Discussion
Since the publication of the previous edition of this book, the epidemiological and demographic profiles of many LMICs and the range of available health interventions have changed significantly. This edition has the benefit of hindsight in looking back at the variety and affordability of interventions that were evaluated in the previous edition, both to see how the optimal mix of strategies may have changed in the intervening period and to ascertain trends.
Lessons
Three lessons are broadly applicable. They relate to communicable diseases, noncommunicable diseases, and technological progress.
Communicable Diseases
Interventions to treat communicable diseases have been highly cost-effective in the past and remain so despite new challenges, such as drug-resistant pathogens and vectors. Although much progress has been made in lowering the burden of disease associated with vaccine-preventable illnesses, diarrhea, and to a lesser extent with acute respiratory infections, progress made on other diseases, such as malaria and TB, has been rolled back by such challenges as parasite resistance in the case of malaria and the HIV epidemic in the case of TB. An important exception may be diseases for which vaccines have been available, where significant gains in health have been achieved. In general, discerning a link between the availability of effective, affordable interventions in 1993 and a significant effect on the disease burden since that time is difficult because of the problem in defining the appropriate counterfactual of what would have happened in the absence of interventions that were implemented.
Noncommunicable Diseases
Compared with 13 years ago, many more cost-effective interventions have been evaluated and are being used for noncommunicable diseases, which continue to grow in importance as populations undergo the epidemiological transition. Many of these interventions have been available for more than a decade; however, their costs have dropped as key drugs have gone off patent. Acute management of stroke and myocardial infarction using aspirin, beta-blockers, and nitroglycerin costs as little as US$15 to US$30 per DALY averted and ranks among the most cost-effective interventions available in LMICs. Even though many of the interventions were first developed in the industrial world, their benefits are now largely available in the developing world. Thus, the challenge lies in the ability of health care systems in LMICs to adopt these interventions on a large scale.
Technological Progress
Much progress has been made in scientific understanding and in the availability of affordable, population-based and personal interventions for preventing and treating HIV/AIDS; however, adequate scaling up of these interventions remains a challenge, with a few notable exceptions. The international health system has shown remarkable technological agility in responding to this epidemic, demonstrating that the world's scientific-industrial machinery is capable of rising to the challenge of emerging diseases when there is sufficient economic motivation for doing so. For instance, combination antiretroviral treatments are currently available for as little as US$150 for a year's supply in some countries. In contrast, monotherapy with zidovudine, or AZT, which was the standard of care 10 years ago, was less effective, more expensive, and much more prone to drug resistance. As before, the challenge does not appear to be in the availability of interventions either to prevent infection in adults or to effectively ensure against transmission from infected mothers to newborns. Rather, the challenge lies in the willingness and ability to fund and deploy the interventions effectively. Clearly, much more remains to be done to develop affordable treatments. However, without a vaccine, the only feasible solution appears to be to aggressively prevent further transmission while treating patients under well-implemented programs that can achieve the high rates of treatment adherence required to maintain the continued effectiveness of drug therapy.7 More generally, the challenge of motivating technological advances for diseases that do not threaten the developed world remains to be addressed.
Importance of Health Systems
In describing efficient means of producing health, this chapter has said little about how such efficiency may be translated into practice. The overall cost-effectiveness of a service level or package of interventions, rather than the cost-effectiveness of individual interventions, is the appropriate indicator to determine which interventions should be used. From a planning point of view, taking the infrastructure as fixed, at least in the immediate future, and then asking how it can best be used to deliver the most cost-effective interventions might be sensible. Where infrastructure is limited, expanding access will have to take priority. Other factors related to health system capacity and infrastructure may play a key role in determining the adoption of interventions. The current evidence on the cost-effectiveness of service levels such as district or referral hospitals is weak. Even though part of the problem lies with the difficulty of valuing the health benefits these facilities produce, more could be done. Chapter 3 presents a more detailed discussion of issues pertaining to health systems, but the broader questions of why some cost-effective interventions are used while others are not is a subject for future inquiry.
Even though much of the technology to significantly reduce the burden of disease already exists, few cost-effective interventions are available for some diseases. Shaping research priorities in a manner that is responsive to the treatment needs of the millions of HIV/AIDS patients and of people suffering from mental disorders across the range of LMICs is a challenge.
Setting intervention priorities efficiently can make a dollar go farther in improving health and can substantively increase available resources. Moreover, without demonstrably improved efficiency in health spending, aid agencies and development partners are unlikely to be persuaded to dig deeper into their pockets to pay for further expansions of health programs. Improving efficiency should not, however, detract from the importance of increasing resources that are available for implementing these interventions and of meeting broader internationally agreed-upon development goals such as the Millennium Development Goals. These objectives are complementary.
The lack of reliable data on costs and effectiveness is an important obstacle to efficient priority setting. Despite the relatively good data on the efficacy of interventions in clinical trial settings, reliable effectiveness data are generally lacking. Furthermore, not enough is known about the costs, extent of coverage, and institutional capacity requirements of interventions in developing countries. The messages presented in this chapter represent the best available information about the relative costs of purchasing health through a wide range of interventions. The challenge that lies ahead is for these messages to move beyond the academic realm: ultimately, it is the extent to which policy makers make the commitment to act on them that will save lives.
