《卫生经济学》课程参考文献（WHO年度报告）：World Health Report 2002_Reducing Risk Promoting Healthy Life_Chapter5 Some Strategies to Reduce Risk

Some Strategies to Reduce Risk cholesterol reduction consists of individuals with combinations of risk factors, such as be- g male, with ischaemic changes, who smoke, are obese, are not physically active and have high blood pressure and high cholesterol (11). Designing interventions for people with a combination of those risk factors might well prove to be more effective than treating people only on the basis of their levels of cholesterol(12). This form of targeted approach will sequently be called the"absolute risk approach The high-risk approach can be viewed as targeting the right-hand tail of the risk factor curves in Figure 5.1(13). The alternative is to try to shift the entire population distribution of risk factors to the left -like shifting the distribution of blood pressure for London civil servants in the direction of that of Kenyan nomads. This has the potential to improve popu lation health to a much greater extent than a high-risk approach, while at the same time reducing the costs of identifying high-risk people. On the other hand, the costs of provid ng an intervention to the entire population would, in this case, be higher than providing it only to people in the right-hand tail. Which approach is the most cost-effective in any setting will depend on the prevalence of high-risk people in the population and the costs of identifying them compared with the costs of the available blood pressure reduction THE ROLE OF GOVERNMENT AND LEGISLATION Some areas of behavioural change are likely to be adopted relatively easily once infor- mation becomes available, assuming that the technology is affordable. Other types of be havioural change will benefit from active government intervention, particularly those where people have high rates of time discount or low rates of risk aversion. Government action is required if the full potential to improve population health through the reduction of alcohol substances. Such. mption is to be achieved, partly because of the addictive nature of these and tobacco con action could be through changes in the law or financial incentives and disincentives. Road safety is another area where a significant number of people might not Figure 5.1 Distributions of systolic blood pressure in middle-aged men in two populations nomads 80 Source: Rose G Sick individuals and sick populations. Intermational Journal of Epidemiology 1985: 14:32-8

Some Strategies to Reduce Risk 105 cholesterol reduction consists of individuals with combinations of risk factors, such as be￾ing male, with ischaemic changes, who smoke, are obese, are not physically active and have high blood pressure and high cholesterol (11). Designing interventions for people with a combination of those risk factors might well prove to be more effective than treating people only on the basis of their levels of cholesterol (12). This form of targeted approach will subsequently be called the “absolute risk approach”. The high-risk approach can be viewed as targeting the right-hand tail of the risk factor curves in Figure 5.1 (13). The alternative is to try to shift the entire population distribution of risk factors to the left – like shifting the distribution of blood pressure for London civil servants in the direction of that of Kenyan nomads. This has the potential to improve popu￾lation health to a much greater extent than a high-risk approach, while at the same time reducing the costs of identifying high-risk people. On the other hand, the costs of provid￾ing an intervention to the entire population would, in this case, be higher than providing it only to people in the right-hand tail. Which approach is the most cost-effective in any setting will depend on the prevalence of high-risk people in the population and the costs of identifying them compared with the costs of the available blood pressure reduction strategies. THE ROLE OF GOVERNMENT AND LEGISLATION Some areas of behavioural change are likely to be adopted relatively easily once infor￾mation becomes available, assuming that the technology is affordable. Other types of be￾havioural change will benefit from active government intervention, particularly those where people have high rates of time discount or low rates of risk aversion. Government action is required if the full potential to improve population health through the reduction of alcohol and tobacco consumption is to be achieved, partly because of the addictive nature of these substances. Such action could be through changes in the law or financial incentives and disincentives. Road safety is another area where a significant number of people might not Source: Rose G. Sick individuals and sick populations. International Journal of Epidemiology 1985; 14:32-8. 0 10 20 30 40 60 80 100 120 140 160 180 200 Systolic blood pressure (mmHg) Population (%) Kenyan nomads London civil servants Figure 5.1 Distributions of systolic blood pressure in middle-aged men in two populations

106 The World Health Report 2002 choose to drive safely, or use seat belts or motorcycle helmets, but government action can encourage them to do so, thereby preventing injuries to themselves and to other people. Increasing prices through taxation certainly reduces smoking (14)even if smuggling increases subsequently(15). A particular focus of this chapter is to explore if this type of government action is cost-effective. In some countries there has been debate about whether governments should play this type of role, and information on the costs and impact on population health are important inputs to this debate. DIFFERENT WAYS OF ATTAINING THE SAME GOAL Different sets of interventions can be used to achieve the same goal and some interven tions will reduce the burden associated with multiple risk factors and diseases. Interven- tions to reduce blood pressure, cigarette smoking and cholesterol all reduce cardiovascular disease, and each has