Session 5.1 – International Perspectives on Priority Setting

Thursday October 30 15:30-17:00

Priority Setting of Health Interventions in Developing Countries: An Overview of Empirical Studies

(Abstract 0011)

Sitaporn Youngkong1, Lydia Kapiriri2, Rob Baltussen1
1Radboud University, Netherlands, 2University of Toronto Joint Centre for Bioethics, Canada

Background: Priority setting in health care in developing countries is often said to be ad hoc and/or history-based. There is no consensus regarding the most appropriate way to determine health priorities.

Objective: The aims of this paper are to review existing empirical priority setting studies, and to define recommendations for future studies, so as to improve evidence-based priority setting in developing countries.

Methods: This paper first proposes a framework for the classification of priority setting studies and its components, and then applies this to existing empirical studies on priority setting of health interventions in developing countries. We searched scientific databases and applied snowballing technique to identify empirical studies on priority setting of health interventions in developing countries.

Results: We identified 13 empirical studies on priority setting in developing countries. Few studies evaluated different groups of stakeholders as respondents (9/13), identified a comprehensive set of relevant criteria (8/13), resulted in a rank ordering of interventions (3/13), deliberated on results (8/13), or evaluated for fairness of the process (2/13).

Policy Implications: Only a few studies exist on priority setting of health interventions in developing counties, and there is ample scope for improvement of their methodologies. A number of recommendations can be made for future studies: (i) the requirement of deliberation, (ii) identification of a comprehensive set of relevant criteria, and (iii) resulting in a rank ordering of interventions. We believe that our suggestions can improve the evidence-based of priority setting in developing countries.

Priority Setting and Rationing – What Difference does it Make?

(Abstract 0117)

Heiner Raspe, Thorsten Meyer
University of Luebeck, Institute for Social Medicine, Germany

In Germany the debate on priority setting and rationing evolves very slowly and has not reached the public, yet. To stimulate and mature the debate we seek to observe experiences in other countries carefully. With reference to the development in Sweden, we aim to analyse differences in the use of the terms priority setting and rationing to render necessary distinctions for further debate.

Methods: Historical and systematic analysis of Swedish prioritisation development by document analyses and expert interviews.

In Sweden, priority setting and rationing are markedly distinct concepts. Priority setting is commonly understood as ‘to place in rank order and choose’. The development of clinical care guidelines with explicit priority ratings within a clinical domain (‘vertical prioritisation’) exemplifies clear prioritisation without rationing. The latter is intrinsically related to the concepts of need and decisions on allocating limited resources, i.e. ‘limiting the possibilities to optimally satisfy needs for health care’. There is a continuum from implicit or inferred to explicit or stated prioritisation or rationing crucial to the debate. Depending on target audiences, the concept of prioritisation is easily being blurred as an umbrella term in political communication. Concepts of rationing differ in scope of its objects: as an economic term for every resource allocation activity, to rationing of needed medical interventions of at least some proven effectiveness, to rationing in situations of basic medical needs.

The consequences of the different uses of both terms are discussed with reference to the international scientific debate and policy implications in Germany.

Understanding the Resource Allocation Decisions of Public Health Officials in the U.S

. (Abstract 0095)

Susan D. Goold, Nancy M. Baum
University of Michigan, United States

Background: Resource allocation decisions lie at the core of public health system operations. Yet despite significant impact on the health of communities, little empirical research has characterized the nature and scope of such decisions confronted by local health department (LHD) officials.

Objectives: This study has four discrete research objectives: 1) to describe the nature and scope of resource allocation decisions officials confront; 2) to identify the processes officials use when they make allocation decisions; 3) to assess the degree of discretion officials report in allocating resources and the factors that influence that discretion; and, 4) to explore whether discretion affects officials’ abilities to assure that their communities’ most important public health needs are met.

Methods: To accomplish these objectives we are conducting a national survey, from May to July 2008, of U.S. LHD officials about resource allocation decisions. We will combine our data with data from the 2008 National Profile survey of the National Association for County and City Health Departments, to analyze how resource allocation decisions, processes and officials’ discretion vary according to various attributes of LHDs' infrastructure and functioning. We will sample 1290 LHD officials, stratified by LHD size.

Results: This research will advance our understanding of resource allocation in public health, and stimulate discussion about the role of administrative discretion in enabling flexible responses to community health. If officials nationwide lack adequate discretion, this has enormous policy significance for governments and those providing grants to public health departments.

Priority Setting in Health Care and Shifting Health Policy Agendas – The Israeli Case

(Abstract 0159)

David Chinitz
Hebrew University – Hadassah , Israel

Background: Regarding “The Global Challenge of Health Care Rationing” noteworthy progress been made, opening the door to new agendas. Israel provides a good case study regarding these phenomena.

Objectives:

• To briefly describe and assess the Israeli health care priority setting process in terms of substantive policy decisions, and accountability;
• To explore the proposition that the process has led both policy makers and members of the public to focus on an even broader view of health policy including, in particular, a focus on health inequalities, prevention and public health.
• To consider implications for theory and other countries, especially the US reform debate.
  

Methods:

• Qualitative research on the health care priority setting process in Israel.
• Longitudinal surveys (1997 – present) of representative population samples, using health vignette and budget pie trade off methodologies, regarding priorities and priority setting processes, health inequalities and public health.

Results:

• The health care priority setting process in Israel has provoked a vibrant public debate on allocation of scarce health resources.
• Not with standing inevitable and legitimate stakeholder politics, the process appears to have led to increased public understanding of health care rationing, and legitimacy.
• The process has influenced policy agendas regarding health finance, health inequalities, prevention and public health.

Policy Implications:

• Public accountability is promoted when a sanctioned decision making body ranks health services within a predetermined budget constraint.
• Politics inevitably intervenes but need not neutralize the explicit priority setting process.
• Health care priority setting leads to health priority setting more generally.