Communicable diseases in the South-East Asia Region of the World Health Organization: towards a more effective responseIndrani Gupta a & Pradeep Guin aa. Institute of Economic Growth, University Enclave, University of Delhi (North Campus), Delhi, 110 007, India.Correspondence to Indrani Gupta (e-mail: email@example.com).(Submitted: 06 August 2009 – Revised version received: 11 December 2009 – Accepted: 11 January 2010.)Bulletin of the World Health Organization 2010;88:199-205. doi: 10.2471/BLT.09.065540IntroductionAlthough disease patterns change constantly, communicable diseases remain the leading cause of mortality and morbidity in least and less developed countries. Despite decades of economic growth and development in countries that belong to the World Health Organization (WHO) South-East Asia Region (http://www.who.int/about/regions/searo), most countries in this region still have a high burden of communicable diseases. This raises some urgent concerns. The first is that despite policies and interventions to prevent and control communicable diseases, most countries have failed to eradicate vaccine-preventable diseases. Second, sustainable financing to scale up interventions is lacking, especially for emerging and re-emerging diseases that can produce epidemics. Finally, in the present global economic and political context, it is important to understand how international aid agencies and donors prioritize their funding allocations for the prevention, control and treatment of communicable diseases. Prioritization is especially critical if one accepts the global public good character of communicable diseases.1,2This paper analyses the current burden of communicable diseases in the region and explores whether the current levels and trends in funding suffice to meet the needs for their control, prevention and treatment. Our analysis considers the health Millennium Development Goals (MDGs) and individual countries economic progress. We attempt to understand whether the current focus of disease prevention is appropriate and to ascertain what changes in direction might enable national and global policy-making to deal more effectively with communicable diseases.Communicable diseasesDisease burdenAlthough communicable diseases can be categorized in different ways, WHO uses three guiding principles for prioritization: (i) diseases with a large-scale impact on mortality, morbidity and disability, such as human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS), tuberculosis (TB) and malaria; (ii) diseases that can potentially cause epidemics, such as influenza and cholera; and (iii) diseases that can be effectively controlled with available cost-effective interventions, such as diarrhoeal diseases and TB.3 According to WHO data on the global burden of disease and the distribution of diseases among countries, communicable diseases contribute slightly more to the total disability-adjusted life years (DALYs) lost in the region (42\%) than in the world as a whole (40\%).4According to WHO,5 low-income countries currently have a relatively higher share of deaths from: (i) HIV infection, TB and malaria, (ii) other infectious diseases, and (iii) maternal, perinatal and nutritional causes compared with high- and middle-income countries. Although these three causes combined pose a lesser burden than non-communicable diseases, they will remain important causes of mortality in the next 25 years in low-income countries. In 2004, all countries of the region except for Indonesia, Maldives, Sri Lanka and Thailand were classified as low-income by The World Bank.Fig. 1 shows the share of the regions contributions to world DALYs lost due to infectious and parasitic diseases. The region bears a disproportionate share of diseases such as Japanese encephalitis, leprosy and dengue, which have been eliminated from most of the world. Countries of the region also contribute a higher share of DALYs due to childhood cluster and tropical cluster diseases than the rest of the world. WHO estimates that the region contributes 27\% of the global burden of infectious and parasitic diseases, 30\% of respiratory infections, 33\% of maternal conditions, 37\% of perinatal conditions and 35\% of nutritional deficiencies. If the first two categories are included under communicable diseases, the regions contribution to the global communicable disease burden is disproportionately high. Diarrhoeal disease is the leading causes of death in the region and accounts for 26\% of all deaths from infectious and parasitic diseases. TB, childhood cluster diseases, HIV infection, AIDS and meningitis are the other four major causes of death in the region. Diseases labelled as a priority by WHO (HIV infection and AIDS, TB and malaria) are common in all 11 countries. For example, the prevalence of HIV infection per 100 000 adult population is 982 in Myanmar, 447 in Nepal and 1144 in Thailand. The prevalence of TB per 100 000 population is 391 in Bangladesh, 253 in India, 244 in Nepal and 789 in Timor-Leste.6Fig. 1. Share of world DALYs due to infectious and parasitic diseases corresponding to the South-East Asia Region of the World Health Organization, 2004DALYs, disease-adjusted life years; STDs, sexually transmitted diseases.The data were obtained from the World Health Organization.4Table 1 shows the annual incidence of selected communicable diseases in the world and in the region. Some of the highest annual incidences worldwide of diarrhoeal diseases, lower respiratory infections, malaria, measles and dengue appear in the region. The