Priority Setting
in Universal health coverage:
Choosing services
Tessa Tan-Torres Edejer
Health Systems Financing
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April 2013
The Three Dimensions (policy choices)
Coverage
Universal
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April 2013
Health
How does one choose needed services?
 What types of services to consider:
–
–
–
–
–
preventive, promotive, curative, rehabilitative, palliative
Across the life course
Across different levels of health facilities
procedures and pharmaceuticals and other medical goods
positive or negative lists
 Main criterion:
– Cost-effectiveness to maximize health; Getting the most out of the available
funding
– Quantifying opportunity costs when choosing less cost effective interventions
 Implementation issues:
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April 2013
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April 2013
Millions miss out on needed health services
Percentage of births by medically trained persons
0
20
40
60
80
100
Q1, Q5 and Average - 22
0
10
20
30
Q5
Q1
Average
Source: Latest available DHS for each country (excl. CIS countries)
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April 2013
40
50
MDG Tracer Conditions:
CEA threshold defined de facto?
 Antenatal care: 4+ visits
 Birth attended by skilled health personnel
 Measles, DTP3, Hib3, HepB3
 Children < 5: ARI visit; sleeping under ITN; ORT diarrhoea
 ART HIV; MCTC HIV + pregnant women
 TB: case detection rate
 Additional as possible (based on burden, CEA threshold,
budget, logistical feasibility)
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April 2013
But cost-effectiveness is not that
straighforward:
 Cost-effectiveness might correlate with the other axes.
– Many cost-effective interventions are for traditional diseases of the poor
– But many cost-ineffective interventions are costly (trauma surgery, cancer
drugs, renal replacement therapy)
 Cost-effectiveness may change:
– Because of drop in prices due to national/global volume of sales /international
pressure (tiered pricing)
– Because of bundling of services (economies of scope);
– Start up costs- special problem
 Even if cost-effective, it may still not be affordable (budget
constraints)
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April 2013
Shifting from pure cost-effectiveness to cost
effectiveness ++
« Quantitative analysis for qualitative insight »
 Begin from CHOICE results (cluster of disease or health sector as a whole)
 Use checklist to identify excluded interventions of equity or priority setting
interest
 Use quantitative techniques to explore concerns & illustrate impact of
alternative choices
– What resources will be released or foregone?
– What existing treatments will have to be displaced?
– What health benefits will be foregone?
– What is society willing to pay for a more equitable choice of interventions?
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April 2013
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Example: Mental health (cluster)
 At a mental health budget level of $3.50 per capita (India), efficiency
results from CHOICE suggest funding the following conditions:
– Epilepsy
– Alcohol treatment
– Depression treatment
 No funding would be allocated to treatment of bipolar disorder or
schizophrenia on efficiency grounds alone
 However, equity & priority-setting considerations (checklist):
– Conditions severe, chronic, lifelong
– Not curable, limited capacity to benefit
– Bad luck in the health lottery
– Interventions are the only means to help
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April 2013
12
Example: Mental health (cluster)
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April 2013
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Implementation issues
 There are already pre-existing services being provided by
governments of varying cost-effectiveness; e.g SHI
providing coverage for hospitalization with a cap; no
description of the disease or intervention being covered
(subsidy).
 Administrative ease
 The patient does not know on consultation what diseases
s/he has or what procedure/medication will be needed
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April 2013
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April 2013
Health expenditures by condition
Sri Lanka 2005
Maternal conditions
Benign neoplasms
Endocrine and metabolic
Congenital anomalies
Blood/Immune Disorders
Female
Oral health
Neonatal causes
Male
Mental disorders
Nutritional deficiencies
Diabetes mellitus
Malignant neoplasms
Musculoskeletal
Genitourinary
Nervous system disorders
Skin diseases
Digestive system
Cardiovascular
Respiratory infections
Chronic respiratory disease
Injuries
Infectious and parasitic
Investigation of signs,symptoms and other contact
0
100
200
300
400
500
600
700
800
Expenditure per capita (Rupees)
17
Fig. 2. Health care choices in a low-income and middle-income country. The vertical axis indicates the level of
public subsidy, the right-side horizontal axis refers to the population volume classified as poor and nonpoor, and the left-side horizontal axis represents clinical health services divided into the minimum and the
essential packages. Public subsidies should be close to 100% for the minimum package for the poor. In
low-income countries the subsidy should fall, perhaps quite sharply, as resources extend to the non-poor
or to interventions outside the minimum package. In middle-income countries the subsidy could extend to
the non-poor and can finance part of the essential package only if the minimum package is assured for the
poor and all cost-effective services are covered for the entire population (WDR93).
MIDDLE-INCOME COUNTRY
LOW-INCOME COUNTRY
Public fiannce share
Public fiannce snare
S/DALY
S/DALY
iNCOME
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Minimum
package
April 2013
Poverty line
Total
population
Essential
package
Income
Minimum
package
Essential
package
Total
population