Essentials of Global Health is a comprehensive introduction to global health. It is meant to introduce you to this topic in well-structured, clear and easy to understand ways. Much of the course will focus on five questions: What do people get sick, disabled and die from; Why do they suffer from these conditions? Which people are most affected? Why should we care about such concerns? What can be done to address key health issues, hopefully at least cost, as fast as possible, and in sustainable ways? The course will be global in coverage but with a focus on low- and middle-income countries, the health of the poor, and health disparities. Particular attention will be paid throughout the course to health systems issues, the linkages between health and development, and health matters related to global interdependence. The course will cover key concepts and frameworks but be practical in orientation. ------------------------------------------------------------------------------------------------------------------------------------------------------- Course Learning Objectives By the end of the course, learners should be able to: • Articulate key public health concepts related to global health; • Analyze the key issues in global health from a number of perspectives; • Discuss with confidence the burden of disease in various regions of the world; how it varies by sex, age, and location; key risk factors for this burden; and how the disease burden can be addressed in cost-effective ways; • Assess key health disparities, especially as they relate to the health of low-income and marginalized people in low- and middle-income countries; • Outline the key actors and organizations in global health and the manner in which they cooperate to address critical global health concerns; • Review key global health challenges that are likely to arise in the coming decades. ------------------------------------------------------------------------------------------------------------------------------------------------------- Value Added of the Course The course seeks to add special value by being comprehensive, by handling each topic in a consistent framework, and by helping learners gain an understanding of well grounded approaches to assessing global health issues and what can be done to address them. ------------------------------------------------------------------------------------------------------------------------------------------------------- The Readings and other materials for Essentials of Global Health For almost every session of Essentials of Global Health, you will see: - Required readings - Recommended readings - Recommended videos We have selected a small number of readings for each session that are central to understanding the content of the session. We have put these under “required readings”. For each required reading, we have also indicated how carefully you should read the material and on what parts of the material you should focus your attention. In addition, we have selected some additional readings that would be very helpful to your understanding the content of each session. The first is a textbook, Global Health 101, third edition. This is a comprehensive introductory textbook that closely follows the content of this Essentials of Global Health course. We have indicated for each session what part of the book you should read. Using this textbook can be very valuable to your mastering the content of the course. The second set of “recommended readings” is some additional readings, mostly from journal articles and reports. For these, too, we have indicated how carefully you should read the material and on what parts of the material you should focus your attention. Learners should note that to access articles from The Lancet they will have to register with the Lancet, if they do not have online access to a library that has The Lancet. Once they are registered, they will be able to sign into The Lancet and access all of its free articles. We have also indicated for most sessions one or two videos that relate to the topic of the session. These are meant to help the learner get a better feel for the topic which is being covered. Most learners will find the videos brief, easy and enjoyable to watch, and very enlightening.
Ethical Priority Setting in Health - Ole Norheim
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From the course by Yale University
Essentials of Global Health
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From the lesson
Module 3: Health Systems and Value for Money in Health
Module 3 focuses on health systems. It first examines the notion of “value for money” in considering investments in health. It then reviews how health systems in different parts of the world are organized; some of the issues they face in effectively and efficiently providing appropriate services of acceptable quality; and what we are learning can be done to address those issues in cost-effective ways.
Meet the Instructors
Richard SkolnikFormer Lecturer, Department of Health Policy and Management, Yale School of Public Health and Lecturer in the Practice of Management, Yale School of Management, 2012-2016
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.
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