WORLD HEALTH ORGANIZATION ⑦he WORLD HEALTH REPORT 999 Caking a Difference
Making a Difference The W ORLD HE ALTH R EPORT 1999 WORLD HEALTH ORGANIZATION
WHO Library Cataloguing in Publication Data world health report 1999: Making a difference 1. World health- trends 2. Health priorities 3. Cost of illne: 4. Health services accessibility 5. Social justice 6. Fover 7. Forecasting 8. Mortality-trends 9 Malaria- prevention and control 10. Smoking- prevention and control 11. World Health Organization I.Title: Making a difference IsBN 92 4 1561947(NLM Classification: WA 540.1) ISSN1020-331 The World Health Organization welcomes requests for permission to or translate its publications, in part or in full Applications and enquiries should be addressed to of Publications, World Organization, 1211 Geneva 27, Switzerland, which will be glad to the latest information hanges made to the text, plans for new editions, and reprints and translations already available Al orld Health Organization 1999 The designations employed and the presentation of the material in this publication, including tables and Healey do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World ountry, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate bor- der lines for which there may not yet be full agreement The mention of specific companies or of certain manufacturers products does not imply that they endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned Errors and omissions excepted, the names of proprietary products are distinguished by blication can be obtained World Health Report 1211 Geneva 27. Switzer rland Fax(41-22)7914870 Thomson Prentice, with the a core team composed of Emmanuela Gakidou, Mie Inoue, and Michel Beusenberg Other contributors were, in alphabetical order, Howard Engers, Catherine Goodman, Emmanuel Guidon, Prabhat Jha, Kamini Mendis, David Nabarro, Jim Tulloch, Jia Wang, and Derek Yach Comments were appreciated from a number of indi- viduals including Anarfi Asamoah-Baah, David Evans, Tore Godal, Joseph Kutzin, Alan Lopez, Christopher Murray, Richard Feto and Nicholas White; additional help was gratefully received from WHO Regional Direc tors and their B dministrative support was provided by Aquilina John-Mutaboyerwa and Shelagh Probst. The report ade Guyonnet The index was prepared by Liza Weinkove and, for the French edition, by Laurent Gaiddon The report was prepared under the general direction of Jonas Store, Executive Director, Director-Gener- aI's Office, and Senior Policy Adviser; Julio Frenk, Executive Director, Evidence and Information for Pblicy; and Susan Holck, Director of Health Information Management and Dissemination African Art, Kampala, uganda, is reproduced with the kind permission of the arae zi Studio and Gallery of The cover painting"Working Woman", by Mr Nuaa Wamala-Nnyanzi, of the Nnyar by Marilyn Langfeld Layout by WHO Gr
ii The World Health Report 1999 WHO Library Cataloguing in Publication Data The world health report 1999: Making a difference 1. World health – trends 2. Health priorities 3. Cost of illness 4. Health services accessibility 5. Social justice 6. Poverty 7. Forecasting 8. Mortality – trends 9. Malaria – prevention and control 10. Smoking – prevention and control 11. World Health Organization I. Title: Making a difference ISBN 92 4 156194 7 (NLM Classification: WA 540.1) ISSN 1020-3311 The World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Office of Publications, World Health Organization, 1211 Geneva 27, Switzerland, which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. © World Health Organization 1999 All rights reserved. The designations employed and the presentation of the material in this publication, including tables and maps, do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. Information concerning this publication can be obtained from: World Health Report World Health Organization 1211 Geneva 27, Switzerland Fax: (41-22) 791 4870 This report was prepared by Dean T. Jamison, Andrew Creese and Thomson Prentice, with the assistance of a core team composed of Emmanuela Gakidou, Mie Inoue, and Michel Beusenberg. Other contributors were, in alphabetical order, Howard Engers, Catherine Goodman, Emmanuel Guidon, Prabhat Jha, Kamini Mendis, David Nabarro, Jim Tulloch, Jia Wang, and Derek Yach. Comments were appreciated from a number of individuals including Anarfi