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Rapid Responses: Rapid Responses published:
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Health, birth rate and poverty
- Richard G Fiddian-Green (16 July 2002)
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Improving health of the global poor
- Anne J Mills, Prabhat Jha (21 July 2002)
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No shift in the balance of power
- John s Sampson, NR14 7JT (23 July 2002)
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International health: bottom up research should be top priority
- Ilyas Q Mirza, Amina Tareen, Specialist Regsitrar in Child & Adolescent Psychiatry (2 August 2002)
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Increased funding for health in the developing countries is important and necessary.
- Debashis Dutt (5 August 2002)
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Richard G Fiddian-Green, Formerly chairman general surgery, University of Massachusetts. None
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There has been an incredible explosion in population in the Transkei and Zululand as I have observed having visited and worked there intemittently since I first left the country forty years ago. I did not see any evidence to support the common view of AIDS, and my visit included seeing every adult and paediatric patient in the Charles Johnson Memorial Hospital in the shadows of Isandalwana. The poverty is as far as I could see a consequence of the birth abd illegitimacy rates exceeding the job growth rate. Providing food for famine relief in Malawi and Zimbabwe and investing in healthcare in Southern Africa will compound the problem unless bith rate is not just contained but reduced relative to the economic growth rate. The equation, therefore, is far more complex that you would have us believe. Is not investment in education the priority in conditions where the only hope that people who survive have is for their childrens' future? |
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Anne J Mills, Professor of Health Economics and Policy London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, Prabhat Jha
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In two recent editorials, Morrow (1) and Smith (2) discuss the CMH 'Macroeconomics and Health' report. Morrow criticizes it for weak technical underpinnings, but mis-interprets the derivation of some of the evidence used. As the co-chairs of the CMH Working Group 5,which was responsible for the analysis of interventions, constraints and costs, we would like to comment on how the CMH conclusions were derived. The report does not assume the existence of functional health systems. The cost analysis took into account the considerable cost of building up the necessary health system infrastructure to achieve high coverage of a set of priority interventions. Moreover, the report of Working Group 5 (3, 4)specifically addresses what can be done in countries where health systems and government effectiveness are very weak. Although the report agrees that the whole set of activities recommended cannot be done in countries without a functional health infrastructure, it does not take the pessimistic view that nothing can be done. Polio eradication is just one example of an approach that can succeed even in highly constrained environments. Morrow suggests that in place of normative estimates, actual data from poor countries on both effects and costs should be used. But the identification of the priority interventions was based on extensive review of the major causes of avoidable mortality between rich and poor countries, and evidence on the effectiveness of interventions against HIV/AIDS, tuberculosis, malaria, childhood diseases, malnutrition, maternal conditions and tobacco use. The cost calculations were based as far as possible on country specific estimates of target populations and existing coverage levels. Unit costs were drawn from an exhaustive search for unit cost data from 83 low-income and African countries. Methods used were independent of those of the World Health Report 2000. Background papers of the intervention reviews and methods were subject to peer review, and are available at www.cmhealth.org/wg5.htm. Smith’s editorial appropriately raises some of the tough questions facing the global community in fighting disease and poverty. We fully agree that there is uncertainty in estimating the impact of health on economic returns (5). However, there is little doubt that poor health is an important dimension of poverty (6). Global goals of poverty reduction must include focused action against the relatively few causes of excess mortality among the global poor. Yours sincerely Anne Mills, Professor of Health Economics and Policy, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT Prabhat Jha, Canada Research Chair of Health and Development University of Toronto, Toronto, Ontario, Canada, M5B 1W8 References: 1. Morrow RH. Macroeconomics and health BMJ 2002; 325: 53-54. 2. Smith R. A time for global health BMJ 2002; 325: 54-55. 3. Jha P, Mills A Improving Health of the Global Poor, The Report of Working Group 5 of the Commission on Macroeconomics and Health, Geneva and London, London School of Hygiene and Tropical Medicine, 2002 (available at http://www3.who.int/whosis/cmh/cmh_papers/e/pdf/wg5_summary.pdf) 4. Jha P, Mills A, Hanson K, Kumaranayake L, Conteh L, Kurowski C, Nguyen SN, Cruz VO, Ranson K, Vaz LM, Yu S, Morton O, Sachs JD. Improving the health of the global poor. Science. 2002 Mar 15;295(5562):2036-9. 5. Alleyne GAO, Cohen D Health, Economic Growth and Poverty Reduction. The Report of Working Group 1 of the Commission on Macroeconomics and Health, Geneva, WHO, 2002 (available at http://www3.who.int/whosis/cmh/cmh_papers/e/pdf/wg1_summary.pdf 6. World Bank “Voices of the Poor”, Washington DC: Oxford University Press for the World Bank, 2001 |
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John s Sampson, general practitioner Heathgate ,Norfolk., NR14 7JT
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Editor –It is shocking to discover that Southern Norfolk primary care trust (population 200,000 with a budget of £147 million)has a Higher health spend than Uganda (per capita health spend US$ 8 for a population of 22 million)1. The report 2. does deserve support but I suspect it will not be implemented due to lack of funds, I await the USA putting forward their funds so the prime minister can follow the lead. Having chaired a primary care group for three years and now the executive committee of a primary care trust, I am very aware of the effects on a health economy of centrally dictated targets with increased funding. Professor Morrow questions whether least developed countries have truly functional health systems. I wonder if we can claim to have a functional health system ? We are increasingly investing for short term targets that have little or no evidence base and questionable health gain. We are left with no effective funds for local priorities that can empower collaborative working with key stakeholders to deliver long term health gain. So far there has been no shift in the balance of power. Reading this report, written almost entirely by high flying academics and economists (of 89 participants I could find one from sub Saharan Africa who had worked at the coal face of health care) I am struck by the similarities of target setting and centralised control over funding. I am concerned that this will fail to empower the countries to deliver sustainable health improvement so desperately needed. The pre set conditions to be targeted might respond better to political and economic reform in the gift of G8 nations, this would leave the least developed nations the self determination to use the additional funds for long term sustainable health improvement appropriate to the local need. Again I see no shift in the balance of power. 1.Wendo C,Uganda hopes funds will bring long-term progress.Lancet2002;360;66 2.World Health Organisation.Macroeconomics and health;Geneva;WHO,2001. Dr John Sampson. General practitioner. Heathgate surgery Norfolk NR14 7JT woodton@easynet.co.uk |
