Igor Rudan, Lakshmi Balaji, Harry Campbell, Mickey Chopra. Global Health Economics: The EQUIST and PATHS Tools. Edinburgh: International Society of Global Health, 2023, pp. 1–135. ISBN 978-1-7385104-0-5.
In an era where global health faces intersecting crises, from persistent infectious diseases to widening inequities in access to care, Global Health Economics: The EQUIST and PATHS Tools arrives as both a technical manual and a conceptual manifesto. The volume sets out to confront one of the most consequential dilemmas in modern public health: how to allocate scarce resources in ways that are not only efficient, but just. Edited by four influential figures in global health research and policy, the book offers a rare synthesis of methodological innovation, empirical application, and philosophical reflection. Its ambition is not modest. It seeks to reshape the analytical foundations of priority-setting in global health.
At its core, this is a book about decision-making under moral constraint. For three decades, global health economics has been dominated by cost-effectiveness analysis (CEA), an approach crystallised by the World Bank’s landmark 1993 report Investing in Health. That framework transformed policy discourse by insisting that investments be judged by measurable returns in health outcomes. Yet, as the editors argue, efficiency alone cannot guide ethical policy. By privileging interventions that deliver the greatest aggregate gains at the lowest cost, CEA risks systematically neglecting the poorest and hardest-to-reach populations. The book’s central contribution is to demonstrate how equity can be operationalised, quantified, modelled, and embedded, within economic decision tools.
The opening chapter provides a sweeping intellectual history of global health economics, situating contemporary debates within a century-long epidemiological transition. A hundred years ago, infectious diseases accounted for the overwhelming majority of deaths; today, non-communicable diseases and conditions of ageing dominate mortality profiles in most middle- and high-income settings. This transformation, driven by antibiotics, vaccines, sanitation, and economic development, has extended life expectancy and reshaped demographic structures. Yet progress has been uneven. In fragile and low-income contexts, infectious diseases remain entrenched, while emerging chronic burdens strain nascent health systems. The chapter’s analytical strength lies in its systems perspective: health outcomes are presented not merely as biomedical phenomena, but as products of infrastructure, governance, economics, and social policy.
From this foundation, the book advances its critique of conventional priority-setting. Health investments, the authors note, occur across three broad domains: direct healthcare delivery, development assistance that shapes upstream determinants, and health research that generates future solutions. Each domain involves distinct stakeholders, governments, multilaterals, industry, philanthropies, whose incentives and timelines diverge. This pluralism complicates rational allocation. Policymakers must weigh disease burden, intervention cost, political acceptability, public expectations, and long-term innovation. The resulting landscape is one in which “unequivocal answers” are rare.
It is against this complexity that the Equitable Impact Sensitive Tool (EQUIST) is introduced. Developed through collaborations among UNICEF, academic institutions, and global partners, EQUIST represents the book’s methodological centrepiece. The tool extends traditional cost-effectiveness models by incorporating distributional consequences, specifically, how interventions affect different socioeconomic strata. In practical terms, it enables policymakers to simulate how scaling specific interventions would influence both mortality reduction and health equity.
The conceptual elegance of EQUIST lies in its triadic modelling of efficiency, effectiveness, and impact. By integrating these dimensions, the tool can identify bottlenecks in service delivery and estimate the costs of overcoming them. For example, reaching rural or impoverished populations often requires higher per-capita investment due to infrastructure deficits and workforce shortages. Conventional models might deprioritise such investments as inefficient. EQUIST, by contrast, reveals their equity-enhancing value and long-term population benefit. This reframing has profound ethical implications: it transforms marginalised populations from statistical afterthoughts into central planning units.
The book’s empirical chapters trace EQUIST’s evolution from conceptual framework to operational platform. Validation exercises across diverse national contexts, including Nigeria, Bangladesh, Peru, and Egypt, demonstrate the tool’s adaptability. One striking finding is that equity-focused strategies can, under certain conditions, avert more deaths than “mainstream” approaches targeting wealthier groups. Such results challenge entrenched assumptions that equity necessarily trades off against efficiency.
Equally important is the tool’s digital integration. EQUIST does not operate in isolation; it draws on major global datasets and modelling systems, including the Lives Saved Tool (LiST), Demographic and Health Surveys, and Multiple Indicator Cluster Surveys. This interoperability transforms it into a policy ecosystem rather than a standalone calculator. The integration with the Marginal Budgeting for Bottlenecks framework further enables fiscal planning, linking epidemiological projections to budgetary realities. Through these linkages, the book illustrates how data science architectures can inform real-world financing decisions.
