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Sebastian Roing

WHO-CHOICE: a look at the effectiveness of different health interventions

This post is a summary of the work and results of WHO-CHOICE[1] , a World Health Organisation program designed to help decision-makers choose interventions that are cost-effective.

What is the most cost-effective way to combat malaria; distributing bed nets to 80% of a population or distributing bed nets to 50% combined with the spraying of walls with insecticide? How are public officials, faced with such problems of designing health systems, to prioritise between different combinations of interventions? How can we reduce the cost of research for developing countries that need to consider new health interventions within their existing cluster of interventions? WHO-CHOICE is a World Health Organisation program charged with 

helping decision-makers choose more cost effective interventions

. They have published some impressive research on a wide range of health-related interventions, stretching from blindness and visual impairment to traffic injuries. Used in combination with other results, this body of research can help decision-makers prioritise more cost effective health interventions.

Imagine you are in charge of a country’s health authority and you want to start a new program for the vaccination of schoolchildren against polio. To know for sure what all the effects of such a program would be, you would have to compare the scenarios with and without the program. But if you decide to implement the program then you will never know what the outcome would have been had you not implemented the program. You will never know the counterfactual. The pervasive problem of not having a counterfactual has no doubt disheartened many social scientists, including myself. How are we to know the effects of an intervention if we don’t know the alternative reality in which the intervention wasn’t conducted? And what if the intervention is too complicated for robust statistical methods such as randomised control trials? How are we even to try and construct the millions of counterfactuals that would be required to analyse the set of combinations of different interventions in public health? Inevitably, policy will sometimes be a shot in the dark, but there is more reason to be optimistic than one would think.

More and more research focuses on cost effectiveness, and produces results in terms of “bang for your buck”; how many disability adjusted life years (DALYs) can be averted per dollar. Previous research has often assessed DALYs averted relative to the cost of an incremental intervention within an existing health system. An example of this would be to look at how many years of blindness can be averted by expanding trachoma antibiotics coverage from 50% to 80%. (1 DALY represents 1.67 years spent with total blindness [2] ). Comparing the result with research on other interventions would enable the decision-maker to embark on the program which promises the best health outcome.

There are a number of problems with this method:

The effectiveness of existing interventions is not considered. It is possible that abolishing the distribution of antibiotics entirely in order to reallocate the resources into operating victims of trachoma would be more cost effective.

The result of the research is only relevant in a setting where there already is 50% coverage of trachoma antibiotics. Other countries could not use the research since they invariably have different existing interventions, and other demographic and epidemiological characteristics.

Following directly from the second problem, a country with already limited resources to spend on health interventions won’t be able to research the many possible health interventions available.

Generalised Cost Effectiveness Analysis (GCEA)

 takes its starting point in a hypothetical “null” scenario where there are no existing health interventions. This may sound very theoretical, but it comes with a few advantages ( but also a few problems, which I will talk about further on). GCEA is only one of the many methodologies and tools of WHO-CHOICE. I will focus on GCEA in this blogpost. Why? Because it formed the basis of a series of interesting articles which were published in the British Medical Journal in 2012, and because it addresses the problems I outlined in the previous section. If you want the full story on GCEA methodology it is available here[3].

I should emphasise that WHO-CHOICE is a program which encompasses many people and many different tools. A typical WHO-CHOICE project would be conducted in consultation with the health ministry of a country, and aim to address the restrictions of that health system, for example, by focusing in on specific costing problems in the scaling up of vaccination coverage.

The first thing we need to recognise is that different countries have different epidemiological and demographic characteristics. These characteristics influence the outcome of a health intervention. However, when conducting GCEA, the WHO-CHOICE program divides the globe into 14 sub-regions with similar characteristics such as to make comparisons of health interventions across countries within these groups meaningful. It was noticed at an early stage that choosing the appropriate basis for the grouping of these sub-regions is one of the major challenges of the approach.

The second thing GCEA does is remove from their model all existing interventions for the countries in a sub-region. This essentially means estimating the cost-effectiveness of all existing, relevant interventions. The point is to get to a common point of reference, the “null” scenario, and then compare the cost-effectiveness of combinations of interventions to assess which diseases/issues should be prioritised to achieve the best health outcome with the available resources. More technically, GCEA is an exercise in mathematical modelling and the method allows for non-linear combination effects of different interventions. WHO-CHOICE uses a range of methods to establish the effects of existing interventions which are outside the scope of this post.

