Better Value at Low Cost

St John the Divine identified, two millennia ago, Four Horsemen of the Apocalypse as agents of the world’s destruction on Judgement Day: disease, famine, war, and civil disorder. Nowadays, no one will dispute the accuracy of this vision but we might change famine to malnutrition and then add ignorance or illiteracy.

It is fashionable these days to identify poverty as the biggest hurdle in taming the Four Horsemen. Blair, busy trying to rescue some of his tattered reputation, has adopted this new rallying cry. I seek to differ. The stumbling block is our inability to find effective low cost policies and actions that stem from understanding of local challenges and opportunities instead of adopting the one-model-fits-all practice beloved by so many national and international agencies.

Hard lesson to learn

Low income countries find it difficult to accept an all too obvious truth: throwing money at services does not guarantee success. This is sadly the case when it comes to the key areas of healthcare and education, but the same applies to all basic services from water supply and sanitation to housing. To be fair, high income countries have similar misconceptions but then they can afford to be profligate with their money. Even here, governments are beginning to change their ways in pursuit of effectiveness and efficiency.

In the so-called developing world the phenomenon can be traced to simple factors. First, elites live in urban areas and demand services similar to those supposedly available in the ‘West’. Often, this is a misunderstanding of what is actually on offer in the ‘West’. Nonetheless, what little money is at hand is devoted to keeping the urban elites happy. Second, high cost schemes offer opportunities for the ruling elites to make money; legitimately or otherwise. Bribes are just as common as fees and commissions to those in the know. Third, linking cost and value is an age old problem for most people in the reasonable, but mistaken, expectation that ‘you get what you pay for’.

This is not necessarily so, and health will be used to illustrate the fallacy of the above assumption.

Better health at a fraction of the cost

“Many deaths of children under 5 years of age could be averted for $10 or less…but the average actual expenditure in poor countries per death prevented…is $50,000 or more.” (WHOs World Health Report 2000: 10) This statement is remarkable only because it mirrors conclusions from numerous other reports and textbooks.

Money does not buy effectiveness. In health terms the magic mix is promotion of public health, focus on primary care, and collaboration between local services. This is now the gospel within the British National Health Service (NHS) following decades of experimentation.

An example from Liverpool gives a glimpse of the wealth of evidence that has been freely available for well over a century. The city was a dreadful place at the height of Britain’s capitalist-driven Industrial Revolution. Two men appeared on the scene who had more effect on health than all the hospitals and doctors put together. The first was William Henry Duncan (1805-1863); appointed Medical Officer of Health in 1847, and James Newlands (1813-1871); appointed as Britain’s first Borough Engineer also in 1847. They worked closely together on a clear public health agenda that recognised the key link between housing, water supply, sanitation, and health. Duncan helped to draft Liverpool’s first Sanitary Act in 1846 and Newlands constructed the world’s first integrated sewerage system. (  End result? Average life expectancy doubled during their years; from an incredible low of 19 years! This low figure was no doubt affected by a high death rate of children at an early age.

Interestingly, the same line of thought was in train across the Atlantic. The Report of the Sanitary Commission of Massachusetts was presented to the state legislature in 1850. It recommended ‘immunisation and communicable-disease control, promotion of child health, improved housing for the poor, environmental sanitation; training of community-oriented health manpower; public-health education; promotion of individual responsibility for one’s own health; mobilisation of community participation through sanitary associations; and creation of multidisciplinary boards of health to assess health needs and to plan programs in response to sound epidemiological evidence.’ (Health Care in the Developing World: Problems of Scarcity and Choice, Evans The New England Medical Journal of Medicine, volume 305 number 19, 1117-1127, November 1981)

Efforts continued to wean health authorities off expensive secondary and tertiary care that have undoubted but limited impact on the health of communities and to focus their attention on other more effective interventions that relied on public health, primary care, and provision of safe water, sanitation, housing, and adequate nutrition. In 1978, WHO and UNICEF held an international conference on the subject in Alma-Ata (now Almaty in Kazakhstan). All the pros and cons were rehearsed but ultimately the impact was limited. (WHOs World Health Report 2000: 14) Basically, the professionals knew best: they decided what people needed, rather than what they wanted, and set out to satisfy the presumed needs through high cost, but less effective, means.

