition that are far
higher than necessary. If use of all the proven effective childhood preventive and treatment interventions, for example,
were to rise from their current levels to 99 percent—95 percent
for breastfeeding—the number of under-five deaths worldwide
could fall by as much as 63 percent (Jones and others 2003).
Deaths from malaria and measles could be all but eliminated,
and deaths from diarrhea, pneumonia, and HIV/AIDS could be
reduced dramatically. If coverage rates of the key maternal
mortality interventions were increased from current levels to
99 percent, an estimated 391,000 maternal deaths worldwide
(74 percent of current maternal deaths) might be averted
(Ramana 2003). One intervention stands out as especially
important: access to essential obstetric care, which accounts for
more than half the maternal deaths averted.
allocations. In practice, however, the amount of extra spending
required would be difficult to attain on present trends and
would even be prohibitively expensive. In the case of East Asia
and the Pacific, for example, if economic growth proceeds as
expected and the other relevant Millennium Development
Targets are attained, the region would achieve the required
rates of reduction of underweight and maternal mortality—
assuming that economic growth is accompanied by the development of appropriate human resources for health—even if
government health spending continues to grow at its current
rate. However, the region would miss the under-five mortality
target. To reach that target, a minimum of 5 percentage points
would need to be added to the annual rate of growth of the
government health share of gross domestic product (GDP).
That would take the projected share of GDP spent on government health programs to 3.7 percent in 2015—more than twice
what it would be if the 1990s pattern of growth continued
(Wagstaff and Claeson 2004).
In Sub-Saharan Africa, the situation is even starker. Even if
faster economic growth materializes and the other targets are
achieved, the share of government health spending in GDP
would need to grow nearly sixfold over the coming decade, taking the share to 12.2 percent of GDP in 2015. This percentage
compares with a 2000 figure of 1.8 percent and a 2015 forecast
of 2.2 percent based on the 1990s annual growth in government spending for health. In conclusion, African countries will
not be able to reach the MDGs simply by multiplying their
health spending along the lines of historical expenditure patterns, because the multiples required are beyond any realistic
expectation of what these governments will be able to do during the next 10 years.
WHAT DO COUNTRIES NEED TO DO?
If the lack of interventions is not holding countries back from
achieving the goals, what is? What do countries need to do to
make progress toward the MDGs?
In countries with good governance, additional government
health spending does reduce child mortality (Rajkumar and
Swaroop 2002). Development assistance has a stronger effect in
countries with strong policies and institutions than in countries with only average-quality policies and institutions—and
an insignificant effect in countries where policies and institutions are weak. This assertion is also consistent with the findings of a study undertaken by the World Bank for the MDG
report, The Millennium Development Goals for Health: Rising to
the Challenges (Wagstaff and Claeson 2004). The study includes
other outcomes with child mortality and uses the World Bank’s
Country Policy and Institutional Assessment index to measure
the quality of policies and institutions.
In principle, well-governed countries with good policies and
institutions could achieve the goals simply by scaling up their
expenditures on existing programs in proportion to current
What Are the Implications?
Poorly governed countries cannot expect to make much
progress toward the MDGs simply by scaling up their expenditures on existing programs in proportion to current allocations. Although well-governed countries could, in principle,
simply scale up existing spending to reach the targets, this
option is unlikely to be affordable for them or their donors.
This situation has two implications:
• First, targeting additional government spending to activities
that will have the largest effect on the MDGs is important
for both sets of countries.
• Second, building good policies and institutions is important
for all countries: doing so increases the productivity not just
of additional spending but also of existing spending commitments. What do better policies and institutions entail in
the health sector? Health systems are very broad, and weak
policies and institutions can arise at several points along
the pathway, from government health spending to health
Millennium Development Goals for Health: What Will It Take to Accelerate Progress? | 185
©2006 The International Bank for Reconstruction and Development / The World Bank
5
outcomes (Claeson and others 2001). Countries can do a
number of things, with help from donors, to build stronger
policies and institutions.
Improving Expenditure Allocations and Targeting
In most countries, government spending gets stuck in the cities
and disproportionately accrues—in a financial sense—to
people who are better off.
Geographic Targeting. Resource allocation formulas can be
used to reduce government spending gaps across regions and
ideally to favor geographic zones that are furthest behind.
These formulas have been used, for example, as part of Bolivia’s
decentralization efforts since 1994 and have been associated
with some large—and pro-poor—improvements in maternal
and child health indicators. Targeting resources to poor regions
and provinces may be most effectively implemented through
nontraditional mechanisms for priority setting and implementation, such as social investment funds. In Bolivia, a recent
impact evaluation concluded that such funds were responsible
for a decline in under-five mortality from 88.5 to 65.6 per 1,000
live births over a five-year period (Newman and others 2002).
Changing the Allocation of Spending across Care Levels.
Spending on health in developing countries is characterized by
a high concentration of spending on secondary and tertiary
infrastructure and personnel. Some governments have tried to
scale back the share of hospital spending. Tanzania, for example, reduced the share of hospital spending from 60 percent in
2000 to 43 percent in 2002. Chapter 3 deals with the issue of
how to couple expenditure reallocations across levels of care
with measures to improve performance at each level of the
health care system.
Targeting Specific Programs. Programs such as those delivering directly observed treatment short course (DOTS) for tuberculosis or integrated management of infant and childhood
illness (IMCI) for child health are good examples of programs
that may yield high returns to government spending at the
margin. A recent World Bank study in India provides further
support for the idea that the way government spending is allocated across programs makes a difference to its effect on the
Millennium Development Indicators (World Bank 2003a).
Successful public health programs—large-scale programs with
a measurable health effect over at least a five-year period—are
further discussed in chapter 8. All successful programs have
several factors in common: technical innovation and stakeholder consensus, strong political leadership, coordination
across agencies and management, effective use of information
and financial resources, and participation of the beneficiary
community.
Targeting Specific Population Groups. Many countries subsidize all government health services for everyone. These blanket
subsidy schemes not only fail to target interventions that give
rise to externalities but also fail to disproportionately benefit
the poor—despite the stronger equity case for subsidizing their
care and the fact that they tend to bear a disproportionate
burden of malnutrition as well as child and maternal mortality.
There are many proven ways to target the poor—for example,
by delivering essential services in clinics or health posts that
only poor families attend or by promoting and delivering services in a way that segments the market and appeals to those in
low-income households.
Targeting Spending to Remove Bottlenecks. A planning and
budgeting approach is to assess—for a country—the health
sector impediments to faster progress, to identify ways of
removing them, and to estimate both the costs of removing
them and the likely effects of their removal on MDG outcomes
(Soucat and others 2002). MDG analysis along these lines—
referred to sometimes as marginal budgeting for bottlenecks
(MBB)—has begun in several African countries and in some
states of India (UNICEF and World Bank 2003). In Mali, key
bottlenecks were identified for supporting home-based practices and delivering periodic and continual professional care.
They included low access to affordable commodities and the
need for community-based support for home-based care; low
geographical access to preventive professional care (immunization, vitamin A supplementation, and prenatal care); shortages
of qualified nurses and midwives; and an absence of effective
third-party payment mechanisms for the poor for professional
continuous care. Important health systems bottlenecks, such as
human resources, drug availability, and health care management, are discussed in chapters 71–73.
Improving Policies toward Households as Producers
and Demanders of Care
Households are at the center of any efforts to scale up; they not
only demand and consume care, but they are also important
producers of prevention and care. Policies to increase coverage
of cost-effective interventions to reach the health MDGs, therefore, need to identify and influence the key constraints to both
the production and the demand for those services at the
household and community levels.
Lowering Financial Barriers. Low income is a barrier to the
use of most health interventions, and economic growth is an
important weapon in the war against malnutrition and mortality. However, social protection programs are also important.
Successful schemes aimed at households and communities are
discussed in chapter 56.
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One part of the affordability equation is price. User charges
for MDG interventions are to be discouraged. Why? Many of
those interventions involve benefits that spill over to people
who do not receive the intervention; high coverage of immunization is a classic example. However, an equity case also can
be made for reducing prices facing the poor and near poor,
even where no spillovers occur. Subsidies should be targeted to
services with spillovers and to the poor. In practice, subsidies
are often badly targeted in at least one respect if not both.
Exceptions exist. In Ifakara, Tanzania, a voucher program for
mosquito nets was launched successfully for pregnant women
and children under five (Schellenberg and others 2001).
Some recent programs, especially in Latin America, have not
only made health care affordable for the poor but have also
made it profitable. Rather than simply reducing the cost of
using specific interventions, these programs provide users with
cash payments, which are linked to specific interventions and
restricted to certain groups—often poor mothers and their
children. The experience with these programs in targeting and
achieving results is encouraging (Mesoamerica Nutrition
Program Targeting Study Group 2002; Morris and others 2003;
Palmer and others 2004).
Risk aversion coupled with the unpredictability of illness
provides a motivation for pooling risks through an insurance
scheme. The Arab Republic of Egypt, for example, introduced
a school health insurance program for all children attending
school. The program resulted in larger increases in coverage
among the poor and achieved considerable effect on use and
out-of-pocket expenditures (Yip and Berman 2001). However,
insurance in the developing world is very limited, and those
who are least able to smooth consumption without insurance
are the least likely to have insurance coverage (Musgrove,
Zeramdini, and Carrin 2002). Another problem is that many of
the schemes are small scale, and evaluations of these schemes
do not generally measure health effect or effect on equity, thus
resulting in limited evidence (Palmer and others 2004).
Providing Information—Enhancing Knowledge. Lack of
knowledge is a major factor behind poor health. It results in
people not seeking care when needed, despite the absence of
price barriers, and it also results in people—especially poor
people—wasting limited resources on inappropriate care.
Ignorance may also result in people not getting the maximum
health gain out of inputs they have available to them and use.
Many people do not know that hand washing confers much of
the health benefit of piped water (see chapter 41). Not surprisingly, piped water has a much greater effect on the prevalence
of diarrhea among the children of the better off and better
educated. Better-educated women—especially those with a
secondary education—achieve better health outcomes for
themselves and their children not by using health-specific
knowledge that they acquire at school, but by using general
numeracy and literacy skills learned at school to acquire healthspecific knowledge later in life. Although better-educated girls
will mean healthier women and healthier children in years to
come, a shorter and more direct route to increasing healthspecific knowledge and skills is through information dissemination, health promotion, and counseling in the health sector.
Several success stories exist. In Brazil, after health workers
trained by IMCI provided information and counseling at
health facilities and in the community, health knowledge
among mothers improved, as did feeding practices (Santos and
others 2001). After only 18 months, the nutritional status of
children in the area improved as well. Social marketing and
media campaigns—for example, malaria and social marketing
of insecticide-treated nets (see chapter 21)—have also proved
effective in some circumstances.
Reducing Time Costs Transportation systems, road infrastructure, and geography influence the demand for care delivered by
formal providers through their effect on time costs, which can
be substantial. In rural communities, where the roads are poor
and the transportation unreliable, the time spent waiting for
the transportation is also a major cost. Time costs tend to be a
major issue for maternal mortality: health centers are unable to
provide essential obstetric care for a complicated delivery, and
women would have to travel to distant hospitals to get
such services. Road rehabilitation and other transportation
projects are important here, but so are subsidies linked to
the use of health services. Malaysia and Sri Lanka provide free
or subsidized transportation to hospitals in emergencies
(Pathmanathan and others 2003). Other options for tackling
inaccessibility include using outreach and establishing partnerships between government and nongovernmental organizations (NGOs), private providers, or community organizations.
Providing Access to Water and Sanitation The availability of
adequate supplies of water and improved sanitation is associated with better maternal and child health outcomes, at least
among the better educated, even after controlling for other
influences. This result is not altogether surprising. Hand washing is easier if the household has piped water that provides
readily available quantities of safe water. The safe disposal of
feces is easier if the household has an improved form of sanitation. The developing world lags well behind the industrial
world in both; the poorer people fare especially badly. They are
less likely to be connected to a network, and the sources they
rely on tend to be more costly per liter than the networked services used by the better off.
The challenge from a health perspective is to get maximum
health benefits from investments in access to water and sanitation infrastructure. Efforts to work across sectors on water and
health, in order to influence the health MDGs, are under way in
Ethiopia, Peru, and Rwanda.
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Improving Health Service Delivery
Health providers—in the public and private sectors, as well as
in both formal and informal sectors—should deliver interventions of relevance to the MDGs. Many are efficient, deliver high
quality services, and are responsive to their patients. Many,
however, are not; many are not even there to deliver any services at all. As a result, resources—public and private—are often
nonexistent, underused, or wasted.
Two things can make a difference. One is the quality of
management. Better management means a clearer delineation
of responsibilities and accountabilities inside organizations,
a clearer link between performance and reward, and so on.
Management means getting accountabilities right within an
organization. The other thing that can make a difference is getting accountabilities right between the organization and the
public (World Bank 2003d).
Improving Management—Increasing Accountability within
Provider Organizations. Management styles in governmentfunded and government-implemented health schemes have
recently begun to change, focusing on performance—that is,
on outputs and outcomes—rather than on inputs and processes. Good performance is rewarded, financially or in some
other way. The focus is on clients and on the belief that an
organization is ultimately accountable to its clients. A clientoriented strategy emphasizes customer choice and satisfaction.
Business techniques enhance performance and are a standard
part of strategic planning.
This new approach is evident in several countries, and elements of the approach are visible in successful nutrition and
child health programs (see chapter 56). For example, in Tamil
Nadu’s Integrated Nutrition Program, community nutrition
workers were given clearly defined duties. Information on outputs not only enabled the community to keep the workers
accountable but also enabled the nutrition workers to see how
their program was working. In Ceara’s Programa de Agentes de
Saude, which is credited with a substantial reduction in child
mortality (Victora and others 2000), health agents and nursesupervisors were assigned clear tasks and given clear responsibilities. The intended outcomes of the program were emphasized to health workers and members of the public, and the
health agents were held accountable through communitybased monitoring and rewarded for good performance.
Governance. The accountability of provider organizations to
the public can be improved through enhanced governance or
contracting. Having community representatives participate in
the governance and oversight of providers can improve the
productivity and quality of public sector providers. In Burkina
Faso, participation of community representatives in public
primary health care clinics increased immunization coverage,
the availability of essential drugs, and the percentage of
women with two or more prenatal visits. In Peru, comparisons
of primary health care clinics with and without community
participation in governance suggested decreases in staff absenteeism and waiting times and suggested increases in perceived
quality by patients (Cotlear 1999). The approach probably
works best for primary care and in situations in which strong
technical and advisory support is provided to community representatives who are close to the service being delivered.
Contracting. Evidence on the effect of contracting within the
public sector is mixed, and the experiences are mainly based
on lessons learned from middle-income countries. In several
countries in Europe and Central Asia, evidence shows a positive
effect from performance-based payment, but that is not necessarily the same as contracting, which can occur without
performance-related pay. The best evidence relates to the use
of target payments for the attainment of a given level of
coverage—for example, for immunization or cervical cytology
at the primary care level (Langenbrunner 2003). In Argentina
and Nicaragua, social security institutes have increased productivity by establishing capitation-based payments for an
integrated package of inpatient and ambulatory services
(Bitran 2001). Key influences on the success of contracts within the public sector include whether the provider has the ability to respond, whether service commitments are congruent
with funding levels, whether output and key components of
performance expectations are easily measurable, and how far
capacity strengthening of the payer or funder is addressed.
Contracting with nonprofit organizations is most common
in low-income countries (see chapter 12, which contains a
longer discussion of contracting with NGOs). Most cases have
had positive effects on target outcome or output variables.
In Bangladesh, contracts with nonprofit organizations for
planning and implementing an expanded program on immunization project were credited with a dramatic increase in
immunization. In Haiti, contracting for a primary health care
package also significantly increased immunization coverage
(Eichler, Auxilia, and Pollock 2001). In Bangladesh,
Madagascar, and Senegal, significant reductions in nutrition
rates were attributed to contracting initiatives (Marek and others 1999). Only a few cases assess efficiency. Contracting with
nonprofits works best when the contractors have wellfunctioning accountability arrangements and strong intrinsic
motivation and when the government makes timely payments
to the NGOs. The government needs to be capable of assessing,
selecting, and managing the ongoing relationship with contractors. The methodological quality of evaluating contracting
is often poor and needs to be improved. An exception is the
Cambodian contracting trial that used a rigorous cluster randomized design, but the intervention groups had greater input
of resources than the control communities, which may have
been partly responsible for the difference in performance.
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Results on contracting with for-profit private service
providers are also mixed. Experience from the hospital sector
warns that weak government contracting capacity often allows
the provider to capture efficiency gains or to expand volume—
not necessarily of cost-effective services—to generate more
income. In Zimbabwe, the cost per service decreased, but the
lack of volume control led to an increase in total cost (McPake
and Hongoro 1995). Other adverse outcomes are possible. In
Brazil, contracting with for-profit hospitals led to increases
in access, but also increases in fraud (false billing) and creamskimming to avoid costly patients (Slack and Savedoff 2001).
These problems seem less pronounced in primary health care.
In Peru and El Salvador, contracting with private primary
health care providers increased access, choice, and consumer
satisfaction (Fiedler 1996). Contracting with for-profit
providers seems to work best when the government invests in
the development of capacity to manage the contracting process
(Mills, Bennett, and Russell 2001); when quality is at least as
high in the private sector as in the public sector; and when the
services involve primary care or other relatively observable
services, such as diagnostic services.
Strengthening Core Public Health Functions
Vulnerable populations need to be protected from risks and
damages, informed, and educated. Public health regulations
need to be established and enforced. Infrastructure needs to be
in place to reduce the impact of emergencies and disasters
on health. All this action needs to be implemented through a
public health system that is transparent and accountable.
Governments in developing countries generally recognize that
these public health functions are important, but they often lack
the capacity and financial resources to implement them.
Indeed, few low-income countries invest in these public health
functions.
By employing public health professionals with core public
health competencies, the government can develop and enforce
standards; can monitor the health of communities and populations; and can emphasize health education, public information,
health promotion, and disease prevention. Public action can
help improve consumer knowledge and change attitudes so
that private markets can operate effectively to meet the needs of
the poor, for example, through social marketing of insecticidetreated bednets to reduce malaria transmission or of condoms
for protection against HIV/AIDS.
Government-Led Monitoring and Evaluation. Integrated
disease surveillance, program assessment, and collection and
analysis of demographic and vital registration data are essential if governments and donors are to ascertain whether policies and programs are positively affecting health goals.
Governments can use a list of intermediate indicators and
proxies for the goals that can help monitor progress, test the
impact of policies, and adjust programs going forward (World
Bank 2001). Such indicators should be simple, easily measurable, representative, easy to understand, scientifically robust, and
ethical. They need to be assessed regularly because the MDGs
themselves are difficult to collect, thus entail delays, and are
therefore not useful for regular monitoring of progress. Greater
investments are needed in systems to monitor these intermediate indicators and to track expenditures on public health.
Although some good practices in surveillance are being
developed—for example, in Brazil, China, and India—few lowincome developing countries can afford to invest in the infrastructure required for strong surveillance systems. Most rely on
alternative short- to medium-term solutions for data gathering, such as intermittent household surveys, health facility
surveys, and simplified facility-based routine reporting. A few
countries have made special efforts to improve the surveillance
of a specific intervention, such as AIDS and tuberculosis treatment or childhood immunization, whereas others have
attempted to monitor progress toward a specific MDG.
INDEPTH (International Network of Field Sites with
Continuous Demographic Evaluation of Populations and
Their Health in Developing Countries), which is supported by
the Rockefeller Foundation with help from other donors, coordinates a range of surveillance sites, many of them in Africa,
and the Health Metrics network aims at improving the quality
of surveillance data. Some governments are explicitly developing or modifying their monitoring and evaluation framework
to focus on the MDGs.
Intersectoral Actions—Going Beyond the Ministry of
Health. A review of the evidence base for the key determinants
of the health and nutrition MDGs identifies significant potential for intersectoral synergies (Wagstaff and Claeson 2004).
Transportation Although roads and transport are vital for
health services, especially for reducing maternal mortality, it is
not just the physical infrastructure that matters. Also important are the availability of transportation and the affordability
of its use, as shown in a study in Nigeria (Eissen, Efenne, and
Sabitu 1997). Transportation and roads complement health
services. A 10-year study in Rajasthan, India, found that better
roads and transportation helped women reach referral
facilities, but many women still died because no corresponding
improvements took place at household and facility levels.
Working with the transportation sector is also important for
reducing HIV transmission in many settings and making
progress on the HIV/AIDS-related MDG.
Hygiene Improved hygiene (use of hand washing) and sanitation (use of latrines and safe disposal of children’s stools) are at
least as important as drinking water quality in shaping health
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outcomes, specifically in reducing diarrhea and associated child
mortality (Esrey and others 1991). Constructing water supply
and sanitation facilities is not enough to improve health outcomes; sustained human behavior change must accompany the
infrastructure investment. By collaborating with other sectors,
the health sector can develop public health promotion and
education strategies and implement them in partnership with
agencies that plan, develop, and manage water resources. The
health sector can also work with the private sector to manufacture, distribute, and promote affordable in-home water purification solutions and safe storage vessels—and advocate for
water, sanitation, and hygiene interventions in strategies to
reduce poverty.
Indoor Air Quality Indoor air pollution is caused by use of
low-cost, traditional energy sources, such as coal and biomass
for cooking and heating, the main source of energy for 3.5 billion people. Indoor air pollution is a major risk factor for pneumonia and associated deaths in children and for lung cancer in
women who risk exposure during cooking (see chapter 42).
Studies in China, Guatemala, and India are under way to
improve access to efficient and affordable energy sources
through local design, manufacturing, and dissemination of
low-cost technologies, modern fuel alternatives, and renewable
energy solutions. The community-based project in China was
initiated by the Ministry of Health, which was troubled by the
leveling off of child mortality reductions among the rural poor
and was seeking ways to influence major environmental determinants of child mortality. The program combines appropriately improved stoves and ventilation with behavior-change
modification; it is in an early stage of implementation, and
results on outcomes are not yet available. Agricultural policies
and practices influence food prices, farm incomes, diet diversity and quality, and household food security. Policies that
focus on women’s access to land, training, and agricultural
inputs; on their roles in production; and on their income from
agriculture are more likely to have a positive effect on nutrition
than interventions without a focus on women, particularly if
combined with other strategies, such as women’s education and
behavior change (Johnson-Welch 1999; Quisumbing 1995).
The MDG agenda highlights the need not only to prioritize
within health to achieve better health outcomes, but also to
better inform priority setting in resource allocations between
sectors, identifying intersectoral synergies and finding ways to
maximize benefits for health.
COSTING AND FINANCING ADDITIONAL
SPENDING FOR THE MDGS
Additional health spending will be required in many countries
to accelerate progress toward the health goals (see chapter 12).
What will it cost, and how will extra spending be financed?
Cost of Achieving the MDGs Globally
The global estimates of what it would cost to achieve the MDGs
range from an additional US$20 billion to US$70 billion a year.
A World Bank study (http://www.worldbank.org/html/extdr/
mdgassessment.pdf) estimates that the additional official
development assistance required to meet the health goals is in
the range of US$20 billion to US$25 billion per year, which is
roughly four times the current amount of official development
assistance spending for health in 2002 (US$6.5 billion) and
three times all external financing, including that of foundations
and loans from multilateral sources (see chapter 13). The dramatic shortfalls in resources required to achieve the MDGs
were emphasized during the 2002 Monterrey Conference on
Financing for Development, which brought significant attention to issues concerning the estimation of the cost of achieving the health MDGs.
Another analysis conducted by the Commission on
Macroeconomics and Health (2001) of the World Health
Organization estimated that an additional US$40 billion to
US$52 billion annually would be required until 2015 to scale up
the coverage for malaria, tuberculosis, HIV/AIDS, childhood
mortality, and maternal mortality (Kumaranayake, Kurowski,
and Conteh 2001). A third study using the production frontiers
approach estimated that between US$25 billion and US$70 billion of additional spending was needed to bring poorly performing countries up to the level of high performers (Preker and
others 2003). A fourth study prepared by the World Bank for the
Development Committee estimated at least US$30 billion annually in additional aid was needed to accelerate all the MDGs,
including health (Development Committee 2003).Whatever the
method of analysis, all global estimates show that reaching the
MDGs will require significant additional resources compared
with the current levels of funding for health.
Cost of Achieving the MDGs in Countries
Global estimates of what it costs to achieve the health MDGs
are not very useful for countries wanting to plan and budget in
order to reach the MDGs. The substantial range of estimates
between US$20 billion and US$75 billion per year to achieve
the MDGs at a global level has led to debates over the most
appropriate costing method for country-specific analysis and
to the development of new costing methodologies for obtaining consistent and reliable estimates to use for policy dialogue
and decision making at the country levels. Some of the methods are summarized in box 9.2.
Preliminary Country Cost Estimates. Table 9.2 provides a
set of preliminary country-level estimates for the cost of
removing bottlenecks and accelerating progress toward the
health MDGs (MBB method) and for the cost of achieving
the health MDGs (Millennium Project tools) in selected
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countries. The estimates are presented for illustration of
orders of magnitude and should not be used for intercountry
comparison.
Encouraging Risk Pooling Rather Than Out-of-Pocket
Spending. Health spending can be broken down into three
categories:
Financing Extra Health Spending
The additional resources needed to reach the MDGs are large
at both country and global levels, as discussed in the previous
section. The key question is how to finance the extra spending
that is needed.
• private (out-of-pocket expenditures and private insurance)
• public (financing from general revenues and social insurance contributions)
• external sources (development assistance).
Box 9.2
Estimating the Cost of Scaling Up to Achieve the MDGs
The following are the country-specific models for MDG
cost analysis:
• The MDG Needs Assessments Model developed by the
United Nations Millennium Project, (Millennium
Project 2004). The Millennium Project model yields
total cost estimates for full coverage of the needs of a
defined population with a comprehensive set of health
interventions in a given year. It uses unit cost of covering one person multiplied by the total population in
need in a given year to yield the direct health cost.
Additional resource requirements are added (on the
basis of assumptions rather than actual inputs) for,
among other items, health system improvement, salary
increases for human resources, administration and
management, promotion of community demand, and
research and development.
• The Marginal Budgeting for Bottlenecks Model developed by the United Nations Children’s Fund, the World
Bank, and the World Health Organization (Soucat and
others 2002, 2004; UNICEF and World Bank 2003). The
MBB model yields additional resources required for
removing a set of health system bottlenecks that are
considered to hinder the delivery of health services to
the population through three delivery modes: familycommunity, outreach, and clinical levels. The MBB
method also estimates the effect on outcomes (for
instance, child and maternal mortality) of increased
coverage and use of the health services provided. First, a
set of high-impact services are selected on the basis of a
country’s epidemiological needs. These services are the
same as those cost-effective priority interventions identified in the relevant disease control priorities chapters.
Second, health system bottlenecks hindering delivery of
these services are identified. Then, strategies for
removal of bottlenecks are discussed, and the inputs are
identified for improving coverage, for example, in a village. Cost estimates are based on these inputs by scaling
up the cost to cover the district, province, or nation.
• Elasticity estimates through econometric modeling developed by the World Bank staff (Wagstaff and Claeson
2004). A few studies have used econometric techniques
to analyze the effect on MDG outcomes of certain crosssector determinants (such as economic growth, water
and sanitation, education, and road infrastructure) as
well as government expenditures on health. Econometric analysis has been used mostly to analyze the
effect of changes in government health expenditures on
outcomes using cross-sectional or panel data at a global
scale. But in one particular study in India, the methodology was used to estimate the marginal costs of averting a child’s death at the state level. The estimates could
vary from as low as US$2.40 per child death in a lowincome state to US$160 in a middle-income state in
India.
• The Maquette for Multisectoral Analysis of MDGs is
under development by the World Bank (Bourguignon
and others 2004). The thesis for this new approach is
that development aid is a key ingredient of a country’s
development process, but its effectiveness has to be
assessed at the country level within each country’s local
implementation and macroeconomic constraints. The
objective of the model is to calculate the financial needs
to attain a targeted path to 2015 and determine an optimal allocation of additional funding toward different
social sectors for the MDGs. This modeling framework
is still at an early stage of development and will be
applied later to countries. This model is anticipated to
draw extensively from results of other models, such as
the elasticity analysis and MBB models.
Source: Millennium Project 2003, 2004; Soucat and others 2004; Bourguignon and others 2004.
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Table 9.2 Alternative Cost Estimates Using Millennium Project and Marginal Budgeting for Bottlenecks Models
Country
Model used
Cost estimate (US$ per capita per year)
Ethiopia
MBB
3.56
Madagascar (Toamasina)
MBB
2.38
Mali (one region)
MBB
3.97
Millennium Project
32.00
Bangladesh
Millennium Project
20.60
Cambodia
Millennium Project
22.50
Ghana
Millennium Project
24.70
Tanzania
Millennium Project
34.70
Uganda
Millennium Project
32.10
Source: Authors.
Private spending absorbs a larger share of income in poorer
countries. In low-income countries, it absorbs a larger share of
GDP, on average, than domestically financed public spending.
In low-income and lower-middle-income countries, it invariably means out-of-pocket expenditures rather than private
insurance (Musgrove, Zeramdini, and Carrin 2002). This situation leaves many near-poor households heavily exposed to the
risk of impoverishing health expenses. The risk is clearly
greater the poorer the country, because poorer countries tend,
on average, to have larger shares of poor people (World Bank
2000). Governments thus have a major role to play in helping
shape effective risk-pooling mechanisms, in addition to
increasing their own spending and targeting it to services for
the poor that will have a large positive effect on the MDGs.
Getting Governments to Spend What They Can Afford
Government spending is an important part of the picture, and
the issue is how much they can afford. Unlike private spending,
government spending as a share of GDP is higher in richer
countries. However, at any given per capita income, a surprising amount of variation occurs across countries in the share of
GDP allocated to government health programs. Countries that
appear able to spend similar shares of GDP on government
health programs end up spending quite different amounts.
How can extra domestic resources be mobilized if countries
are spending less than they can afford? Domestically financed
government health spending comes from general revenues,
social insurance contributions, or both. The amount of general
revenues flowing into the health sector is the product of the
amount of general (tax and nontax) revenues collected by
the government (the general revenue share) and the share of
general revenues allocated to the health sector (the health share
of government spending) (Hay 2003). Low government health
spending could be attributable to either share or both shares
being low. In poorer countries, both shares are typically lower
than they are in richer countries. However, differences exist
across countries that cannot be explained by per capita income
alone.
Countries need to ascertain whether their low spending
is caused by unduly low general revenues or by unduly low
allocations to health and explore ways of making appropriate
adjustments. Bolivia managed to raise its general revenue share
consistently in the 1990s as the result of a sustained reform
process begun in 1983. The health sector there has been one of
the beneficiaries of this growth of tax revenues: government
health spending as a share of GDP grew at an annual rate of
nearly 10 percent in the 1990s.
Although raising domestic resources takes time, countries
that can apparently afford to spend more out of their own
resources should be encouraged to start the process.
Development agencies have a role here—in providing technical
support of tax reform, in helping develop government commitment to health in public expenditure allocations, and in
giving financial assistance, both to ease the adjustment costs
and to provide support while the gap is being closed between
current and affordable spending.
Recognizing the Limits of Development Assistance. Official
development assistance tends to account for a larger share of
government health spending in poorer countries. Development
assistance for health is especially important in Sub-Saharan
Africa. Twelve countries in Sub-Saharan Africa had external
funding exceeding 35 percent of total health expenditures in
2000 (World Bank 1998).
Increased development assistance is needed to achieve the
MDGs. Development assistance, however, is not without its
drawbacks. Many donors require that assistance be kept in
parallel budgets outside the ministry of finance, which risks
undermining government efforts to appropriately plan and
target expenditures. Such off-budget expenditures make it
difficult in some countries to properly target resources to
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particular interventions, geographic locations, or population
groups, even though such targeting may be essential for
improving the effect of expenditures on outcomes and the
probability of reaching the health goals. Donors often require
recipient governments to maintain separate accounts and to
provide separate progress reports, thereby increasing the
administrative burden on weak health ministries. Most important, donor commitments of expenditures in health are short
term, whereas the needs are permanent. Thus, any external
financing must at some point be substituted with additional
domestic revenues or expenditure reallocations. This substitution or transition to domestic sources of funding has typically
been difficult to achieve, leading to a dropoff in effort in
important health programs, such as immunizations and reproductive health services.
Consensus on how to improve aid effectiveness is growing among development partners, and partners at the High
Level Forum on Health MDGs (http://www.hlfhealthmdgs.
org). This agenda includes supporting countries in developing
more MDG-responsive Poverty Reduction Strategy Papers,
tracking resource flows, strengthening monitoring and evaluation, and more effectively dealing with the human resources
crisis in health. Effective monitoring can help ensure that
increased external funds do not simply lead to reduced domestic financing (the fungibility problem) but actually boost overall
spending for health. In concert with moves affecting all development assistance, donors and governments are trying to see
that in the health area external funds are pooled and that ministries can use a common management and reporting format.
In addition, a research agenda to support acceleration toward
the health MDGs is being proposed; it needs to focus on how
to translate knowledge into action and on how to remove
health systems constraints to scaling up coverage of costeffective interventions that are available but do not reach those
who need them (Claeson and others 2004; Task Force on
Health Systems Research 2004).
Bourguignon, F., M. Bussolo, H. Lofgren, H. Timmer, and D. van der
Mensbrugghe. 2004. “Towards Achieving the Millennium
Development Goals in Ethiopia: An Economywide Analysis of
Alternative Scenarios.” World Bank, Washington, DC.
Claeson, M., C. Griffin, T. Johnston, M. McLachan, A. Soucat, A. Wagstaff,
and A. Yazbeck 2001. “Poverty-Reduction and the Health-Sector.” In
Poverty Reduction Strategy Sourcebook. Washington, DC: World Bank.
Claeson, M., A. Wagstaff, E. Bos, P. Hay, and J. Baudouy. 2004. “The Case
for Mobilizing New Research behind the Health Millennium
Development Goals.” In Global Forum Update on Research for Health
2005, 73–75. Geneva: Global Forum.
Commission on Macroeconomics and Health. 2001. “Macroeconomics
and Health: Investing in Health for Economic Development—Report
of the Commission on Macroeconomics and Health.” December 20,
World Health Organization, Geneva.
Cotlear, D. 1999. “Peru: Improving Health Care for the Poor.” Human
Development Department (Latin America and the Caribbean Human
Development) Paper 57, World Bank, Washington, DC.
Development Committee. 2003. “Supporting Sound Policies with
Adequate and Appropriate Financing.” Discussion paper, World Bank,
Washington DC.
Eichler, R. 2001. “Improving Immunization Coverage in an Innovative
Primary Health Care Delivery Model: Lessons from Burkina Faso’s
Bottom up Planning, Oversight, and Resource Control Approach That
Holds Providers Accountable for Results.” Discussion paper, World
Bank, Washington, DC.
Eissen, E., D. Efenne, and K. Sabitu. 1997. “Community Loan Funds and
Transport Services for Obstetric Emergencies in Northern Nigeria.”
International Journal of Gynecology and Obstetrics 59 (Suppl. 2):
S237–44).
Esrey, S. A., J. B. Potash, L. Roberts, and C. Shiff. 1991. “Effects of Improved
Water Supply and Sanitation on Ascariasis, Diarrhea, Dracunculiasis,
Hookworm Infection, Schistosomiasis, and Trachoma.” Bulletin of the
World Health Organization 69 (5): 609–21.
FAO (Food and Agriculture Organization of the United Nations). 2000.
The State of Food Security in the World. Rome: FAO.
Fiedler, J. L. 1996.“The Privatization of Health Care in Three Latin American
Social Security Systems.” Health Policy and Planning 11 (4): 406–17.
Filmer, D., and L. Pritchett. 1999.“The Impact of Public Spending on Health:
Does Money Matter?” Social Science and Medicine 49, pp. 1309–23.
Gwatkin, D., S. Rutstein, K. Johnson, and R. P. Pande. 2000. Socio-economic
Differences in Health, Nutrition, and Population. Washington, DC:
World Bank.
NOTE
Hay, R. 2003. “The ‘Fiscal Space’ for Publicly Financed Health Care.”
Oxford Policy Institute Policy Brief, Washington, DC.
1. Intervention in this chapter refers to the direct action that leads to
prevention or cure.
Johnson-Welch, C. 1999. “Focusing on Women Works: Research on
Improving Micronutrient Status through Food-Based Interventions.”
International Center for Research on Women, Washington, DC.
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194 | Disease Control Priorities in Developing Countries | Adam Wagstaff, Mariam Claeson, Robert M. Hecht, and others
©2006 The International Bank for Reconstruction and Development / The World Bank
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Chapter 11
Fiscal Policies for Health Promotion
and Disease Prevention
Rachel Nugent and Felicia Knaul
Governments use fiscal policy to encourage healthy behavior.
The instruments of government for this purpose are taxes and
subsidies, and direct provision of certain health services for free
or at subsidized rates. Examples of fiscal policies for health are
taxes on tobacco and alcohol, subsidies on certain foods, and
tax incentives for health care purchases.
Government intervention through fiscal policy works best
when public institutions and credibility are strong, the design
and application of the fiscal instruments are appropriate, and
consumers’ and producers’ responsiveness to a price signal is
high. When these conditions are not present, direct provision,
information and education campaigns, or legislation may be
preferable in conjunction with fiscal policy.
The purpose of this chapter is to review country experiences
with promoting health through fiscal policies and to examine
the usefulness and success of these policies. The chapter considers both the role of fiscal policies in the production of health and
the effect of these policies on the well-being of the economy—
fiscal policy for health and healthy fiscal policy.1 Little exists in
the literature linking fiscal policy and health promotion except
in relation to tobacco. This work contributes to filling that gap.
The chapter deals specifically with experiences at the country level with tax policies affecting some goods related to
health, such as food, tobacco, alcohol, and condoms; subsidized
provision of workplace promotion of healthy behavior and
caregiving; and direct subsidies affecting food provision and
fortification, cooking fuels, water purification and soap, condoms, bednets, vaccines, and medical research. The chapter
only touches on health care provision and does not discuss its
financing, either directly by governments or through insurance, because other chapters deal with those topics.
The chapter is divided into five sections:
• The first section provides a general framework through
which fiscal policy options can be considered in terms of
their impact on health and the health sector.
• The next section examines the experiences in developing
countries of using subsidies to achieve health-related objectives (columns 1 and 2 in table 11.1).
• The third section presents examples of how taxes are used
in a number of countries to promote health (column 3 in
table 11.1).
• The next section discusses nonhealth goods where fiscal
policies are often used and have important indirect health
benefits (lower part of column 2 in table 11.1).
• The final section presents conclusions and suggestions for
further research and policy development.
USE OF FISCAL POLICY FOR HEALTH
IN DEVELOPING COUNTRIES
Fiscal policies come in a wide range of designs, but the main
effect is either to alter the price of health-related goods or to
alter the quantity available. Table 11.2 summarizes the health
interventions subject to fiscal policies. The behaviors that
require these interventions are divided into the following
categories:
• unhealthy consumption (foods, tobacco, and alcohol), for
which the most salient fiscal policies are taxes on consumers
and producers, and fines
211
©2006 The International Bank for Reconstruction and Development / The World Bank
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Table 11.1 Fiscal Policies for Health Promotion Covered in Chapter 11
Subsidy
for or tax
imposed on
Health-related
products receiving
direct subsidies
Subsidized
provision
of health
Health-related
products directly
taxed
Government
financing of
health care
Consumer
Medicine
Caregiving (partially covered)
Tobacco
Not covered
Food
Alcohol
Cooking fuel
Food
Water purification
Imported medicine and supplies
Soap
Condoms
Bednets
Producer
Vaccinations
Food additives
Workplace promotion of healthy
behavior (partially covered)
Fuel usage (partially covered)
Medical research
Source: Authors.
• health promotion and disease and accident prevention
(hygiene, pollution, safety, public health, maternal and child
and reproductive health, infectious disease, and healthy
lifestyles), for which the most important fiscal instruments
are subsidies, but which may also be affected by tax policy
• health care goods and inputs, including insurance and
human resources, that may be exempted from taxation,
subsidized, or guaranteed as a constitutional right
• other goods that indirectly promote health (education,
housing, agriculture, energy, charitable giving, charities that
provide targeted subsidies, and so on), which are often subject to their own particular tax regime or sets of subsidies
that affect their production or consumption and, therefore,
also affect health behavior
• research and development initiatives that can be applied to
health and health care goods and are sensitive to tax exemptions and subsidies.
Fiscal interventions can have various rationales, such as
macroeconomic benefits, equity, or efficiency—and promoting
health may or may not be the primary goal. A fiscal policy may
be designed to affect some other sphere of behavior or a good
other than health—for instance, education—and the effects on
health or the use of health care may be indirect. The shaded
boxes in table 11.3 indicate the possible rationale behind each
type of fiscal policy.
A fiscal policy should be effective, efficient, and costeffective and should promote or maintain equity goals. An
effective tax or subsidy reaches the intended target and alters
health-related behavior in the desired manner. An efficient
policy minimizes resource distortions and involves minimal
administrative costs. A cost-effective policy has the lowest cost
relative to the desired health goal.
SUBSIDIES FOR HEALTH AND
HEALTH-RELATED PRODUCTS
Using examples primarily from developing countries, this section of the chapter analyzes the range of subsidies that are
available to promote healthy behavior and the consumption of
health-related goods. The first sections deal with consumer
subsidies both to promote the consumption of healthproducing goods and of health care. The second section discusses producer subsidies.
Consumer Subsidies
Governments use consumer subsidies to encourage the use of a
beneficial product by lowering the price consumers pay—
usually in situations where the consumers are too poor, the
market prices of the good are too high, or both situations
apply—to otherwise achieve a socially optimal consumption
level. Examples include subsidies for staple foods, condoms,
soap, insecticide-treated bednets, cooking fuels, and medicines.
Staple Foods. Ample evidence indicates that food subsidies
are effective in improving nutrition; however, appropriate targeting is often a problem (Alderman 2002). Subsidies may be
targeted to specific foods, specific delivery locales or geographic areas, or specific populations. Often targeting includes
all three.
Food-specific subsidies, whether in the form of general
subsidies, ration cards, quotas, or food stamps, increase food
consumption. They will have a positive effect on health if this
consumption occurs in undernourished populations that
require increased caloric or nutrient intake. In some cases, food
subsidy programs have had unintended macroeconomic and
212 | Disease Control Priorities in Developing Countries | Rachel Nugent and Felicia Knaul
©2006 The International Bank for Reconstruction and Development / The World Bank
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Table 11.2 Use of Taxes and Subsidies to Promote Health by Type of Intervention
Tax
preferences
Taxes
Intervention
Payroll
Consumer
(sales and
value
added tax)
Excise
Production
Input
Fines
Credits and
exemptions
Subsidies
Directorsubsidized
provision
Subcontract
provision
Targeted
consumer
subsidies
Producers
Rights
Foods
Alcohol
Tobacco
Health promotion and disease and accident prevention
Hygiene (soap)
Pollution (for example, fuels)
Safety (for example,
seat belts)
Public health (vaccines,
clean water,
supplementation,
education, and information)
Fiscal Policies for Health Promotion and Disease Prevention | 213
©2006 The International Bank for Reconstruction and Development / The World Bank
17
Unhealthy consumption
Child, maternal, and
reproductive health
(information and
education,
supplementation, and
medical attention)
Infectious disease
(condoms and healthy
workplaces)
Healthy lifestyles
(food, exercise, and
healthy workplaces)
(Continues on the following page.)
©2006 The International Bank for Reconstruction and Development / The World Bank
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214 | Disease Control Priorities in Developing Countries | Rachel Nugent and Felicia Knaul
Table 11.2 Continued
Tax
preferences
Taxes
Intervention
Payroll
Consumer
(sales and
value
added tax)
Health care goods
Insurance
Medical attention
Medicines
Human resources for
health
Other goods that indirectly promote health
Personal leave
Caregiving and family leave
(maternity, paternity, and
chronic illness)
Education (for mothers or
women, early childhood, or
special needs)
Housing (provision, flooring,
and roofing)
Agriculture (type of products
produced or imported)
Energy (types of fuels,
heating, cars, and gasoline)
Charitable giving
Research and development
Source: Authors.
Note: Shaded boxes indicate possible fiscal policies for each type of intervention.
Excise
Production
Input
Fines
Credits and
exemptions
Subsidies
Directorsubsidized
provision
Subcontract
provision
Targeted
consumer
subsidies
Producers
Rights
Table 11.3 Taxes and Subsidies by Policy Rationale
Rationale
Policy
Healthy behavior
Payroll
Consumer (value added tax/sales)
Levy
Excise
Producer
Input
Fines
Subsidies
Tax credits
Direct provision
Fiscal Policies for Health Promotion and Disease Prevention | 215
©2006 The International Bank for Reconstruction and Development / The World Bank
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Taxes
Subsidized provision
Subcontracted provision
Targeted subsidies
Subsidies to producers
Rights
Tax exemptions
Source: Authors.
Note: The shaded boxes indicate the possible rationale behind each type of fiscal policy.
Macroeconomic or
fiscal benefits
Equity
Efficiency
Promotion of another
good or type of behavior
microeconomic consequences (Adams 2000; del Ninno and
Dorosh 2002; Pinstrup-Anderson 1988; Siamwalla 1988). They
become expensive if they are too widely available, can create
incentives for black market activities, and can affect prices and
volumes in agricultural and trade markets.
Indonesia switched from a general rice support system to a
limited subsidy during the 1997 macroeconomic crisis. The
earlier system had successfully reduced food insecurity to low
levels, but higher prices increased the cost of maintaining the
subsidy and led to food being smuggled out of the country
(Tabor and Sawit 2001). The government targeted the new rice
subsidy to the poor and issued ration cards. Within roughly a
year of implementation, the subsidy was reaching an estimated
85 percent of the poor. Only about 10 percent of the subsidy
appeared to be reaching nontarget population groups.
India has subsidized essential consumer goods for decades,
including health-related goods such as food grains, edible oils,
sugar, and fuels (S. Jha 1992). The government rationed certain
goods in the belief that only the truly needy would endure
waiting in lines and purchasing the poorer quality products
that were involved in the subsidy schemes. This is called selftargeting. However, Jha shows that 40 percent of the population
purchased subsidized rice in 1990, only half of whom were
poor. The government recently modified the program to better
target the subsidy to the poor and removed such barriers as
bulk purchasing (Rao 2000).
The Arab Republic of Egypt’s generalized program also illustrates the problems that beset broad food subsidy programs.
The program reached its zenith in 1980, when it subsidized 20
food products and accounted for 15 percent of government
expenditures (Adams 2000). The program has been scaled back
to cover four staple foods and now accounts for 6 percent of
government expenditures. Nevertheless, about 75 percent of
the population holds ration cards entitling them to purchase
the subsidized foods. The program is intended to achieve selftargeting, but the nonpoor purchase many of the subsidized
foods. The program accounts for 44 percent of the total calorie
supply of the poorest quintile group, but in rural areas, the rich
obtain more calories from subsidized food than the poor do.
Musgrove (1993) reviews 104 supplementary feeding programs in 19 countries in Latin America and the Caribbean. The
review covers a range of program sizes, from those serving
1,000 individuals to those supplying 28 million people; of types
of subsidies (namely, food distribution, direct feeding, and
direct payments); of levels of coverage of the targeted population, ranging from 1.9 to 100.0 percent; and of extent of
coverage of the poor, varying from 5.8 to 88.0 percent. The per
capita costs of reaching beneficiaries differed widely. The most
common reasons for program ineffectiveness were spreading
resources too thinly across beneficiaries, targeting foods with
minor health benefits, choosing inappropriate beneficiaries,
and encountering excessive costs in distributing resources.
These kinds of issues underscore the importance of design
considerations and country conditions in creating effective and
efficient food subsidy programs.
In sum, many food subsidy programs avoid the political and
administrative challenges of explicit targeting by allowing universal access to the subsidies on the assumption that the needy
will self-select into the programs. However, Adams (2000)
shows that countries with targeted food programs—for example, Chile, Jamaica, and Peru—provide much higher income
transfers to the poor than do self-targeted programs of the kind
used in Egypt, Morocco, and Tunisia.
Condoms. Preliminary investigation indicates that subsidies
on condoms can be effective in increasing their use in both
general and high-risk populations, but whether price reduction, increased access, or education leads to greater use is not
clear (Price 2001) because information campaigns about the
health benefits of condoms usually accompany price subsidies.
Recent surges in social-marketing schemes to distribute condoms as part of the fight against HIV/AIDS, especially in
Africa, have increased condom use.2
Few researchers have compared HIV infection rates—or
even condom use rates—before and after the introduction of a
subsidy on condoms. Cohen and others (1999) conclude that in
a particular jurisdiction in Louisiana, free distribution through
public clinics and 1,000 small businesses in areas with high levels of HIV and other sexually transmitted diseases achieved
significantly higher condom distribution than a fee-based system (77 percent use during the last sexual encounter compared
with 64 percent) and that the revenues from cost recovery were
insufficient to justify imposition of the fee. The dropoff in
condom use during the cost-recovery period persuaded the
jurisdiction to reinstate the free distribution program.
Another example suggests that promotion and information
are also effective. A social-marketing effort in Turkey in the
early 1990s offered condoms at a commercial price but
included intensive advertising and other promotional efforts. It
achieved sales well beyond original expectations and gained
41 percent of the market share (Yaser 1993).
Water Purification. The U.S. Centers for Disease Control and
Prevention and the Pan American Health Organization
designed the Safe Water System Initiative to improve the quality of drinking water for households that draw their water from
sources outside the home. The principle underlying the initiative is to subsidize storage containers, disinfectant, and education on proper handling to avoid contamination (Quick and
others 1999). Numerous countries have implemented similar
initiatives, including Bangladesh, Bolivia, Burkina Faso, Kenya,
and Zambia. The government provides containers and chemicals at subsidized prices, but the costs are still higher than the
cost of boiling water (Quick and others 2002).
216 | Disease Control Priorities in Developing Countries | Rachel Nugent and Felicia Knaul
©2006 The International Bank for Reconstruction and Development / The World Bank
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Soap. Another proven method for reducing the incidence of
diarrhea and other hygiene-related diseases is hand washing,
with or without soap. Whether the key factor is education or
the subsidized provision of soap is unclear. Some investigators
claim that small-scale programs that subsidize soap and educate households about the benefits of hand washing are selffinancing because of the consequent reduction in disease
(Borghi and others 2002).
Luby and others’ (2001) results from Pakistan suggest that
education alone may be just as effective as education accompanied by soap provision in reducing diarrheal disease. By contrast, Hoque (2003) and other researchers suggest that the cost
of soap is a barrier to its widespread use among extremely poor
populations and that behavioral change may be difficult to
achieve without a subsidy.
Insecticide-Treated Bednets. The degree of subsidization of
bednets has become a controversial issue, with some arguing
for full subsidization and others for partial subsidization. Most
long-term studies indicate that consumers resist purchasing
bednets even at subsidized prices after they have had access to
free bednets (Snow and others 1999).
A number of researchers have undertaken studies in various
locations in Africa to assess the effect of selling bednets rather
than providing them free to vulnerable populations
(Armstrong-Schellenberg and others 2001; Kolaczinski and
others 2004; Snow and others 1999). The key issue is consumers’ responsiveness to changes in the prices of bednets,
through either subsidies or a reduction in taxes and tariffs.
Many households do not own a bednet because they cannot
afford it, while other reasons are lack of information, poor
access to markets, and cultural preferences (Hanson and
Worrall 2002; Simon and others 2002). The evidence suggests
that responsiveness to price changes alone may be modest, but
in combination with removing some of the other barriers,
demand for bednets could increase substantially in malariaaffected regions (Simon and others 2002).
Nigeria removed tariffs and taxes on bednet insecticide in
2001, and the 18 percent price drop resulted in an estimated 9
to 27 percent increase in purchases (Simon and others 2002).
Another study that reviewed a public sector subsidy for bednets
combined with private sector marketing and distribution by
means of a social-marketing scheme concluded that the program was successful because 18 percent of children slept under
bednets as a result; however, the low insecticide retreatment
rate led the authors to conclude that subsidies were needed on
both bednets and insecticide (Armstrong-Schellenberg and
others 2001).
Clean Cooking Fuels. High rates of respiratory illness occur as
a result of exposure to smoke and particle emissions from biomass burning in many developing countries. Fuel subsidy pro-
grams have been designed to promote the use of liquid petroleum gas, natural gas, or kerosene, which burn more cleanly
and emit a low amount of smoke and particulates, but none has
been efficacious or efficient (UNDP 2003).
Liquid petroleum gas subsidies have been shown to benefit
middle- and higher-income families in urban areas rather than
the poor (UNDP 2003). In attempting to target the poor more
accurately, Côte d’Ivoire and Senegal focused subsidies on
smaller liquid petroleum gas cylinders but found that poor
consumers still preferred charcoal (UNDP 2003). Electricity
subsidies in low-income countries are also often skewed toward
the well off, who are more likely than the poor to be connected
to the electricity grid (Alderman 2002).
Medicines and Medical Supplies. In relation to the direct provision of health-related goods, including drugs, supplies, and
services of medical personnel, governments may subsidize and
regulate drug prices, make bulk purchases from manufacturers
for distribution at reduced prices, and distribute certain drugs
with complete or partial subsidies to target populations.
Specific interventions—for instance, antiretrovirals, vaccines,
or reproductive health care—are often more heavily subsidized
or may be targeted by population group or disease—for example, child and maternal health, tuberculosis, and malaria. With
the exception of antiretroviral drugs, the health benefits and
low costs of these medicinal interventions make them good
targets for subsidization.
General Health Care. In developing countries, where informal
sectors tend to be large, providing subsidized health care is an
important tool for health promotion. Some countries have
chosen direct provision of health goods, whereas others combine the public provision of services with subsidized health
insurance for families below a certain income cutoff. Both
models require identifying the families that are unable to afford
health care and the types of services that are considered public
goods.
One example of subsidizing the production and provision
of health care is the Mexican program originally called
PROGRESA and now known as Oportunidades. This program
is also an example of how income transfers for other goods
can affect health and how cross-subsidies can be used to
strengthen the incentive effects of a fiscal policy to promote
healthy behavior. The government launched the program in
1997 to provide subsidized health, nutrition, and education to
poor families. By mid 2004, it was serving the majority of
those living below the poverty line. Oportunidades combines
a cash transfer equivalent to 20 to 30 percent of families’
incomes that includes incentives for positive behaviors in relation to health, nutrition, and schooling with subsidized basic
health interventions. The program is largely financed from
federal budgets.
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Oportunidades is successful both in terms of targeting the
poorest households and in terms of achieving measurable gains
in health, health care use, nutritional status and growth, school
attendance, and school achievement. Gertler (2004), for example, finds significant and cumulative reduction in illness rates
among children, lower prevalence of anemia, and an additional centimeter of growth in the first year of the program.
The program’s success is attributable to many factors,
including a rigorous longitudinal evaluation process; an integrated package of services; and the presence of financial stimuli
tied to school attendance, visits to health clinics, and participation in health education initiatives. Furthermore, the program
incorporates several targeting methods.
Producer Subsidies
Governments use producer subsidies to encourage production
that improves health by lowering manufacturers’ costs in situations in which the private market supply is inadequate to meet
social needs. Examples include medical supplies, vaccines, food
additives, and medical research.
Food Fortification. Governments sometimes subsidize the
fortification of staple foods through the addition of selected
micronutrients as a way of achieving broadly based nutrition
improvements. Challenges involve maintaining a relationship
between the public sector, which initiates and funds the program, and the private sector, which implements the fortification. Incentives for private providers are often needed in the
form of tax exemptions, import preferences, subsidies for startup costs, quality control, and training. Illegal markets selling
nonfortified products at a lower price often arise in response
(Alderman 2002; Dorosh, del Ninno, and Sahn 1996; Rao
2000).
Health Research. Government support for health research
consists of the provision of direct subsidies for private sector
investment, the granting of tax benefits for private research and
development (R&D) investment, the establishment of property
rights and a system to protect them, and the promotion of private goods by other means (OECD 2003). Despite the strong
evidence from developed countries that the private sector will
underinvest in R&D and that tax incentives increase R&D
investment, developing countries should be cautious in applying those results to their own situations. Empirical investigations tend to conclude that producer subsidies for R&D in
developing countries are not effective (Shah 1995; Zee, Stotsky,
and Ley 2002). Many conditions need to be in place to realize
high social returns and to minimize rent seeking and profiteering, including a strong private sector research effort that is
stimulated by the public investment, the presence of appropriate targeting, a transparent and fair set of public laws and insti-
tutions to grant and monitor the tax benefits, and the ability to
forgo alternative public investments.
TAXES AND TAX EXPENDITURES:
DESIGN AND OUTCOMES
The following section describes various examples of the use of
taxation directed at both consumers and producers. This section of the chapter also analyzes the design issues that are
important in order to guarantee that these instruments contribute to achieving healthy fiscal policy.
Taxes on Consumers
Sales taxes—including excise taxes and value added taxes—
and exemptions from those taxes are the most common fiscal
policy tools used to influence consumers’ health purchases.
Examples are exempting medicines and foods from sales tax
and imposing an excise tax on cigarettes and alcohol.
Developed countries often use income tax incentives to provide
deductions and credits for specific health care purchases.
Box 11.1 discusses issues surrounding use of taxes for health.
“Sin” Taxes on Tobacco and Alcohol. A wide range of countries and local jurisdictions have taxed tobacco, with acknowledged success in reducing consumption (P. Jha 1999). The
health benefits of curbing the demand for cigarettes may go
beyond eliminating the health consequences of smoking and
secondhand smoke if consumer expenditures are diverted from
cigarettes to healthier alternatives (for example, food).
Taxes on alcohol are widespread and are used primarily to
raise revenue. Governments typically impose taxes at the producer, wholesale, and retail levels that are levied as a percentage
of the sale price or are based on a flat amount per unit.
Harmful alcohol consumption is controlled through prohibition, government monopolization of sales, “dry” days, restrictions on hours when sales are legal, restrictions on age and
locations for sales and consumption, laws against drinking and
driving, limits to alcohol content, laws against the sale of certain types of alcohol, and licensing.
Alcohol taxes do contribute revenue to government coffers
in developing countries, generally in higher proportions than
in developed countries (WHO 2002a), but smuggling and tax
evasion are common. For example, Zimbabwe raised taxes on
certain beers in 1995 but repealed the increase within months
when tax revenues dropped significantly (WHO 2002a). Some
developing countries have lowered alcohol taxes with consequent negative results. Mauritius experienced a dramatic
increase in drunk-driving arrests, alcohol-related fatalities,
and hospital admissions after it reduced taxes on alcohol
(WHO 2002a). In sum, alcohol taxes do reduce drinking, but
the evidence that such taxes are well targeted to those most at
risk of problem drinking is not strong.
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Box 11.1
Using Taxes to Influence Consumption and Production Behavior
Taxes as a tool for health policy face significant implementation obstacles. First, targeting can be difficult. A
close link must exist between the consumption of the
product or behavior to be taxed and a specific population
with a health risk. For instance, all consumers would pay a
tax on “junk” food, even though it would only present a
health threat to a small percentage of them. The taxed
good must also be appropriately defined in relation to
close substitutes; for example, taxing only certain forms of
tobacco such as cigarettes, but not chewing tobacco, may
increase consumption of the latter. Governments may also
distinguish between locally produced goods and imported
goods, often because of lobby groups. If governments
place a higher tax on the good that is less harmful, this
action will encourage greater consumption of the more
harmful good.
Key weaknesses in using taxes for health policy include
the feasibility of smuggling and the existence of large
informal or illegal markets. Smuggled or contraband
products that cannot be regulated or certified for quality
and safety, such as alcohol or tobacco in particular, may
be more harmful to health than goods that are legally
produced and sold.
Any tax should be efficient in terms of both its administration and its effect on resource allocation. Tax authorities need a well-functioning system for imposing, collecting, and monitoring taxes and taxed products, and the
public should perceive the system as fair and credible in
order to achieve a high degree of compliance.
Finally, a tax should be cost-effective in achieving its
stated goal of improving health outcomes. The net costs of
imposing the tax should compare favorably with the net
costs of using another policy instrument, such as regulation or direct government provision. Depending on the
characteristics of the tax base, the health goal and the
revenue goal may even be at odds.
Source: Authors.
Food Taxes. The issue of taxing unhealthy foods has received
increasing attention in the wake of the Global Strategy on Diet,
Physical Activity, and Health, which was approved by member
countries of the World Health Organization (WHO 2004). The
global strategy points to the rising prevalence of obesity and
overweight in developing countries, along with that of nutrition-related noncommunicable diseases, and recommends that
countries consider fiscal policies and other measures to reduce
those problems.
Governments can use excise taxes to reduce the consumption of unhealthy foods only if tax rates are sufficient to
change consumption in a way that improves health outcomes,
if they tax enough harmful foods or food ingredients, and if
they levy the taxes in an effective manner. Guo and others’
(1999) study in China demonstrates significant potential for
price changes to affect consumption. The researchers studied
dietary intake in a sample of urban and rural Chinese households and show that a 10 percent increase in the price of pork
potentially reduces fat consumption by 8 percent. Energy and
protein intake would both drop by 2 percent. The overall
effect may be different for the poor and the rich. The potentially harmful effects on the poor of increasing the price of
pork would be buffered by substitutions from other food
groups, such as oil, wheat flour, and coarse grains, but concerns remain that overall nutrition would worsen. These
results suggest that using price changes to alter dietary intake
in a setting where overnutrition and undernutrition coexist
may have mixed outcomes.
A natural experiment in Poland during the economic downturn of the 1990s suggests a beneficial role for price policy in a
consumer switch from animal fats to vegetable fats with lower
amounts of trans fatty acids (Zatonski, McMichael, and Powles
1998). A dramatic decline in ischemic heart disease and related
circulatory system diseases during the first half of the 1990s is
most easily explained by the removal of consumer subsidies
from foods of animal origin, the aggressive marketing of margarines, and a general decline in food purchasing power. The
major change in the food supply appeared to be a reduction in
foods containing animal fats; however, no direct relationship
can be conclusively attributed without further study of the
Polish experience and the experiences of other countries
undergoing similar transitions.
Governments may choose to address food-related health
problems by taxing imports of high-fat or high-sugar food;
however, such efforts conflict with rules governing international trade. Fiji, for example, tried to ban the import of mutton flaps, an extremely fatty food that was contributing to the
country’s obesity problem. To comply with its World Trade
Organization obligations, Fiji had to ban the sale of all mutton
flaps, not just imports (Evans and others 2001). One analysis
suggests that the same kind of broad treatment would be necessary to grant subsidies to healthy foods, but taxing unhealthy
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domestic foods alone would probably not pose a problem
under World Trade Organization rules (WHO 2003). Furthermore, avenues for using other regulatory and economic
policies to improve the consumption of healthy foods may be
acceptable under the World Trade Organization Agreement on
Technical Barriers to Trade and the Agreement on Agriculture
if countries can justify them as contributing to legitimate
national health objectives.
Agricultural policies affect food prices, food choices, and
farm incomes in addition to the food security of both rural and
urban populations. Each country must assess the potential for
reorienting its agricultural policies so as to produce a healthier
food supply. Developing countries are generally more likely to
directly subsidize food consumption than food production;
however, they frequently make indirect subsidies available
through the provision of cheap fuel, chemical inputs, water,
and loans to the agriculture sector. These policies may be environmentally and fiscally costly and rarely contribute to
improved population health.
Research is needed on individual countries’ agricultural
policies and food supply needs to make them more compatible
(Nugent 2004). At the same time, the dynamics of food choice
and the effects of price manipulation need to be better understood before tax and subsidy systems can be designed to effectively promote healthy food choices.
Sales Tax Exemptions on Healthy and Staple Foods and
Medicines and Other Health Care Goods. Governments may
set tax policies to ensure that certain expenditures on healthrelated behaviors and health goods are tax deductible or tax
exempt for firms, employers, or individuals. Exemptions
should apply to a limited number of goods that are easily differentiated from goods that are not exempted. Note that in
countries with large informal sectors, income tax systems are
weak, and fiscal policies for the deductibility of credits are
unlikely to be effective.
South Africa provided value added tax exemptions for a
short list of essential foods and found a varied consumption
pattern by commodity, with the poor receiving most of the
benefits of the maize exemption, but few of the benefits of the
milk exemption (Alderman and del Ninno 1999).
Mexico imposes a 15 percent value added tax on almost all
goods. Exemptions include medicines, physician’s services, and
some foods. Recently, a government proposal to make drug and
food purchases eligible for value added tax and to channel the
resulting revenues into financing programs targeted to the
poor has given rise to extensive debate. Those in favor have
argued that the existing subsidy is regressive because most drug
and food purchases are by the wealthy (Fundación Mexicana
para la Salud 2001).
Many developing countries concerned about the spread of
HIV/AIDS have dropped import taxes on condoms, but others
continue to impose tariffs on imports. For example, Malaysia is
a major producer and imposes a 25 percent tax on imports.
Brazil used to impose both an import tax and a distribution tax
that amounted to a total of 45 percent of the original condom
price, but it granted a permanent sales tax exemption when
condom sales increased following a temporary tax holiday.
Taxes on Producers
Producer taxes are usually aimed at discouraging socially
harmful products or processes. They can be imposed either on
the use of certain inputs, such as more heavily polluting fuels,
or on their outputs, such as emissions of air pollutants.
Theoretical and simulation models have examined the use
of taxes on fuels and emissions taxes to control air pollution
(World Bank 1994a, 1994b), but empirical data are lacking.
Models of taxes suggest potential to induce substitution by
cleaner fuels and reductions in overall energy use, but actual
results will depend on the availability of fuel substitutes within
countries. Data on Chilean manufacturing support the possibility of clean fuels substitution but indicate the likelihood of
uneven sectoral incidence of the emissions tax. For example,
bakeries were responsive to changes in relative prices, whereas
metal products plants were unresponsive, and meat packers
were unable to adjust their electricity demand but could reduce
energy from other sources (World Bank 1994b). If this potential were realized on a global or regional basis—for example,
through agreements to the Kyoto Protocol—a double benefit of
reducing harmful externalities and raising significant revenues
might be achieved.
FISCAL POLICY TO PROMOTE HEALTH
The fiscal policies discussed in this chapter in relation to health
and health care goods can be applied to other goods and markets, such as housing and education, some of which may have
important effects on health. This chapter does not provide an
exhaustive discussion of the goods that indirectly promote
health, but it does briefly consider some of these policies in
relation to workplaces, employment leave policies, and day
care. Note that policies focused on formal labor markets will
not be effective in reaching large segments of the population in
many countries. Policies that provide health-related services,
such as day care, that are not based on formal labor market
participation may have a broader effect.
Workplace Health
Governments can use tax relief and financial support to producers to encourage firm-specific actions to promote health.
Many countries mandate safeguards in the workplace and
levy penalties against occupational health violations. Most
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government actions are mandates rather than fiscal policies,
but a combination of approaches may also be used.
A growing area for workplace health promotion is
HIV/AIDS. Bloom and others (2004) suggest that the failure on
the part of most firms to act—even if they correctly perceive
the business, human, and social challenges HIV/AIDS poses—
is attributable to a lack of incentives. Significant externalities
(benefits to society and firms) are likely to result from promoting greater action by firms. Some private firms have begun
providing HIV/AIDS prevention and treatment services to
employees, families, and their communities (“Face Value: AIDS
and Business” 2004). Sometimes government support is
involved, but little information is available to evaluate the
potential of fiscal policy.
Maternity Leave, Sick Leave, and Family Care Leave
Government policy can alter choices regarding different types
of worker leave. Many countries have financial or legislative
support for caregiving, although most focus on children.
Rhum (1998) cites evidence that more than 100 countries—
and almost all the industrial countries—have some legislation
about parental leave, although in several countries it is unpaid.
Caregiving policies that allow people to take time off work
to care for aged and chronically ill family members are
less common than policies for child care, particularly in developing countries, but tax benefits and allowances for these types
of caregiving are becoming increasingly available in the industrial countries (Brodsky, Habib, and Mizrahi 2000; Pijl 2003;
Wiener 2003). Although the provision of services in kind by the
government is still an important mechanism, the trend is
toward empowering consumers by offering subsidies or tax
deductions that allow them to choose among caregiving
options. Countries tend to use a combined approach to financing that relies on payroll taxes imposed on employees and
employers, general taxation, and copayments. Important issues
that developing countries need to address in this respect
include targeting compared with universal provision, the
mechanisms to pay for or to insure care, and the extent to
which long-term care should be integrated into the health care
and social service systems (Brodsky, Habib, and Mizrahi 2000;
WHO 2003).
Day Care and Early Childhood Education
Some countries use targeted fiscal policies, such as income tax
deductions or direct provision, to increase the use and quality
of early childhood education and child care services. Important
health, labor market efficiency, growth, and equity arguments
support subsidizing these services, particularly for low-income
families, because without subsidies women may be forced to
limit their work or to leave the labor market, and families
may have to use low-quality care or leave children unattended.
Van der Gaag and Tan (1997) argue for public subsidies based
on cost-benefit analysis of early childhood development programs. They conclude that the greatest payoff comes from targeting the most deprived families and that the private benefits
are sufficient to expect better-off parents to pay.
Two large-scale, home-based day care programs targeted to
poor families are Community Well-Being Homes (Hogares
Comunitarios de Bienestar) run by the Colombian Institute for
Family Well-Being (Instituto Colombiano de Bienestar
Familiar) in Colombia (Myers 1995) and the Integrated Child
Development Program in Bolivia. The former is an interesting
case of a targeted cross-subsidy because the financing comes
from the wealthier formal sector by means of a payroll tax,
whereas the services are targeted to the poorest families. The
program was 85 percent subsidized in the early 1990s. Parents
paid a proportion of the caregivers’ wages on a sliding-scale
user fee (Young 1996). The Bolivian program includes nutrition, health, and cognitive development interventions and is
one of the few early childhood programs in developing countries that has been formally evaluated (Behrman, Cheng, and
Todd 2000). The evaluation shows that the program significantly increases cognitive achievement, although the results
depend on age and the duration of exposure to the program.
CONCLUSIONS
A broad range of experiences cited in this chapter demonstrates
that fiscal and health policies interact in a number of areas.
Although substantial research has focused on tobacco and alcohol, other links—for example the promotion of health in the
workplace—have been much less recognized or studied, particularly in developing countries.
The research presented in this chapter suggests that fiscal
policy can be a useful tool for influencing health in developing
countries. Nevertheless, budgetary limitations to withstand
pressure for program expansion, leakages to unintended beneficiaries, public compliance with the tax system, and corruption
among both government officials and the public are important
factors to take into account in design and implementation.
Table 11.4 summarizes some lessons learned on the use of fiscal policy to promote health.
Governments may find it worthwhile to examine their use
of fiscal policies to identify the entire range of effects and have
health ministries participate in this exercise. More generally, the
chapter indicates an area for increased interaction between
ministries of health and finance. Healthy fiscal policy and fiscal
policy for health should be topics that are debated, agreed on,
and formalized between the two areas of policy making to
guarantee that those developing fiscal policy take both its economic and its health implications into account.
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Table 11.4 Lessons in Using Fiscal Policy for Health Promotion
Intervention choice
Program design
Instrument design
Policy regime
• Select interventions that directly
• Ensure that the health benefits of
• Choose the appropriate recipients
• Ensure that policy is consistent
address the health objective.
• Ensure that interventions are
sufficient to effect the health
change, but not excessive.
• Choose interventions with high
health returns and low costs
relative to alternatives.
the desired change are apparent
and significant.
• Make sure that the tax base is
adequate and stable and that no
untaxed close substitutes are
available.
• Be aware that a large informal
labor sector will limit the
effectiveness and equity of
benefit delivery.
• Avoid programs whose expenses
may become unsustainable
because of uncontrollable factors.
for a subsidy or tax preference.
• Do not spread the benefits across
too large a group.
• Note that targeting by demographic, geographic, or need categories is more efficient than no
targeting or self-targeting.
• Be aware of the price elasticities
of a taxed good so that its
incidence is clear.
and predictable.
• Ensure that institutions carrying
out a policy are open, accountable, and uncorrupted.
• Consider tradeoffs between efficiency and distributional goals.
• Seek non–health sector opportunities to effect health goals.
Source: Authors.
Rigorous evaluation studies are needed of most of the fiscal
policy interventions discussed in this chapter. Such studies
should address the health, fiscal, macroeconomic, and distributional effects of using fiscal policy to achieve health goals and
should be performed in a range of countries with mixed public and private sector capacity to deliver health services. The
studies should also examine the differing effects of policies in
urban and rural settings and across income quintiles. Of particularly high priority are further studies of the results of subsidizing drugs, medical supplies, and hygiene interventions
with or without education campaigns. Those areas may reveal
new fiscal approaches for addressing the disease burden in
developing countries.
DISCLAIMER AND ACKNOWLEDGMENT
The results and conclusions in this chapter are those of the
authors and do not necessarily reflect the opinions of the institutions for which they work. The authors are grateful to Ana
Mylena Aguilar, Hector Arreola, Ania Burczysnka, Esperanza
Calleja, Marissa Courey, Monica Hurtado, Vanesa Leyva,
Eugenia Rocha, Swathi Sista, and Sinaia Urrusti for excellent
research assistance and to the Mexican Health Foundation’s
Council on Health and Competitiveness and the National
Council for Science and Technology of Mexico for support for
this research.
NOTES
1. The idea of healthy fiscal policy is discussed in Cook and
Vlaisavljevich (1994), Joffe and Mindell (2004), and Secretaría de Salud
(2001).
2. Social marketing is defined as the use of marketing principles to
influence behavior for a socially desirable outcome. It provides a desirable
product at an affordable price with adequate promotion and placement
(that is, access).
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Chapter 42
Indoor Air Pollution
Nigel Bruce, Eva Rehfuess, Sumi Mehta, Guy Hutton,
and Kirk Smith
Access to modern energy sources has been described as a
“necessary, although not sufficient, requirement for economic
and social development” (IEA 2002). It is, therefore, of great
concern that almost half the world’s population still relies for
its everyday household energy needs on inefficient and highly
polluting solid fuels, mostly biomass (wood, animal dung, and
crop wastes) and coal.
The majority of households using solid fuels burn them in
open fires or simple stoves that release most of the smoke into
the home. The resulting indoor air pollution (IAP) is a major
threat to health, particularly for women and young children,
who may spend many hours close to the fire. Furthermore,
the reliance on solid fuels and inefficient stoves has other,
far-reaching consequences for health, the environment, and
economic development.
NATURE, CAUSES, AND BURDEN OF CONDITION
About 3 billion people still rely on solid fuels, 2.4 billion on
biomass, and the rest on coal, mostly in China (IEA 2002;
Smith, Mehta, and Feuz 2004). There is marked regional variation in solid fuel use, from less than 20 percent in Europe and
Central Asia to 80 percent and more in Sub-Saharan Africa and
South Asia.
This issue is inextricably linked to poverty. It is the poor
who have to make do with solid fuels and inefficient stoves, and
many are trapped in this situation: the health and economic
consequences contribute to keeping them in poverty, and their
poverty stands as a barrier to change. Where socioeconomic
circumstances improve, households generally move up the
energy ladder, carrying out more activities with fuels and
appliances that are increasingly efficient, clean, convenient, and
more expensive. The pace of progress, however, is extremely
slow, and for the poorest people in Sub-Saharan Africa and
South Asia, there is little prospect of change.
Illustrated in figures 42.1 and 42.2 are findings for Malawi
and Peru, respectively, from Demographic and Health Surveys
(ORC Macro 2004). The examples are selected from available
national studies with data on main cooking fuel use to represent the situation in poor African and South American countries. The main rural and urban cooking fuels are illustrated in
figures 42.1a and 42.2a; the findings are then broken down
nationally by level of education of the principal respondent
(woman of childbearing age) in figures 42.1b and 42.2b, and in
urban areas by her level of education in figures 42.1c and 42.2c.
Biomass is predominantly, though not exclusively, a rural
fuel: indeed, in many poor African countries, biomass is the
main fuel for close to 100 percent of rural homes. Marked
socioeconomic differences (indicated by women’s education)
exist in both urban and rural areas. During the 1990s, use of
traditional fuels (biomass) in Sub-Saharan Africa increased as
a percentage of total energy use, although in most other parts
of the world the trend has generally been the reverse (World
Bank 2002).
In many poorer countries, the increase in total energy use
accompanying economic development has occurred mainly
through increased consumption of modern fuels by better-off
minorities. In Sub-Saharan Africa, however, the relative
increase in biomass use probably reflects population growth in
rural and poor urban areas against a background of weak (or
negative) national economic growth. Reliable data on trends in
793
©2006 The International Bank for Reconstruction and Development / The World Bank
29
a. Primary household fuel use in urban and rural areas
a. Primary household fuel use in urban and rural areas
Wood, straw
Wood, straw, dung
Charcoal
Charcoal
Kerosene
Kerosene
Electricity
Electricity, gas
0
20
40
60
Percentage
Urban
80
100
0
20
Rural
40
60
Percentage
Urban
80
Rural
b. Primary household fuel use, by level of education of respondent
b. Primary household fuel use, by level of education of respondent
Wood, straw
Wood, straw, dung
Charcoal
Charcoal
Kerosene
Kerosene
Electricity
Electricity, gas
0
20
40
60
Percentage
Primary or less
80
100
0
Secondary or higher
20
40
60
Percentage
Primary or less
80
c. Primary household fuel use in urban areas, by level of education of
respondent
Wood, straw
Wood, straw, dung
Charcoal
Charcoal
Kerosene
Kerosene
Electricity
Electricity, gas
20
40
60
Percentage
Primary or less
80
100
0
Secondary or higher
20
40
60
Percentage
Primary or less
100
Secondary or higher
c. Primary household fuel use in urban areas, by level of education of
respondent
0
100
80
100
Secondary or higher
Source: Unpublished data derived from Demographic and Health Survey.
Source: Unpublished data derived from Demographic and Health Survey.
Figure 42.1 Patterns of Household Fuel Use in Malawi, 2000
Figure 42.2 Patterns of Household Fuel Use in Peru, 2000
household energy use are not available for most countries.
Information is available from India, where the percentage of
rural homes using firewood fell from 80 percent in 1993–94 to
75 percent in 1999–2000 (D’Sa and Narasimha Murthy 2004).
Nationally, liquid petroleum gas (LPG) use increased from 9 to
16 percent over the same period, with a change from 2 percent
to 5 percent in rural areas, and it is expected to reach 36 percent
nationally and 12 percent for rural homes by 2016.
International Energy Agency projections to 2030 show that,
although a reduction in residential biomass use is expected in
most developing countries, in Africa and South Asia the decline
will be small, and the population relying on biomass will
794 | Disease Control Priorities in Developing Countries | Nigel Bruce, Eva Rehfuess, Sumi Mehta, and others
©2006 The International Bank for Reconstruction and Development / The World Bank
30
increase from 2.4 billion to 2.6 billion, with more than 50 percent of residential energy consumption still derived from this
source(OECD and IEA 2004). The number of people without
access to electricity is expected to fall from 1.6 billion to 1.4 billion. Because electricity is used by poor households for lighting
and not as a cleaner substitute for cooking, electrification will
not, at least in the short to medium term, bring about
substantial reductions in IAP.
Levels of Pollution and Exposure
Biomass and coal smoke emit many health-damaging pollutants, including particulate matter (PM),1 carbon monoxide
(CO), sulfur oxides, nitrogen oxides, aldehydes, benzene, and
polyaromatic compounds (Smith 1987). These pollutants
mainly affect the lungs by causing inflammation, reduced ciliary
clearance, and impaired immune response (Bruce, PerezPadilla, and Albalak 2000). Systemic effects also result, for
example, in reduced oxygen-carrying capacity of the blood
because of carbon monoxide, which may be a cause of intrauterine growth retardation (Boy, Bruce, and Delgado 2002).
Evidence is emerging, thus far only from developed countries,
of the effects of particulates on cardiovascular disease (Pope
and others 2002, 2004).
Saksena, Thompson, and Smith (2004) have recently compiled data on several of the main pollutants associated with
various household fuels from studies of homes in a wide range
of developing countries. Concentrations of PM10, averaged
over 24-hour periods, were in the range 300 to 3,000 (or more)
micrograms per cubic meter (g/m3). Annual averages have
not been measured, but because these levels are experienced
almost every day of the year, the 24-hour concentrations can
be taken as a reasonable estimate. By comparison, the U.S.
Environmental Protection Agency’s annual air pollution standard for PM10 is 50 g/m3, one to two orders of magnitude
lower than levels seen in many homes in developing countries.
During cooking, when women and very young children spend
most time in the kitchen and near the fire, much higher levels
of PM10 have been recorded—up to 30,000 g/m3 or more.
With use of biomass, CO levels are generally not as high in
comparison, typically with 24-hour averages of up to 10 parts
per million (ppm), somewhat below the World Health
Organization (WHO) guideline level of 10 ppm for an eighthour period of exposure. Much higher levels of CO have been
recorded, however. For example, a 24-hour average of around
50 ppm was found in Kenyan Masai homes (Bruce and others
2002), and one Indian study reported carboxyhemoglobin levels similar to those for active cigarette smokers (Behera, Dash,
and Malik 1988). The health effects of chronic exposure of
young children and pregnant women to levels of CO just
below current WHO guidelines have yet to be studied.
For additional information on levels of other pollutants in
biomass and coal smoke, see Saksena, Thompson, and Smith
(2004).
Fewer studies of personal exposure have been done than of
area pollution, mainly because measurement of personal PM
typically requires wearing a pump, a cumbersome procedure.
CO can be measured more easily and has been used as a proxy:
time-weighted (for example, 24-hour average) CO correlates
well with PM if a single main biomass stove is used (Naeher
and others 2001). Time-activity and area pollution information
can also be combined to estimate personal exposure (Ezzati
and Kammen 2001). These various methods indicate that personal 24-hour PM10 exposures for cooks range from several
hundred g/m3 to more than 1,000 g/m3 (Ezzati and
Kammen 2001), with even higher exposures during cooking
(Smith 1989). Few studies have measured personal PM exposures of very young children: one study in Guatemala found
levels a little lower than those of their mothers (Naeher,
Leaderer, and Smith 2000).
Health Impacts of IAP
A systematic review of the evidence for the impact of IAP on a
wide range of health outcomes has recently been carried out
(Smith, Mehta, and Feuz 2004; see table 42.1). This review
identified three main outcomes with sufficient evidence to
include in the burden-of-disease calculations and a range of
other outcomes with as yet insufficient evidence.
Studies for the key outcomes used in the burden-of-disease
calculations—acute lower respiratory infection (ALRI),
chronic obstructive pulmonary disease (COPD), and lung
cancer—had to be primary studies (not reviews or reanalyses),
written or abstracted in English (and for lung cancer, Chinese),
that reported an odds ratio and variance (or sufficient data to
estimate them) and provided some proxy for exposure to
indoor smoke from the use of solid fuels for cooking and heating purposes.
A limitation of almost all studies has been the lack of measurement of pollution or exposure: instead, proxy measures
have been used, including the type of fuel or stove used, time
spent near the fire, and whether the child is carried on the
mother’s back during cooking. The studies do not, therefore,
provide data on the exposure-response relationship, although a
recent study from Kenya has gone some way to addressing this
omission (Ezzati and Kammen 2001).
In some countries, household fuels carry locally specific
risks. It has been estimated that more than 2 million people in
China suffer from skeletal fluorosis, in part resulting from use
of fluoride-rich coal (Ando and others 1998). Arsenic, another
contaminant of coal, is associated with an increased risk of
lung cancer in China (Finkelman, Belkin, and Zheng 1999).
There has been concern, however, that reducing smoke could
increase risk of vectorborne disease, including malaria. Some
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Table 42.1 Status of Evidence Linking Biomass Fuels and Coal with Child and Adult Health Outcomes
Health outcome
Age
Status of evidence
Sufficient evidence for burden-of-disease calculation
Acute lower respiratory infections
Children ⬍ 5 years
Chronic obstructive pulmonary disease
Adult women
Lung cancer (coal exposure)
Adult women
Chronic obstructive pulmonary disease
Adult men
Lung cancer (coal exposure)
Adult men
Strong. Some 15–20 observational studies for each condition, from developing
countries. Evidence is consistent (significantly elevated risk in most though not all
studies); the effects are sizable, plausible, and supported by evidence from outdoor
air pollution and smoking.
Moderate-I. Smaller number of studies, but consistent and plausible.
Not yet sufficient evidence for burden-of-disease calculation
Lung cancer (biomass exposure)
Adult women
Tuberculosis
Adult
Asthma
Child and adult
Cataracts
Adult
Adverse pregnancy outcomes
Perinatal
Cancer of upper aerodigestive tract
Adult
Interstitial lung disease
Adult
Ischemic heart disease
Adult
Moderate-II. Small number of studies, not all consistent (especially for asthma,
which may reflect variations in definitions and condition by age), but supported by
studies of outdoor air pollution, smoking, and laboratory animals.
Tentative. Adverse pregnancy outcomes include low birthweight and increased
perinatal mortality. One or a few studies at most for each of these conditions, not
all consistent, but some support from outdoor air pollution and passive-smoking
studies.
Several studies from developed countries have shown increased risk for exposure
to outdoor air pollution at much lower levels than IAP levels seen in developing
countries. As yet, no studies from developing countries.
Source: Smith, Mehta, and Feuz 2004.
studies have shown that biomass smoke can repel mosquitoes
and reduce biting rates (Palsson and Jaenson 1999; Paru and
others 1995; Vernede, van Meer, and Alpers 1994). Few studies
have examined the impact of smoke on malaria transmission:
one from southern Mexico found no protective effect of smoke
(adjusted odds ratio 1.06 [0.72–1.58]; Danis-Lozano and
others 1999), and another from The Gambia found that wood
smoke did not protect children in areas of moderate transmission (Snow and others 1987).
Method Used for Determining Attributable Disease Burden
Smith, Mehta, and Feuz (2004) have provided a full explanation of the calculation of the disease burden associated with
IAP. Summarized here are the methods they used to estimate
the two most critical components of these calculations: the
number of people exposed and the relative risks.
Exposure. The absence of pollution or exposure measurement in health studies required use of a binary classification:
the use or nonuse of solid fuels. The authors obtained estimates of solid fuel use for 52 countries from a range of
sources, mostly household surveys, and statistical modeling
was used for countries with no data (the majority) (Smith,
Mehta, and Feuz 2004). They assumed, conservatively, that all
countries with a 1999 per capita gross national product (GNP)
greater than US$5,000 had made a complete transition either
to electricity or cleaner liquid and gaseous fuels or to fully
ventilated solid fuel devices. To account for differences in
exposure caused by variation in the quality of stoves, they
applied a ventilation factor (VF), set from 1 for no ventilation
to 0 for complete ventilation. In China, a VF of 0.25 was used
for child health outcomes and 0.5 for adult outcomes, reflecting a period of higher exposure (to open fires) before the
widespread introduction of chimney stoves. Countries with a
1999 GNP per capita greater than US$5,000 were assigned a
VF of 0, and all other countries a value of 1, reflecting the very
low rates of use of clean fuels or effective ventilation technologies. The authors obtained the final point estimate for
exposure by multiplying the percentage of solid fuel use by the
VF. They arbitrarily assigned an uncertainty range of ⫾5 percent to the estimates.
Risk. Smith, Mehta, and Feuz (2004) carried out metaanalyses for the three health outcomes with sufficient evidence
(table 42.2). They used fixed-effects models and sensitivity
analysis that took account of potential sources of heterogeneity, including the way in which exposure was defined and
whether adjustment had been made for confounders (Smith,
Mehta, and Feuz 2004).
796 | Disease Control Priorities in Developing Countries | Nigel Bruce, Eva Rehfuess, Sumi Mehta, and others
©2006 The International Bank for Reconstruction and Development / The World Bank
32
Table 42.2 Summary of Relative Risk Estimates for Health
Outcomes Used in Burden-of-Disease Estimates
Age and
sex group
ALRI
Children ⬍ 5 years
8
2.3
1.9–2.7
COPD
Women ⬎ 30 years
8
3.2
2.3–4.8
Lung cancer
(coal)
Number of
studies
Relative
risk
95 percent
confidence
interval
Health
outcome
Men ⬎ 30 yearsa
2
1.8
1.0–3.2
Women ⬎ 30 years
9
1.9
1.1–3.5
Men ⬎ 30 years
3
1.5
1.0–2.5
Sources: Smith, Mehta, and Feuz 2004.
a. Because of the limited quantity and quality of available evidence, the male COPD relative risk
and range have been fixed to include 1.0 (no effect) as the lower estimate.
The Burden of Disease from Solid Fuel Use
Information on the proportions exposed and risk of key disease
outcomes was combined with total burden-of-disease data to
obtain the population attributable fractions associated with
IAP (WHO 2002b). Globally, solid fuels were estimated to
account for 1.6 million excess deaths annually and 2.7 percent
of disability-adjusted life years (DALYs) lost, making them the
second most important environmental cause of disease, after
contaminated water, lack of sanitation, and poor hygiene
(table 42.3). Approximately 32 percent of this burden (DALYs)
occurs in Sub-Saharan Africa, 37 percent in South Asia, and
18 percent in East Asia and the Pacific. In developing countries
with high child and adult mortality, solid fuel use is the fourth
most important risk factor behind malnutrition, unsafe sex,
and lack of water and sanitation, and it is estimated to account
for 3.7 percent of DALYs lost (WHO 2002b).
Overall, there are more female deaths but similar numbers
of male and female DALYs (table 42.3b). The reason can be
found by looking further at the health outcomes. Deaths and
DALYs from ALRI in children under five years of age are
slightly greater for males (table 42.3c). Women experience
twice the DALYs and three times the deaths from COPD (male
smoking-attributable COPD deaths excluded). Far fewer cases
of lung cancer are attributable to IAP, but women experience
about three times the burden of men.
Table 42.3 also shows how the poorest regions of the world
carry by far the greatest burden, particularly for ALRI. More
than half of all the deaths and 83 percent of DALYs lost attributable to solid fuel use occur as a result of ALRI in children
under five years of age. In high-mortality areas, such as SubSaharan Africa, these estimates indicate that approximately
30 percent of mortality and 40 percent of morbidity caused by
ALRI can be attributed to solid fuel use, as can well over half of
the deaths from COPD among women. Because they derive
from WHO risk assessments, these estimates include age
weights, such that years of life lost at very young or advanced
ages count less than years lost in the prime of adult life. Age
weighting makes little difference to the DALYs lost per death up
to age five; how much it affects the DALY cost of adult deaths
depends on the age distribution of deaths from COPD. Because
these are likely to occur at age 45 or beyond, the DALY losses are
underestimated compared with estimates without age weighting that follow the usual practice in this volume.
Other Effects of Household Energy Use
in Developing Countries
A number of other health impacts—for example, burns from
open fires—were not assessed because the burden-of-disease
assessment process allowed inclusion of only those health
effects resulting directly from pollution. Children are at risk of
burns and scalds, resulting from falling into open fires and
knocking over pots of hot liquid (Courtright, Haile, and Kohls
1993; Onuba and Udoidiok 1987). Modern fuels are not always
safe either, because children are also at risk of drinking
kerosene, which is often stored in soft drink bottles (Gupta and
others 1998; Reed and Conradie 1997; Yach 1994).
Families—mainly the women and children—can spend
many hours each week collecting biomass fuels, particularly
where environmental damage and overpopulation have made
them scarce. This time could be spent more productively on
child care and household or income-generating tasks. There are
also risks to health from carrying heavy loads and dangers from
mines, snake bites, and violence (Wickramasinghe 2001).
Inefficient stoves waste fuel, draining disposable income if fuel
is bought. Although women carry out most of the household
activities requiring fuels, they often have limited control over
how resources can be spent to change the situation (Clancy,
Skutsch, and Batchelor 2003). These conditions can combine
to restrict income generation from home-based activities that
require fuel energy (for example, processing and preparing
food for sale).
Homes that are heavily polluted and dark can hinder productivity of householders, including children doing homework
and others engaged in home-based income-generating activities
such as handicrafts. In many poor homes, lighting is obtained
from the open fire and simple kerosene wick lamps, which provide poor light and add to pollution.
Solid fuel use has important environmental consequences.
Domestic use of solid fuels in high-density rural and urban
environments contributes to outdoor air pollution. Many lowincome urban populations rely on charcoal, the production of
which can place severe stress on forests. The use of wood as fuel
can contribute to deforestation, particularly where it is combined with population pressure, poor forest management, and
clearance of land for agriculture and building timber. Damage
to forest cover can increase the distance traveled to obtain wood
and can result in the use of freshly cut (green) wood, dung, and
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Table 42.3 Deaths and DALYs Lost Because of Solid Fuel Use
a. Overall
Deaths
(thousands)
World Bank region
DALYs
(thousands)
Total
burden
(percent)
East Asia and the Pacific
540
7,087
18.4
Europe and Central Asia
21
544
1.4
26
774
2.0
118
3,572
9.3
Latin America and the Caribbean
Middle East and North Africa
South Asia
522
14,237
36.9
Sub-Saharan Africa
392
12,318
32.0
1,619
38,532
100.0
World
b. All causes, by sex
Deaths (thousands)
World Bank region
Male
Female
152
388
East Asia and the Pacific
Europe and Central Asia
Latin America and the Caribbean
Middle East and North Africa
DALYs (thousands)
All
Male
Female
All
540
3,028
4,060
7,087
9
13
21
251
293
544
12
14
26
368
405
774
57
61
118
1,849
1,724
3,572
South Asia
218
304
522
6,641
7,596
14,237
Sub-Saharan Africa
211
181
392
6,901
5,417
12,318
World
658
961
1,619
19,037
19,495
38,532
c. From ALRI (children under age five)
Deaths (thousands)
World Bank region
Male
Female
DALYs (thousands)
All
Male
Female
All
East Asia and the Pacific
40
41
81
1,502
1,535
3,036
Europe and Central Asia
7
6
13
235
204
439
8
7
15
324
281
605
51
44
95
1,794
1,571
3,365
Latin America and the Caribbean
Middle East and North Africa
South Asia
177
178
355
6,228
6,278
12,506
Sub-Saharan Africa
198
153
351
6,777
5,191
11,967
World
481
429
910
16,860
15,058
31,918
d. From COPD (men and women 30 years and over)
Deaths (thousands)
World Bank region
East Asia and the Pacific
DALYs (thousands)
Male
Female
All
Male
Female
All
105
338
443
1,461
2,430
3,891
Europe and Central Asia
2
7
9
16
89
104
Latin America and the Caribbean
4
7
11
44
125
168
Middle East and North Africa
South Asia
Sub-Saharan Africa
World
6
17
23
55
153
208
41
126
167
410
1,314
1,724
13
28
41
124
227
351
171
522
693
2,110
4,336
6,446
Source: Modified by authors to World Bank regions, from Smith, Mehta, and Feuz 2004.
798 | Disease Control Priorities in Developing Countries | Nigel Bruce, Eva Rehfuess, Sumi Mehta, and others
©2006 The International Bank for Reconstruction and Development / The World Bank
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twigs, which are more polluting and less efficient. In some urban
communities, poverty and supply problems are resulting in the
use of plastic and other wastes for household fuel (IEA 2002).
Stoves with inefficient combustion produce relatively more
products of incomplete combustion, such as methane, which
have a markedly higher global-warming potential than carbon
dioxide (Smith, Uma, and others 2000). It has, therefore, been
argued that, although the energy use and greenhouse gas emissions from homes in developing countries are small relative to
the emissions generated in industrial countries, cleaner and
more efficient energy systems could provide the double benefit
of reduced greenhouse gas emissions (with opportunities for
carbon trading) and improved health through reduced IAP
(Wang and Smith 1999).
The evidence available for assessing these effects, which
together could have a substantial influence on health and economic development, is patchy at best. This area is important
for research (Larson and Rosen 2002).
INTERVENTIONS AND POLICY
The uses of energy in the home—for example, for cooking
and keeping warm and as a focus of social activities—have
important attributes that are specific to the locality, culture,
and individual households and are often associated with
established traditions and deeply held beliefs. Encouraging the
use of cleaner and more efficient energy technologies by populations that are among the poorest in the world has not been
easy, but recent years have seen progress being made with
respect to suitable technology that meets the needs of households and with respect to the development of supportive
policy.
Poverty Reduction and the Millennium Development Goals
Given the close relationship between socioeconomic conditions and solid fuel use, poverty reduction must be a key element of policy to alleviate IAP. The United Nations
Millennium Development Goals set targets for poverty eradication, improvements in health and education, and environmental protection; they represent the accepted framework for
the world community to achieve measurable progress (United
Nations Statistics Division 2003). Although reducing IAP
can contribute to achieving a number of these goals, it is particularly relevant to reducing child mortality (Goal 4) from
ALRI.
Goal 7, Target 9, aims at integrating sustainable development into country policies and programs. The proportion of
population using solid fuels has been adopted as an indicator
for Target 9. Alleviating drudgery resulting from collecting fuel
and using inefficient stoves, together with the involvement of
women in implementing changes, can promote gender equality
and empower women (Goal 3). Household energy interventions can also contribute to eradicating extreme poverty
(Goal 1) through health improvements, time saving, and better
environments for education and facilitating income generation
(WHO 2004a).
Interventions
Although the main focus of this chapter is IAP, the many other
ways in which household energy can affect health and development emphasize why interventions should aim to achieve a
range of benefits, including the following:
• reduced levels of IAP and human exposure
• increased fuel efficiency
• reduced time spent collecting fuel and using inefficient
stoves
• reduced stress on the local environment
• increased opportunities for income generation
• contribution to an overall improvement in the quality of the
home environment—in particular, the working environment and conditions for women.
Interventions for reducing IAP can be grouped under three
headings: those acting on the source of pollution, those improving the living environment (aspects of the home), and changes
to user behaviors (table 42.4).
It should not be assumed that an intervention that reduces
IAP will necessarily achieve other aims listed previously. For
example, in colder areas, an enclosed stove with a flue that
reduces IAP may reduce radiant heat and light, forcing households to use other fuels for those purposes. If not addressed
with households, such problems may well result in disappointing reductions in IAP exposure, poor acceptance of interventions, and lack of motivation to maintain them.
Policy Instruments
Although a range of interventions is available, poor households
face many barriers to their adoption, and enabling policy is
needed (table 42.5). This area of practice is complex and evolving, often requiring solutions that are highly setting specific.
INTERVENTION COSTS AND EFFECTIVENESS
The cost-effectiveness analysis discussed in this chapter is based
on recent work by Mehta and Shahpar (2004). The key components of this analysis are described here, with particular
emphasis on the underlying assumptions.
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Table 42.4 Interventions for Reducing Exposure to IAP
Source of pollution
Living environment
User behaviors
Improved cooking devices
Improved ventilation
Reduced exposure through operation of source
• Improved biomass stoves without flues
• Hoods, fireplaces, and chimneys built into the
• Fuel drying
structure of the house
• Improved stoves with flues attached
• Windows and ventilation holes (such as in
Alternative fuel-cooker combinations
roof), which may have cowls to assist
extraction
• Briquettes and pellets
• Charcoal
Kitchen design and placement of the stove
• Kerosene
• Kitchen separate from house to reduce
• Liquid petroleum gas
exposure of family (less so for cook)
• Biogas, producer gas
• Using pot lids to conserve heat
• Properly maintaining stoves and chimneys and
other appliances
Reductions by avoiding smoke
• Keeping children away from smoke—for
example, in another room (if available and safe
to do so)
• Stove at waist height to reduce direct exposure
of cook leaning over fire
• Solar cookers (thermal)
• Other low-smoke fuels
• Electricity
Reduced need for the fire
• Insulated fireless cooker (haybox)
• Efficient housing design and construction
• Solar water heating
Source: Modified from Ballard-Tremeer and Mathee 2000.
Table 42.5 Policy Instruments for Promoting Implementation of Effective Household Energy Interventions
Policy instruments
Examples
Applications
Information,
education, and
communication
Schools
Learning about household energy, health, and development should be integrated in school curricula,
particularly in countries where these topics are a priority for health and economic development. This goal
can be achieved through programs such as the WHO Global School Health Initiative, which promotes
environmental health education, including education about IAP.
Media
Local and national radio, television, and newspapers can be used to raise awareness and disseminate
information on technologies and opportunities to support implementation, such as promotions and microcredit.
These media can be directed at a range of audiences, including decision makers, professionals, and the public
where radio is widely used.
Community education
Opportunities such as adult literacy programs can be used to raise awareness and share experience of
interventions, and innovative methods can be used (for example theater).
Tax on fuels and
appliances
Reduced tax on fuels and appliances may promote development of distribution networks and uptake, and it
may be seen as efficient if there is evidence of health, education, and economic benefits.
Subsidy on fuels and
appliances
General (for example, national) subsidies on fuels such as kerosene have been applied to promote use by poor
households. Subsidies have been found to be inefficient instruments, however, often benefiting the better off
rather than the poor. Time-limited subsidy on specific products (for example, clean fuel appliances, connection
to grid) may be a useful method for promoting initial uptake, generating demand, and thereby providing
market conditions for lower prices and more consistent quality.
Air quality standards
Although some developing countries have air quality standards for urban air, none have them for indoor air in
settings where solid fuels are widely used. Routine monitoring and enforcement is not practical, but it may
be useful to set standards and targets linked to specific assessments. For more routine use, information from
censuses and surveys, such as fuel type, stove type, and venting for smoke, offers a practical alternative for
setting air quality standards for IAP in developing countries.
Design standards for
appliances
Design standards can be applied to safety (prevention of burns, gas leaks, and explosions); venting of
emissions; and efficiency. Although such standards may be difficult to enforce in an informal economy, they
could become valuable with wider-scale production.
Public program
provision of appliances
Large-scale public provision of appliances, such as improved stoves or clean-fuel appliances, has generally
been found unsuitable. Some form of targeted provision or partial subsidy where households have made
informed choices and commit to cost sharing may be useful to stimulate demand and act in favor of equity.
Taxes and subsidies
Regulation and
legislation
Direct expenditures
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Table 42.5 Continued
Policy instruments
Research and
development
Examples
Applications
Funding of finance
schemes
Experience has shown that credit is most likely to be made available and adopted for energy applications
that contribute directly to productive, income-generating activities (such as food processing for sale).
Meeting everyday cooking and space-heating needs is seen as a lower priority. Good opportunities may exist
where biomass fuel is purchased and where cost saving combines with other valued benefits, such as
increased prestige and cleaner kitchens. Support for such schemes, mainly in the form of raising awareness,
skills training in managing funds, and seed funding (the main source of funds being from users) may be
cost-effective.
Surveys
Surveys of fuel and appliance use, knowledge of risks to health, willingness to pay for interventions,
knowledge of and confidence in credit schemes, and the like are important for planning interventions.
Development and
evaluation of
interventions
Evaluation of interventions should be conducted in a range of settings, using harmonized methods, if
possible, that allow local flexibility but permit comparison with other types of interventions and other
locations.
Studies of health
effects
Stronger and better-quantified evidence of the effects on health of reducing IAP, which includes exposure
measurement, is required not only for key outcomes such as ALRI, but also for other health outcomes for
which evidence is currently tentative.
Research capacity
development
Capacity for carrying out a wide range of research—from national and local surveys, to monitoring and
evaluation of interventions, to more complex health studies—requires strengthening in those countries
where the problems associated with household energy and IAP are most pressing.
Source: Authors.
Costs
Intervention costs have a number of components, the relative
importance of which will vary with the type of fuel and device
(box 42.1).
The level of costs incurred by consumers and others, including government, depends not only on the type of intervention
but also on how it is delivered, supplied, and adopted.
Experience indicates that successful interventions are sustainable in local markets, implying that the consumer pays the
majority of initial and recurrent costs. The contributions of
the government, utilities, nongovernmental organizations
(NGOs), and the commercial sector will depend on many factors, including the type of intervention and fuel, location
(urban or rural), existing level of supply and distribution
Box 42.1
Cost Components for Household Energy Interventions
• Fuels, which vary from zero (in direct cash terms, though
not in opportunity cost) for collected biomass to a
U.S. dollar or so per week for kerosene and several
U.S. dollars per week for electricity (where used for
cooking).
• Stove appliances, which vary from zero for a simple
three-stone fire (stones arranged on the floor to support cooking pots, with the fire lit between the
stones), to US$50 (and in some cases more than
US$100) for a good-quality woodstove with a chimney and up to several hundred U.S. dollars for a biogas installation.
Source: Authors.
• Additional appliances—for example, an LPG storage
bottle has a moderately high initial cost but should last
for many years.
• Maintenance costs, which vary from zero for a three-stone
fire up to modest, but not negligible, costs of repairing
(and periodically replacing) woodstoves and chimneys.
Appliances for using kerosene, LPG, and electricity also
require maintenance and periodic replacement.
• Program costs, which apply to various aspects of
provision of energy services, particularly LPG and electricity, but may also include costs of, for example,
establishing more sustainable biomass reserves and
administrative costs.
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Box 42.2
Cost Issues in Switching to Cleaner Fuels for a “Typical” Poor Kenyan Family
Ruth1 and her family live 3 kilometers from a small town
on the main road about one hour by bus from Kisumu.
They are subsistence farmers, with a small income from
selling vegetables, from irregular laboring work obtained
by her husband, and from making and selling handicrafts.
Ruth, a mother of five, cooks over a three-stone fire using
mostly wood, which she collects every other day from
plots up to two hours walking distance from home. She
spends 8 to 12 hours each week collecting wood. Ruth and
her family use about 2 liters of kerosene each week for
wick lamps and for cooking. They use dry cell batteries for
the radio; grid electricity runs nearby, but connection is
far too expensive. In all, the family spends an equivalent of
US$1 to US$2 per week on fuel and batteries.
Through her women’s group, Ruth hears that a few
families are using LPG, now available at a nearby petrol
station. The women say it is very quick and easy to use,
and it keeps pots, clothes, and walls clean. The women and
children seem to feel better, with less cough, runny eyes,
and headaches. But those families run small shops and
have been able to find the money to buy the gas bottle and
cooker.
She talks with her husband about LPG, and although
quite supportive, her husband thinks they cannot afford it.
They could spend a little more on fuel, but income is
irregular. Why abandon free fuel when they are so poor?
Ruth thinks she could earn more money from her handicrafts in the time she saves collecting wood. On balance,
they reckon they could probably afford the cost of the gas
if they could be sure of more regular income, but they do
not know where they could find the money to pay for the
cooker and bottle.
Ruth then learns about a revolving fund set up by her
women’s group with the help of an NGO. If she can make
small regular payments, she and her husband could get a
loan to buy the stove and gas bottle next year. But they
have never saved before, and what if they need money for
medicines or for the children at school? Will they be able
to keep saving each week to make sure they have enough
to refill the gas bottle when needed?
1. Not her real name.
Source: Authors.
networks, and support for credit (for example, seed funds and
fund capital) and targeted subsidies.
Some degree of market support may be required to stimulate demand and to encourage adoption by poor households,
particularly those using three-stone fires (and other simple
stoves) and collected biomass, because those methods do not
incur direct monetary costs. Some countries have applied subsidies on fuels such as kerosene to assist poor families, but
general subsidies are now considered to be an inefficient instrument for this purpose (von Schirnding and others 2002).
Targeted subsidy and small-scale credit may be more appropriate ways of helping poor families acquire new household
energy technologies and can have low default rates. Experience
shows, however, that households are more likely to access credit for directly productive (with regard to income) uses of
energy, rather than for everyday cooking and space-heating
needs. Because the latter are the most important sources of IAP,
more promotion of other benefits is needed, such as improved
family health; fuel cost savings; time saved by faster cooking
and reduced need for biomass; greater prestige; and cleaner
homes, clothes, and utensils. A number of these benefits may
result in reduced expenditure or increased income generation.
Box 42.2 illustrates how these various issues can influence the
decisions of a “typical” poor rural African household considering transition from gathered biomass to predominant use of a
commercial fuel (LPG).
Effectiveness
Most evidence available for assessing intervention effectiveness
deals with the effect on IAP levels and in some cases personal
exposure. No experimentally derived evidence is available,
however, on the effect of reducing IAP exposure on incidence
of ALRI or the course of COPD in adults. A randomized trial
of an improved chimney stove is currently under way in
Guatemala, focusing on ALRI in children up to 18 months of
age (Dooley 2003). A cohort study in Kenya by Ezzati and
Kammen (2001) describes significant exposure-response relationships for all acute respiratory infections—and for ALRI
specifically—associated with the use of traditional and
improved woodstoves and charcoal. However, those effect estimates require confirmation because the study has small numbers of children (93 children under age five, living in 55 homes).
For the other major health outcome, lung cancer, Lan and
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others (2002) reported adjusted hazard ratios of 0.59 (95 percent confidence interval: 0.49 to 0.71) for men and 0.54 (0.44
to 0.65) for women using improved coal stoves compared with
traditional open coal fires in a 16-year retrospective cohort
study in rural China.
Measuring evidence on reductions in pollution and exposure is nonetheless an important step in assessing effectiveness.
Summarized here are the main findings of studies that have
measured pollution levels in homes using traditional open
fires, various improved stoves, kerosene, and LPG (see also
Saksena, Thompson, and Smith 2004) and one that examined
the effect of rural electrification in South Africa (Rollin and
others 2004).
