Population and family planning: an international perspective

Since the 1960s, the U.S. government has supported population and family planning programs in Third World countries, on the grounds that rapid population growth impairs the ability of those countries to develop economically; family planning programs contribute to fertility decline; and such programs help improve the health of mothers and children. Although the United States remains the largest single donor of funding for international population programs, its support has weakened during the eight years of the Reagan administration and patterns of funding for those programs have changed substantially. Since the 1960s, however, contraceptive use has increased in the Third World and fertility has fallen substantially. The decline has been uneven, though--considerable in some countries, moderate in others but very small in many. The performance of family planning programs around the world has varied widely, and questions remain as to what, if anything, can be done to increase success. For the future, three aspects of population and fertility control in developing countries merit special attention: the supply of contraceptive commodities going to family planning programs; the maintenance and strengthening of the family planning infrastructure; and the need to examine the policy implications of differing patterns of fertility and population growth for national development and individual well-being.     

Containing the spread of HIV infection: a world health priority

The World Health Organization (WHO) estimates that the world total of AIDS cases will reach 300,000 by the end of 1988 and 500,000 to 3 million over the next 5 years. AIDS is of special concern to developing countries with their limited, stressed health care systems and the other serious health problems of their populations. Also, AIDS usually strikes the young and productive adults that the economies of these countries can least afford to lose. The Surgeon General of the Public Health Service has challenged the United Nations to make the world's blood supply safe by 1991. Private and public sector leaders could come together, apply the technology and resources available in industrialized countries, and achieve a victory in this facet of the AIDS pandemic. The WHO's global strategy has led to the establishment of national AIDS committees in 151 countries and the preparation of 70 short-term (6-12 months) plans and 25 medium-term (3-5 years) plans for national AIDS control programs.     

Developing applied medical anthropology in Third World countries: problems and actions.

Recognition of the usefulness of ethnographic research in Third World community health projects and programs developed rapidly during the 1980s. As a result, the various agencies and organizations promoting community health programs (UNICEF, WHO, NGOs) have greatly increased their recruiting of social scientists, particularly medical anthropologists, for research and other programmatic activities in primary health care, child survival (especially diarrhea, acute respiratory infections, maternal and child nutrition, infectious disease, and AIDS). However, it has proved very difficult to identify well-trained anthropologists and/or other social scientists for these roles, particularly in Third World countries. This paper examines some of the background of this problem, and presents examples of methodological training (in both qualitative and quantitative research techniques) that seek to increase the skills of social scientists and other researchers in the arena of international community health.     

World Health Organization global oral health strategies for oral health promotion and disease prevention in the twenty-first century

Despite great improvements in oral health in the past decades, oral disease remains a major public health problem worldwide. The burden of oral disease is particularly high among the disadvantaged population groups in both developing and developed countries. The pattern of oral disease reflects distinct risk profiles across countries that are related to living conditions, lifestyles, environmental factors, and the availability and accessibility of oral health services. In several developing countries, people at large do not benefit from preventive oral health programmes. It is expected that the incidence of dental caries will increase in the near future in many of these countries as a result of growing consumption of sugars and inadequate exposure to fluorides. With the rising use of tobacco in developing countries, the risk of periodontal disease, tooth loss and oral cancer may therefore increase. Several oral diseases are linked to non-communicable chronic diseases or conditions that share common risk factors, such as diabetes, obesity and cancer. Similarly, general diseases often have oral manifestations (e.g. diabetes or HIV/AIDS). Worldwide strengthening of public health programmes through implementation of effective oral disease prevention measures and health promotion is urgently needed, and use of common risk factors approaches should integrate oral health within national health programmes. The challenges to oral health improvement are particularly high in developing countries. The World Health Organization Global Oral Health Programme formulates policies and actions for the improvement of oral health, strategies that are fully integrated with chronic disease prevention and general health promotion. At the 60th World Health Assembly in 2007, the WHO Member States agreed on an action plan for oral health and integrated disease prevention, thereby confirming the approach of the Oral Health Programme. The policy forms the basis for future development of oral health programmes.     

