Article in Medicine
Priority setting processes in health care take place in many countries (Rawlins and Culyer, 2004; US Senate, 2010) The rationale behind this is the scarcity of resources and the realization of societal goals. Niessen argues for a transparent process, combining notions of both fairness and efficiency

Many countries are in the process of formalizing the national priority setting process in health care at national and local levels (Rawlins and Culyer, 2004; Baltussen et al. 2010; Douw et al., 2006; US Senate, 2010; Peacock et al. 2006). Commonly, the agreed rationale behind such plans is the wish to attain societal welfare goals, while dealing with scarcity of resources in a fair, efficient, and transparent way.*

The objective is in one way or another to take difficult decisions of what is to be a priority in the implementation of health programs or, more specifically, what to include in a local or national health service package (Peacock et al, 2009; Baltussen et al, 2010). Within the UK, the Programme for Government ‘Freedom, Fairness, Responsibility’ of the new coalition government recently reconfirmed that the National Institute of Clinical Excellence (NICE) is to be supported to arrive at value-based decisions in health care (Coalition, 2010). NICE itself is now reviewing its predominately efficiency-based, extra-welfarist cost per QALY reference case that it has adopted since its inception over 15 years ago. In the US, the passing of the Patient Protection and Affordable Care Act has introduced some new - now explicit - related elements in the priority setting debates in the United States. While it shows an, at least formal, emphasis on effectiveness and efficiency, it’s ‘comparative effectiveness’ approach excludes formal monetary efficiency thresholds such as in the UK or other European countries i.e. an amount that society is willing to pay for a health year gained.

A Case for Combining Equity and Efficiency

In spite of the acceptance of a common rationale, it is an understatement to conclude that there is less agreement on the criteria to be applied in such a decision making process as the debates on rationing health care continue to show. (Goold and Baum, 2008; Donaldson et al., 2008; Peacock et al. 2006). In addition to an effectiveness and efficiency criterion, typical criteria proposed are, from the clinical perspective, the severity of the disease (Michaels, 2006; Norheim OF, 2008) and, from the policy perspective, the societal distribution of disease and disability (Ferner et al. 2010). NICE is among the national agencies that has stated the formal inclusion of social values in the national policy process. (NICE-Citizen’s Council, 2008). Other criteria maybe applied locally as a result of local policy making despite high level national goals and these often lead to variations and trade-offs in regional health service delivery (Wilson et al. 2007).

The past decade has shown the development of systematic techniques to define the rational basis in the allocation of health services. Especially, new health economics research has been reported progress in desirability, methods and feasibility to include equity and other criteria in decision making in a variety of countries and settings. (Peacock et al. 2006, 2009; Green 2009; Baltussen, 2007, 2010; Green and Gerard, 2009; Koopmanschap et al. 2010; Douw et al., 2006; Jehu-Appiah et al. 2009; Baeten et al., 2010; Wilson et al. 2006). Various national proposals and experiences show a potentially substantial and important impact of these criteria on the traditional decision making that has been focused on safety and effectiveness. (Baeten et al, 2010).

We should learn about the scope of existing implicit and explicit criteria used in priority setting approaches in cross-national comparisons and assess how similar or disparate are these criteria. National-level policy makers with these in political arenas across the globe while formulating plans on the extension and distribution of health care services in environments with continuing constrained resources and increased demand. Most of the formulated criteria can be addressed through existing and tested techniques such as discrete choice experiments derived from conjoint analysis and other theories or studies of actual real-life decision making (Green and Gerard, 2009; Ruta et al. 2005; Ryan M, et al. ).

Towards Explicit Priority Criteria for Fairness

Given the diversity and similarities of across countries, one could argue in favor of a more explicit use of multiple criteria in policy making. This seems to be the case in older socialized health systems in Europe such as the UK, especially at local commissioning levels (PCTS) , where decisions are taken with regard to multiple criteria and where MCDA is now under wider consideration at national level (Wilson et al, 2007). When a country needs to design packages for health issues or evaluate the health system for equity and efficiency, a explicit approach to priority setting may be a valuable tool within the formal context of a deliberative process, as also has been concluded in a review of policy making in high-income countries (Peacock et al., 2006). These results show relationships between preferences for attributes that are considered representative of equity or efficiency that may assist stakeholders to make decisions, although the value of their actual weights, of course, will value from country to country, level and stage of decision making, and, possibly, the type of health area under consideration. Additionally, the way in which a criterion is defined (for example, there are many ways of defining equity) will determine what weight it ultimately carries in the decision process. However, these present experiences are only starting point for further formalizing the rationales of decision makers when making health decisions and, additionally, add to the further development of a rational public and participatory policy process in the future. As health care demands will grow, with growing markets, increasing health care needs and increasing aging of populations, the debates will become ever more heated.

There are preference differences for equity and efficiency and these vary across countries. While this may seem like an obvious result to many, it is worth looking at where commonalities and differences may exist for the joint implementation of international health initiatives across the globe, in support of countries that cannot support their own health systems, yet. These preferences undoubtedly reflect the relationships between health and economic growth, including available household budgets, and will always, to some degree, be moderated by political views on distribution of health benefits of the moment. Nonetheless, it would help countries reflect on the state of their efficiency/equity trade-offs in health practice. Health decisions are made taking into account many more factors other than equity and efficiency. Here, we have focused on criteria classified as either equity or efficiency; however, the “other” factors such as organizational and implementation criteria could be a significant influence in decision-making.

In sum, in addition to the use of the effectiveness and the efficiency criterion, we observe that various criteria of fairness play a role in health decision making in the countries that we know across the globe. The past ten years, there has been methodological progress in addressing these elements in policy decisions e.g. in the United Kingdom (Wilson et al. ibid). Here, and elsewhere, further policy debate is taking place as to the relative balance which has, until now, seen efficiency at the national level override local equity and other policy imperatives. Research increasingly present more insights in the minds of various population groups and policy makers. Its findings help to formalize the weighing of criteria further. This will have to be part of a formal transparent process combining fairness and efficiency in health decisions not just in policy making but also, ultimately, in day-to-day settings for real life people.

* The contributions of Andrew Mirelman, Rob Baltussen, Ric Fordham, Francesco Paoluci are acknowledged.


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Professor Louis Niessen
Louis Niessen, MD is a professor International Health and Health Economics at the Liverpool School of Tropical Medicine and University of W

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