(August 2007) Despite important advances in life expectancy, there are still very substantial gaps between the health of people in developing and developed countries. This is especially true for poor people. Almost 12 million young children a year die, many of preventable causes and half related to undernutrition. More than 500,000 women a year die in childbirth. What is the burden of disease in the developing world? What are cost-effective ways in different settings of addressing that burden?

During a PRB Discuss Online, Richard Skolnik, director of international programs at PRB, answered participants’ questions about global health. 

Thank you for taking part in this timely discussion of global health.

August 31, 2007 11 AM EST

Transcript of Questions and Answers

Dr. Thein Thein Htay: In some developing countries, many area experts were assigned for unrelated jobs and then non-qualified persons were asked to lead the Principles as a result of ineffective human resources management, which used to happen on ad hoc basis, influenced by money, political patronage or other considerations. To what extent can such an “Improper and ineffective utilization of existing manpower and their expertises” affect in combating the unfinished agenda in global health?
Richard Skolnik: Manpower. The lack of appropriately trained health personnel is a major issue in the health systems of many countries. It has also recently been the object of considerable attention by a number of groups, including efforts supported by the Rockefeller Foundation. Some countries do not have enough personnel. Many countries find it difficult to post personnel in places where they are most needed. Many health personnel migrate from one country to others, sometimes among developing countries and often to developed countries. These are in addition to the problems in many countries of ensuring that their existing personnel have the needed level of skills and motivation or the problem that you mention of corruption in hiring. Personnel issues are difficult and also beyond the ability of the health sector to solve by itself. However, there has been some success with motivating staff by having them participate in quality improvement exercises, by offering qualifications that are recognized locally but not elsewhere and therefore constrain the movement of staff, and by training the lowest possible level of staff to carry out certain procedures, such as cataracts done by ophthalmic assistants and c-sections done by nurse-midwives. Efforts to reduce corruption in hiring and by contracting out services to NGOs, for example, can also help in some settings to ensure that services are delivered by appropriately skilled and motivated personnel.

D.D.Mestri: My question is, Health is a primary need of not only human being but all the alive bodies. To enhance the health service ‘Health Information System should be enhanced. International, National, State, Province, District, Tahsil, town and even up to small village level this service should be provided. This should be continuous uninterrupted service. With this certainly there will be impact on mortality rate.
Richard Skolnik: Health information systems and the collection and analysis of key health data ARE very important to the management of an effective and efficient health system. First, data are essential for public health surveillance. Second, it is difficult to make health policy without data on the burden of disease and how it relates to selected population groups. Third, it is impossible to manage the health system, assess its effectiveness and efficiency, or improve performance if one does not have data to relate inputs and outcomes. This will be true both for particular efforts, such as the management of a TB program, an immunization program, and AIDS treatment program, or for the system as a whole.

Mary Gorvie: what can be done to ensure that the rural poor in developing countries can access modern health information that will help them improve on their traditional health practices?
Richard Skolnik: We know that considerable improvements in health could be realized just by promoting better health behaviors, including exclusive breastfeeding for six months, the appropriate introduction of complementary foods, better hygiene and hand washing, and eating vitamin rich foods that are available and affordable. My understanding, although I am not at all an authority on behavior change, is that there have been some important successes in promoting better health behaviors through such efforts as social marketing, community-based approaches to growth promotion and monitoring, and information campaigns focusing around “infotainment” such as soap operas. Immunization campaigns have been quite successful in some places to rasie awareness of the importance of immunization, even though rumors have hurt such campaigns in several places. In addition, some people are now optimistic that conditional cash transfers, which are increasingly being used in Central America, encourage families to engage in better health and education practices, and help them defer the costs to the families of doing so. Stemming tobacco use seems easier … if governments could only do one thing, raise taxes. This appears consistently to have reduced the uptake and continuation of tobacco use. Lessons from Cuba, Sri Lanka, the Indian state of Kerala, China after 1949 and Viet Nam in recent years may be useful in understanding how they promoted better health behaviors even while they were still poor countries and even when much of their population, at least in China and Vietnam was not yet very well educated.

Shaligram Adhikari: How about the situation of disability status in Nepal? (data and other information according to WHO).
Richard Skolnik: While I cannot comment on the particular disability status of Nepal, there is clear evidence that many disabilities can be avoided through appropriate practices or interventions. These would include better nutritional status of mothers, better nutrition for children under two, childhood immunization, and early diagnosis and effective treatment of debilitating diseases, such as leprosy or some of the other neglected tropical diseases. These can all be prevented or addressed in low cost ways that are effective and that can reduce the often exceptionally high cost of treating disabilities or of people having to live with them.

