A new international study reveals that doctors have a “general preference for prevention and for spending on the young over the old,” according to the February issue of PLoS Medicine. For example, doctors consistently ascribed a low priority to treating cancer in smokers and schizophrenia and these values, the authors note, “transcended national and sectoral boundaries."

Researchers asked 253 health professionals from Indonesia, Bulgaria, India, Iran, Thailand and South Africa to rank 10 health interventions in order of spending priority from most (rank 1) to least important (rank 10). Overall, childhood immunisation emerged as the intervention that doctors regarded as being most worthy of investment, followed by anti-smoking education for children and, then, GP care for everyday illness. These were followed, in order, by: screening for breast cancer; intensive care for neonates; support for carers of the elderly; treatment for schizophrenia; hip replacement; heart transplant; and cancer treatment for smokers.

The attitudes to preventive healthcare varied little between countries. Childhood immunisation, anti-smoking education for children and breast cancer screening consistently rated highly. However, attitudes to other interventions differed. For example, primary care by a GP was ranked highest by participants in India (rank 2), Iran (rank 3), and South Africa (rank 3). Heart transplant was ranked lowest in Iran (rank 8) and India (rank 9). A relatively small proportion of respondents thought that funding for healthcare should be unlimited, ranging from 32% in Bali (Indonesia) to 10% in South Africa.

However, the authors, including Glenn Salkeld (University of Sydney) and Nick Freemantle (University of Birmingham), commented that the “strong and consistent preference for prevention over cure is quite at odds with the actual spending priorities in most countries." They note that, in 2004, OECD (Organisation for Economic Co-operation and Development) member countries spent an average of only 2.8% of their total health expenditure on organised public and private prevention programmes.

Greatest variation seen in schizophrenia

Attitudes towards schizophrenia treatment showed the greatest variation within countries and ranked consistently low across the six regions. Participants admitted that the generally low levels of funding reflected the stigma surrounding mental illness. Cancer treatment for smokers consistently ranked lowest in all countries, reflecting the influence of individual responsibility. “Smokers were ‘blamed’ for their cancer and were regarded as the least deserving of healthcare spending,” the authors write. “This belief may have been tempered by the perception that treatment for lung cancer may not produce much health gain and hence may not be cost effective.”

The authors also found that the “rule of rescue” – the imperative to save lives in imminent danger - is an important influence on healthcare spending priorities, reflected in, for example, the high priority ascribed to neonatal intensive care. However, they conclude that “greater attention needs to be given to those interventions that are life improving as well as life extending." By Mark Greener


Salkeld G, Henry D, Hill S, Lang D, Freemantle N, et al. (2007) What drives healthcare spending priorities? An international survey of health-care professionals. PLoS Med 4(2): e94. doi:10.1371/journal.pmed.0040094