Providing universal access to modern contraceptive methods: An extended cost-effectiveness analysis of meeting the demand for modern contraception in Ethiopia.

Despite recent advances in access to and use of modern contraception in Ethiopia, further improvement is needed, particularly among poorer women. This extended cost-effectiveness analysis investigated the health outcomes, their distribution, and financial risk protection associated with meeting the demand for modern contraception for all Ethiopian women. We developed five Markov models with wealth quintile-specific input data to investigate the effects of meeting this demand and followed a hypothetical cohort of 1,252,000 women through their reproductive lives from ages 15-49 years. The health outcomes are reported in quality-adjusted life years (QALYs) gained and in intermediate health outcomes, such as the total number of induced abortions, unintended pregnancies, and pregnancy-related deaths averted. The economic effect of meeting the demand for modern contraception was assessed by estimating the financial risk protection benefits in terms of averted out-of-pocket payments and the reduction in the number of cases of catastrophic health expenditure by quintile. Meeting the demand for modern contraception was deemed highly cost effective, with an incremental cost-effectiveness ratio of $96.60/QALY gained per woman. A total of 676,300 QALYs were gained, and approximately 1,900,000 unintended pregnancies, 250,000 induced abortions, and 9000 pregnancy-related deaths were averted over the 35-year period. Most of these gains were achieved among low-income groups. When the demand for modern contraception was met, almost 40,000 cases of catastrophic health expenditure were averted in the poorest quintile. The total governmental cost was higher in all quintiles when the demand for modern contraception was met compared to the baseline scenario, with the largest percentage increase in governmental spending in the poorest quintiles. Meeting the demand for modern contraception fulfills the priority-setting criteria established by the Ethiopian Ministry of Health and makes the Ethiopian health care system more equitable.

Progressive realisation of universal health coverage: what are the required processes and evidence?

Progressive realisation is invoked as the guiding principle for countries on their own path to universal health coverage (UHC). It refers to the governmental obligations to immediately and progressively move towards the full realisation of UHC. This paper provides procedural guidance for countries, that is, how they can best organise their processes and evidence collection to make decisions on what services to provide first under progressive realisation. We thereby use 'evidence-informed deliberative processes', a generic value assessment framework to guide decision making on the choice of health services. We apply this to the concept of progressive realisation of UHC. We reason that countries face two important choices to achieve UHC. First, they need to define which services they consider as high priority, on the basis of their social values, including cost-effectiveness, priority to the worse off and financial risk protection. Second, they need to make tough choices whether they should first include more priority services, first expand coverage of existing priority services or first reduce co-payments of existing priority services. Evidence informed deliberative processes can facilitate these choices for UHC, and are also essential to the progressive realisation of the right to health. The framework informs health authorities on how they can best organise their processes in terms of composition of an appraisal committee including stakeholders, of decision-making criteria, collection of evidence and development of recommendations, including their communication. In conclusion, this paper fills in an important gap in the literature by providing procedural guidance for countries to progressively realise UHC.

Availability and access in modern obstetric care: a retrospective population-based study.

OBJECTIVE: To assess the availability of obstetric institutions, the risk of unplanned delivery outside an institution and maternal morbidity in a national setting in which the number of institutions declined from 95 to 51 during 30 years. DESIGN: Retrospective population-based, three cohorts and two cross-sectional analyses. SETTING: Census data, Statistics Norway. The Medical Birth Registry of Norway from 1979 to 2009. POPULATION: Women (15-49 years), 2000 (n = 1,050,269) and 2010 (n = 1,127,665). Women who delivered during the period 1979-2009 (n = 1,807,714). METHODS: Geographic Information Systems software for travel zone calculations. Cross-table and multiple logistic regression analysis of change over time and regional differences. World Health Organization Emergency Obstetric and Newborn Care (EmOC) indicators. MAIN OUTCOME MEASURES: Proportion of women living outside the 1-hour travel zone to obstetric institutions. Risk of unplanned delivery outside obstetric institutions. Maternal morbidity. RESULTS: The proportion of women living outside the 1-hour zone for all obstetric institutions increased from 7.9% to 8.8% from 2000 to 2010 (relative risk, 1.1; 95% confidence interval, 1.11-1.12), and for emergency obstetric care from 11.0% to 12.1% (relative risk, 1.1; 95% confidence interval, 1.09-1.11). The risk of unplanned delivery outside institutions increased from 0.4% in 1979-83 to 0.7% in 2004-09 (adjusted odds ratio, 2.0; 95% confidence interval, 1.9-2.2). Maternal morbidity increased from 1.7% in 2000 to 2.2% in 2009 (adjusted odds ratio, 1.4; 95% confidence interval, 1.2-1.5) and the regional differences increased. CONCLUSIONS: The availability of and access to obstetric institutions was reduced and we did not observe the expected decrease in maternal morbidity following the centralisation.

