A Grand Convergence in Mortality is Possible: Comment on Global Health 2035

The grand challenge in global health is the inequality in mortality and life expectancy between countries and within countries. According to Global Health 2035, the Lancet Commission celebrating the 20th anniversary of the World Development Report (WDR) of 1993, the world now has the unique opportunity to achieve a grand convergence in global mortality within a generation. This article comments on the main findings and recommendations of the Global Health 2035

The ideal of equal health revisited: definitions and measures of inequity in health should be better integrated with theories of distributive justice

The past decade witnessed great progress in research on health inequities. The most widely cited definition of health inequity is, arguably, the one proposed by Whitehead and Dahlgren: "Health inequalities that are avoidable, unnecessary, and unfair are unjust." We argue that this definition is useful but in need of further clarification because it is not linked to broader theories of justice. We propose an alternative, pluralist notion of fair distribution of health that is compatible with several theories of distributive justice. Our proposed view consists of the weak principle of health equality and the principle of fair trade-offs. The weak principle of health equality offers an alternative definition of health equity to those proposed in the past. It maintains the all-encompassing nature of the popular Whitehead/Dahlgren definition of health equity, and at the same time offers a richer philosophical foundation. This principle states that every person or group should have equal health except when: (a) health equality is only possible by making someone less healthy, or (b) there are technological limitations on further health improvement. In short, health inequalities that are amenable to positive human intervention are unfair. The principle of fair trade-offs states that weak equality of health is morally objectionable if and only if: (c) further reduction of weak inequality leads to unacceptable sacrifices of average or overall health of the population, or (d) further reduction in weak health inequality would result in unacceptable sacrifices of other important goods, such as education, employment, and social security

"What lies beneath it all?" - an interview study of GPs' attitudes to the use of guidelines

Background: General practitioners (GPs) adopt clinical practice guidelines to varying degrees. Several factors have been found to influence application of guidelines in practice and the GP is apparently the key actor. Studies are needed to increase our understanding of how GPs' attitudes influence their use of guidelines. In this study we explored GPs' attitudes to guidelines. Methods: In 2007 we conducted six semi-structured group interviews with a purposive sample of 27 Norwegian GPs. The participants were encouraged to discuss guidelines they were familiar with, the evidence base of guidelines, professional autonomy and doctor-patient relations. We used thematic content analysis to extract central themes and arguments. Results: When deciding whether tfollow guideline recommendations, GPs consider whether guidelines are trustworthy, whether they suit patients and whether the recommended action is feasible. There were two important findings. First, the GP's were concerned that guidelines may be more heavily influenced by economic considerations than clinical ones. Second, in contrast to earlier findings, changes in recommendations and disagreement between experts were mostly viewed positively. Conclusion: This study underscores the need for transparency in the process of development and implementation of guidelines. To enhance the use of guidelines, primary care physicians should be involved in the process of developing guidelines and the process should be transparent and explicit regarding the evidence base and economic considerations.publishedVersio

A grand convergence in mortality is possible: comment on Global Health 2035

The grand challenge in global health is the inequality in mortality and life expectancy between countries and within countries. According to Global Health 2035, the Lancet Commission celebrating the 20 th anniversary of the World Development Report (WDR) of 1993, the world now has the unique opportunity to achieve a grand convergence in global mortality within a generation. This article comments on the main findings and recommendations of the Global Health 2035

Making fair choices on the path to universal health coverage: a prėcis

We outline key conclusions of the World Health Organisation's report 'Making Fair Choices on the Path to Universal Health Coverage (UHC)'. The Report argues that three principles should inform choices on the path to UHC: I. Coverage should be based on need, with extra weight given to the needs of the worse off; II. One aim should be to generate the greatest total improvement in health; III. Contributions should be based on ability to pay and not need. We describe how these principles determine which trade-offs are (un)acceptable. We also discuss which institutions contribute to fair and accountable choices

Public participation: healthcare rationing in the newspaper media

Background It is impossible to meet all healthcare demands, but an open and fair rationing process may improve the public acceptability of priority setting in healthcare. Decision-making is subject to scrutiny by newspaper media, an important public institution and information source for discussions about rationing. In Norway, healthcare rationing has been subject to public debate both before and after the establishment of “The National System for Managed Introduction of New Health Technologies within the Specialist Health Service” (New Methods) in 2013. Aim To describe and assess the development of the public debate on Norwegian healthcare rationing through three cases in print media. Methods We purposively sampled Norwegian newspaper articles between 2012 and 2018 concerning three reimbursement decisions in the Norwegian system. The reimbursement decisions were ipilimumab (Yervoy, n = 45) against metastatic melanoma, nivolumab (Opdivo, n = 23) against non-small cell lung cancer, and nusinersen (Spinraza, n = 68) against spinal muscular atrophy. Cases were analysed separately using the qualitative method of systematic text condensation. Results Our analysis highlighted four common themes—money, rationales, patient stories, and process—and a unique theme for each case. Ipilimumab was uniquely themed by rationing rejection, nivolumab by healthcare two-tiering, and Spinraza by patients’ rights. We found wide media deliberation among a multitude of stakeholders in all cases. Perceptions of rationing were found to be chiefly aligned with previous empirical research. We found that the media reported more frequently on opposition to rationing compared to findings from previous studies on Norwegian healthcare decision-making attitudes. We think this was influenced by our selection of cases receiving extraordinary media attention, and from media sources being subject to political communication from special interest groups. Conclusion We observed that the introduction of New Methods institutionalised Norwegian healthcare rationing and isolated the public debate into conversations between stakeholders and decision makers outside the political sphere. The findings from these three extraordinary debates are not generalisable and should be seen as a stakeholder learning opportunity regarding media coverage and engagement with expensive specialist healthcare decision-making in Norway.publishedVersio

