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If you have $200 to spend on health in a developing country, would you vaccinate 10 children against deadly childhood diseases or provide AIDS treatment to one woman to prevent transmission of HIV to her unborn child? Policy makers routinely face such tough budgetary dilemmas with little expert guidance. The Priority-Setting Institutions for Global Health working group report provides practical means to assist priority-setting efforts in low- and middle-income countries.
Global health initiatives call for greater developing country financing of cost-effective health interventions for an increasingly diverse set of disease control priorities. But while the priorities are many and population demands increase alongside growing educational attainment and technological innovation, public funding–even when augmented by donor contributions or technology price reductions–remains scarce, and difficult decisions must be made.
There are clear health gains to be made from shifting the current distribution of public spending to more cost-effective uses. For example, WHO estimates that reallocating malaria control budgets in Zambia towards a more cost-effective mix of interventions could reduce costs per Disability Adjusted Life Year (DALY) gained by up to 20%. In Thailand, there is room for as much as a 99% improvement in health impact by reallocating spending for cardiovascular disease prevention. Overall, the WHO estimates that low income countries could save as much as 12-24% of total health care spending.
There is also a growing global knowledge base of data, methods and tools to support countries in the adoption and implementation of cost-effectiveness analyses and health technology assessments, as well as a rich literature on the importance of process itself in constructing ethical, transparent and durable public spending decisions in the health sector.
Yet most public spending decisions do not explicitly incorporate evidence or process, even while global health agencies and donors are expecting recipient governments to assume more and more of the expenses of cost-effective interventions over time. The lack of an explicit process also poses an ethical and a practical problem for donors; as when, for example, PEPFAR funds are available to treat only 30% of HIV-positive adults and no formal process is in place to help recipients make the terrible decisions on who receives treatment and who goes without.
The working group on Priority-Setting Institutions for Global Health identified the characteristics of processes and institutions that are capable of transparently and ethically translating scientific and economic evidence and social preferences on health technologies into on-budget priorities in low- and middle-income settings. In addition, the group assessed current and potential international support for priority-setting institutions, recognizing that while public funding decisions are necessarily driven by local structures and values, shared regional or global information bases for decision-making, institutional design, technical accompaniment and peer support would add much needed value and support to traditionally opaque methods of resource allocation.
The groups final report recommends creating and developing fair and evidence-based national and global systems to more rationally set priorities for public spending on health. The report spurred the creation of the International Decision Support Initiative (iDSI), which was launched by NICE International and partners in 2013 to support low and middle income governments and donors in making resource allocation decisions for healthcare. CGD will work with the iDSI partnership to develop a practical guide and set of options for the design, adjustment and evaluation of health benefits plans in the context of Universal Health Coverage.
Priority setting institutions for health working group member, Dr. Lydia Kapiriri, speaks here about her research within a Ugandan hospital and how her findings can be used to improve priority setting practices in developing nations.
Working Group Members
The Working Group brings together a multi-disciplinary group of policy-makers, practitioners, experts and academics from industry, regulatory authorities, donor agencies, technical agencies and universities. Members serve in a personal capacity, independent of their institutional affiliation.
Kalipso Chalkidou (co-chair), National Institute for Health and Clinical Excellence, UK
Amanda Glassman (co-chair), Center for Global Development, USA
Sara Bennett, John Hopkins School of Public Health, USA
Adriana Velazquez Berumen, World Health Organization
Tomasz Bochenek, Jagellonian University, Poland
Michael Borowitz, Organization for Economic Co-operation and Development
Jesse Bump, Georgetown University, USA
Leonardo Cubillos, World Bank Institute
Tessa Edejer, World Health Organization
Ruth Faden, Johns Hopkins Berman Institute of Bioethics
Jeremy Farrar, Oxford University Clinical Research Unit, Vietnam
Armin Fidler, The World Bank
James Fitzgerald, Pan American Health Organization
Ursula Giedion, Independent, Colombia
Charles Hongoro, South African Medical Research Council, South Africa
In late 2015, India’s Ministry of Health affirmed its commitment to universal health coverage (UHC) in a public letter: “We are… committed to ensuring Universal Health Coverage with first priority accorded to the health needs of those who require it the most. UHC with equity is thus our goal.”
