Showing papers in "Bulletin of The World Health Organization in 2000"

The world health report 2000 - Health systems: improving performance

Abstract: Here WHO attempts no less than to rank the vastly different health systems of 191 nations on two one-dimensional measures of performance: (a) ‘‘level of health,’’ represented by disability-adjusted life expectancy (DALE) and (b) an ‘‘index of overall health system performance’’. The latter is calculated as a weighted average of scores on five distinct dimensions: (1) the country’s DALE, (2) the ‘‘distribution of health’’ (based on child mortality distributions within countries), (3) the health system’s ‘‘responsiveness’’ to what people seek from it in terms of ‘‘prompt attention, dignity, autonomy, confidentiality,’’ and so on, (4) an index of the distribution of that ‘‘responsiveness’’ among socioeconomic classes, and (5) the degree of ‘‘fairness’’ with which the health system is financed. The weights for these five measures going into the ‘‘overall health system performance index’’ were culled from a survey of 1006 experts from 125 countries, about half of them on the staff of WHO. The final rankings of countries on both of the two performance measures are not based on the actual values achieved by the nation, but on the ratios of the achieved values to the values that ought to have been achieved, given the country’s educational attainment and spending on health care. The denominator in this ratio was derived from an empirically estimated mathematical relationship that predicts, for any combination of national health spending and national educational attainment, the level of performance that would have been achieved by an efficiently run health system. Because the ultimate rankings emerging from this study are the products of a whole series of inherently subjective analytic judgements on the specific measures of systems performance, on the weights to be attached to each measure and on the model used to compare actual with ideal performance, it is fair to query whether, on balance, so precarious an undertaking does more good than harm. Before addressing that question in regard to the WHO report, it is well to keep in mind that the decision-makers in the socalled ‘‘real world’’ do prefer to have complex phenomena collapsed into one-dimensional indexes. Even professors at top universities despair of multi-line academic transcripts and prefer to see a student’s entire and often varied academic career collapsed into the single, highly dubious measure of the grade point average. Gross domestic product (GDP) is a similarly crude, flawed, onedimensional indicator for national economic performance, as is quarterly earnings per share for a giant corporation. All of these simple measures are the products of whole hosts of precarious assumptions. Yet they are widely used, on the assumption that doing so does more good than harm. Can that assumption be made for the WHO report as well? The chief virtue of the WHO report lies in the challenges it poses for its critics within the health services research community. Could these critics have done better? If so, precisely how? Or can these critics argue that quantitative assessments of this sort are never worth undertaking? In other words, are we stuck in a rut that allows physicians or politicians in every country to proclaim that theirs is ‘‘the best health system in the world’’ without being challenged by data? If that be the verdict of the research community, it would be good to have it flushed out into the open, and on paper. On the other hand, there is reason to wonder whether more good than harm will have been done by the fanfare with which this report was injected into the public media and thence into the world of policy-making. Two requirements should have been met before the report was ready for a major media campaign. First, the WHO research team should have been sure that their estimates are robust. Can they, in good conscience, make that claim? An artificially high ranking, for example, could take the wind out of the sails of desirable health-reform efforts. Similarly, an artificially low ranking could assign a bad grade to past reform efforts that were actually commendable. Rumour in the health services research community has it that France’s no.1 rank was driven in part by a flawed measure of national educational attainment. Under the methodology used by WHO, the more the level of educational attainment or of health spending is underestimated for a country, the higher will be the ratio of actual to ideal performance for that country and the higher will be the nation’s ranking. Second, if the report is addressed to policy-makers, one must judge it poorly written. To be sure, it has a number of fascinating, if chatty, chapters; but these are only loosely connected to the actual work underlying this study. To see what was actually done, one must plough through the cryptic commentary that accompanies the tables in the Annex or dig up and read sundry sources cited in the references. Few policymakers and even fewer journalists will go to that trouble. To be useful as a policy analysis, the report ought to have started with the crisp executive summary that is now de rigueur among policy analysts, certainly in the United States. That summary would have presented the main conclusions emerging from the study and described, in layman’s terms, the methodology that was used to reach these conclusions. Most important of all, the executive summary should have contained the many caveats that must, in good conscience, accompany ambitious analyses of this sort. n

Contamination of drinking-water by arsenic in Bangladesh: a public health emergency

Abstract: The contamination of groundwater by arsenic in Bangladesh is the largest poisoning of a population in history, with millions of people exposed. This paper describes the history of the discovery of arsenic in drinking-water in Bangladesh and recommends intervention strategies. Tube-wells were installed to provide ‘‘pure water’’ to prevent morbidity and mortality from gastrointestinal disease. The water from the millions of tube-wells that were installed was not tested for arsenic contamination. Studies in other countries where the population has had long-term exposure to arsenic in groundwater indicate that 1 in 10 people who drink water containing 500mg of arsenic per litre may ultimately die from cancers caused by arsenic, including lung, bladder and skin cancers. The rapid allocation of funding and prompt expansion of current interventions to address this contamination should be facilitated. The fundamental intervention is the identification and provision of arsenic-free drinking water. Arsenic is rapidly excreted in urine, and for early or mild cases, no specific treatment is required. Community education and participation are essential to ensure that interventions are successful; these should be coupled with follow-up monitoring to confirm that exposure has ended. Taken together with the discovery of arsenic in groundwater in other countries, the experience in Bangladesh shows that groundwater sources throughout the world that are used for drinking-water should be tested for arsenic.