been used separately and together with others at different times and in different settings. The effect of doing two at the same time might be more than would be expected by adding the benefits of doing the two interventions singly, or might be less Much ischaemic heart disease mortality that has traditionally been attributed to particular sk factors is, in fact, caused by those factors in combination with other risk factors(16) Partly as a result of these interactions, risk reduction strategies are generally based on a ombination of interventions rather than just one The decision about which combination should be undertaken for the available resources complex. It is necessary to determine the health gains, and the costs, of doing each pos sible intervention by itself and in combination with the other ways of reducing the burden for a given risk factor or disease. The analysis undertaken for this chapter followed that process by evaluating what would be achieved by each intervention alone and in combina tion with other interventions TECHNICAL CONSIDERATIONS FOR COST-EFFECTIVENESS ANALYSIS The estimates, which provide the basis of the results reported in this chapter, were un- dertaken on a regional basis as part of the WHO CHOICe project. The six WHO regions were divided into mortality strata as described in earlier chapters, resulting in 14 epidemio- logical subregions. The total costs and total effects of each intervention were estimated separately for the 14 subregions. Eventually it is hoped that there will be sufficient data to make estimates at a country level, and even at the subnational level for large countries, but this is not currently possible Subregional analysis offers a valuable basis from which country analysts can work to calibrate the results to their settings. It is much more policy-relevant than a global analysis because the epidemiology, cost structures, and starting points (such as the availability of trained health staff and the history of health interventions)varies less within each subregion than across the world as a whole. The results are used here to identify interventions that are ery cost-effective, cost-effective, and not cost-effective in each subregion. Costs are reported in terms of intermational dollars rather than in US dollars, to account better for differences in cost structures between settings. Unit costs for most regions are higher using international dollars(s) based on purchasing power parity exchange rates than they would be if official exchange rates had been used. Effectiveness is measured in terms of disability-adjusted life years(DALYs) gained by the intervention. A brief descrip

106 The World Health Report 2002 choose to drive safely, or use seat belts or motorcycle helmets, but government action can encourage them to do so, thereby preventing injuries to themselves and to other people. Increasing prices through taxation certainly reduces smoking (14) even if smuggling increases subsequently (15). A particular focus of this chapter is to explore if this type of government action is cost-effective. In some countries there has been debate about whether governments should play this type of role, and information on the costs and impact on population health are important inputs to this debate. DIFFERENT WAYS OF ATTAINING THE SAME GOAL Different sets of interventions can be used to achieve the same goal and some interven￾tions will reduce the burden associated with multiple risk factors and diseases. Interven￾tions to reduce blood pressure, cigarette smoking and cholesterol all reduce cardiovascular disease, and each has been used separately and together with others at different times and in different settings. The effect of doing two at the same time might be more than would be expected by adding the benefits of doing the two interventions singly, or might be less. Much ischaemic heart disease mortality that has traditionally been attributed to particular risk factors is, in fact, caused by those factors in combination with other risk factors (16). Partly as a result of these interactions, risk reduction strategies are generally based on a combination of interventions rather than just one. The decision about which combination should be undertaken for the available resources is complex. It is necessary to determine the health gains, and the costs, of doing each pos￾sible intervention by itself and in combination with the other ways of reducing the burden for a given risk factor or disease. The analysis undertaken for this chapter followed that process by evaluating what would be achieved by each intervention alone and in combina￾tion with other interventions. TECHNICAL CONSIDERATIONS FOR COST-EFFECTIVENESS ANALYSIS The estimates, which provide the basis of the results reported in this chapter, were un￾dertaken on a regional basis as part of the WHO CHOICE project. The six WHO regions were divided into mortality strata as described in earlier chapters, resulting in 14 epidemio￾logical subregions. The total costs and total effects of each intervention were estimated separately for the 14 subregions. Eventually it is hoped that there will be sufficient data to make estimates at a country level, and even at the subnational level for large countries, but this is not currently possible. Subregional analysis offers a valuable basis from which country analysts can work to calibrate the results to their settings. It is much more policy-relevant than a global analysis because the epidemiology, cost structures, and starting points (such as the availability of trained health staff and the history of health interventions) varies less within each subregion than across the world as a whole. The results are used here to identify interventions that are very cost-effective, cost-effective, and not cost-effective in each subregion. Costs are reported in terms of international dollars rather than in US dollars, to account better for differences in cost structures between settings. Unit costs for most regions are higher using international dollars (I$) based on purchasing power parity exchange rates than they would be if official exchange rates had been used.5 Effectiveness is measured in terms of disability-adjusted life years (DALYs) gained by the intervention. A brief descrip-