The industrialised countries are changing course fast

The industrialised, ‘wealthy’ countries have encountered a problem: people are living longer and therefore the percentage of tax payers is diminishing. This presented a twin-pronged crisis. First, diseases of old-age (and affluence) such as cancers, coronary heart disease, and mental illness are imposing a huge and escalating strain on health budgets. On the other hand, it is difficult to increase the budgets sufficiently to meet the challenge.

Suddenly, health decision-makers have become aware of the accumulated evidence that public health, primary health, etc. could contribute handsomely to finding a way out of the dilemma. Over 300 Primary Care Trusts (PCTs) have been established in Britain in the last few years with wide agendas to improve the health of people, reduce the need for those who do become ill to go into expensive hospitals, and to push the various players (e. g. social services) who have an impact on health into closer working relationships.

Nurse practitioners, midwife-led obstetric clinics, telephone advice centres, and even the much maligned matron, have become the norm. The message is clear: first, keep people healthy; and second, unless it is absolutely necessary keep them away from doctors, consultants and most importantly hospitals.

Others are following the trend: Cuban model

Too much money could be worse than too little. For as long as they could afford it ‘wealthy’ countries stuck to an outdated and ineffective system. Pressure on budgets forced them to change direction.

The same happened in Cuba. Here harsh sanctions imposed by the USA on the island for over four decades brought the economy to its knees. Extravagant health spending was not an option. Allowing the health of Cubans to deteriorate was not an option either. Imaginative policies and practices had to be adopted. It goes without saying that old ideas, not unlike those advocated by Duncan and Newlands in Liverpool, and Lemuel Shattuck in Massachusetts, were picked up, dusted, and then put in practice. The results were spectacular.

Cuba’s healthcare system, as with anything else to do with that country, is a minefield for anyone seeking reliable facts. However, one basic fact is now beyond dispute: Cuba has a first class health system achieved at a fraction of the cost associated with this level of success. A strong hint of the foundation for this success lies in the fact that Cuba has had a Ministry of Public Health since 1961.

One of the most detailed studies of Cuba’s Social Services; including education, health, and sanitation, was completed in January 2002. It was commissioned by the World Bank as background for the World Development Report 2004, and undertaken by Dan Erikson, Annie Lord, and Peter Wolf. The report underlines the fact that “Monitoring the health data of the population plays an important role in the evaluation and shaping of health policy.” ( Comparison with the dearth of reliable information within the British NHS is instructive. A good picture of Cuba’s state of health is included in the form of appendices to the report. Basically, life expectancy increased from 64 in 1960 to 76 in 2001. Infant mortality decreased in the same period from 60 to 6.2 per 1000 live births. Maternal mortality in 2001 was 33.9 deaths per 100,000 live births. (World Bank documents in )

Similar positive views were expressed in Summer 2002 in the Harvard Public Health Review. (

Cuba’s health system evolved in the last four decades through three stages: the municipal polyclinic, the ‘medicine in the community’ programme, and then the ‘family doctor-and-nurse teams’ ( The latest stage provides 24 hour access to primary care through doctor-nurse teams. Each is responsible for only about 660-700 people to retain this focus without overburdening the doctors and nurses. The key unit in this system is taken as the family, and knowledge gained by primary care professionals about all members of the family is considered essential to the provision of a more effective service. The family doctor is involved in all aspects of healthcare: seamless progression from primary to tertiary care. The same seamless association is maintained between all services including social care.

Some space was given to healthcare in Cuba to illustrate the principle that effectiveness does not depend on funding alone. Much could be achieved at low cost once the right policies have been defined, implemented, monitored, and then modified sensibly.

Health and poverty are not mutually exclusive

Health could be achieved at lower cost, but it might be thought that such costs might still not be affordable. Here again the picture is quite clear. Basically, the cost of achieving good health (and education, sanitation, nutrition,…) could be so low it would be practically irrelevant to decision-making.

This, seemingly astonishing, aspect is not a new discovery. Evans, et al  reported in 1981 that China, Sri Lanka, and the state of Kerala in India “are examples of countries that have attained a life expectancy close to the level in the industrialised world, with income levels in the range of the least developed countries.”  (Health Care in the Developing World: Problems of Scarcity and Choice, The New England Medical Journal of Medicine, volume 305 number 19, 1117-1127) Similarly, Timberlake (in Africa in Crisis, 1991: 40) wrote, “African countries can expect the greatest improvement in life expectancy from health investments in materials and child health services in rural and urban slum areas, costing less than $2 per capita.”