Dr. Yamini Sarwal: Struggle for daily bread, unemployment and women’s suppression give rise to a substantial degree of mental ill health in developing parts of the world, but is overshadowed by the more obvious conditions of physical ill health. How much attention has been directed to mental health in developing nations by global bodies?
Richard Skolnik: Most low- and middle income countries spend very little on mental health. Yet, the latest studies of the burden of disease highlight that almost 6% of the total burden of disease in low- and middle-income countries stems from depression, bipolar disorder, schizophrenia, and anxiety disorder. Much of this goes “unnoticed” since people may be ill with these diseases but they are not so often the direct cause of death. The most comprehensive studies of “the unfinished agenda” suggest that mental health deserves a much greater priority than given to it, that attention to it can start even in poor countries with efforts to provide psychosocial support to those in need, and that selected people can be referred for treatment with drugs. Uganda is said to be a low income country that has had some successes in developing a community –based approach to mental health, which was supported partly by the African Development Bank. Some case studies of that and how the Ugandans got it on the political agenda would be valuable to examine.

Susan Stout: Hi Richard, Do you think the “IFIs” (World Bank, regional development banks, IMF) are providing effective advice and support to reproductive health programs? How would you suggest that donors to these agencies compare the performance of these agencies to that of the the IFI the new major health initiatives, such as the GFATM?
Richard Skolnik: Hi Susan. Given the social and economic costs of maternal morbidity and mortality, the high rates of sexually transmitted infections, the limited progress in many countries in family planning, and the enormous problem of HIV/AIDS, I believe that more attention to reproductive health would be warranted both by low- and middle-income countries and their development partners. There is good evidence of what works in cost-efficient ways to address these questions and evidence that the failure to address them in many countries has been largely a failure to act with the tools we do have. As the Center for Global Development and others have been stressing, it is very important in a world with a large unfinished agenda and limited resources that we learn “what works.” Like the Center, therefore, I would like to see much more rigorous attention paid to more scientific evaluation of alternative investments; more scientific assessments of ongoing and completed investments; more rigorous comparison of the approaches and outcomes that stem from the efforts supported by different actors and their development partners, to learn, as quickly as we can, what are the most cost-effective approaches overall. We should certainly know today, for example, how the outcomes of efforts supported by the MAP projects of the World Bank compared to outcomes supported by the Global Fund or if the performance based financing of the Global Alliance for Vaccines and Immunization lends itself to better results with immunizations than the work supported by others that is not “performance based.”

David Mping’wa: are we not contributing to increased MMR by too much intervention? sometimes it is good remedy by giving nothing.
Richard Skolnik: Most of the evidence with which I am familiar suggests that it is the lack of appropriate attention that is linked to the almost 530,000 women who of pregnancy-related causes every year and the morbidity associated, for example, with fistula. First, many of these women are undernourished and anemic. Second, many of them have malaria. Third, many women do not get tetanus vaccines. Fourth, many women give birth while unattended or when attended by unskilled helpers and there are important failures to deal hygienically with the birth or to recognize and deal with complications of pregnancy. Finally, too many births, with too little spacing, also place poor women at risk. Many women’s lives could be saved through better family planning, better attention to the nutritional needs of women, attendance at birth by skilled helpers, and an ability of health systems to deal quickly with obstetric emergencies.

yidana godwin: How can we make sure that our development efforts in the developing countries are pro-health because most of the health and health-related problems facing these countries are development induced ones.
Richard Skolnik: As you know, the determinants of health problems are many, including poverty, gender, environment, genetics, social discrimination, etc. However, some problems clearly relate to changes in society, such as the increase of tobacco use, the transition to obesity, road traffic accidents. Although a detailed response to your question would be complicated, I would probably do two things to reduce “change and development-related health issues:”
• Ensure that government policymakers, encouraged forcefully by the community, are responsible for examining the health impacts of their policies, much the way that we do now for certain environmental and social assessments
• Encourage the uptake of policies as early as possible to head off problems before they arise such as raise tobacco taxes, discourage the overuse of “junk foods,” and put in speed bumps, enforce traffic laws, and encourage seat belt and motorcyle helmet use.

