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7.9 Public health sciences and policy in developing countries

7.9 Public health sciences and policy in developing countries
Oxford Textbook of Public Health

7.9
Public health sciences and policy in developing countries

Prayura Kunasol, Khanchit Limpakarnjanarat, and Prasert Thongcharoen

Introduction
Public health policy developed in response to immediate health problems
Policies developed from existing knowledge recommended by international organizations

Poliomyelitis eradication programme

The WHO Expanded Programme on Immunization

The WHO Control of Diarrhoeal Disease programme

The WHO Acute Respiratory Infection Control programme
Policies for the control of specific diseases derived from national scientific research

Hepatitis B vaccination policy

Prevention of HIV transmission from mother to child
Conclusion
Chapter References

Introduction
Developing countries are those countries with a low average income as well as a low gross national product compared with the ‘developed countries’. A shortage of resources prevails in these countries in terms of both national socio-economic development budget and infrastructure, especially in health-care delivery systems and trained human resources. Most developing countries suffer additionally from poverty, political instability, social unrest, and security problems that command the majority of their national budgets. The share of the total budget remaining for health is very small, usually less than 5 per cent, which is a small proportion compared with the developed world (World Bank 1993). Thus, they are often dependent on external support. The limited financial resources result in poor environmental sanitation and high morbidity and mortality from those preventable communicable diseases that have been eliminated from developed countries (Murray and Lopez 1996).
An appropriate health-care delivery system should follow good health planning resulting from a well-formulated public health policy. A shortage of capable health planning personnel leads to inappropriate national health policy development. In the developing countries, the major concern among policy-makers has been curative services (Doherty et al. 1999) to alleviate suffering from the major diseases prevalent in the locality. Thus, priorities are for hospitals to serve the immediate needs of sick patients instead of preventive services that are more cost-effective and impact on a greater proportion of the population. Furthermore, limited knowledge and technologies to ascertain health problems often leads to inappropriate health decisions by leaders. Public health sciences should be the basis for the formulation of public health policy but there is a lack of well-trained health personnel and experts in health planning.
The need to incorporate public health research into the formulation of public health policy in developing countries has to be recognized by policy-makers, especially politicians. Advocacy for appropriate health policy decisions by politicians should be carried out by knowledgeable public health experts. Strategies for public health policy formulation involve active participation by the key stakeholders including:

health providers both in the curative and preventive fields

resource-allocating authorities (e.g. budget bureaux, civil servant commissions, national economic and social development boards)

intended recipients of the policy

representatives of the general population, including the mass media and both local and national politicians.
Priorities in health have to be agreed upon by the majority of the stakeholders before specific policies can be accepted and implemented as a national plan. However, public health policy in developing countries evolves according to existing health problems and changes over time and in different situations.
Public health sciences used in policy formulation include epidemiology, biostatistics, clinical sciences, microbiology, immunology, behavioural sciences, public health administration, and health economics. The majority of these sciences are normally found in schools of public health but not all developing countries have schools of public health. Even in those developing countries where the training institutions for public health exist, they are rarely used to assist in the development of policy formulation and health administration. The design and implementation of health-care delivery systems, particularly primary health care, should be based on public health science principles to ensure their effectiveness in resolving health problems prevalent in the community. The availability of public health sciences, however, is dependent on the existence of training facilities for public health personnel. A shortage of financial support, as well as a lack of training facilities for public health personnel, limits the ability to utilize public health sciences for health policy formulation. Although there is less need for public health sciences for long-standing well-understood major acute infectious diseases, policy formulation and public health intervention are usually less complicated. However, utilization of the public health sciences is essential for dealing with the emerging and re-emerging diseases, and the rapidly increasing prevalence of non-communicable diseases. Development of public health sciences is therefore essential for developing countries to prevent continuing human and economic loss due to unabated health problems.
Developing countries with limited resources need to formulate those health policies that are most cost-effective. Surveillance can identify priority diseases but the use of public health sciences is essential to design effective public health surveillance systems for the early detection of health problems. Effective intervention measures can be implemented based on surveillance. Surveillance systems are also needed to evaluate the effectiveness of health-care delivery systems. Thus, public health sciences are major tools for policy-makers to plan and implement appropriate cost-effective health programmes.
In developing countries, academic institutions have greater access to public health sciences and technology than public health workers since most scientific books are written in English or one of the European languages which few health workers understand. The language barrier may therefore prevent public health workers from learning new technologies and health strategies. The involvement of local health personnel in pilot projects and clinical trials may assist them to learn new developments in health sciences and technology. Networking among research and academic institutions in developed and developing countries can also update the knowledge of the latest technologies of health workers in the public health sciences. The development of an international epidemiological surveillance system, proposed during the Twenty-first World Health Assembly in 1968, was a major step to encourage health workers to utilize public health sciences in planning and monitoring health-care delivery systems in developing countries.
The application of public health sciences and policy in developing countries can be classified into three groups according to the type of health problem and the strategies applied to resolve them.

