Plenary Session VIII: Focusing Investment Towards Cost-Effective Interventions for One Health

Chaired by Nino Künzli

Syed Mohamed Aljunid discussed efficient investment in health information systems. He advocates the use of open-source software. It is important to share information on outbreaks before (on surveillance and prevention), during (on control and screening) and after (on effectiveness and evaluation of measures). The main issues here concern data sources and quality, technology and bureaucracy. Health information systems are currently weak and uncoordinated, yet the need for them is clear. In Malaysia in 1998-9 Nipah virus led to the culling of 1.1 million pigs and an outbreak with 257 human cases. In southeast Asia in 2003 the outbreak of SARS led to 752 cases in Singapore alone. Transportation and health departments had to coordinate their work, for example, regarding the screening of people at airports, ports and other borders. SARS arrived at a level six alert, with human-to-human transfer and half a million cases spread over 160 countries. Multiple stakeholders were involved in control. It is important to look at which interventions were most cost-effective. Improvements in data quality require that more personnel are trained to collect the information. There are also patient confidentiality issues. Bureaucracy thus imposes a series of approval processes which tend to hinder data collection. In the 2000s there was a rise in the use of decision-support systems and artificial intelligence, leading to the formulation of electronic health systems. Countries need to be encouraged to make more use of open-source technology, which, however, has a low rate of penetration in less-developed nations.

Olga Jonas considered the economics of One Health. Zoonotic diseases account for half of livestock losses due to disease. Better data are needed on the total economic impact of diseases. Half the cost of zoonotic diseases is accounted for by spill-over (i.e. non-medical) effects. The majority of the cost of a pandemic resides in avoidance behaviours and absenteeism. Outbreaks can therefore cost billions of dollars. Hence, the impact of SARS on China and Thailand was greater than the cost of the 2004 tsunami. On average, SARS costs US$6.7 billion per annum. Effective and efficient prevention and control would cost $1.9-3.4 bn/yr, seven times more than current expenditure. 'Effectiveness' involves doing the right thing, while 'efficiency' means doing so at the least cost. An effective, efficient approach delays increased costs. If an outbreak is not controlled early in its cycle, the cost of dealing with it goes up exponentially. The annual benefits of preventing pandemics are even greater and thus have an extremely high rate of return. As the prevention process is a public good, it needs stable, adequate funding over time. The excess of benefits over costs amount to tens of billions of dollars per year.

Günter Klein discussed investment in One Health. As interest on debt repayment rises, so investment in public infrastructure falls. However, for example, local water supply in Asia and Africa is cheaper than purchasing clean water from street vendors. Universal access to water and sanitation has a 12-to-1 benefit-cost ratio. When investment is made in sustainable industry, the results do not follow the economic downturns of the business cycle but remain buoyant. Returns tend to be robust. Hence, optimism about investment in sustainable resources makes economic sense.

David Dror considered the question of investment in 'embedded intangibles'. The root question is how to work with communities usefully. When it comes to the real issue, the community level cannot be ignored. However,  the community's tacit and unstructured knowledge is not easily captured by the disciplines. Communities have a different dynamic to individuals. Whereas in the West transactions have been individualised, that is not quite true in the rest of the world, which has a much higher emphasis on communal transactions. The challenge rests in how to create trust for people who want to engage with one. Economically, 'vertical' programmes have been very inefficient. Community, on the other hand, is dynamic in terms of the 'embedded intangibles'. These involve change over time in the human, informational and organisational capital of communities, properties that are very difficult to measure.

In terms of human capital, people want to engage because they see sense in it for the community. Reciprocity is better than solidarity, but it is not monetarised or captured in time. It can be enhanced by awareness, identifying protagonists and encouraging motivation. Organisational capital involves the practices of joint decision making and distributed government within the community. Currently, embedded intangibles are given low priority. An alternative funding mechanism is needed. Giving should embrace peer-to-peer mechanisms. Investors, governments and communities should gain synergy.

Jonathan Rushton gave the business case for the One Health approach. Conventional wisdom suggests that health problems need to be stopped or controlled at source. Economists ask whether prevention is really better than cure? Where avoidable losses are greater than costs of a change in the status of a disease, then investment is worthwhile. There are strong arguments for specific, specialised approaches to animal and human diseases. The One Health approach is very appropriate. Where many people live in geographical isolation, or where facilities have a low throughput and limited interchange or advancement of knowledge, One Health can be very beneficial. But are the benefits of the One Health approach to disease management less than the costs? How does one reach the tipping point? The core of the matter lies in food systems. These govern both under- and over-nutrition (obesity is not really a personal choice). Food security problems include environmental impacts, livestock diseases, food-borne diseases and nutritional impacts. Food systems are therefore central to food security, employment and GDP. In fact, on average food systems account for an average of 12 per cent of global GDP. The answer is to think systematically, research thoroughly and act personally. This is the One Health food systems approach.