Some Strategies to Reduce Risk tion of the methods is found in box 5.1, while full details of the methods and the calcula tions can be found on the WHo web site. 6 It is not much value to provide decision-makers with information on the costs and effectiveness of interventions that are undertaken badly. Accordingly, the results reported here show what would be achieved if the interventions were undertaken in a relatively efficient manner. For example, we assume capacity utilization of 80% in most settings -for example, staff and capital equipment are fully occupied for 80% of the normal working day except when estimating the effect of expanding coverage to very high levels. To reach% of the population it might be necessary to provide facilities in isolated areas where popula tion numbers are insufficient to support such high rates of capacity utilization.The results, therefore, provide guidance on selected interventions that should be given high priority in the policy debate about resource allocation, but only if they are undertaken in an efficient manner Sets of interventions that interact in terms of effectiveness or costs are considered to gether, as stated earlier. For example, interventions to reduce risks associated with hyper- tension and high cholesterol interact. The analysis is based on estimates of the effects on population health of reducing blood pressure alone, reducing cholesterol levels alone, and doing both toget In addition, many of the interventions are evaluated at different levels of coverage. For most, three levels were used (50%, 80%and 95%)and the impact on costs and effects of expanding coverage was incorporated The standard practice in this type of analysis is to discount both the health effects and the costs of the different programmes under consideration. There is no controversy about 5.1 Methods for cost-effectiveness analysis The cost-effectiveness analysis on which this terventions or combinations of interventions. For quantities of inputs required to run each inte reportis based considered what would have hap- example, based on data from earlier chapters, vi- vention were estimated by experts in 17 regions ned if a set of interventions had not been tamin A deficiency increases the risk of dying from of the world and validated against the literature implemented and compared the result with what diarrhoea. The impact of vitamin A supplementa- Some individual-level costs were obtained by happens on their implementation. Through a tion is then mediated in the model by a decrea multiplying unit costs of inputs by the expected four-state population model, the number of in case fatality rate for diarrhoea Effectiveness data utilization of those inputs by the people covered ed over a period of a hun- came from systematic reviews where available. The by the programme. Unit costs for outpatient vis- dred years by a population in the absence of that difference in the healthy life years gained by the its and laboratory tests were obtained from a set of interventions is estimated by inputting population with and without the intervention is review of literature and supplemented by pri parameters of incidence, remission, cause-spe- the impact of the intervention and is entered as mary data from several countries. The total costs valuations reflecting the natural history of the Costs covered in this analysis indude expenses stitutes the denominator of the cost-effective- disease. The parameters reflecting the natural associated with running the intervention, such as ness ratio history of the disease were mostly estimated by administration, training and contact with the me- Stochastic uncertainty analysis was carried back-adjusting current rates using coverage and dia. They also indude costs incurred at the indi- out for key parameters in both the numerator known effectiveness of interventions. The same vidual level such as counselling. Considerableeffort and denominator four-state population model can then be rerun, was exerted to try to standardize the methodol reflecting changes in the parameters due to in- ogy used in collecting and classifying costs. The Sources: (3, 17-19). 5 This is important to keep in mind when benchmarking the estimates in this chapter against those re- sewhere, usually in US dollars. International dollars are derived by dividin by an estimate of their purchasing power parity(PPP)compared to a USS PPPs are the rates of currency onversion that equalize the purchasing power of different currencies by eliminating the differences in s price levels between countries

Some Strategies to Reduce Risk 107 tion of the methods is found in Box 5.1, while full details of the methods and the calcula￾tions can be found on the WHO web site.6 It is not much value to provide decision-makers with information on the costs and effectiveness of interventions that are undertaken badly. Accordingly, the results reported here show what would be achieved if the interventions were undertaken in a relatively efficient manner. For example, we assume capacity utilization of 80% in most settings – for example, staff and capital equipment are fully occupied for 80% of the normal working day – except when estimating the effect of expanding coverage to very high levels. To reach 95% of the population it might be necessary to provide facilities in isolated areas where popula￾tion numbers are insufficient to support such high rates of capacity utilization. The results, therefore, provide guidance on selected interventions that should be given high priority in the policy debate about resource allocation, but only if they are undertaken in an efficient manner. Sets of interventions that interact in terms of effectiveness or costs are considered