Address by Ernest Stern Senior Vice President, Operations of The World Bank to the International Conference on Oral Rehydration Therapy Washington, D. C. - June 10, 1983 HEALTH AND DEVELOPMENT Mr. Chairman, distinguished guests, ladies and gentlemen: I appreciate the opportunity to address this international conference on oral rehyd=ation therapy--a subject so vital to health in developing countries. Diarrheal diseases continue to be a major public health problem and a leading cause of illness and death in children under five throughout the developing world. This conference has highlighted the potential that oral rehydration offers for controlling these diseases. It is essential that this technology now be incorporated as rapidly as possible into effective, broad based health delivery systems. The last two decades have witnessed significant improvements in infant health in the low income countries.l/ • An average of 91% of infants survived the first year of life in 1981 as compared to only 84% in 1960. • Reductions in infant mortality have been the major contributing factor to the increased life expectancy in these countries over the same period and the willingness of an increasing proportion of families to reduce overall family size. 1/ The World Bank defines low income countries as those with a 1980 per capita gross national product (GNP) of $410 or less. ( ( -2- Nevertheless, for the low income countries2/, excluding China and India, infant mortality rates remain more · than 10 to 15 times higher than in the industrial market economies. The death rate in children one to four years of age in these same countries is more than 20 to 30 _ times that in industrial market economies. And the average life expectancy at birth is 26 years less. These disparities are profoundly unacceptable, all the more so since the majority of the direct causes of these infant and child deaths--neonatal tetanus, diarrhea and dehydration, childhood infectious diseases, malaria and respiratory infections, can be effectively and relatively inexpensively controlled by existing measures. Oral rehydration therapy is a prime example. It adds a major weapon to the low cost health system's armory to combat ill health, particularly for the large portion of the world's children under five years . of age who may have three or more potentially life threatening diarrheal episodes each year. Oral rehyration therapy represents the essence of appropriate technology: • it promotes increased self-reliance by providing families with a sense of control over their environment, and strengthening their ability to protect their childrens' health~ • it is adaptable, since it can be used in the formal health sector as well as at home, and it can be produced in a variety of settings as dictated by local circumstances, ranging from pharmaceutical industries to villagers. • ~t can substantially reduce overall health care costs, most profoundly when use.d as part of an early diagnosis and treatment regime which can be expected to significantly reduce the proportion of severe cases. Even in that small proportion of severe cases where intravenous fluids are initially indicated, ORT can quickly replace this much more costly and complex therapy. • it is widely applicable to countries at all levels of development. 2/ Note: For all low income economies, the average infant mortality rate in 1980 was 94/1000 live births; the child death rate was 12/1000 children aged 1-4 years; and the average life expectancy at birth was 57 years. If China and India are excluded, the low income countries' key health status indicators change significantly, with an average 1980 infant mortality r~te of 130/1000, child death rate of 22/1000 and life expectancy at birth of 48 years. In contrast, by 1980 the industrial market economies had reduced infant mortality rates to an average of 11/1000; child death rates to 1/1000 and achieved an average life expectancy at birth of 74 years. ( -3- The Need for an Integrated Approach The development of an appropriate technology is the first vital step in improving the quality and scope of health care. The development and refinement of this technology stands as testimony to the commitment, creativity, and perseverance of a large international body of scientists and health professionals, many of whom are assembled here today. We must now focus on how this technology can be disseminated effectively and adopted within national health care delivery systems. The complex interrelationships between diseases, and the multiple causes underlying excessive infant and child mortality in the developing world demand an integrated response. Redressing just one direct, albeit key, cause of death is insufficient to achieve desired reductions in mortality if the contributory causes remain. The child saved from death by dehydration remains at high risk of illness and death from numerous other causes, among the most important of which is malnutrition. 3 / We need, therefore, to establish health delivery systems which can deal with an array of interrelated problems, and can accommodate change over time as the dominant pattern of illness in the population shifts and new technologies emerge. And, of course, they must be cost-effective and affordable. Appropriate Delivery Systems The accumulating evidence that relatively simple existing technologies can significantly improve infant and child health status challenges us all to get on with the perhaps even greater task ahead--that of designing, implementing and managing appropriate systems which ensure that these technologies are delivered when and where needed. The existence of a technological advance does not necessarily imply its availability. In fact, the vast majority of the population of the low income countries remains relatively untouched by these promising technologies. Among the poorest population groups, key modern health services too often remain inaccessible geographically, economically and socioculturally. The need to develop appropriate delivery systems has been widely recognized within the international health community. Systems development constitutes the core of many of the diverse disease control programs which 3/ Malnutrition isa pervasive and insidious problem; a Pan American Health Organization supported study of childhood mortality in Latin America implicated malnutrition as the most important contributor to excessive mortality in under fives. While fecally related and airborne diseases exceeded malnutrition as the primary cause of death, immaturity (whether prematurity or low birth weight) and nutritional deficiency were the underlying or asso~iated causes of death in 57 percent of the children studied. See R. Puffer and C. Serrano, Patterns of Mortality in Childhood. Washington D.C.: Pan .American Health Organization, 1973. ( -4- have been launched throughout the