1.
Policies developed in response to immediate health problems confronting the community, for example malaria, yaws, and rabies.

2.
Policies developed from existing knowledge, which are recommended by international organizations to address specific health problems, for example the smallpox and poliomyelitis eradication programmes, the Expanded Program on Immunization, the Control of Diarrhoeal Diseases programme, and the Acute Respiratory Infection Control programme.

3.
Control of specific diseases policies which are derived from national scientific research, for example AIDS, hepatitis B, hepatitis A, Japanese B encephalitis, and measles.
These three categories demonstrate how health sciences have contributed to public health policy development in developing countries.
Public health policy developed in response to immediate health problems
A developing country in the 1950s (Thailand) experienced an outbreak of acute haemorrhagic fever resulting in high morbidity and case fatality. There was limited knowledge about the natural history of the disease. Initially, public health policy focused on establishing treatment facilities in the affected areas. The policy was then modified, focusing more on learning about the disease by seeking international support in the 1960s. The intervention strategy for acute haemorrhagic fever subsequently emphasized vector control mainly by insecticides, initially followed by larval control (Bang and Tonn 1993). This is a demonstration of the evolution of policies for disease control in developing countries as public health knowledge increases in which the natural history of health problems are not well established initially and which have limited resources. Public health policy has to be formulated according to the prevailing situation, and will concentrate initially on providing immediate relief by setting up treatment facilities, followed by organization of scientific studies of the disease with assistance from international communities such as the World Health Organization (WHO), and subsequently by initiating effective control strategies. This is currently true for developing countries suffering from newly recognized, emerging, and re-emerging diseases.
Poliomyelitis is another example of an infectious disease that developing countries have had to face in which the initial response was to establish clinical facilities to cope with the disease. Improvement of environmental sanitation resulting in an older age at exposure to poliomyelitis, coupled with a decreasing infant mortality rate, resulted in a large outbreak of acute poliomyelitis in Thailand in 1952. There were more than 300 cases of poliomyelitis treated in Bangkok, which required special treatment facilities such as iron lungs. The King of Thailand himself donated a special fund for treatment and rehabilitation in response to the poliomyelitis epidemic. After the major outbreak in Bangkok, the disease spread throughout the country to other urban and rural areas. The outcomes of disease were not just limited to transient illness and mortality but also included disability, resulting in economic and social problems for families, the community, and health service providers. The foundation for the crippled, also under royal patronage, requested that the government consider oral poliomyelitis vaccination as a public health policy for preventing the disease. This resulted in a request from the Ministry of Public Health to the WHO in 1965 for an epidemiological study on the disease burden caused by poliomyelitis in Thailand and appropriate intervention measures which could be undertaken, including the feasibility of using the oral poliomyelitis vaccine. The last case of poliomyelitis was reported in Thailand in 1997. It is anticipated that poliomyelitis will be declared as eradicated in Thailand by the first few years of the twenty-first century. This example also demonstrates the evolution of policy formulation from a problem based on a knowledge-based response acquired with assistance from an international technical organization.
Rabies is a major health problem for developing countries. Treatment requires postexposure vaccination for people exposed to the animal reservoir, especially stray dogs. The disease has a 100 per cent case fatality rate once established, thus it is potentially a major health problem. The public health policy in Thailand was to provide postexposure vaccination against rabies free of charge using government funds. For religious reasons, a policy for control of the dog population by killing stray dogs was not generally accepted and thus lacked community support. Formulation of health policy towards rabies control in this situation was based on public perception and sensitivity of the community rather than on scientific knowledge and was not cost-effective. A better approach was to vaccinate both domestic and stray dogs, including those living in temple precincts. This policy gradually gained the co-operation and support of the public.