Kakaire Kirunda: For sometime now, I have seen international organisations fund health programs. During this partnership, all is well, but upon pull out you see misery. A while back here in Uganda, a DFID funded project on increased uptake of adoloscent sexual and reproductive health services.But the funding was stopped after one year. The project had picked but what followed was a case of raising appetite and leaving people hungry just after giving them something small to taste.How best can such partnerships be developed to avoid the afore mentioned scenario? How do international aid agences make these projects sustainable?
Richard Skolnik: Sustaining investments in health in countries that are very poor is difficult and many low-income countries may need external assistance to do so, even if they are able to increase the effectiveness and efficiency of public sector expenditure in health and other sectors. It is very important if externally assisted projects are to succeed that the amount of financing available is clear, that it is for an agreed and appropriate length of time, and that it comes as needed, which is not always the case. In addition, countries and their partners need from the design stage of an investment to ensure that a careful analysis has been done of the costs and how the project will be sustained over time. Some people in global health believe that even when concerned about the health of the poor, that there is hope of sustaining investments by encouraging community-based insurance schemes or schemes, like the well-known program of the Aravind Hospital in south India, in which better-off clients croos-subsidize services for the less well-off.

Oluwadare Christopher: how can the issues of corruption and leadership crises be integrated into global health campaigns especially the targed poor nations that are really corrupt nations?
Richard Skolnik: Corruption is a complicated issue that is deeply ingrained in some places and goes way beyond the health sector. Nonetheless, there have been efforts in a number of countries to reduce corruption in the health sector. A paper by Maureen Lewis of the Center for Global Development is a good summary of this topic. Some countries or cities have had success with anti-corruption campaigns. Other countries, including Madagascar, have had success in promoting independent audits of flows of funds in the health system with penalties for adverse findings. Several countries have appointed community boards for health which are part of all information about the budget for health for their community, help to track that budget, and have a direct link to empowered authorities in the event money is misused. Contracting out some services, having the community give “report cards” for services, and improving procurement practices may also be important.

Rahat Bari Tooheen: The question in my opinion is no longer about resources or funding. We have enough of both. However, what is lacking is political will that will mobilize the funding and resources to deal with the unfinished agenda. Funds and resources are often diverted to politically popular issues such as war. How do you think this situation can be addressed?
Richard Skolnik: It is certainly true that in the last decade, there has been an enormous increase in the availability of funds globally to address much of the unfinished agenda in global health. On the other hand, an important part of this funding has been dedicated to HIV and there are still many parts of the agenda that require much more attention in many more settings. While I am not at all an authority on social change, I think there is evidence that the public health community both globally and in particular settings can get more attention to key issues in a number of ways, including:
• Mobilizing around a key theme, as has been done on HIV
• Working out partnerships with new actors, such as with pharmaceutical firms or other private sector actors, as has been done on AIDS drugs and on drug donation programs
• Getting credible “champions” and advocates within countries to highlight, especially to ministries of finance and planning, the economic and social costs of a failure to address health, nutrition, and family planning issues and the relatively low costs and high pay-off from key investments in health
• Working together to ask: what will it take to accomplish some global health goal, intead of spending as much time as we often do explaining why the goal cannot be met. The work on AIDS drugs and multi-drug resistant TB certainly showed the social and political power of this type of effort.

David Burleson: When amount of the 12 or so million child deaths annually is “covert infanticide” responding to the failure of health systems to provide population education and family planning?
Richard Skolnik: While I cannot give a figure for “covert infanticide” it is clear that more than 15% of maternal deaths worldwide are linked to unsafe abortion and that there is substantial morbidity related to unsafe abortion in many countries. These figures suggest that there are many women who become pregnant who did not wish to be pregnant and that there is important “unmet need” for family planning. In Africa the lifetime risk of a women dying of pregnancy related causes is 1 in 16. The number of unsafe abortions, the high ratios of maternal mortality, and the low levels of contraceptive prevalence in many settings and its being at a plateau for some time, all indicate that increasing family planning in many settings is a much needed and potentially very high return investment. You will want to keep your eyes out in the next few months for the new edition of “Family Planning Saves Lives,” by PRB.

