BMJ  2004;328:239-240 (31 January), doi:10.1136/bmj.328.7434.239

Editorial

Exchanging health lessons globally

BMJ issue will focus on lessons rich countries can learn from poor ones

The link between expenditure on health and health outcomes is not straightforward. Despite burgeoning health budgets, few countries in the developed world can claim to be delivering universally high quality, equitable health care. Could they have something to learn from less developed countries, whose meagre resources have long ensured that cost effectiveness is a dominant consideration?

Certainly, massive health bureaucracies and well endowed research institutions do not have a monopoly on wisdom. Examples of industrialised countries adopting treatments and strategies that were developed or pioneered in developing countries range from oral rehydration therapy (which was developed and widely used in Bangladesh before its slow but now global uptake) to limited lists of essential medicines. The experience in low and medium income countries of introducing national policies based on restricted lists of cost effective, affordable medicines over two decades prompted Australia to follow suit in the 1990s, and such a move has been mooted as a solution to escalating costs of medicines in the United States.^{1 2}

Identifying promising initiatives in health practice, policy, education, and development should not be difficult. The Global Health Research Policy Network, led by the Center for Global Development, a think tank based in Washington, is about to publish an evidence based list of 20 successful, large scale global health interventions (www.cgdev.org). Defining the reason for success is a lot harder. Emphasising this, Nancy Birdsell, an economist at the centre, called for more research into "why programmes succeed when they do" at the Global Forum On Health Research in December.

Hardest of all is to recognise the lessons learnt from success or failure, see their wider potential, and successfully adapt them to other healthcare settings. Among the many factors that influence any project, sound management, good leadership, and active community participation are likely to be important. Brazil, for example, has succeeded in reaching and sustaining very high childhood immunisation rates against nine diseases. The last indigenous case of measles was reported in 2000.³ Public support for vaccination campaigns has been strong; temporary shortages of vaccines in 1997 resulted in public protests. This is in sharp contrast to the situation in several developed countries, where intense media coverage of possible side effects of vaccines and failure to mobilise public support have contributed to falls in immunisation rates.

The reluctance of health professionals in developed countries to abandon established treatments in favour of simpler low cost options may be one of the many barriers to adopting practices pioneered in less developed countries. Kangaroo care—keeping very low birthweight infants upright on their mother's chest in direct, skin to skin contact, marsupial style—may be an example. It was developed more than 20 years ago in Colombia in response to overcrowding and lack of resources in special care baby units. Further evidence is needed to confirm promising results of its effect on reducing infant mortality, but it seems to offer additional benefits to mothers.⁴

In November the BMJ will publish a theme issue on "learning from developing countries." Its aim is to flag up innovative, cost effective health initiatives and interventions in developing countries, which have or show clear promise of having useful lessons for health professionals, policy makers, and researchers in the developed world. It also hopes to draw attention to initiatives that may promote learning between developing countries and discuss what we can learn from interventions that have failed.

Original papers for this issue should reach us by the end of May. Authors should discuss the potential of their work for wider learning and adaptation, and suggest what further research is needed to explore this. We also welcome submissions for other sections in this issue. In an increasingly globalised world we have much to learn from each other.

(trichards{at}bmj.com)

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Competing interests: None declared.

Advice to contributors is provided on bmj.com. Submissions should be made to http://submit.bmj.com/ and the covering letter should make it clear that the article is intended for the "Learning from developing countries" theme issue.

The guest editors for this theme issue are Rashad Massoud, director, Quality and Performance Institute, University Research Co, LLC/Center for Human Services, 7200 Wisconsin Avenue, Suite 600, Bethseda, MD 20814, USA; Cesar G Victora, professor of epidemiology, Federal University of Pelotas, CP 464-96001-970 Pelotas, RS, Brazil; James Tumwine, associate professor of paediatrics and president of FAME (Forum of African Medical Editors), Makere University, Kampala, Uganda; and Zulfiqar Bhutta, Husein Lalji professor of paediatrics and child health, The Aga Khan University, Karachi 74800, Pakistan.

References

1. Smith AJ. National drug policy: "an Australian response." Australian Prescriber 1991;14(suppl 1): 21-5.
2. Ellner A. Rethinking prescribing in the United States. BMJ 2003;327: 1397-400.[Free Full Text]
3. Fundação Nacional de Saúde. Países latino-americanos reforçam medidas para a erradicação do sarampo, 21 May 2003. www.funasa.gov.br/not/not422.htm (accessed 26 Jan 2004).
4. Tessier R, Cristo M, Velez S, Giron M, de Calume ZF, Ruiz-Palaez JG, et al. Kangaroo mother care and the bonding hypothesis. Pediatrics 1998;102: 1-8.[Abstract/Free Full Text]

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