Priority setting in developed and developing countries
Priority setting is a normal and important task in any health system. The starting point is current knowledge and evidence, but priority setting is also about judgement, which goes beyond what can be based on evidence. Wherever possible, judgement needs to be based on transparent and systematic methods that are open to question and debate by others.
Public opinion and politics
Politics (in this context) embraces the activities of all those bodies—private, public, and professional alike—whose actions influence health care provision: these have a central place in priority setting, but also need to be transparent and accountable.
Leadership and management
It is essential to understand what leaders or managers are aiming to do in setting priorities at any time, whether this be responding to public pressure, dealing with a financial issue, setting a strategic direction, managing a transformation, or being opportunistic. Whatever is done, there are opportunity costs and there will be unexpected and negative consequences, which need to be anticipated and planned for, wherever possible, and responded to flexibly.
This chapter offers a practical overview of priority setting. It is based on my own experience of running a large health system in a developed country (the National Health Service (NHS) in England, serving 51 million people and spending almost £100 billion a year) and my observation of systems in developing countries. There are many common threads. All systems prioritize through some means or other around key questions such as how much money should be spend on health, what are the most important needs to be addressed, what are the opportunity costs of using a particular therapy, judged by staff time and use of facilities as well as money spent, and what are the investments which need to be made in terms of buildings, research, and staff training? It is seen at its starkest in developing countries, where governments may have only $10 or $20 a head to spend each year on their populations. But it is also evident in the richest country in the world, the United States of America, where insurance systems put limits on coverage and politicians determine the budgets to be spent on disabled and older people. Only the limitlessly rich could have access to limitless health care!
Priority setting and the associated ‘rationing of care’, as it is sometimes referred to in more emotional terms, is a normal part of promoting health and providing health care in any system. It can, however, be done well or badly; it can be based on evidence or on popular perception or misconception. Equally, its unintended and detrimental consequences—because it will have some, even if the benefits outweigh them—can be well managed or simply ignored. Priority setting cannot be a purely rational and empirical process. A good starting point is, of course, the study of all the available evidence about the needs of a population and the clinical evidence about therapies and their relative benefits in cost and health terms.
There is now an increasing body of evidence and knowledge available to policy makers and clinicians. The number of documents, evidence-based protocols and systematic reviews is constantly increasing. The World Health Organization even has a listing of cost-effective interventions, which could be used to determine what are the most effective actions to take for any given amount of money. Why are they not widely used in developing and in developed countries? Why is it that Pang, Gray, and Evans needed to write in 2006 that:
Applying what we know already will have a bigger impact on health and disease than any drug or technology likely to be introduced in the next decade.
It is tempting simply to blame ignorance, prejudice, poor systems, and raw politics. All apply, of course, in some cases, but the answers are more complex.
Judgement, politics, and management
First, there is judgement. This is about how people apply knowledge and goes far beyond what is based on evidence. In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) has developed a systematic approach to the judgement of which therapies to use. This involves clinical and financial assessments and, interestingly, taps into human judgements of value through a Citizens’ Panel. Now there are also many sources of protocols and decision pathways to follow in looking after a patient. These are based on evidence and on consensus judgements of what are the most appropriate routes. Every clinician will also probably recognize the value of individual experience and wisdom in making judgements. The crucial point here is that these expert systems or the wise clinician are valuable, partly because they acknowledge the current state of knowledge in making their judgements.
The second key element is public opinion and politics. In the NHS Plan published in 2000, the United Kingdom government was explicit about targeting improvements in mortality from cancer and coronary heart disease and reductions in waiting times. Many other options were available, but they chose as priorities the issues that were seen as the public’s greatest concerns. The dangers here are obvious. Once something is open to political decision making, there is the risk that lobbying, vested interests, and ‘pork barrel’ politics (spending for projects that are intended primarily to benefit particular constituents or campaign contributors) take over. In this sense of the word, politics covers all the manoeuvring of groups in society, not just the political parties. Doctors, with their powerful position that is often even more powerful in developing than developed countries, are particularly effective lobbyists and politicians in this sense.
In every health system there are examples of decisions that were clearly political: why was this hospital built here, not there? Why were investments made in these clinicians’ services and not those? Why, in developing countries, were prestigious hospital projects funded at the expense of more effective community interventions? Why, in developed countries, is so little spent on public health? Public opinion and politics are, however, fickle. In the United Kingdom in 2000, there was great concern about deaths on the coronary heart disease waiting list. By 2005, when this had been largely solved, politicians received little if any credit. Public opinion had moved on. There were, and always will be, other pressing issues of the day.
While lobbying and politics can lead to some poor decisions, the interesting point is to identify where politics is appropriate. Priority setting is necessarily contextual and societal. The politicians in the United Kingdom were deliberately responding to public dissatisfaction. They recognized that the public were paying for the service and, crucially, that the public needed to see improvements if they were to keep faith with the NHS and continue to support it. In other words, they were making a decision not just about cancer or coronary heart disease but about who was paying for it and about how best to ensure the survival of the NHS. Politicians in other countries will consciously make decisions to demonstrate progress and point the direction for the future.
Priority setting is also about opportunity and sometimes needs to be opportunistic. There is sometimes a time and a place when something can be achieved that would not be possible at another.
Priority setting is also about will and determination. In the United Kingdom, we managers and politicians alike knew that we had to remain focused on a few priorities in order to make progress. We faced considerable opposition before there was visible progress. I recall well someone telling me that it was only after the second year of consistent focus that they knew we were serious about reducing waiting times. It was only in that second year that we saw change and began to generate momentum.
