1. Investing in Global Health “Best Buys” and Priorities for Action in Developing Countries
Fogarty International Center of the U.S. National Institutes of Health, the World Bank, the World Health Organization, and the Population Reference Bureau
2006

2. Can the world tackle its most challenging health problems?
Yes, it can.
And the Disease Control Priorities Project shows you how.
But first, let’s review where we’ve been and where we are now. 2

3. Despite a dramatic improvement in health in the 20th century…
High-income countries
Middle-income countries
Average life expectancy in low- and middle-income countries increased dramatically in the past 50 years, while cross-country health inequities decreased.
In countries with the best health indicators, life expectancy increased 2 ½ years per decade since 1960; LMIC, 5 years per decade.
Improvements in income and education levels contributed to gains; more significantly though, the generation and diffusion of new knowledge and low-cost technologies as accounted for as much as 2/3 of the 2%/year rate of decline in under-5 mortality.
Low-income countries 3

4. Progress has been uneven
LMIC = lower- and middle-income countries
HIC = higher-income countries
Many countries and regions have made significant progress.
Lower- and middle-income countries have made the greatest advances, particularly between 1960 and 1990.
But as a group, they still lag behind high-income countries.
Some countries, such as those in sub-Saharan Africa, made progress between 1960 and 1990, only to fall back after 1990.
Example
Between 1990 and 2002, the average life expectancy in Sub-Saharan Africa dropped from 50 to 46, primarily due to HIV/AIDS. 4

5. Developing countries carry a double disease burden
Percentage of deaths by cause
Low- and Middle-income countries
High-income countries
Health policy makers face continuing challenges.
In the next two decades, as people around the world live longer, major noncommunicable diseases—including heart disease, cancers, and major psychiatric disorders—will fast replace traditional scourges—particularly infectious diseases and undernutrition in children. Both are counted among communicable diseases in the striped blue section.
Already, in high-income countries, communicable diseases are responsible for fewer than 10% of deaths.
It’s a different story in lower- and middle-income countries, which suffer a “dual burden” of communicable and noncommunicable diseases.
Noncommunicable disease accounts for more than half of deaths worldwide. 5

6. The 20th century witnessed the largest global increase in life expectancy in history.
Will the 21st century build on the successes of the last century, plateau, or will we see a retreat from the gains of the past?
What threatens to roll back major health gains?
The increasing prevalence of chronic diseases (including diabetes and cardiovascular disease)
The persistence of high levels of death and disability from infectious diseases (such as malaria, TB, diarrhea, and pneumonia); from malnutrition; and for both mothers and infants, from childbirth.
HIV/AIDS
The rise of drug-resistant bacteria
Alcoholism in Eastern Europe 6

7. The Disease Control Priorities Project offers priorities for action that will help people live healthier, longer lives in developing countries.
How we did it:
The Disease Control Priorities Project had nearly 500 experts worldwide compile and review scientific research on a broad array of diseases and conditions.
We drew on the work of epidemiologists, public health experts, clinical medical specialists, and economists.
We then identified the most cost-effective ways of dealing with health problems responsible for the greatest burden of disease and disability. 7

8. How many years of healthy life can $1 million dollars buy?
In a developing country, the answer is:
100
1,000
10,000
1 to more than 100,000
Correct answer: d) 1 to more than 100,000.
Intervention choice matters. Decision makers can make a small difference or a large difference in terms of years of healthy life purchased. These decisions—about which diseases or conditions should be targeted and how—can mean the difference between death, disability, and a healthy full life.
How decision makers choose to spend their scarce scarce health investment dollars could mean the difference between buying just one more year for someone or 100,000 or more years combined for many people.
Some services or health interventions are good buys. Others are not.
Some of the more cost-effective ways of spending that money include:
Expanding immunization coverage with the six standard child vaccines <cost per year of life bought (DALY): $2-20>
Switching to the use of combination drugs (ACTs) against malaria where resistance to current inexpensive and highly effective drugs <In Sub-Saharan Africa, the price per year of life bought would be from $8-20.>
Treating STIs to interrupt HIV transmission <$10-100>
Improving care of children under 28 days old (including resuscitation of newborns) <cost per year of life bought: $10-400>

9. The best health interventions:
Target major causes of death, disability and illness in developing countries;
Are cost-effective; and
Can be scaled up easily.
The number of people who can be saved from death and disability depends not just on their health status, where they live, and which diseases or conditions decision makers decide to target, but also on the availability of cost-effective health care.
A country that chooses cost-effective interventions can expect major improvements—even with limited resources or funds.
A country doesn’t need to be rich to be healthy. 9

10. How can DCPP help? Helps countries choose the best health investments.
Recommends 10 best health buys that are highly cost-effective in many settings.
Suggests changes to infrastructure (health systems, financing, policies, R&D) to maximize results.
Shows how improving health is possible even where infrastructure is weak.
The next slides will look at some of the developing world’s biggest health problems and suggest what can be done to address those problems.
In red, you’ll see “best buys,” or some of the best ways to tackle the major causes of death, disability, and illness in developing countries. 10

