Best Buys for Public Health
Good health need not be a luxury reserved for the world’s rich. By investing in cost-effective interventions, developing countries can dramatically improve their populations’ health.
What if someone told you that you could save a “year of healthy human life” for just $5 if you spent it on indoor spraying of mosquitoes or promotion of breastfeeding? What if the same gain could be had for only $2 spent on putting speed bumps at dangerous intersections?
If you were a health planner, budgeter, or policymaker, chances are these recommendations would catch your eye. And that’s exactly what they’re meant to do, says George Alleyne, former director of the Pan American Health Organization (PAHO) and one of nine editors of the recently published Disease Control Priorities in Developing Countries, 2nd Edition.
“Everyone in public health wants to know what works and where they should put their resources,” says Alleyne.
The “best health buys” for developing countries are based on the contributions of more than 500 experts from science, epidemiology, health economics, and public health consulted by the Disease Control Priorities Project. They examined the impact of hundreds of diseases and health conditions and the cost-effectiveness of hundreds of interventions. The “Top 10” buys include some surprisingly simple recommendations, including speed bumps to reduce traffic injuries, insecticide-treated bed nets to prevent malaria, and increased taxes on tobacco, which Alleyne terms “the single most cost-effective intervention for preventing cardiovascular disease.” Other recommendations from the study range from directly observed therapy short course (DOTS) for tuberculosis to training programs for birth attendants and salt fluoridation to prevent dental caries.
Health action matters
One of the central arguments of Disease Control Priorities is that technical progress, including health interventions, can have a major impact on health regardless of a country’s level of economic development. During the late 20th century, for example, low- and middle-income countries such as Chile, Costa Rica, Cuba, and Sri Lanka succeeded in improving infant, child, and maternal survival rates by investing in sanitation, immunization, and skilled care during childbirth. Countries at similar levels of development that did not adopt these measures did not see similar gains in health.
“This means that waiting for economic growth to improve health would be a mistake because countries can achieve a great deal by investing in proven interventions,” says Alleyne. “It also means that even a poor country with a relatively weak health system can improve its citizens’ health by investing in the right interventions. This, in a real sense, levels the playing field. Any country can make progress in health if they make the right decisions and the right investments.”
The converse is also true. Health inequalities have arisen precisely because cost-effective interventions have been applied in some places and not in others, or to the benefit of more privileged population groups rather than the less privileged. This can be seen in countries where vaccine-preventable diseases remain a major burden versus countries where routine immunization has reduced those diseases to a bare minimum. It can also be seen in maternal mortality rates, which are dramatically higher in countries where many women deliver babies without help from skilled health care providers.
Disease Control Priorities identifies hundreds of cost-effective health interventions. But what do they have in common? To address this question, the Center for Global Development’s What Works Working Group solicited nominations of successful interventions from Disease Control Priorities’ scientific contributors. The group then selected and analyzed 17 large-scale health interventions whose impact showed a cost-effectiveness ratio of less than $100 per disability-adjusted life year, or DALY, saved.
Their analysis, published separately in Millions Saved: Proven Successes in Global Health, concluded that there was no single formula for success, but that “some key elements recur, namely, political leadership, technological innovation, expert consensus regarding the approach, effective use of information, and sufficient public financial resources.”
Disease Control Priorities points out that proven interventions may work differently in different settings, and their cost-effectiveness can vary widely from one place to another. Family planning programs, for example, tend to be more cost-effective in South Asia and Sub-Saharan Africa than in East Asia and the Pacific. The cost-effectiveness of any intervention tends to increase as the program is scaled up, since the marginal cost of reaching each new person is much lower than the initial set-up costs.
And while a good intervention can work well even in a country with a generally weak health system, its cost-effectiveness will be greater in a well-functioning system. The Integrated Management of Childhood Illness (IMCI) strategy, for example, has proved less cost-effective in countries whose health systems are plagued by high turnover of trained staff and shortages in equipment, supplies, and general funds.