Oluwadare Christopher: though poor nations are poor but sizable foreign fund come in to promote human development especially health issues, how can donors successfully put pressure on this govts to utilise the assistance judiciously. most of the poorest nations are also the most corrupt nations given the fact that these nations naturally are endowned if not better than the developed nations.
Richard Skolnik: This, of course, is a two-edged sword! What some see as a need for conditionality to deal with corrupt governments others may see as interference. I think we should support several approaches and then rigorously evaluate if they work better than the way in which most development assistance has worked historically:
•Build rigorous evaluation into all project designs
•Ensure independent evaluation of outcomes throughout projects/programs
•Ensure very rigorous financial audits that are linked to project outputs and outcomes
•Use more “performance-based” financing, as GAVI and the Global Fund are doing, provided evidence emerges that these approaches produce better outcomes than the way development assistance has largely been financed before

M. Khan Kabooro: Poverty has always been a bottleneck in increasing Health conditions of People, is it true or false? if yes, what steps can be taken to cope with the condition?
Richard Skolnik: We know that poverty IS a powerful determinant of health, partly through its links with education, the lack of political and social power, and the poor environment in which many poor people live, with limited access to safe water and sanitation, etc. There is also a very strong correlation in most low and many middle-income countries between income and access to health services. Immunization rates, for example, of young children are almost perfectly correlated in many countries with income status … the higher the family income the higher the rate of immunization. There is no magic bullet for enhancing the health of the poor in countries that lack a political commitment to the poor. However, there is evidence that a combination of internal and external advocacy by credible “champions” can get the attention of policymakers in many settings. Some “human rights” approached have gotten attention, such as on AIDS drug treatment. However, the arguments advocates make about the health of the poor usually have to go beyond the “human aspects” and help policymakers understand the costs and consequences for society as a whole of neglecting the health of the poor. Jeremy Shiffman at Syracuse University has done a series of interesting articles on the political economy of global health that will of interest to you.

Richard Skolnik: Collecting data on abortion is, indeed, very difficult, given the sensitive nature of the subject. WHO suggests that the best data on unsafe abortion comes from “national community studies” and hospital-based surveys. The Alan Guttmacher Institute has done some important work on data on abortion and I understand some new data has just come out or will soon come out from them. This will be of keen interest to you. My answer to the question that raises the issue of “covert infanticide” provides additional comments on abortion and family planning.

Shaligram Adhikari: respected sir! If it is possiable, please provide me the current data about HIV/AIDS especially Nepal.
Richard Skolnik: The best information about AIDS in Nepal will come, of course, from the national AIDS control organization in Nepal and from UNAIDS. Especially interesting to you will also be the latest UNAIDS Epidemic Update which is available on the web. You will also be interested in reviewing some of the demographic and health surveys that have been done recently that included sampling for HIV.

Graciela Sarrible: What about the local or regional deseases as Mal de Chagas? Millons of personas are concerned but in only one region or continent. is ot Global’ Is it considered?
Richard Skolnik: Chagas disease is a disease of importance to Latin America, but not to the rest of the world. There has also been some excellent progress against Chagas, a case study of which appears in the book “Millions Saved” by Ruth Levine. A number of actors in global health would like to see much more attention to what they call “neglected tropical diseases,” which include Chagas, leprosy, trachoma, the “worms” and Buruli ulcer. They have shown that the burden of disease caused by these conditions is very large, that these diseases affect the poorest people, that they can be terribly debilitating, but that these diseases do not attract sufficient attention from policymakers. They have also suggested a very low cost integrated package of drug treatment that can greatly reduce the burden of these diseases at very low cost. An article will appear September 7 in the Journal of the American Medical Association by Peter Hotez on this subject.

K.K.Shukla: “seeking answer” Due to lack education and awarenes while WHO has pay attantion to various types programme IEC acivities also(e.g. Pulse polio, DPT,etc) in India,yet some of the childs suffering various problems.
Richard Skolnik: You are right in suggesting that there are large numbers of children who die of preventable causes, especially diarrhea, malaria, and pneumonia. There is very good evidence that the number of young child deaths can be reduced through a series of low cost but highly effective interventions, such as:
•Reducing neonatal deaths through safe delivery methods and simple methods for resuscitation, keeping the baby warm, and preparing to deal with pneumonia
•Exclusive breastfeeding for six months and then introduction of appropriate complementary foods
•Immunizating against the basic childhood illnesses
•Promoting the use of bednets and prompt and effective treatment for malaria
•Improving hygiene and handwashing within families
These can all be carried out in community-based ways. Countries that still face high rates of infant and child death should focus on these efforts, particularly among their poorest people, whose burden of disease will be much higher than among better-off people.