to￾gether, as stated earlier. For example, interventions to reduce risks associated with hyper￾tension and high cholesterol interact. The analysis is based on estimates of the effects on population health of reducing blood pressure alone, reducing cholesterol levels alone, and doing both together. In addition, many of the interventions are evaluated at different levels of coverage. For most, three levels were used (50%, 80% and 95%) and the impact on costs and effects of expanding coverage was incorporated. The standard practice in this type of analysis is to discount both the health effects and the costs of the different programmes under consideration. There is no controversy about 5 This is important to keep in mind when benchmarking the estimates in this chapter against those re￾ported elsewhere, usually in US dollars. International dollars are derived by dividing local currency units by an estimate of their purchasing power parity (PPP) compared to a US$. PPPs are the rates of currency conversion that equalize the purchasing power of different currencies by eliminating the differences in price levels between countries. 6 www.who.int/evidence Box 5.1 Methods for cost-effectiveness analysis The cost-effectiveness analysis on which this report is based considered what would have hap￾pened if a set of interventions had not been implemented and compared the result with what happens on their implementation. Through a four-state population model, the number of healthy life years lived over a period of a hun￾dred years by a population in the absence of that set of interventions is estimated by inputting parameters of incidence, remission, cause-spe￾cific and background mortality, and health state valuations reflecting the natural history of the disease. The parameters reflecting the natural history of the disease were mostly estimated by back-adjusting current rates using coverage and known effectiveness of interventions. The same four-state population model can then be rerun, reflecting changes in the parameters due to in￾quantities of inputs required to run each inter￾vention were estimated by experts in 17 regions of the world and validated against the literature. Some individual-level costs were obtained by multiplying unit costs of inputs by the expected utilization of those inputs by the people covered by the programme. Unit costs for outpatient vis￾its and laboratory tests were obtained from a review of literature and supplemented by pri￾mary data from several countries. The total costs for implementing a programme for 10 years con￾stitutes the denominator of the cost-effective￾ness ratio. Stochastic uncertainty analysis was carried out for key parameters in both the numerator and denominator. terventions or combinations of interventions. For example, based on data from earlier chapters, vi￾tamin A deficiency increases the risk of dying from diarrhoea. The impact of vitamin A supplementa￾tion is then mediated in the model by a decrease in case fatality rate for diarrhoea. Effectiveness data came from systematic reviews where available. The difference in the healthy life years gained by the population with and without the intervention is the impact of the intervention and is entered as the denominator of the cost-effectiveness ratio. Costs covered in this analysis include expenses associated with running the intervention, such as administration, training and contact with the me￾dia. They also include costs incurred at the indi￾vidual level such as counselling. Considerable effort was exerted to try to standardize the methodol￾ogy used in collecting and classifying costs. The Sources: (3, 17–19)

108 The World Health Report 2002 the appropriate discount rate to use for costs: the opportunity cost of capital. The discount rate for benefits is often thought to comprise two parts. One is a"pure"time preference for immediate over postponed consumption. The second relates to the fact that, as the pros- perity of a society increases, the utility or benefit to it of a defined unit of consumption is less-that is, there is declining marginal utility of a unit of consumption as income rises Many cost-effectiveness studies have assumed that this applies to health benefits as well and have discounted future health at a rate between 3% and 5% per year. This practice has long been debated, and some people have argued that the discount rate for health benefits should be close to zero and certainly less than the discount rate for costs (20-22) This question is important for the analysis in the following section as it can change the relative priority of interventions. Not all health care programmes achieve results at the same rate. Public health and health promotion programmes in particular may take many years to produce tangible results, and applying a discount rate to the benefits of such pro- grammes will reduce their apparent attractiveness compared with programmes that pro- duce rapid benefits of a similar magnitude Common practice remains to discount costs and benefits at the same rate, so we follow the same practice in our baseline calculations using a rate of 3%.To be consistent with the approach used in Chapter 4 for measuring the burden of disease, age weights are also included in the baseline calculations The recent report of the Commission on Macroeconomics and Health suggested that interventions costing less than three times gDP per capita for each DALY averted repre sent good value for money and that, if a country could not afford to undertake them all from its own resources, the international community should find ways of supporting them (23). This report's classification of interventions is based on this principle, and defines very cost-effective interventions as those which avert each additional daly at a cost less than GDP per capita, and cost-effective interventions as those where each DALY averted costs between one and three times GDP per capita. Finally, cost-effectiveness analyses can be found in the published literature for