The World Health Report 2002 CHILDHOOD UNDERNUTRITION (AND BREASTFEEDING Interventions The childhood interventions were not evaluated in the a subregions where chile undemutrition is not a major cause of burden. Complementary feeding One-time intensive counselling is provided to mothers on the appropriate complementary feeding practices and on the importance of continued breast eding. In addition, all infants aged 6 months to 1 year, regardless of nutritional status, are provided with ready-to-mix complementary food, which is collected every two months from a health centre by the carer. The intervention is estimated to shift positively the overall distribution of weight-for-age for children less than one year of age by 0. 16 standard devia ions(adapted from Caulfield Huffman)(29). It was then assumed that each cohort of children exposed to this intervention would continue to reap the benefits subsequently because of the knowledge and attitudes retained by the carer. Complementary feeding with growth monitoring and promotion. All carers are given an initial intensive counselling session on appropriate complementary feeding prac tices and the importance of continued breastfeeding Carers are provided with growth charts and, during quarterly visits, the weight of the child is plotted and any deviations from ex pected weight gain is discussed. Solutions are suggested and targets for weight gain are set In addition, ready-to-mix complementary food is provided to all children from 6 months to ear of age who have been identified to have poor weight gain or are underweight. Results The impact of the two types of interventions is identical, but the costs of the more fo- used approach of complementary feeding with growth monitoring and promotion are considerably lower than those for complementary feeding alone. Complementary feeding itself is not cost-effective, while complementary feeding with growth monitoring is cost effective in most regions. It is assumed that the benefits of the intervention in terms of carers knowledge gained and attitudes changed will persist until the child is five years old Interactions are considered beloy RON DEFICIENCY Interventions Iron fortification Iron, usually combined with folic acid, is added to the appropriate food vehicle made available to the population as a whole. Cereal flours are the most com on food vehicle and are the basis of the analysis, but there is also some experience with introducing iron to other vehicles such as noodles, rice, and various sauces(30). The pro- portion of the population that consumes the food vehicle in sufficient quantities to absorb sufficient iron varies by region, from 65%to 95%, and this chapter explores the costs and effects in the event that fortification reaches 50%, 80% and 95% of the targeted population Because of likely problems with absorption, fortification is considered only 50% as effica cious as supplementation in the people who are covered, consistent with the assumptions of Chapter 4 Iron supplementation. Iron is provided to pregnant women during antenatal visits The assumed dose follows WHO guidelines, with daily supplementation of 60 mg elemen tal iron, for six months during pregnancy and three months postpartum(31). Three differ- ent levels of coverage are included-50%, 80% and 95%-and it is assumed that only 67% of these women receive an effective dose because of less than perfect adherence(32). Fo
110 The World Health Report 2002 CHILDHOOD UNDERNUTRITION (AND BREASTFEEDING) Interventions The childhood interventions were not evaluated in the A subregions where childhood undernutrition is not a major cause of burden. Complementary feeding. One-time intensive counselling is provided to mothers on the appropriate complementary feeding practices and on the importance of continued breastfeeding. In addition, all infants aged 6 months to 1 year, regardless of nutritional status, are provided with ready-to-mix complementary food, which is collected every two months from a health centre by the carer. The intervention is estimated to shift positively the overall distribution of weight-for-age for children less than one year of age by 0.16 standard deviations (adapted from Caulfield & Huffman) (29). It was then assumed that each cohort of children exposed to this intervention would continue to reap the benefits subsequently because of the knowledge and attitudes retained by the carer. Complementary feeding with growth monitoring and promotion. All carers are given an initial intensive counselling session on appropriate complementary feeding practices and the importance of continued breastfeeding. Carers are provided with growth charts and, during quarterly visits, the weight of the child is plotted and any deviations from expected weight gain is discussed. Solutions are suggested and targets for weight gain are set. In addition, ready-to-mix complementary food is provided to all children from 6 months to 1 year of age who have been identified to have poor weight gain or are underweight. Results The impact of the two types of interventions is identical, but the costs of the more focused approach of complementary feeding with growth monitoring and promotion are considerably lower than those for complementary feeding alone. Complementary feeding by itself is not