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Xin Ya Lim

How to improve women's health in poor countries

It has long been established that women face many health problems largely because of their roles in society 

. However, some of these health problems are also due to the lack of provision of health services irrespective of gender 

 and the lack of governmental commitment to address health problems 

 are two of the crucial factors that result in inadequate facilities and the lack of trained professionals in health services.

Everyday problems, like long waiting periods to see an obstetrician in emergency care, may seem like commonplace issues, but very often they are indirectly due to the poor management of the healthcare system 

. Health-related research could consider the broader picture by evaluating the role of authoritative figures in improving health care.

The focus on personal health problems that many women face in developing nations could be shifted on to policy makers.

the role of the government in addressing maternal mortality, female genital mutilation (FGM), and cervical cancer

. These are some of the most important public health concerns for women in low-income countries, and although there has been progress, local governments and international organisations should continue to address these issues in order to achieve health equity.

Graph: World Economic Forum — How Much Has Maternal Health Improved?

Some direct causes of maternal mortality include risks relating to pregnancy and childbirth as well as the poor quality of the health services 

. Other indirect causes, such as malaria 

 and anaemia from micronutrient deficiency 

 could also increase mortality rates. Though deaths due to malaria are 

hard to estimate and subject to substantial uncertainty

, the World Health Organization (WHO) estimates that malaria accounted for the death of over 10,000 pregnant women in 2009 

Almost all of these deaths occur in developing countries 

, and many of them are preventable. Complications from pregnancy or childbirth are often associated with the lack of effective emergency obstetric care 

, and the lack of family planning programmes 

Pregnant women in developing nations, especially those living in rural areas, lack access to health services 

. There are few obstetric care facilities available, especially in rural parts of these countries. Other barriers include the inadequate quality of the facilities and the shortage of trained staff 

. Even if they are available, the cost of health care services might also prevent mothers from seeking help 

Two crucial factors to reduce maternal mortality are the availability of skilled professionals in delivery (e.g., midwives and obstetricians) and emergency obstetric services (e.g., Caesarean section)

. Unfortunately, most low-income countries spend less than necessary on health services, including emergency obstetric care 

It is important for governments to invest more in infrastructure to prevent maternal mortality. The use of maternal health services would be greater if policy makers were more involved in public spending on maternal health, and financing interventions such as skilled birth attendants and Caesarean section 

. The cost-effectiveness of providing cesarean delivery services can be as low as US$251 for each Disability adjusted life year averted in countries with high maternal morbidity risk

Direct out-of-pocket payments also deter people from utilising health services 

, and this can lead to pregnant women using untrained professionals for delivery and antenatal care, which could result in complications. It is estimated that approximately 16-33% of maternal deaths could be avoided by skilled attendants during delivery 

. These people are trained to address the four main complications commonly experienced in developing nations (obstructed labour, eclampsia, puerperal sepsis, and obstetric haemorrhage) 

, and unskilled attendants are often unable to deal with such issues, which results in death.

 is evidence that long-term government commitment to improving health services for pregnant women can successfully reduce mortality rates in low-income countries 

. Between 2005-2015, maternal mortality rates have been steadily decreasing at the annual rate of 3.4% 

. The maternal mortality ratio has declined from 75 per 100,000 live births in 1990 to 30 per 100,000 live births 2015 

. Policies were implemented to improve maternal health services by expanding the antenatal care services, increasing the number of skilled attendants (e.g., midwives), and introducing family planning programmes 

. Sri Lanka’s active malaria eradication campaigns could also have reduced maternal mortality rates [18-21] as malaria in pregnant women could lead to anaemia 

. Anaemia accounts for 8-16% of the direct causes of maternal deaths worldwide, and is a major contributor to side-effects such as infection, haemorrhage, and eclampsia, which could result in death 

Family planning programmes not only reduce the number of unplanned pregnancies, but also decrease the number of maternal deaths by reducing deaths associated with abortions in the case of unwanted pregnancies 

contraceptives have reduced 44% of maternal deaths in the 172 countries analysed in 2008

. Maternal mortality associated with unsafe abortion is the one that is most easily prevented. Hence, the provision of contraceptives and the access to safe abortions would reduce overall maternal mortality 

Government officials should invest in family planning programmes alongside maternal care, as evidence has shown greater efficacy than maternal care alone in reducing maternal mortality 

. Overall, the significant reduction in maternal mortality when skilled attendants, investment in emergency obstetric care, and education were implemented in Matlab, Bangladesh 

 shows that investment in these measures is crucial.

