Paving tor Health tor all W ow is Health for all going to be paid for? Unless clear answers are found to this question, Health for all is at risk of remaining a dream. This means that it is vital in the first instance to work out the cost of national Health for all plans. A plan that does not take account of costs amounts to no more than window shopping. The world economic situation has changed drastically for the worse since 1977, when Health for all was launched. After the 1981 oil crisis, living standards fell sharply in Latin America, Africa and some of the least developed countries of Asia. Debts incurred when economic prospects seemed much brighter have now to be serviced at interest rates which take 2 by Brian Abei-Smith a formidable slice out of govern- ment budgets. As a result, in many developing countries health budgets have been going down, not up. In ad- dition, the prices of the primary prod- "If Health for all is to be at- tained by the year 2000 the next few years are critical for Member States and WHO as a whole. Member States will have to re- think and reshape their priorities and policies and undertake sounder financial planning for their strategies for Health for all, possibly with WHO collaboration." Dr Halfdan Mahler. Director-General of WHO ucts on which so many of these coun- tries depend for their export earnings have fallen heavily. This limits the amount of foreign exchange which can be spared for imports even of essential drugs and medical equipment. There were hopes when Health for all was launched that the richer North- ern countries would substantially in- crease their health aid to the poorer Southern countries . This has not been happening. The rich countries see themselves as faced with their own internal problems-particularly of sup- porting millions of primarily young people without jobs. They have their own struggles to balance their budgets and some of them, like the develop- ing countries, are short of foreign exchange. W oRLD HEALTH , May 1986 A cataract operation saved this person's sight. In many countries, health services are still beyond the reach of poor people. Photo WHO/S. Armstrong To explain is not to justify. But unpleasant facts must be faced realisti- cally. It now looks as if there are not going to be any Northern fairy-god- mothers rushing to fill in the gap between what health planners want to spend and what ministries of finance will be able and willing to find for the health sector. Even where foreign funds are provided to finance capital projects, recipient countries will still have to find the money for operating costs. The essential problem is that there is a limit to what can be collected from taxes without damage to the economy (for instance, by making exports too expensive) and without conflict with wider Health for all objectives. There may be room for higher taxes on imported luxuries, but at some point tax revenue is bound to fall if luxury goods are priced out of the market. There are administrative difficulties in collecting more money from income tax. This only leaves open the possibil- ity of taxes which fall most heavily on the poor. And making the poor poorer by taxation could seriously damage their health status. Moreover, there are many other fields of socio- economic development competing with the health sector for funds- although some of them can give substantial support to Health for all objectives. So what are the possible alternatives to financing by taxes or external aid? One way of bringing in extra money is to make people who can afford it pay something for the services they use. There are now virtually no developed countries which provide health and social welfare services wholly free to users , whether the users are covered by health insurance or not. If rich countries cannot afford to provide wholly free services to everyone, how can poor countries go on trying to do so? It is clearly inequitable to provide urban populations with a full range of health services without any charge, while there are no services at all within reasonable reach of large sections of the rural population. But the challenge is to find a practicable way of separat- ing those who can afford to pay from those who clearly cannot. Giving peo- ple the right to apply to village leaders WoRLD HEALTH, May 1986 for certificates that they are poor may work only imperfectly. So may attempts to identify those who can afford to pay when they actually come to use the services . Compulsory health insurance is a further way of making this distinction. Generally only those who work for larger employers can be brought into a compulsory insurance scheme. In de- veloping countries these constitute a minority of the working population, but they are usually much better off than those struggling to make a living by self-employment in urban areas or those working as peasant farmers . If the cost of health services used by these employees can . be paid for by their own contributions and those of their employers , tax money can be released to provide further services for the poorer rural population. This is one reason why health insurance is currently being developed or consi- dered in such countries as Indonesia, Syria , Thailand and Zimbabwe. Another way forward is to promote formal voluntary insurance in urban areas or informal community insur- ance in rural areas . There are several examples of ways in which this can be done. For example , the Republic of Korea has tried out schemes using voluntary collectors in rural areas. Thailand has promoted the sale of Health Cards which exempt the family from most charges levied at hospitals and health centres, and has developed revolving drug funds for villages. Facing up to where the money will come from to pay for Health for all is now seen as a crucial step in health planning. Some early national plans proved to be far too ambitious. They started from the assumption that if an ideal plan was made , it was bound to attract funding. When it did not, the narrow outlook of ministries of fi- nance was blamed or the lack of sym- pathy of foreign donors. It is now increasingly accepted that detailed planning must start by looking at all possible sources of finance including money found from redeploying funds within existing services. To be realistic, any national plan has to be tailored to fit the money likely to be made available. This does not mean abandoning Health for all. What it does mean is finding the most efficient way of providing the essential primary health care services to people cur- rently without them , and ensuring greater efficiency in the way in which existing financial resources are used. • Cover: How are we going to pay for Health for All? Design by Peter Davies IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor and this month's Theme Editor : Christiane Viedma Art Editor: Peter Davies News Page Editor : Peter Ozorio World Health appears ten times a year in English, French, German, Portuguese, Russian and Spanish, and four times a year in Arabic and Farsi. Articles and photographs not copyrighted may be repro: duced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health. WHO, Av. Appia. 1211 Geneva 27. Switzerland. Contents Paying for Health for all by Brian Abei-Smith .. . ........ . .. . Community financing in Senegal 2 by Pape M a ree l Sene. . . . . . . . . . . . . . 4 Sweden's plan for 2000 by Marten Lagergren. . . . . . . . . . . . . . 7 Where is the money to come from? by Lee M . Howard . . . . . . . . . . . . . . . . . 9 Singapore's family savings scheme by Kai Hong Phua . . . . . . . . . . . . . . . . 11 A budget for Health for all. . . . . . 16-17 Smallpox eradication: when WHO hit the jackpot by John W ickett. . . . . . . . . . . . 18 Towards equity in health care by Ok Ryun MooA . . . . . . . . . . . . . . . . 20 Equity for the poor by John S. Akin . . . . . . . . . . . . . . . . . 28 • Departments H~alth communications They all wanted you to go to their homes Helene Pour interviewed by World Health. , . . . . . . . . . . . . . . . . 13 Health for all · Mexico : where disaster struck by Alejandro Llano de la Torre . . . . . . . 22 Primary health care; Israel : shifting the resources byAviva Ron ......... , . ... ..... : 24 News Page .. . . . . . . . . . . . . . . . . 30-31 Community financing in Senegal A rural health project in the Sine Saloum area of Senegal has proved to be an effective model for the community financing of primary health care, and has persuaded people to take much more responsibility for their own health by Pape Marcel Sene "W ou Senegalese have achieved a :i@ minor miracle in health , " said Dr Halfdan Mahler a few years ago , at the end of a short visit to Senegal. This " pat on the back" from the Director-General of WHO was, no doubt, chiefly intended to encourage the efforts of this small country of the Sahel , which had no more than a skeletal primary health care pro- gramme only ten years ago. Since then Senegal has embarked on an interest- ing experiment, and has made remark- able progress in developing an effec- tive model for the community financ- ing of primary health care. What some people saw as "cut- price medicine" proved to be highly rewarding. Community financing has truly persuaded people to take much more responsibility for their own health. To give just one example , the funds raised by the system of self- management amounted in 1983-84 to 80 per cent of the budgetary appropri- ations, excluding staff, of Senegal's Ministry of Public Health. At the national level , receipts dur- ing the first year of the project amounted to 303 million CFA francs , or US $800 ,000. Community partici- pation was responsible for the building of 115 maternity units and 49 health posts. In effect , the people and state of Senegal doubled their health care pur- chasing power. An experiment launched in 1975 at Pikine , outside Dakar, as part of a Belgian-Senegalese project for pro- viding primary health care in an urban setting was so successful that the 4 Senegalese authorities decided to try a similar experiment in the countryside. They chose the Sine Saloum area (subdivided in 1984 into the Kaolack and Fa tick areas) for a rural health project financed by the United States Agency for International Develop- At Sine Saloum, community involvement helped build 115 rural maternity wards and 49 health posts. Photo WHO/J. Marquis ment (usAID) . For the past five years , the type of community participation commonly known as the self-manage- ment system has been applied to all ten regions of Senegal. It is the people themselves who manage this system, which is financed by patients' contributions. It covers all hospitals- health centres (department level) , health posts (rural community level) and health huts (village level) . The charge is 100 CFA francs per adult ($0.26) or 50 CFA francs per child for treatment in hospitals and health centres; 50 or 25 CF A francs for adults or children attending health posts. These receipts are administered by health committees which include rep- resentatives of every health hut in the village , so these people have to learn the intricacies of management ; 60 per cent of the receipts are used to buy drugs , 30 per cent for staff expenses (female birth attendant, community health worker) and ten per cent for operational expenses. The aims of the Sine Saloum project were to reduce the number of working days lost through illness and malnutri- tion , to develop maternal and child care facilities at village level and to introduce family planning services. In a country with few economic re- sources, this meant establishing a pro- totype health service adapted to the economic and social conditions of a present population. The hope was that people would learn to be responsible for their own health through a system based on community dynamics . The village came into its own again, so to speak, around the health hut. The council of elders , the rural coun- cil, the mothers' committees and the health committee all meet under the palaver tree to discuss their problems of health, hygiene and cleanliness. They consider how to replace their stock of drugs , the sale of tickets and collection of receipts , and how to pay, in money or in kind, the community health worker whom they themselves have chosen . W oRLD HEALTH, May 1986 Villagers gather near the " health hut" to discuss sanitation, drug supplies and how to pay the health worker. Photo WHO/J. Marquis Human resources, community la- bour and other resources have never been lacking whenever the need arose. Community participation finds expres- sion in a thousand and one ways, including the building of health huts, and payment for care and essential drugs. After the project had been in exist- ence for two years, an initial evalua- tion was made to assess its real impact. Some of the problems that had arisen resulted in changes. The number of health huts was reduced from 600 to 400, and the personnel in each was brought down W oRLD HEALTH, May 1986 from three to two; financial participa- tion was introduced at health post level and a pricing policy for drugs was started , based on the cost of the drug plus transport costs ; mopeds were bought for the supervisors ; and a multisectoral survey of local health began. That these changes were beneficial was proved by the more satisfactory results at the time of a second project assessment in 1982. Some 90 per cent of the villagers were making use of the health huts. Consequently less time, money and effort were wasted than before, when the villagers had to go to a distant health post. The system of community financing has had an impressive impact on pri- mary health care. In 18 months (Jami- ary 1983 to June 1984) the nine medical districts of Kaolack and Fatick (in which there are nine health centres and 79 health posts) contributed more than US $190,000 to the receipts of the self-management system. In all, nearly US $103,000 were spent on buying pharmaceutical products. For the financial year 1983-84, the receipts from the self-management system amounted to 80 per cent of the budgetary allocations , excluding staff, made by the Ministry of Public Health to the health centres and health posts of these two areas . The USAID report states that, taking the medical districts separately, four out of nine raised more than the allocations agreed by the Ministry. The Kaolack district alone reached a figure practically twice (178 per cent) the appropria- tions received from the Ministry of Public Health, thanks to receipts from the self-management system. 