The transition from modelling to policy influence is most vividly illustrated through the Global Financing Facility (GFF). Launched to mobilise billions in support of women’s and children’s health, the GFF required applicant countries to produce evidence-based investment cases. EQUIST became a central analytic instrument in this process. Governments used it to estimate lives saved, identify service gaps, and justify funding allocations. The scale of resulting investments, often tens or hundreds of millions of dollars, underscores the tool’s geopolitical significance.
Beyond EQUIST, the book introduces the PATHS (Pathways to Survival) tool, which complements economic modelling with epidemiological pathway analysis. Whereas EQUIST focuses on allocative optimisation, PATHS maps causal chains linking interventions to mortality outcomes. By visualising how bottlenecks, diagnostic delays, treatment gaps, care-seeking behaviours, translate into deaths, PATHS provides a narrative anatomy of health system failure. Together, the tools form a dual analytic lens: one economic, one systemic.
A notable strength of the volume is its insistence that tools cannot substitute for politics. Data quality, institutional capacity, and political will remain decisive constraints. The authors candidly acknowledge that modelling outputs are only as reliable as the assumptions and datasets underpinning them. In settings with weak surveillance systems, estimates may rely on proxies or extrapolations. Capacity-building and training therefore emerge as integral to implementation. Workshops, cross-country learning, and technical partnerships are portrayed not as ancillary activities but as prerequisites for methodological legitimacy.
The book also engages with broader ideological debates in global health delivery. It contrasts “horizontal” system-strengthening approaches with “vertical” disease-specific initiatives often favoured by philanthropic actors. Each has merits: vertical programmes can accelerate progress against targeted conditions, while horizontal systems ensure sustainable, universal access. The authors argue persuasively that hybridisation, strategic blending of both models, is essential to reach the world’s most marginalised populations.
From a scholarly standpoint, the volume’s interdisciplinary synthesis is impressive. It draws on epidemiology, economics, political science, ethics, and data science, reflecting the inherently hybrid nature of global health. This breadth mirrors real-world decision environments, where resource allocation cannot be reduced to algorithmic outputs. The writing, while technical in places, remains accessible to policy audiences. Case studies anchor abstract frameworks in operational reality.
Yet the book is not without limitations. Its normative stance, favouring equity-weighted allocation, while ethically compelling, may invite debate among economists committed to utilitarian maximisation. Some readers may seek deeper engagement with alternative distributive philosophies or with critiques of quantifying equity itself. Additionally, although the tools are presented as globally applicable, their effectiveness ultimately depends on national data infrastructures that vary widely in quality.
Another area for further development lies in thematic scope. The text focuses heavily on maternal, neonatal, and child health, reflecting historical funding priorities. Expanding analytic modules to adolescent health, non-communicable diseases, and climate-related health risks would enhance relevance in the coming decades. The authors themselves acknowledge these frontiers, suggesting an evolving rather than finished architecture.
Despite these caveats, the book’s impact potential is considerable. It advances global health economics from a discipline preoccupied with efficiency to one capable of integrating justice into its analytic core. In doing so, it operationalises ethical commitments that are often rhetorically invoked but methodologically absent.
For researchers, the volume offers a blueprint for translational analytics, how modelling frameworks can influence financing flows and policy design. For donors, it provides tools to align investments with equity mandates. For governments, it offers a defensible basis for politically sensitive allocation decisions. And for the broader global health community, it signals a maturation of the field: from measuring what is cheapest to measuring what is fairest.
Stylistically, the book balances technical exposition with reflective commentary. Its narrative arc, from conceptual origins to global deployment, imbues methodological discussions with historical momentum. The inclusion of validation studies, platform integrations, and financing applications ensures that the work transcends theory.
In the tradition of influential global health texts, Global Health Economics: The EQUIST and PATHS Tools does more than introduce instruments; it reframes paradigms. Where earlier generations sought to maximise aggregate survival gains, this volume insists that who survives matters as much as how many. That shift, from efficiency to equitable impact, may prove to be its most enduring intellectual legacy.
As global health confronts widening inequalities, climate pressures, demographic shifts, and fiscal constraints, the need for ethically grounded allocation tools will only intensify. This book positions EQUIST and PATHS not as final answers, but as evolving infrastructures for evidence-based justice.
In that sense, the work stands as both a methodological handbook and a moral argument, one that challenges policymakers, funders, and researchers to rethink the calculus of saving lives.