• Governments fail to fund effective programmes
• Donors help supplement underfunded health initiatives
• WHO helps countries make best use of scarce resources
• All countries must support global initiatives
• The example of smallpox

Graphs:

• Limited funding
• Defending our borders

Initiative: Value for money

Some of the poorest countries have no more than $7 a head to spend on health care annually - making it difficult to ensure that even the most basic health needs are met. On average, health expenditures in 1994 in low-income countries were $16 per capita. Comparatively, average health expenditures in high-income countries were more than $1 800 per capita.

Low-income countries spend 4% of GDP per capita on health, half the amount spent by wealthier countries. In many poor countries, spending is even lower. In Cameroon, Indonesia, Nigeria and Sri Lanka, for example, it is less than 2% of their GDP. Donor assistance has helped supplement underfunded health initiatives. However, resources available for such support are relatively small. Health, nutrition and population projects receive less than 5% of donor support, which is a fifth of the amount provided to energy, transportation and communications projects.

Infectious diseases are a neglected concern within this neglected sector. In 1990, bilateral, multilateral, foundation and NGO partners provided just over $800 million to help developing countries control infectious diseases. This represents less than 2% of total donor funds. This sum is considerably stretched since 50% of deaths in low-income countries are caused by infectious diseases.

With these disparities, it is not surprising that a child born in a developing country today runs a 1 000-fold greater chance of dying from measles than a child born in an industrialized country. Or that children born in Singapore are likely to live 40 years longer than children born in Sierra Leone.

However, more money is not the solution when provided to governments that fail to make cost-effective use of resources. In some developing countries, 60% or more of government health expenditures are devoted to meeting the operating costs of urban hospitals and expensive equipment. For the cost of a few expensive operations in such institutions, thousands of lives could be spared from infectious diseases.

One of the most important roles of the World Health Organization is to assist countries in making optimum use of scarce health resources. With a budget representing only $0.01 out of every $30 spent on health worldwide, WHO provides technical and policy guidance that helps increase the impact of larger public and private health budgets.

WHO priorities for the control of infectious diseases in developing countries include childhood immunization, integrated management of childhood illnesses, use of the DOTS strategy to control TB, a package of interventions to control malaria, a package of interventions to prevent HIV/AIDS, access to essential drugs, and the overall strengthening of surveillance and health service delivery systems. Funds are urgently needed for implementing these and other cost-effective interventions to prevent further deaths and suffering.

It is in the best interest of all countries to support global initiatives to control infectious diseases. Any segment of society that ignores the spread of infections among its neighbours does so at its own peril. When a country becomes a weak link in the chain of global surveillance and disease control, everyone is affected. And we must effectively use the tools we have today while there is still a window of opportunity.

Smallpox provides a very striking example. If smallpox had not been eradicated in a few remaining countries in 1977, the world might still be paying a heavy price today. Unforeseen was the imminent emergence of HIV/AIDS.

Immunization with the smallpox vaccine - made from a live weakened virus - would now be fatal for many people whose immune system is impaired by HIV. Just a few years delay and global eradication of smallpox may have become impossible without the discovery of a new vaccine.

Had smallpox not been eradicated - at a cost then totalling $300 million - it could be among the top six infectious killers in the world today. Without past concerted efforts to fight the disease, smallpox would still be causing at least a million deaths a year and costing governments billions of dollars in health care costs.

These lessons have been overlooked. The progress that the world can make today against infectious diseases may not be possible a decade from now. Increased drug resistance and the unforeseen emergence of new microbes could close the current window of opportunity for controlling infectious diseases.