Helping poorer countries make locally informed health decisionsBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c3651 (Published 16 July 2010) Cite this as: BMJ 2010;341:c3651
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The report by Chalkidou et al, 2010 on the role of National Institute
of Health and Clinical Excellence (NICE) outside UK, is promising for many
developing countries. It strengthens the argument that development
assistance should be tied with introducing some scientific approaches
practiced in healthcare system of developed countries e.g. NHS of England.
Healthcare in Pakistan has now got particular attention of donors
and the government. Pertinent to mention is enhancement of health
allocation by the government and development assistance from donors.
Especially financial assistance from Department for International
Development (DFID), Australian Aid (AusAID) and United States Aid for
International Development (USAID) is reaching record levels.
Over the years, most of health sector initiatives in Pakistan followed
supply side perspective. Annual Development programs and five years plans
of successive governments are silent on 'linking healthcare with health'.
The question of efficient and equitable financing/delivery of
healthcare still needs answers from donors and government of Pakistan.
Though there are concerns of efficiency of development assistance by the
legislatives and civil society of the donor countries. Yet this assistance
seems to be piling-up on an already inefficient public healthcare system.
Similarly the government is also striving to improve healthcare system.
But it lacks coherence in policy and has limited expertise to apply
economic principles in healthcare.
Healthcare system are now judged on three principles i.e. equity in
financing and access, efficiency of healthcare delivery, and cost
effectiveness of medical technologies. These principles are built on
combination of theories of health economics, social contract and modern
welfare state. Instead of waiting for a specific model, the above
principles are as relevant to countries like Pakistan as these are for
many western healthcare systems. Below are some of the areas of health
sector in Pakistan, which need attention of NICE international following
1. Resource allocation
Resource allocation to healthcare by the federal and provincial government
follows historical pattern, expert's opinion and donor's direction.
Current year (2010-11) Public Sector Development Program (PSDP) of
Ministry of health is mostly for Maternal and Child health (more than
50%). In addition there are allocations for seven new medical collages.
The USAID allocated 89% of it health budget for reproductive and child
health and DFID and Aus-AID have same priority through their Research and
Advocacy Fund (RAF). The argument of funding to MCH related programs is
indeed Pakistan's poor performance on MDG goals. Yet a simple emphasis on
enhancing supply of MNCH services is not efficient without acknowledging,
the indirect influence of the other health services on maternal and
children health. Similarly in a country with highest doctor to population
ratio in the region and inverse doctor to nurse ratio, perhaps there is
dire need for nursing and paramedic schools. In addition geographical
variation in resource allocation between provinces and districts is worth
exploring. This situation is somewhat similar to NHS resource allocations
before 1976. Disparities of London to other regions were addressed on the
recommendations of Resource Allocations working Party (RAWP). Formula
funding was further refined into a need based weighted capitation formula
for Primary care Trusts (PCT). Government of Pakistan can be supported for
adopting formula funding for healthcare: based on locally available
evidence on healthcare needs.
Contracting of Basic Health Units (BHU) is an indigenous reform started in
1999. It is now implemented in 69 districts. The model has shown some
improvement in services delivery by utilizing its supply side elasticity.
However, it has not experienced such experimentation and refinement as in
NHS i.e. NHS internal market in 1990's to the post 2002 market reform
under 'Third Way' approach of the Labour government. This rich experience
of purchasing can by utilized for reviewing contracting of BHUs in
Pakistan, to improve service delivery, competition in award of contract
and gate keeping role for BHUs.
3. Universal Health coverage
The present political government aspires for universal health coverage on
the analogy of NHS. However it faces two challenges. Firstly, increasing
public health expenditure from 30% to more than 80 % of total spending and
secondly to develop legal and administrative mechanisms for social health
insurance. The present government neither has fiscal space to enhance
allocation to healthcare, nor has the technical expertise to introduce
cross subsidization and large risk pooling. Donor assistance can fill some
gap in financing but more importantly can provide technical support to
build a road map for universal health coverage.
The National Health Services has rich and evolutionary experience of
improving efficiency and quality of health services without compromising
its egalitarian essence. Besides, there are many regional best practices
in healthcare financing and delivery that can be localized. NICE
international, as such, can be even nicer to the people of Pakistan by
helping government to build a better healthcare system. This will not
only improve efficiency of donor's financial assistance to Pakistan but
will also contribute to better utilization of taxes money collected mostly
from poor people of Pakistan.
Competing interests: No competing interests
I agree with the overall spirit of Chalkidou et al's analysis
promoting "locally informed health decisions" in "poorer countries".
However, I found some of the analysis dated, and promoting the National
Institute of Clinical Excellence (NICE) model with no evidence of its
relevance to the developing world. In this regard the following issues
need to be highlighted by the authors in the future.
The review of the "problem" is not new; papers on the infuences
affecting decisions in developing countries from donor priorities, to
individual preferences abound. As the authors mention, the World Health
Organization, the Global Forum for Health Research, and the Council of
Health Research for Development, amongst others, have elaborated these
extensively. Moreover the Disease Control Priorities Project
(www.dcp2.org) is promoting cost effectiveness analysis for decision
making in health. Thus, what is specific in this situation analysis to
warrant a new or different approach?
