Public Health Priority Setting Research Articles

Public health priority setting on a national scale: The Scottish experience

ObjectivesScotland has the lowest life expectancy in Western Europe and significant health inequalities. A national review of public health in 2015 found that there was a lack of coherent action across organisational boundaries, inhibiting progress. This paper describes a rapid (four-month) systematic approach to prioritisation of Scotland's public health challenges, which was evidence-based, transparent and made use of significant stakeholder engagement. Study designCross-sectional survey of stakeholders in deliberative meetings. MethodsAn independent Expert Advisory Group (EAG) was formed to develop a typology of public health priorities, a long-list of potential priorities and ranking criteria. Deliberative stakeholder events were held at which the criteria were refined and priorities scored by participants from a wide range of stakeholder organisations. ResultsThe proposed typology identified three types of public health priorities: risk factors, social factors and system factors; medically defined disease entities were not used deliberately, to facilitate broad stakeholder participation. Fifteen criteria were identified to help identify priority issues, based on the scope of their burden, amenability to change, and multi-stakeholder preferences. Six public health priorities were selected by the EAG based on stakeholder scoring of a long-list against these criteria. ConclusionPrioritisation is important in modern public health but it is challenging due to limited data availability, lack of agreed evidence on effectiveness and efficiency of interventions, and divergent stakeholder views. The Scottish experience nevertheless shows that useful public health priorities can be agreed upon by a wide range of stakeholders through a transparent, participatory and logical process.

Public health priority setting: A case for priority to the worse off in well-being during the COVID-19 pandemic

In Norway, priority for health interventions is assigned on the basis of three official criteria: health benefit, resources, and severity. Responses to the COVID-19 pandemic have mainly happened through intersectoral public health efforts such as lockdowns, quarantines, information campaigns, social distancing and, more recently, vaccine distribution. The aim of this article is to evaluate potential priority setting criteria for public health interventions. We argue in favour of the following three criteria for public health priority setting: benefit, resources and improving the well-being of the worse off. We argue that benefits and priority to the worse off may reasonably be understood in terms of individual well-being, rather than only health, for public health priority setting. We argue that lessons from the COVID-19 pandemic support our conclusions. Keywords: COVID-19, Prioritarianism, Priority Setting, Public Health, Severity

Dutch DALYs, current and future burden of disease in the Netherlands

BackgroundThe Disability Adjusted Life Year (DALY) is a measure to prioritize in the public health field. In the Netherlands, the DALY estimates are calculated since 1997 and are included in the Public Health Status and Foresight studies which is an input for public health priority setting and policy making. Over these 20 years, methodological advancements have been made, including accounting for multimorbidity and performing projections for DALYs into the future. Most important methodological choices and improvements are described and results are presented.MethodsThe DALY is composed of the two components years of life lost (YLL) due to premature mortality and years lost due to disability (YLD). Both the YLL and the YLD are distinguished by sex, age and health condition, allowing aggregation to the ICD-10 chapters. The YLD is corrected for multimorbidity, assuming independent occurrence of health conditions and a multiplicative method for the calculation of combined disability weights. Future DALYs are calculated based on projections for causes of death, and prevalence and incidence.ResultsThe results for 2015 show that cancer is the ICD-10 chapter with the highest disease burden, followed by cardiovascular diseases and mental disorders. For the individual health conditions, coronary heart disease had the highest disease burden in 2015. In 2040, we see a strong increase in disease burden of dementia and arthrosis. For dementia this is due to a threefold increase in dementia as a cause of death, while for arthrosis this is mainly due to the increase in prevalence.ConclusionsTo calculate the DALY requires a substantial amount of data, methodological choices, interpretation and presentation of results, and the personnel capacity to carry out all these tasks. However, doing a National Burden of Disease study, and especially doing that for more than 20 years, proved to have an enormous additional value in population health information and thus supports better public health policies.

