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This special in-depth feature was authored by Dr. Ruth Levine, director of programs and senior fellow at the Center for Global Development.

There have been spectacular improvements in public health over the past half-century. In fact, more progress has been made in this time than in many millennia of earlier human history—especially in developing countries. In 1950, average life expectancy in developing countries was approximately 40 years. Today, it is about 65 years. The death rate for children under five has also been halved during this period.

© WGBH Educational Foundation and Vulcan Productions, Inc./“Rx for Survival”Despite these successes, large gaps in mortality and life expectancy between industrialized and developing countries remain. Ninety-nine percent of total childhood deaths in the world occur in poor countries, for example. Many of the health risks faced by those in developing countries are linked to poverty—poor nutrition, limited access to quality healthcare, and environmental threats.

The global community has increasingly recognized that it cannot rely exclusively on economic and social development alone, however, as the source of health improvements. With the recognition of the toll that diseases like HIV/AIDS takes in many of the poorest countries, and an understanding that infectious diseases that emerge in developing countries have potential worldwide consequences, global commitments to improving health in poor countries have risen to an unprecedented level.

But history shows that it is possible to improve the health of the poor—even in the face of grinding poverty and weak health systems. In Millions Saved, the Center for Global Development (CGD) documented 17 health interventions in poor countries that have succeeded in saving millions of lives. These programs—implemented at national, regional, or global levels—had to meet a set of rigorous selection criteria to be included in the book. The programs, therefore, represented a special fraction of health efforts: they had to be large scale; cost-effective; last at least five years; result in major improvements in human health; and be well evaluated.

Elements of Success

Above all, we learned that poverty does not condemn a health program to failure. Some of the world’s poorest countries have seen major public health successes. Throughout sub-Saharan Africa, for example, a campaign to combat guinea worm reached thousands of poor, remote villages and reduced

There were moments when the disease seemed insurmountable, the technology was still on the drawing board, the funding was nowhere in sight, international agencies were squabbling...

the prevalence of the disease by 99 percent. In Sri Lanka, despite relatively low national income and health spending, commitment by the government to providing a range of “safe motherhood” services led to a decline in maternal mortality—from 486 to 24 deaths per 100,000 live births over four decades. A program in Bangladesh used house-to-house visits to promote the use of oral rehydration therapy to treat dehydration in children and was able to teach 13 million mothers how to make and use a simple salt-and-sugar solution to save the lives of their children.

These achievements did not come without challenges. In almost all of the cases featured in Millions Saved, there were moments when the disease seemed insurmountable, the technology was still on the drawing board (or too expensive, or unusable in developing country conditions), the funding was nowhere in sight, international agencies were squabbling, and no one appeared ready to take up the challenge. In these instances, a combination of science, luck, money, vision and management talent came together to overcome daunting obstacles and transform the lives of millions of individuals and countless communities.

The successes also shared common elements, which were put together in unique ways in each case. While no single recipe emerges, there was a remarkably consistent list of ingredients: political leadership and champions, technological innovation, expert consensus, management that effectively used information, and sufficient financial resources. In some of the cases, the participation of the affected community and the involvement of non-governmental organizations (NGOs) were also central features.

Including NGOs

Most of the cases highlighted in Millions Saved represent achievements of the public sector, but some show the special role that NGOs can play, especially if they have a large reach and strong management. In Bangladesh, the huge NGO BRAC carried out the world’s largest oral rehydration program, reaching more than 13 million mothers and preventing vast numbers of childhood deaths. NGOs such as Sight Savers International have also played a key role in distributing ivermectin—the antibiotic that treats river blindness—throughout sub-Saharan Africa.

NGOs are often able to get to places where governments can’t—or won’t—go and they can be more flexible than the public sector in working with communities. Beyond service delivery, NGOs have a valuable role to play as watchdogs and advocates. For example, health-promoting NGO coalitions in Poland and South Africa formed the backbone of advocacy efforts that led to sweeping tobacco control legislation in both countries.

Managing Well

Good health service delivery requires that trained and motivated workers are in place and that they have the supplies, equipment, transportation, and the supervision to do their job well. This requires good management. Polio has been largely eradicated in Latin America due, in large part, to the establishment of national inter-agency coordinating committees in each country. These committees worked with ministries of health to develop national plans of action, set immunization strategies, and optimize the use of resources. They were composed primarily of technical experts, but also included donor agency representatives from many countries. The plans of action they developed now serve as an important management tool for planning other health interventions.

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