Evidence-based public health: what does it offer developing countries?

The global burden of disease and illness is primarily situated in developing countries. As developing countries have limited resources, it is particularly important to invest in public health and health promotion strategies that are effective. Systematic reviews are central to evidence-based public health and health promotion practice and policy. This paper discusses issues surrounding the relevance of evidence-based public health and systematic reviews to the health of developing countries. It argues that there is a lack of systematic reviews relevant to the health priorities of developing countries; many interventions reviewed can not be implemented in resource-poor situations; and, a limited amount of primary research is conducted in developing countries. The paper further argues that improvements in public health are determined not only by effective health services and interventions, but through an approach that includes other sectors and influences broader structural and systematic barriers to health. Given the social complexity of human development, and the inter-sections amongst different development goals, there is no question that gains in developing country public health are unlikely to emerge from systematic reviews alone, but will require decisions about inter-sectoral collaboration and social policy initiatives. Nonetheless, evidence around intervention effectiveness has an important role to play in addressing health priorities in developing countries and resource-poor areas. The public health evidence base urgently needs strengthening, with dedicated effort towards increasing the relevance of primary evidence and systematic reviews.     

Coverage of vaccines in private health plans: what does the public prefer?

Underinsurance for recommended vaccines in private health plans may affect 15 percent of children and more than 30 percent of adults. We conducted a nationally representative, Web-based study using health plan vignettes to determine adults' willingness to bear marginally higher plan premiums, to assure plan coverage of new vaccines as they are recommended for children and adults. Our results indicate a broad willingness (more than 75 percent of respondents) to pay the higher premiums. Such willingness was associated strongly with perceptions of vaccines' effectiveness and safety. Policymakers, physicians, and public health officials should examine health plan enrollees' preferences as they consider remedies for vaccine underinsurance.     

Achieving universal health insurance in Korea: a model for other developing countries?

As developing countries explore alternative methods to provide universal health insurance coverage, one potential model is South Korea. In twelve years (from 1977 to 1989), Korea was able to achieve universal health insurance coverage first by mandating employer based health insurance coverage for medium and large firms and then by establishing regional health insurance systems for small firms, farmers and the self-employed. A government medical aid insurance program was instituted for low income citizens. The specifics of the plan and some of the issues encountered in implementing the plan may be of interest to developing countries who want to achieve universal health insurance while maintaining a significant role for the private sector.     

Communication in health care delivery in developing countries: which way out?

Most governments in developing countries have adopted frameworks for health development which stressed community based initiatives and intervention at all levels of the health pyramid (WHO, 1992). But even today, most of the rural communities in these countries are still not developed in terms of available health facilities. What then is/are responsible for these failures? Various authors have come up with various reasons, principal amongst which are inadequate resources, lack of planning, insincerity/non-commitment of the governments, lack of modern information technology, etc. This paper examines some of these factors in relation to how they accentuate or hamper healthcare delivery in developing countries, using African rural communities as a study field. The resultant suggestions are a consortium of varying factors, some of which are economic in nature, policy changes, human resources development, and re-orientation of social and government attitudes towards achieving meaningful results in healthcare delivery, particularly in the rural communities.     

The rural bite in population pyramids: what are the implications for responsiveness of health systems in middle income countries?

Background

Health services can only be responsive if they are designed to service the needs of the population at hand. In many low and middle income countries, the rate of urbanisation can leave the profile of the rural population quite different from the urban population. As a consequence, the kinds of services required for an urban population may be quite different from that required for a rural population. This is examined using data from the South East Asia Community Observatory in rural Malaysia and contrasting it with the national Malaysia population profile.

Methods

Census data were collected from 10,373 household and the sex and age of household members was recorded. Approximate Malaysian national age and sex profiles were downloaded from the US Census Bureau. The population pyramids, and the dependency and support ratios for the whole population and the SEACO sub-district population are compared.

Results

Based on the population profiles and the dependency ratios, the rural sub-district shows need for health services in the under 14 age group similar to that required nationally. In the older age group, however, the rural sub-district shows twice the need for services as the national data indicate.