Asamoah-Baah, David Evans, Tore Godal, Joseph Kutzin, Alan Lopez, Christopher Murray, Richard Peto and Nicholas White; additional help was gratefully received from WHO Regional Directors, Executive Directors and their respective staffs. Administrative support was provided by Aquilina John-Mutaboyerwa and Shelagh Probst. The report was edited by Barbara Campanini and Angela Haden, and translated into French by Barbara Audrin and JeanClaude Guyonnet. The index was prepared by Liza Weinkove and, for the French edition, by Laurent Gaiddon. The report was prepared under the general direction of Jonas Støre, Executive Director, Director-General’s Office, and Senior Policy Adviser; Julio Frenk, Executive Director, Evidence and Information for Policy; and Susan Holck, Director of Health Information Management and Dissemination. The cover painting “Working Woman”, by Mr Nuwa Wamala-Nnyanzi, of the Nnyanzi Studio and Gallery of African Art, Kampala, Uganda, is reproduced with the kind permission of the artist. Design by Marilyn Langfeld. Layout by WHO Graphics Printed in France 99/12368 – Sadag – 20000
CONTENTS AESSAGE FROM THE DIRECTOR-GENERAL rogress and Challenges A Corporate Strategy for WHO Ⅺ Improving health outcomes Supporting health sector development A more strategic approach to our work in and with countries Repositioning WHO for the 21st Century PART ONE MAKING A DIFFERENCE IN PEOPLES LIVES ACHIEVEMENTS AND CHALLENGES CHAPTER 1: HEALTH AND DEVELOPMENT IN THE 2OTH CENTURY The 20th Century Revolution in Human Health The precipitous decline in mortality 112 Demographic transition Sources of mortality decline 5 Health and Economic Productivity Macroeconomic evidence Microeconomic analysis Pathways of influence CHAPTER 2: THE DOUBLE BURDEN EMERGING EPIDEMICS AND PERSISTENT PROBLEMS Emerging Epidemics of Noncommunicable Diseases and Injuries 14 Noncommunicable diseases Persistent Problems of infectious Diseases and maternal and Child Disability and mortality The unfinished agenda The persisting and evolving challenges The Avoidable burden of disease PART TWO MAKING A DIFFERENCE IN THE 2IST CENTURY CHAPTER 3 MEETING THE CHALLENGES: HEALTH SYSTEMS DEVELOPMENT Achieving Greater Efficiency Setting priorities Re-thinking incentives to providers
Message from the Director-General iii CONTENTS MESSAGE FROM THE DIRECTOR-GENERAL vii Progress and Challenges viii A Corporate Strategy for WHO xi Improving health outcomes xi Supporting health sector development xiv A more strategic approach to our work in and with countries xv Forging more influential partnerships xvii Repositioning WHO for the 21st Century xviii PART ONE MAKING A DIFFERENCE IN PEOPLE’S LIVES : ACHIEVEMENTS AND CHALLENGES xxi CHAPTER 1: HEALTH AND DEVELOPMENT IN THE 20TH CENTURY 1 The 20th Century Revolution in Human Health 1 The precipitous decline in mortality 2 Demographic transition 3 Sources of mortality decline 5 Health and Economic Productivity 7 Macroeconomic evidence 8 Microeconomic analysis 9 Pathways of influence 10 CHAPTER 2: THE DOUBLE BURDEN: EMERGING EPIDEMICS AND PERSISTENT PROBLEMS 13 Emerging Epidemics of Noncommunicable Diseases and Injuries 14 Noncommunicable diseases 15 Injuries 17 Persistent Problems of Infectious Diseases and Maternal ␣ ␣ ␣ ␣ and Child Disability and Mortality 19 The unfinished agenda 20 The persisting and evolving challenges 21 The Avoidable Burden of Disease 22 PART TWO MAKING A DIFFERENCE IN THE 21ST CENTURY 29 CHAPTER 3: MEETING THE CHALLENGES: HEALTH SYSTEMS DEVELOPMENT 31 Achieving Greater Efficiency 33 Setting priorities 35 Re-thinking incentives to providers 36
wing Progress towards Universal Coverage Risk sharing 3890 Policy choices Providing for the Future: the Role of Research and Development CHAPTER 4 ROLLING BACK MALARIA The Challenge of Malaria The health burden The economic burden The diverse and changing nature of the diseas Malaria Control: Past, Present and Future Control strategies, 1950-1990s rrent technology for effective intervention Future control strategies and research needs 995133581 A Global Programme to Roll Back Malaria CHAPTER 5 COMBATING THE TOBACCO EPIDEMIC The health and Economic Costs of Tobacco Use The economic costs Obstacles to Tobacco Control Lack of information on risks Tobacco use is an addiction 69 Tobacco dealers make enormous profits Principles of Control Using taxes and regulations to reduce consumption