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Lancet. 2007 Sep 22; 370(9592):1032-1033.Cost-effectiveness analysis, as referenced by Davide Mauri and Nikolaos Polyzos, constitutes one of several sources of information considered by policymakers in developing and developed worlds in making decisions about the optimum efficient use of health-care resources. The WHO Commission on Macroeconomics and Health has suggested that interventions costing less than three times a country's per capita gross domestic product per disability-adjusted life year gained can be regarded as good value, and analysts have equivalently applied this threshold to analyses that use quality-adjusted life years (QALYs). Preliminary results from a cost-effectiveness analysis of vaccination with quadrivalent HPV 6/11/16/18 vaccine in Mexico suggest a cost/QALY ratio well below this threshold in that country. Previous analyses in developed world settings have consistently shown that vaccination of girls and young women has a cost-effectiveness ratio within the range typically regarded as cost-effective. In countrieswith the fewest resources, direct assistance and public-private partnerships can help deliver needed medicines to the population at or below development costs-eg, the ivermectin donation for river blindness. Marc Arbyn states that if the cases of vaccine-type-related disease are subtracted from disease due to all types, there are a larger number of cases in women who received vaccine than in those who received placebo. This subtraction assumes that the subset of disease cases due to vaccine HPV types and the subset of cases due to non-vaccine HPV types are mutually exclusive, which is not the case. Coinfections with vaccine and non-vaccine types are common. In the presence of coinfection, the effect of such a subtraction is to ignore the presence of non-vaccine HPV types in disease where a vaccine-type HPV has also been detected. The effect of the subtraction is to preferentially attribute co-infected disease cases only to the vaccine HPV types. Individuals in the placebo group are more likely to have their non-vaccine type-related disease discounted in this way. Owing to the high efficacy of the vaccine, individuals in the vaccine group have less vaccine-type-related disease, and so those in the vaccine group have fewer such coinfection cases. To illustrate this point, an analysis of the numbers of individuals with disease due to vaccine and non-vaccine HPV types in the intention-to-treat population of protocols 013 and 015 is presented in the figure. The parts shaded blue would be the result of subtraction, similar to Arbyn's subtraction. However, the total numbers of cases of disease related to non-vaccine HPV types are 226+56=282 cases in the vaccine group and 193+106=299 cases in the placebo group. There is not an excess of cases caused by non-vaccine HPV types in the vaccine group. (full text)
New York, New York, UNICEF, 2000. 116 p.What happens during the very earliest years of a child’s life, from birth to age 3, influences how the rest of childhood and adolescence unfolds. Yet, this critical time is usually neglected in the policies, programmes and budgets of countries. Drawing on reports from the world over, The State of the World’s Children 2001 details the daily lives of parents and other caregivers who are striving – in the face of war, poverty and the HIV/AIDS epidemic – to protect the rights and meet the needs of these young children. Choices to be made: The opening section makes the case for investing in the earliest years of childhood, before the age of three, when brain development is most malleable and rights are most vulnerable. It sets out the options governments have about where and when to make investments to ensure that children under three have their rights protected and their needs met. And it introduces the importance of early childhood development programmes, not only for children, their parents and caregivers, but for the progress of nations as a whole. A necessary choice: Attention to the youngest children is most needed where it is most difficult to guarantee: in countries where the seemingly intractable grip of poverty, violence and devastating epidemics seriously challenge parents’ hopes and dreams for their children. This section argues that early childcare can act as an effective antidote to cycles of violence, conflict, poverty and HIV/AIDS. The only responsible choice: Parents struggle, often against great odds, to do right by their children. In industrialized and developing countries alike they find advice and aid from informal support networks and community agencies with innovative childcare programmes. The final section describes these experiments and experiences and makes the case why, in the long run, investment in ECD pays off. (excerpt)
IN POINT OF FACT 1990 Sep; (70):1-4.About 50% of children <1 year old in developing countries die during the 1st month of life, and 97% of all infant deaths occur in developing countries. Major factors contributing to these deaths are the mother's poor health before and during pregnancy, unhygienic childbirth practices, and inadequate care after delivery. Low birth weight, linked to mother's health, is considerably related to survival and development and growth. >500,000 women in developing countries die annually due to pregnancy and childbirth. Maternal mortality risk in the poorest countries can be 200 times that of developed countries. Inappropriate timing and spacing, too many pregnancies, unsafe abortion, and insufficient prenatal care and care during delivery contribute to high maternal mortality in developing countries. Mothers <18 years old are at the highest risk of pregnancy complications, delivering a premature infant, and/or death. Postponement of marriage and better access to family planning would improve their and their infants chances of survival. Access to and acceptability of family planning promotes the health of women and children. Literate women and their children are healthier than those of illiterate women. A trained person attends only 20% of births in developing countries. Increasing the number of deliveries with a trained attendant and increasing immunizations of mothers with the tetanus toxoid will greatly reduce mortality. Infants leaving the uterus experience a drop in ambient temperature from 37 to 20 degrees Celsius. If they are not dried off, covered in a dry cloth, and/or allowed to be in physical contact quickly, they can experience considerable heat loss or even death. Further all infants should be exclusively breastfed for 4-6 months to ensure healthy growth and development and to provide protection against infections.