Indoor air pollution in developing countries: a major environmental and public health challenge

Abstract: Around 50% of people, almost all in developing countries, rely on coal and biomass in the form of wood, dung and crop residues for domestic energy. These materials are typically burnt in simple stoves with very incomplete combustion. Consequently, women and young children are exposed to high levels of indoor air pollution every day. There is consistent evidence that indoor air pollution increases the risk of chronic obstructive pulmonary disease and of acute respiratory infections in childhood, the most important cause of death among children under 5 years of age in developing countries. Evidence also exists of associations with low birth weight, increased infant and perinatal mortality, pulmonary tuberculosis, nasopharyngeal and laryngeal cancer, cataract, and, specifically in respect of the use of coal, with lung cancer. Conflicting evidence exists with regard to asthma. All studies are observational and very few have measured exposure directly, while a substantial proportion have not dealt with confounding. As a result, risk estimates are poorly quantified and may be biased. Exposure to indoor air pollution may be responsible for nearly 2 million excess deaths in developing countries and for some 4% of the global burden of disease. Indoor air pollution is a major global public health threat requiring greatly increased efforts in the areas of research and policy-making. Research on its health effects should be strengthened, particularly in relation to tuberculosis and acute lower respiratory infections. A more systematic approach to the development and evaluation of interventions is desirable, with clearer recognition of the interrelationships between poverty and dependence on polluting fuels.

Climate change and vector-borne diseases: a regional analysis.

Abstract: ResumenEl cambio clima´tico y las enfermedades transmitidas por vectores: un ana´lisis regional La vida humana depende de la dina´mica del sistemaclima´tico de la Tierra. Las interacciones entre laatmo´sfera, los oce´anos, las biosferas terrestre y marina,lacriosferaylasuperficieterrestredeterminanelclimadelasuperficiedelplaneta.Laconcentracio´natmosfe´ricadelosgasesdeefectoinvernaderoesta´ aumentandodebidoprincipalmente a la actividad humana, provocando unrecalentamiento de la superficie terrestre.Se estima que la temperatura mundial habra´aumentado como promedio 1,0-3,5 o C para 2100, conlo que aumentara´ tambie´n el riesgo de enfermedadestransmitidas por vectores. El mayor efecto del cambioclima´tico en ese sentido se observara´ probablemente enlos extremos del intervalo de temperaturas requeridopara la transmisio´n (14-18 o C como li´mite inferior, y 35-40 o C como li´mite superior).El clima africano tropical favorece la transmisio´nde la mayori´a de las principales enfermedades mediadaspor vectores, entre ellas el paludismo, la esquistosomia-sis, la oncocercosis, la tripanosomiasis, la filariasis, laleishmaniasis, la peste, la fiebre del Valle del Rift, lafiebre amarilla y las fiebres hemorra´gicas transmitidaspor garrapatas. Se calcula que para 2050 el Sa´hara y laszonas semia´ridas de A´ frica meridional podri´an expe-rimentar un aumento medio de 1,6

A framework for assessing the performance of health systems

Abstract: Health systems vary widely in performance, and countries with similar levels of income, education and health expenditure differ in their ability to attain key health goals. This paper proposes a framework to advance the understanding of health system performance. A first step is to define the boundaries of the health system, based on the concept of health action. Health action is defined as any set of activities whose primary intent is to improve or maintain health. Within these boundaries, the concept of performance is centred around three fundamental goals: improving health, enhancing responsiveness to the expectations of the population, and assuring fairness of financial contribution. Improving health means both increasing the average health status and reducing health inequalities. Responsiveness includes two major components: (a) respect for persons (including dignity, confidentiality and autonomy of individuals and families to decide about their own health); and (b) client orientation (including prompt attention, access to social support networks during care, quality of basic amenities and choice of provider). Fairness of financial contribution means that every household pays a fair share of the total health bill for a country (which may mean that very poor households pay nothing at all). This implies that everyone is protected from financial risks due to health care. The measurement of performance relates goal attainment to the resources available. Variation in performance is a function of the way in which the health system organizes four key functions: stewardship (a broader concept than regulation); financing (including revenue collection, fund pooling and purchasing); service provision (for personal and non-personal health services); and resource generation (including personnel, facilities and knowledge). By investigating these four functions and how they combine, it is possible not only to understand the proximate determinants of health system performance, but also to contemplate major policy challenges.

