The survey respondents strongly supported the importance of considering both cost-effectiveness of interventions and the severity of the condition as criteria for priority setting. This is in line with the current literature on criteria for priority setting, which indicates the importance of both criteria. However, the finding that significantly more people involved in priority setting supported the consideration of cost-effectiveness may be a reflection of their experiences with priority setting at their levels.
The findings in the first two scenarios may be regarded as reasonable and the choices may not have been particularly difficult. In the third scenario, where respondents were forced to make a definite choice between cost-effectiveness and severity, there was a clear preference for the severity of the disease over the cost-effectiveness of intervention. This is surprising, given that Uganda is a context of extreme scarcity of resources; one may have expected a preference for cost-effectiveness. The lack of statistical differences in the responses to this critical question, in relation to age, designation, level of work, and whether or not the respondent considered priority setting to be part of their work, was also surprising. Some differences might have been expected, especially between actors at different levels of priority setting, and health workers and non-health workers; since it is generally believed that people far removed from patients may hold different values.
Our findings should, however, be interpreted with caution. Since the sample was strategic, with a majority of the respondents being health workers, the findings may not be representative for the Ugandan population as such. However, several studies exploring public values in priority setting indicate that the public regards health workers to be their legitimate representatives [32, 33, 2, 34, 4]. Given the weakness of civil society in Uganda, we regard the health workers' preferences as a first proxy for better understanding the public's values. Furthermore, being self-administered, we are unable to rule out the limitation of poor interpretation of the questions. The hypothetical situations may be too simplistic. This was intended since the study was very exploratory in the context. Moreover, given respondents' sensitivity to the phrasing of the questions, [15] we can only cautiously compare our findings with those from other studies, as we did not use exactly the same wording. In the third scenario, for example, the response might have been different if the scenario had consisted in treating one severely ill patient with an expensive treatment or many less severely ill patients with less costly treatments. We are also aware that these responses could differ in different circumstances and may be dependent on the type of respondents [23]. We also recognise the limitations to empirical ethics and the fact that there are additional criteria and values of relevance to priority setting which are not presented in this paper [35]. However we maintain that the findings, provide an initial step to the understanding some of the values held by people from a low-income context, more so since similar results were found in the pre-survey group discussions and in another study in similar settings [36].
Although the questions were different, our findings that the respondents preferred severity might be comparable to the studies carried out in Norway and Australia, both of which are high-income countries [23–25]. This may to some appear unreasonable in this context. However, societal concerns for equality and solidarity, seem to be as relevant in resource-poor settings as they are in resource-rich settings [19, 22, 33].
On the other hand, these results may be explained by lack of respondents' familiarity with these concepts or the way the scenarios were formulated in the number of beneficiaries and the budget limits were not specified. These issues require more exploration since such findings may have implications for the designing of the essential health care package.
The survey respondents' strong preference for severity of disease did not fully comply with what the other actors expressed in the in-depth interviews. In particular, the international development partners, were more positive to setting priorities according to cost-effectiveness of interventions as compared to the survey respondents. This may reflect that it is easier for donors to consider cost-effectiveness of treatments, than it is for health workers who meet the patients directly. In such instances, where the key actors and those representing the interests of the public do not agree on values guiding health policy, explicit negotiation, deliberation and open debates about values are required.
The persistent number of respondents who either insisted on strict equality (3%) (treating both patients as equal), or declined to respond to the questions, may reflect respondents' escape from making difficult decisions, aversion to hypothetical choices or indeed a strong preference for equality [14].
Actors in health
The actors identified in this study are similar to those identified in other countries, apart from the international development partners (donors) and politicians [34]. Donors play an important role in providing resources for the health sector and may therefore influence the resource allocation process [32, 14]. Politicians, especially if democratically elected, may have an important role in representing the public in priority setting [4]. This is becoming increasingly evident in Uganda, which enjoys a democratic system [37]. Although the survey respondents this was not the ideal. The rank given to the judiciary, consumer organisations and insurance companies may be a reflection of the actual role played by these actors. Their role, although recognised as important, remains limited [38, 34].
Although it may be premature to draw policy implications from this preliminary study, there are some general implications. Given the concern for severity of disease shown in this and other studies and the WHO recommendation that services should be responsive to the needs of the people (within limits) [39, 11], decisions not to fund relatively less cost-effective treatments, such as HAART for severely ill patients, may need to be re-examined, especially if severity of disease is indeed a strongly held value in the Ugandan context.
However, if such a decision is to be taken, there'd be need for clear definitions and good evidence. To this end, information from the WHO project Choosing Interventions that are Cost-effective (CHOICE) and the severity of disease data, would be indispensable resources, provided this information is reliable and can openly be discussed [40]. At the theoretical level, we might add that our study suggests the use of a concept discussed by Amartya Sen – that "extra-welfarist" information about severity of disease is a necessary supplement to the "welfarist" framework currently employed in standard cost-effectiveness analysis [41].
In addition, more information on different actors' values is necessary. This information can then be mapped out for the development and definition of essential health care interventions, as illustrated in Fig. 4. With additional resources, government can choose to take either path (a) to include more cost-effective interventions, or path (b) to include more severe (but not necessarily cost-effective) interventions. Any choices made on the trade-off between efficiency and severity should be openly debated to ensure legitimacy.