End-of-life decisions as bedside rationing. An ethical analysis of life support restrictions in an Indian neonatal unit.

INTRODUCTION: Hundreds of thousands of premature neonates born in low-income countries are implicitly denied treatment each year. Studies from India show that treatment is rationed even for neonates born at 32 gestational age weeks (GAW), and multiple external factors influence treatment decisions. Is withholding of life-saving treatment for children born between 28 and 32 GAW acceptable from an ethical perspective? METHOD: A seven-step impartial ethical analysis, including outcome analysis of four accepted priority criteria: severity of disease, treatment effect, cost effectiveness and evidence for neonates born at 28 and 32 GAW. RESULTS: The ethical analysis sketches out two possibilities: (a) It is not ethically permissible to limit treatment to neonates below 32 GAW when assigning high weight to health maximisation and overall health equality. Neonates below 32 GAW score high on severity of disease and efficiency and cost-effectiveness of treatment if one gives full weight to early years of a newborn life. It is in the child's best interest to be treated. (b) It can be considered ethically permissible if high weight is assigned to reducing inequality of welfare and maximising overall welfare and/or not granting full weight to early years of newborns is considered acceptable. From an equity-motivated health and welfare perspective, we would not accept (b), as it relies on accepting the lack of proper welfare policies for the poor and disabled in India. CONCLUSION: Explicit priority processes in India for financing neonatal care are needed. If premature neonates are perceived as worth less than other patient groups, the reasons should be explored among a broad range of stakeholders.

A note on Brock: prioritarianism, egalitarianism and the distribution of life years.

The moral philosopher Dan Brock has argued that equality of health outcomes "even if achievable" is problematic as a goal in its own right-because it is open to the levelling down objection. The levelling down objection to egalitarianism has received surprisingly little attention in the bioethics literature on distribution of health and healthcare and deserves more attention. This paper discusses and accepts an example given by Brock showing that prioritarianism and egalitarianism may judge distributions of health outcomes differently. We should accept that levelling down is never a good thing, all things considered, but that equality often is. By discussing variants of Brock's example, it is demonstrated that if equality, prioritarianism and aggregation are combined, as in a population-wide summary measure of health, such as the health achievement index, this combined set of principles is not open to levelling down. The paper suggests-although a more thorough investigation of the properties of the achievement index is needed-that this measure (a) is always sensitive to inequality in health, (b) is always sensitive to average health, (c) can assign priority to those with lowest health outcomes and (d) is not sensitive to levelling down. Levelling down is not an embarrassment for egalitarians if they adopt a pluralist theory that integrates fairness with goodness. Equality is not the only value egalitarians promote. But equality is so important that we should not reject it.

National HIV treatment guidelines in Tanzania and Ethiopia: are they legitimate rationing tools?

OBJECTIVE: To provide an ethical analysis of whether the Ethiopian and Tanzanian national HIV/AIDS treatment guidelines can be considered legitimate and fair rationing tools. METHOD: Qualitative study and ethical analysis involving guideline documents and interviews with nine key members involved in the development of the guidelines. The analysis followed an editing organising style. The theoretical framework was a guideline-specific framework based on theories of just resource allocation in healthcare and conditions that ensure fair processes in guideline development. According to this framework, legitimate rationing requires reasons for patient selection to be explicit, public and relevant, and decisions must be open to question and revision. RESULTS: The only explicit rationing criteria that both guidelines recommended were clinical antiretroviral treatment indications. Explicit non-clinical rationing criteria were expressed in a separate Ethiopian implementation guideline. Neither of the guideline development processes fully satisfies minimal requirements of procedural fairness. There is a lack of transparency. The reasons for decisions are rarely given and are not publicly available. This reduces the opportunity for public questioning, debate and revisions. The guidelines were based on expert opinion and consensus. Recommendations from the WHO were copied without much discussion, disagreement or adjustment. CONCLUSIONS: The two national HIV treatment guidelines discussed are de facto mechanisms for rationing but were developed using methods that do not fully satisfy the requirements of fair processes.

