Are childhood hearing impairment and healthcare priorities being overlooked?

The number of children with hearing difficulties is increasing throughout the world. Children who are born deaf can suffer permanent disadvantage in speech, language and educational development. What are the opportunities for promoting early detection and management of deafness in babies born in developing countries?

The importance of early detectionof deafness in babies and children was recognised in a resolution of the WorldHealth Assembly (WHA) in 1995. Screening of newborn children for hearingdifficulties has become standard in developed countries. But this is not thecase in developing nations. In this paper the author examines current criteriaused to determine global health care financing priorities, and theopportunities for promoting interventions for early hearing detection servicesin developing countries.

Spending on health care indeveloping countries comes from a mix of public, private, and external donorfinance. Hearing impairment screening for newborns does not figure among thepriorities of the major global health actors such as the World Bank (WB) andUNICEF. Despite the relatively modest size of their contributions to totalhealth spending, these multilateral donors have a strong influence ongovernments’ health financing priorities. However, high levels of out-of-pocketspending on health services indicate that individual preferences must be takeninto account.

• In2002, out-of-pocket spending made up 66 percent of total health care spendingin low-income countries and 50 percent in lower middle-income countries. Thecorresponding figures for external donor finance were 8 percent and 0.9 percentrespectively.
• Governmentcriteria for expenditure include economic efficiency, and ethical and politicalconsiderations. Decisions to embark on screening services may rest on theability to recover costs through health insurance or user fees.
• TheWB and World Health Organisation set priorities using measures of the diseaseburden, including mortality rates, disability adjusted life years (DALYs), and cost-effectiveness analyses of existinginterventions.
• Thereis no data on DALYs associated with childhood-onsethearing impairment. Without this, it is impossible to evaluate thecost-effectiveness of interventions for comparison with other diseases.
• Wherehearing screening of newborns is offered for a fee via the private sector, theevidence indicates that the value people attach to services is higher than thatsuggested by the amount of public funding available for them.
• Evidencefrom pilot programmes demonstrates effective models for service deliverythrough public-private partnerships.

The lack of vital data requiredby current approaches to global health priority-setting means that the prospectfor action in the short term is uncertain. The WHA resolution on detection andtreatment of hearing difficulties in babies and young children has not yet beenincorporated into global health priorities for developing countries. The authorasserts the following. 

• Governmentshave a moral obligation to inform parents about the possibilities for earlydetection and intervention, regardless of their ability to pay, or thegovernment’s ability to provide such services.
• Itis unethical to withhold screening where follow-up services are poor, and toprovide screening services without efforts to improve relevant interventionservices.
• Actionis needed to stimulate public-private partnerships that will provide effectiveinterventions in the first year of life for those who wish to take advantage ofthem.