11. Despite the existence of effective and inexpensive interventions, more than 4 million newborns die each year.
10,000 newborns die each day. The majority of them die in South Asia and sub-Saharan Africa.
Almost 2/3 (64 percent) die in South Asia and Africa.
South Asia = 36 %
Africa = 28% 11

12. Ensure healthier mothers and children
One-half of all child deaths occur
in the first 28 days after birth.
Ensure access to emergency obstetric care.
Keep newborns warm and clean.
Vaccinate children against major childhood killers.
Monitor children’s health to prevent and treat childhood pneumonia, diarrhea, and malaria.
More than 13 million children under age five (including stillbirths) die each year in developing countries.
At least 70 percent of these deaths could be prevented.
A mother’s chance of dying of pregnancy-related conditions is more than 200 times higher in the lowest-income countries than in the highest-income countries.
Major childhood killers include measles, polio, whooping cough, and diphtheria. *It costs as little as US$2 to buy a new year of healthy life by expanding immunization coverage with standard child vaccines.
Ensure access to family planning services to prevent high-risk pregnancies, unsafe abortion, and infant deaths.
**Improving care of children under 28 days old (including resuscitation of newborns) is a highly cost-effective way to extend a life. It costs as little as US$10 for each year of healthy life gained.
Main causes of death in the first 28 days of life: Premature birth, asphyxia, and infections.
Reasons children under age 5 are most likely to die: pneumonia, diarrhea, tetanus, malaria, measles, whooping cough, HIV/AIDS, and malnutrition. 12

13. Promote good nutrition
Poor nutrition contributes to up to 40 percent of the disease burden worldwide.
Provide children and pregnant women essential nutrients.
Promote at least six months of exclusive breastfeeding for infants.
Lower trans fats in processed foods through legislation/regulation.
Essential nutrients can be incorporated into diet, fortified foods, or supplements
Essential nutrients including vitamin A, iron, and iodine can prevent maternal anemia, infant deaths, and long-term health problems
Obesity and excess weight = responsible for much disease and disability linked to cardiovascular disease, type 2 diabetes, cancer, and other chronic conditions. 13

14. Cardiovascular disease is the leading cause of death in low- and middle-income countries.
Deaths in Low- and Middle-Income Countries by Selected Causes, 2001
In developing countries, cardiovascular disease claims nearly three times as many lives as HIV/ tuberculosis, and malaria combined. 14

15. Reduce deaths from cardiovascular disease
Cardiovascular disease is the leading
cause of death worldwide.
Promote the use of aspirin and other inexpensive drugs to treat and prevent heart attack and stroke.
Substitute 2% of trans fat with polyunsaturated fat through regulation.
Help smokers quit through higher cigarette prices and cessation therapy.
CVD (includes heart diseases and stroke) kills nearly 13 million people a year in developing countries = three times as many people in developing countries each year as HIV, tuberculosis, and malaria combined.
A number of factors add to the growing burden of disease associated with CVD in developing countries:
Population aging
Increasing tobacco use
Success in reducing other health problems
Legislation replacing 2 percent of dietary trans fat with polyunsaturated fat could buy one year of healthy life for as little as US$48. 15

16. Stop the AIDS pandemic Offer voluntary HIV counseling and testing.
Forty million people are infected with HIV—26 million are in sub-Saharan Africa.
Offer voluntary HIV counseling and testing.
Promote 100 percent condom use among high-risk populations (i.e., sex workers, injecting-drug users, and men who have sex with men).
Treat other sexually transmitted infections.
Advocate school-based programs to educate teens about STIs and HIV.
The fight against the spread of HIV must include both prevention and treatment.
Interventions must aggressively target the populations at highest risk =
sex workers
injecting drug users and
men who have sex with men.
This would include providing clean needles to injecting drug users.
*It costs as little as US$10 to buy a year of healthy life by treating STIs to interrupt HIV transmission.
*Preventing mother-to-child transmission costs from $50 to $200 to buy a year of healthy life.
Combat the stigma and discrimination surrounding HIV and AIDS 16

17. Stop the spread of tuberculosis
Tuberculosis (TB) is spreading into new populations
and resisting treatment
Treat active TB cases with short-course chemotherapy.
Increase case detection.
Manage multidrug resistant TB with new drugs and drug combinations.
1.7 million people died of TB in 2003; 8.8 million new cases.
More priority actions:
Improve strategies to treat TB in HIV-positive individuals
Develop a low-cost vaccine against pulmonary TB
It costs only US$102 to buy a year of healthy life with short-course chemotherapy
More background:
New drug-resistant strains of TB and co-infection with HIV require more aggressive treatment. 17

