A framework to support the integration of priority setting in the preparedness, alert, control and evaluation stages of a disease pandemic

ABSTRACT

The COVID-19 pandemic, where the need-resource gap has necessitated decision makers in some contexts to ration access to life-saving interventions, has demonstrated the critical need for systematic and fair priority setting and resource allocation mechanisms. Disease outbreaks are becoming increasingly common and priority setting lessons from previous disease outbreaks could be better harnessed to inform decision making and planning for future disease outbreaks. The purpose of this paper is to discuss how priority setting and resource allocation could, ideally, be integrated into the WHO pandemic planning and preparedness framework and used to inform the COVID-19 pandemic recovery plans and plans for future outbreaks. Priority setting and resource allocation during disease outbreaks tend to evoke a process similar to the ‘rule of rescue’. This results in inefficient and unfair resource allocation, negative effects on health and non-health programs and increased health inequities. Integrating priority setting and resource allocation activities throughout the four phases of the WHO emergency preparedness framework could ensure that priority setting during health emergencies is systematic, evidence informed and fair.

KEYWORDS:

• Priority setting
• resource allocation
• pandemic planning
• COVID-19
• Ebola

Introduction

While there is a growing body of literature on the epidemiology and societal response to various disease outbreaks and health emergencies (Bausch & Schwarz, 2014; Emanuel et al., 2020; Gostin et al., 2014; Heymann et al., 2015; The World Bank, 2014; White & Lo, 2020; World Health Organization, 2014), there has been relatively limited discussion on how lessons from previous outbreaks could inform priority setting for future outbreaks. During emergencies, priority setting occurs at different levels and can address decisions with regards to: whether to allocate resources to maximise benefits or not (Emanuel et al., 2020); whether to invest more resources in sustaining the health care system (which is often in poor shape in most low-income countries) rather than focusing intensively on stemming an outbreak (Rid & Emanuel, 2014); and also at the individual level (who should receive the limited drugs, vaccines if available (Daniels, 2005), ventilators, intensive care beds or other medical interventions) (Emanuel et al., 2020). After the outbreak, decisions have to be made with regards to whether to continue investing in preparation for future outbreaks, as opposed to the other health programs (Kieny et al., 2014). These decisions can either be guided by systematic processes such as cost-effectiveness analysis and careful evaluation of the different potential interventions, or by other processes such as the ‘rule of rescue’. According to the literature, the rule of rescue tends to dominate the response to health emergencies (Cookson et al., 2008; Jonsen, 1986; Schöne-Seifert, 2009). This paper draws attention to this pattern and argues that instead, systemic priority setting and resource allocation for health emergencies should be integrated throughout the health systems planning cycle. This will minimise potential for implementation of reactive ‘rule of rescue’ approaches during emergencies and facilitate optimal and more equitable use of resources.

The rule of rescue has been framed by some as an emotionally based plea for resources for individuals in distress. According to McKie and Richardson (2003), the rule of rescue compels individuals or systems to rescue those identifiable individuals or populations in immediate peril, regardless of cost (McKie & Richardson, 2003). Inherently, it prioritises identifiably distressed individuals over statistical lives and is counter to more ‘rational' economic approaches (cost-effectiveness) when allocating resources (McKie & Richardson, 2003). As Jonsen (1986) states:

 … (it is) Our moral response to the imminence of death demands that we rescue the doomed. We throw a rope to the drowning, rush into burning buildings to snatch the entrapped, dispatch teams to search the snowbound …  (McKie & Richardson, 2003, p. 174)

Schöne-Seifert (2009) discusses five dimensions of the rule of rescue (i) the victims’ visibility or identifiability, (ii) acuity of impending death of the victims. (iii) presence of a reasonable chance of effective rescue, (iv) presence of acceptable risks or costs to the rescuers; and, (v) exceptionality of the occurrence (Schöne-Seifert, 2009).