HIV / AIDS in South-East Asia: an update

As of July 1, 1996, 1,393,649 cumulative AIDS cases in adults and children had been reported to the World Health Organization (WHO) from 193 countries since the beginning of the pandemic. HIV infection is a serious public health and developmental problem in southeast Asia, with the WHO estimating more than 3.7 million people to be infected with HIV in the region. This infection extends into the general population and is not confined among people who practice high risk behaviors. As of July 1, 1996, Thailand, India, and Myanmar had reported the largest number of AIDS cases: 41,230, 2940, and 1093, respectively. However, WHO estimates that 2.5 million people are actually infected in India, 800,000 in Thailand, 350,000 in Myanmar, and 95,000 in Indonesia. While Bhutan and North Korea have not yet reported AIDS cases, people in Bhutan have been diagnosed with HIV infection. The health and socioeconomic impact of HIV/AIDS, national plans and programs, the 100% condom use program in Thailand, peer education among sex workers in Calcutta, WHO support for country responses, advocacy and support, promoting appropriate HIV prevention strategies and interventions, HIV/AIDS care as part of primary health care, HIV/AIDS and STD surveillance, and the future role of WHO are discussed.     

Maternal mortality: a problem whose time has come

This article discusses the prevention of maternal deaths in developing countries through the use of contraception. High risk women (those younger than 18, those 35 or older, or those with 4 or more children) have usually been the focus of such efforts. The author argues however that family planning programs which are not focused on any particular age or parity group may actually be more effective. Most women probably use contraceptives to limit family size or for spacing purposes, not to avoid dying in childbirth. In the World Fertility Survey, about 4 in 10 married, fecund women said they wanted no more children, yet 7 in 10 were not using an effective method of contraception. If all these women were able to avoid unwanted pregnancies, an estimated 3 out of 10 maternal deaths could be averted. Other reasons concentrating on certain age or parity groups may be inappropriate include: 1) high risk women have lower birth rates; therefore the majority of maternal deaths may actually occur among "low risk" women, 2) many women wish to stop having children before they reach age 35 or have 4 children, 3) illicit abortions are a major cause of death in developing countries; therefore any unwanted pregnancy is high risk, 4) some women genuinely want more children although they have 4 or more, or are 35 or older, and, 5) confining attention to the usual high risk groups encourages an inappropriately clinical view of contraceptives. The main conclusion is that making family planning services available and accessible to all women is one of the ways which must be used to prevent maternal deaths in the Third World.     

The reach and impact of social marketing and reproductive health communication campaigns in Zambia

Background  

Like many sub-Saharan African countries, Zambia is dealing with major health issues, including HIV/AIDS, family planning, and reproductive health. To address reproductive health problems and the HIV/AIDS epidemic in Zambia, several social marketing and health communication programs focusing on reproductive and HIV/AIDS prevention programs are being implemented. This paper describes the reach of these programs and assesses their impact on condom use.     

Strengthening public health surveillance and response using the health systems strengthening agenda in developing countries

There is increased interest in strengthening health systems for developing countries. However, at present, there is common uncertainty about how to accomplish this task. Specifically, several nations are faced with an immense challenge of revamping an entire system. To accomplish this, it is essential to first identify the components of the system that require modification. The World Health Organization (WHO) has proposed health system building blocks, which are now widely recognized as essential components of health systems strengthening.With increased travel and urbanization, the threat of emerging diseases of pandemic potential is increasing alongside endemic diseases such as human immunodeficiency virus (HIV), tuberculosis (TB), malaria, and hepatitis virus infections. At the same time, the epidemiologic patterns are shifting, giving rise to a concurrent increase in disease burden due to non-communicable diseases. These diseases can be addressed by public health surveillance and response systems that are operated by competent public health workers in core public health positions at national and sub-national levels with a focus on disease prevention.We describe two ways that health ministries in developing countries could leverage President Obama's Global Health Initiative (GHI) to build public health surveillance and response systems using proven models for public health systems strengthening and to create the public health workforce to operate those systems. We also offer suggestions for how health ministries could strengthen public health systems within the broad health systems strengthening agenda. Existing programs (e.g., the Global Vaccine Alliance [GAVI] and the Global Fund Against Tuberculosis, AIDS, and Malaria [GFTAM]) can also adapt their current health systems strengthening programs to build sustainable public health systems.     

