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Tuesday, November 30, 2010

The Way of the Future for Social Services

The purpose of this post is simple. I want to point out the ridiculousness in that we have embraced high quality, low-cost production for things like shoes and cat food, but not for important products in our lives like healthcare and education. Let's think about what industrialization has done to footwear. Three hundred years ago, you probably had to go to your local shoemaker. This shoemaker had to be trained as an apprentice by another expert shoemaker. The only people that made shoes were shoe experts, and because expertise was needed, shoemaking was in their hands. This expertise was rare and hard to come by, so not everyone had access to a shoemaker or one capable of making quality shoes. This shoemaker practiced shoemaking off on his own, requiring him to own all of the tools of the trade, and these capital costs were passed on to the consumer. But eventually shoemakers realized they could make shoes cheaper, and therefore could reach more people and sell to them. They did this with industrialization. They standardized the processes, shifted tasks to non-experts, and increased volume. This lowered costs, standardized quality, and changed our footwear possibilities forever. 

We went from this...

... to this

We now have thousands of footwear choices, at different prices, for different situations. Standardization at first meant less complexity, but by building these systems we now have more footwear options than an individual shoemaker would ever be able to provide. Important to note is that in addition to footwear production being industrialized, so is the sales relationship. Foot Locker doesn't produce sneakers, but they have non-experts that can size your foot, etc. And so industrialization has gone from footwear to finance to food. With industrialization, experts build the systems and the standardized processes to make things happen at scale. But this hasn't happened in medicine and education (and development broadly). These sectors have remained cottage industries. Because of government or non-profit provision, the economic incentive to move to these delivery models hasn't occurred. Because of various professional trade groups, these shifts have been resisted. And the effects are embarrassing. We practice medicine with practically the same delivery model that we had 50 years ago. We practice education with the same delivery model as a 100 years ago.

Yet over the last few decades and centuries, other industries have embraced these shifts. Take for instance the information systems of McDonald's vs. a hospital vs. a classroom. The McDonald's has computer-based ordering which has a workflow that guides low-expertise, task-shifted employees to run a restaurant. With this system, McDonald's can operate thousands of restaurants. The hospital likely has paper records that require experts to write notes readable to other experts. If they happen to be using an electronic system, the workflow still doesn't enable lesser trained non-experts to manage diabetes or follow vaccine schedules or prescribe antibiotics - the system is simply an electronic version of the same medical notes taken by paper records. And similarly in schools, how much has technology been used to enable teachers to manage self- and peer-based learning that is far more effective? Unfortunately, not so much. But these barriers to change don't mean that if industrialized versions are built that they won't be wildly successful.

I am happy to report that this is already where we are going. Many patient safety advocates in the US like Peter Pronovost and Atul Gawande (The Checklist) have similarly been pushing for standardization, although less so for the cost benefits and more so for the quality improvement benefits. Business strategy guru Michael Porter has built an entire literature on the healthcare delivery value chain, and he makes use of these successful examples in his case studies. In India, the Aravind Eye Hospital has built a system of eyecare services that serves a population the size of the United Kingdom, with the same quality outcomes and with over an order of magnitude less cost. And so it should go for social services. Experts make a service standardized.

Standardized means task shifting. Task shifting means scale. Scale means high volume. High volume allows unit costs to be lowered. High volume, standardized, low cost. Those concerned with social services having high quality, low cost, and equitable access should embrace these trends toward industrializing social services. Yes, there will be those that will resist these changes. Some will have reasonable complaints that industrialized services will have to deal with seriously. Many people that resist will simply have vested economic interests or old-fashioned beliefs about how medicine and education should be done. But ultimately, anyone, especially those working in developing countries, who is concerned with equity, social impact, and national financial security will be forced by these successful low-cost examples to see the way of the future.

Monday, November 29, 2010

Is HIV Testing a Waste of Time?

One of the pillars of almost all HIV prevention and reduction strategies is that we should test people for HIV – as many as possible. The CDC has set a goal of universal HIV testing for Americans in the “sexually active” age range of 13 to 65, and stressed that the same should apply worldwide. That article argues that universal testing will assist with surveillance – monitoring the spread of the disease – but given the time it takes to test people a random, representative sample would be much more effective for timely surveillance. If not to track the epidemic, then why test everyone? To help the infected, and encourage behavior change. When I volunteered for HIV-prevention NGO Students for International Change (now Support for International Change) back in 2004, the argument was that if you don’t know your status you can’t protect yourself or your partner.

The unquestioned assumption here is that test results will change people’s behavior (And I mean that in a personal sense – I never bothered to question it). In an article published in the American Economic Review, Rebecca Thornton* asked exactly that question, using condom purchases as her measure of risk-reduction. She ran a field experiment in which she randomly offered people in Malawi a monetary incentive to go to a makeshift “results center” clinic to learn their test results. By randomizing the incentive and varying the distance to the results centers, she is able to correct for potential selection biases in her results. In an observational study, it’s possible that only people who already know whether they have HIV are willing to get tested, in which case you’d see no change in behavior. After correcting for this problem, she does find a behavior change, but it’s not very promising: only HIV+ participants significantly increased their purchases of condoms, and by less than two on average. This isn’t very much: a cost-effectiveness analysis shows that any number of other strategies, such as treating comorbid STIs, would prevent more infections per dollar.

