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Disease Control Priorities in Developing Countries

Dedication

This book is dedicated to Bill and Melinda Gates, whose vision, leadership, and financing over the past decade have catalyzed global support for transforming the lives of the world's poor through inexpensive but powerful health interventions.

Foreword

The 1993 publication of the now classic book, Disease Control Priorities in Developing Countries, by Oxford University Press and of its companion document, the World Development Report 1993: Investing in Health, published by the World Bank that same year, constitute a landmark in the public health literature. For the first time, decision makers and public health practitioners had a comprehensive review of the cost-effectiveness of available interventions to address the most common health problems in the developing world. They were also provided with the useful metric known as disability-adjusted life years to calculate the burden of disease and the cost-effectiveness of interventions more accurately than in the past.

As was the case with the first edition, this second edition of Disease Control Priorities in Developing Countries will serve an array of audiences. One primary audience consists of people working in the health sector, ranging from those who are responsible for making evidence-based decisions to those who practice medicine and public health under often suboptimal field conditions. A second audience consists of people working in finance and planning ministries, who will benefit from the solid recommendations for improving the health of populations through sound resource reallocation and cost-effective practices.

Purpose

The purpose of this book is to provide information about what worksspecifically, the cost-effectiveness of health interventions in a variety of settings. Such information should influence the redesign of programs and the reallocation of resources, thereby helping to achieve the ultimate goal of reducing morbidity and mortality.

Fundamental Policy Considerations

Although economic and budgetary constraints are clearly important considerations, money is not the only limitation. Additional factors fundamental to improving outcomes are the particular circumstances in each country, as well as the individual institutional capacities to deliver goods and services and to implement policies and processes.

Context-specific strategies and responses are essential, because application of the Disease Control Priorities Project's findings will vary according to each country's circumstances: one size does not fit all. Understanding that most health interventions require a minimum level of institutional capacity to deliver goods and services is equally important, and such capacity may have to be built up before money or physical inputs can yield any benefits. Accordingly, goals and priorities should be established and tailored to each country's context.

Transition in Health

Every developing region is facing a transition in its epidemiological profile from an environment with high fertility rates and high mortality from preventable causes to one in which a combination of lower fertility rates and changing lifestyles has led to aging populations and epidemics of tobacco addiction, obesity, cardiovascular disease, cancers, diabetes, and other chronic ailments. The 20th century will be remembered for, among other things, witnessing the largest universal increase in life expectancy in history. While life expectancy is highest in the richest countries, the upward trend is apparent in almost every society. Moreover, in the past 50 years, variations in this health indicator across and within countries have decreased. This convergence of improved life expectancy and reduced variations, which has occurred even in the presence of widening income gaps in many regions, can be explained solely by the impact of knowledge expansion and direct public health interventions.

The increase in life expectancy worldwide will, however, soon reach a plateau, and a retraction has occurred in many countries. HIV/AIDS and civil unrest in Africa, vaccine-preventable diseases and alcoholism in Eastern Europe, and obesity in the United States have reducedor will soon do sothe years of life their populations can expect.

Scaling Up Effective Interventions

The late Jim Grant, former executive director of the United Nations Children's Fund, was one of the first leaders with a vision for setting specific health goals and priorities within a time frame and on a global scale. He recognized the need to raise awareness of the dramatic disparities in children's health and to mobilize political will accordingly. His missionary zeal for universal child immunization and for organizing the first summit of world leaders for children's health and rights in 1990 permitted the scaling up of interventions of proven efficacy. The Millennium Development Goals are a natural consequence of that vision and an extremely useful instrument for maintaining both focus and social pressure. Achieving these ambitious goals will require not only the universal implementation of effective interventions that are currently available, but also the development of new interventions.

Need for Ongoing Research

Today, most vaccines, medical devices, diagnostic tools, and drugs have been subjected to careful investigation in the laboratory, at the bedside, and in the field. However, not enough investment has gone into research to increase well-being and development globally. We need more epidemiological and health systems research to improve the efficiency of available interventions, technological research to reduce their costs, and biomedical research to develop new tools for dealing with as yet unsolved and emerging health problems.

Opportunities and Challenges of Globalization

One of the greatest opportunities and challenges for international public health is globalization. We live in an era when the explosion of trade, travel, and communications is spreading new cultural influences and lifestyles faster than ever before, and the division between domestic and international health problems is becoming increasingly obsolete. At the same time, globalization also permits the spread of risks, pathogens, and other threats. The ever-increasing movement of people everywhere increases the potential for epidemics. Travelers, refugees, and displaced people are more vulnerable to infectious diseases, and their movement contributes to spreading pathogens into new areas. Overall, however, the positive consequences outweigh the negative ones, and cautious optimism about this irreversible trend is justified. Certainly, one of the most valuable contributions of globalization is the rapid accrual and spread of knowledge about useful tools for controlling disease and ways to implement those tools on a large scale.

In recent years, the huge advances in information technology have greatly boosted the globalization of knowledge. Ideally, this should become a tide that lifts all boats to yield global benefits. The challenge is to harness the information technology revolution to foster the growth of economies. One step in the right direction is the open access movement, which promotes and permits free and immediate access to research results and other components of knowledge transfer.

Spending More and Spending Better

It is indeed a paradox to observe that even though the money spent on health worldwide has reached 10 percent of overall global income, that amount is both insufficient and poorly allocated. The World Health Organization's Commission on Macroeconomics and Health and several other global initiatives make a persuasive plea for a larger investment in health. At the same time, this book is dedicated to making the case for better spendingthat is, deriving more health benefits from every dollar spent. The aim should be to reduce inequalities in health investment between and within countries: a 100-fold difference between the rich and the poor in money spent on health services still persists in many places. Despite a lack of clarity about what constitutes the optimum balance of health spending, a larger share should go to prevention. This book looks at several prevention options and clinical interventions that are not being fully implemented.

Selecting Interventions

This book persuasively makes the case that both clinical and public health interventions depend on the capacity of a given country's health system to deliver, noting that some interventions are more demanding than others in terms of infrastructure and human resources. Therefore, both the costs and the likelihood of success of the more complex interventions are a function of the health capacity in place. In addition, decisions about which interventions should be given priority will depend on assessments of the local burden of disease, local health infrastructure, and other social factors as well as on cost-effectiveness analyses. The following chapters identify the health system capacity needed for scaling up a given intervention. Even middle-income countries with relatively better health infrastructure often pursue sophisticated approaches to medical care that result in fewer health gains per amount of money invested. Every country, regardless of level of development, could benefit from the recommendations presented here.

Diagonal Approach

The medical literature has long debated which approach to delivering health interventions is more effective: vertical programs or horizontal programs. Vertical programs refer to focused, proactive, disease-specific interventions on a massive scale, whereas horizontal programs refer to more integrated, demand-driven, resource-sharing health services. This is a false dilemma, because both need to coexist in what could be called a diagonal approach that is, the proactive, supply-driven provision of a set of highly cost-effective interventions on a large scale that bridges health clinics and homes. This approach often starts vertically (polio vaccination, for instance) but moves toward an increasing number of interventions (for example, oral rehydration, other vaccines, residual spraying and bednets for malaria control, micronutrient supplementation, and supervised tuberculosis treatment), making full use of field health workers and existing infrastructure. This could well be the equivalent of a public health polypill.

Multidisciplinary Orientation

What makes this book unique, in addition to its comprehensive scope, is its truly multidisciplinary approach to disease control, which merges the best of the medical and economic sciences. Every recommendation has been carefully researched and documented. Evidence-based approaches must be the foundation for allocating scarce resources. The poor cannot afford anything but the most efficient methods for organizing and implementing health care. This book is a fundamental component for fostering equitable outcomes in health and development. It will inspire all those who seek the highly complex but attainable goal of universal good health for all members of the global community.

