Ole F Norheim

• MD, Dr. Med
• Professor (Full) at University of Bergen

Introduction In Ethiopia, most healthcare expenditures are paid out-of-pocket (OOP), while the burden of kidney disease (KD) is rapidly increasing, posing a major public health challenge in low- and middle-income countries, along with a staggering economic burden. We aimed to quantify the extent of OOP health expenditures and the magnitude of assoc...

Background We have previously shown that an integrated intervention package delivered during preconception, pregnancy and early childhood substantially reduces low birth weight and stunting at 24 months of age compared with routine care. Now we conduct a benefit–cost analysis to estimate the return on investment of this integrated approach in India...

Background Traumatic injuries are rising globally, disproportionately affecting low- and middle-income countries, constituting 88% of the burden of surgically treatable conditions. While contributing to the highest burden, LMICs also have the least availability of resources to address this growing burden effectively. Studies on the cost-of-service...

The practical goal of preventing premature death seems uncontroversial. But the term ‘premature death’ is vague with several, sometimes conflicting definitions. This ambiguity results in several conceptions with which not all will agree. Moreover, the normative rationale behind the goal of preventing premature deaths is masked by the operational de...

This article discusses the fairness of geographically targeted vaccinations (GTVs). During the initial period of local and global vaccine scarcity, health authorities had to enact priority-setting strategies for mass vaccination campaigns against COVID-19. These strategies have in common that priority setting was based on personal characteristics ,...

This World Bank Report offers a new conception of fair decision processes in health financing. It argues that such procedural fairness can contribute to fairer outcomes, strengthen the legitimacy of decision processes, build trust in authorities, and promote the sustainability of reforms on the path to health coverage for all.

This paper reviews the experience of six low-income and lower middle-income countries in setting their own essential packages of health services (EPHS), with the purpose of identifying the key requirements for the successful design and transition to implementation of the packages in the context of accelerating progress towards universal health cove...

Introduction Many families in low-income and middle-income countries have high out-of-pocket expenditures (OOPE) for healthcare, and some face impoverishment. We aimed to assess the effect of Kangaroo Mother Care initiated in community setting (ciKMC) on financial risk protection estimated by healthcare OOPE, catastrophic healthcare expenditure (CH...

Importance: Rising health care costs are a major health policy challenge globally. Norway has implemented a priority-setting system intended to balance cost-effectiveness and concerns for fair distribution, but little is known about this strategy and whether it works in practice. Objective: To present and evaluate a systematic drug appraisal met...

Countries around the world are increasingly rethinking the design of their health benefit package to achieve universal health coverage. Countries can periodically revise their packages by performing sectoral analyses, i.e. by evaluating a broad set of services against a ‘doing nothing’ scenario using a budget constraint. Alternatively, they can car...

Prioritarianism is an ethical theory that gives extra weight to the well-being of the worse off. In contrast, dominant policy-evaluation methodologies, such as benefit-cost analysis, cost-effectiveness analysis, and utilitarianism, ignore or downplay issues of fair distribution. Based on a research group founded by the editors, this important book...

Background It is impossible to meet all healthcare demands, but an open and fair rationing process may improve the public acceptability of priority setting in healthcare. Decision-making is subject to scrutiny by newspaper media, an important public institution and information source for discussions about rationing. In Norway, healthcare rationing...

Most countries have made little progress in achieving the Sustainable Development Goal (SDG) target 3.4, which calls for a reduction in premature mortality from non-communicable diseases (NCDs) by a third from 2015 to 2030. In this Health Policy paper, we synthesise the evidence related to interventions that can reduce premature mortality from the...

In Norway, priority for health interventions is assigned on the basis of three official criteria: health benefit, resources, and severity. Responses to the COVID-19 pandemic have mainly happened through intersectoral public health efforts such as lockdowns, quarantines, information campaigns, social distancing and, more recently, vaccine distributi...

Physical inactivity is the leading cause of non-communicable diseases, and further research on the cost-effectiveness of interventions that target inactivity is warranted. Socioeconomic status is vital in this process. We aim to evaluate the cost-effectiveness of a cycle-network expansion plan in Oslo compared to the status quo by income quintiles....