Environmental lead exposure: a public health problem of global dimensions

Abstract: Lead is the most abundant of the heavy metals in the Earth’s crust. It has been used since prehistoric times, and has become widely distributed and mobilized in the environment. Exposure to and uptake of this non-essential element have consequently increased. Both occupational and environmental exposures to lead remain a serious problem in many developing and industrializing countries, as well as in some developed countries. In most developed countries, however, introduction of lead into the human environment has decreased in recent years, largely due to public health campaigns and a decline in its commercial usage, particularly in petrol. Acute lead poisoning has become rare in such countries, but chronic exposure to low levels of the metal is still a public health issue, especially among some minorities and socioeconomically disadvantaged groups. In developing countries, awareness of the public health impact of exposure to lead is growing but relatively few of these countries have introduced policies and regulations for significantly combating the problem. This article reviews the nature and importance of environmental exposure to lead in developing and developed countries, outlining past actions, and indicating requirements for future policy responses and interventions.

Lithium salts in the treatment of psychotic excitement. 1949.

Abstract: LITHIUM SALTS enjoyed their hey-day in the latter half of last century when, commencing with their introduction by Garrod, they. were vaunted as curative in gout, and so doubtless in a multitude of other so-called gouty manifestations. This followed the demonstration that lithium urate was the most soluble of the urates. It was shown that if pieces of cartilage with urate deposits were immersed in solutions of sodium, potassium and lithium carbonate, the urate was dissolved first from that piece immersed in the lithium carbonate solution. As time went on and lithia tablets were consumed on an ever-increasing scale for an ever-increasing range of ailments, the toxic and depressant effects were more and more commonly seen. Garrod (1859) wrote of lithium carbonate: "When given internally in doses of from one to four grains dissolved in water, two to three times a day, it produces no direct physiological symptom ... their use does not appear to be attended with any injurious consequences." And certainly, in that dosage, there should never be any toxic symptoms. But about fifty years later cases are reported "of cardiac depression and even dilatation, as a result of excessive and continued consumption of lithia tablets" (The Practitioner, 1907). "Cardiac depression and even dilatation" was perhaps very vague physiology, but the note of warning was clear, also the statement in Squires's "Companion to the British Pharmacopoeia" that "lithia salts upset the stomach very easily" (The Practitioner, 1909). What with the hypothetical cardiac depression and the actual mental depression, nausea and giddiness, the uselessness of lithium in most of the conditions for which it was prescribed, and the fact that there was other, more efficacious treatment in the only disease in which it had been shown to be of some value, it is not surprising that lithium salts have fallen into desuetude. Culbreth (1927) says of lithium bromide that it is the most hypnotic of all bromides. The dosage stated there is the relatively enormous one of 10 to 30 grains. It is not stated how often this huge dose might be repeated each day, but one presumes the traditional two to three times. Squires, too, states that "in epilepsy it is the best of all bromides" and gives the dose more conservatively as five to 15 grains. It is worth noting that the hypnotic action of lithium bromide was thought to be due to the fact that, the atomic weight of lithium being so small, weight for weight, lithium bromide must contain more bromide ion than any other bromide. There is no evidence that the lithium ion was recognized as having a marked sedative action superior in some respects to that of the bromide. But 15 grains of lithium bromide repeated three times a day would soon lead, not to bromide, but to far more dangerous lithium, intoxication, and it is little wonder that it has never found favour in the treatment of epilepsy. It is a pity, because properly used, lithium salts might well be an important addition to the anti-convulsant armamentarium. In the course of some investigations by the writer into the toxicity of urea when injected intraperitoneally into guinea-pigs, it appeared desirable to ascertain whether uric acid enhanced this toxicity. The great difficulty was the insolubility of uric acid in water, so the most soluble urate was chosen--the lithium salt. When an aqueous solution of 8% urea, saturated with lithium urate, was injected, the toxicity was far less than was expected. It looked as if the lithium ion might have been exerting a protective effect. To determine this, more observations were made, lithium carbonate being used instead of lithium urate. An 8% aqueous solution of urea kills five out of ten guinea-pigs when injected intraperitoneally in doses of 1-25 millilitres per ounce of body weight. When 0.5% lithium carbonate in an 8% urea solution was injected in the same dosage, all ten animals survived; and this argued a strong protective function for the lithium ion against the convulsant mode of death caused by toxic doses of urea. …

Malnutrition as an underlying cause of childhood deaths associated with infectious diseases in developing countries

Abstract: Introduction Recent estimates suggest that malnutrition (measured as poor anthropometric status) is associated with about 50% of all deaths among children. Although the association between malnutrition and all-cause mortality is well documented, the malnutrition-related risk of death associated with specific diseases is less well described. We reviewed published literature to examine the evidence for a relation between malnutrition and child mortality from diarrhoea, acute respiratory illness, malaria and measles, conditions that account for over 50% of deaths in children worldwide. Methods MEDLINE was searched for suitable review articles and original reports of community-based and hospital-based studies. Findings from cohort studies and case–control studies were reviewed and summarized. Results The strongest and most consistent relation between malnutrition and an increased risk of death was observed for diarrhoea and acute respiratory infection. The evidence, although limited, also suggests a potentially increased risk for death from malaria. A less consistent association was observed between nutritional status and death from measles. Although some hospital-based studies and case–control studies reported an increased risk of mortality from measles, few community-based studies reported any association. Discussion The risk of malnutrition-related mortality seems to vary for different diseases. These findings have important implications for the evaluation of nutritional intervention programmes and child survival programmes being implemented in settings with different disease profiles.

