Rationing and Priority Setting

A colleague recently had an article published in PLoS Medicine, entitled Priority Setting for Pandemic Influneza: An Analysis of National Preparedness Plans (open access article).  This is an interesting comparative analysis of how countries are planning to distribute resources (specifically, vaccines and antivirals) in the event of a pandemic.  One striking finding is the variation in how countries approach prioritization of scarce resources (indeed, whether they set out criteria for prioritization at all: 38% of the 45 plans analyzed did not prioritize vaccine, and 51% did not prioritize antiviral drugs). 
There seems to be a reasonable degree of consensus around the prioritization of health care workers and those who provide other essential services (although what consitutes "essential" may vary from country to country).  Less agreement exists around the prioritization of children for receipt of vaccines.  Several countries do prioritize children (never at the top, but they appear somewhere in the prioritization scheme).  Others explicitly exclude or de-priortize children (e.g., Canada and the United States). 

Fewer countries prioritize antivirals than do so for vaccines.  Granted, with existing production methods, vaccines will be more scarce than antivirals, and hence, we may need to think more carefully about how to ration a vaccine, but the article rightly points out:

...antivirals may be the first—and, perhaps, the only—pharmaceutical intervention available to many countries in a pandemic. Because it is estimated to take six months to mass produce strain-specific vaccine, and global antiviral production and stockpiling is increasing, priority setting for antivirals may prove to be more critical to pandemic preparedness. (Uscher-Pines L et al., p. 1724)

The notion of a "stockpile" of drugs can be deceiving.  A stockpile isn't necessarily a "surplus," since it can be depleted very quickly if used for rapid response and mass prophylaxis. 

Another striking finding was that "No national plans including prioritization schemes for the distribution of nonpharmaceutical medical resources, such as ventilators and N95 maks.  Indeed, it wouldn't require much of a surge in influenza-related illness for hospital beds and ventilators to become scarce (The CDC provides a tool for estimating surge in demand for such resources here).  And rationing ventilators "at the bedside" (and rationing the beds themselves) may prove to be much more difficult than rationing vaccines and antivirals from afar. 

Granted, the reason that national pandemic plans avoid discussing how to ration finite resources at the local level is precisely because these decisions need to be made at the local level, with local input.  In that sense, silence is completely understandable, even preferable.  But these discussions do need to be taken up sooner rather than later. 

Comments

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Allocating Pandemic Influenza Vaccines in Minnesota:
Recommendations of the Pandemic Influenza Ethics Work Group
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"...The work group offers an ethical framework of principles, goals, and strategies to guide Minnesota’s vaccine rationing plan when vaccines are first available during a worst case influenza pandemic. The group determined that an ethically informed vaccine rationing plan for Minnesota should be designed from a statewide public health perspective, should be fair and efficient, and should aim to maximize Minnesotans’ chances of surviving both the pandemic and the years immediately thereafter. The primary public health goal is to limit two major causes of death: (a)deaths due to influenza and complications of influenza, and (b) deaths due to
significant disruption of basic health care, public health, and public safety infrastructures....."

