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3 Prevention and Treatment of Cardiovascular Diseases in Developing Countries Health care spending varies dramatically among countries. For example, in 1992 the United States spent approximately $3,000 per person annually on health care, while the Organization for Economic Cooperation and Development (OECD) average was $1,374 (Ad Hoc Committee, 1996). The funding allocated to prevention compared with treatment also varies among countries; however, these figures are more difficult to obtain. Most governments and private agencies support a mix of prevention and treatment efforts (e.g., educational campaigns to reduce cardiac risk factors and acute care centers that provide state-of-the-art diagnostic equipment and treatment). This chapter addresses current efforts in the prevention and treatment of cardiovascular disease (CVD) in developing countries. DIFFICULTIES IN ASSESSING PATTERNS Three problems complicate the assessment of current patterns of prevention and care of CVD. The first is the difficulty analyzing the data available. Government health care budgets, which are the primary source of support for prevention and treatment, are often assigned to ministries or divisions without designating the specific programs to be supported. It is, therefore, difficult to identify the part of the budget allocated to CVD and even more difficult to identify the allocations to prevention and treatment of CVD. The expenditures for health care by the governments of South Korea and Cameroon provide examples of the allocations being made by middle-and low-income countries. The South Korean health care budget for 1996 was allocated from the Ministry of Health and Social Welfare and comprised 10.5 percent of
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the government's budget. It has four categories: (1) public health education (approximately U.S. $44 million, or 18 percent); (2) communicable disease control (approximately U.S. $64 million, or 26 percent); (3) chronic and mental disease control (approximately U.S. $75 million, or 30 percent); and (4) medical and pharmaceutical programs (approximately U.S. $62 million, or 25 percent). Funding expended on prevention and treatment of CVD could come from three of the four categories, but no information is available on it (Republic of Korea Ministry of Health and Welfare, 1996, 1997). Health expenditures in Cameroon for the same year (1996) were three percent of the national budget, and assigned to the Ministry of Health. This funding was divided into three categories: personnel and salaries (55 percent), pharmaceuticals (4 percent), and buildings and equipment (41 percent) (W. Muna. personal communication, November 1997). The second problem in assessing health care expenditures is the several sources of funding. Although government supports the majority of health care services, other agencies have programs that target CVD prevention and care. These include nonprofit organizations (religious and nonreligious), international agencies, and the private sector. There is currently no compilation of data on programs for CVD prevention and cure for any developing country. The third problem in assessing health care expenditures is the difficulty of categorizing the data. Although sales data are available for aspirin in specific countries, use of aspirin for CVD prevention and treatment are not separated from other uses. Even CVD uses may be for primary prevention (to minimize risk of myocardial infarction or stroke) or for secondary prevention (to prevent a second myocardial infarction). Secondary prevention of CVD further complicates assessing budget allocations. For example, the cost of treatment for heart failure is more than $70 billion annually in the United States alone. Prescribing angiotensin-converting enzyme (ACE) inhibitors in patients with reduced cardiac function decreases the incidence of heart failure, thereby improving the health status of the individual with documented coronary heart disease and reducing health care costs (SOLVD, 1991). Such secondary prevention can dramatically decrease CVD costs. The pharmaceutical data available in developing countries do not, however, address whether an ACE inhibitor is given to prevent the onset of heart failure symptoms or to treat the symptoms of advanced heart failure. THE ROLE OF INTERNATIONALLY SPONSORED PROGRAMS Over the past two decades, several programs developed have been directed toward prevention and control of noncommunicable diseases in general, and many activities targeted CVD risk factors. Five international programs are particularly important for CVD prevention (Grabowsky et al., 1997). Each has a network of collaborating centers or societies linked by shared protocols for demonstration projects:
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The Countrywide Integrated Noncommunicable Diseases Intervention (CINDI) Program. Initiated by the World Health Organization (WHO) in 1984, this program involves 24 member countries, among them Canada and European and East European countries (including Russia and Estonia). Several member countries have developed similar protocols and evaluation methods and conducted national demonstration programs. For example, an antismoking campaign, ''Quit and Win," in 13 countries involved approximately 15,000 people. CINDI created a CINDI Euro Health Action Plan, which will focus on multiple risk reduction through community and primary care programs. Conjuncto de Acciones para la Reducion Multifactorial de las Enfermedades No Transmisibles (CARMEN). This program was initiated in 1995 by the Pan American Health Organization to develop cardiac risk factor reduction programs in Latin American and the Caribbean. Participating countries begin with demonstration projects that are based on CINDI protocols and designed to reduce risk factors such as smoking, high blood pressure, obesity, diabetes, and excessive alcohol consumption. The Inter-American Heart Foundation. The overall mission of this foundation, formed in 1994, is to reduce disability and death caused by CVD and stroke in populations in North, Central, and South America and the Caribbean. Cardiac risk factors are targeted, along with risk factors for rheumatic fever and Chagas' disease. The program, supported by the International Society and Federation of Cardiology and the American Heart Association, promotes partnerships between medical and nonmedical groups to influence health policy and provide educational resources for CVD risk factor campaigns for member organizations. Inter-health. This is an international, collaborative program established in 1984 by WHO. It has 15 members, about one-third of which are developing countries. Although the purpose is to reduce the risks of all noncommunicable diseases, CVD is a focus. Participants monitor the incidence and change in risk factors and have designed community-based demonstration projects. The Inter-health Nutrition Initiative. This program, developed in 1993 by WHO, monitors global trends in food and nutrition intake and evaluates dietary risk factors for CVD and other noncommunicable diseases. THE ROLE OF THE PRIVATE SECTOR In calculating the ratio of prevention to care for CVD, R&D expenditures by the private-sector are an important component of both prevention and treatment of CVD. The market for pharmaceuticals and medical devices to treat cardiovascular conditions is a large one. The overall expenditure on pharmaceuticals was $220 billion (or $40 per capita) and on medical devices and equipment about $71 billion in 1992 (Ballance et al., 1992). Although the current budget for car-
