The 1993 publication of the now classic book, Disease Control Priorities in Developing Countries, by Oxford University Press and of its companion document, the World Development Report 1993: Investing in Health, published by the World Bank that same year, constitute a landmark in the public health literature. For the first time, decision makers and public health practitioners had a comprehensive review of the cost-effectiveness of available interventions to address the most common health problems in the developing world. They were also provided with the useful metric known as disability-adjusted life years to calculate the burden of disease and the cost-effectiveness of interventions more accurately than in the past.

As was the case with the first edition, this second edition of Disease Control Priorities in Developing Countries will serve an array of audiences. One primary audience consists of people working in the health sector, ranging from those who are responsible for making evidence-based decisions to those who practice medicine and public health under often suboptimal field conditions. A second audience consists of people working in finance and planning ministries, who will benefit from the solid recommendations for improving the health of populations through sound resource reallocation and cost-effective practices.

Purpose

The purpose of this book is to provide information about what works—specifically, the cost-effectiveness of health interventions in a variety of settings. Such information should influence the redesign of programs and the reallocation of resources, thereby helping to achieve the ultimate goal of reducing morbidity and mortality.

Fundamental Policy Considerations

Although economic and budgetary constraints are clearly important considerations, money is not the only limitation. Additional factors fundamental to improving outcomes are the particular circumstances in each country, as well as the individual institutional capacities to deliver goods and services and to implement policies and processes.

Context-specific strategies and responses are essential, because application of the Disease Control Priorities Project's findings will vary according to each country's circumstances: one size does not fit all. Understanding that most health interventions require a minimum level of institutional capacity to deliver goods and services is equally important, and such capacity may have to be built up before money or physical inputs can yield any benefits. Accordingly, goals and priorities should be established and tailored to each country's context.

Transition in Health

Every developing region is facing a transition in its epidemiological profile from an environment with high fertility rates and high mortality from preventable causes to one in which a combination of lower fertility rates and changing lifestyles has led to aging populations and epidemics of tobacco addiction, obesity, cardiovascular disease, cancers, diabetes, and other chronic ailments. The 20th century will be remembered for, among other things, witnessing the largest universal increase in life expectancy in history. While life expectancy is highest in the richest countries, the upward trend is apparent in almost every society. Moreover, in the past 50 years, variations in this health indicator across and within countries have decreased. This convergence of improved life expectancy and reduced variations, which has occurred even in the presence of widening income gaps in many regions, can be explained solely by the impact of knowledge expansion and direct public health interventions.

The increase in life expectancy worldwide will, however, soon reach a plateau, and a retraction has occurred in many countries. HIV/AIDS and civil unrest in Africa, vaccine-preventable diseases and alcoholism in Eastern Europe, and obesity in the United States have reduced—or will soon do so—the years of life their populations can expect.

Scaling Up Effective Interventions

The late Jim Grant, former executive director of the United Nations Children's Fund, was one of the first leaders with a vision for setting specific health goals and priorities within a time frame and on a global scale. He recognized the need to raise awareness of the dramatic disparities in children's health and to mobilize political will accordingly. His missionary zeal for universal child immunization and for organizing the first summit of world leaders for children's health and rights in 1990 permitted the scaling up of interventions of proven efficacy. The Millennium Development Goals are a natural consequence of that vision and an extremely useful instrument for maintaining both focus and social pressure. Achieving these ambitious goals will require not only the universal implementation of effective interventions that are currently available, but also the development of new interventions.

Need for Ongoing Research

Today, most vaccines, medical devices, diagnostic tools, and drugs have been subjected to careful investigation in the laboratory, at the bedside, and in the field. However, not enough investment has gone into research to increase well-being and development globally. We need more epidemiological and health systems research to improve the efficiency of available interventions, technological research to reduce their costs, and biomedical research to develop new tools for dealing with as yet unsolved and emerging health problems.