OP165 Health Technology Assessment And Public Health Priority Setting In China

IntroductionSince 2009, China has initiated a national program on free provision of essential public health services. The national program has expanded both in terms of service categories and funding, showing China's great commitment to universal health coverage. However, with slowdown of public input in the health sector, the government decided to prioritize interventions and optimize reimbursement packages. Researchers in the China National Health Development Research Center (CNHDRC)—the Chinese national health technology assessment (HTA) agency were asked to design the tools to facilitate the decision process.MethodsWith multi-criteria decision analysis (MCDA) method, the researchers analyzed value dimensions in public health issues, and built an evidence matrix for the priority-setting decisions. Supported by HTA tools, they appraised interventions and services through literature review and field studies, and projected budget impact of potential adjustment decisions based on cost analysis results. A deliberative process of key stakeholder groups was taken, and their views were counted in making the final recommendations.ResultsBased on evidence review and scores of stakeholders’ judgment, two public health service interventions were recommended for removal, and another two for adjustment (one for merger, one for optimizing care pathway). Cost estimation and potential budgetary impact were also analyzed to support financial decisions.ConclusionsHTA and MCDA are key tools for defining the value criteria, evidence framework, and deliberative process for the essential public health program. However, lack of cost-effectiveness evidence hinders fine-tuned decisions on resource allocation. Continual health economic evaluation needs to be conducted in the near future.

Cost-benefit analysis of vaccination: a comparative analysis of eight approaches for valuing changes to mortality and morbidity risks

BackgroundThere is increasing interest in estimating the broader benefits of public health interventions beyond those captured in traditional cost-utility analyses. Cost-benefit analysis (CBA) in principle offers a way to capture such benefits, but a wide variety of methods have been used to monetise benefits in CBAs.MethodsTo understand the implications of different CBA approaches for capturing and monetising benefits and their potential impact on public health decision-making, we conducted a CBA of human papillomavirus (HPV) vaccination in the United Kingdom using eight methods for monetising health and economic benefits, valuing productivity loss using either (1) the human capital or (2) the friction cost method, including the value of unpaid work in (3) human capital or (4) friction cost approaches, (5) adjusting for hard-to-fill vacancies in the labour market, (6) using the value of a statistical life, (7) monetising quality-adjusted life years and (8) including both productivity losses and monetised quality-adjusted life years. A previously described transmission dynamic model was used to project the impact of vaccination on cervical cancer outcomes. Probabilistic sensitivity analysis was conducted to capture uncertainty in epidemiologic and economic parameters.ResultsTotal benefits of vaccination varied by more than 20-fold (£0.6–12.4 billion) across the approaches. The threshold vaccine cost (maximum vaccine cost at which HPV vaccination has a benefit-to-cost ratio above one) ranged from £69 (95% CI £56–£84) to £1417 (£1291–£1541).ConclusionsApplying different approaches to monetise benefits in CBA can lead to widely varying outcomes on public health interventions such as vaccination. Use of CBA to inform priority setting in public health will require greater convergence around appropriate methodology to achieve consistency and comparability across different studies.

Priority Setting in Public Health: A lesson in ethics and hard choices

Priority Setting in Public Health: A lesson in ethics and hard choices

Developing a CASPER Survey to Assess the Prevalence of Risk Factors for Neglected Tropical Diseases in Texas.

While more than a billion people live at risk of neglected tropical diseases in areas of Asia, sub-Saharan Africa, and Latin America, the degree to which such diseases burden countries like the United States is currently unclear. Even though many neglected tropical diseases such as dengue, leishmaniasis, and Chagas disease are not endemic to the United States, the possibility of their emergence is noteworthy, especially in states like Texas, which has high levels of poverty, a large immigrant population, and a climate amenable to the vectors for these diseases and is geographically proximate to endemic areas. Despite the health threat that emerging neglected tropical diseases may pose, little is known about the prevalence of risk factors for them in the United States. Texas House Bill 2055, enacted on September 1, 2015, mandated the establishment of a surveillance program for neglected tropical diseases in Texas. After reviewing the potential risk factors for transmission in Texas, we developed a 41-question survey that could be implemented using the Community Assessment for Public Health Emergency Response (CASPER) method. In concert with public health surveillance and vector population monitoring, data from CASPERs could be used to quickly and cost-effectively assess the prevalence of risk factors for 10 neglected tropical diseases in Texas or elsewhere in the United States. The data generated by future CASPERs conducted using this survey could be immediately actionable, guiding public health priority setting and decision making.

