The Future of Priority-Setting in Global Health

This book has sought to inform efforts to improve systematic, evidence-based priority-setting by assessing the state-of-the-art of methods for priority-setting, engaging with the fundamental normative issues at stake, and providing specific recommendations for improving current practice. This final chapter, written by the eight editors of this volume, provides seven key recommendations for future priority-setting in global health: (1) A more systematic approach to priority-setting in health is needed; (2) Information on cost-effectiveness is essential; (3) Distributional impact needs to be integrated; (4) Stillbirths need to be integrated; (5) Non-health effects need to be integrated; (6) Process needs to be emphasized alongside substantive criteria; and (7) New methods and tools need to be used and further developed.

Priorities at the Bedside

Out-of-pocket health expenditure is a barrier to accessing basic health care. It imposes major financial burdens, which may drive patients and their families into poverty, which again can aggravate their health conditions. This chapter offers a glimpse into real-life dilemmas and decisions by presenting Ethiopian families’ and health workers’ narratives and experiences of catastrophic health expenditures. The aim is to provide a nuanced understanding of the lived experiences of the people behind the numbers. The chapter draws on material from multiple fieldwork experiences in Ethiopia, from the authors’ experiences as health workers in Ethiopia, and from a national survey of Ethiopian physicians. This material shows how overarching global and national priorities influences families’ and health workers’ allocation decisions. Bringing out the actual dilemmas people face can supplement and inform our understanding of the more theoretical and methodological chapters in this book.

Discounting Future Health

To discount future benefits and costs is to assign them less weight in one’s cost-effectiveness calculations than one assigns to immediate benefits and costs. When the benefits and costs are monetary ones, there is a widespread and theoretically well-grounded consensus that discounting is appropriate. The case of discounting future health is more controversial, and many authors have argued for a zero discount rate for health. Here the author argues that while the usual arguments for discounting money do not apply to health, there are two other good reasons (related, respectively, to uncertainty and to instrumental effects) for discounting health within the simple models that form the basis of much cost-effectiveness analysis. Both of these reasons, however, would be inapplicable in more detailed models that represented uncertainties and instrumental effects explicitly.

Age and the Disvalue of Death

Summary measures of health or well-being must assign a value to averting death and relate it to the value of preventing or curing morbidity. The authors address two key questions about how to value the prevention of death: (1) how the age at which someone dies affects how bad their death is and (2) at what age death starts to be bad for the decedent. Current practice includes, by default, views about both questions that the authors think are mistaken. Regarding (1), the authors argue in favor of gradualism: the value assigned to preventing mortality should gradually increase during early cognitive development, so that the prevention of perinatal deaths is assigned a lower value than the prevention of the deaths of older children. Regarding (2), value should be assigned to preventing deaths from the point of the onset of sentience—at around 28 weeks gestational age—so that the prevention of stillbirths is also valued. The authors tentatively suggest a function for calculating the disvalue of death at different ages and apply this and alternative functions to South African data on interventions to prevent stillbirths and neonatal deaths.

What Really Sets Priorities?

The practice of priority-setting in global health has evolved to include both helpful strengths and extraordinary weaknesses. This chapter explores how context and methods shape the priority-setting process and influence its outcomes through an historical analysis of four cases of decision-making about cholera and diarrheal diseases: in Jamaica in 1850, in London in 1866, by multilateral development agencies in the 1980s, and by Gavi, the Vaccine Alliance in 2006. The chapter focuses on the nature of the state–citizen relationship, the type of evidence used, the methods of analysis employed, and the identity of those whose judgment is applied to explain variation in decision-making. Analyzing these examples suggests that priority-setting has evolved to become a narrow exercise incapable of reckoning broader problems, ill suited to assessing comprehensive solutions, and unlikely to contribute to the development of state capacity. Taken together, these findings argue for rethinking priority-setting methods to better account for a wider range of problems, more participatory processes, and more comprehensive solutions.

A Developing Country Perspective

Governments and development partners have increasingly invested in health over the last two decades with considerable success in many countries. The global community is now transitioning from the Millennium Development Goals to the even more ambitious Sustainable Development Goal (SDG) agenda. Achieving the SDG targets will require additional resources. However, levels of foreign aid are flat or declining, even as the need for domestic resources is on the rise. In consequence, we need more and better priority-setting in global health based on good evidence. This chapter argues that responsible priority-setting by international donors should involve greater focus on improving the quality of aid and on country ownership of development programs. Ultimately, governments should be the major financiers of their own health programs. This means that countries should gradually take increasing responsibilities over their own health systems, and development partners need to make sure that there is seamless transition of funding from aid dependency to self-reliance. Development partners should support countries to (1) acquire the necessary capacity to do their own priority-setting based on quality evidence, and (2) develop and effectively implement their health care financing strategies.

Introduction

This chapter discusses the existing disconnect between global health funding and needs, how to prioritize allocation of resources in response to such needs, and the ways in which stakeholders should make funding decisions. It lays the groundwork for a book that seeks to advance discussion delineating the questions that must be addressed, identify approaches that are clearly unjustifiable, narrow the range of disagreement to make the process of developing a shared framework more tractable, and offer specific recommendations that should be incorporated into a shared framework. The book focuses on four fundamental and related concerns in allocating health resources: (1) the role of cost-effectiveness analysis, (2) inequalities and distributional concerns, (3) what outcomes should be considered, and (4) what the actual practice of allocating resources should look like.

The Role of Public Engagement in Priority-Setting

Recent years have seen growing enthusiasm for public engagement in priority-setting. But despite this widespread support, there remains uncertainty both about the precise benefits of public engagement in priority-setting and about how public engagement activities should be structured in order to realize those benefits. The authors aim to move beyond generalizations about the value of public engagement by presenting several distinct rationales for engaging the public in priority-setting. The authors illustrate how these rationales can be achieved in practice using the case study of directly observed therapy for tuberculosis. They then highlight a number of practical challenges involved in implementing engagement activities and offer advice for addressing them. The chapter pays particular attention to challenges that arise in low- and middle-income countries, where efforts to engage the public face unique structural barriers.

Setting Priorities in the Pursuit of Universal Health Coverage

Priority-setting is fundamental to the fair and efficient pursuit of universal health coverage (UHC). This chapter addresses the key choices in selecting services for UHC and the alternative criteria, tools, and processes to guide these choices. The authors first describe the choices decision-makers have to make on the path to UHC and the recommendations by the WHO Consultative Group on Equity and Universal Health Coverage for how these choices can be made. Using Thailand as a case study, the authors examine how the Thai government has set priorities in its pursuit of UHC. Against this background, the authors discuss alternative criteria, tools, and processes for guiding service selection and the design of benefit packages for UHC. When doing this, the authors consider past experiences in Thailand and other countries and examine how recent developments and the insights from the preceding chapters in this volume can provide directions for the future.

Incorporating Distributional Concerns into Practical Tools for Priority-Setting

The aim of this chapter is to provide examples of how distributional concerns can be incorporated into practical tools for priority-setting, and to discuss the underlying normative technical choices in doing so. The first section presents a Norwegian proposal for how priority to the worse-off can be integrated with cost-effectiveness thresholds for reimbursement policies. The proposed method is simple and not technically very demanding but relates directly to important discussions about the appropriate decision rules for reimbursement of new and costly technologies. The second section presents priority-weighted cost-effectiveness ranking of essential health services in Ethiopia, a low-income country that is in the process of expanding the health services that it covers. Both methods build on existing health economic tools and are motivated by a prioritarian normative framework. The third and final section discusses some underlying normative issues in methods for integrating distributional concerns that have not hitherto been adequately discussed.