The GCEA method therefore addresses the three problems outlined above:

GCEA considers the effectiveness of existing interventions. It is also able to consider the existing health system together with combinations of new interventions.

The result is relevant in many settings. The cost-effectiveness of health interventions relative to the null is comparable across countries. Countries are able to consider health interventions in combination with other interventions which are specific to their country.

This lowers the cost of research for each individual country since results are transferrable. It also helps countries to prioritise between different diseases/issues in terms of resulting benefits.

Three examples of other tools used by WHO-CHOICE are listed below. If you want to know more about these visit the 

 database of the costs of different types of interventions in different sub-regions. The aim has been to produce resource needs estimates for multiple countries – so called global price tags – for a number of disease and programme-specific analyses.

, a publicly available software. Members of WHO-CHOICE were part of the development of this software. The OneHealth Tool is a modular software which allows for program-specific costing and supports the costing, financing and national strategy development for the health sector. For example, what hospital machinery to invest in and where to place it. Country specific analyses are conducted in co-operation with health ministries and experts.

 software, which models the effects of interventions depending on where they are executed geographically, and how many people have access to them. It is based on the type of optimization problem which maximises access to clean water depending on where the wells are dug in an area with clusters of people.

The majority of the results from the many publications of WHO-CHOICE relate to specific interventions and the relative cost-effectiveness of these. It has nevertheless produced a few general conclusions. An interesting example is that 

countries should try to expand high-priority interventions to near-universal coverage before considering second-priority interventions on a limited scale

. An example of this would be to first expand vitamin A and zinc fortification to near-universal coverage before trying to introduce breast cancer treatment (ranked primarily in terms of cost-effectiveness, but inequality and other considerations should also be made). This result comes from WHO-CHOICE’s newest publication “Making fair choices on the path to universal health coverage” (2014).

In 2012, the program published an impressive number of mathematical modelling studies in the British Medical Journal. These compared the cost-effectiveness of health interventions in sub-Saharan Africa and South East Asia. The conclusions and most cost-effective interventions of these reports can be found in the table below Please note that the interventions have not been thoroughly tested, so we should be cautious about the data and the estimates.

It is clear that the cost-effectiveness varies dramatically between different types of interventions, which is also a conclusion reached by Giving What We Can[4] . We can increase the impact of giving more than 1,000 times by choosing the most effective interventions.

The most effective intervention in both sub-Saharan Africa and South East Asia was a strategy to combat vision impairment in the form of chronic otitis. Estimates suggest that only $14 is needed to avert one DALY by distributing antibiotics with 50% coverage. This estimate is comparable with the results of the four charities that Giving What We Can recommends. However, the estimate has been reached using different methods.

Furthermore, this result should perhaps not be taken from the individual donor’s perspective, but rather from the perspective of someone who can influence the health system of that country. A previous post [5] on this blog discusses if blindness is an opportunity for effective giving. The lack of effective charities suggests that individual donors should rather look elsewhere to have confidence in finding effective donation targets.

Discussion and new directions of research

How reliable are the estimates from GCEA and how rigorous is their methodology? As you may suspect, the results of their mathematical modelling studies are not as reliable as a good randomized control trial. However, we need to remember that the research has been conducted from an entirely different perspective. It tries to estimate the effect of an intervention before it has taken place. As with economic and monetary policy, this is often an unavoidable difficulty.

I think two problems with the generalised cost effectiveness methodology are worth highlighting:

It is not exactly clear how it asserts causality in some interventions. Mostly, a combination of expert opinion and mathematical modelling is used to reach estimates of cost effectiveness. The effects of an intervention therefore run a larger risk of being contaminated by some other event which happened simultaneously.