It’s certainly possible to raise issues with that study. First, maybe the results apply only to Malawi, or to the area where the experiment took place. Second, maybe we’re not accurately capturing all the potential risk reductions that people are engaging in. But testing as a way to change behavior faces an even more severe problem. As I noted in a previous post, the risk of HIV transmission peaks during the first 4-8 weeks of infection. The most common HIV tests look for the antibodies the immune system makes to kill off the virus; it’s no coincidence that these antibody tests won’t give a positive result for about 30 days – the “window period”. In the regions of Southern Africa where HIV is most prevalent, the pandemic is driven in large part by sexual encounters during that window period. That means that even if testing does change behavior, it won’t do much to stop new infections.

The HIV "Natural History" Diagram, showing viral load in red.
Note the discontinuity/break in the graph.
So what should we do instead? One solution, proposed by Granich et al. in The Lancet, is to stop trying to induce behavior change at all. Instead, they propose testing everyone and providing ARV treatment for everyone who tests positive, and their simulations project that that could end the pandemic in cost-effective fashion within forty years. If we want to focus on behavior change, the lesson is that we need to target the seronegative – those that either don’t have HIV yet or won’t yet test positive. The current strategy of widespread HIV testing in order to change behavior isn’t a complete waste of time – but it’s not nearly as effective as I used to think.

*Full disclosure: Rebecca is my (unofficial) advisor here at Michigan.

Wednesday, November 24, 2010

Making Culture a Part of Development and Social Justice

So far we’ve had some wonderful articles on specific development or health problems. I would, at the risk of seeming too hand wavy, like to discuss social justice, development, and culture. In particular, what do we mean by social justice? Is the “just society” a plural or singular concept? And what should we make of cultural difference when considering the ends of development?

One answer is to treat culture instrumentally. Under such a perspective culture is treated almost like any other input for development. Like land, labor, capital or forms of human capital, culture needs to be manipulated strategically to produce a desired outcome. Culture may take the form of a type of human capital, or knowledge that can be used for certain developmental ends; for example, local agricultural knowledge about a staple crop. NGOs and development organizations have also found such a perspective useful. Or, culture may be seen as a set of attitudes that hinders or helps a society develop. A fair amount of literature on development uses this perspective—most famously the school of thought known as modernization theory.

Indeed, viewing culture instrumentally allows us to ask and answer very practical questions. What sorts of cultural attitudes promote or hinder development? How might we adjust attitudes or incentivize behavior to achieve these goals? The instrumental perspective takes ideas seriously as motivators of human action. Likewise a strategic approach to culture views culture as something malleable rather than fixed. We can change it. Programs like gender mainstreaming, for example, would not be possible if we viewed culture as relatively fixed or from such a radically relativist perspective that we saw all gender practices as essentially equal or incommensurable.

However, many anthropologists chafe at such a perspective. It reduces culture to a mere variable, and can sometimes assume an undue superiority or objectivity in our own ways of knowing. In effect, it precludes any substantial discussion about what the ends of development should be. It shifts social justice and development from a topic of discussion, a political process, to a technical problem. My argument is that social justice should be both.

One of the primary insights of 20th century anthropological work on development is that it is a profoundly political process. Developmentand the knowledge that drives itinvolves choosing alternatives, a process that is always on some level non-rational, or cultural. This was Foucault’s point—knowledge and power are linked. How and what we quantify, what we consider and do not consider in things like cost-benefit analysis, forms and degree of distribution, how much inequality we as a society are willing to sacrifice for economic growth, all of these are political questions. Development may seem like a technical problem at times, but it is laden with difficult ethical questions and our answers to them are shaped by our particular ideological perspectives.

The other asset anthropologists bring to the table is a humility that comes from taking other ways of life seriously and seeing our own way of life as not necessary but historically and culturally contingent. To put it more bluntly, anthropologists firmly believe and try to show through their work that other people know things and that the fact that other people could conceive of and live so differently from us shows that our own way of living is far from the natural or only way. Anthropology would have us try to understand other people in their own terms and to take them as serious alternatives to our own way of living.
Is this progress? Are there problems with how we
think about development?

At its worst, such a perspective becomes a debilitating form of relativism or na├»ve romanticism of what pre-industrial life was like. But at its best and most convincing it’s a request to pause and step back and to give serious consideration to what other people think and where our own thinking may be limited. In more conventional terms, it’s an attempt to democratize development. Here I mean not democracy as a system of voting where majority rules, but in the sense of equality and a process involving the demos or people—a focus on providing a more equal space for alternative voices to be heard.

Or are anthropologists just romanticizing
pre-industrial life?

In fact, just such a belief is what got me interested in anthropology as an approach to development and in Bhutan, where I study. In my next post I will talk about the issue of “Gross national Happiness” that seems to have become a fad around the world and gained much of its notoriety from Bhutan. Why has “happiness” caught on globally as an economic measurement? What implications, if any, does it have for how we think about development? Is it an example of indigenous culture speaking back to orthodox development?

Monday, November 22, 2010

Endorsed by the Dermatological Society of Nepal

I recently wrapped up a two week vacation with a college buddy of mine in East Africa. For work, I get to travel to Kenya pretty often (we have an office in Nairobi) but had never been to the Maasai Mara, Lamu, or Naivasha. Jaunts to those places as well as a brief detour to the gorillas in Rwanda were amazing, a break much needed.

