A NICE Idea for Priority Setting in Global Health – Amanda Glassman

Summary

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Podcast Summary: The CGD Podcast

Episode: A NICE Idea for Priority Setting in Global Health – Amanda Glassman
Date: March 31, 2014
Host: Lawrence MacDonald
Guest: Amanda Glassman, Senior Fellow, Center for Global Development

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Episode Overview

This episode explores smarter ways to allocate health spending in developing countries, focusing on the announcement of a new partnership—the International Decision Support Initiative (IDSI), supported by the Gates Foundation, the UK Department for International Development, and the Rockefeller Foundation. Amanda Glassman discusses how lessons from the UK’s NICE (National Institute for Health and Care Excellence) can inform better, evidence-based prioritization of health resources globally—potentially saving billions of dollars and millions of lives.

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Key Discussion Points & Insights

The Challenge of Priority Setting in Global Health

• Inefficient Spending Patterns: Developing countries often fund expensive, less impactful treatments while failing to provide essential, cost-effective services to the broader population.

  • India Example: Government subsidies for open heart surgery contrast with persistently low child vaccination rates (01:32).
  • Egypt Example: The government pays for affluent citizens’ overseas medical treatments while 20% of children experience stunting due to malnutrition (02:41).

• Political and Institutional Barriers: Allocations are often shaped by inertia and political demand rather than evidence of impact (02:15–03:10).

  "So with the next dollar spent, the idea is to look at what's the most cost effective use of monies to improve health and hope to try and shift allocations towards those better value for money investments."
  — Amanda Glassman [02:15]

The International Decision Support Initiative (IDSI)

• Funding and Scope: IDSI, initially funded with $3 million (a “tiny tail” compared to global health budgets), aims to build local institutional capacity for health priority setting (04:24–05:34).
• Proof of Concept: Goal is to demonstrate, in a few willing countries, how evidence-based systems can be built for ongoing, rational health investment (04:54).

The NICE Model and Its Global Relevance

• NICE’s Role: Established to advise the UK health system on best-value investments, but increasingly providing guidance internationally (05:34–06:02).

• Adaptation Challenges: NICE’s model, developed for a relatively wealthy country, requires careful adaptation to low- and middle-income contexts with far more limited budgets.

  • Example: Trastuzumab, a breast cancer drug, is 38 times GDP per capita for Bolivia, but less than half in the US, illustrating “huge” affordability gaps (06:02–07:15).

  "The difference in affordability that it represents for Bolivia versus the United States is just a huge order of magnitude."
  — Amanda Glassman [06:02]

• Evolving Benefit Packages: Services covered should expand with increasing resources, not be identical across countries (07:15–07:44).

  • Cost-effective packages need continual evaluation as new technologies emerge.

Lessons and Links to Health Reform in High-Income Countries

• “Death Panels” Controversy: Glassman pushes back on the US debate that frames such bodies as rationing care, arguing instead that they are “life panels” focused on maximizing the impact of limited resources (10:05).

  “First of all, it's a life panel. That's what I think. I think it's more about saying where can we use our public money to get the most health for the spending that we have? That's what NICE is about.”
  — Amanda Glassman [10:05]

The Role of Evidence and Public Consultation

• Process, Not Just Numbers: While cost-effectiveness is central, the best systems allow for transparent consideration of societal values (13:56–15:31).

  • Some societies may prioritize children, others the elderly, and process design should account for these differences.

  “The point is to have a process and rules of the game that allow all kinds of considerations to be brought out, to be discussed in a transparent way, in an evidence based way...”
  — Amanda Glassman [14:28]

• Protecting the Voiceless: Glassman stresses ensuring that groups without political power are represented in decision-making (15:31).

Practical Impact: Price Negotiation and Market Incentives

• Negotiating Power: Insights from cost-effectiveness analyses can help countries negotiate drug prices that reflect true value (12:06–13:30).
• Market Influence: These approaches encourage pharmaceutical companies to develop and price products with cost-effectiveness in mind (12:12).

International Cooperation and the Future

• Growing Partnerships: The IDSI represents expanding technical collaboration between the UK’s NICE and global funders (16:02–16:48).

• US Participation: There is potential for USAID and US health agencies to join in supporting evidence-based priority-setting systems abroad (17:09–17:40).

• Glassman’s Vision: Over the next several years, she hopes to see more developing countries with integrated, institutionalized health benefit planning, bolstered by shared information and technical support (17:55–18:36).