Fast forward to this year’s budget when the Indian government announced its intention to provide dialysis in every district hospital in the country. Kidney failure in India has doubled over the past 15 years; there are about 220,000 new patients with end-stage renal disease (ESRD) each year and the majority are poor.
But if India actually funded and provided dialysis to the population in need, the entire Central government’s public spend on health might be consumed (see Figure). Dialysis, particularly hemodialysis or HD, is expensive. In India, one HD session costs about Rs 2,000 (USD$30), which adds up to more than Rs 300,000 per patient per year (USD$4,465). Of course, there might be economies of scale that could drive down prices and marginal costs over time, but the point is that little thought seems to have been given to the expenditure requirements and trade-offs that a dialysis coverage decision might generate for a health system committed to “UHC with equity”.
Figure: Projected national annual costs of dialysis –if fully implemented- could surpass National Health Mission budget for FY16-17
Calculated using UN population projection data and Veerappan and Abraham (forthcoming) for prevalence rate of 785 per million population for three years. Multiplied projected prevalence by average cost of dialysis per patient (Rs 300,000). Projection is if all patients received average amount and frequency of dialysis treatments. Compared with amount Rs allocated in National Health Mission budget FY16-17.
As in many other countries, politicians have decided what will be subsidized in an ad hoc way. With no clear criteria or explicit process for deciding what health services will be covered with public monies, the measure was simply announced in the Union budget, complete with a tax break for importation of dialysis equipment and a note that the initiative could be implemented through a public-private partnership.
The possible result: implicit and unfair rationing of care—with spending consumed on a first-come, first-served basis, likely in urban areas. As former Health Minister of Maharashtra Suresh Shetty has highlighted, it is difficult to get qualified doctors and technicians to perform dialysis in rural areas. Further, while there is certainly need and demand for dialysis services, many Indian citizens still lack access to the most basic kinds of cost-effective health care: things like oral rehydration salts for diarrhea, vitamin A supplementation, treatment of depression or smoking cessation support, among many others, not least programs that could help prevent ESRD and its precursors (diabetes, hypertension) in the first place.
Now that the decision has been made, authorities in India—and those in Indonesia, Pakistan and Nigeria who are moving ahead with similar initiatives—need to ensure that the dialysis program implemented does not consume the entire budget or crowd out other important uses of public spending on health, thereby working for and not against UHC aspirations.
We suggest three strategies based on other countries’ experiences: (1) more systematic evaluation of options to inform coverage decisions; (2) more systematic attention to the ethical aspects of selecting patients who will receive dialysis in the context of a limited budget and supply constraints; and (3) more attention to cost-effective prevention and management of ESRD pre-cursors such as diabetes and hypertension.
First, policymakers need to evaluate the cost-effectiveness of different kinds of dialysis to choose the most effective and least costly option for coverage. Thailand’s health system provides some insight: in the early 2000s, ESRD incidence increased and there was a push for inclusion of dialysis in the country’s Universal Coverage Scheme (UCS) benefits package. The National Health Security Office (NHSO), Thailand’s payer agency, subsequently commissioned nephrologists and policy researchers to evaluate the cost-effectiveness of different kinds of dialysis. Although their study found that neither hemodialysis (HD) nor peritoneal dialysis (PD) was cost-effective according to their standards, they determined that PD was more cost-effective than HD because PD had a home treatment option, whereas additional infrastructure and human resources were needed to treat patients with HD and HD can be costly for households (even if the service is free) because patients and/or caregivers still need to pay a lot for transport between home and a dialysis center 2-3 times a week. Based on this evidence, the NHSO opted for a PD first policy in Thailand’s UCS benefits package. This kind of analysis and decision is crucial for UHC given—as in Thailand—many nephrologists will own private HD clinics, and will likely advocate for extension of this model, in spite of the untenable costs that may have implications for equity. Attention should also be paid to how a government announcement to cover dialysis in whatever form can affect the price of related products; in Indonesia, for example, PD consumable manufacturers were considering price hikes once an official policy was announced, suggesting that government may wish to negotiate prices ahead of any decision-making.