In any case, at the beginning of the trip I stopped with my buddy at Nakumatt (Kenya's biggest supermarket) to pick up a container of sunscreen for the sunnier places we'd be traveling. We found a Johnson and Johnson's bottle of SPF30 amidst a pretty weak selection though it had captions in Russian and a weird orange sticker that said "Endorsed by the Dermatological Society of Nepal". We wore the sunscreen on hikes in Naivasha and got burned to a crisp. Whatever was in the bottle wasn't sunscreen and we later bought an SPF70 version from a reputable pharmacy that worked like a charm. Of note: a Google search suggests the Dermatological Society of Nepal doesn't exist.

Along the way to Naivasha, my friend pointed out how strange it was to see the stores in most of the towns we passed painted with Safaricom, Zain, or Tusker colors and logos. Lots of stores let these companies paint their stores for free to give them some color and they get a free painted sign for their own business as part of the paint job. Ask Kenyans what their thoughts are on Safaricom, Zain, or Tusker and they will have an opinion; the brands are incredibly well publicized and known and most people hold them in pretty high regard. A microfinance institution, Faulu, seems to have begun to take to this method in Kenya and had a few stores painted out on the road from Mombasa to Nairobi.

Why relay these stories? The poor, in most developing countries, have a ton of information thrown at them and products available on the market that are not checked by regulators. In the context of this, and limited time and money to explore all alternatives, there is a mass default to branded options. A smart Kenyan wouldn't have been suckered on the J&J sunscreen with the weird bottle, they would have known what brands and bottles to look for. But where strong brands don't exist, the cheapest option wins; see counterfeit antimalarial pills sales in most "pharmacies" in Kenya.

Regrettably, no one paid us to post this picture.

Branding is also important because it builds a trust relationship between the consumer and the provider. When Safaricom, Kenya's biggest mobile telecom agency, introduced mobile money there was incredible uptake. Interestingly, and with full knowledge that the Government of Kenya wasn't regulating mobile money or guaranteeing deposits via it, people placed large amounts of their savings with a company they only knew through experience using their mobile phone service service (reliable mobile coverage, prepaid phone balances that had integrity and could be checked instantly, etc.).

But, in global health marketing, there are huge billboards for public health products or messages that have 20+ logos for donor agencies at the bottom (all changing from billboard to billboard). Who of these 20 organizations do I trust? Why should I listen to the Swedish Aid Agency?

Worse, the ads frequently tell people to buy "a malaria net" as opposed to X branded malaria net. Marketing a specific, branded product is important as it allows people to form an opinion on the brand, and its associated company, over time based on their experience. Does the product work? Did it achieve the aim over time? Do my friends use it too? Can I trust purchases and messages from this company in the future?

In public health, it seems we're failing with marketing on two accounts:
- No one organization/coalition is really responsible for coordinating and publishing ads for health campaigns. We can start by getting donors to stop requiring their logos on everything they fund. Let's call this campaign the "Stop Donor-Related Territorial Pissing Urge"
- We're marketing the abstract and failing to build a brand that people trust and emotionally connect with over time. A solution starts with vouching for products that work and that people experience work over time. While perhaps a bit extreme, what about giving marketing money away to companies that make good public health products with some rules on things they need to include in messaging ("buy X malaria net for all of your children under 5", "buy Y condom and stay faithful to the one you love")?

Of course, there are those doing this right like the Healthstore Foundation/CFW Shops and Marie Stopes International. Where are the rest?

Friday, November 19, 2010

Accountability Starts Here

I’ve realized along with Adam that I need to provide some background before going on to more specific issues. Recently I’ve developed a focus on neonatal health, which—as someone most interested in macroscopic, interdisciplinary, systems-level approaches—has been a bit of a departure from my modus operandi. And, in line with the need to take a more nuanced perspective—as Ben alluded to with his own evolving conception of microfinance—I want to use this opportunity to critically assess and justify my focus on neonatal health. I think this can be a useful exercise for all of us (e.g. to ensure we don’t fall into the “sexy disease” trap). Furthermore, I think it can have the most utility when routinized as an ongoing process, with a community of peers to keep us accountable (Richard Levins’ take on how we navigate the often contradictory implications of our triple identities as workers, activists and intellectuals is particularly interesting with regards to this). And, needless to say, it’s also one of the functions I envisioned for this blog.

And so without further ado, why I’ve become interested in neonatal health:

1. Key neglected cause of mortality: Worldwide, 4 million newborn deaths (deaths within the first 28 days of life) occur every year. These deaths have been largely neglected by programs and policymakers until the last decade. The inadequacy of past child survival interventions in reducing the global neonatal mortality rate (NMR) is evident in comparison with the gains made for postneonatal, under-five mortality, which fell by 45% from 1983-1999, whereas global NMR declined by only 11%. Addressing neonatal deaths is now essential to achieving Milenium Development Goal (MDG) 4 on child survival as they constitute nearly 40% of all under-5 child mortality.

2. Equity: Low- and middle-income countries are grossly overrepresented in the burden of neonatal mortality; contributing 99% of total deaths. Disparities exist within these countries as well, as the NMR among the poorest families is 19-44% higher than among the richest.

3. Something can be done! The vast majority of neonatal deaths are preventable, particularly if early detection and proper treatment are administered by caregivers and first-line health workers (1,2,3,4,5,6!).