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diovascular-related expenditures is unknown, an increase can be anticipated in line with increasing incidence of CVD (Murray and Lopez, 1996). The proportion of spending directed to pharmaceuticals is higher in both public and private spending in developing countries than developed countries. For example, in 1992 the public and private sectors together spent 10-30 percent of their health care costs ($44 billion), on pharmaceuticals and equipment in developing countries, compared to approximately 5-20 percent of health care budgets in developed countries (IOM, 1997). Just as health care expenditures do not necessarily translate to improved health status as measured by life expectancy (World Bank, 1993), the proportion of spending for prevention versus treatment may not translate to improved health status. However, most research supports the efficacy of allocating resources to prevention over treatment (Azar and Hofman, 1995; Brownson et al., 1995; King et al., 1995; Krumholz et al., 1993). The applicability of these findings to CVD in developing countries remains to be established. ZAMBIA: A CASE STUDY Zambia is a relatively large country with an area of almost 753,000 km2. The population of 8 million is widely scattered across the country, with 45 percent in rural areas and 55 percent in urban areas. Health care is provided by government institutions, religious organizations, industries (particularly mining companies), the armed services, and practitioners and traditional healers in the private sector. Of these, the government has been the principal provider of care through hospitals and health centers. Religious orders are the second source of care, providing approximately 30 percent of all hospital beds (Martin, 1994). After independence in 1964, the government made a commitment to increase health care for rural populations—a segment that had received little attention prior to this time. Much of this commitment involved increasing hospital beds. Between 1964 and 1987, the number of hospital beds increased from 10,800 to 22,800. These early efforts to improve health care were aimed at treatment rather than prevention, and particularly the treatment of communicable diseases. Moreover, the pattern of allocation of government budgets consistently favored large urban hospitals. For example, in 1980, 3 percent of the population in one urban area received 60 percent of the national health expenditure. The focus on expanding hospital beds meant that Zambia had one of the highest ratios of hospital beds to population in Sub-Saharan Africa (Martin, 1994). A severe economic decline began in 1975, which led Zambia to becoming one of six countries in 1991 to lose its status as a middle-income country. With the economic decline of the late 1970s, the government was unable to maintain its commitment to strengthen the health infrastructure by increasing hospital beds. In 1980, primary health care was introduced by the national government with implementation at the district level to encourage community participation.
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The government provided the health care workers with training focused on prevention. This change responded to a range of serious but preventable health problems and to correct the previous emphasis on treatment and infrastructure. These efforts were rewarded by an increase in female life expectancy from 45 to 57.5 years and in male life expectancy from 41.8 to 55.4 years over the 28-year period between 1964 and 1992 (Lowther and Moonde, 1994). This experience in Zambia illustrates the issues involved in setting priorities for CVD. The improved life expectancy and high immunization coverage of Zambians has created longer life expectancy, and a population needing assistance with CVD prevention. As for many countries, the health care expenditures focus on treatment and hospital infrastructure rather than prevention. A preliminary review of 30 developing countries reveals that at least half of total recurrent public health spending supports hospitals (Barnum and Kutzin, 1993). The demands on governments worldwide for inappropriate curative services may be due, in part, to a lack of information about what is cost-effective. The emphasis on treatment over prevention results in health care systems being oriented to expensive technologies for diagnosis and treatment of heart disease, rather than to community and medical education programs to reduce the risk of CVD. Transferring the Western paradigm of health care will place unrealistic burdens on health care systems with extremely limited resources. FUTURE DIRECTIONS In summary, few data are available on budget allocations by governments to CVD prevention and treatment. The importance of emphasizing the prevention of CVD and its sequelae is recognized by governments and health authorities of some developing countries and is reflected in their prevention and treatment protocols. However, these countries are in the minority. Most have not recognized the increasing role of CVD in disease burden or have recognized it and chosen to dedicate important resources to building and supporting acute care facilities for the diagnosis and treatment of CVD in urban centers. Systematic research is needed to answer the following questions: In developing countries, what is the ratio of money allocated to the prevention of CVD compared to its treatment? Does this ratio have an impact on health status as measured by life expectancy or on the distribution of cardiovascular health within populations? What is the cost-effectiveness of secondary prevention efforts? How does a country develop an optimal combination of governmental and private-sector support for effective prevention and treatment of CVD? What is the role of the public and private sectors in preventing CVD? Can developing country governments work with the private sector to reduce the burden of CVD, or is the private sector engaged only in treatment? These questions await appropriate exploration.
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