some of e interventions discussed in this chapter, which does not, however, simply report the published results. The methods used for estimating costs and effectiveness varies consider- ably across the published studies and their results cannot be compared. Moreover, most provide insufficient information on how they estimated costs to be sure that all possibl costs were included and valued appropriately. This report, therefore, re-estimated costs and effects using a standard approach for all interventions, although each study that could be found was evaluated to determine if the parameters it used could be incorporated CHOOSING INTERVENTIONS TO REDUCE SPECIFIC RISKS The results reported in this chapter are important inputs to two types of policy ques tions.The first is how best to reduce the health burden associated with a specific risk facto where information on the effectiveness and costs of the alternative interventions is one crucial input. The second is how best to reduce the health burden associated with risk factors in general, where information on the effectiveness and costs of interventions aimed as a variety of risk factors is critical. This section covers the first question, by reviewing the cost-effectiveness of selected interventions aimed at some of the main risk factors described

108 The World Health Report 2002 the appropriate discount rate to use for costs: the opportunity cost of capital. The discount rate for benefits is often thought to comprise two parts. One is a “pure” time preference for immediate over postponed consumption. The second relates to the fact that, as the pros￾perity of a society increases, the utility or benefit to it of a defined unit of consumption is less – that is, there is declining marginal utility of a unit of consumption as income rises. Many cost-effectiveness studies have assumed that this applies to health benefits as well and have discounted future health at a rate between 3% and 5% per year. This practice has long been debated, and some people have argued that the discount rate for health benefits should be close to zero and certainly less than the discount rate for costs (20–22). This question is important for the analysis in the following section as it can change the relative priority of interventions. Not all health care programmes achieve results at the same rate. Public health and health promotion programmes in particular may take many years to produce tangible results, and applying a discount rate to the benefits of such pro￾grammes will reduce their apparent attractiveness compared with programmes that pro￾duce rapid benefits of a similar magnitude. Common practice remains to discount costs and benefits at the same rate, so we follow the same practice in our baseline calculations using a rate of 3%. To be consistent with the approach used in Chapter 4 for measuring the burden of disease, age weights are also included in the baseline calculations. The recent report of the Commission on Macroeconomics and Health suggested that interventions costing less than three times GDP per capita for each DALY averted repre￾sent good value for money and that, if a country could not afford to undertake them all from its own resources, the international community should find ways of supporting them (23). This report’s classification of interventions is based on this principle, and defines very cost-effective interventions as those which avert each additional DALY at a cost less than GDP per capita, and cost-effective interventions as those where each DALY averted costs between one and three times GDP per capita. Finally, cost-effectiveness analyses can be found in the published literature for some of the interventions discussed in this chapter, which does not, however, simply report the published results. The methods used for estimating costs and effectiveness varies consider￾ably across the published studies and their results cannot be compared. Moreover, most provide insufficient information on how they estimated costs to be sure that all possible costs were included and valued appropriately. This report, therefore, re-estimated costs and effects using a standard approach for all interventions, although each study that could be found was evaluated to determine if the parameters it used could be incorporated. CHOOSING INTERVENTIONS TO REDUCE SPECIFIC RISKS The results reported in this chapter are important inputs to two types of policy ques￾tions. The first is how best to reduce the health burden associated with a specific risk factor, where information on the effectiveness and costs of the alternative interventions is one crucial input. The second is how best to reduce the health burden associated with risk factors in general, where information on the effectiveness and costs of interventions aimed as a variety of risk factors is critical. This section covers the first question, by reviewing the cost-effectiveness of selected interventions aimed at some of the main risk factors described

Some Strategies to Reduce Risk in Chapter 4. The same organizing format followed in that chapter is followed here. The question of how to decide what combination of those risk factors should be given priority for any given level of resource availability is considered on page 139 CHILDHOOD UNDERNUTRITION The strategy of primary health care was adopted by the World Health Assembly in 1977 and outlined further in the 1978 Declaration of Alma-Ata on Health for All ( 24). The dec laration encouraged governments to strive toward attaining Health for All by ensuring, at a minimum, the following activities: education concerning prevailing health problems, their prevention and control; promotion of food supply and good nutrition; safe water and basic sanitation; maternal and child health care which included family planning immunization against major infectious diseases; prevention and treatment of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs Primary health care emphasized programmatic areas rather