For a hospital-based violence intervention program to succeed, which activity must be undertaken?

Even though different levels of the health care system are associated with distinct types of services, each level requires some capacity for common services. DCP2 discusses a wide range of these cross-level services and related issues, three of which are discussed here.

"…12 percent of the world's disease burden is associated with conditions that could benefit from surgery."

Surgery has often been associated with technology-intensive interventions that can be extremely costly.5 Furthermore, surgery is neither specific to a particular disease or risk factor nor is it exclusive to a particular level of health care. Consequently, its public health potential has often been overlooked by health policy makers. DCP2 gives renewed attention to surgery as a cost-effective health care service for a range of common conditions.

DCP2 estimates that about 12 percent of the world's disease burden is associated with conditions that could benefit from surgery. These conditions cause losses of 21 DALYs per 1,000 people in the Americas and 38 DALYs per 1,000 people in Africa. Injuries account for about 38 percent of these surgical conditions, followed by malignancies and congenital anomalies.

Surgically treatable conditions fall into four general categories:

• surgical care to avert death or dysfunction among injury survivors

• obstetrical complications

• treatment of emergent and life-threatening abdominal conditions

• elective care of simple conditions, including hernias, club feet, and cataracts.

DCP2 defines surgery as services involving sutures, incisions, excisions, manipulation, and other invasive procedures that require local, regional, or general anesthesia. This definition focuses explicitly on the procedures and not on those who perform the surgery or the facility in which it takes place. This permits recognizing that many different kinds of health care workers can perform surgery if properly trained and that it can be done in different places if they are properly equipped. For conditions like cataracts or trachoma, surgery can be conducted via campaigns in which a cadre of workers is trained to screen, identify, and perform simple procedures using mobile facilities (box 6.2). Simple surgery can also be provided at the primary level for injuries, obstetrical complications, or congenital anomalies. District hospitals and referral hospitals can be configured to provide more complex surgical procedures as required.

Treating Cataracts in India.

"…surgeries conducted at a hypothetical community clinic serving a population of 20,000 people…would cost an estimated US$150 to US$350 per DALY averted."

DCP2 estimates the cost-effectiveness of surgeries conducted at a hypothetical community clinic serving a population of 20,000 people. Such a facility would treat approximately 4,000 surgical cases per year and be staffed by a nurse, a skilled birth attendant, and an orderly. The procedures would include treating simple cuts and bruises, removing foreign materials from the body, draining abscesses, treating basic burns, assisting normal deliveries, and treating simple trauma. Such services would cost an estimated US$150 to US$350 per DALY averted. More complicated surgeries, including abdominal and thoracic surgery, head injuries, obstetrical complications, and burn care, would be handled by district hospitals at an estimated cost of US$40 per DALY averted in South Asia and Sub-Saharan Africa, US$70 per DALY averted in East Asia and the Pacific, and close to US$100 per DALY averted in the remaining regions. The cost per DALY averted of surgical services in district hospitals is lower than in primary care facilities because of economies of scale. The fixed costs of district hospital surgeries are higher, but the hospital can be configured to handle a disproportionately larger number of surgeries. Whether these economies are realized in practice depends on reaching appropriate utilization rates.

Surgery can clearly be a significant component of any public health strategy. Surgery can prevent death and chronic disability in injured patients if it is timely and appropriate; it can reduce the risk of mortality and disability from obstructed labor, prepartum and postpartum hemorrhage, and other obstetrical complications; it can resolve a wide range of emergency conditions; and it can have a substantial impact on quality of life through elective surgery for such conditions as cataracts, ear infections, club feet, hernias, and hydroceles. If the right facility is appropriately staffed and equipped, surgery can be a cost-effective and important element of a functioning health system and of a public health policy.

"…surgery can be a cost-effective and important element of a functioning health system and of a public health policy."

Like surgery, emergency medical services represent a cluster of interventions that are not exclusive to any particular medical condition or level of health care.6 The defining feature is that outcomes are extremely time dependent. Emergency medical services address sudden medical conditions that require immediate intervention to avoid death or disability. While emergency services are often equated with ambulances, hospital emergency rooms, advanced technology, and high costs, in practice, emergency medical services are not exclusively focused on rapid transportation and invasive procedures. Rather, good emergency care can often be achieved through improved planning, appropriate training of first responders, effective communication, and innovative approaches to transportation.

"…the disease burden that is relevant to emergency medical services…account[s] for 36 percent of…DALYs."