The responses of the most affected countries during the 2013–2016 West Africa Ebola Virus Disease (EVD) outbreak exhibited all characteristics of the rule of rescue. Although not systematically explored, many studies have established a correlation between a reduction in the availability of non-EVD health care services, and negative health outcomes (Bah et al., 2017; Camara et al., 2017; Delamou et al., 2017; Gamanga et al., 2017; Morse et al., 2016; Plucinski et al., 2015; Sun et al., 2017). Non-EVD health care services in Sierra Leone, Liberia, and Guinea were dramatically reduced or interrupted, as already normally limited human, facility, and equipment resources were re-assigned to support national responses to what would become the world’s deadliest Ebola outbreak. In Liberia, it is estimated that maternal mortality may have doubled, and child mortality increased by up to 20% during the EVD emergency (Morse et al., 2016). Childhood vaccination programs (Camara et al., 2017; Sun et al., 2017), malaria control (Plucinski et al., 2015), maternal and child health care (Delamou et al., 2017), and HIV and TB testing (Bah et al., 2017; Gamanga et al., 2017), programs were also affected. It is likely that the COVID-19 pandemic will result in similar negative outcomes for non-COVID 19 programs if the ‘rule of rescue' is applied.

This paper argues that integrating priority setting and resource allocation during emergencies throughout the pandemic planning and preparedness plans (as opposed to the rule of rescue) would facilitate optimal and more equitable use of resources with better and more equitable health outcomes. We draw on lessons from the previous EVD outbreak to illustrate how systematic priority setting could be better integrated into the WHO pandemic planning and preparedness framework and used to inform the COVID-19 pandemic recovery plans and plans for future outbreaks.

Objectives

Building on previous research on priority setting for resource allocation during the Ebola outbreak, this paper aims to:

1. Describe the impact of using the ‘rule of rescue’ approach to priority setting and resource allocation during disease outbreaks.

2. Discuss how integrating priority setting in the WHO proposed framework for epidemic preparedness and planning could contribute to mitigating the negative impacts of using the rule of rescue in priority setting during disease outbreaks and emergencies.

Methods

The paper is mainly based on a review of relevant documents and experiences of health workers and policy makers who participated in the control of the EVD outbreak in Uganda. The review of the epidemic preparedness plans provided an understanding of how the country planned and prepared for disease epidemics. EVD outbreak experiences are gleaned from a qualitative study which was conducted between 2014 and 2016, using a validated approach to evaluate priority setting for health and involved interviews with policy makers, health development partners and frontline health workers (Kapiriri & Be LaRose, 2019). In the larger study, respondents were asked about their priority setting process, based on 5 cases; one of which was disease outbreaks. Of the 57 respondents involved in the larger study, 23 discussed priority setting for disease outbreaks and its impact on other programs. The respondents discussed how priorities are set before and during a disease outbreak. The discussion covered: the priority setting context, the detailed prioritisation process, the priority setting criteria and the implementation of the identified priorities. Details of these findings were published elsewhere (Kapiriri & Be LaRose, 2019). A prominent theme that emerged from the description was the impact of priority setting for disease outbreaks on other health programs and the health system.

The impact of the disease outbreak prioritisation process on: population health, the health system, and other sectors were discussed. Emerging sub-themes from the ‘impact' theme included: (i) Is it too much, too late? (ii) What about the ‘others’? (iii) Is it the most cost-effective approach? (iv) Does it address the relevant equity concerns?

The paper is divided into two sections. In the first section of this paper, illustrative quotes are used to describe the perspectives of key stakeholders on the effectiveness of priority setting for EVD. The labels reflect the respondent’s level of decision making: P (policy maker); HDP (Health development partner); MOH (Ministry of Health).

In the second part of the paper, we analyse the document review and interviews and discuss how the negative impacts could be mitigated by systematically integrating priority setting through the four phases of the epidemic planning guidelines proposed by the World Health Organisation (WHO) (Table 1).

