A critical review of priority setting in the health sector: The methodology of the 1993 World Development Report

Phnom Penh International University, Phnum Pénh, Phnom Penh, Cambodia
Health Policy and Planning (Impact Factor: 3.47). 04/1998; 13(1):13-31. DOI: 10.1093/heapol/13.1.13
Source: PubMed


The 1993 World Development Report, Investing in Health, suggests policies to assist governments of developing countries in improving the health of their populations. A new methodology to improve government spending is introduced. Epidemiological and economic analyses from the basis for a global priority setting exercise, leading to a recommended essential public health and clinical services package for low- and middle-income countries. Ministries of Health in many countries have expressed an interest in designing a national package of essential health services, using the methodology. Given the apparent importance attached to the study and its far reaching potential consequences, this article provides an overview of the method, the main issues and problems in estimating the burden of disease as well as the cost-effectiveness of interventions. Strengths and weaknesses in the databases, value judgements and assumptions are identified, leading to a critical analysis of the validity of the priority setting exercise on the global level.

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    • "The G-CEA model de-contextualises CEA analyses, eschewing context-specific distributional concerns and taking only limited account of political constraints such that enhanced transferability may come at the price of policy-relevance. Decision-makers attempting to derive a context-specific set of priorities would then have to perform the usual adjustments to the price and quantity of inputs and to the coverage, efficacy and adherence of interventions [18], as well as conducting multiple indirect comparisons (when the null set is not politically feasible in the relevant context and to recover incremental comparisons against current practice) and re-weighting outcomes to reflect context-specific distributional concerns [22,23]. "
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    ABSTRACT: The Health-sector Wide (HsW) priority setting model is designed to shift the focus of priority setting away from 'program budgets'--that are typically defined by modality or disease-stage--and towards well-defined target populations with a particular disease/health problem. The key features of the HsW model are i) a disease/health problem framework, ii) a sequential approach to covering the entire health sector, iii) comprehensiveness of scope in identifying intervention options and iv) the use of objective evidence. The HsW model redefines the unit of analysis over which priorities are set to include all mutually exclusive and complementary interventions for the prevention and treatment of each disease/health problem under consideration. The HsW model is therefore incompatible with the fragmented approach to priority setting across multiple program budgets that currently characterises allocation in many health systems. The HsW model employs standard cost-utility analyses and decision-rules with the aim of maximising QALYs contingent upon the global budget constraint for the set of diseases/health problems under consideration. It is recognised that the objective function may include non-health arguments that would imply a departure from simple QALY maximisation and that political constraints frequently limit degrees of freedom. In addressing these broader considerations, the HsW model can be modified to maximise value-weighted QALYs contingent upon the global budget constraint and any political constraints bearing upon allocation decisions. The HsW model has been applied in several contexts, recently to osteoarthritis, that has demonstrated both its practical application and its capacity to derive clear evidenced-based policy recommendations. Comparisons with other approaches to priority setting, such as Programme Budgeting and Marginal Analysis (PBMA) and modality-based cost-effectiveness comparisons, as typified by Australia's Pharmaceutical Benefits Advisory Committee process for the listing of pharmaceuticals for government funding, demonstrate the value added by the HsW model notably in its greater likelihood of contributing to allocative efficiency.
    Full-text · Article · Feb 2006 · Cost Effectiveness and Resource Allocation
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    • "These value choices will be further described and explored in the following. The choice of hypothetical life expectancy, 80 years for men and 82.5 years for women, is another arbitrary choice [1] [6] [11] [18] which will not be discussed further here. A crucial question is if the value choices can influence practical priority-setting. "
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    ABSTRACT: The "disability adjusted life years" (DALYs) are increasingly used as a tool for decision-making and for describing the distribution of the Global Burden of Disease. The "DALY" combines information about mortality and morbidity, with several value choices such as disability weighting, age-weighting and discounting. These value choices imply that life years are assigned different value, depending on the age and the health state they are in. How robust is the distribution of DALYs to changes in these value choices, and are the choices transparent at the point of use? We calculated the burden attributed to "developmental disability due to malnutrition" and "major depression" with alternative value choices in a simple sensitivity analysis. In particular, we explored the relation between disability weight, health state description and incidence rate. The formulae and information needed was found in the World Health Organisation (WHO) publications using DALYs, and in a survey among international health workers. We found that alternative age-weights, disability weights and discount rate led to an inversion in the ranking of the burden of the two conditions. The DALY loss attributed to "developmental disability due to malnutrition" increased from 14 to 90%, while that of "major depression" sunk from 86 to 10%. The value choices currently used, tend at underestimating the disease burden attributed to young populations and to communicable diseases and this goes against the renewed efforts of the WHO of targeting diseases that are typical of poor populations. While the value choices may be changed, lack of transparency is a more profound problem. At the point of use, the number of DALYs attributed to a condition cannot be fully disaggregated. Hence, one cannot know which part of a DALY loss reflects the age group affected, the prevalence, the mortality rates, the disability weight assigned to it, or to how the condition has been defined. A more transparent and useful approach, we believe, would be to present the years lost due to a disease, and the years lived with a disease separately, without disability weights, age-weights and discounting. This would keep the best of the DALY approach and come closer to the aim of disentangling science from advocacy.
    Full-text · Article · Dec 2004 · Health Policy
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    ABSTRACT: District health systems, comprising primary health care and first referral hospitals, are key to the delivery of basic health services in developing countries. They should be prioritized in resource allocation and in the building of management and service capacity. The relegation in the World Health Report 2000 of primary health care to a ‘second generation’ reform—to be superseded by third generation reforms with a market orientation—flows from an analysis that is historically flawed and ideologically biased. Primary health care has struggled against economic crisis and adjustment and a neoliberal ideology often averse to its principles. To ascribe failures of primary health care to a weakness in policy design, when the political economy has starved it of resources, is to blame the victim. Improvement in the working and living conditions of health workers is a precondition for the effective delivery of public health services. A multidimensional programme of health worker rehabilitation should be developed as the foundation for health service recovery. District health systems can and should be financed (at least mainly) from public funds. Although in certain situations user fees have improved the quality and increased the utilization of primary care services, direct charges deter health care use by the poor and can result in further impoverishment. Direct user fees should be replaced progressively by increased public finance and, where possible, by prepayment schemes based on principles of social health insurance with public subsidization. Priority setting should be driven mainly by the objective to achieve equity in health and wellbeing outcomes. Cost effectiveness should enter into the selection of treatments for people (productive efficiency), but not into the selection of people for treatment (allocative efficiency). Decentralization is likely to be advantageous in most health systems, although the exact form(s) should be selected with care and implementation should be phased in after adequate preparation. The public health service should usually play the lead provider role in district health systems, but non-government providers can be contracted if needed. There is little or no evidence to support proactive privatization, marketization or provider competition. Democratization of political and popular involvement in health enhances the benefits of decentralization and community participation. Integrated district health systems are the means by which specific health programmes can best be delivered in the context of overall health care needs. International assistance should address communicable disease control priorities in ways that strengthen local health systems and do not undermine them. The Global Fund to Fight AIDS, Tuberculosis and Malaria should not repeat the mistakes of the mass compaigns of past decades. In particular, it should not set programme targets that are driven by an international agenda and which are achievable only at the cost of an adverse impact on sustainable health systems. Above all the targets must not retard the development of the district health systems so badly needed by the rural poor. Copyright
    Full-text · Article · Oct 2003 · International Journal of Health Planning and Management
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