Welcome back.

Today, we're going to speak about priority setting in health, with a focus on how

communities and countries can set those priorities in ethical ways.

I'm extremely honored and very grateful that a friend of mine,

Professor Norheim, is joining us from Bergen, Norway.

Professor Norheim is one of leader authorities in the world

on priority setting for investments in health.

He's both a physician and a bioethicist.

He has headed a range of commissions, both in his own country, Norway, and globally.

And now he's assisting the government of Ethiopia in helping to set

priorities in fair and more ethical ways for its own investments in health.

Professor Norheim and I are friends.

And therefore, with his permission, I'm going to refer to him

throughout the interview not as Professor Norheim or Dr. Norheim.

But as Oula, as they say his name in Norwegian.

We're going to ask Oula a number of questions in hope that through his

always thoughtful and clear responses that he can assist us in

better understanding this really, really critical topic.

So Oula, thank you very much.

I can't express enough to you my gratitude.

Let's begin with the following.

Why is it important for countries to set priorities in what you call fair ways?

>> So first, I'd like to say that health, like education, is special in many ways.

Like the philosopher Norman Daniels and the philosopher Mark Jessen has argued.

There are some basic goods in life that are important, and health is one of them.

So to secure equal opportunities in life, providing health care,

like education, is very important.

And all countries need to allocate resources in a fair way.

And for the allocation of health care resources,

I think there is a huge potential for improvement.

So, by better priorities, I think, it's also possible to improve health more and

also distribute health in a more fair way.

And finally, it's possible to organize the health care system and the financing of

the health care system in a way that also can protect against poverty.

So these are the most important reasons why I think it's so

important to look at priority setting in health.

>> Oula, thank you.

How do most countries today, especially low and middle income countries,

actually set their priorities for investments in health?

>> So interestingly, I think they do it in a less than perfect way,

in terms of being systematic, but a lot of what they do makes a lot of sense.

A lot of low income countries, for instance, focus on child health and

maternal health, infectious diseases.

And these are actually usually good priorities.

But there are also ad hoc decisions and

there are some misallocations between sectors.

So for instance, in Ethiopia, the country I know very well,

the coverage for treatment for HIV, for instance, is more than 50%.

But treatment for pneumonia, a condition that's very easy to prevent and

treat, coverage for that condition is actually 30%, only.

And there are several of these kind of examples of

unequal coverage and unequal access to services.

So there is both a potential for improving access and

improving it in a more equal and fair way.

In addition, I would say that countries are also influenced by donors.

And in a positive sense, they've been

influenced to focus on these high priority services for children and mothers.

And as the international community argued,

they should through the millennial development goals.

But there are also other donors that are pushing priorities in a way that's not

always well-aligned with what their country itself would like to prioritize.

So there is a lot of room for improvements, but

we shouldn't describe this situation as too bad in many ways.

A lot of low income countries have achieved a lot of

health gains in the last two decades.

So, if we look at a country like Ethiopia, life expectancy have improved

from 48 in 1990 to 65 today, and that's a huge improvement.

But still, it's possible to do even better.

>> And when you say, if I may, Oula, when you say possible to do even better,

I take it you also mean possible to do even better spending even the same amount

of money by trying to ensure a better prioritized and

fair prioritized allocation for investments in health, correct?

>> Exactly, so I would be the first to argue that

some countries should probably spend more on health.

But the discussion about priority setting takes as a starting point

that it's possible to do better within the resources you have available.

Both in terms, as you said, through improved efficiency, but

also improved fairness in the distribution of health.

>> So that's a perfect lead-in to our next question, which is,

well then, what criteria do you think should actually govern what we call

fair priority setting in health?

>> Yeah, so it's not only my view, but I led the work by WHO.

They asked us to develop a report and develop recommendations for

priority setting.

Countries that wants to move towards universal health coverage.

A lot of countries, more than 50 countries have asked for technical advice.

And one key issue is how to set priorities when you expand your services in

moving towards universal coverage.

So we put together an expert group with ethicists from all

over the world, and some economists.

And we discussed over a period of two years what kind of criteria

are recommended in the literature.

And what are criteria are used and accepted widely.

And we came up with three criteria that, in a general form,

are widely accepted and that we recommend it.

And the first and most important is cost effectiveness.

So, by using cost effectiveness analysis and identifying the kind of services

that can provide much health for as little resources as possible,

you can identify the services that will improve health or maximize health.

And as a professor of ethics,

I would say it would be almost unethical not to look at cost effectiveness.

So that's very important.

But in addition to that, we think that also fair distribution is very important.

So the second criterion is a special priority to the water [INAUDIBLE].

So sometimes there are services that are not so cost effective,

that are targeting people who are worse off.

Either in terms of health itself, like very severely ill,

mental health patients or others.

Or those who are worse off in terms of living in a far away area or

being especially poor.

And priority setting should also take this into account.

So if you want to reduce inequalities in health outcomes, you might sometimes find

that there's a tradeoff between maximizing health and distributing health fairly.

But mostly, we can look at cost effectiveness and

then do some adjustment for the second criteria priority to the worse off.

And finally, the third criterion that we find especially important in low and

middle income countries without a welfare security net or

a welfare state with social protection is the third criterion,

financial risk protection.

We know that a lot of people are paying for services.

And sometimes, families are pushed into poverty simply because they have

to pay for expensive services that are not fully reimbursed by the public system.

So, thinking about selecting the essential health care package by

looking at cost effectiveness, looking at priority to the worse off.

And also, looking at what kind of services will provide

financial risk protection are the three criteria that we recommended.

And of course, each country will have to weigh these criteria and

apply them in different ways that are appropriate for their country.

