Response to The Lancet Commission on Investing in Health 3.0: We Must Prioritise Better

On the 14th October, the Lancet Commission on Investing in Health (CIH) released its third report (CIH 3.0). We welcome this important edition, which comes at a timely moment when domestic and donor resources for health seem to be in peril and the global health architecture is under scrutiny. The paper surveys the field and makes the case that health expenditure is a good investment and good for development. It then shifts away from the previous Commissions’ target of a “Grand Convergence by 2035” of mortality rates between countries, and instead sets a global target of 50 percent reduction of premature mortality by 2050 (“50 by 50”).

In this blog, we argue the reports’ approach to setting priorities globally and by burden of disease, combined with historically determined and (perhaps) politically negotiated modular health system budget envelopes, risks undermining its own objectives. Instead, we argue for an alternative tripartite approach to prioritisation: (1) by services and interventions using standard comparable metrics, such as quality-adjusted life years (QALYs) or disability-adjusted life years (DALYs); (2) carried out by national priority-setting processes accountable to their own populations and with due consideration to the specific context-sensitive evidence and values; and (3) through resource allocation processes that use this evidence and values to quantify and consider trade-offs between priorities, rather than replicate historic inefficiencies and political biases.

This approach can substantially improve health system performance and drive us faster towards the 50 by 50 target. Furthermore, if supplemented through a New Compact with donors to clarify the centrality of domestic financing, it offers a more concrete way forward to improve health financing in settings that receive external assistance, including advancing the key shifts in the global health architecture outlined in the Lusaka Agenda.

We must focus on priority services, not priority diseases

CIH 3.0 calls for a focus on fifteen priority diseases. Prioritising by disease is intuitive and emotive, and thus may even bring new resources into global health, as shown by PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria. However, prioritising by disease undermines the potential for allocative efficiency in health systems and thus reduces the probability of the world achieving 50 by 50. Prioritising by services or by interventions, with each appropriately assessed by cost-effectiveness analysis, offers greater potential. This is for three reasons: 

1. Prioritising by disease or group of diseases is a top-down approach that relies on an arbitrary level of aggregation which merges conditions with varying level of priority and with distinct diagnostic and treatment gaps. For example, in many countries, the group “cancer” may seem a greater priority than “HIV”, but “lung cancer”, and indeed every individual cancer, may not. Prioritising by cost-effectiveness of services overcomes these issues. 

2. Services for the same disease can vary by orders of magnitude in their cost-effectiveness. For example, highly cost-effective anti-hypertensives can produce 10 times more health benefit (DALYs averted) than less cost-effective options. Prioritising by disease restricts sensible consideration of trade-offs between diseases. Carrying out a thought experiment using DCP3 data on cost-effectiveness of interventions, one can easily see how focusing on specific diseases can substantially constrain health system performance (see Figure 1). Here we have identified a set of four top interventions regardless of disease, each very cheap and effective, delivered in a hypothetical low-income country primary healthcare clinic, averting 117 DALYs for $1000. By comparison, consider a highly cost-effective but single disease-focused (HIV) clinic delivering four top HIV interventions, which averts 52 DALYs for $1000. The halving of DALYs averted means, in effect, a disease-focused health system can only save half the lives for the same budget. 

3. Thirdly, CIH is supposed to be forward looking, up to 2050, but a disease focus is not future-proof. What if a lung cancer vaccine is developed with incredible cost-effectiveness in 2035? Would it not be a priority because lung cancer is not? The world needs to shift towards an approach where countries have national or regional priority-setting institutions that review the evidence and their local epidemiology, appropriately implement these decisions, and regularly update their priorities based on the cost-effectiveness of services and gaps in coverage. Importantly, the CIH proposal also risks feeding back into distorting R&D. For it to be of relevance, R&D has to be a dynamic process, able to respond to health systems’ investment decisions, including those of poorer countries.  

Figure 1. Total DALYs averted for $1000 budget spent on top four interventions regardless of disease, versus top four interventions for HIV 

Prioritising must be local, not global

More fundamentally, we posit that it is not possible or desirable to set priorities globally in the manner carried out by CIH 3.0. Priorities are dependent on local epidemiology, cost structures, health system contexts, and social values, and thus must be set by national decisionmakers guided by local assessments. Inappropriate global priority-setting, particularly when backed by major donor financing, can be harmful and, given its size and dependencies, possibly difficult for many low- and middle-income countries to resist or shape. As one of us noted regarding CIH 2.0: “LMICs are especially vulnerable because they often have very limited capacity to challenge the local applicability of global advice or to conduct independent assessments that take due account of local circumstances.” This approach goes against the principle of country ownership and health system strengthening as articulated in the Lusaka Agenda. Instead it returns us to priority-setting by lists devised in Geneva, Seattle, or another global north city.  

As donors decide which of the replenishment “traffic jam” calls to fund, how to track progress on Lusaka, and what the goals should be post-Sustainable Development Goals; they should learn from the advantages and disadvantages of over 20 years of disease-specific approaches and decide how best to evolve the model and focus on system performance and on integration, both led by country policymakers. Integration, not fragmentation, is the word! 

Perpetuating inefficiencies and inequities: when budget setting is guided by precedent and political preferences 

The authors encourage countries to develop 19 modules of services, with the budget of these modules based on historical spending, national strategies, and policymakers’ preferences. Priority-setting in health is a life and death decision and CIH authors are therefore right to acknowledge the major resource allocation decisions will be highly influenced by politics and powerful stakeholders.  

Good decisions, however, are shaped by the explicit (and political) consideration of trade-offs between different health priorities (and modules) through a rigorous evidence-informed priority-setting process. The quantification of trade-offs requires synthesis and deliberation regarding the costs and benefits of alternative services, which in turn requires a common metric of benefits. This latest Commission has decided to reject decades of investment by the health economics community, developing substantial literature on using the QALY or DALY for this purpose. This evidence base is now being used by national agencies to make decisions on allocation of scarce resources the world over. Unfortunately, CIH authors are driving away from this, instead recommending natural unit approaches such as “cost per heart attack avoided,” which, because it cannot be compared to “cost per stroke treated,” for example, explicitly prevents trade-off considerations between diseases.  

Conclusion

We are glad the Commission has once again drawn focus to the important debates around investment in health and how this should be allocated. Critically, we believe the focus on globally defined top 15 disease priorities and modular budgets defined by historical budgets and by political negotiations is misguided and risks perpetuating inefficiencies which become the de facto baseline from which new decisions are made. Instead, countries should use priority-setting institutions to focus resources on top priorities, taking into account the cost-effectiveness of services. Resources within the health sector should then be allocated based on this evidence, to ensure these priorities are delivered. Countries that receive external assistance may then wish to seek donor support for this, for example through a New Compact, where countries finance the highest priority services, and donors enabling the expansion to additional services, ideally through budget support. We believe this is more likely to achieve the noble 50 by 50 goal, and is more in-line with the Lusaka Agenda. 

Appendix. Hypothetical health impact of allocating to four top interventions regardless of disease versus four top interventions within HIV