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Rapid Responses: Rapid Responses published:
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Policies of funding in developing countries
- Dewan S. Billal, Ph.D, Muneki Hotomi MD, Ph.D , Professor Noboru Yamanaka, MD, Ph.D (9 March 2008)
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Disease specific funding supports health systems and communities
- Ade O Fakoya, Alvaro Bermejo, Executive Director International HIV/AIDS Alliance (12 March 2008)
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Do international donors genuinely desire to help solve Africa's health problems?
- Felix ID Konotey-Ahulu (19 March 2008)
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Bumper Stickers won’t get us to primary health care
- Jeremiah Norris (21 March 2008)
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Dewan S. Billal, Ph.D, Postdoctoral Fellow Department of Otolaryngology, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8509, Japan, Muneki Hotomi MD, Ph.D , Professor Noboru Yamanaka, MD, Ph.D
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Sir- In Editorials Jan De Maeseneer and colleagues1 discusses about the distribution of financial support in heath to improve the overall health status in the developing countries in the world. The authors urged that most of the aid allocated to vertical programming rather than horizontal programming in the developing world. The authors proposed to divert 15% of aid to horizontal programming for strengthening primary health care through governments in the developing countries. However the pattern of primary health care is different from one country to another country. A comprehensive study in Bangladesh, in children aged 1-4 years revealed that 26% of all deaths were due to drowning, followed by pneumonia (23%), malnutrition (16%), and diarrhoea (10%)2. The study concluded that there has been a gradual shift in the cause of child deaths in Bangladesh from infectious diseases to noncommunicable diseases and injuries. Most of the drowning deaths occurred before noon when mothers and relatives are busy with household works. Age of the mother (more dying in aged mothers), literacy (less schooling high drowning), family income (less income high drowning), family members (high family members high drowning) are identified as risk factors for dying due to drowning.2 Death due to drowning could be averted by the awareness and proper education of the parents and relatives. In a cohort study between 1976 and 2005 for about 200,000 inhabitants of Matlab in Bangladesh showed that the educational differentials for mortality were substantial; the OR for more than 8 years of schooling compared with no schooling was 0.30 (0.21-0.44) for maternal mortality and 0.09 (0.02-0.37) for abortion mortality respectively.3 In a study in Bangladesh showed that 87% of the mothers sought care for their newborns and some were taken to several different providers, the commonest being homeopaths (38%) and village doctors (37%; quack)4. Among them, 17% were taken to trained providers, and only 5% to government health facilities and seeking care from trained providers was found to be associated with the gender of the neonate, birth order, antenatal care of the mother from trained providers, father's education and monthly expenditure of the family 4. A study by Alex Mercer et al. reported that 24 (11.42%) case mothers said that evil spirits were responsible for sickness and death of their baby, and nine (37.5%) of those cases sought care from a traditional healer who cast spells, applied spirit water and amulets5. Almost all the studies in the developing countries including Bangladesh are concerned about education (not only health), poverty, food security and awareness. To satisfy the Millennium Development Goals by 2015 world leader should be made efforts to raise community awareness regarding health and upgrade the socioeconomic status, to sustain success. In conclusion, 25% of vertical funds might be diverted to government common health fund, from where 15% should be used for primary health care and another 10% for expansion of education, awareness about health, better financial access for the poor, poverty reduction, and food security. We declare that we have no conflict of interest. *Dewan Sakhawat Billal Ph.D Muneki Hotomi MD, Ph.D Noboru Yamanaka MD, Ph.D billalds@wakayama-med.ac.jp Division of Infection and Immunity research Center Department of Otolaryngology-Head and NecK Surgery Wakayama Medical University Wakayama 641-8509 Japan References 1. Maeseneer JD, van Weel C, Egilman D, Mfenyana K, Kaufman A, Sewankambo N, Flinkenflögel M. Funding for primary health care in developing countries. BMJ 2008;336:518-519. 