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This chapter addresses the question of priority setting for competing needs when resources are scarce. It begins with the broader societal perspective, because fair decisions must balance spending on health with spending elsewhere. Next, it addresses competing claims within the health budget itself. The health capability paradigm involves reasoned consensus on allocating resources, based on scientific and deliberative processes. The paradigm emphasizes a collaborative and participatory approach to decision‐making that reinforces individual health agency, while at the same time evaluating outcomes in terms of their substantive merit. Medical appropriateness and clinical practice guidelines allow creation of evidence‐based, standardized health policy that provides optimal care and a universal benefits package of goods and services that support central health capabilities. The chapter also discusses efficiency concerns, resource allocation and age, setting limits, rationing, and how to address hard cases, such as medical futility and those invoked by the ‘bottomless pit’ objection or differing conceptions of ‘reasonable accommodation’. A framework for combining technical and ethical rationality for resource allocation is developed.

This chapter discusses the tensions between the health evidence base and other factors in making prioritization decisions that will influence public health and its practice. It concludes with a challenge to develop better methods for incorporating evidence into health priority setting.

This chapter discusses the differences between individual and population health priorities. It describes the Population Health Evidence Cycle (Ask the question, Collect the evidence, and Understand and use the evidence) as an organizing structure for how to involve the public in priority setting. A new definition of public health is advocated: “Use of theory, experience, and evidence derived through the population sciences to improve the health of the population in a way that best meets the implicit and explicit needs of the community (the public)”.

This chapter focuses on the key questions of who should set priorities, and how. It also examines the complex issues of the underlying factors and attitudes towards priorities. It argues that priority-setting is the most important part of the planning process, and yet it is often not given sufficient attention. It also argues that priority-setting involves a combination of techniques and value judgements.

This chapter focuses on how international experience in using cost-effectiveness information explicitly to inform formulary decisions provides a remarkable contrast to that of the U.S. For a number of years, the U.K., Canada, Australia, and other countries have incorporated cost-effectiveness considerations explicitly into processes for making coverage and pricing decisions about drugs and other technologies. Unlike the U.S., where there has been little public acknowledgment of limits to health resources, a number of European countries—including Norway, Denmark, Sweden, and the Netherlands—established national commissions in the 1980s and 1990s to discuss priorities and choices, and to create an explicit framework for limit setting. While these commissions elicited controversy, they were also greeted by public discussions and broad-based support of the need for a limit-setting process.

This chapter argues that similarities between human populations tend to outweigh differences; that the general priorities of health care systems are of great importance to minority ethnic groups. Public health and health care initiatives must, therefore, cater for the ethnic majority and minority populations simultaneously, with work of equal potential effectiveness and sensitivity. Topics discussed include the nature of priority-setting, and the contribution of pubic health sciences; social values as an underpinning force in priority-setting for ethnic minority groups; the utility and futility of the comparative approach; using epidemiological data to help influence priorities for ethnic minority health; and the impact of choosing priorities on reducing and widening ethnic inequalities in health.

This chapter explores the ethical issues that arise in the course of undertaking epidemiological and international health research, focusing on ethical issues that the researcher inevitably has to grapple with during the conduct of research. These include how to plan and develop international research, the value systems of different cultures and countries, particular issues in low-income countries such as those around priority-setting, equity, and consent, external sponsorship and ethical review of research, and what happens when the research is over. It argues that although following guidelines and adhering to the law are both important, it is critical that the researcher approaches the research with an open mind and willing heart. There is no replacement whatsoever for thoughtfulness, sensitivity, and treating people with respect and dignity.

Some authors have suggested that inequality in health at population level could be explored by using inequality measures derived from measurement of income inequality. Would it make sense to substitute income with health in measures such as the Gini or Atkinson’s index of inequality? The aim of this chapter is to explore if Atkinson’s index of inequality can help us understand trade-offs in health care priority setting, and if yes, how to respond to possible objections to this use. Measures of economic inequality can help us understand trade-offs in health care priority setting. I argue that Atkinson’s index of inequality and the achievement index are able to: a) capture distributive concerns in cases involving inequality in the age of death; b) measure impact of population level interventions (e.g. targeting under-five mortality); c) capture distributive concerns for the worst off; and d) provide an alternative perspective on the disability paradox encountered by cost-utility analysis. Limitations to this approach include distributions involving small health benefits at the beginning of life (the incomplete lives argument) and at the end of life (a special concern for palliative care for terminally ill patients regardless of how much health they have achieved previously). The univariate measures discussed in this paper is only concerned with the distribution of health itself. Additional and normatively relevant types of information are captured in bivariate and multivariate measures.

This chapter examines rationing and priority setting in the health care sector. It investigates why rationing is no longer much discussed in contemporary health policy debates, while it was on every policy maker's lips just a decade ago. It explores how the issues of rationing and priority setting are being addressed in health systems that continue to have to manage growing demand with limited resources.

The introductory chapter sets out a sketch of the theory of public policy investment that we develop in this book. Policy portfolios capture the policy domains and levels of attention that parties in government and electoral competition afford them. They constitute a sophisticated form of responsiveness that acts as an important element of democratic representation. Priority setting in our scheme is conditionally representative, not strictly responsive to public opinion, aware of interrelationships among policy domains, and influenced by non-policy factors important to voters. Conditional representation is distinguished from naïve responsiveness and the idea of statecraft is introduced. A plan of the book is included.

