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

Abstract

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.

Figure 1

Schematic presentation of the three scenarios. Cost-effectiveness of A=B in Scenario 1, A>B in Scenario 2 and 3.

Figure 2

The actual and ideal rank given to various stakeholders' role in priority setting.

Figure 3

Respondent's choices in the three different scenarios.

Figure 4

Potential policy implications for the trade off between cost-effectiveness of intervention and severity of disease. The essential national health package is based on the most cost-effective interventions (line parallel to the x-severity axis) against the leading causes of severity of disease (line parallel to the Y-cost-effective axis). Transparent criteria need to be developed in case of expansion of the package to include other interventions. In case cost-effectiveness is the criteria, then expansion should be in the direction of arrow (a), in case it is severity, then one should consider (b).