Cam Donaldson on the 7th international conference on priority setting in health care

Cam Donaldson Ole Frithjof Norheim and Cam Donaldson (pictured) sum up lessons learned from the 7th International conference on priority setting in health care.

Two weeks ago, we announced that the 7th meeting of the International Society on Priorities in Health Care was taking place at the Sage Gateshead, where 300 delegates from around the world  gathered to discuss issues of how best to manage scarcity of resources in health care from the perspectives of management and clinician practitioners as well as the research perspectives of economists and ethicists. This year’s conference represented a movement towards practical approaches to priority setting. One striking feature was the high number of excellent papers demonstrating the principles and results of programme budgeting and marginal analysis (PBMA).

Many of the presentations focused on pragmatic solutions, on being evidence informed and practical with respect to how well PBMA is working in different settings.

Other major themes to emerge were that priority setting must involve institutions, be context- sensitive and seek procedural solutions involving all stakeholders, including their views on equitable distribution. A “buzzword” in the conference was “disinvestments.”

It is one thing to identify new cost effective interventions, but that does not solve the problem of affordability. How do we identify interventions that should no longer have priority? This is the hard question, and one of the most interesting presentations demonstrated how rarely decision-makers actually achieve genuine reallocation of resources, even with the help of PBMA.

Another focus in this conference, which all participants appreciated, was the presentation of the National Institute for Health and Clinical Excellence (NICE). A significant number of the participants came from similar institutions in Sweden, Norway, Canada and even Taiwan.

Professor Littlejohns, one of the directors at NICE, presented how its work has evolved over time, focusing on the basic principles of being evidence based and transparent, on acknowledging the need to develop fair procedures and involving the public and their values through its citizens’ council.

On the other hand, many participants in the conference – seeing the system from below – asked critical questions about the practice of NICE. Are community values about equitable distribution really integrated in decisions, or does straightforward cost-effectiveness still dominate? How can NICE advice be better integrated in the work and responsibilities of primary care trusts when the key issue is affordability?
One of the keynote speakers, Dr Sheila Tlou (former Health Minister in Botswana), presented with enthusiasm and confidence her country’s priorities in combating HIV/AIDS. Although a small country, its strong focus on budget re-allocations, education, openness, prevention and treatment have helped in slowing down the epidemic and improved the lives of thousands.

Equally vibrant, but less optimistic were many of the other presentations that looked at priority setting under conditions of extreme resource constraints. Good case studies were presented on bedside rationing, the role of the donors, and procedural approaches. A whole session devoted to priority setting and health sector reform in Mexico (initiated by former Secretary of health, Julio Frank) summed up experiences and obstacles so far on how to implement state-of-the-art public health principles and integrating them with open and legitimate procedures.

Indeed, quite a number of presentations focused directly on Daniels and Sabin’s ethical framework called Accountability for Reasonableness. We had expected fewer of them, compared with the 2006 conference in Toronto, but the framework seems to have wide appeal, attracting now also critical, but constructive papers, such as Holm’s paper on “the missing stakeholders” and their lack of influence in procedural approaches.

A new and positive development for our society was the introduction of legal frameworks relevant for priority setting. A whole workshop focused on the role of the courts in health rights litigation and judicial review. Although many think that rights tend to favour the individual over the community, the workshop created lively debate on the relation between negative and positive rights, the right to justification, and the potential of the courts in improving deliberation over rationing decisions.

This conference also allows a wide diversity of perspectives, including fundamental critique of neo-liberalism and its hold on analysis and reforms, a strong defence of giving priority to primary care (30 years after Alma Ata), and philosophical discussions of just principles. 
Another focus was clinical priority setting, where the presenters demonstrate that the field has really developed in the last five to ten years. Clinicians are now familiar with the key concepts of priority setting and are able to integrate these into practical approaches, including the use of clinical guidelines for priority setting and studies of the management of explicit rationing.

Finally, a critical self-reflection after this conference. How can we improve and make the 8th conference in Cape Town (2010) even better and more relevant? Are we becoming too academic? Can we involve more people like Sheila Tlou – top players in health politics? More people like Littlejohns – top institutions and leaders in the evidence-based medicine movement? More on the public side of priority setting and the role of media? How do we compete with other conferences? Can we collaborate better? We have the potential to attract more clinicians, health economists, health systems researchers, philosophers, legal scholars, nurses, NGOs.

These are challenges for the next organizing committee! If you would like to hear more about the Society and its 2010 Conference in Cape Town, please email the president, Ole Frithjof Norheim (,  at the University of Bergen, or Cam Donaldson, Chair of the local organising committee for the Newcastle/Gateshead conference  ( . Cam is also organiser of the recently-established UK Forum on Priority Setting in Health Care, sponsored by the National Institute for Innovation and Improvement.

To register your interest in the forum, all you have to do to get on our email list is email Cam.

Cam Donaldson is Director, Institute of Health and Society and Health Foundation Chair in Health Economics, and NIHR Senior Investigator, Newcastle University. Ole Frithjof Norheim is Professor, Department of Public Health and Primary Health Care, University of Bergen.