Table 1. WHO recommended activities during the four phases of disease epidemics.

Pre-epidemic preparedness	Alert phase	Control phase	Evaluation phase
Establishment of a viral haemorrhagic fever surveillance system	Investigating suspected Ebola including evaluating available resources required	Ebola epidemic control strategy	Declare the end of the epidemic
Infection control precautions in health care settings	Obtaining laboratory results	Coordination and resource mobilisation	Resume social activities and address stigma
Health promotion program	Taking a decision on the basis of laboratory results and the outcome of the investigation	Coordination and resource mobilisation	Resume the activities of the pre-epidemic phase
Collaborate with health services and wildlife health services (Ebola)		Behavioural and social interventions Media	Produce the end of epidemic report
Pre-alert: What should be done if the specimen taken from animals tests positive for Ebola? Assessment of resources		Clinical case management Psychological management Research projects and ethical issues Logistics and safety Environmental management	Keep records on the epidemic Evaluate the management of the epidemic

World Health Organization, 2014.

Results

The impact of the prioritisation and resource allocation processes

According to the respondents, disease outbreaks are considered national priorities and are included in the Essential Health care package. However, due to limited resources, the program is underfunded. Hence once an outbreak is eminent, resources have to be mobilised from other programs. Four themes emerged from the interviews about the respondents’ concerns about this approach to resource allocation during an emergency. Each is discussed in the section below:

Is it too much, too late?

While respondents agreed that during an outbreak resources should be mobilised to respond effectively, they described a root cause as resulting from limited and inadequate resource allocation to f the health sector, leading to a health system that was ill equipped to deal with disease outbreaks.

The respondents discussed the limited routine annual budget allocation to the emergency program. As a result, health workers were only able to effectively implement their activities during a disease outbreak when resources were mobilised from other program areas. Although a lot of resources were mobilized, they often came too late to be used effectively to mitigate the impact of the emergency. As explained by a frontline respondent:

 … So when we have an emergency, I mean when we have an outbreak then we mobilize forces and then we respond but most of the time it will be late, some people will have died. (MOH1)

Hence, respondents identified the need for governments and development assistance partners (DAPs) to plan for, and allocate adequate, earmarked, and ongoing resources to the emergency program before disease outbreaks are eminent. This would enable the ministry of health to implement more systematic priority setting approaches (Russell et al., 1996). It would also enable them to respond to an outbreak in a timely manner:

 … I think … in regard to resource allocation I think the lessons are that you must have some resources to do the investigations quickly. The quicker they are done, the better. So the Ministry must always have some money that can allow the surveillance teams, the laboratory teams, the investigations to go unhindered, and as soon as possible find out what is the cause of the outbreak …  (MOH5)

While respondents were referring to resources to support timely response to a disease outbreak, the resources could also support disease surveillance and modelling. For example, while it might not be possible to predict and assess the cost-effectiveness of all possible interventions for novel outbreaks such as COVID-19, epidemiological modelling and forecasting provide important evidence to support decision making during uncertainty, as has been seen during the current pandemic. But this requires investment in local data infrastructure and modelling capabilities which should be integrated into pandemic planning.

What about the ‘others’?

Consistent with the literature on epidemics and routine services and programs (Boozary et al., 2014; Kruk et al., 2015; Lamunu et al., 2004), respondents expressed great concern about the consequences of resource re-allocation from the other health programs and sectors to disease outbreaks. Direct impacts of the resource re-allocation include increased mortality and morbidity. For example, during the EVD outbreak, increased malaria, maternal and other childhood mortality rates were registered when funds and human resources were diverted from these programs:

 … I can assure you whenever there is an emergency the health system is stressed, we take all the money from malaria, from everywhere and you put it in emergency. What happens? Those essential services don’t continue to run properly. So we have diverted resources from our service delivery, the quality, the accessibility, the scope really has decreased …  (MOH4)

Indirectly, this also occurs through the protections afforded to health human resources, who by virtue of their direct contact with patients, are exposed and end up infected and sometimes with fatal outcomes. In Uganda and West Africa for example, the EVD Ebola outbreak was particularly devastating to the health sector due to the health worker mortality which was attributed to EVD (Evans et al., 2015).

