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    World Bank's cure for donor fatigue [editorial]

    Lancet. 1993 Jul 10; 342(8863):63-4.

    The report "Investing in Health," from the World Bank, reflects recent changes in international health, including AIDS, and the world's attention to Central Europe and the former Soviet Union. Cardiovascular disease is now the leading cause of death in the developing world. The health problems of urban areas and violence (especially towards women) are emphasized, with details on the economic and social impact of ill-health on the household. The cost effectiveness of an essential drugs policy is admitted, and the negative health (and economic) effects of tobacco are described. Public health in developing countries is assessed from an economic viewpoint. It is conceded that in some countries Structural Adjustment Programs (SAP) were indiscriminate and failed to preserve important elements of health services. There is strong evidence that user fees can be disastrous. In China, when drug charges of $30-80 were instituted for tuberculosis in 1981, 1-1.5 million cases remained untreated, producing in turn an additional 10 million infections. Many of the 3 million Chinese who died of tuberculosis during the 1980s could have been saved. There is, however, a controversial estimate of the global burden of disease and the package designed to reduce that burden. This involved estimating, for 131 diseases, the incidence of cases in 1990 by age, sex, and region. Estimates of cost per intervention in terms of disability-adjusted life years (DALY) yield packages of basic services, which would cost $12 per person in low-income countries. An intervention costing less than $100 per DALY is considered a very good buy. The cheapest, at <$25, include promotion of breast-feeding, immunizations, salt iodization and vitamin A supplementation, anthelmintics, smoking prevention, use of condoms, and cataract removal. At >$1000 per DALY are surgical and medical treatment of chronic diseases and cancers and control of dengue fever; this is apparently too expensive for many developing countries.
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