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Ilyas Q Mirza, Locum Consultant in Adult Psychiatry The Roayl London Hospital (St Clement's), 2 (a) Bow Road, E3 4LL, Amina Tareen, Specialist Regsitrar in Child & Adolescent Psychiatry
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We wish to comment on two separate yet related issues raised in editorials on international health1,2,3. Firstly, the scheme for international fellowship is a welcome step towards building capability, it is doubtful that this will help generate good quality actual data from the low-income countries on effects of interventions, which is so desperately required. We fear that the scheme of fellows chosen from national ministries or regional leaders will create yet more health expert/ bureaucrats rather than researchers. We think that an equal immediate emphasis needs to given to encouraging good quality research in the context of low-income countries to inform policy rather than relying on experts estimates. The second issue relates to the need to understand the links between international health and global security. Evidence from high-income countries suggests that shame chronic anxiety and insecurity associated with low status is related to violence, the very psychosocial factors that have been implicated in ill health4. However, so far there is little evidence that this is related to violence between. Little is know about how these factors interact in low-income countries. These require investigation in this context, first, to confirm these findings in low- income country populations, and second, to examine their role in mediating aggression between high and low-income populations of the world. Dr Ilyas Mirza, Locum Consultant in Adult Psychiatry, The Royal London Hospital (St Clement’s), 2 (a) Bow Road, London. E3 4LL. Dr Amina Tareen, Specialist Registrar in Child and Adolescent Psychiatry, Northgate Clinic, Edgware Community Hospital, Burnt Oak, Edgware. HA8 0LD. References: 1. Morrow R H. Macroeconomics and health. BMJ 2002; 325: 53-4. 2. Smith R. A time for global health. BMJ 2002: 325: 54-5. 3. Berwick D M. A learning world for the Global Fund. BMJ 2002; 325: 55-6. 4. Wilkinson R G. Health, hierarchy and social anxiety. Annals of N Y Acad Med Sciences 1999; 48-63. |
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Debashis Dutt, Associate professor, Department of Public Health Administration All India Institute of Hygiene and Public Health. 110 C.R. Avenue. Kolkata. India. 700073.
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It is heartening that poor health has been endorsed as a major contributor to poverty demanding an increase in the funding for health in the poor / developing countries by the World Health Organisation(WHO) and there is support for this(1). This is especially important in view of the current definite trend towards budget cutting and privatisation in the developed as well as in the developing countries(2,3). Cost cutting rather than provision of adequate health services has been the emphasis in most countries despite the recognition that good health is necesssary for economic development. Taking cue from the developed nations (which have different needs and aspirations)or sometimes due to international pressure(as in the case of Structural Adjustment Procedurtes, SAPS)many developing countries have embarked on privatisation reforms(2). The returns from these reforms in the developing countries(that have different health, social and economic environment) has been qeustionable. As high as 40 to 55 percent of the population in the developing countries live in absolute poverty(less than a dollar a day)(4). Housing, water suply, sanitation, living and literacy standards are low for the vast majotrity and populations are faced with a dual load of communicable and non- communicable diseases. Under these circumstances, where populations may be unable to pay, it is not surprising that people (despite having a true need for health care) "delay treatment, borrow money, make less use and eventually suffer more and pay up more" even if thay have to pay for much subsidised "user fees"(5). Though efforts have been made in some instances to guard the poor and exclude essential health services in privatisation reforms, more often than not, these sections have been affected leading to worsening in the health situation, productivity and the economic development in the developing countries(2).The WHO recommendation for scaling up of "essential services for all" is appropriate and necessary and is going to cost much. The amount of spending on health in the developing countries (average 1.1 percent Gross Domestic Product GDP in South East Asia and 1.7 percent GDP in Africa)(4)is grossly inadequate. The limited economy in the developing countries makes it even harder for these countries to increase allocations (though a way has to be found). International aid has helped and is helping developing countries to improve their health situation. As identified(1), though developing countries may not have as much skills in managing large increases in funding, better strategies for fund utilisation and monitoring are being developed(6), and are likely to improve with experience, and this(inadequate skills) should not be a deterrent to the developed nations from funding health care in the developing countries. References: 1.Morrow RH. Macroeconomics and health BMJ 2002;325:53-54. 2.World Health Organisaton(WHO). Evaluation of recent changes in the financing of health services. Report of a WHO study group.(Technical Report Series No.329) Geneva, WHO,1993. 3.Zwi BA, Brugha R, Smith E. Private health care in developing countries: If it is to work it must start from what users need BMJ 2001;323:463-464. 4.World Health Organasation(WHO). World Health Report 1999:Making a dirfference WHO, Geneva,1999:90-119. 5.Ensor T, Sau BP. Access and payment for health care:The poor in Vietnam. Int J of Health Planning and Management 1996;2:69-83. 6.Deptartment of Health and family Welfare, Government of West Bengal(HFW GOWB). Referal manual, West Bengal Health Sector Development Program. HFW GOWB kolkata.1997. |
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