4. Integration: Neonatal health serves as a natural window into reducing maternal mortality (MDG 5; an important contributor to global deaths, and reflective of greater women’s empowerment and equity issues), as pregnancy-related care serves as many women’s first introduction to the health system. And, this window can be extended for ongoing child health interventions.

5. DALYs + Cost effectiveness: Interventions for the continuum of care between maternal, neonatal and child health are especially pertinent when assessing the 10 leading risk factor causes of DALYs for low-income countries (Table 1). Particularly, interventions for childhood malnutrition, safe water/sanitation/hygiene, safe sex (family planning, condom promotion, etc.), breastfeeding and indoor air pollution from solid fuels are correlated with nearly 35% of total DALYs. These risk factors galvanize low-cost, technologically simple health education and behavior change interventions—which provide some the best cost effectiveness ratios ($ per DALY averted) of any in our arsenal (Table 2).

6. Finally, it helps me wrap my head around the ever-complex and often nebulous issues of health systems strengthening, delivery and scale-up. For example, we cannot reduce NMR or maternal mortality without addressing health workforce issues for skilled attendance at delivery or functional referral systems for emergency obstetric care.

Most critically, all the above reasons support my conviction in the principles of community-based primary health care (CBPHC). The principles of CBPHC also provide an incredibly useful guiding framework for the items in #6.In addition to employing a rights-based and equity-orientation to health, they also warn against reductionistic applications of DALYs and cost-effectiveness (see: dangers of Selective Primary Health Care).

The Declaration of Alma Ata affirmed the international community's commitment to primary care, however, follow-through has been lacking.

Instructive operational aims of CBPHC include: 

1.     Integrating ‘preventive, curative and promotive services’ via ‘functional and mutually supportive referral systems’ and multi-cadre ‘health teams’

2.     Targeting all interventions ‘at the most peripheral practicable level of the health services by the worker most simply trained for this activity'; i.e. reach people ‘where they are’ and use community-level health workers

3.     Maximizing acceptability, appropriateness and sustainability of interventions via ‘maximum reliance on the available community resources'

4.     Employing comprehensive approaches which are ‘fully integrated with the services of the other sectors involved in community development'

5.     Empowering via community participation in ‘the planning and implementation of their healthcare'

6.     Embedding feedback loops for improvement and accountability; PHC is the ‘first step in the continuing health care process'
It seems I’ve come full circle on the accountability theme; an unintentional feedback loop! And, as always, I’m excited to be engaged in the process of developing our own community as well.

Thursday, November 18, 2010

Health --> Life Expectancy --> Education?

Last week, Methodlogical contributor Ben Elberger published a fascinating analysis of why we see lower than expected take-up rates of microinsurance in Africa. Microinsurance seems to be a concept that makes so much sense in paper, yet as Ben shows us through his savings and credit cooperative (SACCO) example, doesn’t always transpose into reality:

The story often goes that a charismatic individual starts up a SACCO offering loans at great rates if you save X% upfront. You save over a number of weeks as it's difficult to plunk down all of the money in one go. Some people don't even want loans, they just save with the SACCO because the interest rate offered on savings is also good. The SACCO continues to grow rapidly and then the General Manager takes the savings and runs away. It's a ponzi scheme and the recoverability of savings is next to nil. Those with loans outstanding greater than their upfront savings win but the broad majority have net savings with the SACCO and lose it all.”

The lack of certainty that your microinsurance provider will actually still exist in three months is a powerful worry that underscores the reality of what Kenyans and Ugandans have witnessed over and over again. Similarly, selling someone on any product that has a time horizon of years is difficult when your potential customers are living day-to-day. Uncertainly plagues long-term investment decisions.

But we haven’t yet discussed perhaps the most crucial long-term investment and longest time-horizon investment of all: education. Education involves a huge up-front investment of years of life that could otherwise be devoted to earning income or other productive uses. Furthermore, with such large societal returns to education, especially for primary education, encouraging greater investment in education should be in the best interest of the individual, the community, and society as a whole. But still, uncertainty plagues education investment decisions, as well. A longer time horizon increases the value of investments that pay out over time – so the uncertainty of how long one’s time horizon will be (life expectancy) could play a crucial role in determining how much of an investment in education one chooses to make.

What sort of evidence is out there to show that maybe there does exist a causal chain of health -> life expectancy -> education? In Lorentzen et al’s “Death and Development,” the authors find that a one standard deviation increase in adult mortality is associated with a 9% decrease in educational enrollment rates in Africa, which is about 1/3 of the average enrollment rate. Furthermore, higher adult mortality is associated with increased levels of risky behavior, higher fertility, and lower investment in other dimensions of physical and human capital.

There has also been compelling evidence found in Sri Lanka, as well. Jayachandran & Lleras-Muney examined a sudden drop in mortality risk in Sri Lanka between 1946 and 1953. During those years, Sri Lanka experienced a 70% reduction in the maternal mortality risk and an increased female life expectancy at age 15 by 1.5 years (4.1%). This data is particularly compelling because maternal mortality rates (MMRs) could realistically affect education investment decisions, unlike infant mortality risk, which is realized before educational decisions are made. The authors found that female children in Sri Lanka received on average 0.11 extra years of education per year of life expectancy increase.