This excess health worker mortality and morbidity, due to mental health impacts, has also been the experience with COVID-19 in countries such as Italy where the disease was reported to have killed over 100 physicians (The Local, 2020). These figures do not account for the other formal and informal caregivers who have also been infected and have largely provided caregiving with little to no personal protective equipment (Marsh, 2020; The Local, 2020).

Is it the most cost-effective approach?

The emotional decision making during a disease outbreak which is in part fuelled by the severity of the outbreak as well as public fear and panic makes it difficult for decision makers to rationally assess and evaluate the costs and benefits of the different interventions.

Typically, during outbreaks, there is a flurry of activities that may be uncoordinated, unaccounted for, and whose cost-effectiveness is never assessed. For example, while there is a body of literature on previous EVD outbreaks, there is a distinct lack of literature on the most cost-effective interventions used during those outbreaks. Such an analysis would provide an evidence base and a list of priority interventions which could mitigate the epidemic’s impacts and costs. Moreover, while the public reporting typically outlines the total amount of resources mobilised, there tends to be much less information on whether the resources were allocated fairly and according to systematically identified priorities. While there is agreement that rapid mobilisation and allocation of resources during an outbreak is critical, experiences from past health emergencies could be better harnessed and used to inform future pandemic responses. This would involve, support for systematic evaluation of the cost-effectiveness of the emerging interventions, especially immediately after an outbreak. Such information would provide the necessary evidence for systematic deliberative priority setting processes in between outbreaks.

Does it address the relevant equity concerns?

When equity is defined in terms of prioritising those in greatest need, there are strong arguments for prioritising severe emergencies that affect vulnerable populations (Goddard & Smith, 2001; Kruk et al., 2015; Norheim et al., 2014). However, any kind of prioritisation approach that does not deliberately consider the broader equity implications of an outbreak may perpetuate the already existing societal inequities (Agarwal, 2020; Sen, 2002; van Dorn et al., 2020).

Epidemics, have different impacts based on ones’ socio-economic class, often impacting the poorest and marginalised populations (including women) hardest (The World Bank, 2020). Lack of resources and access to social and health services increases a population’s vulnerability to epidemics. The most vulnerable in society are the least likely to access care; and even if they did, they may not be prioritised to receive limited resources, unless there are deliberate efforts to identify and monitor the impact of priority setting on this population. These inequities were rampant during the EVD outbreak.

Equitable priority setting would require that these vulnerable populations are prioritised – but this is not always the case, especially when resources are limited.

Lessons from EVD for COVID-19?

While it may be premature to identify explicit lessons for COVID-19, it is apparent that there might be consistency between the above EVD lessons and the current pandemic. For example, it is becoming apparent that limited resources to effectively conduct disease surveillance, contact tracing, vaccinate, as well as to respond to the critically ill (for example the lack of personal protective equipment) may have played a significant role in the negative impacts and the spread of COVID-19 across the globe (Stephenson, 2020).

Diversion of resources to COVID-19 has been documented. According to a WHO survey of 163 countries which was completed in May 2020 more than 53% of the countries reported service disruptions in relation to diabetes treatment (49%), Cancer (42%) and Cardiovascular emergencies (31%). Ninety-three percent of the surveyed countries also reported partial or complete re-assignment of health workers from non-communicable disease programs to COVID-19. This is more the case in low-income countries and countries that experienced very high incidence of COVID-19 cases where health services were saturated (WHO, 2020). The impact of this deferral has not been systematically studied.