Health sector priorities and interventions to prevent and manage noncommunicable diseases and injuries (NCDIs) in low- and lower-middle-income countries (LLMICs) have primarily adopted elements of the World Health Organization Global Action Plan for NCDs 2013-2020. However, there have been limited efforts in LLMICs to prioritize among conditions an...

Background Kangaroo mother care (KMC) can substantially enhance overall survival of low birthweight babies. In a large randomized controlled trial, we recently showed that supporting mothers to provide community initiated KMC (ciKMC) can reduce early infant mortality by 25% (hazard ratio (HR) 0.75). With the current analysis we aimed to explore if...

Key Findings n National Noncommunicable Disease and Injury (NCDI) Poverty Commissions were established in 16 low-and lower-middle-income countries (LLMICs) to define local NCDI epidemiology, determine an expanded set of priority NCDI conditions, and recommend cost-effective, equitable health-sector interventions. n Commissions prioritized an averag...

Ethiopia is experiencing an increasing frequency and intensity of slow‐onset and acute disasters caused by climate change, with significant health impacts. Understanding and addressing these impacts involves trade‐offs, which are central to effective priority setting in health and overarching efforts to meet the Sustainable Development Goals. Despi...

The Lancet COVID-19 Commission Task Force for Public Health Measures to Suppress the Pandemic was launched to identify critical points for consideration by governments on public health interventions to control coronavirus disease 2019 (COVID-19). Drawing on our review of published studies of data analytics and modelling, evidence synthesis and cont...

Background In precision medicine biomarkers stratify patients into groups that are offered different treatments, but this may conflict with the principle of equal treatment. While some patient characteristics are seen as relevant for unequal treatment and others not, it is known that they all may influence treatment decisions. How biomarkers influe...

Despite recent advances in access to and use of modern contraception in Ethiopia, further improvement is needed, particularly among poorer women. This extended cost-effectiveness analysis investigated the health outcomes, their distribution, and financial risk protection associated with meeting the demand for modern contraception for all Ethiopian...

Background. Metformin is a widely accepted first-line pharmacotherapy for patients with type 2 diabetes mellitus (T2DM). Treatment of T2DM with glibenclamide, saxagliptin, or one of the other second-line treatment agents is recommended when the first-line treatment (metformin) cannot control the disease. However, there is little evidence on the add...

All countries worldwide have signed up to the United Nations Sustainable Development Goals and have committed to the objective of achieving ‘universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all’....

Background Increasing the coverage of community-based treatment of childhood pneumonia (CCM) is part of the strategy to improve child survival, increase life-expectancy at birth and promote equity in Ethiopia. However, full coverage of CCM has not been reached in any regions of the country. There are no sub-national cost-effectiveness analyses avai...

Background Cost effectiveness was a criterion used to revise Ethiopia’s essential health service package (EHSP) in 2019. However, there are few cost-effectiveness studies from Ethiopia or directly transferable evidence from other low-income countries to inform a comprehensive revision of the Ethiopian EHSP. Therefore, this paper reports average cos...

Estimating the required resources for implementing an essential health services package (EHSP) is vital to examine its feasibility and affordability. This study aimed to estimate the financial resources required to implement the Ethiopian EHSP from 2020 to 2030. Furthermore, we explored potential alternatives to increase the fiscal space for health...

We argue that deliberative decision making that is inclusive, transparent and accountable can contribute to more trustworthy and legitimate decisions on difficult ethical questions and political trade-offs during the pandemic and beyond.

Background Expansion of designated cycling networks increases cycling for transport that, in turn, increases physical activity, contributing to improvement in public health. This paper aims to determine whether cycle-network construction in a large city is cost-effective when compared to the status-quo. We developed a cycle-network investment model...

We argue that deliberative decision-making that is inclusive, transparent and accountable can contribute to more trustworthy and legitimate decisions on difficult ethical questions and political trade-offs during the pandemic and beyond.

To make progress toward universal health coverage, countries should define the type and mix of health services that respond to their populations’ needs. Ethiopia revised its essential health services package (EHSP) in 2019. This paper describes the process, methodology and key features of the new EHSP. A total of 35 consultative workshops were conv...

