Health in Developing Countries

BIBLIOGRAPHY

The most commonly accepted definition of health was proposed by the World Health Organization (WHO) in its 1948 constitution: “Health is a state of complete physical, social, and mental well-being and not merely the absence of disease or infirmity.” Some academics argue that this definition is utopian, and they propose a more narrow definition that considers health to be “the absence of illness” (Alban and Christiansen 1995).

Health is regarded by the WHO as a fundamental human right. The preamble of the WHO constitution states that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being.” However, people do not enjoy the same standard of health in all parts of the world. Many factors influence health status and a country’s ability to provide quality health services for its people. Researchers on health in developing countries try to make sense of these factors and to understand their complex links in “low- and middle-income countries in which most people have a lower standard of living with access to fewer goods and services” (World Bank 2003).

Research on health in developing countries can include the study of clinical and epidemiological aspects of diseases, such as variations in disease frequency in different populations; the natural processes of biology and their relation to disease; the environmental and social determinants of health; and the development, implementation, and evaluation of health policy, which can include, among other things, how health systems should be organized.

The range of disciplines and professionals represented in the study of health in developing countries is very broad. This group can include epidemiologists, sociologists, physiologists, economists, mathematicians, historians, health policy analysts, nurses, doctors, and pharmacists. In recent years, there has been a move toward establishing research partnerships of interdisciplinary teams from both developed and developing countries in an effort to find solutions to the health challenges facing developing countries in the new millennium. The spectrum of diseases studied is wide, and there are major research groups working on topics that include reproductive health, undernutrition, and infectious disease (e.g., tuberculosis, malaria, diarrheal diseases, HIV/AIDS); noncommunicable disease and injury (e.g., diabetes, mental disorders, interpersonal violence); risk factors (e.g., water supply, sanitation, and hygiene); and the consequences of disease and injury (e.g., learning and developmental disabilities).

The global community acknowledges the need to tackle health-related conditions in order to support aspirations toward development of people living in developing countries. An example of this includes the United Nations Millennium Declaration (2000), signed by 189 countries, which includes eight Millennium Development Goals, three of which are related to health: reducing child mortality; improving maternal health; and combating HIV/AIDS, malaria, and other diseases (Travis et al. 2001). The following sections explore how some of these goals are being addressed.

HIV/AIDS poses a serious health, social, and economic threat worldwide, and both rapid action and drastic initiatives are needed to care for adults and children living with and affected by HIV/AIDS, as well as to prevent further infections from occurring. By 2004 AIDS had killed more than twenty million people, and an estimated thirty-four to forty-six million people were living with HIV/AIDS (WHO 2004). The solutions proposed by most experts include implementing a comprehensive HIV/AIDS strategy that links prevention, treatment, care, and support for people living with the virus. Providing effective antiretroviral treatment and new care strategies to strengthen existing prevention programs can result in the improvement of health, the reduction of HIV/AIDS stigma, and the rebuilding of social capital while restoring economic growth (WHO 2004).

According to the WHO’s World Health Report 2003, around 530,000 women die each year in pregnancy or childbirth, and 10.6 million children die every year before they reach the age of five. In many countries, universal access to health care for women and children is not assured. Women and children are often excluded from health-care services, which reinforces inequity in health delivery and increases barriers to progress. The WHO report also states that mortality could be reduced through a wider use of key interventions and a continuum of care for mother and child. Some cost-effective interventions include: expanding immunization coverage; treating diarrhea; preventing the transmission of and mortality from malaria; ensuring the widespread distribution of key micronutrients; improving prenatal and delivery care; and expanding the use of measures aimed at preventing mother-to-child transmission of HIV (Jamison et al. 2006). The most pressing task for reducing child mortality, improving maternal health, and treating and preventing HIV/AIDS consists of putting in place the health-care workforce needed to implement these interventions.

The effectiveness of health systems varies dramatically around the globe, even among countries with similar levels of income and health expenditure. In 2000 the WHO carried out the first analysis assessing the performance of health systems worldwide. The report emphasized that failures in health systems had a more severe impact on the poor. According to the report, out-of-pocket payments for health care exacerbate poverty. In light of this finding, governments should pursue policies that expand insurance and prepayment schemes as a way of reducing excessive out-of-pocket expenses for health care (WHO 2000; van Doorslaer et al. 2006).

International involvement in health care remains common in developing countries, largely because the provision of health care is expensive and few countries can afford universal coverage. International involvement includes the work of multilateral organizations such as the United Nations, bilateral or government-to-government organizations, and the global civil society. In addition, a wide range of global partnerships to finance the fight against major diseases in developing and middle-income countries have flourished since the mid-1990s. Organizations participating in such partnerships include the Global Fund to Fight AIDS, Tuberculosis, and Malaria; the Bill and Melinda Gates Foundation; and the World Bank Multi-country HIV/AIDS Program. It is still too early to assess or predict the effects of these initiatives on health systems. The funds of such initiatives must be managed with caution, and they face daunting problems associated with coordinating their efforts within countries (Brugha 2004; Coovadia and Hadingham 2005).