developing ·world with impetus from and under the leadership of the World Health Organization. The program for control of diarrheal diseases, as has been noted at this conference, has devoted substantial human and financial resources to both operations research in pursuit of cost-effective interventions as well as strengthening program planning, manpower training, and ORT production and logistic capability. But the still largely underdeveloped state of national health systems in the poorer countries continues to be a major obstacle to the efficient operation of existing programs and the effective use of new technologies. And this is exacerbated by the tendency .in developing countries to imitate the high cost, curative care bias of the Western industrial nations. This diverts resources from more urgent and .appropriate health care needs. The lion's share of health sector expenditures in the Third World still is targeted on the service needs of the few to the relative neglect of the many. For example, • in Malawi the two largest urban areas, with 20% of the total population, in 1981 received over 60% of the recurrent government budget for health services. • in Senegal the hospital budget represented 51% of total recurrent public health expenditures in 1981/82 as contrasted to 29% of outlays on all regionalized services. • in the Philippines the 53% of the Ministry of Health's current budget spent on hospitals in 1982 contrasts sharply with the 29% expended on field health services. • Botswana's hospitals accounted for 42% of recurrent health outlays by central and local government in 1978, or nearly double that allocated to lower levels of care. These examples can easily be multiplied. Substantial capital investments--usually supported, if not initiated by, well meaning donors--in equipment and facilities, particularly hospitals, have in many cases locked countries into unsustainable recurrent cost requirements. Capital replacement can be a very costly substitute for adequate maintenance .and repair of such investments. Given the general lack of resources fqr health, increasingly rigorous efforts to obtain cost-effective solutions, which reflect the tradeof f s between capital and recurrent costs and which address the needs of the mass of the population, are required if a major impact on the world's health problems is to be effected. The initiation and viability of primary care oriented systems will, therefore, be dependent to a · large extent on the redirection of existing sectoral policies and programs. This redirection must be not only by the concerned governments but also by the multitude of bilateral, multilateral and domestic and external non-governmental organizations whose activities influence the long-term pattern of health development. This is a ., -r---------" ( (__ \ -5- responsibility which all of us concerned with the improved quality and scope of health care in the developing countries share, and it is an objective toward which we must work. The World Bank's Strategy Although the World Bank has long supported activities which contribute to improved health, mainly but not entirely through population projects, it was not until 1979 that it was decided to lend explicitly for health. We did this because the exclusive focus on family planning limited our ability to function effectively in family planning, particularly in those countries where the subject remains politically and culturally sensitive; but also because we felt that the Bank could make a contribution to health--in planning for it; in improving its efficiency; in integrating it in the planning of development, and in financing high priority needs. Starting in 1979 we have emphasized health sector work to improve our understanding of health needs in a number of developing countries. This has laid the foundation for a lending program of which we now estimate at about $250 million annually over the nex~ few years. I would like to emphasize that while we of course strive to bring about improvements in health for their own sake, an equally important reason for the Bank's increasing involvement in the health sector is that, through common delivery systems as well as the physical and behavioral interrelationships involved, investments in health yield huge developmental benefits through their impact on fertility reduction. This alone would justify our concern with health and, therefore, with ORT. The projects we are supporting form part of a general Bank strategy which is characterized by a three pronged approach: (1) The first prong is institution-building. In developing our lending program, the main focus of our efforts has been on building and strengthening country capabilities at all levels of the health system in five areas fundamental to the successful application of any technology: organizational and financial management and planning; analysis of perceived needs and consumer education; mobilization of resources; manpower development; and monitoring and evaluation--key elements of all first generation Bank-supported health projects. (2) The second prong is packaging of interventions. Bank projections are that the low income co~ntries will have available little more than $4-$5 per capita to spend annually in the public sector on health through the balance of this century. The scarcity of resources makes explicit choice among competing health care needs all the more imperati e, though difficult. Within the Bank's health sector work and lending activities, we have emphasized a quantitative, epidemiologic approach to health decisionmaking. This requires, for a particular country, an assessment of the prevailing health status (the incidence or prevalence, as well as the severity of various diseases), the underlying causes of those diseases, and identification of specific targets for reduction of morbidity and mortality. The least cost package ( ( -6- of interventions necessary to achieve the desired improvement in health status should then · be selected. In this process, family planning interventions tend to play a dominant role. Building health programs on a solid quantitative and analytical base is both information- and time-intensive. Our firm belief, however, is that such analysis is the basis of sound health programming, and essential to strengthening the ability of Health Ministries to participate in the formulation .of development strategies, to improve their own planning capacity and to make effective use of scarce resources. It is within this general framework that Bank economic and technical support has been provided to 33 governments in the conduct of population, health and/or nutrition sector analyses since our health program commenced in late 1979. While we must tailor our lending for health to each country's specific needs, nevertheless, a common set of requirements consistently emerges for low