I had a good conversation with Prabat Jha, one of the primary DCP2 authors, and it has affected the way I'm thinking about these issues. I told him I'd be posting notes to our mailing list which is publicly accessible via the web, and he said that's OK, but you should keep in mind that everything below is my notes and not direct quotes.
My biggest takeaway is that we should be broadening our list of "priority interventions," because there may be some that are highly cost-effective and proven enough to have confidence in despite being not as "straightforward" by our earlier definition. Also reinforced my inclination that there's a lot of value in charities with specific/narrow strategies, as opposed to those that do "everything."
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- The first principle he offered up, in response to my question about how he'd go about recommending charities to donors, was to stress how important the right "technology" (i.e., choosing the right intervention) is, as opposed to other things that people often focus on (such as overhead expense ratio, etc.) Paraphrase: "many of these interventions are things that we know work. The list of diseases and interventions is quite small, now if you want to argue that let's say I'm a small investor or a small philanthropist, what matters is what horse do they put their money on. I'll give you a practical example, the Gates Foundation has a $260 million program on HIV prevention through education among sex workers in India, and this is causing a lot of debate about what did they get from their money, and I would argue that if they step back and look at all the evidence, simply by choosing the right strategy, which was to focus on sex work in HIV transmission in India, they will have done a huge amt of good, whereas if they chose let's say something like ARV treatment for those that are already infected, then they would have gotten 20k, 30k people on treatment, whereas prevention could effectively prevent up to hundreds of thousands of new infections."
- On specific interventions, he stated clearly that we should focus on the 7 interventions on page 51 of the paper he coauthored for the '08 Copenhagen Consensus (see http://www.copenhagenconsensus.com/Default.aspx?ID=1146). The interventions are
- TB case finding & treatment (i.e., DOTS)
- Low-cost drugs for managing heart conditions (aspiring, beta blockers)
- Malaria prevention & treatment (with medication)
- Childhood immunization coverage
- Tobacco taxation (lobbying)
- HIV prevention, particularly education programs targeted at high-risk populations including sex workers
- Building capacity for surgeries
- I explained our idea of "straightforward" interventions and he said it made some sense, but that a lot of the interventions listed above are proven enough that we should be able to have confidence in them when working with a "credible NGO, someone with a bit of track record." I asked how reliably he thinks tobacco taxation can be spread and he thinks it's pretty straightforward, that tobacco taxation is "good politics."
- He is positive on fortification and supplementation; less positive on the approach to surgeries we've favored (developed-world doctors going on missions), and thinks that building local capacity is likely to be more effective. Says that fistula is a particularly complicated surgery and that building local capacity may be less effective for that one; the ones he think local capacity can address well are club foot, lazy eye, cleft, cataracts.
- Personally gives to UNICEF and the Global Fund. Says that "UNICEF did great stuff with immunization program but they've become too broad, but I recommend the Global Fund because they've become very specific." In general, favors funding charities with very specific/narrow/well-defined activities, rather than those that "try to do everything," largely for cost-effectiveness reasons - he gives the example of a maternal mortality program that ends up being a counseling/training/everything program when "what matters are just getting women into deliveries."
- Regarding "general health capacity" (horizontal) programs: "These programs are needed and one of the key things there is to work in parallel with governments and make sure things are sustainable, so I think the Doctors without Borders structure where they set up a parallel health structure is really not sustainable, it's humanitarian relief but it's really not building something sustainable, when things are really terrible that's what you have to do." Says there's no obvious vehicle for funding the right kind of capacity building; "Best thing to do is give it to the NIH foundation or CDC foundation and say you want it for health systems."
- Had lots to say about success and failure stories. Successes: vaccines ("from 3% to 80% getting the essential antigens"), maternal mortality programs in Sri Lanka and China (focused on getting more women to give births in institutions), tobacco control (mostly in Western countries but also Poland), malaria (treatment and spraying-based strategies), condom-based programs for sex workers (Thailand and South India), aspiring & beta blockers for cardio conditions (U.S.), smallpox eradication, "other successes with more focused eradication programs which the Carter Center does," measles elimination in the Americas. Failures: screening for high-risk pregnancies (not practical), water and sanitation in the 80s ("a mixed success at best"). Refers us to A.R. Hinman, "Lessons from previous eradication programs" in a book by Dowdlewr, "The Eradication of Infction Diseases" pp. 19-31 (pub. John Wiley and Sons 1998) for more on eradication program successes & failures.
He seems very focused on cost-effectiveness, perhaps more than I would be (I'd probably rather err on the side of a comprehensive program that creates large life changes even if not every part of the program is as cost-effective as the others).
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