Introduction to the PMAC 2016 Special Issue: “Priority Setting for Universal Health Coverage”

This issue of Health Systems & Reform presents articles prepared for the Prince Mahidol Award Conference (PMAC) in Bangkok, Thailand, from 26 to 31 January 2016, on the theme of “Priority Setting for Universal Health Coverage.” This conference is the world's premier global health policy event that brings together leading policy makers, researchers, and members of civil society from around the world. The meeting also celebrates the Thai government's presentation of the Prince Mahidol Award, which was established in 1992 to commemorate the 100th birthday anniversary of Prince Mahidol of Songkla, who is considered “The Father of Modern Medicine and Public Health of Thailand.”

The theme for PMAC 2016 continues the tradition of focusing on key health policy issues of global importance. The global health community has agreed to pursue the goal of moving toward universal health coverage (UHC) but without much clarity on how to do this or how to set priorities. The seven commentaries and seven articles in this special issue explore these questions from diverse perspectives and provide guidance on what is known, what is recommended, and what still needs to be figured out.

These articles are useful not only to participants at PMAC 2016, who will be discussing these questions in Bangkok in January 2016, but also to policy makers, policy analysts, and concerned citizens in many countries around the world. We all confront difficult choices in both social and personal lives as we move toward UHC. Questions about setting priorities for UHC are not just academic discussions; they have tangible consequences on the health services that real people receive. Priority setting affects what happens in individual lives. In short, priority setting matters, because it affects who gets what.

One critical distinction in discussions about priority setting is the difference between normative and empirical. Debates about priority setting often sit in the realm of the normative, about what should be done. At their heart, these debates are about social values, and they explicitly or implicitly involve questions of philosophy and issues of justification and why certain values should prevail over other values. Many of these normative arguments, however, do not directly engage in the process of justification and simply assume one set of values over another. Less common are essays about the empirical dimensions of priority setting, about what actually happens, how, and why. This debate about the empirical moves us from applied philosophy to political analysis. In other writings, I have argued that both dimensions—the normative and the empirical—are critical to understanding and managing the processes of health system reform and the processes of priority setting.¹ It is useful for readers of this issue to keep the normative/empirical distinction in mind as you peruse the essays that follow, thinking about whether authors are arguing about how priority setting should be done and why or about how priority setting is actually done and how it could be improved.

The issue begins with a series of commentaries from top leaders in global health. Margaret Chan, Director-General of the World Health Organization, opens with a reminder that universal health coverage “cannot provide access to all possible health services” and that “choices must be made and priorities must be set.” The essay summarizes three normative strategies proposed by a World Health Oganization expert committee for making these difficult choices. The commentary also emphasizes the role of national institutions to help set priorities. For me, I wondered whether these national institutions have implemented the proposed three-part strategy and whether they have avoided the five “unacceptable trade-offs” identified. These two important empirical questions are worth keeping in mind as you explore other articles in this issue.

Next, Keizo Takemi, a member of the House of Councillors in Japan, proposes a “T-shaped approach” to health system strengthening, as a guide to setting priorities for UHC. He emphasizes the role of the global community in supporting countries that require assistance in setting priorities and developing priorities. The T-shaped approach stresses the role of management capacity at the local and community levels, using vertical programs as an entry point to strengthen health systems and promote UHC. He highlights Japan's postwar experience with tuberculosis programs as an example of how this approach can work. This proposal recognizes that vertical programs are not going away and that they can be used to advance context-specific steps in moving toward UHC.

Setting priorities for UHC also raises profound conflicts and challenges—and several are identified by John S. Ji and Lincoln Chen in their commentary. They provide a historical review of the development of UHC and then wonder what a truly “globalized” UHC would look like and whether there exists a global responsibility beyond the nation-state for assuring UHC (a normative question). They raise questions about the methods for setting priorities, about who should set priorities, about how to deal with cultural practices (such as traditional medicine) that are not universally accepted, about how vertical programs relate to the UHC movement, and about how UHC goals may be set without an effective delivery system. These serious questions deserve serious analysis and responses.