Encouraging cessation of tobacco use Building tobacco control coalitions, defusing opposition to control measures 74 Tobacco Control what some countries have achieved WHOs Tobacco free Initiative CHAPTER 6: MAKING A DIFFERENCE PART THREE STATISTICAL ANNEX Annex Table 1 Basic indicators for all Member States Annex Table 2 Mortality by sex, cause and WHO Region, estimates for 1998 589%0 Annex Table 3 Burden of disease by sex, cause, and WHO Region, estimates for 1998 Annex Table 4 Leading causes of mortality and burden of disease, estimates for 1998 Annex Table 5 Demographic characteristics of WHO Regions, estimates for 1978 and 1998 111 Annex Table 6 Country performance on infant mortality and female life expectancy outcomes relative to income, 1952-1992 Annex Table 7 Country performance on equity: health conditions of advantaged and disadvantaged groups, around 1990
iv The World Health Report 1999 Renewing Progress towards Universal Coverage 37 Risk sharing 38 Health care coverage 39 Policy choices 40 New universalism 43 Providing for the Future: the Role of Research and Development 43 CHAPTER 4: ROLLING BACK MALARIA 49 The Challenge of Malaria 49 The health burden 49 The economic burden 51 The diverse and changing nature of the disease 51 Malaria Control: Past, Present and Future 53 Control strategies, 1950–1990s 53 Current technology for effective interventions 55 Future control strategies and research needs 58 A Global Programme to Roll Back Malaria 61 CHAPTER 5: COMBATING THE TOBACCO EPIDEMIC 65 The Health and Economic Costs of Tobacco Use 65 Health consequences of tobacco 66 The economic costs 68 Obstacles to Tobacco Control 69 Lack of information on risks 69 Tobacco use is an addiction 69 Tobacco dealers make enormous profits 70 Principles of Control 72 Creating a “fair information” environment 72 Using taxes and regulations to reduce consumption 73 Encouraging cessation of tobacco use 74 Building tobacco control coalitions, defusing opposition to control measures 74 Tobacco Control: what some countries have achieved 75 WHO’s Tobacco Free Initiative 76 CHAPTER 6: MAKING A DIFFERENCE 81 PART THREE STATISTICAL ANNEX 85 Explanatory notes 86 Annex Table 1 Basic indicators for all Member States 90 Annex Table 2 Mortality by sex, cause and WHO Region, estimates for 1998 98 Annex Table 3 Burden of disease by sex, cause, and WHO Region, estimates for 1998 104 Annex Table 4 Leading causes of mortality and burden of disease, estimates for 1998 110 Annex Table 5 Demographic characteristics of WHO Regions, estimates for 1978 and 1998 111 Annex Table 6 Country performance on infant mortality and female life expectancy: outcomes relative to income, 1952–1992 112 Annex Table 7 Country performance on equity: health conditions of advantaged and disadvantaged groups, around 1990 114
Annex Table 8 Malaria: magnitude of the problem by age, sex and WHO Region, Annex Table 9 Tobacco: magnitude of the problem by sex and WHO Region, estimates for 1998 Annex Table 10 Tuberculosis: magnitude of the problem by sex and WHO Region, 116 INDEX TABLES Table 1.1 Life expectancy at birth, selected countries, around 1910 and in 1998 Table 1. 2 Sources of mortality reduction, 1960-1990 Table 2.1 Health status of the poor versus the non-poor in selected countries, around 1990 19 Table 5.1 Tobacco: cigarette consumption, mortality and disease burden by WHO Region 67 Table 5.2 The ten largest tobacco companies, 1997 71 Table 5.3 Goals and principles of tobacco control policies 72 Table 5.4 Principles to guide tobacco control policies in different countries FIGURES Figure 1.1 Age distribution of deaths in Chile, females, 1909 and 1999 cohorts Figure 1.2 Declines in fertility by WHO Region, 1950 and 1998 Figure 1.3 Distribution of the population of the South-East Asia Region, by age and sex, 19502000and2050 2345 Figure 1.4 The role of improvements in income in reducing infant mortality rates Figure 1.5 Links between health and income Figure 2.1 Distribution of deaths by cause for two cohorts from Chile, 1909 and 1999 Figure 2.2 The emerging challenges: DALYs attributable to noncommunicable diseases 134 in low and middle income countries. estimates for 1998 Figure 2.3 The emerging challenges: DALYs attributable to injuries in low and middle ountries. estimates for 1998 Figure 2.4 Distribution of the probability of death, selected countries, around 1990 Figure 