The Sustainable Development Goals (SDGs) are by nature ambitious, with the prospect of all 17 goals being realized by 2030. While addressing these goals remains a priority for every research field in some respect, it's no surprise that the COVID-19 pandemic has had a tremendous impact on these goals being achieved. Wishing to highlight the experiences of researchers themselves during this time, we spoke to Ole Norheim, whose work focuses on the ethics of fair and efficient priority setting in health.
In Part 1 of this feature, Ole shares with us the short- and long-term goals of his work and what the consequences of the pandemic have been on his area of expertise. Read the first part of our interview with him below and stay tuned for Part 2 where he shares his thoughts on where the SDGs need to go from here.
COVID-19 has turned the world of research upside down, for myself and many other researchers. Since I graduated as a young MD in 1991, my research has been totally concentrated on the ethics of fair and efficient priority setting in health. For ten years I worked half of my time in a department of internal medicine at my university hospital, and I spent the other half on research and teaching. Although I enjoyed seeing patients and doing clinical work, I realized that with my particular interests and skills, I could make a difference more effectively by devoting all my time to academic work on fair priority setting, social justice and Universal Health Coverage.
Despite fantastic progress in medicine and science, resource scarcity is a fact of life – and a cause of premature death. All countries ration health services, often through market forces or by ad hoc mechanisms that typically favor elites who have both resources and power. In low- and middle-income countries, hard choices must be made every day between interventions and policies that are all known to be effective. They are simply too costly for all countries to afford. Fair priority setting is key, but there is no agreement on the most effective and fair path towards better health for all. There are always debates on ethical and political values such as efficiency, fairness and equity.
This is why my research interests have centered around ethics, theories of distributive justice, inequality in health, priority setting in health systems, and how to achieve Universal Health Coverage.
The long-term goal of my work is to inform and improve priority setting in health. In my view, priority setting should aim for the greatest number of healthy life years for all, fairly distributed, with financial risk protection.
Then COVID-19 turned our world upside down. It revealed how vulnerable countries are to a new pandemic that affects life, health systems, work, and economies. Those already worse off are especially affected, both by the virus and by the secondary effects it has on the health system and the economy.
I quickly realized that my expertise could be relevant and that my approach had to change gears.
Research is often slow, meticulous and incremental. This is how it has to be. But in an emergency, speed and clarity of purpose are essential.
The challenges I saw as most relevant relate to the fact that the pandemic affects both life and livelihoods, as well as their distribution. I realized that responses would be constrained by scarcity (personnel, PPE, ventilators, and eventually vaccines); that they would require priority setting among competing goals; and that some of these responses had to be global.
My long-term goal was still relevant, to improve and inform better priority setting, but
my short-term goal shifted to simply engaging more directly in communicating to policy makers how ethics and widely established values can inform the way evidence on the impact of the pandemic and public health strategies can be translated into policies.
As I see it, most COVID-related decision-making involves ethical choices: how to allocate scarce resources, such as social security, ventilators and vaccines in a fair and efficient way; how to balance the impact on lives, livelihoods and freedoms when suppression and mitigation measures are implemented; and how should these decisions be made and by whom?
This led me to work in several directions at the same time, starting with activities in my home country Norway and gradually concentrating more and more on global issues.
Our research center does much research in Ethiopia – I was actually born in Addis Ababa and think of Ethiopia as my second home country. Early in 2020, we received early reports from the Ministry of Health in Addis about fears and uncertainties relating to the pandemic. These were leading to reduced use of primary care services because personnel were being deployed to the COVID response and also because patients were becoming afraid of visiting health centers and hospitals. UNICEF also reported delays in measles’ vaccination campaigns in many African countries. We therefore became increasingly alarmed that non-COVID patients would also suffer as a result of the pandemic. We started to discuss how to protect non-COVID patients’ needs for essential services, and how to define really basic services that should be protected even during the pandemic. Building on our earlier work on essential health benefit packages developed by the Disease Control Priorities project, BCEPS, our research center, contributed to recommendations on how to define and protect essential health services in low- and middle-income countries while responding to the COVID-19 pandemic (BMJ Global Health, 2020). We highlighted that it is crucial to ensure that patients not infected by COVID-19 continue to get access to essential healthcare and that the services they need continue to be resourced.
Today, one of the most burning COVID issues is how to fairly allocate vaccines among countries. Promising results are now being reported, but not everyone can have access to vaccines in the first round. So, which countries should receive the first doses? Building on an ethical framework developed in the book Global Health-Priorities: Beyond Cost-Effectiveness (Norheim, Emanuel, Millum (eds), OUP 2020), I worked over the summer with a group of international scholars, philosophers and ethicists. It was led by Zeke Emanuel. Despite much initial disagreement, we found common ground and developed an entirely new proposal. The Fair Priority Model, published by Science in September. The Model offers a practical way to fulfill pledges to distribute COVID vaccines fairly and equitably among countries. We reject vaccine nationalism in its extreme form. Our main values, which we explain in the paper and in which we believe there is common agreement, are simply equal concern, limiting harm, and prioritizing the disadvantaged. Based on these values, we proposed a model for vaccine distribution that would reduce premature deaths and serious economic and social deprivations, with extra priority to the worst-off countries. From this, we developed concrete allocation rules. The main reason for writing this paper was that we were concerned about the alternative models being discussed by WHO and the COVAX facility. At that time, they proposed to distribute an equal percentage of doses to each country. We strongly felt this would favor high-income countries, and not protect disadvantaged countries with higher need, such as India, Peru, Brazil, or South Africa.
Our model is not perfect, but I believe ethicists have a special obligation to participate in the global public debate on what a commitment to equity and fairness implies in an unjust world.
Most recently, my deepest concern has been that some governments’ use of emergency powers in response to COVID-19 has ignored and actually weakened democratic processes. In many countries, civil society groups have been completely side-lined. Policy decisions on suppression or mitigation of the pandemic have a direct impact on the distribution of risks, benefits and freedoms, and they create winners and losers. For people to accept and willingly adhere to burdensome policies, these must be perceived as fair, and people must feel that they have been listened to in the decision-making process. The pandemic has exposed and widened existing social inequalities and trust in our political and scientific authorities is eroding. At the same time, trust in public authorities and among community members has emerged as a decisive factor in many countries’ ability to secure compliance with pandemic regulations and measures. For countries facing difficult trade-offs in response to COVID-19, how can decision-making processes be made more transparent, inclusive and accountable? Working with WHO and others, we have worked to develop an ethical framework for fair processes.
Today’s pandemic situation with the urgent issues involved in responding to COVID-19 have led me to totally reformulate the short-terms goals for my work. I realized that I could not continue to slowly and meticulously build the academic work I was involved in before the pandemic set in.
Look out for Part 2 of this interview coming soon.
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Ole F. Norheim is a physician, professor of medical ethics, and director of Bergen Centre for Ethics and Priority Setting (BCEPS), Department of Global Public Health and Primary Care, University of Bergen. He is also adjunct professor of global health at the Department of Global Health and Population, Harvard TH Chan School of Public Health. Before the pandemic, he shared his time between Bergen, Addis Ababa and Boston.
Norheim’s wide-ranging research interests include theories of distributive justice, inequalities in health, fair priority setting, and how to achieve Universal Health Coverage and the Sustainable Development Goal for health. He chairs WHO’s Technical Advisory Group on Essential Health Benefit Packages.
Norheim chaired the World Health Organization’s Consultative Group on Equity and Universal Health Coverage (2012-2014) and the third Norwegian National Committee on Priority Setting in Health Care (2013-2014).