I always enjoy some good malaria cost-effectiveness chat, however I think we need to move beyond prioritisation of the roll-out of health interventions at the global/donor level. While there is a place for generalised cost-effectiveness analysis, on the whole it’s better to think of cost-effectiveness not as a generalisable property of a technology but as a product of the technology and the context. There is no doubt malaria vaccination (R21 or RTS,S) will be highly cost-effective in some populations and less so in others. The same goes for bed nets and SMC due to mosquito type, seasonality and many other factors. Plus, as others have said, the original post too often treats malaria interventions as alternatives when, in many cases, more important malaria planing will be about where to focus interventions rather than which technology to chose.
There are two broad ways to approach linking cost-effectiveness with context: i) large-scale multi-country, multi-intervention, cost-effectiveness analyses at national or sub-national level. There is a place for this and many organisations do great work in this space, including Givewell. ii) Countries undertake their own analyses and set priorities compared to other healthcare investment options, not so much other malaria interventions both other healthcare. For highly endemic regions, it could well be that nets and vaccination are both very cost-effective and that an MoH should prioritise this over, say, certain oncology treatments. If the MoH still accepts donated vaccine or earmarked vaccine financing (and why wouldn’t it), then the donors aren’t really buying more people vaccinated, they’re buying more people treated for cancer—which might still be a positive contribution, but not what they think they are buying and not the best option.
From where I’m sitting, it seems that global health is rightly moving away from campaigns to back single technologies or disease areas and looking at how to provide less fragmented and more foundational support. That’s not as easy a story to tell to philanthropic donors but there’s increasing recognition of the harm that hundreds of separate earmarked offers of support for this technology or that disease area does. Even in most low-income countries, the government is the main funder of health services and those looking to help should identify appropriate auxiliary programmes to support, not displace or distract.
(Note all the above refers to *roll-out* of vaccines. For R&D a best-guess overall cost-effectiveness estimate makes sense and so does intervention-focused advocacy/engagement.)
Tl;dr it is usually better to consider cost-effectiveness of technologies as context-dependent, rather than an property of the technology, and we should consider systems support over financing technologies that would/should have been bought with domestic financing anyway. We need to empower local planners to consider the full range of health investment options, not try to decide for them.
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A few bonus comments on some questions in the post:
“Is there a reason why including a mixture of cost-effective and somewhat less cost-effective interventions together could be a high-impact outcome?”
- Yes, for example if the combination of interventions brings local R below 1. But it might also be less than expected too. Effectiveness for infectious diseases is non-linear so it’s better to simulate transmission effects. This has been done by several groups.
“Will the cost-effectiveness of bednets/SMC decline over time (e.g. because of diminishing marginal returns of some sort)? If so, might vaccine cost-effectiveness overtake it? “
- Yes, insecticide or drug resistance can result in declining effectiveness of bed nets or prophylaxis.
And on the age-factor of bed net vs vx cost-effectiveness—I would certainly expect this to be taken into account in all decent modelling so would be wary of over correcting in botecs.
Thanks for this considered response Jason.
I would summarise your overall message as “we’re not ready for this yet” and I would partly agree. But EA community and orgs could be part of developing the solution and influencing other donors. We shouldn’t consider EA orgs as separate from bilateral, multilateral or other philanthropic donors. At this point, EA is not an insignificant voice in the global health ecosystem. Also the shift doesn’t need to happen for the sector as a whole, it could be country by country and some countries probably are ready for such an approach. We’re discussing it with a couple.
To some of your more specific points:
I disagree that fungibility is the biggest challenge. Excepting cases of corruption, this simply means the country is effectively choosing the spend on other priorities. Indeed some folks in CGD have argued against the marginal aid approach precisely because they favour the fungible quality of current donations. This isn’t my view but it speaks to an opinion I do share, which is that, in many cases, countries should be given more control over healthcare priority setting.
Of course a common concern is whether country institutions are good faith actors and have the necessary capabilities to adopt a marginal aid approach. This will differ between countries and can be considered on a case by case basis—and will change over time (inc with donor support to strengthen priority setting capabilities, ensure comprehensive delivery on the core package etc). No country administrations are perfect, including in many donor countries, but we need a better framework for how countries transition from receiving support to deliver essential health services to doing so themselves. This is an active process in many countries today (inc where EA supported orgs operate) and has been exacerbated by the recent squeeze on global development financing.
Lastly, you touch on some practical challenges with funding marginal services. I agree that donors with country presence will be best placed participate in the coordination mechanisms necessary for a marginal aid approach, but EA individuals or orgs could i) choose to support intermediaries. There are none at present but it’s not hard to imagine existing organisations adopting the approach. For example, the Global Financing Facility (GFF) has done much to work with countries and donors on better coordinated and prioritised investments (with some success and some challenges). ii) they could also choose to support catalytic investments to strengthen country capabilities rather than earmarked aid for specific services.
I would challenge EAs to rethink the rationale for doing global level analysis to set health priorities in low income countries. In absence of local prioritisation it can be better than nothing, and initiatives like the Disease Control Priorities Project have been helpful. But such approaches are both technically and philosophically limited, and inferior to building local capabilities. Before too long, and with the growing decolonisation/localisation movements, I expect this top-down approach will seem increasingly out-dated.