[Spending and financing in health care: situation and trends]

Being knowledgeable about national health expenditures and sources of financing is essential for decision-making. This awareness also makes it possible to evaluate the equity of allocation and the efficiency of utilization of these resources. Changes in financing have been a substantial component of health sector reform in the Americas. The goal has shifted from merely one of financial sustainability to simultaneously seeking equitable access to quality services. In this article the Pan American Health Organization (PAHO) presents a proposal for analyzing and designing a policy on health financing. The aim of the policy is to identify the mix of financing mechanisms most likely to simultaneously produce financial sustainability, equity, access, and efficiency. The PAHO proposal combines traditional mechanisms for generating resources (public funds from taxes, as well as private health insurance, national health insurance, and user fees) with complementary subsidy mechanisms for vulnerable groups. Health financing strategies ought to explicitly consider the financing both of care for individuals and of health interventions for the general public good, for which public financing is the most equitable and efficient approach.

Vaccine procurement and self-sufficiency in developing countries

This paper discusses the movement toward self-sufficiency in vaccine supply in developing countries (and countries in transition to new economic and political systems) and explains special supply concerns about vaccine as a product class. It traces some history of donor support and programmes aimed at self-financing, then continues with a discussion about self-sufficiency in terms of institutional capacity building. A number of deficiencies commonly found in vaccine procurement and supply in low- and middle-income countries are characterized, and institutional strengthening with procurement technical assistance is described. The paper also provides information about a vaccine procurement manual being developed by the United States Agency for International Development (USAID) and the World Health Organization (WHO) for use in this environment. Two brief case studies are included to illustrate the spectrum of existing capabilities and different approaches to technical assistance aimed at developing or improving vaccine procurement capability. In conclusion, the paper discusses the special nature of vaccine and issues surrounding potential integration and decentralization of vaccine supply systems as part of health sector reform.

Tuberculosis: the global epidemic

The modern era of tuberculosis(TB) began in the mid 1980s. In 1993, WHO took the unique step of declaring TB to be a world emergency. Despite this intervention it is estimated that deaths from TB will increase from 3 million a year currently to 5 million by the year 2050. There are 4 principal reasons: World population's increase, co-infection with HIV/AIDS, poverty and programme decline. Other causes contributing to the global epidemic are multidrug resistant TB, immigration, and indifference. The practical solution must concentrate on the completed correct treatment of the disease particularly in those who are sputum smear positive. For this reason WHO is vigorously promoting the Directly Observed Therapy Short course (DOTS) campaign. Doctors treating TB should ideally be part of the public health system. They should have access to first class bacteriological services, good quality of drugs and should make sure that the patient receives the drugs under supervision. Though the reasons for increasing TB are multifactorial it is within the capability of the world to re-exert control providing that the political will is present.

Stopping poliovirus vaccination after eradication: issues and challenges

Since 1988 reported polio cases worldwide have declined by about 85% and the number of known or suspected polioendemic countries has decreased from over 120 to less than 50. With eradication of poliomyelitis approaching, issues potentially affecting when and how vaccination against poliovirus can be stopped become extremely important. Because of the potential risks and benefits inherent in such a decision, the best available science, a risk-benefit analysis, contingency plans, a stock pile of poliovirus vaccines, and the endorsement by the global policy-making committees will all be needed before vaccination can be discontinued. The scientific basis for stopping polio immunization has been reviewed by WHO. This Round Table article summarizes the current state of knowledge, provides an update on the processes and timelines for certification, containment, and stopping vaccination, and highlights some of the unanswered scientific questions that will be addressed by further research. These include whether transmission of vaccine-derived poliovirus strains could be sustained so that poliomyelitis could re-emerge in a future unvaccinated population and whether prolonged excretion of vaccine-derived poliovirus from individuals with immune deficiencies could be a mechanism through which this could occur.

Nutritional status of breastfed infants in rural Zambia: comparison of the National Center for Health Statistics growth reference versus the WHO 12-month breastfed pooled data set

Cross-sectional data for breastfed infants in rural Zambia were used to evaluate the effect of applying two different data sets as a reference, i.e. the WHO 12-month breastfed pooled data set and the National Center for Health Statistics (NCHS) growth reference in terms of prevalence of malnutrition (stunting, underweight, and wasting). A total of 518 infants who were attending mother-and-child health clinics were included. Age, weight and length were recorded. Anthropometric Z-scores were calculated in two ways: by applying the NCHS growth reference and by using the WHO breastfed data set. Anthropometric Z-scores calculated using the breastfed data set were lower during the first 6-7 months of life compared with those calculated by applying the NCHS growth reference. This resulted in a higher proportion of children aged 0-6 months being classified as stunted and underweight using the breastfed data set versus the NCHS growth reference. After the age of 7 months, similar prevalences of stunting or underweight were observed. Relatively few infants were classified as wasted. In order to adequately assess the prevalence of stunting and underweight in breastfed infants, it is recommended that a new growth reference be developed, as has been initiated by WHO.