Session 1.1 – Theoretical Development in Priority Setting
Thursday October 30 8:30-10:00
Priorities, Priorities, Priorities According to What?
(Abstract 0057)Penelope Mullen
University of Birmingham, United Kingdom
Establishing appropriate criteria is essential to priority setting in health care, whether at the system or individual level. However, whilst it would appear axiomatic that such criteria should reflect and be consistent with the purpose or objectives of the healthcare system, those objectives are often assumed implicitly rather than identified and expressed explicitly – we all know what healthcare systems are for, don’t we?
The absence of explicit identification of the (often competing) objectives of healthcare systems has, in some countries, left the field open to the advocacy of a single, intuitively appealing, objective – that of maximising population health or health gain. But priority setting according to the single criterion of health or health gain maximisation can have adverse consequences which conflict with values such as equity and fairness.
Arguing that priority setting at all levels requires explicit identification of the objectives that societies want for healthcare systems, this paper critically reviews a range of possible objectives. In addition to equity of access, fair financing and responsiveness, the less frequently cited objectives of protection from catastrophic risks and from uncertainty and insecurity - the need to trust and know that health services will be there when needed – are explored and their implications for healthcare priority setting analysed.
It is concluded that, whilst explicit statement of objectives can carry dangers, healthcare priority setting informed by objectives including the need for trust, certainty and security, might better meet the needs and expectations of societies served by those healthcare systems.
Whither Priority Setting Nationally and Globally? A Political Economy View.
(Abstract 0069)Gavin Mooney
Curtin University, Australia
The first part of this paper argues that ‘conventional’ economic approaches to priority setting need to be re-assessed. A new approach is proposed, based on four features: first some set of principles or a constitution, ideally community-based; secondly replacing the current theoretical bases with Elizabeth Anderson’s expressive theory; thirdly communitarian claims; and fourthly overcoming the problems of the lack of credible commitment (as identified by Steve Jan). This approach can be built on to Program Budgeting and Marginal Analysis (PBMA). It also serves to alter the decision-making context, highlighted as being problematical by Craig Mitton and Cam Donaldson.
The second part looks at the power structures in health care and population health more generally. These are examined both nationally and globally. Health care systems need to be seen more as social rather than medical institutions. Globally the push by the World Bank and the IMF to promote the commercialisation of health care is influencing priorities to too great an extent and resulting in major inequities. Their neo liberal economic policies have a major impact on poverty and inequality both globally and within countries. These in turn affect population health.
Recommendations are made for reforming both health care systems and these global institutions to allow priorities to be set according to the ideas in the first part of the paper.
The Missing Stakeholders in Procedural Approaches to Priority Setting - A Problem for legitimacy?
(Abstract 0082)Søren Holm1, 2, 3
1Cardiff University, United Kingdom, 2ESRC Centre for Economic and Social Aspects of Genomics, United Kingdom, 3Section for Medical Ethics, Norway
It is generally accepted that part of the legitimacy of a priority setting decision is related to the right stakeholders being involved in the decision making process.
This paper will:
1) Briefly outline why stakeholder involvement is important at the different levels of priority setting.
2) Present the results of a systematic literature review focusing on which types of stakeholders that have been involved in published priority setting exercises from the national to the clinical level.
3) Argue that certain types of stakeholders are significantly underrepresented, i.e. patients and non-political members of the general public.
4) Discuss to what extent this under representation is a real problem for procedural approaches and how it can be addressed.
Public Value and Priority Setting
(Abstract 0155)Iestyn Williams
University of Birmingham, United Kingdom
The concept of ‘Public Value’ has received considerable attention since being introduced into the public management literature by Moore (1995). An underlying premise of Moore’s perspective is that the public sector should seek to establish how value is understood by citizens and use this knowledge to inform practice. Clearly, the notion of public value thus has potential application to the issue of priority setting in health care. National and local policy makers are increasingly required to make explicit choices between competing areas of investment in a context of resources scarcity. The limits of technocratic approaches and the need to embrace questions of value and process are recurring features of the literature around, for example, technology coverage decision making. This paper reports findings from a literature review on the topics of ‘public value’ and ‘priority setting’. The review is based on a search of relevant academic and practitioner databases as well as an exploratory search of conceptual and empirical material, drawing on the author’s previous work in this area. The experience of priority setters internationally is analysed using frameworks provided by the public value literature. The paper also uses the broader literature on priority setting to critically evaluate the applicability of the public value concept, which has been subject to much critical debate in recent years. The paper concludes that public value is a useful concept when applied to priority setting but that further specification and conceptual clarity is required.