In general, two approaches to delivering health interventions are prevalent. These approaches date back to a debate that started when the Alma-Ata Declaration was adopted at the International Conference on Primary Health Care in Alma-Ata (Almaty), Kazakhstan, in 1978. At that time, the debate centered on two distinctive views on primary health care (PHC) intervention. The first approach, referred to as selective PHC, focuses on diseases with the highest prevalence and morbidity, the highest risk of mortality, and the greatest possibility of control in terms of cost and effectiveness of the intervention (Walsh and Warren 1979). The second approach, named comprehensive PHC, considers health to be more than the absence of disease, and defines health in the holistic sense. Comprehensive PHC considers equity, multisectoral approaches, and community involvement as critical components of any health intervention (Rifkin and Walt 1986).

The debate between advocates of these two approaches has not completely faded, but it has been obscured by the fact that many governments and global health partnerships have implemented the selective PHC approach to tackle HIV/AIDS, as well as tuberculosis and malaria. However, the WHO’s World Health Report 2003 stressed that the principles of the Alma-Ata Declaration remain valid, and should be reinterpreted in light of dramatic changes in the health field since 1978.

Health systems in developing countries need to be strengthened in view of the global health challenges facing them, including the health-care workforce crisis, a lack of financial resources, and poorly organized and financed health systems (WHO 2005). The World Health Report 2003 indicates that despite many reforms, inadequate progress has been made in building health systems that promote collective improvement in health. Solutions could include offering more training for local officials, strengthening health-care infrastructure through restructuring, and developing accountability mechanisms and a larger role for civil society. However, experts agree that context-specific strategies and responses are essential, and goals and priorities should be established and tailored to each country’s context (Sepúlveda 2006). Finally, there is a need for greater research on epidemiology and health systems to improve the efficiency and reduce the costs of available interventions, as well as biomedical research to develop new tools for dealing with emerging health problems (Sepúlveda 2006).

SEE ALSO AIDS/HIV in Developing Countries, Impact of; Developing Countries; Development, Rural; Disease; Ethno-epidemiological Methodology; Health Economics; Human Rights; Public Health; Sanitation; Toilets; World Health Organization

BIBLIOGRAPHY

Alban, Anita, and Terkel Christiansen. 1995. The Nordic Lights: New Initiatives in Health Care Systems. Odense, Denmark: Odense University Press.

Brugha, Ruairí. 2004. The Global Fund: Managing Great Expectations. Lancet 364: 95–100.

Coovadia, Hoosen, and Jacqui Hadingham. 2005. HIV/AIDS: Global Trends, Global Funds, and Delivery Bottlenecks. Globalization and Health 1 (13). http://www.globalizationandhealth.com/content/1/1/13.

Jamison, Dean, Joel Breman, Anthony R. Measham, et al. 2006. Disease Control Priorities in Developing Countries. 2nd ed. Washington, DC: World Bank; New York: Oxford University Press.

Rifkin, Susan, and Gill Walt. 1986. Why Health Improves: Defining the Issues Concerning “Comprehensive Primary Health Care” and “Selective Primary Health Care.” Social Science and Medicine 23 (6): 559–566.

Sepúlveda, Jaime. 2006. Foreword. In Disease Control Priorities in Developing Countries, eds. Dean Jamison et al. 2nd ed. Washington, DC: World Bank; New York: Oxford University Press: xiii-xv.

Travis, Phyllida, Sara Bennett, Andy Haines, et al. 2001. Overcoming Health-systems Constraints to Achieve the Millennium Development Goals. Lancet 364: 900–906.

United Nations. 2000. United Nations Millennium Declaration. http://www.un.org/millennium/declaration/ares552e.htm.

van Doorslaer, Eddy, Owen O’Donnell, Ravi P. Rannan-Eliya, et al. 2006. Effect of Payments for Health Care on Poverty Estimates in 11 Countries in Asia: An Analysis of Household Survey Data. Lancet 368 (9544): 1357–1364.

Walsh, Julia A., and Kenneth S. Warren. 1979. Selective Primary Health Care: An Interim Strategy for Disease Control in Developing Countries. New England Journal of Medicine 301: 967–974.

World Bank: Development Education Program. 2003. Glossary: Developing country. http://www.worldbank.org/depweb/english/modules/glossary.html.

World Health Organization. 1948. Constitution of the World Health Organization. http://www.yale.edu/lawweb/avalon/decade/decad051.htm.

World Health Organization. 2000. The World Health Report 2000—Health Systems: Improving Performance. Geneva: Author. http://www.who.int/whr/2000/en/.

World Health Organization. 2003. The World Health Report 2003—Shaping the Future. Geneva: Author. http://www.who.int/whr/2003/en/.

World Health Organization. 2004. The World Health Report 2004—Changing History. Geneva: Author. http://www.who.int/whr/2004/en/.

World Health Organization. 2005. The World Health Report 2005—Make Every Mother and Child Count. Geneva: Author. http://www.who.int/whr/2005/en/.

Helena Legido-Quigley