percentage of the worlds disease burden contributed by countries of the region is 64 for measles, 36 for TB, 33 for upper respiratory infections, 52 for dengue and 28 for diarrhoeal disease.7 Clearly, communicable diseases present a mixture of challenges for the region, with a variety of them falling under all three WHO categories mentioned above: diseases with high mortality and morbidity, those that can potentially cause epidemics and those that can be controlled with available and proven interventions.Table 1. Annual incidence of selected communicable diseases worldwide and in the South-East Asia Region of the World Health Organization, 2004ahtml, 4kbNational and regional variationsThe share of total DALYs lost due to communicable diseases is higher than the regional average (approximately 30\%) in Bangladesh (48\%), India and Bhutan (44\% each), Myanmar (46\%), Nepal (49\%) and Timor-Leste (58\%). In contrast, this proportion is lower than the regional average in Sri Lanka (15\%), and similar to it in the Democratic Peoples Republic of Korea, Indonesia, Maldives and Thailand.Relatively older diseases such as TB, malaria, cholera and meningitis have recently recrudesced worldwide. At the same time, newer or re-emerging diseases such as infection with influenza A (H5N1) virus (avian flu), severe acute respiratory syndrome (SARS) and chikungunya have reached epidemic proportions in some countries. Many countries are also facing the rapid spread of infection with influenza A (H1N1) virus (i.e. pandemic influenza). In the region, Thailand has reported the most deaths from pandemic influenza, and India and Indonesia have reported a fairly rapid increase in the number of cases. In 2007, India and Indonesia were among the top five countries in the region in terms of the total number of TB cases.8 As for multidrug resistant TB, India contributes the most cases in the region, with Bangladesh ranking fifth.The five infectious and parasitic diseases that contribute the most DALYs lost are generally the same in all countries of the region although variations in the rank order exist. The top-ranking contributor is lower respiratory infections in 8 out of 11 countries; HIV infection and AIDS in Thailand, TB in Indonesia, and malaria in Timor-Leste. Countries of the region are thus facing huge challenges from diseases generally associated with underdevelopment, poverty and a less-than-effective health system, as well as from emerging infectious diseases.4Disease prioritiesIn-country estimates of disease burdens are the best tools for guiding prioritization, but a reliable analysis of how countries set their priorities is not easy because information and data are lacking on internal processes that lead to resource allocation. Unfortunately, ongoing burden of disease calculations are still not a priority in the region, and sustainable technical expertise for these analyses is also lacking. National health accounts, if available, are of some help but may not in themselves make comprehensive accounting of resource allocations for communicable diseases possible. Also, not all countries in the region have national health accounts in a format that allows comparisons of aggregates across countries, and this is true for communicable diseases. If functional allocations are assumed to be indicators of prioritization, then countries appear to be giving different weights to communicable diseases. For example, total health expenditure on the prevention and control of communicable diseases in India (1.4\%) is half the amount Sri Lanka allocates.9,10Another approach to prioritization is to use inputs from international agencies such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. Most countries in the region now have Global Fund resources for the prevention and treatment of these three diseases. Although this funding should be used for additional activities and interventions, there are no data or analyses that clarify whether they have complemented or substituted for the resources regularly allocated to communicable diseases.Disease prioritization is also implicit in MDGs 4, 5 and 6: to reduce child mortality, improve maternal health and combat HIV infection, AIDS, malaria and other diseases, respectively. Because most discussions of MDGs centre on Goal 6, attention is detracted from other conditions whose reduction would lead to a lower burden of communicable diseases. For example, improving maternal health would have a direct, positive impact on child health and reduce child mortality. Although Goal 6 embraces other diseases, in operational terms it includes only TB in addition to malaria, HIV infection and AIDS.11,12 If all three MDGs were addressed seriously, countries would see a reduction in communicable disease incidence. However, it is not clear whether funds are effectively allocated to the various diseases comprised by the three MDGs. For example, there are large global funding windows for the diseases targeted by Goal 6 but fewer windows for childhood disease interventions that go beyond vaccination and attempt to address other fundamental health and development sector issues. Current funding criteria may thus limit the effectiveness of existing strategies.Addressing other MDGs, such as the eradication of poverty and hunger, would also go a long way towardsmeeting health-centred MDGs. In the region, HIV infection is concentrated among populations that are marginalized, have adverse human development indicators and are mobile mostly because of economic reasons. Similarly, TB is seen to