The Telegraph
Since 1st March, 1999
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Most developing countries implementing economic stabilization or adjustment programmes have no way of expanding health spending without increasing revenues from other sources. Heavily indebted poor countries in particular do not have the fiscal space to increase social spending. Yet basic services account for less than half of public spending on education and health in such countries.What can governments do in the face of severe fiscal constraints'

One source of extra funds is official development assistance, and for health, such assistance has been rising — with commitments averaging $3.6 billion a year in 1999-2001, up from $3.3 billion a year in 1996-98. Still, official development assistance for health is equal to just $0.01 of every $100 of donor countries’ gross national product — too little to meet even the basic health needs of developing countries...

How should small health budgets be shared among services and users' This is a key issue for equity, because today poor people lose out. A recent survey of developing countries found that in every case, the poorest 20 per cent of the population receives less than 20 per cent of the benefits from public health spending. They also receive less than the richest 20 per cent (which in many countries includes a large portion of the middle class). But spending on basic healthcare is shared more equitably than total health spending. In some countries poor people make disproportionate use of primary health facilities... Thus, if poor people are to benefit, more resources must go to primary healthcare. More egalitarian spending is strongly reflected in health outcomes...

When resources are limited, less developed rural areas bear the brunt of shortages in medical personnel. Moreover, efforts to deploy medical personnel in underserved areas are usually unsuccessful. In Cambodia, 85 per cent of people live in rural areas but only 13 per cent of government health staff are located there, while in Angola 65 per cent of the population is rural but just 15 per cent of government health professionals work in those areas...

Several measures can be taken to redress imbalances in health care coverage: Increase the number of nurses, paramedics and community health workers...; Use service contracts to require medical personnel to spend a certain number of years in public service...; Have donors fund some recurrent costs. The World Health Organization has recommended a package of essential health services for developing countries, including public health and clinical interventions. But this package cannot be provided without more staff, so donors should cover some recurrent staff costs...

Cash-strapped governments have traditionally tried to ration health care by limiting overall budgets — not directing resources to specific illnesses or diseases. A different approach would be to ration funds based on essential interventions. Mexico has taken this approach, and Bangladesh, Colombia and Zambia are beginning to...

Resources are concentrated in these areas at the expense of the overall health system. Public health care efforts outside of such vertical structures may be gutted. And even vertical programmes, expensive to maintain, may be threatened if donor funds disappear. Vertical programmes may be affordable and prudent only for diseases that offer a reasonable possibility of eradication in a foreseeable period...

Where disease specific programmes are integrated into a working health structure, their likelihood of success is high, as India’s tuberculosis programme demonstrates. More than 200,000 health workers have been trained. Some 436 million people (more than 40 per cent of the population) have access to services. And 200,000 deaths have been prevented, with indirect savings of more than $400 million — more than eight times the cost of programme implementation. Using the strategy of directly observed therapy short-course, India’s programme uses the existing health structure but supplements its activities with additional resources, staff and drugs, with diagnosis and treatment free of charge to patients. Once a decision is made to start a programme in a district, the health administration forms a society, which hires staff for a tuberculosis unit-covering 500,000 people.

The state government trains the doctors and hires the lab technicians. Policy direction, drugs and microscopes are provided by the central government, with financial assistance from the World Bank and bilateral donors.

There are several levels of support, monitoring and supervision. Staff from the government and World Health Organization make site visits. WHO-hired consultants ...provide support to tuberculosis units. The government provides detailed feedback each quarter on the performance of each state and district.

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