Conclusions
A volume as large as this one can provide only a sampling of opportunities and potential pitfalls for investments in health. Indeed, the International Statistical Classification of Diseases (WHO 2003a) takes more than 1,500 pages simply to list the conditions that a health system must address. Yet the diseases accounting for most of the burden can be listed in perhaps half a dozen pages, and the diseases that account for most of the differences in outcome between high- and low-mortality countries can be listed on a page. Chapters in this volume assess 115 population interventions and 204 personal interventions that address most conditions of importance. The conclusions listed in this final section of the chapter simply highlight important conclusions for policy without attempting to summarize the volume as a whole. Chapters 2 and 3 complement this one with a fuller summary.
Table 1.3 provides a sense of the nature of the findings in much of the book, and box 1.4 provides a brief description of the methods. The table shows the number of DALYs that we estimate could be averted (or years of healthy life that could be bought) by spending a million dollars on a few of the interventions addressing major sources of disease burden. If we think of these numbers as the prices for buying health by different means, the price variation is enormous, ranging from one or two DALYs per million dollars up to well over 100,000. All the standard caveats more than apply to these numbers. Nonetheless, they do convey information relevant for policy. Expanding coverage of the currently used mix of vaccines, for example, appears more attractive than does adding new vaccines (except when the lower demands on system capacity of adding new vaccines are considered). Bypass surgery used even in the most appropriate circumstances is an expensive way to buy a year of healthy life, but for many common indications it is inordinately expensive. Findings from table 1.3 exemplify findings of the cost-effectiveness analyses from throughout the book that are summarized in chapter 2.
[Box 1.4]
[Table .]
A general conclusion follows from the preceding discussion. There are many inexpensive ways to reduce mortality rates and improve health. A country that focuses on those interventions can expect to achieve major improvements—even with very limited resources. There are also ways to spend money on health that can dissipate even a substantial budget with almost no return—either for better health or for the financial protection of populations. Intervention selection matters. Many of the good and bad buys are now well known. Some are not, and our main purpose in this volume has been to assemble the evidence based on what is known.
We now turn to more specific conclusions. Different items on the list are relevant in different countries. (Chapter 2 suggests, for example, major differences between the priorities for South Asia and those for Sub-Saharan Africa.) Many interventions or policy changes that are important are not on this list, but they are included in the more extensive discussions in chapters 2 and 3, which synthesize messages from the rest of the book on setting intervention priorities and strengthening health system capacity. Given often quite limited availability of money or political leadership or health system capacity, it will often be necessary to focus the available resources on a few key priorities. Chapter 12 makes it disappointingly clear that, for the low-income countries, not only are financial resources sharply limited now, but prospects for more than modest increases seem unlikely for many years. (Financial constraints in the middle-income countries, although real, are less binding.) Selecting priorities will be hard. This section provides a starting point for discussing which activities should be high priorities. The conclusions are grouped under four headings: interventions; health services, systems, and financing; research and development; and development assistance.
Interventions
1. Standard interventions for reducing under-five mortality have long been known to be highly cost-effective. The challenge is to scale up while conserving and strengthening scarce health system capacity. These interventions include immunization; micronutrient supplement delivery; treatment for diarrhea, malaria, and acute respiratory infections; and improved prenatal and delivery care. In cases of sharply limited resources—financial or health system capacity—often the single highest priority will be expansion of immunization coverage with the basic antigens: poliomyelitis, measles, diphtheria, tetanus, pertussis, and perhaps BCG.
2. Cost-effective interventions exist to address the 50 percent of under-five deaths that occur under 28 days of age, including stillbirths. These are underused relative to interventions for older children, and correcting this neglect is a priority.
3. Standard interventions to treat TB are also known to be highly cost-effective, although probably more demanding of health system capacity than are some of the child health interventions. Scaling up by using already developed models for strengthening relevant health system capacity is a priority.
4. Many well-tested preventive interventions for AIDS are effective and cost-effective. Such interventions include treating STIs, promoting condom use, providing voluntary counseling and testing, promoting peer intervention, using antiretroviral therapies to prevent mother-to-child transmission, ensuring safe blood supplies, and encouraging the use of breast milk alternatives by HIV-positive mothers. Scaling up treatment for STIs may prove particularly important. Much more rapid implementation of these interventions is of highest priority and needs to be accompanied by effective mechanisms of surveillance and evaluation. The appropriate mix and distribution of interventions depends on the stage of the epidemic. In particular, limited financial and institutional resources imply focusing effort on populations at high risk early in an epidemic.
