Priority-Setting Institutions for Global Health

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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 working group is investigating 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.

Related work:

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

Dai Hozumi, PATH, USA

Lydia Kapiriri, McMaster University, Canada/Uganda

Felicia Knaul, Harvard University, USA/Mexico

Zhao Kun, China Health Economics Institute, China

Rachel Nugent, Disease Control Priorities Network, University of Washington, USA

Andres Pichon-Riviere, Instituto de Efectividad Clinica y Sanitaria, Argentina

Diana Pinto, Inter-American Development Bank, USA

Mala Rao, Indian Institute of Public Health, Hyderabad, India

Michael Rawlins, National Institute for Health and Clinical Excellence, UK

Alarico Rodriguez, The National Resources Fund, Uruguay

Lloyd Sansom, University of South Australia, Australia

Jeremy Shiffman, American University, USA

Yot Teerawattananon, Health Intervention and Technology Assessment Program, Thailand

Ignez Tristao, Inter-American Development Bank, Brazil

Sean Tunis, Center for Medical Technology Policy, USA

Damian Walker, The Bill & Melinda Gates Foundation, USA