Cross-national comparisons of the prevalences and correlates of mental disorders.

Abstract: The International Consortium in Psychiatric Epidemiology (ICPE) was established in 1998 by WHO to carry out crossnational comparative studies of the prevalences and correlates of mental disorders. This article describes the findings of ICPE surveys in seven countries in North America (Canada and USA), Latin America (Brazil and Mexico), and Europe (Germany, Netherlands, and Turkey), using a version of the WHO Composite International Diagnostic Interview (CIDI) to generate diagnoses. The results are reported using DSM-III-R and DSM-IV criteria without diagnostic hierarchy rules for mental disorders and with hierarchy rules for substance-use disorders. Prevalence estimates varied widely—from >40% lifetime prevalence of any mental disorder in Netherlands and the USA to levels of 12% in Turkey and 20% in Mexico. Comparisons of lifetime versus recent prevalence estimates show that mental disorders were often chronic, although chronicity was consistently higher for anxiety disorders than for mood or substance-use disorders. Retrospective reports suggest that mental disorders typically had early ages of onset, with estimated medians of 15 years for anxiety disorders, 26 years for mood disorders, and 21 years for substance-use disorders. All three classes of disorder were positively related to a number of socioeconomic measures of disadvantage (such as low income and education, unemployed, unmarried). Analysis of retrospective age-of-onset reports suggest that lifetime prevalences had increased in recent cohorts, but the increase was less for anxiety disorders than for mood or substance-use disorders. Delays in seeking professional treatment were widespread, especially among early-onset cases, and only a minority of people with prevailing disorders received any treatment. Mental disorders are among the most burdensome of all classes of disease because of their high prevalence and chronicity, early age of onset, and resulting serious impairment. There is a need for demonstration projects of early outreach and intervention programmes for people with early-onset mental disorders, as well as quality assurance programmes to look into the widespread problem of inadequate treatment.

Is malnutrition declining? An analysis of changes in levels of child malnutrition since 1980.

Abstract: Nutritional status is the best global indicator of well-being in children. Although many surveys of children have been conducted since the 1970s, lack of comparability between them has made it difficult to monitor trends in child malnutrition. Cross-sectional data from 241 nationally representative surveys were analysed in a standard way to produce comparable results of low height-for-age (stunting). Multilevel modelling was applied to estimate regional and global trends from 1980 to 2005. The prevalence of stunting has fallen in developing countries from 47% in 1980 to 33% in 2000 (i.e. by 40 million), although progress has been uneven according to regions. Stunting has increased in Eastern Africa, but decreased in South-eastern Asia, South-central Asia and South America; Northern Africa and the Caribbean show modest improvement; and Western Africa and Central America present very little progress. Despite an overall decrease of stunting in developing countries, child malnutrition still remains a major public health problem in these countries. In some countries rates of stunting are rising, while in many others they remain disturbingly high. The data we have presented provide a baseline for assessing progress and help identify countries and regions in need of populationwide interventions. Approaches to lower child malnutrition should be based on successful nutrition programmes and policies.

Prevalence of use of complementary/alternative medicine: a systematic review.

Abstract: Reported are the results of a systematic review of the prevalence of use of complementary/alternative medicine. Computerized literature searches were carried out in four databases. Twelve surveys thus found were selected because they dealt with the utilization of complementary/alternative medicine in random or representative samples of the general population. Data were extracted in a predefined, standardized way. Prevalence of use of complementary/alternative medicine ranged from 9% to 65%. Even for a given form of treatment such as chiropractic, as used in the USA, considerable discrepancies emerged. The data suggest that complementary/alternative therapies are used frequently and increasingly. Prevalence of use seemed to depend critically on factors that were poorly controlled in surveys of complementary/alternative medicine. The true prevalence of use of complementary/alternative medicine in the general population remains uncertain.

The urban environment and health in a world of increasing globalization: issues for developing countries.

Abstract: Urban living is the keystone of modern human ecology. Cities have multiplied and expanded rapidly worldwide over the past two centuries. Cities are sources of creativity and technology, and they are the engines for economic growth. However, they are also sources of poverty, inequality, and health hazards from the environment. Urban populations have long been incubators and gateways for infectious diseases. The early industrializing period of unplanned growth and laissez-faire economic activity in cities in industrialized countries has been superseded by the rise of collective management of the urban environment. This occurred in response to environmental blight, increasing literacy, the development of democratic government, and the collective accrual of wealth. In many low-income countries, this process is being slowed by the pressures and priorities of economic globalization. Beyond the traditional risks of diarrhoeal disease and respiratory infections in the urban poor and the adaptation of various vector-borne infections to urbanization, the urban environment poses various physicochemical hazards. These include exposure to lead, air pollution, traffic hazards, and the "urban heat island" amplification of heatwaves. As the number of urban consumers and their material expectations rise and as the use of fossil fuels increases, cities contribute to the large-scale pressures on the biosphere including climate change. We must develop policies that ameliorate the existing, and usually unequally distributed, urban environmental health hazards and larger-scale environmental problems.

