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

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.

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).

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]

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

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.