cost-effective, while complementary feeding with growth monitoring is costeffective in most regions. It is assumed that the benefits of the intervention in terms of carer’s knowledge gained and attitudes changed will persist until the child is five years old. Interactions are considered below. IRON DEFICIENCY Interventions Iron fortification. Iron, usually combined with folic acid, is added to the appropriate food vehicle made available to the population as a whole. Cereal flours are the most common food vehicle and are the basis of the analysis, but there is also some experience with introducing iron to other vehicles such as noodles, rice, and various sauces (30). The proportion of the population that consumes the food vehicle in sufficient quantities to absorb sufficient iron varies by region, from 65% to 95%, and this chapter explores the costs and effects in the event that fortification reaches 50%, 80% and 95% of the targeted population. Because of likely problems with absorption, fortification is considered only 50% as efficacious as supplementation in the people who are covered, consistent with the assumptions of Chapter 4. Iron supplementation. Iron is provided to pregnant women during antenatal visits. The assumed dose follows WHO guidelines, with daily supplementation of 60 mg elemental iron, for six months during pregnancy and three months postpartum (31). Three different levels of coverage are included – 50%, 80% and 95% – and it is assumed that only 67% of these women receive an effective dose because of less than perfect adherence (32). For
Some Strategies to Reduce Risk the women who currently attend antenatal clinics, only the costs of the iron and the addi tional time of the visit were included. However, expansion of coverage for iron supplemen tation purposes beyond current coverage of antenatal visits requires attributing the full cost of the necessary visits to the intervention Results Q Even though many groups in the population are likely to benefit from iron fortification, nly the impact on iron deficiency anaemia in pregnant women(with an impact on mater- nal health and prenatal mortality) has been included in the analysis. This understates the benefit, but these effects probably account for more than 95% of total deaths averted by fortification. Despite this, supplementation and fortification at 50% coverage are estimated to lead to increases in population health of almost 59 million and 29 million DALYs in turn globally when implemented over a 10-year period Supplementation yields greater improvements in population health than fortification in all subregions with high child mortality(all D and E subregions), and at all levels of coverage. In the other subregions, supplementation has a larger impact on population health than fortification for equivalent levels of coverage. On a global basis, supplementation at 80%would gain just over 9 million DALYs per year compared to doing nothing On the other hand, fortification is always less costly than supplementation because it does not require a visit to a provider, and the unit cost of supplementation increases sharply with increasing coverage. This means that the cost-effectiveness of fortification is always lower than the cost-effectiveness of supplementation, regardless of the coverage of fortifi cation. It, then, is the preferred option at low levels of resource availability However, in some settings iron fortification is hindered by the absence of ideal food rehicles that are eaten in sufficient quantities and it might be difficult to ensure coverage even as high as 50%. It is also hindered by the absence of ideal iron compounds that would be favorably absorbed, are stable and nonreactive, with little colour, and no taste of their own. Where people's diets are not based around cereal flours or another convenient food vehicle, supplementation is still a cost-effective option. Indeed, in areas with a high preva lence of iron-deficiency anaemia, it is still very cost-effective to spend the higher amounts on supplementation to achieve the greater population benefit. It is less cost-effective to take this option in areas where the burden from iron deficiency anaemia is relatively low, although the cost-effectiveness of switching from fortification to supplementation is be tween one and three times gDP per capita so does not fall into the band of cost-ineffective VITAMIN A DEFICIENCY Vitamin A deficiency is negligible in the European region of WHO, while deaths due to pneumonia and diarhoea are negligible in AMR-A and WPR-A. The following interven- tions are not evaluated in those areas Vitamin A supplementation. Oral vitamin A supplements are provided to all children nder five years of age twice a year at a health centre. The dose is 200 000 i.u. for children from their first birthday. For those less than one year of age, the dose is 50 000-100 000 it Effectiveness of the intervention is adjusted by adherence. Vitamin A fortification. Fortification of a food staple with vitamin A (in this case as- sumed to be sugar), whether locally produced or imported or whether for industrial or domestic use, is assured through legislation. The amount of vitamin A required is calculat