Socioeconomic inequalities in child mortality: comparisons across nine developing countries

Abstract: This paper generates and analyses survey data on inequalities in mortality among infants and children aged under five years by consumption in Brazil, Cote d'Ivoire, Ghana, Nepal, Nicaragua, Pakistan, the Philippines, South Africa, and Viet Nam. The data were obtained from the Living Standards Measurement Study and the Cebu Longitudinal Health and Nutrition Survey. Mortality rates were estimated directly where complete fertility histories were available and indirectly otherwise. Mortality distributions were compared between countries by means of concentration curves and concentration indices: dominance checks were carried out for all pairwise intercountry comparisons; standard errors were calculated for the concentration indices; and tests of intercountry differences in inequality were performed.

Spatial targeting of interventions against malaria.

Abstract: Malaria transmission is strongly associated with location. This association has two main features. First, the disease is focused around specific mosquito breeding sites and can normally be transmitted only within certain distances from them: in Africa these are typically between a few hundred metres and a kilometre and rarely exceed 2-3 kilometres. Second, there is a marked clustering of persons with malaria parasites and clinical symptoms at particular sites, usually households. In localities of low endemicity the level of malaria risk or case incidence may vary widely between households because the specific characteristics of houses and their locations affect contact between humans and vectors. Where endemicity is high, differences in human/vector contact rates between different households may have less effect on malaria case incidences. This is because superinfection and exposure-acquired immunity blur the proportional relationship between inoculation rates and case incidences. Accurate information on the distribution of malaria on the ground permits interventions to be targeted towards the foci of transmission and the locations and households of high malaria risk within them. Such targeting greatly increases the effectiveness of control measures. On the other hand, the inadvertent exclusion of these locations causes potentially effective control measures to fail. The computerized mapping and management of location data in geographical information systems should greatly assist the targeting of interventions against malaria at the focal and household levels, leading to improved effectiveness and cost-effectiveness of control.

Health inequalities and the health of the poor: What do we know? What can we do?

Abstract: The contents of this theme section of the Bulletin of the World Health Organization on "Inequalities in health" have two objectives: to present the initial findings from a new generation of research that has been undertaken in response to renewed concern for health inequalities; and to stimulate movement for action in order to correct the problems identified by this research. The research findings are presented in the five articles which follow. This Critical Reflection proposes two initial steps for the action needed to alleviate the problem; other suggestions are given by the participants in a Round Table discussion which is published after these articles. The theme section concludes with extracts from the classic writings of the nineteenth-century public health pioneer, William Farr, who is widely credited as one of the founders of the scientific study of health inequalities, together with a commentary. This Critical Reflection contributes to the discussion of the action needed by proposing two initial steps for action. That professionals who give very high priority to the distinct but related objectives of poverty alleviation, inequality reduction, and equity enhancement recognize that their shared concern for the distributional aspects of health policy is far more important than any differences that may divide them. That health policy goals, currently expressed as societal averages, be reformulated so that they point specifically to conditions among the poor and to poor-rich differences. For example, infant mortality rates among the poor or the differences in infant mortality between rich and poor sectors would be more useful indicators than the average infant mortality rates for the whole population.

Reducing deaths from diarrhoea through oral rehydration therapy

Abstract: In 1980, diarrhoea was the leading cause of child mortality, accounting for 4.6 million deaths annually. Efforts to control diarrhoea over the past decade have been based on multiple, potentially powerful interventions implemented more or less simultaneously. Oral rehydration therapy (ORT) was introduced in 1979 and rapidly became the cornerstone of programmes for the control of diarrhoeal diseases. We report on the strategy for controlling diarrhoea through case management, with special reference to ORT, and on the relationship between its implementation and reduced mortality. Population-based data on the coverage and quality of facility-based use of ORT are scarce, despite its potential importance in reducing mortality, especially for severe cases. ORT use rates during the 1980s are available for only a few countries. An improvement in the availability of data occurred in the mid-1990s. The study of time trends is hampered by the use of several different definitions of ORT. Nevertheless, the data show positive trends in diarrhoea management in most parts of the world. ORT is now given to the majority of children with diarrhoea. The annual number of deaths attributable to diarrhoea among children aged under 5 years fell from the estimated 4.6 million in 1980 to about 1.5 million today. Case studies in Brazil, Egypt, Mexico, and the Philippines confirm increases in the use of ORT which are concomitant with marked falls in mortality. In some countries, possible alternative explanations for the observed decline in mortality have been fairly confidently ruled out. Experience with ORT can provide useful guidance for child survival programmes. With adequate political will and financial support, cost-effective interventions other than that of immunization can be successfully delivered by national programmes. Furthermore, there are important lessons for evaluators. The population-based data needed to establish trends in health service delivery, outcomes and impact are not available in respect of diarrhoea, as is true for malaria, pneumonia and other major childhood conditions. Standard indicators and measurement methods should be established. Efforts to change existing global indicators should be firmly resisted. Support should be given for the continuing evaluation and documentation activities needed to guide future public health policies and programmes.