As late as 1988, Thailand and the rest of Asia were considered to be relatively free of HIV infection. However, that year, an explosive epidemic of HIV began among injecting drug users that ultimately spread to all levels of society. Thai officials moved from complacency to action despite controversy about the potential effect on the tourist industry during the ‘Visit Thailand Year’. The government realized that the country could not sustain its high growth in national income in the face of a huge HIV epidemic. The negative effects of uncontrolled HIV/AIDS on tourism, foreign investment, and remittances from Thai nationals working abroad were also recognized. The government decided to launch a policy to control the HIV epidemic by establishing a national AIDS prevention and control committee chaired by the prime minister. Screening of donated blood was established and expanded very quickly nationwide with the provision of reagents for HIV testing. A multisectoral co-ordinated planning and budgeting of HIV/AIDS-related activities among 14 ministries, international funding agencies, and local sources of support. The Thai strategy led to a broad consensus on the importance of taking action. To monitor the epidemic, Thailand established a comprehensive national HIV surveillance system in 1989. Increased spending for the prevention of HIV spread was initiated in 1991. Based on the experience gained from the sexually transmitted disease control programme, condom promotion became the basis of the HIV/AIDS control strategy. The government decided to mandate and enforce a policy of 100 per cent condom use in commercial sex establishments. The immediate impact was increased condom use in brothels and a continued decrease in sexually transmitted disease incidence. The prime minister’s office also launched a national campaign through the mass media to promote changes in the sexual behaviour of the population. Recent surveys have demonstrated that there have been changes in sexual behaviour in Thailand since the campaign was initiated (Nelson et al. 1996).
Policies developed from existing knowledge recommended by international organizations
Poliomyelitis eradication programme
As stated above, poliomyelitis has been a public health problem in developing countries. Much has been learned about the disease in the past two decades which has made eradication possible. Humans are the only reservoir, and a highly effective vaccine is available. These characteristics make a global policy of poliomyelitis eradication feasible (Ruff 1999). However, global eradication of poliomyelitis requires a global effort to achieve a high coverage of poliomyelitis vaccination (over 90 per cent). This requires the implementation of an intensive surveillance and case investigation system, which needs strong commitment from policy-makers and health-care personnel, including allocation of resources. The WHO made eradication of poliomyelitis a programme priority and implemented a global eradication programme based on surveillance and intensive case-finding. Eradication has now been achieved in many countries, both developed and developing alike, and is now found in only a few countries.
The WHO Expanded Programme on Immunization
Immunization has been recognized as one of the most powerful and cost-effective strategies to prevent and control diseases. For this reason, the WHO established the Expanded Programme on Immunization in May 1974. The countries of the South-East Asia region have expressed their commitment to reduce morbidity, disability, and mortality from those diseases for which potent, safe, and cost-effective vaccines are available. The Expanded Programme on Immunization has achieved a decline in all vaccine-preventable diseases. In many countries, this has been achieved through the establishment of vertical programmes to immunize children under 1 year of age systematically. In Thailand, for example, there has been a remarkable decline in many vaccine-preventable diseases, including diphtheria, pertussis, tetanus, measles, and hepatitis B, as well as poliomyelitis.
Following the successful smallpox eradication campaign, which included intensive surveillance, case investigation, and active case-finding, eradication has been proposed for other vaccine-preventable diseases such as poliomyelitis (see above). This policy cannot succeed, however, unless all countries agree to this goal as a health priority. The United Nations International Children’s Emergency Fund (UNICEF) and the WHO Global Programme for Vaccines and Immunization has now been organized and has adopted a framework which differentiates countries based on their capacities and vaccine needs (Batson 1998) as a basis for further action against vaccine-preventable diseases. Futher control must be based on sound public health science as the smallpox and poliomyelitis eradication programmes were.
The WHO Control of Diarrhoeal Disease programme
The high incidence and mortality from diarrhoeal diseases in infants justifies making control of these diseases a public health priority. Giving simple oral rehydration therapy and promoting breast feeding, based on the results of public health research, has greatly reduced childhood deaths from diarrhoea. A further reduction in morbidity requires national co-operation to improve sanitation, which is a difficult goal to achieve.