The policy implications of these findings are compelling: not only do we see quantifiable and large increases in educational investment decisions as life expectancy increases, but this also implies that the benefits of health interventions that improve life expectancy may be larger than we think. The spillover benefits of life expectancy-improving health interventions need to be fully factored into the cost-benefit analysis of investing in health programs, because in terms of educational investments, evidence shows us that the benefits may be substantial.

Especially in costly treatments, such as ARVs, that can substantially increase the life expectancy of HIV/AIDS-infected individuals, the spillover benefits on educational attainment can be substantial. In Africa, 40% of deaths ages 15-49 are AIDS-related. We know that increased life expectancy would lead to higher educational investments – but what we still need to figure out is how to fully account for and quantify the benefits of this higher educational attainment into our ARV investment decisions.

Wednesday, November 17, 2010

The Case for Cost-Effectiveness

It appears I’ve engaged in a bit of a bait and switch.  At the end of my last post I promised to address the issue of HIV-related health expenditures dominating global health budgets and the adverse effects of such overfunding.  And that was my intention.  However, as I sat down to write this post, I realized that, in order to make my argument, I had to establish the importance of cost-effectiveness in global health decision-making.  And so, while my next post will tackle the issue of HIV overspending, today I make the case for cost-effectiveness.

Say you’re on a sinking ship.  There are 1,000 passengers and only spots for 500 people on the lifeboats.  You would, of course, be justified in your outrage regarding the lack of safety precautions.  In general, the ratio of passengers to lifeboat spots should be pretty damn close to 1.  However, as HMS Pangea takes on water, you might be better served to determine who should get those spots on the lifeboats.

There are an infinite number of arguments that can be made for who should be put on those lifeboats. We could identify the healthiest people with the longest life expectancy.  Maybe we should save them so our survivors live for the most years.  Maybe we should we put all the kids on first, after all, children are among those least able to care for themselves and deserve succor first.  Maybe we should throw in a few burly men and women to help guide these individuals and ensure that those in the lifeboats make it safely to land.  Maybe the best swimmers should be left out of the boatsthey have the best chance of making it to land on their own.

The arguments go on and on.  Our task today is not to determine who gets on those lifeboats, but to agree that somehow we need to make sure all 500 spots on those boats are filled in a manner that is both fair and rational.

This kid knows a thing or two about cost-effectiveness.
Erroneus! you say.  The urgency of a sinking ship is not comparable to the inexorable fight against poverty and disease.  But much like a sinking ship, health care and health tragedies change lives in a matter of minutes and hours, not months and years.  Waiting for a dose of life-saving antibiotics may be a race against the clock.  The same holds true for those desperately awaiting the next calorie or the man who needs emergent dialysis because his kidneys quit working weeks ago.  And it holds for the laboring pregnant woman with AIDS who needs antiretrovirals to prevent her child from acquiring HIV.  That these tragedies take place far away does not make them any less urgent.

Fine, you say, there is urgency.  But where is the scarcity?  Is it fair to compare efforts to aid the world’s sick to a sinking ship where only half of the passengers can be saved?  No.  It is an unfair comparison.  More than half of the world’s sick will fail to be rescued.

Resources for global health and development don’t have to be limited.  For about the cost of the Iraq War we could halve the global incidence of HIV in under 25 years.  Or perhaps less fashionably (but more cost-effectively), build a network of clinics throughout Africa, roads to connect them to towns and villages, and train doctors and nurses to staff them.

However, the fact of the matter is, there is a limited pool of money in the world and we all make choices about how it should be spent.  If our private boats were sailing near the aforementioned sinking ship, we would surely offer up some space for the stranded passengers.  But would we have donated to a fund to equip the ship with extra lifeboats to begin with?  Would we have elected to pay higher taxes to support the World Health Organization or USAID?  Let’s put it this way, the last time a major presidential candidate ran on a platform promising to raise taxes, he lost 49 of 50 states.

We all want to help, but there are other things we want as well.  Over the next two decades, Americans will spend more than the sum required to halve the HIV incidence on their pets.  The cost of an average wedding in America is more than the median income in dozens of countries.  I'm writing this on a pretty spiffy MacBook.  Resources for global health and development don't have to be limited.  But they are.  And so, the task falls to us to figure out how best to spend that money.

Cost-effectiveness makes us uncomfortable.  It sounds an awful lot like rationing or like valuing lives against each other.  Yet in medicine, we accept this all the time, even if we don't realize that we're doing it.  In transplant medicine—with fewer organs than patients in need—we are willing to offer the transplant to the person less likely to abuse alcohol or die of something else in the immediate future.  On the battlefields of World War I, the French came up with the notion of triage (from the French word for to separate).  In the chaos of war, army medics could not attend to all the injured soldiers so they made three categories: those likely to die regardless of intervention, those likely to survive regardless of intervention, and those that could survive but only with medical care.  It was the last group that got attention first because, with time at a premium, the medics wanted the biggest bang for their buck.  This system is still used in emergency departments throughout the world. 

In the U.S. medical system, where cost-effectiveness is explicitly not used, overuse of technology and resources is rife.  As such, every unnecessary test and procedure increases costs for insurance companies.  To recoup this loss, insurance companies raise premiums.  As premiums rise, families decide they can no longer afford health insurance and the ranks of the uninsured grow.  The cause and effect may be separated by months and miles, but the connection is very real.

Remind you of your local emergency room?