The decline in child mortality: a reappraisal

Abstract: The present paper examines, describes and documents country-specific trends in under-five mortality rates (i.e., mortality among children under five years of age) in the 1990s. Our analysis updates previous studies by UNICEF, the World Bank and the United Nations. It identifies countries and WHO regions where sustained improvement has occurred and those where setbacks are evident. A consistent series of estimates of under-five mortality rate is provided and an indication is given of historical trends during the period 1950-2000 for both developed and developing countries. It is estimated that 10.5 million children aged 0-4 years died in 1999, about 2.2 million or 17.5% fewer than a decade earlier. On average about 15% of newborn children in Africa are expected to die before reaching their fifth birthday. The corresponding figures for many other parts of the developing world are in the range 3-8% and that for Europe is under 2%. During the 1990s the decline in child mortality decelerated in all the WHO regions except the Western Pacific but there is no widespread evidence of rising child mortality rates. At the country level there are exceptions in southern Africa where the prevalence of HIV is extremely high and in Asia where a few countries are beset by economic difficulties. The slowdown in the rate of decline is of particular concern in Africa and South-East Asia because it is occurring at relatively high levels of mortality, and in countries experiencing severe economic dislocation. As the HIV/AIDS epidemic continues in Africa, particularly southern Africa, and in parts of Asia, further reductions in child mortality become increasingly unlikely until substantial progress in controlling the spread of HIV is achieved.

Public spending on health care in Africa: do the poor benefit?

Abstract: Health care is a basic service essential in any effort to combat poverty, and is often subsidized with public funds to help achieve that aim. This paper examines public spending on curative health care in several African countries and finds that this spending favours mostly the better-off rather than the poor. It concludes that this targeting problem cannot be solved simply by adjusting the subsidy allocations. The constraints that prevent the poor from taking advantage of these services must also be addressed if the public subsidies are to be effective in reaching the poor.

Inequalities in health care use and expenditures: empirical data from eight developing countries and countries in transition

Abstract: This paper summarizes eight country studies of inequality in the health sector. The analyses use household data to examine the distribution of service use and health expenditures. Each study divides the population into "income" quintiles, estimated using consumption expenditures. The studies measure inequality in the use of and spending on health services. Richer groups are found to have a higher probability of obtaining care when sick, to be more likely to be seen by a doctor, and to have a higher probability of receiving medicines when they are ill, than the poorer groups. The richer also spend more in absolute terms on care. In several instances there are unexpected findings. There is no consistent pattern in the use of private providers. Richer households do not devote a consistently higher percentage of their consumption expenditures to health care. The analyses indicate that intuition concerning inequalities could result in misguided decisions. It would thus be worthwhile to measure inequality to inform policy-making. Additional research could be performed using a common methodology for the collection of data and applying more sophisticated analytical techniques. These analyses could be used to measure the impact of health policy changes on inequality.

Factors associated with trends in infant and child mortality in developing countries during the 1990s.

Abstract: The 1990s have seen a remarkable decrease in mortality among infants and children in most developing countries. In some countries, particularly in sub-Saharan Africa, these declines in mortality among children have slowed and are now increasing again. Internationally comparable data derived from survey programmes, such as the Demographic and Health Survey (DHS) programme, are available both to document the changes that have occurred in mortality and to provide insight into some of the factors that may explain these trends in mortality. The factors found in repeated DHS programmes that explain these trends fall into five categories: fertility behaviour; nutritional status, breastfeeding, and infant feeding; the use of health services by mothers and for children; environmental health conditions; and socioeconomic status. Both simple analyses and multivariate analyses of changes in these factors between surveys indicate that all factors affected the mortality trends. However, to explain trends in mortality, the variables themselves had to have changed over time. During the 1990s fertility behaviour, breastfeeding, and infant feeding have changed less than other factors and so would seem to have played a smaller role in mortality trends. This study confirms that trends in mortality during the 1990s were related to more than just a handful of variables. It would, therefore, be a mistake to concentrate policy actions on one or a few of these while forsaking others. Countries with the largest decreases in mortality have had substantial improvements in most of the factors that might be used to explain these changes. In some countries mortality has risen. In part these increases can be explained by the factors included in this study, such as deterioration in seeking medical care for children with fever. Other factors that were not measured, such as the increasing resistance of malaria to drug treatment and the increased prevalence of parental HIV/AIDS, may be contributing to the increases noted.