The WHO Acute Respiratory Infection Control programme
The Acute Respiratory Infection Control programme has been instituted because acute respiratory infections kill more than 4 million children every year in developing countries, most of which are caused by pneumonia. The WHO has developed simple and effective guidelines for the treatment of pneumonia based on research which has been incorporated into its Integrated Management of Childhood Illness Strategy (IUATLD 1998). Thailand incorporated the strategy into its national programme in 1990. Training of health-care workers and pharmacists and the implementation of the WHO guidelines, as revised by local experts, were instituted nationwide in Thailand. With the implementation of epidemiological surveillance, these rates could be assessed. Since the programme was implemented, there has been a reduction in pneumonia mortality and case-fatality rates and a decline in the inappropriate use of antibiotics.
Policies for the control of specific diseases derived from national scientific research
Only a few descriptive studies of policies derived from national scientific research have been reported from developing countries. Research is only one of many equally legitimate elements to be considered by policy-makers (Trostle et al. 1999). A few examples from Thailand will be used here to demonstrate the impact of incorporating research results into policy decision-making and implementation.
Hepatitis B vaccination policy
Public health policy formulated and developed to cope with the hepatitis B problem in Thailand provides an interesting case study. The evolution of public health policy on hepatitis B vaccination began in 1985 when a committee on control and prevention of viral hepatitis was set up by the Ministry of Public Health. The committee recommended vaccination of newborn children with hepatitis B vaccine. The Department of Communicable Disease Control adopted the policy in 1987 and launched the hepatitis B vaccination programme under the Seventh Five-year Public Health Development Plan (1992 to 1996). The rationale behind this was based on several medical and epidemiological studies of hepatitis B carried out by scientists from the Chulalongkorn and Mahidol Universities, the Armed Forces Research Institute of Medical Sciences, and the Ministry of Public Health. The carrier rate of hepatitis B virus was found to be 8 to 10 per cent in the 1980s while the infection rate in the general Thai population was 50 to 75 per cent, a very high endemicity. There were roughly 1 million deliveries every year, of which about 6 to 8 per cent were from hepatitis B carrier mothers resulting in the birth of 30 000 new hepatitis B carriers annually. This group served as a reservoir of hepatitis B virus. The evidence of a strong association between chronic infection of hepatitis B virus and hepatocarcinoma has been well documented. Although both plasma-derived and recombinant DNA hepatitis B vaccines were available, they were very costly.
Several different strategies for a hepatitis B vaccination programme were, therefore, proposed to the Ministry of Public Health with the support of scientific evidence. The evidence included cost-effectiveness analysis as well as operational research to assess the feasibility of an intervention using the existing health-care delivery system. An economic model was designed to compare the strategy of vaccination of all newborn infants without serological screening with other options, that is, vaccinating only newborns from hepatitis B carrier mothers. After reviewing the results of the cost–benefit analysis, the Ministry of Public Health decided to adopt the policy of vaccinating all newborns without screening for the hepatitis B virus carrier status in the mother.
During the period 1988 to 1992, a pilot programme was conducted in two provinces, Chiang Mai and Chonburi, to demonstrate that hepatitis B vaccine could be effectively administered along with other Expanded Program on Immunization vaccines without compromising the success of the existing immunization programme. The results from the pilot study, combined with other immunological studies of hepatitis B vaccination from academic institutes, contributed greatly to the policy of inclusion of hepatitis B vaccine in the existing Expanded Program on Immunization in 1992.
The public health policy on the nationwide hepatitis B vaccination programme was the result of incorporating public health scientific studies, including biomedical, epidemiological, and health economic studies carried out by health scientists in Thai universities, research institutes, and the Ministry of Public Health. The collaboration and exchange of experiences from health institutions and universities played a major role in the public health policy decision to be one of a few countries that included hepatitis B vaccine in the Expanded Program on Immunization programme prior to the WHO recommendation in 1997.
