Death from infectious diseases in developing countries is once again soaring, not only because of the AIDS epidemic, but because of the emergence of drug-resistant strains of such diseases as TB and malaria. Communicable diseases claim more than 14 million lives a year and account for about 80 percent of the difference in life expectancy between people in rich and poor countries. Rapidly expanding international trade and travel increase the speed of transmission of new disease threats. Research is examining the economic impact of these new health dangers, assessing how some health care services—which are already failing to confront routine problems—can meet new health challenges, and estimating the cost-effectiveness of specific interventions to prevent HIV and malaria infection, treat AIDS, and slow the national and international spread of potentially devastating new epidemics.
Reversing communicable disease epidemics is one of the Millennium Development Goals. Major new global initiatives to combat infectious diseases are a welcome development challenge, but they are placing pressures on weak health care systems, posing the risk that large amounts of the additional funding
may be wasted or that critical aspects of health systems may be neglected.
For example, newly available resources for AIDS treatment from the Bank; the Global Fund for AIDS, TB, and Malaria; and the US Government’s PEPFAR program require the hardest-hit countries to immediately increase health spending per doctor by 300 to 900 times GDP per capita. It will be a
challenge to sustain HIV prevention activities and other critical health and non-health development expenditures while scaling up AIDS treatment to this degree. It is not clear whether these reallocations increase or decrease the threat of serious spillovers of disease between countries.
Assisted by the KCP, Bank research focuses on identifying ways to make health services more effective in preventing and treating communicable diseases.
Stepping up prevention
Making programs sustainable
Estimating the impact of communicable diseases
Stepping up prevention
Improving prevention services to reduce exposure to disease. Several East Asian countries have achieved rapid health transitions by emphasizing preventive services and designing incentives for effective policy implementation. In India, whose health transition has been much slower, studies show key gaps in the formulation and implementation of public health regulations, as well as in interagency coordination in service delivery. A detailed comparison of Malaysia and an Indian state will illustrate how the Bank can help clients design and implement these services more effectively.
One KCP-funded project is currently evaluating the effectiveness of malaria prevention programs in a number of diverse high-burden countries. While the causal link between use of effective anti-malaria services and improved malaria outcomes is well established, the relative effectiveness of alternative delivery mechanisms and intervention packages to induce a change in people’s health behavior is not as well understood. Furthermore, little rigorous evidence has been collected on what works, and in which contexts, to inform and sustain a process of organizational learning and evidence-based programmatic choices. It is this gap in knowledge that “Improving Malaria Outcomes through Evidence-Based Program Design “ hope to help address.
Making programs sustainable
Controlling and preventing specific threats to health requires sustainable prevention programs. Three studies have examined means of achieving greater sustainability. First, studies assessing the efficacy of different interventions against malaria and vaccine-preventable diseases noted the need to consider the effects on the overall political economy of health service delivery. They found, for example, that DDT spraying alone is more effective than bed nets alone at controlling malaria, but
that the use of bed nets reduces the need for DDT and the concomitant danger to the environment. Second, vaccination is highly cost-effective for controlling several diseases, but vaccination campaigns can be stymied and could even become counterproductive, by increasing resistance, if their donor support is reduced. A study found that Mexico’s highly successful vaccination program depended on political factors—corporatist state-society relations, presidential leadership, and a supportive international environment. A third study, looking at the establishment and sustainability of aggressive government responses to HIV/AIDS, suggests that two factors are critical: the decentralization of pre-existing political institutions and the strength of the national political community.
While appropriate policy can improve the delivery of health care and provide information on how illnesses can be prevented, research confirms that outcomes are also shaped by household circumstances and choices. Education and access (to information and to facilities) shape how households decide on whether to minimize risks of disease and what (and how much) health care to seek. (See Human Development and Service Delivery.)
Estimating the impact of communicable diseases
More threatening and less understood than AIDS and TB are the rapidly communicated respiratory illnesses like SARS or avian influenza. If not prevented or promptly controlled, an outbreak of one of these diseases could kill millions of people in the country of origin, in the region, or even worldwide.
Because such diseases can spread easily across international boundaries, by airplane passengers or migrating fowl, all countries have an interest in assuring that each implements a vigorous prevention policy. Yet without international coordination, the costs of prevention programs will be borne disproportionately by the poorest people in the poorest countries. With the assistance of the KCP, the Bank’s Development Research Group is currently investigating how various policies that are likely to be employed to contain a human influenza pandemic vary in their costs and benefits and in the distribution of these costs and benefits across countries. The perspective that will be undertaken in this research is a developing country perspective: How will policies that are likely to be undertaken by a specific developed country (either by governments or private individuals) in the event of an outbreak of avian flu likely to affect the citizens of that country, of other developed countries and of developing countries? What are the costs and benefits of various control strategies that developing countries could undertake—and how are the benefits distributed across countries?
Research on HIV/AIDS epidemic
A) HIV/AIDS Treatment
The Bank’s Africa region has launched several initiatives to accelerate the access to antiretroviral treatment (ART) for HIV/AIDS patients. In Burkina Faso, Ghana and Mozambique, the TAP (Treatment Acceleration Project) is supporting different models of public-private partnerships: ARV delivery through associations of persons living with HIV/AIDS, faith based organizations, local and international NGOs, partnerships between government hospitals and private health facilities. The Bank is also supporting ART delivery in other countries. A team in DECRG HD-PS has set-up a series of prospective impact evaluations of those programs delivering ART in the TAP countries, as well as in Rwanda, Kenya, South Africa and India. This work is done in close collaboration with and with the support of the Africa Region (Act Africa and MAP/TAP TTLs), the Global AIDS Program, the HD Vice-Presidency, and also with WHO and UNECA.
The questions addressed by these impact evaluations are
1) Measuring the impact of treatment on the welfare of patients and family members
Over and above lives saved and health outcomes, we will measure the impact on the labor supply of the patient and other family members, the schooling of children and other welfare indicators.
2) What are the effects of ART on HIV transmission and prevention?
Direction of effect
| || Beneficial|
Type of effect
|Biological||Reduce infectiousness||Select for resistance. Longer duration of infectivity|
| Behavioral|| Encourage VCT.|| Off-setting risk behavior, “disinhibition|
3) What are the determinants of treatment success? (i.e. of patient care-seeking behavior and treatment adherence; quantity and quality and of ART services)
4) How to encourage cost-effectiveness and capacity building to reinforce the sustainability of ART delivery and adherence?
We will collect longitudinally and triangulate data from biomedical records, household surveys (HIV patients and general population) as well as health facility and surveys. In some countries, we will, in addition, evaluate some experiments:
- Rwanda: performance-based contracting for HIV/AIDS services in health facilities
- South Africa: food supplement and community health workers for supporting adherence to treatment.
- Kenya: reminders by text messages for improving adherence.
B) HIV/AIDS Transmission and Prevention
This research addresses two areas: (i) understanding the patterns of HIV/AIDS transmission and (ii) the impact of programs designed to affect the incidence of HIV. See Table B. This set of research, relies on household data sources such as the Demographic Health Surveys which includes HIV status of sub-samples of respondents.
C) Socioeconomic Impact of HIV/AIDS
Research in this theme investigates the impact of HIV/AIDS on populations, economies and institutions. It also evaluates social protection mechanisms designed to mitigate the impact of the HIV/AIDS epidemic. Table C gives an overview of existing and planned research.