The Safe Motherhood Initiative: a call for action

An official call for action was issued at the end of the conference on Safe Motherhood held in Nairobi, Kenya, in February 1987. The conference was organized to draw attention to the half million maternal deaths that occur each year. Women in developing countries run 50-100 times the risk of dying in pregnancy or childbirth than their counterparts in developed countries. There are only 2.9 maternal deaths/100,000 live births in developing countries compared to 300-1000 maternal deaths/100,000 live births in developing countries. Illegal abortion from unwanted pregnancies accounts for 25-50% of these deaths. The causes of maternal mortality are rooted in the adverse social, cultural, economic, and political environment women face in the Third World. These causes must be addressed if women's health and status are to be improved in the long term. On the other hand, there is an immediate need for low-cost, effective interventions that can have a major impact on reducing mortality and morbidity from obstructed labor, hemorrhage, toxemia, infection, and complications of abortion. A political commitment must be generated to reallocate resources so that maternal mortality can be reduced by 50% in 1 decade. Needed is an integrated approach to maternal health care that makes it a priority within the context of primary health care services and overall development policy. Women need to be involved in planning and implementing programs and policies to ensure that their needs and preferences are taken in account. In addition, family planning and family life education programs need to be expanded and made socially, culturally, financially, and geographically accessible. These activities need to involve both governments and take advantage of the flexibility, responsiveness, and creativity of nongovernmental organizations.     

To achieve "health for all" we must shift the world's paradigm to "primary care access for all".

Since the early 1950s, the World Health Organization has proposed programs to promote primary health care around the world. From the 1978 Alma-Ata Declaration to the current promulgation of the Millennium Development Goals, the World Health Organization has tried to improve health in developing countries through a focus on disease-oriented (vertical) programs. The World Health Organization and other organizations have not focused on the horizontal role of primary care. The expectations created by these programs have not been met. Evidence demonstrates that the advent of health care through a base of primary care improves health better than through the traditional vertical disease-oriented health programs used around the globe. The global "family" of family medicine must advocate for a shift from the current solutions to one in which the family doctor is part of a well-trained health care team that can function in networks that incorporate the vertical programs into a broad horizontal approach for better access to primary care. Perhaps in this way "health for all" can be achieved.     

The spread of AIDS

At a panel on Acquired Immune Deficiency Syndrome (AIDS) and the 3rd world in January 1988, experts focused on the profound problems generated by the AIDS pandemic. The World Health Organization (WHO) estimates that 3-5 million people in at least 127 countries now suffer from AIDS and that this figure will reach 10-30 million by 2000. The disease represents a highly debilitating force, both socially and economically, even in nations able to afford the approximately $6000/patient cost per year of treating AIDS patients. Panelists suggested that this could prove devastating for the poorer nations. WHO's AIDS program, launched in February 1987, focuses on the development and support of national AIDS control programs. It now operates in 93 countries, and 34 more countries are scheduled to join in 1988. WHO has assisted another 58 countries with shortterm AIDS action plans. The US Agency for International Development has developed a 2-pronged strategy for curbing the pandemic with prevention-emphasis programs operating under WHO.     

Rural health around the world: challenges and solutions

Despite the huge differences between developing and developed countries, access is the major issue in rural health around the world. Even in the countries where the majority of the population lives in rural areas, the resources are concentrated in the cities. All countries have difficulties with transport and communication, and they all face the challenge of shortages of doctors and other health professionals in rural and remote areas. Many rural people are caught in the poverty- ill health-low productivity downward spiral, particularly in developing countries. Since 1992, WONCA, the World Organization of Family Doctors, has developed a specific focus on rural health through the WONCA Working Party on Rural Practice. This Working Party has drawn national and international attention to major rural health issues through World Rural Health Conferences and WONCA Rural Policies. The World Health Organization (WHO) has broadened its focus beyond public health to partnership with family practice, initially through a landmark WHO-WONCA Invitational Conference in Canada. From this has developed the Memorandum of Agreement between WONCA and WHO which emphasizes the important role of family practitioners in primary health care and also includes the Rural Health Initiative. In April 2002, WHO and WONCA held a major WHO-WONCA Invitational Conference on Rural Health. This conference addressed the immense challenges for improving the health of people of rural and remote areas of the world and initiated a specific action plan: The Global Initiative on Rural Health. The "Health for All" vision for rural people is more likely to be achieved through joint concerted efforts of international and national bodies working together with doctors, nurses and other health workers in rural areas around the world.     

