8. Improving the Health of Populations: Lessons of Experience

Cases

From an initial set of nominations received from DCPP authors as well as from other international health researchers, we selected a subset of 17 cases for study. We could not consider many cases that were nominated because of the absence of reliable data. Thus, the 17 cases selected are merely a subset of the many successes in international health that have been achieved during the past 50 years, not the full universe. Nonetheless, the cases draw from all three continents of the developing world—Africa, Asia, and Latin America and the Caribbean—and involve both communicable and noncommunicable diseases as well as curative and preventive care. Most cases are national-level programs, but a few involve regional initiatives, and one is global.

Many near misses did not make the cut. The reasons for this exclusion varied. For example, a program in Costa Rica, El Salvador, and Guatemala to promote hand washing appears to have resulted in a dramatic decline in child morbidity and mortality but did not meet the duration criterion because it was fully operational for only three years (1996-99). In another example, the evidence of a health impact was mixed: a successful schistosomiasis control program in the Arab Republic of Egypt that included treatment of blood flukes in infected individuals was later linked to high prevalence rates of hepatitis C caused by the use of improperly sterilized syringes (Frank and others 2000). Nonetheless, the most common rationale for excluding a case from this study had to do with a lack of consistent documentation and of analysis of the health impact of the program in question. Thus, a reasonable conclusion is that the true universe of cases is much larger than the subset of cases we examined.

Each case reviewed here illustrates how a discrete health intervention or combination of interventions was successfully brought to scale in a specific context. To gain insight into this process, we can distinguish between the intervention—for example, the tool or technology that has been proven to be cost-effective for the treatment or prevention of a given disease—and the programmatic characteristics and policies that contributed to the successful delivery or deployment of the intervention through specially designed programs or projects.

The following list of cases selected for review describes the programs or projects that were scaled up, identifies the specific intervention or interventions deployed, and summarizes the existing evidence about health outcomes and impact:¹

• Chagas disease control. In 1991, seven countries—Argentina, Bolivia, Brazil, Chile, Paraguay, Uruguay, and later Peru—joined forces as part of an initiative for the Southern Cone countries led by the Pan American Health Organization to combat Chagas disease through a combination of surveillance activities, house-to-house spraying, and other vector control methods. Health impact—Disease incidence had fallen by 94 percent by 2000. By 2001, disease transmission had been halted in Chile, Uruguay, and large parts of Brazil and Paraguay. The project is ongoing.

• Diarrheal treatment. In Egypt, the government launched a national program in the early 1980s to promote the use by mothers of locally manufactured oral rehydration salts in a four-part strategy that included tailoring product design and branding to accommodate local preferences and customs; strengthening production and distribution channels, both public and private; training health workers; and using social marketing and a mass media campaign. Health impact—Between 1982 and 1987, infant and child mortality dropped by 36 and 43 percent, respectively. Mortality attributed to diarrhea fell 82 percent among infants and 62 percent among children. The project closed in 1991.

• Guinea worm eradication. Twenty countries in Asia and Sub-Saharan Africa began a global campaign to eradicate guinea worm in the mid 1980s. Led by the Carter Center, the United Nations Children's Fund, the U.S. Centers for Disease Control and Prevention, and the World Health Organization, the campaign promoted improved water safety through deep-well digging, environmental control, and the use of cloth filters for drinking water; health education programs; and case management, containment, and surveillance. Health impact—By 1998, 9 million to 13 million cases of guinea worm had been prevented and global prevalence had dropped by 99 percent. The project is ongoing in three countries.

• Family planning. In Bangladesh, family planning has been promoted since the 1970s through a door-to-door outreach program conducted by young, married women who provide information about limiting family size or spacing pregnancies along with products. An extensive media campaign accompanied the outreach program. Health impact—Contraceptive use among married women in Bangladesh is approximately 50 percent today, compared with only 8 percent in the mid 1970s, and the average number of children per family is 3.3, down from 7 in the mid 1970s. The project is ongoing.

• Hib vaccination. Chile began to include the Hib vaccine as part of its national immunization program in 1996. In The Gambia, a similar initiative was introduced in 1997. Health impact—In Chile, the prevalence of Hib disease fell by 90 percent, and the incidence of pneumonia and other Hib-related illnesses fell by 80 percent. In The Gambia, the number of children developing Hib meningitis fell from 200 per 100,000 to 21 per 100,000 only 12 months following the introduction of the vaccine. The projects are ongoing in both countries.

• HIV/AIDS prevention. Thailand launched the 100 Percent Condom Program in 1991 to address the rising incidence of HIV/AIDS in the country. The program provided boxes of condoms to brothels free of charge, mandated the use of condoms by sex workers, and threatened brothels with penalties and closure for noncompliance. Health impact—By 1992, condom use in brothels had risen to more than 90 percent, up from 14 percent in 1989. The number of cases of new sexually transmitted infections fell from 200,000 in 1989 to 15,000 in 2001, and an estimated 200,000 new infections were averted between 1993 and 2000. The project is ongoing.

