Reforms to the health sector must retain vertical programmes like those for tuberculosis

BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7251.1726 (Published 24 June 2000) Cite this as: BMJ 2000;320:1726
  1. John Crofton, emeritus professor of respiratory diseases, University of Edinburgh (eapretty{at}breathemail.net)
  1. 13 Spylaw Bank Road, Edinburgh EH13 0JW

    EDITOR—Health sector reform has become the policy urged on poor countries in the developing world. Basically it entails transferring responsibility for health services and health budgets to local communities. I am sympathetic to this approach. But its uncritical application by governments has a dangerous obverse.

    Vertical programmes—for instance, central coordination and monitoring of the World Health Organization's DOTS (directly observed treatment short course) programme for control of tuberculosis—may be discouraged. The programme may be suddenly abolished. The economy of scale resulting from national bulk buying of antituberculous drugs disappears. The tuberculosis experts in the Ministry of Health, who provide leadership and coordination and who monitor the programme, are dispersed to other jobs. Suddenly there are no drugs for tuberculosis, either centrally or at the periphery, and no control programme.

    I am told that this has already occurred in Zambia and Ethiopia. It almost occurred in Bangladesh. It is threatening to occur in many other countries.

    With HIV infection and multidrug resistance, the World Health Organization has declared tuberculosis to be a global emergency. It is a desperate race against time to establish good national tuberculosis control programmes, especially in the 22 countries that contain four fifths of the world's cases. National control programmes would prevent the development of multidrug resistance—always the result of bad doctoring—before the alliance of multidrug resistance with HIV infection creates an almost untreatable pandemic (tuberculosis is no respecter of frontiers).

    It is essential to retain the economies of scale offered by the central purchase of drugs and basic diagnostic equipment. It is essential to retain control of central monitoring and coordination and gradually to hand over the major responsibility of the service to local communities as their skill develops. Just as in community development projects in the United Kingdom, professionals continue to be needed in the background to pick up the bits when a local administration fails.

    When I raised this problem at a recent symposium on global health the representative of Save the Children supported me. He said that the child immunisation programme in Uganda had almost collapsed for the same reasons. I have just visited the School of Tropical Medicine in Liverpool and had discussions with people working on tropical disease problems in poor countries. Although sympathetic with the concept of health service reform, many are disturbed by the possibility of the sudden abolition of vertical programmes with no real provision for their effective replacement.

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