Despite these caveats, Disease Control Priorities sends a strong and clear message about the need to base health policy on the right kind of knowledge and evidence. Priorities in Health, a shorter companion volume to the 1,339-page Disease Control Priorities in Developing Countries, offers the following simple but urgent prescription for health policymakers: “Identify the cost-effective interventions for those diseases that impose the largest burdens around the globe or in target regions or populations that exhibit grave need or inequity and determine how to deliver those interventions effectively, efficiently, and equitably.”
What works in...
More than 33 percent of the disease burden and nearly 60 percent of premature deaths among adults can be associated with risk factors adopted or experienced in adolescence, including tobacco and alcohol use, poor eating habits, sexual abuse, and risky sex.
Prevention should be emphasized because so much of the disease burden is preventable. Effective programs include multisector solutions that link health sector interventions with other types of interventions, such as life skills, health and sexuality education, peer education, community involvement, clinical health services, and private sector programs. Programs for adolescents require an approach different from simply applying programs for adults to a younger population. Effective programs for adolescents share a set of common principles, such as recognizing diversity and addressing nonhealth factors that influence youth health. The special needs of poor adolescents must also be addressed.
Alcohol accounts for 4 percent of the global burden of disease, with negative effects ranging from high blood pressure and liver damage to accidental injuries and deaths (greatly outweighing benefits such as reduction in coronary heart disease). In regions where high-risk drinking is more prevalent (Europe and Central Asia, Latin America and the Caribbean, and Sub-Saharan Africa), tax increases are the most cost-effective strategy to reduce alcohol’s negative health impact, followed by advertising bans on alcohol products, reduced access to retail outlets, and brief interventions such as physician advice in primary care. In regions with lower rates of high-risk alcohol use (East Asia, the Pacific, and South Asia), excise taxes are less cost-effective. In South Asia, brief physician advice and random breath testing are both cost-effective, while in East Asia and the Pacific, the most cost-effective interventions are brief physician advice, a comprehensive ban on advertising, and reduced access to retail outlets.
Intervening in the earliest years of life may reduce the possibility that an individual will use violence. Primary interventions take place before violence occurs and include addressing the cultural perceptions of violence, limiting access to lethal weapons, improving parenting, and instituting programs aimed at children. Secondary methods address the immediate effects of violent incidents, while tertiary concerns address the long-term consequences of interpersonal violence. A five-faceted plan allows each country to address interpersonal violence: more accurate data collection, increased research, an emphasis on primary prevention, more widely available victim support services, and a national anti-interpersonal violence prevention plan.
The vast majority of CVD is attributed to such risk factors as obesity, which is escalating in the developing world at an alarming pace, as well as high blood pressure and high cholesterol, extensive tobacco and alcohol use, and low vegetable and fruit consumption. Effective interventions to reduce risk factors in developing countries likely will involve a mix of treatment and education.
Former PAHO Director George Alleyne notes that “tobacco taxation is the single most cost-effective intervention for cardiovascular disease.” Cost-effective medical interventions (for patients with high risk of CVD) include ACE (angiotensin-converting enzyme) inhibitors, beta-blockers, off-patent statins, and aspirin. Compliance could be improved and costs reduced by incorporating several medications into a “polypill” for long-term use. Above all, education is essential. Health care workers need training to implement clinical guidelines, and patients must be educated about the importance of adhering to their medical regimens. These interventions can reap future savings in terms of reduced medical costs and improved quality of life and productivity.
Folic acid fortification of the food supply is one of three cost-effective interventions for learning and developmental disabilities. Prenatal screening and selective pregnancy termination can be highly cost-effective under some conditions, but these methods raise ethical, social, and cultural concerns that may preclude their use. Neonatal screening and treatment for congenital hypothyroidism are highly cost-effective in developed countries, but effectiveness may be reduced in places where only a part of the newborn population can be reached by screening. An intervention that is not recommended is electronic fetal monitoring in labor, because it has been associated with a higher risk of cerebral palsy and is unsuccessful in preventing neurological disability from premature birth.