Emergencies commonly arise from sudden injuries, obstetric complications, and infections, as well as from neglecting slow and chronic conditions. Thus the disease burden that is relevant to emergency medical services overlaps considerably with conditions that have already been discussed in previous chapters, such as maternal conditions and road traffic injuries. In total, such conditions account for 36 percent of the disease burden when measured in DALYs. About one-third of these DALYs are due to injuries; another one-third are related to chronic illnesses like diabetes, CVD, and asthma; and the final one-third are associated with communicable diseases and maternal conditions.

Emergency medical services comprise a continuum of care from first contact with patients until their conditions are stabilized. This includes making a rapid assessment to determine which interventions are most appropriate, arranging for prompt transportation to a facility best suited for treating the condition, and providing immediate emergency care. Once a patient arrives at a facility, emergency care services continue until the patient's condition has been stabilized.

The character of emergency medical services varies considerably across countries and regions. In many rural, low-income contexts, traditional healers such as bone setters may provide first aid, and transportation could be by canoe or animal-pulled cart. In high-income cities, by contrast, it is often characterized by the arrival of paramedical personnel in an ambulance. The key is not to emulate some ideal technology but to improve the organization and planning for emergency care, which can be done at a reasonable cost and would improve the utilization of resources, the care received, and the outcomes.

"…emergency care requires investments be made in facilities that can treat patients once they have been stabilized."

DCP2 highlights a range of issues that hinder low- and middle-income countries from providing adequate emergency care along with some innovative approaches to dealing with these obstacles. First, emergency care requires investments be made in facilities that can treat patients once they have been stabilized. Arranging for rapid transportation to a health facility that is ill-equipped or overburdened serves little purpose. Hence, as with so many other matters, the presence of an effective health care system is important.

"…in Kuala Lumpur…emergency response teams could not find the patient in 20 percent of emergency calls."

Second, rapid forms of communication can make a big difference to survival. In places where traditional telephones are not available, simple radio phones or, increasingly, cell phones can be used. Communication is important for coordinating care between the site of initial care and the facility where the patient will receive treatment, and it also serves to support first responders by allowing them to consult with other medical personnel and receive expert advice at the emergency site.

Third, proper planning can reduce response times and improve care. Sometimes this is as simple as assuring that accurate maps are available and that houses are numbered and streets have signs. One study in Kuala Lumpur found that emergency response teams could not find the patient in 20 percent of emergency calls.

Fourth, transportation has to be accessible at short notice. Vehicles with stretchers are the ideal, but many other means will do. In Malawi, a bicycle ambulance originally aimed at improving emergency obstetric care found regular use in transporting patients with all kinds of emergencies, including injuries.

Studies have found that the primary factor in survival has less to do with the speed of transport than with the effectiveness of life-saving care provided by the responding team. Emergency response systems require skilled and motivated personnel with appropriate supplies, pharmaceuticals, equipment, and support staff for coordination and management. Where resources are available, such systems can rely on full-time personnel with motorized transportation. Where resources are limited, a great deal can still be done with simple, sustainable approaches. For example, recruiting and training motivated citizens who often confront emergencies, such as public transport drivers, can greatly speed responses to emergencies (box 6.3).

Improving Trauma Care in the Absence of a Formal Ambulance System.

"…the use of trained lay responders in combination with trained volunteers…might be highly cost-effective, costing between US$73 and US$706 per death averted or between US$3 and US$27 per life year saved."

DCP2 reviews information on the use of trained lay responders in combination with trained volunteers. Such a program would require 7,500 lay first responders and 150 volunteer paramedics to serve a population of 1 million. The lay first responders could be trained in half a day whereas the volunteer paramedics would undergo 25 days of training. In each case, refresher courses would be required every three years to keep skills and motivation high. Such a program might be highly cost-effective, costing between US$73 and US$706 per death averted or between US$3 and US$27 per life year saved.

When an ambulance is added, costs are substantially higher. The level of cost-effectiveness is nonetheless still within reason. In urban areas, the increased costs are offset by greater utilization. DCP2 estimates that in urban areas, relying on ambulances would cost as little as US$60 per life year saved in South Asia, to about US$111 per life year saved in Latin America and the Caribbean, and US$176 per life year saved in the Middle East and North Africa. In rural areas, ambulance services would cost between two and three times more per life year saved because of lower utilization rates.