affect the marginalized, discriminated against populations, and people living in poverty”.13 Malaria disproportionately affects the poor, especially because its cause is linked to livelihood, migration and living conditions.14,15 However, other communicable diseases are also linked to poverty and underdevelopment. For example, undernutrition is an underlying cause of child deaths associated with diarrhoea, pneumonia, malaria and measles.16A look at the contributions from the region to world DALYs lost on account of different infectious and parasitic diseases (Fig. 1) shows that diseases prioritized by MDG 6 – HIV infection and AIDS, TB and malaria – are actually among the lowest-ranked. In contrast, Japanese encephalitis, leprosy, dengue and childhood cluster diseases in the region contribute much more to the total DALYs lost globally.Eradication of vaccine-preventable diseases could reduce disease burdens effectively. An analysis of data from 97 developing countries shows that immunization coverage is a statistically significant predictor of the infant mortality rate.17 The negative association between the latter and immunization coverage was also established in successive National Family Health Surveys in India.18 Although routine vaccination coverage has reached high levels in many south-east Asian countries, others, such as India, Indonesia, Myanmar and Timor-Leste, have not achieved full coverage.With vector-borne diseases on the rise, there are concerns about the ability of resource-deficient countries to combat large outbreaks. The prevention of outbreaks itself is challenging because of their complex determinants. This situation makes developing countries especially susceptible because the health sector can only play a relatively small role in prevention.19,20 The lack of a good disease surveillance system and the inadequacy of the primary care infrastructure compound the problems and make prevention, control and treatment of vector-borne diseases an urgent challenge.3,21Although progress towards the MDGs seems to be on track for HIV, TB and malaria in many countries of the region, realistic goals in the light of economic growth patterns, development paradigms and health sector realities should include all other major health conditions that affect these countries. It might be more relevant for countries to individually redefine the objectives established for MDG goals 4, 5 and 6 in accordance with their particular realities and disease burdens.The global economic crisisAccording to a recent study of 25 developing countries,22 a decrease in the growth rate of gross domestic product (GDP) by three percentage points in Asia and the Pacific is likely to translate into 10 million more undernourished people, 56 000 more deaths among children < 5 years old, and 2000 more mothers dying in childbirth. Moreover, this decline was predicted to delay the achievement of MDG targets relating to infant mortality and hunger by one year. This finding is important in the context of the recent global financial crisis. Among the 11 countries of the region, the non-financial or real sectors in countries such as the Democratic Peoples Republic of Korea, Indonesia, Timor-Leste and Thailand are much more affected by the global crisis compared to countries in South Asia. The impact of the recession on health spending and health outcomes, and hence on the control of communicable diseases, will be seen in several areas.23 (i) For example, overall budget cuts will result from a shrinking tax base and declining official development assistance. (ii) A possible impact on global health funding for communicable diseases might, in turn, affect national disease control programmes. (iii) Increased poverty and unemployment and declining incomes will lead to unfulfilled or delayed demand for treatment and poorer health outcomes. (iv) Increased subsidies will be needed to combat increased fuel and food prices. (v) Finally, the prices of essential drugs and medical goods will increase.A comparison of the percentage of GDP spent on health in the region (Fig. 2) shows that Timor-Leste and Maldives have been successful in raising resources for health over the years, whereas most other countries have been less successful. India has been able to increase health spending slightly since 2000. Indonesia and Myanmar have a very low ratio of health spending to GDP, whereas the rest of the countries are somewhere in-between. The overall level of health spending, in turn, determines how much spending will potentially be available for communicable diseases. Therefore the data strongly suggest that financing for communicable diseases will remain a source of worry, especially for countries most severely affected by the financial crisis.Fig. 2. Total expenditure on health as a percentage of gross domestic product in countries of the South-East Asia Region of the World Health Organization, 1995-2006The data were obtained from the World Health Organization.6For countries that depend on external funding, the decrease in aid is a major worry. Aid diminishes during economic crises and sometimes does not recover fully to earlier levels.24 A large part of the funds for communicable diseases come from international donors and private foundations based in developed countries. Therefore the current crisis will also have an impact on this flow, which in turn will have a disproportionate impact on communicable diseases programmes.Countries such as Maldives and Timor-Leste need to prepare for the effect of decreasing aid on their health