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p. 7 of 27 BACK | NEXT Executive summary Introduction Regional health context Health status Major trends in the health sector Financing of health services Global commitments to the health sector The Bank’s involvementin the health sector Issues and options The Bank’s health policy

Policy for the Health Sector : Regional health context

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Major trends in the health sector

The epidemiological transition

The epidemiological transition is the shift in the burden of disease from primarily communicable illnesses, such as diarrhea, pneumonia, and tuberculosis (TB), to noncommunicable conditions such as heart attacks, depression, strokes, and cancer (see Box 3 for more information on the burden of disease). Currently, the burden of disease in the region results principally from communicable diseases, maternal conditions, and nutritional disorders. By 2020, the proportion accounted for by non-communicable diseases will nearly double to about 67 percent.¹⁰ Influencing the occurrence of noncommunicable diseases will require the encouragement of healthy behaviors such as avoidance of alcohol and drugs, consumption of a nutritious diet, regular exercise, and cessation of cigarette smoking. Tobacco consumption is high and increasing, and will have devastating health and economic consequences in the DMCs. For example, one out of every six citizens of the PRC alive today will die as a result of smoking. For the region as a whole, 11 percent of the burden of disease will be attributable to cigarette smoking by 2020.

Box 3: The Burden of Disease in the Asian and Pacific region Assessing the burden of disease requires a measure that is able to combine mortality and morbidity in a single number. The most commonly used measure of the burden of disease is the disability-adjusted life year (DALY). The advantages of employing DALYs are (i) they combine mortality, morbidity, and disability in a single measure; (ii) they reflect explicit choices about discounting future benefits, age weighing (morbidity and mortality are given maximum weight at age 22 and lesser weights at younger and older ages), and weights given to different types of disabilities; and (iii) they are an attempt to develop estimates of disease burden that are independent of advocacy efforts by groups interested in specific diseases. The major issues in using DALYs include (i) they are heavily dependent on assumptions about disease incidence in devel-oping countries, about which data are scarce and inaccurate; (ii) they incorporate many assump-tions and the overall sensitivity of the results to these assumptions is significant; and (iii) caution must be used in interpreting changes over long periods because technological advances and some epidemiological changes are difficult to predict. In spite of the difficulties in their use, DALYs can provide a broad picture of the changing burden of disease. Currently, the burden of disease in developing Asia results principally from communicable diseases such as measles, malaria, pneumonia, and diarrhea; maternal conditions; and nutritional disorders (Figure B3.1). In 1990, communicable diseases accounted for 50 percent of the DALYs lost in Asia. Noncommunicable diseases accounted for 35 percent, and injuries the remaining 15 percent. Almost half of the burden of disease (46 percent) accrued to children under five years of age in 1990. By 2020, noncommunicable diseases will account for two thirds of the burden of disease in developing Asia. Among the emerging health threats facing the Asian and Pacific region, three could be prevented by concerted action. Tobacco consumption in Asia is high and increasing. The burden of disease attributable to cigarette smoking will increase by a factor of six (Figure B3.2) between 1990 and 2020, although vigorous public efforts could reduce the threat. Similarly, tuberculosis (TB), despite the fact that it can easily be cured with available drugs, will remain a serious health threat for the poor. The burden of diseases attributable to HIV/AIDS will increase dramatically over the next two decades.

As important as the epidemiological transition is, infectious diseases will remain a critical threat to the health of all Asians. For the poor especially, communicable diseases will continue to be a major cause of mortality and morbidity. This implies that the DMCs will have to confront infectious diseases and malnutrition at the same time as they attempt to deal with chronic illnesses. Tuberculosis, for example, will not significantly decline over the next two decades and the emergence of strains of the disease that are resistant to available medicines has already occurred. The prevalence of these drug-resistant strains will increase substantially unless there is significant improvement in tuberculosis control efforts in the DMCs. The 1994 outbreak of pneumonic plague in India and the 1997 avian flu problem in Hong Kong, China are good examples of the constant health and economic dangers that infectious diseases represent to the whole of Asian society.

The threat of infectious diseases to the health of the region is best exemplified by HIV/AIDS. Its prevalence is increasing dramatically, and some of the DMCs, such as Cambodia, India, Myanmar, Thailand, and Viet Nam, are in the midst of large HIV/AIDS epidemics. Even those DMCs with low HIV prevalence will need to promote safe sexual practices through intensive health education aimed at tangible changes in behavior. A high priority for all the DMCs will be the aggressive treatment of sexually transmitted diseases (STDs) which can help prevent the dramatic spread of the disease. Transmission of HIV/AIDS through intravenous drug use also needs to be addressed if the disease is to be controlled. Like other infectious diseases, HIV/AIDS exacts a heavy toll among the most vulnerable. The poor have less access to information, are less able to afford the costs of prevention, have limited access to diagnosis and treatment, and are more financially vul-nerable when they become sick. Women appear to be at a greater biological risk than men of acquiring the infection and in many cultural settings are less able to negotiate with their partners for safer sex.