Facilitating Progress

We all share global responsibility: governments and international agencies, public and private sectors, and society and individuals all have specific tasks. We must all strive toward more equitable distribution of the benefits of new knowledge to reduce health and development gaps between rich and poor, between countries, and within countries. The second edition of Disease Control Priorities in Developing Countries is a new step in precisely the right direction. If we succeed in conveying the main lessons and messages of this book, public health in developing countries will progress farther and faster.

Director, National Institutes of Health of Mexico Mexico City Mexico Chair, Advisory Committee to the Editors

Preface

In the late 1980s, the World Bank initiated a review of priorities for the control of specific diseases and used this information as input for comparative cost-effectiveness estimates of interventions addressing most conditions important in developing countries. The purpose of the comparative cost-effectiveness work was to inform decision making within the health sectors of highly resource-constrained low- and middle-income countries. This process resulted in the 1993 publication of the first edition of Disease Control Priorities in Developing Countries ( DCP1 ) ( Jamison and others 1993 ). That volume's preface stated its purpose as follows:

Between 1950 and 1990, life expectancy in developing countries increased from forty to sixty-three years with a concomitant rise in the incidence of the noncommunicable diseases of adults and the elderly. Yet there remains a huge unfinished agenda for dealing with undernutrition and the communicable childhood diseases. These trends lead to increasingly diverse and complicated epidemiological profiles in developing countries. At the same time, new epidemic diseases like AIDS are emerging; and the health of the poor during economic crisis is a source of growing concern. These developments have intensified the need for better information on the effectiveness and cost of health interventions. To assist countries to define essential health service packages, this book provides information on disease control interventions for the commonest diseases and injuries in developing countries.

To this end, DCP1 aimed to provide systematic guidance on the selection of interventions to achieve rapid health improvements in an environment of highly constrained public sector budgets through the use of cost-effectiveness analysis.

DCP1 provided limited discussion of investments in health system development. Other major efforts undertaken at the World Bank at about the same time, including the World Development Report 1993: Investing in Health, used the findings of DCP1 and dealt more explicitly with the financial and health systems aspects of implementation ( Feachem and others 1992 ; World Bank 1993 ). Closely related efforts in collaboration with the World Health Organization led to the first global and regional estimates of numbers of deaths by age, sex, and cause and of the burden (including the disability burden) from more than 100 specific diseases and conditions ( Murray, Lopez, and Jamison 1994 ; World Bank 1993 ).

This second edition of Disease Control Priorities in Developing Countries ( DCP2 ) seeks to update and improve guidance on the "what to do" questions in DCP1 and to address the institutional, organizational, financial, and research capacities essential for health systems to deliver the right interventions. DCP2 is the principal product of the Disease Control Priorities Project, an alliance of organizations designed to review, generate, and disseminate information on how to improve population health in developing countries. In addition to DCP2 , the project produced numerous background papers, an extensive range of interactive consultations held around the world, and several additional major publications. The other major publications are as follows:

Global Burden of Disease and Risk Factors ( Lopez and others 2006 ), undertaken in collaboration with the World Health Organization
Millions Saved: Proven Successes in Global Health ( Levine and the What Works Working Group 2004 ), undertaken in collaboration with the Center for Global Development
"The Intolerable Burden of Malaria: II. What's New, What's Needed" ( Breman, Alilio, and Mills 2004 ), undertaken in collaboration with the Multilateral Initiative on Malaria
Priorities in Health ( Jamison and others 2006 ), a brief and nontechnical companion to this volume.

Each product of the Disease Control Priorities Project marries economic approaches with those of epidemiology, public health, and clinical medicine.

While general lessons emerge from the Disease Control Priorities Project, they result from careful consideration of individual cases. The diversity of health conditions necessitates specificity of analysis. Arrow clearly stated the need for technical analyses to underpin health economics: "Another lesson of medical economics is the importance of recognizing the specific character of the disease under consideration. The policy challenges that arise in treating malaria are simply very different from those attached to other major infectious scourges ( Arrow, Panosian, and Gelband 2004 , xixii)." Chapters in this volume address this need for specificity, yet use cost-effectiveness analysis in a way that makes findings on the relative attractiveness of interventions comparable.

DCP2 goes beyond DCP1 in a number of important ways as follows:

While virtually all chapters of DCP1 were structured around clusters of conditions, DCP2 provides integrative chaptersfor example, on school health systems, surgery, and integrated management of childhood illnessthat draw together the implementation-related responses to a number of conditions. These and other chapters reflect DCP2 's inclusion of implementation and system issues.
DCP2 includes explicit discussions of research and product development opportunities.
Although DCP1 dealt with policy mechanisms to change behavior (or the environment), DCP2 attempts to do so in a more systematic way. In particular, a number of chapters assess in depth the public sector instruments for influencing behavior change that were described briefly in DCP1 : information, education, and communication; laws and regulations; taxes and subsidies; engineering design, such as speed bumps; and facility location and characteristics.
Different interventions place different levels of demand on a country's health system capacity. DCP2 builds on earlier work ( Gericke and others 2005 ) in attempting, in some chapters, to identify which interventions require relatively less system capacity for scaling up and which require more.
Although DCP1 briefly discussed the nonhealth outcomes of interventions, DCP2 does so in a more systematic way, including looking at the consequences of interventions (and intervention financing) for reducing financial risks at the household level. Other important nonhealth outcomes include, for example, the time-saving value of having piped water close to the home, the increased labor productivity of healthy workers, and the amenity value of clean air.
An important element of DCP1 was its assumption that to inform broad policy, major changes from the status quo need to be considered, not just marginal ones. For cost-effectiveness analysis, any major change needs to be informed by burden of disease assessments in a way not required for judging the attractiveness of marginal change, because the size of the burden affects total costs and the feasibility of extending the intervention to all who would benefit. This is particularly true when considering research and development priorities, but also applies to control priorities. In this regard, DCP2 continues in the spirit of DCP1 in assessing cost-effectiveness analyses of major changes, but it does so more systematically for each of the six regional groupings of low- and middle-income countries used throughout this volume (see map 1, inside the front cover).

What was becoming clear in 1990 is clearer today: focusing health system attention on delivering efficacious and often relatively inexpensive health interventions can lead to dramatic reductions in mortality and disability at modest cost. A valuable dimension of globalization has been the diffusion of knowledge about what these interventions are and how to deliver them. The pace of this diffusion into a country determines the pace of health improvement in that country much more than its level of income. Our purpose is to help speed this diffusion of life-saving knowledge.

The Editors

References

Arrow, K. J., C. Panosian, and H. Gelband, eds. 2004. Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance . Washington, DC: National Academies Press.

, J. G. Breman , M. S. Alilio , A. Mills . 2004. The Intolerable Burden of Malaria: II. What's New, What's Needed American Journal of Hygiene and Tropical Medicine 71: 2 Suppl 1 - 282

Feachem, R. G. A., T. Kjellstrom, C. J. L. Murray, M. Over, and M. Phillips, eds. 1992. Health of Adults in the Developing World. New York: Oxford University Press.

, C. A. Gericke , C. Kurowski , M. K. Ranson , A. Mills . 2005. Intervention Complexity: A Conceptual Framework to Inform Priority-Setting in Health Bulletin of the World Health Organization 83: 4 285 - 93 (PubMed)

Jamison, D. T., J. G. Breman, A. R. Measham, G. Alleyne, M. Claeson, D. B. Evans, P. Jha, A. Mills and P. Musgrove, eds. 2006. Priorities in Health . Washington, DC: World Bank.

Jamison, D. T., W. H. Mosley, A. R. Measham, and J. L. Bobadilla, eds. 1993. Disease Control Priorities in Developing Countries. New York: Oxford University Press.

