An Agenda for Action
The general improvement in world health status is still marred by too many cases of neglect or failure in the application of life-saving public policy actions. What can be done to redress inequities while also sustaining and furthering historic gains in health? DCP2 tackles this challenge with the latest evidence and cost-effectiveness analysis. It identifies the specific interventions and policy changes that hold the most potential for progress in health. These measures include applying knowledge about cost-effective health interventions in more settings, improving the policies and platforms that support quality health care delivery and reduce barriers to access, generating knowledge in priority areas, and mobilizing additional financial and human resources.
Applying Knowledge to Select Interventions Well
"A large . . . disease burden in low- and middle-income countries is attributable to diseases for which cost-effective interventions are already known . . ."
DCP2 presents what we know about which health interventions work for a comprehensive range of diseases, injuries, and disabilities in many different contexts. A large share of the disease burden in low- and middle-income countries is attributable to diseases for which cost-effective interventions are already known and feasible. Selecting the right intervention for a given disease and context matters. DCP2 demonstrates how decision makers could use cost-effectiveness information along with information on disease prevalence and avertable illness to determine which interventions should be extended and which ones should be questioned. If countries scale up interventions and extend health care services that are cost-effective, the impact on the disease burden could be large.
Improving Health Systems
Improving health systems and reducing barriers to health care will improve the implementation of health interventions. DCP2 gives substantial attention to strengthening health systems, because interventions—no matter how carefully selected—are almost impossible to deliver without such systems. As noted in DCP2 (chapter 3, p. 85), "Cost-effectiveness data reflect largely what can be achieved given a reasonably well-functioning health system. In that sense they can be considered to represent potential cost-effectiveness and need to be supplemented with evidence and guidance on how health systems can be strengthened to provide interventions effectively, efficiently, and equitably" (emphasis added).
Systems can be strengthened, coverage can be extended, and equitable distribution can be achieved in a variety of ways, including increasing service infrastructure, reducing costs, improving quality, and establishing transparency in resource allocation. Increasing input from underserved populations is also imperative, because, as discussed in DCP2 (chapter 3, p. 89), "Strengthening structures of accountability to communities, and introducing mechanisms to ensure that users have a voice in the local health system and can influence priorities, are likely to be important in encouraging good performance."
Determining Priorities for Research
The returns from research in health are extremely high, as illustrated by the potential health gains that could be reached by applying the knowledge available today. Putting resources into research now will permit greater health gains tomorrow, but such resources need to be well targeted. One priority area for research is finding cost-effective interventions for neglected diseases that account for a high burden, particularly among underserved populations. Another essential area of research is on all aspects of the delivery of health care, that is, devising the best and most effective means to get interventions to people who have so far been excluded from its benefits.
"One priority area for research is finding cost-effective interventions for neglected diseases that account for a high burden . . ."
Current imbalances in attention to diseases and delivery include the following areas:
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Drug development. Of 1,233 new drugs marketed between 1975 and 1999, only 13 were approved specifically for tropical diseases.
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Research funding. Even though 85 percent of the global burden of disability and premature mortality occurs in the developing world, less than 4 percent of global research funding is devoted to the communicable, maternal, neonatal, and nutritional disorders that constitute the major burden of disease in developing countries.
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Underutilization of health services by women. This has been well documented overall and for specific diseases. For instance, even though women in India report more illness than men, hospital records show that men receive more treatment. Similarly, in Thailand, men are six times more likely to seek clinical treatment for malaria, a disease that affects women and men similarly (DCP2, chapter 10).
DCP2 identifies priority areas for research in epidemiology, interventions, and health care delivery.
Mobilizing More Resources
DCP2's attention to cost-effectiveness is motivated by the goal of achieving the most value for every dollar spent, but this does not imply that no more dollars are needed. A comprehensive effort to improve health around the world will involve substantial costs.
"In most low-income countries, the total resources available for health interventions are grossly insufficient . . ."
In most low-income countries, the total resources available for health interventions are grossly insufficient relative to the scale of the disease burden and the need for health interventions. Countries need to finance their own health interventions as much as possible, but for the world's low-income countries, external assistance is already, and will continue to be, an important source of funding. Even though development assistance has increased in the last decade, including participation by new private foundations and the formation of new global initiatives, more has been promised than delivered and further commitments are still needed.
In middle-income countries, financial resources may be a less binding constraint in absolute terms, but health interventions must still compete with other uses for resources. If existing resources are misspent or ineffective, lobbying for more resources for health when public allocation decisions are being made becomes more difficult. DCP2 can assist in that process by helping the health sector become more effective and efficient.