Furthermore, in most contexts, the national lock downs (a practice geared to controlling the spread of COVID-19) have been associated with increased mortality due to limited physical access to health facilities or saturation of the health care system (The World Bank, 2020; Wang et al., 2020). The social isolation is also thought to have increased rates of gender-based violence and negatively impacted people’s mental health.

Both EVD and COVID-19 highlighted the negative toll that disease outbreaks had on the health workforce who, in addition to the physical burden, face moral challenges especially when allocating limited resources as was the experience in Italy (The Local, 2020). Furthermore, the COVID-19 outbreak demonstrated the existing inequalities within the health workforce. Racialised minorities were more likely to be employed in more precarious health care work which increased their exposure to the COVID-19 virus (van Dorn et al., 2020). Specifically, minority immigrants were more likely to be employed as personal support workers who were most impacted by the pandemic in many countries (Holroyd-Leduc & Laupacis, 2020; van Dorn et al., 2020; Zagrodney & Saks, 2017; Zeytinoglu et al., 2017).

Similar to EVD, the COVID-19 pandemic and the related public health measures (e.g. the lock downs) have impacted other sectors. However, the burden of the negative consequences seems to have mostly affected vulnerable populations, the precariously employed (especially in countries that lack robust social welfare systems), the disabled, those that live in poor housing conditions and those that lack the resources necessary to maintain hygienic standards (Bhala et al., 2020; Heidinger & Cotter, 2020; Hou et al., 2020).

Furthermore, the COVID-19 outbreak has revealed and accentuated the existing inequities in various countries. There is a disproportionately high prevalence of chronic diseases such as diabetes among marginalised populations and chronic diseases have been associated with poorer COVID-19 outcomes. For example, in the USA COVID-19 has disproportionately impacted black communities; already marginalised, and experiencing higher prevalence of multiple non-communicable diseases, due to previous inequities in the social determinants of health (CDC, 2021; The Editors, 2020). For these vulnerable populations, a vaccine even if developed, may come too late (like the interview discussion above). Furthermore, since they already lack access to health care, they may be less likely to have access to the vaccine.

Discussion

Strategies to mitigate the negative impact: Going beyond the rule of rescue and integrating priority setting in the four phases of the WHO framework

Using resource allocation approaches that are consistent with the rule of rescue have negative consequences especially for the most vulnerable populations. While this approach may be justified, in this section, we discuss how the negative consequences could, in part, be ameliorated by integrating clear and explicit priority setting processes prior to and during the four phases of a disease outbreak. However, first, there is a need for stakeholders to develop broad, but balanced approaches to planning that include specific targeted action plans and guidelines. These plans should include contingencies to ensure the maintenance of routine health programs (e.g. maternal and child health; malaria), which cannot be neglected while managing disease outbreaks. Many of these programs have proven cost-effectiveness, benefit the most vulnerable, save lives and reduce morbidity and should not be sacrificed. This approach responds to the concerns identified in the first section of this paper, by ensuring that resources are not re-allocated from the other programs. To achieve this, local priority setting plans should earmark ‘emergency funds' as well as human resources to be used in exceptional circumstances to prevent the diversion of resources from necessary routine programs. In many low-income countries that lack a robust health sector budget, putting aside resources for emergencies may be perceived by health planners as an unaffordable ‘luxury'. However, we argue that this will prevent some of the critical negative impacts of disease outbreaks. The emergency fund would, in addition to supporting the response activities, facilitate the priority setting activities that are proposed in this paper. We do not propose that priority setting is the most critical activity. However, given the continued mismatch between resources and need, the negative impact of the rule of rescue and the moral distress experienced by those frontline workers who bear the rationing burden; systematic consideration of priority setting in advance of health emergencies would mitigate these negative effects.

The following sections discuss how priority setting could be integrated into the four phases (pre-epidemic preparedness, alert, control, and evaluation) of any disease outbreak, based on the WHO emergency preparedness planning guidelines (World Health Organization, 2014), and how this would contribute to addressing the concerns that were raised by the study participants.