2. Rahman A, Rahman AKMF, Shafi naz S, Linnan M. Bangladesh health and injury survey: report on children. Dhaka: Directorate General of Health Services, Ministry of Health and Family Welfare, Government of the People's Republic of Bangladesh; Institute of Child and Mother Health; United Nations Children's Fund; Alliance for Safe Children, 2005. 3.Chowdhury ME, Botlero R, Koblinsky M, Saha SK, Dieltiens G, Ronsmans C. Determinants of reduction in maternal mortality in Matlab, Bangladesh: a 30-year cohort study. Lancet 2007;370:1320-8. 4. Ahmed S, Sobhan F, Islam A, Barkat-e-Khuda. Neonatal morbidity and care-seeking behaviour in rural Bangladesh. J Trop Pediatr 2001 ; 47:98-105. 5. Mercer A, Haseen F, Huq NL, Uddin N, Hossain Khan M, Larson CP. Risk factors for neonatal mortality in rural areas of Bangladesh served by a large NGO programme. Health Policy Plan 2006;21:432-43. Competing interests: None declared |
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Ade O Fakoya, Senior adviser: SRH/PMTCT The International HIV/AIDS Alliance, Queen's Road Brighton BN1 3XF, Alvaro Bermejo, Executive Director International HIV/AIDS Alliance
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Dear Sir, Madam HIV is an unprecedented global emergency which requires an urgent, co -coordinated global response. It is unfortunate that the many important points within both the editorial (1) and the article on the Alma Ata (2) were detracted from by the suggestions that primary care and health systems have severely suffered because of direct disease specific funding. First, as the article by Gillam itself acknowledges, decisions that led to selective rather than comprehensive primary care approaches and eventually starved primary health care from the political and financial support it required to succeed pre-date most of the current vertical initiatives and certainly AIDS funding. HIV affects the world’s most poor and marginalised communities who often do not have access to basic primary care. In 2000 the nations of the world committed to eight millennium development goals. Three of them, MDG4, on children’s health, MDG5 on maternal health and MDG6 on HIV itself will not be reached if the situation with HIV epidemic is not reversed. Reversing the HIV epidemic requires strengthening of health systems and addressing access to primary care and we welcome the call to support funding. It is not true to however to suggest that investing in HIV has little or minimal effect on health systems, or primary care. The work of many community based organisations funded through the AIDS response has certainly contributed to the primary / community level of health systems. The work of many activists living with HIV/AIDS has changed the dynamics between health workers and their clients / patients leading to much strong community involvement. Over the last few years there have been notable successes with reversing the epidemic in a few countries. Now is the time to ensure that these successes are built on and maintained by integrating the emergency HIV responses into health systems and strengthening the integration with maternal child health, sexual health, TB programmes and communities. There are advantages and disadvantages of providing disease specific funding (DSF) compared to direct government budget support. DSF can be provided urgently and used to target key global priorities; it is also easier to build public and political support for it. There are some disadvantages –it may establish separate, parallel health systems, and these priorities are not necessarily the recipient government priorities. However one important issue is that general funding cannot guarantee allocation to ‘less politically attractive’ or less ‘acceptable’ areas which need to be addressed to reverse the epidemic. Many of those groups who need funding often fall outside of government priorities such as youth, injecting drug users, gay and other men who have sex with men, sex workers etc. The world should learn from the advocacy and leadership which have been demonstrated in the countries which have had successes with the epidemic and use these platforms to advocate for a comprehensive response to HIV that includes strengthening primary care. It should continue to provide money for both disease specific and general health system strengthening. 1. Maeseneer JD, van Weel C, Egilman D, Mfenyana K, Kaufman A, Sewankambo N, Flinkenflögel M. Funding for primary health care in developing countries. BMJ 2008;336:518-519. 2. Stephen Gillam Is the declaration of Alma Ata still relevant to primary health care? BMJ, Mar 2008; 336: 536 - 538 ; doi:10.1136/bmj.39469.432118.AD Competing interests: None declared |