Erin Wheeler: How do you think the “abstinence-only” aspect of some PEPFAR grants is affecting the HIV/AIDS prevention effort in Africa?
Richard Skolnik: My understanding is that studies that have been done suggest that there is not sufficient evidence that “abstinence only” approaches are effective. In addition, I undertstand that the idea of earmarking a certain percentage of PEPFAR funds for abstinence only was felt by many countries and their development partners to overly constrain the development of locally appropriate efforts to stem the HIV/AIDS epidemic. Studies of PEPFAR, I believe, have also indicated this.

Erin Wheeler: In a large portion of the developing world, the family finances are controlled by men, which often limits women’s and children’s access to health care and family planning. What can be done to override this barrier? Should more focus be placed on sensitizing men on the issues of maternal-child health and reproductive health?
Richard Skolnik: You have highlighted an important point. Men and their mothers are often the most powerful people within families. Yet, there is substantial evidence that many health, nutrition, and family planning programs largely ignore men or other important actors in the family and focus largely on women, who may lack the power to act appropriately on health or family planning for themselves or their children. There is now evidence from many countries of efforts to involve men in efforts at family planning, reproductive health, and child health, but these efforts probably need to go much further, along with “empowerment” of women through social and economic efforts, if the health of women and children in the poorest families in low-income countries is to be improved.

Joseph Dwyer: As you have noted, the vast majority of child deaths can be prevented. The medical & technical knowledge & skills exist. How can we rapidly “de medicalize” our approach to child health and truly address the nutrition and immunization issues that depend more on good community work including leadership and management than they do on clinical bottlenecks?
Richard Skolnik: Your point is also a very important one. Many people have forgotten the “promise” of primary health care, the ability of people to influence their own health, even if poor, and community based efforts. In addition, we have “medicalized” a lot of key global health concerns. I have tried in my other responses on child health to indicate how I think we can focus on the health needs of the poor and work with communities to focus on appropriate health behaviors and child caring practices to try to prevent many child health problems before they arise,as well as to treat others in the community. In addition, there is evidence from many countries that by working closely with community-based organizations and other non-governmental organizations that health services will be “closer to the client” and to client needs than would be the case in many governmentally provided health services. As I am sure many know, the case of the Bangladesh Rural Action Committee (BRAC) is among the most famous and most successful efforts at promoting better health for the poor in a community-based way.

charlie teller: Richard, In reviewing the recent trends in health status in all developing countries, the most striking gap is that between steadily declining under-five mortality and the lack of much decline in under-five chronic stunting and undernutrition. What do you think could be done to begin closing this growing gap that leaves so many toddlers disadvantaged for life?
Richard Skolnik: Charlie, It looks, as many predicted, that many children are alive today who may not have been alive some years ago, but that the health and well-being of these children remains poor. One key to ensuring that children develop their full mental and biological potential is to focus on nutrition of mothers and of children from in the womb to about two years of age. Much of the damage done during that period by undernutrition and micronutrient deficiencies cannot be recovered. It is essential to promote exclusive breastfeeding and then appropriate complementary foods and better eating behaviors, etc. Fortification works and is not expensive and could be expanded both in terms of micronutrients and places where it is occuring. Programs on vitamin A have made an important differenece to child health and zinc can stem damage from diarrhea. There is very good evidence about the importance of nutrition and the world needs to focus much more attention on a selected number of nutrition interventions that work at low cost.

Deki: IMR AND MMR is still a problem in Bhutan? Can you suggest some ways in a mountainous country like ours to make some difference?
Richard Skolnik: The geography of Bhutan, (which I have had the good fortune to visit twice) makes it very hard to provide easy access to health services. This suggests that community based efforts at water and sanitation, hygiene, and appropriate nutrition are especially important. In addition, of course, chidlhood immunization is key and Bhutan has made important progress in developing outreach for these efforts. Addressing the most difficult complications of pregnancy does require medical interventions. Given the distance to the few hospitals for many people, Bhutan might want to do what Cuba and Sri Lanka have done, which is to encourage pregnant women to go to health facilities BEFORE their due dates to be sure that they are in a skilled setting when they do give birth.

Amy Tsui: What will it take to finish the global health agenda in financial terms? Will it be the same as the costs remaining after we fall short of meeting the MDGs in 2015?
Richard Skolnik: The financial needs to meet the MDGs will be very substantial. However, there has been a dramatic increase in funding for global health in the last decade.Some countries will meet many of the MDGs and some will not. However, it appears that movement toward meeting them will require a much greater focus in some countries on activities and interventions that have been shown to work at low cost, but which are not sufficiently in place, including: community-based efforts at promoting better hygiene, nutrition, sinc