Can’t we all just play fair?

Multi-disciplinary discussions on priority setting are essential to cost-effectiveness analysis (CEA), or how much an intervention costs and how much it benefits health, i.e. reduces the burden of disease, of global health interventions. The goal is that these discussions will subsequently establish a greater sense of accountability and promote practical efforts in quantitative tool development.

Recent collaboration of this sort was seen at the Global Health Metrics and Evaluation Conference, where panelist explored some of the accountability issues and innovations that are prevalent throughout global health priority setting.[i] The GHME featured speakers with concentrations ranging across the board from ethics to statistics in order to discuss priority setting from all sides. According to Daniel Wikler, Professor of Ethics and Health at Harvard School of Public Health, priority setting relies heavily upon CEA, but CEA is only one tool in priority setting and it is not sufficient enough, unless analyses include an “equity” component.[ii] Wikler’s argument promotes ethical frame-working for analyzing priority setting, such as Norman Daniel’s accountability for reasonableness, which calls for priority-setting institutions to focus less on specific criteria and more on the priority-setting process itself.[iii] If the process is transparently fair and the decision-makers are fair-minded, then priority-setting decisions will be fair.

On the one hand, there are cries for transparency and accountability throughout CEA from ethicists like Daniel Wikler, but in Wikler’s own words, “you can’t pull numbers out of ethicists,”[iv] therefore, we look to the statisticians for the numbers and turn to the analysts in order to delve further into the demands of priority-setting process itself.

Presenting on the same panel at the GHME was Dan Chisholm from the Department of Health Systems Financing of the WHO. Chisholm focuses on the need for evaluation of the equity considerations in CEA, for the development of a priority-setting “checklist,” and for new quantitative tools and analysis.[v] Increased efficiency in establishing equitable global health priority-setting institutions starts with a systematic review of current mechanisms, like CEA. Chisholm proposes that since efficiency and equity do not necessarily lead to the same decisions in policy or the allocation of resources, consequently there is a need for a clearly conceptualized and practically relevant mechanism that can consistently produce evidence and make value-based judgments on health.[vi] Chisholm’s “checklist” aims to enhance study quality and knowledge translation by ensuring that equity concerns are comprehensively considered and held to a standard. This will help both analysts and decision-makers to report and to discuss efficiency and equity within fair decision-making processes (established under accountability for reasonableness).[vii]

The GHME is just one exhibition adding to the growing knowledge base on the adoption and implementation of CEA and the importance of this process in constructing transparent public spending on health. The Center for Global Development’s priority setting institutions for health working group is another multi-disciplinary group of policy-makers, practitioners, experts and academics serving in a personal capacity to bring about evidence that can be used to improve priority-setting practices in developing nations.[viii] Dr. Lydia Kapiriri, Research Coordinator of the Global Priority Setting Research Network in the Joint Centre for Bioethics at the University of Toronto, and a member of the working group, speaks here about her research within a Ugandan hospital, how the notion of accountability for reasonableness will improve priority setting within the hospital, and how her findings are useful to improve priority-setting practices in developing nations.[ix]

Fairness in the distribution of cost-effective programs and resources is a complex and not easily simplified quantification, however, the continuation of multi-disciplinary, international discourse, collaboration, and efforts to refine CEA processes are all signals of future progress.

View full videos from the GHME’s March 16th, 2011 panel on “New quantitative tools for priority setting” here.

[i] Global Health Metrics and Evaluation Conference. Institute for Health Metrics and Evaluation, et al. 16 Mar 2011. Web. 21 Sep 2011. <;.

[ii][iv] “Pulling numbers out of ethicists: Moral components of quantitative tools for priority setting.” Video. The Global Health Metrics and Evaluation Conference. Daniel Wikler. 16 Mar 2011. Web. 24 Sep 2011. <;.

[iii] Daniels, Norman. “The ethics of accountability in managed care reform.” Health Affairs. 17.5 (1998): 50-64. Web. 24 Sep. 2011. <;.

[v-vii] “An equitable CHOICE-Clarifying efficiency: equity trade-offs in health care priority setting.” Video. The Global Health Metrics and Evaluation Conference. Dan Chisholm. 16 Mar 2011. Web. 24 Sep 2011. <;.

[viii] “Priority-Setting Institutions for Global Health.” Center for Global Development. Web. 22 Sep 2011. <;.

[ix] Holewa, Hamish, narr. “#011: It’s No Skin Off My Nose: Why People Take Part in Qualitative Health Research.” International Program of Psychosocial Health Research. Oncology Social Work Australia, 2008. Web. 22 Sep 2011. <;.


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