• Health improvement of the poor using financial incentives. In 1997, the Mexican government launched a new social welfare program designed to help lift rural families out of poverty by providing cash payments in exchange for their participation in nutrition and supplementation programs, their use of prevention and basic health care services, and their children's school attendance. Health impact—After five years, the children of participating families were 12 percent less likely to experience illness than those of non-participating families, and their nutritional status had improved. Adult health indicators also improved. The project is ongoing.

• Maternal health. The Sri Lankan government relied on professional midwives and sustained investments in the country's health care system, including in rural areas, to improve maternal health. Health impact—The maternal mortality ratio fell from approximately 500 per 100,000 live births in 1950 to 60 per 100,000 in 2003. The project is ongoing.

• Measles elimination. In 1996, the seven southern African countries agreed to a coordinated immunization strategy, supported by improved surveillance and laboratory capacity, to eliminate measles by including the vaccine as part of routine immunization for all nine-month-old babies and organizing nationwide catch-up and follow-up campaigns for children age nine months to 14 years. Health impact—The number of measles cases reported annually in the region fell from 60,000 in 1996 to 117 in 2000. The number of deaths attributed to measles fell from 166 to 0 during the same period. The project is ongoing.

• Onchocerciasis control. The discovery of ivermectin (Mectizan) in 1978 and Merck's decision to provide it free of charge to anyone who needed it allowed early successes based on weekly aerial spraying in 11 West African countries to be further consolidated and later expanded to the other 19 endemic countries in Central and East Africa. Health impact—In West Africa, disease transmission has been virtually halted, and 1.5 million previously infected people are now symptom free. In Central and East Africa, the program has helped prevent an estimated 40,000 cases of blindness each year. The Onchocerciasis Control Program (OCP) ended in 2002. The African Programme for Onchocerciasis Control is ongoing.

• Polio elimination. In 1985, the Pan American Health Organization launched a campaign to eradicate polio from the Americas. National vaccine days were held twice a year and were targeted at children under the age of five, regardless of their immunization status, to increase coverage in countries with weak routine immunization programs. An extensive surveillance system and mop-up campaigns to address outbreaks were crucial during the campaign's final stages. Health impact—The last case of polio in the Americas was reported in 1991.

• Salt fluoridation. In Jamaica, a formal agreement between the Ministry of Health and the country's only salt producer introduced fluoridation to salt in 1987 to prevent caries. Health impact—By 1995, the severity of caries in children between the ages of 6 and 12 had fallen by more than 80 percent. The project is ongoing.

• Salt iodination. China launched the National Iodine Deficiency Disorders Elimination Program in 1993. The government requires producers to iodize salt and has stepped up its monitoring and enforcement capacity to ensure compliance. Health impact—Total goiter rates among children between the ages of 8 and 10 years fell from 20.4 percent in 1995 to 8.8 percent in 1999. The project is ongoing.

• Smallpox eradication. The campaign to eradicate smallpox, led by the World Health Organization and heavily financed by the United States, was launched in the mid 1960s. Strong leadership, dedication, and commitment on the part of the international community and the timely discovery of simple, new technologies—for example, the bifurcated needle and the "ring" strategy of surveillance and containment—characterized the effort. Health impact—The World Health Assembly declared smallpox eradicated in May 1980.

• Tobacco control. Poland passed groundbreaking legislation in 1995 imposing strong warning labels on cigarette packages, banning smoking from enclosed workplaces, and prohibiting tobacco sales to minors. South Africa passed similar legislation in 1999 to strengthen a previously imposed tax of 50 percent on the retail price of cigarettes. Health impact—Cigarette consumption dropped 10 percent between 1990 and 1998, resulting in a 30 percent decline in lung cancer among men age 20 to 44, a nearly 7 percent decline in cardiovascular disease, and a decline in the number of babies with low birthweight. South Africa witnessed a 30 percent decline in cigarette consumption in the 1990s, especially among youths and the poor. The projects are ongoing in both countries.

• Trachoma control. The Moroccan National Blindness Control Program, launched in 1991, promoted the use of "SAFE" interventions (surgery, antibiotics to control the infection, facial cleanliness, and environmental improvements), with the goal of eliminating trachoma by 2005. Health impact—Overall prevalence rates have fallen by 75 percent since 1999, and the prevalence of active disease in children under the age of 10 has seen a 90 percent reduction since 1997. The project is ongoing.

• Tuberculosis control. In 1991, China launched a 10-year program in 13 of its 31 mainland provinces to apply the directly observed therapy short course (DOTS) strategy to turberculosis (TB) control. Peru, previously one of 23 high-burden countries that collectively account for 80 percent of the world's new TB cases each year, launched a similar effort the same year. Health impact—Within two years, China had achieved a 95 percent cure rate for new cases and a cure rate of 90 percent for those patients who had previously completed treatment unsuccessfully. The number of people with TB declined by more than 37 percent between 1999 and 2000. The project ended in 2001, but important elements have been incorporated in the 10-year National Plan for the Prevention and Control of TB (2001-10). In Peru, disease incidence declined each year by 6 percent. The program achieved a case detection rate of 70 percent and an 85 percent cure rate. The project is ongoing.