Guidelines for the microbiological quality of treated wastewater used in agriculture: recommendations for revising WHO guidelines

Abstract: Three different approaches for establishing guidelines for the microbiological quality of treated wastewater that is reused for agriculture are reviewed. These approaches have different objectives as their outcomes: the absence of faecal indicator organisms in the wastewater, the absence of a measurable excess of cases of enteric disease in the exposed population and a model-generated estimated risk below a defined acceptable risk. If the second approach (using empirical epidemiological studies supplemented by microbiological studies of the transmission of pathogens) is used in conjunction with the third approach (using a model-based quantitative risk assessment for selected pathogens) a powerful tool is produced that aids the development of regulations. This combined approach is more cost-effective than the first approach and adequately protects public health. The guideline limit for faecal coliform bacteria in unrestricted irrigation (41000 faecal coliform bacteria/ 100 ml) is valid, but for restricted irrigation 410 5 faecal coliform bacteria/100 ml is recommended when adult farmworkers are exposed to spray irrigation. A limit of 410 3 faecal coliform bacteria/100 ml is recommended if flood irrigation is used or children are exposed. The guideline limit for nematode eggs for both types of irrigation is adequate except when conditions favour the survival of nematode eggs and where children are exposed; in these cases it should be reduced from 41 egg/l to 40.1 egg/l.

Defining and measuring health inequality: an approach based on the distribution of health expectancy.

Abstract: This paper proposes an approach to conceptualizing and operationalizing the measurement of health inequality, defined as differences in health across individuals in the population. We propose that health is an intrinsic component of well-being and thus we should be concerned with inequality in health, whether or not it is correlated with inequality in other dimensions of well-being. In the measurement of health inequality, the complete range of fatal and non-fatal health outcomes should be incorporated. This notion is operationalized through the concept of healthy lifespan. Individual health expectancy is preferable, as a measurement, to individual healthy lifespan, since health expectancy excludes those differences in healthy lifespan that are simply due to chance. In other words, the quantity of interest for studying health inequality is the distribution of health expectancy across individuals in the population. The inequality of the distribution of health expectancy can be summarized by measures of individual/mean differences (differences between the individual and the mean of the population) or inter-individual differences. The exact form of the measure to summarize inequality depends on three normative choices. A firmer understanding of people's views on these normative choices will provide a basis for deliberating on a standard WHO measure of health inequality.

A critical examination of summary measures of population health

Abstract: In the past decade, interest has been rising in the development, calculation and use of summary measures of population health, which combine information on mortality and non-fatal health outcomes. This paper reviews the issues and challenges in the design and application of summary measures and presents a framework for evaluating different alternatives. Summary measures have a variety of uses, including comparisons of health in different populations and assessments of the relative contributions of different diseases, injuries and risk factors to the total disease burden in a population. Summary measures may be divided into two broad families: health expectancies and health gaps. Within each family, there are many different possible measures, but they share a number of inputs, including information on mortality, non-fatal health outcomes, and health state valuations. Other critical points include calculation methods and a range of conceptual and methodological issues regarding the definition, measurement and valuation of health states. This paper considers a set of basic criteria and desirable properties that may lead to rejection of certain summary measures and the development of new ones. Despite the extensive developmental agenda that remains, applications of summary measures cannot await the final resolution of all methodological issues, so they should focus on those measures that satisfy as many basic criteria and desirable properties as possible.

Global public-private partnerships: Part I--A new development in health?

Abstract: The proliferation of public-private partnerships is rapidly reconfiguring the international health landscape. This article (part I of two on the subject) traces the changing nature of partnership, and discusses the definitional and conceptual ambiguities surrounding the term. After defining global public-private partnerships (GPPPs) for health development, we analyse the factors which have led to the convergence of public and private actors and discuss the consequences of the trend toward partnership between UN agencies (including the World Bank) and commercial entities in the health sector. Generic factors such as globalization and disillusionment with the UN, and factors specific to the health sector, such as market failure in product development for orphan diseases, are examined. Reviewed are the interests, policies, practices and concerns of the UN, the private-for-profit sector, bilateral organizations, and governments of low-income countries with respect to public-private partnership. While GPPPs bring much needed resources to problems of international health, we highlight concerns regarding this new organizational format. Part II, which will be published in the May issue of the Bulletin, presents a conceptual framework for analysing health GPPPs and explores the issues raised.

Tobacco use by youth: a surveillance report from the Global Youth Tobacco Survey project

Abstract: The Global Youth Tobacco Survey (GYTS) project was developed by the World Health Organization and the US Centers for Disease Control and Prevention to track tobacco use among youth in countries across the world, using a common methodology and core questionnaire. The GYTS is school based and employs a two-stage sample design to produce representative data on smoking among students aged 13-15 years. The first stage consists of a probabilistic selection of schools, and the second consists of a random selection of classes from the participating schools. All students in the selected classes are eligible for the survey. In 1999, the GYTS was conducted in 13 countries and is currently in progress in over 30 countries. This report describes data from 12 countries: Barbados, China, Costa Rica, Fiji, Jordan, Poland, the Russian Federation (Moscow), South Africa, Sri Lanka, Ukraine (Kiev), Venezuela, and Zimbabwe. The findings show that tobacco use in the surveyed age group ranged from a high of 33% to a low of 10%. While the majority of current smokers wanted to stop smoking, very few were able to attend a cessation programme. In most countries the majority of young people reported seeing advertisements for cigarettes in media outlets, but anti-tobacco advertising was rare. The majority of young people reported being taught in school about the dangers of smoking. Environmental tobacco smoke exposure was very high in all countries. These results show that the GYTS surveillance system is enhancing the capacity of countries to design, implement, and evaluate tobacco prevention and control programmes.

