However, I also found the way this was written to be somewhat confusing. Specifically, are the 4 main ideas your ideas, or are they laid out within the report? And how do those ideas fit in with the other figures represented in 1-9?
The first proposal listed is a consulting company that is going to generate profits at hospitals in developed countries and provide free services to hospitals in developing countries. It’s unclear to me that a new consultancy would be profitable. Certainly, many such organizations already exist. Why would the market not have already filled this need? For developing countries, I believe that non-profits such as Red Cross already provide these services as well. So it’s also not clear to me that this is an unmet need. Also, consulting across cultures is very, very tough. All your projected gains can be eaten up by these cultural barriers.
The third proposal is advertising on social media for health products. Could you explain why this would be profitable?
Throughout the post parts 1-9 you cite $ per DALY figures, but I’d be very curious to understand what the evidence base is for any of these. I tried chasing one down just to get an idea for myself. Under part 5:
Screening for hypertension and cholesterol in areas where treatment is affordable ($4/QALY) (p. 397)
This appears to reference this study (or maybe this is a summary of the study?):
It states that in Mexico this screening costs $3.57 per QALY compared to the usual standard of care, so that is a match to the summary. It actually says the cost is negative in South Africa.
I don’t have a great deal of familiarity with these types of studies. I’m curious if this is such a great opportunity why it hasn’t already been acted upon, do you have thoughts on this?
A few thoughts I had that may or may not relate: Regarding the community health workers, maybe practices vary by country, but if they are employed by the government vs. an NGO that would make a difference to the type of intervention e.g. direct vs. advocacy. There also may be challenges with scaling if community health workers only have a certain scope (e.g. they see people in urban settings but the need is in rural settings). The very low cost is contingent on the treatment drug being very low cost, $9 per year, and when the drug costs $149 per year then $2000-5000 per QALY, which is obviously much less impressive. It would be important to know how realistic that drug cost is for the relevant patients. Finally, this is supposed to be an improvement to the current standard of care, it would be helpful to understand that standard of care, which I don’t see laid out in the study.
Thanks! The four project ideas are mine but all the aspects that they cover are from the collection, reported as cost-saving or highly cost-effective. For example, clinic consultancy is not mentioned but hepatitis B (>$13.22/QALY, vol. 3, p. 158) or tetanus toxoid ($3.61/DALY, vol. 8., p. 424) vaccines are. These are examples of the figures from 1-9, which I am not citing for each aspect due to concision. I am hypothesizing that joining them can increase the cost-effectiveness by decreasing the marginal cost of each aspect.
If such consultancies exist in the developed and developing countries, then either they are profitable or useful. Joining and supporting them can be an opportunity and the organization does not need to be developed from scratch. Cultural accessibility could be something that can be either already present, e. g. at the Red Cross or called for in a grant application.
The social media health products would be profitable to social media platforms. Large proportion of Open Philanthropy recommendations are for Good Ventures, a philanthropic foundation of Dustin Moskovitz and Cari Tuna. Dustin Moskovitz owns a share in Facebook (responsible for much of the wealth in EA). Thus, advertisement on Facebook could be, in turn, profitable to this foundation.
I almost entirely deferred to experts on the DALY figures. This example suggests that in this case, the $/DALY was not an overestimate for a subset of countries and that cost-saving treatment is possible in specific contexts. I estimated that the benefit-cost ratio of over 70 is comparable to <$20/DALY. (A Brazilian vector control program for the Chagas disease “cost US$57 per DALY averted or saved US$25 for every dollar spent on prevention” (vol. 5, p. 204). 25/20*54=67.5). I believe that this is because the benefit accrues to the country as a whole, in healthcare savings, productivity, etc, while it is assumed to be paid by a sole donor.
If loans are offered to the government (who would run efficient programs in cost-effectiveness priority settings), then this seems like a great opportunity to the funders. From glancing at major development banks websites, targeting cost-effective healthcare opportunities is not emphasized in their agenda, while infrastructural and regulatory investment is. So, my thought is that finding a loan provider, suggesting cost-saving healthcare opportunities and assisting the government with effective spending of these loans can best address these opportunities, if they are yet uncovered.