Effect of Improved Stoves. In East Africa, cheap improved
stoves without flues, burning either wood or charcoal, are popular. These wood-burning stoves can reduce kitchen pollution
by up to 50 percent, but levels still remain high (Ezzati,
Mbinda, and Kammen 2000). Charcoal emits much less PM
(but with a higher CO-to-PM ratio than wood), and stoves
such as the Kenyan jiko yield particulate levels in the region of
10 percent of those from wood fires.
In a number of Asian and Latin American countries,
improved stoves with flues have been promoted quite extensively, although many such stoves are found to be in poor condition after a few years. Some studies from India have shown
minimal or small reductions in PM (Ramakrishna 1988; Smith,
Aggarwal, and Dave 1983). Other studies, from Nepal, have
shown reductions of about two-thirds, although the very high
baseline levels mean that homes with stoves still recorded total
suspended particulate values of 1,000 to 3,000 g/m3 during
cooking (Pandey and others 1990; Reid, Smith, and Sherchand
1986). Results from Latin American countries are similar,
although the IAP levels are generally lower. Studies have shown
that plancha-type stoves (made of cement blocks, with a metal
plate and flue) reduce PM by 60 to 70 percent and by as much
as 90 percent when they are in good condition. Typical 24-hour
PM levels (PM10, PM3.5 [respirable], and PM2.5 have variously
been reported) with open fires of 1,000 to 2,000 g/m3 have
been reduced to 300 to 500 g/m3, and in some cases to less
than 100 g/m3 (Albalak and others 2001; Brauer and others
1996; Naeher, Leaderer, and Smith 2000). One study from
Mexico found little difference between homes with open fires
and with improved stoves (Riojas-Rodriguez and others 2001),
but the 16-hour levels of PM10 at about 300 g/m3 with open
fires were relatively low.
Improved stoves with flues have so far had little success in
Sub-Saharan Africa, although recent work developing hoods
with flues for highly polluted Kenyan Masai homes reported
reductions in 24-hour mean respirable PM of 75 percent from
more than 4,300 g/m3 to about 1,000 g/m3 (Bruce and
others 2002).
Personal exposures were usually found to have been reduced
proportionately less than area pollution levels. For example, in
Kenya, where hoods with flues achieved a 75 percent reduction
in 24-hour mean kitchen PM3.5 and CO, the woman’s mean
24-hour CO exposure was reduced by only 35 percent (Bruce
and others 2002). Similar results were found for child exposures in a study of improved wood stoves in Guatemala (Bruce
and others 2004). We are aware of only one study that has used
direct measurement of personal particulate exposure in very
young children (Naeher, Leaderer, and Smith 2000). This study,
also in Guatemala, reported mean 10- to 12-hour (daytime)
PM2.5 levels for children under 15 months of age of 279 g/m3
(⫹SD of 19.5) for the open fire and 170 g/m3 (⫹154) for the
plancha stoves, a 40 percent reduction.
Impact of Cleaner Fuels. Good evidence shows that kerosene
and LPG can deliver much lower levels of pollution, although it
is important to determine the extent to which the cleaner fuel
is substituting for biomass. For example, a study in rural
Guatemala comparing LPG with open fires and plancha chimney stoves found that LPG-using households typically also used
an open fire for space heating and cooking with large pots. As a
result, the plancha stoves achieved the lowest pollution levels in
that setting (Albalak and others 2001). Still, a number of studies, mainly from India, show that introducing kerosene and
LPG dramatically reduces kitchen pollution, which perhaps
reflects different cooking requirements and less need for space
heating. In rural Tamil Nadu, two-hour (mealtime) kitchen respirable PM levels of 76 g/m3 using kerosene and of 101 g/m3
using gas contrasted with levels of 1,500 to 2,000 g/m3 using
wood and animal dung (Parikh and others 2001). Personal
(cook) 24-hour exposure to respirable PM was 132 g/m3 with
the use of kerosene as opposed to 1,300 and 1,500 g/m3, respectively, with the use of wood and dung (Balakrishnan and others
2002). Other studies confirm those findings, for example, with
the use of gas in Mexico (Saatkamp,Masera,and Kammen 2000).
Delivering electricity to rural homes requires extensive infrastructure, and most poor people with access to electricity can
afford to use it only for lighting and running low-demand electrical appliances. Without marked improvements in socioeconomic conditions, electrification has little potential to bring
about substantial reductions in IAP. South Africa is one of the
few countries with a large rural population traditionally
dependent on biomass that has the resources for rural electrification. An investigation of three rural villages with similar
socioeconomic characteristics, two not electrified and one electrified, in the North West province found that 3.6 years (average) after connection to the grid, 44 percent of the electrified
homes had never used an electric cooker (Rollin and others
2004). Only 27 percent of electrified homes cooked primarily
with electricity; the remainder used a mix of electricity,
kerosene, and solid fuels. Despite the mixed fuel use, households
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cooking with electricity had the lowest pollution levels. Overall,
homes in the electrified village had significantly lower 24-hour
mean respirable PM and CO levels and significantly lower mean
24-hour CO exposure for children under 18 months of age than
homes in the nonelectrified villages.
Effect of Other Interventions. Little systematic evaluation has
been made of other interventions listed in table 42.4.
Investigation of the potential of improving ventilation has,
overall, shown that although enlarging eaves can be quite effective (Bruce and others 2002), removing smoke generally
requires a well-functioning flue or chimney. Behavioral
changes are currently the subject of an intervention study in
South Africa (Barnes and others 2004a, 2004b).
Cost-Effectiveness Analysis
Although clean fuels can be expected to have a greater health
effect than improved stoves (even those with flues), clean fuels
may be too expensive and inaccessible for many poor communities over the short to medium term. Furthermore, even
though clean fuels may be the best longer-term goal, an intermediate stage of improved biomass stoves may promote change
by raising awareness of benefits and thus creating demand by
improving health, saving time, and mitigating poverty. For
those reasons, this cost-effectiveness analysis (CEA) examines
both improved biomass stove and clean fuel options in the
following scenarios:
• access to improved stoves (stoves with flues that vent smoke
to the exterior), with coverage of 95 percent
• access to cleaner fuels (LPG or kerosene), with coverage of
95 percent
• part of the population with access to cleaner fuels (50 percent) and part with improved stoves (45 percent).
In each case, the intervention is compared with the current
level of coverage of the respective technology or fuel.
Cost Assumptions. The assumptions for costs include program costs, fixed costs (including stoves), and recurrent fuel
costs. Household costs for each region were drawn from the
most comprehensive estimates available in the literature (von
Schirnding and others 2002; Westoff and Germann 1995). For
LPG, costs include the initial price of a cooker and cylinder and
the recurrent refill costs. Assumed household annual costs, discounted at 3 percent, range from US$1 to US$10 for improved
stoves and from US$3 to US$4 for kerosene or up to US$30 for
LPG. Recurrent costs of fuel were found to be the most significant cost for the cleaner fuel interventions. Wood fuel costs are
estimated at US$0.25 per week and assumed to be the same for
traditional and improved stoves.
Costs were estimated separately for cleaner fuel and
improved stove programs, using an “ingredients” approach
(Johns, Baltussen, and Hutubessy 2003) and a costing template
developed by WHO (2003). In summary, all the ingredients—
including administrative, training, and operational costs—
necessary to set up and maintain a given program must be added
up. For regional estimates, costs of all traded goods were in U.S.
dollars, whereas nontraded (local) costs were estimated in local
currency and converted to U.S. dollars using relevant exchange
rates. All costs were annualized using a 3 percent discount
rate. Costs for tradable goods are scaled, using region-specific
standardized price multipliers to reflect the increasing costs of
expanding coverage caused by higher transportation costs to
more remote areas (Johns, Baltussen, and Hutubessy 2003).
Price multipliers were not applied to improved stoves because
they tend to be manufactured locally with mainly local materials.
Program costs were found to make up a small proportion of the
overall intervention costs. Savings from averted health care costs
are not included; because many of these cases currently go
untreated, it can be argued that including treatment costs could
result in inflated cost-effectiveness ratios (CERs).
Effectiveness and Health Outcome Assumptions. For this
analysis, cleaner fuels are assumed to remove exposure completely, whereas improved stoves are assumed to reduce exposure by 75 percent (ventilation factor of 0.25). The effect on
health of the exposure reduction will vary from region to
region, because it depends on current levels of exposure as well
as region-specific rates of morbidity and mortality. A number
of assumptions have been made about households in carrying
out analyses at the regional level. First, regional estimates of
household composition (numbers of people, by age group and
sex) and, hence, the effect of interventions on exposure and
health apply at the level of individual households. Second, the
age distribution of household members is similar in exposed
and nonexposed groups; for example, the number of children
per household is the same irrespective of household fuel use
and ventilation characteristics. That assumption is likely to be
conservative, since poorer, more polluted homes will typically
have higher fertility and more children under five; all other factors being equal, such households would therefore experience a
higher burden of disease from IAP exposure.
The health outcomes included are ALRI and COPD, because
they were responsible for nearly all of the 1.6 million deaths
attributable to IAP. The risk estimates used are those derived
from the meta-analyses, as summarized in table 42.2. Smoking
is an important confounding variable for COPD, particularly
with men, because they generally smoke more than women do
in developing countries. At present, information is sparse on the
independent effect of solid fuel use on COPD in the presence of
smoking. To avoid possible overestimation of the impact of IAP
on COPD, attributable fractions for COPD from solid fuel use
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were applied to disease burdens remaining after removal of
smoking-attributable burdens (Ezzati and Lopez 2004). Current
estimates of exposure are used in combination with estimates of
disease burden to obtain region-specific disease burdens for
exposed and unexposed populations. Regional patterns of disease for 2000 have been used, including incidence, mortality,
remission, duration, and case-fatality rate, obtained from WHO
(2004b). In contrast to the estimates of burden in table 42.3, no
age weighting has been used in the cost-effectiveness analysis.
Health impacts are discounted at 3 percent.
Implementation Period. The implementation period is
10 years, although effects have been evaluated over 100 years in
order to approximate the benefits for an entire population
cohort. Thus, health effects are calculated for a cohort with a
typical age structure for the population concerned that experiences the intervention for 10 years. It is assumed that after
100 years, all of the cohort (including children born during the
10-year implementation period) will have died.
The implementation period has critical implications, particularly in situations in which it takes several years to establish an
intervention (for example, developing local markets for cleaner fuel), in which there are high start-up costs, and in which
disease prevention is experienced in the distant future. This is
especially true for chronic health effects (for example, COPD)
that result from exposure over many years. If the intervention
is implemented and exposure reduced for only 10 years, the
disease burden is effectively deferred by 10 years, whereas
longer-term implementation would result in many more cases
being averted. For this analysis, using the 10-year intervention
scenario specified for the Disease Control Priorities Project-2,
incident cases are deferred by 10 years. For COPD, it is assumed
that reduced exposure results in a milder form of COPD,
accounted for by using a lower severity weighting.
Findings for Cost-Effectiveness Analysis. Findings from the
CEA are expressed, for the four intervention scenarios with differing coverage (50 percent, 80 percent, 95 percent), by region,
as (a) total healthy years gained in each region, (b) CERs in U.S.
dollars per healthy year gained, and (c) healthy years gained per
US$1 million (table 42.6). For all regions, the cleaner fuels yield
the greatest gain in healthy years, but improved stoves also have
a significant effect. The largest total population gains in healthy
years are in Sub-Saharan Africa and South Asia for all types of
interventions and in East Asia and the Pacific (mainly China)
for cleaner fuels.
In the two regions with the largest burden of disease attributable to solid fuel use (Sub-Saharan Africa and South Asia),
CERs are lowest (most favorable) for improved stoves,
although in both regions kerosene has CERs just over twice
those of improved stoves. In East Asia and the Pacific, kerosene
is most cost-effective, followed by improved stove and
clean fuel combinations and then by LPG (for coverage over
50 percent). In Latin America and the Caribbean, kerosene has
the most favorable CER, followed by kerosene in combination
with improved stoves. When the 50 percent and 80 percent coverage scenarios are compared, large differences in the ratio are
seen in regions where coverage for that intervention is already
substantial, and there is much less health gain at lower levels of
coverage. Where no result is given, the specified coverage of the
intervention has already been reached.
Multivariate sensitivity analysis was conducted to assess the
effect of uncertainty in cost and effectiveness estimates. Costs
were assumed to vary with a standard deviation of 5 percent,
and effectiveness by the range of the confidence interval
around the relative risk for each health endpoint. Results for
Southeast Asia are shown in figure 42.3: the “clouds,” or uncertainty regions, illustrate the range of possible point estimates
emerging from the sensitivity analysis. This example is representative because other regions show essentially similar results.
Despite the uncertainty, the ranking of the interventions
remains the same (Mehta and Shahpar 2004).
Discussion. Results of this cost-effectiveness analysis indicate
that an improved biomass stove is the most cost-effective intervention for South Asia and Sub-Saharan Africa, the two regions
with the highest solid fuel–related disease burden. This finding
is important given International Energy Agency projections to
2030, which indicate that biomass will remain the principal
household fuel for the poor in South Asia and Sub-Saharan
Africa and that actual numbers of users will increase over that
period (IEA 2002). Cleaner fuels (particularly kerosene) are the
most cost-effective options for East Asia and the Pacific, the
other region with a high burden of solid fuel–related disease.
Cleaner fuels, in particular LPG, appear relatively costly for
South Asia and Sub-Saharan Africa, but circumstances in individual countries may vary considerably and in ways that make
this fuel much more cost-effective. Sudan, for example, has
abundant cheap supplies of LPG and favorable excise arrangements for imported appliances, which would result in a lower
CER for LPG than in other countries in the region. Furthermore,
as will be discussed later, costs and benefits from the user’s perspective will differ markedly, depending on whether the starting
point is free fuel collection or purchased biomass fuel.
In interpreting the results, one should bear in mind the
assumptions underlying the CEA. Much of the evidence indicates that, although improved biomass stoves may reduce
kitchen pollution by up to 75 percent, the reduction in exposure
of women and children is typically no more than 30 to 40 percent
(equivalent to VF of 0.6 to 0.7). Achievement of the 75 percent
reduction in exposure (VF ⫽ 0.25) assumed for this analysis is
consistent only with well-designed and -maintained chimney
stoves that meet most of the cooking and heating energy needs
of the household and high population coverage (to avoid exposure from neighbors and others). Those conditions may be
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Table 42.6 Intervention Scenarios for World Bank Regions
a. Healthy years gained
Intervention
LPG
Kerosene
Improved stove
Combined (with stove)
Coverage
(percent)
SubSaharan
Africa
Latin America
and the
Caribbean
Middle East
and North
Africa
50
22,160,000
160,000
n.a.
n.a.
44,810,000
2,560,000
80
60,370,000
4,670,000
15,570,000
1,330,000
149,300,000
228,710,000
Europe and
Central Asia
South Asia
East Asia
and the
Pacific
95
75,630,000
11,260,000
22,510,000
4,810,000
184,940,000
568,640,000
50
22,160,000
160,000
n.a.
n.a.
44,810,000
2,560,000
80
60,370,000
4,670,000
15,570,000
1,330,000
149,300,000
228,710,000
95
75,630,000
11,260,000
22,520,000
4,810,000
184,940,000
568,640,000
50
18,010,000
n.a.
n.a.
n.a.
48,880,000
1,120,000
80
40,270,000
1,380,000
6,630,000
n.a.
101,670,000
6,980,000
95
51,540,000
2,600,000
11,640,000
n.a.
128,380,000
32,760,000
LPG
69,250,000
8,650,000
19,540,000
3,230,000
170,340,000
427,350,000
Kerosene
69,250,000
8,650,000
19,540,000
3,230,000
170,340,000
427,350,000
Middle East
and North
Africa
Europe and
Central Asia
South Asia
East Asia
and the
Pacific
b. Cost-effectiveness ratios (US$ per healthy year gained)
Intervention
LPG
Kerosene
Improved stove
Combined (with stove)
Coverage
(percent)
SubSaharan
Africa
Latin America
and the
Caribbean
50
715
1,405
n.a.
n.a.
542
1,695
80
518
783
756
1,221
312
115
95
518
814
762
1,321
314
100
50
84
631
n.a.
n.a.
63
225
80
60
115
95
183
36
14
95
60
106
95
167
36
12
50
25
n.a.
n.a.
n.a.
15
297
80
21
947
457
n.a.
13
587
95
20
1,101
368
n.a.
13
327
LPG
295
761
606
1,375
177
83
Kerosene
45
296
220
507
26
25
Latin America
and the
Caribbean
Middle East
and North
Africa
c. Healthy years gained per US$1 million
Intervention
LPG
Kerosene
Improved stove
Combined (with stove)
Coverage
(percent)
SubSaharan
Africa
Europe and
Central Asia
South Asia
East Asia
and the
Pacific
50
1,400
710
n.a.
n.a.
1,840
590
80
1,930
1,280
1,320
820
3,210
8,680
10,040
95
1,930
1,230
1,310
760
3,190
50
11,970
1,580
n.a.
n.a.
16,000
4,440
80
16,600
8,690
10,500
5,470
27,850
72,840
95
16,620
9,470
10,560
6,000
27,680
85,840
50
39,640
n.a.
n.a.
n.a.
67,330
3,360
80
47,940
1,060
2,190
n.a.
74,750
1,700
95
49,510
910
2,720
n.a.
76,300
3,060
LPG
3,390
1,310
1,650
5,660
5,660
12,020
Kerosene
22,250
3,380
4,550
38,590
35,590
40,730
Source: Authors.
n.a. ⫽ not applicable because the specified coverage of the intervention has already been reached.
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Average annual cost in millions of international dollars
25,000
20,000
15,000
10,000
5,000
0
0
50
100
150
200
250
Average annual gain in healthy years in millions
300
Improved stoves
Kerosene
Propane and LPG
Combination: LPG and improved stoves
Combination: kerosene and improved stoves
Source: Mehta and Shahpar 2004.
Figure 42.3 Multivariate Sensitivity Analysis for Three Types of
Interventions and Combined Intervention Scenarios, Southeast Asia
Region
achievable and should be the goal, but they are not currently
widespread. The relative cost-effectiveness advantage for
improved stoves over cleaner fuel reported here should therefore be viewed as relating more to what might be achievable
with good biomass stoves rather than to what is currently being
achieved. The assumption that kerosene and LPG are equally
clean and achieve zero exposure (VF = 0) presumes, at the very
least, the use of high-quality kerosene fuel and pressurized
burners. In many places, kerosene is of low quality, and the types
of kerosene stoves and lamps used result in poor combustion.
Cost comparisons for the various fuels also need careful
consideration. For example, the cost of solid fuel has been
assumed to be constant for traditional open fires and improved
stoves. As a general assumption this is reasonable, because the
efficiency of “improved” stoves varies, and some may even be
less fuel efficient than are open fires. However, new stove technology is markedly improving efficiency, and some designs
reduce daily fuel consumption by 40 percent or more, resulting
in savings of time (where fuel is collected) and money (where
fuel is bought) (Boy and others 2000).
Transition from biomass (collected free) or charcoal (typically paid for daily in small amounts) to LPG would almost
certainly require changes in saving and budgeting habits for a
poor household (see also box 42.2). Those changes may entail
arranging a loan to purchase the gas bottle and stove and saving
money for the relatively large, periodic outlay to refill the cylinder. Such changes are very likely to have other consequences
for the family that should not be overlooked. However, those
consequences are complex and difficult to allow for within the
current CEA framework. Empirical data are required on how
household budgets change with various interventions and
approaches to implementation.
The calculations have been undertaken for whole regions
and provide no indication of how CERs differ among countries
and specific communities. As local data on exposure, risk
factors, health outcomes, and intervention effectiveness
become available, similar analyses should be conducted at
national and subnational levels.
Averted treatment costs have not been included on the
grounds that most users of solid fuel are poor and have limited
access to health services; many do not seek medical care for ALRI
and even fewer do so for COPD. Inclusion of averted costs would
increase cost-effectiveness. However, efforts to raise awareness
about health risks and the importance of seeking care for ALRI
(and COPD), which should accompany an intervention program, may increase care seeking and costs to the consumer. As
more complete information becomes available, future CEAs
should include treatment costs, with the option of allowing for
an increase in care seeking associated with the intervention.
Interpretation of the results of this CEA, particularly with
respect to comparisons with other types of intervention, needs
to acknowledge that, although public organizations and other
agencies will (or may) have some involvement in funding
intervention programs, most of the cost of market-based interventions will be borne by households and those involved in
production and marketing. Furthermore, it is hoped that, in
addition to reducing IAP, interventions (and the means of
accessing them) will have other positive effects, including on
household budgets, in creating opportunities for income generation and empowering women in decisions about how
energy is used. The promotion of market-based solutions
implies new opportunities for artisans and entrepreneurs, but
also the loss of traditional employment. The balance sheet for
interventions is therefore complex, is specific to the setting, and
will evolve as markets and enterprise develop.
Cost-Benefit Analysis
The CER gives cost per unit of health gained (healthy year)
based on reduced risk of specified disease outcomes (ALRI,
COPD). As discussed earlier, however, household energy interventions can affect a wide range of social, economic, and environmental issues, with important implications for health and
development. In an economic analysis of water and sanitation
interventions, Hutton and Haller (2004) found that time saved
was the most important benefit. Those other effects cannot
easily be expressed in units of health gain. Cost-benefit analysis
(CBA) offers an alternative approach that may be better suited
to environmental health interventions, given that health arguments alone will not motivate the multiple sectors involved in
financing and implementing household energy interventions.
All main benefits in CBA are expressed in a common unit of
monetary value and compared with costs in the cost-benefit
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ratio (CBR). The assessment of costs in CBA would have many
assumptions and methods in common with CEA. The key differences lie in the selection of effects for inclusion as benefits
and the methods for valuing them. In principle, there is no reason all the full range of effects discussed earlier could not be
included (table 42.7), although in practice some, such as global climate effects, may be too uncertain. Where disadvantages of
interventions are identified, they should also be included.
Benefit valuation presents particular challenges: effects are
highly setting specific; evidence for some is limited, and their
effects poorly quantified; and valuation in monetary units of
benefits, such as lost working time averted for women, is difficult because women frequently are unpaid or work in informal
markets. As a result, methods of valuation based on human
capital may not be suitable, and alternative approaches such as
contingent valuation, in which communities are involved in
agreeing on market values for nontradable commodities, may
be preferable. A related issue is valuing benefits that relate to
sustainability and health, which would be experienced after
many years and by subsequent generations. Larson and Rosen
(2002) used a mix of valuation of statistical life and contingent
valuation methods to examine the CBRs for improved stoves
with respect to mortality (Guatemala, East Africa) and morbidity (Pakistan), concluding that ratios appeared favorable.
Although they discuss other benefits, those benefits were not
included in their valuations. Their observation that the favorable CBRs are not reflected in the generally low adoption of
improved stoves led them to conclude that the information
required for assessing household demand correctly is not currently available.
IMPLEMENTATION OF CONTROL STRATEGIES:
LESSONS FROM EXPERIENCE
The past 30 to 40 years have seen many diverse programs on
household energy, from small-scale NGO- and community-led
Table 42.7 Possible Data Requirements for Quantifying Benefits
Impact category
Variables or elements to identify
Direct benefits related to specific health outcomes
Expenditure and time for health care–seeking
Health service use of those with diseases caused by IAP (number of cases, visits or days per case)
Health service use of those having accidents or injuries due to reasons related to fuel use:
Direct: burns, poisoning
Indirect: injuries in collecting fuel
Access features to get to health services (distance, mode of transport, time; average visits per case)
Other consumption related to health care–seeking
Time loss of seeking health care, both of the patient and of those accompanying patient
Other direct benefits in and around the home
Time gained owing to less illness and death
Activities of those with diseases caused by IAP
Impact of disease on activities (time input, productivity)
Value of time of various occupations
Time saving of changed technology
Reduced time spent collecting fuel
Reduced time spent cooking and on other tasks requiring fire or stove
Value of time of various occupations
Income-generating activities achieved through increased time
Impact on household cleanliness and hygiene and need for cleaning
Change in household environment and production
Effect of improved lighting on evening activities (education, production)
Effect of availability of electricity and other fuels on household production activities
Impact on ergonomics related to cooking
Consequences of process of acquiring new
technology and related changes
Increased confidence in capacity of the household to save for immediate or future needs
More involvement of women in decision making with respect to changes in household energy use and
related issues
Indirect benefits related to the environment
Local environment
Impact of fuel scarcity on local environment, average fuel collection time
Global environment
Contribution of local area to greenhouse gases
Increased risk of environmental effects (such as soil fertility) or disasters (such as flooding, landslides)
Source: Authors.
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initiatives to ambitious national programs, the largest of which
has been the installation of some 200 million improved stoves
in rural China. Although few have been subjected to rigorous
evaluation, an assessment has been made of the Indian national
stove program (box 42.3; ESMAP and World Bank 2001); the
Chinese national stove program (box 42.4; Sinton and others
2004; Smith and others 1993); and LPG promotion (box 42.5;
UNDP and ESMAP 2002). Experience with a number of smaller
initiatives has also been reported—for example, the ceramic
and metal stoves in East Africa, which have proved popular and
provided local employment (Njenga 2001), and improved
stove interventions in Guatemala (UNDP and ESMAP 2003).
Implementation of the Chinese national program differed
substantially from that in India. Although the Chinese rural
populations concerned are poor, they do have greater effective
purchasing power than the poor in many developing countries,
allowing development of a program with the majority of con-
sumers purchasing stoves at close to full cost (Smith and
others 1993). Among the key features of the Chinese program
reported to have contributed to its success are decentralization
of administration; a commercialization strategy that provided
subsidies to rural energy enterprise development and quality
control through the central production of critical components,
such as parts of the combustion chamber; and engagement of
local technical institutions in modifying national stove designs
to local needs. National-level stove competitions were held
among counties for contracts, ensuring local interest and
allowing the best-placed counties to proceed first; financial
payments were provided to counties only after completion of
an independent review of their achievements. No large flows
of funds came from the central government (in contrast, for
example, to India); local governments provided the major
financial contributions. As a result, delays and other problems
associated with transferring large amounts of money have been
Box 42.3
Key Features and Lessons from India’s National Stove Program
The Indian National Programme of Improved Cookstoves
was established in 1983 with goals common to many such
initiatives:
• conserving fuel
• reducing smoke emissions in the cooking area and
improving health conditions
• reducing deforestation
• limiting the drudgery of women and children and
reducing cooking time
• improving employment opportunities for the rural
poor.
Although the Ministry of Non-Conventional Energy
Sources was responsible for planning, setting targets, and
approving stove designs, state-level agencies relayed this
information to local government agencies or NGOs. A
technical backup unit in each state trained rural women or
unemployed youths to become self-employed workers to
construct and install the stoves.
Between 1983 and 2000, the program distributed more
than 33 million improved stoves. Despite extensive government promotion efforts, improved stoves now account
for less than 7 percent of all stoves. Among those that have
been adopted, poor quality and lack of maintenance have
resulted in a life span of two years at most and typically
much less. Evaluation of the program identified four main
problems:
• Most states placed inadequate emphasis on commercialization, now seen as crucial for effective and
sustainable uptake.
• Overall, there was insufficient interaction with users,
self-employed workers, and NGOs, so the designs did
not meet needs of households, and there was very poor
acceptance of user training.
• Quality control for installation and maintenance of the
stove and its appropriate use was lacking.
• High levels of subsidy (about 50 percent of the stove
cost) were found to reduce household motivation to
use and maintain the stove.
Some more successfully managed areas of the program
focused resources on technical assistance, research and
development, marketing, and information dissemination.
Recently, the government of India decentralized the program and transferred all implementation responsibility to
state level. Since 2000, the program promotes only durable
cement stoves with chimneys that have a minimum life
span of five years. The introduction of these stoves will
make adhesion to technical specifications and quality control much easier.
Source: Authors, based on ESMAP and World Bank 2001.
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Box 42.4
Household Effects of China’s National Improved Stove Program
In 2002, an independent multidisciplinary evaluation was
undertaken by a team of U.S. and Chinese researchers to
evaluate (a) implementation methods used to promote
improved stoves; (b) commercial stove production and
marketing organizations that were created; and (c) effects
of the program on households, including health, stove performance, socioeconomic factors, and monitoring of
indoor air quality. The first two objectives were assessed
through a facility survey of 108 institutions at all levels. The
third objective was assessed through a household survey of
nearly 4,000 households in three provinces: Zheijang,
Hubei, and Shaanxi. Key findings were as follows:
not among households using combinations of fuels
that included coal or LPG), improved stoves showed
significantly lower PM4 and CO concentrations than
traditional stoves.
• In both children and adults, coal use was associated with
higher levels of exposure (as measured by CO in exhaled
breath) and improved biomass stoves with lower levels.
Reported childhood asthma and adult respiratory disease were negatively associated with use of improved
stoves and good stove maintenance. These results
should, however, be treated as indicative because of
limited sample size.
• The household survey revealed highly diverse fuel
usage patterns: 28 and 34 different fuel combinations
were used in kitchens in winter and summer, respectively. Most households owned at least one or more
coal and one or more biomass stoves. Of the biomass
stoves 77 percent, but only 38 percent of the coal stoves,
were classified as improved. On average, improved
stoves had a mean efficiency of 14 percent, which is
well below the program target of between 20 and 30 percent, but above the mean efficiency of 9 percent for
traditional stoves.
• With respect to air quality (measured with PM4, the
“thoracic fraction” of particulate matter, and CO), coal
stoves showed significantly higher concentrations than
biomass stoves during the summer, but not during the
winter. Among households using biomass fuels (but
Overall, several important conclusions emerge with
relevance to future improved stove programs:
• A wide range of combinations of different fuel and
stove types may limit the effect of an improved stove
program.
• Given the importance of space heating, making available an improved biomass stove for cooking may not be
a sufficient strategy to reduce IAP. Improved coal stoves
need to be promoted among rural Chinese households.
• Even among households using improved stoves, PM4
and CO levels were higher than Chinese national
indoor air standards, implying that a large fraction of
China’s rural population is still chronically exposed to
pollution levels substantially above those determined
by the Chinese government to harm human health.
Source: Authors, based on Sinton and others 2004.
avoided. The Chinese program succeeded in shifting norms:
most biomass stoves now available on the market have flues
and other technical features that classify them as improved.
Experience in the promotion of LPG has also been reported,
for example, from the Indian Deepam Scheme (ESMAP and
World Bank 2004; UNDP and ESMAP 2002) and from the LPG
Rural Energy Challenge (UNDP 2005). The latter initiative,
developed by UNDP and the World LPG Association in 2002,
is promoting the development of new, viable markets for LPG
in developing countries. Key elements include developing partnerships in countries; enabling regulatory environments that
facilitate LPG business development and product delivery;
reducing barriers, for example, by introducing smaller (more
affordable) gas bottles; and raising government and consumer
awareness of costs and benefits. McDade (2004) has recently
identified a number of key lessons emerging from experience
with the promotion of LPG markets (box 42.5).
Electrification has an important role in development (IEA
2002). Evidence from South Africa suggests that communities
with grid access experience lower IAP exposure (Rollin and
others 2004). Electricity is not expected to bring about large
reductions in IAP exposure in most low-income countries,
however, because most poor households can afford it only for
uses such as lighting and running entertainment appliances and
not for cooking and space heating. The International Energy
Agency has recently carried out a detailed review of electrification, including the issues involved in supply and cost recovery
among poor (and especially rural) communities (IEA 2002).
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Box 42.5
Key Lessons Learned in the Promotion of New Markets for LPG in Developing Countries
• LPG can be affordable outside of urban areas, where
wood fuel is currently purchased. On the other hand,
for many consumers who do not participate in the
monetized economy, it will be premature to promote
LPG markets.
• One-time subsidies on appliances could be a good use
of government (or other) resources.
• Microcredit initiatives should emphasize the costsaving and productive potential and should seek to
package both the gas (and appliances) and the
financing.
• Concerns about safe handling, cylinder refilling, and
transportation can be serious barriers to market
expansion. These issues need to be addressed by raising
awareness among consumers and strengthening regulatory environments.
• Appliances for a range of end uses required by consumers must be available.
• Government leadership is essential, backed up by
policy that sets the basic parameters for successful market expansion and avoids conflict between, for example, subsidies on competing fuels that undermine
efforts to promote LPG markets.
• Specific initiatives, such as integrated energy centers (as
in Morocco and South Africa) offer an effective means
of developing markets in rural areas.
Source: Authors, based on McDade 2004.
The key lessons from experience with interventions to date
may be summarized as follows:
• Too often, intervention technologies have been developed
without adequate reference to users’ needs and, as a result,
have been poorly used and maintained or abandoned.
Consequently, it is important to involve users—particularly
women—in assessing needs and developing suitable
interventions.
• Sustainable adoption should also be promoted through
greater availability of a choice of appropriately priced interventions through local commercial outlets (artisans, shops,
markets). This situation will come about only if demand is
sufficient and if producers and distributors recognize this
demand.
• All too commonly, communities most at risk exhibit low
awareness, low demand, and poverty (often extreme
poverty). A combination of user involvement and market
approaches is needed, supported by the promotion and
availability of targeted subsidies or microcredit facilities or
both. The nature and extent of such financial support should
depend on the purchasing power of the community.
• Local initiatives such as those outlined above must be led by
national (and subnational) policy that acknowledges the
contributions of a range of actors (government, business,
NGOs, and so on) and sectors (energy, health, environment,
finance, and so on) and that results in coordinated action.
The instruments listed in table 42.5 should be considered
when developing national policy.
In a recent review of the situation in Guatemala, the United
Nations Development Programme and Energy Sector
Management Assistance Programme (UNDP and ESMAP
2003) found that, despite the almost total reliance of the rural
population on biomass, a marked lack of national policy, leadership, and coordinated action existed in relation to household
energy. Countries need to develop mechanisms for action and
coordination in light of local needs, available institutional
capacity, and leadership potential.
THE RESEARCH AND DEVELOPMENT AGENDA
WHO has, through a process involving multistakeholder meetings and reviews, developed some consensus on research and
development priorities for household energy, IAP, and health
(see for example WHO 2002a). Effective coordination is a prerequisite because of the need for input from, and collaboration
between, many different organizations and “actors” that have
generally not previously worked in partnership on this issue.
One recent response to this need has been the establishment
of the Partnership for Clean Indoor Air, following the
Johannesburg World Summit on Sustainable Development in
2002 (EPA 2004; http://www.pciaonline.org/).
The evidence base on health effects requires further
strengthening, particularly to quantify the effect of a measured
reduction in IAP exposure on the risk of key outcomes (for
example, ALRI). A randomized controlled trial is currently
under way in Guatemala, focusing primarily on ALRI in children up to 18 months of age (Dooley 2003); however, at least
one other such trial on another continent would be desirable.
Also required are observational studies for outcomes for
which few studies currently exist, including tuberculosis, low
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47
birthweight and perinatal mortality, cataracts, asthma, and
cardiovascular disease. A small number of such studies are in
progress, but further effort is required, with perinatal outcomes
being a particular priority.
Despite limitations in the evidence on health effects, what is
known about the health, social, and economic consequences of
current patterns of household energy use in poor countries is
of sufficient concern to press ahead with an active program
of research and development regarding interventions. This
activity should address both the technology (and associated
knowledge and behavior) and the approaches taken for implementation. Although some development and innovation in
technology and fuels (for example, clean fuels derived from
biomass) are likely to be valuable, the single greatest challenge
is to promote wider access to—and adoption of—existing
knowledge and interventions. Projects and programs currently
in progress or being developed should be carefully evaluated
using quantitative and qualitative methods to assess a range of
effects. Work is currently under way to develop suitable methods and tools for this purpose (WHO 2005). Experience and
lessons learned need to be disseminated widely to ensure that
they reach governments, donors, researchers, NGOs, and communities. As part of this effort, WHO is developing a resource
for countries that offers information on the effectiveness of
interventions as well as the enabling factors that facilitate longterm, sustained adoption and use of suitable improved technologies in different settings (WHO 2004c).
Economic assessment, including cost-effectiveness analysis,
has a valuable part to play. Critical issues resulting from limited
evidence have been identified about estimations and assumptions for costs, exposure reductions, health effects, and averted
treatment costs, as well as the current inability to assess national
and subnational cost-effectiveness. CBA may be more suitable
for interventions in this and similar areas but will require better
description of environmental, social, and economic effects and
further development of valuation methods. New health studies
and broadly based evaluations of interventions should help fill
some of these gaps.
Determination of the macroeconomic costs to countries of
current household energy use and the potential gains resulting
from change to more efficient and cleaner options could substantially add to the case for action.
Monitoring progress requires the development and testing
of standard indicators for use in such policy documents as the
World Development Report and for routine application at
national and subnational levels. The Millennium Development
Goal Indicator on the proportion of the population using solid
fuels is a key starting point, and WHO, the reporting agency, is
working to broaden the monitoring of this indicator through
international surveys, such as demographic and health surveys
(ORC Macro 2004), the Multiple Indicator Cluster Survey
(UNICEF 2004), and the World Health Survey (WHO 2004d),
as well as through work on regional and national indicators conducted under the Global Initiative on Children’s
Environmental Health Indicators (WHO 2004e). Future
reporting will need to be further refined by taking into account
differences in cooking practices (for example, type of stove and
cooking location), as well as in fuel use for lighting and heating.
Advocacy for stronger action, internationally and in countries, is required. Products and guidance for a range of audiences
should be prepared, with clear messages on the extent of the
problem, the population groups most affected, what works, and
what should be avoided. Tools such as the recently published
guidelines on estimating the national burden of disease from
solid fuels will help provide local evidence to argue for greater
attention and action (Desai, Mehta, and Smith 2004).
CONCLUSIONS
IAP from solid fuel use is responsible for a large burden of disease among the world’s poorest and most vulnerable populations. Inefficient and polluting household energy systems hold
back development through resulting ill health, constraints on
women’s time and income generation, environmental impacts,
and other factors. Although there is a trend toward cleaner and
more efficient energy with increasing prosperity, little improvement is in prospect for more than 2 billion of the world’s poorest people, particularly in South Asia and Sub-Saharan Africa.
The number of people relying on traditional biomass is
actually expected to increase until 2030.
Although the development of new energy technologies has
a part to play in addressing this problem, many effective interventions are already available. The single greatest challenge is
to dramatically increase the access of poor households to
cleaner and more efficient household energy systems. Much
valuable experience has been gained from successful—and
unsuccessful—programs in household energy over the past
three to four decades. Despite this experience, coherent,
evidence-based policy is lacking in most of the countries concerned, where the lessons from experience now need to be
implemented. Implementation will require greater awareness
of the problem at international and national levels, provision
of support for national collaborative action, and a focus on
supporting appropriate, mainly market-based interventions.
Better information is crucial to this effort, including
stronger evidence of the health effects of IAP exposure; assessment of the social, economic, and environmental benefits of
interventions; and indicators to monitor progress. Economic
analysis can help bring the case for action into policy, but it
needs to be applied at country level and to include a wider
range of benefits. Results from analysis at the regional level
show that interventions can be cost-effective, particularly
improved stoves, as long as these interventions can deliver substantial exposure reductions in practice. This conclusion, as
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well as its qualification, is important given the expectation that
biomass will remain the principal household fuel in many
developing countries for more than 20 years. The balance of
effort and resources put into promoting cleaner biomass interventions rather than cleaner fuels, or vice-versa, will be an
important policy issue for many countries and for the international community (Smith 2002).
With a range of innovative projects and programs under
way in a number of countries and regions of the world, now is
an important time to focus attention and effort on achieving
the health, social, and economic gains that should result from
improvements in household energy systems in developing
countries.
NOTE
1. Particles are typically described according to the aerodynamic diameter, and although the devices used to separate particles of a given size do
not yield a very sharp cutoff, this classification is functionally useful
because smaller particles are able to penetrate farther into the lungs. Total
suspended particles (TSP) include suspended particles of all sizes.
Commonly defined smaller particles include PM10 (up to 10 microns
diameter); respirable PM (includes all very small particles, about 50 percent of those 4 microns in diameter, and none above 10 microns in diameter); and PM2.5 (up to 2.5 microns in diameter).
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Chapter 44
Prevention of Chronic Disease by Means
of Diet and Lifestyle Changes
Walter C. Willett, Jeffrey P. Koplan, Rachel Nugent, Courtenay
Dusenbury, Pekka Puska, and Thomas A. Gaziano
Coronary artery disease (CAD), ischemic stroke, diabetes, and
some specific cancers, which until recently were common only
in high-income countries, are now becoming the dominant
sources of morbidity and mortality worldwide (WHO 2002).
In addition, rates of cancers and cardiovascular disease (CVD)
among migrants from low-risk to high-risk countries almost
always increase dramatically. In traditional African societies,
for example, CAD is virtually nonexistent, but rates among
African Americans are similar to those among Caucasian
Americans. These striking changes in rates within countries
over time and among migrating populations indicate that the
primary determinants of these diseases are not genetic but
environmental factors, including diet and lifestyle. Thus, considerable research has been aimed at identifying modifiable
determinants of chronic diseases.
Prospective epidemiological studies, some randomized prevention trials, and many short-term studies of intermediate
endpoints such as blood pressure and lipids have revealed a
good deal about the specific dietary and lifestyle determinants
of major chronic diseases. Most of these studies have been conducted in Western countries, in part because of the historical
importance of these diseases in the West, but also because they
have the most developed research infrastructure. A general
conclusion is that reducing identified, modifiable dietary and
lifestyle risk factors could prevent most cases of CAD, stroke,
diabetes, and many cancers among high-income populations
(Willett 2002). These findings are profoundly important,
because they indicate that these diseases are not inevitable consequences of a modern society. Furthermore, low rates of these
diseases can be attained without drugs or expensive medical
facilities, an outcome that is not surprising, because their rates
have historically been extremely low in developing countries
with few medical facilities. However, preventing these diseases
will require changes in behaviors related to smoking, physical
activity, and diet; investments in education, food policies, and
urban physical infrastructure are needed to support and
encourage these changes (see box 44.1).
CHRONIC DISEASE PREVENTION
In this section, we briefly review dietary and lifestyle changes
that reduce the incidence of chronic disease. The potential
magnitude of benefit is also discussed.
Recommended Lifestyle Changes
Specific changes in diet and lifestyle and likely benefits are
summarized in table 44.1. These relationships and supporting
evidence are summarized here.
Avoid Tobacco Use. Avoidance of smoking by preventing
initiation or by cessation for those who already smoke is the
single most important way to prevent CVD and cancer (chapter 46). Avoiding the use of smokeless tobacco will also prevent
a good deal of oral cancer.
Maintain a Healthy Weight. Obesity is increasing rapidly
worldwide (chapter 45). Even though obesity—a body mass
index (BMI) of 30 or greater—has received more attention
833
©2006 The International Bank for Reconstruction and Development / The World Bank
53
Box 44.1
The Insulin Resistance Syndrome
In recent years, researchers have recognized the insulin
resistance syndrome (also known as the metabolic syndrome) as a common contributing factor to the development of diabetes, CAD, and some cancers. The syndrome
is characterized by increased waist circumference, low
HDL (high-density lipoprotein) cholesterol, high levels of
triglycerides, hypertension, and glucose intolerance. The
most direct causes are overweight and inactivity, but
dietary factors contribute. Genetic factors, which are
probably beneficial during periods of food shortages, also
play a role. Recent evidence indicates that the populations
of Asia, Latin America, and probably Africa are particularly susceptible (Dickinson and others 2002; Harris and
others 1998).
Table 44.1 Convincing and Probable Relationships between Dietary and Lifestyle Factors and Chronic Diseases
Dietary and
lifestyle factors
CVD
Type 2
diabetes
Cancer
Dental
disease
Fracture
Cataract
Birth
defects
Obesity
Metabolic
syndrome
Depression
Sexual
dysfunction
Avoid smoking
Pursue physical activity
Avoid overweight
Diet
Consume healthy
types of fatsa
Eat plenty of fruits and
vegetables
Replace refined grains
with whole grains
Limit sugar intakeb
Limit excessive calories
Limit sodium intake
Source: Authors’ summary of a review by the WHO and FAO 2003; Bacon and others 2003; Fox 1999; IARC 2002.
Note: Bold ⫽ convincing; Standard ⫽ probable relation; ↑ ⫽ increase in risk; ↓ ⫽ decrease in risk.
a. Replace trans and saturated fats with mono- and polyunsaturated fats, including a regular source of N-3 fatty acids.
b. Includes limiting sugar-based beverages.
than overweight, overweight (BMI of 25 to 30) is typically even
more prevalent and also confers elevated risks of many diseases. For example, overweight people experience a two- to
threefold elevation in the risks of CAD and hypertension and a
more than tenfold increase in the risk of type 2 diabetes compared with lean individuals (BMI less than 23) (Willett, Dietz,
and Colditz 1999). Both overweight and obese people also
experience elevated mortality from cancers of the colon, breast
(postmenopausal), kidney, endometrium, and other sites
(Calle and others 2003).
Many people with a BMI of less than 25 have gained substantial weight since they were young adults and are also at
increased risk of these diseases, even though they are not
technically overweight (Willett, Dietz, and Colditz 1999). For
834 | Disease Control Priorities in Developing Countries | Walter C. Willett, Jeffrey P. Koplan, Rachel Nugent, and others
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54
example, in rural China, where the average BMI was less than
21 for both men and women, F. B. Hu and others (2000) found
that the prevalence of hypertension was nearly five times
greater for those with a BMI of approximately 25 than for the
leanest people. Because many Asians are experiencing adverse
consequences of excess body fat with a BMI of less than 25, the
definition of overweight for Asia has recently been expanded to
include a BMI of 23 to 25 (WHO 2000). For most people,
unless obviously malnourished as an adolescent or young
adult, bodyweight should ideally not increase by more than 2
or 3 kilograms after age 20 to maintain optimal health (Willett,
Dietz, and Colditz 1999). Thus, a desirable weight for most
people should be within the BMI range of 18.5 to 25.0, and
preferably less than 23.
Additional valuable information can be obtained by measuring waist circumference, which reflects abdominal fat accumulation. In many studies, waist circumference is a strong
predictor of CAD, stroke, and type 2 diabetes, even after controlling for BMI (Willett, Dietz, and Colditz 1999). A waist
circumference of approximately 100 centimeters for men and
88 centimeters for women has been used as the criterion for
the upper limit of the healthy range in the United States, but
for many people this extent of abdominal fat would be far
above optimal. Because abdominal circumference is easily
assessed, even where scales may not be available, further work
to develop locally appropriate criteria could be worthwhile. In
the meantime, increases of more than 5 centimeters can be
used as a basis for recommending changes in activity patterns
and diet.
Views about the causes of obesity and ways to prevent or
reduce it have been controversial. Diets low in fat and high in
carbohydrates were believed to limit caloric intake spontaneously and thus to control adiposity, but such diets have not
reduced bodyweight in trials that have lasted for a year or more
(Willett and Leibel 2002). Some researchers have suggested that
diets with a high energy density, referring to the amount of
energy per volume, offer an alternative explanation for the
observed increases in obesity (Swinburn and others 2004), but
long-term studies have not examined this theory. Sugarsweetened beverages contribute significantly to the overconsumption of calories, in part because calories in fluid form
appear to be poorly regulated by the body (E. A. Bell, Roe, and
Rolls 2003). In children, an increase in soda consumption of
one serving per day was associated with an odds ratio of 1.6 for
incidence of obesity (Ludwig, Peterson, and Gortmaker 2001),
and in a randomized trial, replacement of a standard soda with
a zero-calorie diet soda was associated with significant weight
loss (Raben and others 2002). Reductions in dietary fiber and
increases in the dietary glycemic load (large amounts of rapidly
absorbed carbohydrates from refined starches and sugar) may
also contribute to obesity (Ebbeling and others 2003; Swinburn
and others 2004).
Aspects of the food supply unrelated to its macronutrient
composition are also likely to be contributing to the global rise
in obesity. Inexpensive food energy from refined grains, sugar,
and vegetable oils has become extremely plentiful in most
countries. Food manufacturers and suppliers use carefully
researched methods to make products based on these cheap
ingredients maximally convenient and attractive.
Maintain Daily Physical Activity and Limit Television
Watching. Contemporary life in developed nations has
markedly reduced people’s opportunities to expend energy,
whether in moving from place to place, in the work environment, or at home (Koplan and Dietz 1999). Dramatic
reductions in physical activity are also occurring in developing
countries because of urbanization, increased availability of
motorized transportation to replace walking and bicycle riding,
and mechanization of labor. However, regular physical activity
is a key element in weight control and prevention of obesity
(IARC 2002; Swinburn and others 2004). For example, among
middle-aged West African women, more walking was associated with a three-unit lower BMI (Sobngwi, Gautier, and
Mbanya 2003), and in China, car owners are 80 percent more
likely to be obese (Hu 2002).
In addition to its key role in maintaining a healthy weight,
regular physical activity reduces the risk of CAD, stroke, type 2
diabetes, colon and breast cancer, osteoporotic fractures,
osteoarthritis, depression, and erectile dysfunction (table 44.1).
Important health benefits have even been associated with walking for half an hour per day, but greater reductions in risk are
seen with longer durations of physical activity and more
intense activity.
The number of hours of television watched per day is associated with increased obesity rates among both children and
adults (Hernandez and others 1999; Ruangdaraganon and
others 2002) and with a higher risk of type 2 diabetes and gallstones (F. B. Hu and others 2001; Leitzmann and others 1999).
This association is likely attributable both to reduced physical
activity and to increased consumption of foods and beverages
high in calories, which are typically those promoted on television. Decreases in television watching reduce weight
(Robinson 1999), and the American Academy of Pediatrics
recommends a maximum of two hours of television watching
per day.
Eat a Healthy Diet. Medical experts have long recognized the
effects of diet on the risk of CVD, but the relationship between
diet and many other conditions, including specific cancers, diabetes, cataracts, macular degeneration, cholelithiasis, renal
stones, dental disease, and birth defects, have been documented
more recently. The following list discusses six aspects of diet
for which strong evidence indicates important health implications (table 44.1). These goals are consistent with a detailed
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2003 World Health Organization (WHO) report (WHO and
FAO 2003).
• Replace saturated and trans fats with unsaturated fats,
including sources of omega-3 fatty acids. Replacing saturated
fats with unsaturated fats will reduce the risk of CAD (F. B.
Hu and Willett 2002; Institute of Medicine 2002; WHO and
FAO 2003) by reducing serum low-density lipoprotein
(LDL) cholesterol. Also, polyunsaturated fats (including the
long-chain omega-3 fish oils and probably alpha-linoleic
acid, the primary plant omega-3 fatty acid) can prevent
ventricular arrhythmias and thereby reduce fatal CAD. In a
case-control study in Costa Rica, where fish intake was
extremely low, the risk of myocardial infarction was 80 percent lower in those with the highest alpha-linoleic acid
intake (Baylin and others 2003). Intakes of omega-3 fatty
acids are suboptimal in many populations, particularly if
fish intake is low and the primary oils consumed are low in
omega-3 fatty acids (for example, partially hydrogenated
soybean, corn, sunflower, or palm oil). These findings
have major implications, because changes in the type of oil
used for food preparation are often quite feasible and not
expensive.
Trans fatty acids produced by the partial hydrogenation
of vegetable oils have uniquely adverse effects on blood
lipids (F. B. Hu and Willett 2002; Institute of Medicine
2002) and increase risks of CAD (F. B. Hu and Willett
2002); on a gram-for-gram basis, both the effects on blood
lipids and the relationship with CAD risk are considerably
more adverse than for saturated fat. In many developing
countries, trans fat consumption is high because partially
hydrogenated soybean oil is among the cheapest fats available. In South Asia, vegetable ghee, which has largely
replaced traditional ghee, contains approximately 50 percent trans fatty acids (Ascherio and others 1996).
Independent of other risk factors, higher intakes of trans fat
and lower intakes of polyunsaturated fat increase risk of
type 2 diabetes (F. B. Hu, van Dam, and Liu 2001).
• Ensure generous consumption of fruits and vegetables and adequate folic acid intake. Strong evidence indicates that high
intakes of fruits and vegetables will reduce the risk of CAD
and stroke (Conlin 1999). Some of this benefit is mediated
by higher intakes of potassium, but folic acid probably also
plays a role (F. B. Hu and Willett 2002). Supplementation
with folic acid reduces the risk of neural tube defect pregnancies. Substantial evidence also suggests that low folic
acid intake is associated with greater risk of colon—and
possibly breast—cancer and that use of multiple vitamins
containing folic acid reduces the risk of these cancers
(Giovannucci 2002). Findings relating folic acid intake to
CVD and some cancers have major implications for many
parts of the developing world. In many areas, consumption
•
•
•
•
of fruits and vegetables is low. For example, in northern
China, approximately half the adult population is deficient
in folic acid (Hao and others 2003).
Consume cereal products in their whole-grain, high-fiber
form. Consuming grains in a whole-grain, high-fiber form
has double benefits. First, consumption of fiber from cereal
products has consistently been associated with lower risks of
CAD and type 2 diabetes (F. B. Hu, van Dam, and Liu 2001;
F. B. Hu and Willett 2002), which may be because of both
the fiber itself and the vitamins and minerals naturally present in whole grains. High consumption of refined starches
exacerbates the metabolic syndrome and is associated with
higher risks of CAD (F. B. Hu and Willett 2002) and type 2
diabetes (F. B. Hu, van Dam, and Liu 2001). Second, higher
consumption of dietary fiber also appears to facilitate
weight control (Swinburn and others 2004) and helps prevent constipation.
Limit consumption of sugar and sugar-based beverages. Sugar
(free sugars refined from sugarcane or sugar beets and highfructose corn sweeteners) has no nutritional value except for
calories and, thus, has negative health implications for those
at risk of overweight. Furthermore, sugar contributes to the
dietary glycemic load, which exacerbates the metabolic syndrome and is related to the risk of diabetes and CAD (F. B.
Hu, van Dam, and Liu 2001; F. B. Hu and Willett 2002;
Schulze and others 2004). WHO has suggested an upper
limit of 10 percent of energy from sugar, but lower intakes
are usually desirable because of the adverse metabolic effects
and empty calories.
Limit excessive caloric intake from any source. Given the
importance of obesity and overweight in the causation of
many chronic diseases, avoiding excessive consumption
of energy from any source is fundamentally important.
Because calories consumed as beverages are less wellregulated than calories from solid food, limiting the consumption of sugar-sweetened beverages is particularly
important.
Limit sodium intake. The principle justification for limiting
sodium is its effect on blood pressure, a major risk factor
for stroke and coronary disease (chapter 33). WHO has
suggested an upper limit of 1.7 grams of sodium per day
(5 grams of salt per day) (WHO and FAO 2003).
Potential of Dietary and Lifestyle Factors to Prevent
Chronic Diseases
Several lines of evidence indicate that realistic modifications of
diet and lifestyle can prevent most CAD, stroke, diabetes, colon
cancer, and smoking-related cancers. Less progress has been
made in identifying practically modifiable causes of breast and
prostate cancers.
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Box 44.2
Success in Finland
Finland provides one of the best-documented examples
of a community intervention. In 1972, Finland had the
world’s highest CVD mortality rate. Planners examined
the policy and environmental factors contributing to CVD
and sought appropriate changes, such as increased availability of low-fat dairy products, antismoking legislation,
and improved school meals. They used the media; schools;
worksites; and spokespersons from sports, education, and
agriculture to educate residents. After five years, signifi-
One line of evidence is based on declines in CAD in countries that have implemented preventive programs. Rates of
CAD mortality have been cut in half in several high-income
countries, including Australia, the United Kingdom, and the
United States. The most dramatic example is that of Finland
(box 44.2).
Other evidence derives from randomized intervention
studies. These often have serious limitations for estimating the
potential magnitude of benefits, because typically only one or
a few factors are modified, durations are usually only a few
years, and noncompliance with lifestyle change is often substantial. Nevertheless, some examples are illustrative of the
potential benefit. In two randomized studies among adults
at high risk of type 2 diabetes, those assigned to a program
emphasizing dietary changes, weight loss, and physical activity
experienced only half the risk of incident diabetes (Knowler
and others 2002; Tuomilehto and others 2001). The Lyon
Heart Study, conducted among those with existing heart disease, found a Mediterranean-type diet high in omega-3 fatty
acids reduced recurrent infarction by 70 percent compared
with an American Heart Association diet (de Lorgeril and
others 1994).
A third approach is to estimate the percentage of disease
that is potentially preventable by reducing multiple behavioral
risk factors using prospective cohort studies. Among U.S.
adults, more than 90 percent of type 2 diabetes, 80 percent
of CAD, 70 percent of stroke, and 70 percent of colon cancer
are potentially preventable by a combination of nonsmoking,
avoidance of overweight, moderate physical activity, healthy
diet, and moderate alcohol consumption (Willett 2002).
Collectively, these findings indicate that the low rates of
these diseases suggested by international comparisons and time
trends are attainable by realistic, moderate changes that are
compatible with 21st-century lifestyles.
cant improvements were documented in smoking, cholesterol, and blood pressure. By 1992, CVD mortality rates
for men age 35 to 64 had dropped by 57 percent. The program was so successful that it was expanded to include
other lifestyle-related diseases. Twenty years later, major
reductions in CVD risk-factor levels, morbidity, and mortality were attributed to the project. Recent data show a
75 percent decrease in CVD mortality (Puska and others
1998).
INTERVENTIONS
Interventions aimed at changing diet and lifestyle factors
include educating individuals, changing the environment,
modifying the food supply, undertaking community interventions, and implementing economic policies. In most cases,
quantifying the effects of the intervention is difficult, because
behavioral changes may take many years and synergies are
potentially important but hard to estimate in formal studies.
Substantial nihilism often exists regarding the ability to
change populations’ diets or behaviors, but major changes are
possible over extended periods of time. For example, per
capita egg consumption in the United States decreased from
approximately 420 to 270 per year between 1940 and 1990
following recommendations for preventing CAD (though in
reality, the evidence for benefits was meager). Similarly, the
prevalence of smoking, despite its being a physically addictive
behavior, halved among men in the United States between
1965 and 2000. Because changing behaviors related to diet and
lifestyle require sustained efforts, long-term persistence is
needed. However, opportunities exist that do not require individual behavior changes, and these can lead to more rapid
benefits.
Educational Interventions
Efforts to change diets, physical activity patterns, and other
aspects of lifestyle have traditionally attempted to educate individuals through schools, health care providers, worksites, and
general media. These efforts will continue to play an important
role, but they can be strongly reinforced by policy and environmental changes.
School-Based Programs. School-based programs include the
roles of nutrition and physical activity in maintaining physical
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Box 44.3
The Planet Health Program
Planet Health, developed for middle school students, in
the United States, has an immediate goal of reducing television viewing time with the long-range goal of preventing unhealthy weight gain (Gortmaker and others 1999).
Teachers incorporate messages about reducing television
watching, nutrition, and increasing fitness into mathematics, social studies, science, and language arts lessons.
Fitness units and periodic “FitChecks” during physical
education complement the classroom lessons. Teacher
training, student self-assessment using graphs, and student reflection about enjoyable activities that could
replace at least a portion of the time they spend watching
television are key elements. This program has reduced television watching and weight in girls (Gortmaker and others 1999). Because the program is integrated into existing
classes, its cost is minimal.
Box 44.4
Live for Life®
Johnson & Johnson introduced Live for Life in 1979 with
the goal of making its employees the healthiest in the
world (Bly, Jones, and Richardson 1986). In 1993, the
company integrated its health and wellness program with
its disability management, employee assistance, and occupational medicine programs. Instead of using physicians
and nurses to treat symptoms, the combined program
sought to use a variety of health professionals to change
individual behavior and improve health status. Employees
and mental health (box 44.3). School food services should provide healthy meals, both because they directly affect health and
because they provide a special opportunity to teach by example. In many countries, school-based physical education
remains a significant source of physical activity for young people. In China, 72 percent of children age 6 to 18 engage in moderate to vigorous physical activity for a median of 90 to 100 minutes per week (Tudor-Locke and others 2003). Maintaining
these programs should be a high priority because they have
likely contributed to the historically low rates of obesity in such
countries.
Worksite Interventions. Worksite interventions can efficiently include a wide variety of health promotion activities
because workers spend a large portion of their waking hours
and eat a large percentage of their food there. Interventions can
include educating employees; screening them for behavioral
risk factors; offering incentive programs to walk, ride a bicycle,
or take public transportation to work; offering exercise
were offered US$500 in benefit credits for participation.
The program included routine health risk assessment,
health promotion after recovery from a medical event, and
support when returning to work after a major illness. Even
though the intervention program had little effect on bodyweight, physical fitness did increase. By the end of the
third year, savings to the company were more than
US$400 per year per employee.
programs during breaks or after work; improving the physical
environment to promote activity; and providing healthier
foods in cafeterias (box 44.4). Worksite health promotion can
result in a positive return on investment through lower health
costs and fewer sick days.
Interventions by Health Care Providers. Controlled intervention trials for smoking cessation and physical activity have
shown that physician counseling, especially when accompanied
by supporting written material, can be efficacious in modifying
behavior. Studies of dietary counseling by physicians indicate
that even brief messages about nutrition can influence behavior and that the magnitude of the effect is related to the intensity of the intervention (Pignone and others 2003). Identifying
patients who are overweight or obese, or who are gaining
weight but are not yet overweight, is an initial step in preventing and treating overweight. However, many physicians are not
well trained to measure and calculate BMI and identify weight
problems.
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Box 44.5
Reducing Automobile Use in Brazil
Curitiba, Brazil, provides an example of the benefits of a
strategy that reduces automobile use and increases use of
public transportation. In 1965, city planners adopted a
master plan that promoted development along designated
corridors along with a bus system so efficient that it has
virtually eliminated the need for automobiles. Minibuses
Transportation Policy and Environmental Design
Transportation policies and the design of urban environments
are fundamental determinants of physical activity and therefore influence the risks of obesity and other chronic diseases.
Countries can take a number of steps to make positive changes.
Limit the Role of Automobiles. In wealthy countries, the
automobile has strongly influenced the trend toward lowdensity, automobile-based suburban developments, many built
without sidewalks. These sprawling settlements tend to have
few services within walking distance and are usually not linked
to public transporationt. Dependence on automobiles affects
physical activity, because those who use public transportation
tend to walk more. In a prospective study in eight provinces in
China, 14 percent of households acquired a car between 1889
and 1997, and the likelihood of men becoming obese during
the same period was twice as great in households that acquired
a car than in those that did not (A. C. Bell, Ge, and Popkin
2002).
National policies strongly influence automobile use and
dependency. In the United States, low taxes on gasoline, free
parking, and wide streets encourage car ownership: almost
92 percent of U.S. households own at least one car, and 59 percent own two or more cars (Pucher and Dijkstra 2003). In
contrast, in most of Western Europe, narrow streets, limited
parking, and high gasoline prices make the costs of automobile
use almost double those in the United States (Pucher and
Dijkstra 2003). As a result, Europeans walk or bike more and
use their cars approximately 50 percent less than their
American counterparts. Investment in roads rather than in
public transportation creates a vicious cycle: poor public transportation systems lead to more dependency on the automobile.
As car use grows, injuries and deaths associated with automobile accidents also grow. In China, the number of fourwheeled vehicles increased from about 60,000 to more than
50 million between 1951 and 1999, and traffic fatalities
increased from about 6,000 to more than 413,000 (S. Y. Wang
and others 2003). Many innovative strategies have been
are used to quickly and efficiently transport individuals
from residential neighborhoods to express bus lines. These
bus lines run almost every 90 seconds and can carry up to
270 passengers each. Compared with other Brazilian cities
of its size, Curitiba uses 30 percent less gasoline per capita,
and its air pollution is among the lowest in the nation.
developed to discourage private automobile use and to
promote public transportation, walking, and bicycling (see
box 44.5). Singapore has long been in the lead in relation to
such efforts: a combination of limiting the number of licenses
issued, implementing a vehicle quota system, and introducing
a road pricing system has limited personal car ownership and
congestion throughout the country. Other nations and regions
are now enacting similar road pricing systems or congestion
taxes. For example, London’s congestion charging system levies
a fee of approximately US$8 per day for cars entering central
London. Since its inception in 2003, the charge has reduced
congestion in the city and is expected to channel funds back
into the city’s transportation facilities.
Unfortunately some countries, particularly China, have
taken a different approach to their future transportation needs.
Government initiatives that encourage families to buy automobiles include lowering taxes, simplifying registration procedures, and allowing foreign financing. In Beijing alone, residents purchased 400,000 cars in 2003.
Promote Walking and Bicycle Riding. Walking or cycling for
transportation and leisure are effective and practical means of
engaging in physical activity and are still the most common
ways to travel in many developing countries. In Bangkok and
Manila, only 25 percent of travel is by car, motorcycle, or taxi,
compared with 75 percent by public transportation or walking
(Pendakur 2000). In Madras, India, only 8 percent of the population travels by private, motorized transportation; 22 percent of people walk; 20 percent bike; and the rest use public
transportation (Pendakur 2000). In China, approximately
90 percent of the urban population walks or rides a bicycle to
work, shopping, or school each day (G. Hu and others 2002).
Walking or biking is more likely to be prevalent in smaller
cities—that is, those with 1 million to 5 million people—than
in larger ones.
Bicycle riding and walking are also important for children’s
health. Most American children do not walk or bike to school,
even when distances are short (box 44.6). In contrast, almost
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Box 44.6
Walking and Cycling to School
One of the most effective ways to promote walking and
cycling is through local schools. The Safe Routes to School
program (http://www.saferoutestoschools.org/), established in Marin County, California, is a private-public
partnership that created a citywide map of safe biking and
90 percent of Chinese children under 12 walk or ride a bicycle
to school (Hu 2002).
In many areas, the shift toward private car use has not yet
begun and can perhaps be forestalled by policies that benefit
walkers and cyclists rather than drivers. Such policies include
implementing road designs that promote a safe and well-lit
environment for walking and cycling, including traffic-calming
measures to reduce automobile speeds.
Many Western European countries have taken steps to
increase safety for cyclists and walkers. In Germany and the
Netherlands, bike paths serve as travel routes, not just weekend
recreational destinations as they do in the United States. The
former countries have invested heavily in bike paths and have
also created extensive car-free areas in cities, with well-lit sidewalks, clearly marked crosswalks, and pedestrian islands that
have improved safety. Both countries have increased the number of bicycle-friendly streets (on which cars are permitted but
bicycles have the right of way) and have created systems to separate streams of traffic, including cars, pedestrians, and bicycles. A meta-analysis of selected traffic-calming studies in many
countries reported reductions in traffic speed, accidents,
injuries, and fatalities and an increase in bicycle use and walking (Bunn and others 2003).
Design Cities and Towns to Promote Health. Handy and
others’ (2002) comprehensive assessment of recent research on
urban planning concludes that a combination of urban design,
land-use patterns, and transportation systems that promotes
walking and bicycling will help create active, healthier, and
more livable communities. In densely developed cities that
have been built around public transportation rather than away
from it, individuals are much more likely to take public transit,
walk, or bicycle than in other areas and to weigh less and be less
likely to suffer from hypertension (Ewing, Schieber, and Zegeer
2003; Lopez 2004; Saelens, Sallis, and Frank 2003).
Those living in walker-friendly neighborhoods also appear
to be more mentally healthy and are more likely to know their
neighbors, to be socially active, and to participate in the political process (Leyden 2003). In contrast, urban sprawl has been
walking routes and proposed solutions for problem areas.
The program also sponsors walk- and bike-to-school days,
frequent-rider contests, and other promotional events
(Staunton, Hubsmith, and Kallins 2003).
linked to decreases in mental health and social capital
(Frumkin 2002) as well as anger and frustration over long commutes (Surface Transportation Policy Project 1999). Sprawl
adversely affects the elderly in particular because they are
unable to walk to places of interest and many cannot drive.
Such isolation does not promote good physical or mental
health.
The so-called smart growth movement has resulted from
concerns about urban sprawl and unsustainable development
and is encouraging governments worldwide to rethink how
they develop new areas and redevelop older suburbs and cities.
Smart growth principles include mixing land uses, using compact building designs, including a range of transportation and
housing choices, building walker-friendly neighborhoods in
attractive communities with a distinctive sense of place, and
implementing a philosophy of directing development toward
existing communities and the preservation of open space
(Office of the Administrator 2001) (box 44.7).
The involvement of public health practitioners in transportation planning and building design is becoming more
common. In Edinburgh, a health impact assessment conducted
on proposed options for transportation policy showed the
effects of specific choices on both affluent members of the
community and the poor. Its recommendations, now adopted,
included new spending on pedestrian safety, a citywide bicycle
network, more greenways and park-and-ride programs, and
more rail transportation or bus services. Priorities are to benefit pedestrians first, cyclists second, public transportation users
third, freight and delivery people fourth, and car users last.
Establishing criteria for building design can also lead to
increases in physical activity. For example, increasing signage
promoting stair use, as well as the attractiveness of the facilities
themselves, encourages people to use the stairs (Boutelle and
others 2001) (box 44.8).
Improved Food Supply
People’s diets can be enhanced by improving the food supply.
The usual position of the food industry is that it simply
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Box 44.7
Enhancing Urban Life in the Republic of Korea
In Seoul, the government is managing growth by creating
six satellite communities with high-rise residential buildings outside the city center. These communities are
intended to become new job-creation centers and to shift
the balance of employment away from one centralized
location to provide a more regional balance. Major
expressways are being removed to create parks, sidewalks,
and bikeways (http://www.itdp.org/STe/ste6/#seoul).
Box 44.8
Promoting Physical Activity in Brazil
One successful example of increasing activity is Agita São
Paulo, a multilevel physical activity initiative designed for
the 34 million citizens of Brazil’s São Paulo state (Matsudo
and others 2002). The program was launched in 1996 to
increase the public’s knowledge of the benefits of exercise
and expand participation in physical fitness activities by
encouraging people to do 30 minutes of moderate activity
at least five times a week. As elsewhere, program designers
perceived a lack of time as the major factor preventing
daily exercise. They chose three settings as places to promote activity: home (gardening, chores, avoidance of television watching); transportation (walking, taking the
stairs); and leisure time (dancing). Agitol, a prescription
for exercise, was developed for physicians to dispense. Its
provides whatever consumers demand, but this argument is
misleading, because the industry spends more than US$12 billion annually to influence consumer choices just within the
United States and many times this amount globally. Much of
this sum goes to promote foods with adverse health effects, and
children are primary targets.
Improving Processing and Manufacturing. Altering the
manufacturing process can rapidly and effectively improve
diets because such action does not require the slow process of
behavioral change. One example is eliminating the partial
hydrogenation of vegetable oils, which destroys essential
omega-3 fatty acids and creates trans fatty acids. European
manufacturers have largely eliminated trans fatty acids from
their food supply by altering production methods.
Regulations can facilitate changes in manufacturing directly
or indirectly by providing an incentive for manufacturers to
change their processes. For example, in 2003, the U.S. Food and
message is displayed on electricity bills and stickers, and it
is touted by radio stations and other media outlets.
After four years, 55.7 percent of those surveyed had
heard about Agita, 37 percent knew its purpose, and those
who knew of the program’s purpose were more likely to be
active. Agita appears to have played a role in increasing
activity in the region (Matsudo and others 2002). It is
closely linked to a national program to promote healthy
diets and active lifestyles by nutritional content labeling,
promotion of healthy diets in schools, communication of
guidelines for healthy eating, and encouragement of innovative community-based initiatives (Coitinho, Monteiro,
and Popkin 2002).
Drug Administration announced that food manufacturers had
to include trans fatty acid content on the standard food label.
Following imposition of this requirement, several large food
companies said that they would reduce or eliminate trans fats,
and many more are planning to do so (U.S. Food and Drug
Administration 2003). In Mauritius, the government required
a change in the commonly used cooking oil from mostly palm
oil to soybean oil, which changed people’s fatty acid intake and
reduced their serum cholesterol levels (Uusitalo and others
1996). Changes in types of fat can often be almost invisible and
inexpensive. Omega-3 fatty acid intakes can be increased by
incorporating oils from rapeseed, mustard, or soybean into
manufactured foods, cooking oils sold for use at home, or both.
Selective breeding and genetic engineering provide alternative
ways to improve the healthfulness of oils by modifying their
fatty acid composition.
When the consumption of processed food is high, a reduction in salt consumption will usually require changes at the
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manufacturing level, because processed food is a major salt
source. If the salt content of foods is reduced gradually, the
change is imperceptible to consumers. Coordination among
manufacturers or government regulation is needed; otherwise
producers whose foods are lower in salt may be placed at a disadvantage. Unfortunately, good examples are not available.
Another example of improved processing would be to reduce
the refining of grain products, which can be done in small,
almost invisible decrements.
Fortifying Food. Food fortification has eliminated iodine
deficiency, pellagra, and beriberi in much of the world. In
regions where iodine deficiency remains a serious problem,
fortification should be a high priority. Folic acid intake is suboptimal in many regions of both developing and developed
countries. Fortifying foods with folic acid is extremely inexpensive and could substantially reduce the rates of several
chronic diseases. Grain products—such as flour, rice, and
pasta—are usually the best foods to fortify, and in many countries, they are already being fortified with other B vitamins.
Since 1998, grain products in the United States have been
fortified with folic acid, which has almost eliminated folate
deficiency, and rates of neural tube defect pregnancies have
declined by about 19 percent (Honein and others 2001). Where
intakes of vitamins B12 and B6 are also low and contribute to
elevations of homocysteine, as among vegetarian populations
in India, simultaneous fortification of food with these vitamins
should be considered. The effects of fortification on reducing
CVD are not considered proven, but the potential benefits are
huge; therefore, intervention trials to evaluate the effects of
fortification should be a high priority.
Increasing the Availability and Reducing the Cost of Healthy
Foods. Policies regarding the production, importation, distribution, and sale of specific foods can influence their cost and
availability. Policies may be directed at the focus of agricultural research and the types of production promoted by extension
services. Policies often promote grains, dairy products, sugar,
and beef, whereas those that encourage the production and
consumption of fruits, vegetables, nuts, legumes, whole grains,
and healthy oils would tend to enhance rather than reduce
health.
Promoting Healthy Food Choices and Limiting Aggressive
Marketing to Children. Almost every national effort to
improve nutrition incorporates the promotion of healthy food
choices, such as fruits, vegetables, and legumes. Ideally, such
efforts are coordinated among government groups, retailers,
professional groups, and nonprofit organizations, and investment in such efforts should include the careful testing and
refining of social-marketing strategies.
Another strategy is to protect consumers from aggressive
marketing of unhealthy foods. Producers spend billions of dollars a year encouraging children to consume foods that are
detrimental to their health. Manufacturers and fast-food chains
personify food products with cartoon characters; display food
brands on toys; and issue “educational” card games that subvert
children’s natural gift for play, story telling, and make believe.
The willingness to limit advertising depends on a country’s
political culture, but the public clearly distinguishes between
advertising aimed at adults and that targeted at children. For
example, in the United States, 46 percent of adults surveyed
supported restrictions on advertising to children (Blendon
2002). Restrictions can range from banning advertising to
children to limiting the types of products that advertisers may
promote to this audience.
Initiatives at the Community Level
Nations and regions can promote a variety of initiatives to
encourage greater physical activity and better nutrition. These
initiatives are likely to be most effective when they are multifaceted and coordinated and when they are developed with the
active involvement of individuals and organizations within
communities (Puska and others 1998).
Many countries are undertaking efforts to educate their
populations about healthy lifestyles. In the Islamic Republic of
Iran, the Isfahan Healthy Heart Program, a WHO collaborating
center for research and training for CVD control, prevention,
and rehabilitation for cardiac patients, has developed a comprehensive, integrated community intervention that involves
schools, worksites, health care facilities, food services, urban
planners, and the media. Physical activity is promoted by
creating safe routes for walking and bicycle riding and
by organizing recreational walking that involves entire families
(http://ihhp.mui.ac.ir).
South Africa’s Community Health Intervention Programme, a partnership between an insurance company and an
academic institution, has created programs targeted to specific
age groups, including children and older adults. The program’s
twice-weekly classes have reduced blood pressure and increased
strength and balance (Lambert, Bohlmann, and KolbeAlexander 2001) (box 44.9).
Singapore’s Fit and Trim Program uses a multidisciplinary
approach to increase physical activity and healthy diets among
schoolchildren. Between 1992 and 2000, the rate of obesity
declined by 13.1 to 16.6 percent for children age 11 to 12 and
15 to 16 (Toh, Cutter, and Chew 2002) (box 44.10 outlines the
national program for adults).
Economic Policies
Economic policies can have important effects on behavior and
choices, and these policies have been particularly useful in
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Box 44.9
A Comprehensive Intervention Approach in South Africa
The Coronary Risk Factor Study in South Africa (Rossouw
and others 1993) tested community interventions at different levels of intensity in two communities with a third
control community. The target population was Caucasian
South Africans. Interventions included direct media campaigns, public health messages delivered in a variety of ways,
and home mailings. Also included were community activities, such as fun walks, public meetings, involvement of
community-based organizations, free screening for blood
pressure, small-group personal interventions, and encouragement of food substitution in stores and restaurants. The
results showed an improvement in the community risk
factor profile for CAD in the intervention communities,
especially in relation to blood pressure, smoking, and overall risk. The results indicate no additional benefit of the
personal intervention for high-risk individuals beyond that
already offered by the mass media program. Estimated per
capita costs of the heavy intervention program were roughly
four times as much as for the mild intervention program
(US$22 per capita compared with US$5 per capita), and the
low-intervention community received almost the same
level of benefits as the high-intervention community.
Box 44.10
The Singapore National Healthy Lifestyle Program
Because CVD and cancer had become the major causes of
death in Singapore, the government adopted the National
Healthy Lifestyle Program in 1992 (Cutter, Tan, and Chew
2001). This coordinated, multisectoral approach involved
government ministries, health professionals, employers,
unions, and community organizations. The program
aimed at improving the social and physical environment so
as to promote healthy living. Healthy diets, regular physical exercise, and nonsmoking were emphasized. The program used the mass media; legislative measures to discourage smoking; and widespread school, workplace, and community health promotion packages.
reducing the prevalence of smoking (see chapter 46). Policies
that could influence diet and physical activity deserve careful
consideration because they are rarely neutral and often support
unhealthy behaviors. Consider the following examples:
• Subsidies can favor the consumption of less healthy foods,
such as sugar, refined grains, beef, and high-fat dairy products as opposed to fruits, vegetables, whole grains, nuts,
legumes, and fish. Poland provides a striking example of
how changes in subsidies can affect health (box 44.11).
Governments often subsidize foods indirectly by sheltering
them from sales taxes in the recognition that they are essential; however, this logic should not extend to foods with
adverse health effects, such as sugar-sweetened beverages
In a follow-up survey after six years, cigarette smoking
had decreased from 34 to 27 percent among men, the proportion of adults who exercised regularly had increased
from 14 to 17 percent, and the prevalence of obesity was
stable. However, hypertension and high LDL cholesterol
levels had increased modestly. From 1991 to 1999, the agestandardized incidence of myocardial infarction declined
from 98.2 to 83.0 per 100,000 residents (Mak and others
2003) and age-standardized mortality from CAD
decreased from 60.8 to 47.2 per 100,000 residents.
and those high in trans fats. Legislation can make this
distinction, providing a modest economic incentive for
healthier choices and at the same time conveying important
nutritional messages (see chapter 11).
• Use of individual automobiles is often subsidized by building and maintaining highways, providing inexpensive
parking, and imposing low taxes on petroleum products
that do not fully reflect their societal and environmental
costs. Increasing taxes on petroleum products and subsidizing public transportation could have an important effect on
choice of transportation modality, which as noted earlier,
has major effects on health.
• Walking, riding bicycles, and using public transportation
can be promoted by economic policies that, in addition
Prevention of Chronic Disease by Means of Diet and Lifestyle Changes | 843
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63
Box 44.11
Poland: A Dramatic Decline in Heart Disease
After Poland’s transition to a democratic government
in the early 1990s, the government removed large subsidies for butter and lard, and consumption of nonhydrogenated vegetable fat increased rapidly (Zatonski,
McMichael, and Powles 1998). The ratio of dietary
polyunsaturated to saturated fat increased from 0.33
in 1990 to 0.56 in 1999, and during this period mortality rates from CAD dropped by 28 percent (data
provided by W. Zatonski). Changes in smoking and in
the consumption of fruits and vegetables probably
played a minor role in this decrease (see figure).
Risk of Coronary Heart Disease
According to Polyunsaturated to Saturated Fat Ratio
Rate ratio for coronary heart
disease in Nurses’ Health Study
1.2
Poland
1992
1990
1.0
Rate ratio for coronary heart
disease mortality in Poland
1.0
1994
0.8
1996
1999
0.6
0.7
0.4
0.2
0.33
0
0.2
0.56
0.3
0.4
0.5
0.6
Dietary polyunsaturated to saturated fat ratio
Notes: Squares represent data for Poland from 1990 to 1999. Circles are for deciles of
polyunsaturated fat to saturated fat and for risk of coronary heart disease in the Nurses’
Health Study (Hu 1999), which closely predict the observed changes in Poland.
to providing better infrastructure, include discounts on
transportation fares, provide secure bicycle parking, and
reduce health insurance premiums.
COST-EFFECTIVENESS OF INTERVENTIONS
Only a few studies have described interventions for lifestyle
diseases in developing countries.
Modeling Likely Interventions
Primary targets for reducing lifestyle diseases include changing
the fat composition of the diet, limiting sodium intake, and
engaging in regular physical activity.
Using available data, we calculated a range of estimates
under given assumptions for the cost-effectiveness of replacing
dietary saturated fat with monounsaturated fat, replacing
trans fat with polyunsaturated fat, and reducing salt intake. An
increase in moderate physical activity by three to five hours per
week is considered likely to lower the risk of many diseases, but
data to model the cost-effectiveness of this intervention are not
currently available. For further details of methods and assumptions underlying the analyses presented here, see the Web site
version of this book.
Reducing Saturated Fat Content. In the base case, assuming a
3 percent drop in cholesterol and a US$6 per person cost of the
intervention, averting one disability-adjusted life year (DALY)
would cost as little as US$1,865 in South Asia and as much as
US$4,012 in the Middle East and North Africa. The intervention’s effectiveness could be increased by replacing part of the
saturated fat with polyunsaturated fat, which has additional
beneficial effects mediated by mechanisms other than LDL
cholesterol (see tables 44.2 and 44.3).
Replacing Dietary Trans Fat from Partial Hydrogenation
with Polyunsaturated Fat. We could not use the model for
saturated fat to estimate the effects of replacing trans fat with
polyunsaturated fat because only a small part of the benefit is
attributable to reducing LDL cholesterol (F. B. Hu and Willett
2002). Trans fats also adversely affect high-density lipoprotein
(HDL) cholesterol, triglycerides, endothelial function, and
inflammatory markers. In addition, increases in polyunsaturated fat (assuming a mix of N-6 and omega-3 fatty acids) will
reduce LDL cholesterol, insulin resistance, and probably fatal
cardiac arrhythmias.
In calculations that are based only on the adverse effects on
LDL and HDL, replacing 2 percent of the energy from trans fat
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©2006 The International Bank for Reconstruction and Development / The World Bank
64
Table 44.2 Incremental Cost-Effectiveness Ratios, Selected Interventions, by Region
(US$/DALY averted)
Substituting 2 percent of energy from
trans fat with polyunsaturated fat
Media campaign
to reduce
saturated fat
content
Region
East Asia and the Pacific
7 percent CAD reduction
Intervention
Intervention
cost of
cost of
US$0.50/adulta
US$6.00/adult
2,769
73
1,583
40 percent CAD reduction
Intervention
Intervention
cost of
cost of
US$0.50/adulta
US$6.00/adult
Cost saving
227
Reducing salt
content by means
of legislation plus
public education
2,056
Europe and Central Asia
2,929
65
1,670
Cost saving
228
2,170
Latin America and the Caribbean
3,297
40
1,865
Cost saving
225
2,476
Middle East and North Africa
4,012
25
2,259
Cost saving
252
3,056
South Asia
1,865
38
1,014
Cost saving
138
1,325
Sub-Saharan Africa
2,356
53
1,344
Cost saving
184
1,766
Source: Authors’ calculations.
a. Based on the U.S. Food and Drug Administration’s analysis of the costs of the intervention in the United States.
Table 44.3 Two-Way Sensitivity Analysis of the Costs of the
Intervention to Reduce Saturated Fat Content and of the
Relative Risk Reduction in CAD Events, South Asia
(US$/DALY averted)
Relative risk
reduction in CAD
events (percent)
US$0.25
10
Cost saving
Cost per individual
US$3.00
318
US$6.00a
680
5
Cost saving
680
1,403
4b
Cost saving
911
1,865
1
258
3,572
7,188
Source: Authors’ calculations.
a. Threshold analysis reveals that at the base assumption of US$6 for the intervention, no level in
the range of assumed CAD reduction is cost saving.
b. Threshold analysis reveals that at a cost below US$0.36 per individual and a 4 percent
reduction in CAD (base assumption), the intervention is cost saving.
with polyunsaturated fat was estimated to reduce CAD by 7
to 8 percent (Grundy 1992; Willett and Ascherio 1994).
Epidemiological studies, which include the contributions of
the additional causal pathways, suggest a much greater reduction, from about 25 to 40 percent (F. B. Hu and others 1997;
Oomen and others 2001). Another likely benefit is a reduction
in the incidence of type 2 diabetes: estimates indicate that the
same 2 percent reduction would reduce incidence by 40 percent
(Salmeron and others 2001).
Because voluntary action by industry (as has nearly been
achieved in the Netherlands) or by regulation (as occurred in
Denmark) can eliminate partially hydrogenated fat from the
diet, this initiative does not require consumer education, and
the costs can be extremely low. In an analysis required before
implementing food labeling, the U.S. Food and Drug
Administration (2003) estimated that trans fat labeling would
be highly cost-effective. Even though the effect of labeling itself
was estimated to have only a modest effect on consumer
behavior, as noted earlier, it is having a major effect on manufacturers’ behavior.
The potential for reducing CVD rates by replacing trans fats
with polyunsaturated fats will depend on the diets of specific
populations. Whereas the intake of trans fat is low in China, it
is likely to be high in parts of India, Pakistan, and other Asian
countries because of the extraordinarily high content in commonly used cooking fats.
Table 44.2 presents the results of a cost-effectiveness analysis
assuming the two different estimates for CAD reduction: 7 percent and 40 percent. We used costs of US$0.50 per adult per year,
which was the maximal cost in the U.S. Food and Drug
Administration analysis, and of US$6.00 per adult per year using
traditional health education approaches. The lower estimate—
or one even lower—is possible because trans fat can be eliminated at the source rather than depending entirely on changes in
individual behavior. With the lower cost, the smaller effect estimate leads to a cost-effectiveness ratio of between US$25 and
US$73 per DALY averted, depending on the region, and with the
higher-effect estimate, the intervention can be cost saving.
Reducing the Salt Content of Manufactured Foods through
Legislation and an Accompanying Education Campaign.
Table 44.2 shows the base-case cost-effectiveness of a legislated
reduction in salt content. The intervention appears to be relatively cost-effective, with a cost per DALY averted of US$1,325
in South Asia to US$3,056 in the Middle East and North Africa.
Those regional variations are attributable to differing risk profiles across regions as well as to price differentials for the costs
of treating disease sequelae.
The actual blood pressure reduction from lower salt consumption could vary from the base-case assumption, as could
the costs of the education campaign. Table 44.4 shows the
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Table 44.4 Two-Way Sensitivity Analysis of the Costs of the
Intervention to Reduce Salt Content and Its Effectiveness,
South Asia
(US$/DALY averted)
Blood pressure
reduction (millimeters
of mercury)
Cost per individual
US$1a
US$3
US$6
4
9
308
608
3
49
448
847
2b
129
727
1,326
1
368
1,565
2,761
Source: Authors’ calculations.
a. Threshold analysis reveals that at a cost of US$1 per individual, a blood pressure reduction
would have to be greater than 5 millimeters of mercury for the intervention to be cost saving. At
the base-case assumption of a cost of US$6 for the intervention, there is no cost saving threshold
level of reduction.
b. Threshold analysis reveals that at a cost of less than US$0.47 per individual the intervention is
cost-saving.
results of lower costs of the education campaign and higher or
lower effects of the intervention on blood pressure. These
results may argue for initial efforts to focus on reductions in the
use of salt during the manufacturing process with no public
education campaign. The cost-effectiveness of such a change is
high and could be augmented with a public education campaign only if needed to support the legislated change. At lower
implementation costs, the intervention is highly cost-effective,
even with half the assumed effect on blood pressure.
Adopting Physical Activity Interventions. Even though
health experts believe that physical activity interventions are
effective in reducing the risk of lifestyle diseases, no studies of
their cost-effectiveness are available from developing countries.
If people walk voluntarily (the model assumes no opportunity
cost), a net economic benefit would accrue to all segments of
the U.S. population. If we project the economic benefits to the
entire U.S. population and assume 25 percent compliance by
the sedentary population, the voluntary program would generate US$6.8 billion in savings (in 2001 U.S. dollars).
Aggregate Costs of Obesity and Unhealthy Lifestyles
A series of U.S. studies appears to confirm that the avoidable
costs of chronic diseases are substantial, although many developing countries have not yet experienced the full demands on
their health sectors resulting from these conditions. Colditz
(1999) estimates that obesity is responsible for 7 percent of all
U.S. direct health care costs and that inactivity is responsible for
an additional 2.4 percent of all health care costs. Indirect costs
associated with obesity and inactivity account for another
5 percent of health care costs. Pronk and others (1999) assess
the difference in health care costs between adult patients with
and without risk factors for noncommunicable diseases (physical activity, BMI, and smoking status) and find that a healthier lifestyle of physical activity three times per week, a moderate
BMI, and nonsmoking status reduce health care costs by
49 percent compared with an unhealthy lifestyle.
Cost-Effectiveness of Community-Based Interventions
Populationwide and community-based interventions appear to
be cost-effective if they reach large populations, address highmortality and high-morbidity diseases, and are multipronged
and integrated efforts. The full costs of achieving changes in
behavior and policy are often complex and difficult to estimate.
Interventions may yield additional spinoff benefits. For
instance, decisions to reduce children’s television viewing could
easily improve school outcomes as well as reduce childhood
obesity. Similarly, increasing walking and bicycle riding for
transportation could reduce air pollution.
RESEARCH AND DEVELOPMENT PRIORITIES
A number of research and development priorities have been
identified:
• Conduct randomized trials of the use of folic acid and
alpha-linoleic acid to prevent CAD in developing countries.
These interventions cost little, and the potential benefits are
large and rapid.
• Develop prospective cohort studies of dietary and lifestyle
factors in developing and transition countries to refine the
understanding of risk factors in those contexts. To date,
almost all such studies have taken place in Europe and
North America.
• Develop surveillance systems for chronic diseases and for
major risk factors, such as obesity, in developing countries.
• Develop additional multifaceted, community-based
demonstration programs in developing countries to document the feasibility of lifestyle changes and to learn more
about effective strategies.
• Conduct detailed cost-effectiveness analyses of various prevention strategies to modify dietary and lifestyle factors.
RECOMMENDED PRIORITY INTERVENTIONS
An overall objective is to develop comprehensive national and
local plans that take advantage of every opportunity to encourage and promote healthy eating and active living. These plans
would involve health care providers; worksites; schools; media;
urban planners; all levels of food production, processing, and
preparation; and governments. The goal is cultural change
in the direction of healthy living. An important element in
846 | Disease Control Priorities in Developing Countries | Walter C. Willett, Jeffrey P. Koplan, Rachel Nugent, and others
©2006 The International Bank for Reconstruction and Development / The World Bank
66
cultural change is national leadership by individuals and by
professional organizations. Specific interventions will depend
on local physical and cultural conditions and should be based
on careful analysis of existing dietary and activity patterns and
their determinants; however, the following interventions can be
considered (specific interventions for control of smoking are
discussed elsewhere):
• Physical activity:
º Develop transportation policies and a physical environment to promote walking and riding bicycles. This intervention includes constructing sidewalks and protected
bicycle paths and lanes that are attractive, safe, welllighted, and functional with regard to destinations.
º Adopt policies that promote livable, walker-friendly
communities that include parks and are centered around
access to public transportation.
º Encourage the use of public transportation and discourage overdependence on private automobiles.
º Promote the use of stairs. Building codes can require the
inclusion of accessible and attractive stairways.
• Healthy diets:
º Develop comprehensive school programs that integrate
nutrition into core curricula and healthy nutrition into
school food services. Regional or national standards to
promote healthy eating should be developed for school
food services. Programs should also aim at limiting
television watching, in part by promoting attractive
alternatives.
º Work with the agriculture sector and food industries to
replace unhealthy fats with healthy fats, including adequate amounts of omega-3 fatty acids. This goal can be
achieved through a combination of education, regulation, and incentives. Specific actions will depend on local
sources of fat and on regional production and distribution. For example, in areas where palm oil is dominant,
research could focus on developing strains that are lower
in saturated fat and higher in unsaturated fat through
selective breeding or genetic alteration. Labeling requirements or regulation can be used to discourage or eliminate the use of partially hydrogenated vegetable oils and
to promote the use of nonhydrogenated unsaturated oils
instead.
º Require clear labeling of energy content for all packaged
foods, including fast food.
º Use tax policies to encourage the consumption of
healthier foods. For example, high-sugar sodas could be
fully taxed and not subsidized in the same way as healthier foods.
º Emphasize the production and consumption of healthy
food products in agriculture support and extension
programs.
º Implement folic acid fortification if folic acid intake is
low.
º Ensure that health providers regularly weigh both children and adult patients, track their weights over time,
and provide counseling regarding diet and activity if
they are already overweight or if unhealthy weight gain is
occurring during adulthood. Those activities should be
integrated with programs that address undernutrition.
Health care providers should be encouraged to set a
good example by not smoking, by exercising regularly,
and by eating healthy diets.
º Promote healthy foods at worksite food services.
Worksites can also promote physical activity by providing financial incentives for using public transportation
or riding bicycles (and by not subsidizing automobiles
by providing free parking). Providing areas for exercise
during work breaks and showers may be useful.
º Set standards that restrict the promotion of foods high
in sugar, refined starch, and saturated and trans fats to
children on television and elsewhere.
º Set national standards for the amount of sodium in
processed foods.
• National campaigns:
º Invest in developing locally appropriate health messages
related to diet, physical activity, and weight control. This
effort is best done in cooperation with government agencies, nongovernmental organizations, and professional
organizations so that consistent messages can be used on
television and radio; at health care settings, schools, and
worksites; and elsewhere. This effort should use the best
social-marketing techniques available, with messages
continuously evaluated for effectiveness.
º Develop a sustainable surveillance system that monitors
weight and height, physical activity, and key dietary
variables.
Implementation of the recommended policies to promote
health and well-being is often not straightforward because of
opposition by powerful and well-funded political and economic
forces, such as those involved in the tobacco, automobile, food,
and oil industries (Nestle 2002). The solutions will depend on a
country’s specific political landscape. However, experiences in
many countries indicate that alliances of public interest groups,
professional organizations, and motivated individuals can overcome such powerful interests. Strategies should start with sound
science and can use a mix of mass media, lobbying efforts, and
lawsuits. Also, the food industry is far from monolithic, and elements can often be identified whose interests coincide with
health promotion, which can create valuable partnerships. As an
example, the willingness of some margarine manufacturers to
invest in developing products free of trans fatty acids greatly
helped the effort to reduce these fats, because these producers
Prevention of Chronic Disease by Means of Diet and Lifestyle Changes | 847
©2006 The International Bank for Reconstruction and Development / The World Bank
67
then became proponents for labeling the trans fat content of
foods. Protection of children can be a powerful lever because of
almost universal concern about their welfare and the recognition that they cannot be responsible for the long-term consequences of their diet and lifestyle choices.
CONCLUSIONS
Many of the ongoing diet and lifestyle interventions in lowand middle-income countries are relatively recent, and few
have documented reductions in the rates of major chronic diseases. However, the successes of Finland, Singapore, and many
other high-income countries in reducing rates of CAD, stroke,
and smoking-related cancers strongly suggest that similar benefits will emerge in the developing countries.
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Chapter 46
Tobacco Addiction
Prabhat Jha, Frank J. Chaloupka, James Moore, Vendhan
Gajalakshmi, Prakash C. Gupta, Richard Peck, Samira Asma,
and Witold Zatonski
Cigarette smoking and other forms of tobacco use impose a
large and growing global public health burden. Worldwide,
tobacco use is estimated to kill about 5 million people annually,
accounting for 1 in every 5 male deaths and 1 in 20 female
deaths of those over age 30. On current smoking patterns,
annual tobacco deaths will rise to 10 million by 2030. The 21st
century is likely to see 1 billion tobacco deaths, most of them
in low-income countries. In contrast, the 20th century saw
100 million tobacco deaths, most of them in Western countries
and the former socialist economies.
Hundreds of millions of premature tobacco deaths could
be avoided if effective interventions were widely applied in
low- and middle-income countries. Numerous studies from
high-income countries and a growing number from low- and
middle-income countries provide robust evidence that tobacco
tax increases, timely dissemination of information about the
health risks of smoking, restrictions on smoking in public and
workplaces, comprehensive bans on advertising and promotion, and increased access to cessation therapies are effective in
reducing tobacco use and its consequences. Cessation by the
1.1 billion current smokers is central to meaningful reductions
in tobacco deaths over the next five decades. New analyses presented here find that higher tobacco taxes could prevent 3 million tobacco deaths by 2030 among smokers alive today.
Reduced uptake of smoking by children would yield benefits
chiefly after 2050. Price and non-price interventions are, for the
most part, highly cost-effective.
This chapter begins with an overview of smoking trends and
tobacco’s health consequences, followed by a discussion of the
economic rationale for government intervention, with a focus
on the uniquely addictive properties of nicotine. A review of the
effectiveness of tobacco-control policies in reducing tobacco initiation and in increasing cessation follows. A cost-effectiveness
analysis of these interventions is provided. Finally, the constraints to implementing tobacco-control policies are discussed.
SMOKING TRENDS
Tobacco use, in both smoked and nonsmoked forms, is common worldwide. This chapter focuses on smoked tobacco,
chiefly cigarettes and bidis (tobacco hand rolled in the leaf of
another plant, temburi, which is popular in India and parts of
Southeast Asia), because smoked tobacco is more common—
accounting for about 65 to 85 percent of all tobacco produced
worldwide (WHO 1997)—and causes more disease and more
diverse types of disease than does oral tobacco use.
Prevalence
A systematic review of 139 studies on adult smoking prevalence
(Jha and others 2002) found that more than 1.1 billion people
worldwide smoke, with about 82 percent of smokers residing
in low- and middle-income countries. Table 46.1 provides an
update of these estimates for the population in 2000. Globally,
male smoking far exceeds female smoking, with a smaller gender difference in high-income countries. Smoking prevalence is
highest in Europe and Central Asia, where 35 percent of all
adults are smokers.
While overall smoking prevalence continues to increase in
many low- and middle-income countries, many high-income
countries have witnessed decreases, most clearly in men. A
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Table 46.1 Estimated Smoking Prevalence (by Gender) and Number of Smokers, 15 Years of Age and Older, 2000
Smoking prevalence (percent)
World Bank region
Males
Total smokers
Females
Overall
Millions
Percentage of all smokers
East Asia and the Pacific
63
5
34
429
38
Europe and Central Asia
56
17
35
122
11
Latin America and the Caribbean
40
24
32
98
9
Middle East and North Africa
36
5
21
37
3
South Asia
32
6
20
178
15
Sub-Saharan Africa
29
8
18
56
6
Low- and middle-income economies
49
8
29
920
82
High-income economies
37
21
29
202
18
Source: Authors.
study in 36 mostly Western countries, from early 1980 to the
mid 1990s, suggested that the decrease in smoking prevalence
observed among men was caused by the higher prevalence in
younger age groups of those who have never smoked. Among
women, there was little overall change in smoking prevalence
because the increasing prevalence of smokers in younger
cohorts counterbalanced increasing cessation in older age
groups (Molarius and others 2001).
Cessation
Ex-smoking rates are a good measure of cessation at a population level. In some high-income countries, the prevalence rates
of ex-smokers have increased over the past two to three
decades. For example, in the United Kingdom, smoking prevalence among males over age 30 fell from 70 percent in the 1950s
to 30 percent in 2000; female smoking prevalence fell from 40
to 20 percent over the same period. Much of the decrease arose
from cessation. Today, two times as many ex-smokers as smokers exist among those age 50 or over. Currently, 30 percent of
the U.K. male population is made up of former smokers (Peto
and others 2000). Polish male cessation rates have also
increased, partly because of control programs. One of every
four adult Polish males described himself as an ex-smoker
(Zatonski and Jha 2000). In contrast, the prevalence of male exsmokers in most developing countries is low: 10 percent in
Vietnam, 5 percent in India, and 2 percent in China (Jha and
others 2002). Even those low figures may be falsely elevated
because they include people who quit because either they were
too ill to continue or they had early symptoms of tobaccorelated illness (Martinson and others 2003).
health and population policy. Thus, the salient aspects of
tobacco epidemiology are outlined in this section.
Key Messages for the Individual Smoker
More than 50 years of epidemiology on smoking-related diseases have led to three key messages for individual smokers
worldwide (Doll and others 2004; Peto and others 2003).
• The eventual risk of death from smoking is high, with about
one-half to two-thirds of long-term smokers eventually
being killed by their addiction.
• These deaths involve a substantial number of life years forgone. About half of all tobacco deaths occur at ages 35 to 69,
resulting in the loss of about 20 to 25 years of life, compared
with the life expectancy of nonsmokers.
• Cessation works: those adults who quit before middle age
avoid almost all the excess hazards of continued smoking.
Worldwide, about 80 percent of deaths among the 2.7 billion adults over age 30 involve vascular, respiratory, or neoplastic disease. Smoking is associated with an increase in the
frequency of many of these diseases, although important differences exist between and across populations. The following
discussion focuses on the consequences of smoking on adult
mortality. Detailed epidemiological reviews of worldwide mortality from smoking are found elsewhere (C. Gajalakshmi and
others 2000; V. Gajalakshmi and others 2003; Gupta and Mehta
2000; Liu and others 1998; Niu and others 1998; Peto and
others 1994).
Current Mortality and Disability from Smoking
HEALTH CONSEQUENCES OF SMOKING
The health consequences of smoking are often assumed to be
widely understood. In fact, ignorance of the magnitude of
tobacco hazards is widespread in terms of both individual
Recent updates of indirect estimates of global tobacco mortality
(Ezzati and Lopez 2003; M. Ezzati, personal communication,
November 2004) indicate that in 2000, 5.0 million premature
deaths were caused by tobacco. About half (2.6 million) of
those deaths were in low-income countries. Males accounted
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©2006 The International Bank for Reconstruction and Development / The World Bank
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Table 46.2 Tobacco Mortality and Total DALYs by Gender, 2000
(thousands)
Tobacco deaths
World Bank region
Total DALYs
Males
Females
Males
Females
829
274
13,116
4,128
Europe and Central Asia
754
161
12,407
2,686
Latin America and the Caribbean
177
97
2,789
1,613
East Asia and the Pacific
Middle East and North Africa
South Asia
Sub-Saharan Africa
Low- and middle-income economies
28
1,676
554
187
12,397
3,285
105
66
1,659
1,091
2,730
813
44,044
13,357
929
548
12,304
6,866
3,659
1,361
56,347
20,222
High-income economies
World
97
768
Source: Ezzati and Lopez 2003; Mathers and others 2006.
Note: The terms high-income and former socialist economies as used in the text correspond roughly to high-income and Europe and Central Asia regions using the World Bank classification. Low-income
countries corresponds roughly to East Asia and the Pacific, Latin America and the Caribbean, Middle East and North Africa, South Asia, and Sub-Saharan Africa.
for 3.7 million deaths, or 72 percent of all tobacco deaths.
About 60 percent of male and 40 percent of female tobacco
deaths were of middle-aged persons (ages 35 to 69).
In high-income countries and former socialist economies,
the 1 million middle-aged male tobacco deaths were largely
composed of cardiovascular disease (0.45 million) and lung
cancer (0.21 million). In contrast, in low-income countries, the
leading causes of death among the 1.3 million male tobacco
deaths were cardiovascular disease (0.4 million), chronic
obstructive pulmonary disease (0.2 million), other respiratory
disease (chiefly tuberculosis, 0.2 million), and lung cancer
(0.18 million). The specific numbers of deaths from tobacco
and of total disability-adjusted life years (DALYs) by gender
and World Bank region are shown in table 46.2. Disability estimates are not discussed here; however, disability is highly correlated with mortality in most settings.
Past and Future Trends in Mortality
In high-income and former socialist economies with more
complete and reliable mortality statistics, one can measure
the effects of increased smoking prevalence and subsequent
decreases that have been observed among large numbers of
adults. These changes are best documented by examining lung
cancer mortality rates among young adults because lung cancer
is not often misclassified with other causes of death at young
ages and it is almost entirely attributable to smoking.
Age-Standardized Lung Cancer Mortality Rates
Age-standardized male lung cancer rates at ages 35 to 44 per
100,000 men in the United Kingdom had fallen from 18 in 1950 to
4 by 2000. In contrast, comparable French male lung cancer rates
show the reverse pattern (Peto and others 2003; figure 46.1). In
France,the increase in smoking occurred some decades later than
in the United Kingdom, and declines in smoking began only after
1990. Similarly, a large increase in female lung cancer at young
ages was avoided in the United Kingdom, but female lung cancer
at young ages continues to rise in France.
Future increases in tobacco deaths worldwide are expected
to arise from increased smoking by males in developing countries and by women worldwide. Such increases are a product of
population growth and increased age-specific tobacco mortality rates, the latter relating to both smoking duration and the
amount of tobacco smoked. Peto and others (1994) have made
the following calculation: if the proportion of young people
taking up smoking continues to be about half of men and onetenth of young women, there will be about 30 million new
long-term smokers each year. As previously noted, epidemiological studies in developed and developing countries suggest
that half of these smokers will eventually die from smoking.
However, if we conservatively assume that “only” about onethird of smokers die as a result of smoking, then smoking will
eventually kill about 10 million people a year. Thus, for the
25-year period from 2000 to 2025, there would be about 150
million tobacco deaths, or about 6 million deaths per year on
average; from 2025 to 2050, there would be about 300 million
tobacco deaths, or about 12 million deaths per year.
Further estimations are more uncertain, but current smoking trends and projected population growth indicate that from
2050 to 2100 there will be an additional 500 million tobacco
deaths. These projections for the next three to four decades are
comparable to retrospective and early prospective epidemiological studies in China (Liu and others 1998; Niu and others 1998),
which suggest that annual tobacco deaths will rise to 1 million
before 2010 and to 2 million by 2025, when the young adult
smokers of today reach old age. Similarly, results from a large
retrospective study in India suggest that 1 million annual deaths
can be expected from male smokers by 2025 (V. Gajalakshmi
and others 2003). With other populations in Asia, Eastern
Tobacco Addiction | 871
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73
a. United Kingdom
b. France
Death rate/100,000 men, age standardized a
Death rate/100,000 men, age standardized a
18
18
16
16
Males
14
14
12
12
10
10
8
8
6
6
4
4
Females
2
0
1950
Males
Females
2
1960
1970
1980
1990
2000
0
1950
1960
1970
1980
1990
2000
Source: Peto and others 2003.
a. Mean of annual rates in component five-year age groups (35–39, 40–44).
Figure 46.1 Changes in Lung Cancer Mortality at Age 35 to 44 in the United Kingdom and France, 1950–99
Europe, Latin America, the Middle East, and (less certainly)
Sub-Saharan Africa showing similar growth in population and
age-specific tobacco death rates, the estimate of some 450 million tobacco deaths over the next five decades appears plausible.
Almost all of these deaths will be among current smokers.
Tobacco deaths (million)
520
500
500
400
340
300
Benefits of Cessation
Current tobacco mortality statistics reflect past smoking behavior, given the long delay between the onset of smoking and
the development of disease. The prevention of a substantial
proportion of these tobacco deaths before 2050 requires adult
cessation. For example, halving the per capita adult consumption of tobacco by 2020 (akin to the declines in adult smoking
in the United Kingdom) would avert about 180 million tobacco
deaths. Continuing to reduce the percentage of children who
start to smoke will prevent many deaths, but its main effect will
be on mortality rates in 2050 and beyond (figure 46.2; Jha and
Chaloupka 2000a; Peto and Lopez 2001).
Substantial evidence indicates that smoking cessation
reduces the risk of death from tobacco-related diseases. Among
doctors in the United Kingdom, those who quit smoking before
the onset of major disease avoided most of the excess hazards
of smoking (Doll and others 2004). The benefits of quitting
were largest in those who quit before middle age (between ages
25 and 34 years) but were still significant in those who quit later
(between ages 45 and 54 years).
Cessation before middle age avoids more than 90 percent
of the lung cancer risk attributable to tobacco, with quitters
possessing a pattern of survival similar to that of persons who
220
200
190
100
70
0
1950
2000
Baseline
If adult consumption
halves by 2020
2025
2050
If proportion of young adults
taking up smoking halves
by 2020
Source: Jha and Chaloupka 2000a; Peto and Lopez 2001.