In determining cost-effectiveness, we usually look at an outcome related to years lived.  It is fair to question this outcome, as people's contributions to the world are not necessarily tied to their longevity.  However, we would not necessarily agree to base access to care on one's contributions to society in the first place (or even how to measure those contributions).  Longevity is also a problematic measure as people in some parts of the world have much shorter life expectancies than those in other parts.  Is it less cost-effective to help someone in Somalia rather than in France if she will not live as long after a given intervention?  And does cost-effectiveness diminish as those who are treated and live longer require more costly care in the future?  These are important questions and not easily answered.  In global health, if the money is limited (and it always is), then we have to figure out who to give it to and cost-effectiveness offers us a method.  We may not always agree on all of the variables in the equation, but my hope is that we agree that a calculation—even an imperfect one—is necessary.

The argument for cost-effectiveness does rest on the assumption of fungibility, the property of money that it can be substituted for itself.  By way of example, my grandmother used to give her grandchildren money when she visited.  She’d always tell us to spend it on whatever we wanted, except for alcohol.  As my financier cousin explained, despite being an formidable intellectual, our grandmother didn’t really grasp fungibility.  We could use her $20 gift to pay part of our rent and then take $20 out of our rent money to spend on booze.  Problem solved.  In terms of global health spending, cost-effectiveness is only relevant if funding is fungible.  If a donor (or donor country) will only give money if it is spent on HIV interventions, then it is irrelevant if that money could be more efficiently spent on primary care.  In that case, the cost-effectiveness argument has to be made to the donor, not to the NGO that is spending the money.

While this discussion can feel awfully utilitarian at times, it’s important to remember the gravity of its implications.  Proper regard for cost-effectiveness can help more people live longer and healthier lives.  The converse of this is true, too: disregard for cost-effectiveness can lead to unnecessary death and suffering.  Bioethicist and Obama adviser Ezekiel Emanuel and his colleagues put it eloquently when they wrote, “Because resources devoted to international health aid are inherently limited, seemingly economic considerations about cost-effectiveness actually reflect fundamental ethical principles.  The more cost-effectively resources are used, the more lives can be saved.”

We shop around for the best value on cars, computers, even groceries.  For nearly everyone, money is a finite resource and it is imperative that we spend it wisely.  That this should apply to the health needs of the world’s poorest and most vulnerable is merely a logical—and ethical—extension.

Monday, November 15, 2010

Risk Externalities, Sleeping Around, and HIV

One of the basic results of normative economics is that market outcomes under competition are socially optimal – the common claim is that the free market is efficient. Calling market results “good” is certainly a value judgment, but this claim has an appealing basis in positive, scientific economics: the First Fundamental Theorem of Welfare Economics says that allocations in a competitive market are Pareto optimal, so no one can be made better off without making someone else worse off. You might not believe that Pareto optimality should be the sole criterion for judging outcomes (I certainly don’t) but it’s an excellent starting point; if there’s an opportunity to give more pie to Adam without taking any away from anybody else, we should do it.

Most markets turn out to be reasonably close to undistorted and competitive, so economists think that policymakers should keep their hands off and let the miracle of competitive efficiency occur. But there are a number of problems that arise with markets, and these turn out to be very common in healthcare. As a researcher this makes me happy: there’s often nothing too interesting to learn about a competitive market, and “do nothing” isn’t a very sexy policy recommendation. Socially, though, these imperfections are big problems.

One common such imperfection in medical care is the presence of externalities, in particular external risk benefits or costs. An externality is a cost or benefit that accrues to someone other than the decisionmaker (click here for a pretty graph and a basic overview). They’re easy to see in the case of vaccination. When you get vaccinated you protect yourself but you also protect everyone else you come into contact with; every person in your society gains a little bit of herd immunity. Since people don’t experience the full benefit of the vaccine, they’ll tend to get less of it than they should from a societal standpoint. We have a simple solution for this that could have come right out of an economics textbook – vaccines are subsidized, and in many cases mandatory.

Taking one for the team?

This is probably familiar to lots of you, but the nature of lots of preventable illnesses in poor countries is such that risk externalities can be pretty subtle and the solutions much less obvious. To take one example, consider HIV transmission and concurrency vs. serial monogamy in sexual relationships. People in Southern Africa commonly have more than one concurrent sexual partnership; in contrast, people in Asia and the West have no fewer lifetime sex partners, but tend to have only one at a time. The practice of “concurrency” in sexual pairings has been shown to substantially increase transmission rates at a societal level, because the amount of HIV in the bloodstream is highest within the first month. If you don’t have sex with another partner until after that window passes, the odds that you’ll infect them drop substantially. Now suppose we convince someone to stop having more than one sex partner at a time, and instead become serially monogamous. Doing this might convince them to be safer in other ways as well: maybe they’ll have fewer sex partners or less risky sex, both of which would directly protect them. But if all they do is re-sequence their partners to have one at a time, then they get no direct benefit from serial monogamy at all. It is their partners that are protected. The risk benefit of serial monogamy per se, rather than other behavior changes, is entirely external. Even if people understand that serial monogamy is safer, we might see fewer people doing it than we’d like, as they cynically decide to protect only themselves.

My suspicion is that there are a lot more of these sorts of risk externalities present across the field of global health. If you get enough people in an area to use bednets you'll start to cut malaria risk for everyone; male circumcision directly protects only men and not women from HIV, but a circumcised man indirectly protects all his partners. A lot of cool research projects could come out of finding them, measuring them, and figuring out how to design programs and structure incentives to deal with them. I’m still not sure what we should try to do about the concurrent sex partners issue, but the more people I can get to start thinking about this stuff, the more good ideas we're likely to see.

