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Bang for buck

Ami Banerjee
Last edited 26th May 2009
Cost effectiveness is flavour of the week, whether in relation to the NHS, global health or politics. It makes sense to optimise use of limited resources, particularly public goods (e.g. taxpayers’ money). The Gates Foundation (GF) has changed the global health landscape both in terms of scale of funding and policy agenda. This week’s Lancet focused on the GF’s efficiency, based on an analysis of its funded projects [1-3]. It awarded 1094 global health grants over the last decade: a massive US$8·95 billion, of which $5·82 billion (65%) was shared by only 20 organisations. 40% of all funding was given to “supranational” organizations such as the World Health Organisation. Of the remaining amount, 82% went to recipients based in the USA. Just over a third ($3·27 billion) of funding was allocated to research and development (mainly for vaccines), or to basic science research [1]. Firstly, the GF concentrated too much on infectious diseases and HIV/AIDS, despite the major global burden of other diseases. Secondly, its “dominance…risked stifling the diversity of views among scientists” [1]. Thirdly, the vast majority of funding went to 20 organisations and institutions, mainly in the US and UK, with very limited funding to developing country organisations or scientists, which is probably increasing health inequalities. Although the way in which Mr and Mrs Gates use their private money is their prerogative, the authors argue that since global health is a public interest, the GF has a duty to use its funds and its influence more effectively. In the NHS, the economic recession means that the NHS will need to contribute £2.3 billion of the £5 billion of public sector efficiency savings being sought next year. The greater emphasis on efficiency and cost-effectiveness “should not be at the expense of quality“ [4]. “Doctors, meanwhile, should become better leaders, raise quality, and help to reduce wasteful and unfair variations in practice. [5]” Cost-effectiveness is relevant to both these cases, but it has limitations, particularly if an arbitrary threshold per quality-adjusted-life-year (QALY) is the only measure. People who use cost-effectiveness information “should be properly educated as to its strengths and limitations [6]”. Ultimately epidemiology data about outcomes and health service delivery define how effective (including “cost-effective”) treatment is. The UK press has been dominated by the flagrant misuse of public money by politicians to pay for their private expenses. The Daily Telegraph evaluated the “value” of our MPs by comparing their expense claims and how often they showed up to Parliament to vote [7]. Cost effectiveness and an evidence base are crucial wherever public money is being used.
  1. The Bill & Melinda Gates Foundation's grant-making programme for global health 2009 373; 9675: 1645-1653. McCoy D, Kembhavi G, Patel J, Luintel A.
  2. Accelerating the health impact of the Gates Foundation Lancet 2009. 373; 9675: 1584-1585. Black RE, Bhan MK, Chopra M, Rudan I, Victora CG.
  3. Editorial: What has the Gates Foundation done for global health? Lancet 2009. 373; 9675: 1577.
  4. The 2009 budget and the NHS BMJ 2009 338: b1760. Ham C.
  5. Effectiveness, efficiency, and leadership BMJ 2009 338: b1781. Groves T.
  6. The limits of cost-effectiveness analysis Circulation: Cardiovascular Quality and Outcomes 2009. 2; 1: 55-58. Weintraub WS, Cohen DJ.
  7. Best and worst value MPs revealed Daily Telegraph 7 May 2009. Leach B and Leapman B.

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