Global Healthcare Cost Effectiveness Through Research
Healthcare Bang For Buck
Last week on a lunch break, I was nerd-ing out as I am wont to do. It just so happened that this time, my forays into the depths of the interweb (browsing the internet) and, against all odds, found something of worth. I found “Evaluation of current strategies and future priorities for improving health in developing countries”!!! What’s wrong? You don’t look very excited. Perhaps it’s because academic journals mandate that the titles of their articles be as lifeless as the content they head. Not really, but it seems like they do. But in this lifeless shell of a title lives information which could save many lives.
The article is a summary of many years of research and modeling about Cost Effectiveness Analysis (CEA). CEA is a developing field which tries to answer the bargain question: where do I get the most bang for my buck? Some products have a big bang, but also cost a lotta bucks. Some are really cheap in both senses, and what you don’t want to buy is the expensive crappy thing. If it exists, you want the cheap thing that’s high quality. You want the used Toyota Camry, relatively cheap but very high quality despite the low price tag. But what if you didn’t know that Toyota’s were the best cars ever? You would buy the Consumer Report on cars. It’d tell you which cars were a good deal and which weren’t. CEA is like Consumer Report for health.
In some ways, it’s simpler. Instead of there being many aspects of a good car (acceleration, handling, luxury), in healthcare we are concerned only with one: years of quality life. You’re supposed to live 82 years, and when you die before that, you lose years to whatever killed you. If you die at 2 of diarrhea, we count 80 years lost to diarrhea. If you die at 72 of a heart attack, we count 10 years lost to heart disease. Though there is some debate over how to define ‘quality,’ the consensus is that disabled life isn’t as good as normal life and so a year of life without legs is discounted (so it is numerically not as good a year with your legs).
We, in healthcare, are trying to save as many years of life as we can. And we have only so much money to do it with (this is particularly true of Nuru). Using fancy experiments (Randomized Control Trials, or RCTs for short), we can calculate how many years of life an intervention can save, say using bed nets to prevent Malaria. Then we divide the bang (years of life saved) by the buck (dollars spent on the intervention) to get a Cost Effectiveness Ratio measured in dollars per disability adjusted life years (DALYs). Then we can compare apples to apples. If we had $10,000, should we buy bed nets, or should be spray for mosquitoes? Bed nets cost $56 per life year saved ($56/DALY) and spraying costs $118 per life year saved ($118/DALY). Roughly speaking, with our $10,000, we could save 178 years of life (about 2 or 3 kids) with the nets or 85 years (about 1) with the spraying. CEA lets us know that spraying is the Ford Focus of Global Health: looks decent, but certainly not worth the money when there are Camrys available.
Now I’m going to surprise you. You know all the stuff you hear about on the Global Health news? HIV drugs and salts for diarrhea treatment and even bed nets? None of them are on the top 10 list. Here are the 5 most cost-effective treatments in global health: 1. Community treatment of baby pneumonia (did you even know that that was a problem?) $1/DALY; 2. Mass media campaign for safe sex $3/DALY 3. STD treatment and peer counseling of sex workers (prostitutes) $4/DALY 4. Basic TB treatment $6/DALY 5. Newborn package (breastfeeding promotion, support for underweight babies) $8/DALY.
Like any science, this says nothing of the ethics or practicality of any of this. CEA can only tell you about efficiency, not about strategy. Nuru, only in several villages, has no ability to run a national mass media campaign. The other big open question is on ethics; CEA can’t say a thing about right and wrong or moral priority. Is a prostitute’s life as worthy of saving as a baby’s, even if it is cheaper? Is it as strategically important for development? Would a public intervention with prostitutes affect our image and possible impact? Is it ethical to promote condom use? These questions raise extremely strong opinions, some so strong that they are angry with me for even conceding that these are questions. But they are. And we, as development workers, must answer them and hopefully answer them right.
This research is a shock to me. It informs me that my guessing machine is wrong; that some of the stuff I wanted to do isn’t high on the list, and some of the stuff I didn’t know about is. I now have new ideas for programs that I had not considered. The top of the list, treatment of baby pneumonia, is something we are very close to being able to do with our health workers and, thanks to this research, will now be a very high priority for our program. Nuru is using the best of the best for the poorest of the poor. In this case, it is research; we’re building upon the work of others. We are not just doing what feels good or what is fashionable, but to the best of our ability, we are doing what is right.