Note: Peto and others (1994) estimate 60 million tobacco deaths between 1950 and 2000
in industrial countries. This figure estimates an additional 10 million tobacco deaths
between 1990 and 2000 in developing countries. The figure also assumes no tobacco
deaths before 1990 in developing countries and minimal tobacco deaths worldwide
before 1950. Projections for deaths from 2000 to 2050 are based on Peto and Lopez (2001).
Figure 46.2 Tobacco Deaths in the Next 50 Years under Current
Smoking Patterns
have never smoked. In the United Kingdom, among those
who stopped smoking, the risk of lung cancer fell steeply with
time since cessation. For men who stopped at ages 60, 50, 40,
and 30, the cumulative risks of lung cancer by age 75 were
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Lung cancer mortality (percent)
Continued
smoking
15
10
• The addictive nature of tobacco is underappreciated and
poorly understood. Although general awareness of risks is
better in high-income countries, many people still underestimate tobacco’s danger relative to other health risks, and
many smokers fail to fully internalize these risks (Weinstein
1998).
• Smokers may impose costs on others from passive tobacco
smoke or, more controversially, from higher health care
costs (Lightwood and others 2000; Warner 2003).
Stopped age 50
5
Stopped age 30
Never smoked
0
45
55
65
75
Age
Source: Peto and others 2000.
Figure 46.3 Stopping Works: Cumulative Risk of Lung Cancer
Mortality in U.K. Males, 1990 rates
The reader is referred to more detailed discussions on the
welfare economics of tobacco (Barnum 1994; Jha and others
2000; Peck and others 2000; Warner and others 1995; and
several background papers in the Disease Control Priorities
Project Working Paper Series). We discuss nicotine addiction
because this newer evidence has profound implications for
explaining smoking behavior and for devising control policies.
Nicotine Addiction
In addition to the public health burden caused by tobacco,
an economic rationale exists for government to intervene to
reduce tobacco use:
Before the landmark 1988 U.S. Surgeon General’s report, which
suggested that cigarettes and other forms of tobacco are addictive and that nicotine is the major agent in tobacco responsible
for addiction, the prevailing view was that tobacco use was
largely a voluntary behavior or personal choice (Koop 2003).
Since that time, clinicians, behavioral scientists, researchers,
and public health experts have increasingly recognized manufactured tobacco products as some of the most addictive and
deadly dependence-producing substances available. Although
numerous factors have been identified that can contribute to
the reinforcement of the smoking habit—for example, the synergistic and independent effects of other compounds in tobacco
smoke (such as tar and acetaldehyde) or the sensory and environmental stimuli associated with smoking (such as tobacco
advertising)—little debate exists that nicotine is a significant
contributor to the development and maintenance of the smoking habit (Markou and Henningfield 2003). In most aspects of
dependence, nicotine is on par with other powerfully addictive
drugs, such as heroin and cocaine. Newer evidence has converged on the following key points.
• Consumers have inadequate information about the health
consequences of tobacco use (Jha and others 2000; Warner
and others 1995). Specifically, the decision to initiate smoking is made primarily by youths, whose ability to make fully
informed, appropriately forward-looking decisions is
questioned by society in many different contexts (minimum
ages for drinking, driving, and voting, for instance). In
industrial countries, about 80 percent of adult smokers
begin smoking before age 20. Even if children and young
adults have information on future risks, they tend to discount that future risk greatly.
Biological Aspects. Nicotine is a psychoactive drug that triggers a cascade of neurobiological events in the reward areas of
the brain and throughout the body that can, in turn, act in concert to reinforce tobacco use (Markou and Henningfield 2003).
Even a short-term exposure to nicotine has been shown to
induce long-lasting changes of the excitatory input into the
brain’s reward system, which may be an important early step in
the path to addiction (Laviolette and van der Kooy 2004).
Notably, in some experimental models, if nicotine’s neurobiological effects are blocked pharmacologically, or if nicotine is
removed from cigarette smoke, smoking eventually ceases
10 percent, 6 percent, 3 percent, and 2 percent, respectively
(Peto and others 2000; figure 46.3). These results have been
supported by a recent multicenter study of men in four
European countries; for men who quit smoking at age 40, the
study found that the excess lung cancer risk avoided was
85 percent, 91 percent, and 80 percent in the United Kingdom,
Germany, and Italy, respectively (Crispo and others 2004).
Smoking cessation is uncommon in most developing countries,
but some evidence exists that, among Chinese men, quitting
also reduces the risks of total and vascular mortality (Lam and
others 2002).
RATIONALE FOR GOVERNMENT INTERVENTION
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75
(Jarvis 2004). The overwhelming property of nicotine that
leads to its frequent use is the occurrence of nicotine withdrawal, for which cigarette smoke provides rapid relief. Though
each individual differs greatly in his or her sensitivity to nicotine dependence, evidence suggests that most adults are susceptible to the biological effects of nicotine and tobacco
(Picciotto 2003).
Psychological Aspects. In addition to the unique neurobiology of nicotine, the ready availability of tobacco influences the
uptake of smoking as well as the development and maintenance of dependence. With illicit drugs, legal and social barriers constantly test a user’s drive to consume the drug. In
contrast, a smoker is presented with nearly ubiquitous
opportunities and frequent cues to both purchase and use
tobacco because of mass marketing and promotion of tobacco
(Shiffman and West 2003). Young people, who are attracted
to many risk behaviors, such as fast driving or binge drinking,
do not “learn” from early smoking in the way that most young
people become safer drivers and moderate drinkers as adults
(Jha and others 2000; O’Malley, Bachman, and Johnston 1988).
Economics. The traditional economic formulation of costs
and benefits tends not to take into account the unique properties of addiction (see Chaloupka, Tauras, and Grossman 2000
for a review). Newer models have begun to incorporate factors
such as lack of information, regret, and addiction itself. One
key innovation by Gruber and Koszegi (2001, 2002) permits
smokers to be time inconsistent, meaning that, given preferences, smokers would make different decisions at different
points in time. This approach, now widely used within the new
field of behavioral economics, admits conflict between what
smokers would like for themselves today and what they would
like for themselves in the future.
Implications for Control Programs. These newer economic
models have several implications for control programs. First is
the need for much more aggressive tobacco taxation to deter
the development of tobacco smoking. Estimates suggest that,
in the United States, optimal taxation taking into account
smoking initiation and nicotine addiction would be at least
US$1 higher per pack (Gruber 2003; Gruber and Koszegi 2002;
Gruber and Mullainathan 2002). The second implication is
that the usual assumption that higher taxes reduce the welfare
or satisfaction of continuing smokers may not be true. Higher
taxes enhance welfare by acting like an external control device
over the time-inconsistent preferences of smokers, which
would reduce the likelihood of smoking initiation.
The third implication is that the overall economic benefits
of tobacco control, taking into account addiction, are likely to
be substantially positive. Earlier cost-benefit analyses have
shown that if even modest costs are assigned to uninformed
smoking choices, the net economic costs of tobacco are profoundly negative (Barnum 1994; Peck and others 2000). While
some of the methods for such costing have been disputed,
newer economic evidence supports the idea that widespread
hazards of tobacco use lead to major economic costs. Jamison,
Lau, and Wang (2005) have outlined that male survival explains
income growth independent of changes in physical capital,
education, fertility, economic openness, and technical progress.
Thus, if adult male survival in the former socialist economies
of Europe had been that of high-income countries, annual
growth rates over the past three decades would have been about
1.4 percent rather than 1 percent, making 1990 per capita
income about 12 percent higher, or an absolute value of
US$140 billion. The chief determinant of the mortality gap
between the former socialist economies and high-income
countries from 1960 to 1990 is smoking (Peto and others 1994;
Zatonski and Jha 2000). More recent economic studies that
have put a value on “statistical life” suggest that smoking cessation generates huge benefits. For example, Murphy and Topel
(2003) find that in the United States, the value of reduced mortality from all causes between 1970 and 1998 amounted to
US$2.6 trillion per year, or half of gross domestic product
(GDP) growth during the period. Fully US$1.1 trillion per year
arose from reduced heart disease, of which at least one-third
was from reduced smoking and saturated fat in diets (Cutler
and Kadiyala 2003; see chapter 15 for a fuller discussion on the
economic benefits of disease control).
INTERVENTIONS TO REDUCE DEMAND
FOR TOBACCO
Numerous studies, mostly from high-income countries, have
examined the effect of interventions aimed at reducing the
demand for tobacco products on smoking and other kinds of
tobacco use. The small but growing number of studies from
low- and middle-income countries provide useful lessons
about differences in the effect of these interventions between
these countries and high-income countries. The following is a
review of the effect of price and non-price interventions in
reducing demand for smoking, including a discussion of each
intervention’s effect on initiation and cessation. A more complete study of the effectiveness of various interventions is available elsewhere (Jha and Chaloupka 2000b).
Tobacco Taxation
Nearly all governments tax tobacco products. However, significant differences exist across countries in levels of tobacco taxation. Some of these taxes are specific or per unit taxes; others
are expressed as a percentage of wholesale or retail prices (ad
valorem taxes). As illustrated in figure 46.4, taxes tend to be
absolutely higher and account for a greater share of the retail
price (two-thirds or more) in high-income countries. In
874 | Disease Control Priorities in Developing Countries | Prabhat Jha, Frank J. Chaloupka, James Moore, and others
©2006 The International Bank for Reconstruction and Development / The World Bank
76
Average price or tax per pack (US$)
Percentage of tax share
3.5
80
3.0
70
60
2.5
50
2.0
40
1.5
30
1.0
20
0.5
0
10
High-income
countries
Upper-middle- Lower-middleincome
income
countries
countries
Average price
Average tax
Low-income
countries
0
Percentage
of tax share
Source: Authors.
Figure 46.4 Average Cigarette Price, Tax, and Percentage of Tax
Share per Pack, by Income Group, 1996
low- and middle-income countries, taxes are generally much
lower and account for less than half of the final price of cigarettes. In the United States, federal and state excise taxes on cigarettes were one-third lower, in real terms, in 1995 than their
peak level of the mid 1960s. However, taxes rose sharply over the
next eight years and stood at US$1.12 per pack as of 2002.
Well over 100 studies from high-income countries clearly
demonstrate that increases in taxes on cigarettes and other
tobacco products lead to significant reductions in cigarette
smoking and other tobacco use (Chaloupka, Hu, and others
2000). These reductions reflect the combination of increased
smoking cessation, reduced relapse, lower smoking initiation,
and decreased consumption among continuing tobacco users.
Studies from Canada, the United Kingdom, the United
States, and many other high-income countries generally estimate that the price elasticity of cigarette demand ranges from
⫺0.25 to ⫺0.50, indicating that a 10 percent increase in
cigarette prices will reduce overall cigarette smoking by 2.5 to
5.0 percent (Chaloupka, Hu, and others 2000; U.S. DHHS
2000). Estimates from a limited number of studies from lowand middle-income countries suggest a greater price elasticity
of ⫺0.8 in such countries. Recent studies using survey data
have concluded that half or more of the effect of price on overall cigarette demand results from reducing the number of current smokers (CDC 1994; Wasserman and others 1991). Higher
taxes increase both the number of attempts at quitting smoking and the success of those attempts (Tauras 1999; Tauras and
Chaloupka 2003). A study in the United States (Taurus 1999)
suggested that a 10 percent increase in price would result in 11
to 13 percent shorter smoking duration or a 3.4 percent higher
probability of cessation.
Many recent studies from the United States have used
individual-level data to explore differences in the price elasticity of cigarette demand by age, with a particular emphasis on
youth and young adults (Chaloupka, Hu, and others 2000; U.S.
DHHS 2000). Given that most smoking behavior becomes
firmly established during teenage years and young adulthood,
interventions that are effective in preventing smoking initiation
and the transition to regular, addicted smoking will have significant long-term public health benefits. Estimates from these
recent studies conclude that an inverse relationship exists
between price elasticity and age, with estimates for youth price
elasticity of demand up to three times those obtained for adults
(Gruber 2003; Ross, Chaloupka, and Wakefield 2001). Several
recent studies have begun to explore the differential effect of
cigarette prices on youth smoking uptake, concluding that
higher cigarette prices are particularly effective in preventing
young smokers from moving beyond experimentation into
regular, addicted smoking (Emery, White, and Pierce 2001;
Ross, Chaloupka, and Wakefield 2001).
In the United Kingdom and the United States, increases in
the price of cigarettes have had the greatest effect on smoking
among the lowest-income and least educated populations
(CDC 1994; Townsend, Roderick, and Cooper 1998).
Furthermore, it was estimated that smokers in U.S. households
below median income level are four times more responsive to
price increases than smokers in households above median
income level. In general, estimates of price elasticity for lowand middle-income countries are about double those estimated for high-income countries, implying that significant
increases in tobacco taxes in these countries would be effective
in reducing tobacco use.
Restrictions on Smoking
Over the past three decades, as the quantity and quality of
information about the health consequences of exposure to
passive smoking have increased, many governments, especially
in high-income countries, have enacted legislation restricting
smoking in a variety of public places and private worksites. In
addition, increased awareness of the consequences of passive
smoke exposure, particularly to children, has led many workplaces and households to adopt voluntary restrictions on
smoking. Although the intent of those restrictions is to reduce
nonsmokers’ exposure to passive tobacco smoke, the policies
also reduce smokers’ opportunities to smoke. Additional
reductions in smoking, especially among youths, will result
from the changes in social norms that are introduced by adopting these policies (U.S. DHHS 1994).
In Western populations, comprehensive restrictions on
cigarette smoking have been estimated to reduce population
Tobacco Addiction | 875
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77
smoking rates by 5 to 15 percent (see review by Woolery, Asma,
and Sharp 2000) and can also lead to changes in social norms
regarding smoking behavior, especially among youths. As with
higher taxes, these restrictions reduce both the prevalence of
smoking and cigarette consumption among current smokers.
Smoking bans in workplaces generally reduce the quantity of
cigarettes smoked by 5 to 25 percent and reduce prevalence
rates by up to 20 percent (Levy, Friend, and Polishchuk 2001).
No-smoking policies were most effective when strong social
norms against smoking helped make smoking restrictions selfenforcing.
Health Information and Counteradvertising
The 1962 report by the British Royal College of Physicians and
the 1964 U.S. Surgeon General’s Report were landmark tobaccocontrol events in high-income countries. These publications
resulted in the first widespread press coverage of the scientific
links between smoking and lung cancer. The reports were followed, in many countries, by policies requiring health warning
labels on tobacco products, which were later extended to
tobacco advertising.
Research from high-income countries indicates that these
initial reports and the publicity that followed about the health
consequences of smoking led to significant reductions in consumption, with initial declines of between 4 and 9 percent and
longer-term cumulative declines of 15 to 30 percent (Kenkel
and Chen 2000; Townsend 1993). Efforts to disseminate information about the risks of smoking and of other tobacco use in
low- and middle-income countries have led to similar declines
in tobacco use in those countries (Kenkel and Chen 2000). In
addition, mass media antismoking campaigns, in many cases
funded by earmarked tobacco taxes, have generated reductions
in cigarette smoking and other tobacco use (Kenkel and Chen
2000; Saffer 2000). Decreases in smoking prevalence were
largest in Western countries, where the public is constantly and
consistently reminded of the dangers of smoking by extensive
coverage of issues related to tobacco in the news media
(Molarius and others 2001).
In many low- and middle-income countries, a lack of awareness continues to exist about the risks of mortality and disease
posed by smoking. For example, a national survey in China in
1996 found that 61 percent of smokers thought that tobacco
did them “little or no harm” (Chinese Academy of Preventive
Medicine 1997). In high-income countries, smokers are aware
of the risks, but a recent review of psychological studies found
that few smokers judge the size of these risks to be higher and
more established than do nonsmokers, and that smokers minimize the personal relevance of these risks (Weinstein 1998).
Bans on Advertising and Promotion
Cigarettes are among the most heavily advertised and promoted products in the world. In 2002, cigarette companies
spent US$12.5 billion on advertising and promotion in the
United States alone, the highest spending level reported to date
(U.S. Federal Trade Commission 2004). Tobacco advertising
efforts worldwide include traditional forms of advertising on
television, radio, and billboards and in magazines and newspapers as well as favorable product placement; price-related
promotions, such as coupons and multipack discounts; and
sponsorship of highly visible sporting and cultural events.
Numerous econometric studies, largely from the United
Kingdom and the United States, have explored the relationship
between cigarette advertising and promotional expenditure
and cigarette demand. In general, these studies have resulted in
mixed findings, with most studies concluding that advertising
has a small positive effect on demand (Chaloupka, Hu, and
others 2000; Townsend 1993). However, critics of these studies
note that econometric methods, which estimate the effect of a
marginal change in advertising expenditures on smoking, are
ill suited for studying the effect of advertising (Chaloupka,
Hu, and others 2000; U.S. Federal Trade Commission 2004;
Townsend 1993). Approaches used by other disciplines, including survey research and experiments that assess reactions to
and recall of cigarette advertising, do support the hypothesis
that increases in cigarette advertising and promotion directly
and indirectly increase cigarette demand and smoking initiation (U.S. DHHS 1994; U.K. Department of Health 1992).
These studies conclude that cigarette advertising is effective in
getting and retaining children’s attention, with the strength
of the association strongly correlated with current smoking
behavior, smoking initiation, and smoking intentions.
Comprehensive advertising and promotion bans on cigarettes provide more direct evidence on the effect of advertising
these products (Saffer 2000). One study using data from
22 high-income countries for the period 1970 through 1992
provides strong evidence that comprehensive bans on cigarette
advertising and promotion led to significant reductions in cigarette smoking. The study predicts that a comprehensive set
of tobacco advertising bans in high-income countries could
reduce tobacco consumption by more than 6 percent, taking
into account price and non-price control interventions (Saffer
and Chaloupka 2000). However, the study concludes that partial bans have little effect on smoking behavior, given that the
tobacco industry can shift its resources from banned media to
other media that are not banned.
Smoking Cessation Treatments
Near-term reductions in smoking-related mortality depend
heavily on smoking cessation. Numerous behavioral smoking
cessation treatments are available, including self-help manuals,
community-based programs, and minimal or intensive clinical
interventions (U.S. DHHS 2000). In clinical settings,
pharmacological treatments, including nicotine replacement
876 | Disease Control Priorities in Developing Countries | Prabhat Jha, Frank J. Chaloupka, James Moore, and others
©2006 The International Bank for Reconstruction and Development / The World Bank
78
therapies (NRT) and bupropion, have become much more
widely available in recent years in high-income countries
through deregulation of some NRT from prescription to overthe-counter status (Novotny and others 2000; U.S. DHHS
2000). The evidence is strong and consistent that pharmacological treatments significantly improve the likelihood of quitting, with success rates two to three times those when pharmacological treatments are not used (Novotny and others 2000;
Raw, McNeill, and West 1999; U.S. DHHS 2000). The effectiveness of all commercially available NRT seems to be largely
independent of the duration of therapy, the setting in which
the therapy is provided, regulatory status (over-the-counter
versus prescribed therapy), and the type of provider (Novotny
and others 2000). Over-the-counter NRT without physician
oversight have been used in many countries for a number of
years with good success.
Although NRT are successful in treating nicotine addiction, the markets for NRT and other pharmacological therapies are more highly regulated and less affordable than are
nicotine-containing tobacco products. Recent evidence indicates that the demand for NRT is related to economic factors,
including price (Tauras and Chaloupka 2003). Policies that
decrease the cost of NRT and increase availability—such as
mandating private health insurance coverage of NRT, including such coverage in public health insurance programs, and
subsidizing NRT for uninsured or underinsured individuals—
would likely lead to substantial increases in the use of these
products. Given the demonstrated efficacy of NRT in treating
smoking, these policies could generate significant increases in
smoking cessation.
ment of antismuggling laws, and stronger penalties for those
caught violating these laws (Joossens and others 2000). Recent
analysis suggests that, even in the presence of smuggling,
tax increases will reduce consumption and increase revenue
(Merriman, Yurekli, and Chaloupka 2000).
In contrast to the effectiveness of demand-side interventions, there is much less evidence that interventions aimed at
reducing the supply of tobacco products are as effective in
reducing cigarette smoking (Jha and Chaloupka 1999, 2000a).
The U.S. experience provides mixed evidence about the effectiveness of limiting youth access to tobacco products in reducing youth tobacco use (U.S. DHHS 2000; Woolery, Asma, and
Sharp 2000). In addition, the effective implementation
and enforcement of these policies may require infrastructure
and resources that do not exist in many low- and middleincome countries. A preliminary discussion is occurring in
Canada about reducing its number of retail outlets for tobacco
from the current 65,000. Neither the effect of such a move nor
its enforcement costs are well known. Crop substitution and
diversification programs are often proposed as a means of
reducing the supply of tobacco. However, little evidence exists
that such programs would significantly reduce the supply of
tobacco, given that the incentives for growing tobacco tend to
attract new farmers who would replace those who abandon
tobacco farming (Jacobs and others 2000). Similarly, direct
prohibition of tobacco production is not likely to be politically
feasible, effective, or economically optimal. Finally, although
trade liberalization has contributed to increases in tobacco use
(particularly in low- and middle-income countries), restrictions on trade in tobacco and tobacco products that violate
international trade agreements or draw retaliatory measures
(or both) may be more harmful (Taylor and others 2000).
INTERVENTIONS TO REDUCE
THE SUPPLY OF TOBACCO
The key intervention on the supply side is the control of smuggling. Recent estimates suggest that 6 to 8 percent of cigarettes
consumed globally are smuggled (Merriman, Yurekli, and
Chaloupka 2000). Of note, the tobacco industry itself has an
economic incentive to smuggle, in part to increase market share
and decrease tax rates (Joossens and others 2000; Merriman,
Yurekli, and Chaloupka 2000). Although differences in taxes
and prices across countries create a motive for smuggling, a
recent analysis comparing the degree of corruption in individual countries with price and tax levels found that corruption
within countries is a stronger predictor of smuggling than is
price (Merriman, Yurekli, and Chaloupka 2000). Several governments are adopting policies aimed at controlling smuggling.
In addition to harmonizing price differentials between countries, effective measures include prominent tax stamps and
warning labels in local languages, better methods for tracking
cigarettes through the distribution chain, aggressive enforce-
EFFECTIVENESS AND COST-EFFECTIVENESS
OF TOBACCO-CONTROL INTERVENTIONS
Using a static model of the cohort of smokers alive in 2000, we
estimate the number of deaths attributable to smoking over the
next few decades that could be averted by (a) price increases,
(b) NRT, and (c) a package of non-price interventions other
than NRT. Cost-effectiveness of these policy interventions was
calculated by weighing the approximate public sector costs
against the years of healthy life saved, measured in DALYs. The
details of an earlier version of this model have been published
previously (Ranson and others 2002).
Results of Model Projections
The following is an updated analysis, using higher price
increases and a greater effectiveness for NRT than did the
Tobacco Addiction | 877
©2006 The International Bank for Reconstruction and Development / The World Bank
79
Table 46.3 Reductions in Future Tobacco Deaths among Smokers Alive in 2000 from Price Increases of 10 Percent, 33 Percent,
50 Percent, and 70 Percent by World Bank Region
Reduction in number of deaths (millions)
World Bank region
East Asia and the Pacific
Baseline
smoking-attributable
deaths (millions)
173
(percent)
Europe and Central Asia
51
(percent)
Latin America and the Caribbean
40
(percent)
Middle East and North Africa
13
(percent)
South Asia
62
(percent)
Sub-Saharan Africa
23
(percent)
Low- and middle-income countries
362
(percent)
High-income countries
81
(percent)
World
(percent)
443
10 percent
price increase
33 percent
price increase
50 percent
price increase
70 percent
price increase
Low
High
Low
High
Low
High
Low
High
2.9
8.7
9.6
27.5
14.5
37.5
20.3
46.2
(1.7)
(5.0)
(5.5)
(15.9)
(8.4)
(21.7)
(11.7)
(26.8)
0.9
2.6
2.8
8.1
4.3
11.2
6.0
13.8
(1.7)
(5.1)
(5.6)
(16.0)
(8.5)
(22.0)
(11.8)
(27.2)
0.7
2.1
2.3
6.7
3.5
9.5
4.9
11.6
(1.8)
(5.3)
(5.8)
(16.8)
(8.8)
(23.7)
(12.3)
(29.1)
0.2
0.7
0.8
2.2
1.2
3.1
1.6
3.8
(1.7)
(5.2)
(5.8)
(16.6)
(8.7)
(23.2)
(12.2)
(28.5)
0.9
2.6
2.9
8.5
4.4
12.5
6.2
16.0
(2.4)
(8.6)
(9.5)
(27.7)
(14.3)
(40.6)
(20.1)
(52)
0.4
1.1
1.3
3.7
1.9
5.5
2.7
6.6
(1.6)
(4.9)
(5.4)
(15.9)
(8.2)
(23.6)
(11.5)
(28.5)
6.0
17.9
19.7
56.8
29.8
79.2
41.7
98.2
(1.6)
(4.9)
(5.4)
(15.7)
(8.2)
(21.9)
(11.5)
(27.1)
0.6
2.6
2.1
8.5
3.2
12.2
4.5
16.2
(0.8)
(3.2)
(2.6)
(10.6)
(4.0)
(15.1)
(5.6)
(20.0)
6.6
20.5
21.8
65.3
33.0
91.5
46.2
114.3
(1.5)
(4.6)
(4.9)
(14.7)
(7.5)
(20.7)
(10.4)
(25.8)
Source: Authors’ calculations.
original (Ranson and others 2002). This analysis is conservative
in its assumptions about effectiveness and generous in its
assumptions about the costs of tobacco control.
Potential Effect of Price Increases. With a price increase of
33 percent, the model predicts that 22 million to 65 million
smoking-attributable deaths will be averted worldwide, which
is approximately equivalent to 5 to 15 percent of all smokingattributable deaths expected among those who smoke in 2000
(see table 46.3). Low- and middle-income countries account
for about 90 percent of averted deaths. East Asia and the Pacific
alone will account for roughly 40 percent of averted deaths.
Total smoking-attributable deaths averted worldwide range
from 33 million to 92 million for a 50 percent price increase
and 46 million to 114 million for a 70 percent price increase. A
70 percent price increase would avert 10 to 26 percent of all
smoking-attributable deaths worldwide.
Of the tobacco-related deaths that would be averted by a
price increase, 80 percent would be male, reflecting the higher
overall prevalence of smoking in men. The greatest relative
effect of a price increase on deaths averted is among younger
cohorts. Note that these projections use conservative price
increases. In certain countries, such as Poland and South
Africa, recent tax increases have doubled the real price of cigarettes (Guindon, Tobin, and Yach 2002).
Potential Effect of Nicotine Replacement Therapies.
Provision of NRT with an effectiveness of 1 percent is predicted
to result in the avoidance of about 3.5 million smokingattributable deaths (table 46.4). NRT of 5 percent effectiveness
would have about five times the effect. Again, low- and middleincome countries would account for roughly 80 percent of
the averted deaths. The relative effect of NRT (of 2.5 percent
effectiveness) on deaths averted is 2 to 3 percent among individuals age 15 to 59 and lower among those age 60 and older
(results not shown).
Potential Effect of Non-price Interventions Other Than NRT.
A package of non-price interventions, other than NRT, that
decreases the prevalence of smoking by 2 percent is predicted
to prevent about 7 million smoking-attributable deaths (more
than 1.6 percent of all smoking-attributable deaths among
those who smoked in 2000; see table 46.4). A package of interventions that decreases the prevalence of smoking by 10 percent would have an effect five times greater. Low- and middleincome countries would account for approximately four-fifths
878 | Disease Control Priorities in Developing Countries | Prabhat Jha, Frank J. Chaloupka, James Moore, and others
©2006 The International Bank for Reconstruction and Development / The World Bank
80
Table 46.4 Reductions in Future Tobacco Deaths among Smokers Alive in 2000 from Price Increases of 33 Percent, Increased
NRT Use, and a Package of Non-price Measures by World Bank Region
Reduction in number of deaths (millions)
World Bank region
East Asia and the Pacific
Baseline
smoking-attributable
deaths (millions)
173
(percent)
Europe and Central Asia
51
(percent)
Latin America and the Caribbean
40
(percent)
Middle East and North Africa
13
(percent)
South Asia
62
(percent)
Sub-Saharan Africa
23
(percent)
Low- and middle-income countries
362
(percent)
High-income countries
81
(percent)
World
(percent)
443
33 percent price increase
NRT effectiveness
Low elasticity
High elasticity
1 percent
9.6
27.5
1.4
(5.5)
(15.9)
2.8
8.1
(5.6)
5 percent
Non-price intervention
effectiveness
2 percent
10 percent
6.9
2.8
13.8
(0.8)
(4.0)
(1.6)
(8.0)
0.4
2.1
0.8
4.1
(16.0)
(0.8)
(4.0)
(1.6)
(8.1)
2.3
6.7
0.3
1.7
0.7
3.4
(5.8)
(16.8)
(0.8)
(4.2)
(1.7)
(8.5)
0.8
2.2
0.11
0.6
0.2
1.1
(5.8)
(16.6)
(0.8)
(4.2)
(1.7)
(8.4)
2.9
8.5
0.4
2.2
0.9
4.3
(9.5)
(27.7)
(1.4)
(7.2)
(2.8)
(13.9)
1.3
3.7
0.2
0.9
0.4
1.8
(5.4)
(15.9)
(0.8)
(4.0)
(1.6)
(7.9)
19.7
56.8
2.9
14.3
5.7
28.6
(5.4)
(15.7)
(0.8)
(4.0)
(1.6)
(7.9)
2.1
8.5
0.6
3.1
1.2
6.1
(2.6)
(10.6)
(0.8)
(3.8)
(1.5)
(7.6)
21.8
65.3
3.5
17.4
6.9
34.7
(4.9)
(14.8)
(0.8)
(3.9)
(1.6)
(7.8)
Source: Authors.
of quitters and averted deaths. The greatest relative effect of
non-price interventions on deaths averted would be among
younger cohorts.
Figure 46.5 summarizes the potential effect of a set of
independent tobacco-control interventions, using 33 and
70 percent price increases (using a high elasticity of ⫺1.2 for
low- and middle-income regions and ⫺0.8 for high-income
regions), a 5 percent effectiveness of NRT, and a 10 percent
reduction from non-price interventions other than NRT. In
this cohort of smokers alive in 2000, approximately 443 million are expected to die in the next 50 years in the absence
of interventions. A substantial fraction of these tobacco
deaths are avoidable with interventions. Price increases have
the greatest effect on tobacco mortality, with the most
aggressive price increase of 70 percent having the potential
to avert almost one-quarter of all tobacco deaths. Even a
modest price increase of 33 percent could potentially
prevent 66 million tobacco deaths over the course of the
next 50 years. Although NRT and other non-price interventions are less effective than price increases, they can still
avert a substantial number of tobacco deaths (18 million
and 35 million deaths, respectively). The greatest effect of
these tobacco-control interventions would occur after 2010,
but a substantial number of deaths could be avoided even
before then.
Tobacco deaths (millions)
400
443
425
408
377
Death year 2030: 10 million
deaths per year
300
328
versus
7 million deaths
per year
200
100
0
2000
2010
2020
Baseline
NRT with 5 percent
effectiveness
Non-price interventions
with 10 percent reduction
2030
2040
2050
33 percent price increase
70 percent price increase
Source: Authors.
Note: Price increases assume a high price elasticity (–1.2 for low- and
middle-income countries and –0.8 for high-income countries).
Figure 46.5 Potential Effect of Tax Increases, NRT, and Non-price
Interventions on Tobacco Mortality, 2000–50
Tobacco Addiction | 879
©2006 The International Bank for Reconstruction and Development / The World Bank
81
Note that no attempt has been made in this analysis to
examine the effect of combining the various packages of interventions (for example, price increases with NRT, or NRT and
other non-price interventions). A number of studies have compared the effect of price and non-price interventions; few
empirical attempts have been made to assess how these interventions might interact. Although price increases have been
found in this analysis to be the most cost-effective antismoking
intervention, policy makers should use both price and nonprice interventions to counter smoking. Non-price measures
may be required to affect the most heavily dependent smokers,
for whom medical and social support in stopping will be necessary. Furthermore, these non-price measures may be effective
in increasing social acceptance and support of tobacco price
increases.
Cost-Effectiveness of Antismoking Interventions. In general,
price increases are found to be the most cost-effective antismoking intervention. A 33 percent price increase (our base
case scenario) could be achieved for a cost of US$13 to US$195
per DALY saved globally, or US$3 to US$42 in low-income
countries and US$85 to US$1,773 in high-income countries.
Wider access to NRT could be achieved for between US$75 and
US$1,250 per DALY saved, depending on which assumptions
are used. Non-price interventions other than NRT could be
implemented for between US$233 and US$2,916 per DALY
saved (table 46.5). Thus, NRT and other non-price measures
are slightly less cost-effective than price increases but remain
cost-effective in many settings. The cost-effectiveness of NRT is
highly sensitive to the actual price of the NRT. NRT with a price
of US$25 have a cost-effectiveness of US$75 per DALY compared with US$329 for an NRT price of US$150 (data not
shown).
For a given set of assumptions, the variation in the costeffectiveness of each intervention between low- and middleincome regions is relatively small and sensitive to the discount
rate (data not shown). All three interventions are most costeffective in South Asia and Sub-Saharan Africa. The difference
between low- and middle-income countries and high-income
countries is more pronounced. For NRT, the cost per year of
healthy life gained is 3 to 10 times higher in high-income countries than elsewhere. For non-price interventions other than
NRT, the cost in high-income countries is 22 times higher, and
for price increases, almost 42 times higher. Of note, the estimates of cost-effectiveness are given as wide ranges,which reflect
the range of assumptions used.
For price increases, the high-end estimates are roughly 25
times the low-end estimates, and this difference is consistent
among the regions. For NRT, the high-end estimates are 2.5 to
10 times the low-end estimates, varying among the regions. For
non-price interventions other than NRT, the high-end estimates are 20 times the low-end estimates, and this difference is
consistent among the regions.
The cost-effectiveness results can be compared against existing studies only for high-income countries because of a lack
of studies situated elsewhere. Our estimates of deaths avoided
for a 10 percent price increase are conservative compared with
those of Moore (1996) and Warner (1986).
Table 46.5 Range of Cost-Effectiveness Values for Price Increase, NRT, and Non-price Interventions, 2000
(2002 U.S. dollars per DALY saved)
World Bank region
East Asia and the Pacific
Baseline
smoking-attributable
deaths (millions)
173
33 percent price
increase
NRT with
effectiveness of
1 to 5 percent
Non-price interventions
with effectiveness of
2 to 10 percent
Low-end
estimate
High-end
estimate
Low-end
estimate
High-end
estimate
Low-end
estimate
High-end
estimate
2
30
65
864
40
498
Europe and Central Asia
51
3
42
45
633
55
685
Latin America and the Caribbean
40
6
85
53
812
109
1,361
Middle East and North Africa
13
6
89
47
750
115
1,432
South Asia
62
2
27
54
716
34
431
Sub-Saharan Africa
Low- and middle-income countries
High-income countries
World
23
2
26
42
570
33
417
362
3
42
55
761
54
674
81
85
1,773
175
3,781
1,166
14,572
443
13
195
75
1,250
233
2,916
Source: Authors.
880 | Disease Control Priorities in Developing Countries | Prabhat Jha, Frank J. Chaloupka, James Moore, and others
©2006 The International Bank for Reconstruction and Development / The World Bank
82
COMPREHENSIVE TOBACCO-CONTROL
PROGRAMS
In recent years, several governments, mostly in high-income
countries, have adopted comprehensive programs to reduce
tobacco use, often funded by earmarked tobacco tax revenues.
The programs generally have similar goals for reducing tobacco
use:
•
•
•
•
preventing initiation among youths and young adults
promoting cessation among all smokers
reducing exposure to passive tobacco smoke
identifying and eliminating disparities among population
subgroups (U.S. DHHS 1994).
Furthermore, the programs have one or more of four key
components: community interventions engaging a diverse set
of local organizations; countermarketing and health information campaigns; program policies and regulations (such as
taxes, restrictions on smoking, bans on tobacco advertising,
and access to better cessation treatments); and surveillance and
evaluation of potential issues, such as smuggling (U.S. DHHS
1994). Programs have placed differing emphasis on these four
components, with substantial diversity among the types of
activities supported within each component. Disaggregating
current tobacco-control program spending reveals that the
greatest effect can be achieved through a focus on macro-level
changes, such as policy change. Recent analyses from the
United Kingdom and United States clearly indicate that these
comprehensive efforts have been successful in reducing tobacco
use and in improving public health (Farrelly, Pechacek, and
Chaloupka 2003; Townsend, Roderick, and Cooper 1998; U.S.
DHHS 1994). In California, for example, the state’s comprehensive tobacco-control program has produced a rate of
decline in tobacco use double that seen in the rest of the United
States.
The cost of implementing control programs is low.
Table 46.6 provides the estimated total costs of implementing
price and NRT interventions by World Bank region. Current
estimates of the costs of implementing a comprehensive
tobacco-control program range from US$2.50 to US$10 per
capita in the United States. The U.S. Centers for Disease
Control and Prevention recommends spending US$6 to US$16
per capita for a comprehensive tobacco-control program in the
United States (CDC 1999). Canadian spending on tobaccocontrol programs was approximately US$1.70 per capita in
1996 (Pechmann, Dixon, and Layne 1998). At the highest recommended spending level (US$16 per capita) in the United
States, annual funding for a comprehensive tobacco program
would equal only 0.9 percent of U.S. public spending, per
capita, on health.
Evidence from the United States demonstrates that states
with the greatest prevalence of smoking have a greater marginal
effect with their tobacco-control spending, suggesting that the
potential gains from modest investments in comprehensive
tobacco-control measures are large. Each US$10 spent per
capita on tobacco control annually has resulted in a 55 percent
reduction (variation of 20 to 70 percent) in per capita cigarette
consumption (Tauras and others 2005). In the United States,
US$10 translates into 0.03 percent of per capita GDP in 2003.
Table 46.6 Estimated Cost of Price Intervention and NRT Programs
(2002 U.S. dollars)
Cost of NRT (US$25 to US$150) (millions)
Cost for price increase (millions)
World Bank region
East Asia and the Pacific
GDP (billions)
Low-end estimate
(0.02 percent GDP)
1,802
360
High-end estimate
(0.05 percent GDP)
901
To treat 1 percent of
current smokers
To treat 5 percent of
current smokers
US$25
US$50
US$150
US$25
US$50
US$150
1,079
2,158
6,474
5,395
10,791
32,372
Europe and Central Asia
1,136
227
568
318
635
1,906
1,588
3,176
9,529
Latin America and the Caribbean
1,673
335
836
250
500
1,500
1,250
2,500
7,499
Middle East and North Africa
694
139
347
84
169
506
422
843
2,530
South Asia
655
131
327
2,312
1,926
3,853
11,558
2,312
1,926
Sub-Saharan Africa
319
64
159
868
723
1,447
4,340
868
723
6,279
1,256
3,138
4,911
6,111
15,686
24,553
20,490
54,579
High-income countries
25,992
5,198
12,996
3,034
2,529
10,114
15,172
3,034
2,529
World
32,271
6,454
16,134
7,945
8,640
25,800
39,725
23,524
57,108
Low- and middle-income countries
Source: Authors.
Tobacco Addiction | 881
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83
CONSTRAINTS TO EFFECTIVE
TOBACCO-CONTROL POLICIES
Although substantial evidence exists concerning the effectiveness of numerous policy interventions to reduce tobacco use,
the use of these interventions globally is uneven and limited
(see a more formal analysis in Chaloupka and others 2001).
World Bank data reveal that ample room exists to increase
tobacco taxes. In 1995, the average percentage of all government revenue derived from tobacco tax was 0.63 percent.
Middle-income countries averaged 0.51 percent of government revenue from tobacco taxes, while lower-income countries averaged only 0.42 percent. An increase in cigarette taxes
of 10 percent globally would raise cigarette tax revenues by
nearly 7 percent, with relatively larger increases in revenues
in high-income countries and smaller increases in revenues in
low- and middle-income countries (Sunley, Yurekli, and
Chaloupka 2000). Despite this evidence, price increases have
been underused. Guindon, Tobin, and Yach (2002) studied 80
countries and found that the real price of tobacco, adjusted for
purchasing power, fell in most developing countries from 1990
to 2000.
Why does so much variation exist in tobacco-control
policies? The political economy of tobacco control has been
inadequately studied. A few plausible areas of interest are outlined here. First, the recognition of tobacco as a major health
hazard appears to be the impetus for most of the tobaccocontrol policies in many high-income countries. Some evidence shows that improved national capacity and local needs
assessment could increase the likelihood that tobacco-control
measures will be adopted. For example, econometric analyses
in South Africa geared to local policy requirements substantially
increased the willingness of the government to implement
tobacco-control policies (Abedian and others 1998). Second,
tobacco-control budgets are only a fraction of what is required.
Funding is needed not so much to implement programs as to
fight off tobacco industry tactics and to build popular support
for control. Third, the most obvious constraint to tobacco
control is political opposition, which is difficult to quantify.
Opposition from the tobacco industry is well organized and
well funded (Pollock 1996).
A key tool for addressing political opposition is earmarking
tobacco taxes. Earmarking has been successfully used in several
countries, including Australia, Finland, Nepal, and Thailand.
Of the 48 countries currently in the World Health
Organization’s European region, 12 earmark taxes for tobacco
control and other public health measures. The average level of
allocation is less than 1 percent of total tax revenue (WHO
2002). Earmarking does introduce clear restrictions and inefficiencies on public finance, and for this reason alone most
macroeconomists do not favor earmarking, no matter how
worthy the cause. However, analysis suggests that the efficiency
or “dead-weight losses” from earmarking tobacco taxes are
minimal (Hu, Xu, and Keeler 1998). Furthermore, earmarking
tobacco taxes can be justified if governments use the funds to
benefit those who pay (the benefits principle), provide assured
funding for tobacco-control policies and programs, and secure
public support for new or higher tobacco taxes. Earmarked
taxes also have a political function in that they help concentrate
political winners of tobacco control and thus influence policy.
Earmarked funds that support broad health and social services
(such as other disease programs) broaden the political and civil
society support base for tobacco control. In Australia, broad
political support from the Ministries of Sports and Education
helped convince the Ministry of Finance that raising tobacco
taxes was possible. Indeed, after an earmarked tax was passed,
the Ministry of Finance went on to raise tobacco taxes further
without earmarking (Galbally 1997). Additionally, targeting
revenue from tobacco taxes to other health programs for the
poorest socioeconomic groups could produce double health
gains—reduced tobacco consumption combined with
increased access to and use of health services. In China, a
10 percent increase in cigarette taxes would decrease consumption by 5 percent and would increase government revenue by
5 percent. The increased earnings could finance a package of
essential health services for one-third of China’s poorest
100 million citizens in 1990 (Saxenian and McGreevey 1996).
Finally, a key pillar in tobacco control that can help overcome some of these constraints is the Framework Convention
on Tobacco Control (FCTC). The World Health Assembly
of the World Health Organization adopted the FCTC in
May 2003. It consists of a series of negotiated protocols within
a general framework. The first three protocols are negotiations
covering smuggling, advertising, and treatment of tobacco
addiction. Countries agreeing to the negotiated protocols are to
adopt appropriate legislation and, if necessary, implement the
appropriate measures. As of February 2005, 168 countries had
signed the FCTC, 57 had ratified it, and it had come into force
on February 27, 2005.
CONCLUSION
Worldwide, only two large and growing causes of death exist.
One is HIV-1 infection, and the other is tobacco. On current
consumption patterns, about 1 billion people in the 21st
century will be killed by their addiction to tobacco. Strong
evidence shows that tobacco tax increases, the dissemination
of information about health risks from smoking, restrictions
on smoking in public places and workplaces, comprehensive
bans on advertising and promotion, and increased access to
cessation therapies are effective both in reducing tobacco use
and in improving the health of populations. Despite this
evidence, these policies, especially higher taxes, have been
882 | Disease Control Priorities in Developing Countries | Prabhat Jha, Frank J. Chaloupka, James Moore, and others
©2006 The International Bank for Reconstruction and Development / The World Bank
84
applied aggressively only in a few high-income countries, covering a small proportion of the world’s smokers. Limited
implementation of effective tobacco control in developing
countries is due to political constraints as well as the lack of
awareness of the unique effectiveness and cost-effectiveness
of these interventions.
ACKNOWLEDGMENTS
We thank Allison Gilbert for help with the cost-effectiveness
analyses and Hellen Gelband, Andra Ghent, and Dhirendra
Sinha for comments.
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Chapter 47
Alcohol
Jürgen Rehm, Dan Chisholm, Robin Room, and Alan D. Lopez
This chapter provides an overview of epidemiology of alcohol use and health consequences as well as introducing costeffectiveness interventions to reduce alcohol-related harm.
EPIDEMIOLOGY OF ALCOHOL USE AND
ALCOHOL-RELATED DISEASE CONDITIONS
Alcoholic beverages and the problems they engender have
been familiar fixtures in human societies since the beginning
of recorded history. Because alcohol is causally related to
more than 60 International Classification of Diseases codes
(Rehm, Room, Graham, and others 2003), disease outcomes
are among the most important alcohol-related problems.
Depending on the pattern of consumption, alcohol is also
protective against diseases, most important among them,
coronary heart disease (Rehm, Sempos, and Trevisan 2003).
However, the net effect is negative, and 4 percent of the global
burden of disease is attributable to alcohol, or about as much
death and disability globally as is attributable to tobacco and
hypertension (Ezzati and others 2002; WHO 2002). Alcohol
thus constitutes a serious public health problem (Room,
Babor, and Rehm 2005). Evidence-based preventive measures
are available at both the individual and the population levels,
with alcohol taxes, restrictions on alcohol availability, and
drinking-and-driving countermeasures among the most
effective policy options (Babor and others 2003). This chapter
reviews the cost-effectiveness of different interventions in
developing regions of the world.
Dimensions of Alcohol Related to Disease
The relationship between alcohol consumption and health and
social outcomes is complex and multidimensional (Rehm and
others 2004). As figure 47.1 shows, alcohol consumption is
linked to acute and long-term health and social consequences
through three intermediate mechanisms—toxic and beneficial
biochemical effects, intoxication, and dependence (Babor and
others 2003; Rehm, Room, Graham, and others 2003)—as
follows:
• Toxic and beneficial biochemical effects. These effects of
alcohol consumption may influence chronic disease in
either beneficial or harmful ways. Accepted beneficial effects
include the influence of moderate drinking on coronary
heart disease through reduction of plaque deposits in arteries, protection against blood clot formation, and promotion
of blood clot dissolution (Zakhari 1997). Examples of
harmful effects include increased risk for high blood pressure and for liver damage (Rehm, Room, Graham, and
others 2003) and direct toxic effects on acinar cells triggering pancreatic damage (Apte, Wilson, and Korsten 1997) or
hormonal disturbances (Emanuele and Emanuele 1997).
These are just examples, because alcohol exposure is associated with a multitude of toxic effects on different organs.
• Intoxication. Alcohol intoxication is a powerful mediator for
acute health outcomes, such as accidental or intentional
injuries or deaths, although intoxication can also be implicated in chronic health and social problems and in certain
forms of heart disease. The subjective feeling of intoxication
is mainly caused by the effects of alcohol on the central
nervous system, and these effects are felt and can be measured even at light to moderate consumption levels (Eckardt
and others 1998).
• Dependence. Alcohol dependence is a clinical disorder in its
own right, but it is also a powerful mechanism sustaining
alcohol consumption and mediating its impact on both
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Patterns of
drinking
Average
volume
in terms of high-risk drinking occasions and also in terms of
drinking in public settings and the proportion of drinking that
occurs outside of meals (for further details, see Rehm and
others 2004).
Epidemiology of High-Risk Alcohol Use
Toxic and
beneficial
biochemical
effects
Chronic
disease
Intoxication
Dependence
Accidents and
injuries
(acute disease)
Acute social
and
psychological
problems
Chronic social
and
psychological
problems
Source: Adapted from Babor and others 2003.
Figure 47.1 Model of Alcohol Consumption, Intermediate Outcomes,
and Long-Term Consequences
chronic and acute physiological and social consequences of
alcohol (Drummond 1990). In the quantitative analyses
reported in this chapter, alcohol dependence—and alcoholuse disorders (AUDs) in general—will be considered only as
a health outcome related to high-risk alcohol use.
This chapter, including the section on the cost-effectiveness
of interventions, focuses primarily on health consequences,
although later it briefly discusses the social consequences of
high-risk drinking and recommended interventions. The epidemiological calculations are taken from Ezzati and others’
(2002) comparative risk analysis (CRA) and the World Health
Organization (WHO) assessment of the global burden of disease (WHO 2002). (For further information, see Mathers and
others 2003; Rehm, Rehn, and others 2003; Rehm, Room,
Graham, and others 2003; Rehm, Room, Monteiro and others
2003; Rehm and others 2004). The CRA defines alcohol exposure using two measures: the average volume of alcohol consumption and patterns of drinking (figure 47.1). It then relates
these exposure measures to disease outcomes.
The average volume of consumption has been the conventional measure of exposure in alcohol epidemiology (Bruun
and others 1975) and has been linked to many disease categories following the seminal work of English and others (1995;
see also Rehm, Room, Graham, and others 2003). Patterns of
drinking have been linked mainly to two categories of disease
outcome: acute effects of alcohol (such as accidental and intentional injuries) and cardiovascular outcomes (mainly coronary
heart disease). The CRA defines patterns of drinking primarily
The intervention analyses presented in this chapter focus on
average high-risk drinking, although patterns of drinking were
also incorporated into the disease burden calculations. Highrisk drinking is defined in sex-specific terms as drinking
20 grams per day or more of pure alcohol on average for
females and 40 grams per day or more of pure alcohol on average for males (a bottle of table wine contains about 70 grams of
pure alcohol). This definition of high-risk drinking is fairly
standard in alcohol epidemiology and was first introduced by
English and others (1995) on the basis of Australian guidelines.
Originally, English and others (1995) used two categories: hazardous drinking (defined as drinking between 20 and 40 grams
per day of pure alcohol on average for females and between 40
and 60 grams per day of pure alcohol for males) and harmful
drinking (defined as drinking 40 grams per day or more of pure
alcohol on average for females and 60 grams per day or more of
pure alcohol on average for males). These categories have been
used in almost every comprehensive meta-analysis on alcohol
and disease since 1995 (see Rehm, Room, Graham, and others
2003 for an overview). However, critics asserted that the terms
hazardous drinking and harmful drinking were not neutral;
thus, the CRA uses drinking categories II and III, referring to
the term high-risk drinking when both categories are considered together. High-risk drinking thresholds differ by sex
because the risk for chronic disease is related to lower volumes
of drinking for women than for men; thus, the thresholds for
high-risk drinking were set to reflect an approximately similar
risk of chronic disease.
Table 47.1 shows the distribution of high-risk drinking by
age and by World Bank region. The table excludes the Middle
East and North Africa because prevalence rates of high-risk
drinking are considerably lower than 1 percent and this situation is unlikely to change in the near future.
Calculating the burden of high-risk alcohol use that is
avertable by means of effective interventions requires additional
epidemiological data—in particular, rates of incidence to and
remission from high-risk alcohol use and the relative fatality of
high-risk alcohol users compared with non-high-risk alcohol
users. We derived remission rates from studies of natural
recovery from alcohol problems, which found an average of
10.9 years to remission (Sobell, Ellingstad, and Sobell 2000),
with an adjustment of plus 20 percent for older age groups and
minus 20 percent for younger age groups. We set the relative risk
of mortality for high-risk alcohol users age 15 to 44 at 2.5 and the
relative risk for older age groups at 1.3 for men and 1.4 for women
(Gmel, Gutjahr, and Rehm 2003; Rehm, Gutjahr, and Gmel
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Table 47.1 Prevalence of High-Risk Drinking by Gender, Age Group, and Region, 2000
(percentage of the population)
Age group (years)
Region
Gender
15–29
30–44
45–59
60–69
70ⴙ
Europe and Central Asia
Male
Female
20.8
11.2
18.7
10.4
21.4
11.5
15.2
7.9
8.1
5.7
Latin America and the Caribbean
Male
Female
9.7
6.8
11.1
7.5
10.6
6.5
7.9
5.8
3.4
3.1
Sub-Saharan Africa
Male
Female
10.4
3.1
14.3
4.7
12.9
5.1
11.3
3.2
8.4
2.2
East Asia and the Pacific
Male
Female
6.2
0.3
7.5
0.2
7.1
0.1
6.5
0.1
5.0
0.0
South Asia
Male
Female
0.8
1.2
2.5
0.4
0.3
0.4
0.1
0.0
0.0
0.0
High-income countries
Male
Female
18.0
10.9
17.9
8.7
16.2
9.8
10.9
6.8
7.6
5.4
Source: Authors’ calculations based on Rehm, Rehn, and others 2003 and Rehm and others 2004.
Note: The criteria for high-risk drinking were set sex specific (for details see text).
2001). Using WHO disease-modeling software, we derived an
internally consistent epidemiological profile of current high-risk
alcohol use in each region, including specifications of incidence
and the relative risk of mortality, with currently observed rates of
prevalence, remission, and risk of mortality as inputs. A final
input parameter is the disability level for high-risk alcohol use,
which we estimated at 0.154 (where zero equals no disability);
this is a weighted average based on the severity breakdown of
high-risk drinkers from the CRA (80 percent category II, or
hazardous; 20 percent category III, or harmful). The preference
values for these health states of 0.11 and 0.33, respectively, are
derived from Stouthard, Essink-Bot, and Bonsel (2000).
Relationship between High-Risk Drinking and AUDs
Assessing the relationship between high-risk drinking and
AUDs is not a straightforward exercise. Even though high-risk
drinking over a long period entails the risk of AUDs, that all
people with AUDs are also high-risk drinkers does not automatically follow. First, neither the definition of alcohol dependence nor WHO’s (1993) definition of harmful use includes
actual consumption levels. An individual is considered dependent if at least three of the following criteria apply:
• strong desire or compulsion to take the substance
• impaired control and physiological withdrawal if the substance is reduced or ceased
• tolerance to the effects of the substance
• preoccupation with use of the substance
• persistent use despite clear evidence of harmful consequences.
By contrast, harmful alcohol use is defined as a pattern of
use that is causing damage to physical or mental health. Thus,
whereas many of these criteria are associated with high-risk
alcohol use, no strict classificatory rule indicates that people
with AUDs are a subcategory of high-risk drinkers.
Second, the prevalence of AUDs is often derived from surveys, where the operationalization usually requires that three
symptoms be present in a lifetime and at least one of these criteria be present within the past 12 months (see, for example,
Demyttenaere and others 2004, table 2). Thus individuals may
be categorized as alcohol dependent even if they are currently
abstaining from alcohol.
Third, qualitative studies across a wide range of cultures
have found that the criteria used for diagnosing AUDs often
have different meanings and implications in different cultural
settings (Room and others 1996; Schmidt and Room 1999). For
instance, in the United States over the past decade, the level of
reported AUDs increased despite decreases in high-risk drinking (Grant and others 2004). This fact has been explained in
terms of changes in drinking norms and social attitudes during
a period when the United States has become a “drier” culture.
Thus, the measurement of AUDs is quite complex and culturally dependent. Moreover, AUDs are only one outcome of alcohol consumption and, in many parts of the world, not the most
important one. As a result, we decided to focus on high-risk
alcohol consumption rather than AUDs.
Relationship between Alcohol Use and
Disease Categories
The exact procedures for quantifying the risk of disease attributable to alcohol are described in detail elsewhere (Rehm,
Room, Graham, and others 2003; Rehm and others 2004).
For most chronic disease categories, investigators have derived
alcohol-attributable fractions of disease by combining
Alcohol | 889
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prevalence and relative risk estimates based on meta-analyses
(Corrao and others 2000; English and others 1995; Gutjahr,
Gmel, and Rehm 2001; Ridolfo and Stevenson 2001; Single
and others 1996, 1999). For depression, we drew alcoholattributable fractions from mental health surveys, looking at
the rates of comorbidity and the order of onset of depression
and alcohol disorders. For coronary heart disease, we modeled
the interaction of average volumes and patterns of drinking
based on multilevel analyses that include temporal information as covariates (Gmel, Rehm, and Frick 2003; Rehm and
others 2004). For the final estimates, we based alcoholattributable fractions on these multilevel results for all countries,
except for developed countries with relatively favorable drinking
patterns (Australia, Japan, and countries in North America and
Western Europe), which are not discussed here because the focus
is on developing countries. For injuries, we took a similar multilevel approach to quantify the interaction of the average volume
of consumption and patterns of drinking in determining
alcohol-attributable fractions (Rehm and others 2004).
Thus the analysis includes the following major disease
categories:
• chronic disease
º cancer (mouth and oropharyngeal, esophageal, liver,
female breast)
º neuropsychiatric diseases (AUDs, unipolar major depression, epilepsy)
º diabetes
º cardiovascular diseases (hypertensive diseases, coronary
heart disease, stroke)
º gastrointestinal diseases (cirrhosis of the liver)
º conditions arising during the perinatal period (low
birthweight)
• injury
º unintentional injury (motor vehicle accidents, drowning,
falls, poisonings, other unintentional injuries)
º intentional injury (self-inflicted injuries, homicide, other
intentional injuries).
We did not include other disease categories that are clearly
alcohol-related, such as fetal alcohol syndrome, because the
current analysis was based on the CRA and was, thus, limited
to the global burden-of-disease categories.
Social Determinants of Exposure and Risk
Alcohol-specific risks to health are in part determined and
modified by social determinants. For example, Harrison and
Gardiner (1999) find that for men age 25 to 69 in England and
Wales in 1988–94, those in the lowest socioeconomic status
category, unskilled labor, had a 15-fold greater risk for alcoholrelated mortality than professionals in the highest category
had. These differences cannot be explained by the overall volume of drinking, which actually tended to be greater for those
in higher socioeconomic groups. Rather, the differences can be
explained by the fact that more of the drinking of those in
lower socioeconomic status categories is in high-risk patterns;
that is, depending on the use values for drinking in the culture,
poor drinkers may see little point in wasting resources on
drinking that is not to intoxication. Poorer drinkers are also
likely to be less protected physically and socially from possible
harm arising from drinking, such as injuries and chronic and
infectious diseases. Mäkelä (1999) finds that multiple dimensions of socioeconomic status are required to capture all the
adverse interactions of socioeconomic status with alcoholrelated mortality.
A critical macroeconomic question is how a country’s level
of economic development is related to alcohol-related risks to
health. The impact of alcohol on disease and mortality may be
more potent in countries with greater poverty and nutritional
deficiencies (Isichei, Ikwuagu, and Egbuta 1993; Room and
others 2002, 119–30). However, most of the risk relationships
between alcohol and disease have been derived from studies in
established market economies, and the extent of systematic
research is currently insufficient to allow quantification of this
phenomenon. As a result, the estimated disease burden cited
here may be considered as a lower-bound estimate of the actual
alcohol-attributable disease burden in developing countries.
BURDEN OF DISEASE RELATED TO HIGH-RISK
ALCOHOL USE
In the following sections, the procedures to estimate alcoholrelated burden of disease are described, as well as the limitations of the used approach.
Determining the Alcohol-Related Burden of Disease
Table 47.2 breaks down alcohol-attributable disability-adjusted
life years (DALYs) by disease category and World Bank region
using a constant 3 percent per year discount rate, but with no
age weighting. Results differ from those of the CRA (Ezzati and
others 2002; Rehm and others 2004; WHO 2002) because of
the use of non-age-weighted DALYs.1
Determining the Burden of Disease Related to High-Risk
Alcohol Consumption
In determining the burden of disease related to high-risk alcohol consumption, we first divided the burden of disease
between chronic and acute disease. For chronic disease, we
assume that almost the entire disease burden reported in the
CRA is associated with high-risk alcohol use. Indeed, the overall disease burden in the CRA is an underestimate, because
drinking up to 20 grams per day of pure alcohol by females and
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92
Table 47.2 Alcohol-Attributable DALYs by Disease Category and World Bank Region, 2001
(thousands of DALYs)
Disease category
Europe
and
Central Asia
Latin America
and the
Caribbean
Sub-Saharan
Africa
Middle East
and North
Africa
East Asia
and the
Pacific
South
Asia
High-income
countries
World
Chronic disease
Maternal and perinatal
conditions
12
7
39
1
2
29
6
105
526
296
635
25
2,820
189
1,103
5,594
Neuropsychiatric
2,159
3,315
1,035
89
4,726
1,444
4,752
17,600
Vascular
2,639
926
556
40
1,751
1,199
⫺2,488
5,209
Other noncommunicable
diseases
1,175
739
504
27
997
306
1,153
5,126
Subtotal chronic disease
6,511
5,283
2,769
182
10,296
3,167
4,526
33,634
Unintentional
4,127
1,984
2,308
135
3,613
2,222
1,753
15,619
Intentional
1,822
1,872
1,074
9
927
567
571
6,755
Cancer
Injury
Subtotal injury
Total DALYs attributable
to alcohol
Total DALYs from all diseases
Proportion of DALYs
attributable to alcohol (percent)
5,949
3,856
3,382
144
4,540
2,789
2,324
22,374
12,460
9,139
6,151
326
14,836
5,956
6,850
56,008
116,502
104,287
344,754
65,570
346,225
408,655
149,161
1,535,871
10.7
8.8
1.8
0.5
4.3
1.5
4.6
3.6
Source: Authors’ calculations based on Rehm and others 2004 and WHO 2002.
Note: Negative DALYs can occur because certain patterns of alcohol have cardio-protective effects.
up to 40 grams per day of pure alcohol by males is globally
associated with a net beneficial effect in relation to chronic disease. However, this effect occurs mainly in countries with moderate drinking patterns (Rehm, Sempos, and Trevisan 2003),
which tend to be high-income countries (Rehm, Rehn, and
others 2003). Although high-risk but regular drinking patterns
may also have some beneficial effects, such effects are not
important in countries with binge drinking patterns. (For the
association between alcohol and coronary heart disease, see
McKee and Britton 1998; Puddey and others 1999; Rehm,
Sempos, and Trevisan 2003; for consequences on modeling the
regional burden of disease, see Rehm and others 2004.)
For injuries, which are considered to be acute outcomes, we
started by separating out the proportion of injury not caused
by high-risk drinking, which we accomplished by assuming
that injuries are linearly related to per capita consumption
(Rehm and others 2004).2 This assumption is probably conservative, because high-risk drinkers in countries with binge
drinking patterns are likely to have more frequent and intensive
drinking occasions, and the risk of injury usually rises
logarithmically with the amount of drinking on a specific occasion (see, for example, National Highway Traffic Safety
Administration 1992). Following this initial calculation, we
could calculate the proportion of per capita consumption
related to high-risk drinking in each region, thereby determining the proportion of injury caused by high-risk drinking
(table 47.3). Together with our calculation of the chronic
disease burden attributable to high-risk alcohol use, this percentage enabled us to estimate the overall disease burden
attributable to high-risk alcohol use: whereas 3.6 percent of the
global burden was attributable to alcohol drinking generally,
2.8 percent was attributable to high-risk drinking.
Limitations of the CRA Approach
The CRA’s estimates of the global and regional alcohol-related
burden of disease are based on a number of assumptions, of
which the following are the most crucial:
• The estimates of per capita consumption and unrecorded
consumption for different countries do not contain substantial measurement error.
• The distribution of consumption as derived from surveys is
similar to actual distribution in the population.
• The relationships between alcohol and chronic disease
derived from meta-analyses of cohort and case-control
studies are stable among countries and regions.
Alcohol | 891
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93
Table 47.3 DALYs Attributable to High-Risk Average Alcohol Consumption by Disease Category and Region, 2001
(thousands of DALYs)
Disease category
Europe and
Central Asia
Latin America and
the Caribbean
Sub-Saharan
Africa
East Asia and
the Pacific
South Asia
High-income
countries
World
Total chronic disease
6,510
5,283
2,770
10,296
3,167
4,526
33,634
Total injury
3,149
1,500
1,693
1,532
514
1,092
9,207
Total DALYs attributable
to high-risk alcohol
consumption
9,659
6,783
4,463
11,828
3,681
5,618
42,841
116,502
104,287
344,754
346,225
408,655
149,161
1,535,871
8.3
6.5
1.3
3.4
0.9
3.8
2.8
Total DALYs from
all diseases
Proportion of DALYs
attributable to high-risk
alcohol consumption
Source: Authors’ calculations based on Rehm and others 2004 and WHO 2002.
Some evidence indicates that per capita consumption can be
reliably estimated, and information on this indicator is available for the vast majority of countries (Rehm, Rehn, and others 2003). With respect to survey information, reliability and
worldwide coverage are lower. However, because the overall
volume of consumption and, thus, the average volume per
capita are based on production and sales estimates, the measure
of the volume of drinking overall can be considered reliable.
These factors leave the stability of relationships between alcohol and chronic disease as the most crucial part of our estimates. Some indications suggest that relative risks may not be
the same in developing countries as in developed countries (for
example, for tobacco and lung cancers, see Liu and others
1998). Thus, the CRA’s estimates may be biased, most likely
toward an overestimation of the impact of alcohol.
One additional problem pertains to the usual epidemiological approach as applied to alcohol. Most information about
alcohol and chronic disease is derived from cohorts. Because
cohorts are frequently not representative of the population as a
whole, specific patterns of consumption such as binge drinking
are often not represented, and thus their influence cannot be
analyzed (Rehm, Gmel, and others 2003). Unfortunately, the
patterns most often missing are those that are the most detrimental with respect to health; thus, the impact of alcohol on
chronic diseases that are influenced by patterns of drinking
other than average volumes is underestimated.
INTERVENTIONS FOR REDUCING
HIGH-RISK DRINKING
The next two sections estimate the burden of disease attributable to high-risk alcohol consumption that is currently being
averted or could be averted by a range of personal and nonpersonal intervention strategies and calculate the expected costs
and cost-effectiveness of such interventions. Methods and
analyses draw on Chisholm and others (2004), adjusted as necessary to conform to the analytical standards of this volume,
including the specification of all costs in U.S. dollars rather
than international dollars.
Population Model
We determined intervention effectiveness using a state transition population model (Lauer and others 2003), which traces
the development of a regional population taking into account
births, deaths, and the specified risk factor—in this case, highrisk alcohol use. In addition to population size and structure,
the population model uses a number of epidemiological
parameters (incidence and prevalence, remission, and causespecific and residual rates of mortality) and assigns age- and
gender-specific health state valuations to both the disease in
question and to the nondiseased population. The output of the
model is an estimate of the total healthy life years experienced
by the population over a lifetime period (100 years).
We ran the model for a number of possible scenarios,
including no intervention at all (natural history), current intervention coverage, and scaled-up coverage of current and possible new interventions. For the intervention scenarios, we used
an implementation period of 10 years for an intervention program (after which epidemiological rates return to their natural
history levels), from which we derived the number of additional DALYs averted each year compared with the case for no
intervention at all. We discounted DALYs at 3 percent but did
not age weight them.
Effectiveness
A number of interventions have been evaluated and shown
to be effective in reducing alcohol use, yet their level of
892 | Disease Control Priorities in Developing Countries | Jürgen Rehm, Dan Chisholm, Robin Room, and others
©2006 The International Bank for Reconstruction and Development / The World Bank
94
implementation remains low in all but a handful of countries
and their potential effect on population-level health has rarely
been assessed. By contrast, some interventions without clearly
established effects continue to be widely used, including, for
example, mass media public information campaigns and
school-based education aimed at reducing alcohol consumption. Recent reviews of measures to reduce alcohol misuse have
assessed the quality of the evidence for four types of interventions specifically aimed at reducing high-risk alcohol use
(Babor and others 2003; Ludbrook and others 2002):
• policy and legislative interventions, including taxation of
alcohol sales, laws on drunk driving, restrictions on retail
outlets, and controls on advertising
• measures to better enforce these interventions, such as random breath testing of drivers
• mass media and other awareness campaigns
• brief interventions with individual high-risk drinkers.
On the basis of these reviews, we included the following
strategies and intervention effects in our analysis: drinkingand-driving legislation and random breath testing, taxation
of alcoholic beverages, reduced hours of sale in retail outlets,
and advertising bans (included as population-based interventions) and so-called brief interventions (included as interventions aimed at personal behavior). We considered including
one other intervention strategy—mass media or school-based
awareness campaigns—but omitted it in the final analysis on
the grounds that evidence for its effectiveness was weak, both in
terms of methodological quality and in terms of its effect on
consumption (as opposed to transfer of information or knowledge alone) (Babor and others 2003; Edwards and others 1994;
Foxcroft and others 2003; Foxcroft, Lister-Sharp, and Lowe
1997; Ludbrook and others 2002).
Drunk-Driving Legislation and Random Breath Testing.
Drunk-driving laws and reinforcement policies, such as
random breath testing of drivers, influence fatal and nonfatal
traffic injuries among both high-risk alcohol users and other
members of the population, such as passengers and pedestrians. We assessed two independent effects on alcohol-related
traffic injuries, but note that evidence for these effects comes
from the developed countries, where road infrastructures and
driving patterns may differ significantly from those in the
developing world. The first intervention was drunk-driving
laws, estimated to reduce traffic fatalities by 7 percent if widely
implemented across a region. The second was enforcement by
random breath testing, estimated to reduce fatalities by 6 to 10
percent in regions partially implementing such a strategy and
by 18 percent with wide implementation. The effect on nonfatal injuries was estimated to be a reduction of 15 percent
(Peek-Asa 1999; Shults and others 2001). In each region, we
applied these estimated effects to the proportion of total deaths
and of years lived with a disability attributed to alcohol-related
traffic accidents (table 47.4).
Taxation on Alcoholic Beverages. Excise taxation on alcoholic
beverages primarily affects the incidence of drinking through
reduced consumption. Effects are measured in terms of price
elasticity, which relates the change in consumption to the size
of the price increase (table 47.5). We derived price elasticities,
adjusted downward by one-third to reflect possible reduced
price responsiveness among high-risk drinkers, with reference
to preferred type of alcoholic beverage (beer, wine, or spirits)
by region, built up from country-level data (WHO 2003b).
This downward adjustment of price elasticities for high-risk
drinkers is a conservative approach; most of the literature
found similar effects on high-risk and dependent drinkers as
on social users (Babor and others 2003; see also Farrell,
Manning, and Finch 2003).
Price elasticities ranged from ⫺0.3 for the most preferred
beverage category to ⫺1.5 for the least preferred (Babor and
others 2003; Levy and Ornstein 1983). For a beer-drinking
region where wine is the second-most preferred beverage type,
for example, elasticities were set as follows: beer ⫺0.3, wine
⫺1.0, distilled spirits ⫺1.5. We performed sensitivity analysis
around these elasticities. We evaluated three rates of excise tax
on alcoholic beverages: the current rate of tax, a 25 percent
increase over the current rate, and a 50 percent increase over the
current rate. We adjusted estimated reductions in the incidence
of high-risk alcohol use by the observed or expected level of
unrecorded consumption resulting from illicit production and
smuggling (for instance, an estimated 35 percent of alcohol
consumption in Eastern Europe and Central Asia is unrecorded, a proportion that was modeled to increase by 10 to 15 percent with the tax increases). In regions with rates of unrecorded
consumption already greater than 50 percent (South Asia and
Sub-Saharan Africa), tax increases can actually have a regressive
impact on incidence if accompanied by a rise in the already high
level of unrecorded (and therefore untaxed) consumption.
Reduced Hours of Sale in Retail Outlets. Access to and availability of alcohol can be dramatically reduced by prohibition or
rationing, but implementing and sustaining such strategies
without adverse effects, such as black markets and poisonings
from home-produced alcohol, present considerable challenges.
A more modest strategy is to reduce the hours of sale of retail
outlets selling alcoholic beverages (for example, no sales for offpremise consumption for a 24-hour period at the weekend),
which in Scandinavia has reduced consumption and alcoholrelated harm (Leppänen 1979; Nordlund 1984; Norström and
Skog 2003). On the basis of these studies, we modeled a modest reduction of 1.5 to 3.0 percent in the incidence of high-risk
drinking and 1.5 to 4.0 percent in alcohol-related traffic
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Table 47.4 Effectiveness of Drinking-and-Driving Legislation and Its Enforcement
(per 100,000 population)
Effectiveness of
drinking-and-driving laws
and random breath testing
Attributable fractions
(per 100,000 deaths)
Deaths
attributed to
traffic accidentsa
Deaths
attributed to
alcohol-related
traffic accidentsa
Reduced
deaths
(per 100,000)
Reduced
years lost due
to disability
(per 100,000)
World Bank region
WHO
subregion
Europe and Central Asia
Europe B
Male
Female
1,473
542
657
74
141
16
77
6
Europe C
Male
Female
2,197
799
1,396
223
299
48
193
30
Americas B
Male
Female
4,358
1,514
2,053
220
439
47
148
12
Americas D
Male
Female
2,599
1,093
861
101
184
22
64
6
Africa D
Male
Female
2,159
1,079
417
90
89
19
43
9
Africa E
Male
Female
2,075
1,027
803
123
172
26
107
17
Southeast Asia B
Male
Female
7,809
2,343
1,993
127
427
27
164
8
Western Pacific B
Male
Female
3,629
1,790
723
157
155
34
66
12
Southeast Asia D
Male
Female
3,689
1,451
591
53
126
11
45
3
Latin America and
the Caribbean
Sub-Saharan Africa
East Asia and the Pacific
South Asia
Sex
Source: Deaths attributed to traffic accidents: WHO 2003a; deaths attributed to alcohol-related traffic accidents: Rehm and others 2004.
B ⫽ low child mortality, low adult mortality; C ⫽ low child mortality, high adult mortality; D ⫽ high child mortality, high adult mortality; E ⫽ high child mortality, very high adult mortality.
a. Percentages for all age groups combined shown here.
fatalities, depending on the regional pattern of drinking, with
the largest effects in regions with the highest levels of high-risk
drinking occasions.
Advertising Bans. Public health specialists are becoming
increasingly interested in the effect of a comprehensive ban on
alcohol advertising, including advertising on television and
through radio and billboards. However, available evidence
from econometric studies suggests a modest effect on consumption at best, even for a comprehensive ban, arguably
because of the continuing presence of other alcohol marketing
strategies, such as product placement or event sponsorship
(Grube and Agostinelli 2000; Saffer 2000; Saffer and Dave
2002). Here we consider the potential effects of a comprehensive advertising ban (television, radio, and billboards) by modeling a 2 to 4 percent reduction in the incidence of high-risk
alcohol use, depending on regional drinking patterns.
Brief Interventions. We modeled brief interventions (such as
physician advice provided in primary health care settings),
which involve a small number of education sessions and psychosocial counseling, to influence the prevalence of high-risk
drinking by increasing remission and reducing disability.
Efficacy reviews of brief interventions reveal an estimated 13
to 34 percent net reduction in consumption among high-risk
drinkers (Higgins-Biddle and Babor 1996; Moyer and others
2002; Whitlock and others 2004), which, if applied to the total
population at risk, would reduce the overall prevalence of
high-risk drinking by 35 to 50 percent, equivalent to a 14 to
18 percent improvement in the rate of recovery over no treatment at all. After taking into account adherence (70 percent)
and potential treatment coverage in the population (50 percent of high-risk drinkers), however, we estimated remission
rates to be between 4.9 and 6.4 percent higher than natural
history rates.
894 | Disease Control Priorities in Developing Countries | Jürgen Rehm, Dan Chisholm, Robin Room, and others
©2006 The International Bank for Reconstruction and Development / The World Bank
96
Table 47.5 Effect of Taxation on the Incidence of High-Risk Alcohol Use
Prevalence by preferred
beverage (percent)
©2006 The International Bank for Reconstruction and Development / The World Bank
97
World Bank
region
WHO
subregiona
Most
preferred
Next
preferred
Least
preferred
Europe and
Central Asia
Europe B
0.45
(spirits)
0.30
(beer)
Europe C
0.68
(spirits)
Americas B
Latin America
and the Caribbean
Sub-Saharan
Africa
East Asia and
the Pacific
South Asia
Rate of taxation
by preferred beverage (percent)
Price increases (percent)b
Elasticity Elasticity Elasticity
ⴚ0.3, most ⴚ1.0, next ⴚ1.5, least
preferred preferred preferred
Most
preferred
Next
preferred
Least
preferred
0.25
(wine)
0.29
0.36
0.44
0.13
0.16
0.20
0.12
0.15
0.18
(current rate)
(25 percent increase)
(50 percent increase)
⫺0.04
⫺0.05
⫺0.06
⫺0.08
⫺0.09
⫺0.11
⫺0.11
⫺0.13
⫺0.15
0.21
(beer)
0.11
(wine)
0.65
0.81
0.98
0.13
0.16
0.20
0.25
0.31
0.38
(current rate)
(25 percent increase)
(50 percent increase)
⫺0.08
⫺0.09
⫺0.10
⫺0.08
⫺0.09
⫺0.11
0.53
(beer)
0.30
(spirits)
0.17
(wine)
0.16
0.20
0.24
0.49
0.61
0.74
0.22
0.28
0.33
(current rate)
(25 percent increase)
(50 percent increase)
⫺0.03
⫺0.03
⫺0.04
Americas D
0.58
(spirits)
0.39
(beer)
0.03
(wine)
0.26
0.33
0.39
0.21
0.26
0.32
0.25
0.31
0.38
(current rate)
(25 percent increase)
(50 percent increase)
Africa D
0.79
(beer)
0.16
(spirits)
0.05
(wine)
0.36
0.45
0.54
0.41
0.51
0.62
0.35
0.44
0.53
Africa E
0.49
(beer)
0.30
(spirits)
0.21
(wine)
0.28
0.35
0.42
0.50
0.63
0.75
Southeast
Asia B
0.88
(spirits)
0.12
(beer)
0.00
(wine)
0.30
0.38
0.45
Western
Pacific B
0.88
(spirits)
0.11
(beer)
0.01
(wine)
Southeast
Asia D
0.89
(spirits)
0.11
(beer)
0.00
(wine)
Nonrecorded or
untaxed consumption
(percent)
Effect (percent)c
Baseline
Lowerd
Uppere
0.34 (current rate)
0.37 (10 percent increase)
0.39 (15 percent increase)
⫺0.05
⫺0.05
⫺0.06
⫺0.03
⫺0.04
⫺0.04
⫺0.06
⫺0.07
⫺0.08
⫺0.20
⫺0.24
⫺0.27
0.36 (current rate)
0.40 (10 percent increase)
0.42 (15 percent increase)
⫺0.06
⫺0.06
⫺0.07
⫺0.04
⫺0.05
⫺0.05
⫺0.08
⫺0.09
⫺0.09
⫺0.22
⫺0.25
⫺0.28
⫺0.18
⫺0.22
⫺0.25
0.29 (current rate)
0.32 (10 percent increase)
0.34 (15 percent increase)
⫺0.08
⫺0.09
⫺0.10
⫺0.06
⫺0.06
⫺0.07
⫺0.10
⫺0.12
⫺0.13
⫺0.04
⫺0.05
⫺0.06
⫺0.12
⫺0.14
⫺0.16
⫺0.20
⫺0.24
⫺0.27
0.22 (current rate)
0.24 (10 percent increase)
0.25 (15 percent increase)
⫺0.06
⫺0.07
⫺0.08
⫺0.04
⫺0.05
⫺0.05
⫺0.08
⫺0.09
⫺0.10
(current rate)
(25 percent increase)
(50 percent increase)
⫺0.05
⫺0.06
⫺0.07
⫺0.19
⫺0.23
⫺0.25
⫺0.26
⫺0.30
⫺0.34
0.77 (current rate)
0.85 (10 percent increase)
0.89 (15 percent increase)
⫺0.02
⫺0.01
⫺0.01
⫺0.01
⫺0.01
⫺0.01
⫺0.03
⫺0.02
⫺0.02
0.38
0.48
0.57
(current rate)
(25 percent increase)
(50 percent increase)
⫺0.04
⫺0.05
⫺0.06
⫺0.22
⫺0.26
⫺0.29
⫺0.28
⫺0.32
⫺0.36
0.47 (current rate)
0.52 (10 percent increase)
0.55 (15 percent increase)
⫺0.08
⫺0.08
⫺0.09
⫺0.06
⫺0.06
⫺0.06
⫺0.10
⫺0.11
⫺0.11
0.40
0.50
0.60
0.00
0.00
0.00
(current rate)
(25 percent increase)
(50 percent increase)
⫺0.05
⫺0.05
⫺0.06
⫺0.19
⫺0.22
⫺0.25
0.00
0.00
0.00
0.36 (current rate)
0.39 (10 percent increase)
0.41 (15 percent increase)
⫺0.04
⫺0.05
⫺0.05
⫺0.03
⫺0.03
⫺0.03
⫺0.05
⫺0.06
⫺0.07
0.17
0.21
0.26
0.09
0.11
0.14
0.11
0.14
0.17
(current rate)
(25 percent increase)
(50 percent increase)
⫺0.03
⫺0.04
⫺0.04
⫺0.06
⫺0.07
⫺0.08
⫺0.10
⫺0.12
⫺0.14
0.27 (current rate)
0.32 (10 percent increase)
0.31 (15 percent increase)
⫺0.02
⫺0.03
⫺0.03
⫺0.02
⫺0.02
⫺0.02
⫺0.03
⫺0.04
⫺0.04
0.40
0.50
0.60
0.25
0.31
0.38
0.00
0.00
0.00
(current rate)
(25 percent increase)
(50 percent increase)
⫺0.06
⫺0.07
⫺0.08
⫺0.13
⫺0.16
⫺0.18
0.00
0.00
0.00
0.79 (current rate)
0.87 (10 percent increase)
0.91 (15 percent increase)
⫺0.01
⫺0.01
⫺0.01
⫺0.01
⫺0.01
⫺0.01
⫺0.02
⫺0.01
⫺0.01
Source: WHO 2003b.
a. B ⫽ low child mortality, low adult mortality; C ⫽ low child mortality, high adult mortality; D ⫽ high child mortality, high adult mortality; E ⫽ high child mortality, very high adult mortality.
b. Price rise caused by tax ⫽ [percentage of tax/(1 ⫹ percentage of tax)] ⫻ elasticity ⫻ 2/3 (high-risk drinkers less responsive).
c. Effect ⫽ sum of (prevalence ⫻ price increase) for each beverage ⫻ (1 ⫺ percentage of unrecorded consumption).
d. Lower-range elasticities ⫽ ⫺0.2, ⫺0.7, ⫺1.2.
e. Upper-range elasticities ⫽ ⫺0.4, ⫺1.3, ⫺2.0.
Costs
Costs covered in the analysis include program-level costs associated with running the intervention (such as administration,
training, and media costs) and patient-level costs (such as costs
of primary care visits). Program-level costs include resource
inputs used in the production of an intervention at a level
above that of the patient or providing facility, such as central
planning, policy, and administration functions, as well as
resources devoted to preventive programs, such as the enforcement of drunk-driving legislation by police officers (Johns and
others 2003). We derived estimated quantities of resources
required to implement each intervention for 10 years at the
national, provincial, and district levels with reference to the
region’s prevailing characteristics—for example, the stability
and efficiency of tax systems, the volume of traffic (for breath
testing), and the strength of antidrinking sentiment as indicated
by existing alcohol controls (advertising bans, restricted sales).
In this analysis, patient-level resource inputs used in the provision of a given health care intervention (for example, hospital
inpatient days, outpatient visits, medications, and laboratory
tests) are relevant only to brief interventions. We estimated an
average of four primary care visits per year for the intervention
itself, plus an additional 0.33 outpatient visits (20 percent ⫻
1.67 visits) and 0.25 inpatient days (5 percent ⫻ 5 days) (see,
for example, Fleming and others 2000). We applied these
patient-level resource inputs to the 50 percent of prevalent
high-risk alcohol users in receipt of brief advice in year 1 and
(because we model an enduring effect for 10 years) year 6 and
to the 50 percent of incident cases in years 2 to 5 and 7 to 10.
Note that, throughout, the costing does not include possible
offsetting revenues for the government, for instance, from
drunk-driving convictions and, in particular, from the revenues likely to result from increased alcohol taxes.
Unit costs and prices of program- and patient-level resource
inputs include the salaries of central administrators; the capital
costs of vehicles, offices, and furniture; and the cost per outpatient visit (see chapter 7 for an overview of the costing methodology, plus prices by World Bank region). All costs are
expressed in U.S. dollars for 2001 and are discounted at an
annual rate of 3 percent.
males (the proportion for random breath testing rises to 80 to
90 percent because of the higher proportion of deaths and
injuries attributed to traffic accidents among men). A clear difference is also apparent between regions with relatively high
rates of high-risk alcohol use (that is, prevalence in the total
population greater than 5 percent) and regions with generally
low levels of high-risk drinking (that is, less than 2 percent).
As shown in table 47.6, in the three regions with a higher
prevalence of high-risk alcohol use—Europe and Central Asia,
Latin America and the Caribbean, and Sub-Saharan Africa—
the most effective interventions were taxation and brief physician advice to individual high-risk drinkers, with each averting
more than 500 DALYs per million population per year. The
remaining control strategies—random breath testing, reduced
access to alcoholic beverage retail outlets, and a comprehensive
advertising ban—mainly produced effects in the range of 200
to 400 DALYs averted per million population per year. In the
two regions with lower rates of high-risk drinking (particularly
among the female population), by contrast, the burden that is
avertable through taxation is very much reduced (10 to 100
DALYs averted per million population per year). In South Asia,
the most effective intervention is enforcement of drinkingand-driving laws by means of random breath testing, because
of the higher rate of traffic-related injuries than elsewhere as
well as the low levels of high-risk drinking.
Population-Level Costs
Table 47.7 summarizes the costs and cost-effectiveness of each
intervention and of two combination strategies by region. The
most costly interventions to implement in all regions were random breath testing and brief physician advice in primary care.
The higher costs of brief advice stem from a combination of
patient-level costs in the provision of the intervention itself (an
average annual cost of US$7 to US$20 per treated case), plus
program costs associated with administration and training primary care providers (15 to 40 percent of total costs). Random
breath testing is also a relatively resource-intensive intervention
to implement because of the need for regular sobriety checkpoints administered by law enforcement officers. Other interventions, including taxation, had a per capita cost in the range
US$0.02 to US$0.13, depending in part on the efficiency of the
tax collection system and the degree of antidrinking sentiment.
COST-EFFECTIVENESS OF INTERVENTIONS
In the following section, we provide results relating to the
population-level health effects, costs, and cost-effectiveness of
the evidence-based interventions previously reviewed.
Population-Level Effects
Except for random breath testing, two-thirds of the total population-level health gain from these interventions was among
Population-Level Cost-Effectiveness
Compared with doing nothing, taxation is the most costeffective population-level strategy in Europe and Central Asia,
Latin America and the Caribbean, and Sub-Saharan Africa, the
three regions with a relatively high prevalence of high-risk
drinking (table 47.7). At the current rate of tax, for example,
each DALY averted costs US$104 to US$225, equivalent to
4,435 to 9,633 DALYs averted per US$1 million expenditure.
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Table 47.6 Population-Level Effects of Interventions to Reduce High-Risk Alcohol Use by World Bank Region
Coveragea
(percent)
Europe and
Central
Asia
Latin America
and the
Caribbean
Sub-Saharan
Africa
East Asia
and the
Pacific
South Asia
20,241
12,894
6,685
6,263
2,652
Burden of disease (DALYs/million population)
Total effect (DALYs averted/
million population/year)
Excise tax on alcoholic beverages
(current situation)
0.95
685
586
697
83
13
Excise tax on alcoholic beverages
(25 percent increase)
0.95
756
654
724
96
10
Excise tax on alcoholic beverages
(50 percent increase)
0.95
828
719
764
109
8
Reduced access to alcoholic beverage
retail outlets
0.95
441
287
386
203
32
Comprehensive advertising ban
on alcohol
0.95
395
243
406
226
20
Random breath testing of motor
vehicle drivers
0.80
284
307
197
181
125
Brief advice to heavy drinkers by
a primary care physician
0.50
1,328
713
539
362
80
Combination: highest tax ⫹
brief advice
2,048
1,360
1,237
447
83
Combination: highest tax ⫹
advertising ban ⫹ random breath
testing ⫹ brief advice
2,551
1,784
1,715
790
210
Reduction in current burden (percent)
Excise tax on alcoholic beverages
(current situation)
0.95
0.03
0.05
0.10
0.01
0.01
Excise tax on alcoholic beverages
(25 percent increase)
0.95
0.04
0.05
0.11
0.02
0.00
Excise tax on alcoholic beverages
(50 percent increase)
0.95
0.04
0.06
0.11
0.02
0.00
Reduced access to alcoholic
beverage retail outlets
0.95
0.02
0.02
0.06
0.03
0.01
Comprehensive advertising ban
on alcohol
0.95
0.02
0.02
0.06
0.04
0.01
Random breath testing of motor
vehicle drivers
0.80
0.01
0.02
0.03
0.03
0.05
Brief advice to heavy drinkers by
a primary care physician
0.50
0.07
0.06
0.08
0.06
0.03
Combination: highest tax ⫹
brief advice
0.10
0.11
0.19
0.07
0.03
Combination: highest tax ⫹ advertising
ban ⫹ random breath testing ⫹ brief advice
0.13
0.14
0.26
0.13
0.08
Source: Chisholm and others 2004.
a. Refers to the modeled percentage of all high-risk drinkers exposed to the intervention.
Advertising bans had a cost per unit of effect similar to that of
reduced access to sales outlets, US$134 to US$380, equivalent
to 2,631 to 7,442 averted DALYs per US$1 million dollars
expenditure, whereas random breath testing had the highest
estimated cost per DALY averted: US$973 to US$1,856 per
DALY, approximately 500 to 1,000 DALYs averted per US$1
million dollars expenditure. Brief physician advice provided in
primary care settings had an average cost-effectiveness in the
range of US$204 to US$502 per DALY averted, or close to 2,000
to 5,000 averted DALYs for every US$1 million expenditure.
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Table 47.7 Costs and Cost-Effectiveness of Interventions to Reduce High-Risk Alcohol Use by World Bank Region
Coveragea Europe and Latin America
(percent) Central Asia and the Caribbean
Sub-Saharan East Asia and
Africa
the Pacific
South Asia
Total cost (US$ million/year/million population)
Excise tax on alcoholic beverages (current situation)
0.95
0.10
0.13
0.07
0.04
0.04
Excise tax on alcoholic beverages (25 percent increase)
0.95
0.10
0.13
0.07
0.04
0.04
Excise tax on alcoholic beverages (50 percent increase)
0.95
0.10
0.13
0.07
0.04
0.04
Reduced access to alcoholic beverage retail outlets
0.95
0.10
0.10
0.06
0.03
0.03
Comprehensive advertising ban on alcohol
0.95
0.07
0.09
0.05
0.03
0.02
Random breath testing of motor vehicle drivers
0.80
0.53
0.47
0.19
0.18
0.07
Brief advice to heavy drinkers by a primary care physician
0.50
0.36
0.36
0.11
0.08
0.04
Combination: highest tax ⫹ brief advice
0.44
0.48
0.18
0.12
0.07
Combination: highest tax ⫹ advertising ban ⫹ random
breath testing ⫹ brief advice
0.97
0.97
0.39
0.30
0.15
Cost-effectiveness relative to no intervention
(US$/DALY averted)
Excise tax on alcoholic beverages (current situation)
0.95
141
225
104
516
2,671
Excise tax on alcoholic beverages (25 percent increase)
0.95
127
202
100
447
3,654
Excise tax on alcoholic beverages (50 percent increase)
0.95
116
184
95
394
4,641
Reduced access to alcoholic beverage retail outlets
0.95
216
340
152
146
827
Comprehensive advertising ban on alcohol
0.95
185
380
134
123
1,123
Random breath testing of motor vehicle drivers
0.80
1,856
1,542
973
984
531
Brief advice to heavy drinkers by a primary care physician
0.50
270
502
204
224
462
Combination: highest tax ⫹ brief advice
216
350
143
269
845
Combination: highest tax ⫹ advertising ban ⫹
random breath testing ⫹ brief advice
381
546
229
383
707
DALYs averted/US$ million expenditure
Excise tax on alcoholic beverages (current situation)
0.95
7,107
4,435
9,633
1,937
374
Excise tax on alcoholic beverages (25 percent increase)
0.95
7,847
4,953
10,007
2,239
274
Excise tax on alcoholic beverages (50 percent increase)
0.95
8,590
5,442
10,553
2,536
215
Reduced access to alcoholic beverage retail outlets
0.95
4,638
2,940
6,580
6,856
1,209
Comprehensive advertising ban on alcohol
0.95
5,417
2,631
7,442
8,139
891
Random breath testing of motor vehicle drivers
0.80
539
648
1,027
1,016
1,882
Brief advice to heavy drinkers by a primary care physician
0.50
3,705
1,992
4,891
4,460
2,163
Combination: highest tax ⫹ brief advice
4,627
2,859
7,016
3,718
1,184
Combination: highest tax ⫹ advertising ban ⫹ random
breath testing ⫹ brief advice
2,621
1,833
4,364
2,612
1,415
Source: Chisholm and others 2004.
a. Refers to the modeled percentage of all high-risk drinkers exposed to the intervention.
Starting from the current situation in these regions, the
most efficient strategies for reducing high-risk alcohol use
would be tax increases (additional gains are obtained at virtually no extra cost because the costs of tax administration and
enforcement remain relatively constant whatever the rate of
tax), followed by the introduction or escalation of comprehensive advertising bans on alcohol products, reduced access to
retail outlets, and the provision of brief interventions such as
physician advice in primary care. Even a multifaceted strategy
made up of an increase in taxation plus full implementation of
the other interventions considered here has a favorable ratio of
costs to health benefits.
In East Asia and the Pacific and South Asia, the two regions
with lower rates of high-risk alcohol use, a comparison of
intervention costs and effects to a no-intervention scenario
reveals that current practice—namely, excise taxes on alcoholic
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beverages—is not the most efficient response to the existing
burden of alcohol use. The reduced efficiency of taxation in
these lower-prevalence regions is related both to the distribution of the fixed costs of administering and enforcing alcohol
tax legislation across a smaller target population of drinkers
and to underlying drinking patterns: more than 85 percent of
all alcohol consumption falls into a single preferred drink category, spirits, which therefore diminishes the scope for reducing the consumption of less preferred but more elastic categories of alcoholic beverages. In South Asia, targeted strategies
such as brief physician advice and random breath testing have
the lowest cost per DALY averted (around US$500), while taxation policies are the most expensive at more than US$2,500
per DALY averted. In East Asia and the Pacific, the most costeffective interventions are brief physician advice, a comprehensive ban on advertising, and reduced access to retail outlets
(below US$250 per DALY averted).
Implications and Limitations of Sectoral
Cost-Effectiveness Analyses
This cost-effectiveness analysis offers a new approach to generating economic evidence that can inform public health policy
on alcohol in a wide range of cultural and epidemiological
settings (Chisholm and others 2004). Resulting estimates of
cost-effectiveness can inform policy makers not only by determining the efficiency of existing resource allocation and
practices, but also by identifying priorities for future alcohol
control strategies. Furthermore, use of a common methodology
enables comparison with cost per DALY estimates for other
risk factors or disease entities, which may constitute an important argument when considering priorities for the allocation
of scarce health care resources. However, the application of a
broad sectoral approach using entire regions as the unit of
analysis clearly limits the approach’s use in specific country
contexts, where demographic or epidemiological characteristics, as well as treatment costs and coverage, may not coincide
with estimates for the region as a whole. In addition, extrapolation of the extent of intervention effects from relatively
information-rich countries to other sociocultural settings
lessens the precision of derived estimates of population-level
health gains.
Although an ongoing analytical step is to calibrate results
at the country level, the primary purpose and utility of the
sectoral approach is to identify interventions that are clearly
cost-effective as opposed to those that clearly do not seem to
offer good value for money. In this respect, the primary conclusion to be drawn from the analysis is that in regions with
high or moderate rates of high-risk alcohol use, a number of
intervention strategies can have a notable effect on population
health, including both individual-based interventions, such as
brief physician advice at the primary care level, as well as
population-wide measures, such as taxation of alcoholic beverages. Of these, taxation has the most sizable and least resourceintensive effect on reducing the avertable burden of high-risk
alcohol use. In regions where high-risk alcohol use represents
less of a public health burden, targeted approaches such as brief
physician advice as well as other intervention strategies that
restrict the supply or promotion of alcoholic beverages appear
to be the most cost-effective mechanisms, although greater
empirical support for the efficacy of these interventions in
these localities is clearly needed before considering their widespread implementation.
Even though sectoral cost-effectiveness analysis pursues a
societal perspective, considerable challenges remain in relation
to the appropriate measurement of certain societal costs and
effects that fall outside the boundaries of the health system.
Therefore, this analysis has not been able to successfully capture potential reductions in workforce and household productivity losses among high-risk drinkers, nor does it incorporate
the economic costs associated with alcohol-related crime, violence, and harm reduction. It also does not value the time spent
by patients and informal caregivers in seeking or providing care
and support. Including these modest additional costs and substantial incremental effects is likely to improve the costeffectiveness ratios of all interventions, but to a variable and
currently unknown extent.
ECONOMIC BENEFITS OF INTERVENTIONS
By design, estimates of the burden of alcohol do not include
most social harm and harm to people other than the drinker;
however, the burden of social problems from drinking can be
at least as significant as the health burden. The burden attributable to alcohol in the CRA estimates is actually a substantial
underestimate of the full harm alcohol imposes on human
welfare. The estimates reported earlier reflect primarily the
chronic disease and injury effects of drinking. Because the CRA
focused on disease and disability, the estimates were not
designed to take account of the social harm and problems that
are particular to alcohol and that result for the drinker and for
others as a consequence of a person’s drinking (Klingemann
and Gmel 2001). These problems are quite prevalent in many
populations (Room and others 2003) and are also affected by
the interventions listed earlier.
Some information on the relative burden of alcohol for
social services versus health services is available for a handful of
societies. In an estimate of the staffing and service costs attributable to alcohol in different service systems in Scotland for
fiscal year 2001/02, for instance, health services accounted for
only 21 percent of the estimated costs, whereas social services
accounted for 19 percent, and criminal justice and fire services
accounted for 60 percent (Catalyst Health Consultants 2001, 3).
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If those estimates are used as a rough gauge of the burden to
society, the illness and disability burden of alcohol may thus
constitute half or less of the total burden when social problems
are also taken into consideration.
Thus, policies that affect the levels of alcohol-related health
and social harm not only are a matter of intervening to save
people from the detrimental effects of their own behavior, but
also potentially have a broader effect on the health and wellbeing of families and of associates of drinkers. This issue is
especially relevant for women: even though men predominate
among high-risk drinkers worldwide (Rehm and others 2004;
Room and others 2002), women bear much of the burden of
harm from others’ drinking, not only in such forms as domestic violence, but also in such forms as diversion of family
resources from greater needs.
IMPLEMENTATION OF CONTROL STRATEGIES:
LESSONS OF EXPERIENCE
The following paragraphs provide a few concrete examples of
interventions or policy changes that illustrate the actual implementation and effects of control strategies in developing societies (the examples are taken from Room and others 2002).
Tax Rate Reduction and the Resulting Disease
Burden in Mauritius
Mauritius, an island nation in the Indian Ocean, has a population of about 1 million. These people are of Indian, African,
European, and Chinese origin. By religious affiliation, 53 percent are Hindu, 29 percent are Christian, and 17 percent are
Muslim. Tourism is the third-ranked industry in terms of hard
currency earnings. In June 1994, the government drastically
lowered customs duties on imported alcoholic beverages to
80 percent from rates that had ranged from 200 percent for
wine to 600 percent for whisky and other spirits (Abdool 1998).
The government made the change under pressure from the
hotel industry, which claimed that tourists were not purchasing
enough alcohol because of its high prices (Lee 2001). Other reasons given for the change were to reduce unofficial imports
from abroad and to make better, more refined alcoholic beverages available to the local population. Despite little evidence to
support the view, there were claims in the public discussion that
better-quality alcohol would result in fewer health problems.
The effects of the change were felt mainly by Mauritians
rather than tourists, as follows:
• Arrests for driving with blood alcohol over the legal limit
made primarily in connection with traffic crashes increased
by 23 percent between 1993 and 1997.
• Admissions of alcoholism cases to the island’s psychiatric
hospital shot up in 1994. The 1995 rate was more than twice
the 1993 rate, and the rate rose again slightly in 1996 and
1997. Medical specialists in Mauritius agree that patients
with alcohol problems account for an increasing portion
of admissions in general medical wards and now represent
between 40 and 50 percent of bed occupancy (Abdool
1998).
• Age-adjusted death rates per 100,000 population for chronic
liver disease and cirrhosis rose from 32.8 for males and
4.0 for females in 1993 to 42.7 for males and 5.3 for females
in 1996 (WHO 1999, 2000).
Even though available statistics are limited, the reduction in
alcohol import taxes clearly had a substantial negative effect on
the health of Mauritians. Thus, the government’s 1997 call for
control measures for alcohol—specifically, new permits for
licensed premises, increased excise duties on alcohol, and limitations on bars’ opening hours—was not surprising. Alcohol
taxes were increased somewhat in the 1999/2000 budget (U.S.
Department of State 1999). However, an analysis by World
Bank staff that did not take health effects into account called
for further reductions in maximum tariff rates, identifying
Mauritius as having an antitrade bias on the basis of the structure of its alcohol and tobacco taxes (Hinkle and HerrouAragon 2001).
Wallace and Bird (2003) suggest the following general principles for setting and collecting alcohol taxes in the context of
developing societies from the perspective of revenue generation rather than public health (see also Tax Policy Chief
Directorate 2002):
• Countries around the world need revenues they can raise
relatively efficiently, but this need is probably more critical
in the case of developing nations. That said, alcohol taxes are
probably a good bet for future revenues.
• Excise taxes on alcohol should be set by alcohol content,
rather than as a percentage of the price.
• Tax rates should be logically defined so that alcoholic beverages with similar alcohol content are treated similarly, with
stronger alcohol beverages taxed more heavily.
• Analyses of revenue-maximizing rates should be conducted
to determine a range of tax rates that is likely to maximize
government revenues.
• Tax systems should be designed to be as simple as possible
to allow for the maximum efficiency of tax administration.
Reduced Access through Locational Prohibition in Brazil
The second example involves the institution of a new control
on alcohol availability in an environment where it is likely to
be combined with driving. Although we have modeled the
effects of another, better studied availability control (namely,
closing on a weekend day), a wide variety of possible
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measures is available to control the time and place of alcohol
purchase or drinking (Babor and others 2003; Room and others 2002). Even though in this case the particular control was
extremely limited in scope, it appears to have had measurable
effects.
Traffic deaths are an important source of mortality in Brazil,
amounting to 3.6 percent of overall mortality. The few available
studies suggest that alcohol plays a significant role in traffic
casualties. For instance, one study in São Paulo found positive
blood alcohol levels in 72 percent of pedestrian deaths and
32 percent of driver and passenger deaths of persons age 13 and
older (Carlini-Cotrim and Chasin 2000).
In 1985, motivated by concern about alcohol and impaired
driving and about the lax enforcement of drinking and driving laws, a conservative party politician from the state of São
Paulo introduced legislation to prohibit alcohol sales in commercial facilities that had access to state highways. Even
though the bill passed in the legislature, its implementation
was delayed by the state’s alcohol producers and commercial
and industrial federations, which claimed that the law would
be a barrier to improved facilities for travelers, would encourage people to carry bottles in their cars, and would restrict
individual freedoms. Discussion in the press was also generally
unsympathetic. In August 1988, however, a new state governor from the same party implemented the law. At that time,
the press was slightly more supportive. Since then, the law has
been on the books, although site visits to restaurants and
snack bars along a state highway in 1997 suggested a low level
of compliance. In 1995, another legislator from the same
party proposed repealing the law on the grounds that no
studies proved that it lowered traffic accidents. The repeal
passed the legislature without significant public debate, but
the state governor vetoed it. Undaunted, the same legislator
then proposed a law to criminalize buying as well as selling
alcohol along state highways. That law passed but has not yet
been implemented.
A study by Carlini-Cotrim, Pinsky, and Serrano Barbosa
(1998) assesses the effects of the intervention. Finding data for
a controlled study comparing traffic casualties on state highways with casualties on federal highways, which were unaffected by the law, proved impossible. The best data available were
on crashes and crashes resulting in injuries per 10,000 vehicles
traveling on three short highway systems administered by a private agency. Linear regressions on those data for 1983–93
showed that the law had made a significant difference in the
number of accidents resulting in injuries on all three roads and
a significant difference in all accidents on two of the roads. A
separate analysis on estimated accidents and accidents with
injuries per 10,000 vehicles in two geographic areas of the state
did not show significant effects of the law. Overall, the analyses
do provide some support for the law having a beneficial effect
on the rate of traffic casualties.
Drunk-Driving Enforcement in South Africa
No published studies are available of the implementation of
random breath testing in a developing country. However, some
data are available on a campaign to increase drunk-driving
enforcement in South Africa, a strategy that has often shown
some effects, although weaker and less lasting than those of
random breath testing.
The minister of finance launched a short-term campaign,
ARRIVE ALIVE, for the period October 1997 to January 1998,
in response to the high rate of traffic fatalities and injuries. The
campaign’s main aim was to mobilize all available traffic policing, control, and education resources to reduce traffic accidents
on South African roads by at least 5 percent, especially in the
Western Cape, Gauteng, and KwaZulu Natal provinces, because
75 percent of all accidents occurred in those provinces. The
ARRIVE ALIVE campaign targeted, in turn, what were considered the three critical factors having the greatest impact on
injuries: failing to wear seat belts, drinking and driving, and
speeding. Unofficially, the campaign came to be called “belts,
booze, and bats out of hell.”
As many of the parties interested in road safety as possible
were involved, with funding drawn from a variety of government and business sources. The campaign included a number
of components particularly relevant to alcohol use. New equipment purchased by the provinces included alcohol screening
devices, alcohol evidentiary units, and so-called booze buses
(vehicles containing all the technology needed to check breath
and blood alcohol levels). Sentences were increased to underline the point that traffic violations are serious offenses, with a
three-month suspension of a driver’s license and an increased
maximum fine for a first conviction for drunk driving and with
license suspension for one to five years for second offenders.
Traffic supervisors underwent intensive training courses before
the start of the campaign.
Because the aim of the campaign included educating road
users, advertisements covering aspects of the campaign were
run on the radio, on television, and in movie theaters throughout the country. Supplements were published in national and
provincial newspapers. Private companies, such as a supermarket chain and an automobile manufacturer, also promoted
the campaign. A national transportation center, established to
collect and collate data from local and provincial authorities,
operated for 12 hours every day throughout the campaign.
Traffic authorities staffed an additional 80 roadside communications points, and at selected points on certain routes, road
signs were erected and updated to display the percentage of
speed limit and drinking-and-driving violations and the rate of
seat belt use in that area.
A total of 776 enforcement points were set up on 195 strategic routes in the selected provinces. Posters, pamphlets, key
rings, and license decals were produced for distribution and
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display at roadblocks in the three provinces. Between October
1, 1997, and January 17, 1998, 6,674 notices of prosecution
were issued for alcohol-related traffic offenses, 83 percent of
which were issued in the intervention provinces.
Comparison studies showed a decrease in the drinking rate
of drivers in the three provinces, whereas the other six
provinces, as a group, showed an increase. KwaZulu Natal had
the lowest drinking rate of all drivers throughout the campaign
(3 to 7 percent), and the Western Cape had the most dramatic
decrease (from 12.0 to 9.3 percent in October). Except for in
Gauteng, the drinking rates for pedestrians decreased from
more than 15 percent to less than 7 percent. Overall, during the
months targeted, drinking-and-driving rates decreased by 2 to
4 percent, as measured by breath testing. The total number of
crashes decreased by 8 percent, and fatalities dropped by 9 percent. The ratio of benefits to costs for the intervention was estimated as 4 to 1, based on an investment in the campaign of
R50 million, or about US$4.4 million at 2002 rates (ARRIVE
ALIVE Campaign 2000).
Despite the potential inconvenience of roadblocks and other
enforcement activities, the public generally perceived the campaign positively. The liquor retail and hospitality industries
complained about decreased sales, and tow truck operators
complained about reduced business.
Even though driver behavior improved during the focus
months, violations often increased after the focus was changed,
for example, from drunk driving to seat belt use. This finding
emphasizes the need for sustained enforcement as opposed to ad
hoc campaigns. (This example was summarized from ARRIVE
ALIVE Campaign 2000 and Cerff and Plüddemann 1998.)
Implementation of Brief Interventions in Several
Developing Countries
In the first phase of the WHO Collaborative Project on
Identification and Management of Alcohol Related Problems
(Saunders and Aasland 1987), a screening measure suitable for
use in both developing and developed countries—the alcoholuse disorders identification test—was developed to identify
people at risk for alcohol problems among those attending primary health care services. In the second phase, a multicenter
clinical trial of brief intervention procedures designed to
reduce the health risks associated with hazardous alcohol use
was carried out in primary health care settings in Australia,
Bulgaria, Costa Rica, Kenya, Mexico, Norway, the Soviet Union,
the United Kingdom, the United States, and Zimbabwe (Babor
and others 1994).
