Ole F. Norheim Professor in Medical Ethics and Philosophy of Science

1. Choosing servicesIntegrating Concerns for Cost-Effectiveness, Financial Protection, and the Worse Off Ole F. Norheim Professor in Medical Ethics and Philosophy of Science Dept. of Global Public Health and Primary Care University of Bergen ole.norheim@igs.uib.no

2. Plan • Background • Cost-effectiveness • Financial protection • Priority to the worse off • Classification of priority health services

3. Key question • Should financial protection and distributional concernsbe incorporated into decision rules for publicly financed health services?

4. Priority group classification • Universal Coverage can be defined as access to key health services for all at an affordable cost • High-priority services • Normal-priority services • Low-priority services Key services

5. How to classify services? • Cost-effectiveness thresholds < 1 GDP per capita 1-2 GDP per capita > 3 GDP per capita (Macroeconomics and Health 2002, WHO CHOICE)

6. Selected 65 health services from WHO-CHOICE database (AfrE) Child health services Maternal and newborn health services Infectious disease services Non-communicable disease services Converted all costs to Int $ 2005 (WHO-CHOICE team BMJ series 2005-2012) Example

9. Two problems with CEA • Ignores financial risk protection • Ignores distribution of healthy life years

10. Financial risk protection • Publicly financed health services provide • Financial risk protection • Health • Peter Smith : • If no one buys supplementary services, or • a well-functioning voluntary supplementary insurance market • service selection on the basis of standard cost-effectiveness ratios will maximize welfare (health + income) (P. Smith, Health Economics 2012) • When there is substantial out-of-pocket payment for supplementary services, this is not so.

11. High cost services may be favored over low cost services, at least among services with similar cost-effectiveness ratios. • My interpretation: • Financial risk protection could act at least as a tiebreaker for services with identical cost-effectiveness ratios.

13. Two problems with CEA • Ignores financial risk protection • Ignores distribution of healthy life years

15. Integrating distributive concerns with CEA • An “Atkinson’s” social welfare function applied to health would judge: • (60, 45) as better than (80, 25) (Adler, OUP 2012) • Health prioritarianism would assign higher weights to benefits for B (Ottersen, JME 2013)

17. 1 1.5 2

22. Opportunity cost of implementing top 5 interventions for 5 mill $ 42748 DALYs 41190 DALYs = 1558 DALYs

23. Opportunity cost • Health prioritarianism • Knows the cost in terms of DALYs NOT averted • Can provide reasons for re-ranking: • some priority to the worse off

24. Priority group classification – tentative proposal

25. Ex ante / ex post prioritarianism • Distributive weights based on final – not expected – individual disease burden for various conditions

26. Imagine you can help group A or B – who would you help?

27. Imagine you can help group A or B – who would you help?

29. Ex post: Even if we only know the outcome, but not who will be affected, we can evaluate alternative outcomes