The return of public health to local government in England: changing the parameters of the public health prioritization debate?

ObjectivesTo explore the influence of values and context in public health priority-setting in local government in England. Study designQualitative interview study. MethodsDecision-makers' views were identified through semi-structured interviews and prioritization tools relevant for public health were reviewed. Interviews (29) were carried out with Health and Wellbeing Board members and other key stakeholders across three local authorities in England, following an introductory workshop. ResultsThere were four main influences on priorities for public health investment in our case study sites: an organizational context where health was less likely to be associated with health care and where accountability was to a local electorate; a commissioning and priority-setting context (plan, do, study, act) located within broader local authority priority-setting processes; different views of what counts as evidence and, in particular, the role of local knowledge; and debates over what constitutes a public health intervention, triggered by the transfer of a public health budget from the NHS to local authorities in England. ConclusionsThe relocation of public health into local authorities exposes questions over prioritizing public health investment, including the balance across lifestyle interventions and broader action on social determinants of health and the extent to which the public health evidence base influences local democratic decision-making. Action on wider social determinants reinforces not only the art and science but also the values and politics of public health.

Tradeoffs in resource allocation at state health agencies.

Priority setting is at the core of resource allocation. In recent years, priority setting in public health has occurred in the context of a difficult authorizing environment, one in which politicians have shown increasing interest in reducing the footprint of government, even during times of increased demand for social services. In this context of austerity, tradeoffs abound. These tradeoffs may occur not only within a single programmatic area in public health (e.g., cutting an infant mortality program vs a "Children With Special Health Care Needs" program) but also at a broader, more abstract level (e.g., favoring programs that are relatively more efficient for one population vs less efficient for programs serving a population in greater need of services). This project was undertaken to provide more insight into tradeoffs within state health agencies with regard to what types of tradeoffs exist and how often they occur. To characterize these tradeoffs, we engaged in a mixed-methods project where we first conducted 45 semistructured interviews with public health leaders across 6 state health agencies. Tradeoffs were elicited through open-ended questions and probes and qualitatively coded and analyzed. Next, we conducted a national survey across all state health agencies, receiving 207 responses (66% response rate). Survey respondents were asked to rate how frequently they encountered particular tradeoffs and how difficult they were to resolve. The most frequently encountered tradeoffs were "insufficient funding for a program versus no funding for a program" (84% rating as frequently/very frequently encountered) and prioritizing "current versus future need" (80% rating as frequently/very frequently). More than 50% of respondents said that they encountered 7 of the 11 tradeoffs frequently or very frequently and found 10 of the 11 difficult or very difficult to resolve. Forty-two percent of respondents rated "services for younger groups versus services for older groups" as difficult/very difficult to resolve.

The implications of fundamental cause theory for priority setting.

Application of fundamental cause theory to Powers and Faden's model of social justice highlights the ethical superiority of upstream public health interventions. In this article, I assess the ramifications of fundamental cause theory specifically in context of public health priority setting. Ethically optimal public health policy simultaneously maximizes overall population health and compresses health inequalities. The fundamental cause theory is an important framework in helping to identify which categories of public health interventions are most likely to advance these twin goals.

Community views and public health priority setting: how do health department priorities, community views, and health indicator data compare?

New York, like many other states, provides county-level health statistics for use in local priority settings but does not provide any data on public views about priority health issues. This study assessed whether health department priorities are notably different from community concerns about health, and how both groups' priorities compare with local health statistics. Data from a 2009 rural survey on community health concerns were compared to priorities named by the seven area county health departments, and to local health indicator data. Health care/insurance cost (60%), obesity (53%), and prescription cost (41%) were leading community concerns, regardless of age, education, sex, or Internet in the home. Six of seven county health departments selected access to quality health care (which includes health care/insurance cost) as a leading public health priority, but only three identified obesity. The following leading local health issues were suggested by health indicators: Physical activity and nutrition, Smoking, and Unintentional injury. Health departments diverged from community priorities, from health indicator data, and from one another in choosing priorities. Adding a question about community health priorities to existing state telephone surveys on health behavior and lifestyle would provide an important tool to local health departments.