Female genital mutilation (FGM) is defined as “the partial or total removal of the female external genitalia or other injury to the female genital organs for non-medical reasons” 

. FGM has negative health consequences for those who have undergone the procedure, including, commonly, shock caused by pain or haemorrhage, infections, and pain when passing urine and faeces. Other long-term consequences include increased risk of complications during childbirth and increased risk for urinary tract infections (UTIs). Women who are subjected to FGM are also more likely to suffer from psychiatric disorders, such as depression and anxiety 

Currently, there are over 100 million girls under the age of 15 who are subjected to FGM 

. In many African nations, FGM is ingrained in their cultures. Although the practice is less popular than before, action could still be taken to ensure that the practice of FGM is completely eradicated.

FGM was recently included in the new Sustainable Development Goals (SDGs) to “eliminate all harmful practices, such as child, early and forced marriages and female genital mutilations.” (Target 5.3). The WHO 

 has called for governments to establish legislative measures to protect girls from FGM, and promote awareness and public support to end the practice. 

Sadly, governments rarely prioritise FGM in their agenda.

The elimination of FGM requires the full commitment of government 

. Countries where FGM is prevalent should introduce stricter laws to prosecute adults (e.g., parents, community leaders) who allow girls to be subjected to FGM, and implement policies to raise the awareness of the harmful consequences of FGM at the same time. Medical practitioners who perform FGM on their clients should undergo disciplinary proceedings, and have their medical licenses revoked 

. An interagency statement (including UN Human Rights, UNICEF, and WHO) has urged governments to undertake these measures 

Governments should also liaise with community leaders, as illegal practices are prevalent despite the ban in some countries. It has been suggested that greater dissemination of information about FGM is crucial to improving practices 

. By garnering the support of community elders, awareness of the harmful consequences of FGM could be improved.

Cervical cancer is the second most common cancer amongst women under the age of 35 in the world, and the most prevalent cancer in developing countries

. Most cases are linked to certain types of human papillomavirus (HPV), which are commonly passed on during sexual activity. As such, cervical cancer is preventable with regular HPV testing or HPV vaccines. These interventions can be highly cost-effective (

major public health concern (especially in sub-Saharan African countries), but unfortunately it is not given the priority that it deserves

. Evidence showed that effective HPV screening programmes can promote early detection of cervical cancers 

Currently, in the UK, all girls aged between 12 and 13 years are offered HPV vaccination as part of the NHS childhood vaccination programme. However, due to the lack of financial resources, many developing countries are unable to introduce such programmes. Currently, only eight developing countries - Ghana, Kenya, Lao PDR, Madagascar, Malawi, Niger, Sierra Leone, and Tanzania - have received funding from GAVI to introduce pilot programmes 

Another cost-effective alternative would be to target HPV screening in high-risk women 

, and implement educational programmes at the same time. Educating people about cervical cancer is an effective preventative measure and promotes help-seeking behaviour at the same time 

The WHO suggests that countries should implement the control of cervical cancer through establishing a national cancer control programme, and integrating cervical cancer into primary sexual and reproductive health services.

Alternatives to the expensive cytology-based screenings could include visual inspection of the cervix after application of 3-5% of acetic acid (VIA) as well as other VIA methods using magnification devices, visual inspection after the application of Lugol's iodine, or HPV DNA testing, all proposed alternatives to cervical cancer prevention screening tests 

These are merely some of the issues that many women face in developing nations. There are more deep-seated factors underlying these problems. For instance, 

the status of women (i.e., the political, educational, cultural roles they play in society) has a direct impact on their access to healthcare. Therefore, when we address these problems, we also need to consider the role of women as well as the cultural differences between various countries.