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Felix ID Konotey-Ahulu, Kwegyir Aggrey Distinguished Professor of Human Genetics, University of Cape Coast, Ghana Consultant Physician Genetic Counsellor in Haemoglobinopathies, 10 Harley Street, London W1G 9PF
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Do international donors genuinely desire to help solve Africa’s health problems? The editorial of Jan De Maeseneer, Nelson Sewankambo and colleagues, March 8 p 518 [1] and Stephen Gillam’s analysis [2] assume all donors are equally trustworthy. Africans fear “official policies” meant to better their lot. We react like the ancient Roman who, when Greeks donated a wooden horse said: “Equo ne credite, Teucri! Quidquid id est, timeo Danaos et dona ferentes” [Do not trust the horse, Trojans! Whatever it is, I fear the Greeks even when they bring gifts) [Virgil. Aenid ii; 48 (70 – 19 BC)] The authors [1 2] request “major international donors to assign 15% of their vertical budgets by 2015 to strengthen primary health care in developing countries”. But 2 contradictory principles operate which undermine this. TWO IRRECONCILABLE PRINCIPLES Alma Ata success will result in population rise, contrary to G8 wishes. Ghana, identical size as Britain with 70 million people, has 20 million yet is said to have population explosion, so would G8 transfer funds from vertical programming into horizontal programming schemes to strengthen public health? HISTORICAL EVIDENCE (a) I met Professor Sewankambo [1], at St Francis Hospital in Uganda after a ward round on AIDS patients with Dr Miriam Duggan who told me she “was saddened by the way external research agencies lost interest” whenever she “mentioned the need for going round the villages to follow up and treat patients that had been discharged” [3] (b) President Thabo Mbeki has been criticised for arguing that spending large amounts of money on HIV/AIDS “may undermine broader health services..” (Gillam’s exact words) [2]. Mbeki knows that primary health care systems “deliver better health outcomes at lower costs”? [2] (c) Cuba is the best known example where primary health care “delivers better health outcomes and greater public satisfaction at lower costs” [2], but is never applauded for this achievement. FUNDAMENTALS (a) We need to examine schemes ostensibly to “avert a malaria disaster”, but which worsen things. We remember what “official policy” in the 1960’s which stopped spraying of mosquitoes did to child mortality figures in subsequent years. The Trojan horse donors confessed later that cessation of spraying was a mistake. Then came another “official policy”: “Spraying produces cancer, stop it”, only to be confessed later that it did not. Now Ghanaian doctors showed that the present medicated bed nets introduced through yet another “official policy” are no better than those we used to keep us malaria-free. Effect of the net on babies inhaling chemicals, and on the mosquitoes in creating resistance to them, needs looking into. (b) Would donor countries give money to cover our open drains and help “Role back Malaria”, when they know that 3 million deaths would be prevented? (c) Why should African governments pin hopes on a 30 year-old declaration which states that “health is a fundamental right”, without telling us that Alma Ata also demanded building our own latrines and drilling bore holes? If health is our right, where is our responsibility for our health? (d) The days of “free health care” are gone. Dr Kwame Nkrumah indulged us with “free health care” and “free education” but then we had just emerged from ‘Gold Coast’. The gold ran out, and Nkrumah was overthrown. Ghanaians, till today, have not come to terms with the fact that we now need to pay something towards health care delivery. But are we natives to blame for all our woes? GLOBALISATION PRESSURE There is external pressure forced on developing countries, aggravating their woes. Lasting help is required to deflate this pressure. We say to the IMF, World Bank, and