The project’s aims were to study the influence of simple
advice and brief counseling, to examine the moderating role of
reduced consumption on the prevention of alcohol-related
problems, and to evaluate the cross-national generalizability of
brief intervention techniques. The project’s hypothesis was
that the amount of change in alcohol consumption over a
nine-month period would be proportional to the intensity of
the intervention provided by a trained primary health care
professional. The results showed a significant effect of interventions on both consumption and intensity of drinking
among males, but the intensity of the intervention was not
related to the amount of change in drinking behavior; 5 minutes of simple advice turned out to be as effective as 20 minutes of brief counseling (Babor and Grant 1992). The female
sample was too small for the results to attain significance, and
the intervention did not significantly affect men’s frequency of
dependence symptoms, problems related to alcohol, or concern expressed by others (WHO Brief Intervention Study
Group 1996).
The findings suggest that in a population of high-risk
drinkers, behavior change is more a function of motivational
factors and social influence than of the moderation skills and
social learning techniques that behavioral self-control training
packages typically use. Changes in drinking were not attributable solely to the small number of patients who achieved an
abstinence goal, nor to the small number who gave up daily or
almost daily drinking. Rather, changes seem to have been distributed across a broad spectrum of the drinkers who reduced
their consumption by small, but clinically meaningful,
amounts.
RESEARCH AND DEVELOPMENT AGENDA
Research and development needs in the area of alcohol consumption are large and multidimensional. The work reported
in this chapter represents best estimates from the available data,
some of which were developed to fill the needs of the analysis;
however, we cite few figures for the developing world for which
we can say that the underlying data are so good that they could
not usefully be improved. Nevertheless, more and better data
are available on alcohol than on many other health topics.
The health and social burdens of alcohol are clearly
extremely large in most developing societies. Thus, the most
urgent focus should be on development and evaluation projects to study the outcomes of various policy and program
interventions. The projects must necessarily be attuned to what
is politically feasible in a particular time and place. They are
likely to include natural experiment studies, where the research
tracks the effects of changes that governments undertake,
whether those changes are expected to increase or to decrease
the extent of alcohol problems. Where possible, the projects
should include experimental and quasi-experimental studies,
whereby the effects of a change at intervention sites are studied
in comparison to outcomes at control sites, with random
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assignment where possible. Costing data should be included to
permit cost-effectiveness analysis.
Also important are process studies—that is, research on
how policy makers decide on policy changes, how they
implement them, and what the reactions and sequelae are. For
example, deciding to introduce a new alcohol tax may be the
easiest part of an initiative, but actually implementing it in a
developing society with a great deal of unrecorded alcohol in
the informal market and with poorly guarded borders may be
much more difficult. Currently, no international mechanism or
nexus exists for developing and disseminating practical knowledge about implementing effective alcohol control strategies
between developing countries.
At this time, nearly all studies of alcohol interventions come
from a limited range of developed countries. Extending knowledge and experience in and between developing societies is
urgently needed.
A secondary need, but one that is also important, is to
extend the epidemiological database in developing societies on
levels and patterns of drinking and on the health and social
consequences of drinking. To this end, better estimation of
unrecorded alcohol consumption is needed. Which dimensions
of drinking patterns matter for what kinds of outcomes needs
to be studied in the context of different kinds of developing
societies. Studies of the effects that the interaction of drinking
levels and patterns with poverty and social exclusion have on
the extent of alcohol-related problems are also necessary.
Because most of our knowledge about the health effects of
drinking concerns mortality, studies of alcohol’s role in various
kinds of morbidity should be emphasized. Another area where
data are lacking is the social harm arising from drinking, for
which we cannot presently make the kinds of estimates that are
possible to make for harm to health. Developing and reaching
consensus on ways to measure the social harm caused by drinking is a substantial agenda for both the developed and the
developing world.
Developing the epidemiological database can provide clues
to etiology to be pursued further by biomedical and social
researchers and, thus, offers hope for the development of new
treatments or preventive interventions. It can provide information on the distribution of drinking patterns and problems in
subpopulations that can be used to guide targeting and prevention and treatment priorities. However, from a short-term
policy perspective, the most important function of developing
the epidemiological database in a particular country may be
providing a base for creating political will for action. For example, the development of devices to measure blood and breath
alcohol and the collection of data on drinking and driving that
they made possible were prerequisites for developing the political will and support for implementing drinking-and-driving
countermeasures in industrial countries.
CONCLUSION
The burden of disease attributable to alcohol in the developing
world is considerable, and the social harm not accounted for in
this analysis increases the costs. However, known interventions
can reduce the burden by up to 25 percent, depending on the
region of the world. Compared with other interventions in the
health care field, these interventions are quite cost-effective, but
given the nature of many of the interventions, caution is needed.
In particular, the following recommendations can be given:
• Interventions and research about their effectiveness are
based mostly on experiences from established market
economies; thus, the levels of effectiveness estimated in our
analysis should be treated as broad indications. Depending
on actual methods of implementation, individual interventions could be more or less effective.
• Interventions should ideally be modeled on the basis of the
specific environment (that is, countries or provinces) and
on the harm distribution in the respective environment,
including social harm.
• General principles, such as restricting access to alcohol,
should be attuned to local cultures and traditions when
interventions are formulated.
• Population measures must take into account the complex
interplay of public opinion and balance the interests of different groups and stakeholders with conflicting values. One
of these stakeholders is, of course, the alcohol industry.
If policy makers keep these principles in mind, reducing the
alcohol-related health burden could be one of the most costeffective targets of population-level health programs in developing countries. This target is even more attractive because the
measures discussed will also reduce the alcohol-related social
burden, thereby further contributing to development.
NOTES
1. The global burden of disease attributable to alcohol is 4.0 percent
using age-weighted DALYs and 3.6 percent using non-age-weighted
DALYs. This difference can be explained by the many alcohol-attributable
outcomes occurring during adolescence and young adulthood, when age
weights are higher.
2. The CRA defined per capita consumption as average consumption of
pure alcohol per person 15 years old or older.
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Chapter 48
Illicit Opiate Abuse
Wayne Hall, Chris Doran, Louisa Degenhardt, and Donald Shepard
Illicit drugs are those banned by international drug control
treaties. They include cannabis products (for example, marijuana, hashish, and bhang); stimulant drugs (such as cocaine
and methamphetamine); so-called dance-party drugs (such as
3, 4-methylenedioxymethamphetamine, also known as ecstasy
or MDMA); and illicit opioids (for instance, heroin and
opium) and diverted pharmaceutical opioids (such as
buprenorphine, methadone, and morphine) (see annex 48.A).
Worldwide, 185 million people were estimated to have used
illicit drugs during 1998–2002 (UNODC 2004; UNODCCP
2002). Cannabis was the most widely used illicit drug, with
146.2 million users in 2002, or 3.7 percent of the global
population over age 15. The stimulant drugs were the next
most widely used illicit drugs: 29.6 million people worldwide
used amphetamines; 13.3 million used cocaine; and 8.3 million
used ecstasy. An estimated 15.3 million, or 0.4 percent of the
world population age 15 to 64, used illicit opioids; more than
half used heroin and the remainder used opium or diverted
pharmaceutical opioids. Illicit opioids continue to be the major
illicit drug problem in most regions of the world in terms of
impact on public health and public order (UNODC 2004).
Even though cannabis use accounts for about 80 percent of
illicit drug use worldwide, the mortality and morbidity attributable to its use are not well understood, even in developed
countries (W. Hall and Pacula 2003; Macleod and others 2004;
WHO Programme on Substance Abuse 1997). The same is true
of the morbidity and mortality attributable to cocaine and
amphetamine-type stimulants (Macleod and others 2004).
Dance-party drugs have been used for too short a time in most
developed societies to enable a good assessment of their potential for harm (Boot, McGregor, and Hall 2000; Macleod and
others 2004). The remainder of this chapter is concerned with
disease control priorities for illicit opioid dependence, because
dependent users account for most of the illicit opioids consumed and experience most of the harm such dependence
causes (W. Hall, Degenhardt, and Lynskey 1999).
NATURE, CAUSES, AND HEALTH CONSEQUENCES
OF ILLICIT OPIOID USE
Before considering interventions, we briefly summarize what is
known about the antecedents, causes, and health consequences
of illicit opioid use.
Antecedents of Heroin Use
Law enforcement efforts to reduce the availability of heroin
aim to increase its price, deter illicit drug use, and promote
social values that discourage heroin use (Fergusson, Horwood,
and Lynskey 1998; Hawkins, Catalano, and Miller 1992;
Newcomb and Bentler 1988). These gains may be at the cost of
increasing harm among the minority who use opioids despite
the prohibition—for example, by encouraging injecting use as
the most efficient way to use an expensive drug and increasing
needle sharing because clean injecting equipment is not freely
available (Rhodes and others 2003; Strathdee and others 2003).
Two aspects of the family environment are associated with
increased rates of both licit and illicit drug use in young people
in developed countries. The first is exposure to a disadvantaged
home environment, with parental conflict and poor discipline
and supervision; the second is exposure to parents’ and siblings’ use of alcohol and other drugs (Hawkins, Catalano, and
Miller 1992). In developed countries, children who perform
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poorly in school because of impulsive or problem behavior and
those who are early users of alcohol and other drugs are most
likely to use illicit opioids (Fergusson, Horwood, and SwainCampbell 2002). Affiliation with drug-using peers is a risk factor for drug use that operates independently of individual and
family risk factors (Fergusson, Horwood, and Lynskey 1998;
Hawkins, Catalano, and Miller 1992).
Health Consequences of Heroin Use
The following sections describe the major health consequences
of heroin use. They include dependence, increased mortality
and morbidity attributable to drug overdoses, and bloodborne
viruses.
Heroin Dependence. In household surveys, 1 to 2 percent of
adults in Australia, the United States, and Europe report using
heroin at some time in their lives (Australian Institute of
Health and Welfare 1999; EMCDDA 2002; SAMHSA 2002).
The highest rates are typically among adults age 20 to 29. Selfreported heroin use in population surveys probably underestimates rates of use because heroin users are undersampled and
those who are sampled underreport their use (W. Hall, Lynskey,
and Degenhardt 1999).
In developed countries, one in four of those who report
heroin use become dependent on it (Anthony, Warner, and
Kessler 1994). People who are heroin dependent continue to
use heroin in the face of problems that they know (or believe)
to be caused by its use. These problems include being arrested
or imprisoned, having interpersonal and family problems,
catching infectious diseases, and suffering from drug overdoses. Many heroin users who seek treatment have typically
been daily heroin injectors, although in Europe (EMCDDA
2002), North America (Office of National Drug Control Policy
2001), and parts of Asia, illicit opioid users also smoke or
“chase” the drug (inhale the fumes released when heroin is
heated) (UNODC 2004).
The American Psychiatric Association defines drug dependence as “a cluster of cognitive, behavioral, and physiologic
symptoms indicating that the individual continues use of the
substance despite significant substance-related problems”
(American Psychiatric Association 1994, 176). In the fourth
edition of the association’s Diagnostic and Statistical Manual of
Mental Disorders (1994,), a diagnosis of substance dependence
requires that three or more of the following occur together:
At any time in the same 12-month period:
1. tolerance, as defined by either of the following:
a. need for markedly increased amounts of the substance
to achieve intoxication or desired effect
b. markedly diminished effect with continued use of the
same amount of the substance;
2. withdrawal, as manifested by either of the following:
a. the characteristic withdrawal syndrome for the
substance
b. the same (or closely related) substance is taken to relieve
or avoid withdrawal symptoms;
3. the substance is often taken in larger amounts or over a
longer period than was intended;
4. there is a persistent desire or unsuccessful efforts to cut
down or control substance use;
5. a great deal of time is spent in activities necessary to obtain
the substance (e.g., visiting multiple doctors, driving long
distances), use the substance (e.g., chain smoking), or
recover from its effects;
6. important social, occupational, or recreational activities are
given up or reduced because of substance use;
7. the substance use is continued despite knowledge of having
a persistent or recurrent physical or psychological problem
that is likely to have been caused or exacerbated by the
substance.
Indirect estimation methods suggest that in Australia, the
United Kingdom, and the European Union fewer than 1 percent of adults age 15 to 54 are heroin dependent (EMCDDA
2002; W. Hall and others 2000). Research in the United States
indicates that dependent heroin users who seek treatment or
who come to the attention of the legal system may use heroin
for decades (Goldstein and Herrera 1995; Hser, Anglin, and
Powers 1993), with periods of use punctuated by abstinence
(Bruneau and others 2004; Galai and others 2003), drug treatment, and imprisonment (Gerstein and Harwood 1990). When
periods of abstinence are included, dependent heroin users use
heroin daily for 40 to 60 percent of the 20 years that they typically are addicts (Ball, Shaffer, and Nurco 1983; Maddux and
Desmond 1992).
Illicit opioid use increased in Asia, Europe, and Oceania
and, to a lesser extent, in Africa and South America in the
1990s, but it has stabilized or declined since 2000 (UNODC
2004). Most illicit opioid users (7.8 million) live in Asian countries that surround the major opium-producing countries,
Afghanistan and Myanmar. Europe accounts for about 25 percent of illicit opioid use (4 million users or 0.8 percent of the
adult population age 15 to 64). Two-thirds of users are in
Eastern Europe, which reported large increases in illicit opioid
use during the second half of the 1990s (Atlani and others
2000; Hamers and Downs 2003; Kelly and Amirkhanian 2003;
Rhodes and others 1999; Uuskula and others 2002).
Illicit opioid use stabilized in much of Asia between 2000 and
2002 (UNODC 2004) as a result of decreased opium production
after the rapid expansion during the 1990s (Dorabjee and
Samson 2000; Reid and Crofts 2000). After 2000, India and
Pakistan reported stabilizing rates of illicit opioid use but
increased injection of pharmaceutical opiates (Ahmed and
others 2003; Dorabjee and Samson 2000; Strathdee and others
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2003). China has reported a steady rate of growth in illicit opiate
use in its southern and northern provinces (Beyrer 2003; Beyrer
and others 2000; Yu and others 1998) and a 15-fold increase in
the number of registered opioid addicts between 1990 and 2002,
bringing the total to about 1 million (UNODC 2004).
Oceania experienced a marked rise in heroin use in the late
1990s, largely driven by a dramatic increase in the availability of
heroin in Australia (Darke, Topp, and others 2002; W. Hall,
Degenhardt, and Lynskey 1999). In late 2000, an abrupt heroin
shortage resulted in a large reduction in fatal and nonfatal
overdoses (Day and others 2004; Degenhardt, Day, and Hall
2004).
account for 25 to 33 percent of deaths of young adult males
(EMCDDA 2002).
Mortality, Morbidity, and Heroin Dependence. In developed
countries, dependent heroin users have an increased risk of
premature death from drug overdoses, violence, suicide,
and alcohol-related causes (Darke and Ross 2002; Goldstein
and Herrera 1995; Vlahov and others 2004). Heroin users
treated before the HIV epidemic were 13 times more likely to
die prematurely than their peers (Hulse and others 1999), with
opioid overdose the most frequent cause of death (W. Hall,
Degenhardt, and Lynskey 1999). In countries with a high
prevalence of HIV infection, AIDS is a major cause of premature death among drug users (EMCDDA 2002; UNAIDS and
WHO 2002). Fatal opioid overdose deaths increased in many
developed countries during the 1990s before declining after
2000 (UNODC 2004).
In parts of Asia, Eastern Europe, and the United States, the
sharing of contaminated injecting equipment accounts for a
substantial proportion of new HIV infections (EMCDDA
2002; UNAIDS and WHO 2002; UNODC 2004). Injecting
opioid use has been a major driver of HIV epidemics in China
(Yu and others 1998), Myanmar (Beyrer and others 2000), the
Russian Federation and former Soviet republics (Hamers and
Downs 2003), and Vietnam (Beyrer and others 2000; Hien
and others 2001).
The prevalence of infection with hepatitis B and C viruses
among injecting drug users is greater than 60 percent in
Australia (National Centre in HIV Epidemiology and Clinical
Research 1998), Canada (Fischer and others 2004), China
(Ruan and others 2004), the United States (Fuller and others
2004), and the European Union (EMCDDA 2002). Chronic
infection occurs in 75 percent of infections, and 3 to 11 percent
of chronic hepatitis C virus carriers develop liver cirrhosis
within 20 years (Hepatitis C Virus Projections Working Group
1998).
Heroin-related deaths primarily occur among young adults
and account for a large number of life years lost in developed
societies. In Australia in 1996, for example, such deaths
accounted for 2.2 percent of life years lost, with each death
accounting for 22 years of life lost (Mathers, Vos, and
Stephenson 1999). In Scotland and Spain, opiate-related deaths
Degenhardt, Hall, and others (2004) estimate the contribution
of illicit opioid dependence to the global burden of disease
using data on deaths caused by opioid and other drug overdoses, suicides and accidents, and HIV/AIDS. When estimates
of morbidity attributable to illicit drug use were added in, illicit
opioid use accounted for 0.7 percent of global disabilityadjusted life years (DALYs) in 2000 (WHO 2003).
These estimates suggest that illicit opioid use is a significant
global cause of premature mortality and disability among
young adults. Even so, they probably underestimate the disease
burden attributable to illicit opioids, because they omit differences across subregions in the quality of data on causes of mortality and estimates of mortality and morbidity attributable to
hepatitis and violence (Degenhardt, Hall, and others 2004).
Economic Costs of Illicit Opioid Use. In Canada, Xie and
others (1996) calculate the costs of illicit drugs as 0.2 percent
of gross domestic product (GDP). In Australia, Collins and
Lapsley (1996) estimate the economic costs of illicit drug abuse
at 2 percent of GDP.
CONTRIBUTION OF OPIOID DEPENDENCE
TO THE GLOBAL BURDEN OF DISEASE
INTERVENTIONS FOR ILLICIT OPIOID
DEPENDENCE
Methods adopted to control the problems arising from illicit
opioid dependence include source-country control; interdiction of supply into end-use countries; enforcement by the
police force and the criminal justice system of legal prohibitions on the supply, possession, and use of opioids; treatment
of those who are opioid dependent, both voluntarily and under
legal coercion from the criminal justice system; school-based
and mass media preventive educational programs; and regulatory policies restricting the prescription of opioids (Manski,
Pepper, and Petrie 2001).
Prevention of Heroin Use
Countries use a variety of interventions in attempts to prevent
the initiation of use of illicit drugs such as cannabis (Manski,
Pepper, and Petrie 2001; Spooner and Hall 2002), in the belief
that early initiation of cannabis use leads to an increased
risk of using illicit opioids (Fergusson, Horwood, and
Swain-Campbell 2002). These interventions include legal prohibitions on the manufacture, sale, and use of opioid drugs
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for nonmedical purposes; enforcement of these sanctions by
law enforcement officials by means of fines and imprisonment;
and enforcement of restrictions on medically prescribed opioids to prevent their diversion (Manski, Pepper, and Petrie
2001). Preventive measures also include mass media and
school-based educational campaigns about the health risks of
opioid and other illicit drug use (Spooner and Hall 2002). It is
unclear how effective these interventions are in preventing
cannabis use and even less clear whether they reduce the initiation of opioids (Caulkins and others 1999; Manski, Pepper, and
Petrie 2001).
The most popular interventions against illicit opioid use in
many developed societies have been the interdiction of drug
supply and the enforcement of legal sanctions against the possession, use, and sale of opioid drugs (Manski, Pepper, and
Petrie 2001). As a consequence, imprisonment is the most common intervention to which many illicit opioid users have been
exposed (Gerstein and Harwood 1990). In Asia and Eastern
Europe, high rates of imprisonment of drug users have been a
factor in HIV transmission, because drug users engage in highrisk injecting while imprisoned (Beyrer and others 2000).
Interventions to Reduce Heroin-Related Harm
The most effective intervention to reduce bloodborne virus
infection arising from illicit injecting of opioids and other
drugs is the provision of clean injecting equipment to reduce
users’ risks of contracting or transmitting bloodborne viruses.
This intervention has been widely supported in most developed
countries, but it has been incompletely adopted in developing
countries that have problems with the concept of facilitating
the injection of illicit drugs (UNAIDS and WHO 2002). Vaccinations are available against hepatitis B but not hepatitis C.
These important interventions are covered in chapter 18.
A number of strategies can potentially reduce deaths from
opioid overdoses (Darke and Hall 2003; Sporer 2003). First,
injecting drug users can be educated about the dangers of combining the use of opioids with alcohol and benzodiazepines
(McGregor and others 2001), both of which heighten the risk
of a fatal opioid overdose (Darke and Zador 1996; WarnerSmith and others 2001). Heroin users also need to be discouraged from injecting in the streets or alone, thereby denying
themselves assistance in the event of an overdose. These interventions have yet to be evaluated.
A second strategy is to encourage drug users who witness
overdoses to seek medical assistance and to use simple resuscitation techniques until help arrives. A more controversial
option is to distribute the opioid antagonist naloxone to highrisk heroin users (Darke and Hall 1997; Strang and others
1996). Neither of these interventions has been evaluated.
A third strategy is to provide supervised injecting facilities
in areas with high rates of injecting opioid use (Dolan and
others 2000; Kimber and others 2003). Supervised injecting
facilities have been introduced in Germany, the Netherlands,
and Switzerland (Dolan and others 2000; Kimber and others
2003), but their effect on overdose deaths has not been rigorously evaluated to date. A supervised injecting facility was evaluated in Australia, but the evaluation was limited by the concurrent onset of a heroin shortage that resulted in a 40 percent
decline in overdose deaths (Kaldor and others 2003).
A fourth strategy is to increase methadone maintenance
among older, high-risk opioid-dependent people, because individuals enrolled in methadone maintenance treatment (MMT)
are substantially less likely to suffer from a fatal overdose
(Caplehorn and others 1994; Gearing and Schweitzer 1974;
Langendam and others 2001).
Treatment Interventions for Dependent Opioid Users
The range of treatment interventions includes voluntary programs such as detoxification, abstinence-oriented treatments,
and oral Methadone maintenance treatment, as well as involuntary options imposed by criminal justice systems.
Detoxification. Detoxification is supervised withdrawal from
a drug of dependence that attempts to minimize withdrawal
symptoms. It is not a treatment for heroin dependence; it
provides a respite from opioid use and may be a prelude to
abstinence-based treatment (Mattick and Hall 1996).
Naltrexone is a longer-acting opiate antagonist than naloxone; it can be used to accelerate the opioid withdrawal process.
Ultra-rapid opioid detoxification accelerates withdrawal by
giving the patient naltrexone under general anesthetic. There is
no evidence that accelerated withdrawal in itself reduces the
high rate of relapse to heroin use in the absence of further
treatment (W. Hall and Mattick 2000).
Abstinence-Oriented Treatments. Abstinence-oriented treatments aim to achieve enduring abstinence from all opioid
drugs by providing some type of intervention after withdrawal
to reduce the high rate of relapse to opioids (Mattick and Hall
1996). The interventions may include social and psychological
support only or such support supplemented by pharmacological methods.
Residential treatment in therapeutic communities and outpatient drug counseling may entail encouraging patients to
become involved in self-help groups such as Narcotics
Anonymous. These approaches share a commitment to achieving abstinence from all opioids, using group and psychological
interventions to help dependent heroin users remain abstinent.
Therapeutic communities and drug counseling are usually provided through specialist addiction or mental health services.
The former are residential, and the latter are provided on an
outpatient basis.
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No randomized controlled trials of therapeutic communities or outpatient drug counseling have been carried out.
Observational studies in the United Kingdom (Gossop,
Marsden, and Stewart 1998; Gossop and others 1997) and the
United States (Hubbard and others 1989; Simpson and Sells
1982) have found that therapeutic communities and drug
counseling were less successful than MMT in attracting and
retaining dependent heroin users, but they substantially
reduced heroin use and crime among those who remained in
treatment for at least three months (Gerstein and Harwood
1990; Gossop, Marsden, and Stewart 1998; Gossop and others
1997). Some evidence indicated that therapeutic communities
may be more effective if they are used in combination with
legal coercion to ensure that heroin users are retained in treatment long enough to benefit from it (Gerstein and Harwood
1990).
Recovering drug users run Narcotics Anonymous groups
using an adaptation of the 12-step philosophy of Alcoholics
Anonymous. Some individuals use these groups as their sole
form of support for abstinence, whereas for others these groups
complement therapeutic communities that are based on the
same principles. Such groups are usually not open to people
who are in opioid substitution treatment programs.
The most extensive research on self-help has been in the
treatment of alcohol dependence. Treated alcoholics who participate in Alcoholics Anonymous groups have higher rates of
abstinence than those who do not (see, for example, Tonigan,
Connors, and Miller 2003; Tonigan, Toscova, and Miller 1996).
The good outcome in those who attend Alcoholics Anonymous
meetings may reflect the self-selection of motivated participants into self-help groups. Recent studies that have attempted
to control for this possibility using sophisticated statistical
methods have produced mixed results, with some showing the
persistence of an effect of self-help after correction (Tonigan,
Connors, and Miller 2003) while others do not (Fortney and
others 1998).
Shepard and others (forthcoming) evaluate the effect of selfhelp participation on substance abuse 24 months after treatment for members of a mixed population of substance abusers
treated at two treatment facilities in the United States, some of
whom had problems with heroin. They find that participation
in self-help groups was associated with longer abstinence from
all drugs. Correction for self-selection did not eliminate the
association in one treatment setting, but it made the results
much more equivocal in the other.
Oral Methadone Maintenance Treatment. This treatment
substitutes a long-acting, orally administered opioid for the
shorter-acting heroin, with the aim of stabilizing dependent
heroin users so that they are amenable to rehabilitation (Marsh
and others 1990; Ward, Hall, and Mattick 1998). When given in
high or blockade doses, methadone blocks the euphoric effects
of injected heroin, allowing the individual to take advantage of
psychotherapeutic and rehabilitative services.
Every one of the small number of randomized controlled
trials of MMT compared with placebo or no treatment has
produced positive results (W. Hall, Ward, and Mattick 1998;
Mattick and others 2003). Large observational studies show
that MMT decreases heroin use and criminal activity and
reduces HIV transmission while patients remain in treatment
(Gerstein and Harwood 1990; Simpson and Sells 1990; Ward,
Hall, and Mattick 1998). MMT is the best-supported form of
opioid maintenance treatment (Farre and others 2002; Marsch
1998; Mattick and others 2003).
Buprenorphine is a mixed agonist-antagonist that also
blocks the effects of heroin. When given in high doses, its
effects can last for up to three days, while its antagonist effects
substantially reduce overdose and abuse (Oliveto and Kosten
1997; Ward, Hall, and Mattick 1998). Meta-analyses have found
that buprenorphine is effective in the treatment of heroin
dependence (Mattick and others 2003) and is of equivalent efficacy to MMT when delivered in primary health care and specialist treatment settings in Australia (Gibson and others 2003).
Bammer and others (2003) have proposed injectable heroin
maintenance as a way of attracting into treatment those heroin
users who are not interested in or have failed to respond to
MMT. This method has recently been evaluated in the
Netherlands (Central Committee on the Treatment of Heroin
Addicts 2002) and Switzerland (Perneger and others 1998;
Uchtenhagen, Gutzwiller, and Dobler-Mikola 1998). Perneger
and others (1998) report a randomized controlled trial of
injectable heroin maintenance in people who had failed at
MMT. Stabilizing and safely maintaining heroin addicts on
injectable heroin (self-administered on-site in a comprehensive
health and social service) proved feasible for six months and
substantially improved their health and social well-being. The
Swiss trials showed that it was possible to maintain opioid
addicts on injectable heroin for up to two years (Rehm and
others 2001; Uchtenhagen, Gutzwiller, and Dobler-Mikola
1998). A recent randomized controlled trial in the Netherlands
(Central Committee on the Treatment of Heroin Addicts 2002)
confirms the findings of Perneger and others (1998).
Criminal Justice Interventions for Dependent Illicit Opioid
Users. The most common intervention for illicit opioid
dependence in most developed societies is imprisonment
(EMCDDA 2003; Gerstein and Harwood 1990). Imprisonment
is not intended to be a health intervention. Nonetheless, it is an
ineffective way of reducing opioid dependence, when judged
by the high recidivism in longitudinal studies of dependent
heroin users (see, for example, Hser, Anglin, and Powers 1993;
Manski, Pepper, and Petrie 2001).
Legally coerced treatment is treatment that is legally forced
on those who have been charged with or convicted of an
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offense to which their drug dependence has contributed
(W. Hall 1997). It is most often provided as an alternative to
imprisonment, under the threat of imprisonment if the person
fails to comply with the treatment (W. Hall 1997; Manski,
Pepper, and Petrie 2001; Spooner, Hall, and Mattick 2001). Its
major justification is that it is an effective way of treating
offenders’ drug dependence that reduces the likelihood of their
offending again (Gerstein and Harwood 1990). A consensus
view prepared for the World Health Organization (WHO)
(Porter, Arif, and Curran 1986) was that compulsory treatment
was legally and ethically justified only if the rights of the
individuals were protected by due process and if the treatment
provided was effective and humane.
Research into the effectiveness of legally coerced treatment
for opioid dependence has been limited to observational studies
(W. Hall 1997; Manski, Pepper, and Petrie 2001; Wild, Roberts,
and Cooper 2002). Anglin’s (1988) quasi-experimental studies
of the California Civil Addict Program provide the strongest
evidence of efficacy. These studies compared heroin-dependent
offenders who entered the program between 1962 and 1964
with a group of similar offenders who went through the criminal justice system during the same period. They found that compulsory hospital treatment followed by close supervision in the
community substantially reduced heroin use and crime.
The effectiveness of less coercive forms of treatment has
been supported by analyses of the effectiveness of communitybased treatment provided while on probation or parole
(Hubbard and others 1989; Simpson and others 1986). These
studies showed that individuals who entered community-based
therapeutic communities and drug-free outpatient counseling
under legal pressure did as well as those who did so voluntarily
(Hubbard and others 1988; Simpson and Friend 1988). The
recent creation of specialized drug courts in the United States to
process those arrested for drug-related offenses awaits rigorous
evaluation (Belenko 2002; Manski, Pepper, and Petrie 2001).
Legally coerced MMT is also effective. The strongest
evidence comes from a study in which drug offenders were randomly assigned to parole with and without community-based
MMT (Dole and others 1969). This study showed a greater
reduction in heroin use and lower rates of incarceration among
those enrolled in MMT in the year following their release from
prison. These findings are supported by observational studies
that found no major differences in response to MMT between
those who enrolled under legal coercion and those who did not
(Anglin, Brecht, and Maddahain 1989; Brecht, Anglin, and
Wang 1993; Hubbard and others 1988).
Economic Evaluations of Interventions for Illicit
Opioid Dependence
The few published economic evaluations of treatment interventions for illicit opioid dependence indicate varying levels of
cost-effectiveness.
Detoxification. The National Evaluation of Pharmacotherapies for Opioid Dependence Project in Australia conducted a cost-effectiveness analysis of five interventions:
• naltrexone-induced rapid opioid detoxification under
anesthesia
• naltrexone-induced rapid opioid detoxification under
sedation
• conventional inpatient detoxification
• conventional outpatient detoxification
• buprenorphine outpatient detoxification.
A successful outcome was defined as achieving abstinence
from heroin for one week (Mattick and others 2001).
Rapid detoxification under sedation was the most costeffective method of detoxification (US$2,355 for one week of
abstinence) and conventional outpatient detoxification the least
cost-effective (US$12,031). Rapid detoxification under anesthesia achieved high rates of abstinence in the first week, but its
expense reduced its cost-effectiveness (Mattick and others
2001).
Doran and others (2003) compared the cost-effectiveness of
detoxification from heroin using buprenorphine in a specialist
Australian clinic and in a shared care setting. They conducted
a randomized controlled trial with 115 heroin-dependent
patients receiving a five-day treatment regime of buprenorphine. The specialist clinic was a community-based treatment
agency in Sydney. Shared care involved treatment by a general
practitioner, supplemented by weekend dispensing and some
counseling at the specialist clinic. They estimate that buprenorphine detoxification in the shared care setting was US$17 more
expensive per patient than the costs of treatment at the clinic
(US$236 per patient).
Drug-Free Treatment. The limited economic evaluations of
drug-free treatment have used data from observational studies
of treatment outcomes in samples of patients who have mixed
substance abuse problems that include opioids. For example,
Shepard, Larson, and Hoffmann (1999) calculate a range of
estimated costs for achieving an abstinent year in 408 patients
at two different treatment facilities in the United States. The
cost-effectiveness depended on the severity of the problem and
the intensiveness and cost of the intervention. For outpatients
with the least severe drug problems, the cost of an abstinent
year was US$7,000, whereas the same outcome in patients with
more severe problems who received long-term residential treatment cost US$20,000.
Shepard and others (forthcoming) use these data to estimate the cost-effectiveness of involvement in mutual selfhelp groups, such as Alcoholics Anonymous and Narcotics
Anonymous, in sustaining abstinence for up to 24 months after
treatment. They find a positive association between self-help
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involvement and abstinence 12 and 24 months after treatment. Applying statistical methods to correct for the effects of
self-selection into self-help, they find that in a Veterans
Administration hospital, the effects of self-help on abstinence
persisted after the statistical correction, but at the other site, the
results depended on the method of analysis that was used. They
estimate the cost of achieving an abstinent year by means of
self-help in the year following treatment at US$13,000, all of
that due to the costs that participants incurred in attending
a group.
Oral Opioid Maintenance Treatment. Goldschmidt’s (1976)
economic evaluation of MMT found that it was as effective
as a therapeutic community intervention and twice as costeffective. Cartwright’s (2000) review of the literature since 1976
identified a number of studies, all of which reported positive
benefit-cost ratios for MMT.
Gerstein, Harwood, and Suter’s (1994) California Drug and
Alcohol Treatment Assessment study is the most comprehensive cost-benefit analysis carried out to date. The authors examine the effects of treatment—residential programs, outpatient
programs, and methadone programs—on alcohol and drug
use, criminal activity, health and health care utilization, and
source of income. For each treatment modality, they found that
the benefits during the first year of treatment significantly
exceeded the cost of delivering the care. The benefit-cost ratio
was 4.8 for residential treatment and 11.0 and 12.6 for outpatients and discharged methadone participants, respectively.
Doran and others (2003) compared the cost-effectiveness
of buprenorphine and methadone treatment for opioid
dependence. In a randomized controlled trial, 405 subjects
were randomly assigned to each treatment at one of three
specialist outpatient drug treatment centers. The study found
that treatment with methadone was less expensive and more
effective than treatment with buprenorphine, but the difference in cost (US$143 per additional heroin-free day gained)
had a wide range of uncertainty around it (⫺US$1,469 to
US$1,284).
The National Evaluation of Pharmacotherapies for Opioid
Dependence Project also provided a cost-effectiveness analysis
of methadone, buprenorphine, LAAM (levo-alpha-acetylmethadol), and naltrexone maintenance treatments (Mattick
and others 2001). The daily costs of these maintenance treatments were similar for methadone and LAAM, but naltrexone
was slightly more expensive. Buprenorphine maintenance
treatment (BMT) was more expensive, but its cost-efficiency
could have been improved to make its cost similar to that for
the other treatments. MMT was the most cost-effective treatment for opioid dependence because it achieved one of the
highest rates of retention in treatment among the four pharmacotherapies examined. Naltrexone treatment was the least
cost-effective.
The costs of injectable heroin maintenance in the Dutch
study was between US$18,015 and US$23,243 per patient per
year (Bammer and others 2003). Most of the costs arose from
the supervision of heroin use and the security required to prevent the diversion of heroin to the black market. Injectable
heroin maintenance needs to produce substantially greater
benefits for each participant than MMT to make it as costeffective as MMT.
Economic Modeling of the Cost-Effectiveness of Opioid
Maintenance Treatment. Barnett (1999), using data on the
efficacy of MMT in reducing mortality derived from
Gronbladh, Ohlund, and Gunne’s (1990) Swedish study and
U.S. cost data, estimated that MMT saved an additional year of
life at a cost of US$5,900. Barnett, Zaric, and Brandeau (2001),
using a similar approach, estimated that the use of buprenorphine by patients who would not use methadone would cost
less than US$45,000 per quality-adjusted life year. Overall,
however, they found that BMT was much less effective and
more costly than MMT. Zaric, Barnett, and Brandeau (2000)
assessed the economic benefits of using MMT to reduce HIV
transmission in heroin users. They found that for heroin users
living in a community with a high prevalence of HIV infection,
expanding MMT use produced an additional year of qualityadjusted life at a cost of US$8,200.
Comparing the Cost-Effectiveness of Different Interventions
Comparative cost-effectiveness analyses of these interventions
face major obstacles because the small number of published
studies used different methods to cost interventions and different endpoints to assess the outcome of treatment. The following list, therefore, only ranks treatment interventions in the
approximate order of their cost-effectiveness. We believe that
estimates of their likely contribution to DALYs worldwide
would be too speculative.
• Detoxification. Buprenorphine and supervised naltrexoneaccelerated withdrawal delivered on an outpatient basis are
the most efficient and effective ways to achieve withdrawal
from opioids.
• Self-help groups. These groups provide the simplest form of
postwithdrawal support for enduring abstinence and are
also a low-cost intervention, because patients bear most of
the costs; however, they have a low rate of uptake, and their
effectiveness is only modest.
• Oral opioid agonist maintenance treatment. This form of
treatment is the most widely used intervention for illicit
opioid dependence in developed societies. It has a better
uptake than other interventions, and it is moderately effective under the usual delivery conditions.
• Drug-free residential treatment. This form of treatment has a
relatively low rate of treatment uptake and is costly because
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of its residential character and the need for intensive staffpatient interaction. It is effective for the minority of people
who are retained in treatment long enough to benefit from
it (usually three months). Retention in treatment may be
improved if patients enter treatment under some form of
legal coercion.
• Naltrexone maintenance treatment. This form of treatment
has not been rigorously evaluated.
• Injectable opioid maintenance. This intervention is a more
expensive variant of agonist maintenance treatment that has
been used for patients with more severe cases of dependency
but for whom retention and treatment outcomes have been
good.
Calculation of the Averted, Avertable,
and Unavertable Burden
Assuming that the disease burden from opioid dependence is
potentially avertable, we used the following approach to estimate the avoidable burden of opioid dependence. We initially
modeled the avertable burden using MMT and used this model
for BMT. The first step was to establish the base case for opioid
dependence using 2002 as the baseline year. We established the
model of the base case for opioid dependence for regions and
subregions according to WHO country classifications. We used
population estimates for each region for those age 15 to 59, the
age range in which heroin dependence is most prevalent. We
incorporated Degenhardt, Hall, and others’ (2004, table 13.1)
figures for the prevalence of opioid use by region, assuming
that the prevalence was 30 percent higher among male users
than female users.
We obtained population-attributable fractions related to
opioid dependence from the editors of this volume. We used
nine relevant WHO categories to estimate the burden of disease attributable to opioid dependence—namely HIV/AIDS,
drug-use disorders, road traffic accidents, poisonings, falls,
fires, drownings, other unintentional injuries, and self-inflicted
injuries.
We calculated the mortality rate for opioid deaths by dividing the number of deaths by the estimated number of users. We
took estimates of years of life lost (YLLs) and years lived with
disability (YLDs), by gender, for each region from data
obtained from the editors of this volume. We then used those
estimates to calculate the DALYs for male users, female users,
and all users (YLL ⫹ YLD ⫽ DALY). We discounted the YLLs,
YLDs, and DALYs using a 3 percent discount rate.
The second step was to estimate the avertable burden by
treatment with methadone or buprenorphine. Using the population and prevalence data, we assumed, in the first instance,
that 50 percent of those dependent on opioids entered treatment. In the sensitivity analysis, we varied this proportion from
25 to 75 percent coverage. On the basis of Caplehorn and
others’ (1994) meta-analysis, we assumed that MMT reduced
mortality by 25 percent. In the sensitivity analysis, we varied
the reduction from 15 to 35 percent (using the confidence
intervals around the estimated reduction). We assumed that
the reduction in mortality associated with BMT was 20 percent, which we varied in the sensitivity analysis from 10 to
30 percent. Finally, we assumed that those who were alive and
in treatment experienced a 25 percent reduction in disability,
consistent with the Dutch disability weights.
The third step was to estimate the burden for those not
treated. For those users not in treatment, we calculated DALYs
using the original mortality rates.
The fourth step was to estimate the total avertable burden
from treatment with methadone or buprenorphine by (a) adding
the results of the second and third steps, the revised DALYs for
those in treatment, and the residual for those not in treatment
and (b) subtracting those figures from the base case estimates.
The fifth step was to cost the interventions using data on
MMT and BMT from Doran and others (2003). They estimated
the cost of MMT at $A 1,415 and of BMT at $A 1,729 for six
months of treatment.We converted these estimates into U.S. dollars and multiplied them by two to provide yearly estimates
of treatment costs of US$1,732 for MMT and US$2,117 for BMT.
We applied relative price weights for each region using the
Western Pacific as the reference case (1.00). We calculated the
relative price weights for each cost type using data provided by
the World Bank. The prices are a reflection of the public health
systems in each region, and as far as possible they reflect the
opportunity cost of health care resources in these regions.
Results. Our results are presented in table 48.1. We explored
various combinations of coverage and reductions in mortality
for MMT and BMT. For each intervention, as coverage and
reductions in mortality increased, the number of DALYs averted
increased. The wide discrepancies in DALYs averted within
regions primarily reflect differences in population-attributable
fractions for HIV/AIDS. Costs increased as a consequence of
increased coverage for both interventions, whereas results for
cost-effectiveness differ by both intervention and mortality.
The cost-effectiveness analysis suggests that for MMT (with
a coverage of 25, 50, or 75 percent and reductions in mortality of
35 percent) the cost in international dollars per DALY averted
ranges from a low of $128 in Africa, with high child and adult
mortality where the prevalence of illicit opioid dependence is
low (0.01 percent), to a high of $3,726 in Eastern Europe, with
low child and adult mortality where the prevalence of illicit
opioid dependence is high (0.55 percent). Across all the
regions, the average cost-effectiveness ratio for MMT (with 25,
50, and 75 percent coverage and 35 percent reduction in mortality) is estimated at $2,236 per DALY averted.
Assessment. The results shown in table 48.1 provide a first
approximation of the potential avertable burden in DALYs if
914 | Disease Control Priorities in Developing Countries | Wayne Hall, Chris Doran, Louisa Degenhardt, and others
©2006 The International Bank for Reconstruction and Development / The World Bank
116
Table 48.1 Cost-Effectiveness Results
Total effect (DALYs averted per 1 million population)
Eastern
Mediterranean
The
Americas
Africa
Southeast
Asia
Europe
Western
Pacific
Coverage
(%)
Mortality
(%)
MMT
25
15
125
79
153
107
158
179
105
117
MMT
50
15
251
158
306
214
316
358
210
MMT
75
15
376
237
459
321
474
538
315
MMT
25
25
150
81
184
121
173
217
MMT
50
25
300
163
369
243
347
MMT
75
25
450
244
553
364
520
MMT
25
35
174
84
216
136
189
256
198
165
69
329
122
92
63
43
MMT
50
35
349
167
432
272
378
511
396
331
139
657
244
184
126
87
MMT
75
35
523
251
648
408
566
767
594
496
208
986
367
276
189
130
BMT
25
10
113
78
137
100
150
160
82
105
43
166
48
38
32
22
BMT
50
10
226
156
274
199
301
320
163
210
85
331
97
75
65
44
BMT
75
10
339
234
412
299
451
480
245
315
128
497
145
113
97
67
BMT
25
20
138
80
169
114
166
198
128
129
53
231
78
59
45
31
BMT
50
20
275
160
337
228
332
397
256
258
107
462
156
119
89
61
BMT
75
20
413
240
506
342
497
595
384
388
160
693
234
178
134
92
BMT
25
30
162
82
200
129
181
237
175
153
64
296
107
81
57
39
BMT
50
30
324
165
400
258
362
473
350
307
128
592
215
162
114
78
BMT
75
30
487
247
601
386
543
710
524
460
192
888
322
243
171
117
Treatment
AFR-D AFR-E AMR-A AMR-B AMR-D EMR-A EMR-D EUR-A EUR-B EUR-C SEAR-B SEAR-D WPR-A WPR-B
48
198
63
234
96
397
126
352
144
595
190
151
141
59
264
93
435
303
283
117
527
652
454
424
176
791
48
39
26
97
77
53
145
116
79
70
51
35
185
140
102
70
278
211
152
105
Total costs (US$ per 1 million population)
MMT
25
15, 25, 35
0.10
0.01
0.25
0.06
0.12
0.95
0.65
0.20
0.16
0.35
0.06
0.19
0.07
0.03
MMT
50
15, 25, 35
0.19
0.02
0.50
0.11
0.24
1.90
1.30
0.40
0.32
0.71
0.11
0.39
0.13
0.07
MMT
75
15, 25, 35
0.29
0.03
0.74
0.17
0.36
2.86
1.95
0.60
0.49
1.06
0.17
0.58
0.20
0.10
BMT
25
10, 20, 30
0.12
0.01
0.30
0.07
0.15
1.16
0.80
0.24
0.20
0.43
0.07
0.24
0.08
0.04
BMT
50
10, 20, 30
0.24
0.03
0.60
0.14
0.29
2.33
1.59
0.49
0.40
0.86
0.14
0.47
0.16
0.08
BMT
75
10, 20, 30
0.35
0.04
0.91
0.20
0.44
3.49
2.39
0.73
0.59
1.29
0.20
0.71
0.24
0.12
Cost-effectiveness (US$ per DALY averted)
MMT
25, 50, 75
15
768
136 1,618
520
755
5,315
6,213
1,711
3,379
1,782
875
3,984
1,716
1,284
MMT
25, 50, 75
25
643
132 1,342
458
688
4,381
4,300
1,419
2,764
1,341
597
2,749
1,301
974
MMT
25, 50, 75
35
552
128 1,146
408
632
3,726
3,288
1,212
2,339
1,074
453
2,099
1,048
784
BMT
25, 50, 75
10
1,041
168 2,204
682
969
7,269
9,764
2,329
4,646
2,606
1,396
6,277
2,493
1,867
BMT
25, 50, 75
20
855
164 1,793
595
880
5,869
6,210
1,895
3,716
1,869
867
3,975
1,809
1,354
BMT
25, 50, 75
30
726
159 1,510
527
805
4,921
4,553
1,598
3,096
1,458
629
2,909
1,419
1,062
DALYs averted per US$1 million spent
MMT
25, 50, 75
15
1,302
7,363
618
1,922
1,325
188
161
585
296
561
1,142
251
583
779
MMT
25, 50, 75
25
1,556
7,575
745
2,185
1,453
228
233
705
362
746
1,676
364
768
1,027
MMT
25, 50, 75
35
1,811
7,787
873
2,448
1,582
268
304
825
428
931
2,210
476
954
1,275
BMT
25, 50, 75
10
961
5,939
454
1,465
1,032
138
102
429
215
384
717
159
401
536
BMT
25, 50, 75
15
1,170
6,112
558
1,681
1,137
170
161
528
269
535
1,153
252
553
739
BMT
25, 50, 75
20
1,378
6,286
662
1,896
1,242
203
220
626
323
686
1,590
344
705
942
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MMT and BMT were applied to 50 percent of the opioiddependent population in each region. Because the methods and
data used to estimate avertable DALYs are subject to certain
limitations, those results should be considered preliminary.
RELEVANCE TO DEVELOPING COUNTRIES
Much of the epidemiological research on illicit opioid dependence, its disease burden, and its societal harm comes from
Australasia, Europe, and the United States. The major exception is research on the role of injecting drug use in HIV transmission in developing countries (see, for example, Beyrer and
others 2000; Yu and others 1998). In addition, research on the
effectiveness and cost-effectiveness of interventions for illicit
opioid dependence has been conducted primarily in developed
countries (Ward, Hall, and Mattick 1998), with the exception of
studies of the effectiveness of methadone treatment in Hong
Kong, China (see, for instance, Newman and Whitehill 1979),
and in Thailand (Vanichseni and others 1991), both of which
showed comparable effectiveness to that found in developed
countries (W. Hall, Ward, and Mattick 1998).
Translating findings on interventions for opioid dependence in developed countries into disease control priorities for
opioid dependence in developing countries presents three
major challenges. First, countries differ in the scale of illicit
opioid use and in the resulting disease burden. This variation
reflects the effects of differences in the prevalence of injecting
and noninjecting opioid users; the dependent opioid users’
access to treatment and health services for overdoses, bloodborne viruses, and other complications of drug use; the access
to needle and syringe programs; the extent to which illicit
opioid use is concentrated in socially disadvantaged minority
groups; and the capacity of public health services to monitor
and respond to emerging infectious disease and drug-use epidemics. The burden is likely to be greatest in settings where the
primary route of administration is injecting and where public
and personal health services are poorly developed, as appears to
be the case in Asia and in Eastern Europe.
Second, societal wealth and health care infrastructure
affect the capacity of developing societies to treat illicit opioid
dependence. A country’s capacity to provide opioid substitution
treatment will be affected by the cost of oral opioid drugs, such
as methadone, LAAM, and buprenorphine, and the existence of
specialist drug treatment centers; trained medical, nursing, and
pharmacy staff; and a drug regulatory system, which are
required so as to deliver opioid substitution treatment safely
and effectively. Few developing countries possess this infrastructure. However, examples exist of apparently successful drug
substitution programs, using such tools as sublingual buprenorphine, that have been conducted with minimal resources in
extremely poor settings (Crofts and others 1998).
Third, in societies with a sizable illicit opioid dependence
problem, cultural attitudes and beliefs will affect societal
responses, especially attitudes toward illicit opioid use and
dependence (Gerstein and Harwood 1990). A critical determinant of the social response will be the relative dominance of
moral and medical understandings of drug dependence in general and opioid dependence in particular. A moral model of
addiction sees addiction as largely a voluntary behavior, in
which case it is seen as an excuse for bad behavior that allows
drug users to continue to take drugs without assuming responsibility for their conduct (Szasz 1985). In this view, drug users
who offend against the criminal code should be imprisoned
(Szasz 1985). This model is the dominant one in many developed societies, which imprison drug users at high rates without
any effect on the prevalence of drug abuse. Countries that
adopt punitive policies toward drug users are reluctant to
embrace harm reduction measures, such as needle and syringe
programs and opioid maintenance treatment (Ainsworth,
Beyrer, and Soucat 2003). A medical model of addiction, by
contrast, recognizes that dependent opioid users require specific treatment if the sufferer is to become and remain abstinent
(see, for example, Leshner 1997).
These competing views will affect the societal acceptability
of opioid maintenance and abstinence-oriented approaches to
the treatment of opioid dependence (Cohen 2003). Those who
have a moral view of addiction will tend to prefer drug-free and
self-help approaches toward treatment. Supporters of medical
models of addiction will favor some form of opioid substitution treatment and the provision of clean needles and syringes
to reduce the transmission of bloodborne viruses by injecting
opioid and other drug users. Stronger advocacy by international organizations and agencies is needed for the adoption of
such harm reduction measures as needle and syringe programs
and agonist substitution programs.
RESEARCH AND DEVELOPMENT
Two main areas are important for research and development.
First, better estimates are needed of the prevalence of illicit opioid dependence and prospective studies of the morbidity and
mortality that it causes in both developed and developing
countries. These estimates are especially needed in countries
where illicit opioid use is high because of their proximity to
source countries. Second, we need evaluations of the effectiveness and cost-effectiveness of self-help, drug-free, and oral opioid substitution treatment in developing countries. A priority
should be the identification of safe, innovative, and less expensive ways of effectively delivering culturally acceptable forms of
opioid maintenance treatments in developing countries. This
effort may require experimentation with a range of substitute
opioids, such as buprenorphine, and cheaper options, such as
codeine and opium tincture.
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CONCLUSIONS: PROMISES AND PITFALLS
Illicit opioid use, especially injecting use, contributes to premature mortality and morbidity in many developed and developing societies. Fatal overdoses and HIV/AIDS resulting from the
sharing of dirty injecting equipment are major contributors
to mortality and morbidity, and the economic costs of illicit
opioid dependence are substantial. Illicit opioid dependence
generates substantial externalities that are not included in
burden-of-disease estimates, principally law enforcement costs
incurred in handling drug dealing and property crime.
The most popular interventions for illicit opioid dependence in many developed societies have been law enforcement
efforts to interdict the drug supply and enforce legal sanctions
against the use of opioid drugs. One consequence of this strategy has been that most illicit opioid users have been exposed
to the least effective intervention: imprisonment for drug or
property offenses. Prisons rarely take the opportunity to treat
dependence using opioid maintenance or to reduce the harm
caused by illicit opioid use by providing access to clean injecting equipment.
In treatment settings, the most popular interventions have
been detoxification (which is not a treatment but a prelude to
treatment) and drug-free treatment (which is the least attractive and the least effective in retaining opioid-dependent people in treatment). Opioid agonist maintenance treatment has
been ambivalently supported in many developed societies
despite its being the treatment for which there is the best evidence of effectiveness, safety, and cost-effectiveness. The range
of opioid agonists available for maintenance treatment is
increasing. A number of developed countries have approved
the use of BMT, which the limited data suggest may be approximately equivalent to MMT in efficacy and cost-effectiveness.
Opioid antagonists have a niche role in the treatment of opioid
dependence because of poor compliance and an increased
risk of overdose on return to heroin use. Their efficacy may
improve with the development of long-acting injectable forms
of the drug.
ANNEX 48.A: PREVALENCE OF USE, ADVERSE
HEALTH EFFECTS OF AND INTERVENTIONS
FOR CANNABIS, COCAINE, AMPHETAMINES,
AND MDMA USE AND DEPENDENCE
Cannabis
Cannabis is the most widely used illicit drug globally, with
about 150 million users, or 3.7 percent of the world’s population age 15 and older (UNODCCP 2003). Patterns of cannabis
use have been most extensively studied in Australia, Canada,
the United States, and Europe (W. Hall and Pacula 2003).
Europe generally has lower rates of use than Australia, Canada,
and the United States, with the highest rates in Denmark,
France and the United Kingdom (EMCDDA 2002; W. Hall and
Pacula 2003). The limited data from developing countries
suggest that, with some exceptions (for example, Jamaica and
South Africa), rates of cannabis use are lower in Africa, Asia,
the Caribbean, and South America than they are in Europe
and in English-speaking countries (W. Hall, Johnston, and
Donnelly 1999).
Surveys in the United States have found long waves of
cannabis use among young people since 1975. Cannabis use
increased during the 1970s to peak in 1979, before declining
steadily between 1980 and 1991. Use rose sharply in 1992 and
increased throughout the 1990s, before leveling off in the late
1990s (Johnston, O’Malley, and Bachman 1994a, 1994b). There
was also a rise in cannabis use during the early 1990s in
Australia, Canada, and some European countries (W. Hall and
Pacula 2003).
The natural history of cannabis use in the United States
typically begins in the mid to late teens and reaches its maximum in the early 20s before declining in the mid to late 20s.
Only a minority of young adults continue to use cannabis into
their 30s (Bachman and others 1997; Chen and Kandel 1995).
Getting married and having children substantially reduces rates
of cannabis use (Bachman and others 1997).
Cannibis use can have several adverse health effects, as discussed below.
Acute Effects of Cannabis Use. The most frequent unpleasant
effects of cannabis use are anxiety and panic reactions, which
most often occur in users who are unfamiliar with the drug’s
effects. Psychotic symptoms such as delusions and hallucinations may be experienced following very high doses. There are
no cases of fatal cannabis poisoning in the medical literature,
and the fatal dose in humans is likely to exceed what recreational users are able to ingest (W. Hall and Pacula 2003).
Cannabis intoxication impairs a wide range of cognitive and
behavioral functions that are involved in driving an automobile
or operating machinery (Beardsley and Kelly 1999; Jaffe 1985).
It has been difficult to determine whether these impairments
increase the risk of being involved in motor vehicle accidents
(Smiley 1999). Studies of the effect of cannabis on driving performance on the road have found only modest impairments,
because cannabis-intoxicated drivers drive more slowly and
take fewer risks than drivers intoxicated by alcohol (Smiley
1999).
Cannabinoids are found in the blood of substantial proportions of persons killed in motor vehicle accidents (Bates and
Blakely 1999; Chesher 1995; Walsh and Mann 1999), but these
findings have been difficult to evaluate because they have not
distinguished between past and recent cannabis use
(Ramaekers and others 2004). More recent research using better indicators of recent cannabis use has found a dose-response
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relationship between cannabis and risk of motor vehicle
crashes (Ramaekers and others 2004). Cannabis used in combination with alcohol substantially increases risk of accidents
(Bates and Blakely 1999; Ramaekers and others 2004).
Health Effects of Chronic Cannabis Use. Cannabis smoke is
a potential cause of cancer because it contains many of the
same carcinogenic substances as cigarette smoke (Marselos and
Karamanakos 1999). Cancers have been reported in the aerodigestive tracts of young adults who were daily cannabis smokers
(W. Hall and MacPhee 2002), and a case-control study has
found an association between cannabis smoking and head and
neck cancer (Zhang and others 1999). A prospective cohort
study of 64,000 adults did not find any increase in rates of head
and neck or respiratory cancers (Sidney and others 1997).
Further studies are needed to clarify the issue.
Three studies of different types of cancer have reported
an association with maternal cannabis use during pregnancy
(W. Hall and MacPhee 2002). There have not been any increases
in the rates of these cancers that parallel increases in rates of
cannabis use (W. Hall and MacPhee 2002).
High doses of cannabinoids impair cell-mediated and
humoral immunity and reduce resistance to infection by
bacteria and viruses in rodents (Klein 1999). Cannabis smoke
impairs the functioning of alveolar macrophages, the first line
of the body’s immune defense system in the lungs. The doses
that produce these effects have been very high, and extrapolation to the doses used by humans is complicated by the fact that
tolerance to these effects develops (Hollister 1992). There is as
yet no epidemiological evidence that rates of infectious disease
are higher among chronic heavy cannabis users. Several large
prospective studies of HIV-positive homosexual men have not
found that cannabis use makes it more likely that HIV-positive
men develop AIDS (W. Hall and Pacula 2003).
Chronic administration of tetrahydrocannabinol (THC)
disrupts male and female reproductive systems in animals,
reducing testosterone secretion and sperm production, motility, and viability in males and disrupting ovulation in females
(Brown and Dobs 2002). It is uncertain whether cannabis use
has these effects in humans because of the limited research on
human males and females (Murphy 1999).
The use of cannabis during pregnancy is associated with
smaller birthweight (English and others 1997; Fergusson,
Horwood, and Northstone 2002), but it does not appear to
increase the risk of birth defects (W. Hall and Pacula 2003). In
some studies, infants exposed to cannabis during pregnancy
show behavioral and developmental effects during the first few
months after birth; these effects are smaller than those seen
after tobacco use during pregnancy (Fried and Smith 2001).
The changes that cannabis smoking causes in heart rate
and blood pressure are unlikely to harm healthy young adults,
but they may harm patients with hypertension, cerebrovascular
disease, and coronary atherosclerosis (Chesher and Hall 1999;
Sidney 2002). One controlled study suggests that cannabis use
can precipitate heart attacks in middle-aged cannabis users
who have atherosclerosis in the heart, brain, and peripheral
blood vessels (Mittleman and others 2001).
Regular cannabis smoking impairs the functioning of the
large airways and causes chronic bronchitis (Tashkin 1999;
Taylor and others 2002). Given that tobacco and cannabis
smoke contain similar carcinogenic substances, it is likely that
chronic cannabis smoking increases the risks of respiratory
cancer (Tashkin 1999).
Psychological Effects of Chronic Cannabis Use. Psychological
effects of chronic cannabis use can include a dependence
syndrome, cognitive effects, and psychotic disorders.
Dependence Syndrome A cannabis dependence syndrome
occurs in heavy chronic users of cannabis (American
Psychiatric Association 1994). Regular cannabis users develop
tolerance to THC. Some experience withdrawal symptoms on
cessation of use (Kouri and Pope 2000), and some report problems controlling their cannabis use (W. Hall and Pacula 2003).
The risk of dependence is about 1 in 10 among those who ever
use the drug, between 1 in 5 and 1 in 3 among those who use
cannabis more than a few times, and about 1 in 2 among daily
users (W. Hall and Pacula 2003).
Cognitive Effects Long-term daily cannabis use does not
severely impair cognitive function, but it may more subtly
impair memory, attention, and the ability to integrate complex
information (Solowij 1998; Solowij and others 2002). It remains
uncertain whether these effects are due to the cumulative effect
of regular cannabis use on cannabinoid receptors in the brain or
whether they are residual effects of THC that will disappear after
an extended period of abstinence (W. Hall and Pacula 2003).
Psychotic Disorders There is now good evidence that chronic
cannabis use may precipitate psychosis in vulnerable individuals (see, for example, Arseneault and others 2002; van Os and
others 2002; Zammit and others 2002). It is less likely that
cannabis use can cause psychosis de novo, because the incidence of schizophrenia has either remained stable or declined
while cannabis use has increased among young adults
(Degenhardt, Hall, and Lynskey 2003).
Effects of Cannabis Use on Adolescents. Cannabis use has a
number of effects on adolescents.
Gateway Hypothesis Adolescents in developed societies typically use alcohol and tobacco before using cannabis, which in
turn, they use before using hallucinogens, amphetamines,
heroin, and cocaine (Kandel 2002). Generally, the earlier the
age of first use and the greater the involvement with any drug
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120
in the sequence, the more likely a young person is to use the
next drug in the sequence (Kandel 2002). The role played by
cannabis in this sequence remains controversial (W. Hall and
Lynskey forthcoming; W. Hall and Pacula 2003).
The simplest hypothesis is that cannabis use has a pharmacological effect that increases the risk of using drugs later in the
sequence. Equally plausible hypotheses are that it is due to a
combination of (a) early recruitment into cannabis use of
nonconforming and deviant adolescents who are likely to use
alcohol, tobacco, and illicit drugs; (b) a shared genetic vulnerability to dependence on alcohol, tobacco, and cannabis; and
(c) socialization of cannabis users within an illicit drug–using
subculture, which increases the opportunity, and encouragement to use other illicit drugs (W. Hall and Pacula 2003).
Adolescent Psychosocial Outcomes Cannabis use is associated
with early withdrawal from high school, early family formation,
poor mental health, and involvement in drug-related crime. In
the case of each of these outcomes, the strong associations in
cross-sectional data are more modest when account is taken of
the fact that cannabis users show characteristics before they use
cannabis that predict these outcomes. For example, they have
lower academic aspirations and poorer school performance than
peers who do not use cannabis (Lynskey and Hall 2000; Macleod
and others 2004). Nonetheless, the evidence increasingly suggests that regular cannabis use adds to the risk of these outcomes
in adolescents already at risk (W. Hall and Pacula 2003).
Interventions for Cannabis Dependence. Although many
dependent cannabis users may succeed in quitting without
professional help, some are unable to stop on their own and
will need assistance to do so. There has not been a great deal of
research on pharmacological treatments for cannabis dependence, although a recent study trialed divalproex sodium with
promising results (Levin and others 2004). Limited research
exists on the effectiveness of different types of psychosocial
treatments for dependent cannabis use (Budney and others
2000; Copeland and others 2001; Stephens, Roffman, and
Simpson 1994). These approaches have involved short-term
cognitive behavioral treatments modeled on similar treatments
for alcohol dependence, usually given in three to six sessions on
an outpatient basis.
In all of these studies, rates of abstinence at the end of
treatment have been modest (20 to 40 percent), and subsequent high rates of relapse mean that rates of abstinence after
12 months have been very modest (Budney and Moore 2002).
Nonetheless, treatment does substantially reduce cannabis use
and problems. These outcomes are not very different from
those observed in the treatment for alcohol and other forms
of drug dependence (Budney and Moore 2002). Much more
research is needed before sensible advice can be given about the
best ways to achieve abstinence from cannabis.
Cocaine
After cannabis, cocaine is one of the most widely used illicit
drugs in developed and developing societies. Some 14 million
people were estimated to have used cocaine globally in 2003,
with demand for treatment second only to heroin (UNODCCP
2003). The highest rates of reported cocaine use—and the best
data on trends in cocaine use—come from the United States,
the world’s largest cocaine market. Rates of cocaine use in the
United States increased from the mid 1970s until 1985, when
5.7 million Americans age 12 and older reported using cocaine
in the preceding month. Rates of cocaine use in the preceding
month have declined steadily since 1985. In 2000, 11.2 percent
of Americans over age 12 reported that they had used cocaine
at some time in their lives, and 0.4 percent (800,000 people)
reported weekly cocaine use (SAMHSA 2001). Among young
U.S. adults age 18 to 25, lifetime prevalence was 14.9 percent in
2001, rising slightly to 15.4 percent in 2002 (SAMHSA 2003).
In 2002, annual prevalence figures from student surveys were
15 percent lower than 1998 figures and 60 percent lower than
1985 figures (UNODCCP 2003). A more recent study of U.S.
adults age 35 years found that 6 percent of men and 3 percent
of women had used cocaine within the preceding 12 months
(Merline and others 2004).
The reported prevalence of cocaine use in other developed
societies is much lower than that in the United States. In
Europe, for example, rates of lifetime cocaine use range from
0.5 percent to 5 percent (EMCDDA 2003), compared with
12.3 percent among American adults in 2001 (SAMHSA 2001).
Rates of cocaine use in Australia resemble those in Europe, with
4.3 percent of adults reporting lifetime use (Darke and others
2000).
The prevalence of cocaine use is likely to be lower in developing societies, but the poor quality of the available data makes
it difficult to be sure (UNDCP 1997). There probably has been
an increase in cocaine use in some developing countries in
recent years, but it is difficult to estimate the size of the increase
(United Nations Commission on Narcotic Drugs 2000). The
region with the highest rates of cocaine use among developing
societies is likely to be Central and South America. The botanical source is indigenous to the region and has traditionally
been used by local populations. Moreover, several nations in
Central and South America have a history of production and
export to global markets. Recent reports indicate that cocaine
abuse is increasing in South America (UNODCCP 2003), and
a recent household survey on drug abuse in São Paulo, Brazil,
estimated cocaine prevalence at 2.1 percent (Galduroz and
others 2003).
Adverse Health Effects of Cocaine. Most cocaine use is infrequent; regular cocaine use (monthly or more frequently) can
be a major public health problem. Regular cocaine users who
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inject cocaine or smoke crack cocaine are especially likely to
develop dependence and to experience problems related to
their cocaine use (Platt 1997). In the United States, it has been
estimated that one in six of those who ever use cocaine become
dependent on the drug (Anthony, Warner, and Kessler 1994).
High rates of cocaine dependence are found among people
treated for alcohol and drug problems and among arrestees in
the United States (Anglin and Perrochet 1998).
In large doses, cocaine may be harmful in both cocainenaive and cocaine-tolerant individuals (Platt 1997; Vasica and
Tennant 2002). The vasoconstrictor effects of cocaine in large
doses place great strains on a number of the body’s physiological systems (McCann and Ricaurte 2000). Effects on the cardiovascular system can result in a range of difficulties, from
chest pain to fatal cardiac arrests (Lange and Hillis 2001).
Neurological problems include cerebral vascular accidents such
as strokes or seizures. Other effects of cocaine can include gastrointestinal problems such as vomiting, colitis, and bowel
infarction and respiratory problems such as asthma, respiratory
collapse, pulmonary edema, and bronchitis. Hyperthermia
may occur because of the increased metabolism, peripheral
vasoconstriction, and inability of the thalamus to control
body temperature (Crandall, Vongpatanasin, and Victor 2002).
Obstetric complications can include irregularities in placental
blood flow, premature labor, and low neonate birthweight
(Majewska 1996; Platt 1997; Vasica and Tennant 2002).
Adverse health effects from cocaine are potentially fatal and
can occur among healthy users irrespective of cocaine dose and
frequency of use (Lange and Hillis 2001; Vasica and Tennant
2002). Although the likelihood of health problems may
increase with dosage and frequency of use, there is wide individual variation in reactions to cocaine and, therefore, no specific combination of conditions under which adverse health
effects can be predicted. There is no antidote to cocaine overdose as there is for an overdose of heroin (Platt 1997).
The impact of cocaine on mental health is also complex.
Although cocaine can produce feelings of pleasure, it may also
result in negative psychological symptoms such as anxiety,
depression, paranoia, hallucinations, and agitation (American
Psychiatric Association 1994). Regular cocaine users experience
high rates of psychiatric disorders. In the United States, regular
cocaine users report high rates of anxiety and affective disorders (Gawin and Ellinwood 1988; Platt 1997). The repeated use
of large doses of cocaine can also produce a paranoid psychosis
(Majewska 1996; Manschreck and others 1988; Platt 1997; Satel
and Edell 1991). People who are acutely intoxicated by cocaine
can become violent, especially those who develop a paranoid
psychosis (Platt 1997).
Animal studies suggest that cocaine use may be neurotoxic
in large doses—that is, it can produce permanent changes in
the brain and neurotransmitter systems (Majewska 1996; Platt
1997). It is unclear whether use is also neurotoxic in humans.
Previous studies have documented a variety of neuropsychological effects of cocaine use, including deficits in memory and
problem solving (Beatty and others 1995; Hoff and others
1996; O’Malley and others 1992). More recently, a twin study
indicated that cocaine may lead to impaired attention and
motor skills up to one year after the conclusion of heavy use
(Toomey and others 2003).
The method by which cocaine is administered can result in
adverse health effects (Platt 1997). Snorting cocaine through
the nose can lead to rhinitis, damage to the nasal septum, and
loss of the sense of smell. Smoking cocaine can lead to respiratory problems, and injecting cocaine leads to the risks of infections and bloodborne viruses associated with all injecting drug
use.
Users who inject cocaine, either on its own or in combination with heroin (“speedballs”), inject much more frequently
than other injecting drug users and, as a consequence, engage
in more needle sharing, take more sexual risks, and have
higher rates of HIV infection (Chaisson and others 1989;
Schoenbaum and others 1989; van Beek, Dwyer, and Malcolm
2001). Associations between cocaine use and HIV risk-taking
have been reported in Europe (Torrens and others 1991),
Australia (Darke and others 1992), and the United States
(Chaisson and others 1989). Recent Australian research
has indicated that injecting cocaine users report more problems related to injecting drug use—such as vascular problems,
abscesses, and infections—than other injecting drug users
(Darke, Kaye, and Topp 2002).
The link between cocaine use and HIV risk is not restricted
to those who inject cocaine. Crack smoking has been linked to
higher levels of needle risk, sexual risk taking, and HIV infection (Chaisson and others 1989; Chirgwin and others 1991;
Desjalais and others 1992; Grella, Anglin, and Wugalter 1995).
Two mechanisms probably underlie the relationship between
cocaine use and HIV infection. First, the short half-life of
cocaine promotes a much higher frequency of injecting by
users than that seen in heroin injectors. Second, cocaine itself
disinhibits and stimulates users, encouraging them to take
greater risks with sexual activity and needle use (Darke and
others 2000).
Cocaine is associated with a risk of intentional injuries and
injuries in general. A recent review reported that 28.7 percent of
people with intentional injuries and 4.5 percent of injured drivers tested positive for cocaine (Macdonald and others 2003).
Users are also at risk of death from an accidental overdose of
cocaine. A recent study of accidental deaths from drug overdose
in New York between 1990 and 1998 found that 70 percent of
deaths were caused by cocaine, often in combination with opiates (Coffin and others 2003). The causes of cocaine-related
deaths are usually related to cardiovascular complications
(Vasica and Tennant 2002), but death may also be due to brain
hemorrhage, stroke, and kidney failure (Brands, Sproule, and
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Marshman 1998). Injection of cocaine is most likely to cause an
overdose, followed by smoking it, with intranasal use involving
the least risk (Pottieger and others 1992).
Much less is known about nonfatal cocaine overdose. A
study in Miami, Florida, found that 40 percent of users had
overdosed on cocaine at least once (Pottieger and others 1992).
More recently, a study in Brazil found that 20 percent of users
had experienced an overdose, with 50 percent knowing someone who had died from an overdose (Mesquita and others
2001). A study in Sydney, Australia, found that 17 percent of
injecting cocaine users and 6 percent of noninjecting cocaine
users had ever overdosed, with 9 percent and 3 percent, respectively, overdosing in the preceding 12 months (Kaye and Darke
2003). Frequency of cocaine use, severity of dependence, and
route of administration did not predict an overdose, supporting the view that cocaine overdose is an unpredictable event.
Interventions for Cocaine Dependence. Efforts at intervention have included pharmacological treatments as well as psychotherapy and cognitive behavioral therapy.
Pharmacological Interventions Despite much research effort
there are no effective pharmacological treatments for cocaine
dependence (Kreek 1997; McCance 1997; Mendelson and
Mellon 1996; Nunes 1997; Silva de Lima and others 2002; van
den Brink and van Ree 2003). Attempts have been made to
develop longer-acting agonist drugs that act on the same
molecular targets as cocaine without producing its euphoric
effects (for example, methylphenidate) (Kreek 1997) or that
block its rewarding and euphoric effects (McCance 1997).
There has also been a search for drugs that indirectly change
the effects that cocaine has on the brain by acting on other
neurotransmitter systems, such as the serotonergic system
(for example, fluoxetine) (McCance 1997). None of these
approaches has produced an effective pharmacotherapy for
cocaine dependence (Lima and others 2003; Platt 1997; Soares
and others 2003).
Development of pharmacological therapies for cocaine
dependence and their evaluation is complicated by the multiple
interactive processes that may have contributed—for example,
coexisting substance abuse or mental health issues (Mendelson
and Mellon 1996). Many of the approaches to the treatment of
cocaine dependence have also been used in treating patients
with alcoholism and other substance abuse disorders.
A number of drugs have been used to treat cocaine based on
their relevance to the symptoms of cocaine dependence (Silva de
Lima and others 2002; van den Brink and van Ree 2003). The
frequency of depressive symptoms has led to the exploration of
the effectiveness of antidepressant drugs. Desipramine has been
used with mixed effectiveness for cocaine detoxification and the
maintenance of abstinence (Covi and others 1994; Gawin,
Kleber, and Byck 1989), but it appears to be most effective when
there is evidence of previous or consequent symptoms of
depression. Other antidepressants have been used with mixed
results: imipramine and trazodone have been found to have
more adverse effects than desipramine, and fluoxetine has not
been found to be effective (Mendelson and Mellon 1996). A
recent systematic review found no current evidence to support
the use of antidepressants in the treatment of cocaine dependence (Lima and others 2003).
Dopamimetic drugs have also been used to treat cocaine
dependence; such treatments are based on the action of cocaine
to block reuptake of dopamine. Unfortunately, although some of
these drugs are relatively effective, they also result in quite
severe adverse effects (Mendelson and Mellon 1996). Current
evidence does not support the clinical use of dopamine agonists for cocaine dependence (Soares and others 2003). Opioid
antagonists (for example, naltrexone) or opioid mixed agonistantagonists (such as buprenorphine) have been explored, on
the basis that cocaine dependence may be accompanied by
dependence on opiates. Although there have been problems
with compliance with naltrexone therapy (National Research
Council Committee on Clinical Evaluation of Narcotic
Antagonists 1978), buprenorphine has shown promising preclinical and clinical trial results (Kosten, Kleber, and Morgan
1989). Other promising directions include cannabinoid receptor antagonists and cortisol synthesis inhibitors (van den Brink
and van Ree 2003) and vaccination against the effects of
cocaine (Kantak 2003), but there is as yet no evidence on the
effectiveness of any of these interventions.
Acupuncture has also been used to treat cocaine dependence. Auricular acupuncture is frequently used, but the small
number of trials that have been conducted have not provided
sufficient evidence of effectiveness (van den Brink and van Ree
2003).
Psychotherapy and Cognitive Behavioral Therapy The lack of
evidence for pharmacological therapy means that treatment
for cocaine dependence currently relies on cognitive behavior
therapies combined with contingency management strategies.
Unfortunately, psychosocial treatments for cocaine dependence
are also of limited effectiveness. Treatments such as therapeutic
communities, cognitive behavioral treatments, contingency
management, and 12 step–based self-help approaches benefit
cocaine-dependent people by reducing their rates of cocaine
use and improving their health and well-being, but rates of
relapse to cocaine use after treatment remain high (Platt 1997).
Mendelson and Mellon (1996) conclude that there are no
specific cognitive or behavioral interventions that are uniquely
effective in treating cocaine dependence. However, some success
has been demonstrated with incentive-based programs in which
rewards are provided for urine samples that are free of cocaine,
although there is doubt about whether results are sustained
(Roozen and others 2004). Such programs are generally more
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effective when the patient’s family and friends are involved
(Higgins and others 1994). Petry and others (2004) suggested
that contingency management was effective in reducing
cocaine use in a community-based treatment setting. They
found that the benefits of treatment depended on the magnitude of reward, with those earning up to US$240 obtaining better results than those earning up to US$80. They suggested that
this form of intervention may work best for people with more
severe dependence on cocaine.
A multicenter investigation examining the efficacy of four
psychosocial treatments for cocaine-dependent patients concluded that individual drug counseling in combination with
group drug counseling showed the most promise for effective
treatment of cocaine dependence over two forms of traditional
psychotherapy (Crits-Christoph and others 1999). Community
reinforcement involving an intensive, biopsychosocial, multifaceted approach to lifestyle change has shown positive effects
over four to six weeks and has the advantage of being tailored
to individual goals (Roozen and others 2004).
The few studies of the long-term effects of treatment have not
shown particularly encouraging results. A one-year follow-up of
the U.S. Drug Abuse Treatment Outcome Studies reported that
reductions in the use of cocaine in the year following treatment
were associated with longer duration of treatment, particularly
six months or more in long-term residential or outpatient treatments (Hubbard, Craddock, and Anderson 2003). A five-year
national follow-up study of 45 U.S. treatment programs found
that only 33 percent of the sample had highly favorable outcomes (Flynn and others 2003).
Amphetamines
According to WHO, amphetamines and methamphetamines
are the most widely abused illicit drugs after cannabis, with an
estimated 35 million users worldwide (Rawson, Anglin, and
Ling 2002).
In Australia, the lifetime prevalence of amphetamine use is
between 6 and 8 percent in the general population, making
amphetamines the most commonly used illicit drug after
cannabis during that period (Makkai and McAllister 1998). In
1998, the lifetime prevalence of amphetamine use was highest
(25 percent) among male users age 20 to 29.
The use of amphetamines is generally less frequent than that
of opioids (Darke and Hall 1995; Darke, Kaye, and Ross 1999; W.
Hall, Bell, and Carless 1993; Hando, Topp, and Hall 1997;
Vincent and others 1998). This pattern is no doubt due to the
physical and psychological toll taken by regular amphetamine
use. Although such use is less frequent overall, however, there is
widespread bingeing on amphetamines, with frequent use over
several consecutive days, which may be followed by benzodiazepine use to “come down.” Polydrug use is particularly common among amphetamine users, who show a marked preference
for stimulant drugs such as hallucinogens and cocaine (Darke
and Hall 1995; Hando and Hall 1994; Vincent and others 1998).
Globally, Europe is the main center of amphetamine production, particularly Belgium, the Netherlands, and Poland, with
production increasing in Eastern Europe (UNODCCP 2003).
Half of all Western European countries reported an increase in
amphetamine abuse in 2000, but in 2001 the figure fell to 33 percent (UNODCCP 2003). Lifetime use of amphetamines is
reported to be between 0.5 percent and 6 percent among
European Union countries, with the exception of the United
Kingdom, where the figure is 11 percent. Denmark and Norway
also have relatively higher rates of use (EMCDDA 2003).
Adverse Health Effects of Amphetamine Use. Amphetamine
users who inject the drug are at high risk of bloodborne infections through needle sharing. Amphetamine users are as likely
as opioid users to share injection equipment (Darke, Ross,
Cohen, and others 1995; Darke, Ross, and Hall 1995; W. Hall,
Bell, and Carless 1993; Hando and Hall 1994; Kaye and Darke
2000; Loxley and Marsh 1991). In addition, the youth of
amphetamine users places them at risk of sexual transmission
of diseases such as HIV and hepatitis B virus (although not
hepatitis C). Primary amphetamine users have been demonstrated to be a sexually active group, and small proportions
engage in paid sex to support their drug use (Darke, Ross,
Cohen, and others 1995; Hando and Hall 1994). Among gay
and bisexual men, amphetamines may be used to enhance sexual encounters, which may lead to unprotected anal intercourse
and increased risk of HIV infection (Urbina and Jones 2004).
High-dose amphetamine use, especially by injection, can
result in a schizophreniform paranoid psychosis, associated
with loosening of associations, delusions, and hallucinations
(Gawin and Ellinwood 1988; Jaffe 1985). The psychosis could
be reproduced by the injection of large doses in addicts (Bell
1973) and by the repeated administration of large doses to normal volunteers (Angrist and others 1974).
High proportions of regular amphetamine injectors describe
symptoms of anxiety, panic attacks, paranoia, and depression.
The emergence of such symptoms is associated with injecting
the drugs, greater frequency of use, and dependence on amphetamines (W. Hall and others 1996; McKetin and Mattick 1997,
1998). Recent evidence also suggests that women may experience more emotional effects of amphetamine intoxication than
men and higher rates of anorexia nervosa than women without
amphetamine disorders (Holdcraft and Iacono 2004).
In sufficiently high doses, amphetamines can be lethal
(Derlet and others 1989). However, the risk is low compared
with the high risks of overdose associated with central nervous
system depressants such as heroin. Typically, amphetaminerelated deaths are associated with the effects of amphetamines
on the cardiovascular system—for example, cardiac failure and
cerebral vascular accidents (Mattick and Darke 1995).
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There is evidence that amphetamines are neurotoxic
(Robinson and Becker 1986). Evidence from animal studies
indicates that heavy amphetamine use results in dopaminergic
depletion (Ellison 1992; Fields and others 1991). The few studies of the neuropsychological effects of amphetamine abuse
report findings similar to those found with cocaine abuse.
Deficits in memory and attention have been attributed to
amphetamine use (McKetin and Mattick 1997, 1998). More
recently, a twin study indicated that amphetamine abuse might
lead to impaired attention and motor skills up to one year after
the conclusion of heavy use (Toomey and others 2003).
Interventions for Amphetamine Dependence. Treatment for
methamphetamine abuse has been a relatively recent development and has generally been based on previous treatments for
cocaine abuse (Huber and others 1997). Cretzmeyer and others (2003) reviewed treatments for methamphetamine abuse,
noting that there has been little research on the effectiveness
of drug treatment, probably because many amphetamine
users use multiple drugs. The combination of methamphetamine use with use of marijuana or other sedating drugs indicates that effective treatments need to address the use of multiple drugs. A Cochrane Review concluded that evidence for
success in treatment of amphetamine dependence is very limited, with no pharmacological treatment demonstrated to be
effective (Srisurapanont, Jarusuraisin, and Kittirattanapaiboon
2003).
An early study explored the use of aversion therapy in a
multimodal treatment program using educational groups,
individual counseling, occasional family counseling, and aftercare planning. The intervention paired an aversive stimulus
(either chemical or electrical) with the act of using methamphetamines. Cocaine use was also treated in this way. After
12 months, 53 percent of patients were abstinent and the
researchers noted that their results were promising, despite a
number of limitations to the study (Frawley and Smith 1992).
An intervention combining imipramine, a tricyclic antidepressant, with intensive group counseling has been evaluated
with cocaine and methamphetamine abusers. Patients received
either a low or higher dose (as needed) of imipramine, as well
as intensive group counseling and access to medical and psychiatric care. Those who received the higher dose stayed in
treatment longer, but the results did not support the use of
imipramine for methamphetamine abuse (Galloway and
others 1994).
The Matrix Program for methamphetamine and cocaine
abusers has also been evaluated. The Matrix Program uses a
cognitive behavioral approach with an emphasis on relapse
prevention (Huber and others 1997). The study evaluated the
effectiveness of three conditions: Matrix treatment alone,
Matrix treatment plus desipramine, and Matrix treatment plus
placebo (Shoptaw and others 1994). The researchers concluded
that those who received more Matrix treatment had better
abstinence rates than those who had less treatment but that
desipramine had no effect on treatment outcome.
J. Hall and others (1999) conducted an evaluation of the
effectiveness of the Iowa Case Management Project. The project was designed to supplement interventions provided by a
drug abuse treatment agency and is a comprehensive social
work intervention, including outreach activities and provision
of limited emergency funds. The results of the evaluation
showed that comprehensive case management was effective in
improving employment status among amphetamine users subsequent to treatment. There was an almost significant lower
incidence of depression among those who received the program compared with controls. Drug use decreased significantly
for clients in both control and program conditions.
More recently, an Australian study evaluated the effectiveness of brief cognitive-behavioral interventions among regular
users of amphetamines (Baker, Boggs, and Lewin 2001). The
researchers found a clinically significant reduction in daily
amphetamine use among the intervention groups compared
with controls and concluded that further studies of brief
cognitive-behavioral interventions are feasible and warranted.
Although some promising interventions have been identified
to assist methamphetamine abusers, no single treatment
option has yet been established as better than any other in a
randomized controlled trial (Cretzmeyer and others 2003).
Methylenedioxymethamphetamine
Methylenedioxymethamphetamine is more widely known
as ecstasy or MDMA. In Australia, the lifetime prevalence of
MDMA use increased from 1 percent of the population in 1988
to 4.6 percent (about one in 20 persons ) in 1998, with 2.3 percent reporting MDMA use in the preceding 12 months (Topp
and others 1998). In 2001, 6.1 percent of Australians age 14
years or older reported lifetime use of MDMA, with 2.9 percent
reporting use within the preceding year (Degenhardt, Barker,
and Topp 2004). Rates of use are generally higher among males
than females (3.1 percent versus 1.5 percent). MDMA use in
the preceding 12 months is most common among those age
20 to 29 (5 percent of females and 12 percent of males) (Topp
and others 1998).
The availability of MDMA has also increased, as indicated by
the proportion of the population who have been offered MDMA
(from 4 percent in 1988 to 7 percent in 1991) (Makkai and
McAllister 1998), with 14 percent of those age 14 to 29 reporting
that they had been offered MDMA in the preceding year.
Research suggests that the pattern of MDMA use changed
during the 1990s (Topp and others 1998). Users of MDMA are
commencing use at a younger age, and they appear to be using
larger doses more frequently. The incidence of bingeing on
MDMA appears to have increased, as does the prevalence of the
parenteral use of this drug. The increase in the use of MDMA
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by injection has been noted among surveys of MDMA users
and of injecting drug users generally.
An examination of trends in the United States suggested
that, although the use of MDMA has increased over time, its
prevalence is significantly less than that of other drugs of abuse
(Yacoubian 2003b). A study of 14,520 U.S. college students
indicated 6 percent lifetime use of MDMA, 3 percent within the
preceding 12 months, and 1 percent within the preceding
30 days. Those who had used MDMA in the preceding
12 months were more likely to be white and a member of a fraternity or sorority and to have used a range of other drugs
(Yacoubian 2003a). Rates of use are much higher in surveys of
club attendees. A recent U.S. survey found 86 percent reporting
lifetime use, 51 percent 30-day use, and 30 percent use within
the preceding 2 days (Yacoubian and others 2003).
Abuse of MDMA had showed signs of decreasing in Western
Europe but has recently shown signs of increase (UNODCCP
2003). Although MDMA use appears to be still diffusing, in
2003 only four countries (Ireland, the Netherlands, Spain, and
the United Kingdom) reported a rate of more than 3 percent
use among young adults in the preceding 12 months
(EMCDDA 2003). In the United States, use declined in 2002 for
the first time, but it increased in other regions, particularly the
Caribbean, parts of South America, Oceania, Southeast Asia,
the Near East, and southern Africa (UNODCCP 2003).
Lifetime experience of MDMA is reported to range from
0.5 percent to 5 percent in European Union countries, with use
more common in the Netherlands (EMCDDA 2003).
Population survey findings from New Zealand reported an
increase in the preceding-year use of MDMA from 1.5 percent
in 1998 to 3.4 percent in 2001. The increase was particularly
evident among young men age 20 to 24 (from 4.3 percent to
12.5 percent) (Wilkins and others 2003).
Adverse Health Effects of MDMA. Early studies of MDMA
use in Australia and the United States documented relatively
few problems associated with the drug’s use (Beck 1990; Beck
and Rosenbaum 1994; Downing 1986; Solowij, Hall, and
Lee 1992). A survey of 100 MDMA users (Solowij, Hall, and
Lee 1992) found that the most common adverse effects were
the side effects of acute use, such as appetite loss, dry mouth,
palpitations, and bruxism (teeth grinding). Among the few
heavy users in the study, only two reported feeling dependent
on the drug.
With a change in the pattern of MDMA use in Australia,
there has been an increase in the MDMA-related harms
reported (Topp and others 1998). Some of the acute physical
and psychological adverse effects that MDMA users have
attributed to the use of this drug include energy loss, irritability, muscular aches, insomnia, and depression. More chronic
adverse effects were also reported, including weight loss,
depression, energy loss, insomnia, anxiety, and teeth problems.
A recent U.K. study of 430 regular users of MDMA reported
that 83 percent of participants reported low mood and 80 percent experienced impaired concentration. Long-term effects
of MDMA included the development of tolerance to MDMA
(59 percent), impaired ability to concentrate (38 percent), and
depression (37 percent) (Verheyden and others 2003).
Physical symptoms that were perceived as being due to
MDMA use alone (Topp and others 1998) included an inability
to urinate, blurred vision, vomiting, numbness or tingling, loss
of sexual urge, and hot and cold flushes. As with amphetamines,
the use of MDMA to facilitate sexual encounters may lead to
risky sexual behavior and risk of sexually transmitted infections
such as HIV. Studies of gay and bisexual men have found an
association between MDMA use and high-risk sexual behavior
(Urbina and Jones 2004).
MDMA has been implicated in a growing number of deaths,
both in Australia and in other countries (Henry, Jeffreys, and
Dawling 1992; Solowij 1993; White, Bochner, and Irvine 1997).
Although the reasons for extreme reactions have yet to be
clearly determined, deaths have most often been attributed to
hyperthermia when MDMA was used at dance venues. A combination of sustained exertion, high ambient temperatures, and
inadequate fluid replacement appears to compound the effect
of MDMA on thermoregulatory mechanisms, causing a rapid
and fatal rise in body temperature (Topp and others 1998).
Some deaths have been attributed to excessive water consumption, which causes cerebral edema (Cook 1996; Matthai and
others 1996).
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Part Three
Strengthening Health Systems
• Strengthening Public Health Services
• Strengthening Personal Health Services
• Capacity Strengthening and Management Reform
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Chapter 53
Public Health Surveillance: A Tool for
Targeting and Monitoring Interventions
Peter Nsubuga, Mark E. White, Stephen B. Thacker, Mark A.
Anderson, Stephen B. Blount, Claire V. Broome, Tom M. Chiller,
Victoria Espitia, Rubina Imtiaz, Dan Sosin, Donna F. Stroup, Robert
V. Tauxe, Maya Vijayaraghavan, and Murray Trostle
What gets measured gets done.
—Anonymous
Public health surveillance is the ongoing systematic collection,
analysis, and interpretation of data, closely integrated with the
timely dissemination of these data to those responsible for
preventing and controlling disease and injury (Thacker and
Berkelman 1988). Public health surveillance is a tool to estimate the health status and behavior of the populations served
by ministries of health, ministries of finance, and donors.
Because surveillance can directly measure what is going on in
the population, it is useful both for measuring the need for
interventions and for directly measuring the effects of interventions. The purpose of surveillance is to empower decision
makers to lead and manage more effectively by providing
timely, useful evidence.
Increasingly, top managers in ministries of health and
finance in developing countries and donor agencies are recognizing that data from effective surveillance systems are useful
for targeting resources and evaluating programs. The HIV and
severe acute respiratory syndrome (SARS) epidemics underscored the critical role of surveillance in protecting individual
nations and the global community. For example, in 2005, China
rapidly began to expand its surveillance and response capacity
through its Field Epidemiology Training Program (FETP);
Brazil and Argentina chose to use World Bank loans to develop
surveillance capacity; and the U.S. Agency for International
Development (USAID) redesigned its surveillance strategy to
focus on the use of data to improve public health interventions
(USAID 2005). Additionally, the guidelines for implementing
the 2004 draft revised International Health Regulations require
World Health Organization (WHO) member states to have
key persons and core capacities in surveillance (http://
www.who.int/csr/ihr/howtheywork/faq/en/#draft).
Just as decision makers require competent, motivated economists to provide quality technical analyses, they also need
competent staff members to provide scientifically valid surveillance information and communicate the results as information
for action. Competent epidemiologists and surveillance staff
members are not a luxury in developing countries; they are a
necessity for rational planning, implementation, and intervention (Narasimhan and others 2004).
DEFINITIONS AND BASIC CONCEPTS
In this chapter, we use the following definitions:
• Indicator: a measurable factor that allows decision makers
to estimate objectively the size of a health problem and
monitor the processes, the products, or the effects of an
intervention on the population (for example, the number
of new cases of diarrhea, the proportion of children fully
997
©2006 The International Bank for Reconstruction and Development / The World Bank
137
•
•
•
•
•
•
•
immunized in a district, or the percentage of high school
students who report that they smoke at least one cigarette a
day).
Active surveillance: a system employing staff members to
regularly contact heath care providers or the population to
seek information about health conditions. Active surveillance provides the most accurate and timely information,
but it is also expensive.
Passive surveillance: a system by which a health jurisdiction
receives reports submitted from hospitals, clinics, public
health units, or other sources. Passive surveillance is a relatively inexpensive strategy to cover large areas, and it provides critical information for monitoring a community’s
health. However, because passive surveillance depends on
people in different institutions to provide data, data quality
and timeliness are difficult to control.
Routine health information system: a passive system in which
regular reports about diseases and programs are completed
by public health staff members, hospitals, and clinics.
Health information and management system: a passive system by which routine reports about financial, logistic, and
other processes involved in the administration of the public
health and clinical systems can be used for surveillance.
Categorical surveillance: an active or passive system that
focuses on one or more diseases or behaviors of interest to
an intervention program. These systems are useful for program managers. However, they may be inefficient at the district or local level, at which staff may need to fill out multiple forms on the same patient (that is, the HIV program, the
tuberculosis program, the sexually transmitted infections
program, and the Routine Health Information System). At
higher levels, allocating the few competent surveillance
experts to one program may leave other programs underserved, and reconciling the results of different systems to
establish the nation’s official estimates may be difficult.
Integrated surveillance: a combination of active and passive
systems using a single infrastructure that gathers information about multiple diseases or behaviors of interest to
several intervention programs (for example, a health
facility–based system may gather information on multiple
infectious diseases and injuries). Managers of diseasespecific programs may be evaluated on the results of the
integrated system and should be stakeholders. Even when an
integrated system is functioning well, program managers
may continue to maintain categorical systems to collect
additional disease-specific data and control the quality of
the information on which they are evaluated. This practice
may lead to duplication and inefficiency.
Syndromic surveillance: an active or passive system that uses
case definitions that are based entirely on clinical features
without any clinical or laboratory diagnosis (for example,
collecting the number of cases of diarrhea rather than cases
of cholera, or “rash illness” rather than measles). Because
syndromic surveillance is inexpensive and is faster than systems that require laboratory confirmation, it is often the
first kind of surveillance begun in a developing country.
However, because of the lack of specificity (for example, a
“rash illness” could be anything from the relatively minor
rubella to devastating hemorrhagic fevers), reports require
more investigation from higher levels. Also an increase in
one disease causing a syndrome may mask an epidemic of
another (for example, rotavirus diarrhea decreases at the
same time cholera increases).
In the specialized area of surveillance for biologic terrorism, syndromic surveillance refers to active surveillance of
syndromes that may be caused by potential agents used by
biologic terrorists and sometimes refers to alternative measures such as increases in the use of over-the-counter drugs
or increases in calls to emergency departments.
• Behavioral risk factor surveillance system (BRFSS): an active
system of repeated surveys that measure behaviors that are
known to cause disease or injury (for example, tobacco or
alcohol use, unprotected sex, or lack of physical exercise).
Because the aim of many intervention program strategies is
to prevent disease by preventing unhealthy behavior, these
surveys provide a direct measure of their effect in the population, often long before the anticipated health effects are
expected. These surveys are useful for providing timely
measures of program effectiveness for both communicable
and noncommunicable disease interventions.
OBJECTIVES OF SURVEILLANCE SYSTEMS
Public health surveillance provides the scientific and factual
database essential to informed decision making and appropriate
public health action. The key objective of surveillance is to provide information to guide interventions. The public health
objectives and actions needed to make successful interventions
determine the design and implementation of surveillance systems. For example, if the objective is to prevent the spread of
epidemics of acute infectious diseases, such as SARS, managers
need to intervene quickly to stop the spread of disease.
Therefore, they need a surveillance system that provides rapid
early warning information from clinics and laboratories. In
contrast, chronic diseases and health-related behaviors change
slowly. Managers typically monitor the effect of programs to
change risky behaviors such as tobacco smoking or chronic diseases once a year or even less often. A surveillance system to
measure the population effects of a tuberculosis control program might provide information only every one to five years—
for example, through a series of demographic and health surveys. The principle is that different public health objectives and
the actions required to reach them require different information
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Box 53.1
Different Objectives, Different Data, Different Systems
Objective
Action
Data
System
Detect epidemics
Monitor intervention programs
Monitor impact of policy change
Monitor health system
Epidemic response
Program monitoring
Health policy
Resource allocation
Early warning information
Program indicators
Health indicators
Administrative data
Active surveillance
Health information
Health information
Health information and
management
Source: Nsubuga, Eseko, and others 2002.
systems. The type of action that can be taken, when or how often
that action needs to be taken, what information is needed to
take or monitor the action, and when or how frequently the
information is needed should determine the type of surveillance or health information system (box 53.1).
Table 53.1 Utility of Surveillance Data
Immediate detection of
Epidemics
Newly emerging health problems
Changes in health practices
Changes in antibiotic resistance
Changes in distribution of population at risk for
disease
PRINCIPLES AND USES OF SURVEILLANCE
Periodic dissemination for
Foege, Hogan, and Newton (1976) state that “the reason for
collecting, analyzing, and disseminating information on a disease is to control that disease. Collection and analysis should
not be allowed to consume resources if action does not follow.”
The fundamental principle of public health surveillance is that
the surveillance should be designed and implemented to provide valid (true) information to decision makers in a timely
manner at the lowest possible cost. Because managers are
unlikely to need to make interventions to address small differences between areas, sacrificing precision makes sense to
improve timeliness and save resources that can be used for
public health interventions. The utility of surveillance data can
be viewed as immediate, annual, and archival, on the basis of
the public health actions that can be taken (table 53.1; Thacker
and Stroup 1998b).
Estimating magnitude of a health problem,
including cost
Assessing control activities
Setting research priorities
Determining risk factors for disease
Facilitating planning
Monitoring risk factors
Monitoring changes in health practices
Documenting distribution and spread of
disease and injury
Stored information for
Describing natural history of diseases
Facilitating epidemiologic and laboratory
research
Validating use of preliminary data
Setting research priorities
Documenting distribution and spread of
disease and injury
ESTABLISHING AND MAINTAINING
A SURVEILLANCE SYSTEM
What is worth doing is worth doing right. Managers who
decide to use public health surveillance as a management tool
must recognize that they will need to commit political support
and human and financial resources. As with every health system, competent, motivated health workers need to be found or
trained and provided with career paths and supervision. After
a manager decides to create a surveillance system, there are six
steps to establishing the system. Because the system must adapt
constantly to changes in the population and the physical
Source: Adapted from Thacker and Stroup 1998b, 65.
and social environment, these steps are linked continuously
(figure 53.1; Thacker and Stroup 1998a).
ANALYSIS AND DISSEMINATION
OF SURVEILLANCE DATA
Surveillance information is analyzed by time, place, and
person. Knowledgeable technical personnel should review data
regularly to ensure their validity and to identify information
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Establish goals
Develop case definitions
Select appropriate personnel
Acquire tools and clearances for collection,
analysis, and dissemination
Implement surveillance system
Evaluate surveillance activities
Source: Adapted from Thacker and Stroup 1998a, 119.
Figure 53.1 Elements in Establishing and
Maintaining a Surveillance System
of use to top managers. Simple tables and graphs are most
useful for summarizing and presenting data. Timely dissemination of data to those who make policy and implement
intervention programs is critical to the usefulness of surveillance data.
The rapidly evolving field of public health informatics,
which deals with collection, classification, storage, retrieval,
analysis, and presentation of large amounts of health data,
offers the potential for truly integrated public health surveillance based on data standardization, a communications infrastructure, and policies on data access and sharing. Surveillance
will benefit by incorporating a systematic approach to standards for data content. For example, the U.S. Centers for
Disease Control and Prevention (CDC) has used standardsbased systems to support automatic electronic reporting of
diagnostic laboratory results of notifiable diseases, thereby
both increasing the number of cases reported and receiving
results more rapidly (Effler and others 1999). Use of data standards facilitates comparability of surveillance information
over time (for example, measurement of effect of program
interventions), across different surveillance approaches (for
example, facility-based reporting compared with sample surveys), and across countries and regions. To be credible, a standard should be developed through an open, participatory
process, by an internationally recognized accredited standardsdevelopment organization that is also capable of long-term
maintenance and evolution of the standard. Public health data
needs extend into multiple areas beyond clinical medicine (for
example, environmental toxins, unintentional injury, and food
safety).
One international standard computer program used in
many countries’ information systems is Epi Info, an epidemiology surveillance and biostatistics program widely used around
the world for the analysis of surveillance data (http://www.cdc.
gov/epiinfo). CDC created, maintains, and distributes Epi Info
at no cost to users.
SURVEILLANCE AS A COMPONENT OF NATIONAL
PUBLIC HEALTH SYSTEMS
WHO and the World Bank cite public health surveillance as an
essential function of a public health system (World Bank 2001).
When linked to policy and program units, surveillance information improves the efficiency and effectiveness of health
services by targeting interventions and documenting their effect
on the population.
A critical challenge in the health sector in developing countries is to ensure quality and effectiveness of surveillance and
public health response in an environment of decentralization.
National-level program and surveillance system managers
may lose control of the quality and timeliness of locally collected data. This situation can be avoided by training local
decision makers in how to use information to meet their
needs and negotiating with them over the core information
collected by each district local unit. National-level managers
or donors can also improve information quality by sponsoring national surveillance scientific and quality assurance networks, linking funding to provision of adequate data, and
performing periodic surveys to confirm the results of local
reporting. If the responsibility for implementing programs is
devolved to local managers, then national-level managers need
only a few summary indicators, rather than the detailed information they may be used to. District or local managers tend
to prefer integrated systems to minimize filling out redundant
forms.
Donors need surveillance data to target and evaluate their
investments. If they perceive weakness in the national system,
they may create parallel nongovernmental surveillance systems
to gather data directly to meet their needs. These systems
invariably pay workers more than government jobs do, so the
most competent people in the government system may leave to
work for the parallel system. Although this system meets
donors’ short-term needs, it invariably weakens government
systems. Parallel systems may weaken the very ministries that
they are meant to help and may not be sustainable after external funding ends. Therefore, parallel systems are inherently
inequitable and should be used only as a last resort.
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Public health
Response
Data
collection
Data
generation
hemisphere
Data
use hemisphere
Interpretation
Analysis
Source: Authors.
Figure 53.2 Surveillance and Response Conceptual Framework
SURVEILLANCE AS A TOOL TO IMPROVE
PUBLIC HEALTH
Managers need focused, timely, scientifically sound information
that provides evidence to make decisions on interventions for
improving the health of the population in their jurisdiction.
Simply collecting data and presenting them are not enough.
Using Surveillance Information for
Evidence-Based Decisions
A major gap in promoting effective surveillance lies between
the production of data and the ability to convert those data into
usable information and then initiate the appropriate public
health action. Surveillance and response can be described in
terms of a data generation hemisphere and a data use hemisphere
(USAID 2005). The data generation hemisphere is the traditional view of surveillance, whereas the data use hemisphere is
the public health response that begins with interpretation of
the data from the surveillance system (figure 53.2).
Substantial attention and the accompanying resources in
surveillance have been devoted to the prompt and complete
production of surveillance data. Although developing countries
experience weaknesses in both hemispheres, more attention is
needed to creating and strengthening the local capacity within
developing countries to identify and manage effective responses
to disease outbreaks and public health conditions of national
and international concern. In some disease-specific programs,
this capacity has to be imported through short-term expatriate
assistance. Even when local capacity is developed, it is often
specific to the disease program, making transfer of skills to
other areas problematic. The failure to develop this indigenous
capacity has limited the ability of developing countries to build
national surveillance systems that respond to both international
public health threats and local health concerns. This capability
is essential to the sustained development of countries.
Role of Field Epidemiologists in Providing Evidence
Developed countries have constructed their public health and
disease control strategies by using the principles of field epidemiology. Developing countries need to build and sustain
human capacity in field epidemiology. Strengthened field
epidemiologic capacity can serve a country in the following
specific areas:
• providing a response to acute problems
• providing the scientific basis for program and policy
decisions
• implementing disease surveillance systems
• supporting national health planning
• making resource allocation decisions
• allocating the human capacity base for national health
priorities.
Specific competencies that should be developed include, but
are not limited to, the ability to accomplish the following:
• design, implement, and evaluate surveillance for a health
event
• identify and assess an actual public health problem
• design and conduct a scientific investigation
• analyze and interpret data from an investigation
• recommend logical and practical public health actions after
the analysis and interpretation of data
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• be proficient in all aspects of diseases of public health
importance (for example, HIV and AIDS, sexually transmitted diseases, malaria, tuberculosis, and zoonoses).
These competencies need to be tailored to the various levels
of the health care system.
Since 1975, CDC and WHO have collaborated with more
than 30 countries to strengthen health systems and address
training needs for disease detection and response in a countryspecific, flexible, and sustainable manner. More than half of the
world’s population now lives in a country where surveillance,
investigation, and response are carried out by staff members
and trainees of FETPs and allied programs, which include
the Epidemic Intelligence Service in the United States, the
European Program for Intervention Epidemiology Training,
and Public Health Schools without Walls (PHSWOWs). These
programs generally function within central ministries of health
and may not be visible outside the public health system. It can
be argued that these programs provide most of the surveillance
of and response to emerging infections in the world, in addition to training most of the public health workers who manage
surveillance systems at the top level. FETPs are two-year courses
designed to provide a ministry with a motivated, professional
group of field epidemiologists with the expertise to respond to
managers’ needs for evidence, perform surveillance, respond to
outbreaks, and train and supervise technical personnel at other
levels (White and others 2001).
Other models have evolved. Guatemala’s marriage of its
FETP (part of a larger, Central American FETP) with the Data
for Decision Making program (Pappaioanou and others 2003)
exemplifies this successful local adaptation. Data for Decision
Making recruits health workers from the community and subdistrict levels to receive training in surveillance and outbreak
investigation in the context of their daily work. This training is
delivered as a series of linked workshops with practical fieldbased projects, providing short-term service at the local levels.
The most promising graduates of the course are selected for
further training in an FETP. India, with its decentralized system, complex cultural and population dynamics, and wide
variance in the sophistication of public health institutions,
provides another model for strengthening national surveillance. The World Bank initiated the Integrated Disease
Surveillance Project, which develops the capacity of local and
midlevel surveillance workers in India. Additionally, FETP
graduates are recruited as the project’s surveillance officers at
the state level to coordinate the surveillance activities of the
hundreds of local health workers throughout the states.
SELECTED SURVEILLANCE STRATEGIES
Surveillance systems need to be designed and implemented to
meet top management’s needs for focused, reliable, timely
evidence gathered efficiently and presented effectively. Because
these needs differ, depending on management’s needs, a number of different strategies have been developed. Here are some
of the most useful.
Sentinel Surveillance
In a sentinel surveillance system,a prearranged sample of reporting sources agrees to report all cases of defined conditions, which
might indicate trends in the entire target population (Birkhead
and Maylahn 2000).When properly implemented, these systems
offer an effective method of using limited resources and enable
prompt and flexible monitoring and investigation of suspected
public health problems. Examples of sentinel surveillance are
networks of private practitioners reporting cases of influenza or
a laboratory-based sentinel system reporting cases of certain
bacterial infections among children. Sentinel surveillance is
excellent for detecting large public health problems,but it may be
insensitive to rare events, such as the early emergence of a new
disease, because these infections may emerge anywhere in the
population.
Periodic Population-Based Surveys
Population-based surveys can be used for surveillance if they
are repeated on a regular basis (Thacker and Berkelman 1988).
Examples of population-based surveys in surveillance include
the BRFSS in the United States, HIV-prevalence surveys,
household surveys, and the demographic and health surveys that many developing countries conduct every five years
(http://www.orcmacro.com). Population-based surveys require
careful attention to the methodology, particularly the use of
standard protocols, supervision of interviewers, comparable
sampling strategy, and standard questionnaires. These surveys
require a clear definition of the target population to which
the results can be generalized, and they need careful attention
to the sample size, based on efficiency and the epidemiologic
characteristics of the health condition under surveillance (for
example, rare conditions require substantial samples).
Supervising interviewers and maintaining high response rates
are critical to avoid bias. Because the surveys are repetitive, population changes (caused, for example, by mortality or mobility)
might bias results.
