The Importance of a Multi-Criteria Approach in Health Priority Setting

Deciding how to allocate limited resources in healthcare is a complex task. Policy makers face numerous criteria when choosing interventions: improving overall health, addressing inequalities, tackling life-threatening conditions, and operating within financial and practical limits. However, the process is often ad-hoc, influenced by intuition, heuristics, or political motives rather than a systematic evaluation of these criteria. This creates inefficiencies and may result in resources not being used optimally, leading to missed opportunities for improving public health.

One major challenge is the sheer complexity of the decisions involved. A health intervention might be chosen because it maximises the health of the general population, but this choice might overlook the needs of vulnerable groups. Alternatively, an intervention might prioritise the poor or chronically ill but fail to address urgent, life-threatening conditions. Policy makers also have to weigh practical concerns, such as costs or the availability of skilled healthcare workers, and political pressures often further complicate decision-making. These factors highlight the difficulty of making rational, balanced choices in the absence of robust frameworks.

Over the years, several tools have been developed to aid health priority setting, including evidence-based medicine, burden-of-disease studies, cost-effectiveness analysis, and equity analysis. While each tool provides valuable insights, they tend to focus on a single criterion, such as economic efficiency or disease burden. In reality, healthcare decisions require the consideration of multiple criteria simultaneously. For example, improving primary care is often shown to be more effective than investing in specialised care, yet many countries still allocate disproportionate resources to tertiary care, as seen in Ghana. This misallocation is a result of failing to systematically evaluate all relevant factors.

Moreover, societal values complicate the decision-making process. Societies may prioritise vulnerable groups, such as the poor, children, or women of reproductive age, considering them more deserving of care. Similarly, there may be preferences for interventions targeting economically productive individuals or those facing life-threatening conditions. At the same time, some societies may deprioritise care for individuals perceived as engaging in irresponsible behaviours, such as smokers. These societal preferences add another layer of complexity to priority setting, requiring careful trade-offs between competing values.

Practical and political considerations further complicate matters. Budget constraints and workforce availability often limit the feasibility of certain interventions. Additionally, political interests, lobbying by influential groups, or pressure from international donors can skew decision-making. For example, health funding in developing countries frequently benefits wealthier populations or regions, even when greater benefits could be achieved by focusing on the poor. Such decisions may reflect the political self-interest of policy makers rather than a genuine effort to maximise social welfare.

When confronted with these complexities, policy makers often simplify the problem using intuitive or heuristic methods, which can lead to important information being ignored. Worse, decisions may be based on political motives rather than societal needs. These tendencies result in ad-hoc, poorly rationalised decisions that fail to consider the full range of relevant criteria or the trade-offs involved.

This highlights the need for a more systematic, transparent, and evidence-based approach to health priority setting. Multi-criteria decision analysis (MCDA) offers a promising solution. MCDA is well-established in other fields and provides a framework for evaluating multiple criteria simultaneously. By applying MCDA to healthcare, policy makers can make more informed decisions that balance competing priorities, align with societal values, and maximise social welfare. Early examples of MCDA applications in health show its potential to address complex allocation challenges.

Healthcare systems worldwide are under increasing pressure from growing health needs and rapid technological advancements. To use public funds effectively, policy makers must adopt approaches that go beyond traditional, single-criterion tools. MCDA offers a comprehensive and rational framework for navigating the complexities of priority setting, ensuring that resources are allocated in ways that are both efficient and equitable. As health systems evolve, incorporating MCDA into decision-making processes will be essential for achieving better outcomes and optimising resource use.