For example, many low-income countries are patriarchal societies where the ultimate decision lies in the hands of the men in the family, such as the husbands, fathers, or brothers (e.g., Ethiopia, Nigeria, India) 

. The perception of male superiority is also prevalent in many Asian societies, and people may be reluctant to pay for the cost of health services for women. Additionally, women who live in rural areas also do not often have driving licenses or do not own motorised vehicles, which would impede their access to health care services, especially those with specialised care facilities 

it is crucial to push for women empowerment around the globe.

 Health organisations should liaise with organisations such as UN Women to educate people on the importance of women's rights, including their rights to health services.

Government officials have an important role to play.

 The lack of political support thus far has contributed to the slow progress. 

By advocating for political figures to be more involved in women’s health, effective altruists can have a more far-reaching impact on improving the lives of women in developing nations. For instance, effective altruists can conduct more research on effective ways to encourage governments to implement the measures mentioned above. Those who are interested in policy-making can collaborate with others to conduct cost-effectiveness analyses on various implementations that can improve the health systems.

They can also play a part in advocacy, by 

urging for government officials to commit to reduce maternal mortality rates, FGM cases and the prevalence of cervical cancer.

 By donating to NGOs, these organisations are not only pressuring the governments in developing nations to invest more in health, but also making a statement by highlighting the importance of addressing these issues. In fact, 

official development assistance for health to NGOs has significantly increased government health spending across the various developing countries

. Public health issues are undoubtedly political. 

It is time for us as effective altruists to urge the governments to fully commit to these health problems.

http://www.who.int/mediacentre/factsheets/fs348/en/

http://www.who.int/mediacentre/factsheets/fs241/en/

https://www.afro.who.int/health-topics/cervical-cancer

Juliet Bowater

Can cancer interventions ever be cost-effective?

With cancer costs in the USA spiralling into many tens of thousands of dollars

, and costs of some new biological treatments approaching £100,000 

, you could be forgiven for overlooking cancer interventions in developing countries as too expensive to be cost-effective.

Not so, according to the 2015 Disease Control Priorities 3rd Edition (DCP3)

cost-effective cancer intervention and treatment strategies

, offering an “Essentials Cancer Intervention Package” designed to reduce deaths from cancer, tailored to the wealth of a country and the infrastructure available. The 2011 World Health Organisation (WHO) “Best Buys” document

 also details highly cost-effective strategies for cancer intervention which could save millions of lives in the coming century, and which require relatively little infrastructure.

Cancer incidence worldwide - DCP-3 cancer report

Tobacco-related deaths are increasing rapidly, especially in low and middle income countries (LMICs)

, and tobacco use threatens to kill far more in the coming decades than it has in the past. By the middle of this century, it has been estimated that tobacco-related deaths will reach 10 million per year

With up to 2/3 of smokers dying of smoking-related diseases

 and losing, on average, 10 years of life (DCP3)

, it’s hardly surprising that both the WHO and DCP3 recommend tobacco intervention as one of their top global health priorities. In 2013, the World Health Assembly introduced a target for tobacco control 

, calling for a 1/3 reduction in use by 2025, with the aim of saving 200 million lives.

Tax boosts to increase cigarette price have been shown to reduce smoking, especially amongst young people 

. A report by the World Bank estimated that for every 10% increase in cigarette cost, tobacco consumption would drop by 4% in high income countries (HICs) and 8% in low income countries (LICs). Young people are also more likely to quit and less likely to start when prices are high

The WHO therefore recommends that excise taxes should account for 70% of cigarette cost

. A report by the Asian Development Bank stated that increasing the price of cigarettes by 50% through taxation would avert 27 million tobacco-related deaths in China, India, Thailand, the Philippines and Vietnam alone

. Price increases hit the poorest smokers in a population hardest 

but the taxes are not considered to be regressive

 since those with low income are the most likely to quit and gain the intended health benefits (for more information on this see our blog post - 

“Is Tobacco Control a “Best Buy” for the Developing World

Alongside price increases, education is also vital. The WHO Global Adult Tobacco Survey for China showed that only 23% of Chinese adults knew that smoking caused lung cancer, heart attacks and strokes

. This lack of awareness affects the poorest in a population the most, with those who are illiterate unable to read warning labels.

