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Rapid Responses: Rapid Responses published:
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Some people work hard to achieve the millenium development goals
- Ulf R. Dahle (12 November 2005)
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Achieving the MDGs: political and social determinants need further study
- Saroj Jayasinghe (15 November 2005)
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Improving Health in Developing Countries
- James G Danaher (18 November 2005)
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Cost Effectiveness Studies Need More Facts than Fervor
- Carol Adelman, Jeremiah Norris (2 December 2005)
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Ulf R. Dahle, senior scientist Norwergian Institute of Public Health
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EDITOR- Wibulpolprasert et al write in BMJ (1) that a series of papers demonstrate that important cost effective interventions are not being implemented adequately in developing countries, to secure the fulfilment of the millennium goals (2). Previously the BMJ and others have reported similar observations (3). Reduction of the child mortality rate and control of major infectious diseases are among the most important goals. Although there is room for improvement in the progress to achieve these goals, time limited targets are valuable since they help facilitate coordinated actions, mobilise resources, and promote a sense of urgency. Worldwide progress is, after all, being made toward decreasing maternal and neonatal mortality, spread of HIV and AIDS, tuberculosis (TB), and malaria. Women's health has become a priority in many developing countries, nearly 1 billion people gained access to improved water sources during 1999-2002, eradication of polio and measles is within reach, nutrition-education campaigns have been initiated, and India is expected to reverse the rise in TB incidence and halve TB prevalence and death rates by 2015 (4, 5). All these advances, and the people that have ensured them, are easily forgotten when the attention is continuously focusing on the failing parts of the millennium goals. REFERENCES: 1. Wibulpolprasert S, Tangcharoensathien V, Kanchanachitra C. Are cost effective interventions enough to achieve the millennium development goals? BMJ 2005;331:1093-1094. 2. Simwaka BN, Theobald S, Amekudzi YP, Tolhurst R. Meeting millennium development goals 3 and 5. BMJ. 2005;331:708-9. 3. Evans DB, Adam T, Tan-Torres Edejer T, Lim SS, Cassels A, Evans TG, et al. Achieving the millennium development goals for health: Time to reassess strategies for improving health in developing countries? BMJ 2005;331: 1133-6. 4. World Health organization. http://www.who.int (accessed 11.11.05) 5. Williams BG, Granich R, Chauhan LS, Dharmshaktu NS, Dye C. The impact of HIV/AIDS on the control of tuberculosis in India. Proc Natl Acad Sci U S A. 2005;102:9619-24. Competing interests: None declared |
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Saroj Jayasinghe, Associate Professor, Department of Clinical Medicine Faculty of Medicine, Kyney Road, Colombo 8, Sri Lanka
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The WHO-Choice and other studies provide useful information to formlate strategies for developing countries to achieve MDGs. However, in this debate, the politico-cultural dimensions of exceptionally performing countries do not receive adequate attention. In 2003, all 24 nations with infant mortality of above 100 (except Afghanistan and Iraq) were in Africa with poor resources, continuing political instability and internal conflicts (1). Two generations ago most of Africa was suffering from oppressive colonization, slave trade and exploitation. This would mean deprivation, social exclusion, insecurity and instability, all well known determinants of illness and premature death. In contrast Sri Lanka or Kerala in India, with exceptional health indices had less oppressive colonisation and no slavery. The inter- generational transfer of these disadvantages (in Africa) and advantages (in Sri Lanka or Kerala) cannot be discounted, as suggested by the asset approach to health outcomes (2). In the 1930s-1950s the governments in Sri Lanka and Kerala, were pushed by independence movements linked to socialist ideals (within and outside the government) to provide more equitable distribution of social welfare measures (3, 4). Such developments were often brutally suppressed in Africa as recent as 1960s. Other favourable factors were that both Kerala and Sri Lanka had indigenous cultures and religions which promoted female literacy (currently nearing 90%) and valued education (5). Partly as a result of the above factors and health investments, Sri Lanka was able to reduce its infant mortality from 141 to 100 between 1946 and 1947, and to 50 by 1968. There is debate on the relative contribution made by malaria control and improvement in health services for the initial rapid drop (6). However, econometric analysis suggests that from 1952-81, government health expenditures mattered much more towards reduction in IMR than per-capita GDP and investment in education (7). Thus in all probability, what money (e.g. health investments), infrastructure (e.g. opening of health centres) and information (e.g. female literacy) bought for Sri Lanka and Kerala were underpinned by this accumulation of health advantages from their respective histories and cultures. Fortunately they embarked on their own development goals towards equity and social justice, often going against the preferences of the then UN, the WHO and the World Bank, and, without waiting for an evidence base or studies on cost-effective interventions to guide their destiny. REFERENCES (1) Millennium Indicators Database. Data Series. Infant mortality rate (0- 1 year) per 1000 live births (UNICEF estimates) http://unstats.un.org/unsd/mi/mi_goals.asp (accessed 15 November 2005) (2) Murray CJL, Chen LC. In search of a contemporary theory for understanding mortality change. Social Science and Medicine. 1993; 36: 143 -155. (3) Sanderatne N. Economic Growth and Social Transformations. Tamarind Publications, 2000 Colombo. (4) Desai M. Indirect British rule, state formation, and welfarism in Kerala, India, 1860-1957. Social Science History; 200;29: 457-88. (5) Caldwell JC. Health transition: the cultural, social and behavioral determinants of health in the third world. Social Science and Medicine; 1993; 36: 125-135. (6) Langford CM. Reasons for the decline in mortality in Sri Lanka immediately after the Second World War: a re-examination of the evidence. Health Transition Reviews. 1996;6:3-23. (7) Anand S and Kanbur SMR. Public policy and basic needs provision: intervention and achievement in Sri Lanka. In: eds: Dreze J and Sen A. The Political Economy of Hunger (volume 3). Oxford, Oxford University Press.1991. 299-331 Competing interests: None declared |