Second, the government should consider the equity, ethics, and social and legal implications in making decisions about who will benefit from the dialysis program. The approach in one hospital in South Africa is interesting. In 2010, after learning that white patients were almost four times more likely to be accepted for dialysis treatment than nonwhites at Tygerberg Hospital, provincial officials and medical professionals in South Africa created an official, transparent and accountable system to decide which patients would receive dialysis treatment on a priority basis, given the limited budget and capacity. This idea has been around for some time in the framework of Accountability for Reasonableness, but is receiving increasing attention in operational settings as in the South African example, among others. As India plans its dialysis program, it is important that guidelines are explicit for every step of dialysis selection and treatment, and that the ethical implications of such decisions are addressed and managed.
Finally, to combat the staggering increase of ESRD, prevention is key. Rather than spending all of the funding allocated to kidney disease on tertiary care options, the Indian government must consider prevention efforts as an equally important, if not more important, priority. Dialysis is only a Band-Aid to the problem; risk factor prevention, diabetes management and screening programs and other prevention measures need to be implemented to stop the disease at its root, as the Prime Minister himself has pointed out.
And tracking and discussing what countries actually do—as in this blog post- is also important, and follows on our continued work on priority-setting, since the way in which health systems cope in balancing these demands has major implications for global health’s UHC dreams.
Thanks to Anit Mukherjee and Yot Teerawattananon for their input on this blog post.
 HD uses a man-made membrane to filter wastes and extra fluid from the blood, while PD uses the lining of the abdominal cavity and dialysate solution to remove wastes and extra fluid from the body.
The topic of priority-setting has gained some serious momentum since CGD’s 2012 seminal working group report: in January, nearly 1,000 policymakers, practitioners, researchers, donors, and advocates gathered at the 2016 Prince Mahidol Awards Conference (PMAC) in Bangkok, Thailand, to discuss priority-setting for universal health coverage (UHC).
Representatives of global organizations and government health agencies of low- and middle-income countries (LMICs) kicked off the conference in an opening plenary (pictured below), recognizing the importance of priority-setting as demands for health services increase in limited resource environments. And the Bill and Melinda Gates Foundation announced additional support to the International Decision Support Initiative, set up in 2013 following CGD’s report (see recent our blog post and podcast for more about why this is such great news).
Pictured: Opening plenary, moderated by Amanda Glassman (CGD) with Untung Suseno Stuarjo (Secretary General, Ministry of Health, Indonesia), Soonman Kwon (Professor and Dean of the School of Public Health, Seoul National University, Republic of Korea), Michael Rawlins (Former Chair, NICE, United Kingdom), Tim Evans (Senior Director for Health, Nutrition and Population, World Bank), and Lincoln Chen (President, China Medical Board)
CGD was pleased to help organize several sessions, including one titled, "Missed opportunities and opportunity costs: reprioritizing UHC decisions in light of emergence of new technologies and continued budget constraints." Here are a few takeaways from the session:
"Old" technologies can be "new" for low- and middle-income countries
The pace of technological growth in health is quick: each year, large numbers of new medicines and devices enter global markets. While some new technologies can be cost-saving or extend lives, others can be effective but extremely costly, and still others are just costly without being transformational for UHC goals.
Meanwhile, public resources available for health, even if they see an uptick, don’t increase at the same pace as the availability of new technologies. As a result, adoption of a new technology may imply disinvestment and reallocation away from other uses of public monies or crowding out of more cost-effective uses of spending toward UHC goals.
It is therefore important for LMICs to keep in mind that some technologies that have been available in other countries can still be "new" to their health systems—and to give those technologies the same consideration as the shiny new ones. As Kun Zhao, director of health technology assessment at the China National Health Development Research Center, put it, "your ‘old’ can still be ‘new’ for me." Investing in these older, potentially more cost-effective, technologies could be an opportunity for LMICs to enhance value for money.
Priority-setting has a role in global health
The decision to adopt an intervention or not is one challenge; knowing what’s on the market or potentially coming to market is another.
We’re seeing more and more innovation—defined by Amie Batson, chief strategy officer at PATH, as "not just the new and expensive, but new approaches that significantly affect access and effectiveness compared to standard of care"—in LMICs, by those who understand the needs of the poor. And, as Batson underscored, it is important that LMICs are able to identify and adapt the innovations that are appropriate for their health systems.