Some Strategies to Reduce Risk 111 the women who currently attend antenatal clinics, only the costs of the iron and the additional time of the visit were included. However, expansion of coverage for iron supplementation purposes beyond current coverage of antenatal visits requires attributing the full cost of the necessary visits to the intervention. Results Even though many groups in the population are likely to benefit from iron fortification, only the impact on iron deficiency anaemia in pregnant women (with an impact on maternal health and prenatal mortality) has been included in the analysis. This understates the benefit, but these effects probably account for more than 95% of total deaths averted by fortification. Despite this, supplementation and fortification at 50% coverage are estimated to lead to increases in population health of almost 59 million and 29 million DALYs in turn globally when implemented over a 10-year period. Supplementation yields greater improvements in population health than fortification, in all subregions with high child mortality (all D and E subregions), and at all levels of coverage. In the other subregions, supplementation has a larger impact on population health than fortification for equivalent levels of coverage. On a global basis, supplementation at 80% would gain just over 9 million DALYs per year compared to doing nothing. On the other hand, fortification is always less costly than supplementation because it does not require a visit to a provider, and the unit cost of supplementation increases sharply with increasing coverage. This means that the cost-effectiveness of fortification is always lower than the cost-effectiveness of supplementation, regardless of the coverage of fortification. It, then, is the preferred option at low levels of resource availability. However, in some settings iron fortification is hindered by the absence of ideal food vehicles that are eaten in sufficient quantities and it might be difficult to ensure coverage even as high as 50%. It is also hindered by the absence of ideal iron compounds that would be favorably absorbed, are stable and nonreactive, with little colour, and no taste of their own. Where people’s diets are not based around cereal flours or another convenient food vehicle, supplementation is still a cost-effective option. Indeed, in areas with a high prevalence of iron-deficiency anaemia, it is still very cost-effective to spend the higher amounts on supplementation to achieve the greater population benefit. It is less cost-effective to take this option in areas where the burden from iron deficiency anaemia is relatively low, although the cost-effectiveness of switching from fortification to supplementation is between one and three times GDP per capita so does not fall into the band of cost-ineffective interventions. VITAMIN A DEFICIENCY Interventions Vitamin A deficiency is negligible in the European region of WHO, while deaths due to pneumonia and diarrhoea are negligible in AMR-A and WPR-A. The following interventions are not evaluated in those areas. Vitamin A supplementation. Oral vitamin A supplements are provided to all children under five years of age twice a year at a health centre. The dose is 200 000 i.u. for children from their first birthday. For those less than one year of age, the dose is 50 000–100 000 i.u. Effectiveness of the intervention is adjusted by adherence. Vitamin A fortification. Fortification of a food staple with vitamin A (in this case assumed to be sugar), whether locally produced or imported or whether for industrial or domestic use, is assured through legislation. The amount of vitamin A required is calculated
112 The World Health Report 2002 based on an estimation of the amount of recommended daily allowance anticipated to be taken in from other sources and the average per capita intake of sugar in different settings A trend analysis of a number of different fortification programmes in central America shows relative reduction of about 60% in the prevalence of vitamin A deficiency associated with the introduction of fortification (33). Intervention includes provision of guidelines for qual ty control of sugar fortification in the mills, regular visits to mills by inspectors, and regular sampling and testing of sugar taken from mills, markets and homes for vitamin A content Samples from homes are taken opportunistically during mass surveys carried out for other Results As with iron, vitamin A fortification is more cost-effective than supplementation in regions, because of its lower costs. Supplementation will, however, have a substantia large benefit in terms of population health- approximately twice as high as fortification although at a higher cost. It is also very cost-effective in its own right. Both remain either cost-effective or very cost-effective in all regions included in the analysis when coverage is increased to the maximum possible level ZINC DEFICIENCY Interventions Zinc supplementation. During one of the first immunization contacts in infancy, the ealth worker prescribes zinc gluconate or sulfate(10 mg in solution) as part of a routine Thereafter, the zinc solution is administered by a carer at home daily to every child until the child reaches five years of age. Effectiveness of the intervention is adjusted by expected adherence for medications needing to be taken daily. Zinc fortification