Genomics and equal opportunity ethics.

Genomics provides information on genetic susceptibility to diseases and new possibilities for interventions which can fundamentally alter the design of fair health policies. The aim of this paper is to explore implications of genomics from the perspective of equal opportunity ethics. The ideal of equal opportunity requires that individuals are held responsible for some, but not all, factors that affect their health. Informational problems, however, often make it difficult to implement the ideal of equal opportunity in the context of healthcare. In this paper, examples are considered of how new genetic information may affect the way individual responsibility for choice is assigned. It is also argued that genomics may result in relocation of the responsibility cut by providing both new information and new technology. Finally, how genomics may affect healthcare policies and the market for health insurance is discussed.

Responsibility in health care: a liberal egalitarian approach.

Lifestyle diseases constitute an increasing proportion of health problems and this trend is likely to continue. A better understanding of the responsibility argument is important for the assessment of policies aimed at meeting this challenge. Holding individuals accountable for their choices in the context of health care is, however, controversial. There are powerful arguments both for and against such policies. In this article the main arguments for and the traditional arguments against the use of individual responsibility as a criterion for the distribution of scarce health resources will be briefly outlined. It is argued that one of the most prominent contemporary normative traditions, liberal egalitarianism, presents a way of holding individuals accountable for their choices that avoids most of the problems pointed out by the critics. The aim of the article is to propose a plausible interpretation of liberal egalitarianism with respect to responsibility and health care and assess it against reasonable counter-arguments.

Complicated deliveries, critical care and quality in emergency obstetric care in Northern Tanzania.

Our objective was to determine the availability and quality of obstetric care to improve resource allocation in northern Tanzania. We surveyed all facilities providing delivery services (n=129) in six districts in northern Tanzania using the UN Guidelines for monitoring emergency obstetric care (EmOC). The three last questions in this audit outline are examined: Are the right women (those with obstetric complications) using emergency obstetric care facilities (Met Need)? Are sufficient quantities of critical services being provided (cesarean section rate (CSR))? Is the quality of the services adequate (case fatality rate (CFR))? Complications are calculated using Plan 3 of the UN Guidelines to assess the value of routine data for EmOC indicator monitoring. Nearly 60% of the expected complicated deliveries in the study population were conducted at EmOC qualified health facilities. 81.2% of the expected complicated deliveries are conducted in any facility (including facilities not qualifying as EmOC facilities). There is an inadequate level of critical services provided (CSR 4.6). Voluntary agencies provide most of these services in rural settings. All indicators show large variations with the setting (urban/rural location, level and ownership of facilities). Finally, there is large variation in the CFR with only one facility meeting the minimum accepted level. Utilization and quality of critical obstetric services at lower levels and in rural districts must be improved. The potential for improving the resource allocation within lower levels of the health care system is discussed. Given the small number of qualified facilities yet relatively high Met Need, we argue that it is neither the mothers' ignorance nor their lack of ability to get to a facility that is the main barrier to receiving quality care when needed, but rather the lack of quality care at the facility. Little can be concluded using the CFR to describe the quality of services provided.

Quantifying quality of life for economic analysis: time out for time tradeoff.

The "Time trade-off" (TTO), is the most widely used method to "quality adjust" life years for "QALYs" in cost utility analysis. In this paper we ask if it is theoretically likely that the TTO is valid for this use. The TTO consists in a trade off between longevity and quality of life. Firstly, we argue that it is impossible to control for all factors that may influence one's willingness to sacrifice lifetime. Secondly, that longevity and quality of life are too closely interrelated for the hypothetical trade off to reveal real preferences. Thirdly, that the TTO handles the value of a life year inconsistently because it simultaneously assumes that it changes (as an outcome measure) and that it doesn't change (as a currency unit). Lastly, we ask whether the difficulties stem from an inherent contradiction in trying to quantify quality of life. The problems theoretical validity an internal consistency, contrast the use of the results as exact measurements. We conclude that cost utility analysis based on TTO cannot be trusted as a tool for setting priorities in health.

[Knowledge must be combined with values for decision making in uncertainty]. / Kunnskaper må kombineres med verdier ved beslutninger under usikkerhet.

