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In three editions, CGD authors showcase more than 30 rigorously evaluated case studies of successful interventions, upending conventional pessimism about public health challenges in developing countries and drawing broad lessons about what works in global health. With a foreword by Bill Gates, Millions Saved is a key resource for health policy decision makers, implementers and students worldwide.
Cement is poured, and children in Mexico have less diarrhea. Acetic acid is applied, and cervical cancer claims the lives of fewer women in India. Poor households receive regular cash transfers in South Africa, and girls reduce sexual activity. These are a few cases in which large-scale efforts to improve health in low and middle-income countries have succeeded, and are among a new generation of success stories that CGD and the Disease Control Priorities Network (DCPN) will feature in the third edition of Millions Saved, set for release in 2015.
This is the first blog in a series of two. Read the second here. This is a joint post with Miriam Temin. Miriam is coordinating editor for the new edition of Millions Saved.
After a comprehensive literature review, expert consultations, public calls for proposals, and advisory group meetings, we’ve mostly decided on a short list of cases for the new edition of Millions Saved—a book of case studies that document global health successes at scale. Selected interventions range from helmet laws to universal health coverage programs—but one of the most well-known global health efforts of the last decade, malaria control, hasn’t made our list -- at least not yet (for more on what did make the list, check back here in the coming months).
The sudden death of World Health Organization director general Lee Jong-wook at the start of the World Health Assembly has created a leadership vacuum at a time when the WHO faces immense challenges. Ruth Levine, who heads CGD's Global Health Policy Research Network, argues that the WHO leadership must become more independent so that science can shape public health policies and practice.
Q: What is the most pressing challenge facing the WHO today?
A: The WHO needs to figure out its place within an increasingly complicated group of funders, technical agencies, and advocacy voices in global health. The WHO is far from being the single authoritative voice or influence in the field and it weakens itself when it tries to do too much. It should focus on strengthening technical expertise around what might be called regional and global public goods: surveillance of infectious diseases, with transparent global reporting; stimulating investment in neglected diseases; and generating sound scientific knowledge about how to implement public health programs with broad social benefits.
Q: In your blog post on Lee Jong-wook's sudden death you urged greater independence in the leadership of the WHO. What do you mean by independence, and how can it be assured?
A: The WHO is severely hampered by a budget inadequate to its mandate and a staffing arrangement in which key positions are year-to-year appointments. Governance of the organization is fundamentally and explicitly political: the organization is responsible to ministers of health, who tend to be politicians, not people with deep technical expertise. Of course, there are notable exceptions, but by and large the organization is governed by a political body. Because of this, WHO seems to be in a perpetual cycle of trying to raise resources for programs that might be attractive to one or another interest group, but might not really be the most important to achieve better health. The WHO also faces intense scrutiny about some of its decision making – for example, how it recommends and pre-qualifies pharmaceutical products for use in developing countries - and has not always been able to be clear about the rules of the game. It’s almost as if the U.S. Centers Disease Control and Prevention or the FDA were directly managed by the U.S. Congress. The WHO would be stronger with a more arms-length relationship between the governing bodies and the technical work of the organization.
Q: How will the new director general of the WHO be selected?
A: According to the WHO Constitution, the director general is appointed by the World Health Assembly on the nomination of a 32-member Executive Board. The member states vote and in the past there has been lots of politics and horse-trading. As in the other international organizations where governance and leadership have been criticized, the process would be better if it were more truly merit-based rather then reflecting which region’s turn it is and other political considerations.
Q: What personal characteristics do you think are most important in the future leader of the WHO?
A: A strong commitment to science and evidence, and an ability to be politic without being political; that is, somebody who understands issues of national sovereignty and the sensitivities of different interest groups without subjugating technical decisions to such considerations.
Q: What can ordinary people do to help ensure that Dr. Lee’s successor will be adequate to these challenges?
A: The selection of the next director general will be decided by member countries' ministers of health. In the U.S. context this means Secretary of Health and Human Services, Mike Leavitt, who is currently in Geneva for the World Health Assembly. (Note: Staff in Sec. Leavitt’s office told CGD they are not authorized to give out his e-mail. They suggested that Americans interested in the U.S. role in the selection of the next director general of the WHO fax him at (202) 690-7203.)
The central objective of the "What Works?" Working Group is to document a series of implementation experiences in international health that are judged to be successful using a high standard of evidence. The working group has closely examined possible international public health "success stories." Of the sixty success cases submitted by Disease Controls Priorities Project authors, only twenty cases were selected.
Each case met the following criteria (and had sufficient evidence base):
Sustainability of at least five years
Intention to address a health concern of importance (judged by burden of disease estimates)
Impact (generally judged by disability-adjusted life years)
Polio elimination (The Americas) A region-wide polio elimination effort led by the Pan American Health Organization reached almost every young child in the Americas, eliminating polio as a threat to public health in the Western Hemisphere.