Schistosomiasis, Soil-Transmitted Helminthiasis, and Sociodemographic Factors Influence Quality of Life of Adults in Côte d'Ivoire

BackgroundBurden of disease estimates are widely used for priority setting in public health and disability-adjusted life years are a powerful “currency” nowadays. However, disability weights, which capture the disability incurred by a typical patient of a certain condition, are fundamental to such burden calculation and their determination remains a widely debated issue.MethodologyA cross-sectional epidemiological survey was conducted in the recently established Taabo health demographic surveillance system (HDSS) in south-central Côte d'Ivoire, to provide new, population-based evidence on the disability caused by schistosomiasis and soil-transmitted helminthiasis. Parasitological results from stool, urine, and blood examinations were juxtaposed to quality of life (QoL) questionnaire results from 187 adults. A multivariable linear regression model with stepwise backward elimination was used to identify significant associations, considering also sociodemographic characteristics obtained from the Taabo HDSS database.Principal FindingsPrevalences for hookworm, Plasmodium spp., Trichuris trichiura, Schistosoma haematobium and Schistosoma mansoni were 39.0%, 18.2%, 2.7%, 2.1% and 2.1%, respectively. S. mansoni and T. trichiura infections of any intensity reduced the participants' self-rated QoL by 16 points (95% confidence interval (CI): 4–29 points) and 13 points (95% CI: 1–24 points), respectively, on a scale from 0 (worst QoL) to 100 points (best QoL). The only other statistically significant effect was a 1-point (95% CI: 0.1–2 points) increase on the QoL scale per one unit increase in a calculated wealth index.Conclusions/SignificanceWe found consistent and significant results on the negative effects of schistosomiasis and soil-transmitted helminthiasis on adults' self-rated QoL, also when taking sociodemographic characteristics into account. Our results warrant further investigation on the disability incurred by helmintic infections and the usefulness of generic QoL questionnaires in this endeavor.

Modeling causes of death: an integrated approach using CODEm.

BackgroundData on causes of death by age and sex are a critical input into health decision-making. Priority setting in public health should be informed not only by the current magnitude of health problems but by trends in them. However, cause of death data are often not available or are subject to substantial problems of comparability. We propose five general principles for cause of death model development, validation, and reporting.MethodsWe detail a specific implementation of these principles that is embodied in an analytical tool - the Cause of Death Ensemble model (CODEm) - which explores a large variety of possible models to estimate trends in causes of death. Possible models are identified using a covariate selection algorithm that yields many plausible combinations of covariates, which are then run through four model classes. The model classes include mixed effects linear models and spatial-temporal Gaussian Process Regression models for cause fractions and death rates. All models for each cause of death are then assessed using out-of-sample predictive validity and combined into an ensemble with optimal out-of-sample predictive performance.ResultsEnsemble models for cause of death estimation outperform any single component model in tests of root mean square error, frequency of predicting correct temporal trends, and achieving 95% coverage of the prediction interval. We present detailed results for CODEm applied to maternal mortality and summary results for several other causes of death, including cardiovascular disease and several cancers.ConclusionsCODEm produces better estimates of cause of death trends than previous methods and is less susceptible to bias in model specification. We demonstrate the utility of CODEm for the estimation of several major causes of death.

Epidemiological burden of minor, major and fatal trauma in a national injury pyramid

The impact of trauma on population health is underestimated because comprehensive overviews of the entire severity spectrum of injuries are scarce. The aim of this study was to measure the total health impact of fatal and non-fatal unintentional injury in the Netherlands. Epidemiological data for the four levels of the injury pyramid (general practitioner (GP) registry, emergency department (ED) registers, hospital discharge and mortality data) were obtained for the whole country. For all levels, the incidence and years of life lost (YLL) owing to premature death, years lived with disability (YLD) and disability-adjusted life-years (DALYs) were calculated. Unintentional injury resulted in 67 547 YLL and 161 775 YLD respectively, amounting to 229 322 DALYs (14.1 per 1000 inhabitants). Home and leisure, and traffic injuries caused most DALYs. Minor injury (GP and ED treatment) contributed 37.3 per cent (85 504 DALYs; 5.2 per 1000) to the total burden of injury, whereas injuries requiring hospital admission contributed 33.3 per cent (76 271 DALYs; 4.7 per 1000) and fatalities contributed 29.5 per cent (67 547 DALYs; 4.1 per 1000). Men aged 15-65 years had the greatest burden of injury, resulting in a share of 39.6 per cent for total DALYs owing to unintentional injury. The highest individual burden resulted from death (19 DALYs per patient). Trauma causes a major burden to society. For priority setting in public health and the identification of opportunities for prevention it is important that burden-of-injury estimates cover the entire spectrum of injuries, ranging from minor injury to death.