A number of interventions are particularly appropriate for developing countries because the savings in medical costs associated with short- and long-term complications of diabetes greatly exceed the costs of interventions such as glycemic control, blood pressure control, and foot care. In addition, assuring adequate access to insulin and promoting patient education—both relatively low-cost interventions—should be top priorities for developing countries. Moreover, interventions that empower patients, such as reminders to make follow-up appointments, can be successful components of diabetes programs.
Preventive strategies include promotion of exclusive breastfeeding of infants; improved feeding practices to prevent or treat malnutrition; vaccination against rotavirus, cholera, and measles; improved water and sanitation facilities; and promotion of personal and domestic hygiene. Recent case management advances include reformulated oral rehydration therapy (ORT) and zinc supplementation. Some of these involve trade-offs. For example, while ORT and water and sanitation interventions are more effective than either breastfeeding promotion or vaccinations in reducing morbidity and mortality, they are less cost-effective. In addition to proven case management and prevention strategies, public-private partnerships for vaccine development, improved ORT practices, and low-technology solutions to enhance water quality at the point of use offer promising avenues for combating diarrheal diseases in the short term.
Despite the alarming speed with which HIV/AIDS continues to spread around the world, several countries have achieved significant successes in curbing its transmission, including interventions that promote condom use, target populations that transmit the virus in both high- and low-risk groups, and focus on surveillance and control of sexually transmitted infections. Evidence is mounting in support of certain interventions, including school-based sex education, peer education for sex workers, avoidance of unwanted pregnancies among infected mothers, use of antiretroviral therapy by infected mothers, needle-exchange programs for illegal drug users, and implementation of blood safety practices such as screening all donated blood. Countries with low-level epidemics should emphasize interventions that target individuals at especially high risk of being infected or transmitting the virus. Countries experiencing generalized epidemics should target their entire population.
Efforts to cut the malaria burden in half by 2010 involve a number of strategies, including early diagnosis and treatment; proper use of drugs, including new artemisinin-based therapies; intermittent preventive therapy during pregnancy and infancy; use of insecticide-treated nets; and vector control.
Maternal and perinatal conditions represent the single largest contributor to the global disease burden; thus, reducing the burden is an international priority. Best approaches include population-based interventions to promote healthy behaviors and reduce mistimed pregnancies; nutritional interventions to address undernutrition or micronutrient deficiencies in women of reproductive age; and a continuum of care for mother and baby, including birth preparedness, involvement of the father, adequate primary-level care, access to emergency obstetric and hospital care, and delivery and postpartum care. The most successful interventions are those that are employed in combination.
Cost-effective interventions include outpatient treatment with first-generation antipsychotic or mood-stabilizing drugs as well as psychosocial counseling for schizophrenia and bipolar disorder, and treatment with selective serotonin reuptake inhibitors for depression and panic disorder. These interventions can be implemented as the first steps to overcoming cultural, financial, and structural barriers that prevent people from seeking and receiving treatment.
Addressing newborn mortality requires links within the continuum of care from maternal health through pregnancy, childbirth, early neonatal care, and general child health. This creates a particular challenge in poor countries struggling with inadequate levels of skilled care and unstable health care systems. Nevertheless, community-level interventions form a first step. These encompass essential newborn care at time of birth, which can be carried out at home by trained alternative health workers; basic newborn resuscitation using a self-inflating bag and air; and extra care for small babies, especially feeding and warming.
Not only are high-impact, low-cost, feasible interventions available, but they could avert close to 70 percent of the world’s neonatal deaths. An interim, phased-in strategy may be most effective in developing countries. For example, community services could be used now, as professional care is being strengthened. While countries continue to seek funding for more comprehensive health systems, simpler approaches at the family-community level and through outreach services can save many lives.
Few health interventions are as cost-effective as programs that promote appropriate feeding and correct micronutrient deficiencies, with iodine supplementation or fortification being the most widespread and successful. Nutritional interventions not only preserve or improve cognitive function but also contribute to improved adult stature and worker productivity. In addition, reducing malnutrition frees scarce health resources to be allocated to other health crises. While progress has been made in correcting vitamin A deficiency and promoting breastfeeding, important challenges remain in combating iron and zinc deficiencies.
