Fair priority setting in global health

Course leader
Professor Ole Frithjof Norheim, Department of Global Public Health and Primary Care and Centre for Intervention Science in Maternal and Child Health, University of Bergen.

Lecturer
Daniel Wikler, Professor , Department of Global Health and Population, Harvard University.

David Watkins, physician-scientist, Departments of Medicine at the University of Washington and University of Cape Town.

James Love-Koh, Research Fellow affiliated with the Global Health Economics and Economic Evaluation teams, University of York.

The participants will learn about key ethical principles for fair priority setting in global health, how to evaluate equity in access to health services and fairness in the distribution of health outcomes, and how to combine quantitative tools for equity measurement with standard health economic evaluations.

Course structure
The course is divided into two parts:

Part 1: Will cover theoretical concepts of equity, fairness and health maximization, and how they are applied in global and national health care priority setting. These will be linked to widely agreed global frameworks such as the Sustainable Development Goals and Universal Health Coverage.

Part 2: Will cover hands-on exercises in equity analysis, starting with assignments in excel, moving to ADEPT (Software platform for equity analysis developed by the World Bank), and Stata with DASP (Distributive Analysis Stata Package).

The first part is theoretical, and consists of a mixture of lectures, group work and discussions on the main topics described above. Students are required to participate in group work on assigned topics. This includes daily student-active teaching exercises, with alternating group compositions and presentation of results for the class.

The second part consists of combinations of theory and practice, and students will work through exercises on their own laptops on a “learning by doing” principle. Each day will be organized around assignments that must be completed individually. The softwares Microsoft Excel, ADEPT, and Stata will be used throughout the course.

Requirements
Interest in distributive justice and health. Basic skills in Excel software is required, and basic skills in Stata software recommended.

Suggested readings
Ethics of priority setting

1. Wikler, D., Brock, D. W. (2007). Population-level bioethics: mapping a new agenda. In Dawson A, Verweij, M. (eds.). Ethics, prevention, and public health. Oxford: Oxford University Press: 78-94. An excellent introduction to population-level bioethics.
2. Bognar, G. & Hirose, I. (2014). Chapter 4 in The Ethics of Health Care Rationing: An Introduction. London: Routledge. Intro to a key philosophical textbook on the ethics of health care rationing.
3. Ord, T., (2013). The moral imperative towards cost-effectiveness in Global Health. Center for Global Development essay. A strong defense of Utilitarianism in health care resource allocation.
4. Daniels, N. (2001). Justice, health, and healthcare. American Journal of Bioethics, 1(2): 2-16. A short summary of the most important theory of justice and health.
5. Sen, A. K. (2002). Why health equity? Health economics, 11(8), 659-666. Sen’s nuanced view on health equity with respect to gender, personal responsibility, and process.  
6. Anand, S., The concern for equity in health. J Epidemiol Community Health, 2002. 56: p. 485-7. Introducing the Atkinson index applied to health.
7. Ottersen T. Lifetime QALY prioritarianism in priority setting. Journal of Medical Ethics, 2013;39:175–80. An alternative take on health inequalities.
8. Wolff, J. (2012). Chapter 2: The human right to health and its critics. In his The Human Right to Health. New York: Norton: 13-38. Introduction to key concepts and international documents.
9. Rumbold B, Baker R, Ferraz O, Hawkes S, Krubiner C, Littlejohns P, Norheim OF, Pegram T, Rid A, Venkatapuram S, Voorhoeve A, Wang D, Weale A, Wilson J, Yamin AE, Hunt P. Universal health coverage, priority setting, and the human right to health. Lancet. 2017 Apr 26. pii: S0140-6736(17)30931-5. doi: 10.1016/S0140-6736(17)30931-5. Paper arguing that the right to health can aid priority setting and that fair priority setting is essential to the realisation of the right to health. 
10. WHO. Making fair choices on the path to universal health coverage. Final report of the WHO Consultative Group on Equity and Universal Health Coverage. 2014. World Health Organization: Geneva. Policy guidance.
11. Jamison, D.T., et al., Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition. Lancet, 2017. Summary of recommendations on priority setting from nine DCP3 volumes. 