Levine, R., and the What Works Working Group. 2004. Millions Saved: Proven Successes in Global Health . Washington, DC: Center for Global Development.

Lopez A. D., C. D. Mathers, M. Ezzati, D. T. Jamison, and C. J. L. Murray, eds. 2006. Global Burden of Disease and Risk Factors . New York: Oxford University Press.

Murray, C. J. L., A. D. Lopez, and D. T. Jamison. 1994. "The Global Burden of Disease in 1990: Summary Results, Sensitivity Analysis, and Future Directions." In Global Comparative Assessments in the Health Sector: Disease Burden, Expenditures, and Intervention Packages , ed. C. J. L. Murray, and A. D. Lopez, 97138. Geneva: World Health Organization.

World Bank. 1993 . World Development Report 1993: Investing in Health . New York: Oxford University Press.

Editors

Dean T. Jamison is a professor of health economics in the School of Medicine at the University of California, San Francisco (UCSF), and an affiliate of UCSF Global Health Sciences. Dr. Jamison concurrently serves as an adjunct professor in both the Peking University Guanghua School of Management and in the University of Queensland School of Population Health.

Before joining UCSF, Dr. Jamison was on the faculty of the University of California-Los Angeles, and also spent many years at the World Bank, where he was a senior economist in the research department; division chief for education policy; and division chief for population, health, and nutrition. In 199293, he temporarily rejoined the World Bank to serve as director of the World Development Report Office and as lead author for the Bank's World Development Report 1993: Investing in Health .

His publications are in the areas of economic theory, public health, and education. Dr. Jamison studied at Stanford (B.A., philosophy; M.S., engineering sciences) and at Harvard (Ph.D., economics, under K. J. Arrow). In 1994, he was elected to membership in the Institute of Medicine of the U.S. National Academy of Sciences.

Joel G. Breman, M.D., D.T.P.H., is senior scientific adviser, Fogarty International Center of the National Institutes of Health, and comanaging editor of the Disease Control Priorities Project. He was educated at the University of California, Los Angeles; the Keck School of Medicine, the University of California; and the London School of Hygiene and Tropical Medicine. Dr. Breman trained in medicine at the University of California—Los Angeles County Medical Center; in infectious diseases at the Boston City Hospital, Harvard Medical School; and in epidemiology at the U.S. Centers for Disease Control and Prevention.

Dr. Breman worked in Guinea on smallpox eradication (196769); in Burkina Faso at the Organization for Coordination and Cooperation in the Control of the Major Endemic Diseases (197276); and at the World Health Organization, Geneva (197780), where he was responsible for orthopoxvirus research and the certification of smallpox eradication. In 1976, in the Democratic Republic of Congo (formerly Zaire), Dr. Breman investigated the first outbreak of Ebola hemorrhagic fever.

Following the confirmation of smallpox eradication in 1980, Dr. Breman returned to the U.S. Centers for Disease Control, where he began work on the epidemiology and control of malaria. Dr. Breman joined the Fogarty International Center in 1995 and has been director of the International Training and Research Program in Emerging Infectious Diseases and senior scientific adviser. He has been a member of many advisory groups, including serving as chair of the World Health Organization's Technical Advisory Group on Human Monkeypox and as a member of the World Health Organization's International Commission for the Certification of Dracunculiasis (guinea worm) Eradication. Dr. Breman has written more than 100 publications on infectious diseases and research capacity strengthening in developing countries. He was guest editor of two supplements to the American Journal of Tropical Medicine and Hygiene : "The Intolerable Burden of Malaria: A New Look at the Numbers" (2001) and "The Intolerable Burden of Malaria: What's New, What's Needed" (2004).

Anthony R. Measham is comanaging editor of the Disease Control Priorities Project at the Fogarty International Center of the National Institutes of Health; deputy director of the Communicating Health Priorities Project at the Population Reference Bureau, Washington, DC; and a member of the Working Group of the Global Alliance for Vaccines and Immunization on behalf of the World Bank.

Born in the United Kingdom, Dr. Measham practiced family medicine in Dartmouth, Nova Scotia, before devoting the remainder of his career to date to international health. He spent 15 years living in developing countries on behalf of the Population Council (Colombia), the Ford Foundation (Bangladesh), and the World Bank (India). Early in his international health career (197577), he was deputy director of the Center for Population and Family Health at Columbia University, New York. He then served for 17 years on the staff of the World Bank, as health adviser from 1984 until 1988 and as chief for policy and research of the Health, Nutrition, and Population Division from 1988 until 1993.

Dr. Measham has spent most of his career providing technical assistance, carrying out research and analysis, and helping to develop projects in more than 20 developing countries, primarily in the areas of maternal and child health, family planning, and nutrition. He was an editor of the first edition of Disease Control Priorities in Developing Countries and has authored approximately 60 monographs, book chapters, and journal articles.

Dr. Measham graduated in medicine from Dalhousie University, Halifax, Nova Scotia. He received a master of science and a doctorate in public health from the University of North Carolina in Chapel Hill and is a diplomat of the American Board of Preventive Medicine and Public Health. His honors include being elected to the Alpha Omega Alpha Honor Medical Society; being appointed as special professor of International Health, University of Nottingham Medical School, Nottingham, United Kingdom; and being named Dalhousie University Medical Alumnus of the Year in 20001.

George Alleyne, M.D., F.R.C.P., F.A.C.P. (Hon), D.Sc. (Hon), is director emeritus of the Pan American Health Organization, where he served as director from 1995 to 2003. Dr. Alleyne is a native of Barbados and graduated from the University of the West Indies in medicine in 1957. He completed his postgraduate training in internal medicine in the United Kingdom and did further postgraduate work in that country and in the United States. He entered academic medicine at the University of the West Indies in 1962, and his career included research in the Tropical Metabolism Research Unit for his doctorate in medicine. He was appointed professor of medicine at the University of the West Indies in 1972, and four years later he became chair of the Department of Medicine. He is an emeritus professor of the University of the West Indies. Dr. Alleyne joined the Pan American Health Organization in 1981, in 1983 he was appointed director of the Area of Health Programs, and in 1990 he was appointed assistant director.

Dr. Alleyne's scientific publications have dealt with his research in renal physiology and biochemistry and various aspects of clinical medicine. During his term as director of the Pan American Health Organization, he dealt with and published on issues such as equity in health, health and development, and international cooperation in health. He has also addressed several aspects of health in the Caribbean and the problems the area faces. He is a member of the Institute of Medicine and chancellor of the University of the West Indies.

Dr. Alleyne has received numerous awards in recognition of his work, including prestigious decorations and national honors from many countries of the Americas. In 1990, he was made Knight Bachelor by Her Majesty Queen Elizabeth II for his services to medicine. In 2001, he was awarded the Order of the Caribbean Community, the highest honor that can be conferred on a Caribbean national.

Mariam Claeson, M.D., M.P.H., is the program coordinator for AIDS in the South Asia Region of the World Bank since January 2005. She was the lead public health specialist in the Health, Nutrition, and Population, Human Development Network, of the World Bank (19982004), managing the Health, Nutrition, and Population Millennium Development Goals work program to support accelerated progress in countries.

Dr. Claeson coauthored the call for action by the Bellagio study group on child survival in 2003, Knowledge into Action for Child Survival, and the World Bank's 2005 report on The Millennium Development Goals for Health: Rising to the Challenges . She was a member of the What Works Working group hosted by the Center for Global Development that resulted in the report Millions Saved: Proven Successes in Global Health 2005. Dr. Claeson coauthored the health chapter of the Poverty Reduction Strategy source book, promoting a life-cycle approach to maternal and child health and nutrition. As a coordinator of the public health thematic group (19982002), she led the development of the strategy note Public Health and World Bank Operations and promoted multisectoral approaches to child health within the World Bank and in Bank-supported country operations, analytical work, and lending.

