First Word
Setting priorities in health
Cost-effectiveness analysis has won growing acceptance as a tool to help policymakers allocate health resources more effectively. The approach promotes better health outcomes by using evidence, knowledge, and analysis to inform decisions about which health interventions to use. It also promotes accountability by encouraging decisions based on objective criteria about how to advance the public good. This is particularly important in the health sector, where misspent funds can mean lives lost.
The Disease Control Priorities Project, the subject of our cover story, "Best Buys for Public Health," uses cost-effectiveness analysis to identify the most efficient interventions to improve health in the developing world. Its findings were presented at a special session of the 2006 Directing Council meeting at Pan American Health Organization (PAHO) headquarters last September. In addition to the 10 best buys, the project also highlights 17 initiatives described as among the world's most successful large-scale public health interventions. These include the PAHO-led campaign to eliminate polio from the Western Hemisphere and the more recent Southern Cone Initiative to Control/Eliminate Chagas Disease, as well as the PAHO-supported salt fluoridation program in Jamaica. (The 17 case studies were selected by the Center for Global Development's What Works Working Group and published in 2005 as Millions Saved: Proven Successes in Global Health.)
It is tempting—and perhaps legitimate—to ask whether all the health interventions used in PAHO's technical cooperation programs would pass the test of cost-effectiveness. The results of such a test would, of course, be relative; some would emerge as more cost-effective than others. But in reality, the data required to make such assessments often do not exist or are at best difficult to identify. To cite two examples from other articles in this issue: How would we meaningfully assess the cost-effectiveness of Fique Sabendo, a public service campaign that seeks to reduce HIV/AIDS rates by encouraging all sexually active Brazilians to get tested? How would we measure the cost-effectiveness of efforts to encourage healthier lifestyles (in a holistic sense) through health-promoting schools? Does the difficulty of demonstrating the cost-effectiveness of these programs diminish their worth?
To their credit, the Disease Control Priorities Project and other proponents of cost-effectiveness analysis acknowledge that it is only one tool among many that should be used in public health policymaking. Other criteria-epidemiological, medical, political, cultural, and ethical-play a role as well. In its various reports, the Disease Control Priorities Project insists that the principle of equity should be a separate and equally important criterion in allocating health resources. This is particularly important in Latin America and the Caribbean, where "macro" indicators of health have risen steadily in recent decades but millions of people continue to suffer illness and premature death due to dramatically unequal access to health. Health inequity is an enduring problem that cannot be resolved through technical means. It requires attention to the social determinants of health as well as special efforts to target those who are in greatest need.
One of the key messages of the Disease Control Priorities Project is a hopeful one for those concerned about equity: Rich and poor countries alike can improve (and have improved) their populations' health through "technical progress," that is, by applying the appropriate knowledge and technology to health problems. Developing countries do not need to wait for long-term socioeconomic gains to achieve better health (indeed, good population health is a requisite for socioeconomic development). Fortunately, PAHO and its member countries understand this and are currently developing a new Health Agenda for the Americas that will define our region's collective health priorities and actions over the next 10 years. As we progress in this effort, we would do well to examine closely the findings of efforts like the Disease Control Priorities Project while embracing equity and solidarity as our guiding principles.
Mirta Roses Periago
Director,
Pan American Health Organization
Articles:
HIV: What You Know Can Help You
Genetics in the Service of the People
Columns:
First Word
Setting priorities
in health
Last Word
Unhealthy competition
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