Economists are not global health’s most popular human resource. They usually show up to dampen enthusiasm by nattering on about budget constraints, trade-offs and incentives. In the HIV/AIDS field in particular, health economists and their work have been viewed with profound skepticism. At a recent debate, talking about choices and budget constraints was labeled “dangerous” to fundraising by one participant.
Yet a new view of the contribution of economists to global health is emerging. At the International AIDS Economics Network (IAEN) meeting earlier this month, Ambassador Eric Goosby gave a terrific overview of the policy questions that need to be addressed by the field and the role that economists need to play in improving the efficiency and effectiveness of the HIV/AIDS response. In his words:
How do policy makers decide where funds should be invested? How do we measure value for investment in health systems in the absence of standard indicators? Can we assess prevention benefit while accounting for the treatment benefit as well? How do we achieve allocative efficiency—that is, putting our money where it will have the greatest impact?
These questions underscore the importance of economic analysis for the next phase of the HIV response. Together, we need to establish and implement a research agenda for economic analysis and apply the results to the global HIV response. We will need to adapt to these more complex intervention models and press for stronger metrics to better define value for the expenditures being tracked. Most of all, we will need collaborative strategies to help countries collect and apply economic data for their program planning.
Economic analysis provides us with results that show us how to make programs more efficient; provides accountability for our programs to those who support this work, and supports advocacy to policy makers who have to consider the economic dimensions of investments.
You as the health economists focused on this work have an amazing opportunity, together, in dialogue with program leadership, to move this forward, to understand it better, so we can increase our effectiveness at dropping morbidity and mortality and I want to end today with a challenge to all of us to step up to it.
Those of us who have a little grey hair or lost some of it know that this is a different time. We have seen … economic pressures … push more people in policy-making positions into conversations that have brought central cost-effectiveness analysis, comparative effectiveness, looking at the variation across our implementing colleagues/partners in their ability to do the same work, the same outcome, with less money. In very many ways I think this economic severity has pushed us dramatically into what I think is the correct alignment of thinking.
Medical communities have had a lot of distrust of cost-effectiveness analysis. I know all of you in this room have butted up against your clinical colleagues who saw that every time you came with a cost effectiveness analysis, a service provision capability, a testing modality, CT scan vs MRI, suddenly those services became more difficult to access from a clinician’s perspective. And from a clinician’s perspective, seeing a body of patients in front of them, it is not the correct spot or locus of a cost effectiveness analysis. Economic analysis really needs to be part of a policy discussion that doesn’t involve or corrupt the patient-provider relationship.
So I think that we have evolved in this moment where now, from my perspective, economic analysis becomes a tool for us to preserve program and expand program to drop more morbidity and more mortality. And I really do think it’s a glimmer moment where the window has opened for you [economists] to establish your relevance but do it with compassion and consideration in how you speak about it. Cost-effectiveness analysis is not a perfect fit to a medical model; but it is an essential fit. And I think you are really at the forefront of harmonizing that integration with clinical, programmatic, and health system decision-making to preserve program and services for the population we are supposed to serve.