Prior to joining the World Bank, Dr. Claeson worked with the World Health Organization from 1987 until 1995, in later years as program manager for the Global Program for the Control of Diarrheal Diseases. She has several years of field experience working in developing countries; in clinical practice at the rural district level in Bangladesh, Bhutan, and Tanzania; in national program management of immunization and diarrheal disease control programs in Ethiopia; and in health sector development projects in middle- and low-income countries.

David B. Evans, Ph.D., is an economist by training. Between 1980 and 1990, he was an academic, first in economics departments and then in a medical school, during which time he undertook consultancies for the World Bank, the World Health Organization, and governments. From 1990 until 1998, he sponsored and conducted research into social and economic aspects of tropical diseases and their control in the United Nations Children's Fund, United Nations Development Programme, World Bank, and World Health Organization Special Programme on Research and Training in Tropical Diseases. He subsequently became director of the Global Programme on Evidence for Health Policy and then the Department of Health Systems Financing of the World Health Organization, where he is now responsible for a range of activities relating to the development of appropriate health financing strategies and policies. These activities include the World Health Organization's CHOICE project, which has assessed and reported the costs and effectiveness of more than 700 health interventions, the costs of scaling up interventions, the levels of health expenditures and accounts, and the extent of financial catastrophe and impoverishment caused by out-of-pocket payments for health and which has assessed the impact of different ways to raise funds for health, pool them, and use them to provide or purchase services and interventions. He has published widely in these areas.

Prabhat Jha is Canada research chair of health and development at the University of Toronto. He is also the founding director of the Centre for Global Health Research, St. Michael's Hospital; associate professor in the Department of Public Health Sciences, University of Toronto; research scholar at the McLaughlin Centre for Molecular Medicine; and professeur extraordinaire at the Universit de Lausanne, Switzerland.

Dr. Jha is lead author of Curbing the Epidemic: Governments and the Economics of Tobacco Control and coeditor of Tobacco Control in Developing Countries . Both are among the most influential books on tobacco control. He is the principal investigator of a prospective study of 1 million deaths in India, researching mortality from smoking, alcohol use, fertility patterns, indoor air pollution, and other risk factors among 2.3 million homes and 15 million people. This work is currently the world's largest prospective study of health. He also conducts studies of HIV transmission in various countries, focusing on documenting the risk factors for the spread of HIV and interventions to prevent the spread of the HIV/AIDS epidemic. His studies have received more than $5 million in peer-reviewed grants.

Dr. Jha has published widely on tobacco, HIV/AIDS, and health of the global poor. His awards include a Gold medal from the Poland Health Promotion Foundation (2000), the Top 40 Canadians under Age 40 Award (2004), and the Ontario Premier's Research Excellence Award (2004). Dr. Jha was a research scholar at the University of Toronto and McMaster University in Canada. He holds an M.D. from the University of Manitoba and a D. Phil. in epidemiology and public health from Oxford University, where he studied as a Rhodes Scholar at Magdalen College.

Anne Mills, Ph.D., is professor of health economics and policy at the London School of Hygiene and Tropical Medicine. She has more than 20 years of experience in research pertaining to health economics in developing countries and has published widely in the fields of health economics and health planning, including books on the role of government in health in developing countries, health planning in the United Kingdom, decentralization, health economics research in developing countries, and the public-private mix. Her most recent research interests have been in the organization and financing of health systems, including the evaluation of contractual relationships between the public and private sectors and the application of economic evaluation techniques to improve the efficiency of disease control programs.

Dr. Mills has had extensive involvement in supporting the health economics research activities of the World Health Organization's Tropical Disease Research Programme. She founded, and is head of, the Health Economics and Financing Programme, which has become one of the world's leading groups in developing and applying theories and techniques of health economics to increase knowledge on how best to improve the equity and efficiency of developing countries' health systems. She has acted as adviser to a number of multilateral and bilateral agenciesnotably, the United Kingdom Department for International Development and the World Health Organization. She guided the creation of the Alliance for Health Policy and Systems Research and chairs its board. Most recently, she has been a member of the Commission for Macroeconomics and Health and cochair of its working group on improving the health outcomes of the poor.

Philip Musgrove is deputy editorglobal health for Health Affairs, which is published by Project HOPE in Bethesda, Maryland. He worked for the World Bank (19902002), including two years on secondment to the World Health Organization (19992001), retiring as a principal economist. He was previously an adviser in health economics at the Pan American Health Organization (198290) and a research associate at the Brookings Institution and at Resources for the Future (196481).

Dr. Musgrove is an adjunct professor at the School of Advanced International Studies, Johns Hopkins University, and has taught at George Washington University, American University, and the University of Florida. He holds degrees from Haverford College (B.A., 1962, summa cum laude); Princeton University (M.P.A., 1964); and Massachusetts Institute of Technology (Ph.D., 1974).

Dr. Musgrove has worked on health reform projects in Argentina, Brazil, Chile, and Colombia and has dealt with a variety of issues in health economics, financing, equity, and nutrition. His publications include more than 50 articles in economics and health journals and chapters in 20 books.

Advisory Committee to the Editors

J. R. Aluoch Professor, Nairobi Women's Hospital, Nairobi, Kenya

Jacques Baudouy Director, Health, Nutrition, and Population, World Bank, Washington, DC, United States

Fred Binka Executive Director, INDEPTH Network, Accra, Ghana

Mayra Buvinic Director, Gender and Development, World Bank, Washington, DC, United States

David Challoner, Co-Chair Foreign Secretary, Institute of Medicine, U.S. National Academies, Gainesville, Florida, United States

Guy de Th, Co-Chair Research Director and Professor Emeritus, Institut Pasteur, Paris, France

Timothy Evans Assistant Director General, Evidence and Information for Policy, World Health Organization, Geneva, Switzerland

Richard Horton Editor, The Lancet, London, United Kingdom

Sharon Hrynkow Acting Director, Fogarty International Center, National Institutes of Health, Bethesda, Maryland, United States

Gerald Keusch Provost and Dean for Global Health, Boston University School of Public Health, Boston, Massachusetts, United States

Kiyoshi Kurokawa President, Science Council of Japan, Kanawaga, Japan

Peter Lachmann Past President, U.K. Academy of Medical Sciences, Cambridge, United Kingdom

Mary Ann Lansang Executive Director, INCLEN Trust International Inc., Manila, Philippines

Christopher Lovelace Director, Kyrgyz Republic Country Office and Central Asia Human Development, World Bank, Bishkek, Kyrgyz Republic

Anthony Mbewu Executive Director, Medical Research Council of South Africa, Tygerberg, South Africa

Rajiv Misra Former Secretary of Health, Government of India, Haryana, India

Perla Santos Ocampo President, National Academy of Science and Technology, San Juan, Philippines

G. B. A. Okelo Secretary General and Executive Director, African Academy of Sciences, Nairobi, Kenya

Sevket Ruacan General Director, MESA Hospital Ankara, Turkey

Pramilla Senanayake Chairman, Foundation Council of the Global Forum for Health Research, Colombo, Sri Lanka

Jaime Seplveda, Chair Director, National Institutes of Health of Mexico, Mexico City, Mexico

Chitr Sitthiamorn Director, Institute of Health Research, and Dean, Chulalongkorn University, College of Public Health, Bangkok, Thailand

Sally Stansfield Associate Director, Global Health Strategies, Bill & Melinda Gates Foundation, Seattle, Washington, United States

Misael Uribe President, National Academy of Medicine of Mexico, Mexico City, Mexico

