Changes in Life Expectancy, 1960-2002

By World Bank Region

Years
100

6770 6969 6871 69

6567
64 63
56 58
47 50 50
50 44 46
39 40

0
E. Asia/ Europe/ Latin M. East/ South Sub- World
Pacific Central America/ N. Africa Asia Saharan
Asia Caribbean Africa

1960 1990 2002

Note: Data for Europe/Central Asia, 1960 are not available.

Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 1.1
 Reducing Under-five Mortality
How much health will a million dollars buy?
Estimated DALYs
Cost Per DALY Averted Per Million
Service or Intervention (US$) US$ Spent
Improving care of children under 28 days
old (including resuscitation of newborns) 10-400 2,500-100,000
Expanding immunization coverage with
standard child vaccines 2-20 50,000-500,000
Adding vaccines to the standard child
immunizations (particularly Hib and HepB) 40-250 4,000-24,000
Switching to combination drugs (ACTs)
against malaria where resistance exists
(Sub-Saharan Africa) 8-20 50,000-125,000

Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 1.3.
 Preventing and Treating HIV/AIDS
How much health will a million dollars buy?
Estimated DALYs
Cost Per Averted Per Million
Service or Intervention DALY (US$) US$ Spent
Preventing mother-to-child transmission
(antiretroviral drugs for preventing mother-to-
child transmission; breastfeeding substitutes) 50-200 5,000-20,000
Treating STIs to interrupt HIV transmission 10-100 10,000-100,000
Using antiretroviral therapy that achieves high
adherence for a large percentage of patients 350-500 2,000-3,000
It is possible that more
Using antiretroviral therapy that achieves high years would be lost
adherence for a small percentage of patients than saved.*

*Due to limited gains by individuals and potential for adverse behavior changes, more years may be lost than saved.
Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 1.3
 Preventing and Treating
Noncommunicable Diseases
How much health will a million dollars buy?
Cost Estimated DALYs
Per DALY Averted Per
Service or Intervention (US$) Million US$ Spent
Taxing tobacco products 3-50 24,000-330,000
Treating heart attacks with inexpensive drugs 10-25 40,000-100,000
Treating heart attacks with inexpensive drugs plus
streptokinase* 600-750 1,300-1,600
Treating heart attack and stroke survivors for life
with a daily polypill 700-1,000 1,000-1,400
Performing coronary artery bypass surgery in high
risk cases** >25,000 <40
Using bypass surgery for less severe coronary artery
disease** Very high Very small
*Costs and DALYs are in addition to using inexpensive drugs only. **Incremental to treatment with polypill.
Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 1.3
 Cervical Cancer and
Surgically Treatable Conditions
How much health will a million dollars buy?

Cost Per Estimated DALYs Averted

Service or Intervention DALY (US$) Per Million US$ Spent
Detecting and treating cervical
cancer 15-50 20,000-60,000
Operating a basic surgical ward at
the district hospital level that focuses
on trauma, high-risk pregnancy, and
other common surgically treatable
conditions 70-250 4,000-15,000

Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 1.3
 The Burden of Disease, 2001
Low- and Middle- Income High-Income World
DALYs DALYs DALYs
(Stillbirths (Stillbirths (Stillbirths
DALYs included) DALYs included) DALYs included)
Total DALYs
(thousands) 1,387,426 1,260,643 149,161 148,316 1,536,587 1,412,600
Causes of Death (percent)
Communicable
diseases,
pregnancy
outcomes,
nutritional
deficiencies 39.8 33.6 5.7 5.4 36.5 30.5
Non-
communicable
conditions 48.9 52.4 86.7 87.2 52.6 56.4
Injuries 11.2 12.1 7.5 7.5 10.9 11.6

Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 1.A2
 Efficiency of Interventions

Cost-effective
Neglected
High interventions used
Opportunities
widely
Cost-
effectiveness
Interventions for
Low Interventions to
which scaling up is
scale back
inefficient

Low High

Current Coverage

Source: Disease Control Priorities in Developing Countries, second edition, 2006, Figure 2.1
 Definition prevention
The whole of measures – inside and outside the
framework of the health care system –
intended to protect and promote health and to
prevent disease and health problems.

