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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