Global Health Watch 1 in one file

package, although the same principles would apply. A closer inspection of
the package reveals its serious shortcomings. At best, the minimum package
would avert no more than one third of the estimated burden of disease
in low-income countries and less than a fifth in middle-income countries.
Examples of care that would be excluded from public funding in poorer countries
include: emergency treatment of moderately severe injuries; treatment of
childhood meningitis; and treatment of chronic conditions including diabetes,
cataract, hypertension, mental illness and cervical cancer (Segall 2003).
Secondly, the health maximizing approach used by the Bank relied on a limited
definition of health outcome. Consider the case of a single-handed poor
farmer who develops a disabling inguinal (groin) hernia. His condition would
be excluded from publicly funded treatment because the number of ‘disabilityadjusted
life years’ that would be gained by the farmer would not represent
good value for money. What is not considered is how the hernia could undermine
the farmer’s ability to provide for his family, thus impoverishing them
and thereby undermining their health. The calculation of ‘disability-adjusted
life years’ gained would be different if these considerations were taken into
account.
The World Bank also tended to apply CEA to discrete interventions rather
than those interventions that have more complex direct and indirect impacts
on health. Water provision is a good example. Access to adequate volumes of
clean water not only reduces the incidence of diarrhoeal disease, intestinal
worms, skin and eye diseases, but also improves child and maternal health
indirectly by enabling women (who are usually the ones collecting water) to
spend more time on other activities such as child care or household and economic
tasks. However, the Bank did not classify improving access to clean
water as a cost-effective health intervention.
Finally, although priority setting exercises are sound in principle, the Bank
defined the goal of efficiency to mean the maximization of aggregate health
gain for a given expenditure. The issue as to which people or population groups
gained additional health was less important as the policy focus moved away
from the prioritization of people in greatest need to the prioritization of interventions
that would contribute most to aggregate health gain. The links
between this approach with the Bank’s stated intention to help the poor were
only indirect. First, the interventions for inclusion in the minimum package
were also selected according to the estimated population burden of disease
they would address – as the poor constitute a high proportion of the population
and make a substantial contribution to the total burden of disease, their
disease patterns would be influential in the selection of interventions. Second,
Approaches to health care
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