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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