Public Health Priority Setting

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Public Health Priority Setting

• Likwang Chen
• Centre for Health Policy Research and Development
• Institute of Population Health Sciences
• National Health Research Institutes
• Taiwan
• February 16, 2009

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Information and evidence

• Better information and evidence create better
  opportunities for better public health policies.
• Lack of information and evidence causes
  under-investment in public health.
• The World Health Report 2008

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Priority and sustainability

• No single top priority
• Incremental improvement
• Lasting effort

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Goals of priority-setting

• To improve efficiency in producing health
• To reduce inequality (inequity) in health

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Major targets of public health policies priority
health conditions

• High-burden diseases, such as the ten leading
  causes of death
• Vulnerable groups and stages of life courses,
  such as the poor, the disabled, the aborigines,
  the elderly, and children

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Taiwans ten leading causes of death in 2007

• 1. Malignant neoplasms
• 2. Heart disease
• 3. Cerebrovascular disease
• 4. Diabetes mellitus
• 5. Accidents and adverse effects
• 6. Pneumonia
• 7. Chronic liver disease and cirrhosis
• 8. Nephritis, nephrotic syndrome and nephrosis
• 9. Suicide
• 10. Hypertensive disease

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Focus population in the Taiwan Healthy People
2020

• Child youth
• Elderly population
• Indigenous groups
• Socially or economically disadvantaged population
• People with disabilities

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Main purposes of public health policies

• To reduce
• excess loss of life expectancy or
  quality-adjusted life expectancy due to premature
  death (loss of valuable lives, waste of valuable
  social resource)
• unnecessary financial burden to National Health
  Insurance/Services (loss of quality of life,
  waste of valuable social resource)
• unjustifiable inequality in health status/health
  behaviour (unfulfilled chances of improvement)

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Excess loss of life expectancy or
quality-adjusted life expectancy

• Modifiable health risks (environment and
  lifestyle)
• pollutants
• occupational hazards
• unhealthy lifestyle
• lack of injury protections
• Main sources of knowledge for formulating
  policies
• the literature
• administrative and survey data ---
  cross-sectional and longitudinal

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Unnecessary financial burden to National Health
Insurance/Services

• Avoidable hospitalisations preventable through
  primary prevention (health risks mentioned above)
  and/or primary health care
• acute upper-respiratory infections, lower
  respiratory infection, gastroenteritis and
  dehydration, asthma and chronic bronchitis, and
  acute injury and poisoning --- Agency for
  Healthcare Research and Quality Hakim and
  Bye,2001,Pediatrics
• Main sources of knowledge for formulating
  policies
• the literature
• administrative and survey data ---
  cross-sectional and longitudinal

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Unjustifiable inequality in health status /
health behaviour

• Ameliorable inequality
• inequality among areas with similar
  socio-economic conditions
• Main sources of knowledge for formulating
  policies
• administrative and survey data --- cross-sectional

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Excess loss of life expectancy or
quality-adjusted life expectancy --- Examples in
studies by Professor J.D. Wang and his colleagues
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Gain from removing preventable health risks

• Injury protection
• Utility gained from the helmet law was 6240
  quality-adjusted life years (QALYs) in Taipei in
  1998.
• Environmental protection
• In 1992, Taiwan had 649 female workers in 23
  manufacturing factories with lead-acid battery
  exposure. Utility from implementing an effective
  national industrial hygiene program to reduce
  these female workers blood lead by 15 µg/dl is
  124 QALYs for their offspring utility from a
  program reducing the level by 10 µg/dl is 89
  QALYs.

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Unnecessary financial burden to National Health
Insurance/Services --- A case of preventable
hospitalisations in children under 2 years of age
under Taiwans National Health Insurance
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Method

• Data Taiwans National Health Insurance data for
  children born between July 1, 2003 and June 30,
  2004
• Design For each childs first two years of life,
  the frequencies of hospitalisations for acute
  upper-respiratory infections, lower respiratory
  infection, gastroenteritis and dehydration,
  asthma and chronic bronchitis, and acute injury
  and poisoning, and the corresponding expenditures
  were calculated the outcomes were compared
  between poor children and their better-off
  counterparts.
• Statistical methods the negative binomial
  regression and the log-linear regression

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Preliminary findings

• The probability of having preventable
  hospitalisations in the first two years of life
  for poor children was 29, while that for
  better-off children was 19.
• The average length of stay due to preventable
  hospitalisations for poor children was 4 times of
  that for better-off children (4 days versus 1
  day).
• On average, a poor childs NHI expenditure on
  preventable hospitalisations was 3 times of that
  for a better-off child (16,619 Taiwan dollars
  versus 5,028 Taiwan dollars).
• Excess use of inpatient care for poor children is
  mainly for two disease types lower respiratory
  infection, and acute injury and poisoning.

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Unjustifiable inequality in health status/health
behaviour --- A case regarding priority public
health problems in Taitung County
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Method

• Data Taiwans National Health Interview Survey
  in 2002
• Design Comparison of the 95 confidence
  intervals of various indicators reflecting health
  status and health behaviour among Taitung and
  other counties with similar socio-economic
  conditions (Yun-Lin County, Chia-Yi County,
  Hua-Lian County, Ping-Tung County, and Peng-Hu
  County)

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Findings

• Priority health status problems in Taitung
  included hypertension, heart disease, stroke,
  asthma, and osteoporosis.
• Priority health care problems in Taitung
  included care for hypertension and diabetes and
  utilization of preventive care.
• Priority health behaviour problems in Taitung
  included tobacco use, alcohol use, and betel nut
  chewing.
• In particular, females in Taitung had worse
  conditions than females in other counties.

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An example of guessing what consequences a health
policy will bring about --- Health information
dissemination for reducing the prevalence
of betel nut chewing in Taitung
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Central value of health policy research

• Identifying the causes of a phenomenon that is
  worthy of attention --- So, experimental research
  design is important.
• Predicting the consequences of a health policy
  --- So, simulation methods are substantially
  helpful.

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Random experiments and Natural experiments
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Difficulties for simulating health policy effects
due to data availability in the real world
--- Quite often we can just guess what
consequences a health policy will bring about
indirectly
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Better public health priority setting
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Keys to success

• Capacity of conducting systematic research and
  accumulating evidence
• Leadership --- sciences, arts and ethics

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Beyond health sector activities

• Recommendations from the Commission on Social
  Determinants of Health of WHO
• Improve daily living conditions
• Tackle the inequitable distribution of power,
  money and resources
• Measure and understand the problem and assess the
  impact of action

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Beyond-local-scale initiatives

• Public health interventions beyond the level of
  local government (examples in The World Health
  Report 2008)
• Altering individual behaviours and lifestyles
• Tackling hygiene and the broader determinants of
  health
• Secondary prevention (screening diseases, etc.)
• such as taxation of alcohol and tobacco, food
  safety regulation, environmental protection, etc.

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Accountability and trust

• Rapid response
• Participation
• Deliberation
• Revision
• This is not only about ethics. This is an
  important factor for success, especially in
  democratic societies.

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• Thank you for listening!