choosing services

CHOOSING SERVICESThe case for cost-effectiveness

Toby OrdResearch Fellow, Oxford UniversityPresident, Giving What We Can

Key services• Universal coverage is defined in terms of access to key services• Countries moving towards universal coverage must therefore identify what services are key• Also need to prioritize among these key services when expanding the range of services accessible at an affordable cost

Examples• Typically targets the whole population or the part which is least likely to obtain affordable access to a comprehensive package• Package of minimum, basic, or essential services or benefits• Ghana, Nigeria, Rwanda, Vietnam, Mexico

• Typically emphasize:• Vaccination, child health, maternal care

Prioritization

Cost-effectiveness• Sounds boring, but it is the core of what health systems

are about• Effectiveness = health benefit• Cost-effectiveness = providing the most health benefit for

a given budget

• We typically measure health benefit in DALYs• A measure of the years of life saved and morbidity

prevented

Cost-effectiveness• Some interventions deliver much more health benefit for

a given budget• It is not a matter of 10% better or 50% better• but hundreds or thousands of times better

• It isn’t the only important thing, but it is the core

What does a DALY cost?

0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2DALYs / £1,000

Treatment of Kaposi’s Sarcoma

Antiretroviral therapy

£20,000 / DALY barrier

What does a DALY cost?

0 1 2 3 4 5 6 7 8 9DALYs / £1,000

Treatment of Kaposi’s Sarcoma

Antiretroviral therapy

Prevention of transmission during pregnancy

What does a DALY cost?

0 1 2 3 4 5 6 7 8 9DALYs / £1,000

Treatment of Kaposi’s Sarcoma

Antiretroviral therapy

Prevention of transmission during pregnancy

What does a DALY cost?

0 5 10 15 20 25DALYs / £1,000

Distribution of condoms

Treatment of Kaposi’s Sarcoma

Antiretroviral therapy

Prevention of transmission during pregnancy

What does a DALY cost?

0 5 10 15 20 25DALYs / £1,000

Distribution of condoms

Treatment of Kaposi’s Sarcoma

Antiretroviral therapy

Prevention of transmission during pregnancy

What does a DALY cost?

0 10 20 30 40 50 60DALYs / £1,000

Distribution of condoms

Treatment of Kaposi’s Sarcoma

Antiretroviral therapyPrevention of transmission

during pregnancy

Distribution of bed nets

What does a DALY cost?

0 10 20 30 40 50 60DALYs / £1,000

Distribution of condoms

Treatment of Kaposi’s Sarcoma

Antiretroviral therapyPrevention of transmission

during pregnancy

Distribution of bed nets

Dramatic differences in cost-effectiveness

(DALYs per $1,000)

Facts about the CE distribution

• If you funded them equally, the top 20% would produce 80% of the value

• The best intervention is 10,000 times better than the worst• The best intervention is 100 times better than the median• If you choose two at random, on average one is 100 times better

How important is cost-effectiveness?• Prioritizing on cost-effectiveness is:

• The difference between saving a life and saving 100 lives• Failure to prioritize on cost-effectiveness is:

• Letting 100 die to save 1• ‘Not seeing the forest for the trees’• Squandering 99% of the value we could produce• Wasting public funds• Unfairly privileging the few at the expense of the many• Helping the rich or powerful at the expense of the poor

• Example: spending $1m on dialysis instead of on DOTS• Buying 20 years of life for some at the expense of 20,000 years for others

The biggest moral issue in global health• Not the most exciting• Not the most philosophically interesting• Not the most technically interesting or challenging

• But the core of the issue• (Actually securing large amounts of good health for the public)• It should be the starting point for priority setting

Other concerns (GPS Health)• Severity of health condition• Realization of potential• Past health loss• Rarity of health condition• Socio-economic status• Area of residence

• Sex and gender• Race, ethnicity, religion• Productivity• Care for others• Catastrophic health expenditure

Quantitative combinations of criteria

Cost per DALY (multiples of GNI / capita)

0 1 2 3 4 5 6 7 8 9Basic

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Quantitative combinations of criteria

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Cost per DALY (multiples of GNI / capita)

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Quantitative combinations of criteria

0 1 2 3 4 5 6 7 8 9

Cost per DALY (multiples of GNI / capita)

0 1 2 3 4 5 6 7 8 9

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Health gains & financial protection - per $1M

Health gains & financial protection - per $1M

Health gains & financial protection - per $1M

Health gains & financial protection - per $1M

Health gains & financial protection - per $1M

Health gains & financial protection - per $1M

Health gains & financial protection - per $1M