A proposal to declare neurocysticercosis an international reportable disease.

Abstract: Neurocysticercosis is an infection of the nervous system caused by Taenia solium. It is the most important human parasitic neurological disease and a common cause of epilepsy in Africa, Asia, and Latin America, representing enormous costs for anticonvulsants, medical resources and lost production. Neurocysticercosis is a human-to-human infection, acquired by the faecal-enteric route from carriers of intestinal T. solium, most often in areas with deficient sanitation. Intestinal tapeworms cause few symptoms, but adult taeniae carried by humans release large numbers of infective eggs and are extremely contagious. Ingestion of poorly cooked pig meat infested with T. solium larvae results in intestinal taeniosis but not neurocysticercosis. With a view to hastening the control of taeniosis and neurocysticercosis we propose that neurocysticercosis be declared an international reportable disease. New cases of neurocysticercosis should be reported by physicians or hospital administrators to their health ministries. An epidemiological intervention could then be launched to interrupt the chain of transmission by: (1) searching for, treating and reporting the sources of contagion, i.e. human carriers of tapeworms; (2) identifying and treating other exposed contacts; (3) providing health education on parasite transmission and improvement of hygiene and sanitary conditions; and (4) enforcing meat inspection policies and limiting the animal reservoir by treatment of pigs. We believe that the first step required to solve the problem of neurocysticercosis is to implement appropriate surveillance mechanisms under the responsibility of ministries of health. Compulsory notification also has the major advantage of providing accurate quantification of the incidence and prevalence of neurocysticercosis at regional level, thus permitting the rational use of resources in eradication campaigns.

The concept of stewardship in health policy

Abstract: There is widespread agreement that both the configuration and the application of state authority in the health sector should be realigned in the interest of achieving agreed policy objectives. The desired outcome is frequently characterized as a search for good governance serving the public interest. The present paper examines the proposal in The World Health Report 2000 that the concept of stewardship offers the appropriate basis for reconfiguration. We trace the development of stewardship from its initial religious formulation to more recent ecological and sociological permutations. Consideration is given to the potential of stewardship for encouraging state decision-making that is both normatively based and economically efficient. Various dilemmas that could impede or preclude such a shift in state behaviour are examined. We conclude that the concept of stewardship holds substantial promise if adequately developed and effectively implemented.

Global public-private partnerships: part II - what are the health issues for global governance?

Abstract: This is the second of a two-part review of global public-private partnerships (GPPPs) for health development. Part I was published in the April issue of the Bulletin (Vol. 78, No. 4). The recent emergence of GPPPs is rapidly reconfiguring the international health landscape. While most multilateral and bilateral agencies are currently grappling with how to proceed, there is little information in the public domain concerning how individual partnerships work and to date very little consideration of the many implications of this trend. This paper differentiates between product-based, product development-based and issues/systems-based GPPPs and describes a number of examples of each type in the health sector. The benefits of these initiatives, not least the major resources which they harness for specific health problems, are identified. The final section of the paper explores the implications and dilemmas posed by GPPPs. It discusses whether or not shared goals can transcend conflicting values and mandates and how governance of partnership arrangements may transform and undermine certain attributes of multilateral organizations. The paper concludes that the current climate of goodwill between public and private sectors offers an opportunity that should not be missed: it can be used not only to foster new partnership but to ensure that partnership is truly in the interests of international public health.

Reducing child mortality in India in the new millennium.

Abstract: Globally, child mortality rates have been halved over the last few decades, a developmental success story. Nevertheless, progress has been uneven and in recent years mortality rates have increased in some countries. The present study documents the slowing decline in infant mortality rates in India; a departure from the longer-term trends. The major causes of childhood mortality are also reviewed and strategic options for the different states of India are proposed that take into account current mortality rates and the level of progress in individual states. The slowing decline in childhood mortality rates in India calls for new approaches that go beyond disease-, programme- and sector-specific approaches.

Unsafe injections and the transmission of hepatitis B and C in a periurban community in Pakistan

Abstract: Following reports of frequent deaths associated with jaundice and chronic liver disease among adults in a periurban community of Karachi, Pakistan, an investigation was conducted to evaluate the relationship between injections and viral hepatitis infections, to identify the reasons why patients received frequent injections, and to observe the injection practices employed in clinics. Two hundred and three adult patients were interviewed as they left each of the 18 area clinics. Practitioners were interviewed and three consecutive injections were observed at each clinic. Eighty-one per cent of patients received an injection on the day of the interview. Of the 135 patients who provided a serum sample, 59 (44%) had antibodies against hepatitis C virus and 26 (19%) had antibodies against hepatitis B virus. Patients who received more injections were more likely to be infected with hepatitis C. If oral and injected medications were equally effective, 44% of patients preferred injected medication. None of the practitioners knew that hepatitis C could be transmitted by injections. Non-sterile syringes and needles that had been used earlier in the day on other patients were used for 94% of the observed injections. Interventions to limit injections to those which are safe and clinically indicated are needed to prevent injection-associated infections in Pakistan and other low-income countries.