5 Cultivating the community garden is the way to self-sufficiency in food and good health . Photo WHO/FAO/Banoun/Carraciolo The same applies to the financing of pharmaceutical products. Receipts from the self-management system are nearly one and a half times (146 per cent) the amounts allocated by the Ministry. One result has been a larger supply of drugs to health centres and health posts , from which it may be assumed that patients have benefited. Thanks to the administrative reform launched in 1972 in Senegal , eight per cent of the budget of rural com- munities is devoted to buying drugs. In Sine Saloum , US $650,000 were ap- plied between 1981 and 1983 to re- placing, repamng , equipping and building health posts and rural mater- nity units . In addition , 318 rural maternity units and 73 health posts were built from these funds , which are also community funds. According to one official working with the rural health project, the factors that make Senegal an outstanding primary health care laboratory are the willingness to discuss , the positive way in which its institutions have developed , the fortuitous transfer of technology and the readiness of private enterprise to help. One result that is difficult to quan- tify is that people have grown used to managing public affairs; this will undoubtedly be an asset for future projects. Nevertheless, given that what has been done so far has been essentially curative , future emphasis will have to be placed on the preventive aspect of primary health care. Supervision, could be improved, and so could the drug distribution system. The health workers have welcomed a project for providing the national pharmaceutical supply service with terms of reference that would better enable it to carry out its task, and the setting up of phar- maceutical depots at area and depart- mental level is likely to improve the supply of essential drugs to health centres, posts and huts. These various measures, which will supplement other policy provisions re- lating to primary health care , will help to convert this "minor miracle" into a major miracle. • 6 W oRLD HEALTH , May 1986 Sweden's plan for 2000 A policy of 11 good health and health care on equal terms for the entire population 11 underlies HS 90-a special project which foresees the shape of the health services in the 1990s by Marten Lagergren weden is one of the few coun- tries in the world so far to have drawn up a detailed health strategy right up to the year 2000. Precisely with WHO's goal of Health for all in mind, the government brought into force a new Health and Medical Services Act on 1 January 1983, based on a policy of "good health and health care on equal terms for the entire population. " And the vehicle to bring about the aim of the Act is a special project called "HS 90-the Swedish Health Services in the 1990s." HS 90 has already produced a large number of reports on different aspects of health development. The points of departure and the guidelines pre- sented in these reports coincide with the strategic health policy drawn up by the Europeans Region of WHO. And the inain HS 90 survey-which dealt with health policies (preventive ef- forts), structure of the health care system, and staffing and education planning-formed the basis of a bill which was passed by the Parliament in Stockholm on 7 June last year. Within the context of HS 90, Swe- den's National Board of Health and Welfare has made quantitative esti- mates of the cost and manpower requirements which the proposed structural changes will call for. This cannot exactly be regarded as a na- tional plan, since one key factor of the health care system is its decentralisa- tion to regional authorities, which will Today's newborn child will be a teenager in the year 2000. Sweden's detailed health strategy is already looking ahead to that time. Photo WHO/E. Mandelmann WoRLD HEALTH, May 1986 have considerable autonomy in finan- cial matters. But the estimates at least give an indication of the new direction to be chosen and the likely demand for resources. Swedish health care is predomin- antly organized and financed by the public sector. Only five to six per cent is contributed by the private sector, and present planning rests on the assumption that this proportion will be retained. The new policy will devote a larger proportion of resources to preventing disease and injury; and it will em- phasis development and expansion of primary health care and encourage the active participation of all sectors of society in tracking down health hazards. The planners recognise that the shape of the future health care system must reflect the corresponding fea- tures of contemporary society, other- wise it will be out of tune and not capable of achieving its goals. It must therefore take note of the growing number of the elderly, especially the very old ; this is bound to increase the load on the health care system and reinforce the need for efficient coop- eration between the medical and the social sector. It must take into account the limited economic growth rate, as compared to the decades before the oil crisis, and changes in the employment situation. There will be fewer pos- sibilities for "informal" care in the social network due to the increasing participation of women in working life, greater numbers of people living alone, and more broken homes. Urbanisation and higher education- al levels, especially among the elderly, will lead to changing expectations and behaviour among patients, which in Health care in Sweden is already preparing to meet the special needs of the elderly, who will form an increasingly large proportion of society. Photo W HO/E. Mandelmann turn will call for altered roles on the part of professional care-takers. Tech- nological developments may create new opportunities but may also give rise to difficult ethical problems and an altered scale of priorities and changing attitudes and values-for in- stance, personal responsibility and freedom of choice with regard to medical treatment, the quality of life and even death-may easily come into conflict with professional values and interests. Consequently the HS 90 study en- visages a profound change in the struc- ture of the health system. This change 8 can be summarised as a general move- ment from specialised care in large central institutions to primary care and to health care in small local institu- tions, or the home . The total number of beds will only be reduced by 11 per cent, but this conceals a much more dramatic change in structure, since the number of psychiatric beds is sup- posed to decrease by 50 per cent and the number of beds in country hospi- tals (secondary and tertiary care) by 28 per cent. The number of visits to doctors in out-patient care, on the other hand, is planned to increase by 14 per cent. Even then, the average number of visits per inhabitant (3 . 7 by the year 2000) will be low compared to most European countries. Despite these reductions, the costs of the health care system will continue to rise, though at a far more modest rate than in the previous decades. This is, firstly, because the reduced number of beds will inevitably have the effect that the remaining patients will re- quire more intensive care during shor- ter lengths of stay; so the number of staff per bed must increase to cope with the more demanding pressure of work. Secondly, a dominant part of the costs consists of staff wages, and wages are bound to follow the general development of wages in society-that is, approximately the rate of economic growth. Health care represented 7.8 per cent of Sweden's gross national pro- duct in 1983, and will reach 8.0 per cent in the year 2000. Secondary and tertiary care (other than psychiatric), as a share of the total health budget, will drop from the 1983 figure of 60 per cent to 48 per cent in the year 2000; psychiatric care will fall from 17 per cent to 13 per cent; and prim- ary health care will rise from 23 per cent to 39 per cent. There will be a significant change in the composition of staff to meet the new demands-especially in out-pa- tient care. The number of doctors and fully-trained nurses will increase more rapidly than the rest of the staff. In 1983, doctors represented 4.9 per cent and nurses 21 per cent of the health personnel; in 2000, the figures will be 6.0 per cent and 24 per cent respec- tively. Auxiliary nurses will drop from 49 to 47 per cent, and technical and clerical staff from 25 to 23 per cent. The HS 90 plan represents a very serious effort to change the structure of the Swedish health care system into a shape that is more consistent with the new goals as indicated by WHO, and as expressed in the Swedish Health and Medical Services Act. De- centralisation means that the actual development of care will be to a large extent controlled by the regional au- thorities-the county councils. But these bodies have already shown a firm determination to pursue the agreed national policy. These changes are already getting under way, and their effect will be to ensure that health care in Sweden will indeed result in "good health and health care on equal terms for the entire popula- tion" in 14 years' time. • W oRLD HEALTH, May 1986 Where is the money to come lrom? The health sector has not yet begun the task of financial mobilisation. Without special efforts to accelerate the rate of financing, Health for all goals could be set at risk Y hroughout the history of WHO, the appeal for international technical and financial coopera- tion has been a recurrent theme. But since the 1978 Alma-Ata Conference on primary health care, joint appeals by WHO's Member States have taken on a special urgency. The challenge to greatly extend access to essential health services on a global scale carries with it an inevitable risk that national expectations may exceed the realistic potential of combined national and international financial resources. In- flation, high interest rates, and mount- ing external debt have often per- suaded national development au- thorities to restrict health investments in favour of other sectors of the economy. The present climate of international economics has seldom been worse in human history ; all the more reason for paying well-informed and professional attention to financial alternatives if we wish to accelerate progress towards health. Indeed, the more dismal the scene, the greater is the need for objective knowledge about potential financial supply (both national and international) and about economi- cally feasible demand for financial resources . World Bank data showed that 148 developing countries were collectively spending some US $26,000 million in 1980 from their official government public budget. Selected country studies have suggested, that these same countries may, on average , be W oRLD HEALTH, May 1986 by Lee M. Howard spending as much as four times more in private than public expenditures, or a sum total of $130,000 million in public plus private expenditures. Yet external financial cooperation in health totalled only $3,900 million in 1982. This is a comparatively small external input. However it construc- tively supports health development by Preventive measures such as immunization are in the long term much cheaper than curative ones-a crucial factor to consider in the present gloomy climate of international economics. Photo WHO/L. Solmssen providing financing for such new efforts as planning, sector analysis , trials, training, research, and the test- ing of economically feasible pro- gramme alternatives for extending ser- vices on a national scale. Sources of finance In 1984, the total flow of external financing for all development pur- poses was $91,870 million. Just over one-third ( $35,7 50 million) is trans- ferred in the form of grants and low- cost loans which are called "official development assistance". Most health financing is tranferred in this form. A little less than two-thirds of the total ($54,000 million) represents commer- cial loans from official agencies, inter- national and private banks. Private and non-governmental organizations contributed $2,500 million. The primary source of this financ- ing, other than private and voluntary contributions to NGOs, is the annual budget of contributing governments located primarily in Europe, North America, and the Western Pacific (Ja- pan , Australia , and New Zealand). The respective parliaments authorise such fundings to be channelled through each government's national development cooperation agency to multilateral banks, cooperative groups such as the European Economic Com- munity, and various agencies of the United Nations. Substantial develop- ment funding is also granted to non- governmental agencies. 