Laboratory-Based Surveillance
The methods used for infectious disease surveillance form a
spectrum that evolves with the economic development of a
country. Foodborne disease (FBD) surveillance, for example,
is divided into four distinct levels of surveillance. Each level is
more complex and has greater capacity for controlling and
detecting disease, but it also depends on more resources and
infrastructure (figure 53.3).
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Improving capacity and infrastructure
No formal
surveillancea
Syndromic
surveillanceb
Lab-based
surveillancec
Integrated
food-chain
surveillanced
Outbreak detection can occur at all levels, but ability increases
along the spectrum
Source: Authors.
a. Without a formal surveillance, only large or unusual outbreaks can be detected.
b. Syndromic surveillance is based on groups of signs or symptoms indicative of a
common diagnosis, such as acute gastroenteritis.
c. Laboratory-based surveillance relies on laboratory-confirmed pathogens, such as
Salmonella or Shigella.
d. Integrated food-chain surveillance uses data from across the food chain.
Figure 53.3 Spectrum of Case-Based Foodborne Disease
Surveillance
For FBD, surveillance for clinical syndromes is the most
common method of surveillance in the developing world.
Surveillance of FBD outbreaks that are investigated by public
health authorities is often a useful means of monitoring both
the safety of the food supply and the activities of the public
health system. Although both surveillance for clinical syndromes and outbreak surveillance will remain important,
the future in FBD is in laboratory-based surveillance. If
microbiologic diagnosis is sought routinely for a sample of
patients with acute gastroenteritis, then surveillance based on
those diagnoses is possible. For enteric bacterial pathogens
such as Salmonella or Shigella, determining the serotype of the
strains in central reference laboratories allows more rapid and
complete identification of epidemics, which may otherwise
lead to preventable death and disability.
Laboratory-based surveillance systems require resources,
facilities, and training. A central public health reference laboratory is essential for quality assurance and quality control and
support. Such a laboratory-based system might begin with systematic referral of a sample of strains isolated at a sample of
sentinel clinics, plus those strains that are part of outbreaks. A
systematic sampling scheme provides better data than a more
haphazard attempt at universal reporting. Regular sharing of
information between the public health microbiology laboratory and epidemiologists is critical for the information to be used
successfully.
The utility of serotyping as an international language
for Salmonella subtypes has led to its widespread adoption. In a
recent survey, 61 countries reported that they used Salmonella
serotyping for public health surveillance (Herikstad, Motarjemi,
and Tauxe 2002). A collaborative WHO program called
Global Salm-Surv promotes the use of Salmonella serotyping
internationally among countries that wish to upgrade their
national capacity for FBD surveillance (http://www.who.int/
salmsurv/en).
Molecular subtyping is now expanding the power of
laboratory-based surveillance to detect outbreaks in the background of sporadic cases by distinguishing the molecular
“fingerprint” of an outbreak strain. CDC maintains PulseNet,
an Internet-based network of all U.S. public health laboratories
that uses a standardized genotyping method called pulsedfield-gel-electrophoresis (PFGE) as the basis for a national
database of PFGE subtypes (Swaminathan and others 2001).
Standardized subtyping protocols have now been developed for
seven pathogens, and next-generation, gene-based technologies
are under development for the future. Similar networks are
developing around the world, with PulseNet Europe and
PulseNet Canada already active and discussions rapidly
advancing for PulseNet Asia Pacific and PulseNet Latin
America. As with Salmonella serotyping itself, the global use of
standard genotyping will facilitate the detection of multicontinent clusters.
Integrated Disease Surveillance and Response
The Integrated Disease Surveillance and Response (IDSR)
strategy, first developed in Africa, links epidemiologic and laboratory data in communicable disease surveillance systems at
all levels of the health system, with emphasis on integrating
surveillance with response (WHO 1993, 1998). Districts
were identified as a focus for strengthening efforts in collecting
timely data, analyzing the collected data, and using the generated information for public health responses. The IDSR strategy
is based on core activities, including case-patient detection,
registration, and confirmation; reporting, analysis, use, and
feedback of data; and epidemic preparedness and response (for
example, outbreak investigations, contact tracing, and public
health interventions). Support functions include coordination,
supervision or performance evaluation, training, and resource
provision for infrastructure, including communication
(Nsubuga, Eseko, and others 2002).
Key steps in implementing the IDSR strategy include sensitizing key health authorities and stakeholders; conducting situational analysis; preparing a strategic IDSR plan; identifying
and training a motivated, competent workforce; developing
national IDSR technical guidelines; implementing the plan;
and monitoring and evaluating implementation to improve
performance (WHO 2000b). Assessment of the existing
national surveillance and response activities provides baseline
data to measure progress; to identify and build consensus on
the national priority communicable diseases; to identify
surveillance gaps of the selected priority diseases; to document
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Table 53.2 Steps in the Development of the Philippine National Epidemic Sentinel Surveillance System
Steps
Data side
Human capacity side
1.
Identify the health problems thought to cause burden
disease.
Consult top managers, donors, international agencies, and experts.
2.
Determine who will make interventions.
Involve users in design.
3.
Determine information users’ need to make interventions.
Involve users in design.
4.
Decide how often decision makers need reports.
Involve users in design.
5.
Identify who collects, tabulates, and analyzes reports and
who disseminates information.
Identify manager and staff to analyze, report, and enter data.
6.
Design report.
Involve users and staff in design.
7.
Make table shells.
Involve staff in design.
8.
Design questionnaire.
Involve staff in design.
Pilot questionnaire.
Involve staff in implementation and evaluation.
10.
9.
Pilot data flow and analysis.
Involve staff in implementation and evaluation.
11.
Pilot system.
Train staff in system and involve them in evaluation.
12.
Run system.
Involve staff in ongoing training and quality assurance monitoring.
13.
Evaluate system: Was information used? Are data and
analysis of good quality?
Involve staff and users in design of external evaluation and in review of
evaluator’s report.
Source: Adapted from White and McDonnell 2000, 311.
the strengths, weaknesses, and opportunities of the existing
systems; and to make appropriate recommendations. The
WHO Regional Office for Africa, collaborating with its partners, has prepared tools and guidelines for implementation of
IDSR at the country level. Indicators to monitor the performance of the surveillance and response systems have been prepared and field tested and are now in use in Africa.
Example: The Philippine National Epidemic
Surveillance System
In the late 1980s, the Philippine Department of Health
(PDOH), relying on its integrated management information
system, detected less than one outbreak per year in a population
of more than 60 million people. In 1989, the PDOH designed
the National Epidemic Sentinel Surveillance System, a hospitalbased sentinel surveillance system that encompasses both the
flow of data and the personnel requirements needed to make
the surveillance system work effectively (table 53.2). After the
pilot study demonstrated promising results, the PDOH created
personnel positions and a supervisory structure for sentinel
physicians, nurses, and clerks in regional epidemiology and
surveillance units (RESUs) integrated into the public health
system. In 1995 alone, the system detected and formally investigated about 80 outbreaks, including 25 bacteriologically
confirmed outbreaks of typhoid and 5 of cholera. As the
Philippines developed HIV serological and behavioral risk
surveillance, the RESU staff conducted surveys in their communities. By integrating surveillance functions that were based
on the skills of the workforce, PDOH was able to avoid the
duplications, inefficiencies, and sustainability problems of multiple vertical systems (White and McDonnell 2000).
Informal Networks as Critical Elements
of Surveillance Systems
WHO and other agencies frequently receive telephone calls or
informal reports about urgent health events. WHO publishes an
informal list of these“rumors,”which allows public health workers to respond to health risks promptly rather than waiting for
formal reports (http://www.who.int/csr/don/en/). The graduates of FETPs, PHSWOWs, and similar programs that provide
competency-based on-the-job training in ministries of health
make up one of the most important informal networks.
FETPs and allied programs both train epidemiologists and
provide service to their ministries of health. For example, a student in the Brazilian FETP was assigned to review routine data
on patients with leishmaniasis. She noted that some patients
had symptoms of heavy metal poisoning, and further study
indicated that a drug being used to treat leishmaniasis was contaminated with heavy metals. The drug was reformulated, and
the problem was resolved. When this study was presented at a
regional meeting of the Training Programs in Public Health
Interventions Network (a network of FETPs and allied training
programs), other countries banned the drug until it was reformulated (CDC 2004a).
Large categorical surveillance systems are expensive, and
staff members might become complacent, especially if the
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disease under surveillance is rare. For example, the polio surveillance system for acute flaccid paralysis in the Western
Hemisphere detected no cases in July 2000. A trainee from the
FETP of the Dominican Republic, while investigating a case
of suspected poisoning in a child, documented the first outbreak of circulating vaccine-type poliovirus in the Western
Hemisphere since 1991. There were 13 confirmed cases in the
Dominican Republic and 8 cases in Haiti. Her investigation
led to national immunization days in both countries, which
raised immunization levels and stopped the outbreak (Kew
and others 2002).
THE ROLE OF SURVEILLANCE IN
MAJOR OUTBREAKS
It seems incredible that a disease as devastating as AIDS could
have spread silently to many countries over many years before
it was detected and before effective control measures were
implemented in the 1980s. In recent years, surveillance and
response systems at all levels have been more effective at identifying and preventing spread of infectious diseases.
Example: Surveillance and Global Response to SARS
An epidemic of severe pneumonia of unknown etiology was
detected in Guangdong province, China, in November 2002,
and control measures were instituted on the basis of the way
the disease spread from person to person. In February and
March 2003, the disease spread to Hong Kong (China) and
then to Vietnam, Singapore, Canada, and elsewhere (WHO
2003b). This new disease was named severe acute respiratory
syndrome, and a preliminary case definition was established on
the basis of initial epidemiologic investigations. A novel coronavirus (SARS-CoV) was identified as the causative agent in
March, and mapping of the full genome was completed in
April. This global pandemic ended in July 2003, as transmission
was interrupted in Taiwan (China), after more than 8,000
patients in 26 countries and five continents were affected and
774 deaths were confirmed (Peiris and others 2003).
WHO spearheaded the global effort to control this pandemic, working with national and subnational health workers.
In China, the FETP, which was initiated in October 2001 in the
China Center for Disease Control, mobilized all 20 of its
trainees, and they contributed substantially to the surveillance,
investigation, and control of the SARS outbreak, working with
local health officials (CDC 2003a). In Canada, which had the
most cases of SARS outside Asia, 8 of the 10 FETP residents
were involved in the SARS outbreak. They instituted surveillance, conducted epidemiologic investigations, designed prevention and control guidelines, responded to inquiries from
the media and the public, and planned and implemented
epidemiologic studies (http://www.phac-aspc.gc.ca/cfep-pcet/
outbreaks_e.html).
The success of this global effort to control the first new epidemic disease of the 21st century depended on a combination
of open collaboration among scientists and politicians of many
countries and the rapid and accurate communication of surveillance data within and among countries. Rapid global spread
was recognized, and a global surveillance network was established on the basis of an agreed-upon case definition that was
sufficiently specific to ensure effective reporting.
Public health surveillance is critical to recognizing new cases
of SARS and differentiating this disease from other causes of
severe respiratory illness, especially influenza (Heymann and
Rodier 2004). Ongoing research into sources in the environment as well as clinical, laboratory, and epidemiologic concerns
will improve surveillance for this critical public health problem. Notably, this highly contagious disease—for which there is
neither a vaccine nor a cure—was controlled by competent,
dedicated health workers with access to excellent communications. SARS presented a greater challenge than smallpox, for
which long incubation periods and vaccine facilitate control
(Mack 2005). Although it is reassuring that national, regional,
and global systems were effective in controlling SARS, there is
no reason to rest on our laurels. The only certainty is that there
will be more new challenges, very possibly including further
outbreaks of SARS.
Example: Avian Influenza in Thailand
The disastrous pandemic (worldwide epidemic) of influenza in
1918 is thought to have originated from epidemics in birds, as
were the influenza pandemics of 1957 and 1968 (Ungchusak
and others 2005). In early 2004, large epidemics of avian
influenza were recognized in birds in eight Asian countries; by
November, the disease had spread from birds to 44 humans,
73 percent of whom died (Ungchusak and others 2005). This
contagion sparked fears that the highly lethal avian virus might
be adapting to spread from person to person, which could
cause extensive health and economic damage around the
world. In Thailand, avian influenza was investigated by FETP
graduates and others in the Thai Ministry of Health in partnership with CDC. By applying field epidemiologic techniques
supported by laboratory studies, they detected that the virus
was being spread from human to human in a family. It is likely
that person-to-person transmission may have occurred in
other countries, where field epidemiology was not used.
The Thai example is important for achieving the following:
(a) raising global awareness of the potential of a global catastrophe early enough that plans can be made to avert or decrease
harm and (b) demonstrating that, as with SARS, the disease
could be controlled with proven field epidemiologic methods
supplemented by good communications, without vaccines,
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drugs, or a high-technology laboratory or surveillance system
(Mack 2005).
Example: Ebola in Uganda, the Role of the PHSWOW
On October 8, 2000, a second-year student in the Ugandan
PHSWOW returned to Gulu district in northern Uganda for
his field project. He found a hospital jammed with patients
with high fevers, diarrhea, and bleeding. He diagnosed viral
hemorrhagic fever. He called the Ministry of Health in
Kampala, where that weekend a graduate of the PHSWOW was
in charge of taking calls about epidemics. She agreed with
his diagnosis and arranged for samples to be rushed to the
National Institute for Virology in South Africa, the nearest
WHO reference center for viral hemorrhagic fevers. When the
minister of health arrived at his office the next day, the graduate briefed him. Recognizing the gravity of the situation, the
minister sent the graduate to head the public health team surveillance and control team in Gulu, and the student headed the
clinical team that established infection control in hospitals and
treated patients.
Laboratory tests quickly confirmed that the illness was
Ebola hemorrhagic fever, which usually kills more than 50 percent of those infected (Heymann 2004). Public health surveillance was difficult for several reasons. Because the disease was
severe and rapidly fatal, rural villagers feared that they might be
stigmatized if the government knew about cases in their area.
Some sought out traditional healers; others fled as soon as they
realized they had been exposed, which prompted outbreaks in
two other districts. Gulu was a politically unstable area, and
some villages were difficult to reach because of rebel or bandit
activity. The Ugandan government mobilized its military to
help with case finding and invited WHO, CDC, and other
international teams to assist. Patients with Ebola infection
require intense nursing and medical attention to control bleeding, diarrhea, and fevers. Some patients bleed easily, and all
their secretions can be highly infectious. Hospitals in Gulu were
desperately short of supplies to control the spread of infection
from so many patients simultaneously. In spite of this situation,
Ugandan health workers selflessly cared for the sick. By
January 23, 2001, a total of 425 cases had occurred, the largest
Ebola outbreak recorded. Only 53 percent of the patients had
died, a proportion far less than the 88 percent reported in the
1976 Ebola outbreak in the Democratic Republic of Congo (formerly Zaire) and other previous epidemics (WHO Report of an
International Commission 1978). Sadly, 22 health care workers
were infected. Because the team from the Ugandan Ministry of
Health set up active surveillance nationwide, the other two
outbreaks, started when infected Gulu residents fled to distant
villages, were quickly detected and controlled. International
observers commented, “National notification and surveillance
efforts led to the rapid identification of these foci and to effective containment” (CDC 2001).
The Ugandan Ministry of Health invested in developing
competent, motivated health workers through the PHSWOW,
an active partnership with Makerere University, the Rockefeller
Foundation, CDC, and WHO. Both students and graduates
contributed to the ministry’s ability to rapidly identify and
control this dangerous epidemic. Because the minister had
timely evidence, he was able to notify other countries quickly
and to bring in international teams before the disease spread
further. Partially because of the lessons learned from this epidemic, Uganda has become one of the leading countries in
implementing the IDSR program.
SURVEILLANCE FOR SPECIFIC CONDITIONS
Surveillance systems are important tools for targeting, monitoring, and evaluating many health risks and interventions.
Because managers need a wide variety of information for specific interventions, systems have been developed and tested to
meet those needs.
Environmental Public Health Surveillance
Surveillance for environmental public health practice requires
the collection, analysis, and dissemination of data on hazards,
exposures, and health outcomes (figure 53.4; Thacker and
others 1996).
Health outcomes of relevance include death, disease,
injury, and disability. However, relating those outcomes to
specific environmental hazards and exposures is critical to
Agent is a hazard
Agent is present in environment
Hazard
surveillance
Route of exposure exists
Host is exposed to agent
Agent reaches target tissue
Exposure
surveillance
Agent produces adverse effect
Adverse effect becomes clinically apparent
Outcome
surveillance
Source: Thacker and others 1996.
Figure 53.4 The Process of Adverse Effects and the
Corresponding Surveillance
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environmental public health surveillance. Hazards include
toxic chemical agents, physical agents, biomechanical stressors,
and biologic agents that are located in air, water, soil, food, and
other environmental media. Exposure surveillance is the monitoring of members of the population for the presence of an
environmental agent, its metabolites, or its clinically inapparent (for example, subclinical or preclinical) effects.
Four challenges complicate environmental public health
surveillance. First, the ability to link specific environmental
causes to adverse outcomes is limited by our poor understanding of disease processes, long lead times, inadequate measures
of exposure, and multiple potential causes of disease. Second,
data collected for other purposes rarely include sufficient information to meet a case definition for a condition caused by
an environmental agent. Third, public alarm is often out of
proportion to the hazard of concern, and sentiment will often
influence public policy disproportionately to scientific information. Fourth, biologic markers will become increasingly
critical elements of environmental exposure surveillance.
Obtaining data on exposure, which can include estimates
derived from hazard data through sophisticated modeling
or direct measurements of individual exposure obtained from
use of personal monitors (for example, passive air samplers),
is generally impractical in developing countries. Childhood
blood lead levels are the only biomonitoring data that are collected routinely in several countries, either in national surveys
or from screening programs for children at high risk.
Health outcome surveillance as applied to environmental
public health is similar to traditional surveillance efforts. In the
United States, the focus is on surveillance for birth defects;
developmental disabilities (for example, cerebral palsy, autism,
and mental retardation); asthma and other chronic respiratory
diseases (for example, bronchitis and emphysema); cancer; and
neurological diseases (for example, Parkinson’s disease, multiple sclerosis, and Alzheimer’s disease) (McGeehin, Qualters, and
Niskar 2004). Other nations have different sets of priority conditions for surveillance. Disease registries, vital statistics data,
annual health surveys, and administrative data systems (for
example, hospital discharge data) are sources that have been
used for monitoring health conditions. The challenges mentioned previously have constrained our ability in all nations,
regardless of level of development, to establish and maintain
effective and comprehensive environmental public health surveillance systems. As we invest in understanding the enlarging
threats in the global environment, we must overcome these
challenges and establish improved surveillance systems. The
health of the global community depends on this investment.
Injury Surveillance
Injuries are a major public health problem and are among the
10 leading causes of death worldwide, killing an estimated
5 million persons each year and causing high rates of disability.
People from all economic groups are at risk for injuries, but
death rates caused by injury tend to be higher in developing
countries (Peden, McGee, and Sharma 2002). Injury surveillance includes monitoring the incidence, causes, and circumstances of fatal and nonfatal injuries. Injuries are classified by the
intention of the act into two groups: unintentional injuries and
violence-related injuries. WHO (Holder, Peden, and Krug 2001)
and the Pan American Health Organization (Concha-Eastman
and Villveces 2001) have developed guidelines for establishing
injury surveillance systems in developing countries.
If the range of fatal and nonfatal injuries, as well as the risk
factors that can lead to injury, are to be fully captured, surveillance systems need to be established in multiple settings. Fatal
injuries can be captured by using forensic or death certificate
data. A far greater number of injuries are nonfatal and can
be tracked through hospital- or primary care–based systems.
Systematic information on nonfatal injuries, including prevalence, incidence, and related risk behaviors can also be obtained
through ongoing population-based surveys.
Critical points should be addressed when planning an injury
surveillance system in a developing country. First, data sources
need to be clarified. In some developing countries, routine data
on injuries are not always captured in health information
systems. It is therefore necessary to consider other sources of
data—for example, law enforcement agencies, coroners, or
medical examiners. Next, the events and variables in an injury
surveillance system should be defined according to the objectives of the system. Criteria such as the intentionality (violencerelated injuries versus unintentional injuries); the outcome
(fatal injuries versus nonfatal injuries); and the nature of
violence-related injuries (physical, sexual, psychological, deprivation, or neglect) should be considered when establishing the
system. Finally, case definitions and coding procedures should
be defined before implementing the system.
For example, the Nicaraguan Ministry of Health, in collaboration with CDC and the Pan American Health Organization,
began developing and implementing an injury surveillance
system in 2001 (Clavel-Arcas, Chacon, and Concha-Eastman
2004). The system, based on the medical facility emergency
department (ED), collects data on injuries in keeping with the
Injury Surveillance Guidelines established by WHO (Holder,
Peden, and Krug 2001). Under the system, a reportable case is
defined as a patient who died from or was treated for an injury
in the ED. Cases include patients with unintentional and violence-related injuries.
ED staff members identify cases and collect data in five
hospitals in Nicaragua. Information used to complete the
instrument is collected directly from the patients or their
representatives. An ED admission clerk collects basic demographic data on the patient’s arrival. ED medical staff members
(physicians and nurses) collect the remaining information
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(for example, location, mechanism of injury, nature, severity,
and circumstances surrounding the injury) during triage and
assessment.
The hospital epidemiologist collects data collection forms
daily from the ED, reviews the quality of data, and requests data
from the ED staff if the forms are incomplete. The statistician
reviews data daily. The country project coordinator also monitors the quality of the data periodically. Using Epi Info 2002
programs developed specifically for this project, the project
coordinators analyze trends and identify potential risk factors
(Noe and others 2004). The information is used to produce
monthly reports for dissemination. Information is reported at
both the regional and the country levels.
Injury prevention programs in Nicaragua use surveillance
data to assess the need for new policies or programs and to
evaluate the effectiveness of existing policies and programs. For
example, the municipality of León is using the information
from the hospital to monitor the increase in suicide attempts
among youths abusing pesticides and to evaluate an intersectoral campaign to promote life that includes primary through
tertiary prevention strategies.
Surveillance for Biologic Terrorism
Surveillance for biologic terrorism is conducted primarily for
outbreak detection and management. Surveillance must support early detection of an incident of biologic terrorism and its
characterization in the same manner as for the detection and
control of naturally occurring outbreaks of infectious diseases.
Early detection of outbreaks can be achieved by the following
(Buehler and others 2004):
• timely and complete receipt, review, and investigation of
disease case reports, including the prompt recognition and
reporting to or consultation with health departments by
physicians, health care facilities, and laboratories
• improvement of the ability to recognize patterns indicative
of a possible outbreak early in its course (for example, by
using analytic tools that improve the predictive value of data
at an early stage of an outbreak or by lowering the threshold
for investigating possible outbreaks)
• receipt of new types of data (such as purchases of health
care products, absences from work or school, symptoms
presented to a health care provider, or orders for laboratory
tests) that can signify an outbreak earlier in its course.
Environmental detection systems for microbial pathogens
and toxins of concern for biologic terrorism might also be
categorized as new types of data early in the course of an outbreak, before infection (Meehan and others 2004). The primary
surveillance tools for event detection and management are
the traditional disease-reporting systems for notifiable diseases
discussed elsewhere in this chapter. These core surveillance
tools should be robust before new data types can be considered
for supplementing public health surveillance.
Syndromic surveillance is an investigational approach by
which health department staff members, assisted by automated
data acquisition and generation of statistical signals (computerized algorithms), monitor disease indicators continually to
detect outbreaks of disease earlier and more completely than
might otherwise be possible with traditional reportable disease
methods (Buehler and others 2004).
CDC’s list of biologic terrorism agents and diseases can be
found at http://www.bt.cdc.gov and an updated list of references dealing with syndromic surveillance is at http://www.cdc.
gov/epo/dphsi/syndromic/.
Complex Emergency Surveillance
The key elements in planning a disaster surveillance system are
establishing objectives, developing case definitions, determining data sources, developing simple data collection instruments, field testing the methods, developing and testing the
analysis strategy, developing a dissemination plan for the
report or results, and assessing the usefulness of the system.
The surveillance needs are different in the preimpact, impact,
and postimpact phases (Binder and Sanderson 1987).
The role of surveillance in disaster situations has included
the following broad framework of activities:
• predisaster activities (for example, hazard mapping, provision of guidelines, and training for medical and rescue
teams)
• continuous monitoring and surveillance for priority health
problems in affected populations (for example, in the posttsunami surveillance in Tamil Nadu, India, a one-page
instrument was used for 10 priority health conditions for
daily active surveillance in displaced populations at camps)
• prospective surveillance of affected populations focusing on
the natural history of exposure and health effects and longterm effects of stress disorders among survivors.
Surveillance in Refugee Populations
Support of relief efforts following national and global disasters
has been a relatively new application of epidemiologic practice
for the public health professionals. Nevertheless, since the initial CDC involvement with the United Nations in a large-scale
relief effort concerning approximately 20 million displaced
people affected by the 1967–70 civil war in Nigeria, CDC staff
members have participated in several assessments of the health
needs, damage, and nutrition in refugee populations resulting
from man-made and natural disasters. The more notable and
extended actions were conducted in the 1979–82 Khmer
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Thailand-Cambodia refugee-relief action, followed by longterm public health surveillance of Somalian refugees
(1980–83), periodic but comprehensive health and nutritional
assessments of Afghan refugees in Pakistan (1980–2002), and
growth and nutritional assessments of internally displaced
populations—especially children—in the Democratic People’s
Republic of Korea (1990s) and southern Sudan. Although these
relief efforts occurred many years and many thousands of miles
apart, they shared several important characteristics:
• Large numbers of people were in fixed camps or on the
move searching for food and shelter. These needs were usually addressed by external aid agencies and many times
caused local environmental degradation (fuel, temporary
housing, water pollution, and so on).
• Refugees, after the initial phase, competed with indigenous
populations for scarce jobs, leading to social strife and
stress. Refugees were also exploited and suffered violence—
additional factors leading to stress and social maladjustment.
• No administrative structure to provide and coordinate
assistance of the necessary magnitude existed before the
crisis, and thus, it had to be created after the fact.
• Assistance was complicated by the uncertainty associated
with military activity, crime, and hostile governments.
• Data that were relatively simple to gather and analyze
provided health workers and administrators information
needed to plan and monitor assistance and its impact.
• Close collaboration with other local and international
relief organizations (such as the United Nations High
Commissioner for Refugees, the International Red Cross,
the United Nations Children’s Fund, WHO, and USAID)
was essential to instituting and sustaining a meaningful surveillance system for refugees that led to interventions.
The major goal of these activities is to identify and eliminate
preventable causes of morbidity and mortality. Planning
requires effective use of existing knowledge about characteristic or predictable demographic patterns, easily applied health
indicators, and avoidable errors of omission or commission. As
in disasters, the principles of surveillance (data collection, data
analysis, response to data, and assessment of response) and
other public health techniques should be an integral part of
relief efforts. Retrospective evaluation of these efforts has also
proved useful (CDC 1983).
Chronic Disease Surveillance Systems
Development and evaluation of policies for health improvement require a reliable assessment of the burden of disease and
injury, an inventory of the disposition of resources for health,
assessment of the policy environment, and information on the
cost effectiveness of interventions and strategies. In all these
areas, consideration of noncommunicable (mostly chronic)
conditions becomes critical. In 1999, noncommunicable
diseases were estimated to cause approximately 60 percent of
the deaths in the world and 43 percent of the global burden of
disease (WHO 2000a). WHO forecasts that by 2020 the burden
of disease from noncommunicable diseases for developing and
newly industrialized countries will have increased more than
60 percent (Murray and Lopez 1996).
Some developing countries have found it difficult to acquire
and analyze accurate mortality statistics regularly, let alone
morbidity and quality-of-life information. Ensuring development, implementation, and widespread use of noncommunicable disease data for better decisions on resource allocation is
critical to improving the quality of lives and promoting a more
equitable future for health within and between countries.
Hypertension, elevated blood cholesterol, tobacco use,
excessive alcohol consumption, obesity, and the multiple diseases linked to these risk factors are a global public health problem. In one study, smoking, high blood pressure, and high
cholesterol alone explained approximately two-thirds to threefourths of heart attacks and strokes (Vartiainen and others
1995). Until recently, surveillance for risk factors was an activity commonly associated with developed countries (Holtzman
2003). However, recently WHO has increased attention to noncommunicable disease surveillance by developing tools and
working to achieve data comparability between countries
(WHO 2003c). Data on key health behaviors, obesity, hypertension, lipids, and diabetes are collected inconsistently in
developing countries, especially in Africa. Data on tobacco use
are available through the Global Youth Tobacco Survey
(http://www.cdc.gov/tobacco/global).
Incidence data (the number and proportion of new cases in
a population) are limited in developing countries. However,
India’s National Cancer Registry program may serve as a notable
exception (http://icmr.nic.in/ncrp/cancer_regoverview.htm).
In 1981, the Indian Council of Medical Research, recognizing
that there was a lack of information on follow-up of cancer
patients to assess quality of care, instituted a cancer registry network. The network provides data on the magnitude and patterns
of cancer in eight areas of India to enable studies of the histologic features correlating with prognosis and association studies
(for example, whether a history of vasectomy is associated with
cancer of the prostate). Another important example relates to
the widespread use of folic acid in China and the resultant
reduction in incidence of birth defects (Kelly and others 1996;
Wald 2004).
Surveillance data have been critical in establishing the
importance of obesity as a public health priority in the United
States. Data for individual states provided by CDC’s BRFSS
have enabled individual health departments to document their
obesity epidemic (Sturm 2003). These data provide a measure
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of the effectiveness of interventions to meet the control
objectives. The BRFSS is a practical tool for developing and
middle-income countries, as Jordan demonstrated when it
implemented a BRFSS in 2002; the first survey documented
substantial levels of obesity, especially among women, combined with low levels of physical activity (CDC 2003b).
Table 53.3 Health Expenditures by National Income Level of
Countries, 2001
Income groupa
Government expenditures
on health as a
percentage of gross
domestic product
Total expenditures
on health as a
percentage of gross
domestic product
6.30
10.74
High income
ECONOMICS OF PUBLIC HEALTH
SURVEILLANCE SYSTEMS
The outbreak of SARS in 2003 demonstrates the far-reaching
economic impact of not having an effective global public
health surveillance system in place, with an estimated reduction in real gross domestic product of more than US$1.0 billion
in Canada (Darby 2003) and estimated income losses in the
range of US$12.3 billion to US$28.4 billion for East and
Southeast Asia as a whole (Fan 2003).
Public health surveillance is considered a global public good
(Zacher 1999), particularly when it is used for eradication of
such diseases as poliomyelitis. As eradication campaigns
decrease the number of cases, maintaining systems to find the
last few cases becomes more expensive. Often, the majority of
the costs for these systems fall on hard-pressed developing
countries. This factor raises questions of fairness and equity.
For example, as poliomyelitis becomes rare, it ceases to be a significant risk to national populations, whereas other diseases,
such as malaria and diarrhea, typically are major causes of
morbidity and mortality. In such countries, it seems most fair
and efficient for the global community to finance eradication
campaigns, leaving national systems free to address the diseases
that most affect their populations. The negative impact of
globally mandated eradication surveillance systems can be
mediated or reversed by leveraging on the eradication program’s infrastructure to gather surveillance data for diseases of
concern to local governments (Nsubuga, McDonnell, and
others 2002). A similar case can be made for influenza early
warning systems in countries that gather information that will
be used to create vaccines that will benefit other populations
but not their own. Equity demands that the countries that
benefit from such systems finance them.
Public health surveillance systems serve an essential function in preventing and controlling disease spread within and
across national borders. Although the private sector benefits,
it lacks the incentive to invest in public health surveillance
systems, and sovereign states depend on the contribution of
others (WHO 2002); this situation has important implications
for the financing of public health surveillance systems. Even
within national borders, the difficulty of quantifying the benefits of surveillance systems for individual communities leads to
neglect by local authorities, providing the economic rationale
for funding by the national government. Developing countries
Upper-middle income
3.68
6.41
Lower-middle income
2.58
5.63
Low income
1.22
4.78
Source: World Bank 2004.
a. All World Bank member economies with populations of more than 30,000 are classified into
income groups, divided according to 2003 gross national income per capita, calculated using the
World Bank Atlas method. The groups are low income, US$765 or less; lower-middle income,
US$766 to US$3,035; upper-middle income, US$3,036 to US$9,385; and high income, US$9,386 or
more.
are reportedly the weak link in the global surveillance framework, although they bear the greatest burden of disease, emerging and reemerging old pathogens, and drug-resistant
pathogens (U.S. GAO 2001). The greatest need for surveillance
systems is in these countries, but most lack both the resources
and the political will to build human capacity and finance the
systems (table 53.3). Resource constraints and intense pressure
to provide care and treatment services lead public health
authorities in the poorest countries to spend resources on
surveillance (U.S. GAO 2001). Because the costs and benefits
derive from surveillance systems spilling across national borders, donors should assist with capacity building in countries
that have been unable to invest the human and material
resources required.
An interesting and unresolved feature of these global public
goods—the solution to their adequate provision and supply
rests at local, national, and sometimes regional levels—has
prompted the international health community to advocate for
capacity building in developing countries rather than for consolidation of the fragmented systems at the global level (WHO
2002).
Standard tools of economic evaluation (Meltzer 2001) have
been used to compare the benefits and costs of several public
health interventions. The public good characteristics of surveillance systems, with benefits that are not easy to quantify, make
the use of such tools difficult to implement in practice. However,
economic evaluation of laboratory surveillance systems to
detect specific disease-causing organisms have been undertaken
in the developed world by comparing benefits and costs now
and in the future (Elbasha, Fitzsimmons, and Meltzer 2000).
These evaluations have not been done in developing countries
and are needed. At best, an analysis of the benefits and costs of
existing or proposed surveillance systems is feasible. This analysis requires an estimate of the cost of illness and answers the
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question of how many cases of a particular disease need to be
prevented by the surveillance system to be exactly equal to the
expenditure on the system.
Given expenditures on specific health interventions or programs, one can, by using traditional econometric tools, apply
the data on health outcomes from the surveillance systems as
inputs to economic analysis. Surveillance also clearly leads to a
cost saving if it prevents the need for expenditure on treating
patients.
FUTURE OF SURVEILLANCE
Public health agencies, ministries of finance, and international
donors and organizations need to transform surveillance from
dusty archives of laboriously collected after-the-fact statistics
to meaningful measures that provide accountability for local
health status or that deliver real-time early warnings for devastating outbreaks. This future depends in part on developing
consensus on critical surveillance content and developing
commitment on the part of countries, funding partners, and
multilateral organizations to invest in surveillance system infrastructure and to use surveillance data as the basis for decision
making. This vision of the future assumes a coherent, integrated
approach to surveillance systems that is based on matching the
surveillance objective with the right data source and modality
and on paying attention to country-specific circumstances
while maintaining global attention to data content needs.
Information technology and informatics can help in attaining this vision. Specifically, technology can facilitate the collection, analysis, and use of surveillance data, if data standards are
developed and compatible systems are established. Data collection for surveillance would be an automatic by-product of any
electronic systems used to support clinical care. Under this scenario, an automatic electronic message would be sent to the
responsible public health jurisdiction with information about
a health event (for example, death, disease, or injury), including all relevant information from the electronic health record
about the patient, provider’s name, patient’s home address, risk
factors, previous immunizations, and treatments. Even before
this ideal capacity becomes widespread, technology such as cell
phone–based systems could accelerate collection of key data
(for example, occurrence of a viral hemorrhagic fever outbreak). The rapid penetration of cell phones in developing
countries might obviate the need for prohibitively expensive
landline-based systems. An accelerated system of wireless
Internet access might also transform the capacities to which a
local health post or a district health official might have access.
These systems should also be considered as means for collecting information beyond traditional data. For example,
telemedicine access can permit views of a rash illness to be
shared with national or international medical specialists.
Analysis of surveillance data can also be transformed by
using available technology. Software that is Web-enabled,
together with the advances in geographic information system
software and global positioning devices, means that anyone
with Internet access can potentially apply the latest version of
software running on a distant server in the national capital to
local data to generate up-to-date maps and graphs describing
health status in that jurisdiction.
Use of surveillance data can also be transformed.
Sophisticated algorithms can be applied to data as it is collected
to determine when (and how) an alert should be sent to local,
national, or even international health officials to indicate a
need for immediate investigation. Increasingly sophisticated
visual display techniques and creation of custom channels with
data of particular relevance to groups of data users are just
some of the tools already being used to put public health content on the desktop of anyone with broadband, secure Internet
access.
Realization of this future vision does not require technology
beyond what is already feasible, but the following factors are
needed:
• the organizational and political will to develop and coordinate the needed systems and standards that will enable those
systems
• appropriate attention to individual privacy and system
security
• removal of the financial and logistical barriers to broadband
Internet access
• a strategic multisectoral approach to accelerating national
infrastructure among the poorest developing nations.
GLOBAL SURVEILLANCE NETWORKS
Globally, infectious disease surveillance is implemented
through a loose network that links parts of national health care
systems with the media, health organizations, laboratories, and
institutions focusing on particular disease conditions. WHO
has described a “network of networks” (U.S. GAO 2001) that
links existing regional, national, and international networks of
laboratories and medical centers into a surveillance network
(figure 53.5).
Government centers of excellence (for example, CDC, the
French Pasteur Institutes, and FETPs) along with WHO country and regional offices also contribute to disease and health
condition reporting. Military networks, such as the U.S.
Department of Defense’s Global Emerging Infectious Disease
System, and Internet discussion sites, such as ProMed
(http://www.promedmail.org) and Epi-X (http://www.cdc.gov/
epix), also supplement the reporting networks. In 1997, WHO
started the Global Outbreak Alert and Response Network, and
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151
UNHCR
and UNICEF
country
offices
WHO
collaborating
centers and
laboratories
Epidemiology
training
networks
National
public
health
authorities
Military
laboratory
networks
WHO
regional and
country
offices
Global
Public Health
Intelligence
Network
Internet
discussion
sites
Nongovernmental
organizations
Media
press
Formal
Informal
Source: U.S. GAO 2001.
a. UNHCR represents the United Nations High Commissioner for Refugees.
b. UNICEF represents the United Nations Children’s Fund.
Figure 53.5 Global Infectious Disease Surveillance Frameworks
it was formally adopted by WHO member states in 2000. The
network has more than 120 partners around the world and
identifies and responds to more than 50 outbreaks in developing countries each year (Heymann and Rodier 2004).
The International Health Regulations are the only binding
international agreements on disease control. The regulations
provide a framework for preventing the international spread of
disease through effective national surveillance coupled with the
international coordination of response to public health emergencies of global concern by using the guiding principle of
maximum protection, minimum restriction (WHO 2003a).
The current regulations apply only to cholera, plague, and yellow fever; they require WHO member states to notify WHO of
any cases of these diseases that occur in humans within their
territories and then give further notification when the territory
is free of infection. The regulations are being revised to include
the development of national core capacities and national focal
persons who have the competencies of graduates of FETPs and
allied training programs. Programs established to improve the
capacity of both epidemiologists and laboratorians to collect,
use, and interpret surveillance and outbreak data (for example,
the collaborative WHO program in foodborne diseases called
the WHO Global Salm-Surv) are also important components
in developing global surveillance networks.
RESEARCH AGENDA IN PUBLIC HEALTH
SURVEILLANCE
Developing nations share surveillance needs with the rest of the
world, yet they are challenged by economic limitations, weak
public health infrastructure, and the overwhelming challenges
of poverty and disease. As a result, countries in the developing
world often depend on the research efforts of others, or they
collaborate with others to conduct the research necessary for
their surveillance needs. Within individual countries, surveillance systems are essential in measuring disease and injury burden as a first step in establishing public health priorities that
lead to policies and programs.
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152
The major research question for surveillance is how to
develop and maintain a cadre of competent, motivated surveillance and response workers in developing countries. Other
questions include how to design and maintain surveillance systems for these problems, especially morbidity systems for
chronic diseases. Standard methods can be used to evaluate
existing surveillance systems, which, in turn, will help define
surveillance needs (Romaguera, German, and Klaucke 2000).
Developing countries have used the IDSR strategy, which provides an efficient approach to data collection and analysis.
Unfortunately, the majority of developing countries have limited surveillance systems for noninfectious diseases; instead,
existing data systems (for example, vital records, motor vehicle
crash records, or insurance claims data) are potential sources of
surveillance data. In other settings, even these data sources are
scarce, and approaches such as verbal autopsies and recurrent
surveys might be alternatives (White and McDonnell 2000).
Surveillance for risk factors is another challenge, and
BRFSSs need to be validated and applied more widely in developing countries. Surveillance for injuries, environmental hazards (such as traffic intersections that are associated with high
rates of injuries), and exposures to chemical or biological
agents is a key public health concern with few examples of
effective application anywhere in the developed or less developed parts of the world. Rigorous research is required in this
field (Thacker and others 1996).
The burgeoning use of electronic data systems and the
almost universal availability of the Internet provide a tremendous opportunity for more timely and comprehensive surveillance in all parts of the world. Yet in this rapidly emerging field,
critical needs exist, including the following:
•
•
•
•
•
competent, motivated health workers
data standards (Lober, Trigg, and Karras 2004)
global policies and practices for international surveillance
useful software (Dean 2000)
evaluation of the effectiveness of all these applications.
New approaches that must be evaluated by using standard
methods (Romaguera, German, and Klaucke 2000) include the
following:
• IDSR for infectious diseases
• syndromic surveillance (CDC 2004b) for terrorism and
emergency response
• laboratory-based surveillance methods to enhance diagnostic accuracy and increase timeliness of recognition of outbreaks and interventions (Swaminathan and others 2001).
• conduct surveillance for multiple competing risk factors
that lead to a single condition (for example, smoking, cholesterol, hypertension, and overweight for heart disease)
• conduct surveillance for the adverse effects of drugs
• interpret ecologic data relative to data collected on individuals (Greenland 2004)
• measure cost-effectiveness of alternative approaches to surveillance (for example, integrated compared with categorical approaches)
• link data sources effectively (for example, hazard, exposure,
and outcome data for environmental diseases)
• build and sustain human infrastructure in developing
countries
• strengthen evidence-based decision-making cultures in ministries of health and finance.
CONCLUSION
Public health surveillance is an essential tool for ministries of
finance, ministries of health, and donors to effectively and
efficiently allocate resources and manage public health interventions. To be useful, public health surveillance must be
approached as a scientific enterprise, applying rigorous methods to address critical concerns in this public health practice
(Thacker, Berkelman, and Stroup 1989). Although the surveillance needs in the developing world appear to differ from those
in the developed world, the basic problems are similar. In a time
when we are confronted with SARS and avian influenza, the
need to integrate global networks is undeniable, and research in
how these concerns are addressed is essential. Collaboration
among practitioners, researchers, nations, and international
organizations is necessary to address the global needs of public
health surveillance.
ACKNOWLEDGMENTS
The authors would like to acknowledge ORISE Fellow Danielle
Backes of the Division of International Health, Coordinating
Office for Global Health, U.S. Centers for Disease Control and
Prevention, for her invaluable help in preparing this chapter.
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Chapter 54
Information to Improve Decision Making
for Health
Sally K. Stansfield, Julia Walsh, Ndola Prata, and Timothy Evans
The new source of power is not money in the hands of a few, but information in the hands of many.
—John Naisbitt and Patricia Aburdene, Megatrends 2000
This chapter focuses on the collection and management of
public health information, in contrast to clinical information,
which concerns individual patient care encounters. Even
when aggregated, clinical data are necessary, but not sufficient,
to inform efforts to improve the health of populations. While
substantial attention has been focused on these facility-based
clinical consultations and the health management information
system (HMIS) used to track the relevant data, we focus here
on the broader health information system (HIS) needed to
inform decisions at individual, facility, district, and national
levels. Considered here are the routine data collection systems
upon which program management, planning, monitoring,
and evaluation depend. Information needs for specific tasks,
such as for research or for program evaluation, are discussed
in the chapters on research (chapters 4 and 7). Other chapters
in this volume refer to information needs to enable disease
control or to evaluate programs and improve the delivery of
interventions. Those interested in these issues should also pay
special attention to chapter 53 and chapters 70–73. This
chapter bridges the global and the local issues; it makes the
case for strengthening the evidence base for action through
comprehensive health information systems that include census, vital events, monitoring, public health surveillance,
resource tracking, facility-based service statistics, and household surveys.
INTRODUCTION
From infancy on, we receive information that gives form to our
thinking and problem solving. The method by which a phenomenon is measured shapes societal perceptions of it and the
collective efforts to affect it. Likewise, the choices we make in
the collection and use of information for health will determine
our effectiveness in detecting problems, defining priorities,
identifying innovative solutions, and allocating resources for
improved health outcomes. Despite those fundamental realities, there has been little awareness to date of the ramifications
that greater information use can have for advancing health, and
even less attention has been given to systems needed to provide
timely, accurate, and relevant information.
An example of the formative power of information for policy change lies in the history of the United Nations’ Standard
System of National Accounts, created by Richard Stone more
than 50 years ago. The annual reporting of these accounts by
most countries shapes our impressions of the relative position
of nations, defines our views of the differential opportunities
offered to their citizens, and drives the content of national and
global political discourse (Jolly 2002). Another example is the
measurement of disability-adjusted life years (DALYs), which
has shaped priorities for investment in global health over the
past decade.
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However, data or information alone will not transform outcomes. Data, which are simple measures of characteristics of
people and things, have little inherent meaning or value.
Analysis of the data enables the identification of patterns,
thereby creating information. Finally, the use of information to
generate recommendations, rules for action, and behavior
change signifies the creation of knowledge that is used to make
decisions and change human behavior.
Good decisions on effective policies, services, and behaviors
require timely, accurate, and relevant information. Health information is required for strategic planning and the setting of
priorities; clinical diagnosis and management of illness or
injury; quality assurance and quality improvement for health
services; detection and control of emerging and endemic disease; human resource management; procurement and management of health commodities (including drugs, vaccines, and
diagnostics); regulation of toxic exposures; program evaluation;
research; and other types of policies and programs (Walsh and
Simonet 1995). Citizens require such information to choose
healthy behaviors, to demand effective policies and services, and
to hold their governments accountable for the allocation and
use of resources for health. Internationally, information is
required to meet transnational needs, such as for the detection
and control of consequences of epidemics and infectious diseases, results-based management of development assistance
programs, and advocacy for increased financing for health.
Several recent trends further enhance the pressures to
deliver better health information. Global epidemics, such as of
severe acute respiratory syndrome (SARS) and “bird flu,” have
amply demonstrated the need and potential benefits of sensitive and transparent systems for tracking health events.
Donors, including the Global Fund and the Global Alliance for
Vaccines and Immunization (GAVI), increasingly demand
performance measures and detailed evidence to justify new
requests for support. “Basket” funding and sectorwide approaches place further responsibilities on countries to define
their own priorities. Decentralization and devolution of budgetary controls have shifted much of this growing burden to
the periphery, requiring districts to provide local evidence as a
basis for decisions. Tracking progress toward the Millennium
Development Goals for health requires empowering countries
to measure key indicators and produce evidence-based strategic plans to achieve and document that progress. Furthermore,
nearly every chapter in this volume cites the need for better
information, including through research dependent on a
health information system, to accelerate improvements in
health.1
Yet there is a striking disconnect between the need for information and the ability to respond to that need. To collect,
collate, analyze, and communicate the necessary information
in a timely and understandable fashion requires organized
processes and procedures and a comprehensive HIS. However,
donor-driven and disease-specific initiatives have actually
undermined efforts to develop a comprehensive HIS by creating separate, parallel, and often duplicative systems to meet the
need for each funding source.
Health information and the systems for its supply are a public good, meeting the defining criteria of being nonexcludable
(in that, once the information is in the public domain, it is difficult to withhold from users) and nonrival (in that consumption of the information does not lessen its availability for use by
others). As a public good, the supply of health information is the
primary responsibility of governments: national governments
for information within these jurisdictions, and international
agencies and national governments together for international
comparative information and global summary data.
Harmonizing the data collection, standards, best practices,
and other elements of a national and global HIS has several
advantages. Standardization enables economies of scale for
training, hardware and software, and processes. Routine health
information is a summative good in that the collation of each
contribution produces a cumulative increase in the value of the
public good, strengthening the credibility and importance of
that information. Furthermore, standardization of systems
improves the reliability and comparability of information, both
within nations and across national and regional boundaries
(Cibulskis and Hiawalyer 2002).
SYSTEMS AND SUPPLY OF HEALTH INFORMATION
To create an effective HIS, governments must finance the system, create the necessary policy environment (for example,
through legislation and regulation), and develop systems and
services for the collection, collation, dissemination, and use of
health information. A substantial portion of the national health
information is fully within the control of government health
officials. However, information from the private health sector
and other parts of the government is also required. Table 54.1
lists some of the data required and their sources. A principal
challenge is the integration of these intra- and extrasectoral
functions into a single, comprehensive HIS.
Direct Expenditures for Health Information
As for most public goods, the production of health information
is mostly financed by government appropriation. Budget support for the HIS comes through both the ministry of health
and a national statistics office (NSO) in most countries. The
NSO is usually responsible for collecting information through
the national census and most household surveys. For the least
developed countries especially, bilateral and multilateral
donors are essential sources of finance, particularly for HIS
planning, infrastructure development, and training. In Africa,
it has been estimated that grants or loans from donors account
for between 20 and 70 percent of the financing for statistical
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Table 54.1 Health Information from Sources Outside
the Health Sector
Health information
Responsible agency
Census and national surveys:
Income and poverty distribution
Household expenditure for health
Coverage with health interventions
National statistical office
National expenditures for health, economic
development indicators, and industrial
production and distribution data
Ministry of finance
Employment data:
Human resources for health
Occupational health information
Ministry of labor
Import data:
Pharmaceuticals and vaccines
Capital equipment and health commodities
Ministry of trade
Food production and security information and
nutritional status data
Ministry of agriculture
Military health service statistics
Ministry of defense
Patterns of transportation injury (including
motor vehicle accidents)
Ministry of transportation
Literacy rates and school health program
information
Ministry of education
in the management of health information. There should be protection from political interference and full empowerment of the
health statistics office to make public statements in response to
criticisms of reports and the underlying methods. Ethical practices for protecting privacy and confidentiality must be well
understood, and procedures should be in place to deal with
breaches in these standards. Accuracy and reliability should be
stated as expectations and ensured through periodic review of
data collection methods and through benchmarking with internationally credible definitions of indicators. A client orientation
should be instilled and users of data regularly consulted in
defining outputs and formats for the presentation of data.
Systems for Collection, Management, and Analysis
Source: Authors.
systems overall. Revenue generated by selling statistical products and services accounts for 10 to 20 percent of the financing
for national statistical systems (Economic Commission for
Africa 2003). User fees or taxes for use of information products
and services can partially offset the costs of developing and
maintaining the information system. In many countries, taxes
and tariffs on computer equipment and government regulation
of communications and Internet use remain barriers to public
access to health information. Cost must not be a barrier to use
of health information for the public good.
Information Policy
Sound information systems require a legislative and regulatory
environment that encourages and supports effective HIS
development. At the global level, many efforts have been made
to establish international standards and policy frameworks for
statistical data (United Nations Statistical Commission 1994).
These policy frameworks are used to establish mandates for
collection of basic health data (such as a decennial census or
surveillance for reportable infectious diseases), to ensure the
independence of official statistical agencies, to reinforce professional ethics, and to create norms for data quality and
dissemination.
Another key policy intervention, less tangible though equally
critical, is the creation of a culture of quality and transparency
Most developing countries have no comprehensive strategy for
information management, reflecting the fractal nature of
donor and national investments in these systems. Interventions
to improve the HIS in the least developed countries, often
donor driven, have often focused only on a specific subsystem,
primarily for health service statistics, and have neglected other
components of the HIS.
An effective HIS requires an overarching architecture that
defines the data elements, processes, and procedures for collection, collation, presentation, and use of information for decision making throughout the health sector (see box 54.1). This
information architecture promotes comparison and integration of data elements from a variety of subsystems. As O’Carroll
(2003) points out, such a comprehensive design enables phased
system development, reduces redundancy, increases efficiency,
and improves interoperability. Interoperability is critical to
ensuring, for example, that census data, vital statistics, and
health facility data can be integrated to generate rates, ratios,
cost-effectiveness estimates, and other information required to
compare options for health investment.
The Pan American Health Organization (PAHO) has led the
Regional Core Health Data Initiative “to facilitate speedy access
to basic information on the health situation in the countries of
the Region.” This initiative has involved an international consultation and agreement on the priority data, collection methods, and indicators. The initiative has shown that it is possible
to create a regional database of essential, consistent, valid, standardized, timely, and regular information. PAHO has used the
information to set its priorities, whereas countries have applied
the results to design health programs and to allocate resources
to upgrade their information systems. In the future, the plan is
to expand the systems to subnational districts (PAHO 2004).
Other WHO regions, including the Asia Pacific, are instituting similar initiatives with Web-based publication of core
health indicators.
Data Collection. No single mechanism for data collection is
adequate to meet the needs for public health decision making.
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Box 54.1
The Health Metrics Network: Harmonizing Investment in HIS Development
Developing countries, multilateral agencies, bilateral
donors, and technical resource agencies have recently
come together to form a global Health Metrics Network
(HMN) that is designed to provide guidance for the
development of the HIS, both in meeting national information needs and in producing the required indicators for
tracking progress toward global goals. The HMN will provide the first consensus technical framework for HIS
architecture and a plan for development of national health
information systems. This HMN Framework includes a
blueprint for iterative improvements in the HIS; descriptions of core data collection subsystems (census, surveys,
vital events monitoring, service statistics, and resource
tracking); and procedures for management and dissemination of information.
Source: Authors.
These needs can be met using a combination of the six key health
information subsystems: census, household surveys, public
health surveillance, vital events monitoring, health service statistics, and resource tracking. Surveys are conducted on a sample in order to limit costs, whereas the other subsystems are more
often designed to cover the entire population. In most developing countries, public health surveillance—except for certain disease-specific efforts—is conducted through passive reporting
from health facilities. Especially where utilization rates are low,
this facility-based surveillance may be considered a sample or
“sentinel”surveillance strategy.Vital events monitoring is, ideally, universal; however, many countries use a phased introduction
of vital events monitoring that makes it functionally a sentinel or
sample-based data collection effort during the transition to universal coverage.
A national census every 10 years is an irreplaceable component of a national information system because it provides
denominator data for so many indicators and sampling frames
for subsequent sample surveys. The major costs of a census
come from activities to establish the census maps, enumerate
populations, enter data, and analyze the results. The cartographic costs can often be shared with other government
departments, because the resulting updated maps can be
instrumental in carrying out other critical public functions.
Sample surveys of households are a mainstay of health information collection in the developing world. They provide data
on service utilization; coverage of health interventions
(for example, immunization); morbidity (self-reported illness
or disability); pregnancy outcomes; mortality levels, differentials, and trends; and causes of death (through associated verbal
autopsy; that is, expanded interviews in the case of death to
determine cause on the basis of signs and symptoms before
death).
Surveys are, almost without exception, funded externally in
the least developed countries and are not seen within the country as being part of a health information “system.” They are, in
fact, generally undertaken to compensate for the lack of information available through routine systems (AbonZahr and
Boerma 2005). The investment in surveys has thereby enabled
donors and developing countries to sustain their neglect of the
development of comprehensive and sustainable national health
information systems. The United Nations Population and
Statistics Divisions and the European Statistical Office (EUROSTAT) also support household survey work. Differences in
methodologies among these surveys are currently a barrier to
the comparison of results. The World Bank’s Managing for
Development Results Roundtable, held in Marrakech,
Morocco, in 2004, recommended harmonization of these surveys to eliminate duplication.
Nonetheless, surveys offer an important source of information that transcends most of the selection bias that is inherent
in service statistics. Especially in the least developed countries,
where vital events registration systems and census taking are
embryonic or nonexistent, surveys represent the only source
of unbiased information about demography, socioeconomic
status, coverage, morbidity, mortality, health expenditures, and
other characteristics of the population. Where substantial proportions of the population use private health services, household surveys are particularly important. Even industrial countries rely on periodic community-based sample surveys for
immunization coverage, for health service utilization rates, and
for information on household health expenditures (Perrin,
Kalsbeek, and Scanlan 2004).
The World Health Organization (WHO) recommends using
periodic surveys to monitor coverage, such as for immunization
programs, especially in view of the shortcomings of service statistics for obtaining these measures (Murray and others 2003).
Some household surveys collect biological and clinical specimens, such as blood, saliva, urine, and self-collected vaginal
swabs, or they check swabs for anemia, HIV, disease antibodies,
vitamin A, and other conditions. However, the performance
characteristics of most diagnostic technologies (for example,
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cost, ease of field use, sensitivity, and specificity) are designed
for clinical use and do not lend themselves readily to use in population surveys, especially in remote areas of developing countries. Moreover, the collection of diagnostic information along
with individual identifiers introduces complex ethical issues in
the notification of people with treatable conditions, the financing of any required treatments, and the use of the specimens for
other studies (Ties Boerma, Holt, and Black 2001).
Public health surveillance has been defined as the “ongoing
systematic collection, analysis, and interpretation of data on
specific health events affecting a population, closely integrated
with the timely dissemination of these data to those responsible for prevention and control” (Thacker and others 1996). In
developing countries, surveillance usually focuses primarily on
a set of notifiable diseases, mainly infectious, which health care
providers and laboratories are often required by law to report.
Some nations also track risk factors for important diseases,
injury events, adverse drug reactions, cancers, and pregnancy
outcomes. Surveillance may be intensified over a period of
years to enable targeting of special interventions for the control
or elimination of diseases such as polio, tetanus, or measles.
Active surveillance or screening of populations for target
diseases may also be used in specific circumstances, such as
during peak seasons for the disease or during natural disasters,
when the potential for epidemics may be high.
Most passive surveillance data, however, are incomplete.
Reliance on surveillance for reportable diseases diagnosed in
health facilities omits diseases diagnosed among those who go
to private providers or who are too poor to go to any health
facilities. Even in health facilities, reportable diseases are often
underrecognized or cannot be confirmed in laboratories that
have inadequate resources. Sentinel surveillance methods and
registries maintained in a few selected sites may be more representative of the entire population and more cost-effective in
identifying and reporting the target diseases or health conditions; however, an outbreak may go undetected in a geographic
area without a sentinel site. Special regional surveillance may
also be used where populations are vulnerable to special health
risks. The Vigisus project in Brazil, for example, has developed
a system of epidemiologic and environmental surveillance for
the prevention and control of disease among indigenous
populations in the Amazon region (http://www.br.undp.org/
propoor/BRA97028a.htm). Despite the methodological hazards, public health surveillance is essential for both national
and global planning and preparedness, especially in view of the
risks of regional expansion (for example, of meningitis and
polio) or global spread of recent epidemics (for example, of
SARS and bird flu).
Vital events monitoring is the continuous, compulsory, and
(in most cases) universal civil registration of key vital events,
such as births, deaths (sometimes including fetal deaths), marriages, divorces, and migrations. In many countries, vital events
monitoring systems function poorly and may be found only as
remnants of past colonial administrations. In 2003, 115 of 192
WHO member states reported mortality data with causes of
death, capturing about one-third of global deaths, or 18.6 million deaths per year. In South Asia, only 60 percent of births are
registered (22.5 million), and in Africa, only 30 percent (17 million). Alternatives to universal registration include the sample
registration systems used in China and India and the demographic surveillance sites in Tanzania. The International
Network of Field Sites with Continuous Demographic
Evaluation of Populations and Their Health in Developing
Countries (INDEPTH), an association of longitudinal vital and
health statistics surveillance sites in 17 countries, can provide
technical support and training for development and management of these demographic surveillance sites (http://www.
indepth-network.org/). The UN Statistics Division has developed principles and recommendations for vital statistics
systems to guide countries in their development (http://
unstats.un.org/unsd/demographic/sources/civilreg/civilreg
methods.htm.)
Vital events monitoring systems may also be enhanced to
determine causes of death, whether those deaths occur within
health facilities or in the community. When deaths occur outside the health care system, a verbal autopsy, or structured interview of the relatives of the deceased, can assist in determining
the cause of death. Verbal autopsies can, however, be used reliably to diagnose only those few conditions that have characteristic clinical signs or patterns of signs that can be recognized by
family members or by the health workers who review the interview data. WHO is now developing standardized tools for
verbal autopsy that will enhance the sensitivity and specificity
of these instruments and permit comparisons over time and
across geographics.
Health service statistics are critical management tools for
both preventive and curative services. The statistics are collected at each level: community outreach service points, primary care facilities, and district and regional referral hospitals.
Information from clients and providers documents the quantity
and quality of services and enables managers to detect and
solve problems in order to improve health outcomes and efficiencies. This health information subsystem must be “flexible
and capable of adapting to local needs, while at the same time
allowing for standardization of health care quality assurance
indicators, and subsequent ability to measure and compare the
quality performance of health facilities nationwide” (DuranArenas and others 1998). A principal barrier to improving service quality in many health care facilities is the lack of reliable
systems for managing and retrieving individual patient
records.
Service statistics are especially powerful when they can be
compared with population-based measures from censuses and
surveys to estimate rates and ratios, such as disease incidence or
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service coverage rates. Most service statistics subsystems track
data only from public sector providers and facilities. Future
improvements must implement systems and incentives to ensure reporting of service data from the private sector.
The resource-tracking subsystem must enable measurement
and management of human resources; facilities; commodities
(pharmaceuticals, vaccines, and other consumables); and
finances. Human resource tracking provides a mechanism for
licensing health service providers and accrediting health facilities. Licensure and accreditation can be paired with incentives
to ensure service quality and private sector contributions to
achieving public health goals.
The national health account (NHA) framework provides
methods for measuring total national expenditures for health
from household, public, private, and donor sources. NHA data
document the sources of health financing, the amount spent
for services, the distribution of funds across services and interventions, and the distribution of health benefits from those
services and interventions. An NHA framework tracks the flow
of funds, for example, from the ministry of health to health
providers and government service programs or from households to pharmacies and private providers. These internationally comparable data enable benchmarking of performance
among countries (Peters and others 2000).
Of the 68 countries that have implemented NHAs, only
one-third have used the framework more than once. However,
19 of 21 countries studied can report at least one instance in
which the NHA system has informed and shaped policies (De
and others 2003). For example, South Africa’s NHA analysis
documented a higher per capita health expenditure in the richest districts, leading to intensified efforts to mitigate these
inequities (Abt Associates 2003).
Information and Communications Technologies. The rapid
evolution of information and communications technologies
(ICT) over the past 30 years has immense implications for the
potential speed, cost, and effectiveness of an HIS. But a “digital
divide” persists, with poor countries failing to benefit fully from
these ICT advances. Lack of access to reliable power sources,
absence of Internet connectivity, inability to procure computer
equipment and appropriate software, and inadequate technical
support are some of the barriers. African users account for only
1 percent of the world’s Internet traffic, 80 percent of which is
in South Africa (http://www3.sn.apc.org/africa). Although less
than 0.001 percent of the Internet use in Africa is among health
professionals, this usage is growing rapidly.
Internet access in health facilities can make the HIS more
effective and efficient by enabling instantaneous transmittal of
data to central locations. Internet access in facilities can also
speed data transmission and improve clinical outcomes by providing access to evidence-based decision support for clinical
care (Godlee and others 2004; McLellan 2001). Even in remote
areas where no telephone or cable access exists, satellite technology can provide access to e-mail. Several countries, such as
Bolivia and Peru, have successfully used satellite telephone
technologies to enable continuous Web-based updating of
health databases. Because the effectiveness of epidemic control
often depends on timely detection and reporting of outbreaks,
e-mail and telephone technologies have shown particular
promise for use in disease surveillance. In Peru, for example,
100 percent reporting was achieved and sustained within six
months of rollout of a pilot surveillance system using cellular
telephones (Lescano and others 2003). The system is to be
expanded to national coverage this year.
Although individual citizens will not soon have equal access
to ICT, these technologies can immediately be better used to
improve public health. Automation of data entry and analysis
can ease data capture, validation, analysis, and transmittal of
health information. District managers can generate reports
with tables and charts and transmit them to central levels,
which can then apply this knowledge to improve local management. Special prompts and “exception reports” can alert managers to unexpected findings that require double-checking or
immediate interventions (for example, outbreaks of infectious
disease, low immunization coverage, or other management
problems).
Use of free software, such as the U.S. Centers for Disease
Control and Prevention’s Epi Info, can lower costs, but often
these software packages require substantial adaptation to local
needs, along with additional training and technical support.
Acquisition of computer equipment should be viewed not as a
one-time capital expenditure but as a long-term commitment
to buy periodic upgrades, maintenance, and technical support.
Experience shows that purchase of inexpensive software and
computers, such as in the Eastern Cape Province of South
Africa, may actually increase overall costs when they require
early replacement with more adequate alternatives.
Geographic information system (GIS) technologies have
also been successfully used in districts in several countries to
enable mapping and visual representation of the geographic
distribution of risk factors, disease, and services. A desktop GIS
viewer and mapping software are available in several shareware
versions, including the WHO’s “Health Mapper,” so that maps
can be produced at little cost. Other potentially promising
technologies include electronic scanners and personal
digital assistants for data capture (http://www.healthnet.org)
and global positioning systems to facilitate the mapping
process.
The principal barriers to improved information systems,
however, are human, not technological. Substantial investment
in training and technical support must accompany the introduction of any new technology. If the HIS is not functionally
solid, introducing ICT will likely only worsen existing
problems.
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Dissemination and Use of Health Information
Information is a means to the end of improving health, but the
availability of reliable information does not guarantee its use or
improved decision making. Because decisions are often driven
as much by politics as by evidence, it is critical to design information systems to meet the needs of decision makers and to
create a culture of evidence that provides incentives and accountability for evidence-based decision making. Extensive
dissemination promotes widespread use and accountability.
The many users of information include the following:
•
•
•
•
•
•
•
•
•
•
health ministries at national, regional, and district levels
researchers and evaluators
legislative and policy analysts
nongovernmental organizations and consumer organizations
advocacy groups
private sector health providers and insurers
communities, including groups of patients
journalists
donors and international agencies concerned with health
individuals and families.
The literature on health information systems is replete with
complaints of the neglect of existing information, yet remarkably little is known regarding the effectiveness of interventions
to improve the use of information. The NHA experience (De
and others 2003) suggests that policy makers are most likely to
use information when it contributes to and informs a preferred
government direction, especially if that information is not
available to stakeholders outside the health ministry. But systems and dissemination patterns for information can be engineered to ensure that clients, providers, and managers will seek
and use information to inform decisions. Standard procedures
can be developed to ensure analysis and use of data at the level
at which it is collected. Training of health workers can be
designed to include both basic and refresher training in the
analysis and interpretation of data that are relevant to each job.
Expectations of information use can be built into routine job
requirements, including use of evidence for planning, data
requirements for periodic reporting to supervisors, and use of
information during performance reviews. Groups of managers
can be convened across districts or regions for benchmarking,
in which each manager presents and compares performance
data and is rewarded for transparency and learning. These
practices will result only from intense training in analysis and
use. For example, Loevinsohn (1994) demonstrated that fewer
than half of midlevel managers were able to use the information system even to identify best- and worst-performing districts. Nonetheless, if managers use the information, and if
improved efficiency and coverage with interventions is the
result, the HIS becomes exceedingly cost-effective.
Information will “allow the public, their elected representatives, or donors to determine whether they are obtaining value
for money” (Cibulskis and Hiawalyer 2002; see also Mackay
1998). Providing full access to the media will help to accelerate
expectations of evidence-based decision making and accountability. Civil society, including nongovernmental organizations,
should be the principal users of information to create and sustain
citizen demand for quality services. The Healthy Communities
Foundation’s “dashboard” of lead indicators of health system
performance exemplifies one promising example of the visual
display of data (http://whatcom.healthycities.org/demo/
aboutus.htm). Such dissemination and use of health information has enhanced government accountability for improved
health in Papua New Guinea, where reports of local government
performance in improving health systems transformed election
results (G. Hiawalyer, personal communication).
BENEFITS, COSTS, AND COST-EFFECTIVENESS
OF IMPROVED INFORMATION
There is broad agreement that information—plus the knowledge it enables—creates value. Yet it is challenging, indeed, to
quantify the added value of information. Information, after all,
is necessary but never sufficient to achieve improved outcomes.
Other resources—human, material, and financial—are
required for change. Nonetheless, it is possible to define the
interventions necessary to improve health information and to
draw on a few studies to estimate the cost and cost-effectiveness
of these investments.
Strengthening of Systems
The steps involved in strengthening HIS include securing funding for a review of the current HIS and planning reforms and
then using that plan to secure funding for implementing the
reforms. The reforms depend on legislation and regulations
that delineate the requirements, incentives, and disincentives
for collecting the needed information. Finally, the review of the
current HIS includes a situational analysis and outline of a plan
that involves a comprehensive information architecture that is
linked to both national and international needs.
The HMN Framework includes assessment and planning
tools and HIS standards that will guide strengthening of systems. Full implementation will likely take at least 36 months,
and the effects on decision making and health outcomes will be
detectable only after approximately five years.
Benefits and Effectiveness of Improved Information
The value of health information can be characterized in terms
of cost savings; system efficiencies (for example, increased
coverage or quality of services); or improved health outcomes
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(for example, DALYs saved or improved health equity).
Information can also be used to increase overall resources for
health. Publications such as this volume, World Development
Report 1993: Investing in Health (World Bank 1993), and the
report of the Commission on Macroeconomics and Health
(2000), are important examples of evidence that has been used
to change health policies and increase resources for health.
The industrial world holds examples of the use of information to make service provision more effective and efficient. A
quality improvement and evidence-based decision assistance
program for diabetes patients in the United States created a net
savings of US$510,133,2 primarily by averting hospitalizations
(Petrakos 1998). The U.S. Institute of Medicine estimates that a
computerized system for managing physician orders for medications costing US$1 million to US$2 million could “pay for
itself in three to five years” and prevent injury to hundreds of
patients per year (Kohn, Corrigan, and Donaldson 2001).
There are also promising examples of the benefits and effectiveness of improved information from developing countries.
Quality improvements driven by better information in Bolivia
resulted in a 300 percent increase in hospital utilization rates
(Pappaioanou and others 2003). In rural Mali, populations
enrolled in a community-based information system calculated
delivery costs for childhood immunization to be US$1.47 per
child, compared with US$2.79 per child among populations
not registered (Zayan, Berggren, and Doumbia 1992).
Better information can also improve efficiencies in the management of pharmaceutical resources. For example, implementing a subnational information system in the Eastern Cape
province of South Africa led to improved access to pharmaceuticals, with a 39 percent reduction in stockouts of essential
drugs. Such improvements undoubtedly lead to better health
outcomes, which may result in increased productivity and consequently an increase in the growth rate of the gross domestic
product (Jamison, Sachs, and Wang 2001; Nordhaus 2002).
Costs of Improved Health Information
Few studies have documented the costs of an HIS. Kleinau
(2000) estimated the resource requirements for health service
statistics, the most expensive of the six subsystems. Using similar assumptions, we have calculated updated costs.
This estimate includes only the public sector facilities, not
private sector reporting systems. Reporting from private
providers would likely include a more limited set of reported
data: diseases, vaccinations, possibly staffing, and minimal utilization. Table 54.2 summarizes the total annual costs and per
capita costs of the six health information subsystems.
The costs of a facility-based services statistics subsystem of
the HIS (table 54.3) can be assumed in most developing countries to include routine public health surveillance, because
these data are obtained at health facilities when ill patients are
Table 54.2 Cost of Essential HIS Subsystems
Total cost
(US$ million)
Per capita
cost (US$)
Low
income
High
income
Low
income
High
income
Health service statistics
4.8
25.9
0.16
1.66
Public health surveillance
(included with health
service statistics)
0
0
0
HIS subsystem
0
Census
7.5
30.0
0.25
1.0
Household surveys
0.6
1.0
0.02
0.03
Vital events surveillance
1.5
6.0
0.05
0.20
Resource tracking
1.5
3.0
0.05
0.10
15.9
65.9
0.53
2.99
Total
Source: Authors.
Note: Table is based on a population of 30 million. Household survey costs are based on the
experience of the demographic and health surveys during 2001–2003 (Macro International,
personal communication). Costs vary by sample size and by length of the survey instrument;
Macro International estimates, an average cost of US$100 per survey participant. A sample of
6,000 is assumed for the low-income setting, and a sample size of 10,000 is assumed for the
high-income setting. Cost estimates for vital events monitoring are based on demographic
surveillance sites. In the high-income setting, the annual costs are assumed to quadruple.
Resource-tracking costs are based on the experience of national health accounts (Abt Associates,
personal communication), and the Egyptian Budget Tracking system. Similar costs are estimated
for human resources and commodities.
brought for treatment. The additional costs of program-specific
surveillance (for example, in support of polio eradication or
tetanus elimination programs) could be assumed with a
minor marginal investment in addition to facility-based and
community-based information systems, including for vital
events surveillance.
The calculated range for per capita annual costs of a comprehensive HIS—US$0.53 to US$2.99—compares closely to the
estimates from a country setting in which those data have been
obtained, including a low-resource country (Tanzania) with a
per capita cost of approximately US$0.50 (Rommelmann and
others 2004) and a high-resource country (Mexico) with a per
capita cost of approximately US$1.00. The Health Metrics
Network (HMN) Technical Task Force South Africa has also
estimated costs of the HIS at approximately US$26 million
(165 million rand) for a population of 43 million, yielding a per
capita cost of US$0.60. The highest range of the estimate would
apply in countries with higher salaries and a more comprehensive HIS.
Estimations of the Cost-Effectiveness of Interventions
to Improve Health Information
The Tanzania Essential Health Interventions Program (TEHIP)
is perhaps the best source of evidence for the cost-effectiveness
of improved health information. The project was designed to
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Table 54.3 Annual Costs of the Facility-Based Services Statistics Subsystem of an HIS
HIS cost
Low-resource setting
High-resource setting
Primary care facility
One person (salary US$4,514/year) spends 10 percent
of time at each of 6,000 facilities (US$2,708,400)
Two people (salary US$10,351/year each) spend
20 percent of time at each of 6,000 facilities
(US$24,842,400)
First referral level
One person (salary US$4,514/year) spends 25 percent
of time at each of 1,000 facilities (US$1,128,500)
Two people (salary US$10,351/year each) spend
75 percent of time at each of 1,000 facilities
(US$15,526,500)
District hospital
Two people (salary US$4,514/year each) spend
20 percent of time at each of 300 facilities
(US$541,680)
Two people (salary US$10,351/year each) spend
100 percent of time at each of 300 facilities
(US$6,210,600)
Regional level
Three people (salary US$10,962/year each) spend
50 percent of time at each of 15 facilities
(US$246,645)
Three people (salary US$25,134/year each) spend
100 percent of time at each of 15 facilities
(US$1,131,030)
National level
Six people (salary US$10,962/year each) spend
50 percent of time (US$32,886)
Ten people (salary US$25,134/year each) spend
100 percent of time (US$251,340)
Subtotal (personnel)
US$4,658,111
US$47,961,870
Primary care facility
US$100/year
US$400/year
First referral level
US$250/year
US$1,000/year
District hospital
US$500/year
US$2,000/year
Regional
US$1,500/year
US$5,000/year
National
US$5,000/year
US$30,000/year
Subtotal (supplies)
US$7,350
US$38,400
Personnel
Data collection instruments and supplies
Information technology: computers and software
Primary care facility
0
0
First referral level
0
0
District hospital
0
20 percent use of each of two computers with
software at US$1,100 at each of 300 facilities
(US$132,000)
Regional level
0
Two dedicated computers with software at US$1,100
at each of 15 facilities (US$33,000)
National level
50 percent use of each of four computers with
software at US$1,100 (US$2,200)
10 dedicated computers with software at US$1,100
(US$11,100)
Subtotal (information technology)
US$2,200
US$176,100
Training cost
US$180,000
US$1,730,000
Total cost
US$4,847,661
US$49,906,370
Per capita cost
US$0.16
US$1.66
Source: Authors.
Note: Based on a model country with a total population of 30 million.
test how evidence can be used to decentralize health sector
planning at the district level and to what extent evidence-based
priority setting would result in improved health outcomes. The
project budgeted for a marginal investment of US$2.00 per
capita for the information and for health interventions,
although only US$0.80 per capita was actually spent. The
slightly increased investment covered training in the use of the
information to set priorities and to better manage the most
cost-effective interventions. The information systems included
a district burden-of-disease intervention priority profile, district health accounts, a district cost information system, and
district health service mapping. Management and technical
support strengthened the district and regional health sector
use of the information for management and administration.
Communities participated in the ownership and management
of health facilities. The cost-effectiveness estimates in this
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Box 54.2
The Tanzania Essential Health Interventions Program
TEHIP is a partnership between Tanzania’s Ministry of
Health and the International Development Research
Centre. The project was established to determine the feasibility of an evidence-based approach to health planning
at the district level. Testing the premise of the World
Bank’s (1993) World Development Report 1993: Investing in
Health, TEHIP enabled district health planners in two of
Tanzania’s 117 districts to collect and use burden-ofdisease and cost-effectiveness data to get the best value for
money from national investments in health. Interventions
included door-to-door collection of data and training or
technical support for managers in the analysis and use of
the data for decision making. TEHIP districts allocated
services to high-burden diseases, resulting in a tripling of
clinic utilization rates and increased treatment effectiveness. With a per capita increase in spending of only
US$0.80, district health managers achieved a 47 percent
reduction in child mortality rates.
Source: Authors.
Table 54.4 The Effectiveness of Evidence-Based Resource Allocation in Improving Health
Year
Number of
children
⬍ 5 years
Probability
of dying
(birth to
5 years)
Mortality
rate
(⬍ 5 years)
Total
deaths
1999
31,000
135.5
34
2000
31,500
119.0
25
2001
32,000
110.0
2002
32,661
114.0
Deaths
averted
DALYs
gained/
death
1,054
—
—
—
—
791
263
41
10,850
11,511
25
803
251
41
10,332
10,643
26
853
202
41
8,303
8,304
29,487
30,458
Total DALYs gained
Total
DALYs
DALYs
discounted
at 3 percent
Source: Authors.
Note: 1999 is baseline year; therefore, no deaths were averted.
section are based solely on the declines in mortality of children
under five years of age, even though adult mortality also
decreased. To ensure a conservative estimate of the costs of the
HIS, we used a per capita cost of US$2.00—higher than the
actual investment for TEHIP and at the high end of the range
of costs for a comprehensive HIS estimated in table 54.2—
US$0.53 to US$2.99. All costs were ascribed to the information
system, because there were no improvements in the interventions themselves. Expenditures and deaths before 2002 were
discounted by 3 percent annually (see box 54.2).
The demographic and epidemiologic data were taken from
the Rufiji district, where the most complete data were available.
The estimate of the number of children under age five (32,661)
is based on the 2002 census results. The Ministry of Health,
census, and Rufiji Demographic Surveillance System estimates
range from 31,000 to 36,000 children for 2003. Because of this
discrepancy, the decline in the total fertility rate, from 5 to 4.7
(5 percent), is taken into account in estimating the number of
children less than five years of age for 1999 to 2001. The probability of dying before five years of age declined by 15.6 percent,
and because of declining fertility, each year has 1.5 percent
Table 54.5 Costs of Evidence-Based Resource Allocation for
Improving Health
Total cost at US$2
per capita (US$)
Discounted
cost (US$)
Year
Population
1998
186,809
373,618
420,510
1999
191,012
382,024
417,448
2000
196,515
393,030
416,966
2001
202,176
404,352
416,482
2002
208,000
Total costs
416,000
416,000
1,969,024
2,087,406
Source: Authors.
fewer children than the preceding year. DALYs saved from each
child death averted is estimated at 41.2. The resulting calculations of effectiveness are summarized in table 54.4.
The estimates of cost are based on population size projected
back from the 2002 census results, assuming an average annual
growth rate of 2.8 percent. Costs incurred in 1998 are included
because we assume that it takes at least two years (1998 to 2000)
of improving the HIS before health benefits accrue.
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Cost per DALY saved (US$)
800
700
600
500
400
300
200
100
0
5
10
20
30
Percentage increase in hepatitis B immunization coverage
attributable to investment in HIS
40
High-cost setting (US$2.00 per capita)
Low-cost setting (US$0.80 per capita)
capita less than US$997; World Bank 2002). Figure 54.1 shows
that, for the high-prevalence countries (Miller and McCann
2000), the investment in a comprehensive HIS is highly costeffective (US$159 to US$126 per DALY saved for low-cost settings and US$757 to US$597 per DALY saved for high-cost
settings), even if the investment results in only minor increases
in immunization coverage. A similar analysis for countries with
a lower prevalence rate of hepatitis B demonstrates that the cost
per DALY saved is higher, but the investment in an HIS still
yields a savings of DALYs at a cost that is well below the GNP
per capita for the majority of the low-income countries.
These calculations of the cost-effectiveness of investments
in an HIS are highly conservative, because they consider health
benefits within a single population group (children, in the case
of TEHIP) or a single disease problem (hepatitis B). They
therefore underestimate the true cost-effectiveness of investment in an HIS, which can drive improvements in program
efficiency and effectiveness across a broader range of health
interventions.
Source: Authors.
Figure 54.1 Cost-Effectiveness of Health Information Systems: Cost
per DALY Saved Because of Increases in Coverage Attributable
to HIS
FINANCING OF IMPROVED HEALTH
INFORMATION
Using these figures for effectiveness (table 54.4) and cost
(table 54.5), we find that the cost-effectiveness of the HIS that
results in improved evidence-based resource allocation and
child health may be conservatively estimated at US$68.50 per
DALY gained (US$2,087,406 to gain 30,457 DALYs). Even in
the poorest countries, this is well below the gross national
product (GNP) per capita benchmark for what is considered
worthwhile for government investment in health.
This analysis for the TEHIP project is based solely on child
deaths averted. But the improvement in health information
would also yield substantial benefits for adult populations. For
example, HIS-driven increases in coverage with hepatitis B vaccine have varied between 5 and 33 percent (Miller and McCann
2000). These increases in coverage with hepatitis B immunization will result in incremental reductions in death and disability
among adults attributable to hepatitis B–induced cirrhosis and
liver cancer, thereby averting the loss of substantial numbers of
DALYs in low-income countries (World Bank 2002). Hepatitis B
vaccine is a cost-effective addition to an existing immunization
program, with a cost per death averted of US$11 to US$15
(US$193 to US$262 per DALY saved). But efficiency and coverage can be substantially improved with an additional investment in the HIS. The cost per DALY saved by incremental
investment in the HIS can be calculated using estimates of costs
of the HIS from table 54.2, plus the estimates of cost and deaths
averted because of immunization from Miller and McCann
(2000) for populations in all low-income countries (GNP per
The annual per capita cost, estimated earlier, of US$0.53 to
US$2.99 for a comprehensive HIS, represents a substantial
portion of the current per capita health expenditure for many
developing countries. These figures include capital and recurrent costs, although they do not include the costs of any external
technical assistance. Because most countries have already made
a substantial investment in a HIS, the actual incremental costs to
improve the existing HIS likely are much less. Salaries, which
account for more than 90 percent of HIS costs, are expenditures
that are already being made in most settings, so the marginal
cost of HIS improvements would be primarily the initial development costs of planning, training, technical assistance, and
information technology upgrades. Furthermore, the costs of
HIS improvements may be fully offset or even exceeded by the
savings from the resulting improvements in efficiencies in the
health care system.
Existing funding is adequate to strengthen systems substantially in all low-income and lower-middle-income countries
primarily through the major international initiatives (Global
Fund to Fight AIDS, Tuberculosis, and Malaria; President’s
Emergency Plan for AIDS Relief; and Multi-country AIDS
Program of the World Bank). All these funders recommend
that 3 to 7 percent of grants and loans be allocated to monitoring and evaluation. Several bilateral development agencies and
the multilateral development banks will provide financing for
HIS reform, including the U.S. Agency for International
Development (USAID) through the MEASURE (Monitoring
and Evaluation to Assess and Use Results) Project, which is
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designed to improve and institutionalize the collection and use
of data for health policy development and program monitoring. The HMN offers some financial assistance to countries that
are preparing for and planning HIS reform and will assist countries in negotiating financing packages that blend loan funding
with grants from bilateral donors to implement those reforms.
Several international agencies support strengthening systems for national statistics that extend beyond the health sector. STATCAP (Statistical Capacity Building), which is a new
lending program offered by the Partnership in Statistics for
Development in the 21st Century (PARIS21) through the
World Bank, supports the development of national statistical
systems. The separate Trust Fund for Statistical Capacity
Building offers smaller amounts of grant funding to prepare
the statistical master plan that is required for obtaining a
STATCAP loan. Although short-term project funding can often
be secured for system development, the resulting system and its
recurrent costs must be within the country’s capacity to sustain
it, both technically and financially.
opment of the district-level HIS. The HMN will create an
alliance of countries committed to a parsimonious consensus
technical framework and encourage donors to cooperate with
and strengthen the HMN-sanctioned HIS architecture in
participating countries.
The predictors of success in developing and maintaining an
HIS are as follows:
• high-level commitment to HIS development and the linked
changes in management
• a champion of HIS reform who engages the stakeholders
and can work across sectors
• an information architecture that is simple, is structured to
drive decision making at the level that data are collected,
provides incentives and accountability for performance, and
links health information subsystems
• investment in training and increased status for the people
who manage the HIS.
RESEARCH AND DEVELOPMENT
IMPLEMENTATION OF CHANGE:
LESSONS OF EXPERIENCE
Underinvestment is the root cause of the nearly universal
weaknesses in the HIS in developing countries. This failure is
reflected in the poorly paid and undervalued HIS staff; in the
irregular and unreliable transmittal of data from the periphery;
in the underreporting of events, including births, deaths, and
morbidity; and in the failures to base planning and decision
making—at both the district and the central levels—on credible evidence (Azubuike and Ehiri 1999).
When the need for HIS improvement is identified, ministries of health should explicitly state the characteristics they
need in a reformed system and quantify the expected benefits.
A common mistake made in implementing HIS change is failing to recognize the associated need for change in management
processes and organizational culture. In contrast, recent HIS
reforms in Niger (Mock and others 1993) and Uganda
(Gladwin, Dixon, and Wilson 2003) have had unprecedented
success because they have been aligned with broader management reforms and changes in organizational culture. Failure to
adjust management roles with HIS changes can constrain
effectiveness, such as when HIS managers are not given the
necessary increased status and authority to demand reports
and trigger corrective actions (Gladwin, Dixon, and Wilson
2003). Failure to invest adequately in training, especially in
skills for presentation and communication of results, may also
inhibit the use of health information. The demand from international organizations and global programs, such as the
Expanded Program on Immunization and Stop TB, for reports
on vast numbers of indicators has retarded the smooth devel-
An effective HIS delivers routine information that enables
informed policy making and management but also promotes
health research. Routine information systems may serve as a
research platform, but the HIS itself should also be a subject
of research. Research should drive the continual refinement of
HIS methods and tools, thereby ensuring expanding and welldocumented returns on our investments in health.
The instruments and methods of the HIS must be continually refined to improve its effectiveness and reduce its costs. For
the phased introduction of vital events monitoring, for example, there is a pressing need for the development and validation
of methods for projecting subnational results to national rates
of birth and death. More research is needed to develop and test
new methods for rapid assessment in order to obtain timely
and affordable information to solve management problems. As
field-appropriate and cost-effective diagnostic technologies are
developed, research should be performed to document the utility of obtaining biomarkers in household surveys.
Documenting improved outcomes and lower costs will provide evidence for policy makers on the effectiveness of HIS
investments. To better decide how to improve the HIS, decision
makers will need documentation of the costs and effects of
introducing ICT in support of the HIS. Existing and emerging
technologies should be tested for their cost and effectiveness in
assisting field-based data capture, instantaneous data transmission, GIS-based mapping of indicators, and compelling presentation for decision making by policy makers, managers, and
other stakeholders. Research and development efforts are
needed to devise software—or preferably shareware—that is
specifically tailored to support the consensus technical framework developed by the HMN.
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Bailey and Pang (2004) point out the need for more research
in the developing world to better understand users’ information needs. In fact, research is needed to better document the
entire information value chain, with special attention to
improving the identification of information needs, to overcoming the natural disincentives to information sharing, and
to enabling better use of information for constructive change.
At present, there is still a need to improve the access to information and knowledge in the developing world. However, the
future will bring the larger challenge of improving the management and use of information and the knowledge such information can bring. Research in the HIS will be instrumental
in both accelerating equitable access to information and
improving the management and use of knowledge for
improved health.
CONCLUSIONS
More than ever before, it is in the mutual interest of the developing and industrial worlds to invest in strengthening systems
for collection and management of health information
(Stansfield 2005).
The trend toward “basket” funding for health and sectorwide approaches makes the need for priority setting all the
more acute. Priority setting depends on accurate information.
The success of efforts to reduce poverty and health inequity
will depend on the existence of information systems to detect
those problems, facilitate the design of solutions, and track
progress toward eliminating the problems. Countries and
donors must, therefore, accelerate and harmonize their investments in information systems.
Within countries, the trend toward decentralization of
authority for management of health resources has led to further challenges for the HIS, as well as to greater reliance on the
information it provides to inform decision making. It is clear
from the instructive failures of underresourced systems that the
accuracy and value of information reported to the national
level will depend on that information’s perceived value in the
periphery. Information is relevant only if it is used to solve a
local problem or if it helps to generate innovation that solves a
local problem (Bailey and Pang 2004). Therefore, the decentralization of authority will be successful only with better information systems to support decisions at the periphery, and
evidence-based decision making will be possible only if authority can be devolved to the periphery. This decentralization,
along with increasing cooperation and collaboration across
sectors to improve health outcomes, makes it all the more
critical to present data in simpler ways that are understandable
and compelling to a broader and nontechnical audience.
Although historically neglected, investments in comprehensive development of the HIS will clearly deliver good value for
money. Improvements in the HIS can accelerate broad
improvements in health if they are engineered to reflect, reinforce, and even drive health sector reforms. Even more compellingly, investments in the HIS can make health the “thin
edge of the wedge,” giving governments and politicians a positive experience with information sharing and overcoming the
natural disincentives to transparency and accountability. HIS
investments hold the promise, therefore, not only of transforming public health, but also of accelerating progress toward
good governance in every sector.
NOTES
1. Sauerborn and Lippeveld (2000) have defined a health information
system as the “set of components and procedures organized with the objective of generating information that will improve health management
decisions at all levels of the health system.”
2. The dollar amounts given are quoted from the references and are not
adjusted for current dollar value.
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Chapter 58
School-Based Health and Nutrition
Programs
Donald A. P. Bundy, Sheldon Shaeffer, Matthew Jukes, Kathleen
Beegle, Amaya Gillespie, Lesley Drake, Seung-hee Frances Lee,
Anna-Maria Hoffman, Jack Jones, Arlene Mitchell, Delia Barcelona,
Balla Camara, Chuck Golmar, Lorenzo Savioli, Malick Sembene,
Tsutomu Takeuchi, and Cream Wright
The paradigmatic shift in the past decade in our understanding
of the role of health and nutrition in school-age children has
fundamental implications for the design of effective programs.
Improving the health and nutrition of schoolchildren through
school-based programs is not a new concept. School health
programs are ubiquitous in high-income countries and most
middle-income countries. In low-income countries, these programs were a common feature of early, particularly colonial,
education systems, where they could be characterized as heavily
focused on clinical diagnosis and treatment and on elite
schools in urban centers. This situation is changing as new
policies and partnerships are being formulated to help ensure
that programs focus on promoting health and improving the
educational outcomes of children, as well as being socially progressive and specifically targeting the poor, girls, and other disadvantaged children. This evolution reflects five key changes
in our understanding of the role of these programs in child
development.
• First, ensuring good health at school age requires a life cycle
approach to intervention, starting in utero and continuing
throughout child development. In programmatic terms this
requirement implies a sequence of programs to promote
maternal and reproductive health, management of childhood illness, and early childhood care and development.
Promoting good health and nutrition before and during
school age is essential to effective growth and development.
• Second, operations research shows that the preexisting
infrastructure of the educational system can often offer a
more cost-effective route for delivery of simple health interventions and health promotion than can the health system.
Low-income countries typically have more teachers than
nurses and more schools than clinics, often by an order of
magnitude.
• Third, empirical evidence shows that good health and nutrition are prerequisites for effective learning. This finding is
not simply the utopian aspiration for children to have
healthy bodies and healthy minds, but also the demonstration of a systemic link between specific physical insults and
specific cognitive and learning deficits, grounded in a new
multisectoral approach to research involving public health
and epidemiology, as well as cognitive and educational
psychology.
• Fourth, the provision of quality schools, textbooks, and
teachers can result in effective education only if the child is
present, ready, and able to learn. This perception has additional political momentum as countries and agencies seek to
achieve Education for All (EFA) by 2015 and address the
Millennium Development Goals of universal basic education and gender equality in education access. If every girl
and boy is to be able to complete a basic education of good
quality, then ensuring that the poorest children, who suffer
the most malnutrition and ill health, are able to attend and
stay in school and to learn while there is essential.
1091
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Morbidity as a proportion of peak value
1
0.9
0.8
Ascaris
0.7
0.6
School-age
children
0.5
0.4
Schistosoma
haematobium
Cerebral malaria
0.3
0.2
0.1
Diarrhea
0
0
5
10
15
Age (years)
20
25
30
Source: Bundy and Guyatt 1996.
Figure 58.1 Age Distribution of Infection-Specific Morbidity
• Finally, education, including education that promotes positive health behaviors, contributes to the prevention of
HIV/AIDS—the greatest challenge for generations to come.
School health and nutrition programs that help children
complete their education and develop knowledge, practices,
and behaviors that protect them from HIV infection as they
mature have been described as a “social vaccine” against the
disease.
Because of the success of child survival programs, the number of children reaching school age (defined as 5 to 14 years of
age) is increasing and is estimated to be 1.2 billion children,
with 88 percent living in less developed countries (U.S. Census
Bureau 2002). As figure 58.1 illustrates, the pattern of disease is
age specific. A large body of evidence shows that these conditions affect cognition, learning, and educational achievement
(see Jukes, Drake, and Bundy forthcoming; Pollitt 1990 for
reviews of this extensive literature).
This chapter focuses on the health, nutrition, and education
of the school-age child and on the programs that can be implemented at school age to promote positive outcomes.
INFECTIOUS DISEASE AND SCHOOL-AGE
CHILDREN
A range of infectious diseases affect school-age children.
Helminth Infections
Between 25 and 35 percent of school-age children are estimated to be infected with one or more of the major species of
worms (Bundy 1997; see also chapter 24). The most common
and important infections are caused by geohelminths (the
roundworm Ascaris, the whipworm Trichuris, and the two
species of hookworms Ancylostoma and Necator) and by the
schistosomes (Schistosoma spp.), which give rise to a wide range
of chronic but largely nonspecific symptoms. The most intense
worm infections and related illnesses occur at school age
(Partnership for Child Development 1998b, 1999) and account
for some 12 percent of the total disease burden and 20 percent
of the loss of disability-adjusted life years (DALYs) from communicable disease among schoolchildren (World Bank 1993).
Infected schoolchildren perform poorly in tests of cognitive
function; when they are treated, immediate educational and
cognitive benefits are apparent only for children with heavy
worm burdens or with concurrent nutritional deficits.
Treatment alone cannot reverse the cumulative effects of lifelong infection or compensate for years of missed learning, but
studies suggest that children are more ready to learn after treatment for worm infections and may be able to catch up if this
learning potential is exploited effectively in the classroom
(Grigorenko and others forthcoming). In Kenya, treatment
reduced absenteeism by one-fourth, with the largest gains for
the youngest children who suffered the most ill health (Miguel
and Kremer 2004).
Malaria
Up to 5 percent of children infected with malaria early in life
have residual neurological sequelae (Snow 1999). In areas of
unstable transmission, malaria accounts for 10 to 20 percent of
all-cause mortality among school-age children (Bundy and
others 2000), and those who have suffered repeated attacks have
poorer cognitive abilities. In Kenya, primary school students
miss 11 percent of school days because of malaria, equivalent to
4 million to 10 million days per year (Brooker and others 2000).
Oral antimalarial treatment reduced school absenteeism by
50 percent in Ghana (Colbourne 1955); the use of insecticidetreated bednets in Tanzania reduced malaria and increased
attendance (Shiff and others 1996). Girls in The Gambia were
more than twice as likely to enroll in primary school if they had
received malaria prophylaxis in early childhood (Jukes and
others submitted).
HIV/AIDS
Although school-age children have the lowest infection prevalence of any age group (figure 58.2), an estimated 3.8 million
children under 15 years of age have been infected with HIV and
more than two-thirds have died (UNAIDS 2002). Even uninfected children suffer physically, socially, and psychologically
through death or illness in their family (World Bank 2002). The
proportion of orphans, most of whom are of school age, has
risen from 2 to 15 percent in some African countries, with
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172
Acute Respiratory Infection
a. Male Cases
Acute respiratory infection, the most common acute infection
in school-age children globally, is a significant cause of absenteeism. Research in industrial countries (Cohen and Smith
1996) finds that flu infection affects attention and reaction
time; colds primarily affect hand-eye coordination, as well as
reduce the ability to tolerate high levels of noise and other distractions common to the classroom.
Percent infected in each age group, as a percentage of cases
45
40
35
30
25
20
MALNUTRITION, NONINFECTIOUS DISEASE,
AND HEALTH AND EDUCATION
15
10
Malnutrition and noninfectious disease also affect school-age
children.
5
0
0–4
5–14
15–19
20–29
30–39
Age group
40–49
50⫹
Malnutrition
Stunting (low height for age) is a physical indicator of chronic
or long-term malnutrition, whereas underweight (low weight
for age) is an indicator of both chronic and acute malnutrition.
Both are common in school-age children (figure 58.3).
Girls who are better nourished are more attentive and more
involved during class, and boys have improved classroom
behavior and increased activity levels. One Z-score increase in
height for age is associated with an increase of 0.1 standard
deviation (SD) in tests of arithmetic and language. Stunted
children enroll in school later than other children. School foodservice programs have been successful in improving school
attendance.
b. Female Cases
Percent infected in each age group, as a percentage of cases
50
45
40
35
30
25
20
15
10
Z-score
0
5
0
0–4
5–14
15–19
Botswana
Tanzania
20–29
30–39
Age group
Côte d’Ivoire
Zimbabwe
40–49
50⫹
Malawi
Source: UNAIDS epidemiological fact sheets 2000.
Note: Figure shows percentage of males (top) and females (bottom) infected with HIV
in each age group (as a percentage of all HIV-infected males and females,
respectively), for five countries in Africa. Infection peaks at a younger age in women
than in men, and the lowest prevalence of infection occurs in school-age children.
⫺0.5
⫺1.0
⫺1.5
⫺2.0
⫺2.5
⫺3.0
Figure 58.2 Age Prevalence of HIV/AIDS
⫺3.5
6
AIDS accounting for 50 percent of this increase. The number of
orphans is expected to reach more than 25 million by 2010.
School-age children with HIV infections have lower IQ
levels and poorer academic achievement, language, and visual
motor functioning. These deficits can be reduced or reversed
with antiretroviral therapy. The improvement is greater for
children of school age than for younger children.
7
8
9
10
11 12 13
Age (years)
Ghana
Tanzania
14
India
Vietnam
15
16
17
18
Indonesia
Source: Data from Partnership for Child Development 1998a.
Note: Z-scores of less than ⫺2 indicate stunting.
Figure 58.3 Mean Z-Scores of Height-for-Age of Boys in Five
Countries
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Short-Term Hunger
Hunger, which reduces ability to perform school tasks, is readily reversed by feeding. Children age 11 to 13 years in Jamaica
improved their scores on arithmetic tests after one semester of
receiving breakfast at school because they attended more regularly and studied more effectively (Simeon 1998). Missing
breakfast impairs performance to a greater extent for children
of poor nutritional status, who also benefit most from food
intervention (Pollitt, Cueto, and Jacoby 1998; Simeon and
Grantham McGregor 1989).
Micronutrient Deficiency
Micronutrient deficiencies may take several different forms,
each with negative impacts on children’s ability to perform well
in school.
Iron Deficiency. Iron deficiency, the most common form of
micronutrient deficiency in school-age children, is caused by
inadequate diet and infection, particularly by hookworm and
malaria (Hall, Drake, and Bundy 2001). More than half the
school-age children in low-income countries are estimated to
suffer from iron deficiency anemia (Partnership for Child
Development 2001). Children with iron deficiency score 1 to 3
SD worse on educational tests and are less likely to attend
school. Iron supplementation reduces these deficits.
Iodine Deficiency. Iodine deficiency affects an estimated
60 million school-age children; studies indicate prevalence
rates between 35 and 70 percent. Iodine deficiency is related to
lowered general cognitive abilities and tests scores. No conclusive evidence shows that iodine supplementation improves
cognitive abilities in this age group (Huda, GranthamMcGregor, and Tomkins 2001).
Vitamin A Deficiency. Vitamin A deficiency affects an estimated 85 million school-age children. The deficiency, which
causes impaired immune function and increases risk of
mortality from infectious disease, is an important cause of
blindness. Recent studies suggest that this deficiency is also
a major public health problem in school-age children.
Multiple-micronutrient supplements have improved cognitive function and short-term memory in schoolchildren and
have reduced absenteeism caused by diarrhea and respiratory
infections.
Obesity
An estimated 17.6 million children worldwide are overweight.
Obesity is associated with underperformance in education. In
low-income countries obesity is still rare, but the prevalence in
the children of many middle-income countries is similar to
that in the United States.
ESTIMATING THE BURDEN OF DISEASE
The cost per DALY of school health programs has been estimated at US$20 to US$34, implying that the programs are at
least as cost-effective as many other public health “best buys”
(Bobadilla and others 1994). However, current methods of
estimating the burden for school-age children result in a significant underestimation of both the developmental consequences of disease and malnutrition at school age and the overall benefits for health and development of school health and
nutrition programs.
There are two key reasons for this underestimation. The first
issue relates to time scales. Many serious diseases in adulthood,
including heart disease and carcinomas, are a consequence of
unhealthy practices established in early life. This later burden
can be substantially and cost-effectively averted by early intervention, particularly by school-based life-skills programs. For
example, in the United States (Del Rosso and Marek 1996),
US$1 invested can avert US$18.80 spent on the later problems
caused by tobacco and US$5.70 on problems of drug and alcohol abuse. DALY estimates cannot capture these downstream
consequences of upstream intervention and instead attribute
the disease burden to the adult age group in which it appears.
This kind of estimate is particularly misleading in the case of
HIV/AIDS, for which prevention education at school age is
effective in averting later infection and disease (World Bank
2002), and in the case of estimates of intergenerational effects,
in which ensuring the health of an adolescent girl may help
secure the health of her baby born a few years later.
The second issue is illustrated by experience with helminth
infections. In 1990, the burden was first estimated at 18 million
DALYs, close to the value for tuberculosis, measles, and malaria.
This estimate reflected the ubiquity of infection and the longterm consequences of cognitive impacts. In 2001, the estimate
was only 4.7 million DALYs (WHO 2003), and during the intervening years one estimate put the value as low as 2.6 million.
This extraordinary variability is caused in part by different
emphases on the cognitive and health impacts and illustrates
how, for very common conditions, even minor changes in disability weight can affect the overall values. This variability also
reflects the importance of a sectoral perspective, because the
low estimates reflect a focus on health, whereas the higher
estimates include impact on educational achievement and
child development.
The scale of the burden of disease in terms of cognition is
illustrated by estimating the impact of stunting, anemia, and
helminths on the cognition of the estimated 562 million schoolage children in developing countries. According to typical
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deficits in test scores attributable to these diseases, the total global loss of points ranges from 600 million to 1.8 billion IQ points,
an additional 15 million to 45 million cases of mental retardation (defined here as IQ less than 70), and a loss of between 200
million and 524 million years of primary schooling (Jukes,
Drake, and Bundy forthcoming). Although the precision of
these striking figures may be open to debate, they clearly show
that even minor cognitive deficits resulting from ubiquitous
conditions can result in an extraordinarily large scale of effect.
INTERVENTIONS
In light of the significant effects of ill health and malnutrition
on educational outcomes, the role of effective health promotion and simple school-based programs to deliver low-cost
interventions becomes increasingly important (Bundy and
others 1992). Other chapters provide information on the
integrated management of childhood illness, early child development, and adolescent health (see chapters 63, 27, and 59,
respectively). The focus here is on ill health and malnutrition at
school age and the role of the formal and nonformal education
sector in delivering interventions.
Developing a Programmatic Approach
The focus of school health and nutrition programs in lowincome countries has shifted significantly over the past two
decades away from a medical approach that favored elite
schools in urban centers and toward an approach that
improves health and nutrition for all children, particularly the
poor and disadvantaged. This change began in the 1980s, when
research showed not only that school health and nutrition programs were important contributors to health outcomes but
also that they were essential elements of efforts to improve education access and completion, particularly for the poor.
In an effort to reconceptualize the relationship between
health and education, the United Nations Education, Scientific,
and Cultural Organization (UNESCO) hosted a series of workshops on this topic in the 1980s (Bundy 1989; Halloran, Bundy,
and Pollitt 1989) and supported one of the first authoritative
reviews of the area (Pollitt 1990). Similarly, the United Nations
Development Programme, in conjunction with the Rockefeller,
Edna McConnell Clark, and J. S. McDonnell Foundations supported the creation of the Partnership for Child Development
to strengthen the evidence base across the education and health
sectors and to support the dissemination of information
(Berkley and Jamison 1990; Bundy and Guyatt 1996). This paradigm shift coincided with the World Conference on Education
for All in Jomtien, Thailand, in 1990 and led to renewed efforts
by countries and agencies to develop more effective programmatic approaches to school health and nutrition.
The United Nations Population Fund (UNFPA) has pioneered population and family life education (PopEd) as an
intrinsic part of school curricula. In 1994, the International
Conference on Population and Development placed specific
emphasis on school health, including reproductive and sexual
health. Efforts at country level have addressed PopEd both
within the school system and outside, and the concept has
evolved to include references to family life education, sex education, HIV/AIDS awareness and prevention, and life-skills
programs. Today, approximately 84 countries have UNFPAsupported school health programs.
In 1995, the World Health Organization (WHO) launched
its Global School Health Initiative to foster the development of
health-promoting schools (HPSs) (WHO 1996). The concept
started in Europe in the early 1990s, based on the Ottawa
Charter of Health Promotion (WHO 1986; European
Commission 1996), which recognized that health is created by
caring for oneself and others, by being able to make decisions
and have control over one’s life and circumstances, and by creating conditions that support health for all. WHO’s European
Regional Office, the Council of Europe, and the Commission of
the European Communities widely promoted the concept of
HPSs to foster healthy lifestyles and develop environments conducive to health (European Commission, WHO Europe, and
Council of Europe 1996). Although definitions vary among
regions, countries, and schools, an HPS may be characterized as
one that is constantly strengthening its capacity as a healthy setting for living, learning, and working. The initiative fosters the
development of HPSs by the following:
• consolidating research and expert opinion to describe the
nature and effectiveness of school health programs
• building capacity to advocate for the creation of HPSs and
to apply the components to priority health issues
• strengthening collaboration and national capacities to assess
the prevalence of important health-related behaviors and
conditions and to plan and implement policies and programs that improve health through schools
• creating networks and alliances, including regional networks.
The key elements of how this approach is interpreted today
are listed in table 58.1.
In the mid 1990s, the United Nations Children’s Fund
(UNICEF) began promoting the Child-Friendly Schools
framework as a holistic way to promote children’s rights as
expressed in the Convention on the Rights of the Child
(UNICEF 1990) and children’s access to education as stated in
the World Declaration of Education for All (UNESCO 1990).
This approach included a gender-sensitive component, which
was further strengthened when girls’ education became the
first priority in UNICEF’s Medium Term Strategic Plan,
2002–5. Another key element is skills-based health education,
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Table 58.1 Characteristics of Agency-Specific School Health and Nutrition Programs, within the FRESH framework
FRESH
framework
Health-promoting
schools (WHO)
Child-friendly
schools (UNICEF)
Policy
Respects an individual’s
well-being and dignity
Respects and realizes the rights of
every child
Provides multiple opportunities
for success
Acts to ensure inclusion, respect,
and equality of opportunity for all
children
Acknowledges good efforts and
intentions as well as personal
achievements
PopEd (UNFPA)
Global school feeding
campaign (World Food Program)
Creates a supportive and enabling
policy environment for reproductive
health and HIV prevention for
young people
Focuses on the poorest and most
food-insecure communities.
