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Priority setting in health care: unburdening from the burden of disease

Priority setting in health care: unburdening from the burden of disease Priority setting in health care is inevitable. The key question, because resources for health care are limited, is not whether to prioritise but how to prioritise. Ideally this is done on the basis of a process of choice with explicit value judgements. Otherwise priorities still get set, albeit with confusion over what values are informing the process. WHO and the World Bank have invested enormous effort into estimating the Global Burden of We have grave reservations about the use of such data in any priority setting approach. It is proposed by these organisations that such burden be calculated on the basis of DALYs, i.e. Disability Adjusted Life Years, which combine measures of quantity of life with quality of life. It is questionable as to whether DAL.Ys are the best measure of health status available. However, greater concern is warranted over the notion of the burden of disease (BOD) per se. In addressing priority setting in health care, are estimates of the BOD really useful? There is a serious risk that BOD calculations do three things that are better avoided: first, they divert scarce analytical resources away from more fruitful pursuits such as calculating the incremental and decremental cost-effectiveness ratios for various interventions; second, they distort priorities by placing the emphasis on the big problems rather than the best buys; and third, they focus on diseases rather than on interventions. Ideal priority setting requires a number of components, not least of which is an identification of its purpose. There are two important issues in addressing this question. First, there is efficiency: the question of how, with the available resources, the overall beneficial effects can be maximised. Such effects include improving survival and quality of life, but also possibly: reassurance, respect for autonomy and dignity, etc. Second, there is equity-the fairness of any distribution of health care resources. With respect to both these issues, we are clear that, at least at the macro level of priority setting, the community ought to have a say in what their health services are about. At the micro (clinical) level, while this is less feasible, decision makers ought to be cognisant of the expectation that they act as the community’s agents. Setting priorities begins with an assessment of what health-care resources are currently being spent on what, and then proceeds to examine what pattern of resource deployment can achieve most benefit. This can be done by considering whether moving say $1000 or $1,000,000 from one program to another is likely to result in an overall increase in net benefits. Altering the balance of resource deployment to increase benefits is the key to priority setting. This key is shaped by the simple economic notions o f opportunity cost (the benefit foregone in the best alternative use of the resources) and the margin (embracing the idea that implementing the results of any priority setting exercise has to be about altering the balance of resource use). Such an approach is encompassed within, for example, program budgeting and marginal analysis which is currently being adopted in Australia in some of New South Wales, the Northern Territory and South Au~tralia.~ To what extent does priority-setting based on BOD meet the requirements we have outlined? If efficiency is a goal, our answer is that it does not. Efficiency is about ‘best buys’ i.e. whether, in terms of health gain and other benefits, available money is better spent on one program or another, requiring an alteration in the balance of investment between programs on that basis alone. Estimates of the relative total burden of different diseases do not help. They are at best superfluous but, as they occupy analysts who calculate them, there is a definite opportunity cost. They may also distort priorities if the size of the problem is used as a criterion for deciding where to allocate scarce resources. A big black hole may be a huge resource consumer with no benefit. A small and less black hole, where affordable and effective interventions are available, may be a far better buy. It is sometimes argued that politicians can be persuaded to act by indicating to them that cancer or heart disease or whatever is ‘a big problem’. They should be informed that it is best to seek out the best buys in terms of interventions, big or small, that work. These may sometimes be for unfashionable or small disease groups or a service which reaches effectively across disease groups. It might seem that estimates of the BOD in different populations would help to decide on an equitable allocation of health-service resources. Clearly, however, not all diseases are equally amenable to health-service interventions. Far better in this context is the notion of need as ‘capacity to benefit’ from health services, which does not require overall estimates of BOD. The same logc as we have applied to services is also relevant to applied research, although the establishment of what constitutes ‘marginal value-added for the research dollar’ is more difficult, with questions of reducing uncertainty likely to loom large. Where first to establish systematic reviews of the effectiveness of interventions may in part be decided by the relative size of health problem^.^ This, however, is usually sufficientlywell known not to require onerous estimates of BOD. There is a need to avoid being overzealous in regulating for research funding-serendipity cannot be rationally planned. Additionally, there may be an argument for some research funding being reserved for backing ‘informed hunches’ and previous winners. Australian priority setting needs three things. First, there is a need to recognise yet again that priority setting in health care is about intervening in AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1997 vot. 21 NO. 7 F EDITORIALS such a way that the best buys get implemented whatever the level of resources available. This in turn means looking at how the current balance of resource use can be improved, in the sense of moving some resources from one program of care to another, if by so doing the benefits of health care are greater or better. Second, explicit objectives need to be kept at the forefront of the minds of those setting priorities. 'Third, in the longer run there is a need to investigate what patients and citizens want from their health services, accepting that this may well extend beyond the most easily measurable health outcomes. The South Australian Health Commission, in their purchasing strategy, is already funding work to investigate this issue. It is the marginal cost effectiveness and equity of different forms of interventions, not the size of the disease burden, that should drive priority setting. Health policy-makers in Australia today would do better to look at what is already being advanced on priority-setting methods in Australia, than to burden themselves with BOD ideas. Gavin Mooney, Les Irwig and Stephen Leeder Department of Public Health and Community Medicine, Uniuersity of Sydney http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Priority setting in health care: unburdening from the burden of disease

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References (2)