9 Where is the money to come from? It is hard to arrive at an accurate estimate of all sources for health financing. But the principal sources in 1982 for most health, population, nu- trition , water supply and sanitation projects were: - The bilateral agencies. Direct gov- ernment-to-government coopera- tion represents about one-third of all recorded concessional financing for health-some $1 ,300 million . Examples of such agencies are the Danish International Development Agency (DANIDA), the Japan Over- seas Economic Cooperation Fund (OECF) , and the United States Agency for International Develop- ment (US AID). Multilateral financing organiza- tions, such as the World Bank , Afri- can Development Bank , Asian De- velopment Bank, Inter-American Development Bank, and the Euro- pean Economic Community. These supplied $1,160 million in health- related grants and loans during 1982. The. loans are often negoti- ated at commercial rates and con- centrate on capital investment ven- tures such as water supplies and sanitation systems. - Non-governemental sources. These accounted for 18 per cent of all health contributions and equalled the total input by United Nations health-related special agencies. An estimated five per cent of this con- tribution is attributable to the well- known international foundations, while the larger proportion is ad- ministered by very large numbers of private and charitable organiz- ations. - The United Nations organizations. 10 Not all of the specialised agencies would prefer to be considered as financing agencies . WHO, however, representing 12 per cent of the global financial resource for health, provides a critical resource , for technical and professional coopera- tion. UNICEF (United Nations Chil- dren's Fund), UNFPA (United Na- tions Fund for Population Ac- tivities), and UNDP (United Nations Development Programme) make direct transfers to developing coun- tries for programme operations. - Private and commercial sources. The potential for private sector cooperation at concessional rates merits increased attention. For ex- ample , the countries of Latin America , Asia (including Japan) and Africa were reported to have consumed pharmaceutical products in 1980 with a total value of $10,350 million. Drug consumption represents a high proportion of all international health costs in de- veloping countries. Price reductions by national or international com- panies could be considered as one mechanism for concessional financ- ing . Concessional pricing is already a practice among certain interna- tional companies, and this trend should be encouraged where the high-volume requirements of Health for all objectives can be met with products of high quality and low cost. - Identifying sources. On a global scale , aside from private commercial institutions for which there is no health-specific estimate, there are over 50 official bilateral, multilat- eral, and UN institutions and at least 1,500 non-governmental organiza- tions. For each country or region, the number and variety of sources will vary. Identifying and describing these sources for each recipient country represents one of the basic requisites for effective external fi- nancial planning. External financing is derived predo- minantly from development-related institutions, not only the bilateral or- ganizations and banks, but the NGOs themselves. Development orientation is characteristic of almost 85 per cent of all external financing for health. This alone suggests why it is important for health authorities, national and in- ternational, to appreciate the prevail- ing mechanisms through which de- velopment authorities at the national level cooperate with development authorities m external financing institutions. WHO's budget represents about 12 per cent of total " external " financial resources even though these funds are used predominantly for technical cooperation rather than financial transfer. Given the multi-sectoral de- velopment orientation of contributing governments , it is not foreseeable that WHO itself could become a significantly larger source of external financing for health. On the other hand, since it has the largest international cadre of health professionals , WHO could play a critical role in strengthening the capabilities of health ministries and institutions to accelerate financial mobilisation for health . The major donors are global in distribution , although concentration of effort may be limited to a smaller number of countries. National devel- opment authorities , the UNDP resident representative , and the Organization for Economic Development and Cooperation in Paris are among the sources which may help to assess the potential of external organizations for cooperation in each country or region. In the WHO Region of the Americas , guidance on sources has been circu- lated to all ministries of health and to WHOIPAHO country representatives. Within the annual availability of external financing of general develop- ment, which at present stands at around $35,000 million, recent de- mand for health financing has varied between eight and ten per cent. The external financial authorities them- selves indicate that health demand has by no means reached its potential limits. Nor has the health sector yet begun to organize effectively for the task of financial mobilisation. And without special efforts to accelerate the rate of financing, there is serious risk to the achievement of Health for all goals within the brief period of the next 14 years. Fortunately, financial mobilisation requires no fundamentally new strategy. It does require a working knowledge and adaptation of develop- ment financing procedures that have evolved over the past 30 years . It also calls for a level of trained professional attention and organization which is commensurate with the realistic fiscal requirements for achieving the techni- cal programme goals. • W oRLD HEALTH, May 1986 Singapore's lamily savings scheme Medisave is a uniquely Singaporean solution to local public . health problems. But its basic notion of "saving for a rainy day" can have important implications for any society Y he bulk of medical costs in Sin-gapore are incurred by a domi-nant infrastructure of govern- ment hospitals , but there is a growing private hospital sector. The former is subsidised heavily from public taxes whereas the private hospitals are financed by a mix of personal pay- ments , limited insurance coverage and employment benefits which include company plans for workers or their families. Faced with mounting costs of the medical services, the Ministry of Health started looking at various op- tions to change the health financing system. The problem is to keep the balance between demand pressures and supply capacity . With growing affluence and greater health con- sciousness , many people now want more and better services. The government wants to provide a good health service of the highest quality, which is not only available and accessible to the population , but is also affordable and has to be paid for . So prior savings have had to be enforced to meet the expected rising costs of health care. These considerations form the underlying basis for the National Health Plan formulated by the Minis- try of Health in 1983. Its key proposal , the Medisave Scheme, attempts to impose compulsory savings and re- structure the present system of health care financing . The principal objectives of the National Health Plan are to secure a healthy, fit and productive population through active prevention and promo- tion of healthy lifestyles , and to im- prove cost-efficiency in the health W oRLD HEALTH, May 1986 by Kai Hong Phua services. In addition to promoting in- dividual responsibility for maintaining good health , it aims to build up finan- cial resources so as to provide the means to pay for medical care during illness. Compulsory savings for medical care are regularly set aside by the transfer of six per cent of earnings into a personal Medisave Account. This forms part of the monthly Central Provident Fund (CPF) contribution which consists of 25 per cent of salaries contributed by the employee , and is matched by an equal amount from the employer. The CPF was started in 1955 as a compulsory sav- ings scheme for all workers in Singa- pore. It is designed to provide for old age retirement or permanent incapaci- ty. Previously , Singaporeans could withdraw all their CPF savings at the age of 55, but now a minimum balance of US $15,000 (US $1.00 is about 2.2 Singapore dollars) has to be left in the Fund for medical care. The Medisave Account can be with- drawn to pay for hospital charges and some outpatient procedures , such as minor surgery, which are costly but do not require the patient to stay in hospital. Medisave does not cover general ambulatory treatment , for which the cost in Singapore is con- sidered affordable . Nor is it intended to cover long-term chronic illnesses, since other modes of care already provided through subsidised govern- ment programmes and by voluntary Singapore's Medisave health system enables even the poorest families to pay for hospital expenses and other costs incurred through illness. Photo WH O/K.H. Phua/P. Gaspar 11 Singapore's family savings scheme and charitable bodies continue to play a major role. Medisave can be used to pay for the medical expenses of immediate family members. It covers spouses, parents and children. So there is a shared family responsibility to look after the welfare of its members. It is hoped that Medisave will act also as a finan- cial incentive for the entire family to remain fit and well together, and to avoid incurring medical expenses for individual members. The Medisave Scheme was first im- plemented in all government hospitals from April 1984. Initially, Medisave accounts were allowed to pay for the full charges of hospital stay in lower- priced wards and only a partial com- ponent for the more expensive rooms. This was gradually extended to cover completely all categories of govern- ment hospital charges. Withdrawal rates for private hospi- tal charges, however, were subjected to a daily maximum, depending on the type of case . The scale of charges was first introduced as a pilot project in- volving the new National University Hospital from June 1985 onwards. Teething problems were ironed out before the scheme was extended to other approved private hospitals from January this year. In essence, Medisave serves as an additional source of personal financing for medical expenditure incurred by individual families. With this ·shift in public cost-sharing, government tax revenue has been freed to meet other priorities and to improve the public health services, especially as regards preventive and chronic health care. As the dominant health financing and payment scheme, Medisave is in- tended to control effective demand through the price mechanism. Pay- ment for medical care will more often be made at the point of utilisation, and this tangible nexus between payment and consumption will reflect the real costs of health care and prevent over- use . Medisave will also be able to cater for different consumer preferences over a range of ward accommodation, either in the public or private hospi- tals. So within certain limits it can be used to provide complete coverage for 12 Payment for hospital treatment is usually made at the point of utilisation, a factor which more directly reflects the real cost of health care and helps to prevent over-use. Photo WHO/K.H . Phua/P. Gaspar lower-priced wards with the basic es- sential services, or to subsidise the more expensive hospital charges if preferred . Thus the Medisave Scheme of Sin- gapore represents a major departure from the social security schemes of other countries in several key areas. It will not be a common pool of funds, to be used indiscriminately by any gov- ernment coming under pressure from interest groups to respond to more apparent short-term problems, since it is a scheme which only covers depen- dent family members. This fits in with the concept that the basic social and economic unit of any society should be the family nucleus, in which caring for the welfare of its membes, including its sick and aged, is to remain a collective but more personal responsibility. The aim is not to erode desirable tradition- al values such as filial duty and close family ties. Where there are genuine difficulties, for instance where an en- tire family is unable to pay the medical expenses of its sick, only then does the state step in to subsidise health care from public taxes. The idea is to pro- mote self-reliance and not to act as a crutch; but for those in need, a safety net is still available. Another feature of Medisave is that, unlike tax-based financing, it does not place an undue burden on the employ- ed and the young, and does not subject public expenditure to the vagaries of economic cycles. The present genera- tion of wage-earners is obliged to save for the future, instead of relying on the uncertain taxes of the next generation for support later. This is in line with official policy to promote financial independence among the aged, whose medical needs are expected to increase in the years ahead . Although Medisave is a uniquely Singaporean solution to local prob- lems, nevertheless some useful lessons can be universally applied. The two axioms of "charity begins at home" and "saving for a rainy day" can form the backbone for viable long-term financing of increasingly expensive health care in any society. Such a compulsory family-centred savmgs scheme can have important implica- tions for countries which intend to restructure their welfare systems and wish to avoid potential social problems arising from a lack of financial plan- ning for the future . This is especially significant in the light of competing claims on the scarce financial re- sources that are available to enable countries to pay for Health for all . • W oRLD HEALTH , May 1986 Health Communications They all wanted you to go to their homes ... ow does a poor country go about asking for the help it needs? Generally by submit- ting a "project request" to a bilateral or multilateral financing agency in the form of a document written by nation- al specialists for consideration by in- ternational specialists. The contents are governed by precise rules that may preclude the author from de- scribing the actual conditions under which the people for whom the pro- ject is intended are actually living . Sometimes that "living" means "barely subsisting" . The document will be read by a funding agent who is swamped with such requests