Horses of the Apocalypse hunt together

The basic problems faced by most needy people on earth are closely linked. Equally, reducing one problem could also help to ameliorate others. This is particularly noticeable in the case of health, nutrition, water quality, and sanitation. “Around 7 out of every 10 deaths among children under the age of five in developing countries can be attributed to a few main causes: acute respiratory infections, diarrhoea, measles or malaria. Malnutrition contributes to about half of these deaths…A child deficient in vitamin A, for example, faces a 25 per cent greater risk of dying.” (UNICEF, The State of the World’s Children 2005)

What is the cost of vitamin A? The answer has been known for long: “daily diet can be changed, usually at little cost, to include small amounts of green leafy vegetables; or 2 cent vitamin A capsules can be given three times a year to children over six months of age, or vitamin A can be added to sugar or cooking oil.” (UNICEF, The State of the World’s Children 1995)

Lack of iodine is just as damaging to health; including cretinism and mental impairment, and equally cheap to remedy. Again, the easy way to deal with this problem has been known since the turn of the twentieth century: minor change to diet or add iodine to salt at a cost of “about 5 cents per person per year”, UNICEF estimated back in 1995.

Of course when basic lack of knowledge is brought into the equation the impact could be substantial and sustained. This applies in particular to incidence of HIV/AIDS. Is the emergency exaggerated? You decide: the percentage of 15 to 49 year-olds in Botswana who are HIV/AIDS positive is 37.3 (Swaziland 38.8). Treatment after infection is prohibitively expensive at over $300 per capita per year. About 93 percent of those who need antiviral therapy in developing countries simply go untreated. (UNICEF, The State of the World’s Children 2005) However, prevention (safe sex) is ridiculously cheap. In some cases condoms are provided free of charge. Public information might be possible in countries where literacy is reasonable, but in areas of high illiteracy the task is virtually impossible. The link between primary education and public health could not be more obvious.

Indigenous knowledge and local coping strategies

Sadly, those living in poorer countries, and their leaders in particular, have been conditioned to think that tried and tested coping strategies and native knowledge are somehow inferior to ‘modern methods’. Water containers made of earthenware pottery were used in the Middle East for many centuries to filtrate water into storage vessels. Most impurities were eliminated, and the water was cooled through evaporation in the process of filtration. This reasonably efficient has all but disappeared. The list of such instances to depressingly long.

Is water scarce? This is undeniably the case but you would not have thought so when you look at the water resources extravagantly wasted. Up to 60 percent of treated and pumped water in the developing countries never reaches its intended users due to illegal tapping and leakage. Such losses cost Latin Americans between $1 billion and $1.5 billion each year, it was estimated in 1997. (UNICEF, The Progress of Nations, 1997) There is no reason to believe that this waste has been brought under control since then.

Desalination of brackish and sea water is one area where technology has potential to help poorer countries. The European Desalination Society (EDS), the Middle East Desalination Research Centre (MEDRC) and others have managed to reduce the cost and improve efficiency. The most promising aspect is the availability of small units driven by  wind and solar power; energy usually accounts for  up to 80 percent of the cost of desalination. Despite these improvements, governments of poor countries continue pursue models based on highly urbanised Western societies.


I was prompted to write this article because of the overwhelming focus on poverty reduction. As mentioned before, the latest recruit to this laudable cause is Blair’s government in Britain. There is nothing wrong with pursuing such a lofty aim, but often action falls short of rhetoric. We have known for decades that poorer nations require about 50 billion dollars a year to get out of the mess that goes for living in these countries. We also know that whilst it is easy to find the cash to mount wars; the recent war on Iraq has cost about 200 billion dollars already, it is almost impossible to find the money to help poorer nations.

In the meantime, cheap measures that would produce near-miraculous effects on the standard of living of four out of every five people on earth are obstinately shunned in favour of ideal solutions that remain on the drawing board. As I said before, there is nothing new about this message. However, is it not time for us to give sensible policies and actions a chance? The measures are not dramatic and they will certainly not grab the headlines, but is this a good enough reason to condemn most of the world’s population to a life of abject misery?