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 boats—they 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.

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!