PU335 Unit 7 Ethics of Priority Setting Paper Example

One Grant, Three Good Causes: A Unit 7 Ethics of Priority Setting Paper on Spending Scarce Health Funds in Rural Haiti

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Purdue University Global

PU335: Global Health

Unit 7 Ethics of Priority Setting Paper

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[Date]

The grant, department and options are composite; the ethical frameworks and sources cited are real.

The Decision

The Central Plateau borders the Dominican Republic and is largely rural and mountainous. The committee must choose among three proposals of similar cost:

1. Maternal and newborn care. Train and equip skilled birth attendants in four remote communes and fund transport to referral hospitals for complications.

2. Hypertension. Screen adults at existing clinics and supply low-cost medication, addressing the rising stroke burden described in Unit 3.

3. HIV treatment support. Fund community workers to help people on HIV treatment stay on it, reducing treatment failure.

All three would save lives. None can be funded in full alongside another.

Why Priority Setting Is an Ethical Question

Choosing one option means not choosing the others, and people will be affected by both decisions. In their narrative review of the leave-no-one-behind principle, Oehring and Gunasekera (2024) treat the pull between equity and efficiency in allocating resources as one of the central dilemmas global health has to face. Priority setting cannot avoid that tension, so the question is how to make the choice fairly and transparently.

Utilitarian Reasoning

A utilitarian approach asks which option produces the greatest total health benefit, often measured in healthy life years gained per dollar. Newborn and maternal care tends to perform well on this measure in settings like rural Haiti, because deaths it prevents occur at the very start or in the prime of life, saving many years each. HIV treatment support also protects many years and prevents onward transmission. Hypertension treatment prevents strokes and heart attacks later in life, so each death averted saves fewer years, though disability prevented counts too.

The limit of the approach is that it can favor large numbers of moderate benefits over the needs of the worst off, and it depends on uncertain estimates.

Prioritarian Reasoning

A prioritarian approach gives extra weight to benefits for those who are worst off. Women giving birth in remote communes without skilled attendants, and their newborns, face some of the highest risks of death anywhere in the Americas and have the fewest alternatives. People on HIV treatment are also disadvantaged, but already have access to treatment. On this view, the maternal and newborn proposal has a strong claim.

Rights-Based Reasoning

A rights-based approach asks what the right to health requires, including attention to the most marginalized and to core obligations such as maternal and child health care. General Comment 14, discussed in Unit 2, treats reproductive, maternal and child health care as a priority obligation. That supports the first proposal, while also reminding the committee that people living with HIV are entitled not to have their treatment undermined.

The WHO Criteria for Fair Choices

The World Health Organization's consultative group on equity and universal health coverage proposed that countries expand services in a way that considers three criteria together: cost-effectiveness, priority to the worse off and financial risk protection, and that they do so through fair, transparent and accountable processes (World Health Organization, 2014). Norheim (2016) explains that these criteria will sometimes pull in different directions and that unacceptable trade-offs, such as expanding coverage for the better off first, should be avoided.

Applied. Maternal and newborn care scores well on cost-effectiveness and priority to the worse off, and transport funding protects families from the catastrophic costs of emergency referral. Hypertension treatment scores moderately on all three. HIV treatment support scores well on cost-effectiveness and protects an existing investment, but its beneficiaries are already better served than women in remote communes.

Every framework the committee might use points first to the women giving birth farthest from help, and the hard part is saying out loud what that costs the other two groups.

What the Numbers Would Need to Show

A committee working on utilitarian grounds would want local estimates, not only global averages. For the maternal proposal, the key figures are the number of births in the four communes each year, the share now attended by a skilled provider and the expected fall in maternal and newborn deaths if that share rose. For hypertension, they are the number of adults with high blood pressure, the share who would stay on treatment and the strokes averted over three years. For HIV, they are the number of people on treatment and the rate at which they stop. In Haiti, many of these figures are uncertain, so the committee should test whether its choice changes when estimates move up or down. If the ranking holds across plausible ranges, the decision is more robust.

Sustainability After Three Years

Each option also has a different future when the grant ends. Trained birth attendants keep their skills, and transport arrangements can be absorbed by the department if they prove their value. Hypertension treatment requires medicine for life, so a three-year grant risks starting patients on drugs they cannot continue. HIV support protects treatment that is already funded by other donors. This consideration reinforces the maternal choice, but it also warns against starting long-term treatment programs on short-term money.

Trade-Offs Stated Openly

Choosing the first proposal means some adults will have strokes that hypertension treatment could have prevented, and some people with HIV may fall off treatment without community support. The committee should state this openly, ask the donor whether any savings or future funding could support the other proposals and record the reasons for its decision.

A Fair Process

The decision should be made through a process that is transparent, uses clear criteria, includes representatives of the communities affected, including women from the remote communes and people living with HIV, provides reasons and allows the decision to be revisited as evidence or funding changes. These features matter because a decision that cannot be justified to those it disadvantages will lose legitimacy. In practice, the committee could hold two open meetings in the communes, publish its scoring of each option in Haitian Creole and French and set a date, perhaps after eighteen months, to review whether the chosen program is meeting its targets.

Recommendation

Fund the maternal and newborn proposal, with a commitment to seek separate support for HIV treatment retention, which protects an existing investment, and to integrate blood pressure screening into antenatal care at no extra cost where possible.

Conclusion

Utilitarian, prioritarian and rights-based reasoning, and the World Health Organization's criteria for fair choices, all favor investing first in maternal and newborn care in Haiti's remote communes. The choice has real costs for other groups, which a fair process must name, justify and try to reduce.

References

Norheim, O. F. (2016). Ethical priority setting for universal health coverage: Challenges in deciding upon fair distribution of health services. BMC Medicine, 14, 75. https://doi.org/10.1186/s12916-016-0624-4

Oehring, D., & Gunasekera, P. (2024). Ethical frameworks and global health: A narrative review of the "leave no one behind" principle. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 61. https://doi.org/10.1177/00469580241288346

World Health Organization. (2014). Making fair choices on the path to universal health coverage: Final report of the WHO Consultative Group on Equity and Universal Health Coverage. https://www.who.int/publications/i/item/9789241507158