Protects young people from early
and unwanted pregnancy, sexually
transmitted diseases, sexual
abuse, and violence
Serves as platform for essential
package approach that includes
water, sanitation, and
environmental measures
Strengthens HIV/AIDS and sexual
Provides education that is affordable and reproductive health education
programs
and accessible
Supports learning through good
nutrition
Gives priority to girls and
AIDS-affected children
Is gender sensitive and girl friendly
Is flexible and responds to diversity
Sees and understands the whole
child in a broad context
Enhances teacher capacity, morale,
commitment, and status
School
environment
Is healthy
Is healthy, safe, and secure
Provides opportunities for
physical education and
recreation
Is protective emotionally and
psychologically
Education
Provides skills-based health
education
Promotes quality learning outcomes
Fosters health and learning
Promotes access to education
Provides skills-based health
education, including life skills
relevant to children’s lives
Services
Provides school health services
Promotes physical health
Provides nutrition and foodsafety programs
Promotes mental health
Ensures access to youth-friendly
sexual and reproductive health
services
Provides food
Targets young people in school
and out of school
Promotes community and school
partnerships
Promotes and supports
deworming
Provides programs for counseling, social support, and mental
health promotion
Provides health promotion
programs for staff
Includes school and community
projects and outreach
Supportive
partnerships
Engages health and education
Is child centered
officials, teachers, teachers’
Is family focused
unions, students, parents, health
Is community based
providers, and community
leaders in efforts to make the
school a healthy place
Ensures active participation of
parents, youths, community
leaders, and organizations
Source: Summarized from World Bank Fresh Toolkit (2000), WHO (1996), and personal communications from Arlene Mitchell and Sheldon Shaeffer (May 2005).
including life skills, which has been promoted through
UNICEF with partner organizations as part of HPSs, childfriendly schools, and the framework for Focusing Resources on
Effective School Health (FRESH). Research shows that this
approach is more effective than traditional strategies, which
tend to be didactic and to focus on scientific information
alone. In contrast, skills-based health education uses the experiences of students as the starting point and explores the links
between knowledge, attitudes, and the interpersonal skills
required to promote health and learning (UNICEF, WHO,
World Bank, UNFPA, UNESCO 2003). The approach is interactive, activity based, and flexible so that it can be used to
address a range of health and social issues, including
HIV/AIDS, sanitation, drug use, violence and bullying, nutrition, and cross-cutting issues such as gender and culture. Some
key elements of how the child-friendly schools approach is
interpreted currently, including its focus on healthy and protective learning environments, are listed in table 58.1.
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Also during the 1990s, the World Bank Human Development Network sought to support countries in implementing
school health and nutrition programs (Del Rosso and Marek
1996; World Bank 1993) and launched an International School
Health Initiative with the aim of raising awareness among decision makers in the education sector.
Thus, the 1990s were characterized by the creation of a
number of apparently separate programs to promote and support school health. However, analysis at the country level
revealed that although the various agency initiatives used
different “prisms” to view school health—public health for
WHO, quality education for UNESCO, and child rights for
UNICEF—the core activities for all the programmatic
approaches were essentially the same.
FRESH Framework
A major step forward in international coordination and cohesion was achieved when the FRESH framework was launched
at the World Education Forum in Dakar in April 2000 (World
Bank FRESH Toolkit 2000). Among the early partners in this
effort were the Education Development Centre, Education
International, the Partnership for Child Development,
UNESCO, UNICEF, the World Food Programme (WFP),
WHO, and the World Bank. This partnership recognizes that
the goal of universal education cannot be achieved while the
health needs of children and adolescents remain unmet and
that a core group of cost-effective activities can and must be
implemented across the board to meet those needs and to
deliver on the promise of EFA.
The expanded commentary on the Dakar Framework for
Action reflects the recommendations of this partnership and
describes three ways in which health relates to EFA: as an input
and condition necessary for learning, as an outcome of effective
quality education, and as a sector that must collaborate with
education to achieve the goal of EFA. In the follow-up to the
Dakar Forum, UNESCO designated FRESH as an interagency
flagship program that will receive international support as a
strategy to achieve EFA.
The FRESH framework, which is based on good practice
recognized by all the partners, provides a consensus approach
for the effective implementation of health and nutrition
services within school health programs. The framework
proposes four core components that should be considered in
designing an effective school health and nutrition program
and suggests that the program will be most equitable and
cost-effective if all of these components are made available,
together, in all schools:
• Policy: health- and nutrition-related school policies that are
nondiscriminatory, protective, inclusive, and gender sensitive and that promote the nutrition and physical and psychosocial health of staff, teachers, and children
• School environment: access to safe water and provision of
separate sanitation facilities for girls, boys, and teachers
• Education: skills-based education, including life skills, that
addresses health, nutrition, HIV/AIDS prevention, and
hygiene issues and that promotes positive behaviors
• Services: simple, safe, and familiar health and nutrition services that can be delivered cost-effectively in schools (such as
deworming services, micronutrient supplements, and nutritious snacks that counter hunger) and increased access to
youth-friendly clinics.
The FRESH framework further proposes that these four
core components can be implemented effectively only if they
are supported by strategic partnerships between the following
groups:
• health and education sectors, especially teachers and health
workers
• schools and the community
• children and others responsible for implementation.
Adopting this framework does not imply that these core
components and strategies are the only important elements;
rather, implementing all of these in all schools would provide a
sound initial basis for any pro-poor school health program.
The common focus has encouraged concerted action by the
participating agencies. It has also provided a common platform on which countries, agencies, donors, and civil society
can support all programs, including agency-specific programs
(table 58.1). Another important consequence of the FRESH
consensus framework has been to offer a common point of
entry for new efforts to improve health in schools, as illustrated by the three examples in box 58.1.
This consensus approach has increased significantly the
number of countries implementing school health reforms. The
simplicity of the approach, combined with the enhanced
resources available from donor coordination, has helped
ensure that these programs can go to scale. Annual external
support from the World Bank for these actions approaches
US$90 million, targeting some 100 million schoolchildren.
Common Interventions
Table 58.2 lists some specific interventions commonly combined within the school health intervention package, but it
should be recognized that not all of these interventions will be
needed or be appropriate for all locations. Some interventions
are synergistic: for example, worm infection will be addressed
by the provision of latrines, the promotion of hand washing,
relevant health and hygiene education, and deworming
services. Similarly, HIV/AIDS infection among youths will be
addressed by ensuring girls’ participation in school, offering
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Box 58.1
Three Efforts to Improve Health in Schools
The Multiagency Effort to Accelerate the Education
Sector Response to HIV/AIDS in Africa
This effort, coordinated by a Working Group of the
UNAIDS Inter-Agency Task Team on HIV/AIDS and
Education, promotes the FRESH framework specifically
and helps education systems do the following:
• adopt policies that avoid HIV/AIDS discrimination
and stigmatization
• provide a safe and secure school environment
• provide skills-based health education, including life
skills, in schools to promote positive behaviors and
healthy lifestyles
• improve access to youth-friendly health services.
More than 36 countries and a similar number of agencies, bilateral donors, and nongovernmental organizations have collaborated in this effort since November
2002.
The Global School Feeding Campaign of the WFP
This campaign has gone beyond providing food aid to
develop a programmatic link between nutrition and education. Working with partners, including national governments, parent-teacher and other community organizations,
UNICEF, WHO, the World Bank, UNESCO, and the Food
and Agriculture Organization, the campaign promotes the
following:
• policies that make food aid conditional on girls’ participation in education
• an essential package that includes school sanitation and
water and environmental improvement
• nutrition education that improves the quality of students’ diets and HIV prevention education
• nutrition services that include food, deworming, and
alleviation of short-term hunger.
Some 70 countries have begun to implement these
principles and activities since 2002.
The Partnership for Parasite Control
Led by WHO and involving a broad range of development
partners, this initiative promotes public and private efforts
to include deworming in school health services, following a
resolution of the 54th World Health Assembly to provide by
2010 regular deworming treatment to 75 percent of schoolage children at risk (an estimated target population of 398
million). Of 41 target countries in Africa, 19 have begun
school-based deworming programs since 2001.
Source: Authors.
skills-based health education (including life skills), offering
peer education, providing access to health clubs, and providing
access to treatment for sexually transmitted infections (STIs) at
clinics. It is also apparent that whereas some interventions
promote multiple outcomes—for example, skills-based health
education and life-skills development can help promote positive behaviors that prevent STIs and substance abuse—other
interventions may have a single focus, such as iron supplementation to avoid anemia.
Nevertheless, it is apparent that out-of-school children cannot benefit from many of the important components of
school-based programs, such as skills-based health education
and life-skills development programs to prevent HIV/AIDS.
Reaching these children requires more flexible approaches that
combine the best of nonformal, informal, and communitybased approaches (see chapter 59).
Out-of-School Children
A key issue in addressing the costs of the new approach to
school health and nutrition programs is the significant savings
offered by using the school system infrastructure rather than
that of the health system as the key delivery mechanism. The
school system provides not only a preexisting mechanism, so
costs are at the margins, but also a system that aims at being
pervasive and socially progressive. Some important interventions, especially in terms of health education, may be virtually
cost free; they require only policy changes that result in doing
things differently.
More than 100 million school-age children are out of school;
60 percent are girls (UNESCO 1993). School health programs
in Guinea and Madagascar have demonstrated that many of
these children will take advantage of simple services, such as
deworming, provided in schools (Del Rosso and Marek 1996);
the school acts essentially as a community center. It also has
been demonstrated that deworming programs in schools benefit out-of-school children by reducing disease transmission in
the community as a whole (Bundy and others 1990).
COST-EFFECTIVENESS OF INTERVENTION
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Table 58.2 Common Interventions within a School Health Program
FRESH category
Intervention
Expected outcome
Policy
1. Child rights, avoidance of discrimination and stigmatization, gender
sensitive, child centered
1. Inclusion of all children
2. Inclusion of pregnant girls and mothers in education
2. Specific inclusion of girls
3. Enforcement of code of practice for teacher behavior zero tolerance policy
3. Avoidance of harassment and abuse
4. Collaboration between health and education sectors
4. Effective implementation
1. Access to safe water
1,2,3,5. Reduced infection
2. Hand washing
4. Reduced drop out of adolescent girls
Environment
3. Provision of sanitation
4. Gender-separate sanitation
5. Garbage disposal
Education
1. Curriculum addressing health, hygiene, and nutrition
2. Life-skills program
2. Lifelong positive behaviors such as avoidance of
HIV/AIDS and substance abuse
3. Peer education program
4. Health-promoting clubs
Services
1. Improved knowledge and skills to promote good
health, hygiene, and nutrition
3, 4. Reinforcement of positive behaviors
1. Deworming for intestinal worms and schistosomiasis
1. Reduction in worm infection
2. Prompt recognition and treatment of malaria
2. Reduction in impact of malaria
3. Insecticide-treated nets
3. Reduction in incidence of malaria
4. Micronutrient supplements
4. Reduction in anemia and malnutrition
5. Breakfast, snacks, and meals
5. Avoidance of hunger
6. First-aid kits
6. Management of injuries
7. Referral to youth-friendly clinics
7. Access to specific treatment
8. Counseling and psychosocial support
8. Mental health
Source: Authors.
Table 58.3 Annual per Capita Costs of School-Based Health
and Nutrition Interventions Delivered in Schools
Condition
Intervention
Cost (US$)
Intestinal worms
Albendazole or mebendazole
0.03–0.20
Schistosomiasis
Praziquantel
0.20–0.71
Vitamin A deficiency
Vitamin A supplementation
Iodine deficiency
Iodine supplementation
Iron deficiency and anemia
Iron folate supplementation
Refractive errors of vision
Spectacles
Clinically diagnosed
conditions
Physical examination
Undernutrition, hunger
School feeding
0.04
0.30–0.40
0.10
2.50–3.50
11.50
21.60–151.20,
21.26–84.50a
Sources: Del Rosso and Marek 1996; Partnership for Child Development 1999; WHO 2000.
a. For South America and Africa, costs are standardized for 1,000 kilocalories for 180 days.
Annual costs of providing some common school-based
interventions to students are given in table 58.3. This table
illustrates two important points. First, some of the most widely
needed interventions can be provided at remarkably low cost.
Second, significant diversity exists in the cost of interventions,
which is affected by factors such as local capacity, location and
remoteness of communities, and community values and opinions; hence, these factors must be borne in mind when identifying a school health package. (See chapter 41 for details of the
costs of sanitation provision.)
Not illustrated in the table is the cost advantage of using the
existing school infrastructure for delivery. Estimates for delivery of simple interventions (such as anthelmintic pills or
micronutrient supplements) suggest that the teacher-delivery
approaches listed here may be one-tenth of the cost of the more
traditional mobile health teams and yet equally effective
(Guyatt 2003). As with all education innovations, however,
the additional cost of teacher orientation and training (inservice as well as preservice) needs to be factored into the costs
of using the education system for delivery of health services.
ECONOMIC BENEFITS OF INTERVENTION
The most obvious benefit of school health interventions is
arguably through the economic returns of improved adult health
outcomes. Studies have increasingly documented a causal effect
of adult health (broadly defined) on labor force participation,
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wages, and productivity in developing countries; Strauss and
Thomas (1995) present an overview of economic studies in this
area. For example, height has been shown to affect wage-earning
capacity as well as participation in the labor force for both
women and men (Haddad and Bouis 1991). The effect of health
on productivity and earnings may be strongest where low-cost
health interventions produce large effects on health, such as lowincome settings where physical endurance yields high returns in
the labor market. For a 1 percent increase in height, Thomas and
Strauss (1997) find a 7 percent increase in wages in Brazil compared with a 1 percent increase in the United States.
However, the apparent benefits of school health and nutrition programs will be underestimated when measured using
only mortality or health-related disability metrics because these
measures do not capture the impact of ill health on cognitive
development or educational outcomes. Evidence over the past
decade suggests these impacts have effect sizes in the range 0.25
to 0.4 SD and have implications for the child’s education and for
life beyond school, including future earning potential. We investigate those implications by considering the economic benefits
in terms of IQ and school attendance and by comparing school
health programs with traditional education interventions.
Economic Benefits of Long-Term Improvements in IQ
School health interventions can yield considerable economic
benefits through returns to wages and productivity if they
translate into improved cognitive functioning and IQ in adulthood.
For the United States, Zax and Rees (2002) estimate conservatively that an increase in IQ of 1 SD is associated with an
increase in wages of more than 11 percent, falling to 6 percent
when controlling for other covariates. Similar estimates for the
relationship between IQ and earnings have been made for
Indonesia (Behrman and Deolalikar 1995) and Pakistan
(Alderman and others 1997) and in a review of developing
countries (Glewwe 2002). In South Africa, an increase of 1 SD
in literacy and numeracy scores was associated with a 35 percent
increase in wages (Moll 1998). Extrapolating these results, a 0.25
SD increase in IQ, which is a conservative estimate of the benefit resulting from a school health intervention, would lead to an
increase in wages of from 5 to 10 percent.
Economic Benefit of Improved School Attendance
School health interventions can raise adult productivity not
only through higher levels of cognitive ability, but also through
their effect on school participation and years of schooling
attained. Healthier children are more likely to attend, and modest improvements in examination scores can be associated with
continuation in schooling.
Malaria chemoprophylaxis given in early childhood in The
Gambia led to an increase of more than one year in primary
schooling. In preschool children in Delhi, iron supplementation was associated with an increase of 5.8 percent in rates of
participation at the preschool level (Bobonis, Miguel, and
Sharma 2004). In western Kenya, deworming treatment
improved primary school participation by 9.3 percent, with an
estimated 0.14 additional years of education per pupil treated
(Miguel and Kremer 2004). On the basis of crude estimates of
returns to schooling, an increase of 9.3 percent in participation
rates results in a return of US$44. Miguel and Kremer (2004)
conclude that these benefits still outweigh the costs even if
increased school participation leads to greater costs in teacher
compensation through the need for additional teachers. They
note that the benefit-cost ratio remains over 10 even if the rate
of return to an additional year of schooling is as low as 1.5 percent. These results suggest that for realistic estimates of returns
to schooling, the net present discounted value of lifetime earnings is likely to be high compared to the costs of treatment even
for small gains in school participation.1
In the absence of studies estimating the direct link between
school health interventions and school participation, the relationship can be estimated indirectly by considering the effect of
interventions on test scores and the implications that improved
test scores have for school participation. Improvements in cognitive function can be converted into an equivalent number of
years of schooling. For example, Jukes and others (2002) found
that heavy schistosomiasis was (nonsignificantly) associated
with a decrease in arithmetic scores of 1.35 marks (0.25 SD).
An extra year of schooling was associated with an increase in
arithmetic scores of 2.24 marks (0.42 SD). Thus, the negative
effect of heavy schistosomiasis was equivalent to missing just
over half a year of schooling. The cognitive gains from an extra
year of schooling can also be estimated retrospectively: in a
study of adults in South Africa, each additional year of primary
schooling was associated with a 0.1 SD increase in cognitive test
scores (Moll 1998). According to these estimates, a typical
increase of 0.25 SD associated with school health and nutrition
programs is equivalent to an additional 2.5 years of schooling.
Liddell and Rae (2001) assessed the direct effect of test
scores on grade progression in Africa. Each additional SD
scored in first-grade exams resulted in children being 4.8 times
as likely to reach seventh grade without repeating a year of
schooling.2 According to these estimates, an increase of 0.25 SD
in examination scores, which is typically achieved by school
health and nutrition programs, will make children 1.48 times3
as likely to complete seventh grade, which implies that the extra
cumulative years of schooling attributable to the school health
intervention average 1.19 years per pupil. The previous estimates for added years of schooling owing to school health
interventions range from seven months to two years. Increased
years of schooling are associated with, among other outcomes,
higher worker productivity and generally higher productivity
in nonmarket production activities, including greater farmer
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efficiency and productivity (Jamison and Lau 1982;
Psacharopoulos and Woodhall 1985; Strauss and Thomas
1995). Psacharopoulos and Patrinos (2002) summarize a wide
range of studies that focus on individual wage earnings. For
Sub-Saharan Africa, they find a 12 percent rate of return to one
additional year in school, compared with 10 percent for Asian
countries. These returns are very high, even allowing for a portion of the return to years of schooling to be capturing ability
and factors other than schooling itself (Card 2001).
Education brings benefits beyond improved earnings. One
year of extra education for girls can lead to a reduction of from
5 to 10 percent in infant mortality (Schultz 1993). Five extra
years of education for women in Africa could reduce infant
mortality by up to 40 percent (Summers 1994).
tional cash-transfer approach is, in both cases, apparently at the
lower end of effectiveness and the higher end of cost.
Economic Benefits of Programs
Policy and Economic Issues in Defining Sectoral Roles
in Intervention
The educational gains from school health and nutrition
programs should be considered in the context of alternative
educational inputs, such as improving teacher salaries and
qualifications, reducing class size, improving school facility
infrastructure, and providing instructional materials. Many
studies relate student outcomes to school characteristics, but
few of these studies provide information on the relative or
actual costs of the educational inputs. The costs, however, are
substantially greater than for the school health interventions
considered here. Despite the higher costs, the evidence from the
few randomized evaluations that have been conducted suggests
that the scale of effect of additional education inputs is typically
low (see discussion in Miguel and Kremer 2004). A review of
studies showed that instructional materials (such as additional
textbooks) had the highest productivity, raising student test
scores significantly more than other inputs for each dollar
spent. However, even these interventions have only a weak
effect. In a randomized experiment in Kenya, for example, providing textbooks had no effect on the bottom three quintiles of
students and raised test scores by only 0.2 SD for the upper two
quintiles. Relating these results to the findings in the previous
section and to the annual per pupil costs, school health interventions appear very cost-effective compared to the highestproductivity, more traditional education inputs.
Recently, conditional cash-transfer programs have been
viewed as potentially very cost-effective methods to increase
school enrollment. These programs are generally large in scope,
representing a commitment of between 0.1 and 0.2 percent of
gross national income. The Progresa program in Mexico is
estimated to have increased enrollment by 3.4 percent and to
have increased schooling by 0.66 years, with an average cash
transfer (for grades 3 to 8) of about US$136 per child per
school year (assumed to be 180 days). Gains from a similar
program in Nicaragua were estimated at 0.45 years of school at
a cost of US$77 per year. If we compare these results with those
presented for school health and nutrition programs, the condi-
IMPLEMENTATION OF PROGRAMS AND LESSONS
FROM EXPERIENCE
The FRESH framework provides strategic guidance, but the
practical design of actual programs reflects differences in local
needs and capacity. Successful and equitable programs in lowand middle-income countries are characterized by a focus on
school-based delivery, on a public health paradigm that minimizes the need for clinical intervention and reliance on health
service facilities, and on participation of the public sector and
civil society locally.
A negative correlation between income level and both ill health
and malnutrition is clearly demonstrated both in cross-country
comparisons and within countries (see de Silva and others
2003), partly because poverty promotes both disease and an
inadequate diet. Similarly, children who are not enrolled in
school come from households with lower income levels (Filmer
and Pritchett 2001). This fact suggests that school health services
that are pro-poor and specifically linked to efforts to achieve
universal participation in education will have a greater return.
Early school health programs, particularly in colonial Africa,
were intended to serve the minority of children who had access
to school in urban centers or elite boarding facilities. They relied
on specific infrastructures and services—such as mobile health
teams, school visits, school nurses, and in-school clinics—that
were additional to the normal range of health service provision.
This approach has proven difficult to make universally available,
even in middle-income countries. A school nurse program in
KwaZulu-Natal, for example, achieved inadequate coverage (18
percent of the target population) and little referral or follow-up
treatment of cases of ill health detected, despite a relatively high
investment of US$11.50 per student targeted per year (World
Bank FRESH Toolkit 2000). As shown in the following examples, using the FRESH framework approach reduces costs significantly and enhances both coverage and outcomes.
An important element of the new approach to school health
is a focus on minimizing the need for clinical diagnosis. Mass
delivery of services, such as deworming and micronutrient supplementation, is preferable on efficacy, economic, and equity
grounds to approaches that require diagnostic screening
(Warren and others 1993).
Sectoral Roles in Implementation
Table 58.4 gives examples from low- and middle-income
countries of how the four core components of FRESH are
being supported by different approaches. In about 85 percent
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1102 | Disease Control Priorities in Developing Countries | Donald A. P. Bundy, Sheldon Shaeffer, Matthew Jukes, and others
Table 58.4 Nine Low- and Middle-Income Countries and How They Use FRESH
Program
approach
Country
examples
Public sector:
public sector–
supported and
–implemented
Outcomes (Costs
per child per year)
Policy
Environment
Health education
Health services
Guinea,
Ghana, and
Tanzania
In all three countries, the Ministry of Education (or in
Ghana, its executive body, the Ghana Education
Service) implements the program under the guidance
of the Ministry of Health, on the basis of a formal
policy agreement. In Tanzania, the Ministries of
Community Development and of Local Government
are also parties to the agreement. The existing inservice teacher training and supply-line infrastructures are used to prepare teachers and supply the
necessary materials.
Separate sanitation facilities for girls and boys in
all new schools; access to
potable water in all
schools.
Health, hygiene, and nutrition education as part of the
formal curriculum.
Deworming (for both schistosomiasis and intestinal
worms) provided by teachers twice a year; in Guinea,
this service is followed
by iron folate
supplementation.
In three years, in Guinea—
1.1 million students, in
Ghana—577 schools and
83,000 students (US$0.54), in
Tanzania—353 schools and
113,000 students (US$0.89).
Parastatal support
for public sector
intervention
Madagascar
The Community Nutrition Programme provides training and support to the Ministry of Education on the
basis of a formally agreed-on health policy for the
education sector. In all schools in the 43 poorest
districts (44 percent of all districts), the program
prepares teachers and provides materials. In
addition, the program also provides Parent-Teacher
Associations (PTAs) with access to a social fund to
support construction of facilities. Each PTA can
request up to US$500, with a 20 percent community
contribution based on an annual parental contribution
of US$0.16.
Access to potable water
and hand-washing facilities, in all schools; where
requested by PTAs,
construction of latrines,
wells, fences, and sports
facilities.
A formal health education
curriculum, supported by
community information,
education, and
communication (IEC).
Twice-yearly deworming
and iron folate (for three
months) delivered by
teachers; test kits to
confirm iodization of local
sources of salt; where
requested by PTAs,
provision of food
preparation facilities.
In three years, 14,000 teachers trained in 4,585 schools,
430,000 students (US$0.78
to US$1.08 per capita per
year).
Social fund: public
sector support for
community
intervention
Tajikistan
The Ministry of Labor and Social Protection, with the
Ministries of Education and of Health, have developed a memorandum of understanding that sets out
health policies for the education sector. The program
channels resources through PTAs, which identify and
assist needy children. A training program, delivered
by NGOs, prepares PTA members to develop proposals of up to US$5,000 for their school to support
activities selected from a menu of items.
Provision of sanitation
facilities, potable water,
and sports facilities.
Training of teachers in
health promotion.
Training of teachers to
provide first aid, micronutrients, and deworming;
provision of food preparation facilities.
The program targets the
100,000 neediest children in
all 200 schools in the six
poorest districts of Tajikistan
(US$1 per capita per year).
©2006 The International Bank for Reconstruction and Development / The World Bank
183
Private sector:
community
payment for
NGO-implemented
intervention
Indonesia
The NGO Yayasan Kusuma Buana has a formal agreement with the education department in Jakarta and
three other major cities to train teachers, perform
diagnostic tests, and provide medicines and materials. The NGO offers Papanicolaou smear tests and
referral services to teachers. Unit costs are low
because parasite diagnosis involves mass screening
in a central laboratory (approximately 2,500 diagnoses per day) and medicines are obtained at preferential rates from two commercial partners.
Not included in program.
Nutrition and hygiene
education as part of the
curriculum.
Stool examination by the
laboratory and deworming
by teachers as necessary
twice a year; iron folate
provided by teachers twice
a year (for three months).
The program has been in
existence for 17 years and
currently reaches 627
schools and 161,000 students, at a cost to parents of
US$0.10 annually.
NGO implementation with financial
support from
public sector
Burkina Faso,
Malawi, and
the Philippines
The international NGO Save the Children U.S.A.
implements school health and nutrition activities in
nonformal schools created with support from government, local communities, and private donations.
Separate sanitation facilities for girls and boys and
access to potable water.
Health, hygiene, and nutrition education as part of the
curriculum supported by
extracurricular IEC activities
Deworming and micronutrient supplementation
(vitamin A and iron)
provided by teachers
annually.
In three years, in Burkina
Faso, 42,000 students plus
nonenrolled children in 171
schools (US$2). In four years,
in Malawi, 122,000 children
in 181 schools (US$3). In four
years in the Philippines,
23,000 children in 53 schools
(US$6).
Source: Authors.
School-Based Health and Nutrition Programs | 1103
of programs reviewed, school health and nutrition programs
are delivered and funded by the public education sector, with a
formal role for the health sector in design and supervision.
Although this public sector “mainstream” model has proven
the most popular approach, it is not the only successful one. In
some cases, the public sector has identified appropriate options
and developed operational manuals but then has used a social
fund to provide direct support to communities and has used
schools to select and implement the most relevant actions
locally, often with the assistance of nongovernmental organizations (NGOs). In other cases, services have been contracted out
by the public sector, and in some middle-income countries, the
move toward a demand-led approach has resulted in a private
sector service.
The private sector approach has proven sustainable over
nearly two decades in urban Indonesia but may require a technical infrastructure and local market base that are inappropriate for predominantly rural low-income countries. The
approach is modeled on a program initiated in Japan in 1948,
which relied on private sector technicians, working independently at first but later formalized within the Japan Association
of Parasite Control, who conducted stool examinations and
then treated infected individuals for a per capita fee equivalent
to approximately US$0.74 in 2004. At its peak, the private
sector program conducted some 12 million examinations
annually, implying a turnover of nearly US$9 million at today’s
prices. The prevalence of roundworm infection fell from a
high of 73 percent in 1949 to less than 0.01 percent by 1985.
Although a private sector response is effective in some circumstances, overall the characteristics of school health and
nutrition programs make a compelling case for public sector
intervention. First, treatment externalities may create external
benefits to others in addition to the benefit for the treated
individual. This situation is clearly the case for communicable
disease interventions, especially against worm infection. Second,
some forms of intervention (such as vector control, health
education campaigns, epidemiological surveillance, and interventions that have strong externalities) are almost pure public
goods; that is, no one can be excluded from using the goods or
service they deliver,and thus the private sector is unlikely to compete to deliver these goods. Finally, there is typically little private
demand for general preventive measures,such as information on
the value of washing hands. None of these factors is an argument
against a private sector role in service delivery, but they do
suggest that private sector demand is likely to be greater in
middle-income populations and where public sector actions
have created a demand.
Roles of Key Stakeholders in Implementation
There are many ways to approach the delivery of school health,
but these diverse experiences suggest common features—in
particular, the consistency in the roles played by government
and nongovernmental agencies as well as other partners and
stakeholders (table 58.5). In nearly every case, the Ministry of
Education is the lead implementing agency, reflecting both the
goal of school health programs in improving educational
achievement and the fact that the education system provides
the most complete existing infrastructure for reaching schoolage children. However, the education sector must share this
responsibility with the Ministry of Health, particularly because
the latter has the ultimate responsibility for health of children.
It is also apparent that the program’s success depends on the
effective participation of numerous other stakeholders, including civil society, and especially the beneficiaries and their parents or guardians. The children and their families are the clients
of these programs, and their support for program implementation is critical to the program’s success.
Key Issues in Designing Effective Programs
The diverse experiences of school health programming suggest
some key elements that are common contributors to success in
many programs.
• Focus on education outcomes. Making explicit links among
school health programs and learning and education sector
priorities (especially EFA and gender equity) helps ensure
the commitment of the sector to program support and
implementation.
• Develop a formal, multisectoral policy. Education sector
actions in health require the explicit agreement of the health
sector. This potential tension can be resolved by defining
sectoral responsibilities at the outset; failure to enter into
dialogue has led, in Africa and Central Asia, to some health
sectors resisting teacher delivery of deworming drugs,
despite WHO recommendations.
• Initiate a process of wide dissemination and consultation.
Because there are multiple stakeholders, implementers,
enablers, and gatekeepers, a process of consultation is necessary to establish ownership and to identify obstacles before
they constrain progress. The process should involve at least
community-based organizations, NGOs, faith-based organizations, pupils, and teacher associations. In one country
in East Africa, lack of prior agreement on the content of
sexuality education delayed implementation for more than
three years.
• Use the existing infrastructure as much as possible. Building
on existing curriculum opportunities and the network of
formal and nonformal teachers will accelerate implementation and reduce costs. Programs that rely on the development of new delivery systems—mobile school health teams,
a cadre of school nurses—take longer to establish and are
expensive and complicated to sustain and take to scale.
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Table 58.5 Roles of Agencies, Partners, and Stakeholders in School Health and Nutrition Programs
Partner
Roles
Comments
Ministry of Education
Lead implementing agency
Health and nutrition of schoolchildren is a priority for EFA.
Lead financial resource
Education policy defines school environment, curriculum, duties of teachers.
Education sector policy
Education system has a pervasive infrastructure for reaching teachers and
school-age children.
Lead technical agency
Health of school-age children has lower priority than clinical services, infant
health.
Ministry of Health
Health sector policy
Health policy defines role of teachers in service delivery, procurement of
health materials.
Other public sector agencies
(for example, Welfare, Social
Affairs, local government)
Support for education and health systems
Private sector (for example,
health service, pharmaceuticals, publications)
Specialist service delivery
Sector has major role in drug procurement and training materials production.
Material provision
Sector has specialist roles in health diagnostics.
Civil society (for example,
NGOs, faith-based
organizations, PTAs)
Training and supervision
At the local level, organizations serve as gatekeepers and fund holders and
may target implementation.
Teacher associations
Definition of teachers’ roles
School health programs demand an expanded role for teachers.
Community (children,
teachers, parents)
Partners in implementation
Communities are gatekeepers for the content of health education (especially
moral and sexual content) and for the role of nonhealth agents (especially
teachers) in health service delivery; pupils are active participants in all aspects
of the process at the school level.
Fund holder
Ministries of local government are often fund holders for teachers and schools
and for clinics and health agents.
Ministries of Welfare and Social Affairs provide mechanisms for providing
social funds.
Local resource provision
Organizations provide additional resource streams, particularly international
NGOs.
Definition of acceptability of curriculum and
teachers’ roles
Supplementation of resources
• Use simple, safe, and familiar health and nutrition interventions. Success in rapidly reaching all schools depends on
stakeholder acceptance, which is more likely if the interventions are already sanctioned by local and international agencies and are already in common use by the community.
• Provide primary support from public resources. Compelling
arguments exist for public investment in school health programs: the contribution to economic growth, the high rate
of return, the large externalities, and the fact that the majority of interventions are public goods.
• Be inclusive and innovative in identifying implementation
partners. Although public resources are crucial for school
health programs, contributions from outside the public sector can be vital. NGOs have proven effective in supporting
public sector programs through training and supervision,
particularly at local levels.Although market failure appears to
have largely precluded the private sector from effectively
implementing national programs in low-income countries,
examples of successful contributions do occur, particularly
in dense urban populations and in middle-income countries.
Communities supplement program finance at the margins.
RESEARCH AND DEVELOPMENT AGENDA
Reliable evidence suggests that ill health and malnutrition
affect education access, participation, completion, and achievement, and that school-based health and nutrition programs
can provide a cost-effective and low-cost solution. This evidence does not imply, however, that no uncertainties exist.
Cost-Effectiveness of School-Based HIV/AIDS Prevention
Substantial evidence suggests that skills-based health education,
including life-skills development programs, can promote positive behaviors and reduce the risks of exposure to HIV infection,
and that girls’ education programs have similar effects (Kirby
2002). Evidence also exists for a positive effect of completing
education on HIV prevalence (de Walque 2004; World Bank
2002). What is lacking is direct evidence about the contribution
that school-based prevention programs can make in reducing
the incidence of HIV infection, as well as evidence for the relative cost-effectiveness of such programs compared with existing
efforts to promote education completion and girls’ education.
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Cost-Effectiveness of Malaria Programs
Malaria occurs commonly in schoolchildren, particularly in
areas of unstable transmission in Africa and Asia. It is a leading
source of mortality in this age group and adversely affects education by reducing school attendance, cognition, learning, and
school performance. Current school-based approaches focus
on knowledge of the disease and the use of impregnated bednets but do not address the need for treatment of affected children. Yet presumptive treatment by teachers has been shown to
significantly reduce mortality (Pasha and others 2003), and
intermittent preventive treatment also shows considerable
promise (Brooker and others 2000). There is a need to confirm
the success of school-based treatment in different epidemiological settings and to address questions about the cost and sustainability of this approach.
Cost-Effectiveness of Targeting Food Aid
The high prevalence of malnutrition in children continues to
be a major challenge for low-income countries. Providing food
to children at school is often seen as an important part of the
solution and is a major focus for food aid. However, the nutrition literature suggests that ensuring good nutrition earlier in
life—certainly before 3 years of age, but perhaps earlier—is
essential to ensuring an appropriate development trajectory
throughout life (see chapter 27). Where food is limiting, it raises
the question whether the first target should be preschool rather
than school-age children. This debate has been blurred by
admixing the nutrition outcomes with broader social and education issues. Clearly, providing a meal at school is socially
desirable and can offer education benefits for children who
otherwise would have to walk often long distances home to eat
or remain hungry. It is also clear that schools represent an
extensive and established network for providing nutrition
interventions to very large numbers of children at a low cost
per child. No comparable network exists to reach preschool
children. However, from a nutritional perspective, it remains
unclear whether ensuring good nutrition early in life has more
effect on subsequent development—including educational
achievement—than providing food at school age.
In consequence, the clearest benefit of school health and nutrition programs is measurable in terms of education outcomes
and their economic returns. The scale of benefit is significant:
school health and nutrition interventions can add four to six
points to IQ levels, 10 percent to participation in schooling, and
one to two years of education. This scale of benefit can add 8 to
12 percent to labor returns and provide a rate of return that
offers a strong argument for public sector investment.
Compelling evidence suggests that education qua education
can help protect individuals from HIV infection. Achieving EFA
goals and combining this outcome with school health programs
that help establish lifelong positive behaviors are now recognized
as essential to the multisectoral prevention response to
HIV/AIDS.
The scale of the education benefit and the role of education in
the fight against HIV/AIDS mean that school health and nutrition programs are today seen as a priority for both the education
and the health sectors. This focus, in turn, has resulted in a shift
toward public health rather than clinical intervention and
toward school-based delivery rather than health system
approaches. These policy changes enhance cost-effectiveness
and social progressiveness, because delivery through the school
system is an order of magnitude less costly than using health systems and in low-income countries is better targeted to the poor.
These changes in emphases have coincided with significant
technical and political policy reform. Technical consensus
around the FRESH framework has encouraged countries and
agencies to develop programs around a common coordinating
principle, while the political imperative has been strengthened
by the recognition that school health and nutrition programs
are essential to achieving EFA and the Millennium Development Goals and are at the center of the preventative response
to the HIV/AIDS pandemic.
Although much of this change has evolved over the past two
decades, significant acceleration has occurred since the World
Education Forum in 2000. Today, a majority of low-income
countries have recognized the need for school health and nutrition programs and are seeking to implement them.
NOTES
CONCLUSIONS
The rationale for school-based health and nutrition programs
and the approach to their implementation have undergone a
paradigm shift over the past two decades.
The traditional perception of these programs as seeking to
improve the health of schoolchildren cannot be justified on the
basis of mortality or public health statistics alone. Instead, it is
increasingly recognized that a major—perhaps the major—
impact of ill health and malnutrition on this age group is that on
cognitive development, learning, and educational achievement.
1. These calculations assume the following: a return to an additional
year of school is 7 percent; wage gains are earned over 40 years in the
workforce, discounted at 5 percent per year with no wage growth; annual
wage earnings are US$400 per year, which is below the estimated agricultural and nonagricultural annual wages for low-income countries (World
Bank 2003). The opportunity costs of the additional schooling (child
labor) have not been considered but are likely to be negligible.
2. These calculations assume that a pupil’s falling behind the equivalent of one year in test scores has the same effect on earnings as losing
one year of schooling; that the advantage that third graders have over
second graders, for example, is the same as the advantage someone who
has studied for a total of three years has over someone who has studied
for two years; and that the impact of first-grade examination scores on
1106 | Disease Control Priorities in Developing Countries | Donald A. P. Bundy, Sheldon Shaeffer, Matthew Jukes, and others
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the probability of transition from one class to the next is the same at
each grade level.
3. If an increase of 1 SD in exam scores leads to children being 4.8 times
as likely to reach seventh grade, the increased likelihood of reaching seventh grade because of a 0.25 SD increase can be calculated as EXP (0.25 ⫻
LN(4.8)).
Filmer, D., and L. H. Pritchett. 2001. “Estimating Wealth Effects without
Expenditure Data—or Tears: An Application to Educational
Enrolments in States of India.” Demography 38: 115–32.
Glewwe, P. 2002. “Schools and Skills in Developing Countries: Education
Policies and Socioeconomic Outcomes.” Journal of Economic Literature
40: 436–82.
Guyatt, H. L. 2003. “The Cost of Delivering and Sustaining a Control
Program for Schistosomiasis and Soil-Transmitted Helminthiasis.”
Acta Tropica 86: 267–74.
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Chapter 61
Natural Disaster Mitigation and Relief
Claude de Ville de Goyet, Ricardo Zapata Marti, and Claudio Osorio
Sudden-onset natural and technological disasters impose a
substantial health burden, either directly on the population or
indirectly on the capacity of the health services to address primary health care needs. The relationship between communicable diseases and disasters merits special attention. This chapter
does not address epidemics of emerging or reemerging diseases, chronic degradation of the environment, progressive climatic change, or health problems associated with famine and
temporary settlements.
In line with the definition of health adopted in the constitution of the World Health Organization (WHO), the chapter
treats disasters as a health condition or risk, which, as any other
“disease,” should be the subject of epidemiological analysis,
systematic control, and prevention, rather than merely as an
emergency medicine or humanitarian matter. The chapter
stresses the interdependency between long-term sustainable
development and catastrophic events, leading to the conclusion
that neither can be addressed in isolation.
DISASTERS AS A PUBLIC HEALTH CONDITION
According to the International Federation of Red Cross and
Red Crescent Societies, internationally reported disasters in
2002 affected 608 million people worldwide and killed
24,532—well below the preceding decade’s annual average
mortality of 62,000 (IFRC 2003). Many more were affected by
myriad local disasters that escaped international notice.
Disaster has multiple and changing definitions. The essential
common element of those definitions is that disasters are
unusual public health events that overwhelm the coping capacity of the affected community. This concept precludes the
universal adoption of a threshold number of casualties or vic-
tims. What would be a minor incident in a large country may
constitute a major disaster in a small isolated island state. Not
only are “quantitative definitions of disasters unworkably simplistic” as noted by Alexander (1997, 289), but when based on
the economic toll or the number of deaths, they are also misleading with regard to the immediate health needs of the
survivors or their long-term impact on the affected country.
Classification of Disasters
In the early 1970s, a series of well-publicized disasters (the civil
war and resulting famine in Biafra, the cyclone in Bangladesh,
and the earthquake in Peru) triggered the scientific interest of
the international public health community.
Disasters can be classified as natural disasters, technological
disasters, or complex emergencies. The latter include civil wars
and conflicts. These classifications are arbitrary and refer to the
immediate trigger—a natural phenomenon or hazard (biological, geological, or climatic); a technologically originated problem; or a conflict. In reality, all disasters are complex events
stemming from the interaction of external phenomena and the
vulnerability of man and society.
The human responsibility in so-called natural disasters is
well acknowledged. The term natural disaster remains commonly used and should not be understood as denying a major
human responsibility for the consequences.
Disaster Terminology
The following definitions are adapted from those proposed by
the Secretariat of the International Strategy for Disaster
Reduction (ISDR), a United Nations (UN) body established to
sustain the efforts of the International Decade for Natural
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Disaster Reduction (UN/ISDR 2004) and the WHO World
Health Report 2002 (WHO 2002):
US$ billions
700
• Hazards are potentially damaging physical events, which
may cause loss of life, injury, or property damage. Each hazard is characterized by its location, intensity, frequency, and
probability.
• Vulnerability is a set of conditions resulting from physical,
social, economic, and environmental factors that increase
the susceptibility of a community to the effects of hazards.
A strong coping capacity—that is, the combination of all the
strengths and resources available within a community—will
reduce its vulnerability.
• Risk is the probability of harmful consequences (health burden) or economic losses resulting from the interactions
between natural or human-induced hazards and vulnerable
or capable conditions. In a simplified manner, risk is
expressed by the following function:
600
12
500
10
400
8
300
6
200
4
100
2
0
0
Richest Nations
Economic losses
Figure 61.1 Disaster Losses, Total and as Share of Gross Domestic
Product, in the Richest and Poorest Nations, 1985–99
8
6
4
Geographic Distribution of Risk. Natural disasters do not
occur at random. Geological hazards (earthquakes and volcanic
eruptions) occur only along the fault lines between two tectonic
plates on land or on the ocean floor. However, the local population often does not recognize the implications (the risks), as
shown in the December 2004 tsunami in the Indian Ocean.
Rockslides
10
El Niño phenomenon
Annual growth of GDP in Ecuador compared with preceding year (percent)
12
0
⫺2.0
⫺4.0
⫺6.0
⫺8.0
19
8
19 0
8
19 1
8
19 2
8
19 3
8
19 4
8
19 5
8
19 6
8
19 7
8
19 8
8
19 9
9
19 0
9
19 1
9
19 2
9
19 3
9
19 4
9
19 5
9
19 6
9
19 7
9
19 8
9
20 9
0
20 0
01
Health and relative economic losses of natural disasters disproportionately affect developing countries (Alexander 1997;
UN/ISDR 2004). More than 90 percent of natural disaster–
related deaths occur in developing countries. Even though the
economic losses are far greater in industrial countries, the percentage of losses in relation to gross national product (GNP) in
developing countries far exceeds that percentage in industrial
countries (figure 61.1).At an individual level,a sudden reduction
of US$5,000 from an annual income of US$50,000 is worrisome;
however, the ongoing loss of US$50 from a monthly income of
US$100 may be catastrophic.
For this reason, statistics of economic damage and mortality
alone are not true indicators of the effect of disasters on the
health and development of people and communities.
Disaster impact statistics show a global trend: more disasters
occur, but fewer people die; larger populations are affected, and
economic losses are increasing (IFRC 2000).
Losses as percentage of GDP
Source: UN/ISDR, 2004.
2
Distribution and Risk Factors
Poorest Nations
Earthquake North-East
A public health approach to disaster risk management will
aim to decrease the vulnerability by adopting prevention and
mitigation measures to reduce the physical impact and to
increase the coping capacity and preparedness of the health
sector and community, in addition to providing traditional
emergency care (response) once the disaster has occurred.
14
El Niño phenomenon
Risk ⫽ ƒ (Hazards ⫻ Vulnerability)
Percentage of GDP
16
Years
Source: UN/ISDR, 2004.
Figure 61.2 Annual Growth of Gross Domestic Product and
Occurrence of Major Natural Disasters in Ecuador, 1980–2001
Hydrometeorological hazards do not follow a wellestablished distribution. Although the areas subject to seasonal
flood, drought, or tropical storms (cyclones, hurricanes, or
typhoons) are well known locally, global warming may possibly
redraw the map of climatic disasters. As the National Research
Council (1999, 34–35) notes, “This change is far from uniform.
A pattern of response ‘modes’ appears to be involved, in which
warming is concentrated in northern Asia . . . while large
regions of the northern Pacific and North Atlantic Oceans and
their neighboring shores have actually cooled.” El Niño–related
fluctuations in relation to the gross domestic product (GDP) of
Ecuador are shown in figure 61.2.
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The risk of massive technological disasters, such as the catastrophic release of chemicals in Bhopal, India (methyl isocyanate), in December 1984, is serious in countries with significant industry (WHO 1992, 1996). Very few countries are
immune to public health risks from hazardous chemical substances (from insecticides to industrial by-products) or discarded radioactive material from therapeutic or diagnostic use.
Technological hazards increase rapidly with the unregulated
industrialization of developing countries and the globalization
of the chemical industry, suggesting that chemical emergencies
may become a major source of disasters in the 21st century.
locations, particularly urban areas. Following Hurricane Mitch
in Tegucigalpa, Honduras, families that were relocated from
flooded areas to safer (but inconveniently remote) ground were
rapidly replaced by new illegal settlers. In 2003, families killed
by a landslide in Guatemala had been warned about their vulnerability but were unable to afford resettlement in safer (and
more costly) areas. Subsidies alone may not have prevented this
effect, given the overarching issue of land ownership by a few in
Central America.
Factors Affecting Vulnerability. Vulnerability to all types of
disasters—and to poverty—is linked to demographic growth,
rapid urbanization, settlement in unsafe areas, environmental
degradation, climate change, and unplanned development.
Losses fall under three categories, which may have both direct
and indirect components:
Age The importance of age as a factor of vulnerability can be
significant in situations where physical fitness is necessary for
survival. The higher fatality among children, elderly, or sick
adults following the 1970 tidal wave in Bangladesh (250,000
fatalities) and the 2004 tsunami in Asia (more than 180,000
dead or missing) illustrates this point.
Gender Reports on immediate morbidity and mortality
according to gender are not as conclusive. An Inter-American
Development Bank paper indicated that 54 percent of the
3,045 people who died as a result of Hurricane Mitch in
Nicaragua were male (IDB 1999). Stereotypes of gender vulnerability at the time of impact often do not apply. Depending
on the type of disaster, far more significant vulnerability factors
than gender or age are the time of day of the impact (and,
therefore, the occupational activity of each group) and the
structural vulnerability of housing, factories, and public buildings, including the location of the victims within the buildings.
Following disasters, increased vulnerability of women is commonly noted in temporary settlements, where violence and
sexual abuse are common. Specialized health care also may not
be available (Armenian and others 1997).
Poverty Economic vulnerability might play a much greater
role than age and gender. What has been noted regarding the
greater vulnerability of poor countries also holds true at the
community and family levels. Disasters predominantly affect
the poor. Poverty increases vulnerability because of the
unequal opportunity for healthy and safe environments, poor
education and risk awareness, and limited coping capacity. A
notable exception was the 2004 tsunami in Banda Aceh,
Indonesia, where the middle- and upper-class neighborhood
close to the shore was particularly affected.
A major example is the settlement of a large number of economically disadvantaged populations in highly vulnerable
Short-Term Health Burden
• lives and disabilities (both direct damage and an indirect
consequence)
• direct losses in infrastructure and supplies (direct impact)
• loss or disruption in the delivery of health care, both curative and preventive (indirect impact).
The immediate health burden is directly dependent on the
nature of the hazard. National health budgets of developing
countries are, in normal times, insufficient to meet the basic
health needs of the population. In the aftermath of a major disaster, authorities need to meet extraordinary rehabilitation
demands with resources that often have been drained by the
emergency response (as distinct from the resources destroyed
by the event). Beyond the immediate response, decision making in the allocation of resources among sectors is mostly influenced by the magnitude of the economic losses rather than by
the health statistics (principally the disability-adjusted life year,
or DALY, losses) or social costs.
Earthquakes. As noted by Buist and Bernstein (1986), in the
past five centuries, earthquakes caused more than 5 million
deaths—20 times the number caused by volcanic eruptions. In
a matter of seconds or minutes, a large number of injuries
(most of which are not life-threatening) require immediate
medical care from health facilities, which are often unprepared,
damaged, or totally destroyed, as was the case in the earthquake
in Bam, Iran, in 2003. In the aftermath of that earthquake,
which resulted in 26,271 deaths, the entire health infrastructure
of the city was destroyed. All traumas were evacuated by air to
the 13 Iranian provinces long before the arrival of the first foreign mobile hospitals. Table 61.1 illustrates the accelerated pace
with which priorities evolve and overlap in the first week following an earthquake.
After a few weeks, national political solidarity and external
assistance wane, and the local budgetary resources are drained.
At the same time, health authorities face the overwhelming task
of providing services to a displaced population, rehabilitating
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Table 61.1 Health Priorities Following Earthquakes
Priority
Time period
Comments
Search and rescue
0 to 48⫹ hours
Returns are rapidly diminishing. Most effective work is done by local teams.
Trauma care
0 to 48 hours: initial lifesaving carea
48 hours to 6 months: secondary care
External assistance generally arrives too late for initial care. Traumas may
include burns and crush syndrome, especially in urban areas. Paraplegics and
amputees require long-term care.
Routine medical emergencies and
primary health care
Resumes as soon as the need for acute
lifesaving care subsides (within 24 hours)
Emergencies include earthquake-related cardiovascular emergencies and
premature births.
Attention to the dead
Varies. Not a public health issue but a
social and political one
Priorities are identification and ritual burial.
Disease surveillance
Urgent—within 48 hours, unsubstantiated
rumors of impending epidemics will be
circulating
Surveillance is a sensitive public information and education issue. A simple,
syndrome-based system is needed that will involve humanitarian
organizations.
Provision of safe water
A predominant issue within 48 hours
The challenge is to provide a sufficient quantity of reasonably safe water.
Temporary shelter
48 hours to several months
Sanitation and provision of health services is a main issue. Accommodating
families near their residence is preferable to setting up camps.
Provision of food
3 days to 6 weeks
Food provision is a social or economic issue. Food stocks and agricultural
output are not affected by earthquakes.
Psychosocial care
7 days to 6 months
Mental health assistance is best provided by local personnel, if available.
Source: de Ville de Goyet 2001.
a. Following the earthquake in Mexico City in 1985 (10,000 deaths), bed occupancy rates did not exceed 95 percent despite the loss of 5,829 hospital beds.
health facilities, restoring normal services, strengthening communicable disease surveillance and control, and attending to
the long-term consequences, such as permanent disabilities,
mental health problems, and possibly long-term increases
in rates of heart disease and chronic disease morbidity
(Armenian, Melkonian, and Hovanesian 1998).
Tsunamis. Earthquakes on the ocean floor may cause catastrophic tidal waves (tsunamis) on faraway shores. Waves
caused by the seismic event crest at less than a meter in open
seas, but they are travel several hundred kilometers per hour, so
when they reach shallow waters, they can be 10 meters high.
Damage on the coast can be extensive. Usually, the number of
survivors presenting severe injuries is small in proportion to
the number of deaths.
Volcanic Eruptions. Volcanoes persist as a serious public
health concern, though they are often overlooked by authorities and communities lulled by long periods of inactivity.
Eruptions are preceded by a period of volcanic activity, which
provides an opportunity for scientific monitoring, warning,
and timely evacuation.
Some issues, such as ash fall, lethal gases, lava flow, and projectiles, although of concern to the public, are of minimal
health significance: Ash fall causes a significant burden on
medical services but is unlikely to result in excess mortality
or significant permanent problems. However, ash fall affects
transportation, communications, water sources, treatment
plants, and reservoirs. Studies by Bernstein, Baxter, and Buist
(1986) following the 1980 eruption of Mount St. Helens
(United States) reviewed the transient, acute irritant effects of
volcanic ash and gases on the mucous membranes of the eyes
and upper respiratory tract as well as the exacerbation of
chronic lung diseases with heavy ash fall. Concentrations of
volcanic gases are rapidly diluted to nonlethal levels, which lead
to inconvenience but negligible morbidity for the general public. Lava flows present little health risk because of their very
slow speed of progression. Mortality caused by ballistic projectiles from a volcanic eruption is minimal.
Attention to these public concerns may distract the authorities from preparing for the greatest factors of mortality: the
pyroclastic flows (Mount Pelé in Martinique, in 1902, with
29,000 deaths) and lahars. Lahars are mud flows or mud and
ash flows caused by the rapid melting of a volcano’s snowcap,
as in Colombia in 1985 (23,000 deaths), or caused by heavy
rains on unstable accumulations of ash, as in the Philippines in
1991. Historically, pyroclastic explosions or lahars have caused
about 90 percent of the casualties from volcanic eruptions.
Potential contamination of water supplies by minerals from
ash; displacement of large populations for an undetermined
period of time (over five years in Montserrat, a small island in
the Caribbean); accompanying sanitation problems; and mental health needs are of great public health significance (PAHO
2002a). Among the long-term problems, the risk of developing
silicate pneumoconiosis requires further investigation.1
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Climatic Disasters. Many communities and health services
have learned to live with seasonal floods of moderate intensity.
Periodically, the magnitude of the phenomenon exceeds the
local coping capacity and overwhelms the resources of the
health systems. The health burden associated with seasonal
floods is well known locally: increased incidence of diarrheal
diseases, respiratory infections, dermatitis, and snake bites. The
actual risk of compromised water supplies depends on the level
of contamination of the community’s water supply before the
disaster, compared with contamination after the flooding.
Saline contamination is a long-term issue following sea surges
and tsunamis. Prolonged flooding endangers local agriculture
and occasionally requires food assistance on a large scale. The
primary factors of morbidity remain overcrowded living conditions and poor water and sanitation in temporary settlements and other areas where water and sanitation services have
deteriorated or are suspended.
Mortality and morbidity caused by tropical storms (hurricanes in the Atlantic Ocean and typhoons in the Pacific Ocean)
result from, in increasing order of importance, high winds,
heavy rainfall, and storm surge. When Hurricanes Mitch and
George hit the Caribbean in 1998, traumatic injuries (lacerations or electrocution) caused by high winds of up to 150 miles
per hour were relatively few; deaths from extensive rainfall
(leading to flash floods and landslides) constituted the bulk of
the more than 13,000 fatalities (PAHO 1999). In the
Bangladesh delta, storm surges up to 6 meters traveled unimpeded over hundreds of kilometers and claimed between
250,000 and 500,000 lives in 1970 and up to 140,000 lives during five cyclones in the 1990s—primarily during one storm in
1991. Another cost is the need for specialized psychosocial
assistance to large numbers of the population who survive the
sustained violence of nature.
Cumulative mortality caused by small, undocumented
mudslides and rockslides from water-saturated, unstable slopes
probably approach the toll from well-known landslides
(earthquakes in Peru in 1970 and in El Salvador in 2001, and
the rains in Caracas, Venezuela, in 1999). Morbidity problems
are often minimal, as survivors in the path of the landslide
are few.
Impact on Communicable Diseases
Disasters related to natural events may affect the transmission
of preexisting infectious diseases. However, the imminent risk
of large outbreaks in the aftermath of natural disasters is overstated. Among the factors erroneously mentioned is the presence of corpses of victims, many buried beneath rubble. Dead
bodies from a predominantly healthy population do not pose a
risk of increased incidence of diseases (Morgan 2004).
Catastrophic incidence of infectious diseases seems to be confined to famine and conflicts that have resulted in the total failure of the health system.
In the short term, an increased number of hospital visits and
admissions from common diarrheal diseases, acute respiratory
infections, dermatitis, and other causes should be expected following most disasters (Howard, Brillman, and Burkle 1996;
Malilay and others 1996). This increase may reflect duplicate
reporting (diarrhea cases were reported through both the
emergency and the routine surveillance systems in Maldives
after the 2004 tsunami), a temporary surge in surveillance, and
medical attention available to an otherwise underserved population rather than representing a genuine change in the epidemiological situation.
In the medium term, heavy rainfalls may affect the transmission of vectorborne diseases. Following an initial reduction
as mosquito-breeding sites wash away, residual waters may
contribute to an explosive rise in the vector reservoir. When
associated with a breakdown of normal control programs, this
rise in the vector reservoir may lead to epidemic recrudescence
of malaria or dengue. Retrospective studies (Bouma and Dye
1997; PAHO 1998; UN/ISDR 2004, 156) all confirm a direct
but delayed relationship between the intensity of rainfall
(regardless of the existence of flooding) caused by the El Niño
phenomenon and the incidence of malaria. Flooding has contributed to local outbreaks of leptospirosis (in Brazil and
Jamaica, for example; PAHO 1982) and hepatitis A in Latin
America and Africa (WHO 1994).
In summary, what can be expected and prevented is a local
surge in problems that the health services are normally used to
handling.
Long-Term Impact and Economic Valuation
In addition to the delayed impact on transmission and control
of endemic diseases and the burden of disabilities (paraplegia,
amputation, burns, or chronic or delayed effects of chemical or
radiological exposure), the health sector bears a significant
share of the economic burden. Disasters must be seen in a systemic (that is, intersectoral) manner: what affects the economy
will affect the health sector—and vice versa. After the emotional response of the first few days, decision makers in a crisis
react primarily to political and economic realities, not to health
indicators. Economic valuation of the social burden—that is,
placing a monetary value on the cost—becomes a critical tool
as the various sectors compete for scarce resources. The health
sector, in particular, must learn how to use this tool in spite of
being absorbed by its immediate relief responsibilities.
Valuation of Disasters. The Economic Commission for Latin
America and the Caribbean (ECLAC) has developed over the
decades a methodology for the valuation of disasters (ECLAC
2003). This tool, intended for reconstruction, has also proved
its usefulness by developing historical records of major events,
particularly of the health burden expressed in economic terms.
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Valuation is made using all possible sources of information,
from georeferenced satellite mapping and remote sensing to
more conventional statistical data, direct observation, and surveys, with a reliance on information gathered immediately after
the event. Economic valuation rests on the basic concepts of
direct damage and indirect losses.
Direct damage is defined as the material losses that occur
as an immediate consequence of a disaster.2 Direct damage is
measured first in physical terms. The physical loss includes
assets, capital, and material things that can be counted: hospital beds lost, equipment and medicines destroyed, damaged or
affected health service installations (number and type of installations, stocks of medicines, laboratory facilities, operating
rooms, and so on), and pipes and water plants destroyed.
The physical plant then is valued both in terms of discounted present value and estimated replacement cost. Reconstructing facilities with the same vulnerability and level of
service as before would be unacceptable; the affected health
infrastructure must be replaced by more resilient and efficient
installations to ensure better and sustainable service. This need
is most evident in developing countries where impacts tend to
be concentrated in those most at risk (the poor, marginalized,
and less resilient sectors of the population).
Indirect effects refer to production of goods and services that
will not occur as an outcome of the disaster, reduced income
associated with those activities not occurring, and increased
costs to provide those goods and services.
In the case of health services, indirect effects encompass
both the income losses associated with the diminished supply
of health care services and the increased costs of providing the
services following the disaster. Indirect effects are valued at
the current market value of goods or services not produced
and the costs associated with the necessary provision of services under emergency, disaster-related conditions. Both compo-
nents of the cost of illness—the cost of treatment and the cost
of lost opportunities (lost income and employment, loss of
time and productivity)—are sharply increased. The social burden is heavier on the poorest, who are unable to adjust their
willingness to pay to absorb the additional expenses of alternative (private) providers of care.
The same approach applies to the economic valuation of
lives lost. Kirigia and others (2004) found a statistically significant impact of disaster-related mortality on the GDP of African
countries. One single disaster death reduced the GDP per
capita by US$0.01828. Lost lives are given a higher economic
value in places where productivity is high.
Because economic valuation uses standard sectored procedures that allow comparability of results, it can be used in the
decision-making process and for policy formulation since it
identifies sectors, geographical areas, and vulnerable groups
that are more severely affected economically. Over the years, a
number of conceptual improvements have been made to allow
for the measurement of aspects not included in national
accounting systems—to bring attention to environmental
losses as a cross-cutting issue; to highlight the contribution of
specific groups, namely women, as agents for change; and to
focus on the better management of both the emergency and the
reconstruction processes. It is also a valuable tool for preparedness and mitigation of future damage.
Table 61.2 summarizes the valuations made by ECLAC over
the years for Latin America and the Caribbean in terms of deaths,
affected populations, and economic losses (2003 values). Of
interest are the decrease in the number of deaths and the increase
in total damage (in particular, indirect damage) over time.
The distribution of direct and indirect damage in the health
sector also varies. According to ECLAC (2003), direct damage
between 1998 and 2003 in Latin America ranged from 44.6 percent to 77.2 percent of total damage.
Table 61.2 Impact of Disasters in Latin America and the Caribbean
Population
Date
Damage (2003 US$ millions)
Deaths
Affected
Total
Direct
Indirect
1972–80
38,042
4,229,260
9,376
5,420
3,956
1981–90
33,638
5,442,500
19,603
13,916
5,687
1991–2000
11,086
2,318,508
20,902
10,401
10,501
2001–2002
Total of major events 1972–2002
Overall estimate including small disastersa
Average per year
120
4,828,470
4,498
2,270
2,228
82,886
16,818,738
54,379
32,007
22,372
103,608
21,023,422
67,974
40,009
27,965
3,454
700,781
2,266
1,334
932
Source: ECLAC 2003.
a. The full image should include the recurrent small disasters that do not make the headlines but have a cumulative negative effect. Such disasters can be more pervasive and damaging to the development process because their economic, social, psychological, and political effects are hardly perceived. An estimate of the average losses of small disasters would be at least 25 percent greater than
those of large disasters.
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Specific Damage to the Health Infrastructure. Damage to
housing, schools, channels of communication, industry, and so
on contributes to the health burden. However, the following
analysis focuses on the health infrastructure (understood as
health care facilities, including hospitals, health centers, laboratories, and blood banks) and the drinking water and sanitation
infrastructure.
Damage to Hospitals and Health Installations Most data and
examples presented here come from Latin America and the
Caribbean because of the disaster reduction programs in the
health sectors of those regions. In the past two decades, damage
to approximately 260 hospitals and 2,600 health centers resulted
in interruption of services at a direct cost of US$1.2 billion. In
the 1985 earthquake in central Mexico, 5,829 beds were
destroyed or evacuated (PAHO 1985), at a direct cost of
US$550 million (ECLAC 1998). Hurricane Gilbert (1988)
damaged 24 of the 26 hospitals on Jamaica, and the El Salvador
earthquake (2001) resulted in the loss of 2,000 beds—40 percent of the country’s hospital capacity (PAHO 2002b). The
health burden is not limited to the loss of medical care. The
control of communicable diseases and other public health programs suffer from loss of laboratory support and diagnostic
capabilities of hospitals. Further research on the actual impact
of these losses, in terms of DALYs, is essential.
A common misperception is that damage to critical health
facilities is promptly repaired. Experience shows that damaged
health infrastructure recovers at a slower pace than infrastructure in other service sectors, such as trade, roads, bridges,
telecommunications, and even housing. For example, as a result
of the earthquake that affected El Salvador in 1986, renovation
of the general hospital, the most sophisticated referral hospital
in the capital, was completed 15 years after the earthquake. The
only national pediatric facility was fully rehabilitated and
strengthened six years after the earthquake. Two years after the
earthquake of 2001 in El Salvador, several key hospitals still
remained vacated or services were transferred to unsuitable
temporary facilities. The factors are many: low priority assigned
to a nonproductive sector, the sector’s inexperience in developing comprehensive proposals for funding, conflicting attempts
to use the reconstruction process to influence the ongoing
reform and decentralization processes, the novelty of the engineering and design issues for safe hospital construction, the
complicated negotiation process for loans, and the administrative inexperience of the health sector in executing large investment projects. Indeed, few large health installations have been
built directly by developing countries in the past decades.
Damage to Water and Sewage Systems The primary goal of
water and sewage systems is to safeguard the public health of
the population. For that reason, these systems are considered
part of the health infrastructure.
The developmental burden is significant. In the past 30 years
in Latin America and the Caribbean alone, an estimated 400
urban water supply systems and 1,300 rural systems (in addition
to 25,000 wells and 120,000 latrines) were severely damaged, at
an estimated cost of almost US$1 billion—a major setback to
efforts to expand coverage and improve those services. In severe
flooding, the sudden interruption of these basic services coincides with the direct effect on the transmission of waterborne or
vectorborne diseases. In the case of earthquakes, the number of
people who are adversely affected by water shortage may far
exceed those injured or suffering direct material loss.
As in the case of health care facilities, the rehabilitation of
public water systems is slow, particularly for communityowned or community-operated rural systems, which may not
be repaired for decades. The foregoing demonstrates the need
for water authorities to harmonize their short-term objectives,
which are oriented almost exclusively to increasing the coverage of these services, with the long-term objective of reducing
vulnerability to extreme natural hazards.
INTERVENTIONS: FROM RESPONSE
TO PREVENTION
The immediate lifesaving response time is much shorter than
humanitarian organizations recognize. In a matter of weeks, if
not days, the concerns of both the population and authorities
shift from search and rescue and trauma care to the rehabilitation of infrastructure (temporary restoration of basic services
and reconstruction). In Banda Aceh, Indonesia, after the
December 2004 tsunami, victims were eager to return to normalcy while external medical relief workers were still arriving in
large numbers.
Response and Rehabilitation
Immediate emergency response is provided under a highly political and emotional climate. The public demands visible, albeit
perhaps unnecessary, measures at the expense of proven low-key
approaches. The international community, eager to demonstrate its solidarity or to exercise its“right of humanitarian intervention,”undertakes its own relief effort on the basis of the belief
that local health services are unwilling or unable to respond.
Donations of useless medical supplies and medicines and the
belated arrival of medical or fact-finding teams add to the stress
of local staff members who may be personally affected by the disaster. The cultural disregard of the humanitarian community to
cost-effective approaches in times of disaster and the tendency to
base decisions on perceptions and myths rather than on facts
and lessons learned in past disasters contribute to making disaster relief one of the least cost-effective health activities.
The responsibilities of the national or local health authorities are significant.
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Assessment of the Health Situation. A country’s ministry of
health is expected to assess the health situation. To influence the
course of humanitarian response, this assessment must be rapid
and, therefore, simple; transparent in collaboration with the
main actors—nongovernmental organizations (NGOs) and
donors; and technically credible. The input of WHO, as the lead
agency in health matters, is most valuable. Confusion should be
avoided between assessing emergency needs and inventorying
or valuating the damage. In the first hours or days, relief actors
base their decision making on the ministry of health’s assessment of what is required and, more importantly, what is not
required for emergency response. Later, the international
community will request detailed data, such as the number of
persons affected, buildings damaged, and monetary valuation.
Mass Casualties Treatment. Following natural disasters,
hospital capacity may be considerably reduced by actual damage to the facility or, in the case of a seismic event, an often
unnecessary—but hard to reverse—evacuation. Triage of
patients is required in order to first treat those likely to benefit
most, rather than the terminally injured or those whose care can
be delayed. Lifesaving primary care takes place in the first six
hours (the golden rule of emergency medicine), making most of
the foreign field hospitals irrelevant for intensive acute care of
traumas (WHO and PAHO 2003). Effectiveness of immediate
care will depend on local preparedness before the disaster, not
on faraway resources.
Strengthened Surveillance, Prevention, and Control of
Communicable Diseases. Because the surveillance, prevention,
and control of communicable diseases are strengthened, the
anticipated massive outbreaks generally do not actually occur.
Traditional surveillance systems that are based on periodic
notification of diseases by the health services are inadequate in
a crisis situation. Early warning requires flexible and simple
syndrome-based monitoring in temporary settlements and
health centers, with information collected not only by the official health services but also by the medical humanitarian
organizations. Systems that do not include consultation with
NGOs are unlikely to succeed.
Disease control programs in place before the disaster are the
fruit of local experience and external technical advice. In a disaster situation, there is generally no need to resort to new and
expensive control measures. The key is to quickly resume,
strengthen, and better monitor the routine control programs.
No public health concerns justify the hurried disposal of
corpses through mass burial or unceremonious incineration.
This practice is socially and culturally damaging. In addition,
improvised mass immunization campaigns, especially by
external relief groups, should be discouraged in favor of opportunistically strengthening national routine immunization
coverage, especially in temporary settlements.
Environmental Health. Typical interventions in the aftermath
of disasters include strengthening the monitoring and surveillance of water quality, vector control, excreta disposal, solid
waste management, health education, and food safety.
A first priority is water supply. It is often preferable to have
a large quantity of reasonably potable water than a smaller
amount of high-quality water (UNHCR 1998). Massive distribution of water purification disinfectants can be effective if the
public is already familiar with their use and not confused by
the availability of many different brands and concentrations
of donated chemicals.
Health education and hygiene promotion efforts target populations in shelters, temporary camps, collective kitchens, or
prepared food distribution centers.
The cost-effectiveness of the external relief effort could
often be increased by shifting resources from the overattended
medical response to the improvement of environmental health
in temporary settlements.
Transparent Management of Donations and Supplies. If
donations and supplies are managed transparently during the
emergency, the flow of assistance to the intended beneficiaries
will be improved. Unsolicited and often inappropriate medical
donations compete with valuable relief supplies for scarce
logistical resources. Good governance is critical, and effective
logistics cannot be improvised following a disaster. A humanitarian supply management system developed by PAHO and
WHO successfully helped developing countries improve
transparency and accountability in managing humanitarian
supplies and donations (de Ville de Goyet, Acosta, and others
1996).
Coordination of the Humanitarian Health Effort. Coordination of the humanitarian health effort is essential to maximize
the benefit of the response effort and ensure its compatibility
with the public health development priorities of the affected
country. Effective coordination in the health sector must do the
following:
• Be comprehensive and include all external health actors.
• Be based on mutual respect rather than regulatory authority
alone. Dialogue and consultation are more effective than
enforcement.
• Benefit all parties, starting with the victims. It should aim to
support and facilitate the activities of other partners.
• Be evidence-based and transparent. Information is made to
be shared and used, not jealously guarded.
Coordination cannot be improvised in the aftermath of a
disaster. Preparedness before the occurrence of the hazard is
essential.
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Emergency Preparedness of the Health Sector
Prevention and Mitigation
Effective response by national health authorities cannot be
impromptu. Ministries of health that neglected to invest in
capacity building before emergencies have generally experienced
serious difficulties in exercising their technical and political
leadership in the immediate aftermath of a disaster. Disaster
preparedness is primarily a matter of building institutional
capacity and human resources, not one of investing heavily in
advanced technology and equipment.
Building local coping capacity is one of the most costeffective ways to improve the quality of the national response
and the external interventions.
Disaster preparedness is not merely having a disaster plan
written by experts. It must involve the following:
The slogan “prevention is better than cure” was invented by the
health sector. However, this sector has been slow to adopt the
concept of preventing deaths and injuries from disasters
through the mitigation (that is, reduction) of damage to its
own facilities. As is unfortunately often the case, political action
is often triggered only by a major disaster, such as the collapse
of Hospital Juarez in Mexico in the earthquake of 1985; in that
disaster 561 patients and employees died, (Poncelet 1997).
Evaluating the damage (the past vulnerability) helps establish
mitigation criteria for the future.
The level of protection required for each health installation
must be negotiated—from life protection, which prevents an
immediate structural collapse to permit the evacuation of people; to investment protection, which minimized the economic
losses; to operational protection, which guarantees the sustainability of services under any extreme circumstances. Though
a commercial or office building may be structurally designed
only to prevent loss of lives, key hospitals must remain operational during the times they are most needed.
Local engineering and architectural experts play a key role in
developing the knowledge, technical abilities, and costeffectiveness analysis to establish mitigation priorities. Technical
mitigation guidelines prepared at a global level (PAHO, WHO,
World Bank, and ProVention Consortium 2004) need to be
adapted to local culture, conditions, and resources.
Reducing the physical vulnerability of infrastructure
can take place on three different occasions (UN/ISDR 2004,
324):
• Identifying vulnerability to natural or other hazards. The
health sector should seek information and collaborate with
other sectors and institutions (civil protection, meteorology,
environment, geology) that have the primary responsibility
for collecting and analyzing this information.
• Building simple and realistic health scenarios of a possible
and probable occurrence. It is challenging enough to prepare for a moderate-size disaster; building and sustaining a
culture of fear based on unrealistic worst-case scenarios may
serve the corporate interests of the disaster community but
not the interests of the public at large.
• Initiating a participative process among the main actors to
develop a basic plan that outlines the responsibilities of
each actor in the health sector (key departments of the
ministry of health, medical corps of the armed forces, private sector, NGOs, UN agencies, and donors). What matters
is the process of identifying possible overlaps or gaps and
building a consensus—not the paper plan itself. Disasters
often present problems that are unforeseen in the most
detailed plans.
• Maintaining a close collaboration with these main actors. A
good coordinator is one who appreciates and adapts to the
strengths and weaknesses of other institutions. Stability is
essential. Changes of key emergency staff members during a
disaster situation or when a new administration or minister
take over have occasionally complicated the tasks.
• Sensitizing and training the first health responders and
managers to face the special challenges of responding to
disasters. Participation of external actors (UN agencies,
donors, or NGOs) in designing and implementing the training is critical. The incorporation of disaster management in
the academic curriculum of medical, nursing, and public
health schools should complement the on-the-job training
programs of the ministry of health, UN agencies, and
NGOs. Well-designed disaster management training programs will improve the management of daily medical emergencies and accidents as well.
• When reconstructing the infrastructure destroyed by a disaster.
At that time, risk awareness is high, political will is present,
and resources are available.
• When planning new infrastructure. Reducing vulnerability
is most cost-effective and politically acceptable when it is
included at the earliest planning and negotiation stage,
whether it involves a 1 to 2 percent additional cost for wind
resistance or a 4 to 6 percent additional cost for earthquake
resilience. Full resistance to any damage is prohibitively
expensive.
• Strengthening of existing facilities (retrofitting). This most
expensive measure has been adopted by several developing
countries (Chile, Colombia, Costa Rica, Mexico, Peru, and
others) to protect their most critical health facilities. In the
earthquake in Colombia in 1999, partial retrofitting of the
main hospital is credited for saving the installation. Costs
vary greatly (see table 61.3).
Mitigation of Damage to Hospitals. Mitigation does not
pretend to eliminate all possible damage from hazards but aims
to ensure the continuing operation of the health facility at a
level previously defined by the health authority. Hospitals
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Table 61.3 Retrofitting of Hospitals in Costa Rica
Hospital
Hospital Mexico
Number of beds
Duration of
retrofitting (months)
Cost of
retrofitting (US$)
Percentage of total
value of the hospital
600
31
2,350,000
7.8
Children’s Hospital
375
25
1,100,000
4.2
Hospital Monseñor Sanabria
289
34
1,270,000
7.5
Source: PAHO and WHO 2000.
should be subject to stricter norms than other less critical
facilities that are designed to prevent only total collapse and
loss of life.
Hospital mitigation interventions fall into three categories:
• Functional mitigation to ensure that the necessary supporting infrastructure services permit continuing operation:
water, electricity, road access, communications, and so
forth. Improving routine maintenance will facilitate operations under normal circumstances and in the event of
extreme hazards.
• Nonstructural mitigation to reduce losses and health injuries
from falling or moving objects. Measures include, for
instance, proper anchoring of equipment for earthquakes or
strong winds or the location of only noncritical services on
flood-prone floors.
• Structural mitigation to ensure the safety of the structure
itself (columns, beams, load-bearing walls).
Given the high economic, health, and political costs represented by the avoidable loss of critical health facilities, health
authorities and funding agencies should require that, in all new
health infrastructure projects, natural hazards be a decisive
factor for selecting the facility’s location and for formulating
the specifications at the earliest stage of the process.
Mitigation of Damage to Water Systems. Unlike hospitals,
water supply systems are geographically extensive and thus are
exposed to different types of hazards. The search for technical
solutions is more complex, given the diversity of the water
system’s components. Finally, in many countries, the health
authorities have no jurisdiction over the construction or operation of those services owned or administered by many local or
municipal agencies.
Even a short disruption of water services may have serious
and direct implications for the health of individuals, the operation of health services, and the community at large through its
impact on business. A probabilistic model studied the disruptive potential of a water outage in the event of an earthquake
in Los Angeles county in the United States. As noted by the
authors, “water outage is more likely to be disruptive for businesses in some industries, such as health services, than for
others” (Chang and Chamberlin 2004, 89).
The health sector should, therefore, coordinate with the
institutions in charge of constructing, operating, and maintaining water and sanitation services, both urban and rural, to
promote reduction of the vulnerability of existing systems. The
health sector should also ensure that health aspects and mitigation of damage be included in the regulatory framework and
operating procedures of water and sanitation services.
Protecting the water supply is feasible in developing
countries. The Costa Rican Institute of Aqueducts and
Sewage Systems reduced the vulnerability of one of the main
aqueducts of the country, the Orosi Aqueduct. Over 10 years,
Costa Rica invested almost US$1.5 million in studies and
reinforcements, an amount equivalent to 2.3 percent of the total
cost of the aqueduct. This investment would prevent a loss of
nearly US$7.3 million in direct damages alone (FEMICA 2003).
INTERVENTION COST, COST-EFFECTIVENESS,
AND ECONOMIC BENEFITS
The highly emotional and sensationalized climate of disaster
response has long prevented the adoption of a costeffectiveness approach in decision making. When survival of
both people and political institutions is threatened, perceptions
and visibility tend to prevail over facts and analysis, resulting in
a lack of evidence-based studies on costs and benefits.
The willingness to spend hundreds of thousand of dollars
per victim rescued from a collapsed building in a foreign country is a credit to the solidarity of the international community,
but it also presents an ethical issue when, once the attention has
shifted away, modest funding is unavailable for the mid-term
survival of tens of thousands of victims.
Cost-Effectiveness of Selected Humanitarian Interventions
Emergency health interventions are more costly and less effective than time-tested health activities. Improvisation and rush
inevitably come with a high price. The preferential use of
expatriate health professionals; the emergency procurement
and airlifting of food, water, and supplies that often are available locally or that remain in storage for long periods of time;
and the tendency to adopt dramatic measures contribute to
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making disaster relief one of the least cost-effective health
activities.
Search and Rescue. Few developing countries have established
the technical capacity to search for and attend to victims
trapped in confined spaces in the event of the collapse of multistory buildings. Industrial nations routinely dispatch search
and rescue (SAR) teams. Costs are high and effectiveness is
reduced by delayed arrival and quickly diminishing returns.
Following the 1988 earthquake in Armenia, in the former
Soviet Union, the U.S. SAR team extracted alive only two victims at a cost of over US$500,000. In Turkey in 1999, 98 percent of the 50,000 people pulled alive from the rubble were salvaged by relatives and neighbors. In Bam in 2003, the absence
of high-rise and reinforced concrete buildings ruled out the
need for specialized teams. Nevertheless, according to UN statistics, at least US$2.8 million was spent on SAR teams. An
alternative solution consists of investing these resources in
building the capacity of local or regional SAR teams—the only
ones able to be effective within hours—and training local
hospitals to dispatch their emergency medical services to the
disaster site.
Field Hospitals. The limited lifesaving usefulness of foreign
field hospitals has been discussed. Again, the lessons learned
from the Bam earthquake are clear. The international community spent an estimated US$10.5 million to dispatch approximately 10 mobile hospitals,3 which arrived from two to five
days after the impact, long after the last casualty had been
evacuated to other Iranian provinces. This delay alone, hard to
reduce further, rules out any significant contribution to immediate trauma care and led the hospitals to compete for routine
outpatient care with the teams of Iranian volunteers from
across the country. A few of the mobile hospitals, better prepared to meet nontrauma needs and to stay much longer than
the usual two to three weeks, have been invaluable. No data are
available on the number of lives actually saved by mobile hospitals (that is, lives that would not have been saved by local
means). Less understood are the negative effects of such hospitals on local health services, which are often marginalized
and discredited for their lack of technology and sophistication
but which must cope once the external facility leaves.
The cost of mobilizing a mobile hospital for a few weeks
often exceeds US$1 million, funds that would be more productive in the construction and equipping of a simple but
sturdy temporary facility. Such an approach was adopted by
the U.S. Army Southern Command in Wiwili, Nicaragua, in
the aftermath of Hurricane Mitch. In the case of Bam, Iran, the
cost of rebuilding the entire primary and secondary health
care facilities and teaching institutions was estimated by the
government of Iran to be US$10.75 million, an amount very
similar to that expended for the dispatch of field hospitals
from the international community. Guidelines for the use of
foreign field hospitals are available from WHO and PAHO
(2003).
In-Kind Donations. Unsolicited donations of inappropriate
medical supplies not only are of limited use, but often cause
serious logistic, economic, and political problems in the recipient country. Warehousing those supplies and, in many
instances, building facilities (incinerators, for example) for the
safe disposal of pharmaceutical donations diverts humanitarian funds from more effective uses. Recipient countries collectively share part of the responsibility by not clearly indicating what they do not want to receive and by not speaking out
once inappropriate items arrived.
Disease Prevention and Control. Postdisaster interventions
in surveillance and control of communicable diseases should
focus on strengthening existing programs. Benefits will outlive
the crisis. Improvised mass immunizations (instead of
improved sanitation and public awareness) and vector control
by aerial spraying or fogging (instead of breeding-site reduction or waste disposal) are just two examples of wasteful
managerial decisions.
Shelters. Tent cities should be a last resort. Family-size tents
may be expensive and do not last long. Establishing large settlements is easy, but such settlements are difficult to sustain and
nearly impossible to terminate. They come with their own sanitation problems and social shortcomings (lack of privacy, loss
of family identity, and loss of empowerment). Distributing
construction material (or, preferably, cash subsidies) is more
cost-effective and tailored to the needs and priorities of end
users.
Cash Assistance. Developed societies long ago abandoned the
distribution of in-kind relief goods and services to their
nationals in favor of direct financial assistance in the form of
subsidies, grants, or tax relief. The individual is free to determine actual priorities and to seek the most cost-effective source
of services (shelter, medical, food, or other). It is therefore surprising that external assistance from these same countries
remains focused on the costly delivery of predetermined services or commodities.
The most immediate lifesaving needs can be addressed only
locally with existing resources and capacity. No cash contribution will meet those immediate needs. Beyond the acute phase,
in many countries with market economies, most other services
and goods are easily procured by those with financial means,
suggesting that income availability is often the single limiting
factor in rehabilitation.
Undoubtedly, this approach would affect considerably the
type (and number) of humanitarian actors by transferring
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power and decision making to the local beneficiaries and
relying on local economic forces for delivery to the end user. It
may also bring its own set of problems (and abuses), though
perhaps that is a small cost, considering the economic and
social benefits of the most interested party—the victim—being
in charge.
Cost-Effectiveness of Prevention and Mitigation
The social benefits of making hospitals and water systems more
resilient to the effects of natural hazards are recognized but too
rarely applied. On the economic side, mitigation also increases
the investment capacity in the health sector by preventing
losses and the need for reconstruction (PAHO and UN/ISDR
1996; Bitrán 1996).
The most compelling case for the cost-effectiveness of
mitigation can be made during the planning phase for new
installations, when costs of additional structural safety are
minimal. Although the social benefits of prevention and risk
management are more evident in the health sector than in others, further studies are needed to provide decision makers with
quantified parameters of the economic benefits brought about
by investment in risk management and disaster reduction.
PAHO and UN/ISDR (1996) studies indicate that such
increased investment fluctuates between 4 and 8 percent of a
hospital’s local construction cost. When the value of services lost
is added to the infrastructure loss, the additional investment is
reduced to between 2 and 4 percent of direct and indirect losses
observed. Even though this is a gross estimate that requires further research in other regions and types of health facilities, the
figure is ratified by the estimated cost of reinforcement, which
fluctuates but averages between US$2,000 and US$5,000 per
bed, compared with the average cost of a new hospital bed of
between US$100,000 and US$150,000 (at 1996 prices).
Prevention of chemical and radiation accidents can be a
highly cost-effective expense that is normally absorbed by the
respective industries. Respect for existing norms in the use of
radiotherapy and diagnostic equipment and, once such equipment is decommissioned, its proper disposal reduces DALYs
from accidents at a modest cost.
Mobilization of Resources
Funding for preparedness and response programs follows rules
and procedures that are distinct from those applicable to development projects. Most donors maintain a specific office or
department for humanitarian affairs with a separate budget
line. Procedures are also streamlined for quick response to
unexpected situations. Processing a request takes a matter of
days in emergencies and takes months for preparedness or mitigation projects, but it can take years in typical development
projects negotiated with donors or financial institutions.
From a ministry of health point of view, competition for
disaster resources is with other sectors or humanitarian organizations, not within the sector (as it would be, for instance, with
malaria or tuberculosis control projects).
Funding for Preparedness. “By strengthening our public
health planning for natural disasters and disease outbreaks, we
will be in a better position to care for our populations, regardless of the type of hazard that confronts our health departments” (Rottman 2003, 1). This message, addressed to the
public health community in the United States, is even more
pertinent for developing countries. Most humanitarian offices
in more developed countries allocate a modest but increasing
proportion of their funds for predisaster capacity building. The
capacity of the ministries of health to secure directly nonreimbursable funding depends on the following:
• The existence of an established disaster program within the
ministry, demonstrating a long-term commitment to health
disaster preparedness.
• An ongoing dialogue with local representatives of donors
and their prior involvement in disaster-related activities or
meetings of the health sector.
• A realistic projection of concrete activities, taking into consideration the efforts of others, especially NGOs. One- or
two-year training or capacity-building projects are more
likely to be supported than those of longer duration that
have recurrent costs or involve the purchase of equipment
(radios, vehicles).
• The technical endorsement and support of WHO and other
UN agencies.
A multisectoral preparedness component is also increasingly included in loans negotiated in the aftermath of disasters.
Intended to strengthen the capacity of the civil protection
agency, the funding is no substitute for local political commitment to assume recurrent expenses, the only guarantee of
sustainability.
Resources for Emergency Response. The amount of external
resources available for response, financial or material, is influenced by the type of hazard, geopolitical considerations, and
the number of deaths (rather than that of survivors in need of
assistance). Funding is channeled mostly through humanitarian NGOs, the Red Cross system, or multilateral organizations,
rather than through national governments. Consequently, the
priority of the health authorities, rather than to seek direct contributions to the ministry, should be to ensure that health needs
are properly identified and adequately covered by those agencies benefiting from the donations. Ministries of health often
can obtain indirect financial support for their own activities
through UN projects.
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Concentrating on several key factors will improve the flow
of external resources toward health priorities:
within their ministries of health. Some lessons can be learned
from this process:
• Issuing a rapid and reliable assessment of what is needed and
what is not needed for the emergency response, rather than
waiting for a detailed assessment of the physical damage.
• Focusing on tomorrow’s emergency health problems.
External response is unable to address today’s short-lived
problems.
• Keeping a long-term view. Funding for emergency response
is limited to a few months, whereas the health problems
caused by the disaster will stay much longer. Projects should
offer sustained benefits beyond their conclusion.
• Recognizing shortcomings in governance when in contact
with the many bilateral fact-finding or assessment missions
coming to the disaster site.
• The occurrence of a major disaster in the country or its
neighbor is the initial catalyst for health authorities to recognize that disasters represent public health risks that must
be addressed in an institutionalized manner.
• Access to and support from the political level has determined the success or failure in coordinating the external and
domestic health response.
• A multihazard program covering the entire health sector is
most effective. Assigning responsibility for coordination
and management among different technical departments
according to the type of hazard (chemical or natural, for
instance) does not work.
• A risk management program should cut across departments
(medical care, epidemiology, water supply, sanitation, nutrition, and so forth) of the ministry of health and become sector wide.
• The synergy between normal development, preparedness,
and disaster response activities should be recognized.
Poor development practices increase vulnerability, whereas
preparedness improves the attention to daily health
challenges. Programs narrowly focused on operational
response have generally failed.
Funding for Reconstruction. Funding for reconstruction is
multisectoral and is often coordinated by an international
financing institution (global or regional), together with a consortium of large donor countries. The health sector will compete with other social priorities and the “productive” sectors in
an arena where the health burden (measured in DALYs) does
not carry the same weight as economic factors. Success will
depend on an exhaustive monetary valuation of the health
damage, rapid formulation of projects, political support from
the country’s highest authorities, and technical support and
endorsement of specialized UN agencies and larger NGOs.
Funding for Mitigation of Damage. Protecting the national
capital investment of the health sector is primarily the responsibility of the country at risk. Development agencies or financial institutions may contribute only marginally to the actual
cost of retrofitting installations or improving the design of new
facilities.
Modest funding for pilot or demonstration prevention programs may be available from both the humanitarian and the
development sources of donor countries. Humanitarian offices
may support promotion of the concept, development of guidelines or studies on vulnerabilities, and training.
The health sector will benefit from close contacts with
financial institutions, the ministry of foreign affairs, and other
national ministries. Negotiations to ensure that new installations are able to withstand disasters must be initiated at the
earliest opportunity, and the corresponding additional costs
should be considered in the earliest stages of the project.
IMPLEMENTATION OF CONTROL STRATEGIES:
LESSONS OF EXPERIENCE AND CHALLENGES
FACED
All countries in Latin America and the Caribbean have established programs and structures for disaster risk management
In Asia, the Asian Disaster Preparedness Center also has
documented some interesting experiences (http://www.adpc.
ait.ac.th/).
THE RESEARCH AND DEVELOPMENT AGENDA
Disasters in any one country are relatively infrequent. In addition
to being a dangerous temptation for the authorities to postpone
preventive actions, this infrequency is an impediment for
research and institutional memory.On one hand,the humanitarian culture tends to raise ethical questions on the role of observers
at a time when action at all costs is expected. On the other hand,
few health academicians wish to embark on projects when control groups and time for advance planning are unavailable.
Particularly encouraging are the increased numbers of publications and guidelines by UN organizations and NGOs and
the trend toward organizing workshops on lessons learned a
few months after a major disaster. These meetings of national
experts and officials together with representatives from external actors are invaluable for identifying and sharing operational or institutional successes and failures for the collective
benefit of other countries at risk.
Epidemiological Research
Most of the DALYs attributable to disasters occur immediately
at the time of the disaster. Epidemiological research should,
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therefore, complement engineering studies to design better
facilities and preparedness measures. After the initial disaster,
basic questions need to be answered: How many secondary
deaths and disabilities can actually be prevented by improving
search and rescue and trauma care? How critical is the time factor in reducing DALY losses and assessing the effectiveness of
foreign SAR and field hospitals teams? How can researchers
objectively assess the risk of outbreak following disasters? In
particular, how can they better differentiate between cases
attributable to increased transmission and those resulting from
improved surveillance and medical attention provided to the
victims? What is needed are data to put to rest unquestioned
assumptions and clichés. The alternative is to continue to divert
scarce resources away from routine disease control programs
and toward costly measures of doubtful effectiveness.
Strategic Research
Research is required that will compare the effectiveness of preparedness and response strategies and approaches:
• With respect to preparedness, how should researchers assess
the effectiveness of training and coordination versus that of
investing in hardware and stockpiles? For instance, will the
accreditation of hospitals based on their safety and readiness
improve their disaster performance?
• With respect to mitigation, how should limited funding for
retrofitting health facilities be allocated? Is nonstructural
mitigation a workable alternative in the absence of structural measures?
• With respect to response, what is the effect of international
assistance in terms of reductions in DALY losses that could
not be achieved locally? Is it contributing to strengthening the
capacity of the developing countries? What type of humanitarian assistance has proven to be development friendly?
• Finally, how should researchers measure the effectiveness
of preparedness or mitigation given the unpredictability of
disasters?
Economic Research
Humanitarian response is resistant to concepts of costeffectiveness. Economists should contribute to the comparative
study of the immediate and long-term effects of external interventions versus less costly alternatives such as relying on local
resources and building local capacity. A cost-benefit analysis of
international medical interventions prior to and during a
disaster situation is also overdue.
Economic assessment of the damage to the health sector
remains focused on physical losses and fails to sufficiently
consider the broader burden on a society caused by the loss of
health services over a sustained period. Refining the existing
methodology and developing quantitative indicators to estimate those indirect costs should be a research priority.
CONCLUSIONS
Natural hazards are not likely to decrease in the foreseeable
future. Though geological events may occur independently of
any human control, available data suggest that mankind plays a
role in global climate. Technological hazards may also increase
rapidly as a result of the unregulated development of industries
in most countries and possibly the use of weapons-grade hazardous substances against civilian populations. An increase in
the number of hazards should not mean that the resulting
health burden will also increase. A sustained effort is needed to
minimize risk, both by reducing vulnerability through prevention and mitigation and by increasing capacity through preparedness measures.
A Strategic Approach
The prime objective of a developing country is to develop.
Emergencies and disasters have proven to be major obstacles
and setbacks in the path toward sustainable development.
Conversely, the shortcomings in development programs and
institutions reduce the effectiveness of the health response in
times of crisis. Development and disaster risk management
cannot be addressed separately. Reducing risk is not a luxury
reserved for more developed societies; it is a necessity in countries with fragile economies and health systems. It is clearly a
public health priority.
Disasters, as any other public health problem, need to be
addressed on a long-term and institutionalized basis through
the establishment in the ministry of health of a program or
department for prevention, mitigation, preparedness, and
response for all types of disasters. Trends in Latin America suggest that such an approach in the context of sustainable development contributes to narrowing the gap in disaster-related
deaths and disabilities (as measured by DALYs) between industrial and developing countries.
Disaster risk reduction is not merely a health issue. The economic and political dimensions should not, however, be
allowed to overshadow the fundamental fact that disasters are,
above all, human tragedies incompatible with the definition of
health adopted by the WHO constitution. On one hand, the
health sector should adapt and use the methodology of economic valuation of disaster impact as developed by ECLAC; on
the other hand, the financial world should also learn to give
equal consideration to the health burden (DALYs) in its decision making for development or reconstruction. For this to take
place, health and humanitarian actors need to dramatically
improve the availability of data.
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Disaster risk reduction is not the exclusive domain of a few
experts or officials. It is the collective responsibility of all disciplines and programs in the health sector, as well as a remarkable tool or gateway for collaboration with other sectors. Alone,
the ministry of health cannot reduce the health burden or play
its coordinating role in the response.
Disaster risk reduction is unlikely to produce immediate
results. It requires sustained commitment over the years.
Learning from Errors
Learning from past disasters is difficult. At a national level, the
relatively long periods between major disasters result in few
decision makers having prior disaster management experience.
At an international level, the frequent turnover of relief workers ensures that many of the actors are relatively inexperienced
and susceptible to adopting myths and clichés, which are rarely
challenged by the media and the academic world. It is time for
an international initiative to identify the best practices, and it is
time for affected countries and scientists to point out the inadequacies of responses.
Humanitarian health interventions, as any other health
intervention, should be subject to cost-benefit reviews that
compare their benefits in terms of DALY loss reduction to
other alternatives, including a possible shift of international
emphasis from immediate medical response to preparedness or
rehabilitation projects.
Local health services are best situated to address the health
consequences of disasters. They should be better prepared to
do so. A formalized mechanism to transmit and share those lessons learned from past errors and to build the response capacity is required in the health sector.
Finally, the greatest potential for saving lives is in reducing
the risks and the vulnerability through better infrastructure,
land-use management, public awareness, and training.
The challenge in risk reduction is to sustain public support
and political will in periods of calm. International organizations—WHO in particular—have a unique and critical role to
play as advocates for a long-term approach to disaster risk
management in the context of sustainable development.
ACKNOWLEDGMENTS
The field of disaster epidemiology, a concept first introduced
in the early 1970s by M. F. Lechat of the University of Louvain
in Belgium, is now calling on many disciplines and fields of
knowledge. The authors express their gratitude to Caridad
Borras for her contribution on radiological disasters and to
Jean-Luc Poncelet, Karl Western, Guy Arcuri, Steve Devriendt,
and Roberto Jovel for their advice, comments, and suggestions.
This chapter relies heavily on the successes and failures of
the health sectors in Latin America and the Caribbean, a region
where a sustained effort over 25 years, with the support of
PAHO, WHO, and donor countries, traced the way to the
reduction of risks from extreme events. This chapter owes
greatly to a large number of experts and professionals in the
health sector of those countries.
NOTES
1. In a nonnatural phenomenon, such as the attacks in New York on
September 11, 2001, a similar risk has been detected and is perceived as a
remnant potential long-term health risk similar to the effect of air contamination from ash from volcanoes.
2. Evidently these direct losses are not easy to determine in longdeveloping events (such as the ones associated with slow processes or
climatic variability), because over time there will be overlapping damage,
in contrast to the damage that occurs in sudden events such as hurricanes
or earthquakes.
3. Data came from reports of the UN Office of Coordinator for
Humanitarian Affairs (http://www.reliefweb.org), supplemented by
authors’ estimated costs for donors that did not report actual costs.
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Chapter 62
Control and Eradication
Mark Miller, Scott Barrett, and D. A. Henderson
The Controversy: Control or Eradication?
We cannot refrain altogether from examining the roots of this controversy if only because the extreme views for and
against eradication have exerted and are still exerting a . . . highly detrimental influence on public health practice.
—P. Yekutiel, Eradication of Infectious Diseases: A Critical Study
Eradication of an infectious disease is an extraordinary goal. Its
possibility became apparent as soon as Edward Jenner demonstrated an ability to provide immunity to smallpox. Writing in
1801, Jenner observed that, through broad application of vaccination, “it now becomes too manifest to admit of controversy
that the annihilation of the Small Pox, the most dreadful
scourge of the human species, must be the result of this practice” (Jenner 1801). Louis Pasteur claimed that it was “within
the power of man to eradicate infection from the earth” (Dubos
and Dubos 1953). And yet, by and large, public health has proceeded with more modest goals of local and regional disease
control. Notable successes have occurred. Indeed, some diseases now thought of as “tropical” were previously endemic in
temperate climates. Systematic application of hygiene, sanitation, environmental modification, vector control, and vaccines
have led, in many countries, to the interruption of transmission
of microbes causing such diseases as cholera, malaria, and
yellow fever.
Intensive efforts to eliminate breeding sites of the yellow
fever mosquito vector, Aedes aegypti, interrupted transmission
of this disease in Havana in 1901 and throughout Cuba soon
thereafter. Subsequently, yellow fever and malaria were able to
be controlled in Panama, thus permitting construction of the
Panama Canal. In 1915, the Rockefeller Foundation launched
an effort to eradicate the disease worldwide. Transmission
appeared to have ceased in the Americas by 1928, but then cases
reappeared, and by 1932, it became clear that a nonhuman
endemic focus was serving to reinfect areas otherwise free of
yellow fever. In the 1930s, F. L. Soper set out to eradicate the
Aedes aegypti vector from the Americas. By 1961, Soper reported
that he had largely succeeded except for the United States, where
the program received little support. By the 1980s, Aedes aegypti
had become reestablished in Central and South America.
In 1953, Brock Chisholm, the first director-general of the
World Health Organization (WHO), tried to persuade the
World Health Assembly (WHA) to undertake smallpox eradication, but a number of countries objected on the grounds that
eradication was not technically feasible. Instead, in 1955,
under the leadership of his successor, Marcolino Candau,
WHO began a global effort to eradicate malaria primarily by
means of household spraying of DDT. The relatively sophisticated science of malaria control was abandoned in favor of this
simplistic technology (Jeffrey 1976). Despite an expenditure of
more than US$2 billion, the effort failed.
Even while the malaria eradication effort was under way, the
Soviet Union, in 1958, proposed to the WHA that smallpox be
eradicated. A resolution to this effect was offered in 1959 and
passed unanimously. However, the resolution provided little
international funding or support. Over the next seven years,
disease transmission was interrupted in some 30 countries in
Africa, Asia, and South America, but endemic smallpox persisted in the Indian subcontinent, Indonesia, most of SubSaharan Africa, and Brazil. WHO launched an intensified effort
in 1967 to eradicate the disease within a decade. This new
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resolution included an annual budget of US$2.4 million, to be
paid according to the WHO scale of assessments. The resolution passed by the narrowest of margins, but a reinvigorated
effort was soon under way and paved the way for a historic
public health achievement (Henderson 1988). Following an
extraordinary worldwide effort, the last case of smallpox was
isolated in October 1977, and the disease was certified as being
eradicated in 1979, 170 years after Edward Jenner first dreamed
of that possibility. Understanding how and why smallpox
eradication succeeded is essential to the study of control and
eradication.
The smallpox success was inspirational, even though the
leaders of WHO’s smallpox eradication effort cautioned that,
among all the diseases that might be considered candidates for
eradication, smallpox was unique (Fenner and others 1988)
and that they foresaw no other disease as a candidate for eradication (Henderson 1982). At a meeting convened by the
Fogarty International Center of the National Institutes of
Health in 1980, scientists, public health officials, and policy
makers discussed the merits of eradicating other diseases, with
schistosomiasis, dracunculiasis, poliomyelitis, and measles
identified as possible candidates (Henderson 1998a). However,
no consensus was reached at that time on moving forward with
any of those diseases.
Poliomyelitis became the next principal target when mass
vaccination campaigns, proposed by Albert Sabin (1991),
proved remarkably successfully in Cuba and Brazil. In 1985,
an American Health Organization coordinated campaign was
launched to interrupt poliovirus transmission in the Americas
by 1991, and this effort succeeded. Some believed that global
eradication might be possible, although others were concerned
that the far less developed infrastructure of health, transportation, and communications services in many parts of Asia and
Africa would make it an unachievable task. In 1988, the WHA
adopted a resolution to eradicate polio, but at that time, a
longer-term strategy for ending polio vaccination was neither
formulated nor agreed on by the public health and scientific
community.
The WHA has adopted only one other resolution to eradicate a disease—guinea worm, or dracunculiasis. The eradication of this disease can be achieved by applying simple technologies for providing water that is free of the vector copepod
and parasite and for treatment of patients with the disease. This
eradication program has made steady progress but has been
hampered in part by civil and political unrest and lack of program priority because of low mortality and low incidence in
some remaining endemic areas. However, given the environmental restriction of the parasite to rural tropical areas and its
relatively low transmissibility, eventual global eradication
seems within reach.
One other case—that of measles—is worth noting. A number of public health authorities have raised the possibility of
eradicating that disease. In the Americas, spurred on by the
success of regional cessation of transmission of wild poliovirus,
eventual consensus was reached to intensify measles control
efforts, primarily through surveillance and periodic pulse
application of measles vaccine in national campaigns. As a consequence, transmission of measles virus was temporarily interrupted in the Americas on several occasions but reestablished
again by importations (CDC 1998a). Although the U.S. Centers
for Disease Control and Prevention (CDC) and WHO have
advocated extending measles “elimination” through vaccination campaigns and second-dose opportunities to other
regions (Biellik and others 2002; CDC 1998a, 1998b, 1999a,
1999b, 2003d, 2004b, 2004d, 2004f), the intensive control
efforts required to break transmission of this highly infectious
agent make global eradication unlikely at this time.
DEFINITIONS
Yekutiel (1980, 5–8) provides an excellent treatise on the concept of eradication, which includes a summary of the multiple
definitions that have been formulated (Andrews and Langmuir
1963; Cockburn 1961, 1963; Payne 1963a, 1963b; Spînu and
Biberi-Moroianu 1969). A conference devoted to eradication
held in Dahlem, Germany, in 1997 (Dowdle and Hopkins
1998) set out to provide precise definitions for control, elimination, eradication, and extinction in a biological, economic, and
political context (Dowdle 1998, 1999; Ottesen and others
1998); however, a number of eminent public health officials
(Cochi and others 1998; de Quadros 2001; Goodman and
others 1998b; Henderson 1998b; Salisbury 1998) challenged
these definitions at two subsequent meetings at the CDC
(Goodman and others 1998a, 1998b) and the U.S. Institute of
Medicine (Knobler, Lederberg, and Pray 2001).
Unfortunately, broadly accepted, standard definitions for
key concepts pertaining to disease control and eradication do
not exist in the literature. Making matters more confusing,
certain of the concepts have been given names that are part of
our everyday language and so are easily misinterpreted by nonspecialists as meaning something different from the meanings
understood by those who are preoccupied with eradication
programs. Most unfortunate is the all too casual use of the
words elimination and eradication to promote programs that
cannot reasonably be expected to achieve the promise implicit
in these words. Moreover, the two words themselves are commonly used interchangeably.
Control
Two concepts are central to this chapter: control and eradication. By control, we mean a public policy intervention that
restricts the circulation of an infectious agent beyond the level
that would result from spontaneous, individual behaviors to
protect against infection (Barrett 2004).
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Although control is a range rather then a level, a particular
level of control may be an aim of policy. Because every choice
entails consequences, choice of the “optimal” level of control
requires economic analysis. Optimal here is defined in relation
to the model that gives rise to the result. Control is local and so
needs to be looked at from the local perspective. Because one
country’s (or region’s) control may affect other countries
(regions), a global perspective exists as well. The level of control that is optimal for one country (region) may not be optimal from the perspective of the world as a whole. Thus, a need
exists to distinguish between, say, a locally optimal level of control and one that is globally optimal.
Finally, control requires ongoing intervention. Sustaining a
given level of control requires an annual expenditure.
Eradication
Eradication differs from control in that it is global. The term
denotes the certified total absence of human cases, the absence
of a reservoir for the organism in nature, and absolute containment of any infectious source. Eradication permits control
interventions to stop or at least to be curtailed significantly.
Finally, eradication is binary. Control levels can vary, but a
disease is either certified as eradicated or not.
Every disease can be controlled, even if only by using simple
measures, such as quarantine. The ultimate achievement of
control is eradication. But not every disease that can be controlled can be eradicated. Very few diseases, in fact, are potential candidates for eradication. The criteria for the feasibility for
eradication as a preference over control are discussed in the
section titled “Economic Considerations.”
Elimination
Control and eradication are the essential concepts, but two
other terms bear mention. The first is elimination. Some who
are concerned with eradication programs have explicitly
defined this term to denote the cessation of transmission of an
organism throughout a country or region. In contrast, eradication is defined as a global achievement. Like control, elimination is location-specific and would require ongoing interventions to be sustained in order to prevent reemergence of the
disease from microbe importations.
Two problems exist with the term elimination. First, it has
been used to describe different phenomena, not just that
described in the definition given above. For example, some
public health officials have promoted programs aimed at “eliminating a disease as a public health threat,” which is interpreted
to mean reducing incidence to an “acceptable” level but not
necessarily to zero. This usage is very different from the one
outlined above and is almost certain to be misunderstood.
Second, the definition of the word elimination in common use,
as applied to disease control, is indistinguishable from eradica-
tion. The 1993 edition of the New Shorter Oxford English
Dictionary, for example, defines eliminate as to “remove, get rid
of, do away with, cause to exist no longer.” This same dictionary defines eradicate as “pull up or out by the roots, uproot,
remove or destroy completely, extirpate, get rid of.” This ambiguity invites misunderstanding among those not intimately
involved in an eradication effort. For purposes of clarity, we seldom use the term elimination in this chapter and then only to
signify control measures sufficient to interrupt microbe transmission in a specified area.
Extinction
Finally, the literature sometimes refers to extinction as a possible policy goal. In the context of infectious disease control, the
concept is problematic for two reasons. First, proving that an
organism has become extinct is impossible. To do so would
require demonstrating not only that the organism no longer
exists in nature but also that it no longer exists in any controlled environment—a practical impossibility. Second, de
novo synthesis of viral agents from published genomes
(Cello, Paul, and Wimmer 2002) now put the concept in peril,
although much research remains to be done in this area.
Extinction, in the context of infectious diseases, may no longer
be irreversible.
Clearly, policy making will be improved by stating the goal
of any particular intervention in precise language.
FRAMEWORKS FOR ERADICATION
Numerous issues need to be considered in planning expanded
control measures that lead, possibly, to regional cessation of
transmission or global eradication of disease. These complex
issues will be further examined in the chapter.
Scientific Considerations
Scientific considerations include the nature of potential reservoirs for disease-causing microbes or their vectors, technologies available for interrupting disease transmission, changes in
host capabilities to deter infections and disease, and satisfactory containment of organisms in laboratories.
Geographic and Environmental Controls. The limit of
endemicity for microbes and their associated diseases is determined in part by their ability to exist in nature outside the
human host. Both geographic and temporal variations determine the ecological niche of microbes, resulting in variable
annual incidence rates throughout the world. This niche limitation is further extended to intermediary vectors and hosts in
complex biological systems. Natural environmental barriers
also may isolate the habitats of helminths. Infectious agents that
are not limited to an environmentally restricted intermediary
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host or those that have longer latent periods, thereby allowing
translocation, may have a global pattern of distribution.
Examples include the highly transmissible viral agents such as
measles, rubella, influenza, and varicella. Although these agents
are not geographically constrained, their transmission patterns
are directly and indirectly influenced by seasonal environmental factors and population-based immunity.