When it comes to these new innovations, Alexandre Barna, head of unit at CEDIT, France and representative of the EuroScan Network, and Sang Moo Lee, executive director in the Office of Research Planning at NECA Korea, showed that health technology assessment and horizon scanning are part of the process and highlighted resources available to all countries to support priority-setting. For example, EuroScan provides a collaborative platform to share information on emerging health technologies; South Korea uses a modified version of EuroScan’s toolkit to identify and assess new technologies.
Priority-setting can make new products more affordable
The Pharmaceutical Management Agency of New Zealand (PHARMAC) uses a relative prioritization list of medicines (using a QALYs per $1 million metric) and is uniquely legally mandated to stay within a certain budget. As such, despite a relatively small population which can mean less leverage, PHARMAC has the ability to negotiate very low drug prices. Rachel Melrose, manager of the policy team at PHARMAC, showed us the result: prices of the 30 most commonly prescribed drugs in New Zealand are one-third of the cost in the US, and actual total drug expenditure in 2014 was less than half of the estimated expenditure.
Be mindful of incentives for innovation
What incentives for innovation are created by priority-setting? What are potential unintended consequences of priority-setting? "What if health technology assessment and if all the bureaucratic controlling of new products stifles innovation?" Andreas Seiter, senior health specialist at the World Bank, asked. "Investors might take their money to other sectors. How would we know whether this was happening?" These are important questions to consider.
"If we want to support innovation," Karl Claxton, a professor in the Department of Economics and the Centre for Health Economics at the University of York, argued,"give a strong signal of what we’re able to pay."His research on how new technologies can displace existing, potentially more cost-effective uses of public health funds provides one method for how countries could arrive at a "willingness to pay" benchmark for a new technology. With awareness of such a benchmark, external assistance can be focused on where it’s required (i.e., where countries can’t pay the generic costs); donors can target funding where there isn’t incentive for manufacturers; and health systems can access new technologies.
As priority-setting remains firmly part of the UHC agenda, we at CGD are excited to continue thinking about these topics and engaging with the International Decision Support Initiative (iDSI) as it scales up. In the meantime, we encourage you to check out the presentations from our PMAC session here and from all other sessions here.
Pictured: Parallel Session 2.2 panelists – Rachel Melrose (Policy Team, PHARMAC New Zealand), Andreas Seiter (Senior Health Specialist, World Bank), Amie Batson (Chief Strategy Officer, PATH), Karl Claxton (Professor, University of York UK), Alexandre Barna (Head of Unit, CEDIT France), Kun Zhao (Director of HTA, CNHDRC China), Sang Moo Lee (Executive Director, Office of Research Planning, NECA Korea)
No one really understands why the first letter is lower case and the rest are in capitals. But one thing that is clear to anyone who has heard of iDSI is that it fills a growing gap in how developing countries decide how to allocate their strained health budgets. The International Decision Support Initiative is a network of expert organizations that helps policymakers make effective, efficient, and ethical decisions about how to prioritize limited resources. And it just got bigger, thanks to a new grant to scale up its operations (you can read about it here).
With evidence and rational decision-making at its heart, it is no surprise that iDSI began as the recommendation of a report by a 2012 CGD Working Group. Its chair and director of our global health program, Amanda Glassman, tells me in a new podcast that iDSI will become increasingly important in the years ahead.
“What really matters right now for middle-income countries, which are most of the countries in the so-called developing world, is how they choose to spend their own public resources. So informing that process with evidence and with good process, for me, it’s the only way forward,” she says.
So why is iDSI needed? Because some countries currently spend large amounts of money on ineffective treatments such as prescribing vitamins or sending a few patients overseas for costly procedures, while many thousands at home go without basic health provisions. In addition, as countries become wealthier, richer donor nations will move away from entirely underwriting their health sectors, and low- and middle-income countries (LMICs) will increase their own public health spending; thus the need for better priority-setting will skyrocket. And as more countries aim towards universal health coverage (UHC), it will be even more crucial to get the most health for their money.