Priority setting is also about leadership and management. The decisions you make, although based on knowledge, need to take account of what you are trying to achieve and how you are planning to achieve it. Exercising judgement, responding to public opinion, and providing leadership and management are all necessary components of priority setting, but all need qualification and all have consequences.
Qualifications and consequences
The obvious question to ask at this point is what stops judgement, politics, and management riding roughshod over rational and empirically-based knowledge? Don’t these arguments simply allow anything to be done under the heading of priority setting, and how can we make sure we don’t end up with arbitrary and expedient priorities? I think that the best response to these questions is to consider how we can qualify judgement, politics, and management and how we can manage the consequences of decisions. Judgement, applied well, is largely but not entirely about balance. It is about taking into account all the relevant aspects of a situation. Arguably, we would not have achieved many of our targets in the NHS if they did not make any clinical sense or make sense to any clinicians. There needed to be some level of clinical support. Some targets were based purely on current medical knowledge, such as the targets to provide thrombolysis speedily after a myocardial infarct or to increase revascularization rates. Others, such as speeding up emergency treatment, were seen as appropriate for some but not all conditions. Peoples’ beliefs and attitudes are also highly relevant, whether clinicians or members of the public. Examples from many countries show that the public often has clear views, e.g. in Oregon, where members of the public were asked to rate conditions in priority order for expenditure. The NICE example is perhaps the most sophisticated current example of a systematic way of bringing all these factors together to make a judgement. But such a system will not solve all our problems of judgement at the clinical or the societal level. Individuals and organizations still need to take responsibility for judgement and decisions. My experience does, however, lead me to believe that we need some systematic, consistent, and open way to bring together the various elements in a judgement about priority setting. NICE has taken a bold and important step in this direction.
This argument provides a good lead into the discussion about politics. NICE operates outside the political system and gains its legitimacy through a consistent and open methodology. Transparency and accountability play a similar role in a political system. Governments make decisions based on politics and public opinion and judgements about the needs of particular groups in society or of society as a whole. In health, as in other areas, such decisions and judgements are enhanced through consultation, communication, debate, transparency, and accountability. These considerations also apply to the other participants in the politics of health. Private and public organizations and professional groups all make decisions which affect the availability of treatments to patients.
Pharmaceutical companies—not surprisingly, given that they are business organizations—have concentrated on developing drugs they can sell in developed markets and have ignored the needs of the poor. Governments and donor organizations have had to step in to provide the incentives for investment in the diseases which primarily affect poor people and poor countries. In doing so they have changed the companies’ priorities. These companies have enormous influence over many other aspects of health care and are also coming under increasing pressure to be transparent and accountable about the results of trials and about their decision-making processes. Professional organizations can also promote or block access to treatment. Sometimes this is about roles, standards and professional protectionism. In Brazil, for example, doctors have threatened strike action over the government’s decision to allow nurses to prescribe certain drugs. Elsewhere nurses prescribe these drugs safely and effectively. In both cases, there is a strong argument that business and professional groups alike need to demonstrate transparency and accountability in the public realm to those, the general public, who will ultimately pay for and benefit, or not, from their decisions.
Decisions about priorities, however taken, will inevitably have some difficult consequences, some of which will be unforeseen. This could happen in a number of different ways. In the United Kingdom, some of the NHS Plan targets were resisted by clinicians because they were seen as ‘distorting’ priorities. For example, it was argued, rightly, that requiring all patients to be treated and out of hospital emergency departments in 4 hours ignored the fact that some patients needed a longer time there for tests and observation. We responded nationally by asking a senior clinician to identify to what proportion of patients this would apply and to exclude this percentage from the target. A more serious problem was that some managers and clinicians changed figures and reports to improve their performance against the targets. This may happen in any measurement system and needs to be anticipated, identified when it happens and dealt with very firmly. In the NHS, amongst other actions, we asked the independent Audit Commission to do spot checks on measurements.
Managing priorities has opportunity costs. In the NHS, we realized that for a relatively small amount of extra funding we could dramatically reduce waiting times for cataract surgery. However, at that time we wished to maintain our emphasis on existing priorities rather than add another, particularly one which seemed to favour a relatively less serious operation over other more serious ones. A year later, when waiting times were falling fast, we made the investment in cataract surgery, with dramatic results.
More serious is the current situation in developing countries. Tackling HIV/AIDS, tuberculosis, and malaria are priorities alongside maternal and child health in the Millennium Development Goals. The death and disability from these diseases, and the fact that so much can be done to ameliorate them, provides ample reason for this priority. However, this clear focus has consequences. In particular, the action of the ‘vertical’ funds set up to tackle these diseases is damaging broad based or ‘horizontal’ health systems in some countries. The projects funded by the vertical funds are well resourced and attract staff and attention away from basic services. In some countries the amount available to tackle these three diseases is greater than the expenditure on all other aspects of health, and inevitably has an unintended distorting effect. In the last year great efforts have been made to align these vertical programmes with other ‘system strengthening’ initiatives so as to gain the benefits of having priorities whilst not damaging other services.
The simple point here is that thought and planning needs to be given to identifying all the consequences of priority setting, good and bad, and there need to be ways to respond flexibly where problems arise.
Priority setting is both normal and important. Done badly, it can be arbitrary and expedient. Done well, it can bring together evidence, disciplined judgement, accountable politics and clear sighted leadership to improve health.
Crisp N (2010). Turning the world upside down: the search for global health in the 21st century. RSM Press, London.Find this resource:
Pang T, Gray M, Evans T (2006). The 15th grand challenge for global public health. Lancet, 367, 284–6.Find this resource: