Values and the Future Canadian Health Care

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Normative Issues in International Health
Priority-setting Projects

• Nuala Kenny, OC, MD, FRCP(C)
• Department of Bioethics, Faculty of Medicine
• Christine Joffres Ed.D
• School of Health Services Administration
• DALHOUSIE University
  

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Acknowledgements

• This work is part of a 3yr study funded by
• The Canadian Institutes for Health Research
• Nova Scotia Health Services Research Foundation
• Newfoundland Labrador Centre for Applied Health
  Research
• Ontario Ministry of Health and Long Term Care
• (RC2-0873-03)

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Project Team

• T. Rathwell, T. Nestman, N. Kenny, C. Joffres and
  S. Jreige
• Dalhousie University, Halifax, Nova Scotia
• R. Deber, P. Conrad, H. Chappell
• University of Toronto, Toronto, Ontario
• D. Neville, R. Chafe
• Memorial University of Newfoundland

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Objectives

• To identify the importance of the new convergence
  of policy sciences and bioethics
• To understand better how a sample of countries
  have addressed normative concerns in
  priority-setting exercises
• To formulate an ethical framework for more
  robust, coherent and meaningful analysis of
  normative concerns in health priority-setting

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What Are Normative Issues?

• Descriptive ethics-what people say they value or
  values deduced from observation
• Theoretical ethics-coherent framework for
  justifying
• Normative ethics-concerned with the ought
  regarding action or choice

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Normative Issues and Public Policy

• Public policy is
• A moral enterprise decision for others
• A manifestation of public values
• Both a product and a process
• About identity and prophecy

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Values in Health Priority-Setting
Political Policy advice
Values
Economic Social
Healthcare Evidence
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A Typology of Values

• Values are
• Terminal beliefs regarding the preferred
  end-state or goal
• Instrumental-beliefs regarding the means to
  the end-state or goal
• Procedural-process values
• Substantive-criteria values

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Methods

• Review of normative issues in health
  priority-setting as identified in health policy
  and ethics literature
• Conceptual analysis of national priority setting
  experiences from 10 countries for identification
  of normative issues

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General Observations from Literature Review

• Policy literature is identifying explicitly the
  importance of normative issues in
  priority-setting
• Ethics literature focus is on the concepts of
• Justice, health, medical need, equity,
  solidarity, effectiveness, efficiency,
  cost-effectiveness, appropriate care, fair
  accountable and transparent process
• The emergence of ethical frameworks and sets
  of guiding principles in policy documents
  without theoretical justification, ordering or
  conflict resolution identified

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Classic Normative Concepts in A Sample of
Priority-Setting Projects

• Dignity
• Universality
• Equity/ equality
• Solidarity
• Security
• Personal responsibility
• Acceptability

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Classic Normative Concepts in A Sample of
Priority-Setting Projects

• Effectiveness/ cost-effectiveness
• Benefit
• Meaningful
• Appropriate
• Efficiency
• Special group/ worse off considerations

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Identified Values re the End State

• Ultimate ends/goals of priority-setting not
  generally clearly identified
• Health is variously defined
• Universality/Reduction of health inequities
• Solidarity

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Identified Values re Practical Goals

• Comprehensiveness (definition of a minimum
  package of core services)
• Formal assessments of needs for specific services
  with the purpose of purchasing health care
  services
• Value for money spent on health

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Identified Values re Process

• Citizen engagement of various types
• Evidence and expertise e.g., health economics
  administration
• Involvement of specific groups patients
  organization, disenfranchised groups
• Democratic principles/ political authority

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Identified Values re Criteria

• Human dignity
• Personal responsibility
• Solidarity
• Reduction of health disparities
• Greater needs take precedence over lesser ones
• Equity of access to services equity of outcome
• Special group health
• Acceptability (public, political or social)

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Identified Values re Technical Criteria

• Expected benefit
• Necessary care and appropriate care
• Burden of disease/severity of illness
• Effectiveness
• Efficiency (technical, operational and cost)
• Quality and evidence
• Safety

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Identified Values re Operational Criteria

• Cost utility
• Net benefit
• Cost effectiveness, cost efficiency
• PBMA (programme budgeting and marginal analysis)
  

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Observations

• Limited success of most prioritization
  experiences
• Lack of common vocabulary regarding normative
  issues such as values and principles
• Difficulty in ranking and operationalizing
  values identified in documents

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Observations

• Universality is generally limited to citizens or
  residents
• Under and over-representation of specific
  groups/participants
• The medical model of health
• The difficulty of defining medically necessary
  services

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Observations

• Need to explore/debate the values underlying the
  prioritization criteria, processes, and
  definitions (health, need) informing the
  prioritization experiences.
• Need to clarify the values in evidence
• Confusion regarding the set effectiveness,
  cost-effectiveness, efficiency, cost-efficiency
  and cost-utility

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Observations

• There is a conflation of priority setting and
  cost-containment exercises
• The role of the public remains indeterminate
• There is a lack of intersectoral collaboration
  across the continuum of health care and the
  services focused on the socio-economic
  determinants of health

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Some Conceptual Challenges

• If the normative issues in health
  priority-setting exercises are to be meaningful
  we need to clarify
• The nature of solidarity
• The importance of social and public goods
• The role of political power and values in the
  process
• The values inherent in the organization and
  financing of health care
• The nature and scope of public accountability
• Respect for pluralism its limits
• Competing conceptions of justice

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Challenges

• Clarify the distinction between true priority
  setting experiences and cost-containment
  exercises
• Clearly identify the role of citizen engagement
• Improve intersectoral collaboration across the
  continuum of health care and the services focused
  on the socio-economic determinants of health

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Recommendations

• The desired end state ought to be identified
  clearly
• Health priority-setting ought to be situated
  within social policy priority-setting
• Trade-offs must be identified and justified
  according to core values
• Values and normative statements must be justified
  within a theoretical framework

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Recommendations

• The values inherent in many normative concepts
  need further exploration e.g., evidence and
  health
• The ordering of values and justification for
  choice between competing values needs to be
  clarified