Ariel Pablos-Mendez and colleagues at the U.S. Agency for International Development emphasize that UHC “is not a pipedream for developing countries”—and they refer to specific countries that changed the social contract in health (empirical). They argue that providing essential health services requires attention to both selecting cost-effective interventions and targeting the poorest and most vulnerable populations (a combination of objective utilitarian values and Rawlsian egalitarian values).² They also stress the importance of increasingly raising domestic financial resources for countries with greater capacity, stating directly, “Donors are not expected to pay for health insurance premiums.” Instead, they believe, donors should focus on global public goods (normative), which can help facilitate national health system transformations over time—helping countries with the tools and guidance of how to move toward sustainable UHC.

The Rockefeller Foundation has been a prominent force in promoting the global movement toward UHC. Judith Rodin, the foundation's president, calls not only for setting priorities but for setting “smart” priorities, which she says means keeping UHC affordable for national economies and making difficult decisions.² Through its grants and partnerships with expert technical organizations, such as Thailand's Health Intervention and Technology Assessment Program and an international unit of the National Institute for Health and Care Excellence in England, the foundation supports the development of national institutions and processes for priority setting, “by creating manuals and tools for practitioners, building capacity in Asia and Africa, and encouraging the use of data and evidence for improved decision making.” These themes are reflected in many of the essays in this issue.

The next commentary, by Anne Mills, discusses the “challenges of prioritization.” She notes the limitations of economic tools in setting priorities and suggests that economic tools should not “necessarily dictate policy decisions.” She recognizes the role of both political and ethical factors and states that complex social decisions should not be “excessively” driven by the analytical method used. Policy makers also need to prioritize broader “public health packages and public health systems.” This is a particularly useful caution when setting priorities. The essay reminds me of something that I have long felt (although it is not directly stated in this essay): perhaps the utility of cost-effectiveness analysis is inversely proportional to the complexity and social importance of the problem at hand. In a sense, it is important to keep in mind the cost-effectiveness of using cost-effectiveness.

The last commentary, by Timothy G. Evans and Toomas Palu, presents the view from the World Bank on “setting priorities and building prosperity” through universal health coverage. The paper begins by emphasizing that the move to UHC is motivated by values both from the World Health Organization and the World Bank. The authors note that in the context of limited resources, “The rapidly growing science related to rational choice and relative cost-effectiveness will help inform better decision making.” They conclude by calling for countries and development partners to work together in “prioritizing priority setting,” in order to help countries “realize the promise of UHC for their citizens.”

The second half of the issue presents seven research articles on different aspects of priority setting for UHC, expanding on many themes introduced in the commentaries. Taken together, the articles provide a comprehensive and complex introduction to the topic of priority setting for UHC, which will be pursued in depth at PMAC 2016.

Rebecca Dittrich and colleagues examine the theory and practice of the international right to health and how it affects priority setting. They give particular attention to the role of litigation in assuring the right to health, sometimes to provide what governments have promised to do but not done in practice and sometimes to force governments to provide what they do not want to do. This trend toward “judicialization” is a growing global phenomenon. The authors are particularly attracted to the idea of what they call “rational priority setting,” although a more practical and operational definition of rational would have been helpful. In addition, the authors seem to assume that countries have a unified health system with a single governmental priority-setting process, which differs from the fragmented structures and processes that exist in most countries.³ This fragmentation significantly complicates the analysis of litigation in promoting “rational” (and fair) priority-setting processes for UHC.

In his article, John Cairns examines three key challenges that confront the use of cost-effectiveness analysis in priority setting, in deciding on which services should be funded by a third-party payer: (1) the determination of an appropriate cost-effectiveness threshold; (2) the valuation of health benefits; and (3) the tension between cost-effectiveness and the broader affordability and sustainability of health services. As Cairns points out, these (apparently) technical questions are important, regardless of other factors that go into health policy decisions and regardless of whether those decisions use public deliberation. Policy makers who plan to use cost-effectiveness analysis as an input for decisions on priorities need to understand these issues and especially the assumptions involved (or have trusted advisors who do). What seem to be technical questions include important value-based dimensions; they are less technical than they might seem.