and who, in his office in New York, Paris, Geneva or wherever, will have no time to study in depth the whole range of factors to be considered if a problem is to be viewed in the round. What is to be done about this situation? Helene Pour, who is in charge of information, education and communication on labour and popu- lation matters at the International Labour Organisation (ILO). had the idea of working with the craftsmen of the "unstructured sector" of Bamako, Mali, to draw up a project request in the form of a film entitled "Sinin ye Sigi" ("Preparing for the future") . The "unstructured sector" is the name given to a grouping of economic units producing goods and services on a small scale . The craftsmen of Mali's capital formed this association on their own initiative in order to get a better return for their efforts while at the same time improving their methods, launching new products on to the Malian market and sharing their knowledge of the available outlets. In W oRLD HEALTH , May 1986 working on this ILO-supported project they gradually came to realise how interdependent all the things are that make up the life of a society: work, education, the environment, the fam- ily, health . And that was how the idea arose of complementing the project with another one which, if accepted, would have the support of the United Nations Fund for Population Activities (UNFPA) and would be concerned main- ly with health and family welfare. The request was prepared in the form of a video film with the help of a camera team from Mali . The actors? Well, they were just the craftsmen themselves and their families. "They all wanted you to go to their homes," the film commentary says, meaning by "you" the potential provider of funds, "and we are taking you there." The video cassette was then ap- pended to the document that had been drafted on behalf of the Bamako craftsmen . As a result, they both arrived simultaneously on the desks of those whose job it would be to scrutinise the project and submit it for approva l to the competent authorities. Presented in this novel form, the project was approved a few weeks later, that is, in record time . Was that a coincidence or was it really because the authorities appealed to had under- stood more clearly the problems and real needs of this Bamako community? Making a video film helped to bridge the gap between two worlds hitherto sepa- rated : the world of men and the world of women. Photo W HO/P. Rocher 13 That is the question World Health put to Helene Pour in an interview. HeiEme Pour: The reason for our choosing the video medium is clear enough. We wanted the providers of funds to see the actual places where the potential beneficiaries of a project worked, lived, perhaps struggled. WHO: What exactly does this film show? HP: lt shows the craftsmen's every- day activities, how they work, how they try to solve their problems and how they regard their family situation. The film then takes us among the families themselves and gets the craftsmen's wives to talk. lt shows the environment they live in, their state of health, their homes, the socia l and health problems to be overcome, how they try to make ends meet by doing other jobs outside work- shop hours. the activities the women take on in order to cope better. lt shows everything - the whole daily round . WH: Does that mean that every detail included was chosen for a precise purpose, to provoke questions and provide answers? HP: Yes, indeed . The idea was to bring this community and its living 14 conditions right into the offices of the providers of funds . WH: Would it be true to say that the shooting was done entirely by Ma- lians, and that it was the community itself that made is own film? HP: Yes, in a way . The shooting was in fact done entirely by Malians, and I accompanied them . This led to my discovering some interesting things that the Malians also discovered at the same time - for example, the gut- ters in Bamako, which are the breed- ing places for a lot of diseases rife in the capita l. The townspeople don't see them any more. They were very surprised that anybody would want to film a gutter or a water distribution system. WH: Do you think that making this film helped them to get a better grasp of their problems and needs, and did it bring them something new into their daily lives? HP: Yes, and in an unexpected way. The shooting took three days . Every evening the craftsmen saw what we had filmed during the day, for we did not want to hide anything from them; it was one hundred per cent participa- tion. That was when they suddenly started to notice the details of their Health communications Left : "Every evening, the craftsmen saw what we had filmed during the day, for we did not want to hide anything from them : it was one hundred per cent participation". Right: By forming an association to ensure a better return from their work, the crafts- men of Mali realised how interdependent so many things are : work, education, the environment, the family, health. Photos WHO/P. Rocher daily lives, things they tended not to see any more, like the gutters. WH : Was it these craftsmen them- selves who realised that it was essen- tial to include a health component in their efforts to improve their lot. and in particular spacing of births? HP: No. That emerged naturally from the conversations we had with the craftsmen before the project was for- mulated and before the film was shot. When they declare in the interviews we did at their homes that they have, for example, 41 dependants in one case and in another 1 02, they are themselves struck by this detail. And that leads them on to make the con- nection with their living conditions. But they dwelt particularly on ques- tions of health and the environment, and above all they suddenly began to look differently at their way of life and at al l the interconnections between its various constituents: their working, housing and health conditions, their incomes and nutrition, their education and employment-all seen in the round . WH: Do you think that by making this film you enabled a new type of ex- change to get started between men and women? In particular, do you W oRLD HEALTH, May 1986 think that the women got a better understanding of the-let's say-pro- fessional problems of the men. and that the men for their part got a better idea of women's problems in daily life and in particular the size of families? HP: Yes. The shooting of this film does seem to have been the needed link. I mean. we realised that the men and women didn't have much oppor- tunity to discuss these things, for cultural reasons. for fear of confront- ing certain problems. By tackling them with the men on the one hand and with the women on the other. we did-1 believe- create this link. The men were suddenly more aware of the difficulties that hitherto only the women had to face. such as chil- dren's health and the matter of extra earnings, while they for their part faced questions of production and marketing of their products. Conversely, the women too were able to discover what their husbands were doing, what they worried about and why. A transfer of information took place. with the result that there is now a remarkable current of mutual understanding between the men and the women. So much so that the W oRLD HEALTH, May 1986 women have embarked upon income- generating activities in their hus- bands' own workshops, while the men are attending courses on health and taking part in specific projects where they can apply the knowledge they have acquired. WH: Would you say that this partici- pation has given the craftsmen grea- ter motivation. not only in their work and where their health is concerned but also for the whole of their life in society? HP: Yes. I think so . They were already highly motivated in their work. This is a project that has led them to group together. to form their own organiza- tion, not only in the field of production but also in marketing their products . Perhaps it had never occurred to them before to get together to organize other aspects of their life . For exam- ple, an improvement in their incomes will enable them to buy a certain number of ordinary consumer pro- ducts. Well, they have already de- cided to group together for this in the same way as for production. Again, neighbourhood pharmacies are going to be set up as a feature of the project. They'll first construct a model pharmacy, built of wood or metal. Then they are going to run the phar- macies at the neighbourhood level. In other words, they are going to apply the knowledge they have acquired in the realm of production and marketing to the social and health areas. WH: As far as you know. is this the first time a project request has been submitted in the form of a video? HP: As far as I know this is the first time video has been used in this way. While the technique itself is not new. it seems to me very desirable to use it for illustrating development activities. whether it be to put things in context at the time a project is drawn up, for training purposes. or even for evaluat- ing the situation afterwards . WH: Do you think this method could be broadened so as to apply to areas of a more technical nature-health for instance? HP: Certainly; health and many other things . The relatively low cost of pro- ducing a video film. the flexible ways it can be used. and the fact that you can immediately view what has been filmed, offer enormous advantages. After all, why shouldn't aspects of development be promoted with the care. the accuracy and the resources that they deserve? • 15 A budget for health for all r r j F rr ~ W oRLD HEALTH, May 1986 ATE ENTS W oRLD HEALTH, May 1986 SOCIAL SECURITY o money, no Health for all . Yet in many countries health budgets are being drastically cut as a re- sult of inflation and the world recession . Cutbacks present problems in the short run, but they also provide opportunities to re-examine the deployment of re- sources so as to bring them in line with Health for all priorities . Most countries are still lacking a master plan that will husband health resources between now and the year 2000. However such a plan is the only way for countries to identify seri- ous shortfalls, to find potential new resources. to make better use of exist- ing ones, and to span the current gap be- tween what must be provided and what reasonably can be financed from available sources. Our artist has suggested how, by drawing funds from all possible sources and combining them in an imaginative way, any given country can formulate the first essential key to equity in health: a budget for Health for all by the year 2000. Design by Peter Davies SMALLPOX ERADICATION When WHO hit the jackpot The total cost, over 13 years, of wiping out smallpox was US $200 million. The consequent savings to the world since the late 1970s can be estimated at $1,000 million per year! i n 1796 Edward Jenner discovered that vaccination protected against the killer disease smallpox. In his monograph published in 1801 he pre- dicted that this practice would lead to the annihilation of the disease. De- spite the fact that smallpox was one of the most feared killer diseases, it was not eradicated until 1977-just 181 years after his discovery. Why the delay? In part, it was due to a lack of global coordination and cooperation which was finally pro- vided by WHO. And money too was lacking. As always, economic con- siderations played a major role. Even in the 1920s, smallpox was considered an inevitable part of life by most people and it was still occurring all over the globe. However, by the 1950s the more developed nations, that is, those with money to devote to public health measures, had elimi- nated endemic smallpox. But to main- tain their smallpox-free status, they had to remain alert to importations and maintain routine vaccination, con- trol and quarantine measures. This was expensive. The United Kingdom, for example, spent US $3,800,000 controlling outbreaks in 1962-63 fol- lowing importations, over and above routine costs. The establishment of the World Health Organization in 1948 provided a forum for discussing the global eradication of smallpox, but it was the Pan American Sanitary Office (PASO) which first decided to support eradica- tion in the Americas and make funds 18 by John Wickett available. PASO spent $11,126 in 1953, apparently the first multilateral expen- diture towards eradication. The fol- lowing year, WHO spent $7,998 on activities associated with smallpox but Eradicating smallpox from the world cost some money-but saved much more. World Health announced the campaign's success in May 1980. Photo WHO not in the context of eradication; in following years modest sums were put towards vaccine production. In May 1958, at the 11th World Health Assembly, the delegation from the USSR proposed that WHO support the global eradication of smallpox and offered 25 million doses of vaccine. Interestingly, the second paragraph of Resolution WHA11.54 referred to: "the economic aspect of the question, which shows that the funds devoted to the control of and vaccination against smallpox throughout the world exceed those necessary for the eradication of smallpox in its endemic foci and conse- quently the destruction of the sources from which the infection arises and spreads, and clearly indicates that the eradication of smallpox might in future make vaccination and all expenditures involved in its application redundant. " WHO's Director-General reported to the Executive Board in January 1959 that the cost of global eradication would be approximately $97,742,900 (excluding China). This was based on a calculation of 10 US cents per head to vaccinate all 977 million people living in endemic areas. In May 1959, the 12th World Health Assembly adopted the goal of global eradication of smallpox. However, no funds were allocated. A special account was opened in the Voluntary Fund for Health Promotion but this account received only