Possibly, this has not yet been acted upon due to the overall reluctance of prevention, if this is relates to lifestyle. In this example, hypertension could relate to unhealthy diet and limited exercise. People may hesitate to be screened since that could suggest a lifestyle change. Some decisionmakers may reflect the public attitudes, so changes are relatively slow. Lobbies can be another reason. For example, tobacco lobby spending can prevent taxation or regulation of tobacco products. Fear of deeper issue uncovering could be a third, more rare, cause. For example, paying vineyard workers in alcohol in South Africa has been banned but screening could suggest that this is being done, even if the hypertension cause is unrelated.
I think that CHW recommendations should be generally more direct—it can be assumed that government is interested in pro bono upskilling of the workers and does not need to be extensively lobbied to share a training resource (e. g. online), unless they would have to pay for the training. Practices that are locally useful should be suggested to both government and NGO employees. I think that the easiest would be to develop some online training courses that have some shared core and ‘specializations’ for different settings (rural, urban, by different community characteristic). Employees would not need to study for what they already know and would learn what they are missing.
There is the question whether to take into account the drug production cost or the price paid by the patient/healthcare provider, if that is subsidized or free. Then, the cost-effectiveness can easily vary by an order of 10 or more.
Unless otherwise specified (e. g. providing artesunate rather than quinine for severe malaria), the cost-effectiveness of is in comparison to non-intervention, which is assumed as the current practice (or was in some of the studies). The volumes have been written in 2015-2017, so an updated understanding on what has improved and is remaining can be valuable. My guess is that about 80% of the need is still unmet, except for infectious diseases, where maybe 40% can be already covered, due to pharmaceutical company commitments and large philanthropy, such as the Bill and Melinda Gates Foundation, funding.
Thanks for posting, I found this interesting.
However, I also found the way this was written to be somewhat confusing. Specifically, are the 4 main ideas your ideas, or are they laid out within the report? And how do those ideas fit in with the other figures represented in 1-9?
The first proposal listed is a consulting company that is going to generate profits at hospitals in developed countries and provide free services to hospitals in developing countries. It’s unclear to me that a new consultancy would be profitable. Certainly, many such organizations already exist. Why would the market not have already filled this need? For developing countries, I believe that non-profits such as Red Cross already provide these services as well. So it’s also not clear to me that this is an unmet need. Also, consulting across cultures is very, very tough. All your projected gains can be eaten up by these cultural barriers.
The third proposal is advertising on social media for health products. Could you explain why this would be profitable?
Throughout the post parts 1-9 you cite $ per DALY figures, but I’d be very curious to understand what the evidence base is for any of these. I tried chasing one down just to get an idea for myself. Under part 5:
Screening for hypertension and cholesterol in areas where treatment is affordable ($4/QALY) (p. 397)
This appears to reference this study (or maybe this is a summary of the study?):
https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2015.0349
It states that in Mexico this screening costs $3.57 per QALY compared to the usual standard of care, so that is a match to the summary. It actually says the cost is negative in South Africa.
I don’t have a great deal of familiarity with these types of studies. I’m curious if this is such a great opportunity why it hasn’t already been acted upon, do you have thoughts on this?
A few thoughts I had that may or may not relate: Regarding the community health workers, maybe practices vary by country, but if they are employed by the government vs. an NGO that would make a difference to the type of intervention e.g. direct vs. advocacy. There also may be challenges with scaling if community health workers only have a certain scope (e.g. they see people in urban settings but the need is in rural settings). The very low cost is contingent on the treatment drug being very low cost, $9 per year, and when the drug costs $149 per year then $2000-5000 per QALY, which is obviously much less impressive. It would be important to know how realistic that drug cost is for the relevant patients. Finally, this is supposed to be an improvement to the current standard of care, it would be helpful to understand that standard of care, which I don’t see laid out in the study.