>> Well, thank you, that was beautifully stated.

But what about criteria that some others have raised, for example?

Such as attention to rare diseases, attention to age, or

attention to personal responsibility?

>> Yeah, so each country will have to consider a range of criteria.

But in the Making Fair Choices document from WHO,

we lifted up and emphasized these three criteria.

And I'd like to start with age, which is very much discussed.

And in a way, our criteria on cost effectiveness and

priority to the worse off will indirectly affect age.

So by maximizing health and by looking at the worse off, we will tend to set

priorities in a way that will advantage those with least health.

And that will, in many instances, mean the young, so

indirectly our criteria affect age.

But we and few ethicists will say that age in itself should be a criteria.

My personal view is that it's very hard to develop criteria for

priority setting that are completely age neutral.

Because we all want to live long and good lives.

So it's hard to be completely age neutral.

But it's a controversial criteria, and

there should be public debate about this criteria.

The same goes for rare diseases.

In high income countries, like in my country Norway and the UK and others,

there is a discussion about giving extra priority to so-called

orphan drugs that are often very costly.

Treating a patient with a genetic disease might cost 100,

$200,000 per disability, adjusted life year averted.

And that's too costly, of course, in a low income setting.

We believe that rare diseases should not be given extra priority,

if it's a very severe condition.

So we are targeting the worse off, and if it's cost-effective to treat them and

it can provide financial risk protection, the main concerns are captured.

But ethically, we don't think there is a ethical relevant difference between

having a rare disease or a common disease.

That said, there are special circumstances here that we should think about.

For instance, that it's hard to provide evidence for rare diseases.

It's rare to find good clinical trials, for instance, documenting the effects.

So you might want to have a lower threshold when you assess

the quality of the evidence for rare diseases.

And also,

I should say that rare diseases tend to be ignored in the international community.

We talk about pneumonias and HIV and malaria and the very common diseases.

And for example, childhood cancers that are quite rare,

they can be cured in over 90% of the cases.

And it's not that expensive to treat them, so

we tend to ignore some of the rare diseases.

And if they are cost effective and targeting the worse off,

I think we should consider a higher priority for those kind of services.

Finally, you asked about personal responsibility.

I think in a welfare state or the Nordic type,

I think we need to discuss that issue a lot.

Because maybe we tend to ignore responsibility for your own disease.

But in a low income setting, I don't think that argument should be very prominent.

I think, basically, when people are dying of unnecessary

infections, other risk factors, I think the state has

the basic responsibility to provide safe environment,

to provide protection and prevention vaccines and other services.

So I don't think the discussion about personal responsiblity should be very

prominent in a low income setting.

>> Oula, can you give us examples of countries of whatever

income group that are actually making a conscious effort to set priorities for

health investments in what we would call fair ways?

And please don't be shy if it's appropriate to even

mention your own country of Norway.

>> Yeah, I'd like to first talk about the UK.

Every country's looking to the UK because they were quite early on in establishing

an institution, the National Institute for Clinical Evidence, NICE, to

set up an institution that do systematic review, that do cost effective analysis.

And that provides clear recommendations on priority setting for the health services.

But they have tended to focus almost exclusively on cost effectiveness, and

that have been criticized in other countries.

So for instance, in the Nordic countries, especially Sweden and Norway,

we have said that equity and fair distribution is also important.

And we have tended to emphasize severity of disease or

priority to the worse off as important.

And that has been put into system with open transparent priority

setting with basic institutions, both in Norway and Sweden.

And it's fairly well-accepted in the country now that we need to set priorities

and that we have achieved somewhat good results in terms of priority setting.

In other countries, I would like to mention also Thailand.

Thailand has been famous for both moving towards universal health coverage,

but also setting up institutions inspired by NICE in the UK.

And they have a broader set of criteria.

They look at cost effectiveness, but they also look at equity.

They also look at finance or risk protection.

So I think countries, in low and middle income countries could learn a lot

from Thailand in the way that they have institutionalized priority setting and

the set of criteria they are using.

Chile, Mexico also have very interesting models.

So there are lots of good, positive experiences around the world for

how to improve priority setting.

>> And Oula, let me just ask you one more, along this vein, is there anything else

that either individual countries could do, or the global collective could do,

to try to enable more countries to engage in fair priority setting for health?

>> Yeah, I think evidence on the thinking around priority

setting is a kind of global public good.

So we should share this kind of information,

the evidence we have on cost effectiveness of services.

There are a lot of initiatives of that kind.

And we should sit and share experience on how to improve priority setting.

And I think it's possible to train health professionals and

to train people working in the ministries and

other organizations to learn about the principles of economic evalations,

systematic reviews, health technology assessments.

And their ideas about fair and equitable distribution.

And having training and having the evidence is

a way to build capacity to make the system more able to do and

make better and more fair [COUGH] decisions.

>> Oula, I can't thank you enough.

I'm extraordinarily grateful to you that you would take time from your very busy

schedule to join us from the beautiful, beautiful city of Bergen, Norway today.

I know that your very thoughtful and very beautifully stated

responses have added an enormous amount of value to our course.

And I'm sure that the learners who enroll in the course will be very grateful

as well that they have an opportunity to learn about fair priority setting in

health from someone as thoughtful, from someone as clear-thinking, and

someone who's so important to this work that's going on,

both within individual countries and globally.

So I wish you very well.

And I'll look forward to being in touch with you in the next few days about

the next phase of our collaboration.

But please accept my warmest and most profound thanks.

>> Thank you very much.

Thank you.

Ethical Priority Setting in Health - Ole Norheim

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