Trygve Ottersen

Lifetime QALY prioritarianism in priority setting

Two principles form the basis for much priority setting in health. According to the greater benefit principle, resources should be directed toward the intervention with the greater health benefit. According to the worse off principle, resources should be directed toward the intervention benefiting those initially worse off. Jointly, these principles accord with so-called prioritarianism. Crucial for its operationalisation is the specification of the worse off. In this paper, we examine how the worse off can be defined as those with the fewer lifetime Quality-Adjusted Life Years (QALYs). We contrast this proposal with several alternative specifications.

Addressing Antibiotic Resistance Requires Robust International Accountability Mechanisms

A proposed international agreement on antibiotic resistance will depend on robust accountability mechanisms for real-world impact. This article examines the central aspects of accountability relationships in international agreements and lays out ways to strengthen them. We provide a menu of accountability mechanisms that facilitate transparency, oversight, complaint, and enforcement, describe how these mechanisms can promote compliance, and identify key considerations for a proposed international agreement on antibiotic resistance. These insights can be useful for bringing about the revolutionary changes that new international agreements aspire to achieve.

Lifetime QALY prioritarianism in priority setting: quantification of the inherent trade-off

BackgroundMultiple principles are relevant in priority setting, two of which are often considered particularly important. According to the greater benefit principle, resources should be directed toward the intervention with the greater health benefit. This principle is intimately linked to the goal of health maximization and standard cost-effectiveness analysis (CEA). According to the worse off principle, resources should be directed toward the intervention benefiting those initially worse off. This principle is often linked to an idea of equity. Together, the two principles accord with prioritarianism; a view which can motivate non-standard CEA. Crucial for the actual application of prioritarianism is the trade-off between the two principles, and this trade-off has received scant attention when the worse off are specified in terms of lifetime health. This paper sheds light on that specific trade-off and on the public support for prioritarianism by providing fresh empirical evidence and by clarifying the close links between the findings and normative theory.MethodsA new, self-administered, computer-based questionnaire was used, to which 96 students in Norway responded. How respondents wanted to balance quality-adjusted life years (QALYs) gained against benefiting those with few lifetime QALYs was quantified for a range of different cases.ResultsRespondents supported both principles and were willing to make trade-offs in a particular way. In the baseline case, the median response valued a QALY 3.3 and 2.5 times more when benefiting someone with lifetime QALYs of 10 and 25 rather than 70. Average responses harbored fundamental disagreements and varied modestly across distributional settings.ConclusionIn the specific context of lifetime health, the findings underscore the insufficiency of pure QALY maximization and explicate how people make trade-offs in a way that can help operationalize lifetime prioritarianism and non-standard CEA. Seen through the lens of normative theory, the findings highlight key challenges for prioritarianism applied to priority setting.

Development assistance for health: what criteria do multi- and bilateral funders use?

After years of unprecedented growth in development assistance for health (DAH), the system is challenged on several fronts: by the economic downturn and stagnation of DAH, by the epidemiological transition and increase in non-communicable diseases, and by the economic transition and rise of the middle-income countries. This raises questions about which countries should receive DAH and how much, and, fundamentally, what criteria that promote fair and effective allocation. Yet, no broad comparative assessment exists of the criteria used today. We reviewed the allocation criteria stated by five multilateral and nine bilateral funders of DAH. We found that several funders had only limited information about concrete criteria publicly available. Moreover, many funders not devoted to health lacked specific criteria for DAH or criteria directly related to health, and no funder had criteria directly related to inequality. National income per capita was emphasised by many funders, but the associated eligibility thresholds varied considerably. These findings and the broad overview of criteria can assist funders in critically examining and revising the criteria they use, and inform the wider debate about what the optimal criteria are.

Synergies and tensions between universal health coverage and global health security: why we need a second ‘Maximizing Positive Synergies’ initiative