Pictorial warnings have been used to try and re-balance this inequality in some countries

, and there is evidence that pictorial warnings improve awareness of dangers of smoking and reduce the number of young people starting 

. Packaging controls are also important in reducing the impression that some cigarette brands are less harmful than others 

Total advertising bans have been effective in reducing cigarette consumption

, especially in low/middle income countries (LMICs)

, and bans on smoking in the workplace have also been shown to reduce consumption 

Large investments from The Bill and Melinda Gates Foundation and Bloomberg Philanthropies have gone towards increasing awareness of the dangers of tobacco, funding research and collecting data, and pushing for changes in policy to reduce tobacco use

Liver cancer has one of the highest mortality rates of any primary cancer. In 2012, it caused 746,000 deaths out of 782,000 cases 

. Highly cost-effective interventions are available to reduce the number of people who get the disease, and these interventions are recommended by both WHO and DCP3.

Hepatitis B vaccination is the first line of defence. Hep B is a cancer-causing virus responsible for around 60% of hepatocellular carcinoma (the most common type of liver cancer) in LICs 

. The virus attacks the liver, sometimes setting up an infection which can last for years. 15-45% of those with long-term infection will develop serious complications such as cirrhosis and liver cancer during their lifetime 

The majority of countries now aim to vaccinate children at birth, but coverage at birth is still low in some areas 

. Initial vaccination within 24 hours is very important in preventing mother-child transmission, which often results in dangerous long-term infection

. Increasing vaccine coverage should decrease Hep B infection rates and hence liver cancer incidence

 has more information on the cost-effectiveness of vaccination. As with 

, Giving What We Can did not find any promising vaccination funding opportunities.

Targeting other region-specific causes of liver cancer may also be cost-effective. High rates of liver fluke infection occur in some areas of eastern Asia, especially within the Mekong River Basin in Southeast Asia, where around 40 million people are infected

. The worms can infect a host for many years, causing damage to the liver’s bile ducts which can eventually lead to cancer

. Treatment with Praziquantel can clear the infection, though people in the area are often quickly reinfected by eating raw fish dishes 40.

Liver flukes are not the only parasite to play a role in cancer. Infection with Schistosoma haematobium has long been associated with bladder cancer 

, and is recognised as a cause of cancer by the IARC 

. Studies in the 1970s and 80s noted that bladder cancer was more common in areas in which Schistosoma haematobium infection was common

 and biopsies of tumours showed high incidence of schistosome infection 

. This neglected tropical disease is easily and cheaply treatable, and two of Giving What We Can’s recommended charities - the 

 - can provide treatment for around $2 per person per year.

Poor food storage can also lead to higher rates of liver cancer. Aspergillus flavus and Aspergillus fumigatus can infect staple foods during cultivation, including peanuts, rice and corn

. In areas where these foods are then stored in warm, high humidity environments, the fungus is able to grow, producing the highly potent aflatoxin. This toxin causes DNA mutations and is associated with both liver and lung cancer.

In people with chronic Hep B infection, exposure to aflatoxin increases the chance of liver cancer by 30-fold. Improved grain storage and cultivation methods can reduce the amount of the toxin that people consume, and with 4.5 billion people currently exposed to aflatoxin, the potential for reducing suffering is enormous.

The final WHO “Best Buys” are designed to reduce deaths from cervical cancer. Screening and treatment for early cervical lesions have been shown to be cost-effective. Opportunistic screening with an acetic acid test is low-cost and cancerous/precancerous lesions can be removed on the same day 

Since high-risk strains of Human Papilloma Virus (HPV) are responsible for up to 98% of cervical cancer cases 

, HPV screening can also be highly effective in averting deaths from cervical cancer. Screens are low-cost and some can be done at home, so women who do not want to come to the clinic or undergo a cervical examination can still be screened 

Vaccination against HPV virus strains 16 and 18 (those most commonly associated with cervical cancer) is also highly cost-effective in some areas

. These vaccinations are included in the DCP3 recommendations, though not the WHO “Best Buys” list. HPV-16 and -18 are responsible for more than 70% of cervical cancers 

, with HPV-16 detected in 57% of cervical cancers and HPV-18 detected in 17% 

. Along with 6 less common strains, these HPV types are responsible for over 90% of cervical cancer cases.

Blog

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