Public payers around the world are increasingly using cost-effectiveness thresholds (CETs) to assess the value-for-money of an intervention and make coverage decisions. However, there is still much confusion about the meaning and uses of the CET, how it should be calculated, and what constitutes an adequate evidence base for its formulation. One wi...

Public payers around the world are increasingly using cost-effectiveness thresholds (CETs) to assess the value-for-money of an intervention and make coverage decisions. However, there is still much confusion about the meaning and uses of the CET, how it should be calculated, and what constitutes an adequate evidence base for its formulation. One wi...

https://www.fhi.no/publ/2020/rad-om-prioriterte-grupper-for-koronavaksinasjon-i-norge/ Folkehelseinstituttet har fått i oppdrag fra Helse- og omsorgsdepartementet å organisere koronavaksinasjonsprogrammet. Som en delleveranse av oppdraget har Folkehelse- instituttet etablert en ekstern ekspertgruppe i etikk og prioritering. Denne etikk- rådgivning...

The Norwegian Ministry of Health and Care Services has commissioned the Norwegian Institute of Public Health to organise the national coronavirus immunisationation programme. As a partial delivery of the assignment, the Norwegian Institute of Public Health has established an external expert group in ethics and prioritisation (henceforth: the ethics...

In recent years, it has become commonplace among the Global Burden of Disease (GBD) study authors to regard the disability-adjusted life year (DALY) primarily as a descriptive health metric. During the first phase of the GBD (1990-1996), it was widely acknowledged that the DALY had built-in evaluative assumptions. However, from the publication of t...

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a rules-based synthesis of the available evidence on levels and trends in health outcomes, a diverse set of risk factors, and health system responses. GBD 2019 covered 204 countries and territories, as well as first administrative level disaggregations for 22 countr...

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a rules-based synthesis of the available evidence on levels and trends in health outcomes, a diverse set of risk factors, and health system responses. GBD 2019 covered 204 countries and territories, as well as first administrative level disaggregations for 22 countr...

Incorporating equity in HTA and CEA

Highlights Distributional Cost-Effectiveness Analysis (DCEA) provides information about the equity impacts of health technologies and programmes It can provide distributional breakdowns of effects and opportunity costs by equity-relevant social variables and/or disease categories It can also use equity weights to summarise equity impacts and analys...

In health outcomes terms, the poorest countries stand to lose the most from these disruptions. In this paper, we make the case for a rational approach to public sector health spending and decision making during and in the early recovery phase of the COVID-19 pandemic. Based on ethics and equity principles, it is crucial to ensure that patients not...

The Fair Priority Model offers a practical way to fulfill pledges to distribute vaccine fairly and equitably.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

This chapter explains how you can use level-dependent social welfare functions (SWFs) to evaluate health distributions in a manner that is founded on explicit, challengeable, and consistent ethical principles. A level-dependent social welfare function (SWF) weights health gains for one person or group relative to another as a function of their abso...

This chapter shows how informal normative concerns about health equity raised by decision makers can be translated into formal health equity objectives that are amenable to quantitative analysis using distributional cost-effectiveness analysis (DCEA). It also clarifies the kinds of ethical concerns that can and cannot be addressed by DCEA. Four way...

This chapter shows how to quantify and compare the baseline health between and within disease categories using three main health concepts—current health, future health, and lifetime health—and shows how each concept can be measured using three main metrics—absolute health achievement, absolute health shortfall, and relative health shortfall. Differ...

In this chapter we discuss some of the challenges facing the field of distributional cost-effectiveness analysis (DCEA). We cover four methodological challenges for researchers: (1) modelling complexities such as economies of scale, spillovers, and behavioural responses; (2) ex post DCEA based on distributions of realized outcomes rather than expec...

This chapter introduces the basic measurement concepts needed to understand and critically appraise distributional cost-effective analysis (DCEA) findings about equity impacts and trade-offs. It starts by introducing the key questions that research users need to ask about DCEA findings, drawing on basic concepts from the literature on measuring ine...

This chapter is a guide to designing a distributional cost-effective analysis (DCEA) for research commissioners and producers. It describes the main components of DCEA and how they can be combined in different ways to inform decision-making in various contexts. The appropriate design of a DCEA will depend on the objectives of the relevant decision-...