Opportunities and Challenges of Globalization

One of the greatest opportunities and challenges for international public health is globalization. We live in an era when the explosion of trade, travel, and communications is spreading new cultural influences and lifestyles faster than ever before, and the division between domestic and international health problems is becoming increasingly obsolete. At the same time, globalization also permits the spread of risks, pathogens, and other threats. The ever-increasing movement of people everywhere increases the potential for epidemics. Travelers, refugees, and displaced people are more vulnerable to infectious diseases, and their movement contributes to spreading pathogens into new areas. Overall, however, the positive consequences outweigh the negative ones, and cautious optimism about this irreversible trend is justified. Certainly, one of the most valuable contributions of globalization is the rapid accrual and spread of knowledge about useful tools for controlling disease and ways to implement those tools on a large scale.

In recent years, the huge advances in information technology have greatly boosted the globalization of knowledge. Ideally, this should become a tide that lifts all boats to yield global benefits. The challenge is to harness the information technology revolution to foster the growth of economies. One step in the right direction is the open access movement, which promotes and permits free and immediate access to research results and other components of knowledge transfer.

Spending More and Spending Better

It is indeed a paradox to observe that even though the money spent on health worldwide has reached 10 percent of overall global income, that amount is both insufficient and poorly allocated. The World Health Organization's Commission on Macroeconomics and Health and several other global initiatives make a persuasive plea for a larger investment in health. At the same time, this book is dedicated to making the case for better spending—that is, deriving more health benefits from every dollar spent. The aim should be to reduce inequalities in health investment between and within countries: a 100-fold difference between the rich and the poor in money spent on health services still persists in many places. Despite a lack of clarity about what constitutes the optimum balance of health spending, a larger share should go to prevention. This book looks at several prevention options and clinical interventions that are not being fully implemented.

Selecting Interventions

This book persuasively makes the case that both clinical and public health interventions depend on the capacity of a given country's health system to deliver, noting that some interventions are more demanding than others in terms of infrastructure and human resources. Therefore, both the costs and the likelihood of success of the more complex interventions are a function of the health capacity in place. In addition, decisions about which interventions should be given priority will depend on assessments of the local burden of disease, local health infrastructure, and other social factors as well as on cost-effectiveness analyses. The following chapters identify the health system capacity needed for scaling up a given intervention. Even middle-income countries with relatively better health infrastructure often pursue sophisticated approaches to medical care that result in fewer health gains per amount of money invested. Every country, regardless of level of development, could benefit from the recommendations presented here.

Diagonal Approach

The medical literature has long debated which approach to delivering health interventions is more effective: vertical programs or horizontal programs. Vertical programs refer to focused, proactive, disease-specific interventions on a massive scale, whereas horizontal programs refer to more integrated, demand-driven, resource-sharing health services. This is a false dilemma, because both need to coexist in what could be called a diagonal approach—that is, the proactive, supply-driven provision of a set of highly cost-effective interventions on a large scale that bridges health clinics and homes. This approach often starts vertically (polio vaccination, for instance) but moves toward an increasing number of interventions (for example, oral rehydration, other vaccines, residual spraying and bednets for malaria control, micronutrient supplementation, and supervised tuberculosis treatment), making full use of field health workers and existing infrastructure. This could well be the equivalent of a public health polypill.

Multidisciplinary Orientation

What makes this book unique, in addition to its comprehensive scope, is its truly multidisciplinary approach to disease control, which merges the best of the medical and economic sciences. Every recommendation has been carefully researched and documented. Evidence-based approaches must be the foundation for allocating scarce resources. The poor cannot afford anything but the most efficient methods for organizing and implementing health care. This book is a fundamental component for fostering equitable outcomes in health and development. It will inspire all those who seek the highly complex but attainable goal of universal good health for all members of the global community.

Facilitating Progress

We all share global responsibility: governments and international agencies, public and private sectors, and society and individuals all have specific tasks. We must all strive toward more equitable distribution of the benefits of new knowledge to reduce health and development gaps between rich and poor, between countries, and within countries. The second edition of Disease Control Priorities in Developing Countries is a new step in precisely the right direction. If we succeed in conveying the main lessons and messages of this book, public health in developing countries will progress farther and faster.