Zhengguo Wang Professor, Chinese Academy of Engineering, Daping, China

Witold Zatonski Professor, Health Promotion Foundation, Warsaw, Poland

Contributors

Taghreed Adam World Health Organization

Sarah Adomakoh Chronic Disease Research Centre, University of the West Indies Associates for International Development

Olu Akinyanju Sickle Cell Foundation, Nigeria, University Teaching Hospital, Nigeria

Mark A. Anderson U.S. Centers for Disease Control and Prevention

Sevgi O. Aral U.S. Centers for Disease Control and Prevention

Samira Asma U.S. Centers for Disease Control and Prevention

Cristian Baeza World Bank

Rob Baltussen Erasmus MC

Delia Barcelona United Nations Population Fund

Scott Barrett Johns Hopkins University

John H. Barton Stanford University

Jane Batt University of Toronto, St. Michaels Hospital

Angela Bayer Johns Hopkins University Bloomberg School of Public Health

Kathleen Beegle World Bank

Genevive Begkoyian United Nations Children's Fund

Jere R. Behrman University of Pennsylvania

Nicole Bellows University of California, Berkeley

Sandra E. Bendeck University of Texas at Southwestern

Stefano Bertozzi Instituto Nacional de Salud Pblica

Jeff Bethony George Washington University

Alok Bhargava University of Houston

Sohinee Bhattacharya University of Aberdeen

Zulfiqar A. Bhutta Aga Khan University

Nancy Birdsall Center for Global Development

David Bishai Johns Hopkins University

Robert E. Black Johns Hopkins Bloomberg School of Public Health

Barry R. Bloom Harvard School of Public Health

Stephen B. Blount U.S. Centers for Disease Control and Prevention

Cynthia Boschi-Pinto World Health Organization

Douglas Bratthall World Health Organization Collaborating Centre, Centre for Oral Health Sciences, Malmo University

Carol Brayne University of Cambridge

Joel G. Breman Fogarty International Center, National Institutes of Health Disease Control Priorities Project

Logan Brenzel World Bank

Dan W. Brock Harvard Medical School

Simon Brooker London School of Hygiene and Tropical Medicine

Peter Brooks University of Queensland

Claire V. Broome U.S. Centers for Disease Control and Prevention

L. Jackson Brown American Dental Association

Martin L. Brown National Cancer Institute, National Institutes of Health

Nigel Bruce University of Liverpool

Jennifer Bryce Independent consultant

Colin H. W. Bullough University of Aberdeen

Donald A. P. Bundy World Bank

Alexander Butchart World Health Organization

Mayra Buvinic World Bank

Sandy Cairncross London School of Hygiene and Tropical Medicine

John Cairns London School of Hygiene and Tropical Medicine

Balla Camara Ministry of Public Health, Guinea, Ministry of Education, Guinea

Pierre Cattand Association against Trypanosomiasis

Laura E. Caulfield Johns Hopkins University Bloomberg School of Public Health

Frank J. Chaloupka University of Illinois at Chicago

Vijay Chandra World Health Organization, Regional Office for South-East Asia

Heng Leng Chee National University of Singapore

Suephy Chen Emory University, Atlanta Veterans Administration Medical Center

Thomas Cherian World Health Organization

Tom M. Chiller U.S. Centers for Disease Control and Prevention

Dan Chisholm World Health Organization

Lester Chitsulo World Health Organization

Jeffrey Chow Resources for the Future

Mushtaque Chowdhury Bangladesh Rural Advancement Committee, Columbia University

Mariam Claeson World Bank

Luke B. Connelly University of Queensland

Joseph Cook International Trachoma Initiative

Rodrigo Correa-Oliveira Centro de Pesquisas Rene RachouFIOCRUZ

Mark Cullen Yale University

Patricia M. Danzon Wharton School, University of Pennsylvania

Haile T. Debas University of California, San Francisco

Louisa Degenhardt University of New South Wales

Lisa M. DeMaria Instituto Nacional de Salud Pblica

Nilanthi de Silva University of Kelaniya, Sri Lanka

Phillippe Desjeux Institute for OneWorld Health

Claude de Ville de Goyet Independent consultant

John Dirks International Society of Nephrology, University of Toronto

Jane Doherty University of the Witwatersrand, South Africa

Chris Doran University of Queensland

Ogobara K. Doumbo University of Bamako, Mali

Gerrit Draisma Erasmus MC

Lesley Drake St. Mary's Medical School

Maureen S. Durkin University of Wisconsin Medical School, University of Wisconsin-Madison

Adriano Duse University of the Witwatersrand, South Africa, National Health Laboratory Service

Courtenay Dusenbury Emory University

Christopher Dye World Health Organization

Michael M. Engelgau U.S. Centers for Disease Control and Prevention

Dirk Engels World Health Organization

Mike English Kenya Medical Research Institute, University of Oxford

Victoria Espitia-Hardeman U.S. Centers for Disease Control and Prevention

Roberto Estrada Universidad Autnoma de Guerrero, Mexico

David B. Evans World Health Organization

Timothy Evans World Health Organization

Qiu Fang World Bank

Piet Feenstra Royal Tropical Institute, Netherlands

Becca Feldman Harvard School of Public Health Instituto Nacional de Salud Pblica

Alan Fenwick Imperial College

Elisa Fernndez Inter-American Development Bank

Marilyn Fingerhut National Institute for Occupational Safety and Health, United States

Katherine Floyd World Health Organization

Kathleen M. Foley Memorial Sloan-Kettering Cancer Center, Weill Medical College of Cornell University

Olivier Fontaine World Health Organization

Susan Foster Boston University School of Public Health

Julia Fox-Rushby Brunel University, United Kingdom

Julio Frenk Secretaria de Salud de Mexico

Kevin D. Frick Johns Hopkins Bloomberg School of Public Health

Suthat Fucharoen Mahidol University, Thailand

Vendhan Gajalakshmi Epidemiological Research Center, India

Rae Galloway World Bank

Helene Gayle Bill & Melinda Gates Foundation

Thomas A. Gaziano Brigham and Women's Hospital, Harvard Medical School

Hellen Gelband Institute of Medicine, National Academies

Amaya Gillespie United Nations Study on Violence against Children

Julian Gold Prince of Wales Hospital, Australia

Sue J. Goldie Harvard School of Public Health

Chuck Golmar World Health Organization

Richard Gosselin University of California, Berkeley

Pablo Gottret World Bank

Eduardo Gotuzzo Universidad Peruana Cayetano Heredia, Hospital Nacional Cayetano Heredia, Peru

Wendy J. Graham University of Aberdeen, London School of Hygiene and Tropical Medicine

Robert Grant J. David Gladstone Institutes, United States

Brian Greenwood London School of Hygiene and Tropical Medicine

Prakash C. Gupta Healis-Sekhsaria Institute of Public Health, India Arnold School of Public Health, United States

M.G. Guzmn Pedro Kouri Tropical Medicine Institute, Cuba

Anne Haddix Rollins School of Public Health, Emory University

Wayne Hall University of Queensland

Neal A. Halsey Johns Hopkins University Bloomberg School of Public Health

Joe Harford National Cancer Institute, National Institutes of Health

Roderick Hay Queen's University Belfast

Robert M. Hecht International AIDS Vaccine Initiative

D. A. Henderson University of Pittsburgh Medical Center

Martin Hensher Department of Health, United Kingdom

Susan Herman University of Pennsylvania

Eduardo Romero Hicks Secretaria de Salud Guanajuato, Mexico University of Guanajuato, Mexico

Anna-Maria Hoffman United Nations Educational Scientific, and Cultural Organization

Karen J. Hofman Fogarty International Center, National Institutes of Health

King K. Holmes University of Washington, Harborview Medical Center

Charles Hongoro London School of Hygiene and Tropical Medicine Aurum Health Research Institute

