Letters Criteria for scarce resources

Apply criteria to improve health systems in developing countries

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e546 (Published 14 February 2012) Cite this as: BMJ 2012;344:e546
  1. David Beran, researcher and lecturer1,
  2. John S Yudkin, emeritus professor of medicine2
  1. 1University of Geneva, Faculty of Medicine, Division of International and Humanitarian Medicine, Rue Gabrielle-Perret-Gentil 6, 1211 Geneva 14, Switzerland
  2. 2University College London, London, UK
  1. david.beran{at}unige.ch

Shelton proposes 20 criteria to make the best use of scarce resources in developing countries.1 This new approach to prioritising healthcare interventions may, however, omit considerations strengthening health services as well as some ethical issues.

We have scored insulin use in type 1 diabetes in a typical resource poor setting. With a score of around 70-80, this intervention would be “discarded.” But, although the burden of disease is low, the life expectancy of an untreated child with type 1 diabetes is less than a year.2 Access to insulin is unique as no alternatives exist to ensure survival. The proposed criteria should therefore include a moral and ethical perspective, highlighting such issues as the existence of alternative treatments, the cost (human and financial) of doing nothing, and equity, given that insulin availability in high income settings guarantees nearly normal life expectancy.

Shelton states that strengthening health systems should be a priority. Instead of using these criteria to rank different interventions, could they not be used to integrate different measures to improve health systems? For example, strengthening the health system in Mozambique for diabetes has improved drug procurement for insulin and other drugs for non-communicable diseases and led to improved sustainability and scalability, as well as improved health worker training and patient education.3 This diabetes specific work has also had impacts on the management of hypertension and other non-communicable diseases. Scoring and comparing different interventions continues to create an environment of competition between health issues rather than an overall approach to improving health systems.4 Donors, including President Obama’s Global Health Initiative, should aim at improving health systems rather than taking disease specific approaches.


Cite this as: BMJ 2012;344:e546


  • Competing interests: None declared.

  • David Beran is adviser to the board and John S Yudkin chairman of the International Insulin Foundation, London, UK.