The global epidemiology of the HIV/AIDS pandemic and its projected demographic impact in Africa.

The global epidemiology of HIV/AIDS has evolved to the point that the pandemic now predominantly affects heterosexuals, especially in developing countries. This article summarizes the status of the HIV/AIDS pandemic as of the early 1990s; provides estimates and short-term projections of AIDS mortality in a hypothetical country of sub-Saharan Africa; projects the potential demographic impact of AIDS in a hypothetical sub-Saharan country; and describes the major problems associated with modelling the long-term demographic impact of this pandemic. Estimated AIDS cases and deaths up to 1992 were extrapolated from public health surveillance data and through use of the WHO model. Estimates of HIV seroprevalence were based on available HIV serological data. For developed countries, HIV estimates developed by national experts and/or national AIDS programmes were used, and for developing countries estimates by regional experts were used or were prepared by WHO. For the first half of the 1990s, projections of AIDS cases and deaths were derived from the WHO model; beyond the mid-1990s, the potential effects of AIDS on selected demographic indicators were derived from a demographic projection model developed by the World Bank. Although estimates and long-term projections cannot be made with great precision, the general dimensions of the HIV/AIDS pandemic have been more clearly delineated now at the start of its second decade. Epidemiological data indicate that in industrialized countries, where extensive spread of HIV began in the late 1970s or early 1980s, the majority of HIV infections occurred during the first half of the 1980s.(ABSTRACT TRUNCATED AT 250 WORDS)     

The changing role of the World Bank in global health

The World Bank began operations on June 25, 1946. Although it was established to finance European reconstruction after World War II, the bank today is a considerable force in the health, nutrition, and population (HNP) sector in developing countries. Indeed, it has evolved from having virtually no presence in global health to being the world's largest financial contributor to health-related projects, now committing more than $1 billion annually for new HNP projects. It is also one of the world's largest supporters in the fight against HIV/AIDS, with commitments of more than $1.6 billion over the past several years. I have mapped this transformation in the World Bank's role in global health, illustrating shifts in the bank's mission and financial orientation, as well as the broader changes in development theory and practice. Through a deepened understanding of the complexities of development, the World Bank now regards investments in HNP programs as fundamental to its role in the global economy.     

AIDS treatment in Africa: the risk of antiretroviral resistance

--In recent years, implementation of antiretroviral therapy in developing countries with a high prevalence of HIV-1 has been recognised as a public health priority. Consequently, the availability ofantiretroviral combination therapy for people with HIV is increasing rapidly in sub-Saharan Africa. --HIV treatment programmes are implemented according to the standardised, simplified public health guidelines developed by the World Health Organization (WHO). --However, the implementation of treatment programmes in Africa is hindered by several factors, including the lack of adequate immunological and virological laboratory monitoring, insufficient support for adherence to therapy, vulnerable health care systems and the use of suboptimal drug combinations. --These suboptimal treatment conditions increase the risk that resistant virus strains will emerge that are less susceptible to standard first-line combination therapy, thus threatening the long-term success of the treatment programmes. --The WHO has initiated HIVResNet, an international expert advisory board that has developed a global strategy for surveillance and prevention of antiretroviral drug resistance. --The Dutch initiative known as 'PharmAccess African studies to evaluate resistance' (PASER) is contributing to this strategy by creating a surveillance network in sub-Saharan Africa.     