sectors. Bhutan is somewhat less dependent on external funding and may therefore be able to escape the impact of declining aid. Although the current crisis has not significantly affected overseas development assistance in Nepal,25 the impact on communicable diseases linked to or aggravated by poverty and poor living conditions is likely to be severe enough to warrant serious attention from aid agencies. Myanmars economic growth has not translated into health sector gains, and this country also depends on foreign aid to augment its resources. Similarly, Bangladesh already faces increasing poverty and adverse health indicators, and the current crisis is likely to worsen the situation. Stimulus packages, implemented by some countries, may be needed.26 Maldives, a much smaller country, is in a better position to cope with the impact of the crisis since it has already received stimulus measures from domestic and international organizations. Timor-Leste, which is heavily dependent on aid, will need help to maintain its levels of investment in the health and social sectors.The impact of shrinking economic growth and aid on vulnerable populations has direct implications for communicable diseases programmes. Global financing to fight communicable diseases is not always aligned with the disease priorities of developing countries, and since donors tend to imitate each others funding decisions, the real needs of developing countries may be overlooked.27 Applying the concept of global public good to health funding decisions would help reprioritize financing for communicable diseases and eliminate the distortions caused by disease-specific funding.2 These priority issues are more relevant now that economic growth, especially in many donor countries, has slowed significantly.DiscussionThe global response to the financial crisis has been to maintain the quantity of aid to the extent possible, so as not to jeopardize progress towards the MDGs.28 For example, The World Bank is planning to triple the loans it provides to the health sector.29 However, inefficiencies and inadequate management within the health sector in many countries of the region reduce the effectiveness of aid. The issue of aid effectiveness has now received serious attention from development agencies, and among the concerns are the lack of harmonization and alignment, problems with predictability and the need for common arrangements and procedures.30 A high-level WHO consultation on the impact of the global crisis on health31,32 identified the need to make health spending more effective and efficient and to ensure adequate aid levels.As has been powerfully stated, every change in demography, vegetation, land use, technology, economics and social relations is also a potential change in the ecology of pathogens and their reservoirs and vectors and therefore a change in the pattern of infectious disease epidemiology”.33Preventing and responding to traditional, emerging and re-emerging communicable diseases is therefore a complex endeavour that will not succeed if it is limited to simply increasing the funds available to fight selected diseases. In times of financial crisis it is important for donor countries to find innovative solutions to enhance the effectiveness of their reduced volume of aid.34Although the 11 countries of the region are on different trajectories of growth and development, their struggle to eliminate underdevelopment and poverty has driven them to a high-growth strategy. However, high-growth policies are increasing the population vulnerable to communicable diseases. Clearly, economic growth alone is not the solution. The 2009 Global monitoring report of the International Monetary Fund and The World Bank calls the current crisis a development emergency because the potential increase in vulnerable populations may delay progress in the fight against communicable diseases.35Funding needs to be much more carefully matched to disease and health system priorities in each country. Although the MDG health goals are important benchmarks, programme goals should be more relevant, inclusive and realistic. They should be multisectoral and take into account both the realities of the health sector and the development path chosen by the country. Global health and development initiatives need to expand their focus to include diseases and conditions that are less well known or less discussed, while at the same time addressing socioeconomic and health sector constraints in each country. This approach would go a long way towards making aid more effective. Moreover, it would make donors and policy-makers more aware of traditional vaccine-preventable childhood diseases, traditional and emerging vector-borne diseases and respiratory infections, which remain among the most important contributors to high disease burdens in the WHO South-East Asia Region.Ultimately, countries should set their own priorities for the prevention, control and treatment of communicable diseases. It is up to each country to convince the world of where its priorities lie. The global public good character of some communicable diseases warrants concerted world action. Nevertheless, significant gaps in funding as well as regional variations require a more diverse set of national and international aid measures. Although regional and global collaboration is critical, future policies for reducing the burden of communicable diseases in the region will only be affective if they are based on evidence and country-led.
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