Integrating priority setting activities during the pre-epidemic phase

During the pre-epidemic phase, the WHO guidance document recommends the following activities: establishing surveillance and infection control mechanisms, health promotion, resource assessment and planning (World Health Organization, 2014). We propose that priority setting should be an integral part of these planning activities.

Priority setting activities that could be implemented during the pre-epidemic phase include: establishing a priority setting institution or committee and sub-committees that would be responsible for establishing and implementing explicit and fair priority setting procedures during the subsequent phases, identify and validate priority setting criteria, establish fair priority setting mechanisms, and facilitate the development of modifiable cost-effectiveness models It is important that the established institutions/ priority setting committee and sub-committees represent a wide range of relevant stakeholders. The committees should have the capacity to set disease outbreak priorities and to develop clear, explicit, participatory, and fair priority setting processes. Most importantly, they should be deemed legitimate (based on either their composition, capacity and/or how they are convened) (Ottersen & Norheim, 2014). It is important that priority setting criteria and processes are discussed and determined during the pre-pandemic phase and not during the outbreak when anxieties and emotions are running high, making it harder to have rational discussions about these critical topics. Criteria such as cost-effectiveness, population impact, feasibility and most importantly equity may be considered since they are also commonly recommended in the literature Articulation of equity as a guiding priority setting criterion is an important first step in ensuring that the response is equitable, a concern that was raised by our respondents. Lack of explicit priority setting processes and criteria pre-pandemic means that when there is an outbreak, these criteria and processes are established during the outbreak during which time the decision makers and frontline workers bear the responsibility of making the initially poorly guided decisions.

During the pre-pandemic phase, the priority setting institutions/ committees should conduct public consultations on the priority setting criteria and processes that should be used during disease outbreaks. There are several priority setting approaches e.g. Programme Budgeting and Marginal analysis (PBMA), Multi-Criteria Decision analysis (MCDA), Accountability for Reasonableness (A4R) that could be considered during this stage. In addition to developing the criteria and prioritisation approach, the priority setting institutions/committees should establish clear communication strategies for publicising the principles, criteria, and priority setting decisions; as well as clear mechanisms for appealing any of the priority setting decisions (Rid & Emanuel, 2014), during this phase.

During the pre-pandemic phase, the priority setting institutions/ committees could also commission cost-effectiveness modelling and related studies, whose result would provide evidence which would inform the priority setting and resource allocation decisions (Kapiriri & Be LaRose, 2019). While epidemics differ and cost-effectiveness analyses for one outbreak may not be the same as the next; generalisable and adaptable models could be developed based on previous similar outbreaks. For example, in the case of COVID-19, infectious disease models developed during the SARS outbreak have been useful and were quickly modified to reflect the specific uniqueness of COVID-19. Local data and data infrastructure would also be needed to support the modelling but together, would ensure that local evidence is used to support for decision making.

The established principles, processes and criteria should be validated and tested for their acceptability and feasibility. There should also be explicit plans for evaluating the prioritisation processes after the disease outbreak. Based on the results, priority setting improvement strategies could be implemented. Establishing this decision-making infrastructure during the pre-pandemic phase would ensure that once the epidemic is eminent, the institutions can facilitate transparent, participatory, evidence informed and fair priority setting processes to support systematic and ethical priority setting and resource allocation decision making (Evans et al., 2015). As such careful pre-pandemic planning would, at the planning level, address all the challenges identified by our respondents.

Priority setting activities during the alert phase

The WHO guidance document recommends conducting case investigation, and confirmation during the alert phase (World Health Organization, 2014). Integrating priority setting within this phase would involve reminding the public and relevant stakeholders about the principles, processes and criteria that were established during the pre-epidemic phase. It may be possible that some of the principles and criteria that were established are not reflective of the epidemiology of the current epidemic, communication on these during this phase will ensure that the criteria are revised to reflect the unique characteristics of each epidemic. Any potential disagreements with regards to the process, and/ or the criteria should be addressed during this phase.

