When policymakers make choices about policies to fund and implement, they need to balance a range of objectives, including the needs and concerns of the population affected, the short-term versus long-term potential benefits of policies, competing demands for resources, and concerns about equitable, nondiscriminatory allocation of resources. While consulting summary measures like the number of disability-adjusted life years averted by a particular policy are useful, such an assessment may be insufficient to address all of these considerations. The reality of decision-making means that there are also a range of political constraints to consider. Understanding which political constraints are unavoidable and which may have flexibility, but incur a cost, are key aspects of the political analysis of health system decision-making. IHME seeks to provide a set of clear guidelines and tools to make transparent these constraints and the costs associated with them, to help inform how best to dedicate resources to get the maximum impact in improving population health in the future.
A given set of policies or interventions may be projected to achieve the maximum aggregate gains to population health, but that does not necessarily mean that set is the right one to fund, implement, and scale up. Achieving equity and fairness are critical dimensions of the success of any health system and need to be considered just as rigorously as any of the summary health measures, such as the burden of disease, in a given country. The Equity and Fairness in Decision-making research team’s work considers the additional dimensions of equity and political considerations that policymakers regularly face. It provides a way to systematically take into account the particular context in which policymakers make decisions and incorporates carefully thought out ethical considerations.
Key Activities
- Develop guidelines to assess the multiple nonfinancial dimensions of choice in health policy
With colleagues at the Harvard School of Public Health, the research team is developing a set of heuristic guidelines to help researchers incorporate dimensions of equity and fairness into their cost effectiveness calculations. These guidelines will help researchers consider these dimensions more systematically and clearly in cost effectiveness estimates for a wide range of interventions as part of the Disease Control Priorities Network. We intend to convene a small group of ethicists to consider the multiple perspectives on these issues and to produce a series of papers exploring these perspectives from which the guidelines will be distilled. The guidelines will take into account the following four dimensions:
- Intertemporal choice: The period for which costs and benefits should be assessed, the way in which costs and benefits should be aggregated over time, and the assumptions made about secular trends in population health are issues that remain controversial in cost effectiveness analysis.
- Decision perspectives: There are three questions that policymakers often ask about health resource allocation. How should health budgets be allocated to maximally improve population health? How should additional societal resources that can impact health be allocated to maximally improve population health? What policies will produce health gains at a cost per unit of population that is below society’s willingness to pay for health gains? The research team will consider whether any of these questions deserve priority or if they should be balanced in some way.
- Fairness and distributional concerns: When making decisions about allocating resources, policymakers usually want to consider fairness and distributional concerns, such as access to and uptake of interventions, in addition to their desire to maximize population health improvement. The research team will formulate a range of practical analytical steps to help decision-makers balance these concerns.
- Political constraints: Because there are many more possible policy options than those that can be feasibly legislated or implemented, real world constraints on decision-making need to be explicitly characterized. Political science can provide important input into which constraints are fixed, which are more malleable, and how this influences policy choices.
Impact
The Equity and Fairness in Decision-making research team aims to provide researchers with an explicit set of guidelines to use when considering intertemporal choice, decision perspectives, fairness and distributional concerns, and the political constraints of a potential health intervention. These guidelines will allow for the systematic inclusion of these factors into cost effectiveness assessments, enhancing the utility of those assessments for policymakers to get the maximum impact in improving population health.
