Cardiovascular, respiratory, and related chronic disorders are an increasing concern in low- and middle-income countries (LMICs). In 2010, 19 percent (408.7 million) of total disability-adjusted life years (DALYs) and 39 percent (17.0 million) of total deaths in LMICs were attributable to cardiovascular and circulatory diseases, chronic respiratory diseases, diabetes mellitus, and chronic kidney diseases combined. The burden in LMICs accounts for 85 percent and 80 percent of global cardiovascular, respiratory, and related chronic disorder DALYs and deaths, respectively (IHME 2013).
Several treatment options are available for each disease, ranging from generic pharmacologic treatments, such as aspirin for vascular disease, metformin for diabetes, and salbutamol for chronic respiratory disease, to invasive procedures, such as coronary artery bypass graft surgery for vascular disease or kidney transplant for chronic kidney disease. These invasive procedures are often costly and resource intensive, placing a large burden on a country’s health care system.
Governments face tough allocation choices for limited public resources across many competing priorities, as each country strives to achieve universal coverage of essential health care services under the Sustainable Development Goals. The large and growing burden of cardiovascular, respiratory, and related chronic disorders forces public payers to allocate, or at least consider allocating, increasing resources to these diseases and conditions. This chapter explores the difficulty of rationing health resources in LMICs. Governments and public payers may allocate resources using priority-setting policy tools such as essential medicines lists (EMLs), health benefit plans, and health technology assessment (HTA) agencies. Yet, the processes used to arrive at allocation decisions are rarely evidence based, transparent, or participatory.
Furthermore, although the focus of this chapter is on high-cost treatment, the need for a legitimate and evidence-driven priority-setting process applies to all health conditions and diseases, and preventive measures cannot be ignored; the priority-setting process is not complete without considering local evidence on the costs and benefits of both prevention and treatment.
The chapter is divided into three sections. The first section frames the topic of priority setting in health. The second section explores a case study that shows how national essential medicines lists (NEMLs) largely fail to influence prescription shares of types of insulin for which marginal cost-effectiveness has not been fully established in several LMICs. The third section examines a second case study that shows the complexity of the priority-setting process in Thailand’s decision to include dialysis in the national health insurance (NHI) plan’s benefits package.
© 2017 International Bank for Reconstruction and Development / The World Bank.