From Rio to Iragua--sustainability versus efficiency and equity for preventive health interventions.

Abstract

Preventive interventions in the health sector are an essential component of public health work. The authors of the 1993 World Development Report ( World Bank 1993) suggested that in resource-poor countries only US$ 4.2 per capita per year would buy a basic preventive public health package including EPI Plus, school health, micronutrient supplementation, health education, nutrition advice and family planning, tobacco and alcohol prevention programmes, vector control and AIDS prevention. As evidence from research emerges, new interventions are added to the existing ones, such as insecticide-treated nets (ITNs) for malaria control. This basic package consists of feasible and highly cost-effective interventions for a bargain price. Some are one-off expenses (for example childhood vaccines) while others represent recurrent cost (for example the insecticide treatment of nets). Unfortunately even this is well above what a large number of low-income country governments are currently investing in the provision of health services. Where is the difference going to come from? Clearly, when government budgets are tight, it must be provided by either the population or an outside donor. Governments and donors are increasingly asking people to contribute to the cost of health care in general and preventive services in particular, and presenting this as necessary if the provision of services is to continue. Undoubtedly cost-sharing has an important role to play in the future of health care services in low-income countries, but we also need to be acutely aware of its consequences for the population and for socio-economic development. Unfortunately cost-sharing in health has come at a time when structural adjustment policies are imposing an ever-growing list of demands on the population: food subsidies are being dropped, many social services and utilities that used to be free or very lowcost (education, water, etc.) are now being charged for. This rising demand on household resources not only diminishes access to basic services for a large number of the world's population, but also reduces their ability to invest in other productive activities. In this context, health does not usually feature among most people's top priorities, as shown by community-based studies ( Tanner 1989). Food, water and housing take precedence over anything else. While paying for curative services might be acceptable and is indeed daily practice in many countries, paying for preventive interventions is not well accepted. Some interventions with a directly beneficial component – such as ITNs which reduce nuisance insect-biting as well as malaria transmission – are perhaps more willingly paid for than for example vaccinations, whose benefits are not as clearly perceived ( Nichter 1995). Donor support helps to fill the gap left by the growing inability of governments to deliver services. Unfortunately, the need of long-term support for well-structured, decentralized and effective public health interventions conflicts with the growing feeling among donors that health interventions, both curative and preventive, need to be made ‘sustainable’. While there has never been an agreement in the public health world as to what that means exactly, it is quite clear from a donor perspective that it is often equivalent to phased dis-investment. Other definitions of ‘sustainability’ have been proposed, for example focusing on the complex interaction between population and health services and on the concept of health itself ( Tanner 1998). The usual consequence of donor dis-investment is either that the programme terminates or that another donor steps in; neither outcome fits the concept of ‘sustainability’ easily. When new opportunities for interventions arise, donor agencies often support their development and deployment up to the point when they turn into a recurrent cost in the annual budget – which they eventually get tired of supporting. Even successful and indispensable programmes such as the Expanded Programme of Immunization (EPI) are increasingly facing such donor fatigue. Unfortunately, the problem does not disappear as the fatigue sets in, and the situation can deteriorate rapidly, as recent epidemics of measles and malaria in Africa have shown. Most preventive health services cannot be made sustainable, and this is true for both rich and poor societies. The word ‘sustainable’ draws on a paradigm from an ecological understanding of the world enshrined at the Rio Earth Summit – a paradigm that does not apply to the provision of social services in Iragua, a typical African village. Unlike the environment, which is usually at its best when left alone, health is only sustained through permanent investment in its development and maintenance. Criteria of medium- and long-term sustainability suitable for ‘productive’ development activities (such as cattle-farming or improved agricultural production) do not apply to health because no direct returns can be expected from a child that does not die or from a disease episode that is prevented. Besides the increased productivity of a healthy population, savings in health care expenses can be expected, but it is difficult to see this as a return on investment because illness episodes are often financed by a complex web of social interactions rather than by one household. Hardly any preventive health intervention will run effectively and consistently without investment by the public sector. Even inexpensive and highly cost-effective programmes such as stricter tobacco policies require state intervention, sophisticated technical advice and material support to be developed and maintained. Cost-sharing is of course possible up to a certain level (as discussed above), but we urgently need to quantify the consequences of ever-increasing household contributions to basic services, in order to understand their impact on access and economic production. Reforming the health system, for example by changing the mode of operations and financing, will not alter the basic need for subsidizing preventive services. For donor agencies, giving support to preventive health interventions is both a moral and a practical imperative in societies which cannot yet fully afford even basic curative services. Donor support permits rational choices on the basis of feasibility and cost-effectiveness and addresses the key issues of equity and efficiency. Without external support a large number of the poorest people in the world would be denied cost-effective health interventions, an unacceptable prospect. The concern with ‘sustainability’ of programmes invariably tends to shift the focus of development programmes away from the poorest towards the better-off ( Harvey 1991). Of similar importance is the fact that donor involvement in securing key public health interventions is potentially the best approach to ensure efficient use of resources and to maximize the skills of service providers. If the constraint to become ‘sustainable’ is removed, the most feasible and cost-effective strategies can be selected. EPI is a classic example of a preventive intervention with substantial external funding that is best organized nationally, through existing health services, and with a unity of purpose and action that made it very successful. Asking Mother and Child Health (MCH) staff to recover some of the cost from mothers would not only jeopardize the mothers' willingness to bring their children for vaccination, but would also distract the staff (especially in peripheral health services) from providing an efficient and high-quality service, which is their essential task ( Harvey 1991). There is little doubt that attempting total ‘sustainability’ of the EPI programme would destroy it. There is no room for donor fatigue, only for better service and more efficient use of resources. Another example with a completely different implementation approach is that of ITN promotion. It seems increasingly clear that large-scale deployment of ITNs will only happen as a result of an alliance between the private and public sectors, at national and local levels. While the private sector should largely bear the responsibility for distributing nets and insecticide to most of the population, some investments from the public sector are required to share the cost of developing the market; to regulate it; to promote the intervention; and to target subsidies for the most vulnerable groups. As illustrated by a recent social marketing programmes ( Armstrong Schellenberg et al. 1999 ), this private-public alliance is feasible and an efficient use of public resources. It draws on the fact that ITNs are as much a commercial commodity as a valuable public health tool, and that there is substantial willingness to pay for them. Despite this very positive situation, making the intervention ‘sustainable’ in the sense of withdrawing any outside resource could only be done by drastically increasing the price of both nets and insecticide (especially for those groups targeted for specific subsidies) and therefore reducing access. This would seriously affect equity since the poorest segments of the population are also most at risk for death from malaria, and it would reduce the overall community effectiveness of the intervention, since high coverage levels lead to more mosquitoes killed and therefore lower transmission levels for everybody. Rather than focusing long-term on sustainability of health interventions in an ecological sense – a goal unlikely ever to be achieved – we might therefore be well-advised to think instead about: Feasibility – what are realistic options for large-scale implementation? Efficiency – what is the best use of all available resources, considering all feasible options? Levels of subsidy – or from the user's point of view – what level of cost recovery can be borne by, and is acceptable to, the majority of the population? Our efforts should therefore continue to be primarily directed towards operational and resource optimization of public health interventions. A major challenge for individuals and institutions involved in such interventions is to assist in the fight against donor fatigue through timely and repeated inoculations of public health caffeine at every possible occasion. The author is the recipient of a PROSPER senior fellowship from the Swiss National Science Foundation (grant # 32–41632.94). Thanks to Dr Don de Savigny and to Jennifer Jenkins for useful comments.