Intro
At the most general level, priorities in health are clear: identify the cost-effective interventions for those diseases that impose the largest burdens—around the globe or in target regions or populations that exhibit grave need or inequity—and determine how to deliver those interventions effectively, efficiently, and equitably. Science and medicine have shown that many interventions can be effective. Combining this knowledge with economic analyses of cost-effectiveness identifies which interventions can achieve the greatest health gains with a given level of resources. Making such health gains a reality requires implementing the selected interventions, a challenge that countries with effective health systems are better able to handle, but one that countries without effective health systems can deal with by improving their existing health systems or constructing them where they are lacking.
Thus while health priorities are relatively easy to define, they are far more difficult to address, but doing so is possible. Indeed, investigators have carefully documented a number of recent public health successes in a search for lessons that will enable further successes.
The What Works Working Group, convened by the Center for Global Development's Global Health Policy Research Network, collected nominations from DCP2 authors regarding successful public health interventions (Levine and others 2004). The working group examined the nominations and identified 17 cases that met 5 explicit criteria:
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They were implemented on a significant scale: national, regional, or global.
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They addressed a problem of major public health significance as measured by disability-adjusted life years (DALYs).
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They lasted at least five consecutive years.
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They were proven to be cost-effective, costing less than about $100 per DALY averted.
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They documented evidence of a clear and measurable effect on health outcomes, not just coverage rates or process indicators.
The stories behind these 17 cases were then researched and published in Millions Saved: Proven Successes in Global Health (Levine and others 2004). DCP2, chapter 8 summarizes these cases and provides additional insights into these public health successes, including some of the factors that helped make success possible (box 2.1).
[Box 2.1 ]
The 17 cases that emerged from the selection process are not the only public health successes, nor are they necessarily representative of public health successes in recent decades,1 but the collection is a treasure trove for those involved in public health. All the cases have been carefully analyzed for lessons regarding leadership, financing, collaboration, strategies, role of the public sector, constraints, and much more.
An important message for policy making that emerges from this collection is that success can come in many forms. Countries have achieved successes in the most trying institutional contexts and policy environments; against diseases of many different kinds, both infectious and noncommunicable; and with many different intervention methods, including those based on providing products (for example, vaccines), providing services (such as prenatal care or simple surgery), promoting behavior change (for instance, using condoms, filtering water, or practicing good hygiene), or reducing environmental risks (for example, spraying larvicides or building latrines). Some key elements recur, namely, political leadership, technological innovation, expert consensus regarding the approach, effective use of information, and sufficient public financial resources, and some types of challenges may be easier to meet than others, but no single ingredient is sufficient and no single combination ensures success. Rather, these stories convey the message that success is possible, demonstrated, and varied.
"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."
"By 1998, between 9 million and 13 million cases of guinea worm had been prevented, and global prevalence had dropped by 99 percent."
" measles cases reported annually fell from 60,000 in 1996 to 117 in 2000."
"Between 1990 and 1998, Poland experienced a 30 percent decline in lung cancer among men age 20 to 44, a nearly 7 percent decline in CVD, and a decline in the number of babies born with low birthweights."
The wide range of approaches adopted to improve health presented in DCP2 further demonstrate this point. DCP2 does not offer a single prescription for improving health, but assesses the many interventions and implementation strategies that have worked in different places. This section presents just a few of these public health success stories, selected to illustrate some of the important messages in DCP2 about the nexus between selecting cost-effective interventions and delivering them effectively. Specifically, these cases
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succeeded despite weak, or even absent, health systems (smallpox eradication)
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were conducted in ways that built or strengthened weak health systems (control of onchocerciasis [river blindness] and polio)
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were aimed directly at building a health system (improving maternal health)
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furthered existing health systems (Haemophilus influenzae type B [Hib] vaccination)
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moved beyond health systems (control of trachoma).
"Countries have accomplished major public health successes even under conditions of dire poverty, weak or nonexistent health care infrastructure, and civil unrest or war."