5. Antiretroviral drugs have been successful on a wide scale in high-income countries (and in some upper-middle-income countries—notably Brazil and Mexico) in sharply reducing viral load and extending the life expectancy of patients who are HIV positive. Health system capacity for achieving durable benefits from antiretroviral drug use at scale in resource-constrained environments, however, remains to be demonstrated. Failure to achieve good adherence in such an environment would provide minimal benefits to the patient, increase risks of drug resistance, and incur substantial costs: the financial and human losses could be enormous. Multiple approaches to successful maintenance on antiretroviral drugs should be tried and evaluated in large-scale pilots or as part of implementation scale-up. Given the magnitude of the AIDS problem, undertaking and evaluating variations in implementation (including possible variation in the choice of first-line drugs) in parallel rather than serially is important. This approach is not now being used. Similarly important is being rigorous in dropping unsuccessful implementation models before they consume substantial resources that could otherwise have greatly affected AIDS prevention or other priorities in the health sector.
6. Control of tobacco use is the cornerstone of proven approaches to primary prevention of heart disease, stroke, chronic pulmonary disease, and many types of cancer. Instruments for control of tobacco use centering on taxation and improved public information are well established.
7. A range of potential approaches to changing dietary and exercise patterns of populations would, if successful, reduce problems of obesity, hypertension, and dyslipidemia and their consequences for vascular disease. Successes are rare but suggestive that large-scale efforts could be worthwhile. Careful impact evaluation will be essential to ascertain whether these investments deliver value for money.
8. Lifetime medical management—eventually using variants of the polypill—of individuals at high risk for stroke or ischemic heart disease is cost-effective and important for tens of millions of individuals. The clearest indications of high risk are a previous vascular event or diabetes.
Health Services, Systems, and Financing
9. Focused funding for particular diseases or programs—for example, TB or immunization—is a fact of life in many low-income countries. Using such funding to build health system capacity is feasible as well as desirable, but it is far from automatic. As capacity grows, the potential advantages of categorical programs are likely to fade while a more integrated (but still outcome-oriented) health system assumes responsibility for dealing with the relevant conditions.
10. Quality of clinical care makes an enormous difference, both to the cost of care and to health outcomes. Tangible actions can be taken to improve quality: important among them is having each provider do a few things well rather than many things poorly.
11. Strengthening capacity for surgery at the district hospital level is a frequently neglected priority. Major important uses of this capacity will be to deal with injuries and obstetrical emergencies.
12. In low-income countries public funding for health will remain highly constrained as a percentage of GDP for the foreseeable future. Targeting these funds to provide universal access to a limited number of interventions that are high priority for poor people is both efficient and equity enhancing, but it will require clear setting of priorities, particularly for incremental resources as they become available.
13. Middle-income countries can learn from the OECD experience that universal public financing of a substantial package of clinical care is both efficient and equity enhancing.
Research and Development
14. Impact evaluation of interventions in many domains is an essential priority and should be done around planned variations in implementation. One specific area of importance is evaluation of effective ways to manage lifelong drug use—for example, for AIDS, secondary prevention of vascular disease, diabetes, and major psychiatric disorders.
15. Public-private partnerships such as the Medicines for Malaria Venture and the International AIDS Vaccine Initiative provide promising models for developing important new drugs, vaccines, and diagnostic products to deal with the major diseases of poverty as well as the problem of drug resistance and microbial evolution more generally.
Development Assistance
16. Development assistance for health has begun to become performance based, and this trend should accelerate, along with making development assistance more stable and long term (contingent on performance). This change may involve at least a partial shift away from the sectorwide approaches to development assistance that recent evidence suggests may lead to neglect of focus on outcomes. It will require renewed attention to outcome measurement.
17. Resistance of the malaria parasite that is responsible for most deaths to chloroquine and SP is now widespread and rapidly increasing. A particular challenge is overcoming financial and institutional barriers to virtually complete replacement of those drugs with ACTs, which minimize resistance and can decrease transmission. Absent such an effort, malaria mortality is likely to continue rising. A centralized procurement mechanism receiving subsidies from development assistance agencies and making low-cost ACTs available to public and private supply chains globally would address this problem.
18. Investing in global capacity to respond effectively to a new influenza pandemic, particularly within the resource constraints of low-income countries, is a priority for the international system. Such capacity would include effective surveillance, surge manufacturing capacity for drugs and vaccines, stockpiles of drugs that could be used to attempt to contain epidemics, and mass media messages and public policies prepared in advance to be deployed if needed.
19. Because research and development is so important for health and because it is a classic international public good, a substantial fraction of incremental development assistance for health should go to research and development.
The content of these specific recommendations, and of recommendations throughout this volume, point to the enormous potential we now have to reduce further the human and financial burden of ill health. Scientific advance created this potential. Its more widespread realization requires the focused attention of health systems to finance and deliver priority interventions.
