Financing essential clinical health services

Ensuring delivery of a package of essential clinical services providing both welfare improvements and better health to everyone, especially the poor, through public finance, or publicly mandated finance.

A minimum package of essential clinical services would include sick-child care, family planning, prenatal and delivery care, and treatment for tuberculosis and sexually transmitted diseases. It would also include some treatment for minor infection and trauma and advice and alleviation of pain. This can be best achieved by investing in district health infrastructure and devoting a greater share of government health budgets to the operations of lower-level facilities, and particularly to non-salary recurrent items (such as basic drugs). This is happening in a number of countries: (a) Senegal has set annual targets for increasing its spending for drugs, transport and maintenance; (b) Ghana is trying to reduce the number of civil servants working for the Ministry of Health; (c) India is diverting health spending from state governments (which account for more than three-quarters of total public spending for health) into more cost-effective uses by earmarking funds for immunization, treatment of leprosy and tuberculosis, and AIDS control; Mozambique increased government outlays for health in 1992/93 as part of a broader package of economic reform and Mauritania is also committed to substantial rises in government health spending during 1992-96, both supported by international donor funding.

The comprehensiveness and composition of a clinical care package of high cost-effectiveness will vary from country to country, taking into account epidemiological conditions, local preferences and health needs, and the level of income. The provision of hospital-based emergency care other than the interventions mentioned above would depend on day-to-day capacity and availability of resources, but might include treatment of most fractures and well as appendectomies. At modest increases in spending, relatively cost-effective measures for the treatment of some common noncommunicable conditions could be included. Examples include: low-cost protocols for treatment of heart disease using aspirin and anti-hypertensive drugs; treatment for cervical cancer; drug treatment of some psychoses; and removal of cataracts.

The most sophisticated facility required to deliver the minimum elements of the essential clinical package is a district hospital. Providing services in lower-level facilities allows costs to be contained at modest levels for minimal versions of the essential clinical package. The cost is about US$8 per person each year in low-income countries and $15 in middle-income countries. Widespread adoption of an essential clinical package would have a tremendous positive impact on the health of people in developing countries. If 80% of the population were reached, it is estimated that 24% of the current burden of disease in low-income countries and 11% of that in middle-income countries could be averted.