Ole Frithjof Norheim

Responsibility in health care: a liberal egalitarian approach

Lifestyle diseases constitute an increasing proportion of health problems and this trend is likely to continue. A better understanding of the responsibility argument is important for the assessment of policies aimed at meeting this challenge. Holding individuals accountable for their choices in the context of health care is, however, controversial. There are powerful arguments both for and against such policies. In this article the main arguments for and the traditional arguments against the use of individual responsibility as a criterion for the distribution of scarce health resources will be briefly outlined. It is argued that one of the most prominent contemporary normative traditions, liberal egalitarianism, presents a way of holding individuals accountable for their choices that avoids most of the problems pointed out by the critics. The aim of the article is to propose a plausible interpretation of liberal egalitarianism with respect to responsibility and health care and assess it against reasonable counter-arguments.

Healthcare rationing—are additional criteria needed for assessing evidence based clinical practice guidelines?

In 1995 the case of “Child B” reached the headlines of British newspapers and stirred public debate about the decision to withhold a second bone marrow transplant from a child with acute myeloid leukaemia. 1 2 The decision was based on the weakness of scientific and clinical evidence of the treatments efficacy. It was also argued that the decision was in accordance with guidelines for patient selection that were already in place for such specialised treatment. A central issue is why judgments such as this are not perceived as legitimate, even when they are based on clinical guidelines. The explanation may lie partly in the fact that the guidelines used have not been developed through a process considered as legitimate. Why should the patient, her parents, or the public accept some little known guidelines developed within the closed communities of medical experts? This issue is valid for all types of clinical practice guidelines. In this article, I examine guidelines as a mechanism for rationing and argue that this mechanism can be improved by involving the patient and the public. #### Summary points Clinical practice guidelines can be mechanisms for rationing and tools for improving the quality of rationing decisions However, additional criteria for assessing the acceptability of evidence based clinical practice guidelines are needed Rationing decisions based on guidelines could be acceptable if guidelines are developed through open and fair procedures Guidelines used for rationing should be accessible to the public and explicit reasons for recommendations should be provided Rationing can be defined as the withholding of potentially beneficial health care through financial or organisational features of the healthcare system in question. The definition is broad enough to encompass the view that withholding of treatment perceived to be beneficial should be seen as a question of rationing. One of the basic assumptions in …

Guidance on priority setting in health care (GPS-Health): the inclusion of equity criteria not captured by cost-effectiveness analysis

This Guidance for Priority Setting in Health Care (GPS-Health), initiated by the World Health Organization, offers a comprehensive map of equity criteria that are relevant to health care priority setting and should be considered in addition to cost-effectiveness analysis. The guidance, in the form of a checklist, is especially targeted at decision makers who set priorities at national and sub-national levels, and those who interpret findings from cost-effectiveness analysis. It is also targeted at researchers conducting cost-effectiveness analysis to improve reporting of their results in the light of these other criteria.The guidance was develop through a series of expert consultation meetings and involved three steps: i) methods and normative concepts were identified through a systematic review; ii) the review findings were critically assessed in the expert consultation meetings which resulted in a draft checklist of normative criteria; iii) the checklist was validated though an extensive hearing process with input from a range of relevant stakeholders.The GPS-Health incorporates criteria related to the disease an intervention targets (severity of disease, capacity to benefit, and past health loss); characteristics of social groups an intervention targets (socioeconomic status, area of living, gender; race, ethnicity, religion and sexual orientation); and non-health consequences of an intervention (financial protection, economic productivity, and care for others).

Introduction of the patient-list system in general practice. Changes in Norwegian physicians' perception of their gatekeeper role.

Objective – To explore whether the patient-list system, recently introduced in general practice, has influenced general practitioners’ (GPs’) self-perception as gatekeepers. Design – Structured focus group interviews with GPs and a short self-administered questionnaire. Setting – Primary care within the public health care system in Norway. Group interviews were conducted 6 months to 1 year after the patient-list system was introduced in June, 2001. Subjects – 81 GPs attending tutorial groups or specialists’ continuous education groups. Outcome measures – GPs’ experience with the reform as stated in 11 group discussions, recorded, transcribed and systematically analysed through coding and extracting of the informants’ statements. The questionnaire provided background information about each participant. Results – The doctors generally perceived themselves as less concerned with the gatekeeper role under the new system. They felt it more important to provide better services and keep patients satisfied. The practitioners explained this shift using three contextual factors: increased and more visible competition, higher expectations from the patients and more responsibility assigned to the GP. Conclusion – GPs in Norway have experienced a shift in power in the physician–patient relationship favouring the patient. The GPs consciousness of the gatekeeper role has diminished. We question whether the new system lessens the incentive to consider resource use in decision-making.

