Diplomacy and Health: The End of the Utilitarian Era.

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 cost-effective 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.