Susan Horton Wilfrid Laurier University, Canada

Peter J. Hotez George Washington University

Fleur Hourihan University of Newcastle, Australia

Guy Hutton Swiss Tropical Institute

Adnan A. Hyder Johns Hopkins Bloomberg School of Public Health

Steven Hyman Harvard University, Harvard Medical School

Giuseppina Imperatore U.S. Centers for Disease Control and Prevention

Rubina Imtiaz U.S. Centers for Disease Control and Prevention

Michael T. Isbell Independent consultant

Dean T. Jamison University of California, San Francisco, Disease Control Priorities Project

Jean Jannin World Health Organization

Philip Jenkins World Health Organization

Prabhat Jha University of Toronto, Centre for Global Health Research

T. Jacob John Christian Medical College (retired), National HIV/AIDS Reference Center, India (retired)

Jack Jones World Health Organization

David E. Joranson University of Wisconsin Comprehensive Cancer Center World Health Organization

Manjul Joshipura Academy of Traumatology, India, Apollo Hospitals, India

Matthew Jukes Imperial College London

Alka M. Kanaya University of California, San Francisco

Scott Kasner University of Pennsylvania

Ronald Kessler Harvard Medical School

Gerald T. Keusch Boston University Medical Campus, Boston University School of Public Health

Peter Kilima International Trachoma Initiative

Sally Kingsland National Centre for Epidemiology and Population Health, Australian National University

Tord Kjellstrm Australian National University, National Institute of Public Health, Sweden

Keith P. Klugman Rollins School of Public Health, Emory University

Felicia Knaul Fundacin Mexicana para la Salud, Secretaria de Educacin Pblica de Mexico

Rudolf Knippenberg United Nations Children's Fund

James C. Knowles Independent consultant

Olive C. Kobusingye World Health Organization Regional Office for Africa

Jeffrey P. Koplan Emory University

Daniel Kress Bill & Melinda Gates Foundation

A. Kroeger World Health Organization

Richard Laing Boston University School of Public Health, now World Health Organization

John R. La Montagne (Deceased) National Institute of Allergy and Infectious Diseases, National Institutes of Health

Claudio F. Lanata Instituto de Investigacin Nutricional, Peru

Ana Langer EngenderHealth

Carlene M. M. Lawes University of Auckland

Joy E. Lawn Save the ChildrenUSA, Institute of Child Health

Ramanan Laxminarayan Resources for the Future

Seung-Hee Frances Lee Save the ChildrenUSA

Christian Lengeler Swiss Tropical Institute

P. R. Lever Royal Tropical Institute, Netherlands

Ruth Levine Center for Global Development

Joseph Lipscomb Rollins School of Public Health, Emory University

Madhumita Lodh Commonwealth Department of Transport and Regional Services, Australia

Alan Lopez University of Queensland, Harvard School of Public Health

Elizabeth Lule World Bank

Antoine Mah Programme National de Lutte Contre le SIDA

Adel Mahmoud Merck & Company Inc., Case Western Reserve University

Margaret Maier RAND Corporation

Lisa Manhart University of Washington

Bala Manyam Texas A&M University HSC School of Medicine

Paola Marchesini World Health Organization

Maureen S. Marshall Task Force for Child Survival and Development

John B. Mason Tulane University School of Public Health and Tropical Medicine

Gaverick Matheny University of Maryland

Colin McCord Columbia University

Martin McKee London School of Hygiene and Tropical Medicine

Tonya McLeod Emory University

Tony McMichael Australian National University

Anthony R. Measham World Bank (retired), Disease Control Priorities Project

Jeffrey Mecaskey Axios International

Andr Mdici Inter-American Development Bank

Carol Ann Medlin University of California, San Francisco

Sumi Mehta World Health Organization, Health Effects Institute

Bjrn Melgaard World Health Organization

David Meltzer University of Chicago

Kamini Mendis World Health Organization

James Mercy U.S. Centers for Disease Control and Prevention

Catherine Michaud Harvard School of Public Health

Mark Miller Fogarty International Center, National Institutes of Health

Anne Mills London School of Hygiene and Tropical Medicine

Andrew Mitchell Harvard School of Public Health

Arlene Mitchell World Food Programme

Charles Mock University of Washington, Harborview Medical Center

Antonio Montresor World Health Organization

James Moore U.S. Centers for Disease Control and Prevention

Chantal Morel London School of Hygiene and Tropical Medicine Oxford Outcomes

Luis Morillo Javeriana University

Roy D. Mugerwa Makerere University, Uganda, Case Western Reserve University

Jo-Ann Mulligan London School of Hygiene and Tropical Medicine

Philip Musgrove Health Affairs, Disease Control Priorities Project

Vasant Narasimhan Novartis Pharma AG, Switzerland

K. M. Venkat Narayan Centers for Disease Control and Prevention, Rollins School of Public Health at Emory University

Mike B. Nathan World Health Organization

Karin B. Nelson National Institute for Neurological Disorders and Stroke, National Institutes of Health

Isaac Ngugi KEMRI/Wellcome Trust Programme, Kenya

Mounkaila Noma African Programme for Onchocerciasis Control

Charles Normand University of Dublin, Trinity College, London School of Hygiene and Tropical Medicine

Robyn Norton George Institute for International Health, University of Sydney

Peter Nsubuga U.S. Centers for Disease Control and Prevention

Rachel Nugent Population Reference Bureau, Fogarty International Center, National Institutes of Health

Thomas O'Brien Brigham and Women's Hospital

Adesola Ogunniyi University of Ibadan, University College Hospital, Nigeria

Iruka N. Okeke Haverford College, Eidgenossische Technische Hochschule, Switzerland

Nancy Olivieri Hemoglobinopathy Research Program, University Health Network, Canada

Claudio Osorio Pan American Health Organization

Mead Over World Bank

Ariel Pablos-Mendez World Health Organization, Columbia University

Fred Paccaud University of Lausanne University of Montreal

Nancy S. Padian University of California, San Francisco

Rajesh Pandav World Health Organization, Regional Office for South-East Asia

Vikram Patel London School of Hygiene and Tropical Medicine

Vikram S. Pathania University of California, Berkeley

John W. Peabody University of California, San Francisco, University of California, Los Angeles

Richard Peck University of Illinois at Chicago

Margie Peden World Health Organization

Poul Erik Petersen World Health Organization

Ndola Prata University of California, Berkeley

Alexander S. Preker World Bank

Max Price University of the Witwatersrand, South Africa

Pekka Puska National Public Health Institute, Finland

Zahidul Quayyum University of Aberdeen

Sadanand Rajkumar University of Newcastle, Bloomfield Hospital

Ambady Ramachandran M.V. Hospital for Diabetes, India, Diabetes Research Centre, India

K. D. Ramaiah Vector Control Research Centre, India

Geetha Ranmuthugala Australian National University

Fawzia Rasheed Independent consultant

K. Srinath Reddy All India Institute of Medical Sciences, Initiative for Cardiovascular Health in the Developing Countries

Eva Rehfuess World Health Organization

Jrgen Rehm Centre for Addiction and Mental Health, Canada, ISGF/ARI, Switzerland

Jan H. F. Remme World Health Organization

Giuseppe Remuzzi Mario Negri Institute for Pharmacological Research, Italy, Azienda Ospedaliera Ospedali Riuniti di Bergamo, Italy

Serge Resnikoff World Health Organization

Stephanie A. Richard Johns Hopkins University Bloomberg School of Public Health

Frank Richards U.S. Centers for Disease Control and Prevention, The Carter Center of Emory University