the G8: (1) Thank you for pressing democratic government on us, and for cancelling our huge debts. (2) Please stop dictating the price of our raw materials (3) Remove tariffs on our produce and allow us to sell to Europe (4) You subsidize your farmers and dump rice and sugar on our markets. Why? (5) You allow your banks to accept billions from our corrupt dictators, and then keep all the money when they die. Why? (6) Why do you always advise devaluation of our currency? Michel Chossudovsky argues convincingly that present globalisation of everything doctrine is really “the globalisation of poverty” [4]. G8 will soon realise that Africa is increasingly looking East. THE CHINA CLOUT Everywhere you go in Ghana today you find Chinese building roads, clinics, hotels, farms and dams. Since President J F Kennedy who helped build our Volta River Hydro-electricity Dam there has not been similar frenetic dam building activity like we see the Chinese doing with the Bui River Dam presently. They are also equipping the Ghana Air Force. Chinese Health Care Systems are springing up like they are doing in the UK now. Chinese help to clear gutters, and build underground drainage systems. Plantations of Artemisia Annua that they have used for 2000 years to treat malaria are springing up in Ghana in a way Alma Ata would approve of. As they are doing all this unaccompanied by Chairman Mao’s Red Book, no one is as afraid of them. A PERSONAL TESTIMONY British medical education in the 1950’s equipped me to evaluate health systems for both acquired and hereditary disease [5]. Managing Trustees of The Volta Fund was my main national supporter, with WHO and International Atomic Energy Agency as my external funders. These three bodies helped me to control the mounting Sickle Cell Disease burden through genetic counselling and family size limitation [6]. Other external funders I applied to wanted their experts to control my work. How could these authors [1 2] ensure success of ‘15by2015’ if donors insist they would send their “official policy” planners to override local experts, some of whom trained in the best universities in the world? SO WHOM DO NATIVES TRUST MOST TO PROVIDE GENUINE HELP? Historically, those who have made the biggest difference in Africa include workers with sincere Christian commitment, eg Missionary Establishments, WORLD VISION in Ghana, MEDICAL AVIATION FELLOWSHIP in Kenya and MEDAIR that is doing superb emergency work in war torn southern Sudan. To these expatriates the Alma Ata Declaration is not something to be feared, but a necessary help for the African. Competing interests; None declared 1 Maeseneeer JD, Van Weel C, Egilman D, Mfenyana K, Kaufman A, Sewankambo N, Flinkenflogel M. Funding for primary health care in developing countries. Money from disease specific projects could be used to strengthen primary care. BMJ 2008; 336: 518 – 19. [BMJ 2008 doi:10.1136/bmj.39496.444271.80] 2 Gillam S. Is the declaration of Alma Ata still relevant to primary health care? BMJ 2008; 336: 536-38. [BMJ 2008 doi:10.1136/bmj.39469.432118.AD 3 Konotey-Ahulu FID. Clinical epidemiology, not seroepidemiology, is the answer to Africa’s AIDS problem. BMJ 1987; 294: 1593 – 94. [20 June] 4 Chossudovsky Michel. The Globalisation of Poverty – and The New World Order. Centre for Research in Globalisation (CRG) Montreal 2003 (Second Editon) 5 Ringelhann Bela, Konotey-Ahulu FID. Haemoglobinopathies and thalassaemias in Mediterranean areas and in west Africa: Historical and other perspectives 1910 t0 1997 – A Century Review. Atti delli’Accademia delle Scienze di Ferrara, Vol 74: Anno Accademico 174, 1996-97, pp 267- 307. 6 Konotey-Ahulu FID. The Male Procreative Superiority Index (MPSI): Its relevance to genetical counselling in Africa. In FIFTY YEARS OF HUMAN GENETICS. A Festschrift and Liber Amicorum To Celebrate The Life and Work of GEORGE ROBERT FRASER Edited by Oliver Mayo, Carolyn Leach. Wakefield Press August 2007, pp 48-50. Kent Town. South Australia 5067. ISBN 978 1 86254 7537. Competing interests: None declared |
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Jeremiah Norris, Director, Center for Science in Public Policy Hudson Institute 20005