Potential Reservoirs. A microbe and associated disease can
not be eradicated if the microbe is capable of persisting and
multiplying in a reservoir. Microbes that thrive in nonhuman
species may reemerge if control efforts cease, thus leaving
human populations susceptible. Similarly, if the infectiousness
of a human is long lived or could lead to potential recrudescence, surveillance efforts would have to continue as long as the
last individual remained potentially capable of transmitting
infection, as would be the case with tuberculosis or hepatitis B
infection.
Transmissibility. The inherent rate of a microbe’s ability to
cause secondary infections is defined by an organism’s reproductive rate in a fully susceptible (R0) and partially susceptible
(R) population. The reproductive rate of organisms that infect
individuals only once because of durable immunity is inversely
proportional to the average age of infection in an endemic
area. Agents that cause childhood infections, such as viral respiratory agents, are far more transmissible than helminths and
subsequently require more intensive control efforts to interrupt
transmission.
Natural Resistance to Reinfection. Many natural infections
induce long-lived immunity to reinfection. Although the most
commonly used vaccines have been available for fewer than
50 years—less than the lifetime of an individual—they, too, are
assumed to offer long-lasting immunity. Because eradication
depends on reducing susceptible populations in potentially
endemic areas, long-lived protection through immunization or
natural disease is important to successful programs.
Laboratory Containment. Laboratory specimens containing
the organism targeted for eradication could serve as reservoirs.
Considerable effort may be necessary to ensure their maximum
security. That these microbes may be inconspicuous in specimens collected for other purposes poses special challenges.
This situation is especially true for the poliomyelitis virus,
which may be found in many stool specimens collected for
studies completely unrelated to current poliomyelitis eradication efforts.
Operational Considerations
Optimization of control requires a fundamental appreciation
of the biological systems that govern the ecology of microbes
and their intermediary and human hosts. The reproductive
rate, R, is influenced by many local factors, including population density (of vectors, intermediary hosts, and humans) and
other environmentally determined conditions, all highly variable throughout the world. For a disease to be controlled to
stop transmission, the intervention-altered reproductive rate
must be maintained below 1.0. At the same time, all reservoirs
of the responsible microbe must be controlled.
Three main components of possible eradication programs
are
• surveillance, including environmental sampling where
appropriate and clinical testing
• interventions, including vaccination and chemotherapy or
chemoprophylaxis or both
• environmental controls and certification of eradication.
Each of these components must be undertaken at local,
community, national, regional, and global levels. Eradication
differs from control in that it is expected to be permanent.
Success depends on having adequate surveillance to identify
potentially infectious persons and on stopping transmission
before infection of a new cohort of susceptible persons arises
as a result of births, migration, or the waning effectiveness of
prophylactic measures.
Disease Surveillance. Effective surveillance requires a sensitive
system to detect the presence of microbes within the environment, intermediary hosts, and clinical cases. Surveillance and
response systems need to be more efficient than the rate of transmission of the targeted agent. As eradication progresses, the sensitivity of detection systems must be steadily enhanced to detect
all existing foci. Nonclinical or latent infections pose formidable
barriers to eradication efforts. Operationally, the need for nearperfect sensitivity comes at the expense of lower specificity.
Thousands of skin lesions from suspected smallpox patients
were tested in reference laboratories during confirmation of
smallpox eradication, and tens of thousands of stool specimens
are being examined for poliovirus. Highly sensitive systems used
to detect measles cases in the Americas began to identify a greater
proportion of rubella and parvovirus infections because of the
nonspecific surveillance of rash illness. Such findings are important because the identification of other diseases that mimic the
targeted disease can lead to a misdirection of resources.
However, the ability to detect such similar clinical cases can serve
as a proxy measure for the adequacy of surveillance. For example, identification of a minimum incidence of cases of acute flaccid paralysis that is not related to polio has served as an indicator
of adequate efforts of case finding for polio.
Interventions. Interventions to block transmission of the targeted infectious agent should be easy to deploy and adaptable
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to diverse conditions, given the global goal of eradication. Cost
considerations and local acceptance of the required sacrifices
(both short and long term) are crucial for success.
Interventions may be designed for environmental control of
microbes, isolation (quarantine) of clinically infectious individuals to limit their contacts with susceptible persons, treatment of clinical cases to limit the duration of infectiousness, or
reduction in the infected pool of individuals through immunoor chemoprophylaxis.
Certification. The last tool for eradication is a certification
process whereby independent, respected parties certify the
absence of disease transmission or the existence of any specific
microbe in an uncontrolled reservoir, including laboratories
(Breman and Arita 1980). Although certification can be
implemented on a regional basis, it must ultimately be done
globally. Certification is one of the greatest challenges in any
eradication effort, given the exceedingly great difficulty of verifying a negative finding in a reasonably short period of time.
When certification is completed, curtailment of control measures should be possible.
Strengthening control efforts sufficiently to achieve eradication is a difficult and expensive task. It requires that scaling up
of such efforts occur over a wide area—at the community,
national, regional, and global levels. Its efficacy depends heavily
on the adequacy of local financial and human resources, as well
as on a broad range of logistical factors.
Economic Considerations
Control and eradication programs have many economic
dimensions: private versus social net benefits, short-term versus long-term net benefits, and local versus international net
benefits. Such interventions also have implications for existing
public health programs.
Private versus Social Net Benefits. Individuals have private
incentives to protect themselves from disease—by means of
vaccination, for example. But when individuals protect
themselves—when they elect to be vaccinated—they offer a
measure of protection to others by helping limit the spread of
infection. In brief, the social benefit of vaccination is greater
than the private benefit alone. As more people become vaccinated, the marginal private and social benefit of vaccination—
that is, the benefit of vaccinating an additional susceptible
person—declines. The marginal private benefit is likely to fall
because, as more people are vaccinated, the probability of a susceptible person becoming infected falls. The marginal social
benefit is likely to fall for the same reason and for one other: as
more people become protected, the total number of susceptible
persons falls. The marginal social benefit of vaccination falls
sharply at the critical level of immunization—the level at which
herd immunity is conferred on all susceptible persons. When a
population is immunized to this level, a disease ceases to be
endemic, and imported infections cannot spark an epidemic.
This level is determined by the epidemiology of a disease,
but whether it pays to vaccinate to this level depends on the
economics, and the economics depend in turn on the social
costs and not only the social benefits of vaccination. These
costs consist of the direct costs of producing, distributing, and
administering a vaccine. The economics depend also on the
costs borne by the individuals who are vaccinated, such as those
incurred by individuals who experience vaccine complications.
The proportionate costs of reaching people who live in remote
areas and those who are at special risk, such as migrants and the
homeless, increase as the fraction of the population vaccinated
increases.
The economics of varying levels of disease control depend
on the relationship between the marginal social benefits and
the marginal social costs of vaccination. As vaccination levels
increase, the marginal social benefits of vaccination fall, whereas the marginal social costs rise. Social welfare is maximized
where these two relations intersect, which might be called the
“optimal” level of vaccination—a level that may or may not
achieve cessation of transmission or eradication.
Short-Term versus Long-Term Net Benefits. Control programs require ongoing intervention. Sustaining a given level of
protection requires that, over time, a certain proportion of new
susceptible persons be vaccinated. Eradication differs from
control in being permanent. The economics of eradication
must therefore take account of long-term benefits as well as
short-term costs.
The long-term benefits of eradication consist of avoided
future infections and vaccination costs—a dividend. To calculate this benefit, one projects future infection and vaccination
levels in the absence of eradication, attaches values to these,
and discounts them. If this sum exceeds the costs of eradication, then eradication enhances social well-being, and it therefore should be undertaken.
In deciding on the benefits of eradication, the cost of future
infections and vaccination should ideally be compared with the
best alternative to eradication: the level of optimal control
(Barrett and Hoel 2003).
The costs of eradication must also take into account ongoing surveillance requirements, laboratory containment, and
perhaps the maintenance of stockpiles of vaccine in the chance
event of disease reemergence. From an economic perspective,
attractive candidates for eradication are those diseases that
some countries have themselves targeted for interruption of
transmission nationally or regionally.
Local versus International Net Benefits. Control differs from
eradication in another important way. Control refers to
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location-specific interventions. Eradication, by contrast, is
global. In economic terms, eradication is a global public good.
No country can be excluded from the benefit of eradication,
and no country’s consumption of that benefit diminishes the
amounts available to other countries. Control, by contrast,
supplies only a local public good.
Eradication requires a global effort. A disease can be eradicated only if microbe transmission ceases everywhere. This
spatial dimension to eradication is of fundamental importance
because no world government can implement an eradication
policy; the WHA can declare its support for eradication, but
WHO does not have the power to enforce the execution of a
national program in support of that goal. The outcome experienced by any country depends not only on whether the country itself eliminates the disease within its borders but also on
whether all other countries do so. Indeed, eradication is a
weakest-link public good.
Whether eradication is achieved depends on the level of
control adopted by the country that undertakes the least
control. In practical terms, any country in which disease is
endemic can prevent eradication from being achieved. In 2004,
the global polio eradication initiative, after investing more than
US$3 billion and involving some 20 million volunteers over a
period of 16 years, was placed at risk of failure by the actions of
one local administration. In the Kano state of Nigeria, local
leaders claimed that the polio vaccine was tainted with the
AIDS virus and sterility drugs and declined to participate in a
national immunization day program. The European Union
then declined to pay for the national program in Nigeria,
believing the money would be wasted (Roberts 2004). One
consequence was the subsequent spread of polio to nine formerly polio-free countries. Concerted efforts by WHO later
persuaded local leaders in Nigeria to rejoin global efforts, but
special vaccination programs had to be launched over a population area of more than 300 million persons. This situation
dramatically illustrated the vulnerabilities inherent in a
weakest-link public good.
What are the incentives for states to participate in an eradication effort? To begin, assume that countries are symmetric,
meaning that all countries have the same benefits and costs of
control. Assume as well that eradication is feasible. Four possible situations then exist (Barrett 2003):
• First, the global net benefit of eradication may be negative—
the cumulative programmatic costs outweigh the net present value of the cumulative benefits. In this case, elimination
would also yield a negative net benefit to every country, and
so no country would eliminate the disease.
• Second, the global net benefit of eradication may be so large
that each country would choose to eliminate the disease
even if others did not. In this case, all countries would
eliminate the disease, and the disease would therefore be
eradicated. In these two cases, no need exists for an international policy.
• Third, each country may have an incentive to eliminate a
disease only if all other countries have eliminated it. In this
case, achieving global eradication requires coordination.
Here a role exists for international policy, but all that is
required is for each country to be assured that all others will
eliminate the disease.
• Finally, and noting that the “last” country to eliminate a disease would get just a fraction of the global dividend from
eradication, under some circumstances no incentive may
exists for this country to eliminate the disease—even if all
other countries have done so and even if the entire world
would be better off if it did. This case is the most worrisome,
because implementation of the efficient outcome would
likely require enforcement.
All this hypothesizing assumes that countries are symmetric, and of course they are not. Some countries gain less from
control and would gain less from eradication than others. Some
are unable to implement an elimination program, even if they
would very much like it to succeed. In these situations, achieving an eradication goal will require international financing and
technical assistance, with the countries that benefit most from
eradication compensating the other countries for the costs of
eradicating the disease. National and international reproach
are often expressed if a country lags in its eradication efforts.
International financing has been a key element in all eradication programs.
We have thus far looked at eradication from the perspective
of only the self-interests of states. But eradication also has
implications for development. In particular, eradication has
two advantages over control programs. The first is that the rich
countries may gain directly if the goal is achieved, giving them
a vested interest in ensuring that the goal is achieved. The second is that eradication is permanent, making an investment in
eradication financially sustainable. This second advantage is
important because financial sustainability has proved to be a
key problem for disease control programs in developing countries (Kremer and Miguel 2004).
Vertical versus Horizontal Programs. Control and eradication programs cannot be viewed in isolation. All programs have
implications for the delivery of comprehensive primary care
services. An important question is whether targeted, or socalled vertical, programs draw critical resources away from
other health care programs or whether they serve instead to
augment competence and capacity. The evidence is mixed.
Evidence suggests that disease-specific systems can serve
to expand polyvalent services (Aylward and others 1998).
Smallpox eradication, for example, gave many national governments the confidence to introduce the Expanded Program on
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Immunization, with the ability to deliver vaccines and
micronutrients in routine schedules and through national campaigns. However, other evidence suggests that some vaccination
programs have adversely affected primary health services
(Steinglass 2001; Taylor, Cutts, and Taylor 1997) and may have
even increased costs. Implementation of international initiatives can also expose conflicts of priorities. The polio eradication initiative, for example, has successfully vaccinated children
in the poorest of countries against this disease, but in some
of these countries it has failed to timely include the coadministration of measles and other common childhood vaccines, which would have had a much greater effect on child
mortality.
DISEASE-SPECIFIC CASE STUDIES
In this section, we apply the reasoning developed previously to
provide an empirical analysis of the three most recent eradication programs—smallpox and the two ongoing programs,
poliomyelitis and dracunculiasis.
Smallpox
As noted before, smallpox eradication was achieved in October
1977, 11 years after the intensified program began. Following
implementation of a rigorous certification procedure, the
WHA declared smallpox eradicated in 1980.
Fenner and others (1988) have estimated the annual benefits of smallpox eradication to developing and industrial countries (see table 62.1). These aggregate estimates, obtained by
Table 62.1 Benefits and Costs of Smallpox Eradication
(Millions of U.S. dollars)
Annual amount
Beneficiary
India
722
United States
150
All developing countries
1,070
All industrial countries
350
Total annual benefit
1,420
Expenditure
Total international, on eradication
98
Total national, by endemic countries
200
Combined total, on eradication
298
Benefit-cost ratio
International expenditure
483:1
Combined total expenditure
159:1
Source: Adapted from Fenner and others 1988.
prorating estimates of the benefits of eradication for India and
the United States to all developing and industrial countries,
respectively, suggest that developing countries benefited
more from smallpox eradication than industrial countries.
Qualitatively, a consistent picture emerges: smallpox eradication was not only an extraordinary investment for the world; it
was also an investment that benefited every country, rich and
poor alike.
When the eradication effort began, smallpox was no longer
endemic in most industrial countries. Nonetheless, these countries needed to maintain populationwide immunity under the
threat of possible imported cases from endemic countries.
They would gain from eradication not only through the cessation of vaccination and its associated costs but also by being
able to decrease the number of quarantine inspectors at ports
of entry and by averting costs of care related to the adverse
events from this live vaccine.
The still-endemic countries would also save vaccination
costs, although most were vaccinating only a comparatively
small proportion of their populations. The greater benefit to
them was the avoided cost of disease, including the extraordinary death toll. A number of developing countries had
accorded smallpox prevention a high priority, as was evidenced
by the number that succeeded in interrupting transmission
without international assistance. This list includes China,
which was not a member of WHO at the time the eradication
effort commenced.
Indeed, and as shown in table 62.1, the still-endemic countries contributed an estimated two-thirds of the US$298 million cost of eradication. International sources funded the
balance. If the latter cost is interpreted as the incremental cost
of achieving eradication, the benefit-cost ratio of global smallpox eradication was over 450:1, a singularly high figure. Even
including the expenditure by endemic countries, the benefit of
eradication exceeded the cost by an unusually large amount.
Brilliant (1985) calculated the annual costs of the smallpox
eradication campaign for India to be about US$17 million per
year, including indirect costs (lost productivity caused by
adverse reactions to vaccination) and opportunity costs (health
workers being diverted from other programs). These costs were
only a fraction of the annual benefits of eradication to India,
which, by Brilliant’s calculations, were US$150 million. The
benefit estimates by Fenner and others (1988) are much larger,
and those of Ramaiah (1976) are smaller, but all three studies
draw the same (qualitative) conclusion: smallpox eradication
was a good investment for India. Basu, Ježek, and Ward (1979,
312) present estimates identical to those in Ramaiah (1976),
but without giving attribution.
Originally, India had decided to undertake a smallpox program just one month after the WHA voted to eradicate the disease globally in 1959. The attempt failed, however, largely for
administrative reasons (Basu, Ježek, and Ward 1979; Brilliant
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1985; Fenner and others 1988). Essentially, India had an
economic incentive to control smallpox on its own (Brilliant
1985, 33) but lacked organizational capacity and an effective
strategy for achieving this goal. Note, however, that India had
other health priorities, including family planning. According to
Brilliant (1985, 33), “for India’s health planners, occupied then
by emergencies and competing political demands on scarce
resources, the long-term benefits from disease eradication were
not a great motivation. Health planners are sensitive to immediate political realities, and the benefits of smallpox eradication
would be realized only at some future time when the $3 million
annual expenditures for smallpox could be applied to other
health problems. In the meantime, however, the cost of putting
so many scarce resources into one program rather than into
many health needs was high.”
Table 62.2 provides estimates of the benefits of smallpox
eradication to the United States. The total benefit of eradication to the United States is about the same order of magnitude
as India’s, but the breakdown is different. Whereas India
benefited mainly from avoided infections, the United States
benefited mainly from avoided vaccinations. By the time the
eradication program was launched, the United States had
already interrupted smallpox transmission, but vaccination
was costly, both in economic and human health terms (a small
number of people died every year from infections arising from
the live vaccine). Defending the nation from imported
infections imposed additional costs.
In health terms, smallpox eradication saved millions of lives;
in economic terms, it yielded a benefit many times greater than
the cost. Identifying another investment that has yielded comparable returns and has benefited every country is difficult.
One reason that the economics of smallpox eradication were so
favorable is that all countries had strong incentives to join in
Table 62.2 Benefits of Smallpox Eradication to the United
States, 1968
(Millions of U.S. dollars)
Amount
Direct costs for medical services
Vaccination
92.8
Treatment of complications
0.7
Indirect costs, loss of productivity
Work losses attributable to vaccination and reactions
41.7
Permanent disability attributable to complications
0.4
Premature death
0.1
Cost of international traffic surveillance and delays in
clearance of vessels
Total
14.5
150.2
Source: Sencer and Axnick 1973; see also Fenner and others 1988, table 31.2.
the eradication of the disease. A huge organizational effort, but
only a relatively small incremental cost, was needed to achieve
eradication. The specter of global terrorism has recently caused
some countries to prepare themselves for a possible smallpox
attack by stockpiling vaccine. Although such actions reduce the
benefits of eradication, the economics remain favorable.
Smallpox, however, was a special case. Many attributes of
the disease and the vaccine favored eradication. The vaccine
was heat stable and required only a single dose to protect a person for a period of at least 5 to 10 years. Vaccination was easily
performed and protected immediately on application. Every
individual who became infected exhibited a typical, easily recognized rash, thus permitting accurate surveillance without
recourse to laboratory diagnosis. The disease spread slowly so
that transmission could readily be stopped by isolating the
patient and vaccinating contacts within the area.
Poliomyelitis
The polio eradication program, launched by the WHA in 1988,
has made substantial progress (CDC 2003a, 2003b, 2003c,
2004a, 2004c, 2004e, 2004g, 2005). The incidence of paralytic
poliomyelitis in children fell by more than 99 percent, from an
estimated 1,000 cases per day worldwide in 1988 to fewer than
4 cases per day in 2003. The number of poliomyelitis-endemic
countries also fell, from 125 in 1988 to just 6 by 2003
(Afghanistan, the Arab Republic of Egypt, India, Niger, Nigeria,
and Pakistan). This laudable reduction was the result of
repetitive vaccination campaigns with easily administered oral
polio vaccine to whole regions, to nations, and to large subpopulations.
During 2004, however, polio immunization activities in
northern Nigeria were halted for an extended period for fear
of tainted vaccines, and this permitted the development of epidemics extending throughout the country. The disease spread
as well to 10 other African countries and to Saudi Arabia,
Yemen, and Indonesia. Transmission has again been reestablished in several African countries (Burkina Faso, Central
African Republic, Chad, Côte d’Ivoire, and Sudan). Heroic
efforts are being made to control these outbreaks by large-scale
immunization, but in countries such as these, where health
services are stressed and the health, communication, and transportation infrastructures are weak, disease transmission is difficult to interrupt. Meanwhile, other countries throughout the
world that appear to be polio free are continuing their vaccination programs but finding it increasingly difficult to maintain
a momentum of interest, effort, and financing.
The difficulties of maintaining credible surveillance systems
throughout the developing countries were vividly demonstrated by the discovery of polio in Sudan in May 2004, more
than three years after the last case had been reported (CDC
2005). In the interim, specimens from 75 to 90 percent of such
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212
cases were processed in the laboratory, and measures of
surveillance for acute flaccid paralysis cases were reported to
have been entirely satisfactory. At first, the Sudanese cases were
considered to have resulted from importations from Nigeria,
and, indeed, some cases were. However, from more detailed
laboratory studies, it was determined that type 1 wild virus
had been circulating undetected for more than three years and
type 3 virus for nearly five years.
Clearly, stopping the continuing transmission of wild
poliovirus is itself a formidable challenge, the success of which
is by no means certain. A problematic discovery since the global eradication program began was the finding that individuals
with particular immunologic disorders shed polio vaccine
virus for many months to years, thus serving as a reservoir for
this virus. The virus, in turn, can revert to a neurovirulent
form, which is capable of causing outbreaks of disease
(Bellmunt and others 1999). Such individuals may be wholly
without symptoms and impossible to identify except through
fecal cultures. Moreover, no treatment is known to stop them
from shedding virus. They pose an all but insurmountable
challenge to the current poliomyelitis eradication effort.
The program is further hampered by the tool that has provided so much success—oral poliovirus vaccine (OPV). In
resource-poor environments, poliomyelitis is best controlled
with the inexpensive, live, and easily administered oral vaccine.
The live vaccine is excreted and can infect other susceptible
contacts. The ability of OPV to immunize others indirectly
makes it an ideal vaccine for achieving high levels of
population-based immunity, especially in lower socioeconomic
populations that are the most difficult to reach. However, the
excreted virus occasionally reverts to a pathologic state, causing
not only cases but outbreaks of vaccine-associated paralytic
polio, which may not emerge until months or even years after
the vaccine has been administered (Kew and others 2004).
Unfortunately, the alternative inactivated polio vaccine (IPV) is
not immediately an option in many nations, not least because
global manufacturing capacity could not begin to meet
demand. Other problems include the current cost differential
between OPV and IPV, the increased difficulty of administering the vaccine by syringe and needle, and the need to achieve
higher coverage rates with IPV because it does not spread from
person to person as does OPV.
Tragically, if OPV use were discontinued, in the absence of
alternative immunity, polioviruses would likely circulate
silently (Eichner and Dietz 1996) and reemerge. Preliminary
results from a model presented by WHO indicate a greater than
60 percent chance of an outbreak within two years of the possible global cessation of OPV (WHO 2004) because of continuous circulation of undetected live vaccine viruses that can
revert. Outbreaks have already been observed in several regions
where decreasing use of live vaccine has left pockets of susceptible persons who eventually have been exposed to vaccine-
derived pathogenic viruses (Kew and others 2002). Such an
outbreak could occur with disastrous speed because the polio
virus is far more contagious than that of smallpox. In developing countries, virtually all cases of polio occurred among those
under five years of age, older persons having been protected by
the natural immunity of earlier infection. Within five years
after vaccination ceased, therefore, the population immunity
level in the developing countries would be no better than it was
before vaccination was introduced. With this is mind, it seems
questionable as to whether all health ministers could be persuaded to call for a country-wide cessation of poliomyelitis
vaccination itself, given the uncertainties of virus detection in
so many remote and inaccessible areas of the world.
By definition, eradication implies certifying cessation of
virus transmission and the absence of reservoirs so that control
interventions can cease. As noted earlier in this chapter, it is
only for this reason that eradication yields a dividend.
Although the interruption of wild poliomyelitis virus transmission is theoretically feasible, the obstacles to achieving and
maintaining this goal are formidable. At this time, it is difficult
to foresee a future that does not envisage a continuing vaccination program, perhaps with IPV use in countries that can
afford the substantial additional costs entailed and with OPV
use in all other countries.
The polio eradication initiative, like that for smallpox, has
had to rely primarily on voluntary donations provided both to
WHO and bilaterally. Playing an especially important role have
been the Rotary International Foundation and the Bill &
Melinda Gates Foundation. From 1988 to 2004, more than
US$3 billion was spent on the effort (WHO 2003).
What are the economics of polio eradication? Bart, Foulds,
and Patriarca (1996) developed the first global cost-benefit
analysis of polio eradication, beginning with the costs incurred
since 1986, the year that the Pan American Health Organization launched a regional eradication effort, and extending to
2040. They assumed that eradication would be achieved in
2005, using OPV, and that vaccination would cease after eradication had been certified. Benefits (like costs, discounted at
6 percent) reflect the avoided costs of acute care and avoided
vaccination costs after certification. Their analysis showed that
the initiative would break even by 2007 and yield a net benefit
to the world of more than US$13 billion by 2040—an encouraging result, but it was based on the assumption that all vaccination would stop abruptly in 2005.
Khan and Ehreth (2003) developed a similar analysis but
provided regional detail. They estimated the costs and medical
costs avoided of polio immunization and eradication over the
period 1970 to 2050, assuming that vaccination could cease
after 2010. As table 62.3 shows, Khan and Ehreth estimated that
polio immunization and eradication would entail a negative
net cost overall, with Europe and the Americas saving the most
and with other regions incurring a positive net cost. Compared
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Table 62.3 Net Costs of Polio Immunization and Eradication
(Millions of U.S. dollars)
WHO region
Africa
Americas
Eastern
Mediterranean
Europe
Medical care
cost savings
Immunization costs
Net costs
Cost/DALY
saved
1,100
3,942
2,842
442
76,900
25,460
⫺51,440
⫺4,983
1,930
3,512
1,582
426
Continue OPV
Low-income countries
Middle-income countries
17,249
⫺21,001
⫺2,780
Southeast Asia
1,270
6,519
5,249
1,041
Western Pacific
8,670
10,327
1,657
356
128,120
67,009
⫺61,111
⫺1,457
Source: Khan and Ehreth 2003.
Note: Cost savings, immunization costs, and net costs are present values for 2000 in millions of
U.S. dollars, calculated for the period 1970–2050 and discounted at 5 percent. These estimates
assume that immunization by OPV can cease after 2010.
with other health interventions, this cost to developing
countries may still be comparatively cost-effective. However,
Khan and Ehreth comment that the cost per disability-adjusted
life year (DALY) saved is high for developing countries (see
table 62.3). As they explain (Khan and Ehreth 2003, 705), “This
implies that without the financial support from developed
countries of the world many developing countries would not
have opted for polio interventions for implementation. From
the developed countries’ point of view, providing support
for the polio program is not simply helping the poor and
the disadvantaged, it actually represents a good economic
investment.”
Unfortunately, both of these cost-benefit studies have
substantial limitations. First, both show that eradication is
economically attractive if one incorporates all costs and benefits
from the inception of this program. Because eradication has not
yet been achieved, this approach mixes retrospective evaluation
and prospective analysis (historical expenditures and benefits
are sunk and so are irrelevant to the current situation). Second,
benefits and costs are calculated in both studies relative to a
world without immunization. A better approach would be to
calculate the net benefits of eradication compared with the
alternative of an optimal control program. The choice is not
between doing nothing and eradication. It is between an
optimal level of control and eradication. Finally, both studies
assume that vaccination can cease in 2005 or 2010. As explained
previously, this possibility is highly unlikely.
A more recent analysis by Sangrujee, Cáceres, and Cochi
(2004) calculates the costs for 15 years following the goal of
certification of eradication in 2005 for three different scenarios:
continued use of OPV, OPV cessation with optional use of the
killed or inactivated polio vaccine, and OPV cessation with
universal IPV. Table 62.4 shows their results.
Total
Universal IPV
487
4,418
12,196
12,196
12,196
6,409
6,409
6,409
19,969
19,092
23,023
1,120
1,320
1,120
21,089
20,412
24,143
High-income countries
Subtotal
Stop OPV
1,364
Global response capacity
38,250
World
Table 62.4 Postpolio Eradication Costs
(Millions of U.S. dollars)
Source: Sangrujee, Cáceres, and Cochi 2004.
Note: Costs are expressed in present value terms, calculated over the period 2005 to 2020, and
discounted at 3 percent.
The respective cost to middle- and high-income countries is
the same for all three scenarios, reflecting the assumption that
the high-income countries will switch to IPV by 2005 and
middle-income countries will do so between 2006 and 2008.
The scenarios differ only for the low-income countries. In the
first scenario, these countries are expected to continue routine
immunization using OPV; in the second, immunization ceases
in 2011, followed by a system of surveillance and response. In
the third scenario, the low-income countries join the others in
switching to IPV between 2008 and 2010. Of these three scenarios, the second comes closest to the 2005 post-eradication
strategy now advocated by the polio eradication program
leadership.
Unfortunately, this analysis is also deficient. First, interruption of transmission will not occur before 2006, and certification will take an additional three years. Hence, analysis of
post-eradication costs should begin in 2009 at the earliest, with
the costs of continuing immunization needing to be borne up
until that time. Second, the analysis assumes a capacity to supply IPV that exceeds current estimates. It is not obvious that this
scenario is feasible or, if it were, if the costs of scaling up production are adequately reflected in the calculations. Third, and
most importantly, table 62.4 indicates that only low-income
countries would benefit from polio eradication over this 15-year
time scale—and yet the table does not include any estimate of
the risk these countries would bear of a possible outbreak.
Although this analysis suggests that the discontinued use of
OPV promises the greatest return to eradication, this assumes
that circulating vaccine-derived polioviruses could be contained if and when they emerged. However, preparing for this
possibility would require a far more effective global surveillance system than now exists, maintenance of a laboratory
infrastructure, and stockpiles of OPV. In addition, controlling
outbreaks with OPV without the risk of viruses reverting to
virulence will be exceedingly difficult in the setting of an accelerating proportion of immunologic-naive individuals. The use
of OPV in this scenario could very well cause poliomyelitis to
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again become endemic. In any case, the estimated cost of any of
the strategies exceeds $20 billion.
The economics of polio eradication are thus not as favorable
as concluded by either Bart, Foulds, and Patriarca (1996) or
Khan and Ehreth (2003). Both studies assume that vaccination
can cease without IPV being used as a substitute anywhere,
both exclude the costs of maintaining a response capacity, and
neither accounts for the real threat of reemergence. Sangrujee,
Cáceres, and Cochi (2004) take account of two of these considerations, but their analysis calculates only the costs for 15 years,
ignoring both the risk of reemergence and the benefits of
eradication. Hence, each study provides only a partial glimpse
of the economics of polio eradication and does not adequately
address the fundamental difficulty (inability) of stopping
vaccination and maintaining eradication.
In conclusion, although the economics of polio eradication
may have been thought to be favorable by some (Aylward and
others 2003), they are far less favorable than were the economics of smallpox eradication, even assuming that polio vaccination could cease.
This last omission is especially relevant to the study’s analysis of the eradication program in Sudan. The study projected
that, by 1998, infections would cease everywhere except Sudan.
(Plainly, this prediction was wrong, although Sudan is the
largest problem for the program, mainly because of the ongoing civil war, which has limited accessibility to endemic areas;
see Hopkins and others 2002.) It then calculates the net present
value of eliminating the disease there. The results are not
promising. They show that eradication is attractive only if the
disease can be eliminated in Sudan within five years. However,
this analysis ignores the dividend that eradication would earn
Sudan. It also disregards the most important feature of
eradication—that if the disease were certified to have been
eliminated from its last stronghold, it would yield a benefit to
all potentially vulnerable countries. Thus, the economics of
eliminating dracunculiasis from Sudan, if that is where the
disease makes its last stand, will be much more attractive than
suggested by this analysis.
Dracunculiasis
Of the several attempts to eradicate diseases, all but one has
failed. Even the exception, smallpox, barely succeeded despite
the many factors favorable to eradication. Whether any eradication effort will ultimately succeed or fail cannot be known
with certainty at the time it is launched. Eradication entails
risk. Money spent on eradication may not ultimately pay a
dividend. Health risks may also exist. If eradication fails and
vaccination levels drop after the eradication goal is abandoned,
susceptible persons who were previously shielded from infection may become infected at a later age, when the disease can
cause greater harm. The risk also exists that, even if eradication
succeeds, the disease may be reintroduced by accidental or
deliberate release.
The reasons for potential failure of an eradication effort are
many. A nonhuman host may not be discovered until the number of infected humans drops to a very low level (as happened
with yellow fever). The tools of eradication may be vulnerable
to resistance (insecticides and drugs in the case of malaria).
Political problems and civil strife may prevent an eradication
program from being executed in critical areas where the disease
makes its last stand (a problem today for guinea worm).
Termination of vaccination may leave populations vulnerable
to microbe reintroduction from an unforeseen reservoir or
vaccine strain reversion (a risk now facing the poliomyelitis initiative). Another potential reason for failure is the inability
to raise the financial resources needed to complete programs
that extend beyond expected targets. All eradication programs
have experienced serious financial stringencies during the
course of their execution.
Most eradication programs to date have been launched
as visionary, far-reaching efforts but with vastly incomplete
Dracunculiasis, or guinea worm disease, is a nematode infection, which is controlled not by vaccination but by education of
the affected population, provision of nematode-free water
through wells or filtration, and treatment of cases. It is not a
global disease but found only in the rural areas of a few very
poor tropical countries. This last difference is especially important from an economics perspective. It means that international financing of a guinea worm eradication program needs
to rely more heavily on development assistance rather than on
the self-interest of donor countries.
Thus far, the eradication program has been successful in
reducing the number of cases of guinea worm 99 percent from
the 1986 level (Carter Center 2004). The geographic range of
the disease has also been reduced from 20 to just 12 countries.
Although this achievement is important, eradication remains
elusive many years beyond 1995, the year that the WHA set for
eradication in 1991 (Cairncross, Muller, and Zagaria 2002, 232).
Only one cost-benefit study of the guinea worm eradication
program has been published (Kim, Tandon, and Ruiz-Tiben
1997), and it is unfortunately flawed in a number of respects.
First, as indicated previously, eradication costs should be compared with those associated with an alternative optimal control
program. Second, the cost-benefit analysis applies to the period
1987 to 1998 and thus is backward looking. The analysis can
reveal whether the money spent previously yielded a benefit in
excess of the cost (it did), but it cannot reveal whether eradication was worth pursuing at the time that this study was
undertaken. Finally, it takes no account of the investment
decision of eradication—the main reason for pursuing the
eradication goal in the first place.
CONCLUSIONS
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information. Basic epidemiological information and knowledge
of the effectiveness and operational constraints of interventions
and costs in different settings are often inadequate, and the
required monitoring, evaluation, training, and research components of the program may be absent. If a program’s administrators lack a careful, probing analysis of the epidemiology of the
various candidate diseases or of the technologies available, and
if their comprehension of the potential costs and who would
bear them is limited, a program is likely to founder, causing a
dispirited staff, confused beneficiaries, and donor fatigue and
ambivalence. It is crucial that the eradication methodologies
and assumptions in those regions of the world that would be
most likely to pose the most significant problems be tested and
addressed before launching an eradication program and that
evaluation and research continue during the program.
Proposals for disease eradication have seldom been brought
to the WHA with specific plans, costs, and uncertainties fully
laid out. Nor have the expected sources of fiscal support and
needed country support been addressed with specific commitments requested of the members. The WHA has only a limited
deliberative capacity, and too much cannot be expected of its
members in session. However, designated special committees of
the WHA can and should be appointed, consisting of both
visionary eradicationists and field-experienced public health
and social science personnel. The WHA should take up the
question of eradication only after the subject has been thoroughly vetted and sufficiently large-scale pilot programs in the
most problematic areas have clarified that an adequate understanding of the epidemiology exists and that the appropriate
technologies are available.
In the past, members have not voted for a specific program
for which all the uncertainties have been laid out and the benefits and costs associated with different outcomes have also
been calculated. Nor, with one exception, have they voted for a
resolution imposing responsibilities, including financing obligations, on individual states. The next time a proposal to eradicate a disease is presented to the WHA, it should be comprehensive. It should demonstrate why the effort is worth taking,
even if the final outcome is uncertain; it should bind states,
morally if not legally, to fulfill the pledges needed to see the
program through to its completion; and it should prepare contingencies should the eradication effort fail.
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Chapter 70
Improving the Quality of Care
in Developing Countries
John W. Peabody, Mario M. Taguiwalo, David A. Robalino,
and Julio Frenk
Although the quantity rather than quality of health services has
been the focus historically in developing countries, ample evidence suggests that quality of care (or the lack of it) must be at
the center of every discussion about better health. The following examples are illustrative: In one study evaluating pediatric
care in Papua New Guinea, 69 percent of health center workers
reported that they checked for only two of the four examination criteria for pneumonia cases. Only 24 percent of these
workers were able to indicate correct treatment for malaria.
When clinical encounters were observed at aid posts, providers
met minimal examination criteria in only 1 percent of cases
(Beracochea and others 1995). In a study in Pakistan, only
56 percent of providers met an acceptable diagnostic standard
for viral diarrhea, and only 35 percent met the acceptable standard for treatment (Thaver and others 1998).
QUALITY DEFINITION AND POPULATION
FRAMEWORK
These deficiencies in quality of care represent neither the
failure of professional compassion nor necessarily a lack of
resources (Institute of Medicine 2001). Rather, they result from
gaps in knowledge, inappropriate applications of available
technology (Murray and Frenk 2000), or the inability of organizations to change (Berwick 1989). Local health care systems
may have failed to align practitioner incentives and objectives,
to measure clinical practice, or to link quality improvement to
better health outcomes.
Increasing evidence, much of it developed since the mid
1990s, shows that quality can be improved rapidly. However, to
improve clinical practice—and thus quality of care—quality
must be defined and measured, and appropriate steps must be
taken (Silimper and others 2002). This chapter highlights
approaches to improving clinical practice and quality of care
that take place over months instead of years. Indeed, better
quality can improve health much more rapidly than can other
drivers of health, such as economic growth, educational
advancement, or new technology.
Definition and Framework
Health systems provide health actions—activities to improve
or maintain health. These actions take place in the context of
and are influenced by political, cultural, social, and institutional factors (shown along the edges of figure 70.1).
Demographic and socioeconomic makeup, including genetics
and personal resources, affect the health status of individuals
seeking care. Access to the health care system is required to
obtain the care that maintains or improves health, but simple
access is not enough; the system’s capacities must be applied
skillfully. Thus, quality means optimizing material inputs
and practitioner skill to produce health. As the Institute of
Medicine defines it, quality is “the degree to which health
services for individuals and populations increase the likelihood of desired health outcomes and are consistent with
current professional knowledge” (Institute of Medicine 2001,
244).
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Institutional
Factors
Political
Factors
Health Policy Reforms
Demographic
and Socioeconomic
Factors
Health
Care
Access
Structure
Process
Health
Outcomes
The Quality of Care
Cultural
Factors
Social
Factors
Source: Peabody and others 1999.
Figure 70.1 Quality-of-Care Framework
Elements of Quality. Quality comprises three elements:
• Structure refers to stable, material characteristics (infrastructure, tools, technology) and the resources of the organizations that provide care and the financing of care (levels of
funding, staffing, payment schemes, incentives).
• Process is the interaction between caregivers and patients
during which structural inputs from the health care system
are transformed into health outcomes.
• Outcomes can be measured in terms of health status,
deaths, or disability-adjusted life years—a measure that
encompasses the morbidity and mortality of patients or
groups of patients. Outcomes also include patient satisfaction or patient responsiveness to the health care system
(WHO 2000).
Structural measures are the easiest to obtain and most commonly used in studies of quality in developing countries. Many
evaluations have revealed shortages in medical staff, medications and other important supplies, and facilities, but material
measures of structure, perhaps surprisingly, are not causally
related to better health outcomes (Donabedian 1980). Although
higher technology or a more pleasant environment may be conducive to better-quality care, the evidence indicates only a weak
link between such structural elements and better health outcomes (Donabedian 1988). The notable exceptions are cases in
which physical improvements either increase access to primary
care in very poor settings or increase the volume of a clinical
procedure, such as cataract surgery, that is specifically linked to
better health outcomes (Javitt, Venkataswamy, and Sommer
1983). At best, however, structure is a blunt approximation of
process or outcomes; structural improvements by themselves
rarely improve the health of a population.
Process, by contrast, can be measured with every visit to a
provider. Measuring process is difficult, however, particularly
in developing countries. The private nature of the doctorpatient consultation, a lack of measurement criteria, and the
absence of reliable measurement tools have limited the ability
to assess process (Peabody, Tozija, and others 2004). However,
new methods are being developed that can provide valid measurements of clinical practice (Thaver and others 1998). In addition, evidence-based clinical studies have steadily revealed
which process measures lead to better health outcomes. This
combination of ubiquity, measurability, and linkage to health
outcomes makes the measurement of process the preferred way
to assess quality.
Although good outcomes are the objective of all health
actions, outcomes alone are not an efficient way to measure
quality for two reasons. The first is the quality conundrum. A
patient may receive poor-quality care but may recover fully, or
a patient may receive high-quality care for an illness such as
cerebral malaria and still not recover. Second, adverse health
outcomes are relatively rare and obviously do not occur with
every encounter.
The classic framework of structure-process-outcome is well
established. However, in recent years the concept of quality has
been expanded to include specific aims for improvement. For
example, the Institute of Medicine’s (2001) landmark report,
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Box 70.1
The Institute of Medicine’s Six Elements of Quality
1. Patient safety. Are the risks of injury minimal for
patients in the health system?
2. Effectiveness. Is the care provided scientifically sound
and neither underused nor overused?
3. Patient centeredness. Is patient care being provided in a
way that is respectful and responsive to a patient’s preferences, needs, and values? Are patient values guiding
clinical decisions?
4. Timeliness. Are delays and waiting times minimized?
5. Efficiency. Is waste of equipment, supplies, ideas, and
energy minimized?
6. Equity. Is care consistent across gender, ethnic, geographic, and socioeconomic lines?
Source: Institute of Medicine 2001.
Crossing the Quality Chasm, broadens the concept to include
other, more contextual elements to illuminate how process
changes can improve care. It focuses on six aims: patient safety,
effectiveness, patient centeredness, timeliness, efficiency, and
equity (see box 70.1).
Quality Assessment Perspectives. We can look at the Institute
of Medicine’s aims from two perspectives: patient perception,
and technical or professional assessment. Patients’ perceptions
of quality depend on their individual characteristics and affect
their compliance, follow-up decisions, and long-term lifestyle
changes (Zaslavsky and others 2000). Interpersonal relationships, cultural appropriateness, and gender sensitivity—long
thought to be luxuries of wealthier countries—are also major
determinants of patient access and utilization in developing
countries. These findings have led to the inclusion of patient
satisfaction and patient responsiveness as outcome measures.
Technical assessment concerns whether providers meet normative standards for appropriateness of care or adherence to
explicit evidence-based criteria. Although patient perception or
satisfaction is important, researchers increasingly rely on objective, evidence-based quality criteria that can be more readily
linked to better health outcomes at both the individual and the
population levels.
Population-Level Considerations. Quality is typically
assessed through the interaction between individual doctors
and patients. However, emerging evidence shows that the
average quality of care given by groups of doctors and other
providers is an important determinant of overall community
health status. For example, in a cross-sectional analysis in the
former Yugoslav Republic of Macedonia, researchers found not
only that patients’ heath status was significantly higher in areas
where quality was higher but also that the overall self-reported
health status of those members of the general population who
had not recently received care was higher (Peabody, Tozija, and
others 2004).
Our quality-of-care framework supports these findings.
When process is improved among groups of providers,the aggregate improvement in quality leads to better health outcomes for
the entire patient population. In addition, resources can be allocated among clinical interventions based on actual effectiveness
and the overall impact of care on the population. For example,
cancer chemotherapy may be available and may prolong the lives
of cancer patients.However,it may result in fewer lives saved than
the expansion of coverage of directly observed treatment shortcourse coverage for tuberculosis patients.
QUALITY OF CARE IN DEVELOPING COUNTRIES
The process of providing care in developing countries is often
poor and varies widely. A large body of evidence from industrial countries consistently shows variations in process, and
these findings have transformed how quality of care is perceived (McGlynn and others 2003). A 2002 study found that
physicians complied with evidence-based guidelines for at least
80 percent of patients in only 8 of 306 U.S. hospital regions
(Wennberg, Fisher, and Skinner 2002). It is important to note
that these variations appear to be independent of access to care
or cost of care: Neither greater supply nor higher spending
resulted in better care or better survival. Studies from developing countries show similar results. For example, care in tertiary
and teaching hospitals and care provided by specialists may be
better than care for the same cases in primary care facilities and
by generalists (Walker, Ashley, and Hayes 1988).
One explanation for variation and low-quality care in the
developing world is lack of resources. Limited data indicate,
however, that high-quality care can be provided even in environments with severely constrained resources. A study in Jamaica,
which used a cross-sectional analysis of government-run
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primary care clinics, showed that better process alone was linked
to significantly greater birthweight (Peabody, Gertler, and
Liebowitz 1998). A study in Indonesia attributed 60 percent of
all perinatal deaths to poor process and only 37 percent to economic constraints (Supratikto and others 2002).
Cross-system or cross-national comparisons provide the
best examples of the great variation in clinical practice in developing countries. In one seven-country study, researchers
directly observing clinical practice found that 75 percent of
cases were not adequately diagnosed, treated, or monitored and
that inappropriate treatment with antibiotics, fluids, feeding,
or oxygen occurred in 61 percent of cases (Nolan and others
2001). Another study compared providers’ knowledge and
practice in California and FYR Macedonia, using vignettes to
adjust for case-mix severity. Although the quality of the overall
or aggregate process was lower in FYR Macedonia, a poor
country, the top 5 percent of Macedonian doctors performed as
well as or better than the average Californian doctor (Peabody,
Tozija, and others 2004).
In a study commissioned for this chapter, an international
team measured quality in five developing countries (China,
El Salvador, India, Mexico, and the Philippines), using the
same clinical vignettes at each site. The team evaluated the
process for common diseases according to international,
evidence-based criteria. Quality varied only slightly among
countries. The within-country range of quality of doctors was
10 times as great as the between-country range. Such wide
variation strongly suggests that efforts to improve health
status must involve policies that change the quality of clinical
care.
POLICY INTERVENTIONS TO IMPROVE QUALITY
The success of quality improvement policies can be measured
by their ability to raise the average level of health and reduce
variation in quality. Two types of policies are intended to
improve quality and thus health outcomes:
• those that influence provider behavior by altering the structural conditions of organization and finance or that involve
the design and redesign of health care systems
• those that directly target provider behavior at the individual
or the group level.
Within each category, the evidence is examined to see the
effect of the policy on the health outcomes of populations.
Interventions Affecting Provider Practice by Changing
Structural Conditions
Although structural components such as materials and staff
are not strongly linked to outcomes, other components of
structure—organization and finance—can influence process
by changing the socioeconomic, legal and administrative,
cultural, and information context of the health care system.
Legal Mandates, Accreditation, and Administrative Regulations. Legal mandates, accreditation, and administrative regulations affect quality by controlling entry into the practice of
health care. These policies include the licensing of professionals and facilities, their accreditation or certification to perform
certain procedures, and the formal delineation of functions
that various types of health workers can legally perform.
Although these policies assume that providers’ prior qualifications are good predictors of actual performance in health care
delivery, there is little evidence that such policies have a positive
effect on process or outcomes. They are more successful at barring unqualified persons from practicing than at ensuring
quality among those who are allowed to practice. A review of
health sector regulations in Tanzania and Zimbabwe, for example, revealed that the regulations primarily control entry into
the market and ensure a minimum standard of quality
(Kumaranayake and others 2000).
Hospital accreditation, with its periodic reviews of health
facility performance standards, can potentially provide ongoing regulatory pressure for improvement. To date, research has
not demonstrated that hospital accreditation programs are
linked to improvements in health outcomes. In a randomized
controlled trial of a hospital accreditation program in the
KwaZulu-Natal province of South Africa, researchers showed a
conclusive link between the implementation of the program
and improvements in the accreditation standard indicators.
However, they were unable to link those indicators to improvements in health outcomes (Salmon and others 2003).
Malpractice Litigation to Enforce Legal Mandates To be
effective in promoting quality, malpractice litigation must rely
on adequate legal and judicial systems, which are deficient in
most developing countries. In India, one of the few developing
countries with the appropriate legal structure in place, inclusion of the medical sector under the Consumer Protection Act
of 1986 allows victims to receive redress for negligent medical
practice. Although improvements have resulted, some argue
that the system needs greater involvement of professional
organizations to be effective (Bhat 1996).
Professional Oversight Peer review is as old as professional
societies. The power and the influence of such societies vary
widely among countries (Heaton 2000). Large provider organizations, such as hospitals or public health institutions, often
routinely collect information on provider practices and patient
outcomes and use those data to guide, educate, supervise, discipline, or recognize providers. In the Philippines, public health
managers used a checklist of 20 observable behaviors against
which health workers in remote provinces were rated. The
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performance of providers in facilities where workers were
reviewed was significantly better than in comparable facilities
that did not adopt the reviews (Loevinsohn, Guerrero, and
Gregorio 1995). Others, however, assert that the “quality by
inspection” environment engendered by oversight leads to an
antagonistic relationship between workers and managers and
precludes cooperative problem solving and continuous
improvement (Berwick 1989). A qualitative study evaluating
supervisor-provider interactions in health care facilities in
Zimbabwe found that supervisors were adept at giving technical feedback but were not as proficient at making suggestions
for improvement or at working with providers and patients to
solve problems (Tavrow, Kim, and Malianga 2002).
National and Local Clinical Guidelines In many industrial
countries, evidence-based clinical guidelines are used to ensure
high-quality care, better health outcomes, and cost-effective
treatments. (Examples of institutions supporting this approach
are the U.K. National Institute for Clinical Excellence, the U.S.
Agency for Healthcare Research and Quality, and the Dutch
College of General Practitioners.) Guidelines are typically
developed for a clinical disease or symptom. They should be
derived from evidence-based criteria resulting from welldesigned clinical investigations or expert opinion. Because they
are derived from empirical studies, guidelines in developing
countries can, in principle, be identical to those in industrial
countries. When resource constraints limit transferability, diagnostic and treatment guidelines may have to be modified.
Technologies such as x-ray studies have gained widest acceptance in preventive and primary care services, such as integrated
management of childhood illness, where they serve both as
clinical standards and as educational guides. Including physicians in the development and review of guidelines has proved
particularly effective in the challenging process of implementing guidelines.
Sharing Information on Quality Improvement Technology.
Worldwide interest in quality has given rise to new professional
bodies, scientific publications, and institutions dedicated to
sharing ideas and innovations in quality improvement.
Organizations such as the Robert Wood Johnson Foundation,
the Nuffield Trust, and the Institute for Healthcare
Improvement cultivate ideas for improvement, bring people
and organizations together to learn from each other, and take
action to achieve results. Although the sharing of information
on quality health care practices has long been an established
part of provider education and training networks, the sharing
of information on successful systemwide policies for process
improvements could potentially accelerate the scale-up of
quality practice.
One organization active in developing countries is the
Council on Health Research for Development (COHRED),
which promotes, facilitates, and evaluates the Essential
National Health Research strategy in such countries as Benin,
the Arab Republic of Egypt, and Indonesia. COHRED aims to
develop a system of effective health research to improve health
services, including quality of care. The Quality Assurance project funded by the U.S. Agency for International Development
has studied and shared information about quality in the developing world since 1990. Under the Quality Assurance project
umbrella, researchers have studied and implemented quality
measurement and improvement interventions and have used
these case studies to develop a library of tools and articles to
promote global quality improvement.
Public-Private Provision of Care. In most health care systems,
a professional regulatory framework governs the network of
civil servants delivering health care. These civil servants operate
alongside autonomous, self-governed, private providers—
independent for-profit physicians and health clinics and nonprofit nongovernmental organizations (NGOs). Two conclusions arise from the often heated debate about the right balance
between public and private services. First, private practitioners
provide a significant amount of care in developing countries.
Second, though there is no one prescription for striking the
right public-private mix, in some cases the public regulatory
framework has led to private provision of higher-quality care.
The government of Senegal successfully contracted with
community-based groups for preventive nutrition services.
Eighteen months after nutrition services were implemented,
severe malnutrition disappeared among children age 6 to
11 months (Marek and others 1999). The success of the program has led to its expansion nationwide.
Targeted Education and Professional Retraining. Continuing
medical education is a common approach to improving clinical practice, but it neither changes clinical practice nor
advances health outcomes (Davis and others 1995). Newer
techniques—targeted education, case-based learning, and
interactive and multimodel teaching techniques—have had
some success. In Guatemala, distance education targeting diarrhea and cholera case management increased accurate assessment and classification of diarrhea cases by 25 percent.
Rehydration did not improve, however, and improvements in
counseling were insignificant (Flores, Robles, and Burkhalter
2002). In Tanzania, training staff in the control of acute respiratory infections of young children yielded reductions in
under-five mortality within two years (Mtango and Neuvians
1986).
Organizational Change. In recent years, organizational
change in the health care system has been shown to influence
quality of care and to further the six aims of the Institute of
Medicine by focusing on the continual design and redesign of
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systems. The emphasis is on developing organizational and
individual capabilities where they most profoundly affect the
process of care. Design and redesign interventions assume that
simply adding a new resource or a new process in isolation will
not improve care because better care is the product of many
processes working together. Although change interventions
have not been widely used in the developing world because
they require large investments to plan and implement, four
related models of organizational change have been successful in
changing provider practice in developing nations:
• Total Quality Management in health care Advances in
business management practices to continually design and
redesign systems for quality improvement have been effectively adapted for health systems. In Total Quality Management, also known as Continuous Quality Improvement,
teams use mutually reinforcing techniques in a cycle of planning, implementing, evaluating, and revising to improve the
quality of clinical and administrative processes. These techniques include process mapping, statistical quality control,
and structured team activities. In rural Bihar, India, private
practitioners who treat sick children were provided with
standard case-management information, were given feedback on their performance, and were tracked and monitored
over time. This strategy produced significant improvements
in practitioners’ case-management skills (Chakraborty,
D’Souza, and Northrup 2000). In Malaysia, anesthesia safety
has been improved through the implementation of
consensus-based protocols that emphasize (a) communication among the operating, recovery, and ward team members; (b) individual feedback; and (c) frequent monitoring
to identify areas for improvement (Tan 1999).
• Collaborative Improvement Model The early success of Total
Quality Management techniques has given rise to a related
model, the Collaborative Improvement Model. It addresses
broad and complex systemic processes within health care
systems and has facilitated the scale-up of quality improvements. This model, designed to continuously improve organizational and individual performance, comprises four elements: definition of an aim, measurement, innovation, and
testing to see whether the innovation meets the original aim.
This approach strikes a pragmatic balance between the need
for action and the need to be scientifically grounded. It has
been used with success in Peru and the Russian Federation. In
Peru, the collaborative improvement model was used by multidisciplinary teams in 41 clinics to design changes aimed at
achieving world-class tuberculosis care. The preliminary
results have led to impressive changes in the process of care,
but it is too early to determine whether they have been effective in improving quality (Berwick 2004).
• Plan-Do-Study-Act cycle The Plan-Do-Study-Act (PDSA)
cycle calls for action-oriented learning in quality improve-
ment. Team members using the PDSA model design a
quality-improvement intervention (plan), implement it on
a small scale (do), evaluate the results (study), and implement or alter the intervention accordingly (act). Often multiple PDSA cycles are necessary before the appropriate
improvement method can be identified. All improvement
techniques that involve the design and redesign of systems
use some form of the PDSA cycle. Successful scale-up of a
PDSA prototype is possible with careful leadership oversight. A team of investigators in Russia’s Tula province
developed a series of successful interventions for adults who
have poorly controlled hypertension. The interventions,
which were started in 20 clinics, were expanded to 500 clinics within 18 months. The scale-up resulted in a sevenfold
increase in patients receiving hypertension management at
the primary care level and an 85 percent reduction in admissions for hypertension. In Tver province, the same group
addressed problems related to prenatal care. They began
with 5 hospitals and scaled up to cover all 42 hospitals and
all maternity clinics in the province. The result was a 99 percent reduction in newborns with hypothermia and a reduction in pregnancy-induced hypertension from 44 percent
to 6 percent (Berwick 2004). Although the experience of
researchers implementing interventions that are based on
system redesign in the developing world has been largely
positive, it is not clear whether the resources and leadership
exist to bring these interventions to scale through country
or regional policies. Further evidence is needed concerning
the real-world feasibility and cost-effectiveness of system
redesign.
• Internal enabling environment Creating the right environment for change involves leadership and leadership training,
clinicians empowered to make quality improvement decisions, and resources for quality improvement planning
activities (Silimper and others 2002). The internal enabling
environment in Costa Rica promoted strong leadership that
led to the adoption of structural adjustment loans in the
early stages of health sector reforms. The loans were used to
maintain such public health programs as mother and child
nutrition, even though public spending dropped and prices
increased dramatically (Peabody 1996). An enabling environment can also be created by teams of individuals, each
representing different stakeholder groups (physicians,
nurses, staff members, patients, and so forth) or simply by a
strong leader with an interest in teamwork and the resources
to support a discrete quality improvement function for team
members.
Interventions Directly Affecting Provider Practice
Practitioners are often forced to provide care in uncertain settings. Technical limitations may reduce the ability to diagnose
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or predict outcomes, or they may have only probabilistic
knowledge about the efficacy of their proposed treatment for a
particular patient. The nature of clinical practice is often solitary, and physicians have few available ways to gauge their clinical acumen and skills. Performance-based feedback, however,
can reward high-quality care and increase knowledge about
appropriate actions. If the feedback mechanism is effective, it
can also serve as the basis for establishing systemwide incentives for improving quality of care.
Training with Peer Review Feedback. In Mexico City, physician retraining on treatment of diarrhea, combined with the
concurrent creation of a peer-review structure, decreased the
use of antibiotics and increased the use of oral rehydration
therapy (ORT). These improvements continued to be seen in
a follow-up evaluation 18 months later (Gutierrez and others
1994). The approach has been effectively expanded to prescribing practices for rhinopharyngitis among primary care
physicians, using an interactive training workshop and a managerial peer-review committee (Perez-Cuevas and others
1996).
Performance-Based Remuneration. A potentially powerful
instrument for accelerating quality improvements involves
making payments directly to providers who meet quality standards that are based on process indicators associated with
favorable patient outcomes. Systems that tie performance to
remuneration use relatively small incentives—equivalent to
3 to 10 percent of the provider’s total compensation.
Performance-based remuneration has been successfully used
in the United States to compensate both private and public
providers (McBride, Neiman, and Johnson 2000).
Examples of performance-based incentives come from
developing countries too. The Nicaraguan Ministry of Health
has implemented a pilot program in six hospitals that offers an
incentive bonus (a maximum average of 17 percent of hospital
revenue) for facilities that achieve performance targets that
include quality measures (Jack 2003). In Haiti, a performancebased payment scheme was set up for NGOs that provided
services to the population. The scheme resulted in all three participating NGOs reaching target immunization coverage rates
(Eichler, Auxila, and Pollock 2001). Thus, payment for specified
and observable performance (in terms of provider effort, client
coverage, or health impact on the population) can be usefully
applied to NGOs and private providers.
The specific features of performance-based remuneration
are crucial. A study evaluating the South African government’s
experience in contracting with private organizations to operate
district hospitals found no cost savings—in fact, the government was spending more than if it provided the services itself.
The contracting may have failed because remuneration was not
based on specific process or outcome measures. Instead, the
contractor’s obligation, the methods of monitoring performance, and the sanctions for nonperformance were only minimally specified (Broomberg, Masobe, and Mills 1997).
High Volume of Care. Evidence exists that a high volume of
care by individuals or institutions leads to better health outcomes (Habib and others 2004). Physician experience (learning)
and practice (repetition) lead to fewer complications, less
resource use, and better quality for a variety of procedures, such
as cataract surgery and laparoscopy (Brian and Taylor 2001).
More complex procedures, including endarterectomy, cancer
surgery,and coronary bypass surgery,have shown similar effects.
Volume effects leading to better health outcomes are not
confined to surgical procedures (Zgibor and Orchard 2004).
Facilities specializing in the care of chronic diseases such as diabetes, myocardial infarction, and heart failure are also associated with better outcomes. Debate exists over how much of the
volume effect is due to specialist care. The benefits of highvolume care persist, however, even after controlling for referral
and case-mix biases. When carefully trained nonphysicians are
substituted for physicians, volume effects persist but can be
accomplished at significantly lower costs. In one study, nurse
practitioners and physician’s assistants were able to provide
high-quality care for common outpatient conditions such as
hypertension, diabetes, asthma, otitis media, pharyngitis, and
back pain at substantially lower costs than that of physicians
(Douglas and others 2004).
Performance-Based Professional Recognition. Providers
work in a community of peers in which professional status,
prestige, and recognition are often as valuable as material
rewards. Nonmonetary incentives, such as public recognition
or disclosure, administrative privileges, and awards from professional organizations, can promote improvements in quality.
Uganda, for example, implemented the Yellow Star Program as
part of a broader health services improvement project. This
program evaluated health facilities on a quarterly basis, using
35 indicators of technical and interpersonal quality, and
awarded a large yellow star to facilities that scored 100 percent
in two consecutive quarters. The star was then prominently displayed outside the facility.
The Mexican Ministry of Health has implemented a strategy
that combines the accreditation and the training strategies
discussed earlier with nonmonetary incentives. The National
Crusade for Quality in Health Care introduces quality-oriented
incentives to health facilities and medical schools. It also
includes public recognition in an effort to encourage learning
and to change practice. The National Crusade has already generated measurable improvements in the responsiveness of
state-level health systems (Secretaría de Salud de Mexico 2003).
Both types of policies examined in this section are associated with better quality and better health outcomes—lower
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premature mortality and avoidable morbidity, increased
patient satisfaction, and more health-seeking behaviors. When
effective, these policies result in increased coverage rates, better
prescribing patterns, and increased adherence to clinical guidelines. They can spell the difference between an individual’s
survival or death, between an individual benefiting from the
encounter with the health sector or being harmed by it, and
between an individual and society rising from poverty or sinking deeper into it.
MEASURING QUALITY
Improving quality requires that we measure it accurately. The
successful outcomes discussed in the previous section rely on the
links between policy and changes in clinical practice. Such links,
however, can be created and demonstrated only when valid and
reliable measures of process are easily understood, inexpensive
to obtain, resistant to manipulation, and related to better health
outcomes.
Measuring Structure
Material measures of structure abound. Numerous facilitybased surveys in developing countries have cataloged capital
equipment and staffing levels, and financial reports track budgets and expenditures (but rarely production costs). Facility
inventories of drugs and supplies are generally available; service
utilization figures are routinely reported to national-level
authorities. Such measurements, however, are often beside the
point. Even when material structural deficiencies are corrected,
they are not reliably linked to changes in health outcomes.
Measuring the organization and financing of health care is more
difficult. Although descriptions of the organization and financing of health systems exist, objective functional assessments of
systems (such as patient flows, the patient referral system, or
details of the relative pricing of services) are less often available.
or obtaining payments, for example) and thus lack crucial
clinical details. One prospective study showed that charts identified only 70 percent of items performed during the clinical
encounter (Luck and others 2000). In a related analysis, 6.4 percent of the items recorded in the chart were false and had never
really occurred.
Where resources and infrastructure are sufficient, the electronic medical record (EMR) is becoming a priority for health
systems worldwide. EMR technology promotes uniformity, legibility, and communication, which can lead to guideline use
and reduce prescription errors. It also holds the promise of
managing populations rather than individuals by aggregating
patients into groups. However, the EMR has not always lived up
to its potential. In many countries, some impressive successes
have occurred—as have spectacular failures, costing billions of
dollars (McConnell 2004). The great heterogeneity in recordkeeping practices, problems with medical records (both paper
and electronic), and costs of trained medical abstractors have
led to a search for other reliable ways to measure quality.
Direct Observation and Recording of Visits. Direct observation and recording of visits is a commonly used approach in
developing countries (Nolan and others 2001). Ethically, the
provider and the patient must be informed of the observation
or recording, which introduces participation bias because
provider behavior may change as a result of being evaluated. In
addition, trained observers are costly, and variation between
observers is difficult to remedy.
Technical advances have mitigated longstanding difficulties in
measuring process. Five approaches and their strengths and
weaknesses merit consideration: chart abstraction, direct
observation and recording of visits, administrative data, standardized patients, and clinical vignettes.
Administrative Data. Administrative data, collected for purposes of managing the delivery of care, are available in all but
the poorest settings. A data collection system, once established,
is ubiquitous and can provide information on charges and
many cost inputs. Administrative data, however, lack sufficient
clinical detail to be useful in evaluating process. In a 2003 study,
an incorrect diagnosis was recorded in the data 30 percent of
the time (although the diagnosis was made correctly). Overall,
these data reflected the actual clinical diagnosis only 57 percent
of the time (Peabody, Luck, Jain, and others 2004). As information systems advance, accuracy problems may be mitigated,
although the lack of adequate clinical detail will continue to
limit the use of administrative data.
Chart Abstraction. Chart abstraction, or review of the medical record, has long been used to measure technical quality.
Such familiar quality evaluations as clinical audits, physician
report cards, and profiles are based on chart abstraction. The
core strength of the medical record is that it is ubiquitous and
can generally be obtained after each encounter. Chart reviews,
however, suffer from problems of legibility when notes are
handwritten. Often they are generated for reasons other than
recording the actual events of the clinical visit (legal protection
Standardized Patients. Standardized patients can be a gold
standard for process measurement (Luck and Peabody 2002).
Trained to simulate illness, standardized patients present themselves unannounced into a clinical setting to providers who
have previously given their consent to participate in the study.
At the conclusion of the visit, the standardized patient reports
on the technical and interpersonal elements of process.
Standardized patients are reliable over a range of conditions
and provide valid measurements that accurately capture
Measuring Process
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variation in clinical practice among providers over time.
However, they are expensive and useful only for adult conditions and only those conditions that can be simulated. Thus,
they are not practical for routinely evaluating quality.
Clinical Vignettes. Clinical vignettes were developed explicitly
for measuring quality within a group of providers and
evaluating quality at the population level. Vignettes are responsive to variation in quality, and providers readily accept them if
they are given anonymously (Peabody, Luck, Glassman, and
others 2004). More than 20 vignettes have been used in 13
countries around the world. They can be administered on
paper, by computer, or over the Internet. Providers are typically
presented with several cases. When process is being measured
for many providers, each provider is presented with the same
case or set of cases, thus eliminating the need for case-mix
adjustment. The provider completing the vignette is asked to
take a history, do an examination, order the necessary tests,
make a diagnosis, and specify a treatment plan. The questions
are open ended and include interactive responses that simulate
the visit and evaluate the physician’s knowledge. In two separate, prospective validation studies among randomly selected
providers, vignettes consistently demonstrated greater predictive validity of process than did the abstracted medical record.
Vignettes have been validated against the gold standard of
standardized patient visits, and they reflect actual clinical practice, not just physicians’ knowledge. Vignettes have several
other advantages. Because exactly the same case can be given to
many providers, vignettes are useful for comparison studies.
They are also useful for pre- and postevaluations of policy
interventions designed to improve quality. Finally, they are
inexpensive to administer and straightforward to score, making
them particularly useful in developing countries.
ECONOMIC BENEFITS AND COSTS
OF QUALITY CARE
Policy interventions can lead to higher-quality process of care
and can rapidly improve a population’s health outcomes, but is
quality improvement cost-effective? This section shows that it
is. We compare the economic benefits of better quality of care
at the individual and population levels with the costs of implementing quality improvement interventions. We then discuss
why these interventions not only increase individual and social
welfare but also are cost-effective in the long run.
Individual Economic Benefits
Individuals benefit from better quality of care because they are
physically, emotionally, and mentally healthier. These benefits
can be quantified subjectively by self-report, objectively by
physiological assessments (such as blood pressure), and monetarily by measuring income. Other things being equal, a healthy
individual generates more income than one who is often sick.
This benefit goes beyond the period of illness. Research on early
childhood development has shown that higher-quality prenatal
and postnatal care not only decreases mortality but also
improves subsequent school performance, which is critical to
future labor productivity (Van der Gaag 2000). The monetary
benefits of better individual health can be assessed by examining
the individuals’ expected income in the context of a life cycle
model. Expected income depends on the risk of death at various
points in time and the corresponding opportunities for educational attainment. This scenario can be simulated by improving
quality and then estimating how much the higher quality lowers
mortality and increases education attainment, both of which
increase an individual’s future income (see figure 70.2).
Social Macroeconomic Benefits
Societies that have healthier populations also have higher levels
of human capital and a greater capacity to generate wealth.
Higher quality of care for the individual increases society’s
human capital by reducing both the number of premature
deaths (thus increasing the labor force) and the amount of temporary or permanent disability (thus improving worker productivity). Providers and insurers also benefit from lower costs
by avoiding unnecessary or inappropriate care. Thus, society
benefits from both better health and lower public expenditures
for treatment, which can then be reallocated to other productive
uses. Interventions that improve quality have an especially high
social value when they have large positive externalities (for
instance, when better process reduces the incidence of a communicable disease). Sometimes, however, society benefits but
some stakeholders do not. For example, physicians who provide
better preventive care may experience less demand for their curative services and associated resources.
Several attempts have been made to estimate the correlation
between health outcomes and long-term economic growth.
The high prevalence of such diseases as malaria has been linked
in some studies to a slowing of economic growth by one to two
percentage points per year. These studies were severely limited
by the number of countries and by the many unobserved factors excluded from the models (Sachs 2001). These limitations
suggest another way to estimate the benefits of higher quality
on health outcomes and long-term economic growth. Because
diagnostic accuracy and treatment of malaria can be improved
with better-quality care, improving quality should increase
national income through reductions in mortality rates.
Indeed, cross-country data suggest that a one-year increase
in life expectancy is associated with an increase in the gross
domestic product (GDP) growth rate of 1 to 4 percentage points
(Bloom, Canning, and Sevilla 2001). Our own simulations show
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Increase in present value
expected income
(percent)
120
100
80
60
40
9
7
20
5 Effect of
0
nine policy
intervention
scenarios on
quality
3
3
8
1
13
18
23
Unemployment rate (percent)
Source: Authors’ calculations.
Note: These results model the effect on income of a policy intervention that leads to higher quality. The effect is
determined as an increase in the present value of income for varying rates of unemployment. Higher quality is
based on nine different scenarios of quality improvement. For each successive scenario, infant mortality rates
are reduced by 1 percent and educational attainment is increased by 5 percent. The baseline possibilities are
for the Islamic Republic of Iran.
Figure 70.2 Economic Benefits of a Quality Intervention That Reduces Child Mortality Rates
and Leads to Higher Educational Attainment
Accumulated gains in GDP
during a 50-year period
relative to current GDP
0.20
0.18
0.16
0.14
0.12
0.10
0.08
0.06
0.04
0.02
0
5.0
4.0
3.0
2.0
0.01
0.015
0.02
0.025
1.0
0.03
0.035
Yearly
decline
in child
mortality
rates
(percent)
0.04
Change in GDP growth rate from one year
increase in life expectancy
Source: Authors’ calculations.
Figure 70.3 Gains in GDP Resulting from Reductions in Child Mortality Rates
that quality improvements can result in as much as a 5 percent
annual reduction in child mortality rates, which can generate,
over 50 years, economic gains equivalent to 18 percent of current GDP (see figure 70.3). Similar results would be obtained if
the effect of better quality on morbidity and disability were
simulated.
Economic Costs
Policies that improve the quality of care have both direct and
indirect costs. Direct costs relate to the human and physical
resources needed to implement the intervention. Indirect costs
come from more subtle changes, including alterations in the
quantity of health services provided, in provider demand for
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various inputs (such as equipment and medication), in the
market prices of heath care, in government health budgets, and
ultimately in the macroeconomy. For interventions at the local
level, such as training doctors in a particular region, it is usually
sufficient to measure direct costs. Although the level of
detail required can be overwhelming when the interventions
are complex, the calculations are usually straightforward. The
costs of local interventions depend on local prices of such
inputs as labor, transportation, training kits, food, space rental,
and accommodations. The cost of training providers in the
appropriate treatment of childhood illnesses ranges from a
low of US$1 to a high of US$430 (Santoso, Suryawati, and
Prawaitasari 1996).
The direct and indirect costs of interventions at the central
or local government level are harder to quantify. Expanding
training programs to all public providers, enforcing standards
for private and public providers, changing payment systems, and developing policies to protect consumers against
malpractice are macro-level interventions that have direct
program-level costs. They affect the economy as a whole by
changing the allocation of public resources and the relative
prices of goods and services. Macroevaluations of health
policy interventions are seldom conducted, even though systemwide interventions are likely to have the highest effect on
quality and health-related benefits.
Cost-Effectiveness of Improved Process
Two interventions that vividly illustrate the cost-effectiveness
of improvements in clinical practice and outcomes have been
chosen: detection and treatment of acute respiratory illnesses
and appropriate drug use and treatment for diarrhea.
Better Treatment of Pneumonia in Children. Part of the high
mortality from childhood pneumonia in the developing world
can be explained by poor-quality care, which is defined as the
inability either to accurately diagnose or to treat the disease.
Our prototype intervention has two cost components: the cost
of implementing an educational activity for providers and the
cost of treating nonsevere and severe childhood pneumonia.
The former component is based on a study and uses conservative high-end cost estimations (Kelley and others 2001); the
latter is the midpoint from another study (Stansfield and
Shepard 1990). The number of lives saved depends on the
effect of the intervention—that is, the change in the percentage of cases diagnosed and treated; the prevalence rate of both
types of pneumonia; the population covered by each provider;
the case-fatality ratio; and the effectiveness of the treatment.
Both the case-fatality ratio and the effectiveness ratio were
fixed at middle values suggested by earlier work (Stansfield
and Shepard 1990). For the other parameters, a large range of
variation was considered, producing 450 scenarios. Finally, six
impact levels were considered, which were based on two previous studies (Chakraborty, D’Souza, and Northrup 2000;
Mtango and Neuvians 1986).
The analysis showed that, under average conditions,
improving quality of care for conditions of acute respiratory
illness can be very cost-effective. When the baseline quality is
low and the disease prevalence is high, an intervention that
raises quality has a cost-effectiveness ratio of US$132 to
US$800 per life saved; if the policy intervention is ineffective or
the prevalence of pneumonia is low, the average cost of saving
a life could be more than US$2,000. When 60 percent of cases
are already appropriately diagnosed and treated, the costeffectiveness ratio rises to US$5,000 per life saved.1
Better Treatment of Diarrhea. Diarrhea remains one of the
leading causes of childhood morbidity and mortality in the
developing world. The diarrhea incidence rate among children
in resource-constrained countries can reach six to seven
episodes per year (Thapar and Sanderson 2004). ORT is the
accepted standard of care for acute diarrhea. Unfortunately, a
large proportion of cases are still treated with nonrehydration
medication, including antibiotics and antidiarrheals. Improved
diagnosis of dehydration and reduced use of unnecessary medications, however, lead to better outcomes.
Various interventions can make sizable changes in the diagnostic and prescribing patterns of providers. Verbal case review,
combined with a package of additional intervention referred
to as INFECTOM (Information, Feedback, Contracting with
Providers to Adhere to Practice Guidelines, and Ongoing
Monitoring), increased the proportion of cases treated correctly
from 16 percent to 48 percent (Bloom, Canning, and Sevilla
2001). One study reports that small group, face-to-face interventions reduced antimicrobial prescriptions by 16 percent
and antidiarrheal prescriptions by 7 percent among a group
of providers treating acute diarrhea in Indonesia (Santoso,
Suryawati, and Prawaitasari 1996). The same study showed that
formal seminars reduced antimicrobial use by 10 percent and
antidiarrheal use by 7 percent. On the basis of these studies, an
average cost per intervention was used, ranging from US$25 to
US$125.
The savings from switching to a less costly treatment (instead
of antibiotics, for example) were subtracted from the direct
costs that are related to implementing the training activity.
Because other savings, such as those related to a lower use of
inpatient services, were ignored, the estimates are conservative.
Savings could be greater: Two years after an ORT unit was established at the Kamuza Central Hospital in Malawi, 50 percent
fewer children with diarrhea were admitted to the pediatric
ward, and those admitted required 56 percent less intravenous
fluid for rehydration (Martines, Phillips, and Feachem 1990).
Again, the number of lives saved depends on the disease
prevalence; the effect of the policy on treatment quality; the
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population covered by each provider; the average case-fatality
ratio, which was set at 6 per 1,000 on the basis of Snyder and
Merson (1982); and the effectiveness of the treatment. For the
latter parameter, reductions in mortality rates following ORT
treatment of 40 to 60 percent and reductions in effectiveness
ratios of 5 to 100 percent have been reported (Shepard, Brenzel,
and Nemeth 1986). Accordingly, the effectiveness ratio was set
at 80 percent. As before, alternative values for the other parameters were adopted, generating 450 scenarios.
Educational interventions to improve the quality of care for
treatment of diarrheal diseases are also highly cost-effective. In
general, the cost of saving a life through educational interventions is less than US$500 and could be as low as US$14.
Scenarios with high cost per life saved (more than US$6,000)
are when prevalence rates are low or when implementation
costs for quality-related interventions are high.
Although the data available to estimate the costs and
benefits of health outcomes and process are limited, these
simulations, combined with published reports of successful
policy interventions, clearly show the cost-effectiveness of
interventions that improve health outcomes through better
quality of care. However, reliable measures of quality are necessary to design and evaluate these interventions.
Such studies should be complemented by cost-benefit and
cost-effectiveness analyses. Sometimes, in public health emergencies, for example, control groups may not be practical or
ethical, in which case real-time operations research is an
acceptable substitute.
In the area of research topics, top priority should be given
to quality monitoring and assurance strategies to gain an
understanding of exactly what the health system is contributing to society and at what cost. Quantifying the associated
costs of different variants of quality monitoring and assurance
strategies should also be a high-priority item on the quality
research agenda. The second priority should be to increase the
evidence base regarding the effects on provider behavior of
public policies concerning quality of care and whether they
lead to better health outcomes. We need to learn more about
the long-term effects of different contracting and remuneration policies on providers’ practices and the consequent
results of such policies for health outcomes. Finally, we need
to understand how contracting and remuneration policies
affect problems unique to the developing world, such as the
use of doctor substitutes and the migration of skilled
providers to wealthier countries.
CONCLUSION
RESEARCH AGENDA ON QUALITY
Most of the issues discussed throughout this chapter represent
important topics for research. Establishing a research agenda
requires prioritizing both the type of research and the topics to
be studied. Quality-of-care research must also strike a balance
between relevance to decision making and excellence in scientific rigor (Frenk 1992).
Observational studies are needed to document the extent
and correlates of quality at various levels: individual providers,
institutional providers, health care systems, and whole populations. Apart from offering much-needed basic descriptions
(especially in developing countries), these studies can test specific indicators of the dimensions of quality and can compare
the measurement approaches discussed earlier.
Intervention studies introduce planned changes into health
care settings and assess their consequences. It is fundamentally
important that intervention studies compare one provider
group or policy alternative with another. In addition, control
groups must be used so that any observed change can be
attributed to the intervention itself rather than to another
source of variation. The external validity of studies is often
undermined by the choice of highly specific sites, making it difficult to generalize the findings and to build a body of sound
evidence. If randomized trials cannot be conducted, the preferred option is quasi-experimental studies with clear control
groups and longitudinal designs (Peabody and others 1999).
Good quality means that providers are able to manage an individual’s or a population’s health care by timely, skillful application of medical technology in a culturally sensitive manner
within the available resource constraints. Eliminating poor
quality involves not only giving better care but also eliminating
underprovision of essential clinical services (systemwide
microscopy for diagnosing tuberculosis, for example); stopping
overuse of some care (prenatal ultrasonography or unnecessary
injections, for example); and ending misuse of unneeded services (such as unnecessary hysterectomies or antibiotics for viral
infections). A sadly unique feature of quality is that poor quality can obviate all the implied benefits of good access and effective treatment. At its best, poor quality is wasteful—a tragedy in
severely resource-constrained health care systems. At its worst,
it causes actual harm.
Despite the urgency of improving health in developing
countries, quality of care has been largely ignored. Both
providers and patients agree this must change, but how can this
goal be reached? From the information marshaled for this
chapter, we can draw five conclusions:
• Better quality leads to better health outcomes in developing
countries.
• Process, the proximate determinant of health outcomes, can
be measured in valid and reliable ways, such as clinical
vignettes and electronic medical records.
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• Measured in the above ways, the process of care in developing countries is poor.
• The process of care can be improved in the short term.
• Policies affecting structural conditions, including the actual
process of care or the continual design and redesign of the
health care system, have been shown to be effective in developing countries.
We believe that two broad strategies would help to rapidly
improve health care quality in developing countries:
• encouraging explicit comparative research on outcomes and
process
• disseminating empirical findings on quality variation.
Encouraging Explicit Comparative Research on Outcomes
and Process
Comparisons highlighting different outcomes can be compelling. For example, when 30-day mortality rates for coronary
artery bypass surgery at various facilities were disclosed in the
United States, care started to shift from many low-volume hospitals to high-volume hospitals (Chassin 2002). In developing
countries, comparisons show that the insured are more likely
to have cesarean sections than are the uninsured (Barros and
others 1991). Although critics of comparative analysis are justified in saying that systems and populations vary, such criticism misses an important point: Differences in outcome highlight possibilities that help in the search for the underlying
causes of poor quality. Although poor quality may have many
causes, one of them is almost always poor clinical practice,
which can be remedied. We also favor a league or summary
table approach to making comparisons. In this approach, the
providers being compared agree on criteria before prospective
assessments are done. The data for the comparison should be
of the highest quality; the league tables themselves should
be easy to interpret; and the findings should be rapidly available (Devers, Pham, and Liu 2004). The league table itself
should be set up at the regional, national, and international
levels so that a variety of benchmarks are available.
Implementing quality comparisons will greatly facilitate the
process of policy evaluation and cost-benefit analysis and help
indicate directions for future research. Access to accurate, consistent quality-of-care data will compel external funders, such
as the World Bank, to build quality assurance into their lending
and development programs. As major health programs such as
the Global Fund to Fight AIDS, Tuberculosis, and Malaria are
scaled up around the world, mechanisms to measure and
improve care quality will grow more important.
Disseminating Empirical Findings on Quality Variation
Public dissemination of information on quality, particularly in
low-literacy countries, does not seem to create the individual-
based choice market that many have envisaged. Instead, it
motivates managers and providers to undertake changes that
improve the delivery of care (Schneider and Lieberman 2001).
Outside pressure—perceived or real—appears to extend the
quality debate beyond traditional boundaries, allowing for
innovative collaborations and “out of the box” thinking
(Devers, Pham, and Liu 2004). Nongovernmental and private
organizations involved in health care delivery should also be
required to report basic quality measures, perhaps as a condition for funding, thus ensuring that similar pressure to improve
quality is exerted outside the public sector.
Public dissemination can create shock waves when poor
quality is “discovered,” leading to popular demand to increase
quality. For example, findings of widespread medical errors in
the United States, estimated to have resulted in as many as
98,000 deaths per year, launched the medical safety revolution
(Institue of Medicine 2001). Dissemination among physicians
and surgeons by means of report cards and ratings has been
effective at changing clinical practice. One advantage of dissemination among providers is that the results can be more
refined and technical than ratings meant for wider audiences.
Dissemination is the responsibility of public research and public initiative. Because dissemination is inherently controversial,
it requires public financing—even more than other public
goods (Jamison, Frenk, and Knaul 1998).
Ultimately, improving quality is about value. In health care,
price is not a reliable proxy for quality and cannot be used as
a guide. Because patients and consumers cannot directly
observe quality, their ability to demand high-quality services is
limited, and they are often left to settle for a market that has
suboptimal equilibrium and poor quality of care. In addition,
providers often lack knowledge of optimal treatments and
technologies and thus are not aware of how they can produce
higher-quality care. Because the provider-patient interaction
is so private and personal, quality of care is hard to observe
and to measure. New measurement tools, however—such as
clinical vignettes and the electronic medical record—are being
developed and improved. As research links care with outcomes and cost inputs, we can expect to have more accurate
and reliable data about clinical practice for use in making
quality assessments.
Investments in quality, however, must be judged critically as
well. When we invest in quality, an investment can be beneficial
but can come at a cost. So while quality goes up, value can go
up or down—or costs can go up while quality actually goes
down or stays the same, thus pushing the value of care down
and undermining other efforts to improve quality. Finally, as
we showed for acute respiratory illness and diarrhea, quality
can go up and costs go down, thus increasing overall value.
Examples of this optimal outcome must be actively sought out
and reported, because the success of a given investment cannot
be known in advance (Berwick 2004).
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231
Improving health status does not have to rely solely on
macroeconomic growth or other long-term development indicators. Health outcomes can be rapidly improved in the short
term by ensuring the appropriateness of the circumstances
or setting under which the health care encounter occurs
(structural improvement) or by increasing the likelihood that
health care providers behave in ways most beneficial to
patients under the prevailing circumstances (process improvement). However, this improvement will not occur spontaneously or routinely, despite the best intentions of beneficiaries, providers, and governments. Quality improvement tools
and technologies and information on successful quality
improvement policies must be consistently shared among
developing countries to build local capacity. Funding and
incentives must also be consistent with high quality. Finally,
the political will to ensure that quality becomes a top priority
on the health reform agenda must be sustained.
Davis, D. A., M. A. Thomson, A. D. Oxman, and R. B. Haynes. 1995.
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NOTE
1. As a reference, if the average expected value of a life is close to
US$30,000, even the highest cost-effectiveness ratio found in the analysis
(US$12,000 per life saved), would imply a cost-benefit ratio below 50 percent, assuming an initial average wage of US$1,000 growing at 2 percent
per year, a 5 percent discount rate, and unchanged mortality rates.
Gutierrez, G., H. Guiscafre, M. Bronfman, J. Walsh, H. Martinez, and O.
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Volume with Outcome in Pachoemulsification Surgery.” British Journal
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Chapter 71
Health Workers: Building and Motivating
the Workforce
Charles Hongoro and Charles Normand
Policy on human resources for health should support health
policy objectives and be a means for achieving policy goals. The
implication of such a focus is that health systems development
should start by identifying the tasks that must be carried out
and the skills needed to perform them. Meeting policy goals
depends on being able to recruit, train, and retain staff with the
necessary bundles of skills. Traditionally, skills are defined by
membership of a profession, especially medicine, nursing, midwifery, and the allied health professions. Low- and middleincome countries (LMICs), often from necessity, have widened
the range of health care workers to meet the service needs, with
some people trained in extremely basic skills and others receiving enhanced training, such as nurses trained in emergency
obstetrics. What is meant by a doctor or nurse also varies.
Even though structures and institutions vary widely, some
problems are common to most LMICs. First, persuading
doctors to work in remote rural areas is difficult, and they typically do not remain long in such posts. Second, emigration of
doctors and nurses is extensive. Third, it is common for doctors
to work in both the public and the private sectors (referred to
as dual practice), sometimes harming public services. Dual
practice may encourage doctors to skimp on their public health
efforts, to pilfer supplies, and to induce demand for their
private services (Bir and Eggleston 2003).
Many health sector human resource (HR) problems are
predictable from a simple labor market perspective, given the
combinations of incentives confronting health care workers
and the constraints policy makers face. Experience in LMICs
shows how problems have arisen and what policies have
succeeded.
Economics predicts that employers will employ workers as
long as the additional value of their services is at least as great
as the cost of employing them, and workers will work if the
rewards are of greater value than those accruing to other uses
of their time. If key professionals are in short supply, higher
salaries will be needed to attract them. Workers will invest in
training if they value higher future incomes and more interesting work above the costs of income lost during training and of
fees paid for training programs. This chapter focuses on how
health systems might build and improve HR capacity.
Appropriate HR capacity is critical for the effective implementation of disease control interventions. Salaries account
for 50 to 80 percent of health sectors’ recurrent costs (Bach
2000). Table 71.1 shows the number of physicians and nurses
per 100,000 population in selected countries. The number of
health workers is related to the level of development because
of the tight resource constraints facing LMICs and because of
supply constraints, often exacerbated by migration of skilled
workers (Awases, Gbary, and Chatora 2003) and prevalence of
AIDS. In Africa, where the disease burden is high and increasing rapidly, the number of health workers is particularly low.
Most African countries export health professionals to highincome countries.
A study in six African countries showed that most health
workers intend to migrate for higher salaries. In Ghana, 70 percent of 1995 medical graduates had emigrated by 1999 (Awase,
Gbary, and Chatora 2003). Pay differentials provide strong
incentives to migrate. For example, a junior doctor in the
United Kingdom averages a monthly salary of US$3,029 and a
registered nurse averages US$1,500, compared with US$300
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Table 71.1 Numbers of Physicians and Nurses, Selected
Countries and Country Groups, 1998
Country
Angola
Bangladesh
Physicians
per 100,000
population
Nurses
per 100,000
population
Physiciannurse
ratio
5
100
0.05
19
11
1.7
HEALTH CARE PROVISION AND ASSOCIATED
HUMAN RESOURCE NEEDS
Studies on developing services to meet the Millennium
Development Goals emphasize the importance of making
health workers with the appropriate skills available and motivating them (Jha and Mills 2002). The problems include lack
of technical skills, low motivation, and poor support networks
(Kurowski and others 2003). This chapter, therefore, focuses
on HR planning, training and professional development,
incentives for workers to accept and stay in posts and to
deliver services, and alternatives to conventional professional
groups.
Boliviaa
29
14
2.1
Botswana
20
100
0.2
Brazil
136
44
3.1
Burkina Faso
⬍3
20
0.15
Central African Republic
⬍3
⬍10
0.3
20
50
0.4
106
94
1.1
Incentives and Motivation
4
5
0.8
57
34
1.7
7
67
0.1
The labor market model outlined earlier provides a framework
for analyzing the role of incentives. A health worker will accept
a job if the benefits of doing so outweigh the opportunity cost.
Improving recruitment and retention requires either offering
higher rewards that make alternative employment less attractive or making qualifications less “portable”—that is, less likely
to be recognized in other countries. The development of new
health professions in many countries is a way of reducing the
portability of qualifications, thereby reducing the opportunity
cost of jobs at home. Another advantage is that training can be
more specific to local health system needs, but ensuring quality
and safety are important issues.
Health workers will choose to train and increase their skills
if the rewards of doing so exceed the cost. In general, the supply of skilled professionals rises as rewards increase, because
more will seek training, more will return to the workforce, and
fewer will move to other jobs or other countries. Because health
workers value both financial and nonfinancial rewards, they
will work for lower salaries if other job characteristics are
attractive.
The causes of health HR problems in developing countries
are complex, and attempts to address them must reflect this
complexity. Table 71.2 suggests a framework for exploring
links between factors at individual, organizational, and
health system levels. The framework is inspired by a systems
approach, which gives prominence to the roles of and relationships between different component parts in influencing
the whole.
The individual health worker level serves as a starting
point for exploring the determinants of health worker behavior and performance (Kyaddondo and White 2003).
Performance here means productivity and quality of services.
Individuals respond to individual concerns through coping
strategies, such as informal and dual practices, with associated
consequences. There are multiple links between individual
health worker behavior and organizational and systemic
factors. Organizational and system arrangements define
Equatorial Guinea
India
Nepal
Pakistan
Papua New Guinea
b
Peru
10
7
1.4
South Africa
20
100
0.2
Sri Lanka
37
103
0.4
Low-income countries
73
132
0.6
Middle-income countries
142
278
0.5
High-income countries
286
750
0.4
Global average
146
334
0.4
Global median
114
233
0.5
Sources: PAHO 2003; Support for Analysis and Research in Africa 2003.
a. 1999 data.
b. 1996 data.
per month for a Ugandan medical officer and US$180 for a
registered nurse.
Scaling up service provision using current provision models
would require large increases in resources and could require a
change in strategy by development partners toward supporting
recurrent costs (Jha and Mills 2002). The labor market model
indicates that higher salaries would be needed to attract additional staff members, so funding would have to increase more
than in proportion to the number of staff members employed.
Many LMICs pay health workers on civil service scales,
which they control to contain overall government spending.
This practice further widens the gap between salaries for
professionals at home and abroad.
Although improved economic performance and increased
development assistance may allow some increases in health
spending, in most LMICs it is not plausible that such increases
would be sufficient to make the necessary skills available without a range of strategies, including better regulation, stronger
incentives, and initiatives to make key skills available at lower
cost.
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Table 71.2 Framework for Diagnosing HR Issues
in the Health Sector
Level
Issue
Individual health worker
Internal capacity
Knowledge, skills, competencies, attitude
Remuneration
Salary and perquisites, payment methods
Work environment
Immediate environment
See organizational-level issues
Distant environment
See systemic-level issues
Productivity
Outputs or outcomes per given unit of
time or per individual or group of
individuals
Responses to organizational
and systemic constraints
Low motivation, morale, productivity, and
quality of services
Informal practices, for example, unofficial
fees, dual practice, misuse of public
resources, and unethical practices
Emergence of unskilled informal
practitioners
Organizational level
Presence or absence of an appropriate
physical and operational context—that
is, availability of materials and facilities
to deliver services of acceptable quality,
workload management, and organizational norms and practices (organizational
culture, management and leadership
styles)
Organizational autonomy across key
strategic and functional issues
Systemic level
Level of bureaucracy and decentralization
in the health system, and funding and
regulatory arrangements
Policy context—for example, pro-market
policies and diversification of the health
care market in the spirit of a publicprivate mix
Socioeconomic and political context
Medico-legal policy and enforcement
Source: Authors.
Note: This chapter uses a narrow definition of health system that considers socioeconomic and
political issues as part of a wider context.
the incentive context for health workers and influence both
organizational and individual performance.
Therefore, the configuration of the health system must
create incentives for appropriate supply and deployment of
health workers. HR development experts tend to focus more
on problems encountered in the lower tiers of this framework.
Political pressure for short-term solutions partly explains
why many countries do not address HR problems comprehensively. The wider context can also be important. Good
governance at the national level is necessary to make policy
interventions at the health system level or below effective.
Financial Incentives
Most of the comparatively scarce evidence on the relative
importance of financial and other incentives for health workers
at the individual level comes from developed countries. Two
findings emerge from recruitment and turnover studies. First,
at extremely low salaries, financial incentives are particularly
important (Normand and Thompson 2000). Second, at least
half of the variation in turnover can be attributed to financial
incentives (Gray and Phillips 1996). These findings leave considerable scope for improving retention using organizational
changes, but such changes will be only partially successful if
much better financial rewards are available elsewhere.
International migration has increased as restrictions on
moves to high-income countries have been eased (Bach 2000).
Many developed countries have shortages of health professionals and actively recruit from low-income countries, thereby
raising the opportunity cost of remaining at home.
Health Care Systems’ Responses to Health Worker Issues
Health sector reforms have been widespread in recent years,
often with international support. These reforms tended to
focus more on structures and financing and less on resource
issues (Martineau and Buchan 2000). Other government
reforms aimed mainly at improving efficiency and reducing
the cost of government administration have often had large
effects on the health workforce (Adams and Hicks 2000;
Corkery 2000). Some changes have attempted to introduce
better incentives, such as performance-related pay and renewable contracts, and to remove underperformers and ghost
workers. Evidence on the effects of these reforms suggests that
more emphasis should have been placed on designing incentives to improve performance and retention and on moving
further away from workforce quotas and norms. Using the
three levels of analysis, the following sections consider policies,
management, and incentives and how they can help match
skills to needs.
HEALTH CARE STAFF
Workforce planning should be dynamic and should link policy
goals to staff members’ skills and numbers and to performanceenhancing incentives.
Workforce Planning to Meet Policy Goals
Several factors make workforce planning in health particularly
difficult, including changing needs as service models change,
long training time for some professions, and lack of direct government control over the number of professionals being
trained, for example, because of the growth of private medical
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schools, such as in Bangladesh, or because of people going
overseas for training (although Singapore has addressed this
problem by restricting the colleges that the government recognizes for registering doctors). The greatest difficulty comes
from the unpredictable loss of skilled staff members to private
health sector jobs, jobs abroad, and jobs outside health. Thus,
a close link exists between HR planning and incentives and regulation. In Ghana, nurse training has often been the only available form of tertiary education for women, and many of those
who are trained do not practice.
A key to more rational workforce planning is better coordination between health planning and planning for training and
education. Powerful interest groups can oppose the expansion
of training. Training establishments often oppose change because it may disrupt existing arrangements and threaten current
staff members. The development of new professional groups
faces particular resistance from existing professional groups,
which, quite correctly, perceive the new groups as posing a threat
to their interests. For example, some dentists in South Africa
expressed concern over training of dental technicians who carry
out a wide range of preventive and restorative dentistry at lower
fees (Matomela 2004).
Models for HR needs are easy to devise, but determining
the appropriate model parameters is difficult. For example,
health planners must estimate the length of a nursing career—
potentially up to 45 years but often much less, especially if
nurses are willing to work outside nursing (Phillips and others
1994). Good data are needed on dropout rates from training.
HR sections of health ministries are usually poorly resourced,
have low status, and work with poor-quality data, and this
situation must be changed if planning is to improve.
Basic Skills Training and Continuing Skill Development
Whereas the quality of basic training of health professionals
varies widely in LMICs, the provision of continuing education
and development is almost universally inadequate. Hence, skill
levels of staff members fall over time. Evidence indicates that
good-quality continuing professional development is a positive
incentive and helps to retain staff members. Requirements to
undertake continuing education can be made a condition of
continued professional registration and can thereby provide
some guarantee of competence.
Good basic education includes development of both professional skills and learning skills. Basic training and continuing
development should be planned together. In many cases, the
large investment in basic training is lost because of lack of
maintenance, so that shifting some resources to updating and
renewing skills is efficient.
A further challenge is to align the content of training to the
skills professionals need. Many training programs in LMICs
provide skills oriented toward service needs in developed
countries, although there have been attempts to change this
balance. For example, more than 25 percent of Malawi’s
curriculum for medical students focuses on community health.
Given that any training program can cover only a portion of relevant knowledge, focusing on locally relevant topics is increasingly important. Educational reforms in many medical schools
in Africa and elsewhere are based on the community-based
educational model (Jinadu, Olofeitime, and Oribador 2002).
Numbers and Types of Health Professionals
Categories of workers result from combinations of previous
and current needs, national traditions, interest group pressures,
and historical accidents. Doctors, nurses, and some paramedical professions have wide international recognition but vary
in definition. Professional traditions and professional bodies
bring some safeguards for quality and safety, and at best,
professionals champion the needs of patients. Membership of
a recognized profession can bring desirable independence from
management. However, internationally recognized qualifications make it easy for professionals to migrate to countries
offering higher incomes and better careers.
Most developing countries have new categories of staff that
do not match internationally recognized professions (Buchan
and Dal Poz 2003). Examples include nurses with extended
training and roles and people working at subnurse levels with
training of a few weeks to three years. Bangladesh has family
welfare visitors, health assistants, and medical assistants who
might elsewhere be classified as nurses or auxiliary nurses; in
Uganda, clinical officers have three years of training and work
as subdoctors; and nursing aids in Uganda have three months
of training. Training is for specific roles without the generic
training in conventional professions. Typically, such employees
are mobile nationally, but they do not transfer easily across
countries.
In the labor market model, employers want to employ staff
members if their contribution to service provision is of greater
value than the cost of their employment. Because those with
portable qualifications can work in other countries, salary levels needed to retain workers reflect that possibility. Theory suggests that staff members will develop new skills if such an
investment of their time and money produces significantly
increased salary or benefits. Many countries cannot fulfill their
requirements for health workers, but normally this difficulty
reflects salaries that are too low to attract staff. However, raising salaries may make employment of the full complement of
staff members unaffordable.
Staffing norms serve little useful role if the salaries needed
to fill the posts are unaffordable. Decisions about how many
people should be employed and in what capacities should be
based on the contributions those employees will make and the
costs of employing them. Staffing norms can be useful for
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planning, but they require careful analysis of affordability of
care, the skills needed, and the way to provide those skills most
efficiently. Several countries have of necessity turned to new
models of provision using staff skilled in the delivery of key
elements of high-priority services, such as immunization and
emergency obstetric care.
Safety and Effectiveness of New Health Professions
Research on the new professions is limited, and much of the
material is anecdotal (Buchan and Dal Poz 2003). A growing
literature from developed countries indicates that nurses can be
safe and effective in place of doctors in primary care (Venning
and others 2000). The fear is that the absence of a formal profession and the lack of internationally recognized training
could damage quality and safety. This issue is important, but
even if new professionals are less safe than doctors, they may be
much safer than the absence of a service such as emergency
obstetric care. In some countries, new professions play a major
part in the provision of services. A good example is Malawi,
where clinical officers with extensive training (but much less
than that of doctors) are a major resource, carrying out surgical procedures and administering anesthetics as well as providing medical care. In some countries, regulations govern such
extended roles (McAuliffe and Henry 1995).
Fenton, Whitty, and Reynolds’s (2003) study of emergency
cesarean sections carried out by clinical officers in Malawi
found that the overall maternal death rate was 1.3 percent,
which is high, but much lower than if services had not existed.
Perinatal deaths were 13.6 percent. None of the anesthetists was
medically qualified, but outcomes were better when these practitioners had received anesthetics training (maternal deaths
were 0.9 percent compared with 2.4 percent). The researchers
found no significant difference in outcome between medically
qualified surgeons and those trained as clinical officers. Care
should be taken in interpreting the results of one study, but it
does suggest that well-trained clinical officers can safely substitute for doctors in providing some important procedures.
Human Resource Policy and New Staff Groups
New staff groups are increasingly providing essential services in
LMICs. In Zimbabwe, a new cadre called primary health care
nurses, whose qualifications are lower than general nurses,
was introduced in 2003 to curb external migration by nurses
(Chimbari 2003). At the system level, such a development
requires regulation and standard setting; at the service provision
level, appropriate supervision and management is needed; and
at the individual level, incentives and training need to be considered. Employing fully qualified doctors and nurses might be
the safest option, but failing to provide services because of
staffing constraints is unlikely to be the next best option.
HEALTH WORKER INCENTIVES
The World Health Report 2000 defines incentives for health
workers as “all the rewards and punishments that providers face
as a consequence of the organizations in which they work, the
institutions under which they operate, and the specific interventions they provide” (WHO 2000, p. 61). Health workers face
a hierarchy of incentives or disincentives generated by the work
they do, the way they are paid, and the organizational and system context in which they work. Incentives are generally
designed to accomplish the following:
•
•
•
•
•
to encourage providers to furnish specific services
to encourage cost containment
to support staff recruitment and retention
to enhance the productivity and quality of services
to allow for effective management.
Responses of providers to incentives depend on context and
on the stage of their career. Incentives that induce productivity
vary with experience, stage in a career path, and changes in
providers’ social responsibilities. Ideally, incentive structures
should recognize the evolutionary nature of work expectations.
Typically, incentives vary by type of employer: nongovernmental organization, public, or private. Public sector incentives
tend to be the weakest because resource constraints and
bureaucratic rules on civil servant employment constrain the
use of both financial and nonfinancial incentives.
Typology of Incentives
Extrinsic incentives can be individual and organizational, monetary and nonmonetary (table 71.3). Discussions of provider
behavior in LMICs have focused mainly on financial incentives,
partly because of their low income levels compared with industrial countries. The challenge is to establish an optimal mix of
financial and nonfinancial incentives that generate the desired
behavior of health workers.
Experience from vertical programs for priority diseases or
services—for example, poliomyelitis, malaria, family planning,
and sexually transmitted diseases—provide evidence about different incentives. Programs often offered staff members better
pay and incentive packages than those other public health
workers received (Beith and others 2001). The exact effects of
stronger incentives are unknown, but these programs generally
succeeded, as evidenced by the eradication of leprosy, the near
eradication of poliomyelitis in many countries, and the large
drop in average fertility in developing countries in the 1990s.
Successful vertical programs used combinations of incentives, including better salaries, field and transportation
allowances, streamlined management, specialized training,
better facilities and material resources, and results-oriented
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Table 71.3 Typology of Incentives
Individual
incentives
Organizational
incentives
Environmental
incentives
Financial
Internal
Amenities
Salary
Autonomy
Transportation
Pensions
Accountability
Job for spouse
Illness, health, accident,
and life insurance
Market exposure
School for children
Travel and transport
allowances
Child care allowance
Rural location allowance
Heat allowance
Financial responsibility
External
Governance
Public finance policy
Regulatory mechanisms
Retention and professional
allowances
Subsidized meals,
clothing, and
accommodation
Nonfinancial
of health system capacity, which depends in part on the alignment of health workers’ objectives with policy and with system
goals.
Aligning health worker and system objectives is difficult.
The aim is to have satisfied health workers who are motivated
to work harder (Hicks and Adams 2001). Evidence is limited,
but financial and nonfinancial incentives are mutually reinforcing, and changing the culture of the health system to make
goals more readily understood and shared can make financial
incentives more powerful. Such change in the organization of
health care can be politically sensitive because it can give health
sector workers advantages over other public employees.
Incentives may have conflicting effects. For example, decentralization might create the autonomy needed for effective
management, but without transparent management and career
structures and job security, providers might view such a change
as a threat (Kyaddondo and White 2003). Getting the balance
right requires understanding the socioeconomic and political
circumstances and may be helped by using participatory
approaches to policy making and implementation.
Vacation days
Flexible working hours
Context
Access to training and
education
Sabbatical and study leave
Planned career breaks
Occupational health
Functional and
professional autonomy
Technical support and
feedback systems
Transparent reward
systems
Valued by the organization
Source: Adapted from Zurn 2003.
Note: These are mostly extrinsic incentives.
management to support improved health worker productivity
and program performance. Goals were clearly specified, were
understood and shared by the staff, and were often linked to
incentives. The choice of vertical structures also reflects the
perceived difficulties of using existing health systems, with
their excessive bureaucracy, underfunding, and lack of capacity
to implement integrated disease control.
Vertical programs must eventually be reintegrated into the
system. The HIV/AIDS pandemic is a good example of a disease that might require targeted interventions until the capacity
of health systems in LMICs improves to a level that allows the
disease to be managed like other diseases. The success in integrating vertical programs depends on the parallel development
Context is defined here from an individual or an organizational
provider’s perspective. It constitutes what Adams and Hicks
(2000) refer to as external incentives—that is, methods used by
health systems to control the activities of health organizations
or funders.
The power of incentives depends on context. Health systems
in developing countries have varying cultural and economic
histories that shape providers’ expectations and responses to
incentives. Financial incentives are strong when health workers’
incomes are low, as in most developing countries. Nevertheless,
examples of strong nonfinancial incentives exist in countries
such as Thailand, where family ties and kinship affect health
workers’ decisions on where to work. Such nonfinancial incentives affect the size of the financial incentives needed to change
where people choose to work.
History and experience determine a country’s working culture and norms. In developing countries, most health systems
are large bureaucracies whose management is driven centrally
by guidelines, standards, and reporting systems. Incentives
in such systems work against innovation, risk taking, and
improved efficiency. A possible approach is to introduce
changes that are based on the ideas of so-called new public
management. New public management replaces line management with contracts or agreements between funders and policy
makers on the one hand and providers on the other. Providers
are given more managerial autonomy and are controlled by
means of contracts and regulation. This approach can more
easily embody new financial incentives, and autonomous
providers can develop cultures that are more innovating. Such
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a radical change in managerial context can, in principle, make
other incentives easier to use.
Other dimensions of context are the regulatory framework
and its enforcement. Most developing countries have regulations governing the activities of the health sector. These regulations tend to be outdated or poorly enforced (Bloom, Han,
and Li 2001). The main reason for regulatory ineffectiveness is
low institutional capacity and widespread corruption. The
symptoms of regulatory failure are widespread informal activities, dual practice, malpractice and medical negligence, and the
presence of unqualified drug sellers (for example, in Bangladesh
and Tanzania) and practitioners (as in India) (Bhat 1996;
Killingsworth and others 1999; McPake and others 1999).
Where the regulatory system is dysfunctional, providers tend to
pursue their individual interests, often in private practice, to the
detriment of organizational and system performance. Effective
incentive systems that are based on performance require regulation and governance structures that minimize the common
problems of patronage and corruption (Rasheed 1995).
Health system organization factors include governance and
the degree of decentralization. Links exist between working
culture and norms and the structural aspects of health system
organization. The locus of control and decision making play an
important part in health worker behavior. In theory, designing
incentive schemes that are responsive to health workers’
needs is much easier in a decentralized system. This theory is
based on the belief that subnational units are better placed to
make effective decisions on funding, regulating, and organizing
frontline activities than are centralized units. However, experience in developing countries shows that lack of capacity at
subnational levels has constrained decentralization, sometimes
leading to unintended effects such as wrong priorities (Bloom,
Han, and Li 2001). Any move toward decentralization requires
investment in new management skills and capacities.
Incentives in Practice
Many countries have attempted to reform their economies and
health sectors to improve general economic and health system
performance. For example, Cambodia, the Arab Republic of
Egypt, Uganda, and Zambia have attempted civil service reforms
(Corkery 2000). These reforms include attempts to reduce the
size of the civil service to lower costs and to improve productivity using incentives such as formal employment contracts and
performance-based pay and promotion. Such reforms have been
largely unsuccessful in developing countries because of the political difficulties in reducing the size of the civil service. Structural
and organizational changes are typically unpopular with labor
unions, especially if union members perceive them as threatening their well-being. Experience also underscores the difficulties
of aligning system and organizational objectives with individual
providers’ objectives (Martineau and Buchan 2000).