Countries should not neglect emergency medical services. At a minimum, improved planning and communications and additional training of volunteers can make a substantial difference to survival in emergency situations. Emergency medical services are another element requiring coordination in the health care service system, linking trauma scenes and other emergency sites to appropriate interventions at various levels of care. To be cost-effective, strategies must be appropriate to local conditions, whether this involves training bus drivers in first response care, engaging bicycle taxis, or equipping professional paramedics.

In the last 50 years, the number of effective medications for preventing and treating diseases has grown enormously.7 Some have prevented millions of people from contracting diphtheria, tetanus, polio, and measles. Others have treated bacterial and viral infections, such as pneumonia, TB, and HIV/AIDS. A large class of drugs is now available for dealing with chronic illnesses such as diabetes, CVD, and depression. Others are essential for palliative care.

"In the last 50 years, the number of effective medications for preventing and treating diseases has grown enormously."

The supply of drugs is critical for effective health care interventions. Policies to ensure that appropriate drugs are available to those who need them must address a range of issues:

• financial issues include funding for carrying out basic research and commercial development, defining and protecting intellectual property rights, and assuring affordability

• logistical issues relate to procurement, storage, and distribution

• clinical issues pertain to ensuring appropriate prescription practices and adherence to prescribed drug regimens

• incentive issues affect the involvement of pharmaceutical companies, private health care providers, pharmacies, and publicly financed or managed health services in drug research, development, and marketing.

The availability of drugs is highly uneven and exacerbates the inequitable distribution of health care around the world. Some 30 percent of the world's population lacks regular access to essential medications, ranging from 26 percent of Southeast Asians (excluding India), 29 percent of those in the WHO Eastern Mediterranean, Region, and 47 percent of Africans, to 65 percent of Indians. Meanwhile, the 15 percent of people who live in high-income countries consume approximately 90 percent of all medications (as measured by value).

"Some 30 percent of the world's population lacks regular access to essential medications…"

Private pharmaceutical companies and governments in high-income countries have focused on developing drugs that address the disease burden in their own countries. Of 1,325 new medicines that became available between 1975 and 1997, only 11 were specifically developed for tropical diseases. In the past decade, a few international initiatives have sought to redress this uneven distribution of benefits from medications. Some aim to improve access to essential medications that are already available, as is the case with GAVI and the Global Fund to Fight AIDS, Tuberculosis and Malaria. The goal of others is to promote research and development of new vaccines, treatments, or easier-to-administer drug regimens. These include Doctors Without Borders' Drugs for Neglected Diseases initiative, public research into developing vaccines for malaria, and new therapies for drug-resistant TB.

The key objectives of drug policies are to increase access to effective medications, improve and ensure their quality, and promote rational prescription practices by providers and rational use by patients. WHO has assisted numerous low- and middle-income countries to adopt national drug policies that include selecting a list of essential medications, assuring their affordability, regulating their quality, encouraging regular supplies, and promoting rational use.

The essential drug list is an important element of drug policy, because it focuses attention on the least expensive alternatives for treating priority categories of disease. In this way it simplifies the process of procurement, purchase, training, and use. WHO's guidelines include a list of 320 drugs in 559 formulations. Most of the countries that have used these guidelines list fewer than 300 drugs, ranging from a low of 180 drugs in Liberia to a high of 389 in the state of Karnataka, India. Like the drug list, the list of recommended vaccines has also increased through time as new ones have become available. Most countries still adhere to the original vaccines that were promoted as EPI (against TB, diphtheria, tetanus, pertussis, polio, and measles), but since these were first promoted, WHO has recommended adding new vaccines, such as those for hepatitis B, Hib, and yellow fever in countries where it is endemic.

"The essential drug list…focuses attention on the least expensive alternatives for treating priority categories of disease."

Procurement processes must pay attention not only to obtaining the best price but also to assuring the quality of the drugs and the reliability of the supply. For this reason, countries have been switching from open tender methods, which use price as the primary selection criterion and only secondarily consider quality and reliability, to restricted tender methods, which require bidders to submit information about their companies' reliability, financial stability, production quality, and past performance. Only manufacturers who are prequalified can enter the next stage at which bids are sought and the lowest bid is selected.

In general, drug prices have tended downward. This is due, in part, to the natural cycle of drug development. A new drug is usually protected by a patent, which restricts supply and keeps prices high until the patent protection expires or compulsory licensing is enacted and generic manufacturers can enter and compete. Some prices have declined dramatically as a consequence of collective negotiations, international advocacy, and public pressure, notably those of drugs to treat TB and HIV/AIDS, some of which have fallen by more than 90 percent in recent years.