  “I'd like to see even more governments in developing countries with institutions stood up and functioning to help define health benefits plans in the context of universal health coverage.”
  — Amanda Glassman [17:55]

The Ongoing Role of CGD

• Continued Engagement: CGD aims to keep highlighting the importance of rational priority-setting and to help adapt lessons as universal health coverage expands (18:52).

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Notable Quotes & Memorable Moments

• “The idea is governments are spending more and more every day in developing countries. So it's with that next dollar that they start to think about their investments in a way that's informed by the best evidence on impact and the best evidence on cost.”
  — Amanda Glassman [03:13]

• “It’s a life panel. That’s what I think... Where can we use our public money to get the most health for the spending that we have?”
  — Amanda Glassman [10:05]

• “A new technology might not be cost effective at one price, but at a certain price it does become cost effective and it does become affordable. So doing these kinds of analyses can also help countries negotiate better with manufacturers.”
  — Amanda Glassman [12:06]

• “Every society has different values and views on these kinds of things. The point is to have a process and rules of the game that allow all kinds of considerations to be brought out, to be discussed in a transparent way, in an evidence-based way, and to come to some decision in that way.”
  — Amanda Glassman [14:28]

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Timestamps for Important Segments

• 00:47 – 01:32: Announcement of IDSI and NICE’s dual national/international role
• 01:32 – 03:45: Striking examples of irrational health spending and political challenges
• 04:24 – 05:34: Scope and ambition of IDSI’s proof-of-concept approach
• 06:02 – 07:15: The challenges of translating NICE recommendations to low-income countries (breast cancer drug example)
• 10:05 – 10:54: Addressing the US “death panels” debate and re-framing as “life panels”
• 12:06 – 13:30: The impact of cost-effectiveness analysis on drug pricing and market incentives
• 13:56 – 15:17: The role of public consultation and inclusion of societal values in decision-making
• 17:55 – 18:52: Glassman’s long-term hopes for institutionalized priority setting in more countries

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Conclusion

The episode offers a compelling look at how evidence-based technical collaboration, such as the IDSI, can empower developing countries to spend health dollars more wisely, ultimately advancing universal health coverage. Amanda Glassman articulates both the political and practical challenges, emphasizing the need for gradual, society-specific, and inclusive processes. The episode convincingly frames priority setting not as rationing or “death panels,” but as responsible, life-maximizing stewardship of scarce resources—an approach that may be increasingly relevant across both high- and low-income settings.

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Transcript

[A]

Welcome to the Global Prosperity wonkcast. I'm Lawrence MacDonald. My guest today is Amanda Glassman. She's a Senior fellow here at the center for Global Development and the director of our Global Health Program. Amanda, welcome to the show.

[B]

Thank you.

[A]

You have been a leader in urging both donors and developing countries to think more rationally about how they allocate the billions of dollars that are spent every year on health. And recently you received some good news. What was that?

[B]

We learned that the Bill and Melinda Gates foundation and the UK aid agency have funded the International Decision Support Initiative IDSI at NICE International. NICE is a UK government agency, autonomous, that in most of its work advises the National Health Services on their priorities for spending. They look at what's best value for money for the National Health Service. But they also have an arm that works internationally helping developing country governments and to some extent donors develop their own processes and institutions to assess cost effectiveness in their setting because that's where effectiveness really matters. The technology is great, but looking at whether that technology is effective in the country is what really matters.

[A]

I want to go straight to the alarming status quo. In your recent blog post explaining why this new priority setting body can be potentially valuable, saving billions of dollars and maybe millions of lives, you mentioned some striking examples. In India, for example, they subsidize open heart surgery, but child vaccination rates remain low. I mean that seems like sort of a no brainer that you would say we're going to make sure that, you know, we've got adequate vaccination rate coverage before we use public dollars for surgery. At the same time, if I'm a well connected affluent Indian and I've got government health insurance and I need heart surgery, I'm sure as hell going to try and get it.

[B]

That's right. And that's exactly the situation most countries are facing right now. There is growing education, there's growing wealth, there are growing demands on the health care system. And when budgets are that inertially in a demand responsive way, that's what you get. So with the next dollar spent, the idea is to look at what's the most cost effective use of monies to improve health and hope to try and shift allocations towards those better value for money investments.

[A]

Just to think about how hard this must be politically. Another example you have that really strikes me. You say that in Egypt a fifth of children are stunted. As we know that means that they are born below weight and height averages for their ages, so they're not receiving basic nutrition. And yet Egypt has Been paying for presumably affluent citizens mostly to go overseas for medical treatment, putting them on planes, sending them off for probably advanced cancer and heart surgery and other kinds of stuff.