It’s been a short and speedy evolution for iDSI. Following that CGD report, the initiative was set up in 2013 by the UK’s NICE (National Institute for Health and Care Excellence) and Thailand’s HITAP (Health Intervention and Technology Assessment Program), with funding by the UK’s DfID, the Bill and Melinda Gates Foundation and, earlier, the Rockefeller Foundation. Originally, it focused on five countries—Indonesia, India, Vietnam, China, and South Africa—and it is credited with helping those countries make better healthcare spending decisions. Recently, the Gates Foundation announced a $12.8 million grant to scale up the practical support iDSI offers to countries that aspire to UHC. This will mean not only working harder in the five flagship nations, but also expanding its geographical reach, particularly into sub-Saharan Africa.
We think of iDSI as a classic CGD success story: we started by identifying a problem in the economics of health (the inefficiencies of LMIC health budgets and a lack of processes and institutions to help prioritize health spending), we convened a group of experts to focus on the problem, found a toehold, and worked it until we came up a new simple, low-cost solution. Now we are delighted that policymakers and funders have seen—and realized—the potential.
As Glassman says, “I feel that’s exactly what CGD was created for. To come up with what makes sense, try and get all of these different people working in the same direction, and now it has a life of its own. Our job is to collaborate and to support and celebrate but it’s… bigger than us now and I think that’s what CGD is all about!”
The International Decision Support Initiative, initially launched as the result of a CGD working group, is scaling up, and that’s good news for people making life-and-death decisions in low- and middle-income countries. It means more data on what works and more guidance on how to get the most out of scarce resources for health.
Health-care decisions are hard everywhere. The United States, for example, spends almost one-fifth of its total national income on health but still has a hard time deciding whether health insurers should cover a new treatment for Hepatitis C. Imagine the scale of that challenge in a place like Ethiopia, where physicians (1 for every 32,000 people), money, and almost every other resource are in short supply.
Read full article here.
Many health improving interventions in low-income countries are extremely good value for money. So why has it often proven difficult to obtain political backing for highly cost-effective interventions such as vaccinations, treatments against diarrhoeal disease in children, and preventive policies such as improved access to clean water, or policies curtailing tobacco consumption?
Cost-effectiveness studies compare the costs and benefits of different interventions with the aim of improving decisions on the allocation of scarce resources for health. Or, put simply, they allow policy-makers to set priorities for health spending and consider how the next dollar available can get more health for the money.
The Bill & Melinda Gates Foundation (BMGF) funds about a fifth of all published cost-effectiveness studies on interventions to address AIDS, tuberculosis, malaria, and vaccine-preventable diseases in low- and middle-income countries. BMGF also plays a high-profile role in promoting the concept of cost effectiveness as a criterion for global health decision making and spending.
But for cost-effectiveness studies to actually improve decisions, methods must be appropriate and reporting must be clear and accurate. If not done well, these analyses can be difficult to interpret and can lead to suboptimal or even incorrect decisions.
So BMGF recently commissioned NICE International, the University of York, and the Health Intervention and Technology Appraisal Program (Thailand) to develop the Gates Reference Case, a principle-based standardized methodology for economic evaluation in developing countries. The principles are described in detail here, and cover issues of transparency, comparators, better use of evidence, and measures of outcomes, among others. Using these principles, they also assess retrospectively how published BMGF-funded studies have fared since 2000.
The results of the study were disappointing. Paraphrasing the report:
“Most studies provided insufficient information about currency conversions and/or methods for adjusting costs to account for temporal disparities. Where information was provided, crude exchange rates were frequently used to convert unit costs drawn from other settings (often high-income countries). There was poor adherence to the three key methodological specifications for DALY estimation, raising significant concerns as variant approaches to DALY calculation limit comparability between studies. Although widely considered as the most comprehensive method of dealing with the various sources of uncertainty in economic evaluations, few studies presented probabilistic sensitivity analyses. Generalizability and transferability of results and equity implications of evaluated interventions were discussed in less than one-third of all reviewed studies. Only 35% of studies discussed the affordability of the interventions being assessed, despite these studies being undertaken in very resource-limited settings.”
Bottom line: it is tough to use this body of evidence to make better decisions.