Providing a clear rationale, and preferably evidence, to explain why
a model of decision making based on NICE in the United Kingdom will work
in a developing country? In fact the paper does not proposed a model how
such a process can be integrated and adapted (or evidence from any work
that has been done) to the specific context of a developing country. This
gives the impression that the authors are proposing one specific model, as
opposed to supporting locally grown and developed models that achieve the
The three examples they quote - Thailand, Mexico, and Turkey - are
all middle income countries. What is the relevance of the NICE model for
low income countries? Thailand and Mexico have evolved their own model of
supporting evidence based decisions which provide an ideal case study for
other countries. And yet some of the greatest need is in low income
nations in Africa and South Asia where such processes are being tested and
Other organizations, networks, and institutions have been working to
promote evidence based decisions for many years - albeit with variable
success. How does the proposed model build or complement these previous
efforts? For example, Evidence Informed Policy Network (EVIPNET) is one
effort promoting similar ideas as a global network (www.evipnet.org);
while Future Health Systems is another multi-country project supporting
local data for health decisions (www.futurehealthsystems.org). More
importantly the notion of health policy units associated with ministries
of health is also being tested. Recognizing the limitation of space, it
is important for the authors to contextualize their proposal and provide
some comparative analysis.
I strongly support the notion of evidence based health decisions but
also recognize that the nature and quality of the evidence might come from
local, national or global contexts. It is the capacity to seek, summarize
and analyze such evidence in a timely, relevant and pro-policy format that
is much needed in the developing world. Policy makers are demanding this;
it is timely to explore appropriate models for addressing this gap.
 Chalkidou K, Levine R, Dillon A. Helping poorer countries make locally
informed health decisions. BMJ, 341:284-6, 2010
 Gilson L, McIntyre D. The interface between research and policy: case
study from South Africa. Soc Sci Med 67(5):748-59, 2008
 Hyder AA, Corluka A, Winch PJ, et al. Health Pol Plan, 14 June 2010
(EPub ahead of print)
Competing interests: No competing interests
We agree that empowering local authorities to make decisions is
critical to enhance local decision making. South Africa has a history of
such efforts both preceding and following the fall of Apartheid
(1,2,3,4,5). Over the past 18 months we have established an initiative to
support and strengthen this process in South Africa. An extensive and
rewarding consultation with stakeholders culminated in a national-level
Steering Committee to provide high-level direction and oversight. At the
launch of this initiative (6), Dr. Molefi Sefularo (the late Deputy
Minister of Health), noted that SA needed “increased capacity, as a
country, to make better, quality and informed decisions in the health
The broad goals of PRICELESS SA (Priority Cost Effective Lessons for
Systems Strengthening) are to 1) Ensure that priority setting for health
care systems is based on good evidence; and 2) Support the development of
evidence-based information and tools to determine how best to use
existing/scarce resources so that health systems work more effectively and
efficiently. To maximize the usefulness of this information for resource
allocation decisions, work is underway in close collaboration with local
policy makers and analysts and their engagement so far has been highly
encouraging. One of the key innovations that is that the economic
evaluation will measure not just traditional vertical interventions, but
will address how to gain efficiency for an intervention(s) at lower cost
across the key service delivery “platforms” that are used to deliver
public health and medical care interventions. Tools are being developed
and field tested to determine whether they can provide nationally-relevant
results. Several cost-effectiveness analyses of district health / primary
care platforms are underway including their articulation with integrated
approaches to the management of chronic disease including vascular illness
and/or TB/HIV; and Maternal and Child Health.
PRICELESS SA is part of a wider network of countries including India that
are beginning to undertake similar efforts as part of the Disease Control
Priorities Network (DCP-N) based at the Institute for Health Metrics and
Evaluation at the University of Washington, Seattle. The success of the
PRICELESS SA initiative over time will depend on several issues, not least
of which, as noted in your article is the promotion of local technical
expertise in order to carry this kind of work forward. An intensive
workshop to enhance proficiency and provide researchers in South Africa
with the practical skills to compile burden of disease data and to model
the cost-effectiveness of health interventions recently took place.
Participants included government representatives from Ministries of Health
and Finance at both national and provincial level. Developing further
technical competence in SA is essential to realize the gains from the
government’s considerable investment in health.
Hon Senior Lecturer, University of Witwatersrand School of Public Health
MRC/Wits Rural Public Health and Health Transitions Research Unit, School
of Public Health, University of the Witwatersrand, Johannesburg, South
Director, Division of International Science Policy, Planning and
Evaluation Fogarty International Center, National Institutes of Health,
Bethesda, USA firstname.lastname@example.org
Director and Associate Professor, MRC/Wits Rural Public Health and Health
Transitions Research Unit, University of Witwatersrand School of Public
Health, Johannesburg, South Africa
6. Cherry M. Setting priorities for health spending in South Africa. S Afr
J Sci 2009;105(7-8):245-246.
Competing interests: No competing interests