The demographic transition

Improvements in health (with consequent in-creases in life expectancy) and declining fertility in all the DMCs mean that the proportion of elderly will rapidly increase in the coming years. The proportion of the population that is over 60 years old will increase from 7.5 percent in 1990 to almost 12 percent in 2020, and the absolute number will increase from 200 million to 455 million. This rapid increase has important implications for the health policies of the Bank and its DMCs. Much of the disease burden among the elderly results from chronic, noncommunicable diseases that are difficult and expensive to treat. Indeed, almost all the shift toward noncommunicable diseases that will occur between 1990 and 2020 will be due to demographic changes. Because the elderly need more and more expensive health care, the demand for health services, and their cost, will increase dramatically as populations age. Moreover, the increase in the elderly population is being accompanied by the disintegration of family and community support systems for the aged, resulting from, among other factors, rapid urbanization and decreases in the ratio of workers to elderly dependents. With fewer traditional support systems available, DMC governments will have to begin developing mechanisms to finance health care for the elderly. The challenge in developing these mechanisms will be to ensure that they do not reduce the resources available for other priorities such as preventive health care and maternal and child health services.

Urbanization

Over the next three decades, the urban population of the region is expected to increase dramatically from 1.2 billion in 1995 to 2.5 billion in 2025 and more than 400 million will reside in cities of 10 million or more.¹¹ Available data from household surveys indicate that, on average, urban populations enjoy better health status than those in rural areas. For example, in Papua New Guinea, the IMR is 34 per 1,000 live births in the cities but 87 in the countryside, a pattern that is observed in all the countries in the region. However, this simple type of analysis hides the large disparities that exist between income classes. A study in Manila showed that the IMR was 2.8 times higher in a slum area than for nonsquatter areas. Hence, the urban poor suffer from health conditions that are significantly worse than simple rural/urban comparisons suggest.

Much of the difference in health status between the urban poor and other sectors of society results from the greater prevalence of infectious diseases due to high population densities, poor ventilation, and inadequate nutrition. For example, TB is prevalent among the urban poor because inadequate ventilation and lack of light allow the TB bacterium to survive longer in the air and spread the infection. Vaccine-preventable diseases such as polio and measles are also more prevalent in crowded cities and efforts to control these diseases will flounder if the urban slums remain as a large reservoir of infection. The urban environment also significantly contributes to the health problems of the urban poor. The lack of safe water and adequate sanitation likely results in greater prevalence of diarrhea: in the slums of Dhaka, diarrhea is twice as prevalent as it is in the rural areas of Bangladesh.12 In addition, lead and air pollution are more serious threats to city dwellers than to rural residents.

In the urban areas, people have access to a wide variety of health care pro-viders, including for-profit modern hospitals, private practitioners, pharmacies, NGOs, public sector health facilities, and traditional healers. This array of service providers compels governments to consider their role in the health sector. Given the extensive network of providers, there is a less obvious need for the public sector to be involved in the direct provision of health care, particularly for the emerging middle class. However, the public sector will still have to ensure that (i) the poor have adequate access to affordable services; (ii) there is delivery of public goods such as health education and vaccination; and (iii) there is coordination, support, and regulation of private sector activities, including the enforcement of environmental health regulations.

Technological trends in health

Technological advances in the last few years and exciting new developments on the horizon provide tremendous opportunities for the DMCs to significantly improve the health of their populations. For example, one of the outstanding successes in public health in developing countries in the last 20 years has been the advent of widespread child and maternal immunization. In the region as a whole, measles immunization coverage in 1995 reached 84 percent of children, resulting in almost 500,000 lives being saved every year. So far, immunization efforts have focused on just six diseases where low-cost vaccines are available: measles, pertussis, tetanus, diphtheria, polio, and TB. However, with advances in biotechnology, the next 10 to 15 years will witness the introduction of powerful new vaccines against some of the most important infectious diseases affecting the people of the region. The most exciting developments are occurring in vaccines against rotavirus (a major cause of diarrheal deaths in children) and pneumococci (the leading cause of pneumonia, which is the principal cause of death in children under five).

Two other promising areas of technological advance in the next decade will be easier diagnosis of important diseases and better access to information. Recent discoveries provide more accurate, inexpensive, and practical means for diagnosing illnesses, particularly infectious diseases. For example, a newly developed test can accurately make the diagnosis of the most dangerous type of malaria based on a finger-prick blood sample.¹³ This test will be of particular use in places without access to highly trained staff, well-equipped laboratories, and electricity. Information technologies may also increase policymakers’ access to high-quality information. The world wide web will increase policymakers’ physical access to information, and systematic reviews of research studies will improve the quality of the available information. For example, researchers have formed the Cochrane Collaboration¹⁴ to summarize and dis-seminate the results of trials in clinical medicine and public health. These summaries provide a powerful tool for policy analysis by allowing officials to understand the results of all relevant studies.

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