18. Control malaria
Malaria claims the lives of 1 million children yearly, and it threatens nearly one-half of the world’s population.
Provide universal access to insecticide-treated nets in areas where malaria is endemic.
Expand intermittent preventive treatment for pregnant women.
Subsidize artemisinin combination therapy to ensure effective treatment.
More background:
More than 1 million children die each year of malaria-related anemia, brain damage, and other complications.
If left untreated in pregnant women, malaria can cause newborns to suffer from low birth weight, which can lead to a range of neurological impairments.
Expanding malaria preventive intermittent treatment for pregnant women reduces severe maternal anemia and newborn deaths.
Finance more effective drugs, especially artemisinin combination therapies (ACT) to ensure effective treatment.
In Sub-Saharan Africa, US$7 could buy a pregnant woman enough intermittent preventive treatment with a drug other than sulfadoxine-pyrimethamine to extend her life a year. 18

19. Most smokers now live in low- and middle-income countries.
Where Smokers Live
Low- and Middle-income Countries
High-income Countries
More than 1.1 billion people worldwide now smoke.
In the 20th century, there were more than 100 million tobacco-related deaths.
Most of them occurred in western countries and former socialist countries of the Soviet bloc.
This century, we will likely see 1 billion tobacco deaths—most in low-income countries. 19

20. Combat Tobacco Use
Tobacco-related diseases are the fastest-growing cause of disease and disability in developing countries.
Tax tobacco products to increase consumers’ costs by at least 33% to curb smoking.
Restrict smoking in public places and workplaces.
Provide nicotine replacement therapy and other cessation tools.
Ban tobacco advertising.
Tobacco use accounts for 1 in every 5 deaths among men over age 30 and
1 in every 20 deaths among women over age 30.
Of the estimated 1.1 billion people who smoke, 4 in 5 live in low- and middle-income countries.
Today, tobacco use kills an estimated 5 million people each year. Without aggressive curbs on tobacco use, tobacco-related deaths will double to 10 million per year by 2030.
The best way to reduce the toll from tobacco over the next half century is to get current smokers to quit.
Taxing tobacco products to increase consumers’ costs by at least one-third could curb smoking and reduce the prevalence of cardiovascular disease, cancer, and respiratory disease.
Taxing tobacco could cost between US$3-50 for each year of healthy life gained. 20

21. Reduce fatal and disabling injuries
Injuries and violence caused more than
5 million deaths in 2001, with an especially heavy toll on young men.
Install speed bumps at dangerous intersections.
Increase penalties for speeding; awareness through media; and law enforcement.
What is the single largest cause of serious injuries worldwide? Traffic crashes.
Traffic-related injuries will increase dramatically as motor vehicle ownership rises in developing countries.
Installing speedbumps is the most cost effective method of prevention. Each US$5 spent on speed bumps translates into another year of healthy life.
In comparison, $107 spent on bicycle helmet legislation in China buys one more year of healthy life.
And $467 spent on motorcycle helmet legislation in Thailand buys another year of life.
Increasing speeding penalties and installing speed bumps could cost just US$21 per year of life extended.
In Brazil, speed bumps are sometimes called “sleeping policemen. They are cheaper and more dependable than a life officer at an intersection.
Will need to:
Ensure safer driving by enforcing laws against speeding and drunk driving
Make roads safer with pedestrian walkways, traffic signals, and guardrails
Improve motor vehicle safety by installing seat belts and enforcing safety standards 21

22. Ensure equal access to high-quality health care
In many countries, women, rural residents, and the poor have less access to quality health care.
Train health workers to perform basic surgical procedures and treat common medical conditions.
Help providers choose the most cost-effective interventions.
Equity is a major subtext throughout DCP2; virtually every chapter addresses equity issues.
Unless equity considerations become a key part of policymaking and of monitoring outcomes, interventions may widen instead of narrow inequity gaps.
With the appropriate health interventions, scarce personnel and resources can be stretched to better serve disadvantaged groups.
Other priority actions:
Plan staffing to address health care needs.
Offer incentives to recruit, retain, and raise the performance of health care workers. 22

23. None of these improvements will be sustainable unless we strengthen
health systems.
Stewardship and regulation
Organizational structures
Human resources
Target resources
Important elements include:
Stewardship and regulation
Increase accountability of health systems to communities
Ensure users can influence priorities
Update regulations that govern private providers
Organizational structures
Use contracts with NGOs to deliver services where government capacity is limited or weak
Human resources
Improve recruitment and retention
Reduce migration of doctors and nurses
Target resources
Use resource-allocation formulas to ensure geographic equity
Use financial incentives and subsidies to address priority interventions
Provide inforamtion and training to help managers adapt services to local disease burden 23

24. Will this be the century of disease?
Four challenges:
HIV/AIDS
Cardiovascular disease
Avian flu/emerging infections/pandemics
The persistence of high, but preventable levels of malaria, TB, diarrhea, and pneumonia
The answer depends on our next move.
If we do nothing, we risk sliding backwards. 24

25. Countries don’t have to be rich in order to be healthy
Countries don’t have to be rich in order to be healthy. Given today’s tools and resources, much better health should and can be the norm—in countries rich and poor alike.
There’s no reason people in developing countries should be left behind when it comes to health. 25

26. For more information, visit us at www.dcp2.org