donations of vaccine. Countries .were urged to mount vacci- nation programmes in the belief that 80 per cent vaccination coverage would eliminate the disease. Tangible support was only forthcoming from P ASO (which had become the Pan American Health Office (PAHO) in 1958) and from the USSR which gave substantial amounts of vaccine on a WoRLD HEALTH, May 1986 bilateral basis direct to several coun- tries in Asia. Progress was minimal , despite the conviction that the eradication of smallpox would pay for itself in no more than a few years. Finally, the Intensified Smallpox Eradication Pro- gramme was voted a regular budget allocation of $2.4 million by the World Health Assembly in 1966. It was esti- mated that eradication would take 10 years , from 1967 to 1976, and would cost $180 million , of which $48.5 million (27 per cent) was to come from international assistance (wHo , other organizations and bilateral aid). In 1967, estimated expenditure from all international sources was $6.5 million , coming primarily from the WHO Voluntary Fund for Health Promotion , the UN Expanded Pro- ramme of Technical Assistance , PAHO , USA bilateral support to 19 countries in western Africa, and USSR bilateral vaccine donations in Asia. Thirteen years later, on 9 December 1979, the eradication of smallpox was certified by a Global Commission. The last case occurred in Somalia on 26 October 1977. Two years of careful verification were necessary to reassure the world that it was safe to terminate routine vaccination. The estimated to- tal cost over 13 years was just under $200 million split equally between international and national inputs. Was it worth it? Or rather how much was it worth to have done it? Putting a dollar figure to this involves some very sweeping assumptions , but it is interesting to try - at least to get an idea of the order of magnitude involved. A study was undertaken to estimate the costs associated with the protec- tion of the United States against smallpox in 1968. This was before that country stopped routine vaccination, in 1971. The breakdown was as fol- lows: - Vaccine administration and treat- ment of complications (physician and hospital services, vaccines and drugs, surveillance for complica- tions) $93 ,460 ,000 - Earnings lost from time off work for vaccination and consequences of vaccination complications $42,196,000 W oRLD HEALTH, May 1986 A young Somali, Ali Maow Maalin, was the last naturally occurring smallpox case in the world. That was in October 1977. Photo WHO/J. Wickett - International surveillance, traffic clearance and time lost waiting for clearance $14,462,000 $150,118,000 Vaccination costing the US $150,118,000 in 1968 for a popula- tion of 200 ,710 ,000 equals 75 cents a head . This is exclusive of any cost associated with eradication efforts; it is a passive burden. Can we extrapo- late and come up with a global figure? Why not . Obviously , the United States is at the top end of the scale; not all countries would be spending 75 cents per person. It seems reasonable though to assume we might pro-rate this amount based on relative Gross National products (GNP) per capita. Erring on the conservative side if any, we can calculate the saving to the nations of the world at the end of 1979 (when the Global Commission cer- tified smallpox eradication) at some $1 ,000 million per year. So smallpox eradication paid for itself in less than three months , and the annual return on the $200 million investment works out at 500 per cent! Looked at from another angle, the United States recouped the entire $489 ,782,640 which it contributed to- wards WHO's regular budget between 1948 and 1979, in just three years. An investment in health is always a positive step; a determined invest- ment can bring spectacular dividends. Health is wealth. • 19 Towards equity in health care By devising new schemes of health insurance and medical assist- ance to benefit the poor, the Republic of Korea is trying to provide equitable access to health care regardless of the ability to pay i t came as a surprise to many elders in rural areas of the Republic of Korea when the Scheme was first introduced in 1977. They said , " You have to live long to get the benefits . Even though everything is free , the doctors and nurses are still kind to us. " Activities under the Scheme were reported from the villages to the Blue House (Presidential Office) directly on a daily basis for the first couple of months-the only health programme to have been treated in such a way. In 1977, the Medical Assistance Scheme and the first compulsory health insurance programme of the Republic of Korea both came into being in response to a question asked the previous year by the former Presi- dent Park Chung Hee: "How much does it cost to pay for health services for the poor? " The Medical Assistance scheme is a programme for the needy , supported 80 per cent by the central government and 20 per cent by the local auth- orities , except in Seoul where the cost is shared equally. The Ministry of Health and Social Affairs sets the standards of eligibility for benefits , and the local government is respon- sible for assessing cases and for day- to-day management. There are two categories of bene- ficiary , the indigent and the low income group. The indigent are those aged over 65 , the disabled , children under 18 without parents or with pa- rents over 60 , and people residing at welfare facilities. These people receive yellow identity cards . The lower in- come group consists of those with an average income less than a certain amount and subsistence farmers. The level was set a 40,000 Won (about US $50) per person per month in 1985. People in this group are pro- 20 by Ok Ryun Moon vided with green identity cards. The selection of eligible persons is made once a year . The yellow card holders receive medical care free of charge , whilst the green card holders have to pay 20 per cent of the in-patient fees (except in Seoul where they pay 50 per cent) . The Scheme enables them to receive prim- ary health care at private clinics desig- nated by the Ministry of Health and Social Affairs or from health centres The health scheme in the Republic of Korea extends insurance cover to wives and hus- bands, parents and children. Photo WHO/P. Boucas and community health practitioners , and they are referred to secondary and tertiary hospitals if necessary. About half of the medical facilities nation- wide are designated for this purpose. Independent fee schedules are in use, the level of which is slightly lower than those of health insurance. The fee level has. gradually been raised from 60 per cent in 1977 to 83 per cent in 1985 ; this was done to prevent the quality of care from deteriorating and to safeguard the beneficiaries from suffering from some kind of stigma. Though there have been occasional delays in payment owing to the short- age of local government funds , the Scheme has been operating smoothly to the benefit of 3.3 million peo- ple-600,000 indigents and 2.7 million low income people. This is eight per cent of the total population. Interest- ingly, all patients with sexually trans- mitted diseases are treated free of charge , irrespective of the eligibility requirement in the Medical Assistance Scheme. Compulsory health insurance also saw the light of day in 1977. The government initiated its employee health insurance programme (called " Class I Scheme " ) , beginning with firms with 500 workers or more. The programme has been steadily ex- tended to include firms with 300 workers in 1979, with 100 workers or more in 1981 , and now to the firms with 16 workers or more . Dependents are also insured; these include spouses, parents and descendants, either aged below 20 or handicapped, who are maintained mainly by the insured. In practice , livelihood maintenance means the condition of living together with the insured for over six months. The government's share of financing is limited to a small contribution toward administration. The Class I Scheme is run by the 145 autonomous insurance societies that constitute the Federation of Korean Medical Insurance Societies. Another compulsory programme (called " Class Ill Scheme") was launched for government employees, private school employees and their dependents in 1979, and the following year was extended to cover the depen- dents of military personnel. Entitle- ments to retirement pensions have progressively widened to cover gov- W oRLD HEALTH, May 1986 Today people are recognising that the health of every individual is a social concern and responsibility. Photo WHO/P. Boucas ernment employees, private school teachers, military personnel, the war injured and the disabled. The Class Ill Scheme is run by the Korean Medical Insurance Corporation and its 13 re- gional offices . Here the government is playing the role of employer for civil servants and pensioners, and is sub- sidising the contributions of the pri- vate school employees. Both the Class I and Ill Schemes are financed by a percentage of payroll (3.2 per cent and 5.2 per cent respec- tively, on average), the deductions being shared, in principle, equally be- tween employees and employers. User fees are a significant source of finance. Insured patients pay 30 per cent of the cost at private clinics, 50 per cent at hospital outpatient departments, and 20 per cent for in-patient care . The range of insured services is fairly broad for both in- and out-patient care, including diagnosis, treatment and surgery, drugs and appliances, maternity care, limited dental care and W oRLD HEALTH , May 1986 hospital care at ward level excluding meals. Extending health insurance to the self-employed ("Class 11 Scheme") , particularly the rural population, posed new problems. Three different models have been tried. The first, based on voluntary insurance, proved difficult to expand nationwide ; it also tended to attract high-risk individuals and resulted in higher costs. The sec- ond was a compulsory insurance mod- el. The government has gradually extended this to the self-employed residents of one city and five rural counties since 1981. This demonstra- tion programme now covers about 410,000 people . The third was a semi- compulsory model for eleven specific occupational groups, including taxi- drivers, barbershop and beauty par- lour operators, artists and writers, grain dealers, meat sellers and market vendors . As of December 1984, 42.1 per cent of the total population were covered by health insurance. To this figure can be added the 8.0 per cent of be- neficiaries in the Medical Assistance Scheme, making a total of 20.3 million people or 50.1 per cent of the total population. Even though most of the covered population are employees and the present coverage of the rural population is not all it should be, this seems to be a substantial achievement during the past nine years . Such a rapid expansion has not been made without cost. The present health insurance set-up does not yet benefit the jobless, self-employed farmers and workers in small factories. And there is still a wide gap between the price paid for the same medical procedures, carried out by the same medical pro- viders, on behalf of the insured and of the non-insured. Nor has the present system yet succeeded in curbing the cost of medical care and in encourag- ing the use of low-cost alternative care . The system is mainly oriented toward curative services and tends to ignore the other essential elements of primary health care in urban areas . The compulsory insurance model is the one most likely to be adopted for the self-employed on a national scale in the near future . This is because it is in accordance with the principle of social insurance, and because accep- tance of social insurance by the public has been improving. The questions remain-how to finance it, and how to provide equitable access to health care regardless of ability to pay? The Korean Institute of Population and Health has recommended that the government impose a special tax on soft drinks, and divert the current use of a special tax on tobacco and alcohol for educational purposes into national health insurance. But it is thought unlikely for the time being that the government will accept the tax re- venue approach as the method of financing health insurance for the rural population. As for the question of equitable access to health care, the indigent and persons with very low incomes are still not adequately insured, and this is a prerequisite not only for equity in health services but for Health for all itself. A further increase in the number of beneficiaries from the Medical Assist- ance Scheme is expected to relieve the plight of the destitute . Eventually there could be an additional 3.2 mil- lion persons , thus reaching about 15 per cent of the total population. Coverage by the compulsory health insurance system was 3.2 million in 1977, and 17.1 million in 1984. These two major financing programmes are working together towards Health for all in the Republic of Korea. • 21 Health for All Mexico : where disaster struck by Alejandro Llano de la Torre exico's Health for all pro- gramme embodies explicit strategies for overcoming the difficult economic situation and bring- ing about the necessary changes so as to expand and improve health ser- vices. At the national level, a number of working options have been selected , a scale of priorities has been established, and financial policies for allocating and using resources have been determined. 