The clue to prevention is the search for causes

and especially the root social causes of
disease.
 Perspectives on Prevention
• Disease category: CVD, HIV, malaria
• Risk factor: smoking, nutrition, sexual behaviour
• Method: protection, promotion, disease
prevention
• Instrument: vaccinations, screening, legislation,
treatment/profilaxis, vector control, IEC, …
• Target group: pregnant women, school children
• Scale: Individual, Collective
• Phase of intervention: primary, secundary, tertiary
prevention
 Methods of prevention
• Health protection
• helmets, water, food inspection, regulations for buildings, …
• Health promotion
• promote health lifestyle through health education (smoking,
alcohol, hygiene, nutrition habits, sports)
• reinforce compliance with treatment, info on screening,
vaccination, etc.
• stimulate good behaviour in traffic, etc
• Disease prevention
• Caries (fluoride), Measles (vacc.), Hypertension (drugs), Cervix
cancer (screening), Malaria (bednets),etc.
-------------------
Besides prevention you have:
• Curative care
• Rehabilitation and social reintegration
 Health promotion
• includes health education and the fostering of
healthy living conditions and life-styles.
• Activities are directed toward individuals,
families, groups, or entire communities,
helping people identify needs, get useful
information and resources, and take action to
achieve change.
 Health promotion
"...the process of enabling people to increase
control over, and to improve, their health. To
reach a state of complete physical, mental
and social well-being, an individual or group
must be able to identify and to realize
aspirations, to satisfy needs and to change or
cope with the environment".
Health promotion is a dynamic process that
facilitates the engagement of all people and
all groups in various social contexts.
 five main health promotion
strategies

• build healthy public policy;

• create supportive environments;
• strengthen community action;
• develop personal skills and;
• re-orient health services.
 Health protection
• control and reduce the exposure of the
population to environmental or personal
hazards, conditions, or factors that may
cause health problems.
• Health protection includes immunization,
infectious disease surveillance and outbreak
investigations, water purification, sewage
treatment, control of infectious wastes,
inspection of restaurant food services, and
numerous other activities.
 Health protection
• Road safety
• Environmental interventions
• Regulations for buildings
• Food inspections and regulations
• Drinking water
• Labour conditions
• Helmets, safety belts
• Safety packaging, regulations for toys (childeren)
 Health Promotion
• Lifestyle/behaviour
(smoking, sex, alcohol, food, personal hygiene, exercise)
• Adequate/timely use of services, compliance, participation
in vaccination or screening programs
• Compliance with rules in traffic,…

• Sometimes combined with ‘protective’ measures:

(iodisation of food, taxes on cigarettes, warning labels, alcohol
controls in traffic, )
 Phase of intervention
• Primary prevention
• Secundary prevention
• Tertiary prevention / treatment / care
• (case detection requiring case definition, diagnostic
process, treatment, case holding/ follow up)
Disease prevention: Prevention and stage of disease

Primary prevention Secundary prevention Tertiary prevention

Preclinical phase Clinical phase

First detectable First signs and

pathofysiological symptoms
changes detectable by
patient

Average Average moment

detection moment by of first visit to
screening health services by
patient
 Primary Prevention
• Intends to prevent diseases by minimizing
or taking away risk factors/determinants
• Target: ‘healthy’ population
• Determinants can be exogeneous or
endogeneous
• Contribution of factor must be known
• Effective intervention needed
 Secundary Prevention
• Early detection
• Disease can be treated in early stage
• Target: people with subclinical or
inconscient disease
• Outcome: Prevalence may first increase,
improved quality of life, prolonged life
expectancy
 Care
Tertiary prevention
• Intends to halt, reduce or compensate a state
of ill health
• Target: people who demand for care
• Outcome: quality of life or reduction in
mortality
 Primary/secundary prevention:
strategies
• Health promotion
• Vaccination
• Legislation & regulations
• Medication (profylaxis, early treatment)
• Screening / diagnostic tests
• Environmental alteration & Vector control
 Cervix Carcinoma

• Vaccination: Papilloma virus

• Microscopic smear
• Cryosurgery / surgery
 Health Policy
-Intersectoral policies (Health protection, health promotion, primary prevention): Healthy public policies
-Organisation of health care delivery
-Allocation and planning of resources
-Global aspects: Monitoring & research, Target groups, International aspects, Institutional framework

Health care delivery system / Health Sector

Rehabilitation Financing
Primary Secundary Curative Instit. care of of health
prevention prevention care elderly care system