Secondly, there is clearly a trade-off between making the results transferrable across countries and reliability. This ties into the problem of choosing an appropriate basis for the 14 sub-regions. WHO-CHOICE articulates this problem elegantly:

“In some sense, there is a trade-off between making CEA {cost effectiveness analysis} information precise to a given context and the time and resources required for that contextualization. Our preference for the more general use of CEA is an indication of how we see the outcome of that trade-off. We believe that the more general use of CEA, to inform sectoral debates on resource allocation, is where CEA can make the greatest contribution to health policy formulation.”[6]

In this context, it would be very interesting to see some future research on diseases not yet covered by the series published in the British Medical Journal, such as malaria, HIV/AIDS and intestinal worms. One general benefit of the WHO-CHOICE program is 

the identification of issues where additional spending and interventions can make a huge difference

. While the individual donor should focus attention on more reliable research on specific charities, such as the ones recommended by Giving What We Can, 

WHO-CHOICE can help guide research into the most effective areas in the future

WHO CHOICE: Guide to Cost-Effective Analysis

How to make the most of tax deductibility in the US

Giving What We Can is not only about donating to the most effective causes, but also donating in a way that maximizes the impact of a donation. One of the ways of doing this is by using tax deducibility. The aim of the article is to explain to US taxpayers the key rules that govern charitable contribution deductions for the purposes of the US Federal Income Tax, as well as of the other alternatives, which enable you to make the most out of the donated money.

First of all, when deciding whether you would like to itemize your deductions, you need to remember that you will be giving up the standard deduction, which amounts to $6,200 in the 2014 tax year if your filing status is single. Therefore, for the charitable contribution deductions to be beneficial for the purposes of reducing the taxable income they should exceed that sum, otherwise you will end up paying more income tax. However, there is a long list of other itemized deductions that count towards the total, which can be used alongside your charitable contributions.

If you want to claim the deductions, you must file your income taxes using 

 and list your itemized deductions on Schedule A (in the same document).

The total of your deductions may be limited if your 

$300,000 if married filing jointly or qualifying widow(er)

See the instructions for Schedule A (Form 1040 above) for more information about this limit.

In order for a taxpayer to be able to deduct the charitable donations from their pre-tax income, there are certain criteria that the donor, and the charity, has to meet.

1. The donation must be made to an organization which is qualified to receive deductible contributions.

The examples of qualified organisations include:

Churches, synagogues, mosques and other religious organisations.

Nonprofit hospital and medical research organisations.

The status of a tax-exempt non-profit charitable organization benefits the donor by allowing him to deduct the contributions from his income for the federal tax purposes. The exceptions to this rule include the situations when the organization uses any of its net earnings to benefit a private shareholder or if it attempts to influence political campaigns or legislation.

The detailed criteria for the organisation to qualify can be found 

The easiest way to find out whether the status of an organisation enables you to deduct your contributions is to either ask the organisation itself or use the 

Deworm The World Initiative, Against Malaria Foundations and Project Healthy Children, charities which have been recommended by Giving What We can as some of the most-effective giving opportunities, are all exempt from federal income tax and exempt under section 501(c)(3) of the Internal Revenue Code, allowing you to rely on charitable contribution deductions.

2. The type of contribution will determine whether it is deductible.

The contributions which are not deductible for the tax purposes include:

A contribution to a non-qualified organization,

The part of a contribution from which you received or expect to receive a benefit,

In case you benefit from a charitable contribution, you can still deduct it from your income; however what you can deduct will be limited to the amount of contribution that is more than the value of the benefit you receive.

The rule of thumb is that you can deduct monetary contributions you make to, or for the use of, a qualified organisation.

Generally, your deduction for charitable contributions cannot be more than 50% of your AGI. Any charitable donation can also be carried forward and taken the next year for the period of up to 5 years.

, you are entitled to deduct the value of that property on the tax return for that year. The similar limit of no more than 50% of your AGI applies to the donations in the form of property.

The amount of your charitable contribution is based on the fair market value of the property at the time of the donation.

There are some limitations on claiming the deductions from donations in the form of capital gain property.

If you are contributing property that would have yielded a long-term capital gain in a sale, then the deduction for the contribution is limited to 30% of your adjusted gross income in the year of donation if the donee is a public charity, and limited to 20% if the donee is a private foundation.

If the property which you decided to donate would have produced an 

 or a short-term capital gain (one year or less) had you sold it, then you are eligible to deduct only the adjusted basis in the property. This means that the amount of deduction is the property’s basic value, and not the amount of its appreciated market value.