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Arguable, the Alma Ata declaration “has been implemented only partially in developing countries”, mainly because there are so many more failed states today than in 1978. Although donors expended hundreds of millions of dollars on WHO’s ‘Health for All’ by the Year 2000, WHO never provided the global health community with a rudimentary accountability. Instead, it funded a new initiative in 2000, the $2 million Macroeconomics and Health: Investing in Health for Economic Development. (1) There are no references in this report to ‘Health for All’, either in the main text, the Notes, or even in the Glossary, any of which might have indicated that some lessons were learned. The Macroeconomics study soon went the way of Health for All, giving way to WHO’s failed ‘3 by 5’ programme on AIDS treatment in December 2003 (2); then to the Commission on the Social Determinants of Ill Health in 2006; and now to the “15 by 2015” campaign, by which WHO is recommending that 15% of donor funding for HIV/AIDS, TB and malaria be taxed for broad based primary health care activities. This reallocation of donor resources would permit developing countries to achieve by 2015 what they were unable to do through Health for All and previous campaigns. WHO believes that primary health care hasn’t been effective in developing countries. This is contrary to a UNICEF report of September 2007, which stated that mortality for the under-five population dropped from 20 million per annum in 1960 to 9.7 million in 2006. (3) This dramatic decline in vital health statistics occurred at a time when the population in the developing world increased from 2.7 billion to 4.8 billion over the same time frame. Health improvements of this magnitude would have been impossible if our most vulnerable population groups lacked access to primary health care. As in all previous global campaigns on health improvements, WHO posits success on ever increasing resource flows from donors, irrespective of their macroeconomic effects within recipient countries. A report by the Center for Global Development in Washington, D. C. found: “Aid levels are already fairly high. Nearly half of the countries are receiving aid worth more than 50% of government expenditures and more than one-third above 75%. Aid flows can give governments even less of a reason to go through the tedious task of building and improving tax administration if they can get more resources from donors than their own citizens.” (4) Taxation, and its lack thereof, affects the quality of governance in the developing world. Many of these governments do not need to make much tax effort because they have large—and growing, donor resource flows. “State elites are then financially independent of citizen-taxpayers. This changes the political incentives that they face and the ways in which they seek to obtain, use and retain power.” (5) At the 2005 G8 Summit in Gleneagles, Scotland it was proposed that the donor community increase aid to African countries by $50 billion per annum over and above their Official Development Assistance commitments by 2015. On their part, African countries were to contribute $25 billion within the same time frame. (6) While some donors have since increased their aid over and above their original 2005 levels, there is no sign that African countries have taken any concrete steps to meet their commitments. This is consistent with past promises. In the 2002 Abuja Conference in Nigeria, developing countries signed on to a commitment that pledged them to the allocation of 15% of their national budgets for public health activities. None have complied thus far. If bumper sticker campaigns worked, then we should all get behind them. But looking at WHO’s past record is like standing in a hall of mirrors. Sources: 1.Jeffrey Sachs, et al., Macroeconomics and Health: Investing in Health for Economic Development, WHO, Geneva, December 20, 2001. 2.Progress on Global Access to HIV Antiretroviral Therapy: A Report on “3 by 5”, WHO, Geneva, March 2006. 3.Donald M. Mcneill Jr., “Child Mortality at record low: UNICEF predicts further drop”, International Herald Tribune, September 13, 2007. 4.Todd Moss and Arvind Subramanian, “After the Big Push? Fiscal and Institutional Implications of Large Aid Increases”. Center for Global Development, Washington, D. C., October 2005. 5.Mick Moore, How Does Taxation Affect the Quality of Governance, Institute of Development Studies, Working Paper 280, United Kingdom, April 2007. 6.“Our Common Interest: Report of the Commission for Africa”, a multi -country Commission chaired by Prime Minister Tony Blair in preparation for the G8 meeting in July 2005, March 11, 2005. Competing interests: None declared |
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