Friday, November 12, 2010

Root Solutions

We often talk about root causes of poverty and health issues because tackling root causes can be more economical, can result in less suffering, or both. Many (like me) are of the mindset that we must address both problems and their causes because there is a moral imperative to both prevent suffering and to help those that in the end are affected. In the health world, medicine is often criticized for not focusing enough on prevention and public health is often criticized for not valuing treatment. This dichotomy between treatment and prevention is overly simplistic - ultimately there are many steps along a pathway of risk factors and negative outcomes that can be targeted for interventions. Significant amounts of research have gone into elucidating these causal pathways of risk factors and problems, and now many problems are well-understood.

Other research has focused on interventions that specifically target various points along the causal tree of risk factors and outcomes for health and poverty issues. Here again, our research has provided us with many products and services that we now understand to be efficacious. We know that if you take an individual or a community with A, B, or C and give them X, Y, or Z, that they will be better off.

But knowing the XYZs isn’t enough. The important next step is understanding how to deliver these interventions, how to get them to the people that would benefit from them. Given that we have arsenals of health-improving and poverty-reducing interventions that are proven efficacious yet often lag in reaching or never reach the populations that would benefit most from them, many people are now talking about the so-called delivery gap. To tackle this we will need to focus on, and study, this gap in implementation much more than advocates, researchers, practitioners, policymakers, funders, and the press have in the past. These groups have often framed the discussion on problems (to show that we must act) and their direct solutions (to show that there are things we can do). But with the delivery gap in mind, in addition to focusing on the problem of, for example, malaria and the solution of bednets, we must realize that new focus is required on the systems that are successfully and unsuccessfully delivering bednets. We can’t just focus on bednets, HIV drugs, microcredit, crop-rotation, and other products and services. Knowing the solutions that work is great. But if we truly care about impact, then knowing how to get them to people that need them is required. Therefore, just as it is important to not solely focus on end-problems but also root causes, so must we not only focus on end-solutions, but also focus on their root solutions.

Most proximal to end-solutions are the platforms that offer products and services used by government and non-government service delivery organizations. These platforms consist of things we often take for granted, like hospitals, clinics, schools, and stores. There has been, and still is, often very little evidence for the efficacy of these platforms. This analysis is often difficult to do. One reason is that analysis of platforms cannot be removed from the context of the products and services that they offer nor from the context of the clients and communities to whom interventions are delivered. You can imagine a medical record system making a huge difference in health outcomes for chronic diseases that require the use of historical information, but offering much less benefit for acute emergencies. The reverse is also true - typically we take the platform for granted when analyzing the efficacy of interventions. We regularly do this by holding the platform constant between intervention and control groups. This is similarly misguided. Often an intervention, which would be effective if delivered by a frontline healthcare worker, is ineffective at the population level when delivered by a clinic. Therefore if a clinic-based platform were used for both control and intervention, a good intervention might appear worthless.

Community health workers play a major role in global health task-shifting and service delivery.

Other root solutions are more distal to service delivery organizations, but are also extremely important. These are things that enable and support service delivery organizations to do produce the most impact and might include new roles for academia in global health and development, the development of impact metrics, improving accountability mechanisms, attracting adequate levels of donor and investment capital, and many, many others.

I am certainly not the first to recognize the importance of these issues, and I am very glad to see that in the last few years many have focused on the issue of improving delivery. Some of my favorite examples: The field of social enterprise has been working on business models and impact evaluation metrics that can support these solutions. Academics and policymakers have begun to focus on the nascent field of health system strengthening. Jim Kim and Peter Pronovost have called for NIH to have not just basic science and clinical science divisions, but also one focused on delivery or implementation research. The Doris Duke Charitable Foundation has funded 4 large primary health care scale up implementation studies in Africa. The US stimulus package included funding for comparative effectiveness research. There is emphasis on task-shifting and community health workers to address human resources gaps. New funding mechanisms, like the Global Fund, with potentially better accountability mechanisms, are emerging. Advocates for neglected tropical diseases, surgical disease, and chronic diseases have replicated the model that HIV advocates used to build movements which create awareness and policy changes and ultimately yield funding for research and programming. There is heavy support for mobile technologies that are being developed and piloted to improve a variety of health and poverty initiatives. All of these efforts are part of a complex web of root solutions that will ultimately enable the successful delivery of proven interventions to the people that would most benefit from them.

These trends are very positive, but the delivery gap is immense. In my future posts I hope to provide analysis of what is being addressed and what needs to be addressed for improved global health and development delivery. With a systems view, I will not just examine delivery organizations themselves, but also the global ecology that enables or distracts delivery organizations from making an impact. I will also look to other fields and sectors for models that may be relevant to improving delivery in global health and development. These are just a few of the topics I hope to write posts (or series) about:

- Frontline health and development workers
- Academic roles in global health and development for the 21st century
- The anti-poverty value chain
- Successful models for social impact

I am really looking forward to reading everyone’s posts on this blog and any comments that people have. Please be in touch with any stories or ideas!

Monday, November 8, 2010

Health insurance as a gateway drug?