The use of fluoride has proved effective against cavities through a variety of different mediums, including its addition to centralized water supplies where possible as well as to salt, toothpaste, and milk, and via fluoride capsules and rinses. Nationalized oral health programs demonstrate a decline in caries, though the effectiveness of specific programs is unknown. The prevention of oral disease proves to be more cost-effective than restorative treatment after the onset of disease. Good examples are community mobilization and public policy to combat oral disease, in conjunction with programs instructing preschool and elementary school-age children in proper oral hygiene.
Regular deworming helps reduce malnutrition and improves motor and language development in very young children; has a positive effect on nutritional status, physical fitness, growth, and language development in school-age children; and improves maternal hemoglobin as well as birth weight and child survival. The advantage of periodic deworming lies in its simplicity: Only one tablet per individual, which can be administered by people without medical training, is required. Until new approaches become available, whether a hookworm vaccine or improved sanitation infrastructures, deworming for school-age children remains the most practical way to control helminth infections in the developing world.
Primary health care
Evidence from high-income countries may well be applicable to the developing world: A strong orientation to primary care is likely to result in better health levels and lower health care costs. The creation of dynamic health teams at the primary level is one of the main requirements for scaling up effective primary care. In many settings, the opportunity exists to increase the efficiency of primary care teams by giving attention to working conditions, assuring functioning equipment, and maintaining a stable drug supply. The challenge in these countries is not only to inject additional resources—financial and human—into the primary care sector but also to make a political commitment to the centrality of general primary care in the battle against devastating diseases and their causes. Efficient primary care in turn paves the way for major health and development gains that provide good value for the money.
Health systems It is possible to deliver good-quality care even in resource-poor settings. Legal mandates and regulations, professional oversight, peer review, and resource allocation formulas are among the tools available to decision makers and managers. With these tools, health systems can be strengthened in different country contexts to deliver interventions effectively, efficiently, and equitably. But the best strategies often are incremental and gradual and encompass action at all levels, from increasing leadership at the national level to enhancing support at the local level.
Studies from high-, low-, and middle-income countries show that tobacco use can be reduced through interventions such as tobacco tax increases, information about health risks, restrictions on smoking in public and workplaces, bans on advertising and promotion, and increased access to cessation therapies. For reasons that have not been adequately studied, the use of policy interventions such as sales taxes to reduce tobacco use is uneven around the globe. The most obvious constraint to tobacco control comes from the tobacco industry, which is well organized and well funded. But earmarking tobacco taxes for uses that the public will support can be a key political tool for effecting change. The World Health Organization’s 2003 Framework Convention on Tobacco Control may also encourage signatory countries to implement appropriate measures.
Risk factors that increase the frequency and severity of road traffic injuries include greater traffic volume, increased speeds, consumption of alcohol, and the failure to wear helmets while operating two-wheeled vehicles. Preventive programs formed in conjunction with law enforcement and community organizations can reduce road traffic injuries through lowered speed limits, “speed bumps,” police enforcement, and helmet laws, among other measures. Education, better laws and their enforcement, and engineering may all be potentially cost-effective. Research and development are needed to adapt successful programs from developed countries.
The cost-effectiveness of short-course drug therapy for TB has been central to the global promotion of directly observed treatment short course (DOTS) by the World Health Organization. However, the DOTS approach alone may not be sufficient to bring TB under control, and interest is growing in other methods, such as developing a more effective vaccine, treating latent TB infection, testing for TB drug resistance, treating HIV coinfection, and active case finding. It is not clear how money can be best allocated for TB control; although DOTS programs are a good value, their full cost may be greater in countries where a broader investment in the health sector is needed.
Immunization program costs can be lowered by using the most efficient mix of delivery strategies, reducing vaccine waste, and reducing the number of doses required to achieve immunity. Targeted approaches also could yield high returns, especially in regions with poor control of vaccine-preventable diseases. In some countries, however, the challenge will be to sustain high immunization coverage in the face of community perception that vaccine-preventable diseases no longer constitute a major public health threat.