The intervention has the same characteristics as for Vitamin A fortifi cation except the food vehicle is wheat, not sugar. Note that in the absence of effectiveness data,the assumption has been made that zinc fortification is half as efficacious as zinc supplementation, consistent with that made for iron fortificatic As with iron and vitamin A, zinc supplementation and fortification both prove to be very cost-effective interventions in all subregions. Fortification is more cost-effective than sup plementation and is also slightly more cost-effective than vitamin A supplementation in most regions evaluated. Even though zinc fortification is very cost-effective, erall impact on population health of this intervention is lower than the gains associated with vitamin a fortification ons where vitamin a deficiency is a problem. It should, of course, be remembered that no large-scale zinc fortification programme has yet been car- ried out, so the results are based on the effect on health of assumed increases in zinc intake DTHER INDIVIDUAL- BASED INTERVENTIONS FOCUSING ON CHILDREN UNDER FIVE YEARS OF AGE Interventions Although not strictly risk-reducing strategies, two ways of reducing the risk of death associated with the risk factors outlined above are considered here Oral rehydration therapy Health workers are trained to use an algorithm for the as- sessment and management of dehydration caused by diarrhoea in children under five years of age Children brought to a health facility with watery stools are assessed for signs of
112 The World Health Report 2002 based on an estimation of the amount of recommended daily allowance anticipated to be taken in from other sources and the average per capita intake of sugar in different settings. A trend analysis of a number of different fortification programmes in central America shows a relative reduction of about 60% in the prevalence of vitamin A deficiency associated with the introduction of fortification (33). Intervention includes provision of guidelines for quality control of sugar fortification in the mills, regular visits to mills by inspectors, and regular sampling and testing of sugar taken from mills, markets and homes for vitamin A content. Samples from homes are taken opportunistically during mass surveys carried out for other purposes. Results As with iron, vitamin A fortification is more cost-effective than supplementation in all regions, because of its lower costs. Supplementation will, however, have a substantially large benefit in terms of population health – approximately twice as high as fortification – although at a higher cost. It is also very cost-effective in its own right. Both remain either cost-effective or very cost-effective in all regions included in the analysis when coverage is increased to the maximum possible level. ZINC DEFICIENCY Interventions Zinc supplementation. During one of the first immunization contacts in infancy, the health worker prescribes zinc gluconate or sulfate (10 mg in solution) as part of a routine. Thereafter, the zinc solution is administered by a carer at home daily to every child until the child reaches five years of age. Effectiveness of the intervention is adjusted by expected adherence for medications needing to be taken daily. Zinc fortification. The intervention has the same characteristics as for Vitamin A fortification except the food vehicle is wheat, not sugar. Note that in the absence of effectiveness data, the assumption has been made that zinc fortification is half as efficacious as zinc supplementation, consistent with that made for iron fortification. Results As with iron and vitamin A, zinc supplementation and fortification both prove to be very cost-effective interventions in all subregions. Fortification is more cost-effective than supplementation and is also slightly more cost-effective than vitamin A supplementation in most regions evaluated. Even though zinc fortification is very cost-effective, the overall impact on population health of this intervention is lower than the gains associated with vitamin A fortification in regions where vitamin A deficiency is a problem. It should, of course, be remembered that no large-scale zinc fortification programme has yet been carried out, so the results are based on the effect on health of assumed increases in zinc intake. OTHER INDIVIDUAL-BASED INTERVENTIONS FOCUSING ON CHILDREN UNDER FIVE YEARS OF AGE Interventions Although not strictly risk-reducing strategies, two ways of reducing the risk of death associated with the risk factors outlined above are considered here. Oral rehydration therapy. Health workers are trained to use an algorithm for the assessment and management of dehydration caused by diarrhoea in children under five years of age. Children brought to a health facility with watery stools are assessed for signs of
