Priority-setting in global health
In global health, priority-setting is a term used for the process and strategy of deciding which health interventions to carry out. Priority-setting can be conducted at the disease level, the overall strategy level, research level, or other levels.
Definitions
Priority-setting is the act of deciding which health interventions to carry out, and can occur at several levels of granularity. Priority-setting can occur at the following levels:- health budget level
- overall strategy level
- disease level
- intervention level within each disease
- drug level
- research level
Metrics
Various metrics have been used to compare interventions. These include:- Disability-adjusted life year per unit cost, quality-adjusted life year, and other forms of cost-effectiveness analysis
- Reasons that the disease burden has persisted
- Adequacy of funding
Who sets the priorities?
- Governments: "In most countries, health spending by governments vastly outpaces international health aid, so governments set most health priorities."
- Non-profits and companies that assist governments
- If a country is using a Health in All Policy approach, then priority-setting is done by stakeholders who do not directly deal with health.
- International organizations
- Foundations
- Private donors : "A common outcome is a negotiated set of priorities that reflect some domestic needs and some technical, political, and economic considerations defined largely by the interests of donors." In some highly aid-dependent countries, donors "have huge influence on health priorities".
History of organizations and programs working on priority-setting
According to Amanda Glassman et al., global-level priority-setting has occurred since at least the 1980s, though these efforts have only focused on a few aspects.The following table is a timeline of organizations and programs working on priority-setting.
| Years active | Event | Level at which prioritization occurred | Metric or methods used | Operating costs/funding level | Results and impact |
| 1977–present | WHO Model List of Essential Medicines is published. | Among medicines | Produced explicit list of medicines. As of 2016, at least 156 countries have created national lists of essential medicines based on the WHO's model list. | ||
| 1984 | Demographic and Health Surveys is conceived. | Improving data quality | 380,000,000 | Data from the DHS has been analyzed by various papers. | |
| 1987–1989 | The Oregon Health Services Commission is established to prioritize within the US Medicaid program. The HSC would publish their first prioritized list of health services in 1993. The HSC would be abolished in 2012. | Health services | Originally a cost-per-utility formula, but then expert judgment and a method of splitting health services into categories and ranking within categories | "This time greater emphasis is placed on preventive services and chronic disease management, reflecting the fact that providing health care before reaching crisis mode will prevent avoidable morbidity and mortality." | |
| 1987–1990 | Commission on Health Research for Development is established in 1987 and would publish Health Research: Essential Link to Equity in Development in 1990. | Research | Meetings with experts | Produced several reports, including the final report, Health Research: Essential Link to Equity in Development. Resulted in the establishment of the Council on Health Research for Development to promote priority-setting in low- and middle-income countries. | |
| ? | Essential National Health Research | ||||
| 1993 | Disease Control Priorities in Developing Countries is published by the Disease Control Priorities Project. | Disability-adjusted life year | - | ||
| 1993 | The World Bank publishes the 1993 World Development Report. | Health interventions | Disability-adjusted life year | ||
| 1994 | World Health Organization's Ad Hoc Committee on Health Research Relating to Future Intervention Options | Research and development | Produced the 1996 report "Investing in Health Research and Development". | ||
| 1995 | Multiple Indicator Cluster Surveys | Improving data quality | |||
| 1998 | WHO-CHOICE, a program that helps countries choose health system priorities, is developed. | ||||
| 1998 | Global Forum for Health Research | Research and development | Structured interviews and literature review | Produced a list of 17 priorities. | |
| 2000 | Council on Health Research and Development | Review of previous efforts | |||
| 2001 | Center for Global Development | ||||
| 2002 | Marginal budgeting for bottlenecks is conceived. | ||||
| 2003 | The Bill & Melinda Gates Foundation announces the Grand Challenges in Global Health, for which it initially provides $200 million in funding. | Research and development | Scientific board | 550,000,000 | Out of more than 1000 submissions, 14 were selected by the scientific board as "grand challenges". |
| 2003 | The initial version of the Lives Saved Tool by Johns Hopkins University is created. | ||||
| 2004 | Global Forum for Health Research develops the "Combined Approach Matrix". | Various | CAM itself is the method, but takes into account disease burden, present level of knowledge, cost-effectiveness, macro-economic policies, etc. | Rudan et al.: "The tool has proven to be highly useful for systematic classification, organization, and presentation of the large body of information that is needed at different stages of priority setting process, so that the decisions made by the members of decision-making committees could be based on all relevant and available information, rather than their own personal knowledge and judgment." | |
| 2004 | The Copenhagen Consensus holds its first conference. | ||||
| 2005 | Health Metrics Network launches. The partnership would dissolve in 2013. | Improving data quality | 50,000,000 | Various | |
| 2006 | Second edition of Disease Control Priorities in Developing Countries by the Disease Control Priorities Project is published. | ||||
| 2007 | The Lancet publishes a series of papers on priorities in international health. | Research | Delphi method | ||
| 2007 | Health Intervention and Technology Assessment Program is established. | Various | |||
| 2007 | Institute for Health Metrics and Evaluation launches. | Improving data quality, burden of disease | 105,000,000 | ||
| 2008 | Supporting Independent Immunization and Vaccine Advisory Committees Initiative is founded. | Among vaccines | |||
| 2009 | EVIDEM Collaboration is established. | Health interventions | Literature review, "discussions with stakeholders", and multicriteria decision analysis | ||
| 2013 | International Decision Support Initiative launches as the result of a Center for Global Development working group. | Health interventions | 12,800,000 |
Reception
Rudan et al. says that priority-setting efforts have relied on "consensus reached by panels of experts" and as a result have not been systematic enough, and that this has "often made it difficult to present the identified priorities to wider audiences as legitimate and fair".Glassman et al. notes that criticisms of priority-setting include "the weak data on which estimates of burden, cost, and effectiveness relied; the value judgments implicit in disability-adjusted life year age weighting and discounting decisions; and treatment of equity issues, as well as the political difficulties associated with translating a ground zero package into a public budget based on historical inputs"; and the consideration of only health maximization at the expense of other objectives such as fairness.
Glassman et al. also notes how there are more cost-effectiveness studies for LMICs, but that these are unlikely to be actually applied to priority-setting processes.
Jeremy Shiffman has said that some bodies such as the Institute for Health Metrics and Evaluation and The Lancet are prominent in priority-setting due to their dominion rather than data and analysis, and also notes that the process of creating the Sustainable Development Goals was not sufficiently transparent.