Juan A. Rivera Instituto Nacional de Salud Pblica, Mexico

S. Adibul Hasan Rizvi Sindh Institute of Urology and Transplantation

David A. Robalino World Bank

Anthony Rodgers University of Auckland

Khama Rogo World Bank

Robin Room Stockholm University

James E. Rosen World Bank

Mark L. Rosenberg Task Force for Child Survival and Development

Linda Rosenstock University of California, Los Angeles

David Sanders University of the Western Cape

Lorenzo Savioli World Health Organization

Richard M. Scheffler University of California, Berkeley

George Schieber World Bank

Arrigo Schieppati Mario Negri Institute for Pharmacological Research, Italy, Azienda Ospedaliera Ospedali Riuniti di Bergamo, Italy

Gabriel Schmunis Pan American Health Organization

Helen Schneider University of the Witwatersrand, South Africa

C. J. Schofield London School of Hygiene and Tropical Medicine

A. Seketeli African Programme for Onchocerciasis Control

Malick Sembene Ministry of National Education, Senegal

Sheldon Shaeffer United Nations Educational, Scientific, and Cultural Organization

Raj J. Shah Bill & Melinda Gates Foundation

Sonbol A. Shahid-Salles Disease Control Priorities Project, Population Reference Bureau

Brian Sharp Medical Research Council

Alexandra Shaw AP Consultants

Donald Shepard Schneider Institute for Health Policy, Heller School, Brandeis University

Rupendra Shrestha Australian National University

Xiao Shu-Hua National Institute of Parasitic Diseases, China

Donald Silberberg University of Pennsylvania

Eric A. F. Simoes University of Colorado Health Sciences Center Children's Hospital

Lone Simonsen National Institute of Allergy and Infectious Diseases, National Institutes of Health

Susheela Singh Alan Guttmacher Institute, United States

Arthur S. Slutsky St. Michael's Hospital, University of Toronto

Andrew Smith World Health Organization

Kirk Smith School of Public Health, University of California, Berkeley

Peter C. Smith Centre for Health Economics, University of York

Robert W. Snow Centre for Tropical Medicine, University of Oxford, Kenya Medical Research Institute

Soekirman Institut Pertanian Bogor, Indonesia

Geoffrey C. Solarsh Monash University, Australia

Dan Sosin U.S. Centers for Disease Control and Prevention

Frank E. Speizer Harvard Medical School, Harvard School of Public Health

Sally K. Stansfield Bill & Melinda Gates Foundation, University of Washington

Richard W. Steketee PATH

Jayanthi Ramanathan Stjernswrd Malm University

Stephen E. Straus National Center for Complementary and Alternative Medicine, National Institutes of Health

Donna F. Stroup U.S. Centers for Disease Control and Prevention

Mario M. Taguiwalo Department of Health, Republic of the Philippines

Tsutomu Takeuchi School of Medicine, Keio University, Japan

Caroline Tanner Parkinson's Institute

Robert V. Tauxe U.S. Centers for Disease Control and Prevention

Stephen B. Thacker U.S. Centers for Disease Control and Prevention

William Theodore National Institute for Neurological Disorders and Stroke, National Institutes of Health

Amardeep Thind University of Western Ontario, University of California, Los Angeles

Stephen Tollman Medical Research Council, University of the Witwatersrand, South Africa

Ana Cristina Torres World Bank

Murray Trostle U.S. Agency for International Development

Vivian Valdmanis University of the Sciences in Philadelphia

W. H. van Brakel Royal Tropical Institute, Netherlands

Anna Vassall Royal Tropical Institute, Netherlands

Cesar G. Victora Universidade Federal de Pelotas, Brazil

Maya Vijayaraghavan U.S. Centers for Disease Control and Prevention

Theo Vos University of Queensland

Judith L. Wagner Institute of Medicine, United States

Adam Wagstaff World Bank

Julia Walsh University of California, Berkeley

Prawese Wasi Siriraj Hospital, Mahidol University

Hugh Waters Johns Hopkins University Bloomberg School of Public Health

David Weatherall University of Oxford

Jeny Wegbreit University of California, San Francisco

Mark E. White U.S. Centers for Disease Control and Prevention

Nicholas J. White Mahidol University, Thailand, University of Oxford

Harvey Whiteford University of Queensland

Daniel Wikler Harvard School of Public Health

Suwit Wilbulpolprasert Ministry of Public Health, Thailand

Walter C. Willett Harvard School of Public Health, Harvard Medical School

Desmond E. Williams U.S. Centers for Disease Control and Prevention

Lara J. Wolfson World Health Organization

Anthony Woolf Peninsula Medical School, United Kingdom, Royal Cornwall Hospital, United Kingdom

Cream Wright United Nations Children's Fund

Merrick Wright Independent consultant

Michel Zaffran World Health Organization

Ricardo Zapata Marti United Nations Economic Commission for Latin America and Caribbean

Witold Zatonski Cancer Center and Institute of Oncology, Poland Health Promotion Foundation

Ping Zhang U.S. Centers for Disease Control and Prevention

Zhen-Xin Zhang Peking Union Medical College Hospital, Chinese Academy of Medical Science

Jelka Zupan World Health Organization

Acknowledgments

Preparation of this volume required efforts over four years by many institutions and almost 1,000 individuals: chapter coauthors, advisory committee members, peer reviewers, copy editors, and research and staff assistants. We have many contributions to acknowledge. We particularly thank our chapter authors, who worked extremely hard through a long and exacting process of writing, review, and revision. We also owe much gratitude to the institutional sponsors of this effort:

The Fogarty International Center (FIC) of the U.S. National Institutes of Health. The FIC supported both the senior editor and one of the co-managing editors of this project, as well as support staff. Gerald Keusch, former director of the FIC, initiated and facilitated this effort, and FIC's acting director, Sharon Hrynkow, continued to provide support and counsel.
The World Bank. Successive directors of the World Bank's Health, Nutrition, and Population Department, Christopher Lovelace and Jacques Baudouy, provided support, guidance, and critical reactions and facilitated the involvement of Bank staff as coauthors and reviewers.
The World Health Organization. Successive leaders of the World Health Organization's Evidence and Information for Policy Cluster, Christopher Murray and Timothy Evans, coordinated the involvement of the World Health Organization, which had been agreed by Gro Harlem Brundtland, then the director-general.
The Bill & Melinda Gates Foundation. Richard Klausner, Sally Stansfield, and Beth Peterman arranged for the foundation to provide major financial support and interacted closely with us throughout the past four years. Initial conversations with and encouragement from William Gates Senior are gratefully acknowledged.

In undertaking the work leading to this volume, we benefited from the close engagement of three institutions that helped organize and host consultations and arranged for background analyses to be undertaken. These institutions were the London School of Hygiene and Tropical Medicine (Anne Mills), the University of Toronto's Center for Global Health (Prabhat Jha), and Resources for the Future (Ramanan Laxminarayan). The Center for Global Development (Ruth Levine) collaborated with the chapter authors in an effort to identify proven successes in global health, the results of which were used both in this book and in a separate publication. We are grateful to each of these institutions and individuals.

We were particularly fortunate to have the strong collaboration of the Inter-Academies Medical Panel (IAMP), an association of the medical academies or medical divisions of the scientific academies of 44 countries. David Challoner and Guy de Th cochaired the Steering Committee of the IAMP and invested much time and effort into facilitating the collaboration. In particular, the IAMP helped establish the productive Advisory Committee to the Editors, chaired by Jaime Seplveda, on which many members of the IAMP Steering Committee served. The IAMP's second global meeting hosted the launch of this volume in Beijing in April 2006, and the IAMP also sponsored the peer review process for all the chapters. We are most grateful to David Challoner and Guy de Th, as well as to Jaime Seplveda and other members of the Advisory Committee to the Editors. The U.S. member of the IAMP, the Institute of Medicine of the National Academy of Sciences, played a critical role in facilitating all aspects of the IAMP's collaboration. Patrick Kelley, Patricia Cuff, Dianne Stare, Stacey Knobler, and Leslie Baer at the Institute of Medicine and Mohamed Hassan and Muthoni Fanin at the IAMP managed this effort and provided critical, substantive inputs.