Some Strategies to Reduce Risk dehydration by a trained health worker. If severely dehydrated, the child is rehydrated in he health facility or referred to a higher-level facility if necessary. Children still able to take in fluids are provided with oral rehydration salts reconstituted in boiled then cooled water at a specified concentration. Advice is given on the frequency of the rehydration and also on danger signals for which the carer should watch. Programme implementation of this intervention has been estimated to achieve a relative reduction in case fatality rate of 36% (34,35) Case management of pneumonia. Health workers are trained to assess and manage respiratory distress in children. A child brought to a health facility with a cough is assessed by a trained health worker for presence of rapid breathing and other signs of respiratory distress. Depending on which signs are present, the child is referred to a hospital for intra venous treatment with antibiotics, is prescribed a five-day course of antibiotics with in structions for follow-up, or the carer is provided advice on supportive management and on monitoring the respiratory status of the child. A metaanalysis of several large, community based trials estimated that the intervention produced a relative reduction of 50% in case fatality rate(36). This effectiveness estimate was subsequently adjusted for adherence Results The relative magnitude of the effect varies with epidemiology. For example, vitamin A supplementation achieves greater health effects than oral rehydration therapy in some ar- eas(AMR-B, SEAR-B and WPR-B)but in the others the reverse is true. Both oral rehydra tion therapy and case management of pneumonia achieve substantially greater benefits than zinc fortification and supplementation, despite the zincinterventions being more cost- ffective. Both forms of treatment are still very cost-effective in their own right in all COMBINED INTERVENTIONS TO REDUCE RISKS IN CHILDREN UNDER FIVE YEARS OF AGE lost of the childhood interventions considered above prove to be very efficient ways of aproving population health. Zinc fortification, under the current assumption of effective ess is, perhaps, the surprise, being more cost-effective than the other options in all re gions. To the extent that the same food vehicles could be used to fortify zinc and iron, the cost-effectiveness of the combined intervention would be even more attractive, making it one of the most attractive options available of any type of intervention. However, zinc for- tification by itself, despite its cost-effectiveness, would have a smaller impact on population health than the other interventions discussed in this section except for food supplementa tion. Moreover, it has yet to be used on the scale assumed for these calculations As yet there is little evidence from field studies about the impact of multiple interven- tions designed to improve the health of children under five years of age. An evaluation study to assess the impact of the integrated management of childhood illness strategy is currently under way(Box 5.2), which should provide evidence in the near future. In the meantime, we have modelled the interactions between the different combinations of inter- ventions relating specifically to children described above(for example, not including iron taking into account synergies in terms of costs and effects Except for the regions where Vitamin A deficiency is not a major cause of burden(EUr- B and EUR-O), the combination of zinc with Vitamin A fortification(or supplementation with treatment of diarrhoea and pneumonia is the most cost-effective combination of preventive and curative actions, well under the cut-off point for very cost-effective interventions
Some Strategies to Reduce Risk 113 dehydration by a trained health worker. If severely dehydrated, the child is rehydrated in the health facility or referred to a higher-level facility if necessary. Children still able to take in fluids are provided with oral rehydration salts reconstituted in boiled then cooled water at a specified concentration. Advice is given on the frequency of the rehydration and also on danger signals for which the carer should watch. Programme implementation of this intervention has been estimated to achieve a relative reduction in case fatality rate of 36% (34, 35). Case management of pneumonia. Health workers are trained to assess and manage respiratory distress in children. A child brought to a health facility with a cough is assessed by a trained health worker for presence of rapid breathing and other signs of respiratory distress. Depending on which signs are present, the child is referred to a hospital for intravenous treatment with antibiotics, is prescribed a five-day course of antibiotics with instructions for follow-up, or the carer is provided advice on supportive management and on monitoring the respiratory status of the child. A metaanalysis of several large, communitybased trials estimated that the intervention produced a relative reduction of 50% in casefatality rate (36). This effectiveness estimate was subsequently adjusted for adherence. Results The relative magnitude of the effect varies with epidemiology. For example, vitamin A supplementation achieves greater health effects than oral rehydration therapy in some areas (AMR-B, SEAR-B and WPR-B) but in the others the reverse is true. Both oral rehydration therapy and case management of pneumonia achieve substantially greater benefits than zinc fortification and supplementation, despite the zinc interventions being more costeffective. Both forms of treatment are still very cost-effective in their own right in all subregions. COMBINED INTERVENTIONS TO REDUCE RISKS IN CHILDREN UNDER FIVE YEARS OF