Chapter 341 - The Moral Imperative Towards Cost-Effectiveness[1]

Cost-effectiveness is one of the most morally important issues in global health. This claim will be surprising to many, since conversations about the ethics of global health usually focus on more traditional moral issues such as justice, equality, and freedom. While these issues are also important, they are often overshadowed by cost-effectiveness. In this note, I shall explain how this happens and what it means for global health.

The cost-effectiveness landscape in global health

The importance of cost-effectiveness is due to the fact that it varies so much between different interventions. Let us start with a simplified example to show how this becomes a moral consideration. Suppose we have a $40,000 budget which we can spend as we wish to fight blindness. One thing we could do is to provide guide dogs to blind people in the United States to help them overcome their disability. This costs about $40,000 due to the training required for the dog and its recipient.[1] Another option is to pay for surgeries to reverse the effects of trachoma in Africa. This costs less than $20 per patient cured.[2] There are many other options, but for simplicity, let us just consider these two.

We could thus use our entire budget to provide a single guide dog, helping one person overcome the challenges of blindness, or we could use it to cure more than 2,000 people of blindness. If we think that people have equal moral value, then the second option is more than 2,000 times better than the first. Put another way, the first option squanders about 99.95% of the value that we could have produced.

This example ill.u.s.trates the basic point, but it is also unrealistic in a couple of ways. Firstly, it is rare for treatments in the United States to be traded off against treatments elsewhere. A health budget is normally more restricted than this, with a constraint that it is only spent on people in a particular rich country, or only spent on people in a designated category of poor countries. Secondly, we often have a spectrum of options. Thirdly, and most importantly, the class of interventions under consideration is often broad enough that it is difficult to make direct 'apples to apples' comparisons between the effects of two interventions.

Health economists and moral philosophers have an answer to the third of these issues. They use measures of health benefits that are powerful enough to be able to compare the values any two health benefits. The standard measure in global health is the Disability Adjusted Life Year (DALY). This measures the disvalue of health conditions in terms of the number of years of life lost due to the condition plus the number of years lived with disability multiplied by a number representing the severity of the disability. For example, a condition that caused one to die 5 years prematurely and to live the last 10 years with deafness would be valued as 5 + (10 x 33.3%) = 8.33 DALYs.