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James G Danaher, Retired NHS GP 33 Ashby Road Ravenstone Coalville Leicestershire LE67 2AA
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In 1950, the population in that arc of high human fertility made up of Africa and the Middle East to Pakistan (excluding Turkey) amounted to 310 million. It now stands at 1200 million, and is estimated to be over 2,400 million by 2050. (Figures from United Nations World Population Prospects 2004 Revision) This population increase of over two billion people in a century is in great part due to the spread of western medical expertise. It has been a great feat, and last week’s BMJ with four articles dealing with the developing world shows that we hope – now with the help of many others – to sustain the effort. The scale of this success in saving lives can be illustrated by a few examples of population increase in the decade 1990-2000. In those ten years, Iraq increased by over 6 million to bring the number of Iraqi’s to 25 million; Afghanistan increased by 9 million to reach 24 million; Pakistan increased by 31 million taking the total to 142 million; and Nigeria increased by 27 million to total 117 million. (In 1950, the population of these four countries was 5 million, 8 million, 37 million, and 33 million respectively. In 2050, the population of these four countries - as estimated by the UN - will become 63 million, 97 million, 304 million, and 258 million, respectively.) In the 1950’s and 1960’s it was generally accepted that this rate of population increase, if left unchecked, would make the eradication of poverty impossible. In recent decades this insight has been almost completely lost. Nevertheless, even coming fifty years too late, family planning remains by far the most effective - and cost effective – means of relieving poverty and improving health in developing countries. Gerald Danaher
Competing interests: None declared |
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Carol Adelman, Director, Center for Science in Public Policy Hudson Institute 20005, Jeremiah Norris
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In its editorial “Are cost effective interventions enough to achieve the millennium development goals?” (November 12) the BMJ raises timely issues on how to achieve these goals. The BMJ is correct that, “policy makers need robust evidence.” It is incorrect, however, to conclude that, “David Evans and colleagues provide that evidence.” In “Cost effectiveness analysis of strategies for maternal and neonatal health in developing countries,” Evans et al. claim that small- scale preventive interventions for newborn babies and mothers are extremely cost effective. The authors also admit that “considerable uncertainty surrounds the inputs used in this analysis,” and concede that the current coverage of such health programs is insufficient and that there is a paucity of large-scale effectiveness trials for reducing maternal mortality. This is hardly “robust evidence.” The editorial and related articles contain no mention of the unreliability of maternal mortality data. As global health expert Amir Attaran pointed out in the New York Times (September 13), scientists for the United Nations Millennium Project admit that only a handful of countries can show that maternal mortality is improving, because it is so hard to measure. Especially in poor rural areas, with few doctors and many home births that are mourned privately, data are non-existent. In “Time to reassess strategies for improving health in developing countries,” Evans and his colleagues assume that increased donor aid is essential to reducing maternal mortality and achieving MDGs, citing Bangladesh and Egypt. World Bank data, however, fail to associate foreign aid, or what is called Official Development Assistance (ODA), with improved maternal mortality rates. In 1990, ODA to Bangladesh was $19 per capita, falling to $7 in 2002. Yet, its maternal mortality rate also continued to fall, from 514 per 100,000 live births in the late 1980s, to 382 in 2002. For Egypt, ODA was $104 per capita in 1990, down to $19 in 2002. Despite substantially lower donor aid, its maternal mortality rate fell by 50 percent. Evans et al. focus on narrow donor-funded, government-led interventions when major reductions in maternal and infant mortality are achieved through many other factors. A 2000 Bulletin of the WHO states that “a 1997 examination of cross-national variation in child and infant mortality found that 95 percent of the differences could be explained by differences in income, income distribution, women’s education, ethnicity, and religion.” The U.N. has to take measurement and evidence more seriously. In September 2005, U.N. deputy secretary general Louise Frechette said she didn’t want the millennium summit meeting to be “distracted by arguments over the measurement of the MDGs.” As long as this attitude remains part of MDG culture, the “robust evidence” desired by the BMJ will continue to elude us. Carol C. Adelman, Dr. P.H.
Jeremiah Norris
Competing interests: None declared |
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