Determinants
of health
(Culture, lifestyle,
socioeconomic factors,
Health Status of the Population
gender, genetics, ( Mortality, morbidity, quality of life,
employment, social healthy life expectancy, DALY / DALE ….)
networks,…)
 Relative risk
For individuals the appropriate measure is relative
risk; that is, risk in those exposed divided by risk
in those unexposed.
Relative risk measures the association between
disease outcome and exposure to a risk factor. It
does not reveal the proportion of disease attributable
to the factor or the magnitude of the disease in the
population.
Other forms of measurement suggest that about half the
disease in the world appears to be unrelated to risk factors.
 Risk vs Population approach
Rose’s paradox
“A large
number of people at small risk may give
rise to more cases of disease than the small
number who are at high risk”.

Rose, G.A., The strategy of preventive medicine, New York, Oxford University Press,
1992.
Is prevention always better than
cure? And cheaper?
 Examples
• Access clean water – diarrhoea
• Persuading people to stop smoking
• Safe driving
• Having more exercise
 Example of a causal web

Physical
Age Ac tivity

DM
Fat Intake

LDL-Chol CHD
BMI

DBP
Smoking

A B m arks a postulated influe nce from A to B

(McKinlay 1999, Am.J.PH)
What gets diabetes—genes, cell, organ system, individual,
or social group? (McKinlay, Marceau, THE LANCET • Vol 356 • August 26, 2000)
 Risk Factors in WHO 2002
Comparative Risk Assessment
• Malnutrition (underweight)
• Micronutrient deficiency (Zn,
Fe, Vit-A)
• Hypertension
• Cholesterol
• Obesity/BMI
• Lack of fruit & veg
• Physical inactivity
• Lack of contraception
• Unsafe sex
• Unsafe medical injection
• Childhood sexual abuse
• Tobacco (active smoking)
• Illicit drugs
• Alcohol
• Lead (Pb)
• Water/hygiene/sanitation
• Climate change
• Indoor air pollution
• Urban outdoor air pollution
• Occupational hazards (several types)
 Global Burden of Disease from Top 10 Risk Factors
plus se le cte d othe r risk factors

Underweight
Unsafe sex
Blood pressure
Tobacco
Alcohol
Unsafe water/sanitation-E*
Child cluster vaccination
Road traffic accidents
Cholesterol
Indoor smoke-E

Overweight Other environmental

Other Environmental
Low fruit and veg RiskRisk
Factors
Factors
Occupational (5 kinds)-E
Lead (Pb)-E
Urban outdoor air-E
Climate change-E

0.0% 2.0% 4.0% 6.0% 8.0% 10.0%

Percent of All DALYs in 2000
 Indian Burden of Disease from Top 10 Risk Factors
and Selected Other Risk Factors

Underw eight

Unsafe w ater/sanitation-E*

Indoor sm oke-E

Unsafe sex

Iron deficiency

Tobacco

Blood pressure

Child cluster Vaccination

Cholesterol

Road traffic accidents

Zn Deficiency Other environmental

Low fruit & veg Risk factors
Occupational (5 kinds)-E

Lead (Pb)-E

Clim ate change-E

Urban outdoor air-E

0% 2% 4% 6% 8% 10% 12% 14%

Percent of All DALYs in 2000

 Chinese Burden of Disease from Top 10 Risk Factors

Alcohol
Blood pressure
Tobacco
Road traffic accidents
Underweight
Occupational (5 kinds)-E
Indoor smoke-E
Overweight
Low Fruit & Veg
Cholesterol

Other environmental
Unsafe water/sanitation-E Risk factors
Urban outdoor air-E
Lead (Pb)-E
Climate change-E

0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0%

Percent of All DALYs in 2000
 USA Burden of Disease from T op 10 Risk Factors
Plus Selected Others

Tobacco
Alcohol
Overweight
Blood pressure
Cholesterol
Road traffic accidents
Low fruit and vegetable intake
Physical inactivity
Illicit drugs
Occupational (5 types)

Unsafe sex
Iron deficiency Environmental
Childhood sexual abuse
Risk Factors
Urban air pollution
Lead exposure
Unsafe water, sanitation and hygiene
Indoor smoke from solid fuels
Climate change
0% 2% 4% 6% 8% 10% 12% 14%

Percent of All DALYs in 2000