2.5 DALYs attributable to conditions in the unfinished agenda in low and middle income, countries, estimates for 1998 Figure 2.6 Infant mortality rate related to income Figure 2.7 Reductions in wild poliovirus transmission between 1988 and 1998 Figure 3.1 Infant mortality rate relative to income, China, 1962-1992 Figure 3.2 Global immunization coverage, 1987-1997 Figure 3.3 Who bears the risk of health care costs? The impact of different financing schemes and provider payment systems Figure 3.4 Health insurance status of China's population, 1981 and 1993 Figure 3.5 Funding, risk pooling and coverage pattems Figure 3.6 Alternatives for moving towards prepaid health services Figure 4.1 Malaria risk across sub-Saharan Africa according to population density Figure 4.2 Comparative cost-effectiveness of selected malaria control interventions in a typical low income African country, US$, 1995 Figure 4.3 Comparative affordability of selected malaria control interventions total cost of full coverage as a percentage of a public sector health care budget for a typical low income African country Figure 5.1 Premature deaths from tobacco use, projections for 2000-2024 and 2025-2049 66 Figure 5.2 Trends in per capita cigarette consumption, 1971, 1981 and 1991 Figure 5.3 Age at which nicotine addiction starts, USA, 1991
Message from the Director-General v Annex Table 8 Malaria: magnitude of the problem by age, sex and WHO Region, estimates for 1998 115 Annex Table 9 Tobacco: magnitude of the problem by sex and WHO Region, estimates for 1998 115 Annex Table 10 Tuberculosis: magnitude of the problem by sex and WHO Region, estimates for 1998 116 INDEX 117 TABLES Table 1.1 Life expectancy at birth, selected countries, around 1910 and in 1998 2 Table 1.2 Sources of mortality reduction, 1960–1990 5 Table 2.1 Health status of the poor versus the non-poor in selected countries, around 1990 19 Table 5.1 Tobacco: cigarette consumption, mortality and disease burden by WHO Region 67 Table 5.2 The ten largest tobacco companies, 1997 71 Table 5.3 Goals and principles of tobacco control policies 72 Table 5.4 Principles to guide tobacco control policies in different countries 73 FIGURES Figure 1.1 Age distribution of deaths in Chile, females,1909 and 1999 cohorts 2 Figure 1.2 Declines in fertility by WHO Region, 1950 and 1998 3 Figure 1.3 Distribution of the population of the South-East Asia Region, by age and sex, 1950, 2000 and 2050 4 Figure 1.4 The role of improvements in income in reducing infant mortality rates 5 Figure 1.5 Links between health and income 11 Figure 2.1 Distribution of deaths by cause for two cohorts from Chile, 1909 and 1999 13 Figure 2.2 The emerging challenges: DALYs attributable to noncommunicable diseases in low and middle income countries, estimates for 1998 14 Figure 2.3 The emerging challenges: DALYs attributable to injuries in low and middle income countries, estimates for 1998 18 Figure 2.4 Distribution of the probability of death, selected countries, around 1990 20 Figure 2.5 DALYs attributable to conditions in the unfinished agenda in low and middle income, countries, estimates for 1998 21 Figure 2.6 Infant mortality rate related to income 23 Figure 2.7 Reductions in wild poliovirus transmission between 1988 and 1998 24 Figure 3.1 Infant mortality rate relative to income, China, 1962–1992 34 Figure 3.2 Global immunization coverage, 1987–1997 38 Figure 3.3 Who bears the risk of health care costs? The impact of different financing schemes and provider payment systems 39 Figure 3.4 Health insurance status of China’s population, 1981 and 1993 40 Figure 3.5 Funding, risk pooling and coverage patterns 41 Figure 3.6 Alternatives for moving towards prepaid health services 42 Figure 4.1 Malaria risk across sub-Saharan Africa according to population density and climate 52 Figure 4.2 Comparative cost-effectiveness of selected malaria control interventions in a typical low income African country, US$, 1995 57 Figure 4.3 Comparative affordability of selected malaria control interventions: total cost of full coverage as a percentage of a public sector health care budget for a typical low income African country 58 Figure 5.1 Premature deaths from tobacco use, projections for 2000–2024 and 2025–2049 66 Figure 5.2 Trends in per capita cigarette consumption, 1971, 1981 and 1991 67 Figure 5.3 Age at which nicotine addiction starts, USA, 1991 70