This past week, I wrapped up a trip to East Africa as part of my work with a microcredit organization. I was initially inspired to enter the microfinance field based on the "give the poor a loan, grow a business, success abounds" story. Naive? Sure. I was one of those richly educated graduates new to development with little field experience hoping to find that one thing blocking the poor from unimaginable wealth and development. Silver bullets, as Danika noted, don't exist in development.

After a few years seeing microfinance in Africa, I largely believe microcredit helps a small subsection of the poor to grow their microbusinesses into small enterprises on to medium enterprises and eventually into major employers. For the rest, loans make businesses a little bigger or provide an income smoothing device and commitment mechanism. Don't get me wrong, going from $1/day to $2/day or even allowing the $1/day to be the same each day is still valuable. In meeting borrowers around Africa, I've continued to hear that loans allow families to pay for kids' school fees (either because of additional money earned from businesses or by allowing a family to access a lumpy sum of money difficult to otherwise save to pay for a semester's fees) and the downstream benefits to these children from continuous education can be critical when human capital in a country is low. In the least developed places (e.g., South Sudan), I've learned that profits from loans can allow a family to feed all the children each day.

The real lesson of microfinance is that profiled extremely well in Portfolios of the Poor: the poor use and need a wide range of financial services. Loans are one piece, often one of the smaller pieces, of the puzzle and complement savings and insurance that are critical mechanisms to handling shocks that hit the poor daily.

However, Timothy Ogden and a range of others have pointed out a strange problem with microinsurance:
Microinsurance is one of those maddening products in development circles because it makes perfect sense (so much so that its a bit surprising it hasn’t evolved on its own) but the existing offerings haven’t had much success—take-up rates are typically very low.
If you ever travel to Kenya or Uganda, ask someone about a SACCO (savings and credit cooperative) that went bust. The story often goes that a charismatic individual starts up a SACCO offering loans at great rates if you save X% upfront. Upfront compulsory savings is typical in Africa for legitimate microfinance or even bank loans. Back to the SACCO: You save over a number of weeks as it's difficult to plunk down all of the money in one go. Some people don't even want loans, they just save with the SACCO because the interest rate offered on savings is also good. The SACCO continues to grow rapidly and then the General Manager takes the savings and runs away. It's a ponzi scheme and the recoverability of savings is next to nil. Those with loans outstanding greater than their upfront savings win but the broad majority have net savings with the SACCO and lose it all.

We take for granted that our financial institutions rarely go under and when they do our deposits are insured. In the absence of that, it's a bit more difficult to trust a financial service provider and the bias is to obtain funding from the provider (read: loans), even at higher costs, rather than save or purchase a service.

An extension of this dilemma is the lower than expected real demand for microinsurance. Insurance is predicated on paying premiums before you get paid out as a way to hedge against the potential for real negative shocks (i.e., fire, car accident, etc.). The poor, as it happens, get hit with shocks more frequently. They are also wary, though of obtaining microinsurance when they don't know the provider (especially the provider's staying power) all that well. Furthermore, it's hard to sell someone with a time horizon largely focused on this week and that agricultural insurance will make sense over the 3 year horizon.

Health insurance, in the category of insurance, is a unique offering in that it hedges against major shocks (catastrophic health events including ER visits) and pays out somewhat frequently for routine health needs (primary doctor visits and, in the case of Africa: diarrhea in children, parasites, etc.). Purchasers of the policy get a payout in the near term providing some kind of assessment of the insurer and recouping some of the premium. Anecdotally, the uptake of health insurance sold by Kenyan microfinance institutions is pretty strong and some microfinance institutions even require purchase as part of the loan as health-related shocks are a leading cause of loan default for small traders in many places.

A Rwandan man shows off his health insurance card.

From Ogden's post:
Chris Udry of Yale presented an experiment in Ghana that tackles these questions. The experiment was based on a large question: why do farmers underinvest in their farms? Is it that they lack investment capital or that they are risk averse? To take this on, the program provided some farmers with rainfall insurance, some with cash grants, some with both and of course a control group. Bucking the trend of small impacts, the study found significant impacts on farm investment: farmers in the treatment group bought more fertilizer, planted more acreage, and hired more labor. Unsurprisingly come harvest time they had higher yields and more income. They missed fewer meals and their children missed less school.
With such large and positive impacts you would expect that the farmers would be interested in buying insurance for the following year—and they were. But subsidizing a year of insurance to generate clients isn’t a great way to scale microinsurance. So Udry’s team looked at demand among friends, neighbors and acquaintances of the participants to see if word spread and generated demand beyond the original participants. They found that demand did spread along social networks with those who knew multiple participants more likely to be interested in purchasing insurance, particularly if they knew someone who had gotten an insurance payout. But the really exciting thing about Udry’s research is the significant benefits participants achieved.
For farmers, agriculture shocks are among the most pernicious. They cause farmers, ex ante, to invest in lower yielding options that are more hardy (e.g., cassava grows everywhere and under very harsh conditions) but provide less income. For those that take a bet on higher yielding crops like coffee or tea, one bad season can cause a family to go hungry and curtail key development expenses.

Why mention agriculture and health insurance together? Insurance in its purest form, paying a premium to mitigate the highly negative impacts of rare events, may be a hard sell to the poor. But health insurance may be less so because of how visceral the impacts of not being able to go to the doctor are and the more frequent payouts. If insurance companies started there, built their brand and reputation among the poor, might they be able to sell and expose the poor to the value of products like agriculture insurance?