Publisher
Wiley
Copyright
Copyright © 1997 Wiley Subscription Services, Inc., A Wiley Company
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1467-842X.1997.tb01779.x
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Abstract

Priority setting in health care is inevitable. The key question, because resources for health care are limited, is not whether to prioritise but how to prioritise. Ideally this is done on the basis of a process of choice with explicit value judgements. Otherwise priorities still get set, albeit with confusion over what values are informing the process. WHO and the World Bank have invested enormous effort into estimating the Global Burden of We have grave reservations about the use of such data in any priority setting approach. It is proposed by these organisations that such burden be calculated on the basis of DALYs, i.e. Disability Adjusted Life Years, which combine measures of quantity of life with quality of life. It is questionable as to whether DAL.Ys are the best measure of health status available. However, greater concern is warranted over the notion of the burden of disease (BOD) per se. In addressing priority setting in health care, are estimates of the BOD really useful? There is a serious risk that BOD calculations do three things that are better avoided: first, they divert scarce analytical resources away from more fruitful pursuits such as calculating the incremental and decremental cost-effectiveness ratios for various interventions; second, they distort priorities by placing the emphasis on the big problems rather than the best buys; and third, they focus on diseases rather than on interventions. Ideal priority setting requires a number of components, not least of which is an identification of its purpose. There are two important issues in addressing this question. First, there is efficiency: the question of how, with the available resources, the overall beneficial effects can be maximised. Such effects include improving survival and quality of life, but also possibly: reassurance, respect for autonomy and dignity, etc. Second, there is equity-the fairness of any distribution of health care resources. With respect to both these issues, we are clear that, at least at the macro level of priority setting, the community ought to have a say in what their health services are about. At the micro (clinical) level, while this is less feasible, decision makers ought to be cognisant of the expectation that they act as the community’s agents. Setting priorities begins with an assessment of what health-care resources are currently being spent on what, and then proceeds to examine what pattern of resource deployment can achieve most benefit. This can be done by considering whether moving say $1000 or $1,000,000 from one program to another is likely to result in an overall increase in net benefits. Altering the balance of resource deployment to increase benefits is the key to priority setting. This key is shaped by the simple economic notions o f opportunity cost (the benefit foregone in the best alternative use of the resources) and the margin (embracing the idea that implementing the results of any priority setting exercise has to be about altering the balance of resource use). Such an approach is encompassed within, for example, program budgeting and marginal analysis which is currently being adopted in Australia in some of New South Wales, the Northern Territory and South Au~tralia.~ To what extent does priority-setting based on BOD meet the requirements we have outlined? If efficiency is a goal, our answer is that it does not. Efficiency is about ‘best buys’ i.e. whether, in terms of health gain and other benefits, available money is better spent on one program or another, requiring an alteration in the balance of investment between programs on that basis alone. Estimates of the relative total burden of different diseases do not help. They are at best superfluous but, as they occupy analysts who calculate them, there is a definite opportunity cost. They may also distort priorities if the size of the problem is used as a criterion for deciding where to allocate scarce resources. A big black hole may be a huge resource consumer with no benefit. A small and less black hole, where affordable and effective interventions are available, may be a far better buy. It is sometimes argued that politicians can be persuaded to act by indicating to them that cancer or heart disease or whatever is ‘a big problem’. They should be informed that it is best to seek out the best buys in terms of interventions, big or small, that work. These may sometimes be for unfashionable or small disease groups or a service which reaches effectively across disease groups. It might seem that estimates of the BOD in different populations would help to decide on an equitable allocation of health-service resources. Clearly, however, not all diseases are equally amenable to health-service interventions. Far better in this context is the notion of need as ‘capacity to benefit’ from health services, which does not require overall estimates of BOD. The same logc as we have applied to services is also relevant to applied research, although the establishment of what constitutes ‘marginal value-added for the research dollar’ is more difficult, with questions of reducing uncertainty likely to loom large. Where first to establish systematic reviews of the effectiveness of interventions may in part be decided by the relative size of health problem^.^ This, however, is usually sufficientlywell known not to require onerous estimates of BOD. There is a need to avoid being overzealous in regulating for research funding-serendipity cannot be rationally planned. Additionally, there may be an argument for some research funding being reserved for backing ‘informed hunches’ and previous winners. Australian priority setting needs three things. First, there is a need to recognise yet again that priority setting in health care is about intervening in AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1997 vot. 21 NO. 7 F EDITORIALS such a way that the best buys get implemented whatever the level of resources available. This in turn means looking at how the current balance of resource use can be improved, in the sense of moving some resources from one program of care to another, if by so doing the benefits of health care are greater or better. Second, explicit objectives need to be kept at the forefront of the minds of those setting priorities. 'Third, in the longer run there is a need to investigate what patients and citizens want from their health services, accepting that this may well extend beyond the most easily measurable health outcomes. The South Australian Health Commission, in their purchasing strategy, is already funding work to investigate this issue. It is the marginal cost effectiveness and equity of different forms of interventions, not the size of the disease burden, that should drive priority setting. Health policy-makers in Australia today would do better to look at what is already being advanced on priority-setting methods in Australia, than to burden themselves with BOD ideas. Gavin Mooney, Les Irwig and Stephen Leeder Department of Public Health and Community Medicine, Uniuersity of Sydney

Journal

Australian and New Zealand Journal of Public Health – Wiley

Published: Dec 1, 1997

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