Big programmes, big errors

Abstract

For how long have health organisers know that cost-effectiveness of vertical programmes is usually low? UNICEF seems to have learnt this at last. Near-bankruptcy is obliging it to withdraw from its ambitious vaccination campaigns, leaving an important vacuum behind. An example is Niger, where polio-3 coverage in 1995 was estimated at 23%, but not for lack of efforts. Until 1996, the Ministry of Health, encouraged by international agencies, was organising expensive vaccination campaigns. These created important opportunity costs, without solving the low vaccination coverage. But the light is shining in WHO offices. After eradicating smallpox, WHO specialists want to eradicate poliomyelitis. Of course, this is feasible on paper. Moreover, cost-benefit analysis is always positive because it would save vaccines and operational costs for eternity. For a few difficult public health specialists who believe in the development of integrated, decentralised, and sustainable health services, WHO has reserved some arguments: national vaccination campaigns bring in money to reinforce infrastructures. (Where and how?) And says that an epidemiological network of laboratories will be put up reinforcing surveillance systems (is this a priority and who will bear future costs?). Let us examine some facts. Poliomyelitis is disappearing gradually from the world, mainly thanks to routine vaccination in integrated services. Once eradication is in sight, vertical programmes take the lead. For Niger, costs for organising national vaccination days in 1997 are estimated at US$2492 million: $414 000 should come from development projects and $11 000 from the government. All this to avoid some 40 yearly cases of poliomyelitis (the number reported in Niger in 1996). Many hidden costs also exist (use of cars, salaries, preparatory meetings, &c); nor are epidemiological surveillance costs included. Instead of a cost-benefit analysis alone, one should look at perverse effects and opportunity costs. Perverse effects include paralysis of the development of health services (time investment), interruption of permanent health services, and the misleading promotion of vertical programmes to the detriment of the credibility of district health systems. In terms of opportunity costs and alternative strategies, allocation of these funds, were they available, to integrated health services (supervision, drugs, vaccines, health centres, and district hospitals) would solve most health problems for a much higher proportion of Niger's population than at present (in Niger, 68% of the population has no reasonable physical access to health services). Routine vaccination coverage would readily increase to more acceptable levels, and would contribute to general human development (what is the development contribution of 40 cases of poliomyelitis less, in a country in which child mortality was estimated at 31·8% in 1992 and maternal mortality 0·7%?). I agree that it would take longer before poliomyelitis would be completely eradicated, but is the overall objective to eradicate or to be more healthy? Clearly, poor countries cannot refuse such a worldwide programme, despite negative effects, especially with their low budgets. If WHO and the developed world think such an eradication programme is their priority (it is definitely not that of developing countries) and they want to impose it on the rest of the world, why do they not pay the whole bill?