This phase should also involve critical priority decision with regards to which activities to prioritise, especially where financial and human resources are constrained. The institutions should consider and prioritise g the other health programs and sectors that are impacted by the outbreak. Within the outbreak interventions, it is not uncommon to find research activities competing with response activities, since they may all require the same personnel. Such research activities divert funding and human resources from the response and control activities. The priority setting institutions/ committee should engage in participatory clarification of the kinds of routine health system programs and research that should be prioritised during an outbreak. Arguably, research that supports decision making during the outbreak e.g. research on the costs, and the effectiveness of the interventions, and the impact of the outbreak (on other programs and different populations, especially the most vulnerable), should be prioritised.

Priority setting activities during the control (outbreak response and containment) phase

The WHO guidance document proposes several activities during this phase. These include implementation of control strategies, coordination of resource mobilisation, implementing behavioural and social interventions, case management and research (World Health Organization, 2014). Once an outbreak is underway, the imperative is to save lives. It is during this phase that the rule of rescue is often applied. However, in addition to the rule of rescue, some of the principles and criteria that were developed in the initial phase should support priority setting decisions. For example, if the cost-effective modelling identified the most cost-effective interventions, the mobilised resources should be allocated to these interventions as priorities during this phase. Furthermore, while applying the ‘rule of rescue’, decision makers must decide which of the most affected populations/ persons to ‘rescue'. For example, while severely ill COVID-19 patients might require ventilators, clinicians would need guidance in cases where there are two equally ill patients who require the same ventilator. The criteria, such as equity, developed during the pre-epidemic phase would be useful here.

Furthermore, integrating rational prioritisation would ensure that the need to allocate and prioritise disease outbreaks is balanced with the need to sustain other important health programs and critical services. For example, while there is a COVID outbreak, children are still contracting and dying of malaria and other related illnesses and there are growing concerns about the excess mortality from non-COVID related non-communicable (Bayntun & Rockenschaub G, 2012; Gostin & Friedman, 2015; Kass, 2014). Contingency plans established in the initial phase would ensure that routine services are sustained throughout the outbreak.

This phase should also involve the implementation of the prioritised research. While there is a temptation to accept any kind of research which is already funded (including research which may not be relevant to the given context or outbreak); having pre-determined criteria and principles for prioritising research during disease outbreaks would support the optimal use of both human and financial resources during the pandemic control phase, to ensure that the resources are allocated to the most equitable and cost-effective interventions, while ensuring that the other sectors and health programs are sustained throughout the outbreak.

Priority setting activities during the post-epidemic phase

During this phase the WHO recommends resuming of the social and the preparedness phase activities, addressing stigma (if relevant) and evaluating the response (World Health Organization, 2014). The post-epidemic evaluation should also include an assessment of how the priority setting plans (mechanisms, processes, and criteria) were implemented and the public’s response to the implementation of the priority setting plans. Furthermore, in addition to the total mortality and morbidity data and the amount of funds mobilised and disbursed (The World Bank, 2014), it is critical that the relevant stakeholders and implementers reflect on the degree to which the resource allocation reflected the identified priorities, based on the criteria that was developed in the first phase. Here the focus should be on assessing if the resource allocation reflected the core values of fairness, equity, cost-effectiveness as well as any additional criteria that is relevant to the priority setting context (Bausch & Schwarz, 2014; Kapiriri & Martin, 2010; Rid & Emanuel, 2014). The evaluation should also assess the impact of the pandemic on the routine health programs as well as the degree to which the research conducted during the disease outbreak was aligned with the pre-determined criteria. This evaluation should focus on identifying lessons of good practice that should be shared and areas of improvement that should be integrated into the pre-planning phase to strengthen future priority setting processes.