The final chapter of this book, Chapter 20, goes beyond the two sets of variables that are considered within an economic evaluation: costs and outcomes. The issue here is how equity and fairness can be included in the decision-making process by allowing different threshold values for quality-adjusted life years depending on the distributive implications of healthcare programmes. The fundamental question is what type of inequality that policymakers would seek to reduce. Five equity principles in health are discussed, and compared using diagrams and numerical examples. These are equality in (1) future health, (2) future health losses, (3) the proportion of future health lost, (4) lifetime health losses, and (5) lifetime health. While the debate on equity weighting generally involves arguments for accepting higher threshold values, the chapter ends with the contexts when lower threshold values would be appropriate, that is, being cost-effective does not imply that the programme should be publicly funded.

Rhetoric, the craft of persuasion, has received a poor press in modern times. Both in everyday language and in much academic debate rhetoric is seen as something dishonest and undesirable, as manipulation or propaganda, and as such, a disruptive force and a threat to democratic deliberation. However, there is an alternative, affirmative conceptualization of rhetoric, which has its roots in classical scholarship, and is the focus of this chapter. The chapter identifies three fundamental features of rhetoric, and suggests ways in which a rhetorical perspective can enrich the analysis of policy making. Arguments are illustrated with examples from a study of priority setting in primary care, including extracts of talk from the deliberations of a National Health Service Priorities Forum charged with prioritising healthcare resources at a local level, comprising specialists in public health, commissioning and finance managers of the primary care organisation, local general practitioners, and patient representatives.

Access to healthcare is concerned with the processes of gaining entry to the healthcare system. Analysis of access focuses on inequality and inequity in the availability and use of health services. In order to address global inequalities in access to healthcare, international organizations have promoted access to healthcare as a human right. This is linked to the ideal of universal health coverage, with shared funding of some or all healthcare for everyone, as a key strategy for achieving this. At a national level, rational strategies for resource allocation and priority setting are used to promote equity of access in terms of equal access for equal need, but historical inequalities based on the ‘inverse care law’ have been resistant to change. In health systems led by primary care, access to a general practitioner (GP) tends to reduce inequalities in ‘entry’ access to the health system, but the gatekeeping role of GPs may contribute to the development of inequalities of ‘in-system’ access. Wide variations in the utilization of both primary and secondary care services are indicative of access inequalities, but these variations may sometimes reflect clinical uncertainty or poor-quality care. Access inequalities may also arise from personal, social, and cultural barriers experienced by patients in accessing healthcare. These barriers typically represent more severe obstacles for marginalized groups in the population. Promoting equity means ensuring that services are responsive and acceptable to all groups, including those with stigmatized conditions.

Throughout the legislative odyssey of federal policy on comparative effectiveness research from 2002 to 2008, the specifics of the policy took many different forms. While opponents to federally-mandated comparative effectiveness research objected to the policy entirely, proponents of the policy were divided as to where the function should be housed (inside the federal government or outside); how it should be financed (congressional appropriations or fees levied on public and private health insurers and health plans), and how it should be governed (how much representation should each stakeholder have on a governing board). Every specification has its advantages and disadvantages. The two federal mandates currently in force for comparative effectiveness research—the 2003 Medicare Modernization Act and the 2010 Affordable Care Act—differ markedly in placement, financing, governance, research priority-setting methods, and processes, illustrating the fact that every alternative is a balance between advantages and disadvantages.

In this chapter, I discuss the Time-Relative Interest Account (TRIA) and the Life Comparative Account (LCA) and their implications for summary measures of population health and fair priority setting in health care. First, I argue that an extreme interpretation of TRIA is incompatible with the standard practice of measuring population health by life expectancy at birth as an indicator. Implementing a policy of always saving adults before children would decrease life expectancy in a population. This implication is untenable. Second, I argue that a moderate interpretation of TRIA is compatible with earlier attempts to measure the burden of disease in populations by using marginal age weights in the valuation of Disability-Adjusted Life Years lost. The authors of the Global Burden of Disease study subsequently abandoned age weights. Third, I argue that marginal age weights used for determining social priority for health improvements may be appropriate.

Donors to global health programs and policymakers within national health systems have to make difficult decisions about how to allocate scarce health care resources. Principled ways to make these decisions all make some use of summary measures of health, which provide a common measure of the value (or disvalue) of morbidity and mortality. They thereby allow comparisons between health interventions with different effects on the patterns of death and ill health within a population. The construction of a summary measure of health requires that a number be assigned to the harm of death. But the harm of death is currently a matter of debate: different philosophical theories assign very different values to the harm of death at different ages. This chapter considers how we should assign numbers to the harm of deaths at different ages in the face of uncertainty and disagreement.

Concern over the scale of preventable morbidity is compounded by its differential distribution across the population. Economic arguments for prevention have become more prominent and this chapter considers the policy context, influences on priority-setting and enablers and barriers for prioritising prevention in practice. It reviews public health intelligence and assesses a range of decision-support methods, including economic evaluation and return on investment for prevention. The chapter shows that methods for priority-setting were not always suited to addressing equity or longer-term public health investment; data were often inadequate; and modelling skills were in short supply. While disinvestment was increasingly considered a prerequisite for public health investment, this was difficult to achieve. Commissioners made relatively little use of decision-support methods. With economic pressures facing local authorities, prioritisation frameworks will be required to make difficult rationing decisions more transparent: implications of the study for prioritising public health investment are discussed.