Human resources for emergency obstetric care in northern Tanzania: distribution of quantity or quality?

BackgroundHealth care agencies report that the major limiting factor for implementing effective health policies and reforms worldwide is a lack of qualified human resources. Although many agencies have adopted policy development and clinical practice guidelines, the human resources necessary to carry out these policies towards actual reform are not yet in place.ObjectivesThe goal of this article is to evaluate the current status of human resources quality, availability and distribution in Northern Tanzania in order to provide emergency obstetric care services to specific districts in this area. The article also discusses the usefulness of distribution indicators for describing equity in the decision-making process.MethodsWe conducted a quantitative facility survey in six districts of Northern Tanzania. We collected data from all 129 facilities that provide delivery services in the study area. The data includes information on the emergency obstetric care indicators, as described by the WHO/UNICEF/UFPA guidelines for monitoring the provision of obstetric care. The inventory also includes information on the numbers of qualified health personnel at the basic and comprehensive emergency obstetric care level. We analysed the distribution and workload of the available human resources in a wider policy context with a particular focus on equity, use and quality, by means of descriptive statistics and the Spearmans correlation test.ResultsWe determined that there are adequate human resources allocated for health care provision in Tanzania, according to national standards. Compared to similar countries however, Tanzania has a very low availability of health care staff. Most qualified staff are concentrated in a few centralized locations, while those remaining are inequitably and inefficiently distributed in rural areas and lower-level services. Rural districts have restricted access to government-run health care, because these facilities are understaffed. In fact, voluntary agency facilities in these districts have more staff than the government facilities. There is a statistical correlation between availability of qualified human resources and use of services, but the availability of qualified human resources does not automatically translate into higher availability of qualified emergency obstetric care services.ConclusionNational guidelines for human resources for health care in Tanzania require focused revisions in order to reflect the quality indicators more adequately when monitoring and setting criteria for HR distribution. Availability of qualified personnel as well as institutional management and capacity determine the quality of emergency obstetric care services and personnel. The current wide distribution of staff of inadequate quality should be reconsidered. The use of distribution indicators alone is not useful to properly monitor equity. This article suggests increasing access to high-quality health care instead of distributing low-quality services widely.

CAN COST-EFFECTIVENESS ANALYSIS INTEGRATE CONCERNS FOR EQUITY? SYSTEMATIC REVIEW

OBJECTIVES The aim of this study was to promote approaches to health technology assessment (HTA) that are both evidence-based and values-based. We conducted a systematic review of published studies describing formal methods to consider equity in the context of cost-effectiveness analysis (CEA). METHODS Candidate studies were identified through an unrestricted search of the Pub Med and EMBASE databases. The search closed on January 20, 2011. We identified additional studies by consulting experts and checking article bibliographies. Two authors independently reviewed each candidate study to determine inclusion and extracted data from studies retained for review. In addition to documenting methods, data extraction identified implicit and explicit notions of fairness. Data were synthesized in narrative form. Study quality was not assessed. RESULTS Of the 695 candidate articles, 51 were retained for review. We identified three broad methods to facilitate quantitative consideration of equity concerns in economic evaluation: integration of distributional concerns through equity weights and social welfare functions, exploration of the opportunity costs of alternative policy options through mathematical programming, and multi-criteria decision analysis. CONCLUSIONS Several viable techniques to integrate equity concerns within CEA now exist, ranging from descriptive approaches to the quantitative methods studied in this review. Two obstacles at the normative level have impeded their use in decision making to date: the multiplicity of concepts and values discussed under the rubric of equity, and the lack of a widely accepted normative source on which to ground controversial value choices. Clarification of equity concepts and attention to procedural fairness may strengthen use of these techniques in HTA decision making.