The special lower 30% limit on what you can deduct applies for capital gain property if and only if you chose not to reduce the fair market value of the property by the amount that would have been long-term capital gain if you had sold the property.

Every dollar donated to a qualifying charity can be deducted from your estate tax. If you donate $1 million, then $1 million can be deducted from your estate tax. Additionally, there’s no limit to how much you can deduct.

As a result, by leaving testamentary gifts to charitable organisations, individuals can often increase the amount of inheritance available for heirs through tax deductions. A donation not only reduces the amount of the tax owed dollar for dollar, it also reduces the size of the estate to be taxed.

For example, an estate worth $11 million, with $1 million exempt from taxes will owe $5.5 million in estate taxes (55% tax rate on $10 million), leaving $5.5 million for the beneficiaries.

However, if the owner of the estate leaves testamentary gift amounting to $1 million, the taxable income is reduced, and results in a $4.95 million tax total. The estate is also able to rely on a dollar-for-dollar tax deduction for the donations, reducing the tax bill to $3.95, thus increasing inheritance by $550.000.

If you want to deduct a cash contribution, from you income, for the tax purposes, you need to provide evidence that the donation was made.

You must maintain a bank record, payroll deduction records or a written communication from the organization containing its name, the date of the contribution and amount of the contribution. For text message donations, a telephone bill will meet the record-keeping requirement if it shows the information mentioned above.

If your contribution is $250 or more, you need to have an 

 of your contribution from the qualified organisation.

Bear in mind that, when figuring out the amount of contribution, you should not combine the contributions you made over the course of the year; each donation is separate for the tax purposes.

Charitable contributions can significantly affect the amount of estate tax that you need to pay. Even though charitable contributions are not as beneficial for the taxpayer with regard to the amount of payable US Federal Income Tax, tax deductions can still give benefits to the taxpayer - this is addition to the great benefits donations bring to the causes supported. When filling in taxes, it is often well worth looking into what you can deduct and what is the best way of doing so.

Olga Kuznetsova

Can schistosomiasis be eliminated? Lessons from Coca-Cola and other stories.

In 2012, the World Health Assembly declared that elimination of schistosomiasis is feasible. It urged to speed up control and elimination programmes, and called on the World Health Organisation to guide member states in their efforts [1]. In line with its vision of “a world free of schistosomiasis”, the WHO put together a Schistosomiasis Plan, with the end goal to eliminate it as a public health problem by 2025, and to interrupt transmission in many areas by the same time. The Schistosomiasis Control Initiative has already carried out successful campaigns in several African countries, but there is still a while to go before complete elimination takes place. This article summarises the talk given by Dr. Michael French at the SCI 2014 Open Day, and discusses what needs to be done to eliminate schistosomiasis and what the SCI is doing to reach this goal.

Before we continue, we need to define what exactly is meant by “elimination”. At the moment, SCI’s efforts focus on controlling the disease morbidity and eliminating it as a public health problem, i.e. reducing the prevalence below a certain threshold, say, 1%. However, to achieve true elimination, transmission of the disease within a particular area has to be interrupted. For this, the disease has to fall below the “transmission breakpoint” – at which the level of infection is so low that it will inevitably die out. Elimination is then a less ambitious goal than eradication, i.e. bringing all the worldwide cases to zero, as has already been achieved for smallpox and nearly achieved for guinea worm and polio. For the moment there is no goal to eradicate schistosomiasis. For the rest of the article we will be talking about elimination of transmission.

So what is necessary to achieve elimination of schistosomiasis? For its past and ongoing projects, SCI used preventative chemotherapy (PCT) with praziquantel to control disease morbidity. However, more intensive measures are needed for elimination. In areas with a high burden of disease, children as well as adults in high-risk occupations are treated every year. However, even if there is a sharp drop in infection following treatment, there is still a certain amount of infection left in the population (indicated by the red double-headed arrow in the graph), and it is enough to allow re-infection during the year. With subsequent yearly PCT, indicated by green arrows, the number of cases drops but never quite falls below the transmission breakpoint.