In Ethiopia, little is known about the extent of out-of-pocket health expenditures and the associated financial hardships at national and regional levels. We estimated the incidence of both catastrophic and impoverishing health expenditures using data from the 2015/16 Ethiopian household consumption and expenditure and welfare monitoring surveys. W...

I en ideell verden ville vi alle fått medisinsk behandling etter behov. Men i virkeligheten danner ressursknapphet selve rammen for vår eksistens: Vi må prioritere, og velge noe foran noe annet.

Objectives At any point in time, a person’s lifetime health is the number of healthy life years they are expected to experience during their lifetime. In this article we propose an equity-relevant health metric, Health Adjusted Age at Death (HAAD), that facilitates comparison of lifetime health for individuals at the onset of different medical cond...

Background: Cost effectiveness was a criterion used to revise Ethiopia’s essential health service package (EHSP) in 2019. However, there are few cost-effectiveness studies from Ethiopia or directly transferable evidence from other low-income countries to inform a comprehensive revision of the Ethiopian EHSP. Therefore, this paper reports average co...

Background: Cost effectiveness was a criterion used to revise Ethiopia’s essential health service package (EHSP) in 2019. However, there are few cost-effectiveness studies from Ethiopia or directly transferable evidence from other low-income countries to inform a comprehensive revision of the Ethiopian EHSP. Therefore, this paper reports average co...

Modeling an approach in which people who have recovered from COVID-19 are returned to society to reduce interactions between infected people and vulnerable people indicates the effectiveness of such an approach in reducing deaths.

The generation of burden-of-disease (BOD) data has been driven by a desire to inform policy making and priority setting. This chapter examines the uses of BOD data for priority setting. The authors first introduce the most relevant BOD metrics and describe how these have been linked to priority setting. They next discuss the problems with using BOD...

Background Scaling up coverage of community-based treatment of childhood pneumonia (CCM) is part of the strategy to promote equity and reduce under-five mortality rate (U5MR) in Ethiopia. However, urban children with symptoms of pneumonia are still more than twice as likely to receive treatment compared with rural children having similar symptoms....

Background: Increasing the coverage of community-based treatment of childhood pneumonia (CCM) is part of the strategy to improve child survival, increase life-expectancy at birth and promote equity in Ethiopia. However, full coverage of CCM has not been reached in any regions of the country. There are no sub-national cost-effectiveness analyses ava...

Background: Malaria is a public health burden and a major cause for morbidity and mortality in Ethiopia. Malaria also places a substantial financial burden on families and Ethiopia's national economy. Economic evaluations, with evidence on equity and financial risk protection (FRP), are therefore essential to support decision-making for policymake...

Emerging demographic, epidemiological and health system changes in low-income countries require revisions of national essential health services packages in accordance with standard healthcare priority setting methods. Policy makers are in need of explicit and user-friendly methods to compare impact of multiple interventions. We provide experiences...

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 volu...

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...

Although inequality in survival is highly correlated with life expectancy, the authors believe that this form of health inequality should be better understood and that inequality in survival could be another useful summary measure of population health. It is also a motivation for assigning priority to the worse-off in priority-setting. Inequality i...

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 recommend...

Introduction Aiming for universal health coverage (UHC) as a country-level goal requires that progress is measured and tracked over time. However, few national and subnational studies monitor UHC in low-income countries and there is none for Ethiopia. This study aimed to estimate the 2015 national and subnational UHC service coverage status for Eth...

Objectives: At any point of time, a person's baseline health is the number of healthy life years they are expected to experience during the course of their lifetime. In this article we propose an equity-relevant health metric, illness-specific individual Health Adjusted Life Expectancy (iHALE), that facilitates comparison of baseline health for ind...

In a recent paper—The disvalue of death in the global burden of disease—we question the commensurability of the two components of the disability-adjusted life year (DALY)—years lived with disability (YLDs) and years of life lost (YLLs)—and offer a tentative solution to this problem. In an exciting and constructive reply—Is consistency overrated?—ph...

Ethiopia is one of the sub-Saharan African countries contributing to the highest number of maternal and neonatal deaths. Coverage of maternal and neonatal health (MNH) interventions has remained very low in Ethiopia. We examined the cost-effectiveness of selected MNH interventions in an Ethiopian setting. We analysed 13 case management and preventi...