Hib vaccination (Chile and the Gambia) A national Hib vaccination program in Chile reduced the disease prevalence by 90 percent. In 1997, the Gambia introduced Hib vaccines (donated by Aventis Pasteur) into their national immunization program and has virtually eliminated the disease from the country.
Smallpox eradication (Global) A massive global effort spearheaded by the World Health Organization led to the eradication of smallpox in 1977, and inspired the creation of the Expanded Programme on Immunization that continues today.
Measles Immunization (Southern Africa) Measles vaccination campaigns in seven African countries has virtually eliminated measles as a cause of childhood death in southern Africa, and has helped reduce the number of measles cases from 60,000 in 1996 to just 117 four years later.
Onchocerciasis (West Africa) The multi-partner, well-organized international effort delivered Merck’s donated “miracle drug” to dramatically reduce the incidence and impact of the blinding parasitic disease, and to increase the potential for economic development in large areas of rural West Africa.
Chagas disease control (Southern Cone) Through surveillance, environmental vector control and house spraying, a regional initiative has helped Argentina, Bolivia, Brazil, Chile, Paraguay, Uruguay, and Peru decreased the disease burden of Chagas disease.
Trachoma (Morocco) Incidence of trachoma, the leading preventable cause of blindness, has been cut by more than ninety percent in Morocco through a combined strategy of surgery, antibiotics, face washing and environmental controls.
Malaria control/ITNs (Tanzania) A social marketing campaign has dramatically increased the use of insecticide-treated bednets in rural Tanzania and has increased child survival by nearly one-third.
Guinea worm control (SubSaharan Africa) A highly targeted, multi-partner eradication effort focused on behavior change has resulted in the reduction of guinea worm disease prevalence by 98 percent in the twenty endemic African and Asian countries. The program’s success has placed guinea worm in line to be only the second disease to be eradicated.
DOTS/ TB control (China, Peru) A ten-year World Bank funded TB program in China implemented a well-executed intensive short-course chemotherapy (using DOTS approach) that reduced TB prevalence by 40 percent in half of China’s provinces and dramatically improved the cure rate. Likewise, a national TB program in Peru halved TB deaths.
Oral rehydration therapy (NE Brazil) In impoverished Northeast Brazil, the widespread use of oral rehydration therapy cut child deaths due to diarrheal disease from 13 to 4 percent.
HIV control program (Thailand) In Thailand, the government’s “100% Condom Program” targeted at commercial sex workers and other high-risk groups helped prevent the spread of HIV/AIDS relatively early in the course of the epidemic. Thanks to the program’s success in promoting condom use among sex workers, Thailand had 80 percent fewer new cases of HIV in 2001 than in 1991 and has averted nearly 200,000 new cases. Cataract surgery (India) The introduction and widespread use of new surgical technique prevented the loss of sight to cataracts in India, improving success rates from about 10 to 90 percent.
Integrated nutrition intervention (Bangladesh) A World Bank-financed program targeting poor, malnourished children in Bangladesh encompassed multiple elements – education, supplementation, growth monitoring and others – and has reduced severe malnutrition in children under five from 13 to 1 percent.
Salt fortification (China, Madagascar) China’s introduction of iodized salt has significantly reduced the incidence of iodine-deficiency disease (particularly goiter among children, from 20 to 9 percent) and created a sustainable system of private provision of fortified salt.
Safe motherhood (Sri Lanka) Despite relatively low levels of national income and health spending, Sri Lanka’s commitment to providing a range of “safe motherhood” services has led to a decline in maternal mortality from 486 deaths per 100,000 live births to 24 deaths per 100,000 live births over four decades.
Family planning (Bangladesh) In Bangladesh, strong leadership of the family planning program, a sustained outreach strategy and a focus on access to services brought about increases in contraceptive prevalence from 3 to 54 percent (and corresponding decreases in fertility from 7 to 3.4 children per woman) over two decades, far in excess of what would have been predicted based on changes in economic and social conditions alone.
Use of fluoride (Jamaica) Between 1987 and 1995 Jamaica’s National Salt Fluoridation Program demonstrated up to an 87 percent decrease in dental caries in school children and has been regarded as a model for micronutrient interventions.
Tobacco control (Poland, South Africa) Starting in the early 1990’s, the transition to a market economy and a more open society paved the way for health advocates to implement strong tobacco controls in Poland, a country that had the highest rates of tobacco consumption in the world. In South Africa, an increase in taxes on cigarettes is credited with causing a significant reduction in smoking, from 50% in 1990 to 42 percent in 1998.
Overall child health through conditional cash grants (Mexico’s PROGRESA/Oportunidades) Since 1997, Mexico’s PROGRESA program has provided a comprehensive package of nutritional interventions to rural communities through a conditional cash grants program, resulting in lowered rates of illness and malnutrition and increased school enrollment.
Since 2004, the Center for Global Development has been collecting success stories in global health – remarkable cases in which large-scale efforts to improve health in developing countries have succeeded – and releasing them in the book Millions Saved: Case Studies in Global Health (now printed in two editions, with a third edition expected in 2015).