My recent blog post on economics at WHO alongside Tony Culyer’s open letter to incoming Director-General Dr. Tedros generated great feedback and discussion. Below, you can find my views on some of the key points made, as well as WHO health economist Melanie Bertram’s response to the letter here.
WHO employs health economists, but they need more influence
To be clear, WHO is home to some great health economists. To name a few, Agnes Soucat, Joe Kutzin, Evan Blecher, Matt Jowett, Jeremy Lauer, Raymond Hutubessy, and Tessa Edejer are top contributors to the field. However, economists’ work is siloed in a few areas and—as a result—the insights of health economics have had limited impact on the core work of WHO in the disease and public health departments and divisions, where major recommendations are made that inform country decisions on what kinds of health care and products will be subsidized with public monies. That’s a generalization, and things are changing, but I would argue that it is still true that targets, guidelines, policies, and lists mostly omit economic criteria and analysis.
And it’s not true that no one at WHO consults economists in general; there is a history of high-profile advice from economists that specialize in non-health fields—James Heckman on early childhood development and Jeff Sachs on macroeconomics as it relates to health are just a couple of examples. But the economics and market failures in health care and health products is a specialized field that requires specialized skills.
To address this, I propose raising the profile and influence of health economists on core WHO work (more on that below).
WHO authors said no to universal cost-effectiveness thresholds in September 2016 …
Agnes Soucat pointed out that she and WHO co-authors had disavowed the universal threshold guidance in an article published in the WHO Bulletin in September 2016. While I had linked to this article in my original post, I wasn’t aware that this article represented a change in WHO policy. To rectify, this week, WHO posted a more visible link to that article on its website with the sub-heading “Updated guidance from WHO on the use of cost-effectiveness thresholds in decision-making processes.” While this is not the usual form that official WHO guidance takes, it is a very substantive move forward that should be noted and celebrated.
…but there is much more to do to publicize and develop better guidance for decision-making
First, there is an urgent need to publicize the change in the WHO position. I’m not the only one under the impression that 1-3x GDP per capita is still the rule: just this week, I reviewed two papers submitted to journals that cite this WHO paper as a reference to justify an intervention as cost-effective. A more concerted and high-profile effort is needed to reach government decision-makers around the world, as well as global health funders, academic researchers, and—very importantly—advocates for particular interventions who also care about improving health overall in their own and other countries.
Second, WHO will need to provide new guidance on best methods to choose interventions and products for public subsidy, based on locally available budgets and considering opportunity costs, given that everything that offers benefit cannot be provided.
The September 2016 WHO paper implies a threshold might be substituted with “evidence-to-decision frameworks” such as GRADE, now widely in use by WHO expert groups developing lists and guidelines. Yet GRADE does not incorporate economic considerations. The first WHO clinical guidelines to consider any evidence from economic modelling and cost-effectiveness studies were the 2013 HIV Treatment Guidelines, which followed the GRADE process. However, despite the HIV Modelling Consortium’s work clearly showing some of the recommendations were likely to be health subtracting due to budgets not being considered, the final version of the Guidelines were still based on clinical criteria alone. The good news is that the HIV team at WHO now recognizes the limitations of the process and has since been seeking ways to better use economic evidence.
In other disease areas, however, it is not clear how economics is being used at all. The consequence is that countries are being asked to do too much with too few resources, with predictable consequences for lack of access to even the most basic of health care interventions. Take Malawi, for instance—work by the University of York shows the country’s annual health budget would be exhausted by providing only interventions offering health gains at less than $70 per DALY-averted. Aspirational targets and guidelines, set in Geneva or Washington DC, are little help in settings where the severity of resource constraints is so sharp and the decisions facing budget holders so difficult.
Thresholds, budget constraints and prices: next steps
Understanding the budget constraints faced by countries and the opportunity costs of alternative ways of allocating those budgets can also be a guide to what prices effective health care interventions must be delivered within to improve health across a population. Here, most readers agreed that the WHO took a misstep in its initial treatment of the issue at the Fair Pricing Forum; I won’t revisit the arguments that Tony lays out so clearly in his letter, but would suggest that some serious economic work be done to inform guidance to developing countries on product selection, price negotiation, procurement, and contracts, informed by a locally-based threshold, and to set out all the policy options available before heading in a direction that may not yield desired results of increased access and better overall population health.
A chief health economist for WHO—will it work? How could it work?
Many liked the idea of a chief health economist at WHO, but James Love challenged the Twittersphere to give examples of influential chief economists. Several people suggested the IMF’s version of chief economist—someone with both academic experience and policy chops, who gets good results inside the organization, reshapes institutional polices and practices, and influences the organization’s governance bodies and member countries as well (see Olivier Blanchard).
As we wait for Dr. Tedros to name his new team and make plans, I hope he’ll take the chief economist recommendation seriously. While Tony’s letter may have shocked, it is not hyperbole. There is a serious problem in the way the WHO is doing business overall, and better economics is part of the solution.
Thanks to Paul Revill for his valuable input into this blog post.