Causes and circumstances of death in a district hospital in northern Cameroon, 1993-2009

In Sub-Saharan Africa (SSA) sound planning is required as interest increases in the decentralization of healthcare financing and the implementation of a sector-wide approach to health care. For this, improved knowledge of national morbidity and mortality is essential. Data from remote areas of SSA are needed to ensure that public health priority-setting and actions reflect the situation in all regions, not just those easily accessed and readily researched. In order to understand the causes, circumstances and changes over time of death in a remote and underserved region, this study sought information on all deaths in a district hospital over a 17 year period. The study design was a retrospective review of the hospital records (in registers) of all patients hospitalized in Kolofata District Hospital, a rural public hospital in the Far North Region of Cameroon, 1 January 1993 to 31 December 2009. A line listing was extracted of all 1281 inpatient deaths, and this included dates of admission and death; patient name, address, sex and ethnic group; presenting complaint; duration of symptoms; summary of physical examination; and the diagnosis presumed to be the cause of death. Children under the age of 15 years and males comprised the majority of deaths (63.9% and 56.0%, respectively). Causes of death were related to the seasons. Infectious diseases including acute lower respiratory tract infection, malaria and diarrhoeal diseases were the leading causes of death; AIDS caused most adult deaths. A total of 67% of patients presented within 1 week of symptom onset, and 56.8% of deaths occurred on or before the day after admission. Deaths due to AIDS, malaria and complications of pregnancy increased over time. Among Kolofata District residents, death from vaccine-preventable measles and neonatal tetanus were rare, particularly in the later study years. The proportion of deaths attributed to non-communicable diseases did not increase in the 17 year period. To reduce mortality in this world region, priority should be given to the prevention and management of lower respiratory tract infections, malaria, diarrhoeal diseases, AIDS, and the complications of pregnancy. The planning of health resources and activities should take into account seasonal variations in the causes of death. Improvements to emergency services and community education that emphasises the need for earlier presentation when ill should reduce deaths that occur soon after hospital admission. Death due to measles and neonatal tetanus has become rare, a reflection of the effectiveness in this area of the national vaccination program.

P1-68 Epidemiological pattern and burden of drowning in Mazandaran province in Iran

IntroductionDrowning is a serious public health problem in the northern provinces of Iran. The aim of this study was to describe the burden of drowning in Mazandaran province, Iran in...

The epidemiology of hospitalization with diarrhea in rural Kenya: the utility of existing health facility data in developing countries

In developing countries where prospective surveillance is resource-intensive, existing hospital data can define incidence, mortality, and risk factors that can help target interventions and track trends in disease burden. We reviewed hospitalizations from 2001 to 2003 at all inpatient facilities in Bondo District, Kenya. Diarrhea was responsible for 11.2% (n=2158) of hospitalizations. The annual incidence was 550 and 216 per 100,000 persons aged <5 and > or =5 years, respectively. The incidence was highest in infants (1138 per 100,000 persons), decreased in older children, peaked again among 20-29-year-olds (341 per 100,000), and declined among those > or =65 years (157 per 100,000). Female adults had higher incidence than males (rate ratio=1.84, 95% CI 1.61-2.10). Incidence decreased with distance from the district referral hospital (4.5% per kilometer, p<0.0001) and from the nearest inpatient facility (6.6% per kilometer, p=0.012). Case-fatality was high (8.0%), and was higher among adults than young children. Co-diagnosis with malaria, pneumonia, HIV, and tuberculosis was common. Peak diarrhea incidence fell one to two months after heavy rains. The trends revealed here provide useful data for public health priority setting and planning, including preventative interventions. The utility of such data justifies renewed efforts to establish and strengthen health management information systems in developing countries.