The effect of incentives can be assessed in terms of their
objectives (Adams and Hicks 2000). Table 71.4 summarizes
incentive packages used in selected countries. The results shown
should be interpreted with caution, because of problems of
attribution and poor data. Adams and Hicks (2000) argue that
economic incentives in payment mechanisms for physicians
conform to economic logic, but little is known about the
response of other categories of health workers to such incentives.
Experience in Thailand illustrates the labor market model
outlined earlier. In general, public doctors prefer to practice in
urban areas, where conditions are usually more attractive and
opportunities for private practice are better. Thailand pays public doctors who work in rural and remote areas significantly
more than those working in urban areas, and this incentive has
persuaded some to move (Wibulpolprasert and Pengpaiboon
2003). The government also added nonfinancial incentives, such
as changing physicians’ employment status from civil servants to
contracted public employees, providing housing, and introducing a system of peer review and recognition. These initiatives
were coupled with significant environmental changes, including
sustained rural development. In most developing countries,
providers in rural areas are paid less than those in cities, and it is
hard to recruit and retain health workers in rural areas.
China provides another example of how changes in the
environment—for example, the introduction of pro-market
policies—can change provider behavior, in this case from relying on government salaries alone to the use of “red packages”
(Bloom, Han, and Li 2001). These red packages were gifts that
were traditionally exchanged as an expression of mutual
appreciation, but they have now evolved into informal cash
payments from patients to health workers.
Health systems have a spectrum of workers with different
skills and expectations, and incentives for one group can have
negative effects on others (Adams and Hicks 2000). Policy
makers must strike a balance between competing interests of
professional groups and system goals. The unionization of
labor and the growth of professional associations or councils
can give health workers considerable bargaining power.
Solving one problem can create others. This situation often
occurs when governments respond to the grievances of the
most vocal professional groups, usually doctors, and neglect
other groups. This piecemeal approach has caused HR crises,
such as strikes and go-slows. Although health workers are normally somewhat motivated to pursue health policy goals, their
own interests can conflict with those goals. Providing higher
salaries to health workers, by increasing costs, can reduce access
to services by some social groups (Bloom, Han, and Li 2001).
Compensation
Provider payment systems transfer resources from payers (governments, insurers, and patients) to providers (Maceira 1998)
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Table 71.4 Incentive Packages for Health Workers, Selected Countries
Complementary
measures
Objectives
Incentives
Constraints
Results
Recruiting and retaining staff
in the country
Pay competitive salaries
Fiscal policies that increase
the after-tax marginal value
of salaries
Budget limitations
Helped retain physicians in
Bahrain
Service standards and controls to prevent reduced work
effort in the public system
Work effort that may be concentrated in private practice,
leading to a deterioration of
quality in public practice
Considered successful
in Bahrain
Tolerate informal payments
Not applicable
Informal charges that limit
access and may impede
reforms that involve formal
user fees and exemptions
Resulted in widespread use
of informal payments in
Eastern and Central Europe,
Sub-Saharan Africa, and
some East Asian and Pacific
countries (Balabanova and
McKee 2003; Chakraborty
and others 2002; Thompson
and Witter 2000)
Provide higher salaries or
location allowances
(Wibulpolprasert and
Pengpaiboon 2003)
Decentralized administration
Overall staff shortages
Freedom to allocate institutional revenues or savings
from operational efficiency
to fund incentives
Budget limitations
Premium payments for
working in rural areas found
successful in Thailand
(Wibulpolprasert and
Pengpaiboon 2003)
Include seniority awards in
pay scales
Allow after-hours private
practice in public institutions
Recruiting and retaining staff
in rural areas
Base remuneration on
workload
Improved infrastructure and
staff competence
Low public service salaries
Policies to reduce salaries as
a share of operating costs
Professional and lifestyle
disadvantages
In some countries, resulted
in deterioration of public
systems where providers
also engage in independent
private practice (McPake
and others 1999)
Smaller potential for earnings from private practice
than in urban areas
Conflicting financial incentives (for example, loss of
housing allowance in
Bangladesh)
Risks posed by internal
conflicts and civil wars
(for example, Colombia
and Uganda)
Require service in defined
areas as condition of licensing or specialty training
Consistent application of
policies on transfers and
tenure
Provide opportunities for
government-sponsored
further education
Loss of confidence if health
workers perceive the selection process as arbitrary
Providers’ concerns that a
temporary posting may
become indefinite
Aided retention of professionals in Ghana and
Zimbabwe
(Chimbari 2003)
Provide housing and goodquality educational opportunities for health workers’
families
Adequate salary
Budget limitations
Found successful for nurses
but not doctors in Nepal
Recruit trainees from rural
areas
Emphasis on public health
and family practice in
training curricula
Traditionally, overrepresentation of urban area students
in student populations
Found successful in Thailand
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Table 71.4 Continued
Objectives
Incentives
Enhancing the quality and
availability of primary care
Provide training and promotion opportunities for nurses
and medical auxiliaries
Complementary
measures
Clear job descriptions and
criteria for promotion
Train multifunctional health
workers
Pay health workers more if
they do not practice privately
Results
Opposition by professional
associations to expanded
roles for multifunction health
workers in Nepal
Resulted in successful
retraining of health
assistants and other health
workers in rural areas in
Nepal to make them eligible
for promotion
Limited training capacity in
Uganda
Mobilize women volunteers
from communities, traditional
birth assistants, and local
leaders
Encouraging teaching and
research and reducing the
internal brain drain
Constraints
Resulted in regrading of
state-certified nurses to
state-registered nurses in
Zimbabwe (Chimbari 2003;
Pannarunothai, Boonpadung,
and Kittidilokkul 2001)
Allowances perhaps uncompetitive with private practice
earnings
None
In Nepal, found successful in
basic medical sciences but
resulted in massive resignations in clinical departments
Uncommon incentive,
although a few countries (for
example, Thailand) do pay
professional allowances or
nonpractice allowances
Improving the quality of care
Specify clinical guidelines in
provider contracts
License institutions and
professionals based on
defined standards
Pass laws requiring the
registration of drugs and
other potentially dangerous
substances
Leadership role by professional organizations
Vested interests of professional associations
Uncommon in developing
countries
Inclusion in the curricula of
medical schools
Weak peer review systems
Some success recorded in
Cambodia’s contracting
experiment
Tradition of professional
self-regulation
Regulatory capture and a
culture of self-protection
Acceptance of civil and legal
authority
Low capacity to enforce laws
and regulations
Low consumerism and weak
advocacy
Reduced number of hospitals
and unqualified doctors in
Estonia
Resulted in limited success
according to evidence from
most developing countries
(Bhat 1996)
Source: Adapted from Adams and Hicks 2000.
and can be structured to provide financial incentives. Most
studies focus on payment mechanisms for doctors and their
effect on productivity, costs, and quality of services (Bitran and
Yip 1998). Table 71.5 summarizes common payment mechanisms and the desired incentives. The evidence shows that the
operation of payment mechanisms is sensitive to the payment
structure and how it is implemented (Berman and others 1997;
Bitran and Yip 1998; Chomitz and others 1998).
Payment systems are more successful when built on existing
traditions and culture (that is, when they take into account gift
systems or, indeed, levels of corruption). It is normally best to
use a combination of payment methods. For instance, if there
is a shortage of public providers, they might be paid a basic
salary for normal working hours and fees for service for after-
hours work. This method creates incentives for providers to do
extra work and increase throughput, but providers may divert
patients to after-hours services, and the method’s feasibility
depends in part on monitoring and governance standards.
The challenge is to find payment combinations that motivate
providers to provide desired volume and quality of services
while containing costs.
Empirical Evidence on Payment Methods
Evidence of provider payment systems that have successfully
aligned system and provider incentives is still limited (Bitran
and Yip 1998). Interesting findings come from small-scale
experiments such as Cambodia’s New Deal (box 71.1). Health
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Table 71.5 Major Payment Mechanisms
Payment mechanism
Key incentives for providers
Fees for service
Increase the number of cases seen
Increase service intensity
Provide more expensive services
Case payment (for example,
diagnosis-related groups)
Increase the number of cases seen
Daily charge
Increase the number of bed days
through longer stays or more cases
Flat rate (bonus payment)
Provide specific bonus services and
neglect other services
Capitation
Attract more patients to register
while minimizing the number of
contacts with each and minimizing
service intensity
Salary
Reduce the number of patients and
the number of services provided
Global budget
Reduce the number of patients and
the number of services provided
Introducing financial incentives for health workers is costly.
Policy makers in governments and development partners need
to ensure that adequate funding is available and sustainable.
Resources are also needed to improve working environments
and system capacities. Both financial incentives and other
incentives are important, but services are likely to improve only
if financial incentives are strengthened.
Decrease service intensity
Provide less expensive services
Source: Bennett, McPake, and Mills 1997.
workers’ salaries were considered by many to be below the minimum required for a decent life, and workload is increasing
because of HIV/AIDS.
The Cambodian experiment attempted to align individual
health workers’ and system goals through performance-based
bonus payments and a set of internal regulations. Regulations
can alter the working and organizational culture in a way that
allows individual-based incentives to work. There were problems in enforcing penalties for violating regulations. Failure to
enforce regulations may lead providers to lose confidence in the
system. Countries with limited administrative and institutional
capacity should use simple payment mechanisms that are
enforceable within their capacity constraints (Barnum, Kutzin,
and Saxexian 1995). A lesson from the experiment is that the
context matters, and any strategy for offering incentives to
workers must be embedded in traditions and cultural practices.
In a competitive environment, contracts are a useful tool for
aligning health workers’ behavior with organizational and system objectives. In the Cambodian example, contracts between
the purchaser and district-level facilities—and between districtlevel facilities and management committees—were an attempt
to establish accountability structures that specify targeted activities. More interesting was the attempt to transfer some management risk and responsibilities to individual health workers
using subcontracts that permitted management committees to
monitor their activities and pay them accordingly, though
whether the contracts were well specified is not clear, and the
administrative and transaction costs are unknown. The use of
contracts requires management and monitoring capacity.
Group Incentives
Health workers typically work in teams. This system weakens
financial incentives because the efforts of individuals may have
little influence on overall performance. Indeed, individual
incentives can worsen team cooperation. For example, if promotion is competitive and depends on measures of individual
productivity, this approach can be a disadvantage for those who
work for system goals in cooperative ways.
Designing effective group incentives is difficult. Paying
group bonuses for achieving a given level of output can work
only if individual team members feel adequately rewarded for
their efforts and if there is no perceived free-rider problem.
Most of the limited evidence on group incentives is for
developed countries and shows that much depends on the
production process and the organization of the teams (Ratto,
Propper, and Burgess 2002). Group financial incentives tend to
be weak, and using other approaches such as team building,
better sharing of information, and improved working conditions is probably better.
Influence of System Capacities and Sustainability
Issues on Incentives
The theoretical merits and demerits of different incentives are
well understood, but system capacities and financial constraints may limit their applicability. Few developing countries
have health systems that are capable of effectively implementing and operating some of the payment systems shown in
table 71.5. The overall funding for the health sector may be
too low to pay providers more. Also, the skills and expertise
needed to design and implement contract- and case-based payment methods may be inadequate, and the country may lack
the information technology needed to capture relevant data to
support such contract- or case-based payment methods. Most
health workers in developing countries are civil servants, and
the particular needs of health workers may be lost in a general
public service. Some countries are considering delinking
health workers from public service commissions and setting up
independent health commissions to run the health sector. In
Zambia, however, delinking failed because of a lack of capacity
at both the national and the local levels to implement the necessary HR changes (Martineau and Buchan 2000). Evidence
from Trinidad and Tobago suggests that insufficient government commitment impeded the transfer of staff members
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Box 71.1
Cambodia’s New Deal Experiment: The First Year
The New Deal experiment in Sotnikum district, Siem
Reap province, was launched in 2000 by the Ministry of
Health, Médicins Sans Frontiéres, and the United Nations
Children’s Fund. It is an example of a concerted attempt to
break the vicious circle of underpayment of health staff
members and underuse of public health services by tackling the problem of low official income. The New Deal was
developed following wide consultations and consensus
building, and locally credible management structures were
established to monitor and enforce the new framework.
Staff motivation was a major problem among health
workers, as manifested by high levels of absenteeism from
work, low time input at work (an average of one to two
hours a day), and poor quality of services. Informal
charges, drug thefts, and dual practice by public health
workers were common, largely because of their low public
salaries: government staff received US$10 to US$12 per
month, compared with a minimum of US$100 required
for a basic standard of living. At the same time, because of
informal charges and extensive use of unregulated private
services, households spent more than US$30 per inhabitant per year on health services, equivalent to 11 percent of
total household expenditure.
The New Deal was seen as a vehicle for improving
services by enhancing personal income, and its overall
objectives were (a) to improve access to quality health
care, (b) to build up the health system, and (c) to act as a
catalyst for changes in national health policy. The principle underlying the improvements in the personal income
of public health workers was that they would better comply with internal regulations governing (a) job descriptions and working hours; (b) payment of informal fees;
(c) misappropriation of drugs, materials, and funds; and
(d) diversion of patients to private practice.
The district (referral) hospital, health centers, and
operational office were each managed by an elected management committee, and individual contracts were signed
between staff members and management committees. The
contracts stipulated that a bonus would be paid in
exchange for strict adherence to internal regulations. The
benchmark bonus level was set at an average of US$60 to
US$90 per person per month. The management committee was responsible for enforcing the new framework of
accountability. Official fees were also introduced on the
assumption that the population would agree to pay for
better public service.
The district got its funding from government appropriations, user fees, and external subsidies from various
sources; however, given the overall lack of funding available for the scheme, Médicins Sans Frontiéres and the
United Nations Children’s Fund had to provide an initial
injection of funds to support the bonus system.
At the hospital level, individuals signed contracts with
the management committees, and compliance with internal regulations improved. The staff was generally present,
fees were transparent, emergencies were attended at night,
patients received drugs, and informal payments were not
demanded. Use of health services increased significantly
after the arrangement had been introduced. The number
of documented violations was limited, though problems
were encountered in sanctioning penalties. Staff members
started receiving bonuses that gradually grew beyond the
negotiated maximum, creating a hospital debt crisis by
midyear, compounded by understaffing and underemployment problems, which meant that most staff members worked overtime. Nevertheless, the quality of services
improved significantly, and per capita family expenditures
on health fell 40 percent.
Source: Soeters and Griffiths 2003.
from the public service, leading to disillusionment among
workers and effective opposition from unions (England 2000).
In countries with thriving private sectors, devising strong
incentives for public sector workers is difficult. For instance, in
Uganda, the private not-for-profit sector used to have better
working conditions and pay than the public sector and consequently had better staffing levels. The government had to
increase public sector salaries significantly in the 1990s to
attract health workers back. The use of fees for service in the
private sector when public health workers are paid a salary is
likely to encourage private practice among public workers.
Thus, the effects of methods and levels of payments are influenced by what is happening in the private sector.
Optimal Combination of Health Worker Compensation
and Incentives
Although the optimal mix of provider compensation depends
on context and policy objectives, some general policy guidelines
on the design of payment methods to achieve organizational
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and system goals are available. Linking compensation to performance makes intuitive sense, but care is needed in working
out the details. Health workers respond to both financial and
nonfinancial incentives, but the extent of the effect varies, and
the two can interact.
For new payment systems to work well, health workers
must be governed by effective managerial authority. Because
new payment systems aim to encourage particular behaviors
and hold providers accountable, clear responsibility must be
delineated within provider organizations. This delineation
may be easier to achieve if the management of providers has
some autonomy. Evidence from developing countries that
have attempted to introduce managerial autonomy and corporatization of health service institutions, such as public hospitals and medical stores, indicates that delinking health workers
from government control is politically sensitive. Nevertheless,
such organizational or system changes are desirable if new
payment methods are to create the right incentives and
achieve the desired changes.
Part of the context for incentive systems is what type of disease control activities are best provided through markets or
hierarchies. Traditionally, the public sector has been dominant. The economic arguments for government involvement
are well understood, but delivery of services within the framework of government policy objectives can be by private (both
for-profit and not-for-profit) providers. Thus, the private sector is increasingly involved in the social marketing of condoms
and bednets, franchising, and contracting (Bennett, McPake,
and Mills 1997).
From an economic viewpoint the only issues are the cost,
quality, and sustainability of such arrangements. Emerging
evidence on private sector involvement in health services suggests that the private sector is willing to participate in nonclinical disease control activities if the incentive structure is
right. Private not-for-profit providers, such as hospitals and
clinics associated with churches, have traditionally complemented government health care activities, especially in poor
and peripheral populations (Gilson and others 1997). In
recent years, Bangladesh has experimented with contracting
nongovernmental organizations to provide primary care services in urban areas. Lessons from this experience are still
emerging and indicate that, despite many early mistakes,
this form of provision can be innovative and can help make
a break from bureaucratic traditions. Such contracting
depends on having contracting skills in both parties to the
contract. A good understanding of context and incentives is
also crucial.
In summary, incentive or payment packages should attempt
to link payment with individual or group performance and
should be assisted by supportive organizational and system
changes if the desired provider behavior is to be achieved. No
single best combination of payment methods exists.
ADVICE FOR GOVERNMENTS
Governments in developing countries face huge challenges in
strengthening their health systems, especially their HR capacity,
if cost-effective disease control interventions are to achieve
their desired results. Strengthening their systems will entail
developing self-sustaining systems for the supply, use, and
retention of health workers. The following considerations are
important in relation to putting effective policies and incentive
structures in place:
• Countries should explicitly link the planned number of each
category of staff members to health policy goals and set priorities, taking overall resources into account when planning
HR needs.
• Countries should recognize that the salaries necessary to
recruit and retain staff members will depend on the opportunities such workers have for other employment within the
country and abroad, and planned numbers in each category
should be based on this reality.
• Countries should understand both that qualifications that
are recognized internationally are likely to attract higher
salaries and that such qualifications may only be partially
suited to the needs of essential health services in LMICs.
They should focus on developing the most important skills
by training new types of health workers, taking into account
evidence that use of such health workers can be safe when
properly trained. Many countries will be unable to prevent
the loss of professionals with portable qualifications, because
salaries offered will be far below those available elsewhere.
• Countries’ training policies should take into account the
decline in skills over time and the need to allocate scarce
resources between basic training and continuing staff
development.
• Countries should adapt and not imitate compensation and
incentive structures, given the evidence that effective incentive structures depend on local conditions and traditions as
well as on universal principles.
• Policy makers should remember that the availability and
cost of suitably qualified human resources will affect feasibility and cost-effectiveness of disease control interventions.
• When developing vertical disease control programs, program
managers must avoid introducing powerful incentives that
damage existing services by drawing away key personnel.
• Policy makers should identify potentially harmful, unintended consequences when designing regulation and incentive systems. For example, if doctors are allowed to practice
in both public and private services, the effects of private
practice on incentives in public practice tend to be negative
unless carefully monitored.
• Countries should recognize that the use of incentives to
improve performance normally requires good regulatory
frameworks and skilled managerial resources.
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RESEARCH AND DEVELOPMENT AGENDA
New staff categories are emerging in many LMICs, and these
workers are an important part of the workforce. Such staff categories are likely to increase, given migration and the high cost
of employing people with portable qualifications, but little
research is available on the appropriateness and safety of the
new sets of skills, and little is known about the range of new
professions, the content of and approach to training, the extent
of professional supervision, and the outcomes of treatment.
Sharing experience of such staff categories would be valuable.
Priorities, therefore, include a study to map the different new
staff groups in health systems in LMICs and to classify their
tasks, roles, and training, and studies to compare the outcomes
of conventional and new staff groups.
In addition to gaining a better understanding of the patterns, roles, and performance of new staff groups, data are
needed on the length of time such workers remain in their
posts, the extent to which their new qualifications are portable,
and their migration patterns. Information is also lacking on
how best to provide professional supervision for these new staff
groups and how to encourage such employees to be professional in their work.
Limited evidence is available on the relationship of different
health care compensation methods to individual and organizational behavior in developing countries. The following are possible research areas (and some practical steps) that might help
fill information gaps and further understanding of the role of
health worker compensation and incentives in disease control
in developing countries:
• Databases. A useful step would be to set up HR databases
for developing countries as the Pan American Health
Organization has done for its region.
• Literature review. A review of unpublished materials on
countries’ experiences with using different payment and
compensation mechanisms at national or subnational levels
would also be useful. Failed experiments are seldom published, but they provide useful lessons.
• HR supply. Traditional HR planning models are no longer
effective in handling health system dynamics in developing
countries. More research is required to develop HR models
in health that include the effects of HIV/AIDS, migration,
scaling-up of existing interventions, new technology, and
reforms. The underlying question should be how HR supply
mechanisms can meet health systems’ needs in terms of
numbers, knowledge, skills mix, and competencies.
• Demand and utilization. Getting the size of the health
workforce right is important in its own right, but that
alone is insufficient for improving health workers’ motivation and productivity. Research needs to focus on how to
improve the motivation and performance of health workers
in resource-constrained environments and on what is
needed to retain professionals in such settings. We know
little about how health care workers make decisions about a
range of incentives and disincentives generated by organizations and the systems in which they work. For example, what
does it take to convince doctors and nurses to work in rural
and remote parts of a country? To what extent are financial
and nonfinancial incentives important in attracting people
into training as health workers, deploying them to needy
areas, motivating them, and retaining them in the system?
To a significant extent, current problems in improving
access to care, in widening the range of effective services that
are provided, and in improving the quality of care depend on
better matches of skills to needs, better motivation of staff, and
clearer understanding of how improved structures and incentives will work. Perhaps as important is that much of the debate
focuses on developments within traditional patterns of staffing
of services, but new patterns are increasingly emerging, and the
extent of evaluative research is inadequate for drawing strong
conclusions on how such developments can alleviate the constraints facing health systems. The development of incentive
systems should be coupled with the development of organizational and institutional capacity that supports sustainable HR
development in general.
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Chapter 73
Strategic Management of Clinical Services
Alexander S. Preker, Martin McKee, Andrew Mitchell,
and Suwit Wilbulpolprasert
Financial resources alone are insufficient for individuals to
benefit from the opportunities presented by modern health
care systems. Some countries have achieved much better levels
of health than would be expected given their financial resources (Mehotra 2000); many examples of poor-quality care
in countries at all levels of development reflect not only scarce
resources but also inadequate management of what resources
are available (see chapter 70).
Many inputs must come together at the appropriate time and
in the appropriate place to achieve maximum health gain. These
inputs include human resources (in particular, trained staff);
physical resources (such as pharmaceuticals and technology);
and intellectual resources (in the form of evidence and the ability to apply it appropriately). This congruence requires that the
production, distribution, and combination of these resources be
actively managed and that the relations among the various elements that contribute to health care be optimized.
The challenge of bringing these diverse inputs together is
becoming increasingly complex. Until the 1950s, providing
basic care at low cost to large populations was relatively
straightforward, given political will and sufficient resources.
Relatively few effective drugs were available; even fewer drugs
were effective in managing chronic disease. The available technology was limited to simple x-ray machines and chemistry
tests that required few skills to administer. Consequently, scaling up the delivery of basic health care was relatively easy.
The situation in the former Soviet Union illustrates this
state of affairs. Beginning in the 1930s, the Soviet Union implemented a vast system to provide basic health care where almost
none had existed. The very simple care available was sufficient
to produce significant reductions in maternal and childhood
mortality rates. What such a system could not do, however, was
respond effectively to the possibilities opened up by the explosion in diagnostic and therapeutic knowledge that began in the
mid 1960s with the availability of new and easily tolerated
treatments for many common chronic disorders. As individuals became able to survive with their chronic diseases, they aged
and acquired other conditions, many of which could now be
treated effectively, constantly increasing the complexity of the
health care required. The inability to manage this increased
complexity resulted in persistently high mortality rates from
treatable conditions at a time when corresponding mortality
rates were falling in Western countries (Andreev and others
2003).
This situation has certain parallels with that faced by many
low- and middle-income countries today. Through a variety of
mechanisms, a political commitment to the health sector is
manifest in the increased availability of funding, such as
through the Global Fund for AIDS, Tuberculosis, and Malaria
(http://www.theglobalfund.org/en/). Much discussion has
focused on one of the elements of health care that these initiatives will support: the supply of drugs that target the microbiological agents responsible for these three diseases. Yet
improved outcomes will be achieved only if such agents are
linked to the many other elements required to diagnose and
treat these patients. Most obviously, the supply of drugs such as
antiretroviral agents must be coupled with those used to treat
the opportunistic infections that exacerbate AIDS. Care for the
acute episode of illness should be linked to general support for
patients and family members as well as to activities designed to
prevent further spread of the disease. Furthermore, as drugs
to combat infections become more widely available, it is
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probable—unless highly developed prevention systems have
been put in place—that drug resistance will increase; this outcome has been evidenced with tuberculosis in those parts of
the world where treatment has been available but poorly managed, such as the former Soviet Union and Peru (Farmer,
Reichman, and Iseman 1999). The resulting resistant infections
are much more complicated and expensive to treat. The rise in
antibiotic resistance provides one of the most graphic examples
of the consequence of the failure to manage the delivery of
health care (see chapter 55).
Yet even where the financial resources and the political will
exist to deliver effective health care, many health care systems
contain numerous constraints to success (Hanson and others
2003):
• At the first level, that of the community or household, there
may be inadequate demand for services or physical, financial, or social obstacles to their use. This situation calls for
action to increase access and affordability, including health
care financing reforms (see chapter 12). It also requires policies to ensure that services are culturally appropriate, that
they address the particular needs of underserved populations, and that they provide dignity and privacy. Moreover,
services should be physically accessible, both in terms of distance from population settlements and in terms of their
construction—that is, facilities must be responsive to the
needs of persons with disabilities.
• At the second level, the delivery of health care, there may be
a shortage of resources, such as staff members, drugs, and
equipment. However, to bring these resources together
would require actions at the third level that anticipate future
needs, as well as actions that ensure that the needed drugs
and equipment are purchased at the best price possible, are
subject to appropriate quality controls, and are distributed
where needed.
• The third level includes health sector policy and strategic
management. Effective action may be constrained by weak
systems of management that are unable to take into account
the changing health needs of the population and the changing demands on health care providers. Management weaknesses include inadequate pharmaceutical regulation and
supply, ineffective training of health professionals, inability
to engage with civil society, and a failure to put in place
incentive systems to facilitate effective health care.
Constraints at this level may originate outside the country,
as governments are faced with demands by donors to follow
paths that either undermine their policy goals or remove the
flexibility needed to achieve them. Constraints acting at this
level also arise when policies in other areas affect the health
sector, such as when a weak, overly bureaucratic, and
unreformed civil service system implements obsolete regulations; when there are inadequacies in infrastructure, such
as poor communication and transportation links; or when
there are weaknesses in the banking system.
• The fourth level refers to the environmental and contextual
constraints on effective policies. The delivery of effective
care may be affected by the physical environment, including
climate and population dispersion. However, an equally
important constraint is weak governance working within
unsupportive policy frameworks, which may be compromised further by corruption, weak rule of law, political
instability, weak public accountability, and lack of a free
press. For example, de Soto (2000) has shown that, in many
middle-income countries, it is almost impossible even to
create a simple garment repair business because of a failure
of legislative reform, in particular a lack of clearly defined
property rights. As a result, much of the economic activity
in those countries is informal or even marginally illegal, a
response that is of particular concern in health care, given
the scope for unlicensed and incompetent providers to
endanger the public.
This framework underscores the importance of coordinating action at multiple levels. Health services can operate effectively only if policies are in place at the community level to
ensure that those in need have access to services, and only if
policies are in place at higher levels to ensure that the resources
are available to provide those services.
This analysis of different levels demonstrates the importance of taking a systemwide approach to the management of
health services. However, because of limited space, this chapter
focuses primarily on the third level, that of strategic management. It first examines the nature of management in general
and the specificities of management in the health system. It
then explores some issues that arise when managing health
services in different settings. It concludes with an exploration
of some of the strategies used in low- and middle-income
countries to optimize the delivery of care, using a framework
developed by Oliveira-Cruz, Hanson, and Mills (2003).
WHAT IS MANAGEMENT?
One of the earliest definitions of management was that of
French mining engineer Henri Fayol. Writing at the beginning
of the 20th century, he stated, “To manage is to forecast and
plan, to organise, to command, to coordinate, and to control”
(Fayol 1949). Put simply, managing is about assessing probable
future scenarios, deciding how best to respond to them, bringing together the resources needed for that response, and deploying them as effectively as possible. Until relatively recently,
most management research was concerned with industrial
production, for which outputs could be measured relatively
easily. Relatively less attention was given to management of
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Box 73.1
Specificities of Health Care Organizations
Health care services differ from many other organizations
in many ways:
• Defining and measuring outputs is difficult.
• The work involved is more variable and more complex
than in many other organizations.
• Much of the work is of an emergency nature and cannot
easily be deferred.
• The consequences of error can be severe.
• Activities by different groups of staff members are highly
interdependent, requiring a high level of coordination.
• The work involves a high degree of specialization.
• Workers are highly professional, with a primary loyalty
to the profession rather than to the organization.
• There is limited scope for effective organizational or
managerial control over clinicians, the group most
responsible for generating work and expenditure.
• Dual lines of responsibility often create problems of
coordination, accountability, and confusion of roles.
Source: Shortell and Kaluzny 1983.
service industries in general and health care services in particular. As Shortell and Kaluzny (1983) noted, health care services
are different from many other organizations. Of course, many
of the specificities shown in box 73.1 are differences of degree,
with health services sharing many features with other service
organizations. Yet important differences exist.
Managing Health Care Services
During the 1970s, health care services in many countries faced
growing criticism for their perceived failure to articulate explicit goals or to develop the means to achieve them (Enthoven
1985; Griffiths 1984). This failure was contrasted with the perceived success of the private sector, which was seen as more
capable of innovation and more responsive to demand.
These developments gave rise to what has been termed new
public management (Hood 1991), which is characterized by the
following:
• greater role for professional management in the public
sector
• closer scrutiny of the work of professionals, involving performance measurement and target setting
• link between resource allocation and measurable outputs
• “unbundling” of previously integrated units, with contracting for previously integrated services
• shift to competition as a key to reducing costs and an
emphasis on a private-sector management style
• careful use of resources to drive down the cost of labor and
other inputs, where possible.
Recognizing the many reasons for market failure in health
care (Arrow 1963), new public management builds on several
concepts that arise from new institutional economics. Included
in these is contestability (Baumol, Panzar, and Willig 1982), in
which the benefits that competition is thought to bring can
arise even when competition is absent, thus ensuring that the
barriers to market entry are sufficiently low to allow other
providers to emerge. User choice is given priority over most
other goals, including equity.
The enthusiasm for new public management was largely
ideological, reflecting the contemporary rejection of an
expanded role for the state; the extent to which this model was
actually able to achieve what was claimed for it remains highly
contested (Le Grand and Bartlett 1993; Stewart 1998). In particular, critics drew attention to the high transaction costs
involved (Evans 1997) and the lack of evidence that competition can actually bring about the intended improvements in
quality of care (Maynard 1998).
One feature of the new public management is its emphasis
on general management, with managers possessing skills and
expertise that can be applied to any sector. These managerial
attributes are considered to be of greater importance than technical or professional knowledge. As a consequence, in some
countries, the balance of power has begun to shift away from
health professionals and toward general managers. In many
places, the initial enthusiasm has given way to disillusionment
and subsequently to a more balanced view that, though the precise solution will reflect the particular circumstances of the
health care system, what is needed is a partnership between
these two groups.
In some countries, this development will mean that managers must assume a greater role in relation to the delivery of
clinical care. Such an expanded role will extend from their
traditional responsibilities, such as financial controls, hotel
services, and payroll management, to active participation in
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setting and monitoring standards for care delivery, linked to a
responsibility for ensuring that the resources needed for care
delivery are available.
In other countries, this role may involve stepping back a
little. In an analysis of the British National Health Service, in
which the degree of managerial control over the delivery of
health care has proceeded further than in many other industrial
countries, Harrison and Pollitt (1994) note how clinical decision making is increasingly driven by diagnostic and treatment
protocols. Although often developed locally, working arrangements are increasingly specified, with the introduction of
timetabled job plans for medical specialists and much greater
measurement of outcomes. Yet Harrison and Pollitt argue that
the growth of managerial control over professional activity is
likely to be constrained by the increasing involvement of professionals in management, even if they do not fully adopt the
managerial agenda. A further constraint is the persisting ability
of professionals, because of their specialized knowledge, to
resist managerial control and the related unwillingness of lay
managers to extend their control into certain areas in which
they do not feel competent.
Managing for Improved Quality of Care
An increasing volume of research in industrial countries has
focused specifically on managerial and organizational responses
to evidence that health systems often deliver suboptimal care
(Institute of Medicine 2001). Quality of care is addressed in
more detail in chapter 70. However, some of the key messages
from this research are relevant here.
One message is that change must take place at all levels of
the system. In this context, Ferlie and Shortell (2001) identify
four such levels: the individual, the group or team, the organization, and the larger system or environment. They note the
growing evidence that strategies that focus on individuals alone
are unlikely to be successful, whereas those that are embedded
within broader organizational change are more likely to be
effective (Davis and others 1995). A second key message is the
importance of teamwork, with evidence that well-functioning,
multiprofessional teams provide better quality care (Aiken,
Sochalski, and Lake 1997). However, change may be inhibited
by barriers at the level of the organization, including lack of a
consistent focus on quality, inadequate information, lack of
physician involvement, and inadequate managerial support
(Shortell, Bennett, and Byck 1998).
MANAGING CLINICAL SERVICES
IN DIFFERENT SETTINGS
Clinical services are provided in a variety of settings, from the
patient’s home to ambulatory care facilities and hospitals
providing inpatient care. They include those services that
involve direct contact between a patient and a health care professional, as well as indirect contact, such as when a pathologist
provides a diagnosis on a biopsy or blood sample. Reflecting the
focus of much existing research, this section is structured in
terms of different settings of care: ambulatory care, hospitals,
and community care. Unfortunately, rather less research transcends these often artificial and arbitrary divisions to look at the
more important issue of the patient’s journey through the health
care system, given that one of the greatest managerial challenges
facing those delivering clinical services is how to ensure that the
journey is efficiently navigated (McKee and Nolte 2004).
Furthermore, available research that focuses on health facilities
is often difficult to generalize because of the different meanings
attributed to common terms such as hospital, health center,
or more prosaically, hospital bed. For example, a major
teaching hospital in a capital city, such as the Kenyatta National
Hospital in Nairobi (http://www.kenyattanationalhospital.org/
services.html), which offers invasive cardiology, renal transplants, and radiotherapy, is very different from a rural hospital
with perhaps 100 beds and a single operating theater that
provides only the most basic surgical and obstetric care.
Hospitals
Although hospitals are rarely the first places of contact between
patients and health systems, and although hospitals do not provide the greatest share of health care, it is appropriate to begin
with them because they often account for the largest share of
public health sector expenditure (OECD 2003). They are also
particularly difficult to manage for several reasons:
• One reason is the diversity of tasks that a hospital must
undertake (Healy and McKee 2002b). Many hospitals fulfill roles that go beyond the delivery of patient care to provide training and research, support to community-based
facilities, and even local employment or civic identity
symbols.
• A second reason is the blurring of boundaries between
hospitals and the rest of the health care system, which has
occurred as a result of the emergence of many innovative
models of care that cross the boundary between secondary
and either primary or social care. A related issue is the shift
taking place in many countries to managing patients
through a complex combination of short inpatient stays
and visits as an outpatient to specialist clinics and diagnostic facilities (McKee and Healy 2001). This approach is
vastly more complicated to manage than the traditional
model in which patients were admitted to wards from
which they were taken to undergo investigations and treatment at a time convenient for the specialist concerned, a
process managed by senior nurses. The new model requires
new health worker roles, which might be termed case
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managers. These case managers help patients to navigate
the system.
• A third reason is the contrast between the rapidly changing
demands on hospitals and the structural rigidities of hospitals themselves (McKee and Healy 2000). The original justification for creating hospitals as institutions was the need
to concentrate equipment such as operating theaters, x-ray
machines, and laboratories, and expertise such as medical
specialists. Yet changes in the nature of health care are raising questions about how hospitals of the future should be
configured. Many laboratory functions are being replaced
by testing kits that can be used at the bedside, diagnostic
equipment such as ultrasound scanners is being used in primary care, and a new generation of primary care workers
are acquiring greatly augmented skills. In this rapidly changing environment, managers may be faced with aging hospital buildings that may lack sufficient electrical sockets for
the greatly increased amount of equipment now available,
or managers may have staff members with deeply ingrained
ways of working who pose a particularly acute managerial
problem.
These issues can be seen in the Kenyatta National Hospital
in Nairobi, where a new managerial approach was developed
but faced problems because of an unclear understanding of the
kind of services to be provided, weak managerial capacity, and
a lack of focus in targeting services (Collins and others 1999).
In Zambia, financial management and accountability improved
when the hiring of hospital staff was delinked from the national
civil service, yet the process has been derailed on a wider scale
because of trade unions’ resistance to the changes (Hanson and
others 2002).
Ambulatory Care
Ambulatory care, delivered on an outpatient basis, is the commonest form of contact between patients and health care
providers. Although it often receives relatively little attention
from policy makers compared with the more resourceintensive inpatient hospital care, ambulatory care contributes
substantially to health care system performance (Berman
2000). Good management of ambulatory services is essential
because these services are often the entry and exit points for
consumers; however, these services can be difficult to manage
effectively (Waghorn and McKee 2000).
Effective coordination of ambulatory and inpatient services
is needed to ensure that patients are cared for in the most
appropriate settings, thereby reducing inefficiencies such as the
overuse of hospitals for nonemergency care. Such coordination
often involves developing shared protocols for referral and
management. In Benin and Guinea, for example, diagnostic
and treatment decision trees were developed collaboratively
with the local staff, leading to more efficient use of resources
(Levy-Bruhl and others 1997). In Zambia and Tanzania,
strengthening of management capacities in primary care facilities through a team-based approach to decision making that
linked planning to budgeted action plans led to improved client
perceptions of facilities and to a marked increase in utilization
(Few and Harpham 2003). However, the challenges of management in the ambulatory care sector are great in many countries;
this sector is often highly fragmented, with extensive and
largely unregulated private provision and few levers to exert
pressure for change.
Community and Social Care
A particular challenge is how best to link long-term management of medical conditions with community and social care in
those cases in which an effective response to health needs spans
the interface. Management of chronic physical or mental illness
in the elderly, for example, can fall under the responsibility of
home care and volunteer agencies, day centers, day hospitals,
rehabilitation hospitals, and long-term care institutions, as well
as community-based health teams (Bergman, Beland, and
Perrault 2002). A systematic review of community-based care
for elderly people in industrial countries concluded that such
schemes can favorably affect rates of institutionalization and
costs. However, comprehensive approaches involving program
restructuring are often necessary, and cost-effectiveness
depends on the characteristics of the health and social care systems. The review’s authors identified as a critical challenge the
expansion of those programs considered to be successful
(Johri, Beland, and Bergman 2003).
Low-income countries face particular obstacles because
they often lack effective alternatives to hospital care. As a result,
patients are frequently cared for by their families but with little
support, or they are consigned to large, poorly equipped, and
poorly staffed institutions. This situation has stimulated the
development of models of “community care,” in which health
care providers work with communities to deliver services. In
the area of mental health, for example, the World Health
Organization (WHO) has developed models of care that cover
a range of care settings, including community centers and outreach services and residential homes, backed up by access
to hospital outpatient and emergency care (WHO 2001).
Similarly, the complexities of caring for people with disabilities
in low-income countries have led to internationally developed
guidelines that advocate a shared role for heath care providers
and local communities (Helander 2000). Accordingly, effective
coordination of those services clearly depends in large part on
effective management. Shifting from hospital-focused care to
community care introduces many managerial challenges. One
element of an effective response should be to heighten the
autonomy of patients in managing their diseases, but this
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response requires attitudinal changes among providers, who
must commit to a real shift of power to patients, supported by
effective information systems and safeguards for vulnerable
patients (Litwin and Lightman 1996).
Health care systems are generally poor at addressing longterm illnesses, especially when those illnesses require integrated
care spanning primary, secondary, and community providers
(McKee and Nolte 2004; WHO 2001). The often low status
accorded to these conditions in the hierarchy of priorities, coupled with fragmentation between health and social sectors
(WHO 2002), will require greater commitment to managerial
reforms that can improve the delivery of appropriate services.
THE SPECIFICS: WHAT WORKS?
This section turns to those policies that are designed to
enhance the resources available to deliver health care and to
combine them in ways that optimize the potential benefits. It
looks, in turn, at the different elements required to deliver
effective care: human resources, physical resources, intellectual
resources, and the organizational or social resources that bind
them together. The section begins with the most important
resources for health care systems: the people who provide care.
Developing Human Resources
A key element in the delivery of effective health care is how to
provide staff members with the appropriate combination of
skills to do their jobs effectively.
Increasing Skills. In their review undertaken to inform the
Commission on Macroeconomics and Health, Oliveira-Cruz,
Hanson, and Mills (2003) identified 13 studies that assessed the
effects of training to enhance skills. Though the results were
mixed, training programs were overall more likely to have positive rather than negative effects. Several studies focused on
communication and counseling skills, which often lead to
improved client satisfaction. A study from Zambia showed that
training must be linked to other resources; although training
was associated with improved transmission of information,
there was no decline in the number of complaints from clients
who remained unhappy about long waits and short contact
time (Faxelid and others 1997).
Changing Skill Mix. The division of tasks among different
health care workers reflects many considerations, but evidence
about who would be best at doing these tasks is rarely
considered. There may be regulations restricting tasks to one
professional group, such as the right to prescribe, or there may
be cultural norms, which while unwritten have just as great an
effect. Underlying these factors is a set of issues that includes a
difference in the power of different professions, itself often a
reflection of gender relationships in society, with a predominantly male medical profession controlling a predominantly
female nursing profession. However, increasing evidence suggests that traditional demarcations do not support the optimal
ways to provide care, and there is considerable scope for changing the mix of skills involved in delivering many aspects of
health care.
This topic has recently been reviewed systematically by
Sibbald, Shen, and McBride (2004), who have developed a taxonomy of the types of change in skill mixes that are possible
(table 73.1). Their review shows that many tasks undertaken by
one professional group can yield comparable and often better
results when performed by another group. In particular, they
show how nurse-led clinics often achieve better outcomes than
traditional doctor-led service (Connor, Wright, and Fegan
2002; Stromberg and others 2003; Vrijhoef, Diederiks, and
Spreeuwenberg 2000; Vrijhoef and others 2001, 2003).
Table 73.1 A Taxonomy of Changes in Skill Mix in Health Care
Changing roles
Enhancement
Increasing the depth of a job by extending the role or skills of a particular group of workers
Substitution
Expanding the breadth of a job, in particular by working across professional divides or exchanging one type of worker for another
Delegation
Moving a task down a traditional unidisciplinary ladder
Innovation
Creating new jobs by introducing a new type of worker
Changing the interface between services
Transfer
Moving the provision of a service from one health care setting to another (for example, substituting community for hospital care)
Relocation
Shifting the venue from which a service is provided from one health care sector to another without changing the people who provide
it (for example, running a hospital clinic in a primary care facility)
Liaison
Using specialists in one health care sector to educate and support staff members working in another (for example, hospital outreach
facilitators in primary care)
Source: Sibbald, Shen, and McBride 2004.
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Although Sibbald, Shen, and McBride focus their review on
experience in industrial countries, by challenging many deeply
held beliefs they indicate what could be done in other settings
around the world, after taking into account local circumstances
such as the skills and expertise of those involved, as well as any
salient regulatory or training issues.
Strengthening Management
In their review of constraints to health service delivery,
Oliveira-Cruz, Hanson, and Mills (2003) identified 10 studies
that evaluated the effect of management strengthening. The
activities in those studies included the following:
• workshops for identifying and prioritizing managerial
programs
• introduction of regular planning and evaluation cycles
• quality assurance methods
• establishment of routine communication systems
• training activities.
They concluded that the results were generally positive, with
more rational use of funds; greater availability of funds as a
consequence of better planning; improved coordination and
integration of programs; improved methods of working; better
staff morale; enhanced data collection, reporting, and use; and
increased community participation. WHO has developed an
approach to strengthening management that has been successful in a variety of settings (Cassels and Janovsky 1995).
It is important to identify where specific managerial skills
are lacking and to explore different ways of obtaining them,
whether through training, recruitment, or links with related
organizations. For example, improved financial management
in district health teams in Ghana was made possible by integrating staff members from local government accounts offices
(Kanlisi 1991); a similar initiative was successful in The
Gambia (Conn, Jenkins, and Touray 1996). However, a word of
caution is required. Although a management strengthening
exercise undertaken in Tanzania was successful when implemented at the local level, it failed when scaled up because the
same degree of involvement by the originating team was no
longer possible (Barnett and Ndeki 1992).
needs (England 2000; Preker, Harding, and Travis 2000).
Capital charging—requiring managers to explicitly account for
the value of physical assets out of funding allocation or contract revenues—has been developed as a response, successfully
heightening public sector management of capital investments
in the United Kingdom and New Zealand (Heald and Scott
1996). Capital charging has been proposed as a strategy to
stimulate better capital management in developing countries as
well. For example, in Malaysia a corporatized hospital has been
required to reimburse invested capital through dividends, with
the Malaysian government recouping one-third of its original
investment within five years (Hussein and Al-Junid 2003).
Similarly, the Kenyatta National Hospital in Nairobi was
obliged to account for all accruals (for example, property and
depreciation) when it was given greater autonomy. Though
changes in accounting management have experienced some
shortcomings, improvements have been seen in financial transparency, timeliness of reporting, donor satisfaction, and revenue collection (Collins and others 1999).
Within the public sector, changes in line management have
facilitated the incorporation of more explicit infrastructure
concerns into the planning process. The central authority in
Hong Kong (China) has made capital acquisition decisions
jointly with hospitals during annual planning processes (Yip
and Hsiao 2003). The introduction of business planning to district-level planning in Turkmenistan heightened accountability
for maintaining physical infrastructure: use of a global budgeting model (that is, increased autonomy in line management as
well as performance monitoring) led to reduced resource allocation to personnel and a greater than fivefold increase in
maintenance expenditures (Ensor and Amannyazova 2000).
Explicitly managing capital investments in both the short and
the long term may facilitate efficient resource allocation.
Although capital charging is a relatively straightforward
technical solution, capital investment can be particularly susceptible to political derailment (Anell and Barnum 1998). In
the hospital sector, for instance, many transition economy
countries have had difficulty downsizing infrastructure
because those with decision rights to manage capital (that is,
local governments) are different from those who have incentives to do so, such as hospital managers (Jakab and Preker
2003).
Managing Physical Resources
Managing infrastructure and other capital assets such as hospitals and health centers requires investment planning in both
the short term (for example, maintenance) and the long term
(for example, new acquisitions). Historically, however, costs
associated with capital consumption and maintenance have not
been met through operating budgets, resulting in few incentives for public sector health planners to efficiently manage
infrastructure or to respond to market demand and consumer
Strengthening Drug Procurement, Regulation,
and Distribution
Managing pharmaceutical resources is crucial for ensuring
access to essential drugs and promoting their rational use
(Mossialos, Mrazek, and Walley 2004). WHO defines the goals
of rational use of drugs as delivering medications effectively—
appropriate to patients’ clinical needs and at dose levels and
durations appropriate to their individual requirements—and
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at an affordable cost (WHO 1985). The public sector plays a
key role in providing the framework for rational use of drugs
(Quick 1997) through measures ranging from drug regulation
to clinical practice guidelines.
National drug policies (NDPs) can be effective in regulating
private and public sector provision of essential medicines. The
Lao People’s Democratic Republic’s NDP has been important
in improving private pharmacy service quality (Stenson,
Tomson, and Syhakhang 1997). In Burkina Faso, an NDP has
enhanced the performance of rural pharmacies (Krause and
others 1998). At the local and facility levels, increasing
accountability can also lead to a more rational use of drugs. A
simulation exercise in Tunisia that required physicians to relate
pharmaceutical budgeting to involvement in the procurement
process improved prescribing practices by containing costs
while increasing the use of essential drugs (Garraoui, Le
Feuvre, and Ledoux 1999). Enhanced management information systems, with corresponding supervision, monitoring, and
top-level support, have improved contraceptive management
in several countries (Kinzett and Bates 2000). The introduction
of standard treatment guidelines and formularies has reduced
overprescribing in several countries, and educational materials
for consumers in Cameroon increased compliance with antibiotic regimens (Nabiswa, Makokha, and Godfrey 1993).
A comprehensive review of interventions used in SubSaharan Africa, where health systems are plagued by shortages
of supplies, high costs, large-scale use of proprietary drugs,
waste, and theft, provided considerable evidence to suggest
what works in those countries (Foster 1991). Successful interventions included the following:
• selection and precise quantification of drug needs—in
particular, the creation of essential drug lists
• improved procurement, with greater use of generics, competitive bidding, and international procurement agencies
• improved storage and distribution, with better storage conditions, inventory controls, security systems, and use of
prepacked kits.
At the same time, several factors constrain better management of pharmaceuticals. Considerable resources are needed to
adequately monitor NDPs, and implementation can be difficult
(Petrova 2002). Furthermore, much of the pharmaceutical use
is outside the control of the public sector: two-thirds or more of
health problems are self-medicated. Though the public sector
may strive to inform consumers, patients’ nonadherence
remains high (Le Grand, Hogerzeil, and Haaijer-Ruskamp
1999). As in management of other inputs, political considerations can thwart managerial responses. The Republic of Korea
decided to divide its prescribing and dispensing functions
precisely to address high levels of pharmaceutical overuse and
misuse, but it subsequently faced strikes and stiff opposition
from those same stakeholders (Kwon 2003). Management of
pharmaceuticals thus presents a complicated challenge, requiring significant investment and flexible responses.
Using Intellectual Resources
The process of generating, disseminating, and using knowledge
is frequently imperfect. Pang and others (2003) have argued
that a well-functioning health care system must have in place
mechanisms that allow it to access and use research and the
products of research. They highlight the weaknesses of much of
the existing health care research, including fragmentation,
overspecialization, and damaging competition among researchers, who are frequently isolated from other researchers
and from the policy-making community. Drawing on concepts
of the functions of a health system, they identify a series of four
roles for a health research system:
• stewardship, which includes defining and articulating a
vision for a national research system, identifying appropriate priorities, and setting and monitoring ethical standards
• financing, which includes obtaining research funds and allocating them accountably
• creating and sustaining resources, which includes the physical
and human capacity to conduct, absorb, and use research
• producing and using research, which includes generating
valid research outputs; translating research into formats that
inform health policy, practices, and public opinion; and
promoting the use of research to support innovation.
Such a system must be able to answer the many different
questions requiring research, from basic laboratory science,
such as new drug development, through health services
research, such as comparisons of the cost-effectiveness of different drug regimens, to organizational research, such as the
best way of delivering the most cost-effective drug regimen.
Although the majority of health systems and services research
continues to be undertaken in the industrial countries, a growing volume of research addresses the needs of low- and middleincome countries, such as that by the participants in the
Effective Health Care Alliance Programme (EHCAP), an international research network that is undertaking systematic
research within the framework of the Cochrane Collaboration
(http://www.liv.ac.uk/lstm/ehcap/introduction.htm).
Establishing Relationships
The debate about the relative benefits of vertical (in which a
single disorder is tackled by a program managed across levels
from the Ministry of Health to the health care provider) and
horizontal (in which health care for a wide range of disorders
is delivered through a system that is integrated at each level)
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systems of health care delivery has been examined in detail in a
major review of relevant literature by Oliveira-Cruz, Kurowski,
and Mills (2003). They note how many activities lie on a continuum between the two extremes, with the Global Polio
Eradication Initiative more vertical than the Expanded
Programme on Immunization, which in turn is more vertical
than the integrated management of childhood illness
approach. They identify certain features that are often associated with vertical programs and that promote success: specific
objectives, clear work schedules, well-defined techniques, and
frequent supervision. They also identify characteristics that are
often associated with horizontal programs and that can hamper effectiveness: shortage of essential drugs, lack of adequate
staff training, intermittent supervision, and limited backup.
However, they note that horizontal programs have considerable
potential to deliver effective services if they are adequately
funded, staffed, and managed, largely because of their
economies of scale and scope.
To some extent, the approach is determined by the nature of
the program. Vertical programs are most effective when the
technology involved is very sophisticated or when it includes
procedures different from the usual tasks and thus requires specialist skills. Vertical programs may be more appropriate when
there is a need to rapidly achieve major reductions in the burden of a disease, although this situation does not preclude
embedding the management of the program within existing
organizations. These programs are often a response to weak
management capacity in the existing system, although it is
argued that they can perpetuate this problem or even undermine what does exist, diverting the attention of staff members
from their usual tasks. Such programs often have a short time
horizon, either being absorbed into existing systems or brought
to an end. In part, their duration is linked to the source of their
funding, which is often from donors who themselves have a
short time horizon.
Integrating previously vertical programs into mainstream
systems can be successful, as with schistosomiasis programs in
Saudi Arabia (Ageel and Amin 1997) and Brazil (Coura Filho
and others 1992). However, a systematic review of integration
failed to identify consistent benefits, largely because of the very
limited extent of the evidence available and the context-specific
nature of this process (Briggs, Capdegelle, and Garner 2001).
The authors of that review concluded that the question facing
policy makers is not whether one approach is invariably better
than the other; rather, it is how best to build on the synergies
among them to maximize overall benefits. They note, for
example, how the many successes of the Malaria Eradication
Programme in the 1950s and 1960s were not sustained because
active case surveillance was not integrated into routine health
services (see also Bradley 1998).
Successful vertical programs are likely to involve community
participation, but not to the extent that there is overdependence
and subsequent attrition of volunteers. The programs’ developers will have learned lessons from other similar programs, in
relation to both organizational and technical issues. Where
several vertical programs coexist, the programs’ developers
should explore how they can share common elements.
Contracting for Services
The setting of contracts by public agencies to purchase health
care services is increasingly common in a number of low- and
middle-income countries. The theoretical case for contracting
out identifies potential advantages from combining public
finance with private provision. However, there may also be difficulties, such as ensuring that competition takes place among
potential contractors, that competition leads to efficiency, and
that contracts and the process of contracting are effectively
managed; consequently, these advantages may not always be
realized (McPake and Banda 1994).
Unfortunately, the question of whether the advantages outweigh the disadvantages has been the subject of relatively little
empirical study in low- and middle-income countries, and
what exists is often highly context specific. For example, in
Zimbabwe, a comparison of a hospital owned by a colliery,
from which services were purchased by the government, and a
nearby government hospital found that the colliery hospital
offered services of at least comparable quality at prices lower
than the unit costs of the government hospital after capital
costs were included (McPake and Hongoro 1995). However,
failure to establish policies on thresholds for use meant that
growth in expenditure on the colliery hospital was not controlled. The authors argue that contracted facilities can achieve
powerful bargaining positions if there are no viable competitors and the government does not retain the ability to offer an
alternative service. They also identify a need for specific skills to
manage contracts at all levels. Where a policy of contracting is
a response to crises arising from civil service retrenchment
and public expenditure cuts, these skills are unlikely to be
developed.
Another study examined the economic arguments for contracting for district hospital care in South Africa, by using private for-profit providers, and in Zimbabwe, by using nongovernmental (mission) providers (Mills, Hongoro, and
Broomberg 1997). In the South African setting, there were no
significant differences in quality among three contractor hospitals and three government-run hospitals, but the contractor
hospitals provided care at significantly lower unit costs.
However, the overall cost to the government was similar for the
two options because of the additional cost of contracting, with
the efficiency gains captured almost entirely by the contractor.
In Zimbabwe, two district-designated mission hospitals delivered similar quality care at lower cost than did two government
hospitals. However, the contract between the government and
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the missions was implicit, rather than explicit, and was of long
standing. As in the other Zimbabwean example, the authors
identified the importance of developing the government’s
capacity to design and negotiate contracts that allow the government to derive significant efficiency gains from contractual
arrangements.
Increasing Provider Autonomy
A review of cross-country experiences with enhanced autonomy of hospitals found improvements in service delivery. The
most successful cases—in Hong Kong (China) and Tunisia—
applied private sector management techniques and training,
with appropriate performance assessment systems for staff. In
countries where reforms were considered less successful, managers had been granted greater autonomy without suitable
performance-oriented incentives (New Zealand) or vice versa
(Indonesia) (Hawkins and Ham 2003). In the Kenyatta
National Hospital, greater autonomy led to the introduction of
performance appraisal linked to incentives, enabling the dismissal of poor performers and increased benefits and greater
responsibilities for good performers. This change was coupled
with clarification of clinical management roles. Complementing increased salaries for staff nurses, these changes
helped improve the hospital’s strategic management, donor
accountability, and performance reporting (Collins and others
1999).
Implementing such management strategies in a coherent
fashion is not an easy task. Hospital governance in several
Eastern European countries, which has been transferred to
local governments to improve responsiveness, has included
measures such as performance-based payment mechanisms.
Performance did not improve as expected because of an
“inconsistent incentive environment”; rewards and sanctions
were not linked to performance. Important factors in that failure to improve were weak stewardship functions and an
absence of effective governance at the regional level, which
made it difficult to change the initial configuration of the hospital system. Instead, increased hospital autonomy was used to
ensure the survival of the institution rather than to meet the
needs of the population. Thus, a continuing excess of capacity,
inefficiency, and poor responsiveness to patient expectations
remains (Healy and McKee 2002a). A review of experience with
programs that increased autonomy in Sub-Saharan Africa also
identified only modest success in achieving the stated goals
(McPake 1996).
Public or Private Provision?
Although there has been considerable enthusiasm for privatizing state facilities because of the supposed efficiency gains
achieved in the private sector, in reality the evidence is
somewhat mixed. Thus, a study of dispensaries run by the government and by nongovernmental organizations in Tanzania
found considerable variation in both sectors (Gilson 1995).
This finding was consistent with another study in Tanzania of
primary care providers in Dar es Salaam. In the latter, although
the quality of care offered by private providers was, on average,
better, much low-quality care was found in both types of facilities (Kanji and others 1995). Considerable variation in
providers of both types, although with overall better quality
in the private sector, was also reported in a study in Senegal
(Bitran 1995). In summary, there is very little evidence to support the contention that private provision is better than public
provision, and what evidence exists indicates considerable variations in both.
Strategic Purchasing
The quest to deliver effective health care is a dynamic process,
adapting continually to changing health needs and the opportunities that arise that make it possible to respond in new and
better ways. However, health systems that have failed in the past
to respond to these changing circumstances face even greater
problems. The pace of change is constantly increasing, with factors such as greater population mobility contributing to the
reemergence of infectious diseases and with demographic
changes and lifestyle changes giving rise to a new burden of
chronic diseases.
Health care providers have faced difficulties in responding
to this challenge on their own. Although they may possess a
great deal of information about the patient sitting in front of
them and, on the basis of their training and accumulated experience, about what might be done to help that patient, health
care providers confront several important information gaps:
• First, they may know little about those who, despite being in
need of health care, do not seek help. These people will often
be the most disadvantaged in a society, with few means of
making their voices heard.
• Second, they may have inadequate knowledge about newly
emerging treatments or more effective ways of providing
those treatments, especially if the treatments involve creating multidisciplinary teams with new sets of skills, working
in ways outside their experience.
• Third, even if providers introduce changes, they may have
inadequate knowledge of whether such changes have been
effective.
These knowledge gaps provide the justification for action to
improve the delivery of health care at several levels above that
of the individual encounter between the patient and the health
professional. Strategic purchasing brings together a series of
interlinked activities: assessing health needs, using appropriate
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258
Health strategy
SUMMARY
Assess
needs
Monitor
outcome
Specify care
model
Purchase
care
Source: McKee and Brand 2005.
Figure 73.1 A Framework for Strategic Purchasing
evidence to develop models of care that meet priority needs,
creating the appropriate combination of regulations and incentives to implement those models, and then evaluating the
response and reassessing whether the need remains (Figure
73.1). All of these activities should take place within an overall
health strategy that takes into account the goals of a health care
system, such as those defined by WHO (2000), of increasing
health attainment, providing services responsive to the population’s needs and expectations, and financing those services
equitably.
The development of a strategic purchasing function is complicated, requiring high levels of information resources, both
on health needs and on effectiveness. Strategic purchasing
involves using technical and political skills, determining the
needs of the population, identifying evidence of the effectiveness of different care packages, and setting priorities within
limited resources. The last of these components is arguably the
most difficult, given the high level of need and the scarcity of
resources in many places. This list of components highlights
why, in addition to having skills in financial and personnel
management, the effective health service manager needs at least
a working knowledge of clinical epidemiology and economic
evaluation.
Even in industrial countries, the strategic purchasing function is often poorly developed. Given its many interlinked components and the problem of isolating any benefits from wider
changes in the health system, this function is very difficult to
evaluate. Nonetheless, it is included here as a model from
which concepts may be adopted in low- and middle-income
settings.
Health systems worldwide face unprecedented challenges in
responding to the increasing complexity of health care. Systems
that were capable of providing basic care to populations for
whom diseases were either simple or complex but self-limiting
confront a fatal struggle to keep up with the increasing opportunities that modern science has provided. The challenge is
especially great for health systems in low- and middle-income
countries because the global community is no longer willing to
sit back while millions of people die from treatable diseases
such as malaria and tuberculosis and fail to receive lifeprolonging therapies for AIDS. As a consequence, some of the
resources, primarily pharmaceuticals, are being made available
to those who need them. However, the challenge that health
systems face is not simply a lack of money to purchase pharmaceuticals; effective management systems are requisite as well
to create the infrastructure to identify those in need, establish
appropriate treatments, and ensure provision of these treatments as long as necessary. Emerging challenges must be identified, and the necessary resources to deal with them must be
brought together and applied effectively.
Many countries have a clear need to invest in the development of human resources. Although in many cases this investment will require new and wide-ranging human resource
strategies involving training, career progression, and retention,
there seems to be scope for rapid gains from some shorter
forms of training, particularly, in communications skills.
Although the evidence for the effectiveness of current models
of management strengthening is somewhat mixed, gains may
be realized by identifying and filling key gaps, such as those in
financial expertise. Changing the skill mix can do much to
match available skills to tasks.
Much also can be done to manage the capital stock better or,
in most cases, to manage it at all. For example, mechanisms
such as capital charging can focus greater management attention on this issue, although this will work only if sufficient
capacity can be focused. Important gains can be made from
better management of pharmaceuticals, an issue of increasing
importance because of the new funds made available for their
purchase.
Modern health care is based on the growth of knowledge,
and it is as important to manage intellectual resources as it is to
manage people and equipment. Doing so means investing in a
health research strategy that includes the generation, synthesis,
and adoption of knowledge.
Finally, it is necessary to bring these resources together optimally, which raises issues of relationships between different
levels of the system, between the public and private sectors, and
between vertical and horizontal programs. Unfortunately,
despite the large amount of rhetoric on these often highly ideological issues, there is surprisingly little research to inform
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policy. More than ever, the issue of context specificity
reemerges, leading once more to the answer “it depends.”
The delivery of optimal health care requires well-developed
managerial skills to apply methods that are appropriate for
the setting in which they are being applied. However, it also
requires governments to provide oversight of their health systems and to anticipate changes and give managers the tools
with which to respond to those changes.
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Chapter 1
Measuring the Global Burden of
Disease and Risk Factors,
1990–2001
Alan D. Lopez, Colin D. Mathers, Majid Ezzati, Dean T. Jamison, and
Christopher J. L. Murray
In an era when most societies must cope with increasing
demand for health resources, they will inevitably have to
make choices about the provision of health services, even if
those choices are, by default, to continue current practices.
Strategic health planning can accelerate health development
and the attainment of health goals or reduce the cost of
reaching such goals. Such planning must take into account
the needs that the health system must address; that is, policy
makers must be aware of the comparative burden of diseases
and injuries and the risk factors that cause them, and how
this burden is likely to change with the adoption of various
policies and interventions. Needs are, of course, not the
only factors determining service provision, but should be a
critical component of the decision-making and planning
processes.
The issue then becomes how to assess the comparative
importance of risks to health and their outcomes in different demographic groups of the population.What is needed
is a framework for integrating, validating, analyzing, and
disseminating the fragmentary, and at times contradictory,
information that is available on a population’s health, along
with some understanding of how that population’s health is
changing, so that the information is more relevant for health
policy and planning purposes. The Global Burden of
Disease (GBD) framework is the principal, if not the only,
attempt to do so. Features of the GBD framework include
the incorporation of data on nonfatal health outcomes into
summary measures of population health, the development
of methods for assessing the reliability of data and imputing
missing data, and the use of a common metric to summarize
the disease burden from diagnostic categories of the
International Classification of Diseases and the major risk
factors that cause those health outcomes. Figure 1.1 presents
a simplified version of this framework and indicates the
causal chain of events that matter for health outcomes,
identifying the key components and determinants of health
status that require quantification.
Many countries and health development agencies have
adopted the GBD approach as the standard for health
accounting and for guiding the determination of health
research priorities, for example, Australia (Mathers, Vos, and
Stevenson 1999); the state of Andra Pradesh, India
(Mahapatra 2002); Mauritius (Vos and others 1995); Mexico
(Lozano and others 1995); South Africa (Bradshaw and
1
©2006 The International Bank for Reconstruction and Development / The World Bank
263
Distal
socioeconomic
and
environmental
causes
Proximal
determinants
(risk factors)
Diseases and
injuries
Impairments
Functional
limitations
(disability)
Nonhealth
well-being
Death
Source: Mathers and others 2002.
Note: This presentation is intended as a broad schema: for example, some exposures, such as environmental factors, can be proximate causes of disease,
and injuries can lead directly to death.
Figure 1.1 Overview of Burden of Disease Framework
others 2003); Thailand (Bundhamcharoen and others 2002);
Turkey (Baskent University 2005); the United States
(McKenna and others 2005); and the World Health
Organization (WHO 1996).
This chapter begins with a brief history of the work on
burden of disease, including a discussion of the nature and
origins of the disability-adjusted life year (DALY) as a measure of disease burden. Next it discusses applications of burden of disease analysis to the formulation of health policy.
The chapter then summarizes the methods and findings of
the 2001 GBD study, reported in more detail in chapters 3
and 4 of this volume. A concluding section takes stock of the
work on disease burden since the early 1990s and suggests
some key areas for further work.
Following this introductory and summarizing chapter,
chapter 2 describes the demographic underpinnings for the
epidemiological assessments that follow and provides context by briefly reviewing recent changes (from 1990 to 2001)
in key demographic parameters. The chapter also assesses
changes in the cause distribution of mortality among children under five between 1990 and 2001 and the difficulties
of reliably assessing trends in mortality. Chapters 3 and 4
provide the definitive methods and results of the 2001 GBD
study. Chapter 3 reports on deaths and the disease and
injury burden by age, sex, and 136 disease and injury categories. Chapter 4 reports on the disease and injury burden
resulting from 19 risk factors, specifically for a number of
important conditions. Both chapters present results using
the World Bank’s classification of low- and middle-income
countries into six regional groups. Chapter 5 then explores
the robustness of the major findings to uncertainties in the
data and to alternative assumptions concerning construction of the DALY. Chapter 6 examines the implications of
including stillbirths in a global burden of disease assessment. Their inclusion is potentially significant, both because
the numbers are large (3.3 million in 2001), and because
including stillbirths raises major questions about how
to assess the DALY loss associated with deaths near the time
of birth.
HISTORY OF BURDEN OF DISEASE STUDIES
In 1992, the World Bank commissioned the initial GBD
study to provide a comprehensive assessment of the disease
burden in 1990. The study was undertaken for the world as
a whole and for 8 regions (Lopez and Murray 1998; Murray
and Lopez 1996a,d; Murray, Lopez, and Jamison 1994;
World Bank 1993). In order to recommend intervention
packages for countries at different stages of development,
the estimates were combined with analyses of the costeffectiveness of interventions in different populations
(World Bank 1993; Jamison and Jardel 1994). Whereas
earlier attempts to quantify global cause of death patterns
(Hakulinen and others 1986; Lopez 1993) were valuable
initial contributions to building the evidence base for policy, they were largely restricted to broad cause of death
groups, for example, all infections and parasitic diseases
combined, and did not address nonfatal health outcomes.
The methods and findings of the 1990 GBD study have
been widely published and, as noted earlier, have spawned
multiple disease burden exercises (Murray and Lopez
1996c,d; 1997a,b,c).One of the basic principles guiding a burden of disease assessment is that almost all sources of health
data are likely to contain useful information provided they are
carefully screened for validity and completeness.With appropriate methods, investigator commitment, and expert judgment, obtaining internally consistent estimates of the global
descriptive epidemiology of major conditions is possible. To
prepare internally consistent estimates of incidence, prevalence, duration, and mortality for almost 500 sequelae of the
diseases and injuries under consideration, a mathematical
model, DisMod, was developed for the 1990 GBD study to
convert partial, often nonspecific, data on disease and injury
occurrence into a consistent description of the basic epidemiological parameters in each region by age group (Barendregt
and others 2003; Murray and Lopez 1996b).
Many diseases, for example, neuropsychiatric conditions
and hearing loss, and injuries may cause considerable ill
health but no or few direct deaths. Therefore separate
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264
Box 1.1
Disability-Adjusted Life Years
The DALY is a health gap measure that extends the concept of potential years of life lost due to premature death
to include equivalent years of healthy life lost by virtue of
individuals being in states of poor health or disability
(Murray 1996). One DALY can be thought of as one lost
year of healthy life and the burden of disease as a measure
of the gap between current health status and an ideal situation where everyone lives into old age free from disease
and disability. This conceptualization of DALYs as a measure of health, and not of lost utility, is analogous to the
principles of measuring gross domestic product as
summarized by Eisner (1989, p. 7): “Our focus . . . is on
measures of all economic activity related to welfare [for
example, gross domestic product], but not of welfare
itself.” Information on calculating DALYs, on time discounting, and on age weights is provided in chapter 3.
DALYs for a disease or health condition are calculated
as the sum of YLL in the population and YLD for incident
cases of the health condition. YLL is calculated from the
number of deaths at each age multiplied by a global stan-
measures of survival and of health status among survivors,
while useful inputs when formulating health policy, need to
be combined in some fashion to provide a single, holistic
measure of overall population health. To assess the burden
of disease, the 1990 GBD study used a time-based metric
that measures both premature mortality (years of life lost
because of premature mortality or YLL) and disability (years
of healthy life lost as a result of disability or YLD, weighted
by the severity of the disability). The sum of the two components, namely, DALYs, provides a measure of the future
stream of healthy life (years expected to be lived in full
health) lost as a result of the incidence of specific diseases
and injuries in 1990 (box 1.1). The effect of fatal cases (of
disease or injury) is captured by years of life lost, while YLD
captures the future health consequences in terms of sequelae of diseases or injuries of incident cases in 1990 that were
not fatal. (For a more complete account of the DALY measure and the philosophy underlying parameter choices, see
Murray 1996; Murray, Salomon, and others 2002).
DALYs are not unique to the GBD study. The World Bank
used a variant of DALYs in its seminal review of health sector priorities (Jamison and others 1993), and they are
derived from earlier work to develop time-based measures
that better reflect the public health impact of death or illness
dard life expectancy for the age at which death occurs. To
estimate YLD for a particular cause for a particular time
period, the number of incident cases in that period is multiplied by the average duration of the disease and a weight
factor that reflects the severity of the disease on a scale
from 0 (perfect health) to 1 (dead). The weights used in
the 2001 GBD study are listed in detail elsewhere (see
annex tables 3A.6 to 3A.8 in chapter 3).
In addition, in calculating DALYs, the GBD study used 3
percent time discounting and non-uniform age weights
which give less weight to years lived at young and older
ages. For the results reported in this volume and used in the
Disease Control Priorities in Developing Countries, second
edition (DCP2) 3 percent time discounting was applied but
not non-uniform age weights. A death in infancy then corresponds to 30 DALYs, and deaths at age 20 to around 28
DALYs. Thus a disease burden of 3,000 DALYs in a population would be the equivalent of around 100 infant deaths or
to approximately 5,000 persons aged 50 years living one
year with blindness (disability weight 0.6).
at young ages (Dempsey 1947; Ghana Health Assessment
Project Team 1981).
Much of the comment on, and criticism of, the GBD
study focused on the construction of DALYs (Anand and
Hanson 1998; Hyder, Rotllant, and Morrow 1998; Williams
1999), particularly the social choices pertaining to age
weights and severity scores for disabilities. Relatively little
criticism was directed at the vast uncertainty of the basic
descriptive epidemiology for some populations, especially in
Sub-Saharan Africa (see chapter 5 in this volume), which is
likely to be far more consequential for setting health priorities (Cooper and others 1998).
The results of the 1990 GBD study confirmed what many
health workers had suspected for some time,namely,that noncommunicable diseases and injuries were a significant cause of
health burden in all regions, and in some rapidly industrializing regions such as East Asia and Pacific, were already by far
the leading cause of death and disability.Neuropsychiatric disorders and injuries in particular were major causes of lost years
of healthy life as measured by DALYs, and were vastly underappreciated when measured by mortality alone. The original
GBD study estimated that noncommunicable diseases,
including neuropsychiatric disorders, caused 41 percent of
the global burden of disease in 1990, only slightly less than
Measuring the Global Burden of Disease and Risk Factors, 1990–2001 | 3
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265
communicable, maternal, perinatal, and nutritional conditions combined (44 percent), and that 15 percent of the burden was due to injuries. Earlier assessments of global health
priorities based on mortality data attributed no deaths to
mental health disorders and less than half (7 percent) of that
suggested by DALYs to injuries (Lopez 1993).
Estimates of the disease and injury burden caused by
exposure to major risk factors are likely to be a much more
useful guide to policies and priorities for prevention than a
“league table” of the disease and injury burden. In recent
decades, researchers have attempted to quantify the effects of
specific exposures, for instance, tobacco smoking, on mortality from major diseases such as cancers (Doll and Peto 1981;
Parkin and others 1994) or from multiple diseases (Peto and
others 1992; United States Department of Health and
Human Services 1992), either in individual countries or
across groups of countries using comparable methods.
Specific country studies have examined the impact of several leading risk factors (Holman and others 1988; McGinnis
and Foege 1993), but prior to the 1990 GBD study, no global
assessments of the fatal and nonfatal burden of disease and
injury resulting from exposure to multiple major health risks
had been attempted. The 1990 study quantified 10 risk factors based on information about causation, prevalence,
exposure, and disease and injury outcomes available at the
time. The study attributed almost 16 percent of the entire
global burden of disease and injury to malnutrition; another
7 percent to poor water and sanitation; and 2 to 3 percent
to such risks as unsafe sex, tobacco, alcohol, and occupational exposures (Lopez and Murray 1998; Murray and Lopez
1996a; Murray and Lopez 1997a; Murray, Lopez, and
Jamison 1994; World Bank 1993).
APPLICATIONS OF BURDEN OF
DISEASE ANALYSIS
Burden of disease analyses are useful for informing health
policy in at least five major ways as outlined in this section.
Estimates of deaths by cause or years of life lost serve these
same purposes, but for some uses, less well.
Assessing Performance
The burden of disease provides an indicator that can be used
to judge progress over time within a single country or region
or relative performance across countries and regions. In this
application, burden of disease may be considered analogous
to national income and product accounts, developed by
Simon Kuznets and others in the 1930s and culminating in
1939 with a complete national income and product account
for the United Kingdom prepared at the request of the treasury. In subsequent decades, national income and product
accounts have transformed the empirical underpinnings of
economic policy analysis. As one leading scholar put it, “The
national income and product accounts for the United States
. . . , and kindred accounts in other nations, have been
among the major contributions to economic knowledge
over the past half century . . . Several generations of economists and practitioners have now been able to tie theoretical
constructs of income, output, investment, consumption,
and savings to the actual numbers of these remarkable
accounts with all their fine detail and soundly meshed interrelations” (Eisner 1989, p. 1).
Generating Forums for Informed Debate of Values and
Priorities
In practice, assessing the disease burden involves participation by a broad range of disease specialists, epidemiologists,
and often, policy makers. Debating the appropriate values
for, say, disability weights or for years of life lost at different
ages helps clarify values and objectives for national health
policy. Discussing the relationships between diseases and
their risk factors in the light of local conditions sharpens consideration of priorities and of programs to address them.
Identifying National Control Priorities
Many countries now identify a relatively short list of interventions whose full implementation becomes an explicit
priority for national political and administrative attention.
Examples include interventions to control tuberculosis,
poliomyelitis, HIV/AIDS, smoking, and specific micronutrient deficiencies. Because political attention and high-level
administrative capacity are in relatively fixed and short supply, the benefits from using those resources will be maximized if they are directed toward interventions that are both
cost-effective and aimed at problems associated with a high
disease burden. National assessments of disease burden are
one input into the process of establishing a shortlist of disease control priorities.
Creating Knowledge
Medical schools offer a fixed number of instructional hours,
and training programs for other levels and types of health
workers are similarly limited. A major instrument for
4 | Global Burden of Disease and Risk Factors | Alan D. Lopez, Colin D. Mathers, Majid Ezzati, and others
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266
implementing health policy priorities is to allocate this fixed
time resource well. This implies allocating time to training
for interventions where the disease burden is high and costeffective interventions exist.
Information on the disease or risk factor burden is also a
vital input for informing resource allocation for research
and development. In particular, whenever a fixed effort will
have a benefit proportional not only to the size of that effort,
but also to the size of the problem being addressed, estimates of the disease burden become essential for formulating and implementing research and development priorities.
For example, developing a vaccine for a broad range of viral
pneumonias would have perhaps hundreds of times the
impact of a vaccine against hantavirus infection.
Allocating Resources across Health Interventions
A key task for priority-setting analyses in health is to create
the evidence base to stimulate the reallocation of resources
to interventions that, at the margin, will generate the greatest reduction in health loss. When there are major fixed costs
in mounting an intervention, as is the case with political and
managerial attention for national control priorities, burden
estimates are required to improve resource allocation.
Similarly, major fixed costs may be associated with the universalization (or major expansion) of an intervention and, if
so, the cost-effectiveness of the expansion will depend in
part on the size of the burden.
IMPROVING THE COMPARATIVE QUANTIFICATION
OF DISEASES, INJURIES, AND RISK FACTORS: THE
2001 GBD STUDY
The 1990 GBD study represented a major advance in the
quantification of the impact of diseases, injuries, and risk factors on population health globally and by region.Government
and nongovernmental agencies alike have used its results to
argue for more strategic allocations of health resources to disease prevention and control programs that are likely to yield
the greatest gains in terms of population health. The results
have also greatly increased understanding of the basic descriptive epidemiology of diseases and injuries worldwide.
Following publication of the initial results of the GBD
study, several national applications of the methods it used
have led to substantially more data on the descriptive epidemiology of diseases and injuries becoming available, as
well as to improvements in analytical methods and mortality data in a number of countries. By emphasizing substan-
tially more sophisticated approaches than in the past to the
interpretation and presentation of population health data to
policy makers, national burden of disease studies have stimulated efforts to improve and extend the collection of the
health information data that are the basis for such analyses.
A good example is the Islamic Republic of Iran where, over
the last five years, the government has implemented a system of death registration with medical information on
the cause of death that has been extended from four
provinces initially to include 26, or almost all of the country’s provinces. Another example is the government of
Thailand’s extensive verbal autopsy study aimed at addressing major coding deficiencies in Thailand’s national mortality data (Choprapawon and others 2005).
Critiques of the original study’s approach, particularly of
the methods used to assess the severity weightings for disabling health states, have led to fundamental changes in the
way that investigators incorporate health state valuations,
that is, the use of population-based rather than expert opinion as used in the 1990 study, and to substantially better
methods for improving the cross-national comparability of
survey data on health status (Murray, Tandon, and others
2002; Salomon and Murray 2004). Better methods for modeling the relationship between the level of mortality and the
broad cause of death structure in populations that are based
on proportions rather than rates have led to greater confidence in cause of death estimates for developing countries
(Salomon and Murray 2002). In addition, improved population surveillance for some major diseases such as
HIV/AIDS, and the wider availability of data from verbal
autopsy methods, particularly in Sub-Saharan Africa, have
lessened the dependence on models for cause of death estimates, although substantial uncertainty in the use of such
data persists. For more details on these and other methodological advances, see chapter 3 in this volume.
Perhaps the major methodological progress since the
1990 GBD study has been with respect to the quantification
of the disease burden from risk factors. The initial study
quantified the population health effects of 10 risk factors,
but serious concerns exist about the comparability of the
methods and estimates used. Different risk factors have different epidemiological traditions, particularly with regard to
the definitions of hazardous exposure, the strength of the
evidence on causality, and the availability of epidemiological research on exposure and hazard. As a result, comparability across estimates of the disease burden caused by
different risk factors has been difficult to establish. In particular, much of classical risk factor research has treated
exposures as dichotomous, with individuals either exposed
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267
or not exposed, with exposure defined according to an often
arbitrary threshold value, for example, systolic blood pressure of 140 millimeters of mercury as the threshold for
hypertension. Recent evidence for such continuous exposures as cholesterol, blood pressure, and body mass index
suggests that such arbitrarily defined thresholds are inappropriate, because the hazards for these risks decline continuously across the entire range of measured exposure levels,
with no obvious threshold (Eastern Stroke and Coronary
Heart Disease Collaborative Research Group 1998; Ezzati
and others 2004; Rose 1985; WHO 2002).
For the 2001 GBD study, a new framework for risk factor
assessment was defined that examines changes in the disease
burden that would be expected under alternative population
distributions of exposure to a risk factor or groups of risk
factors (Murray and Lopez 1999). Attributable fractions of
disease due to a risk factor were then calculated based on a
comparison of the disease burden expected under the current
estimated distribution of exposure by age, sex, and region
with that expected under a counterfactual distribution of
exposure. One such counterfactual distribution was defined
for each risk factor as the population distribution of exposure
that would lead to the lowest levels of disease burden. Thus,
for example, in the case of tobacco, this theoreticalminimum-risk counterfactual exposure would be 100 percent of the population being never-smokers, for overweight
and obesity it would be a narrow distribution of body mass
index centered around an optimal level of 21 kg/m2 and so
on. The distributions of the theoretical-minimum-risk exposure for the risk factors quantified in the World Health
Organization’s study of comparative risk assessment (the
methodological and empirical basis for the 2001 GBD study)
were developed by expert groups for each risk factor based on
available scientific knowledge of risk factor hazard. The study
also used systematic reviews and analyses of extant sources on
risk factor exposure and hazard in an iterative process that
increased comparability across risk factors (Ezzati and others
2002, 2004). These methods and results are described in more
detail in chapter 4 in this volume.
Risk factors may affect disease and injury outcomes
through other intermediate factors. For instance, some of the
effects of diet and physical activity on cardiovascular diseases
are mediated through changes in such intermediate factors as
weight, blood pressure, and cholesterol. Risk factors may also
affect disease and injury outcomes in combination with one
another. For example, people who smoke and have elevated
blood pressure and cholesterol have substantially higher
probabilities of cardiovascular events. Finally, some risks
have common social and behavioral determinants. For
instance, members of poor households in rural areas are the
most likely to be undernourished, use unsafe water sources,
and be exposed to indoor smoke from solid fuels. Because of
these epidemiological and social characteristics of risk factor
exposure and hazard, policy-relevant analysis should include
an assessment of the health benefits of simultaneous reductions in multiple risks. Multicausality also means that a range
of interventions can be used for disease prevention, with the
specific choices determined by such factors as costs, technology availability, infrastructure, and preferences. A novel
aspect of the analysis of risk factors in the 2001 GBD study is
the development and application of methods for estimating
the disease burden attributable to the combined hazards of
multiple risk factors (Ezzati and others 2003).
The basic units of analysis in the 1990 GBD study were the
eight World Bank regions defined for the World Bank’s
(1993) World Development Report 1993. Designed to be geographically contiguous, these regions were nonetheless
extremely heterogeneous with respect to health development, for example, the region referred to as Other Asia and
Islands included countries with such diverse epidemiological
profiles as Myanmar and Singapore. This seriously limited
the applicability of these regions to comparative epidemiological assessments. Thus the 2001 GBD study followed a
more refined approach. Estimates of overall mortality were
first developed for World Health Organization member
states using different methods for countries at different stages
of health development. The choice of methods was largely
determined by the availability of data (Lopez and others
2002). Age- and sex-specific death rates for countries were
essentially determined using one of three standard approaches: the use of routine life table methods for countries with
complete vital registration; the application of standard
demographic methods to correct for underregistration of
deaths; or the application of model life tables where no vital
registration or survey data on adult mortality were available
(Lopez and others 2002; Murray and others 2003).
The detailed methodological approaches adopted for
estimating cause-specific mortality for countries and the
descriptive epidemiology of nonfatal conditions for countries or subregions are described elsewhere (Mathers and
others 2002; chapter 3 in this volume). This focus on
individual countries as the unit of analysis, as well as the systematic application of standardized approaches for all
countries in any given category of data availability, has vastly
improved the cross-population comparability of disease and
injury quantification.
A final major advance of the 2001 GBD study has been
the systematic attempts to quantify some of the uncertainty
6 | Global Burden of Disease and Risk Factors | Alan D. Lopez, Colin D. Mathers, Majid Ezzati, and others
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268
in both national and global assessments of the disease burden (see chapter 5 in this volume). This uncertainty must be
taken into account when making cross-national comparisons and needs to be carefully communicated to and interpreted by epidemiologists and policy makers alike.
for almost one-fifth of all deaths. In other words, the epidemiological transition from infectious to chronic noncommunicable diseases in this group of countries is already well
established and is of major relevance to health planning.
Leading Causes of Disability
MAJOR FINDINGS OF THE 2001 GBD STUDY
This section, and tables 1.1 and 1.2, summarize the principle findings of the 2001 GBD study. More detailed findings
are reported in chapters 3 and 4.
Global and Regional Mortality
Slightly more than 56 million people died in 2001, 10.5 million (or nearly 20 percent) of whom were children younger
than five years of age. Almost 4 million children died before
1 month of age, with an additional 3.3 million stillbirths
(see chapter 6). Of these child deaths, 99 percent occurred in
low- and middle-income countries. Low- and middleincome countries also account for a comparatively large
number of deaths at young and middle adult ages: 30 percent of all deaths occur at ages 15 to 59, compared with
15 percent in high-income countries. The causes of death at
these ages, as well as in childhood, are thus important for
assessing public health priorities.
Worldwide, one death in every three is from what the
GBD study terms Group I causes (communicable diseases,
maternal and perinatal conditions, and nutritional deficiencies) (see table 1.1). This proportion remains almost unchanged from 1990, with one major difference. Whereas
HIV/AIDS accounted for only 2 percent of Group I deaths
in 1990, it accounted for 14 percent in 2001. Excluding
HIV/AIDS, Group I deaths fell from one-third of total
deaths in 1990 to less than one-fifth in 2001. Virtually all
Group I deaths are in low- and middle-income countries.
In low- and middle-countries, Group II causes (noncommunicable diseases) are now responsible for more than
50 percent of deaths in adults ages 15 to 59 in all regions
except South Asia and Sub-Saharan Africa, where Group I
causes, including HIV/AIDS, remain responsible for onethird and two-thirds of deaths, respectively. Outside these
two regions, developing countries are now facing a triple
burden of disease from communicable diseases, noncommunicable diseases, and injuries (Group III causes). Among
low- and middle-income countries as a group, the three
leading causes of death in 2001 included ischemic heart disease and cerebrovascular disease, which together accounted
The 1990 GBD study brought the previously largely ignored
burden of nonfatal illnesses, particularly neuropsychiatric
disorders, to the attention of health policy makers. The findings of the 2001 GBD study, based on updated data and
analyses, confirm that disability and states of less than full
health caused by diseases and injuries play a central role in
determining the overall health status of populations in all
regions of the world. Neuropsychiatric conditions, vision
disorders, hearing loss, and alcohol use disorders dominate
the overall burden of nonfatal disabling conditions.
In all regions, neuropsychiatric conditions are the most
important causes of disability, accounting for more than
37 percent of YLD among adults aged 15 years and older
worldwide. The disabling burden of neuropsychiatric conditions is almost the same for males and females, but the major
contributing causes are different. While depression is the
leading cause of disability for both males and females, the
burden of depression is 50 percent higher for females than
males, and females also have higher burdens from anxiety
disorders, migraine, and senile dementia. In contrast, the
male burden for alcohol and drug use disorders is nearly six
times higher than that for females and accounts for a quarter
of the male neuropsychiatric burden.
More than 85 percent of disease burden from nonfatal
health outcomes occurs in low- and middle-income countries, and South Asia and Sub-Saharan Africa account for
40 percent of all YLD. Even though the prevalence of disabling conditions such as dementia and musculoskeletal disease is higher in countries with long life expectancies, this is
offset by lower contributions to disability from conditions
such as cardiovascular disease, chronic respiratory diseases,
and long-term sequelae of communicable diseases and
nutritional deficiencies. In other words, people living in
developing countries not only face shorter life expectancies
than those in developed countries, but also live a higher proportion of their lives in poor health.
Burden of Disease and Injuries
The results of the 2001 GBD study reinforce some of the
conclusions of the 1990 GBD study about the importance of
including nonfatal outcomes in a comprehensive assessment
Measuring the Global Burden of Disease and Risk Factors, 1990–2001 | 7
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269
Table 1.1 Deaths and Burden of Disease by Cause—Low- and Middle-Income Countries, High-Income Countries,
and World, 2001
Low- and middle-income
Deaths
All causes
Total number (thousands)
Rate per 1,000 population
Age-standardized rate per 1,000b
Selected cause groups:
I. COMMUNICABLE DISEASES,
MATERNAL AND PERINATAL
CONDITIONS AND
NUTRITIONAL DEFICIENCIES
Tuberculosis
HIV/AIDS
Diarrheal diseases
Measles
Malaria
Lower respiratory infections
Perinatal conditions
Protein-energy malnutrition
II. NONCOMMUNICABLE CONDITIONS
Stomach cancers
Colon and rectum cancers
Liver cancer
Trachea, bronchus, and lung cancers
Diabetes mellitus
Unipolar depressive disorders
Alcohol use disorders
Cataracts
Vision disorders, age-related
Hearing loss, adult onset
Hypertensive heart disease
Ischemic heart disease
Cerebrovascular disease
Chronic obstructive pulmonary disease
Cirrhosis of the liver
Nephritis and nephrosis
Osteoarthritis
Congenital anomalies
Alzheimer and other dementias
III. INJURIES
Road traffic accidents
Falls
Self-inflicted injuries
Violence
High-income
DALYs(3,0)a
Deaths
48,351
9.3
11.4
1,386,709
265.7
281.7
17,613 (36.4)
552,376 (39.8)
552 (7.0)
1,590 (3.3)
2,552 (5.3)
1,777 (3.7)
762 (1.6)
1,207 (2.5)
3,408 (7.0)
2,489 (5.1)
241 (0.5)
35,874 (2.6)
70,796 (5.1)
58,697 (4.2)
23,091 (1.7)
39,961 (2.9)
83,606 (6.0)
89,068 (6.4)
15,449 (1.1)
26,023 (53.8)
696 (1.4)
357 (0.7)
505 (1.0)
771 (1.6)
757 (1.6)
10 (<.1)
62 (0.1)
0 (0.0)
0 (0.0)
0 (0.0)
760 (1.6)
5,699 (11.8)
4,608 (9.5)
2,378 (4.9)
654 (1.4)
552 (1.1)
2 (<.1)
477 (1.0)
173 (0.4)
4,715 (9.8)
1,069 (2.2)
316 (0.7)
749 (1.5)
532 (1.1)
DALYs(3,0)a
7,891
149,161
8.5
160.6
5.0
128.2
Number in thousands (percent)
World
Deaths
DALYs(3,0)a
56,242
9.1
10.0
1,535 871
249.8
256.5
8,561 (5.7)
18,166 (32.3)
560,937 (36.5)
16 (0.2)
22 (0.3)
6 (<.1)
1 (<.1)
0 (0.0)
345 (4.4)
32 (0.4)
9 (0.1)
219 (0.1)
665 (0.4)
444 (0.3)
23 (<.1)
9 (<.1)
2,314 (1.6)
1,408 (0.9)
130 (<.1)
1,606 (2.9)
2,574 (4.6)
1,783 (3.2)
763 (1.4)
1,208 (2.1)
3,753 (6.7)
2,522 (4.5)
250 (0.4)
36,093 (2.3)
71,461 (4.7)
59,141 (3.9)
23,113 (1.5)
39,970 (2.6)
85,920 (5.6)
90,477 (5.9)
15,578 (1.0)
678,483 (48.9)
9,616 (0.7)
5,060 (0.4)
7,945 (0.6)
10,701 (0.8)
15,804 (1.1)
43,427 (3.1)
11,007 (0.8)
28,150 (2.0)
15,364 (1.1)
24,607 (1.8)
9,969 (0.7)
71,882 (5.2)
62,669 (4.5)
33,453 (2.4)
13,633 (1.0)
9,076 (0.7)
13,666 (1.0)
23,533 (1.7)
9,640 (0.7)
6,868 (87.0)
146 (1.9)
257 (3.3)
102 (1.3)
456 (5.8)
202 (2.6)
3 (<.1)
23 (0.3)
0 (0.0)
0 (0.0)
0 (0.0)
129 (1.6)
1,364 (17.3)
781 (9.9)
297 (3.8)
118 (1.5)
111 (1.4)
3 (<.1)
30 (0.4)
207 (2.6)
129,356 (86.7)
1,628 (1.1)
3,175 (2.1)
1,223 (0.8)
5,397 (3.6)
4,192 (2.8)
8,408 (5.6)
4,171 (2.8)
493 (0.3)
1,525 (1.0)
5,387 (3.6)
1,209 (0.8)
12,390 (8.3)
9,354 (6.3)
5,282 (3.5)
2,146 (1.4)
929 (0.6)
3,786 (2.5)
1,420 (1.0)
7,468 (5.0)
32,891 (58.5)
842 (1.5)
614 (1.1)
607 (1.1)
1,227 (2.2)
960 (1.7)
13 (<.1)
84 (0.2)
0 (0.0)
0 (0.0)
0 (0.0)
889 (1.6)
7,063 (12.6)
5,390 (9.6)
2,676 (4.8)
771 (1.4)
663 (1.2)
5 (<.1)
507 (0.9)
380 (0.7)
807,839 (52.6)
11,244 (0.7)
8,236 (0.5)
9,169 (0.6)
16,099 (1.0)
19,997 (1.3)
51,835 (3.4)
15,178 (1.0)
28,643 (1.9)
16,889 (1.1)
29,994 (2.0)
11,178 (0.7)
84,273 (5.5)
72,024 (4.7)
38,736 (2.5)
15,778 (1.0)
10,005 (0.7)
17,452 (1.1)
24,952 (1.6)
17,108 (1.1)
155,850 (11.2)
32,017 (2.3)
13,582 (1.0)
17,674 (1.3)
18,132 (1.3)
471 (6.0)
121 (1.5)
71 (0.9)
126 (1.6)
24 (0.3)
11,244 (7.5)
3,045 (2.0)
1,459 (1.0)
2,581 (1.7)
765 (0.5)
5,186 (9.2)
1,189 (2.1)
387 (0.7)
875 (1.6)
556 (1.0)
167,094 (10.9)
35,063 (2.3)
15,041 (1.0)
20,255 (1.3)
18,897 (1.2)
Source: Chapter 3.
Notes: Numbers in parentheses indicate percentage of column total.
Broad group totals in bold are additive but should not be summed with all other conditions listed in table.
a. DALYs (3,0) refer to the version of the DALY based on a 3% annual discount rate and uniform age weights.
b. Age-standardized using the WHO World Standard Population.
c. Includes only causes responsible for more than 1% of global deaths or DALYs in 2001.
of global population health. They also confirm the growing
importance of noncommunicable diseases in low- and
middle-income countries and highlight important changes
in population health in some regions since 1990.
HIV/AIDS is now the fourth leading cause of the burden
of disease globally and the leading cause in Sub-Saharan
Africa, where it is followed by malaria in second place. Seven
other Group I causes also appear in the top 10 causes for this
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region. The epidemiological transition in low- and middleincome countries has resulted in a 20 percent reduction in
the per capita disease burden due to Group I causes since
1990. Without the HIV/AIDS epidemic and the associated
lack of decline in the burden of tuberculosis, this reduction
would have been closer to 30 percent.
The per capita disease burden in Europe and Central Asia
has increased by nearly 40 percent since 1990, and population health in this region is now worse than all other regions
except South Asia and Sub-Saharan Africa. This reflects
the sharp increase in adult male mortality and disability in
the 1990s, leading to the highest male-female differential
in the disease burden in the world. A significant factor in this
increase is probably the high level of harmful alcohol consumption among men, which has led to high rates of accidents, violence, and cardiovascular disease. From 1991 to
1994, the risk of premature adult (15 to 59 years) death
increased by 50 percent for Russian males. It improved somewhat between 1994 and 1998, but subsequently increased.
The burden of noncommunicable diseases is increasing,
accounting for nearly half the total global burden of disease,
a 10 percent increase from estimated levels in 1990. Almost
50 percent of the adult disease burden in low- and middle
income countries is now attributable to noncommunicable
diseases. The implementation of effective interventions for
Group I diseases, coupled with population aging and the
spread of risks for noncommunicable disease in many lowand middle-income countries, are the likely causes of this
shift. Ischemic heart disease and stroke dominate the burden of disease in Europe and Central Asia and together
account for more than a quarter of the total disease burden.
In contrast, in Latin America and the Caribbean these diseases account for 8 percent of the disease burden, but this
region also has high levels of diabetes and endocrine disorders compared with other regions. Violence is the fourth
leading cause of the disease and injury burden in Latin
America and the Caribbean. Violence does not appear
among the top 10 causes of burden in any other region, but
is nonetheless significant.
Injuries primarily affect young adults and often result in
severe, disabling sequelae. All forms of injury accounted for
16 percent of the adult burden in 2001. In parts of Europe and
Central Asia, Latin America and the Caribbean, and the
Middle East and North Africa, more than 30 percent of the
entire disease and injury burden among male adults aged
15 to 44 is attributable to injuries. Road traffic accidents, violence, and self-inflicted injuries are all among the top 10 leading causes of burden in these regions. The former Soviet
Union and other high-mortality (among adults) countries of
Eastern Europe have rates of injury death and disability
among males that are similar to those in Sub-Saharan Africa.
Burden of Disease Attributable to Risk Factors
As described earlier, a major advance of the 2001 GBD
study has been in creating a unified framework for quantifying the burden of disease and injury attributable to major
risk factors and in applying this framework to exposure and
hazard data for selected major risk factors based on comprehensive and systematic reviews of published literature
and other sources. Notwithstanding the inherent uncertainties in assessing the population-level health effects of risk
factors, the quantification of the burden of disease attributable to the individual and joint hazards of selected risks
suggests that the leading causes of mortality and disease
burden include risk factors for Group I conditions (for
example, undernutrition; indoor smoke from household
use of solid fuels; poor water, sanitation, and hygiene; and
unsafe sex), whose burden is primarily concentrated in
South Asia and Sub-Saharan Africa, and risk factors for
Group II conditions (especially, smoking, alcohol, high
blood pressure and cholesterol, and overweight and obesity),
which are widespread globally (see table 1.2). In low- and
middle-income countries, the leading causes of disease burden included risk factors prevalent among the poor and
associated with Group I conditions (for example, childhood
underweight [8.7 percent of the disease burden in these
regions]; unsafe water, sanitation, and hygiene [3.7 percent];
and indoor smoke from household use of solid fuels
[3.0 percent]), unsafe sex (5.8 percent), and risk factors for
noncommunicable diseases (for example, high blood pressure [5.6 percent], smoking [3.9 percent], and alcohol use
[3.6 percent]). Across high-income countries, risk factors
associated with Group II and Group III conditions were the
leading causes of loss of healthy life (smoking [12.7 percent], high blood pressure [9.3 percent], overweight and
obesity [7.2 percent], high cholesterol [6.3 percent], and
alcohol use [4.4 percent]).
An estimated 45 percent of global mortality and 36 percent of the global burden of disease were attributable to the
joint hazards of the 19 selected global risk factors. The joint
hazards were even larger in regions where a relatively small
number of diseases and their risk factors were responsible
for large losses of life (HIV/AIDS and risk factors for child
mortality in Sub-Saharan Africa; cardiovascular risks,
including smoking and alcohol use in Europe and Central
Asia). Globally, large fractions of major diseases such as diarrhea, lower respiratory infections, HIV/AIDS, lung cancer,
Measuring the Global Burden of Disease and Risk Factors, 1990–2001 | 9
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Table 1.2 Deaths and Burden of Disease Attributable to Risk Factors—Low- and Middle-Income Countries, High-Income
Countries, and World, 2001
Low- and middle-income
Deaths
Total number (thousands)
Rate per 1,000 population
Age-standardized rate per 1,000b
48,351
9.3
11.4
High-income
DALYs(3,0)a
Deaths
1,386 709
265.7
281.7
World
DALYs(3,0)a
7,891
8.5
5.0
Deaths
149,161
160.6
128.2
DALYs(3,0)a
56,242
9.1
10.0
1,535 871
249.8
256.5
Number in thousands (percent)
Risk factor
Childhood and maternal undernutrition
Childhood underweight
Iron-deficiency anemia
Vitamin A deficiency
Zinc deficiency
3,630 (7.5)
613 (1.3)
800 (1.7)
849 (1.8)
120,579 (8.7)
23,933 (1.7)
24,686 (1.8)
27,631 (2.0)
0 (0.0)
8 (0.1)
0 (0.0)
0 (0.0)
67 (<0.1)
789 (0.5)
0 (0.0)
5 (<0.1)
3,630 (6.5)
621 (1.1)
800 (1.4)
849 (1.5)
120,647 (7.9)
24,722 (1.6)
24,686 (1.6)
27,636 (1.8)
6,223 (12.9)
3,038 (6.3)
1,747 (3.6)
2,308 (4.8)
1,559 (3.2)
78,063 (5.6)
42,815 (3.1)
31,515 (2.3)
32,836 (2.4)
22,679 (1.6)
1,392 (17.6)
842 (10.7)
614 (7.8)
333 (4.2)
376 (4.8)
13,887 (9.3)
9,431 (6.3)
10,733 (7.2)
3,982 (2.7)
4,732 (3.2)
7,615 (13.5)
3,880 (6.9)
2,361 (4.2)
2,641 (4.7)
1,935 (3.4)
91,950 (6.0)
52,246 (3.4)
42,248 (2.8)
36,819 (2.4)
27,411 (1.8)
Addictive substances
Smoking
Alcohol use
Illicit drug use
3,340 (6.9)
1,869 (3.9)
189 (0.4)
54,019 (3.9)
49,449 (3.6)
7,890 (0.6)
1,462 (18.5)
24 (0.3)
37 (0.5)
18,900 (12.7)
6,580 (4.4)
2,024 (1.4)
4,802 (8.5)
1,893 (3.4)
226 (0.4)
72,919 (4.7)
56,029 (3.6)
9,914 (0.6)
Sexual and reproductive health
Unsafe sex
Non-use and use of ineffective methods of contraception
2,819 (5.8)
162 (0.3)
80,270 (5.8)
7,411 (0.5)
32 (0.4)
0 (0.0)
909 (0.6)
23 (<0.1)
2,851 (5.1)
162 (0.3)
81,179 (5.3)
7,434 (0.5)
Environmental risks
Unsafe water, sanitation, and hygiene
Urban air pollution
Indoor smoke from household use of solid fuels
1,563 (3.2)
735 (1.5)
1,791 (3.7)
51,622 (3.7)
8,707 (0.6)
41,731 (3.0)
4 (<0.1)
76 (1.0)
0 (0.0)
289 (0.2)
664 (0.4)
2 (<0.1)
1,567 (2.8)
811 (1.4)
1,791 (3.2)
51,911 (3.4)
9,371 (0.6)
41,734 (2.7)
407 (0.8)
65 (0.1)
8,974 (0.6)
5,381 (0.4)
4 (<0.1)
6 (<0.1)
76 (<0.1)
699 (0.5)
412 (0.7)
71 (0.1)
9,050 (0.6)
6,079 (0.4)
22,014 (45.6)
500,066 (36.1)
3,473 (44.0)
51,092 (34.3) 25,488 (45.3)
551,158 (35.9)
Other nutrition-related risk factors and physical activity
High blood pressure
High cholesterol
Overweight and obesity
Low fruit and vegetable intake
Physical inactivity
Other selected risks
Contaminated injections in health care setting
Child sexual abuse
All selected risk factors together
Source: Chapter 4. Note that mortality and disease burden attributable to individual risk factors cannot be added due to multi-causality. See Chapter 4 for details.
a. (some footnote as Table 1.1)
b. Age-standardized using the WHO World Standard Population
chronic obstructive pulmonary disease, ischemic heart disease, and stroke were attributable to the joint effects of the
risk factors considered in this volume. The joint hazards of
these 19 risks for a number of other important diseases and
injuries, such as perinatal and maternal conditions, selected
other cancers, and intentional and unintentional injuries,
which have more diverse risk factors, were smaller, but nonnegligible. The relatively small number of risk factors that
account for a large fraction of the disease burden underscores the need for policies, programs, and scientific
research to take advantage of interventions for multiple
major risks to health (Ezzati and others 2003).
CONCLUSIONS
The substantial scientific and policy interest in the methods
and findings of the 1990 GBD study, the widespread
application of the methods by countries at all levels of
health development, and the adoption of the framework as
the preferred method for health accounting by international health agencies such as the World Health Organization
attest to the critical need for objective and systematic assessments of the disease burden for priority setting in health.
The vast and comprehensive effort to quantify the disease
burden worldwide dramatically changed views about the
10 | Global Burden of Disease and Risk Factors | Alan D. Lopez, Colin D. Mathers, Majid Ezzati, and others
©2006 The International Bank for Reconstruction and Development / The World Bank
272
importance of some conditions, particularly psychiatric
disorders, and drew global public health attention to the
unrecognized burden of injuries. The methodological developments over the past decade, a more systematic approach
to collecting key data and research findings on the health of
populations, and the results of numerous national and subnational burden of disease studies have dramatically
improved the methodological armamentarium and the
empirical base for disease burden assessment, in particular,
the comparability of the estimated contributions of diseases,
injuries, and risk factors to this burden.
As reported in this volume, the 2001 GBD study provides
a comprehensive update of the comparative importance of
diseases, injuries, and risk factors for global health. The
study incorporates a range of new data sources to develop
internally consistent estimates of incidence, prevalence,
severity and duration, and mortality for 136 major causes by
sex and by eight age groups. Estimates of deaths by cause,
age, and sex were carried out separately for 226 countries
and territories, drawing on a total of 770 country-years of
death registration data, 535 additional sources of information on levels of child and adult mortality, and more than
2,600 data sets providing information on specific causes of
death in regions not well covered by death registration systems. Together with the more than 8,500 data sources
(epidemiological studies, disease registers, notifications systems, and so on) used to estimate incidence, prevalence, and
YLD by cause, the 2001 GBD study has incorporated information from more than 10,000 datasets relating to population health and mortality (see chapter 3). This represents
one of the largest syntheses of global information on population health carried out to date.
Much of the research on the burden of disease undertaken over the past decade or so has relied on the methodological and empirical efforts that defined the 1990 GBD study
as a major advance in global public health statistics. Progress
in updating the epidemiological basis for assessing the disease burden from the various diseases and injuries of interest has been uneven, although improvements in the data
and methods available for assessing global and regional
mortality by cause have been substantial, and some
advances have been made in the data for, and epidemiological understanding of some major causes of ill health such as
HIV/AIDS and diabetes mellitus. Nevertheless, making
more reliable estimates of global, regional, and national disease burdens still faces many methodological and empirical
challenges. The substantive agenda, mapped out over a
decade ago (Murray, Lopez and Jamison, 1994) remains
equally valid today and needs to be addressed more systematically if the burden of disease framework is to gain greater
acceptance as the international tool for health accounting.
Assessing and documenting in detail the state of the
world’s health at the beginning of the millennium is a useful undertaking. This volume will provide scholars today
and in the future with a definitive historical record of the
leading causes of the burden of disease for major regions of
the world at the start of the 21st century. An account of
global health at the beginning of the 20th century, or earlier,
would no doubt have been of more than just historical interest, but given the methods of scientific interchange and the
state of scientific and methodological knowledge at the
time, this was impossible.
In presenting the comprehensive findings of the 2001
GBD study, this volume is, in many respects, a culmination of
the effort launched in 1990 and represents the end of the
beginning of global disease burden assessments. The widespread use of disease burden concepts by national and international bodies since the first results were published and the
heightened interest in improving the basic descriptive
epidemiology of diseases, injuries, and risk factors by both
countries and agencies has laid the foundations for future
population health assessments. As programs and policies to
improve health worldwide become more widespread, so too
will the need for more comprehensible, credible, and comparable assessments to periodically monitor world health and
the success, or otherwise, of measures to promote health and
reduce the burden of disease. New initiatives, and perhaps
new global institutions, are required to measure the burden of
disease worldwide and how it is changing, more reliably than
hitherto. This book provides the baseline against which such
progress with global health development will be measured.
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