than diseases, and encouraged community and individual self-reliance and participation, an emphasis on prevention, and a multisectoral approach. Subsequently, the concept of"selective primary health care"was proposed to allow for the scarcity of resources available to achieve health for all. It involved defining strategies focusing on priority health problems(including infant and child mortality), using interven- tions that were feasible toimplement, of low cost, and with proven efficacy(25, 26). UNICEF's GOBI strategy of 1982 emerged from this. At its foundation were four child health inter- ventions which met the above criteria and which were considered to be synergistic-growth monitoring(G), oral rehydration therapy for diarrhoea(O), the promotion of breastfeeding (B)and childhood immunizations( D). Birth spacing/family planning(F), food supplemen tation(F)and the promotion of female literacy(F)were added subsequently( GOBl-FFF) There has been subsequent analysis and discussion of the extent to which the specific interventions can be integrated into primary health care, and whether strategies should be nodified in view of new knowledge and changing circumstances. However, concern with ensuring that child health strategies are based on feasible and affordable interventions that are synergistic and of proven effectiveness -has remained. This chapter builds on that tradition by providing information on the costs and effects of selected interventions target ing key risk factors affecting the health of children. The results not only identify a group of interventions that are very cost-effective, but also illustrate how information on the costs and effectiveness of selected interventions can provide useful insights that can be used to re-assess, from time to time, the need to modify current approaches in view of changing The focus is on interventions aimed primarily at the risk factors identified in Chapter 4 rather than all possible child health interventions. We have selected some interventions that can be delivered on a population-wide basis and some that focus on individuals, to illustrate how the two approaches interact. Childhood immunizations have not been in- cluded because they do not respond to one of the major risk factors of Chapter 4, and because it is already widely accepted that they are cost-effective(28).The fact that interven- tions are not included here, therefore, should not be taken to imply that they are not cost ettective

Some Strategies to Reduce Risk 109 in Chapter 4. The same organizing format followed in that chapter is followed here. The question of how to decide what combination of those risk factors should be given priority for any given level of resource availability is considered on page 139. CHILDHOOD UNDERNUTRITION The strategy of primary health care was adopted by the World Health Assembly in 1977 and outlined further in the 1978 Declaration of Alma-Ata on Health for All (24). The Dec￾laration encouraged governments to strive toward attaining Health for All by ensuring, at a minimum, the following activities: education concerning prevailing health problems, their prevention and control; promotion of food supply and good nutrition; safe water and basic sanitation; maternal and child health care which included family planning; immunization against major infectious diseases; prevention and treatment of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs. Primary health care emphasized programmatic areas rather than diseases, and encouraged community and individual self-reliance and participation, an emphasis on prevention, and a multisectoral approach. Subsequently, the concept of “selective primary health care” was proposed to allow for the scarcity of resources available to achieve health for all. It involved defining strategies focusing on priority health problems (including infant and child mortality), using interven￾tions that were feasible to implement, of low cost, and with proven efficacy (25, 26). UNICEF’s GOBI strategy of 1982 emerged from this. At its foundation were four child health inter￾ventions which met the above criteria and which were considered to be synergistic – growth monitoring (G), oral rehydration therapy for diarrhoea (O), the promotion of breastfeeding (B) and childhood immunizations (I). Birth spacing/family planning (F), food supplemen￾tation (F) and the promotion of female literacy (F) were added subsequently (GOBI-FFF) (27). There has been subsequent analysis and discussion of the extent to which the specific interventions can be integrated into primary health care, and whether strategies should be modified in view of new knowledge and changing circumstances. However, concern with ensuring that child health strategies are based on feasible and affordable interventions – that are synergistic and of proven effectiveness – has remained. This chapter builds on that tradition by providing information on the costs and effects of selected interventions target￾ing key risk factors affecting the health of children. The results not only identify a group of interventions that are very cost-effective, but also illustrate how information on the costs and effectiveness of selected interventions can provide useful insights that can be used to re-assess, from time to time, the need to modify current approaches in view of changing knowledge and circumstances. The focus is on interventions aimed primarily at the risk factors identified in Chapter 4 rather than all possible child health interventions. We have selected some interventions that can be delivered on a population-wide basis and some that focus on individuals, to illustrate how the two approaches interact. Childhood immunizations have not been in￾cluded because they do not respond to one of the major risk factors of Chapter 4, and because it is already widely accepted that they are cost-effective (28). The fact that interven￾tions are not included here, therefore, should not be taken to imply that they are not cost￾effective