Contributing authors include: David E. Bloom – Clarence James Gamble Professor of Economics and Demography in the Department of Global Health and Population, Harvard School of Public Health, Elizabeth T. Cafiero – Research Analyst in the Department of Global Health and Population, Harvard School of Public Health and Michael Chu – Senior Lecturer at Harvard Business School and Managing Director and co-founder of the IGNIA Fund.
This piece is part of a larger collaboration – Antares – between the Harvard School of Public Health and the Harvard Business School. Antares is focused on harnessing the power of private enterprise for public health. Priority-setting is a central theme of the research arm of Antares. For more information, visit www.hsph.harvard.edu.
Health decision makers throughout the world face a multiplicity of challenges. As resource limitations are a fundamental fact of life, choices necessarily have to be made about which challenges to address, and the best way to tackle them. In this piece, we discuss the distinction between the strategic and tactical components of priority setting in health.
STATE OF PLAY: PRIORITY SETTING IN PUBLIC HEALTH
There is no dominant approach to priority setting in the public health arena. Ethicists rely heavily on the principles of fairness and equity in deciding the allocation of resources 1. Political scientists pay heed to the type of government and political participation in a country, the power and influence of stakeholders involved in decision-making, and the electoral implications of resource allocation decisions in health. Human rights lawyers and advocates focus on the extent to which different decisions will respect, protect, or fulfill human rights obligations under international treaties, and uphold particular norms and standards. Health economists typically rely on cost-effectiveness, focusing on the health effects achievable per dollar spent.
DISTINGUISHING BETWEEN THE ‘WHAT’ AND THE ‘HOW’ IN PRIORITY SETTING
Each of the foregoing approaches to priority setting has a corresponding set of biases, strengths and weaknesses. For example, ethicists and human rights specialists pay relatively little heed to the fact that some interventions have bigger health impacts than others per dollar spent. By contrast, health economists typically select health interventions by ranking them in order of their cost-effectiveness and going down the list until the health budget is exhausted. As such, they effectively decide which health conditions to address in the same way as they decide which interventions to use in addressing them.
However, it is essential to employ different criteria to decide which health conditions deserve the most attention (in other words, the “what”) and which specific interventions to use to address them (the “how”). For example, in the health arena, public sector decision-makers may be concerned with diseases that affect poor or vulnerable groups or diseases that cause a great deal of premature mortality. Accordingly, strategic objectives will be set around these issues of importance (e.g., improving access to health care for poor or vulnerable groups). The questions and concerns taken into account to define the ‘what’ do not necessarily indicate how to best accomplish those strategic objectives. A different set of considerations – tactical considerations – will drive decisions about the ‘how’.
Tackling the first layer will allow decision makers to identify priority areas. Once the priority areas have been identified, the second layer of priority setting allows for an answer to the question, ‘Which options for intervention deserve the most resources?’ (see Figure 1 above). At this level, one can use existing tools, such as cost-effectiveness analysis or political analysis, to decide between alternative interventions for reaching the aforementioned goals.
As the example Figure 1 illustrates, among the important issues with the potential for large impact, those that have readily cost-effective interventions are good candidates for implementation. Those without such readily available interventions pinpoint areas for further research and development. Similarly, considerations such as political feasibility or saturation of actors in the space can be used to distinguish among the promising options for intervention.
SCOPE FOR RETHINKING APPROACHES AND TOOLS FOR PRIORITY SETTING
Under the circumstances described above, it is appropriate to determine the ‘what’ and the ‘how’ separately. Much work has been done on the latter 2-8, and existing tools such as cost-effectiveness analysis are helpful for defining action steps for individuals, organizations or governments to take. Given the changing nature of the health landscape, as this issue of Impact describes, there is scope for developing new approaches and tools to make better decisions about how to allocate human, financial or material resources to achieve strategic objectives in public health. Moreover, there is a need to link the two layers of priority setting to guide decisions about allocating public health resources. As famed Chinese military strategist Sun Tzu once said, “Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat.”
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