Twenty criteria to make the best of scarce health resources in developing countries

It is difficult to exaggerate the health needs of developing countries. Consider the formidable core list of priorities in President Obama’s Global Health Initiative: maternal health, diarrhoea, pneumonia, routine immunisable diseases, family planning, nutrition, sanitation, malaria, HIV, tuberculosis, and priority neglected tropical diseases—and each has multiple interventions. Yet, numerous other worthy health conditions clamour for attention. These include infectious diseases such as influenza, meningitis, cholera, and emerging zoonoses but also injuries, mental illness, surgery, palliative care, and chronic diseases. The immense needs dwarf the available resources and fragile overloaded systems. Even basic infrastructure is often lacking—for example, national service provision assessments from Uganda and Tanzania indicate that only 24% and 35%, respectively, of health facilities have regular electricity and only 31% and 34%, respectively, have regular water supply.1 2 Health worker shortages and related system dysfunctions have been described as a “slow-burning crisis.”3 Health workers can perform only a limited number of tasks, and organisational system structures are fragile as well. Accordingly, many effective public health approaches such as water and sanitation, food fortification, or alcohol taxation bypass clinical services entirely.

So what is the best use of resources? Much of the advocacy for health interventions stresses the importance of a particular health problem and the clinical efficacy of proposed interventions. However, true success on a large scale in resource constrained environments requires much more. To help a more systematic approach, I suggest some key criteria that should help both to inform priorities and to improve interventions.