AGE Most of the childhood interventions considered above prove to be very efficient ways of improving population health. Zinc fortification, under the current assumption of effectiveness is, perhaps, the surprise, being more cost-effective than the other options in all regions. To the extent that the same food vehicles could be used to fortify zinc and iron, the cost-effectiveness of the combined intervention would be even more attractive, making it one of the most attractive options available of any type of intervention. However, zinc fortification by itself, despite its cost-effectiveness, would have a smaller impact on population health than the other interventions discussed in this section except for food supplementation. Moreover, it has yet to be used on the scale assumed for these calculations. As yet there is little evidence from field studies about the impact of multiple interventions designed to improve the health of children under five years of age. An evaluation study to assess the impact of the integrated management of childhood illness strategy is currently under way (Box 5.2), which should provide evidence in the near future. In the meantime, we have modelled the interactions between the different combinations of interventions relating specifically to children described above (for example, not including iron) taking into account synergies in terms of costs and effects. Except for the regions where Vitamin A deficiency is not a major cause of burden (EURB and EUR-C), the combination of zinc with Vitamin A fortification (or supplementation) with treatment of diarrhoea and pneumonia is the most cost-effective combination of preventive and curative actions, well under the cut-off point for very cost-effective interventions
114 The World Health Report 2002 This does not imply that other types of interventions are not cost-effective or should be excluded from consideration. It simply illustrates that addition of Vitamin A and zinc inter- ventions to the curative care currently provided routinely in most settings would gain sub- stantial improvements in child health at relatively low cost. BLOOD PRESSURE AND CHOLESTEROL Comprehensive approaches to the control of cardiovascular diseases take account of a variety of interrelated risk factors including blood pressure, cholesterol, smoking, body mass index, low levels of physical activity, diet and diabetes. They use a mix of population-wide and individual-based interventions, and countries that have developed comprehensive poli cies have seen cardiovascular disease mortality fall significantly. In Finland, for example, a omprehensive national strategy that combined prevention, community-based health pro- motion and access to treatment was associated with a 60% decline in mortality rates from cardiovascular diseases over a 25-year period(37-39) Cardiovascular disease risk factors are associated with substantial health burdens in all countries, including the poorest countries, which makes it more important than ever to base strategies for their control on interventions that are affordable, feasible, effective and acceptable to communities. This section contributes to this process by reporting on the effectiveness and costs of selected interventions focusing on blood pressure and choles terol Box 5.3 reports on an intervention aimed at encouraging increased fruit and vegeta ble intake, while smoking is considered in a subsequent section Population-wide and individual-based interventions are evaluated, alone and in combi nation. All possible interventions or combinations could not be included here, nor is it possible to analyse all of the different ways of designing the interventions that are included The information nevertheless shows that certain population-wide interventions that have not yet been widely implemented have the potential to be very cost-effective ways of im proving population health and result in substantial health benefits. It also suggests that the combination of selected individual-based interventions with these population-wide inter- ventions would also be cost-effective in most settings Box 5.2 Integrated Management of Childhood IlIness: interventions that interact itegrated Management of Childhood Iness could have been prevented with available, inex- tion is being conducted in collaboration with (IMCI) is a broad strategy that encourages com- interventions that are already available to Ministries of Health and technical assistance munities and health workers to see the child as children in richer countries. These inequities could partners in Bangladesh, Brazil, Peru, Uganda, and a whole, not just as a single problem or disease. be reduced if IMCI is implemented at high levels the United Republic of Tanzania. The early results MCI helps countries use their scarce health re- of coverage. Over 80 developing countries have of the evaluation are already being used to im sources in efficient ways by combining preven- adopted IMCI as part of their national policy to prove the delivery of child health services in de- childhood illnesses into simple guidelines and up the strategy and to strengthen health systems Republicof Tanzania it has been shown that chil- messages. Countries adapt these guidelines to so that they can deliver IMCI and other child and dren in