Thanks! The four project ideas are mine but all the aspects that they cover are from the collection, reported as cost-saving or highly cost-effective. For example, clinic consultancy is not mentioned but hepatitis B (>$13.22/QALY, vol. 3, p. 158) or tetanus toxoid ($3.61/DALY, vol. 8., p. 424) vaccines are. These are examples of the figures from 1-9, which I am not citing for each aspect due to concision. I am hypothesizing that joining them can increase the cost-effectiveness by decreasing the marginal cost of each aspect.
If such consultancies exist in the developed and developing countries, then either they are profitable or useful. Joining and supporting them can be an opportunity and the organization does not need to be developed from scratch. Cultural accessibility could be something that can be either already present, e. g. at the Red Cross or called for in a grant application.
The social media health products would be profitable to social media platforms. Large proportion of Open Philanthropy recommendations are for Good Ventures, a philanthropic foundation of Dustin Moskovitz and Cari Tuna. Dustin Moskovitz owns a share in Facebook (responsible for much of the wealth in EA). Thus, advertisement on Facebook could be, in turn, profitable to this foundation.
I almost entirely deferred to experts on the DALY figures. This example suggests that in this case, the $/DALY was not an overestimate for a subset of countries and that cost-saving treatment is possible in specific contexts. I estimated that the benefit-cost ratio of over 70 is comparable to <$20/DALY. (A Brazilian vector control program for the Chagas disease “cost US$57 per DALY averted or saved US$25 for every dollar spent on prevention” (vol. 5, p. 204). 25/20*54=67.5). I believe that this is because the benefit accrues to the country as a whole, in healthcare savings, productivity, etc, while it is assumed to be paid by a sole donor.
If loans are offered to the government (who would run efficient programs in cost-effectiveness priority settings), then this seems like a great opportunity to the funders. From glancing at major development banks websites, targeting cost-effective healthcare opportunities is not emphasized in their agenda, while infrastructural and regulatory investment is. So, my thought is that finding a loan provider, suggesting cost-saving healthcare opportunities and assisting the government with effective spending of these loans can best address these opportunities, if they are yet uncovered.
Possibly, this has not yet been acted upon due to the overall reluctance of prevention, if this is relates to lifestyle. In this example, hypertension could relate to unhealthy diet and limited exercise. People may hesitate to be screened since that could suggest a lifestyle change. Some decisionmakers may reflect the public attitudes, so changes are relatively slow. Lobbies can be another reason. For example, tobacco lobby spending can prevent taxation or regulation of tobacco products. Fear of deeper issue uncovering could be a third, more rare, cause. For example, paying vineyard workers in alcohol in South Africa has been banned but screening could suggest that this is being done, even if the hypertension cause is unrelated.
I think that CHW recommendations should be generally more direct—it can be assumed that government is interested in pro bono upskilling of the workers and does not need to be extensively lobbied to share a training resource (e. g. online), unless they would have to pay for the training. Practices that are locally useful should be suggested to both government and NGO employees. I think that the easiest would be to develop some online training courses that have some shared core and ‘specializations’ for different settings (rural, urban, by different community characteristic). Employees would not need to study for what they already know and would learn what they are missing.
There is the question whether to take into account the drug production cost or the price paid by the patient/healthcare provider, if that is subsidized or free. Then, the cost-effectiveness can easily vary by an order of 10 or more.
Unless otherwise specified (e. g. providing artesunate rather than quinine for severe malaria), the cost-effectiveness of is in comparison to non-intervention, which is assumed as the current practice (or was in some of the studies). The volumes have been written in 2015-2017, so an updated understanding on what has improved and is remaining can be valuable. My guess is that about 80% of the need is still unmet, except for infectious diseases, where maybe 40% can be already covered, due to pharmaceutical company commitments and large philanthropy, such as the Bill and Melinda Gates Foundation, funding.