The Office of the Publisher at the World Bank provided outstanding assistance, enthusiastic advice, and support during every phase of production of this volume and helped coordinate publicity and initial distribution. We particularly wish to thank Dirk H. Koehler, the publisher; Carlos Rossel; Mary Fisk; Santiago Pombo-Bejarano; Nancy Lammers; Randi Park; Valentina Kalk; Alice Faintich; Joanne Ainsworth; Enid Zafran; Deepa Menon; and Janice Tuten for their timely, high-quality professionalism.

Donald Lindberg, director of the National Library of Medicine (NLM) of the U.S. National Institutes of Health, and Julia Royall, chief, International Programs, NLM, graciously offered the competent services of the NLM's Information Engineering Branch of the National Center for Biotechnology Information to convert the text into an electronic product available to all visitors to the National Library of Medicine's PubMed Web site. We would like to extend our gratitude to the National Center for Biotechnology Information team membersDavid Lipman, Jo McEntyre, and Mohammad Al-Ubaydli, and Belinda Beckfor their technical expertise and commitment.

With this volume now in the dissemination phase, the Population Reference Bureau is charged to communicate its findings in formats likely to be of use to a range of audiences. We greatly value the work of the bureau's William P. Butz, president, and Nancy Yinger, director of international programs, in rapidly initiating this effort.

Multiple institutions from around the world contributed to organizing and hosting meetings that facilitated the preparation of this book and providing background for such meetings. We greatly appreciate the contributions and hospitality of these institutions, including the following:

Chinese Academy of Engineering and Chinese Academy of Sciences, Disease Control Priorities Project Launch and Inter-Academies Medical Panel Global Meeting, Beijing, China (April 2006)
Italian Ministry of Health, Veneto Region, consultation on child health and nutrition, Venice, Italy (January 2004)
Instituto Nacional de Salud Pblica, Advisory Committee to the Editors meeting, Cuernavaca, Mexico (June 2002)
Institut Pasteur, Advisory Committee to the Editors meeting, Paris, France (March and December 2004)
Johns Hopkins Bloomberg School of Public Health, consultation on maternal and child health, Annapolis, Maryland (May 2002)
Johns Hopkins Paul H. Nitze School of Advanced International Studies, consultation on elimination and eradication of disease, and vaccinations, Washington, DC (October 2004)
Merck & Company Inc., consultation on research and product development priorities, Whitehouse Station, New Jersey (September 2004)
Multilateral Initiative on Malaria, consultations on the burden of malaria:
- National Institute of Medical Research, Arusha, Tanzania (November 2002)
- University of Yaound, Cameroon (November 2005)
National Cancer Institute, National Institutes of Health, consultation on cancer prevention, treatment, and pain control, Bethesda, Maryland (June 2003)
Oswaldo Cruz Foundation, World Health Organization, and Pan-American Health Organization, consultation on tropical infectious diseases, Rio de Janeiro, Brazil (AprilMay 2003)
Universit de Lausanne, consultation on cardiovascular disease, Lausanne, Switzerland (March 2002)
University of California, Berkeley, consultation on learning and developmental disorders, Berkeley, California (August 2003)
University of California, San Francisco, consultation on surgery, San Francisco, California (July 2003)
University of Queensland, School of Population Health, authors' meeting on psychiatric disorders, neurology, and alcohol and other substance abuse, Brisbane, Australia (August 2003)
University of Washington, consultation on sexually transmitted infections, Seattle, Washington (July 2003)
University of the Witwatersrand, consultations on health systems and on capacity strengthening and management reform, Johannesburg, South Africa (July 2004)
World Health Organization, Division of Mental Health, and National Institutes of Health, National Institute of Mental Health, consultation on mental health economics, Geneva, Switzerland (March 2004).

Coordination of the work leading to this publication and background research were undertaken by a small secretariat. Nancy Hancock, Pamela Maslen, and Sonbol A. Shahid-Salles provided outstanding research assistance; Andrew Marshall ably managed the budget and process; Candice Byrne provided key communications guidance, staff and editorial assistance; and Mantra Singh and Cherice Holloway provided staff assistance. Richard Miller, Lauren Sikes and Tommy Freeman of the FIC provided excellent administrative support to the Disease Control Priorities Project. Their work was absolutely essential in producing this book, and we are deeply grateful for their commitment and productivity. With so many authors and institutions involved, we are aware that many more people gave countless hours to this endeavor. We thank them also for their dedication.

The Editors

Disease Control Priorities in Developing Countries

Dedication

Foreword

Purpose

Fundamental Policy Considerations

Transition in Health

Scaling Up Effective Interventions

Need for Ongoing Research

Opportunities and Challenges of Globalization

Spending More and Spending Better

Selecting Interventions

Diagonal Approach

Multidisciplinary Orientation

Facilitating Progress

Director, National Institutes of Health of Mexico Mexico City Mexico Chair, Advisory Committee to the Editors

Preface

Global Burden of Disease and Risk Factors ( Lopez and others 2006 ), undertaken in collaboration with the World Health Organization
Millions Saved: Proven Successes in Global Health ( Levine and the What Works Working Group 2004 ), undertaken in collaboration with the Center for Global Development
"The Intolerable Burden of Malaria: II. What's New, What's Needed" ( Breman, Alilio, and Mills 2004 ), undertaken in collaboration with the Multilateral Initiative on Malaria
Priorities in Health ( Jamison and others 2006 ), a brief and nontechnical companion to this volume.

Each product of the Disease Control Priorities Project marries economic approaches with those of epidemiology, public health, and clinical medicine.

DCP2 goes beyond DCP1 in a number of important ways as follows:

While virtually all chapters of DCP1 were structured around clusters of conditions, DCP2 provides integrative chaptersfor example, on school health systems, surgery, and integrated management of childhood illnessthat draw together the implementation-related responses to a number of conditions. These and other chapters reflect DCP2 's inclusion of implementation and system issues.
DCP2 includes explicit discussions of research and product development opportunities.
Although DCP1 dealt with policy mechanisms to change behavior (or the environment), DCP2 attempts to do so in a more systematic way. In particular, a number of chapters assess in depth the public sector instruments for influencing behavior change that were described briefly in DCP1 : information, education, and communication; laws and regulations; taxes and subsidies; engineering design, such as speed bumps; and facility location and characteristics.
Different interventions place different levels of demand on a country's health system capacity. DCP2 builds on earlier work ( Gericke and others 2005 ) in attempting, in some chapters, to identify which interventions require relatively less system capacity for scaling up and which require more.
Although DCP1 briefly discussed the nonhealth outcomes of interventions, DCP2 does so in a more systematic way, including looking at the consequences of interventions (and intervention financing) for reducing financial risks at the household level. Other important nonhealth outcomes include, for example, the time-saving value of having piped water close to the home, the increased labor productivity of healthy workers, and the amenity value of clean air.
An important element of DCP1 was its assumption that to inform broad policy, major changes from the status quo need to be considered, not just marginal ones. For cost-effectiveness analysis, any major change needs to be informed by burden of disease assessments in a way not required for judging the attractiveness of marginal change, because the size of the burden affects total costs and the feasibility of extending the intervention to all who would benefit. This is particularly true when considering research and development priorities, but also applies to control priorities. In this regard, DCP2 continues in the spirit of DCP1 in assessing cost-effectiveness analyses of major changes, but it does so more systematically for each of the six regional groupings of low- and middle-income countries used throughout this volume (see map 1, inside the front cover).

The Editors

References

Editors

Dr. Alleyne's scientific publications