>The economic crisis means that rather than ask for more money for health, we are going to have to be more careful how we spend it, says — **Andrew Jack** [[When the government, incl. G20 calls for another money to pledge, we must remember that during economic crisis, government and philanthropic spending alike are under pressure]] ## Variable effects [[Safety net]] During crisis, people in developed world with public provision, patients are relatively shielded in the short term while in developing world where largely public healthcare provision is weak and out of pocket spending often dominates, the danger in the short term is much greater. [[social determinants of health]] As Marmot and Bell point out, the crisis has highlighted that while the sums sought in the Commission on the Social Determinants of Health report seemed unattainable a few months ago,[6](#ref-6) far larger amounts of money have since been made available for the bailout of the financial sector, as well as car manufacturers and others struggling industries. The good news is that in recent weeks, many western leaders have indeed shown determination to boost spending in order to limit the fall-out of the crisis. In the US, Barack Obama’s proposals even include large sums to extend healthcare coverage and stimulate a more efficient and effective healthcare system. ## More efficient spending But a more fundamental overhaul of the current global system to reduce the inequalities that Marmot and Bell highlight seems unlikely. [[Health will have to compete for funds against other pressing international priorities including education and climate change]]. It may reopen the debate over how far improved [[health is]] best seen as the driver and point of intervention, rather than the consequence of broader ways to improve human development. Just as important, the crisis will—and should—spark renewed discussion over **how money is best allocated within health**. The UK’s National Health Service may claim achievements in recent years, such as the work of the National Institute for Health and Clinical Excellence; **more open to question is the large proportion of government funding that ended up in higher staff salaries and less than robust performance incentives.** In global health, **there is need for a fresh debate over vertical disease programmes that have diverted resources and medical staff and weakened primary healthcare systems**; the domination of the “big three” infectious diseases of AIDS, tuberculosis, and malaria at the expense of the neglected but still debilitating ones like schistosomiasis, let alone chronic disease early treatment and prevention programmes. There will be painful trade-offs ahead, such as the pressure to continue increasing access to antiretroviral therapy (which once started is morally difficult to stop) at the expense of strengthening HIV prevention programmes to prevent new infections. One glimmer of hope for health in the developing world comes from continued discussions around [[innovative financing]] mechanisms. The Global Fund’s Red and other initiatives have attempted to tap public interest in health, triggering payments directly by consumers. The Global Alliance on Vaccines and Immunisation, for instance, is moving ahead with fundraising through the International Finance Facility on Immunisation (IFFIm). Championed by [[Gordon Brown]], **it “front loads” aid donations by raising money in the capital markets for vaccination now, backed by governments’ promises to pay back from development assistance in future years.**