What if instead it were possible to bring the infection close enough to zero from the very first round of PCT? In the long run, it would save a lot of time and resources. Because closing this gap will almost certainly require more than just PCT, a combined approach maximises the chances of interrupting transmission. For example, there are measures that could prevent infection in the first place. These include improvements in the quality of WASH (water, sanitation and hygiene), snail control (as snails are the intermediate host of the worms), behaviour change with an impact on water contact, and more novel approaches such as development of vaccines or new drugs.

To assess the effectiveness of preventative measures, work is being undertaken at Imperial College to explore the link between WASH and schistosomiasis infections. There are also randomized controlled trials carried out in Zanzibar and Burundi/Rwanda, with several arms of the trials analysing the effectiveness of snail control, enhanced treatment and improved WASH, in addition to the current chemotherapy. Another line of research is looking into vaccines. At the moment there are none commercially available, and even if the candidate compounds currently in clinical trials make it to the market, it will not be for several years. Successful vaccination depends on many factors, and the SCI are developing mathematical models to define which factors would make for optimal protection (e.g. what cross-section and proportion of the population to vaccinate, which life cycle stage of the worm to target, and the level of vaccine efficacy). All in all, these complementary approaches may help to eliminate schistosomiasis, but they are difficult to implement and in some cases not yet available.

What else can be done to improve treatment? One obvious idea is just to reach more people. At the moment no population receives 100% coverage with PCT. Although drugs are in plentiful supply, with millions of doses donated every year by pharmaceutical companies, treatment can be held up by problems with shipment and transportation of drugs within the target country. To address this problem of logistics, a coalition of pharmaceutical companies, logistics companies and NGOs have formed the NTD Supply Chain Forum. The Forum’s main task is ensuring that the drugs clear through customs and reach the national warehouses on time. Another potential solution is inspired by an unlikely company - Coca-Cola. In 2009, a collaboration began that started from the simple question: if Coca-Cola can be delivered to anywhere in the world, why not life-saving medicines? A partnership between Coca-Cola, the Gates Foundation and the Global Fund resulted in Project Last Mile. The Project uses Coca-Cola’s supply chain and logistics to deliver drugs against AIDS, tuberculosis and malaria to ten African countries. At the moment it is not used for drugs against schistosomiasis, but that is an avenue to be explored.

Another option is to re-consider which groups within the population receive treatment. Historically, schistosomiasis control programs have focussed particularly on school-age children, as PCT protects them from the consequences of infection later in life. Indeed, when looking at the infection profile across different age groups, the highest intensity of infection is normally in school-age children and young adults, as shown by the red “baseline” in the graph below. It is assumed that pre-school children suffer only light infection, but in fact there are very few data points to back up this assumption. By not including the very young children in the treatment group, a significant amount of infection may remain in the population. After a round of treatment (F1, blue line), the infection drops with high levels remaining only in the youngest children who were not treated. These levels, however, may be high enough to affect the rest of the population.

SCI are now researching how young children impact on worm transmission to develop better strategies to treat everyone at risk. Furthermore, a collaboration of several companies including Merck is already developing a paediatric formulation of praziquantel that could be given to pre-school children.

Although much progress has already been made by the SCI to combat schistosomiasis, further work requires novel approaches and a better understanding of the disease. For some types of interventions it would require collaboration with other sectors, particularly when the task is outside SCI’s area of expertise. And finally, the basics such as delivering PCT and ensuring wide treatment coverage would need to continue to a high standard, or even improved. Taken together, these approaches may finally bring us towards the elimination of schistosomiasis.

Slides from Dr. Michael French’s talk at the SCI Open Day 2014

Carolina Flores

The World's Hidden and Deadly Hunger

Shocking images of starving children are one of the staple images of extreme poverty. But childhood malnutrition is not limited to such extreme hunger: in fact, millions of children appear normal but are chronically malnourished. The problem of hidden hunger extends widely and has got serious consequences.