22 The government faces a current financial crisis and a consequent shortage of resources . To these prob- lems must be added disparities in services, the under-utilisation of avail- able resources, the high costs of health care, a dispersal of efforts and administrative inertia - all of them ob- stacles that must be removed if the health services are to be expanded and their quality improved. During the period of office of Presi- dent Miguel de la Madrid, new con- stitutional reform had guaranteed the right of all citizens to health protec- tion, despite economic crises and natural disasters. This calls for sus- tained financial efforts , with a reduc- tion in capital outlay and current expenditure, increased investment in health, and maintenance of cur- rent expenditure for the provision of serv1ces . The Department of Health is work- ing closely with the IMSS (Mexican Institute of Social Security), the ISSSTE (Institute of Social Security and Wel- fare Services for State Employees), the DIF (Family Welfare Service), and with the other agencies that make up this strategic sector. In particular, resources are being channelled mainly into protecting the population who are not insured with the IMSS or ISSSTE, the so-called "un- covered population ". The share of this segment in the overall budget for the health and social security sector as a whole has increased from 29 to 32 per cent. In terms of priorities, health has taken a significantly smaller cut com- pared to other sectors in the adjust- ment of expenditure for 1985, while direct expenditure on health services has not been affected in any way. The " uncovered population " in M exico- those without access to services- are a major concern for the health authorities. The overall budget for health and social security provides for extending access as much as humanly possible. Photo WHO/J. Littlewood W oRLD HEALTH , May 1986 In order to make the best of 13 States . Work is going ahead on a budgetary resources, a low-cost. rela- further 27 hospitals whose construc- tively uncomplex model of care was tion had been suspended . worked out to cover the essentials. lt The earthquake which devastated emphasises preventive care rather parts of Mexico City and other cities than curative, integrates manpower on 19 September last year caused and spending policies, and eliminates enormous losses for the hospital in- excessive management costs. frastructure, and obliged the govern- In practical terms, some 3,400 ment to make additional allocations health centres, representing 90 per and investments. President de la cent of the total in existence in M ex- Madrid gave the order to renovate and ico, have been renovated and ex- not just replace what was lost. to panded, and so have 53 hospitals, or change for the better, to respond in 40 per cent of the total. Up to Sep- . the fullest sense to the emergency tember last year, in-patient capacity · created by the earthquake. A Health had been increased by 1 0 per cent Services Reconstruction programme through the construction and oper- has started , which will include a Coor- ation of 20 new hospitals, with a dinating Technical Unit chaired by the total of 1,400 beds distributed over Secretary of Health and sponsored by W oRLD HEALTH, May 1986 A stopped clock fixes the time of the disastrous earthquake last September. The health sector in Mexico is confident that the catastrophe will not represent a long-term block in the nation 's progress towards health for all. Photo L. Sirman © the Pan American Health Organiza- tion, which has made Mexico a gener- ous donation administered through the Mexican Foundation for Health . All the signs are that the setback which the earthquake represented for the health sector in Mexico will not represent a long-term block in the nation's progress towards Health for all. • 23 Primary Health Care Shilling Resources in Israel ~ f we analyse the budget of almost every health care system we will find that hospital care takes up the largest single proportion, usually ac- counting for more than half the total. Although it is clear that most medical care is given outside the hospital and does not require resources generally concentrated in hospitals, little has been done to divert manpower, equip- ment and capital away from these institutions. Today, changes in the economic situ- ation and in the consensus view as to what constitutes good medical care provide us with the rational to shift resources to the community. We now accept that : - a reduction in hospital services holds the greatest potential for cost con- tainment; - patients should be kept within their homes and communities to the ex- tent possible. to minimise the trauma of illness and maximise the sup- port provided by their surroundings. When overnight care is necessary it should be as short as possible, with the hospital stay forming a planned stage in the diagnosis and treatment within the referral chain; - primary health care can be most effective when it is provided in a facility which stimulates team work among health professionals at all levels, ensures continuity of care and encourages a concentration of both knowledge and equipment. Over the last decade, the use of general hospital care has dropped by almost 20 per cent in Israel, despite the significant aging of the population and advances in hospital-based techno- logies. The push to use less in-patient 24 by Aviva Ron care came from the efforts at cost- containment undertaken by Kupat Holim, the health insurance system re- sponsible for over 80 per cent of Israel's population. The decrease in the use of hospital care is very important; no national health policy will promote a reallocation The health service in Israel makes a consid- erable effort to treat patients at home whenever possible, rather than in hospitals. Photo WHO/J. Smith of resources which gives less to hospi- tal care unless it has already been proven that the population is able to do with fewer in-patient days, that is. fewer general hospital beds. When re- allocation to community care involves closing hospital beds, as is now the case in a number of countries including Israel, the difficulties are tremendous. with local political 1ssues often chal- lenging national health care and economic issues. Before shifting resources to com- munity health services, there will prob- ably be attempts to shift from general short-term beds to long-term beds for the chronically ill. and thereby preserve the total number of beds and institu- tions. Positive developments within the hospital complex will include the opera- tion of day care departments for a range of services. from minor surgery to renal dialysis and chemotherapy. In countries where hospital beds were previously considered in short supply, it may be easier to change direction, as building new facilities is always more popular than closing existing services. In both cases. however. the shift to com- munity-based primary health care will require at least two pre-requisites: firstly, the existence of sufficient hospi- tal facilities to provide the necessary back-up in terms of specialist man- power and equipment. on a regional basis; and secondly, commitments by the system responsible for the realloca- tion to strengthen the planning of ser- vices and to undertake the training of manpower for primary health care. Primary health care is a concept that can be practised in different frame- works, by different health professionals working alone or in teams. The basic question we face in seeking the con- tinued effectiveness of the shift in re- sources away from the hospital is how to organize and finance primary health care. lt must be developed on the foundation of a system that encourages primary health care as front-line care, screening referrals to other services and bearing responsibility for the coor- dination of their use. as well as being WoRLD HEALTH, May 1986 responsible for concentrating all medi- cal information on the individual pa- tients . The system which provides this foundation must also guarantee flexibili- ty to deal with local and regional changes In age-structure, disease pat- terns and socio-economic differences in the communities served . In Israel, the framework in which primary health care is provided is the health insurance system mentioned earlier, which integrates prepaid health insurance and the nationwide delivery of comprehensive health services . Primary health care is given in a net- work of over 1 ,260 community-based clinics or health centres, serving popu- lations ranging from several hundred in rural areas to 20,000 in the cities. Each of the community-based clinics has its own drug dispensary. Photo WHO/J. Smith W oRLD HEALTH , May 1986 The clinics are staffed by physicians, nurses, paramedical an.d clerical per- sonnel, most of them on a full-time basis, with no fee-for-service element in their salaries. The insured are regis- tered with a regular primary health care physician (children with a primary paediatrician in urban clinics). each of whom have a list of 1 ,500 members on the average. In smaller rural clinics, basic drugs are dispensed by the doctor and nurse. In larger clinics (serving over 4,000 population), dispensaries are staffed by qualified pharmacists . Basic tests are done in the clinic, and speci- mens are sent to regional laboratories in larger clinics for more sophisticated tests. Patients are referred to regional polyclinics or the out-patient depart- ment of the local hospital for other diagnostic services and specialist care. The entire system is financed by a social security mechanism, with em- ployee and employer contributions pro- viding the main revenues. The only patient charges are a nominal charge for prescription drugs. While this form of organizing primary health care is as old as the health insurance system itself (established in 1911 ), the recent increase in resources for primary health care, resulting from reduced hospital expenditures, has been aimed at strengthening this net- work in four ways. Firstly by changing the scope of prim- ary health care, since the on-going analysis of disease patterns, demo- graphic trends and medical knowledge shows that new roles must be underta- ken by the providers of primary health care. Among the methods are health education, and all stages of prevention, including visits initiated by the doctor to cover individuals in vulnerable age- groups who seldom seek care, or to carry out specific early detection pro- grammes. In terms of resources, health 25 education courses for the regular clinic staff have been introduced, backed up by the addition of trained health educators operating on a regional basis . In the same w ay, allocations for other paramedical health providers. such as dieticians and social workers. support the community clinic staff . Home care is encouraged, and additional rehabilita- tion and housekeeping services are pro- vided in liaison with regional home care units. As techniques are developed, community clinics, particularly those which serve as rural health centres. have introduced a form of "day care" to allow for observation or treatment (such as oral rehydration) over several hours. Secondly by developing team-work. While the doctor and nurse constitute the basic team members, the changing content requires clear definitions of the function of each provider of care in the community clinic . Both roles and defini- tions are being developed. as well as techniques to promote good communi- cations between all clinic staff. Re- sources are also being directed to de- veloping the administration of the clinic. towards more efficient handling of pa- tient demand, medical records, referrals and clinic supplies . At the same time. new models for community participa- tion are developing. Thirdly, new design of the primary health care clinic . A national unit has been established to assist in planning each clinic and examining the popu- 26 lation structure. particularly the epide- miological and socio-economic charac- teristics . Standards have been de- veloped to allow for the efficient flow of patients and staff, adequate space be- ing provided for such new functions as giving health education to groups. Fourthly, involvement in training . In order to create primary health care manpower and maintain its level, the health insurance system itself has de- voted resources to training . One major undertaking is to provide positions for supervised practice over a two-year period for doctors in accredited com- munity clinics . Extensive continuing medical education is available for all clinic doctors by including 24 days a year of post-graduate training as part of the wage agreement. Similar arrange- ments have been developed for nurses. and the nursing school curriculum is being changed to make provision for community medicine. Among the 38 targets set by WHO's European Regional Office on the road to Health for all by the year 2000, Target 27 states that "by 1990, in all Member States. the infrastructures of the deliv- ery system should be organized so that resources are distributed according to need, and that services ensure physical and economic accessibility and cultural acceptability to the population . " The model described here. both in terms of the existing primary health care framework and the directions for addi- tional resources , would seem to pro- Doctors specialising in family medicine spend half of their four-year course in the community clinic. Photo WHO/J. Smith vide the necessary elements to achieve this target. Such a primary health care system, with continu ity between patients and the entire teams, is best placed to introduce health promotion and can play a crucial role in early detection. Preventive methods are too often re- jected because of their high cost and low yield . If some diseases can be prevented by making primary preven- tive measures part of the routine work of the clinic team, at minimal cost. it is very likely that less will be spent on treating the illness. Close involvement in the post-hospital care of the patient with a chronic condition in an advanced stage will also enable the team to use secondary prevention methods to keep the patient in the community with the least possible discomfort. In the past. there has been a certain prestige involved in developing new and highly sophisticated hospital facilities. In aiming for Health for all by shifting resources to primary