Sustaining Primary Health CareBMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7002.460 (Published 12 August 1995) Cite this as: BMJ 1995;311:460
- Veena Soni Raleigh
Anne LaFond Earthscan, £13.95, pp 218 ISBN 1 85383 202 2
Although notable health gains have been achieved in developing countries by improving preventive and curative care, most developing countries are still unable to provide sustainable and affordable quality health care for the majority of their populations. Health care interventions are often short lived, and health gains transient, because national governments cannot afford to maintain the recurrent costs of such interventions. Reconciling short term “quick fixes” with building long term local capabilities for delivering health care--and the financial mechanisms to sustain them--is a goal that has eluded most developing countries, particularly the poorest ones. Foreign assistance has all too often exacerbated these tensions rather than easing them.
In Sustaining Primary Health Care Anne LaFond reviews the experiences of five developing countries (Nepal, Pakistan, Vietnam, Ghana, and Uganda) to analyse how health systems develop in relation to internal and external influences. The book raises some awkward questions about the role, aims, and contribution of external assistance, which constitutes a large proportion (up to 60% in Uganda and well over 30% in Nepal) of the health budgets in many developing countries. Annual government expenditure on health in some of the poorest countries is $1-2 per capita, compared with the World Bank's estimate of $12 for a basic package of clinical and public health services. Foreign aid can increase the domestic contribution several fold; hence it plays an important role in shaping the development of health systems in the Third World.
LaFond shows how the resource constraints imposed by the economic recession of the past decade have determined the guiding principles for external assistance, particularly the need for accountability, which has resulted in a bias towards value for money projects that promise immediate results. This means that long term viability has not always been the underlying consideration, and projects often collapse or lose momentum after outside investment ceases because the recurrent financial commitments are often unaffordable through domestic resources alone. LaFond cites the good example of the global campaigns for universal childhood immunisation in the 1980s, which were effective but difficult to sustain--maintaining effective coverage (80%) at a cost of about $0.50 per capita means that some developing countries would have to spend one half to a third of their health budgets on immunisation alone. Another consequence has been the emergence of “vertical” programmes (immunisation is again a good example) which enable donor agencies to maintain control over their investments and are attractive because they can show quick results. But they damage national capacity by fragmenting health systems into disconnected activities dependent on outsiders and focused on limited health benefits.
LaFond argues that aiming for sustainable health systems in developing countries may mean compromising standards and striking a balance between effectiveness, continuity, and self reliance. The book provides some practical if unpalatable answers: donors need to engage in investments that build long term indigenous capacities even if they do not produce immediate health gains; most interventions require continued external support; and developing countries' governments must implement the institutional reforms necessary to maximise the returns on investment in the health sector. Focusing on integrated basic health systems and far reaching reforms of the health sector may be costly, difficult, and slow to produce results, but it has to be the way forward. --VEENA SONI RALEIGH, senior research fellow, Institute of Public Health, University of Surrey