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Epi Wit & Wisdom Articles
World Bank Conducting Review of
Priorities in Health
Role of Epidemiology in Decision
Making Said to be Oversold
Epidemiology A Tool Not a
Rationale
The World Bank and its
collaborators are nearing completion of a massive 33 chapter review of
health priorities in the developing world. The review seeks to
describe the public health significance of major clusters of diseases
and the cost and effectiveness of currently available technologies for
their prevention and case management. A number of cross-cutting
chapters provide demographic background and discuss issues involved in
assessing priorities, including a chapter on the role of epidemiology
in decision making in public health.
Money is Not Everything
According to Andre Prost and
Michel Jancloes, the World Health Organization authors of the chapter
“Rationales for Choice in Public Health: The Role of Epidemiology,”
the increasing cost of health services has made it imperative for
economic as opposed to strictly technical criteria to be taken into
consideration in making decisions about the provision of health
services. However, “attempts to use an economic rationale as the main,
or even the sole argument, has been opposed by both health providers
and users. They cannot accept the imposition, for financial reasons,
of any limitation on the degree of sophistication of the technology on
one side, or the benefits they may enjoy on the other side. Thus, no
consensus can be reached using cost benefit or cost effectiveness
analyses,” according to the report.
Enter Epidemiology
Because of the shortcomings of
the economic rationale, epidemiology has been promoted as an
alternative tool for decision making in health, according to the
report. The promise of epidemiology--it can describe health and
disease in population groups, identify causes, measure effectiveness
of interventions, document trends--has led to the misconception that
epidemiology can be the ultimate rationale for decision making in
health. The authors set forth the reasons why they believe
epidemiology cannot serve this role in decision making.
Shortcomings
Among the points made about
epidemiologists seeking to use their approach are:
1) The lack of a standard
measure of health status hampers the use of epidemiology as an
instrument for planning and policy setting.
2) The quantitative measures
used by epidemiologists tend to mislead others about the precision of
the estimates developed.
3) Ranking diseases into
priorities for action requires the use of indicators, the choice of
which represents a value judgement. Decision makers may view this as
preempting their decision.
4) Good quality data bases do
not exist in most countries.
5) The search for maximum
efficiency leads to the development of disease-oriented programs. It
is conceptually misleading because it relates cost figures only to
disease control effectiveness, and not to health benefits. On the
practical side, it is almost impossible to focus on a limited number
of diseases at the peripheral-level.
6) The perception of health
needs by people differ, often strikingly, from the assessment of needs
by epidemiologists. Communities use a different value system which
places a greater importance on individual conditions and on adult
morbidity, for example.
7) The epidemiological approach
emphasizes the importance of the determinants, leading to preventive
rather than to curative actions. The public and the majority of the
health profession fail to appreciate the primacy of prevention.
8) The technical rationale, as
provided by epidemiological analyses among others, is relatively low
in the hierarchy of factors that influence decision making. The
failure of the economic rationale to become the instrument of choice
for decision making gives little chance of success to the
epidemiologic rationale. Had it been the case, tobacco would have
already been banned from the face of the earth.
9) The neutral character of the
scientific analysis is perceived as a limitation to the freedom of
judgement, as a technique to impose the concerns of donors rather than
the needs of the beneficiaries.
Double Leap
In the conclusion to their
report, the authors note that the use of epidemiology for making
choices in health policy implies a double leap forward: a leap from
the ranking of diseases to the setting of priority objectives for
action and a leap from the technical priorities to allocating
resources on a selective basis. In both cases, they believe
epidemiology cannot substantiate the move. The tools of epidemiology
are not relevant, and results are often misleading. Epidemiology is
not the neutral tool which can lead to unequivocal and unchallengeable
choices, says the report, and any attempt to impose policy decisions
on the basis of an epidemiological rationale will be rejected.
In closing, the authors warn
that the validity of epidemiology as an analytic tool is at risk of
being denied because of policy-related implications of the data rather
than because of genuine criticisms about the tool itself.
Other Chapters
In addition to the chapter on
epidemiology, the World Bank report contains overview papers (Evolving
Health Sector Priorities; Estimates and Projections of Levels and
Causes of Mortality), reviews of specific topics (Acute Respiratory
Infections, Diarrheal Diseases, Poliomyelitis, Protein-Energy
Malnutrition, Micronutrient Deficiency Disorders, Excess Fertility,
Maternal and Perinatal Health Problems, AIDS and other STD’s,
Tuberculosis, Leprosy, Dengue Yellow Fever and Viral Encephalitis,
Malaria, Helminthic Infections, Leishmaniasis-African Trypanosomiasis-
Chagas Disease, Rheumatic Fever and Rheumatic Heart Disease,
Cataracts, Cancers, Diabetes, Mental Disorders, Vascular Disease,
Chronic Obstructive Pulmonary Disease, Injury, and Oral Health), and
papers on cross cutting themes (The Epidemiological Transition and
Health Priorities; Cost and Cost-effectiveness Analysis of Health
Interventions; The Burden of Illness in the Developing World; Child
Survival: A Continuing Priority, Prevention of Non-Communicable
Diseases, Control of Tobacco Production and Use; and Improving
Environmental Quality).
The overall report is edited by
Dean Jamison and W. Henry Mosley.
Published May 1990 v
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