Life-saving interventions must be delivered to those at greatest
risk through health services. Health services provide the means
for dispatching the tools and supporting the strategies needed
to combat infectious diseases. These services are required to
provide good-quality health care that is affordable, accessible,
equitable and relevant to needs. If progress is to be made, vital
components must include trained and well-motivated staff, laboratories
and microscopes, health centres and facilities for storing medicines,
and vehicles for visiting remote areas.
However, in most developing countries the public health system
is poorly equipped to provide services that meet the main health
needs of the population. Moreover, good quality private health
care is often priced beyond the reach of the poor. The health
systems of many developing countries are so weak that disease
surveillance and reporting systems barely function, making it
difficult to identify disease outbreaks and respond to the most
urgent health needs.
RESOURCES FOR HEALTH SERVICES
Health services are frequently underfinanced in developing countries.
The governments of some poor countries devote as little as US$
10 per capita to health. In many African countries, external
assistance accounts for a large share of government health budgets.
In the early 1990s, 40% of Uganda's health budget was provided
through donor assistance; Gambia met 84% of its health costs
with foreign aid. Throughout the developing world, far greater
amounts of money are often devoted to other areas such as military
spending and the construction of prestigious public facilities.
Even when more money is forthcoming, resources alone are not
sufficient. Governments must use these resources effectively
and target them towards meeting the needs of the poor. In some
countries, 60% or more of government health spending is devoted
to urban hospitals serving just 10% of the population. In Ghana
for example, the more affluent population account for three times
more public health spending than the poor. In 10 developing countries,
between 1992 and 1997, only 41% of poor people suffering from
acute respiratory disorders including tuberculosis
were treated in a health facility compared with nearly 60% of
the affluent. In the same period, only 22% of births among the
poorest 20% of people were attended by medically-trained staff,
compared with 76% among the richest 20%.
Economic constraints many of them imposed externally
often dictate difficult national budgetary decisions. Because
of its burden of debt, Nigeria made cuts in recurrent expenditures
such as payment for health-staff salaries and supply of essential
drugs, in both urban and rural areas. Niger spends more than
twice as much servicing debt as it does on primary health care.
Adjustment policies designed to compensate for inadequate resources,
inequality and poverty resulted in deep cuts in government spending
on health and infrastructure and left Niger's poor and marginalized
people with virtually no access to medical care.
The
combined impact of AIDS, TB and malaria has further stretched
health services beyond their limits. During the late 1980s and
the 1990s, the AIDS epidemic spread rapidly in Africa. In addition
to AIDS, TB and malaria added a massive socioeconomic burden
on already-struggling public health systems. Countries with very
high rates of AIDS were simply overwhelmed, while health professionals
were dying faster from AIDS than they could be trained. In one
Zambian hospital, for example, deaths among health care workers
increased 13-fold in the past decade as a result of AIDS.
When the public sector fails to meet the health needs of the
population, those living in poverty must often opt for more expensive
private medical services. Out-of-pocket payments to private medical
services and traditional healers can exceed public expenditure
and can cost a small fortune compared to the patient's earnings.
Up to 90% of household expenditure on health in India is spent
on private-sector health care, with the poor paying proportionally
far more than the rich. Much of this goes on drugs and treatments
that are not medically justifiable or effective.
A shortage of health professionals
and supplies
Health systems depend on people professionals and support
staff with the necessary education, training, skills and motivation
to do their jobs effectively. However, there is often a mismatch:
an oversupply of qualified staff with an undersupply of infrastructure,
equipment and drugs or vice versa.
Limited
training and low pay for qualified health workers in many developing
countries cause severe problems in service delivery. In Cameroon,
the ratio of health professionals per acre is 1: 400 in urban
areas and 1: 4000 in rural locations, requiring people to travel
great distances to find health care in rural areas. This kind
of imbalance is just as severe in rural areas of Cambodia, where
85% of the population lives, but where only 13% of health workers
are based; and in Angola, where 65% of the population live in
rural areas but only 15% of health workers, the vast majority
of these having opted for better-paid jobs in urban areas.
In some countries, even where trained health staff are in place,
primary care centres and district hospitals lack adequate facilities
to diagnose infections and repeatedly run out of medical supplies
and drugs. For example in Zambia, where the number of TB cases
increased sixfold between 1992 and 1998, proper treatment was
hindered because health facilities kept running out of TB drugs.
It is now widely recognized that protecting a community's health
requires support beyond the responsibilities of doctors, nurses
and professional medical staff. Health services can often be
extended or diversified by using networks of volunteer health
care providers. Religious organizations, other organizations
(such as Rotary International, Zonta International and the Lions
Club) and community organizations provide extensive networks
of volunteers. They can be trained to offer basic services such
as the observation of TB treatment, distribution of insecticide-treated
nets and education on how to prevent infection from HIV. Businesses
and factories can integrate the provision of health services
into the work week of their employees. Schools offer an obvious
forum for educating future generations on how to protect themselves
and their families from deadly diseases. Yet these vast networks
of human resources are often untapped by national health systems.