A kind of courtship is going on between proponents of universal health coverage (UHC) and proponents of global health security (GHS). In our opinion, efforts to make progress on the path to UHC and efforts to improve GHS can be synergistic, but are not self-evidently so. Making this partnership work will require careful thinking and planning. Several comments on ‘lessons from Ebola’ highlight the potential of UHC as a way to improve GHS.1 Simon Rushton, Louis Lillywhite and Bhimsen Devkota argue that the “[p]romotion of health security therefore entails ensuring that effective health systems exist before a crisis, are sustained during and after conflict and disaster, and are at all times accessible to the population.”1 Rob Yates, Ranu Dhillon and Ravi Rannan-Eliya remind us that several epidemics of global concern ‘occurred in settings without universal health coverage where health systems were unable to perform effective public health functions’.1 In a reaction to these ‘lessons from Ebola’, and a preview to the G7 summit in Ise-Shima of May 2016, Gavin Yamey argued that a way to make the case for UHC more compelling ‘could be to link UHC to the worldwide concern about pandemics in the wake of the Ebola crisis’,2 and he encouraged Japan—a longstanding proponent of UHC and GHS—to ‘rouse the G7 nations into action on universal health coverage’.2 Japan indeed promoted UHC and GHS, as an ‘inseparable couple’,3 and the ‘G7 Ise-Shima Vision for Global Health’ outcome document highlights both.4 ### Not a new attempt to create an alliance The present courtship is not new. The 2007 World Health Report, on ‘A safer future: global public health security in the 21st century’,5 highlighted the importance of strong health systems to enhance GHS. Without using the expression UHC, this report tried to tie efforts to make progress towards UHC into …

Vast Majority Of Development Assistance For Health Funds Target Those Below Age Sixty

Development assistance for health targets younger more than older age groups, relative to their disease burden. This disparity increased between 1990 and 2013. There are several potential causes for the disparity increase.

Global health financing towards 2030 and beyond

Universal health coverage and healthy lives for all are now widely shared goals and central to the 2030 Agenda for Sustainable Development. Despite significant progress over the last decades, the world is still far from reaching these goals. Billions of people lack basic coverage of health services, live with unnecessary pain and disability, or have their lives cut short by avoidable or treatable conditions (Jamison et al., 2013; Murray et al., 2015; World Health Organization, World Bank, 2015). At the same time, millions are pushed into poverty simply because they need to use health services and must pay for them out-of-pocket. Fundamental to this situation is the way health interventions and the health system are financed. Numerous countries spend less than is required to ensure even the most essential health services, scarce funds are wasted, out-of-pocket payments remain high and disadvantaged groups get the least public resources despite having the greatest needs

Towards a coherent global framework for health financing: recommendations and recent developments

The articles in this special issue have demonstrated how unprecedented transitions have come with both challenges and opportunities for health financing. Against the background of these challenges and opportunities, the Working Group on Health Financing at the Chatham House Centre on Global Health Security laid out, in 2014, a set of policy responses encapsulated in 20 recommendations for how to make progress towards a coherent global framework for health financing. These recommendations pertain to domestic financing of national health systems, global public goods for health, external financing for national health systems and the cross-cutting issues of accountability and agreement on a new global framework. Since the Working Group concluded its work, multiple events have reinforced the groups recommendations. Among these are the agreement on the Addis Ababa Action Agenda, the adoption of the Sustainable Development Goals, the outbreak of Ebola in West Africa and the release of the Panama Papers. These events also represent new stepping stones towards a new global framework.

Ebola Again Shows the International Health Regulations Are Broken What Can Be Done Differently to Prepare for the Next Epidemic

Epidemics are among the greatest threats to humanity, and the International Health Regulations are the worlds key legal instrument for addressing this threat. Since their revision in 2005, the IHR have faced two big tests: the 2009 H1N1 influenza pandemic and the 2014 Ebola epidemic in West Africa. Both exposed major shortcomings of the IHR, and both offered profound lessons for the future. The objective of this Article is twofold. First, we seek to compare the lessons learned from H1N1 and Ebola for reforming the IHR in order to test the hypothesis that they are similar. Second, we seek to examine the barriers to implementing these lessons and to identify strategies for overcoming those barriers. We find that the lessons from H1N1 and Ebola are indeed similar, and that opportunities to act on lessons from H1N1 were woefully missed. We identify many political barriers to global collective action and implementation of lessons for the IHR. On that basis, we describe strategies to overcome these barriers, which will hopefully be deployed now to reform the IHR before the policy window following Ebola closes, and before the inevitable next epidemic comes. The emerging threat of the Zika virus underscores that we have no time to waste.

Universal Health Coverage and Public Health: Ensuring Parity and Complementarity

The authors reflect on public health strategies and universal health coverage (UHC) as of 2017, and it mentions the United Nations Sustainable Development Goals, as well as the claim that public health interventions are needed to ensure healthy lives around the world. Public health spending data is addressed, along with information about how to ensure parity and complementarity between UHC and public health. The World Health Organization and the World Bank are assessed.