income countries--control of diarrheal, respiratory and other childhood infections; stimulation of appropriate infant and tices; growth and development monitoring; child feeding prac- and control of factors adversely affecting the health of women, particularly during their reproductive years. Behavioral changes in relation to health, nutrition and family planning will be the key to achieving desired improvements in health status. Within this framework, given the strong linkages between high fertility and high maternal and infant mortality, family planning, including child spacing continues to command very high priority. Frequent, successive pregnancies exact a high maternal health toll. Maternal mortality rates are estimated to be up to 100 to 200 times higher in the low income countr~es than in the industrialized world,4/ and total fertility rates are commonly three times greater than in industrial countries. The mother is central to implementation of all key interventions within primary care programs--both as provider, as in the case of ORT, and as key decisionmaker in most countries as to when and where to seek child health care. Protection of her health is . €ssential, therefore, not only to her own welfare but to that of .the entire family. While birth spacing is important--since the risk of children dying is very much greater for infants of short birth intervals as compared to those widely spaced--it is only one aspect of family planning. The continued high levels of fertility in many countries continue to be a major threat to their long-term viability, to the success of economic 4/ World Health Organization. Sixth Report on the World Health Situation: Part - One Global Analysis. Geneva, 1980, p. 129. ,! ~-------~ - ~ ~ ~ - ~~~~~~~~~~=========~=========-~~--. ( ( -7- development and to the prospects of improving the well-being of their population. None of us working to help reduce disease and mortality, can ignore the demographic impact of these changes. We fail in our responsibilities as advisors and supporters, if we do not continue to stress the importance not include as a priority objective of this issue and if we do _ in the expansion of health care delivery systems provision for rapidly expanding family planning services. Reduction of mortality and of fertility cannot be seen as separate objectives of we have the long-term welfare of the developing countries at heart. (3) This brings me to the third prong of the strategy--accelerating socioeconomic development. The successful delivery of key technologies such as ORT is not the end of the road. ORT is still curative care. Thus, while it can be a cost-effective short term response, over the longer term disease prevention, focusing on the key underlying causes of illness and deaths, should command higher priority. Unravelling the seamless web of poverty and associated ill health will require a long term commitment by governments as well as by the diverse public and private organizations involved in development, many of which are represented here. Health development demands more than the application of technology. Its direction and pace will be integrally linked to the national planning process and the political, social and economic policy choices each country makes. Population is the denominator in the most widely used indicators of economic development. The prospect of diminishing returns to labor and continued high unemployment rates suggests that lowering population growth rates is an essential prerequisite to progress. Health development will necessitate significant policy and institutional reforms, and substantial investments in key sectors widely recognized as important to achieving desired health status improvements and fertility decline, notably agriculture and food; water supply and environmental sanitation; education, particularly female education; and housing. Such investments may be included as components of rural and urban development programs. ~o maximize the potential benefits of investments in these areas, the Bank has frequentlj included components which specifically address health objectives, such as population, health and nutrition education. More generally, assistance in projects and policies designed to stimulate economic growth and employment generation will continue to be an essential element of the World Bank's contribution to the alleviation of population and health problems. The general Bank strategy, described above in terms of the three-pronged approach, is illustrated in virtually all Bank-supported ( -8- ( health projects. Following extensive sector ·work, they all aim at facilitating institutional changes which emphasize the orientation of health care delivery systems to meet the needs of the most disadvantaged groups, whose health problems are typically most acute. The packaging of interventions, based upon a system-wide review of demographic and epidemiologic priorities and identification of cost- effective solutions, is illustrated in a project in Mali, where a large-scale population-based epidemiologic survey, combined with evidence about household expenditures on health, helped to identify priorities and assess the financial feasibility of the selected interventions. Similarly, in Peru considerable care has been taken to identify t~ose communities where the epidemiological needs are greatest, and to give them priority in the project design. This choice parallels decisions made in other sectors -to emphasize these same population groups in the provision, for example, of water supplies, education, and income-generating activities. The search for the least cost means of providing health care and the choice of appropriate financing mechanisms are major features of this project. Indeed, cost-effective approaches are sought in all projects: for example, in Malawi, the project should result in considerable savings in the cost of pharmaceuticals; and in Brazil, savings in delivering urban health services will be achieved. More generally, · in all projects, institutional reform, training and education programs, as well as investment in actual health facilities, are designed to build institutional capacity to identify and respond to the most urgent health needs, and to facilitate the introduction of family planning services. Overall, in Bank-supported projects we aim to create an environment in which appropriate choices and appropriate technologies will emerge from the institutions we have helped to build. The increasing use of oral rehydration therapy in project areas will help to accelerate this progress. It will serve ~ot only to address the vital and immediate problem, but it will also help in freeing up resources either to expand and strengthen the general capacity of health care systems, or to address the c auses of poverty and ill health in the developing world. more fundamental _