Practical challenges in implementation

We, however, recognise that what is proposed above and in Table 2 is the ideal. There are several factors that may hamper the implementation of the proposed activities including but not limited to the social, economic, cultural, and political context, political will, limited availability of financial and human resources, to mention but a few. Furthermore, although useful, integrating priority setting would not entirely mitigate the negative impact of disease outbreaks. Disease outbreaks tend to have more adverse effects in contexts with weak social welfare and health care systems which, unless strengthened, present a challenge to any emergency response efforts (Birn et al., 2009). Hence, there is a need to strengthen the resilience and equity of both the health and social systems to enable them to support their populations during the pandemic periods (Boozary et al., 2014; Horton, 2014; The Editors, 2020).

Table 2. Integrating priority setting activities throughout the four phases of disease epidemics.

Phase	Priority setting activities
Pre-epidemic preparedness	• Identify possible priority setting and resource allocation decisions that need to be made during the outbreak; • Hold public consultations and dialogue with regards to priority setting criteria; • Identify key stakeholders to involve in the different priority setting processes; • Identify criteria and principles, including equity to guide the different priority setting decisions; • Establish explicit and fair priority setting processes for the different decisions • Use the identified criteria and principles to prioritise the known interventions that could be implemented within the context • Identify sources, and earmark resources for emergencies to ensure a swift, timely and effective response • Establish plans and resources for sustaining essential routine health programs • Establish cost-effectiveness modelling • Consider cross-program impact.
Alert phase	Validate the proposed plans developed in the pre-epidemic phase.
Control phase (Outbreak Response)	Implement Priority setting and resource allocation processes developed during the preparedness phase with regards to; • Allocating resources to the epidemic, the other health programs and other sectors, • Identifying and allocating resources between competing interventions in response to the specific epidemic, • Equitable rationing of the most cost-effective drugs/ vaccines (if available).
Evaluation phase (Post-epidemic)	Evaluate Priority setting and resource allocation processes at the different phases, and its impact on different populations – especially the vulnerable; other programs and sectors; and the effectiveness of the interventions that were implemented; and use the results to revise and improve the Priority setting processes for future epidemics.

Conclusions

Disease outbreaks are becoming more common and more global than ever. Previous outbreaks may provide critical lessons for future preparedness plans. Prior outbreaks have demonstrated that, if not controlled, disease outbreaks can lead to global health emergencies as seen by the 2017 EVD outbreak and the COVID-19 pandemic (Gostin et al., 2014). These emergencies have been typically characterised by the intense and rapid mobilisation of resources to stem the outbreak (World Health Organization, 2014). It is critical that these resources be appropriately allocated to priority interventions, since such decisions may mean life or death for some (Bausch & Schwarz, 2014; Heymann et al., 2015). Establishing clear and explicit approaches to priority setting and resource allocation for health emergencies in all countries, but especially in low-income countries, is especially pressing since there is evidence that health emergencies are becoming more frequent, severe, and unpredictable amidst resource constraints (World Health Organization, 2014).

While there may be justification for using the rule of rescue at the peak of health emergencies, there is a need to mitigate the negative consequences that result from its exclusive application. This paper extends the priority setting discussion beyond the rule of rescue by suggesting ways that integrating ‘rational' priority setting throughout the four phases of a disease outbreak would mitigate the impact of using the rule of rescue as well as offering opportunities to learn from previous disease outbreaks.

In addition to strengthening and mainstreaming priority setting, national governments should concurrently work to strengthen and build their health care systems’ resilience to enable them to effectively respond to outbreaks in a timely manner. They also need to address the social determinants of health, which contribute to underpin the inequitable distribution of the negative impacts of disease outbreaks.

Acknowledgements

The authors thank the respondents for their time, without which the study would not have been possible.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

The study was funded by the Canadian Institutes for health research (CIHR) funding [Grant# 10558616]. The authors have no conflict to declare.