Just caring: health care rationing and democratic deliberation

1. Just Caring: An Introduction 1.1 The Just Caring Problem: Core Argument 1.2 Rationing Justly: The Moral Challenge 1.3 Applications of the Deliberative Model 2. Just Caring: The Ethical Challenges of Health Care Rationing 2.1 The Story of Coby Howard and Its Lessons 2.2 Why Health Care Rationing is Inescapable 2.3 Renal Dialysis and the Medicare End-Stage Renald Disease [ESRD] Amendments 2.4 The Totally Implantable Artificial Heart [TIAH] 3. Pricing Human Life: Getting Beyond Tragic Choice 3.1 Is Human Life Priceless? 3.2 Tragic Choices or Tragic Disingenuousness: Invisible Rationing 3.3 Invisible Rationing and the Publicity Condition 3.4 Managed Care and Health Rationing: 4. Elements of Health Care Justice 4.1 Is Health Care Morally Special? 4.2 Non-Ideal Justice: A Moral Analysis and Defense 4.3 Pluralism, Justice, and Rational Democratic Deliberation 5. Rational Democratic Deliberation: Scope and Structure 5.1 The Scope of Rational Democratic Deliberation 5.2 Fair Health Care Rationing: Not Markets, Not Physicians, Not Bureaucrats 5.3 Rational Democratic Deliberation: Taking Seriously the Tragedy of the Commons 5.4 Rational Democratic Deliberation: Key Structural Features 5.5 Rational Democratic Deliberation and Fair Health Care Rationing 5.6 Wide Reflective Equilibrium and Just Health Care Rationing 5.7 Priority-Setting, Wide Reflective Equilibrium, and Democratic Deliberation 5.8 Facts, Wide Reflective Equilibrium, and Democratic Deliberation 5.9 Constitutional Principles of Health Care Justice and Rational Democratic Deliberation 5.10 Evaluating the Deliberative Process 5.11 Objections and Responses 6. Just Caring: Setting Limits for Effective Costly Therapies 6.1 Problem Introduction 6.2 Setting Limits: Options in the ESRD Program 6.3 Setting Limits: Options for HIV/AIDS Patients 6.4 Setting Limits: The Case of Artificial Hearts 6.5 Setting Limits: Concluding Comments 7. Just Caring: Last Chance Therapies 7.1 Introduction: Scope of the Problem 7.2 Why Last Chance Therapies? Weak Moral Arguments 7.3 Last Chance Therapies and Rational Democratic Deliberation 7.4 Futility and Last Chacne Therapies 8. Just Caring: Rationing, Catastrophically Ill Patients, and Patients with Disabilities 8.1 Introduction: The Scope of the Problem 8.2 Needs Are Not Enough: Effectiveness Must Matter 8.3 The Oregon Plan and the Disability Critique 8.4 Health Care Justice and the Disability Critique 8.5 Defining the Disabled: Ethical Implications 8.6 Conclusions 9. Is Age-Based Rationing Ever 'Just Enough'? 9.1 Defining the Problem: Can We Accept Natural Limits to Life? 9.2 Justice and Age-Based Rationing: Fair Innings 9.3 The Prudential Life Span Account 9.4 Age-Based Rationing: Major Objections 9.5 Age-Based Rationing: Responses to Objections 9.6 Age-Based Rationing and the Duty to Rescue 9.7 Conclusions 10. Just Caring: Do Future Possible Children Have a Just Claim to a Sufficiently Healthy Genome? 10.1 Introduction 10.2 Framing the Issue 10.3 Preimplantation Genetic Diagnosis [PGD]: A Historical Side Note 10.4 Does Justice Require Public Funding for Limited PGD? 10.5 Concluding Comments: Justice and Genetic Enhancement 11. Organ Transplantation: When is Enough Enough? 11.1 Scope of the Issue 11.2 The Maximization Argument: A Critical Moral Analysis 11.3 The Pittsburg Protocol: How Dead Must Donors Be? 11.4 Organ Procurement and Financial Incentives: A Critical Assessment 11.5 Presumed Consent/Duty to Donate: Critical Remarks 11.6 Justice and Multi-Organ Transplants or Retransplants 11.7 Concluding Comments 12. Just Caring: The Liberalism Problem 12.1 Justice, Health Care Needs and Morally Controversial Interventions 12.2 Liberal Communitarianism: Is It Just Enough? Is It Liberal Enough? 12.3 Resolving the Liberalism Problem: Public Reason and Public Interests 12.4 Concluding Reflections 13. Just Caring: The Ethical Challenges of Priority Setting in Public Health 13.1 Defining the Problem 13.2 The Scope of Public Health: Challenges and Choices 13.3 Health Care Justice and Public Health: When is Enough Enough? 13.4 Setting Public Health Priorities Justly: The Limits of Moral Theory 14. Just Caring: Financing Health Care Fairly 14.1 Why National Health Insurance? 14.2 Why Health Reform? 14.3 Assessing Competing Proposals for Health Reform 14.4 Health Savings Accounts: A Critical Assessment 14.5 Health Care Vouchers: A Critical Assessment 14.6 Single-Player Reform: A Constructive Proposal

