Global Health Priorities Under a Fixed Budget
A low-income country with a health budget of $90 million for 5 million people must choose between two packages. Package A: expand childhood immunisation coverage from 68% to 92% and add oral rehydration and nutrition counselling, costing $30 million. Package B: build a 200-bed specialist cardiac and cancer centre, costing $70 million, serving an estimated 4,000 patients per year. Current under-5 mortality is 78 per 1,000 live births; non-communicable diseases cause 22% of deaths, mostly among people over 55. External donors will fund Package B only if the government co-funds $20 million. A health minister favours Package B for national prestige and to reduce medical travel abroad.
1. Use burden of disease and cost-effectiveness reasoning to compare the two packages.
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Under-5 mortality of 78 per 1,000 signals a large burden of communicable, maternal, perinatal, and nutritional conditions, which Package A targets at the population level. Immunisation and oral rehydration are highly cost-effective: $30 million reaches millions of children and prevents deaths cheaply per case averted. Package B costs $70 million for about 4,000 patients, roughly $17,500 per patient before counting running costs, and addresses conditions causing 22% of deaths, mostly in older adults. On cost per death or disability averted, Package A is far superior. On total burden, Package A reduces premature mortality in children, which carries high years of life lost. Package B reduces suffering for a smaller group and may reduce out-of-pocket catastrophic costs for those families. A defensible judgement: fund Package A first, and negotiate a phased, smaller Package B or regional referral arrangement, because the marginal health gain per dollar is much higher in A.
2. The minister argues that declining to build the centre would be unjust to citizens with cancer and heart disease. Evaluate this equity argument.
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The argument invokes equity, which concerns fairness in distribution of health resources, not merely equal totals. It is valid that patients with cancer and heart disease face real suffering, and that requiring foreign travel imposes catastrophic costs on some families. However, equity must be assessed across the whole population. Spending $70 million on 4,000 patients means forgoing prevention that would benefit millions of children, many of whom have no other access to care. A distributive justice lens favours the option that improves health for the worst-off, and children facing preventable death qualify as the most disadvantaged group. The equity claim is also weakened by the donor condition: co-funding $20 million may divert resources from primary care, deepening inequity. A balanced response would acknowledge the legitimate need, then propose a targeted, lower-cost alternative such as regional cancer services, palliative care, and subsidised referral, which addresses the minister's concern without sacrificing population-level gains.