[B]

Exactly.

[A]

How does one overcome that?

[B]

Well, I think you have to take a marginal approach. We're not going to have a revolution in health systems overnight. But, but the idea is governments are spending more and more every day in developing countries. So it's with that next dollar that they start to think about their investments in a way that's informed by the best evidence on impact and the best evidence on cost.

[A]

So those who are currently getting to get on planes and go off for their cancer treatments, probably that number is unlikely to be coming down. But the future spending, the additional spending would be allocated in a more rational way.

[B]

That's right. I mean, ideally we would also take a look at these really egregious inequities in the system and deal with that as well. And certainly since the fall of the dictatorship in Egypt, we would hope to see less of this kind of allocation going forward. But you know, really, I think realistically you have to think about the next dollar rather than making big shifts in current spending because you have a health system that's there, that's operating already.

[A]

So we were talking before the show began about this international decision support initiative. You mentioned that the supporters include the Gates foundation, the UK Department for International Development, and you also told me the Rockefeller foundation, is that right?

[B]

That's right.

[A]

It's just $3 million. Just to put this in context, global official development assistance is about 125 billion, of which roughly 30%. So let's say somewhere around 30, $40 billion just of donor money, plus many billions of dollars of country's own money is going into health care. Is a $3 million allocation into a decision making, priority setting mechanism going to be the tiny tail that wags the dinosaur?

[B]

Well, I mean, I think first we have to see developing country governments are the ones really in charge in the global health space. Right. They are the ones that are spending the most. So what really matters is actually what governments themselves do in terms of prioritizing their spending going forward. And obviously $3 million is not a lot, but the idea is in this initial phase to show proof of concept, to show that institutions can be built in a very small number of countries that have the willingness to prioritize going forward according to value for money criteria and other criteria. And then perhaps in the next phase we'd hope to see more funding going towards this kind of activity.

[A]

I can imagine if I'm the Minister of Health in, you know, pick a country Minister of Health in Uruguay, that it might be quite useful if there were some regional or international body that said these are the things that we reckon are good value for money and you ought to cover these before you do the other stuff. That would make it a lot easier for me to argue for an efficient allocation of funds than if I'm trying to figure it out all myself. Is that kind of what's going on?

[B]

Well, that is what's going on. And that's why NICE International exists, because country governments were already using NICE's clinical care guidelines, their recommendations on coverage of different kinds of medicines. But the really important difference is that the UK spends a lot more on health and has a much larger economy than some of these other countries. So the decisions are much more difficult in low and middle income countries. And they really can't rely on what NICE puts out there because as I was saying, the budget constraint is really different. So they really do have to prioritize with a very restricted set of resources. And to give you an example, like a common breast cancer drug called Trastuzumab, this is recommended, it's on the essential medicines list at the who. It's something that is considered highly cost effective. But the difference in affordability that it represents for Bolivia versus the United States is just a huge order of magnitude. It's 38 times a GDP per capita in Bolivia. It's less than half of one GDP per capita in the United States. This is for a quality adjusted life year associated with that medicine. So it just gives you a sense of what it represents to adopt that drug for treatment. Right.

[A]

So I'm imagining you might have a range of priorities that would say if you are currently spending X per capita for health, this could be in your essential package. And as your economy grows or resources become available for the outside and your spending increases, more things would go into that package. So it's not to say that same package for everybody, but it's based on the availability of resources. And if money grew on trees, we would all get state of the art treatment for everything.

[B]

Exactly. So it's a gradual process. And the global health community has since 1993, the World Development Report that the World bank put out talked about a cost effective package of services. But the problem was that first it doesn't recognize that there's some existing distribution of spending at countries that cannot necessarily be reallocated to these cost effective services. So it's really a more gradual process and it's a permanent process. Right. Because there are new technologies coming out every day that might represent better value for money than the status quo. So it's really a function that has to exist. The development of this package, the adjustment of this package, the evaluation of the package as well, working to improve health the way that we believe it's something that has to be done over time on a permanent basis. And that's why it's great to have this new initiative that's helping to strengthen the institutions that exist in countries to do this job.