IN TOUCH 1987 Dec; 11(85):21-4.This paper discusses Bangladesh's overwhelming social, economic, and health obstacles to improving child health, and stands behind the UNICEF GOBI-FFF strategy as a low-cost alternative for rapid implementation. GOBI-FFF is an acronym for growth monitoring, oral rehydration, breastfeeding, immunization, food supplements for infants, female education, and family spacing. Specifically, the article endorses growth monitoring with the National Nutrition Council child health and nutrition card. The growth chart should be seen as an approach for the promotion of good health, prevention of malnutrition and infectious disease, and treatment of minor illnesses. The card has been designed for use among children 0-5 years of age at the primary health care level. The card includes messages and information on child health and nutrition. The actual process of growth monitoring requires a growth chart, growth chart manual, and a weighing scale. The paper describes growth measurement as the most scientifically effective measure of a child's nutrition and overall health. It is a simple and inexpensive manner of monitoring child health and nutritional status in the community.
NURSING JOURNAL OF INDIA. 1990 Oct; 81(10):322.Due to a deteriorating economic situation, India has adopted a policy of Selective Primary Health Care (SPHC), a strategy to target the population which can benefit the most from low cost health care--women and children in rural communities. India has set the goal of Health for All by the Year 2000. But the country has been grappling for a way to achieve long-run sustainability of accelerated health programs. Considering that economic conditions have reduced available resources, SPHC represents a realistic program that accurately reflects the health care priorities of the country. 80% of India's population lives in rural areas. Every year, 14 million people die from preventable diseases such as diarrhea, measles, and neonatal tetanus. In 1988 alone, diarrhea and measles cost the lives of 5 million children. SPHC program is goal-specific, and it follows the model by UNICEF's own selective intervention program -- GOBIFFF (Growth monitoring, Oral rehydration, Breastfeeding, Immunization, Female education, Food supplements, and Family planning). SPHC also emphasizes success. The programs has established targets and has monitored results. In 1981, less than 20% of all children were immunized, and less than 1% of all children were treated with oral rehydration solutions (ORS). But by 1987, 50% of all children were immunized against the 6 childhood immunizable diseases, and the number of children treated with ORS increased to over 50%. Although it would be better to combine SPHC with a Comprehensive Primary Health Care program, the current level of commitment and resources are not sufficient. Therefore, SPHC remains the realistic approach.
In: Issues in contemporary international health, edited by Thomas A. Lambo and Stacey B. Day. New York, New York, Plenum Medical Book Company, 1990. 113-33.The causes of mortality and disability in the world are reviewed, and the 4 most important mechanisms for promoting maternal and child health are proposed: female literacy, family planning, community-based efforts and global strategies for international cooperation. The health needs of women, children and adolescents, who make up the majority and the most vulnerable segment of the population, must be met. Malnutrition is the single most important cause of health problems through adult life, and affects 20 million children in Africa alone. Statistics are cited for infant mortality, vaccine-preventable diseases, diarrheal diseases and respiratory infections, infant mortality and maternal mortality. The key determinant of infant survival is female literacy. Existing scientific cooperation is the closet thing we have to a global international community. An example of applied scientific solutions to health care is the risk approach in maternal health care. 2 strategies of scientific cooperation have emerged: the international center model in a country or region to address a specific problem, and the task force model, as used effectively by WHO, UNICEF, and the Task Force for Child Survival. Research topics on health in developing countries are listed that could be tackled by universities and scientific networks, e.g. scientific research is lacking on how to make household hygiene effective in poor countries. A concerted global research effort and surveillance effort is needed for AIDS.
TRANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE. 1989 Jan-Feb; 83(1):10-8.The main causes of infant mortality in 71% of the cases are diarrhea, measles, acute respiratory infection, and neonatal tetanus. A UN child survival strategy includes growth monitoring, oral rehydration, breast feeding, immunization, fertility, food and female literacy (GOBI-FFF). Previous research has shown a correlation between low levels of infant mortality and high levels of female literacy. Educated women are more likely to delay marriage, and childbearing. Child mortality is much higher for those born to women under 20 years old and also much higher for those born within 1 or 2 after the previous birth. Maternal mortality is also higher for mothers under 20 and with closely spaced births of 3 or more children. The majority of adults in developing countries have knowledge of family planning but teen pregnancy is a concern. Better nutrition during pregnancy would decrease infant deaths. Growth monitoring is another way to reduce infant mortality and morbidity. The difficulties are in the reluctance to adapt programs to local traditional methods of growth monitoring and going to direct recording scales. Immunization is estimated to have prevented over 3 million deaths from measles, tetanus, whooping cough and polio in 1984 alone. In spite of progress, only 50% of children in developing countries are immunized against diphtheria, pertussis, polio, and tetanus by the age of 1 year. these activities must be integrated into primary health care and community development projects to make better contact with people needing this service. oral rehydration therapy not only reduces mortality from diarrhea but can reduce morbidity by reducing the duration of the illness and by increasing the weight gain. Breast feeding has been shown in many studies to reduce the risk of deaths of infants. The promotion of breast feeding includes the issues of maternity leave, job security, and child care at the work place.
JOURNAL OF BIOSOCIAL SCIENCE. 1990 Jul; 22(3):365-72.Data from a 1985 survey in 2 urban centers in Sudan, Juba and Wau, were analyzed to assess childhood mortality levels and the effect of UNICEF's health care program. A sample of 5120 mothers (Juba, 3061 and Wau, 2059) with 21,509 children were collected from the towns. Logistic regression analysis was used to delineate determinants of child survival. The child mortality measures denote continued high infant and child mortality levels for Southern Sudan. 3 components of the UNICEF program were significantly associated with child survival: oral rehydration therapy, maternal education and immunization. The study concludes that maternal education is the most important determinant of child survival, affecting both the cure and prevention of child ill- health. (Author's modified).