非传染性疾病全球防控中世界卫生组织的行动及作用

非传染性疾病是当前全球面临的主要健康挑战,是世界卫生组织关注的核心议题之一。随着人口老龄化加剧,中等和低收入国家面临着传染病和非传染性疾病的双重负担,给卫生体系造成严重压力。本文通过梳理世界卫生组织推动非传染性疾病全球防控的行动,总结其发挥的作用及面临的挑战,为全球范围内制定非传染病防控策略提出建议。     

Field experiences integrating family planning into programs to prevent mother-to-child transmission of HIV

This article reviews field experiences with provision of family planning services in prevention of mother-to-child transmission (PMTCT) programs in ten countries in Africa, Asia, and Latin America. Family planning is a standard component of most antenatal care and maternal-child health programs within which PMTCT programs are offered. Yet PMTCT sites often miss opportunities to provide HIV-positive clients with family planning counseling. Demand for family planning among HIV-positive women varies depending on the extent of communities' openness about HIV/AIDS, fertility norms, and knowledge of PMTCT programs. In Kenya and Zambia, no differences were observed in use of contraceptives between HIV-positive and HIV-negative women in the study communities, but HIV-positive women have more affirmative attitudes about condoms and use them significantly more frequently than do their HIV-negative counterparts. In the Dominican Republic, India, and Thailand, where HIV prevalence is low and sterilization rates are high, HIV-positive women are offered sterilization, which most women accept. This article draws out the policy implications of these findings and recommends that policies be based on respect for women's right to informed reproductive choice in the context of HIV/AIDS.     

Population growth-a menace to what?

Originally, many of the initiators of the World Population Conference, which took place in Bucharest in 1974, had hoped that the Conference would imply a final breakthrough for the view that family planning measures should be given top priority in all less-developed countries. In fact, however, the Plan of Action passed by the Conference contains very little relating to population and family planning. Instead, the document is dominated by wordy phrases about the necessity of attaining social and economic development in those countries. Will the insight that family planning programs work efficiently only if they are an integral part of programs for the social and economic development of a country lead to such programs being realized? There is every reason to doubt that the plan of Action will have any such effect. The reasons for the underdevelopment of Third World countries cannot be removed through such United Nations resolutions. In the People's Republic of China, family planning is widely accepted, especially in the towns, and now also among the rural population. Limiting the number of children is considered part of China's development effort. China is a less-developed country that is in the process of rapid social and economic development. The issue at stake in other Third World countries is how to achieve a similar development. As soon as this goal is achieved, family planning efforts are meaningful and have a chance of success. The experience of China demonstrates that even there it took time before the efforts succeeded. There are many Third World countries that could, without much difficulty, support a population considerably larger than the present one. But there are no doubt also a number of countries where the population is already so large that a continued population increase would be harmful. The need to achieve rapid development becomes increasingly urgent, not in the least to make it possible to attain a reduced population growth. The sad truth is that so little development takes place in those countries. Without social and economic development, the present rapid population increase will continue in those countries where there is already an overly dense population.     

Health and economic impact of rotavirus vaccination in GAVI-eligible countries

Background  

Rotavirus infection is responsible for about 500,000 deaths annually, and the disease burden is disproportionately borne by children in low-income countries. Recently the World Health Organization (WHO) has released a global recommendation that all countries include infant rotavirus vaccination in their national immunization programs. Our objective was to provide information on the expected health, economic and financial consequences of rotavirus vaccines in the 72 GAVI support-eligible countries.     

A fundamental shift in the approach to international health by WHO, UNICEF, and the World Bank: instances of the practice of "intellectual fascism" and totalitarianism in some Asian countries.

Navarro has used the term "intellectual fascism" to depict the intellectual situation in the McCarthy era. Intellectual fascism is now more malignant in the poor countries of the world. The Indian Subcontinent, China, and some other Asian countries provide the context. The struggles of the working class culminated in the Alma-Ata Declaration of self-reliance in health by the peoples of the world. To protect their commercial and political interests, retribution from the rich countries was sharp and swift, they "invented" Selective Primary Health Care and used WHO, UNICEF, the World Bank, and other agencies to let loose on poor countries a barrage of "international initiatives" as global programs on immunization, AIDS, and tuberculosis. These programs were astonishingly defective in concept, design, and implementation. The agencies refused to take note of such criticisms when they were published by others. They have been fascistic, ahistorical, grossly unscientific, and Goebbelsian propagandists. The conscience keepers of public health have mostly kept quiet.