PHA-Exch> Funding for primary health care in developing countries

[Claudio Schuftan]

From: Ken Harvey k.harvey at medreach.com.au

Funding for primary health care in developing countries

http://www.bmj.com/cgi/content/full/336/7643/518

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 (www.15by2015.org),
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; {euro}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 (www.globalfamilydoctor.com); Global Health through
Education, Training and Service (www.ghets.org); the Network: Towards
Unity for Health (www.the-networktufh.org); and the European Forum for
Primary Care (www.euprimarycare.org )—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.

Jan De Maeseneer, professor of family medicine1, Chris van Weel,
professor of family medicine2, David Egilman, clinical associate
professor3, Khaya Mfenyana, professor of family medicine4, Arthur
Kaufman, professor of community health5, Nelson Sewankambo, professor of
medicine6, Maaike Flinkenflögel, researcher1

1 Department of Family Medicine and Primary Health Care, Ghent
University, Belgium, 2 Department of Family Medicine, Radboud University
Medical Centre, Nijmegen, Netherlands, 3 Brown University, Providence,
RI, USA, 4 Department of Family Medicine, Walter Sisulu University,
Mthatha, South Africa, 5 Department of Community Health, University of
New Mexico Health Sciences Center, USA, 6 Faculty of Medicine, Makerere
University, Kampala, Uganda.

jan.demaeseneer at ugent.be
Competing interests: None declared.

Provenance and peer review: Commissioned; externally peer reviewed.

References

   1. WHO. The World Health Report 2007. A safer future. Global public
health security in the 21st century. 2007.
www.who.int/whr/2007/whr07_en.pdf.
   2. De Maeseneer J, Willlems S, De Sutter A, Van de Geuchte I,
Billings M. Primary health care as a strategy for achieving equitable
care: a literature review commissioned by the Health Systems Knowledge
Network. 2007.
www.who.int/social_determinants/resources/csdh_media/primary_health_care_2007_en.pdf
.
   3. Gillam S. Is the declaration of Alma-Ata still relevant to
primary health care? BMJ 2008 doi: 10.1136/bmj.39469.432118.AD.[Free
Full Text]
   4. Segall M. District health systems in a neoliberal world: a review
of five key policy areas. Int J Health Plann Manag 2003;18:S5-26.[CrossRef]
   5. WHO. Engaging for health. Eleventh General Programme of Work
2006-2015. 2006. http://whqlibdoc.who.int/publications/2006/GPW_eng.pdf.
   6. De Maeseneer J, van Weel C, Egilman D, Mfenyana K, Kaufman A,
Sewankambo N. Strengthening primary care: addressing the disparity
between vertical and horizontal investment. Br J Gen Pract
2008;58:3-4.[CrossRef][Medline]
   7. Global Fund to Fight AIDS, Tuberculosis and Malaria. A strategy
for the global fund. Accelerating the effort to save lives. 2007.
www.theglobalfund.org/en/files/publications/strategy/Strategy_Document_HI.pdf
.
   8. Brown G. Joint statement with chancellor Angela Merkel on
international health partnership. 2007.
www.primeminister.gov.uk/output/Page12904.asp.
   9. Martinez J. Implementing a sector wide approach in health: the
case of Mozambique. 2006.
www.hlspinstitute.org/files/project/100615/Mozambique_SWAP.pdf.
  10. Pust R, Dahlman B, Khwa-Otsyula B, Armstrong J, Downing R.
Partnerships creating postgraduate family medicine in Kenya. Fam Med
2006;38:661-6.[ISI][Medline]
  11. De Maeseneer J, Flinkenflögel M. Primafamed network for training
family physicians in sub-Saharan Africa, an Edulink-ACP-EU project.
2008. www.primafamed.ugent.be.

Related Article

Is the declaration of Alma Ata still relevant to primary health care?
    Stephen Gillam
    BMJ 2008 336: 536-538. [Extract] [Full Text]

Rapid Responses:

Read all Rapid Responses

Policies of funding in developing countries
    Dewan S. Billal, Ph.D, et al.
    bmj.com, 9 Mar 2008 [Full text]
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