[A]

We're going to take a quick break. When we come back, I'm going to ask you to stretch a little bit. And for those of us who are Americans and watching the unfolding of health care reform in this country, see if there are any lessons to be drawn either from north to south or perhaps from south to north. This is the Global Prosperity Wonkcast from the center for Global Development. My guest today is Amanda Glassman and we're talking about about priority setting for healthcare spending in the international arena. We will be back in a moment. Welcome back to the Global Prosperity wonkast. I'm Lawrence MacDonald. I'm speaking with Amanda Glassman, senior fellow here at the center for Global Development, about a recent announcement that A group of three funders, the Bill and Melinda Gates foundation, the UK aid agency and the Rockefeller foundation have put 3 million, which sounds like a lot to me, but in the grand scheme of things is a tiny little amount into a new international initiative, the International Decision Support Initiative, which is going to offer guidance to countries in terms of allocating their public health doll to get the most bang for the buck. Amanda, I feel like we can't have this conversation, and I know you're going to wince, but we can't have this conversation without saying the words. Death panels. Is nice a death panel?

[B]

No, not at all. I mean, first of all, it's a life panel. That's what I think. I think it's more about saying where can we use our public money to get the most health for the spending that we have? That's what nice is about. And that's what this process do.

[A]

They call it nice because these people are really nice.

[B]

They are really nice.

[A]

Does it stand for something? Tell us what it stands for.

[B]

National Institute for Health and Clinical Excellence.

[A]

National Institute for Health and Clinical Excellence.

[B]

Health and Care Excellence. Actually, they just changed it, but.

[A]

National Institute for Health and Care Excellence. But the word that interests me there is excellence. It's the idea that the best available treatments should be available. You know, within the amount of money that's available, you should choose the ones that are going to make a real difference in people's lives.

[B]

That's right. That's a good thing. It's nice.

[A]

Earlier, when you were working on the CGD report that helped to underpin this announcement by the three funders, and I have the title right here, it is priority setting in Health. You've been a consistent advocate for more rational setting of priorities in public health spending. There was an announcement that that was similar to the one we have now, but it focused primarily on Latin America. What was that all about?

[B]

The Pan American Health Organization has set up a network of organizations that are looking at value for money issues in healthcare spending. And they are working together to try and use these same kinds of tools, cost effectiveness analysis, to decide on whether new medicines and technologies are included on a list for public speakers spending or excluded because it's not good enough value for money. And one of the interesting things that that network has been doing recently is trying to use the results of those analyses to inform price negotiations with companies. So in other words, a new technology might not be cost effective at one price, but at a certain price it does become cost effective and it does become affordable. So doing these kinds of analyses can also help countries negotiate better with manufacturers.

[A]

So the manufacturer then has an incentive to bring the price down to meet a price point where it does become cost effective.

[B]

That's right. And also to think about cost effectiveness during the development of the drugs and devices as well, which is a really important thing. So if you know that a technology that is cost effective at a certain, you know, price per quality, adjusted life year purchased, then you have an incentive to create a product that fits that profile rather than some other profile. I try and charge as much as I possibly can, so that's a really good development, I think.

[A]

So if I'm a pharma executive and I'm making a choice between a small, high priced market in a larger, lower priced market, presumably a lot of things go into that decision, profitability being at the top of the list. But if that larger, lower price per unit market looks like it might be available, I'm going to be a lot more inclined to try and go after it.

[B]

I think that's the idea. Right. And part of the problem has been that purchasing was really fragmented in some countries or it wasn't large scale enough, or the duration of the contracts wasn't long enough. So now countries starting to get their acts together, they're offering longer term contracts, they're being more precise about the kinds of demands that they have. So that also helps them get better prices. And armed with this kind of result from cost effectiveness analyses, they can really offer better terms to manufacturers as well. So hopefully it's win, win for everyone.

[A]

Is this the sort of thing that you expect the International Decision Support Initiative, the IDSI, to begin doing?

[B]

Well, I think they're really focused right now on what do we know about how to run a good process to develop cost effectiveness evidence and to use that evidence in decision making. Probably further down the road they'll focus on this kind of purchasing aspect that comes into play, but right now they're more focused on the upstream portion.

[A]

One of the things that interested me about your report on priority setting is that you left space in it for a public consultation process. So it wouldn't entirely be driven by the numbers. And so, for example, if a society determined that an intervention to save the life of a child, while it might be not a good buy in terms of disability adjusted life years because it's expensive, the fact that that person is seen as innocent would make it a higher public priority than a similar intervention to save the life of 20.