Hidden hunger includes both low weight for age (excluding acute malnutrition, which cannot be considered hidden), and micronutrient deficiency, which is very often associated to low weight for age. The scale of the problem is huge: one out of six children in developing countries is underweight, that is, 

What are the consequences? To start with, 

 children still die of malnutrition every year [2]. The picture is bleak: a shocking 45 [3] to 

 [4] of childhood deaths worldwide are attributable to under-nutrition. Hunger remains the biggest killer of under-five children. Furthermore, malnourished children are both more likely to contract diseases and to die from them. Of childhood deaths from disease, the following percentages can be attributed to under-nutrition [5] :

52.3% for pneumonia – 1 000 000 children

It is important to note that this is not limited to children who are extremely underweight. Though the effect is more pronounced in such cases, if we combine the risk associated with moderate malnutrition with its high prevalence rates, we find that much of the burden of deaths as a result of under-nutrition in young children is attributable to moderate, rather than to severe, malnutrition.

But perhaps the most invisible form of hunger is micronutrient deficiency, which, though not even necessarily associated to low body weight, can seriously reduce span and quality of life. These are some of the consequences of particular micro-nutrient deficiencies [6]:

As for the economic consequences of hunger, start by noticing that it is the main factor in causing childhood stunting, which affects a quarter of all children worldwide [7]. This has got consequences to motor and cognitive development, and to educational achievement, which in turn reduce productivity in adulthood. This and the increased health costs it causes make hunger a heavy burden on the economy. Under-nutrition and micronutrient deficiency cost up to 

 to the global economy [8], and it is estimated that childhood malnutrition costs USD25 billion a year to Africa alone [9]. In contrast, it is estimated that addressing childhood and maternal hunger worldwide would cost only USD10 million [10].

There has been some progress in reducing hunger over the last decades, with the number of undernourished people having decreases by 17% in the last two decades [11] but this is widely acknowledged to be unsatisfactory. For example, the stunting of early childhood growth as a result of malnutrition has decreased only 1% [12] in the last two decades. In comparison, TB cases have declined by 40% [13], and malaria cases by 30% [14]. Also, the improvements there have been are unevenly distributed geographically: for instance, in North Africa and South Asia the improvements have been modest, and in West Africa, the situation has actually worsened [15].

Solving this problem will have to involve agricultural partners, governments, and NGOs, and will likely require economic growth and improved social policy in the affected countries. As components of a solution for this problem, the following have been suggested [16]:

create more nutrition-sensitive programmes that include small farmers and families

increase women’s control of land ownership and farming decisions

widen access to agricultural credit and subsidies to encourage domestic food production

focus more on the energy supplements to pregnant women. In the Gambia, an intervention of this type lead to a 39% reduction in low birth weight cases, one of the important reasons for low body weight for age later on in childhood, and a 40% reduction in infant mortality [17].

Assessing the cost-effectiveness of interventions in these areas is possibly worth investigating. But for now the best opportunity for effective giving to target hidden hunger is micronutrient fortification, as Giving What We Can has acknowledged in recommending Project Healthy Children [18]. Adding important nutrients such as folic acid, iodine, iron, vitamin A, and zinc to staple foods is very cheap, at just a few cents per year per person, and greatly contributes to eliminating the problems caused by micronutrient deficiency. The Copenhagen Consensus has estimated that every UDS1 spent on food fortification results in USD9 benefits to the economy [19].

Micronutrient fortification is not a complete solution to the problem of hunger, but it seems to be the best place to start. The problem has a large scale and, when we consider the suffering it causes, much more should be done to alleviate it. Hidden hunger needs to be brought to light and approached integrating economic and agricultural policy, education, and large-scale health interventions like micronutrient fortification. If you want to start making a difference today, you can donate to Project Healthy Children 

Undernutrition as an underlying cause of child deaths associated with diarrhoea, pneumonia, malaria, and measles

FAO: Understanding the true cost of malnutrition

Voa News: Unicef on the cost of Africa's child malnutrition

Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?

WHO: Prevalence and trends of stunting among pre-school children, 1990-2020

Project Syndicate: Africa's hidden hunger

Blog

WHO-CHOICE: a look at the effectiveness of different health interventions

How to make the most of tax deductibility in the US

Can schistosomiasis be eliminated? Lessons from Coca-Cola and other stories.

The World's Hidden and Deadly Hunger

Against Malaria Foundation: August - September Update

Evidence Action - August Update

Where is the money in development spending?

Blindness: an opportunity for effective giving?

How valuable is medical research?

An Update on Evidence Action