Who Lives? Who Decides? Examining the “How” of Health Care Rationing

This week, PRI's “The World” is airing a piece on global health care rationing called, Rationing Health: Who Lives? Who Decides?Motivated by U.S. attention to Sarah Palin’s “death panels” and Arizona’s  recent decision to stop funding certain organ transplants under Medicaid, PRI’s “The World” has taken a welcome global perspective on the problem of health care rationing, featuring stories from India, South Africa, Zambia, and England.The series’ focus on the “how” of rationing – particularly, on the institutions that do or do not exist to help decision-makers make life-and-death choices – is also welcome.  As is immediately evident from the stories from (or featuring?) developing countries, rationing decisions are often haphazard and inexplicable—they lack transparency, cost-effectiveness evidence, and ethical guidance, and are mostly implicitly implemented through waiting times, distance to clinics, discrimination, and provider inaction. The choices are difficult, yet the opportunity costs of not investing in cost-effective care in poor countries are high.In global health, we continue to focus on methods and metrics in our quest to support evidence-based policy in developing countries – there is no more ubiquitous text than the Disease Control Priorities volumes. But the PRI series makes one thing clear: we must also focus on the institutions and processes that can support transparent, ethical, evidence-based rationing.  Action at the global and regional levels could help to support countries in their efforts to establish and maintain such institutions, and donors could participate in country-led priority-setting processes instead of playing the rationing role themselves.The PRI series is also an appropriate introduction to an upcoming event at CGD. The Center will host a seminar  from 10:00-11:30 a.m. on Friday, January 14, 2010, to examine attributes of durable rationing institutions and their relevance to global health, featuring the CEO of the UK’s National Institute for Health and Clinical Excellence (NICE), Sir Andrew Dillon. (Please RSVP to Katie Stein, program coordinator, if you’re able to attend.My only criticism of the series is the impression that NICE is in danger of imminent collapse. This is not the case. Pricing of all pharmaceuticals is changing which means the UK will no longer be a price-taker, but a price-setter. NICE’s advice is likely to inform pricing decisions for all licensed drugs. The final price will be set by government (so far, it has been set by industry). NICE never had power to prevent the NHS from purchasing drugs. Only positive decisions (about 85% of the total) were mandatory - an entitlement for patients. Final positive decisions will now be subject to local family practitioners who will be budget holders.NICE has not generated a major public backlash - over 60% of people aware of the agency are supportive of their role. Even readers of fairly 'anti-rationing' newspapers (the Daily Mail has never been NICE's greatest fan) appreciate the importance of prioritization - look at the most popular comments at the bottom.Under the reform, NICE is becoming the sole standard-setting agency in the NHS: quality standards for all clinical and social care services, pay-for-performance initiatives for primary and secondary care, regulation and provider accreditation. As described by the DHS: "Quality standards, developed by NICE, will inform the commissioning of all NHS care and payment systems. Inspection will be against essential quality standards...NICE quality standards will be reflected in commissioning contracts and financial incentives."Finally, NICE is not alone – although a great example to study, similar organizations exist in most European countries or are being developed as in China, Brazil, Turkey, and Colombia.