Is cost-effectiveness analysis preferred to severity of disease as the main guiding principle in priority setting in resource poor settings? The case of Uganda

INTRODUCTION: Several studies carried out to establish the relative preference of cost-effectiveness of interventions and severity of disease as criteria for priority setting in health have shown a strong preference for severity of disease. These preferences may differ in contexts of resource scarcity, as in developing countries, yet information is limited on such preferences in this context. OBJECTIVE: This study was carried out to identify the key players in priority setting in health and explore their relative preference regarding cost-effectiveness of interventions and severity of disease as criteria for setting priorities in Uganda. DESIGN: 610 self-administered questionnaires were sent to respondents at national, district, health sub-district and facility levels. Respondents included mainly health workers. We used three different simulations, assuming same patient characteristics and same treatment outcome but with varying either severity of disease or cost-effectiveness of treatment, to explore respondents' preferences regarding cost-effectiveness and severity. RESULTS: Actual main actors were identified to be health workers, development partners or donors and politicians. This was different from what respondents perceived as ideal. Above 90% of the respondents recognised the importance of both severity of disease and cost-effectiveness of intervention. In the three scenarios where they were made to choose between the two, a majority of the survey respondents assigned highest weight to treating the most severely ill patient with a less cost-effective intervention compared to the one with a more cost-effective intervention for a less severely ill patient. However, international development partners in in-depth interviews preferred the consideration of cost-effectiveness of intervention. CONCLUSIONS: In a survey among health workers and other actors in priority setting in Uganda, we found that donors are considered to have more say than the survey respondents found ideal. Survey respondents considered both severity of disease and cost-effectiveness important criteria for setting priorities, with severity of disease as the leading principle. This pattern of preferences is similar to findings in context with relatively more resources. In-depth interviews with international development partners, showed that this group put relatively more emphasis on cost-effectiveness of interventions compared to severity of disease. These discrepancies in attitudes between national health workers and representatives from the donors require more investigation. The different attitudes should be openly debated to ensure legitimate decisions

Response to Our Critics

We reply to critics of the World Health Organisation's Report "Making Fair Choices on the Path to Universal Health Coverage". We clarify and defend the report's key moral commitments. We also explain its role in guiding policy in the face of both financial and political constraints on making fair choices

Equity in public health spending in Ethiopia: a benefit incidence analysis

Inequality in access and utilization of health services because of socioeconomic status is unfair, and it should be monitored and corrected with appropriate remedial action. Therefore, this study aimed to estimate the distribution of benefits from public spending on health care across socioeconomic groups in Ethiopia using a benefit incidence analysis. We employed health service utilization data from the Living Standard Measurement Survey, recurrent government expenditure data from the Ministry of Finance and health services delivery data from the Ministry of Health’s Health Management Information System. We calculated unit subsidy as the ratio of recurrent government health expenditure on a particular service type to the corresponding number of health services visits. The concentration index (CI) was applied to measure inequality in health care utilization and the distribution of the subsidy across socioeconomic groups. We conducted a disaggregated analysis comparing health delivery levels and service types. Furthermore, we used decomposition analysis to measure the percentage contribution of various factors to the overall inequalities. We found that 61% of recurrent government spending on health goes to health centres (HCs), and 74% was spent on outpatient services. Besides, we found a slightly pro-poor public spending on health, with a CI of −0.039, yet the picture was more nuanced when disaggregated by health delivery levels and service types. The subsidy at the hospital level and for inpatient services benefited the wealthier quintiles most. However, at the HC level and for outpatient services, the subsidies were slightly pro-poor. Therefore, an effort is needed in making inpatient and hospital services more equitable by improving the health service utilization of those in the lower quintiles and those in rural areas. Besides, policymakers in Ethiopia should use this evidence to monitor inequity in government spending on health, thereby improving government resources allocation to target the disadvantaged better.publishedVersio

Cost-Effectiveness of Saxagliptin Compared With Glibenclamide as a Second-Line Therapy Added to Metformin for Type 2 Diabetes Mellitus in Ethiopia

Background. Metformin is a widely accepted first-line pharmacotherapy for patients with type 2 diabetes mellitus (T2DM). Treatment of T2DM with glibenclamide, saxagliptin, or one of the other second-line treatment agents is recommended when the first-line treatment (metformin) cannot control the disease. However, there is little evidence on the additional cost and cost-effectiveness of adding second-line drugs. Therefore, this study aimed to estimate the cost-effectiveness of saxagliptin and glibenclamide as second-line therapies added to metformin compared with metformin only in T2DM in Ethiopia. Methods. This cost-effectiveness study was conducted in Ethiopia using a mix of primary data on cost and best available data from the literature on the effectiveness. We measured the interventions’ cost from the providers’ perspective in 2019 US dollars. We developed a Markov model for T2DM disease progression with five health states using TreeAge Pro 2020 software. Disability-adjusted life year (DALY) was the health outcome used in this study, and we calculated the incremental cost-effectiveness ratio (ICER) per DALY averted. Furthermore, one-way and probabilistic sensitivity analysis were performed. Results. The annual unit cost per patient was USD 70 for metformin, USD 75 for metformin + glibenclamide, and USD 309 for metformin + saxagliptin. The ICER for saxagliptin + metformin was USD 2259 per DALY averted. The ICER results were sensitive to various changes in cost, effectiveness, and transition probabilities. The ICER was driven primarily by the higher cost of saxagliptin relative to glibenclamide. Conclusion. Our study revealed that saxagliptin is not a cost-effective second-line therapy in patients with T2DM inadequately controlled by metformin monotherapy based on a gross domestic product per capita per DALY averted willingness-to-pay threshold in Ethiopia (USD 953).publishedVersio