[B]

Something that's really important. I mean, these kinds of mechanisms are not to only use cost effectiveness evidence, though ideally that plays some role, but also to make explicit other values societies have. One of them could be always treating childhood illnesses first. Or in other societies like Japan, they actually value older people more. So maybe they would give more weight to the two interventions that would really improve quality of life for the elderly. So every society has different values and views on these kinds of things. The point is to have a process and rules of the game that allow all kinds of considerations to be brought out, to be discussed in a transparent way, in an evidence based way, and to come to some decision in that way, rather than relying on sort of ad hoc inertial historical budgets or I have a friend who this worked for.

[A]

I'll just buy that that then doesn't come without some risk. I imagine it opens the door for, you know, Egypt putting people on planes and sending them overseas for treatment when one out of five kids is stunted.

[B]

Yeah, I mean, I think the important thing is to have voice at the table to represent these different constituencies in society. And certainly government has a really important role in prioritizing those that don't have a voice in the political process because that's how we ended up in the place we were before. But you know, we're presuming that governments also want to serve the public good, not just specific constituencies. So, you know, the process has to be in place, the stakeholders involved that make sure that all, you know, the people without a voice actually get a seat at the table and have a chance to opine.

[A]

Here in the US in the development community, we're accustomed to looking across the pond, as they say, looking to the UK with envy. And a lot of our envy is directed at the Department for International Development, dfid, which does a terrific job on many things. Hearing about this, I sort of assumed, oh well, this is another good thing that DFID has done. But it's not so simple as that. This is coming out of a different UK government agency. Nice.

[B]

Right, right. I mean, NICE is an autonomous agency operating under the Department of Health. But they just had so many demands from other country governments for cooperation that this has just evolved naturally. And what's so great about this new initiative is that it's a sort of the first modestly scaled partnership between DFID and nice. And I hope it just grows further.

[A]

I guess for those of us who are Americans, this would be like the CDC center for Disease Control, which is primarily for Americans, but it winds up having a big international arm and people look to it for technical support on a whole range of diseases around the world.

[B]

Exactly. It's exactly equivalent to that. And it's true that CDC has a large set of international activities now for the same reason. Reason.

[A]

Can you imagine a situation where the United States would become a supporter of the International Decision Support Initiative?

[B]

Well, I would certainly hope so. I think officials at USAID talk a lot these days about how important health systems are for delivering health improvements. But those health improvements can really only be delivered if we are actually delivering the services that are going to make a big difference for health. So I could easily see a USAID providing some support for this as well.

[A]

We've seen some progress on this. It's very exciting. I know you're proud. The work of you and your colleagues, the members of the working group has contributed to this. Cast your mind ahead two, three, four, five years from now. What would you like to see in this realm?

[B]

Well, I think I'd like to see even more governments in developing countries with institutions stood up and functioning to help define health benefits plans in the context of universal health coverage. So right now we have places like Thailand, Chile, Colombia, Mexico, Ghana, South Africa starting to use these, starting to have a team of people that do this as their full time job. So I hope we're going to see more countries like that I hope that we're learning a lot from what they're doing and I hope that the IDSI is supporting their efforts and broadening access to to the know how and information and legislation and communication that's around these issues going forward.

[A]

Is there something more that the center for Global Development will be doing in this space? I mean, we, I think laid out a lot of the analytics. The announcement of the IDSI cited our work. It's very gratifying for us. Are we kind of done, you know, move on to the next thing or is there still more that a think tank like ours can contribute?

[B]

I think we do need to continue to engage on this issue to illustrate why it matters for global health donors and for developing country governments. So I think we have a role there. And I also will probably undertake some additional work that will look at how to design and adjust benefits plans in the context of universal health coverage. Like what could we learn across countries? What could we learn even from the United States where we have a new essential health benefits plan that hasn't worked out so well in implementation.

[A]

For my part, it's going to take more than just priority setting and health. But I'm struck by that one out of five Egyptian kids who stunted and the wealthy, well connected people getting on planes at government expense. If there's a day when we can fix that, that would be very good too.

[B]

We're working on it. Thanks, Lawrence.

[A]

This has been the Global Prosperity Wonkast from the center for Global Development. My guest today is Amanda Glassman and we've been discussing the announcement of the creation of the International Decision Support Initiative which is going to provide support to countries in making more rational and efficient allocations of their spending on health. You can find the Wonkast online on itunes and on stitcher. Just search for Wonkast or CGD and please sign up to hear a new interview every week. Until next time, I'm Lawrence MacDonald. Thank you for listening, Sam.