Purchasing generic drugs in bulk is by far the easiest way for a country to get the most from a limited budget. When available in the appropriate forms and quality, generics are substantially cheaper than brand name drugs. A study in Malaysia found that 13 brand name drugs were from 4 to 45 times more expensive than the generic equivalents that were included in that country's essential drug list. To facilitate better negotiation and pricing, information on prices is now available internationally via Web sites. A variety of international programs have aimed to improve the affordability of essential drugs for low- and middle-income countries: the United Nations Children's Fund has a vaccine procurement program that handles 40 percent of the global demand, the Pan American Health Organization manages a revolving fund for the Latin American and Caribbean region, and the Gulf Cooperation Council Group Purchasing Program assists with tenders and logistics for six Persian Gulf states.

Procurement is only one element of the cost of supplying drugs, and the local component of drug prices can represent a sizable markup. In Sri Lanka, local costs add 64 percent to the imported price of drugs. In Kenya, the local component is more than 100 percent of the import price. Surveys suggest these levels of markups between import and retail are common. Public policy aimed at reducing this price wedge includes changing tax policies, such as granting exemptions from import duties or value added tax; implementing policies that reduce transportation costs; and introducing marketing regulations.

Once drugs have been selected and purchased, they must be appropriately stored and distributed. When drugs are distributed through public providers, the government must manage the logistics of forecasting demand, moving drugs effectively to where they are needed, making certain that they are stored in appropriate packaging at the proper humidity and temperature, and assuring the disposal of expired medications. To this end, countries have employed various methods, including distributing predefined kits of drugs on a schedule to more flexible and complex systems whereby health facilities place orders. Vaccines present their own challenges, especially the management of a cold chain to ensure that vaccines are kept at proper temperatures until used. When drugs are distributed through private pharmacies, the government's role focuses on monitoring distribution channels to ensure that packaging information is accurate, that appropriate storage is being used to maintain quality, and that expired medications are disposed.

"…as many as half of failures in drug therapies occur because patients do not comply with the prescribed regimen."

Proper prescription and use are the next steps. To be effective, the correct drug needs to be prescribed for the patient's condition with appropriate adherence to the correct dosage and duration of treatment. DCP2 estimates that as many as half of failures in drug therapies occur because patients do not comply with the prescribed regimen. Ensuring patient adherence is an element of the quality of health care services. It is best achieved where the health care system is sensitive and responsive to local attitudes, education, and culture; where health care workers communicate respectfully and clearly with patients; and where community support and information are available.

"Errors by medical staff or pharmacists account for the other half of failures…"

Errors by medical staff or pharmacists account for the other half of failures in drug therapies. Ironically, overprescribing drugs is just as common in low- and middle-income countries, which can ill afford to waste medications, as it is in high-income countries. Studies of IMCI programs in various countries found that better training of health care workers resulted in health outcomes that were similar to or better than average and that costs were often lower because the training led to more rational use of drugs and reduced unnecessary prescriptions (box 6.4). Doctors who also dispense drugs regularly appear to prescribe more drugs than nondispensing doctors, confirming the general recommendation that prescribing and dispensing should be separated whenever possible.

Improving the Use of Antimicrobials Through IMCI Case Management.

"Overuse of drugs for infectious diseases and improper adherence…accelerate the emergence of drug-resistant strains."

Overuse of drugs for infectious diseases and improper adherence can both be devastating to the effectiveness of health care, because they accelerate the emergence of drug-resistant strains. Cheaper drugs for malaria are already becoming ineffective, requiring recourse to costlier ACT. Drug-resistant strains of TB have emerged, requiring more frequent recourse to multidrug therapies and second-line drug regimens. Many of the increasingly resistant infections are common in low- and middle-income countries but not in high-income countries, which reduces the effective demand for research into new treatments to replace the old ones.

To delay the emergence of drug-resistant strains of illnesses requires actions that, concomitantly, improve the quality of health care. Appropriate prescriptions and adherence improve cure rates and inhibit the further spread of an infection. This can be achieved through a range of educational programs for public and private providers and dispensaries. It also requires ensuring a reliable drug supply, reducing financial barriers for people in low-income households, and improving communication with patients to support better compliance. Eliminating the routine addition of antimicrobial supplements to animal feed, as recommended by WHO, is another important component of this strategy.