health care. any loss of such prestige will be more than compensated for by the benefits of a network of modern. well- staffed and well-equipped community health centres, sensitive to the chang- ing needs of the population they serve. • W oRLD HEALTH , May 1986 The poor already pay a high cost tor health Y he question of costs is largely a political issue. This is best exemplified by the fact that many poor countries at present seem to have little trouble in giving a priority to purchasing highly sophis- ticated and expensive medical equip- ment for urban hospitals . The real question is not " What is the cost?" but rather "Who pays and who benefits? " Currently , in most poor countries there is an income transfer from the rural poor to the urban sector through a variety of policies related A leprosy victim in South-East Asia. Pov- erty should be no bar to medical treatment anywhere in the world. Photo WHO/S. Armstrong W oRLD HEALTH. May 1986 to agricultural pncmg, food sub- sidies, and export and import policies . It is clear .... that while good health in poor countries can be achieved , it is not at low cost relative to the economy, and it is likely to involve a reversal of the usual wealth flows from the rural to the urban sector. This gets back to a political commitment to equity. I bring up the issue of costs from one perspective only ; that is , in considering a more egalitarian health strategy, it should be recognised that the poor are already paying a high cost for many of the essentials that are required for health. Typically , this includes extraordinarily high costs for hand-carried water, for commercial pharmaceuticals , for commercial junk food, for artificial baby formula, for ineffective and even dangerous health care and sick- ness care treatments from traditional practitioners , as well as for gaining access to the government health system. A rational health policy would not only save lives but would directly improve the economic circumstances of the poor. This comment by Dr W. Henry Mosley, Director of the International Institute of Health and Population, Johns Hopkins University, Balti- more, U.S.A., appeared in a Rocke- feller Foundation publication entitled "Good health at low cost " , which reported on the experiences of China, Costa Rica, Sri Lanka and Kerala State, India. • 27 Equity tor the poor A health finance system which uses scarce resources, paid for by all taxpayers, to provide services to non-poor patients at zero-prices is far from being fair to the poor @ ne widely supported method of raising revenues to help pay for health services in developing countries is to charge fees for the services. The usual suggestion is that the bulk of revenue collection from fees should come from the curative areas , rather than from charging for services which benefit many in society besides the actual service recipient (for instance , immunization against a communicable disease) , or where the actual beneficiary cannot even be identified (spraying for malaria , for example). Revenues raised in the curative area can reduce the burden on the govern- ment and allow it to use more of its tax revenues for primary health care and preventive services. The most basic economic arguments in favour of fees for services have to do with the notion of efficiency in the use of scarce resources. The basic argument is that no one should con- sume goods or services unless their value to them at least equals the value of the most useful alternative goods and services that could be produced . with the resources used. When goods and services are priced at the cost of all resources used in providing them , such efficiency in resource allocation will be achieved . An obvious corollary of this line of reasoning is that health services pro- vided for " free " (that is , zero priced) will be used not only by those for whom they are of significant value, but also by those for whom the value of the service is only slightly greater than zero. In fact , in such zero price cases , even services that are very expensive to provide will be used by people who value them very little; at the same 28 by John S. Akin time the resources used to produce these not-highly-valued services will be unavailable for producing other services which are highly valued. It is for this reason that fees are suggested as the means to differentiate among those who truly "need " the service and those who do not. The assumption underlying this economic Equity in health : perhaps the most crucial issue of all in the Health for All strategy. Photo WHO/P. Almasy argument is that those who have in- come ar~ those who " should " have income-in other words , that the amounts of income accruing to each person are socially correct. The reasoning continues that , if the income distribution is incorrect , it should be corrected directly by grants to the needy, rather than by interfering with the pricing system's efficiency-produc- ing characteristics. The major argument normally made in opposing the use of fees, on the other hand, is one based on equity. In its most general form the argument goes something like this : " It is unfair to charge fees for something as impor- tant as health services because it is the poor who will be most burdened by the necessity to pay, while the rich who are well able to pay will hardly know the difference. " The basic no- tion is that a fair income distribution will not be achieved directly , and that the poor must be protected indirectly in their purchasing activities rather than being offered aid. A strong case can be made , how- ever, that-even given this objective of protecting the poor in their health purchases in order to provide equity-the statement in quotation marks immediately above will prove to be incorrect in most cases. The provi- sion of services at a zero price (note that I do not use the word " free " ) to all users is in fact often the more inequitable system, because the non- poor receive much of the benefit while the poor pay a significant part of the cost of services through taxes. In most developing countries, taxes on sales or consumption are widely used to pay for public services, including zero- priced health care. Because the poor must buy consumption items , they must pay consumption taxes. So the poor often pay a relatively large pro- portion of the cost of the " free " health services. The notion that zero-priced public health services are " free " seems to explain much of the antipathy to the charging of fees for services. It seems that one reason for preferring zero- priced services is the incorrect as- sumption that money to purchase re- sources need not be raised when the goods are provided by the public sec- W o RLD HEALTH, May 1986 A carefully designed system can provide free , or almost free, services to the poor while collecting much needed revenue from the rich. Photo W HO/A.S . Kochar tor without charge. Once it is under- stood that the choice is not between " free" and " not free " health care, but rather between health services either paid for (at least partly) by fe~s from users or paid for by taxpayers, it becomes much easier to determine which system puts a greater burden on the poor (and on the rich). In a few cases a taxation-supported system will actually be more fair to the poor , but in many others it will not. A health finance system in which the poor are effectively protected from paying (large) fees will be equitable by almost anyone's definition. (It is often desirable to charge a small fee to dissuade frivolous use .) Those who are not poor will pay fees to help finance the cost of health services; inefficient and unwise use of resources will be reduced ; the poor will not be bur- dened by more than nominal fees ; and revenues will be raised so that services for all can be financed with a lessened burden on the usually already over- burdened tax system. The so-called " free" systems may be even more complex in practice. W oRLD HEALTH , May 1986 Because tax revenues are often not sufficient to provide for quality ser- vices at public facilities , even the very poor prefer to pay heavily to use private health services . Yet quite small fees at public facilities would raise enough money to upgrade the ser- vices . In such situations , if service quality can be raised to acceptable levels it is possible that the poor will eventually need to spend less on health care. So the use of fees can actually be more equitable , in the sense of reducing the burden on the poor. In summary, a strong argument can be made that a health finance system which uses extremely scarce resources , paid for by all taxpayers , to provide services to non-poor patients at zero- prices is far from being equitable, or fair to the poor. That such an inequit- able system also provides services at zero-prices (but not at zero tax cost!) to the poor is a relatively weak reason for supporting the continuation of " free " services for the non-poor. A carefully designed system can provide "free" (or almost " free") services to the poor while collecting much- needed revenues from the non-poor. Indeed , a fee system designed with appropriate protection for the poor can greatly improve the fairness of the overall health financing system. • Decision-ma.kers please note ! "The tradition of cost-benefit analysis in development planning means that there is perhaps great- er pressure on the health sector in developing than in developed countries to justify its proposals in economic terms. Thus there is considerable interest in the appli- 'cation of.techn iques of economic evaluation to the health sector. Unfortunately, the lack of econom- ists with an interest in health, and the problems of obtaining ad- equate data on co.sts and conse- nn quences are considerable obsta- cles to good economic evaluation. Moreover, the application of the techniques is still at an early stage and many studies ain) to stretch the boundaries of the discipline rather than to provide practical guidance. The studies done under the aegis of the WHO Expanded Programme on Immunization pro- vide a good example of the way in which early theoretical work can be developed into a methodology capable of application by health service managers. These studies emphasi§e two further points: the importance of choosing issues that are amenable to economic evaluation, where calculations or plausible assumptions can be made of the relationship between ;health ' interventions < and health consequences; and the need for collaborative work between economists, epidemiologists and other health researchers. The results of economic evalu- ation are of assistanceto decision~ makers. but they do not dictate their course of action. While it is important to know the cost-effec- tiveness .. of differer1t< ways of organizing primary . health care activities, other consequences less easy to quantify, such as stimulating community participa- tion and promoting the capacity to 1m1 improve ., individual health, must not be neglected . Decision-mak- ers will wish to take. these also into account when they review the results of economic. evaluation studies." This · is one of the conclusions drawn by the World Health Statis- tics Quarterly in its Vol. 38, No. 4, 1985. devoted to Economic evalu- ation in the field of health. 29 Cigarettes Held Cause of Death Of Non-Smoker Sweden's Insurance Court of Ap- peal, in a first decision of its kind, has awarded compensation to the family of a non-smoking woman after ruling that smoking by her colleagues at their place of work had been "the probable cause" of her death. For almost two decades, Gun Palm, a non-smoker, shared a poor- ly ventilated office in Stockholm with colleagues, several of whom smoked regularly. Although her parents were smokers. they had given up cigarettes. So did her husband, but even during the times when he smoked it was never in their bedroom, or in the family car. In general, he avoided smoking in her presence. Although a life-long non-smoker, she developed lung cancer of a type that almost exclusively occurs among smokers, in 1980 at age 53. "By that time, a sma ll-cell anaplas- tic carcinoma. located in her left lung, was diagnosed," according to a report by Dr Lars M. Ramstrom, director of Sweden's National Smoking and Health Association. "After treatment with cytosta- tics, the tumour disappeared from the x-ray picture," he goes on to say, "but in December 1981, the tumour reappeared and metastases were found in the brain and pleu- ra." She died in February 1982-a victim of what is now called "pas- sive smoking." Photo W HO/T. Farkas Reducing the social acceptability of smoking. A year before her death, the victim had filed for compensation under Sweden's Occupational In- jury Insurance Act. In July 1982, five months after her death, the local social insurance office denied the claim. 