Podcast Summary: Better Value in Health Spending Is a Four-Letter Word – Amanda Glassman

The CGD Podcast | Center for Global Development

Date: February 9, 2016
Host: Rajesh Merchandani
Guest: Amanda Glassman, Director of Global Health Policy at CGD

Overview

This episode dives deep into the challenges of allocating scarce healthcare resources in developing countries and spotlights the International Decision Support Initiative (iDSI). Amanda Glassman discusses how evidence-based prioritization, rather than "first come, first served," can deliver better health outcomes. The discussion centers on iDSI's model of cost-effectiveness analysis, ethical priorities, and international collaboration, following major news about iDSI's scale-up at a conference in Thailand.

Key Discussion Points and Insights

The Problem with "First Come, First Served" in Healthcare

• Opening Premise: In healthcare, relying on "first come, first served" leads to inefficient and sometimes harmful resource allocation, especially in developing countries with limited budgets.
• "Many physicians all over the world admit that [first come, first served] is how they make decisions about which patients get what treatments. [...] It's particularly acute in the developing world where national health budgets are often tiny." (00:35, Rajesh Merchandani)

What is iDSI and How Does It Work?

• Agencies Involved: Led by Thailand's HITAP and the UK's NICE, both experts in health technology assessment.
• Core Method: iDSI enables countries to use cost-effectiveness analysis (CEA) to determine how much health can be gained per unit of currency spent on medical interventions.
• Global Reach: Partnerships with countries like South Africa, Indonesia, and the Philippines allow tailoring to local contexts.
• "They look at the cost, but also the benefits of new medicines, interventions, new policies and how much health they're going to add for every additional patient, peso, pound, or pula that the public sector is going to spend." (01:25, Amanda Glassman)

Irrational Spending Examples and Opportunity Costs

• Misallocation: Funds are often spent on low-impact or unnecessary treatments (e.g., overuse of vitamins or IV fluids in China), while high-impact areas (e.g., child vaccination, TB, HIV/AIDS treatment) are underfunded.
• Transition from Aid: As economies grow and aid recedes, it becomes even more crucial for countries to independently prioritize health spending wisely.
• Memorable insight: "You want the most health for the money that you've invested. So moving away from rationing by first come, first served and moving towards taking decisions with health and well being in mind." (01:57, Amanda Glassman)

The Ethics and Politics of Health Prioritization

• Balanced Decision-Making: Choices aren't just technical—they're also political and ethical. The aim is not simply to maximize cost-effectiveness but also to ensure transparency and fairness.
• Example Dilemma: Spending on second- and third-line HIV drugs for some may mean others lack access to first-line treatments.
• "There is no right decision. But there's a right way to take a decision that is defensible to others." (06:32, Amanda Glassman)
• Fair process is essential with competing products, even for basics like vaccines, to avoid favoritism and ensure decisions are based on health impact, not just price or lobbying.

Thailand as a Model for Evidence-Based Health Policy

• Lead Role: Thailand, through HITAP, exemplifies best practice by expanding coverage and benefits based on cost-effectiveness analysis.
• Regional Influence: Thailand’s approach has inspired similar efforts in the Philippines, Indonesia, Vietnam, and more through HTA Asia Link.
• "They are incredible stars from this perspective. They've always been committed to universal coverage." (08:28, Amanda Glassman)

iDSI's Expansion and Impact

• Scale-Up Announcement: At the recent Thailand conference, the partnership (backed by UK’s DFID and the Gates Foundation) announced plans to expand iDSI’s reach and help more countries apply these methods.
• Proof of Concept: Previous engagements in Indonesia, India, and Vietnam proved the value of local capacity-building for evidence-based policy.
• "They're really making a difference to people. Build first capacity in country to measure the costs and benefits of new medicines or devices themselves but also to inform policy." (07:40, Amanda Glassman)

CGD's Role and Reflections

• Institutional Pride: Amanda celebrates iDSI as an initiative that grew out of CGD's values—bringing together experts to generate smart, actionable recommendations for governments.
• "I feel like that's exactly what CGD was created for—to come up with what makes sense, try and get all these different people […] working in the same direction. And now it has a life of its own. […] It's bigger than us now." (11:33, Amanda Glassman)

What’s Next for iDSI

• Broader Engagement: Deeper collaborations with additional countries and influence on global health funders (e.g., Global Fund, WHO’s essential medicines lists).
• Potential for health technology assessment to inform donor decisions and strengthen health systems globally.

Memorable Quotes

• On the ethical challenge:
  "There is no right decision. But there's a right way to take a decision that is defensible to others."
  — Amanda Glassman (06:32)

• On evidence-based resource allocation:
  "You want the most health for the money that you've invested. So moving away from rationing by first come, first served and moving towards taking decisions with health and well being in mind."
  — Amanda Glassman (01:57)

• On Thailand’s leadership:
  "They are incredible stars from this perspective. They've always been committed to universal coverage."
  — Amanda Glassman (08:28)

• On CGD's mission:
  "I feel like that's exactly what CGD was created for—to come up with what makes sense, try and get all these different people […] working in the same direction."
  — Amanda Glassman (11:33)

Important Segments & Timestamps

• [00:05–01:18] Introduction and framing of the problem
• [01:18–02:36] How iDSI and cost-effectiveness analysis works
• [02:36–04:32] Examples of inefficient health expenditures and opportunity costs
• [05:05–07:12] Ethical and process dimensions of prioritizing health interventions
• [07:18–08:07] iDSI’s track record and new scale-up phase
• [08:12–09:54] Thailand as a regional model in health technology assessment
• [09:54–11:57] CGD’s role in iDSI’s genesis and values
• [12:04–12:52] The future: deeper, broader engagement for iDSI

Conclusion

This CGD podcast episode unpacks the rationale and impact behind more rational, evidence-based health spending in developing countries. Amanda Glassman illustrates both the practical and philosophical aspects of health prioritization. Thailand’s leadership and the iDSI model are held up as beacons, while CGD’s convening and catalyzing role is lauded. With the initiative now expanding, there’s optimism for smarter, fairer, and more effective global health investments.