districts implementing IMCI are receiv- meet their needs and use them to train health family services efficiently and effectively ing better care than those in similar district workers at all levels, improve supervision, make A multicountry evaluation of IMCI effective- without IMCI sure essential drugs are available, and mobilize ness, cost and impact is currently under way to Further information is available at: URL: familiesandcommunitiesinsupportofchildobtaininformationaboutthebarrierstoImCihttp://www.who.int/child-adolescent-health implementationtheeffectsthestrategyhasonandhttp://www.who.int/imci-mce Most of the 10.9 million child deaths in 2000 health services and communities how much it (99% of which occurred in developing countries) costs, and how many lives it can save The evalua-
114 The World Health Report 2002 This does not imply that other types of interventions are not cost-effective or should be excluded from consideration. It simply illustrates that addition of Vitamin A and zinc interventions to the curative care currently provided routinely in most settings would gain substantial improvements in child health at relatively low cost. BLOOD PRESSURE AND CHOLESTEROL Comprehensive approaches to the control of cardiovascular diseases take account of a variety of interrelated risk factors including blood pressure, cholesterol, smoking, body mass index, low levels of physical activity, diet and diabetes. They use a mix of population-wide and individual-based interventions, and countries that have developed comprehensive policies have seen cardiovascular disease mortality fall significantly. In Finland, for example, a comprehensive national strategy that combined prevention, community-based health promotion and access to treatment was associated with a 60% decline in mortality rates from cardiovascular diseases over a 25-year period (37–39). Cardiovascular disease risk factors are associated with substantial health burdens in all countries, including the poorest countries, which makes it more important than ever to base strategies for their control on interventions that are affordable, feasible, effective and acceptable to communities. This section contributes to this process by reporting on the effectiveness and costs of selected interventions focusing on blood pressure and cholesterol. Box 5.3 reports on an intervention aimed at encouraging increased fruit and vegetable intake, while smoking is considered in a subsequent section. Population-wide and individual-based interventions are evaluated, alone and in combination. All possible interventions or combinations could not be included here, nor is it possible to analyse all of the different ways of designing the interventions that are included. The information nevertheless shows that certain population-wide interventions that have not yet been widely implemented have the potential to be very cost-effective ways of improving population health and result in substantial health benefits. It also suggests that the combination of selected individual-based interventions with these population-wide interventions would also be cost-effective in most settings. Box 5.2 Integrated Management of Childhood Illness: interventions that interact Integrated Management of Childhood Illness (IMCI) is a broad strategy that encourages communities and health workers to see the child as a whole, not just as a single problem or disease. IMCI helps countries use their scarce health resources in efficient ways by combining prevention and treatment of the most common childhood illnesses into simple guidelines and messages. Countries adapt these guidelines to meet their needs and use them to train health workers at all levels, improve supervision, make sure essential drugs are available, and mobilize families and communities in support of child health. Most of the 10.9 million child deaths in 2000 (99% of which occurred in developing countries) tion is being conducted in collaboration with Ministries of Health and technical assistance partners in Bangladesh, Brazil, Peru, Uganda, and the United Republic of Tanzania. The early results of the evaluation are already being used to improve the delivery of child health services in developing countries; for example, in the United Republic of Tanzania it has been shown that children in districts implementing IMCI are receiving better care than those in similar districts without IMCI. Further information is available at: URL: http://www.who.int/child-adolescent-health and http://www.who.int/imci-mce could have been prevented with available, inexpensive interventions that are already available to children in richer countries. These inequities could be reduced if IMCI is implemented at high levels of coverage. Over 80 developing countries have adopted IMCI as part of their national policy to improve child health. The challenge now is to scale up the strategy and to strengthen health systems so that they can deliver IMCI and other child and family services efficiently and effectively. A multicountry evaluation of IMCI effectiveness, cost and impact is currently under way to obtain information about the barriers to IMCI implementation, the effects the strategy has on health services and communities, how much it costs, and how many lives it can save. The evalua-