Intended for healthcare professionals


Funding for primary health care in developing countries

BMJ 2008; 336 doi: (Published 06 March 2008) Cite this as: BMJ 2008;336:518
  1. Jan De Maeseneer, professor of family medicine1,
  2. Chris van Weel, professor of family medicine2,
  3. David Egilman, clinical associate professor3,
  4. Khaya Mfenyana, professor of family medicine4,
  5. Arthur Kaufman, professor of community health5,
  6. Nelson Sewankambo, professor of medicine6,
  7. Maaike Flinkenflögel, researcher1
  1. 1Department of Family Medicine and Primary Health Care, Ghent University, Belgium
  2. 2Department of Family Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
  3. 3Brown University, Providence, RI, USA
  4. 4Department of Family Medicine, Walter Sisulu University, Mthatha, South Africa
  5. 5Department of Community Health, University of New Mexico Health Sciences Center, USA
  6. 6Faculty of Medicine, Makerere University, Kampala, Uganda.

The World Health Organization’s World Health Report 2007 deals with access to primary health care as an essential prerequisite for health.1 It acknowledges the importance of the Alma-Ata declaration of 1978, which called for integrated primary health care as a way to deal with major health problems in communities and for access to care as part of a comprehensive national health system. Yet the mission of Alma-Ata—to provide accessible, affordable, and sustainable primary health care for all—has been implemented only partially in developing countries.2 We have therefore instigated the “15by2015” campaign (, which proposes a funding mechanism for strengthening primary health care in developing countries.

In the accompanying analysis article, Gillam notes that most developing countries have failed to provide even basic primary healthcare packages. Weaknesses in primary healthcare services often result from a variety of forces, including economic crises and market reforms, which limit the range and coverage of services and thus their effect on health.3 4 On the positive side, between 1997 and 2002, financial support to improve health care in developing countries increased by about 26%, from $6.4bn (£3.3m; €4.4m) to $8.1bn.5 However, most aid was allocated to disease specific projects (termed “vertical programming”) rather than to broad based investments in health infrastructure, human resources, and community oriented primary healthcare services (“horizontal programming”).6

An example of vertical programming is the enormous donor response to the HIV epidemic. In 2006, although Zambia’s entire Ministry of Health budget was only $136m, the President’s Emergency Plan for AIDS Relief provided the country with an HIV targeted budget of $150m. This unbalanced distribution of health funding occurs across sub-Saharan Africa. Thus, although HIV positive patients receive free care, others with more routine diseases receive poor care and still have to pay. Salaries of healthcare providers working for donor funded vertical programmes are often more than double those of equally trained government workers in the fragile public health sector. This lures government workers to the higher paying vertical programmes and creates an internal “brain drain.” But it is the underfunded primary care clinics and health centres that care for all diseases, including common illnesses such as diarrhoea, malnutrition, and respiratory tract infections, which take many more lives than HIV, tuberculosis, and malaria.

A new global strategy is needed to reinforce community focused primary health care in developing countries. This will require cooperation between ministries, universities, non-governmental organisations, and donors working on health to overcome severe resource constraints, including insufficient numbers of doctors, pharmacists, and other health personnel. Four international organisations—the World Organization of Family Doctors (; Global Health through Education, Training and Service (; the Network: Towards Unity for Health (; and the European Forum for Primary Care ( )—have therefore set up the 15by2015 campaign to foster a better balance between vertical and horizontal aid. This campaign calls for major international donors to assign 15% of their vertical budgets by 2015 to strengthening horizontal primary healthcare systems so that all diseases can be prevented and treated in a systematic way.

This campaign is not acting in a vacuum. A broad approach—orienting funds to governments for comprehensive provision of care—is being implemented in several countries in sub-Saharan Africa.The Global Fund to fight AIDS, Tuberculosis, and Malaria has called for investment to strengthen health systems and tackle social determinants by supporting strategies to reduce poverty.7 The United Kingdom’s prime minister, Gordon Brown, in a joint statement with Germany’s chancellor, Angela Merkel, announced the launch of the “International Health Partnership.”8 The core idea is to encourage low income countries to create comprehensive country-wide health programmes, which would serve as the basis for all foreign assistance for health. Hopefully, other donors will follow these leads.

How would 15by2015 work? Take the example of Mozambique. In 2005, the total health expenditure in the country was $356m. Foreign assistance accounted for $243m, from which $130m was channelled through disease specific vertical funds managed directly by donors.9 We propose that, 15% of the vertical funds from donor organisations (in this example, $19.5m) should be diverted into the government’s common health fund and be earmarked for strengthening primary health care through improvement of infrastructure, health education, and investment in human resources. This amount of money could support 65 health centres for a year. These centres could be staffed by primary care teams including family doctors, mid-level care workers, primary care nurses, pharmacists, and health promoters. If one primary healthcare centre covers a population of 20 000 people, then 65 health centres would give 1.3 million people access to improved primary health care.

Part of the 15by2015 fund could be allocated to support the training and upgrading of skills. It could also be used to provide better pay for health personnel to encourage them to stay in areas where they are needed and to pay for community health workers, mid-level care workers, and “African family physicians” who are a fledgling but emerging force.10 11 The Ministry of Health should monitor the accessibility and quality of this care in a transparent way to ensure that the 15by2015 fund is used most effectively to improve community health.



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