Universal access to HIV treatment in developing countries: going beyond the misinterpretations of the ‘cost-effectiveness’ algorithm

Economic cost-effectiveness analysis (CEA) has been proposed as the appropriate tool to set priorities for resource allocation among available health interventions. Controversy remains about the way CEA should be used in the field of HIV/AIDS. This paper reviews the general literature in health economics and public economics about the use of CEA for priority setting in public health, in order better to inform current debates about resource allocation in the fight against HIV/AIDS. Theoretical and practical limitations of CEA do not raise major problems when it is applied to compare alternatives for treating the same medical condition or public health problem. Using CEA to set priorities among different health interventions by ranking them from the lowest to the highest values of their cost per life-year saved is appropriate only under the very restrictive and unrealistic assumptions that all interventions compared are discrete and finite alternatives that cannot vary in terms of size and scale. In order for CEA to inform resource allocation compared across programmes to fight the AIDS epidemic, a pragmatic interpretation of this economic approach, like that proposed by the Commission on Macroeconomics and Health, is better suited. Interventions, like a number of preventive strategies and first-line antiretroviral treatments for HIV, whose marginal costs per additional life-year saved are less than three times the gross domestic product per capita, should be considered cost-effective. Because of their empirical and theoretical limitations, results of CEA should only be one element in priority setting among interventions for HIV/AIDS, which should also be informed by explicit debates about societal and ethical preferences.

The epidemiology of hospitalized pneumonia in rural Kenya: the potential of surveillance data in setting public health priorities

Surveillance data from inpatient health facilities can be useful for prioritization of public health initiatives, but often are not collected or analyzed in developing countries. We evaluated data on hospitalized patients diagnosed with pneumonia in rural western Kenya to characterize pneumonia epidemiology and mortality. Data were obtained from admission registers of all inpatient facilities from 2001 to 2003 in Bondo District (estimated 2003 population: 255901), which is holoendemic for malaria and has high HIV rates. Inpatients with diagnoses compatible with acute pneumonia were included, and census data (1999) were used to calculate incidence rates by age, sex, season, and residence. From 2001 to 2003, a total of 2466 patients diagnosed with pneumonia were hospitalized with 282 deaths (11.4%). Incidence peaked at 698 per 100,000 person-years among children <5 years of age. A second peak occurred among 20-29 year-olds at 356 per 100,000 person-years; rates were twice as high in women as men in this age group (p<0.001). The incidence in persons >65 years was 121 per 100,000 person-years. Pneumonia incidence peaked during the twice-yearly high malaria seasons, 1-2 months after peak rainfall. Rates of pneumonia decreased with increasing distance of residence from the district hospital (p<0.0001). In Bondo District, the pneumonia burden is greatest among young children and middle-aged adults, the latter peak reflecting the area's HIV epidemic. Access to care likely influenced hospital utilization and thus pneumonia rates, particularly among the elderly. Our findings show that hospital-based data can provide useful information for public health priority setting, such as the introduction of new pneumonia vaccines for children and accelerating the introduction of antiretroviral medications.