In this chapter, I discuss the Time-Relative Interest Account (TRIA) and the Life Comparative Account (LCA) and their implications for summary measures of population health and fair priority setting in health care. First, I argue that an extreme interpretation of TRIA is incompatible with the standard practice of measuring population health by life...

In low-income settings resource constraints force clinicians to make harsh choices. We examine the criteria Ethiopian physicians use in their bedside rationing decisions through a national survey at 49 public hospitals in Ethiopia. Substantial variation in weight given to different criteria were reported by the 587 participating physicians (respons...

Global health research has typically focused on single diseases, and most economic evaluation research to date has analysed technical health interventions to identify ‘best buys’. New approaches in the conduct of economic evaluations are needed to help policymakers in choosing what may be good value (ie, greater health, distribution of health, or f...

Background Out-of-pocket health expenditures can pose major financial risks, create access-barriers and drive patients and families into poverty. Little is known about physicians’ role in financial protection of patients and families at the bedside in low-income settings and how they perceive their roles and duties when treating patients in a healt...

Abstract This comment argues that four critical questions needs to be resolved before MCDA tools can improve priority setting in health: how to merge the quantitative and deliberative elements of MCDA; how to select criteria; how to weigh them, and whom to bring to the table.

Reducing inequalities in health and the determinants of health is a widely acknowledged health policy goal, and methods for measuring inequalities and inequities in health are well developed. Yet, the evidence base is weak for how to achieve these goals. There is a lack of high-quality randomised controlled trials (RCTs) reporting impact on the dis...

Rethinking Society for the 21st Century - by International Panel on Social Progress (IPSP) July 2018

Rethinking Society for the 21st Century - by International Panel on Social Progress (IPSP) July 2018

How can evidence from economic evaluations of the type the Disease Control Priorities project have synthesized be translated to better priority setting? This evidence provides insights into how investing in health, particularly though priority interventions and expanded access to health insurance and prepaid care, can not only save lives but also h...

Background: A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and R...

Objective To examine the association between availability of obstetric institutions and risk of eclampsia, HELLP-syndrome, or delivery before 35 gestational weeks in preeclamptic pregnancies. Study design National population-based retrospective cohort study of deliveries in Norway, 1999–2009 (n = 636738) using data from The Medical Birth Registry...

In response to the incremental creation of an expansive constitutional right to health in Costa Rica, the country’s rights-friendly constitutional chamber of the Supreme Court (known as the Sala IV) unleashed a flood of litigation for medications, treatments, and other health care issues. This development was met by widespread criticism from within...

In response to the incremental creation of an expansive constitutional right to health in Costa Rica, the country's rights-friendly constitutional chamber of the Supreme Court (known as the Sala IV) unleashed a flood of litigation for medications, treatments, and other health care issues. This development was met by widespread criticism from within...

Background This study aims at quantifying the level and changes over time of inequality in age-specific mortality and life expectancy between the 19 Norwegian counties from 1980 to 2014. Methods Data on population and mortality by county was obtained from Statistics Norway for 1980–2014. Life expectancy and age-specific mortality rates (0–4, 5–49...

Background: Patient age is among the most controversial patient characteristics in clinical decision making. In personalized cancer medicine it is important to understand how individual characteristics do affect practice and how to appropriately incorporate such factors into decision making. Some argue that using age in decision making is unethica...

Introduction High healthcare costs make illness precarious for both patients and their families’ economic situation. Despite the recent focus on the interconnection between health and financial risk at the systemic level, the ethical conflict between concerns for potential health benefits and financial risk protection at the household level in a lo...

Background: The first month of life is the period with the highest risk of dying. Despite knowledge of effective interventions, newborn mortality is high and utilization of health care services remains low in Ethiopia. In settings without universal health coverage, the economy of a household is vulnerable to illness, and out-of-pocket payments may...

Most donors of external financing for health use allocation policies to determine which countries are eligible to receive financial support and how much support each should receive. Currently, most of these policies place a great deal of weight on income per capita as a determinant of aid allocation but there is increasing interest in putting more...