A comment on the financing of health services

This graph was published with a letter to the editor of Science magazine. The letter objects to a previous article in Science which suggested that money should be redirected from antiretroviral therapy for AIDS patients to other persons. The graph indicates that AIDS spending grows more slowly than does AIDS burden. One might think that countries should allocate funds to diseases according to the burden the diseases impose on the nation. That is clearly not true. Think about effective preventive programs such as childhood immunizations. If you can successfully immunize all the kids then you can effectively reduce the burden of the prevented diseases to zero.

The authors of the original article respond in part:

we believe that health spending should not be allocated in any strict proportion to disease burden, but rather in proportion to the marginal return in terms of reducing disease burden. We advocate allocating incremental resources to the interventions that save the most life-years per dollar spent.

This is better, but still a simplification. DALYs (disability adjusted life years) are only one measure of the burden of disease, and in my opinion that measure does not fully capture the burden of disease. (Indeed, there are different ways to calculate DALYs.) Even if you accept that early death is equally unacceptable no matter who dies (and certainly we do not insure all members of a family equally), the degree to which a person's activities are limited by a physical disability depends on who that person is and what/he or she does. Think of Stephen Hawking who contributes enormously to world culture and knowledge in spite of almost complete physical immobilization!

An alternative measure is willingness to pay for health services to prevent death and to prevent disability and discomfort. Such a measure, might be in part able to get at how much the health problem distresses the public. A well known example was polio, which people felt was more important than the deaths and disability it caused would have implied. Think of the public willingness to support efforts to save the Chilean miners who were trapped under ground, as compared with the concern for the large number of kids who die each day from malnutrition and preventable diseases.