Chapter 343 - The Moral Imperative Towards Cost-Effectiveness[3]

It can also be seen that due to the skewed distribution, the most effective interventions produce a disproportionate amount of the benefits. According to the DCP2 data, if we funded all of these interventions equally, 80% of the benefits would be produced by the top 20% of the interventions.

It must be noted that these are merely estimates of cost-effectiveness and there may be less variance between the real, underlying cost-effectiveness values. However, even if the most effective interventions are a tenth as effective as these figures suggest and the least effective are ten times better than they appear, there would still be a factor of 150 between them.

Moreover, there have been health interventions that are even more effective than any of those studied in the DCP2. For example, consider the progress that has been made on saving lives lost to immunization preventable illness, diarrhea, malaria, and smallpox, summarized in the following chart:[5]

In all cases, our interventions have led to at least 2.5 million fewer deaths per year. To aid the reader in comprehending the scale of these achievements, I have added a final bar showing the average number of deaths per year due to war and genocide together over the 20th Century (2.3 million). Thus, in each of the four of these disease areas, our health interventions save more lives than would be saved by a lasting world peace.

Moreover, these gains have been achieved very cheaply. For instance in the case of smallpox, the total cost of eradication was about $400 million.[6] Since more than 100 million lives have been saved so far, this has come to less than $4 per life saved — significantly superior to all interventions in the DCP2. Moreover, the eradication also saved significant amounts of money. Approximately $70 million was being spent across developing countries per year in routine vaccination and treatment for smallpox, and more than $1,000 million was lost per year in reduced productivity.[7] Even just in the United States, smallpox vaccination and vigilance cost $150 million per year before eradication.8 The eradication programme thus saved more lives per year than are lost due to war, while saving money for both donors and recipients, paying back its entire costs every few months. It serves as an excellent proof of just how cost-effective global health can be.

The moral case

In these examples, we have seen how incredibly variable cost-effectiveness can be within global health. The least effective intervention in the HIV/AIDS case produces less than 0.1% of the value of the most effective, and if we are willing to look at different kinds of disease, this fraction drops to less than 0.01%. Ignoring costeffectiveness thus does not mean losing 10% or 20% of the potential value that a health budget could have achieved, but can easily mean losing 99% or more. Even choosing the median intervention can involve losing 85% of the potential value.