On the basis of a clinical presentation of a woman with atrial fibrillation and diabetes mellitus, this article examines how medical evidence can be combined with patient preferences in the analysis of clinical choice. Such choices tend to be analysed and discussed without due consideration for patient or public values. It is argued that such an analysis is incomplete until the patient's preferences are incorporated into the model. This is also a way of implementing patient-centred medicine. We discuss how decision theory can be used to clarify clinical choices, sometimes with surprising results for the physician. How to handle situations when the patient's preferences are in conflict with the physician's judgement, is also discussed. It is concluded that good clinical practice must be based on evidence, but it should also take into account the patient's values in choices with uncertain outcomes.

Adoption of new health care services in Norway (1993-1997): specialists' self-assessment according to national criteria for priority setting.

OBJECTIVES: To identify health care services adopted in Norway in the period 1993-1997, and examine them according to proposed national guidelines for priority setting. These guidelines define core services. DESIGN: Two-stage self-administered questionnaire. SETTING: The Norwegian public healthcare system. SUBJECTS: Presidents of all relevant specialist and sub-specialist associations in the Norwegian Medical Association (n=56). OUTCOME MEASURES: Number of adopted services satisfying the priority criteria of core services, according to physician's self-assessment. Number and type of interventions suited for the priority-setting criteria. RESULTS: Thirty-two percent of new technologies satisfied the definition of core services according to specialists' own assessment. Of the 88 responses analysed for the second stage of our survey, fifteen answers (17%) indicated lack of applicability of the priority setting criteria. Loss of applicability was related to diagnostic and procedure-related technologies. CONCLUSIONS: Less than one-half of the assessed technologies adopted in Norway in the period 1993-1997 satisfy proposed national criteria for priority setting. The guidelines are applicable for most interventions, but fail in most evaluations of diagnostic and procedure-related improvements. Independent and systematic evaluations of new technologies are needed within the context of priority setting.

Limiting access to allogeneic bone marrow transplantation in five European countries: what can we learn about implicit rationing?

BACKGROUND: Allogeneic bone marrow transplantation is a complex procedure exemplifying a class of new and emerging treatment modalities involving advanced medical technologies with high costs. OBJECTIVES: To collect available data on volume of allogeneic bone marrow transplantation in five European countries for the period 1990-1994. To assess the opinion of selected physicians on whether they felt that patients that would have benefited from a transplant actually received a transplant in the same period. To assess their opinion on possible reasons for limited access. METHOD: Literature review and mailed self-administered questionnaire to the responsible physician at 76 transplant centres in Denmark, Germany, The Netherlands, Norway, and the UK. RESULTS: Substantial geographical differences in transplantation rates between the five countries studied. For adult patients 62.5% of the respondents felt that there was limited access to allogeneic bone marrow transplantation in the period. For children, the corresponding figure was 37.5%. The reasons for limited access cited most frequently were scarcity of facilities or transplant beds, scarcity of donors, and inadequate referral practices.

Access to health care in the Scandinavian countries: ethical aspects.

The health care systems are fairly similar in the Scandinavian countries. The exact details vary, but in all three countries the system is almost exclusively publicly funded through taxation, and most (or all) hospitals are also publicly owned and managed. The countries also have a fairly strong primary care sector (even though it varies between the countries), with family physicians to various degrees acting as gatekeepers to specialist services. In Denmark most of the GP services are free. For the patient in Norway and Sweden there are out-of-pocket co-payments for GP consultations, with upper limits, but consultations for children are free. Hospital treatment is free in Denmark while the other countries use a system with out-of-pocket co-payment. There is a very strong public commitment to access to high quality health care for all. Solidarity and equality form the ideological basis for the Scandinavian welfare state. Means testing, for instance, has been widely rejected in the Scandinavian countries on the grounds that public services should not stigmatise any particular group. Solidarity also means devoting special consideration to the needs of those who have less chance than others of making their voices heard or exercising their rights. Issues of limited access are now, however, challenging the thinking about a health care system based on solidarity.

[How shall we set priorities among experimental treatment methods?]. / Hva skal vi satse på av utprøvende behandling?

There is an increasing demand from patients to have access to new and promising treatment for severe diseases. Norway has recently started ordinary public funding of large-scale clinical investigation of treatment effect and safety for new treatment modalities. The government has thus established a new principle for funding a sub-category of clinical research: investigational medicine. How should we prioritize between promising clinical protocols when resources are scarce? The article examines criteria for priority setting in investigational medicine: quality of evidence; magnitude of expected benefit from treatment; balance between risks and benefits; quality of the research protocol; cost; and size of patient population. These criteria are applied on a controversial clinical examples, high-dose chemotherapy with hematopoietic stem cell support for metastatic breast cancer.