Diplomacy and Health: The End of the Utilitarian Era

Document Type : Hypothesis


1 University of California, San Francisco, CA, USA

2 Amur Consultancy, Dublin, Ireland


Cost-effectiveness analysis (CEA), as a system of allocative efficiency for global health programs, is an influential criterion for resource allocation in the context of diplomacy and inherent foreign policy decisions therein. This is because such programs have diplomatic benefits and costs that can be uploaded from the recipient and affect the broader foreign policy interests of the donor and the diplomacy landscape between both parties. These diplomatic implications are vital to the long-term success of both the immediate program and any subsequent programs; hence it is important to articulate them alongside program performance, in terms of how well their interrelated interventions were perceived by the communities served. Consequently, the exclusive focus of cost-effectiveness on medical outcomes ignores (1) the potential non-health benefits of less cost-effective interventions and (2) the potential of these collateral gains to form compelling cases across the interdisciplinary spectrum to increase the overall resource envelope for global health. The assessment utilizes the Kevany Riposte’s “K-Scores” methodology, which has been previously applied as a replicable evaluation tool1 and assesses the trade-offs of highly costeffective but potentially “undiplomatic” global health interventions. Ultimately, we apply this approach to selected HIV/AIDS interventions to determine their wider benefits and demonstrate the value alternative evaluation and decision-making methodologies. Interventions with high “K-Scores” should be seriously considered for resource allocation independent of their cost-effectiveness. “Oregon Plan” thresholds2 are neither appropriate nor enforceable in this regard while “K-Score” results provide contextual information to policy-makers who may have, to date, considered only cost-effectiveness data. While CEA is a valuable tool for resource allocation, its use as a utilitarian focus should be approached with caution. Policy-makers and global health program managers should take into account a wide range of outcomes before agreeing upon selection and implementation.


Main Subjects

  1. Kevany S. Diplomatic advantages & threats in global health program selection, design, delivery and implementation: the development and application of the Kevany Riposte. Global Health. 2015;11: 22. doi:10.1186/s12992-015-0108-x
  2. Oberlander J, Marmor T, Jacobs L. Rationing medical care: rhetoric and reality in the Oregon Health Plan. CMAJ. 2001;164(11):1583-1587.
  3. Marseille E, Hofmann PB, Kahn JG. HIV prevention before HAART in sub-Saharan Africa.  Lancet. 2002;359(9320):1851-1856.
  4. Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB. Recommendations of the Panel on Cost-effectiveness in Health and Medicine. JAMA. 1996;276(15):1253-1258.
  5. Kevany S, Benatar SR, Fleischer T. Improving resource allocation decisions for health and HIV programmes in South Africa: Bioethical, cost-effectiveness and health diplomacy considerations. Glob Public Health. 2013;8(5):570-587. doi:10.1080/17441692.2013.790461
  6. Heywood M. South Africa's treatment action campaign: combining law and social mobilization to realize the right to health. J Hum Rights Pract. 2009;1(1):14-36.
  7. Creese A, Floyd K, Alban A, Guinness L. Cost-effectiveness of HIV/AIDS interventions in Africa: a systematic review of the evidence. Lancet. 2002;359(9318):1635-1643
  8. Collins C, Isbell M, Sohn A, Klindera K. Four principles for expanding PEPFAR's role as a vital force in US health diplomacy abroad. Health Aff (Millwood). 2012;31(7):1578-1584. doi:10.1377/hlthaff.2012.0204
  9. Miller GP. Circumcision: a cultural-legal analysis. Virginia Journal of Social Policy and the Law. 2002;7:497-537.
  10. Kevany S. Global health diplomacy, ‘smart power’, and the new world order. Glob Public Health. 2014;9(7):787-807. doi:10.1080/17441692.2014.921219.
  11. Goosby E, Dybul M, Fauci AS, et al. The United States President's Emergency Plan for AIDS Relief: a story of partnerships and smart investments to turn the tide of the global AIDS pandemic. J Acquir Immune Defic Syndr. 2012;60 Suppl 3:S51-S56. doi:10.1097/QAI.0b013e31825ca721
  12. Khumalo-Sakutukwa G, Morin SF, Fritz K, et al. Project Accept (HPTN 043): a community-based intervention to reduce HIV incidence in populations at risk for HIV in sub-Saharan Africa and Thailand. J Acquir Immune Defic Syndr. 2008;49(4):422-431. doi:10.1097/QAI.0b013e31818a6cb5
  13. Dietrich JW. The politics of PEPFAR: the president’s emergency plan for AIDS relief. Ethics Int Aff. 2007;21(3):277-292. doi:10.1111/j.1747-7093.2007.00100.x
  14. McCoy D, Chand S, Sridhar D. Global health funding: how much, where it comes from and where it goes. Health Policy Plan. 2009;24(6):407-417. doi:10.1093/heapol/czp026
  15. Kevany S, Khumalo-Sakutukwa G, Murima O, et al. Health diplomacy and the adaptation of global health interventions to local needs in sub-Saharan Africa and Thailand: evaluating findings from Project Accept (HPTN 043). BMC Public Health. 2012;12:459. doi:10.1186/1471-2458-12-459
  16. Walensky RP, Kuritzkes DR. The impact of the President's Emergency Plan for AIDS Relief (PEPfAR) beyond HIV and why it remains essential. Clin Infect Dis. 2010;50(2):272-275.
  17. Piot P, Coll Seck AM. International response to the HIV/AIDS epidemic: planning for success. Bull World Health Organ. 2001;79(12):1106-1112.
  18. Ravishankar N, Gubbins P, Cooley RJ, et al. Financing of global health: tracking development assistance for health from 1990 to 2007. Lancet. 2009;373(9681):2113-2124. doi:10.1016/s0140-6736(09)60881-3
  19. Fidler DP. Rise and fall of global health as a foreign policy issue. Glob Health Gov. 2011;4(2):1-12.
  20. Fidler DP. After the revolution: global health politics in a time of economic crisis and threatening future trends. Glob Health Gov. 2009;2(2):1-21.
  • Receive Date: 29 May 2016
  • Revise Date: 08 January 2017
  • Accept Date: 24 December 2016
  • First Publish Date: 01 April 2017