Further benefits by early start of HIV treatment in low income countries: survival estimates of early versus deferred antiretroviral therapy.

BackgroundInternational HIV guidelines have recently shifted from a medium-late to an early-start treatment strategy. As a consequence, more people will be eligible to Highly Active Antiretroviral Therapy (HAART). We estimate mean life years gained using different treatment indications in low income countries.MethodsWe carried out a systematic search to identify relevant studies on the treatment effect of HAART. Outcome from identified observational studies were combined in a pooled-analyses and we apply these data in a Markov life cycle model based on a hypothetical Tanzanian HIV population. Survival for three different HIV populations with and without any treatment is estimated. The number of patients included in our pooled-analysis is 35 047.ResultsProviding HAART early when CD4 is 200-350 cells/μl is likely to be the best outcome strategy with an expected net benefit of 14.5 life years per patient. The model predicts diminishing treatment benefits for patients starting treatment when CD4 counts are lower. Patients starting treatment at CD4 50-199 and <50 cells/μl have expected net health benefits of 7.6 and 7.3 life years. Without treatment, HIV patients with CD4 counts 200-350; 50-199 and < 50 cells/μl can expect to live 4.8; 2.0 and 0.7 life years respectively.ConclusionsThis study demonstrates that HIV patients live longer with early start strategies in low income countries. Since low income countries have many constraints to full coverage of HAART, this study provides input to a more transparent debate regarding where to draw explicit eligibility criteria during further scale up of HAART.

Quantifying quality of life for economic analysis: time out for time trade off

The “Time trade-off” (TTO), is the most widely used method to “quality adjust” life years for “QALYs” in cost utility analysis. In this paper we ask if it is theoretically likely that the TTO is valid for this use. The TTO consists in a trade off between longevity and quality of life. Firstly, we argue that it is impossible to control for all factors that may influence one’s willingness to sacrifice lifetime. Secondly, that longevity and quality of life are too closely interrelated for the hypothetical trade off to reveal real preferences. Thirdly, that the TTO handles the value of a life year inconsistently because it simultaneously assumes that it changes (as an outcome measure) and that it doesn’t change (as a currency unit). Lastly, we ask whether the difficulties stem from an inherent contradiction in trying to quantify quality of life. The problems of theoretical validity and internal consistency, contrast the use of the results as exact measurements. We conclude that cost utility analysis based on TTO cannot be trusted as a tool for setting priorities in health.

Impact of ethics and economics on end-of-life decisions in an Indian neonatal unit.

OBJECTIVE: The aim of this article was to describe how providers in an Indian NICU reach life-or-death treatment decisions. METHODS: Qualitative in-depth interviews, field observations, and document analysis were conducted at an Indian nonprofit private tertiary institution that provided advanced neonatal care under conditions of resource scarcity. RESULTS: Compared with American and European units with similar technical capabilities, the unit studied maintained a much higher threshold for treatment initiation and continuation (range: 28–32 completed gestational weeks). We observed that complex, interrelated socioeconomic reasons influenced specific treatment decisions. Providers desired to protect families and avoid a broad range of perceived harms: they were reluctant to risk outcomes with chronic disability; they openly factored scarcity of institutional resources; they were sensitive to local, culturally entrenched intrafamilial dynamics; they placed higher regard for “precious” infants; and they felt relatively powerless to prevent gender discrimination. Formal or regulatory guidelines were either lacking or not controlling. CONCLUSIONS: In a tertiary-level academic Indian NICU, multiple factors external to predicted clinical survival of a preterm newborn influence treatment decisions. Providers adjust their decisions about withdrawing or withholding treatment on the basis of pragmatic considerations. Numerous issues related to resource scarcity are relevant, and providers prioritize outcomes that affect stakeholders other than the newborn. These findings may have implications for initiatives that seek to improve global neonatal health.

Clinical priority setting

Twelve years ago (BMJ 1996;312:1553-4) the BMJ argued that health systems needed to be explicit about rationing and published articles describing different ways of rationing fairly. Here a clinician, two ethicists (doi:10.1136/bmj.a1850), and four health economists (doi:10.1136/bmj.a1872) discuss how their ideas have developed—and been put into practice—since then