Fair distribution and cost-effectiveness

12. Brock, Dan, Norman Daniels, Peter Neumann, and Joanna Siegel. “Ethical and Distributive Considerations.” In Cost-Effectiveness in Health and Medicine, Second Edition., 319–43. New York: Oxford University Press, 2017. A recent summary of the limitations to cost effectiveness as the sole consideration in health resource prioritization.
13. Verguet, S., J.J. Kim, and D.T. Jamison, Extended Cost-Effectiveness Analysis for Health Policy Assessment: A Tutorial. Pharmacoeconomics, 2016. 34(9): p. 913-23. How-to-do introduction to ECEA.
14. Verguet, S., R. Laxminarayan, and D.T. Jamison, Universal public finance of tuberculosis treatment in India: an extended cost-effectiveness analysis. Health Econ, 2015. 24(3): p. 318-32. Applied ECEA.
15. Asaria, M., S. Griffin, and R. Cookson, Distributional Cost-Effectiveness Analysis: A Tutorial. Med Decis Making, 2016. 36(1): p. 8-19. How-to-do introduction to DCEA.
16. Cookson, R., et al., Using Cost-Effectiveness Analysis to Address Health Equity Concerns. Value Health, 2017. 20(2): p. 206-212. Useful review-paper on DCEA.
17. O'Donnel, O., et al., Analyzing Health Equity Using Household Survey Data. A Guide to Techniques and Their Implementation. 2008, The World Bank: Washington DC. The best text-book available on the topic.
18. Wagstaff, A., Inequality aversion, health inequalities and health achievement. J Health Econ, 2002. 21(4): p. 627-41. A social welfare function approach to health equity.
19. Ngalesoni, F.N., et al., Equity impact analysis of medical approaches to cardiovascular diseases prevention in Tanzania. Soc Sci Med, 2016. Applied equity impact analysis from a low-income country.

Course leaders
 

Ole Frithjof Norheim is a physician and professor in medical ethics and philosophy of science, Department of Global Public Health and Primary Care, University of Bergen, and adjunct Professor at the Department of Global Health and Population, Harvard TH Chan School of Public Health. Norheim’s wide-ranging research interests include theories of justice, inequality in health, the ethics of priority setting in health systems and how to achieve Universal Health Coverage and the Sustainable Development Goal for health. He is currently leading, with Stéphane Verguet, the research project Disease Control Priorities – Ethiopia (2017-2020, funded by BMGF). Dr. Norheim serves as a member of the DCP3 Advisory Committee to the Editors. 

Norheim has chaired the World Health Organization’s Consultative Group on Equity and Universal Health Coverage (2012-2014) and the third Norwegian National Committee on Priority Setting in Health Care (2013-2014). Norheim has published more than 150 peer-reviewed papers in journals such as The Lancet, The BMJ, Lancet Global Health, Bulletin of WHO, Journal of Health Economics, PlosOne, Health Policy and Planning, Social Science & Medicine, and Journal of Medical Ethics.

Dan Wikler has been Mary B. Saltonstall Professor of Ethics and Population Health at the Harvard School of Public Health since 2002, where he is also affiliated with university-wide programs including the Harvard Program in Ethics and Health and the Safra Center for Ethics. His public service includes service as “staff philosopher” for the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, and as the first “Staff Ethicist” for the World Health Organization, where he remains a consultant to several programs, including its consultative group on ethical dimensions of universal health coverage (2014). He was co-founder and second president of the International Association of Bioethics. 

Professor Wikler’s published work addresses many issues in bioethics, including issues in reproduction, transplantation, and end-of-life decision-making. In recent years, he has been concerned primarily with bioethical issues arising at the population and global levels, including health resource allocation, the measurement of health and the burden of disease; ethical issues arising in health promotion; and the principles governing the use of human subjects in health research. Among Professor Wikler’s recent works, published with colleagues in the US and abroad, are the World Health Organization’s Casebook in Ethical Issues in International Health Research and Inequalities in Health: Concepts, Measures, Ethics, published by Oxford University Press in a series co-edited by Prof. Wikler under the title Population-Level Bioethics.

David Watkins is a physician-scientist in the Departments of Medicine at the University of Washington and University of Cape Town, and he is a senior researcher with the Disease Control Priorities Network, and his scientific interest is in priority setting for health in low- and middle-income countries, with a particular interest on prevention and control of noncommunicable diseases. 

Dr. Watkins received a bachelor of science from Rhodes College and a doctor of medicine from Duke University before moving to the University of Washington in Seattle, where he completed a residency in internal medicine, an MPH through the Institute for Health Metrics and Evaluation, and a research fellowship in health economics with the Disease Control Priorities Network.

James Love-Koh is a Research Fellow affiliated with the Global Health Economics and Economic Evaluation teams. He joined CHE in 2013 to undertake a PhD on incorporating health inequality concerns into cost-effectiveness analysis, having previously obtained a BA in Philosophy (Kent) and an MSc in Health Economics (York).

James has previously worked at a health economics consultancy, developing decision models for the National Institute of Health and Care Excellence and researching public health evaluation and precision medicine. His research interests are in health equity and decision analytic modelling.