Reference cases have been in the public domain for some time, and have been adopted by the US Panel on Cost-Effectiveness in Health and Medicine, the World Health Organization, and NICE itself, as a means to improve quality and comparability in the conduct and reporting of cost-effectiveness analyses. BMGF adoption could greatly improve the quality of economic evaluation for global health, particularly if the case is used as a condition for funding and a criterion for a specialized peer review as part of the commissioning and oversight of cost-effectiveness studies.
At the recent launch of the Reference Case, the Foundation announced plans to create incentives for researchers to adhere more closely to the best practice principles laid out in the Reference Case. Other cost-effectiveness analysis funders should follow suit; Wellcome Trust/MRC, DFID, USAID, and others could use the same standards and even the same peer review mechanism. Widespread use could enable more meaningful and explicit comparison of analyses and findings across multiple studies, which in turn will allow cost-effectiveness analyses to better guide health care spending decisions in developing countries.
In India, the government subsidizes open heart surgery but fails to provide sufficient vaccinations for all children. In Egypt, the government pays to fly affluent citizens overseas for advanced medical care, yet one out of five Egyptian children are stunted, meaning they are shorter or weigh less than they should for their age because of poor health and insufficient nutrition.
Developing countries and outside donors spend billions of dollars a year on health care in the developing world. Yet without systems for setting priorities, highly effective, low-cost treatments too often go unfunded even as public money is spent on much more expensive procedures.
What can be done? CGD senior fellow Amanda Glassman, my guest on this week’s Wonkcast, believes that part of the solution is to create a new institution that draws upon medical and scientific literature to support low- and middle-income governments and donors in resource allocation decisions for healthcare. This recommendation was first put forth by CGD’s Priority-Setting Institutions for Global Health working group, co-chaired by Amanda and Kalipso Chalkidou from NICE International.
I’ve invited Amanda on the show to tell me more about some encouraging news concerning international progress on health care priority setting:
“We learned that the Bill and Melinda Gates Foundation and the UK aid agency have funded an International Decisions Support Initiative (IDSI) at NICE International,“ a branch of the UK’s National Institute for Health and Care Excellence,” Amanda tells me.
Americans who care about development often look at the UK’s Department for International Development (DfID) with envy, so some may be surprised to learn that NICE is a separate entity whose primary job is to advise the UK’s national health service.
“They also have an arm that works internationally to help developing countries, and to some extent donors, develop their own processes for assessing cost-effectiveness,” Amanda explains. The new funding, a modest $3 million, will make it possible to extend this work.
“The idea is to show that institutions can be built in countries willing to prioritize spending according to value for money criteria,” Amanda explains. “In the next phase, we hope to see more funding going toward this kind of activity.”
Listen to the Wonkcast to learn more about how the new initiative will function, and the importance of tailoring recommendations to country characteristics and values.
“The point is to have a process or rules of the game that allow all kinds of considerations to be brought out and discussed in a transparent way, in an evidence-based way,” Amanda explains.
Universal health coverage (UHC) is now firmly on the global health agenda, and carries with it the ambitious goal of providing “access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost.” So where do we start? A critical first step to delivering on the aspirations of UHC is deciding which services and policies to prioritize and make available. While resources for health care are growing, they are not infinite and hard choices must be made.
Priority-setting processes for health spending specify at least a certain set of policies, services and technologies that will be financed and made available under UHC. Some will also indicate which services or technologies will not be funded and provided. Ideally, the design of a priority setting process is fair, transparent, inclusive and deliberative. And in the best cases, the selection of these services is based on cost-effectiveness and accounts for equity, financial protection and social values in a systematic way.
When priority-setting processes aren’t in place – that is, when resource allocation decisions are made based on past budgets or under pressure from interest group – less health is provided for every dollar spent. Evidence of suboptimal allocation abounds; India subsidizes open heart surgery while child vaccination rates remain low; Colombia purchases more analogous insulins per diabetic than any country in Latin America while diabetes prevention and management programs remain underfunded; and Egypt spent a fifth of its public spending on health to send a few fortunate people overseas for health treatments while a fifth of their children were stunted. (for more examples, see our report on priority-setting institutions here)
Under UHC, it will ultimately be up to countries to set their own priorities for health spending. And that’s great - reallocating a portion of public and donor monies toward the most cost-effective health interventions would save more lives and promote health equity. But too many low- and middle-income countries lack the fair and evidence-based processes and institutions needed to adequately inform funding decisions.