Amanda Glassman and colleagues, in the next article, explain ten processes that are necessary to create an explicit health benefits package, which they consider “the cornerstone of a modern health system that is seeking to make the transition toward universal health coverage.” Interestingly, they stress that cost-effectiveness analysis and other quantitative evidence “form only a part of the entire process.” Completing the entire process successfully requires other kinds of “skills and mechanisms.” They also note that though the benefits package “determines what services should be subsidized by public sources of finance,” it does not consider to whom or how those services should be delivered, how quality should be assured, or how excluded services should be managed. In addition, the article does not deal with the complexities of provider payment mechanisms, which have major impacts on delivery, efficiency, access, and distribution. In sum, constructing and maintaining a benefit package is one key piece of the larger puzzle of UHC.

The article by Katharina Kieslich and colleagues provides an analysis of the empirical dimensions of priority setting by taking a look at two case studies, one in Thailand and one in England. They demonstrate how the actual practices of priority setting combine technical, ethical, and political factors. The article provides a brief overview of the complex topics of technical, ethical, and political factors and then discusses the two cases. Though, admittedly, two cases from two very different countries cannot lead to generalizable conclusions, the authors still suggest some lessons (although the methods for doing so remain unclear). They conclude that (1) different methods of priority setting can produce different recommendations; (2) robust processes are essential; (3) priority setting is inherently political; and (4) transparency can help build political support. Practical lessons on how to manage the technical, ethical, and political different factors would have been helpful (as others have provided¹), but that may be beyond the scope in a brief analysis of two diverse cases of priority setting.

Katharina Hauck and colleagues examine the factors that help explain why cost-effectiveness recommendations are “often not implemented as intended” in practice. This article fits nicely on the empirical side of analyzing the processes of priority setting. But rather than calling these factors, the authors use the term constraints. They ask the question: assuming that a decision maker wants to implement the recommendations resulting from cost-effectiveness analysis, what are the constraints (in addition to budget) that impinge on decision makers and push them away from implementing the technical results? They come up with six constraints. One concern is whether this analysis really gets at the “motivations” of decision makers, as the authors propose. Perhaps decision makers are not single-value maximizers (as they assume) but have multiple values with different weights (perhaps not constant) that they are seeking to achieve. Reframed in this way, the article provides a useful way for thinking about the factors that influence how decision makers might approach priority setting.

Ryan Li and colleagues assess the potential for using health technology assessment to undertake priority setting in health in 17 countries across Asia, Latin America, and sub-Saharan Africa, in order to select a country for an intervention. This article is an empirical and applied example of priority setting. The authors develop five indicators to assist in the selection process. In short, they apply the principles of rational priority setting to the question of where an international activity should promote rational priority setting. This activity was conducted through the international Decision Support Initiative to identify four countries with a strong potential for improving priority-setting processes and finally to select a single country for an intervention, Indonesia. The article illustrates how priority-setting processes can function at the international level (within donor agencies) in helping to increase the potential impacts of aid investments.

The last article in this issue, by Waranya Rattanavipapong and colleagues, presents an economic evaluation of an intervention for noncommunicable diseases in Indonesia to illustrate an actual priority-setting exercise. The study examines the delivery of screening and treatment for diabetes and hypertension, as part of the package of essential noncommunicable disease interventions created by the World Health Organization. The goal was to conduct a health technology assessment exercise in Indonesia to provide information to policy makers and help build national capacity for such analyses. The analysis showed that the current screening program is more cost-effective than a “no-screening” strategy, but it also indicated that a more targeted screening program would be more cost-effective, due to lower costs and only somewhat lower health benefits. Nonetheless, the authors conclude that this better option is likely to be “unacceptable to stakeholders due to the perception of the government intending only to save on costs.” The authors note that the study has a number of positive elements, especially in providing policy makers with a framework for assessing present and future costs and benefits of different policy options—even if the decision makers are not likely to follow the recommendations derived from cost-effectiveness analysis.

This special issue is the first issue of volume 2 of Health Systems & Reform and is aimed at advancing research and health policy translation around Priority Setting for Universal Health Coverage. The collection of commentaries and research articles emphasizes the journal's commitment to improving health systems through reflective analysis and critical investigation.