30 A I Living Memorial' To lndira Gandhi India opened a new, five-year programme of immunization last year on an auspicious date- 19 November, the birthday of the country's late Prime Minister lndira Gandhi. The programme, which aims at protecting against six childhood diseases, was desig- nated as a "living memorial" to her by her son, Prime Minister Rajiv Gandhi . "When we think of the future, our thoughts naturally focus on the needs of chi ldren, " he said at the inaugural ceremony in New Delhi in acknow ledgement of his mother's abiding interest in India's youth. India plans to spend US $270 million in a nation-w ide drive against polio, diphtheria, pertussis (whooping cough) and tetanus as we ll as measles and tuberculosis over the next decade, according to the first issue of Action for Children, the publication of a UN ICEF cit izens' group. More than 350,000 health workers are expected to take part in immuniz- ation of a total of 82 million children and expectant mothers. This is part of the world-wide Expanded Programme of Immuniz- ation, launched by WHO in 1974, that is intended to protect against the six diseases by 1990. The global programme was given added impetus in 1985 by UNICEF through its sponsorship of a declaration ca lled "Universal Child Immunization, 1990. " • •••••• ••••••• ••• ••• ••• •••••• •••••• ••••• • ••••••••••• ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••• ••• ••• ••• ••• ••• ••• • •••••••••••••••••••• ••• ••• ••••••• ••• ••• ••• •••••• ••••••• ••• ••• ••• • •••••• ••• ••• ••••••• ••• ••• ••• ••••••• • •••••••••••••••••••••••••• ••• ••• ••••••• ••• ••• ••• •••••• • •••••••••••••••••••••••••• ••• ••• ••• ••• ••• ••• ••• ••• • ••••••••••••••• ••• ••• ••••••• ••••••••••• ••••••• ••• • •••••••••••••••••••• ••• ••• ••••••• ••••••••••• ••••••• ••• • ••••••••••••••••••• ••• ••• ••••••• •••••••••• •••••• ••• • ••••••••••••••••• Her family appealed, and in 1983 a regional insurance court reversed the decision, ruling that her cancer was an occupational injury in the sense of the .Act. and therefore subject to compensation . This followed testimony from four professors of occupational health stating that- in the absence of "stronger" evidence to the con- trary- passive smoking is "suffi- cient to induce biological effects in terms of impaired lung function, " Dr Ramstrom says in explaining the decision. Now it became the turn of the National Socia l Insurance Board to appeal , taking the case to Swe- den's court of last resort, the Insur- ance Court of Appeal. In November 1985 that court up-held the regional court. saying expert advice from the National Institute of Environ- mental Medicine had supported evidence submitted earlier. Ruling that "this case of lung cancer can be classified as an oc- cupational injury due to passive smoking in the work-place," the high court ordered payment of the equiva lent of US $1 ,000 for funeral expenses plus an annuity for each chi ld up to age 19 amounting to 20 per cent of their mother's yearly salary. Assessing the implications of the case, Dr Ramstrom says that the de- cision wil l "support and accelerate future development towards reduc- ing the social acceptabi lity of smok- ing, and effectively contribute to strengthening the measures to cre- ate smoking-free environments." • What Makes UNICEF Run? Why, UNIPAC " Faster, cheaper, better" are the standards to which UNICEF's Procure- ment and Assembly Centre (UNIPAC) in Denmark holds. lt sends out medical supplies hours after disas- ters; it buys in bulk, therefore at low prices; and it makes certain that drugs and vaccines meet re- quirements of quality. Best of all , it is at the service not only of UNICE F, but also of all UN agencies, and as well of govern- ments and private humanitarian agencies . Indeed, it has been said that it would be difficult to run UNICEF and a multitude of develop- ment programmes w ithout UN IPAC. Some 5,000 items are on stock at its warehouse in the free-port sec- tion of Copenhagen . When disaster strikes, blankets and tents already packed are ready to go, as are WHO Emergency Health kits. Some 90 per cent of stocks, however, are for long-term pro- grammes : water and sanitation supplies, which in 1983 provided clean water for some 13 million people; pharmaceuticals; hospital equipment; teaching materials, as for instance the growth monitoring charts, given thus far to 2.5 million mothers; vehicles- the UNICEF jeep particularly; spare parts; building materials and so forth. In 1985 alone, UNIPAC shipped out drugs and vaccines purchased at a bargain US $40 million but worth Photo W HO/E. Mandelmann Storing some 5,000 items for the survival of children. much more at regular market prices. Without bulk purchasing through public bids, these quan- tities would have cost. at 1980 prices, an estimated US $68 mil- lion . The stock today of essentia l drugs is valued at US $10 million. Some sample items : $5,95 for 1 ,000 choloroquine tablets, 150 mg in strength, against malaria; $0 04 for a litre packet of oral rehydration sa lts against diarrhoea! disease; and $0.07 for a 5 g, tube of tetra- cycline eye ointment against tra- choma. Some 90 per cent of drugs and vaccines purchased were from Western European manufacturers, 5 per cent from Eastern European. There are plans to invite more Third World manufacturers to bid in 1987. And there are plans too, to set up a US $23 million revolving fund to facilitate purchasing by the least developed countries. UNIPAC was set up, seemingly as an afterthought. in 1953- thirteen years after UNICEF's creation . In 1962, it out-grew space availab le at the United Nations and moved to Denmark. That year, it handled goods worth US $3 million . Last year. some two decades late r, the figure reached US $185 million. Over the years UNIPAC's storage space for supplies and equ ipment that are vita l to child survival has increased from just a basement in New York to 23,000 sq. meters in Copenhagen - the size of three footba ll fields put together. • The I Macabre Processions' Are Ending In many a vi llage along the Volta River Basin just a decade ago, a majority of adults suffered from onchocerciasis, a parasitic disease that slowly blinds. Because the blackfly, which transmits the dis- WoRLD HEALTH, May 1986 ease, breeds in fast-flowing wa- ters, onchocerciasis is also called river blindness. lt was then the lot of children, probably already infected by the parasite but not as yet sightless, to lead adults about on a stick. A child taking a string of men through a vi llage in that way was common- place. Now thanks to a programme against onchocerciasis launched in 1974 in seven West African coun- tries - Benin, Burkina Faso, Cote d' lvoire, Ghana, Mali, Niger, and Togo-such macabre processions are becoming just an awful mem- ory of the past. As a resu lt of weekly larviciding of breeding places of the blackfly along some 18,000 kilometers of rivers, the disease's transmission has been stopped in 90 per cent of the 764,000 square ki lometers of the original ly infested areas. Put another way, no new cases are being reported now in an area the size of France and the United Kingdom combined. Even better, WHO says, some three million chi l- dren born over the past decade will never become bli nd. Buoyed by these successes, health workers are now taking the campaign westward- to Guinea, Guinea-Bissau, Senegal, and Sierra Leone- as wel l as extending it to western Mali, and southern Benin, Ghana, and Togo. By adding 556,000 square ki lo- meters to the area of operations, they expect to protect an estimated eight mil lion more people and, just as importantly, cut off routes for re- introduction of the diseases from the west and the south by migrat- ory blackflies capable of flying long distances. Photo WHO Becoming soon an awful mem- ory of times past. The new phase is planned to run for five years, through 1991, at an estimated cost of US $133 mi llion. The fight against onchocerciasis has already cost US $162 mi llion, contributed by 19 countries and institutions'-not a large sum or, as the World Bank says, "less than $1 per protected person a year." • 1 Belg ium, Canada. Federal Republic of Ger- many, Finland. France, Italy, Japan, Kuwai t. Netherlands, Norway, Saudi Arabia, Switzer- land, United Kingdom, United States. OPEC Fund, African Development Bank, UNDP. World Bank and WHO. WoRLD HEALTH , May 1986 News briefs e As UNICEF Turned 40. As part of its anniversary observed 14 April, it was time to pay tribute to the "Goodwill Ambassadors, who lent their talents to UNICEF. " Tarzie Vittachi, the agency's Deputy Director for external affairs, saluted a distinguished roster as follows: "Danny Kaye, the dancing, singing minstrel, and the first Children's Ambassador; Pe/e, who spread the word with his sparkling feet on soccer fields; and Peter Ustinov, Liv Ullman and Tetsuko Kuroyanagi, who moved the hearts and minds of thousands. " And Abba, the Bee Gees, George Harrison. 0/ivia Newton-John, Yoko Ono, Diana Ross, Donna Summers ; Earth Wind and Fire, the Young Menudo, other rock groups ; and David Frost, who organized the music for the UNICEF concert; "And Michae/ Burke and lbrahim Amin, who told the sad story of Ethiopia so poignantly that the world 's understanding was roused to an unprecedented state of generositv " e 'Designer Drugs.' The annual report of the International Narcotics Control Board in Vienna has warned against what are called "designer drugs" - a reference to a new group of drugs now finding its way to the world's big cities. Because the drugs are made by altering the chemical structure of existing ones, they are now unregulated In a related development. the UN General Assembly set 17-26 June 7987 for a world conference on drug abuse in Vienna. Proposed by the UN Secretary-General, Javier Perez de Cuellar, it is yet another recognition of the growing need to crack down on drug trafficking and the illicit production of narcotics and psychotropic substances (chemically produced stimulants such as amphetamines, barbiturates, and hallucinogens). • Gramm-Rudman. The deficit-reducing act passed by the US. Con- gress in December 1985 is referred to simply as Gramm-Rudman. Under it, automatic cuts in the US. budget each year are mandated beginning from fiscal year 1987 and ending in 7991 when, theoretically, the deficit will be eliminated This will affect spending on development programmes. Asked about the implications of the act on the UN system, Patricio Ruedas, UN Under-Secretary-General for Administration and Management gave this reply in an interview last January: " I read in the newspapers every day that there 's great confusion and disarray as to what effect Gramm-Rudman can have on the operations of the US. government .. . so I can only say that the same confusion exists here ... but the implications .. . can be really enormous ... Let 's say, a $7 0 cut this year can be a $30 cut next year, and then a $80 cut two years from now. So the progressive effect ... can be little short of disastrous." The act is named for Senators Phi/ Gramm (Texas), and Warren Rudman (New Hampshire), but Senator Ernest Hollings (South Carolina) is also a sponsor. e Salubritas on Sale. This quarterly newsletter published by the American Public Health Association and the World Federation of Public Health Associations is still alive, according to Heidi Sawyer, associate editor. it used to be distributed free of charge to some 72,000 readers, but now is available for $70 a year, or for $8 for a minimum of eight subscriptions. For details. write : Salubritas. APHA. 1015-15th Street, NW. Washington, D.C 20005 USA. e The Legacy of Vul Brynner. "Now that I'm gone, I tell you: don't smoke, whatever you do. " So said the star of stage and screen, Yu/ Brynner, when asked what he would say on the subject of smoking if given the chance to do so after his death. The hero of "The King and / " and " The Magnificent Seven, " who died from lung cancer in October 7985 at age 65, often spoke of a desire to leave a health education programme as his legacv @ c "' § en _j .9 0 .<::: Now his words are being put to use by the American Cancer Society in a public service announcement that starkly warns of the dangers to health from cigarettes. ===="- In the next issue Not all the diseases that plague humanity can be blamed on microbes and vi ru ses. Among the most distressing of "man-made diseases" are the addictions - to tobacco, to alcohol and to drugs. What these diseases have in common is that they are preventable. World Health in June looks at these three menaces to the world's well-being. Authors of the Month Professor Brian ABEL-SMITH is Pro- fessor of Social Administration at the London School of Economics and Political Science, U.K. Mr Pape Marcel SENE is a journalist working with the Secretariat of the Presidential Office for Senegambia, in Dakar. Dr Marten LAGERGREN works at the Swedish Secretariat for Future Studies in Stockholm. Dr Lee M . HOWARD is with the Office of External Relations Coordi- nation, WHO Regional Office for the Americas/Pan American Sanitary Bureau , Washington , D.C. , USA. Dr Kai Hong PHUA is Senior Tutor in the Department of Social Medicine and Public Health , National Univer- sity of Singapore, where he teaches health economics and administration . Mr John WICKETT is a Consultant with WHO's Smallpox Eradication Programme in Geneva. Dr Ok Ryun MooN is Associate Professor of Health Administration, School of Public Health, Seoul Na- tional University , Seoul , Republic of Korea. Dr John S. AKI is a Senior Econom- ist working at the Population , Health and Nutrition Department of the World Bank , Washington , D .C., USA. Ms Helene PouR is information, Education and Communication Officer on labour and population matters at the International Labour office in Geneva. Mr Alejandro LLANO DELA TORRE is Information Officer at the Depart- ment of Social Communication in the Ministry of Health and Welfare of Mexico. Dr A viva RoN is Director of the Planning and Information Division , Kupat Holim Health Insurance Insti- tution in Tel Aviv, Israel. WORLD HEALTH For readers everywhere 1986 Subscription Rates One year Two years Three years US$ Sw. fr. 12.50 25.- 22.50 45.- 30.- 60.~ ORDER FORM Please enter my subscription to "World Health" as fo llows: One year D Two years D Three years D I enclose cheque/international postal order in the amount of: ____ _ Name: --------~- Street: -----'------'--'--- City: _________ _ Count~: _________ _ World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland World Health is also distributed through the network of international bookstores and sub- scription agencies. For payment in national cur- rencies. please contact your usual bookseller. Playing at doctors is fun today. Health for all will be a reality when they grow up-and it has to be paid for I Photo WHO/A. Blessing
Всемирная организация здравоохранения (ВОЗ / WHO) · Journal articles
World Health: the magazine of the World Health Organization: May 1986 [full issue]: a budget for health for all
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