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If you have $200 to spend on health in a developing country, would you vaccinate 10 children against deadly childhood diseases or provide AIDS treatment to one woman to prevent transmission of HIV to her unborn child? Policy makers routinely face such tough budgetary dilemmas with little expert guidance. The Priority-Setting Institutions for Global Health working group report provides practical means to assist priority-setting efforts in low- and middle-income countries.
Global health initiatives call for greater developing country financing of cost-effective health interventions for an increasingly diverse set of disease control priorities. But while the priorities are many and population demands increase alongside growing educational attainment and technological innovation, public funding–even when augmented by donor contributions or technology price reductions–remains scarce, and difficult decisions must be made.
There are clear health gains to be made from shifting the current distribution of public spending to more cost-effective uses. For example, WHO estimates that reallocating malaria control budgets in Zambia towards a more cost-effective mix of interventions could reduce costs per Disability Adjusted Life Year (DALY) gained by up to 20%. In Thailand, there is room for as much as a 99% improvement in health impact by reallocating spending for cardiovascular disease prevention. Overall, the WHO estimates that low income countries could save as much as 12-24% of total health care spending.
There is also a growing global knowledge base of data, methods and tools to support countries in the adoption and implementation of cost-effectiveness analyses and health technology assessments, as well as a rich literature on the importance of process itself in constructing ethical, transparent and durable public spending decisions in the health sector.
Yet most public spending decisions do not explicitly incorporate evidence or process, even while global health agencies and donors are expecting recipient governments to assume more and more of the expenses of cost-effective interventions over time. The lack of an explicit process also poses an ethical and a practical problem for donors; as when, for example, PEPFAR funds are available to treat only 30% of HIV-positive adults and no formal process is in place to help recipients make the terrible decisions on who receives treatment and who goes without.
The working group on Priority-Setting Institutions for Global Health identified the characteristics of processes and institutions that are capable of transparently and ethically translating scientific and economic evidence and social preferences on health technologies into on-budget priorities in low- and middle-income settings. In addition, the group assessed current and potential international support for priority-setting institutions, recognizing that while public funding decisions are necessarily driven by local structures and values, shared regional or global information bases for decision-making, institutional design, technical accompaniment and peer support would add much needed value and support to traditionally opaque methods of resource allocation.
The groups final report recommends creating and developing fair and evidence-based national and global systems to more rationally set priorities for public spending on health. The report spurred the creation of the International Decision Support Initiative (iDSI), which was launched by NICE International and partners in 2013 to support low and middle income governments and donors in making resource allocation decisions for healthcare. CGD will work with the iDSI partnership to develop a practical guide and set of options for the design, adjustment and evaluation of health benefits plans in the context of Universal Health Coverage.
Priority setting institutions for health working group member, Dr. Lydia Kapiriri, speaks here about her research within a Ugandan hospital and how her findings can be used to improve priority setting practices in developing nations.
Working Group Members
The Working Group brings together a multi-disciplinary group of policy-makers, practitioners, experts and academics from industry, regulatory authorities, donor agencies, technical agencies and universities. Members serve in a personal capacity, independent of their institutional affiliation.
Kalipso Chalkidou (co-chair), National Institute for Health and Clinical Excellence, UK
Amanda Glassman (co-chair), Center for Global Development, USA
Sara Bennett, John Hopkins School of Public Health, USA
Adriana Velazquez Berumen, World Health Organization
Tomasz Bochenek, Jagellonian University, Poland
Michael Borowitz, Organization for Economic Co-operation and Development
Jesse Bump, Georgetown University, USA
Leonardo Cubillos, World Bank Institute
Tessa Edejer, World Health Organization
Ruth Faden, Johns Hopkins Berman Institute of Bioethics
Jeremy Farrar, Oxford University Clinical Research Unit, Vietnam
Armin Fidler, The World Bank
James Fitzgerald, Pan American Health Organization
Ursula Giedion, Independent, Colombia
Charles Hongoro, South African Medical Research Council, South Africa
India's Ministry of Health is committed to universal health coverage and has announced its plan to provide dialysis in the face of rising kidney failure. But providing dialysis for all who need it could consume the entire public health budget. Policymakers need to evaluate affordable dialysis options, pay systematic attention to the selection of who will receive dialysis, and put more emphasis on prevention.
The International Decision Support Initiative, initially launched as the result of a CGD working group, is scaling up, and that’s good news for people making life-and-death decisions in low- and middle-income countries. It means more data on what works and more guidance on how to get the most out of scarce resources for health.
Health-care decisions are hard everywhere. The United States, for example, spends almost one-fifth of its total national income on health but still has a hard time deciding whether health insurers should cover a new treatment for Hepatitis C. Imagine the scale of that challenge in a place like Ethiopia, where physicians (1 for every 32,000 people), money, and almost every other resource are in short supply.
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Many health improving interventions in low-income countries are extremely good value for money. So why has it often proven difficult to obtain political backing for highly cost-effective interventions such as vaccinations, treatments against diarrhoeal disease in children, and preventive policies such as improved access to clean water, or policies curtailing tobacco consumption?
Cost-effectiveness studies compare the costs and benefits of different interventions with the aim of improving decisions on the allocation of scarce resources for health. Or, put simply, they allow policy-makers to set priorities for health spending and consider how the next dollar available can get more health for the money.
Universal health coverage (UHC) is now firmly on the global health agenda, and carries with it the ambitious goal of providing “access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost.” So where do we start? A critical first step to delivering on the aspirations of UHC is deciding which services and policies to prioritize and make available. While resources for health care are growing, they are not infinite and hard choices must be made.