David Egilman

Strengthening primary care: addressing the disparity between vertical and horizontal investment

Recently we have seen an unprecedented increase of financial support to improve health care in developing countries estimated at 26% between 1997 and 2002, from

Tackling NCDs: a different approach is needed.

6.4 billion to

Call for global health-systems impact assessments

8.1 billion.1 While the magnitude of such an investment is a positive development, the vast majority of aid has been allocated towards disease-specific projects (termed ‘vertical programming’) rather than towards more broad-based improvements in population health, such as preventive measures, primary care services, and health workforce development (termed ‘horizontal programming’).nnFor instance, the initiatives of the Bill and Melinda Gates and Clinton Foundations usually focus on specific communicable diseases: 60% address ‘big diseases’ (HIV/AIDS, malaria, and tuberculosis). Rwanda, for example, with an HIV prevalence rate of 3.1 %2 and an annual health budget of

Tackling NCDs: a different approach is needed: authors' reply

37 million,3 received

Editorial policies on financial disclosure.

187 million since 2003 exclusively for HIV/AIDS.nnThirty years ago, in 1978, the Alma-Ata Declaration pointed to the importance of community-oriented comprehensive primary health care for all nations. Improving health required changes in economic, social, and political structures, in addition to access to health care. In this comprehensive or ‘horizontal’ healthcare concept, health care is also a basic human right that requires community participation.nnSome have argued that the Alma-Ata concepts were unattainable because of the costs and numbers of trained personnel required. From this perspective, a selective disease-oriented approach could address the greatest disease burden in the community in less developed countries.4nnThe two positions differ both …

The asbestos TLV: early evidence of inadequacy.

www.thelancet.com Vol 379 May 19, 2012 1873 Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/ The view by Jan De Maeseneer and colleagues that the priority in relation to non-communicable diseases (NCDs) is a health-service response is deeply fl awed. Non-governmental organisations have been struggling, in the current debate stimulated by the UN High-Level Meeting on NCDs, to shift the focus to environmental change to reduce exposure to the drivers of risk behaviours that contribute so strongly to NCDs. Do we really want to continue to live in a world where the oversupply and marketing of tobacco, alcohol, unhealthy processed foods, and soft drinks is tolerated simply to allow continuing profi ts for the shareholders of the transnational corporations producing and distributing them, while the taxpayer funds the health services and pharmaceutical response to the ensuing disease and injury?

Tackling NCDs: a different approach is needed

www.thelancet.com Vol 374 August 8, 2009 433 misinterpretation during MRI. Radiologists with a background in fetal MRI or antenatal ultrasound might be the best placed to develop post-mortem MRI in the fetus, or a perinatal pathologist with a detailed understanding of development and pathological changes. A new specialty in radiology seems to be emerging. In the future, specialists might work in a multidisciplinary team with pathologists to undertake the complete minimally invasive autopsy. Although a multidisciplinary team is expensive, it is probably necessary to reduce error and maintain skills in both specialties. Whatever our personal thoughts are, minimally invasive autopsy is here to stay. The public have been made aware of the procedure through the media and television dramas, and therefore a relative requesting an MRI as an alternative is not unusual, especially when there are religious reasons for objection to an autopsy. Indeed, if the Coroners and Justice Bill completes its parliamentary passage, alternative options to the autopsy should be made available throughout the UK. Crucial to the future of the minimally invasive autopsy is the progress of the techniques and the development of specialist centres, allowing trained personnel to correctly use post-mortem imaging to ensure that the full diagnostic information is obtained. The specialist centres will involve bereavement counsellors, coroners, and forensic medicine experts working alongside radiologists and pathologists. Until we have established how to select cases in which imaging can be part of a minimally invasive autopsy, the traditional autopsy with imaging as an adjunct should be encouraged.