HEALTH CARE/Joan Retsinas

Costing Out Health in the Developing World

"Cheap health" sounds like an oxymoron. In the developed world, it is.

A sophisticated armamentaria keeps us First-Worlders healthy: organ transplants, bypass surgery, multi-drug regimens. Every new advance rates a column in the New York Times, alerting potential patients to this new find -- and a mention in the Wall Street Journal, alerting potential investors to another new find. We who are well-fed, live in orderly societies and drink clean water think of medical advances as expensive entitlements.

In the developing world, though, public health measures can be inexpensive: speed bumps, aspirin, midwives.

Researchers (346 of them, from 34 countries) have turned an economic spotlight on medical expenditures. The Disease Control Priorities Project has issued Disease Control Priorities in Developing Countries, Second Edition ( Funded in part by the Gates Foundation, this tome compares a laundry list of 319 interventions, ranging from coronary bypass surgery to vaccinations to speed-bumps.

The researchers did something startling, and, to American eyes, almost politically incorrect: They did "cost-benefit" analyses of each expenditure. To do so, they made assumptions about life. They began with the premise that the quality of life varies, depending on illness and disability. All lives do not deliver the same "quality" to the individual. Nor do all lives contribute the same value to the nation.

Disability and illness, including nonfatal illnesses, matter; and a statistical investigation into the cost-effectiveness of an intervention should consider the impact on disabilities and illnesses. A life circumscribed by blindness or respiratory distress should not "count" the same as a disability-free, disease-free life. Age, too, matters: An intervention that saves the life of an octogenarian, giving perhaps 2 or 3 additional years, does not yield the same benefit as one that saves the life of a middle-aged woman.

The conclusion of the report was obvious: public health measures in the developing world should not focus exclusively on "saving lives," but on increasing disability-adjusted life-years (DALYs). So this report does not simply rate the ability of an expenditure to save lives, but "costs out" that intervention in terms of DALYs. We Americans who debated the fate of Terri Schiavo rarely discussed the cost-benefit of the tubes that sustained her.

The findings point to comparatively inexpensive interventions with high DALY payoff. Consider speed bumps. In congested urban areas in the developing world, traffic is a kamikaze challenge. Speed bumps slow traffic, thereby reducing the number of accidents that kill and maim. The researchers peg the cost of speed-bumps at $5 for every DALY.

In parts of the world as many as 30% of the population is blind, from trachoma. An eyelid operation that can prevent blindness would cost $39 per DALY. Aspirin and beta-blockers will save lives -- a cheaper intervention per DALY than coronary bypass surgery, where the tab tops $35,000 per DALY. Midwives improve the rate of healthy deliveries: In the developing world, the cost-effectiveness of midwives will be higher than that of expensive technology, which the nations cannot afford.

In a companion volume, the researchers reported success stories. Ghana saw accidents drop at busy intersections by 50% when it introduced speed bumps. In 1996, seven African nations reported 60,000 cases of measles. By 2000, the caseload had plummeted to 117. The reason: inoculations. When China introduced iodized salt, iodine-deficiency in children dropped from 20% to 9%. Sri Lanka's maternal mortality rate is 60 per 100,000 live births (that of Asia is 330 per 100,000 live births). Part of the reason: a reliance on midwives.

Although economics is dubbed the "dismal science," this economic tome offers hope. The report gives leaders in developing nations some evidence-based guidelines as they struggle to raise the health of their populace on limited budgets.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email

From The Progressive Populist, May 15, 2006

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