With that in mind, the Center for Global Development ran a working group on priority-setting institutions during 2011/12, recommending the creation and development of national and global systems to more rationally set priorities for public spending on health. The group called for an interim secretariat to incubate a global facility designed to help governments develop national systems and donors get greater value for money in their grants.
So we’re delighted to announce a new platform that does just that -- the international Decision Support Initiative (iDSI). Recently launched by NICE International, the iDSI will support low and middle income governments, and perhaps donors, in making resource allocation decisions for healthcare. Specifically, the initiative will share experiences, showcase lessons learned and identify practical ways to scale technical support for more systematic, fair and evidence informed priority setting processes. In strengthening priority-setting institutions, the iDSI will be a tool to both improve access to effective health interventions and the quality and efficiency of health care delivery. And importantly, it will help elevate the value of priority setting as a necessary, if not sufficient, condition for attaining and sustaining UHC.
The full announcement from NICE International on the iDSI can be found here and the strategic overview here. For more information on CGD’s work on Priority-Setting, see the report’s brief here and a wonkcast on the topic, here.
Mosquito-zapping lasers, refrigerators for vaccines, and disease modeling: these are the three impressive technologies featured in a TED talk by Nathan Myhrvold. On the first two technologies, I responded in a piece “When engineering met public health” in the Huffington Post. What I didn’t get a chance to talk about was the importance of his third technology – disease modeling:
“One of the problems that you have if you're trying to eradicate malaria or reduce it is you don't know what's the most effective thing to do. Okay, we heard about bed nets earlier. You spend a certain amount per bed net. Or you could spray. You can give drug administration. There's all these different interventions but they have different kinds of effectiveness. How can you tell? So we've created, using our supercomputer, the world's best computer model of malaria, which we'll show you now…”
“By doing these kinds of simulations, we want to eradicate or control malaria thousands of times in software before we actually have to do it in real life; to be able to simulate both the economic trade-offs -- how many bed nets versus how much spraying? -- or the social trade-offs -- what happens if unrest breaks out?
Without a doubt, this software may well be a more powerful technology than a laser zapper or a vaccine refrigerator. Myhrvold notes that the disease modeling software developed by Global Good now informs eradication strategies for polio, HIV/AIDS, tuberculosis and malaria.
We can’t be more supportive of this work, an issue we’ve supported in our CGD Working Group on Value for Money in Global Health. In the Planning Allocation chapters in our More Health for the Money report, we recommend the Global Fund “optimize investments for greatest health impact.” True, the Global Fund is beginning to move in this direction, with its greater focus on targeting programs and grant-funded interventions to key populations. But the Global Fund can do much more by requiring that its recipients systematically consider intervention effectiveness, costs, environment, and other factors into a model, however simple or complex, to maximize health impact.
Detractors will say that these models are too hard, the data aren’t available, and recipients don’t have the technical capacity. But the data requirements for these models are not onerous or burdensome, nor do they need to involve Myhrvold’s supercomputers. Dr Tim Hallett, a reader at Imperial College London, found that impact could increase by 20%, simply by redirecting the same resources to the populations at greatest risk of infection and transmission. Simpler modeling tools producing “good-enough” decisions on how to allocate national resources are needed and are being developed by various groups – and the Global Fund should tap into these activities.
In the meantime, the Global Fund can encourage applicants to talk with networks and organizations such as Myhrvold’s and Hallett’s as well as the various disease modeling consortia (see here, here, and here) to make sure that proposed plans are good value for money. That can start a conversation where ultimately more lives will be saved and more people will benefit. When done appropriately, countries using more information and data can better target their interventions to the right populations and ultimately control, if not eliminate, their epidemics.
Victoria Fan is a research fellow and health economist at the Center for Global Development. She thanks Amanda Glassman, Jenny Ottenhoff, Justin Sandefur, and Huffington Post for their inputs. You can follow Victoria Fan on Twitter at @FanVictoria.