Prioritizing healthcare: Is there any safety in numbers??

Would you tell me, please, which way I should go from here?’  Alice asked the Cheshire Cat.

‘That depends a good deal on where you want to get to,’ said the Cat.

Lewis Caroll, Alice in  Wonderland

Priority setting in healthcare is an interaction of various multifaceted factors and concepts such as

1. Equity in healthcare (who will be treated and for what disease, effectiveness vs efficacy)

2. Legal and constitutional framework (governance, geography)

3. Politics & religion (lobbies, pressure groups, clergy, legislations)

4. Ethics and morality (utilitarian, liberal, freedom to choose)

5. Income disparities (rich and poor)

6. Healthcare indicators (mortality, morbidity, epidemiology, individual vs
community)

7. Socioeconomics (marginalized and/or mainstream)

8. Budgetary support (% of Gross National Income for health sector, public spending, traditions/customs)

9. Cost-effectiveness/Sustainability (interventions vs gains in health, DALYs/QALYs)
Since vital decisions are taken in scenarios formed by incomplete information and likely conflicts between interests and objectives, the subject is extremely sensitive and may even result in political upheaval. Considering increasing global populations, cost-effectiveness assumes even greater significance as resources are limited. Clustering of healthcare and/or services in urban centers/hospitals is observed growing over time, thus increasing disparities and deprivations among masses. A functioning healthcare system is more likely to respond and correct such trends as compared to no health system(s) in many developing countries. The allocation of healthcare resources seeks to address interests of various stakeholders (through consultations) listed as under

I. Patient (seeking care)

II. Provider (autonomous)

III. Insurer (3rd party financiers)

IV. Pharmaceuticals (market driven)

V. Government (resource allocations in light of priorities set)

VI. Health Technologies

Healthcare financing in countries fall into two broad categories

A. Private/out of pocket payments (more affordable to affluent)

B. Tax-funded (covering communities in both urban and rural areas)

Careful deliberations and analysis of these two types of healthcare model clarifies that neither is perfect in terms of equitable distribution of resources, coverage and public satisfaction.

Healthcare in Sweden was revamped through use of demographic and socioeconomic variables as proxy measures of healthcare need, salient features of that policy are summarized as under

  • Redistribution of healthcare
  • Prevention
  • Slow but sustained implementation
  • Healthcare need measured by demography and socioeconomics rather than mortality, morbidity or other health status indicators
  • Increased funding for poor, socially disadvantaged and those with chronic disease(s)
  • Reducing out-of-pocket expenses
  • Analysis is based on individual level data rather than at a small area (ecological) level
  • Actual, rather than estimated, relative costs of health care used
  • Technology assessment

Similarly, Oregon Master Plan (1994) highlighted enhanced Medicaid coverage and limiting service coverage on evidence basis. Chile and Bangladesh are examples among developing nations where choices in health care involved making judgments about the relative priority attached to different objectives and services. Therefore, priorities need to be informed by an understanding of community preferences if they are to gain ownership among those affected. Evidence supports policies based upon the need to show that the way in which priorities are set is fair, logical and reasonable even if consensus on the outcome is not possible.

Ref: A Reader in Health Policy and Management, Edited by Ann Mahon, Kieran Walshe and Naomi Chambers. McGraw Hill 2009

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