The development of human resources in health contributes to capacity building in health research that allows decision-makers to incorporate scientific research into policy formulation. Policy formulation to fight hepatitis B in many developing countries with a high incidence of hepatitis B, such as Thailand, Indonesia, Kenya, and Cameroon, presented a problem since the cost of vaccine was high, far beyond the capacity of most developing countries to pay. Hepatitis B had to also compete with other health problems prevalent in these countries (Muraskin 1995). The public health policy-makers in those countries needed to employ public health research to convince political bodies and the public that the vaccine programme was feasible, practical, and achievable. The experiences in Thailand, Indonesia, and many developing countries demonstrate that co-operation and collaboration between public health researchers, policy-makers, and politicians is essential for the formulation of effective health policies. The strategy used for the control of hepatitis B can also be applied to other public health problems.
Prevention of HIV transmission from mother to child
After the announcement of the success of the study on zidovudine in preventing HIV transmission from mother to infant in the United States and Europe, many developing countries, including Thailand, became interested. However, the cost of treating the mother for the last two trimesters of pregnancy was perceived as too high to implement. The Thai Ministry of Public Health approved a clinical trial of a short course of zidovudine to determine its efficacy in preventing HIV perinatal transmission. In 1998, the study was completed and published (Shaffer et al. 1999). An efficacy of 51 per cent, and the relatively affordable cost of short-term zidovudine treatment of mothers, led the Ministry of Public Health to recommend short-course zidovudine treatment for all HIV-infected mothers in Thailand (Kanshana et al. 2000).
Conclusion
Public health sciences and policy development in developing countries have evolved to address existing health problems. Knowledge gained from research needs to be used by public health administrators for effective policy development, especially in developing countries. Developing countries with limited resources need to formulate health policy appropriate to the problems facing them using the most cost-effective strategies. Application of public health sciences to policy formation can be organized into three strategies: (a) policies developed in response to immediate health problems confronting the community; (b) policies developed from existing knowledge recommended by international organizations; (c) policies for the control of specific diseases derived from national scientific research. For each it is important for public health researchers and decision-makers to co-operate in the formulation of health policy. To achieve this goal it is important to provide training for public health professionals, preferably in national schools of public health as well as abroad.
Chapter References
Bang, Y.H. and Tonn, R.J. (1993). Vector control and intervention. In Monograph on dengue/dengue hemorrhagic fever (ed. P. Thongcharoen). WHO Regional Publication no. 22, SEARO. WHO, Geneva.
Batson, A. (1998). Sustainable introduction of affordable new vaccines: the targeting strategy. Vaccine, 16 (Supplement), 593–8.
Doherty, J., McIntyre, D., Bloom, G., and Brijlal, P. (1999). Health expenditure and finance: who gets what? Bulletin of the World Health Organization, 77, 156–8.
IUATLD (International Union Against Tuberculosis and Lung Diseases) (1998). Communique from the International Conference on Acute Respiratory Infections, Canberra, Australia, 7 to 10 July 1997. Acute respiratory infections: the forgotten pandemic. International Journal of Tuberculous Lung Disease, 2, 2–4.
Kanshana, S., Thewanda, D., Teeraratkul, A., et al. (2000). Implementing short-course zidovudine to reduce mother–infant HIV transmission in a large pilot program in Thailand. AIDS, 14, 1617–23.
Muraskin, W.A. (1995). The war against hepatitis B: a history of the international task force on hepatitis B immunization. University of Pennsylvania Press, Philadelphia, PA.
Murray, C.J.L. and Lopez, A.D. (1996). Global health statistics: a compendium of incidence, prevalence, and mortality estimates for over 200 conditions. Harvard University Press, Cambridge, MA.
Nelson, K.E., Beyrer, C., Eiumtrakol, S., Khamboonruang, C., and Celentano, D. (1996). Changes in sexual behavior and a decline in HIV infection among young men in Thailand. New England Journal of Medicine, 335, 297–303.
Ruff, T.A. (1999). Immunization strategies for viral diseases in developing countries. Review of Medical Virology, 9, 121–38.
Shaffer, N., Chuachoowong, R., Mock, P., et al. (1999). Short-course zidovudine for perinatal HIV-1 transmission in Bangkok, Thailand: a randomised controlled trial. Lancet, 353, 773–80.
Trostle, J., Branfman, M., and Longer, A. (1999). How do researchers influence decision-makers? Case studies of Mexican policies. Health Policy Plan, 14, 103–14.
World Bank (1993). World development report 1993: investing in health. Oxford University Press.

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