Conclusion

The health services needs of an older population will tend towards chronic conditions, rather than the typically acute conditions of childhood. The relatively greater number of older people in the rural population suggest a very different health services mix need. Community based population monitoring provides critical information to inform health systems.

     

Can developing countries achieve adequate improvements in child health outcomes without engaging the private sector?

The private sector exerts a significant and critical influence on child health outcomes in developing countries, including the health of poor children. This article reviews the available evidence on private sector utilization and quality of care. It provides a framework for analysing the private sector's influence on child health outcomes. This influence goes beyond service provision by private providers and nongovernmental organizations (NGOs). Pharmacies, drug sellers, private suppliers, and food producers also have an impact on the health of children. Many governments are experimenting with strategies to engage the private sector to improve child health. The article analyses some of the most promising strategies, and suggests that a number of constraints make it hard for policy-makers to emulate these approaches. Few experiences are clearly described, monitored, and evaluated. The article suggests that improving the impact of child health programmes in developing countries requires a more systematic analysis of how to engage the private sector most effectively. The starting point should include the evaluation of the presence and potential of the private sector, including actors such as professional associations, producer organizations, community groups, and patients' organizations.     

Health maintenance organizations in developing countries: what can we expect?

Health maintenance organizations (HMOs) are a relatively new and alternative means of providing health care, combining a risk-sharing (insurance) function with health service provision. Their potential for lowering costs has attracted great interest in the USA and elsewhere, and has raised questions regarding their applicability to other settings. Little attention, however, has been given to critically reviewing the experience with HMOs in other countries, particularly concerning their introduction to settings other than the USA. This paper first reviews the current experience of HMOs in low- and middle-income countries, including Argentina, Bolivia, Brazil, Colombia, Ecuador, Uruguay, Chile and Indonesia. Secondly, the paper reviews the USA experience with HMOs: prerequisites for the establishment of HMOs in the USA are identified and discussed, followed by a review of the performance of HMOs in terms of cost containment, integration of care and quality of care for the elderly and poor. The analysis concludes that difficulties may arise when implementing HMOs in developing countries, and that potential adverse effects on the overall health care delivery system may occur. These should be avoided by careful analyses of a nation's health care system.     

Ethical oversight of public health research: can rules and IRBs make a difference in developing countries?

Controversies in the conduct of international research continue to pose challenges for the system of ethical review, particularly for developing countries. Although the concept of vulnerability is key to addressing these challenges, ethical review has typically ignored the agency of vulnerable participants and groups in determining what kind of review process is needed. Concurrent with developments shaping the new public health that seek to operationalize empowerment of communities by placing them as initiators and organizers of their own health, ethical review of public health research must find ways to recognize the agency of vulnerable individuals, groups, and communities in the review process if it is to address effectively the ethical dilemmas currently evident in collaborative international research.     

Alcohol control and urban livelihoods in developing countries: can public health aspirations and development goals be reconciled?

This commentary explores how household economic necessity and the public health aspirations set out in the WHO’s global strategy to reduce the harmful use of alcohol might be reconciled in the context of alcohol control in developing countries. The ‘ambiguity’ of alcohol’s role in social and economic development is clear, but, as yet, little progress has been made on how best to integrate alcohol control within development policies in low- and middle-income countries. Without this holistic thinking, alcohol control efforts are likely to be thwarted by liquor’s allure as an accessible micro-enterprise opportunity. Similarly, developmental efforts will be undermined by the severity of alcohol-related harms that now disproportionately affect middle-income countries. Drawing on the example of South Africa, this short commentary explores the complexities of controlling the supply of alcohol when its sale represents a major livelihood strategy amid conditions of high unemployment and constrained access to formal employment markets. The policy preference for closing illegal bars or shebeens in South Africa does not address the ‘causes of the causes’ of why people drink, and therefore why its sale continues to be an attractive livelihood choice. It also does little to provide alternative leisure or employment opportunities, which ultimately threatens the longer term sustainability of policy. We need to better appreciate why selling alcohol is a seductive business opportunity and the potential consequences of this for realising public health aspirations.