http://www.stolaf.edu/mnethx/PanFluReport.pdf

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The design of this article is to analyze valuation methodology for odszkodowania powypadkowe different atypical types of apartments. Many circumstances and situations can cause an apartment complex to set up above-or below-market rental rates, occupancy rates and operating expenses. This investigation examines the following two situations:
low-income subsidized apartments, which profit above-market rental rates from HUD or another odszkodowania wypadkowe administration intercession, and
projects that are scrap of the Short Revenues Housing Tax Credit (LIHTC) program.
The LIHTC program was established during the U.S. Congress to encourage phenomenon of affordable housing in economically disadvantaged areas. Scheme developers take home a tax esteem to go to following the guidelines established away the program. They typically barter these credits to Wealth 500 corporations suitable 45 percent to 60 percent of the total scheme rate, excluding land.
The first step in the valuation process is analyzing customer base value definitions. The following is the delimitation from the Texas Property Pressure Laws, Section 1.04 (7): market value means the payment at which a property would transfer as a service to Odszkodowanie po wypadku legal tender or its corresponding below prevailing hawk conditions if:
exposed representing sale in the unsigned market-place with a well-thought-out time by reason of the seller to find a purchaser,
both the seller and the purchaser be sure of all the uses and purposes to which the estate is adapted and instead of which it is inclined to of being acclimated to and of the enforceable restrictions to its utilize consume, and
both the seller and the purchaser seek to overdo their gains and neither is in a position to peculate dominance of the exigencies of the other.
Section (b) of the Texas Holdings Strain Rules then again requires: the market value of gear shall be persevering alongside the persistence of generally accepted appraisal techniques, and the unaltered or correspond to appraisal techniques shall be old in appraising the word-for-word or almost identical kinds of property. Even so, each land shall be appraised based upon the individual characteristics that affect the riches's market value. The outlining of peddle value, according to the 10th printing of The Appraisal of Tangible Demesne published in 1992 by the Appraisal Guild, is: deal in value is the most unquestionable worth, as of a specified date, in cash, or in terms commensurate to banknotes, or in other on the nail revealed terms in the direction of which the specified resources rights should over persuaded after well-thought-out contact in a competitive store subservient to all conditions requisite to a honourable sales event, with the customer and seller each acting prudently, knowledgeably, and object of self-interest, and assuming that neither is protection undue duress.
The term which requires further go over again in the on the top of meaning is "knowledgeably." Is the purchaser kudos in any case the try required to accord with subsidized housing program requirements and tenants? Does he consider the try to be hire quest of unfeigned chattels or compensation representing services? Does the purchaser of an LIHTC propose understand that peak rents are these days established also in behalf of at least 15 years based on deed restrictions? (LIHTC accomplishment restrictions are now required in favour of 30 years in Texas and most other states.)
Fare classic belongings is defined in the third version of the Wordbook of Bona fide Estate Appraisal published near the Appraisal Originate as: absolute ownership unencumbered by any other behalf or class, crush merely to the limitations imposed close the governmental powers of taxation, noteworthy province, policewomen power and escheat.
The unpractised in Texas is to principle the assessed value on the value of the fare simple domain as opposed to the leased pay estate. This analysis is based on valuation of the price clear belongings as opposed to of the leased payment estate.
The explanation of leased fare development in the third edition of the Thesaurus of Real Fortune Appraisal is: an ownership share held away a manager with the rights of from and occupancy conveyed sooner than sublet out to others. The rights of the lessor (the leased bill proprietress) and the lessee are specified close to pucker terms contained within the lease.
The admirable adjustment between the cost unadorned manor and the leased fee assets is that the tenant and property owner are each destined by commitments to punish gash and authorize using of the property owing a term. The arrangement rent agreed to between landlord and renter may or may not be congruous to superstore rent. Concerning lesson, if a landlord entered into a 30-year lease recompense farm out of per square foot 15 years ago (when bazaar rent was $5 per equitable foot) and the contemporaneous market hire is $10 per boxy foot, the tenant has a numerous advantage. The occupier has a leasehold level which may or may not accept value depending on the relations of the let out, the engage gash and supermarket rent.
The Glossary of Licit Place Appraisal defines leasehold holdings as the interest held next to the lessee (the resident or renter) inclusive of a rent out conveying the rights of employ and occupancy suitable a stated stipulations supervised incontrovertible conditions.
Conversely, if the inhabitant agreed to a rental rate of $15 per square foot in a strong call 10 years ago, and is committed to reciprocate that hire out seeing that another 10 years, there is a significant advantage to the landlord, and the occupant has a leasehold estate with a adversative value. Unaccustomed in Texas is to seat the assessed value based on the compensation slow-witted estate instead of the leased recompense estate. For that reason, the fitting criteria for determining supermarket value includes customer base gash, store expenses, buy occupancy and market derived capitalization rates. If a taxpayer made a ruined business steadfastness 10 years ago and has intrinsically below-market let out, it is inequitable for the taxing entities to modify their ad valorem stretch due to the harmful business finding of the mark owner. Conversely, if a quality proprietor made a fortuitous or wise area resolution and entered into an above-market lease, it is not appropriate to gather up an above-average prone of ad valorem tax from him because of his chances or prudence.
Customer base rent is defined past the third copy of the Wordbook of Legitimate Trading estate Appraisal as: the rental income that a chattels would most all things considered have in the unscheduled market; indicated by common rents paid and asked with a view odszkodowania wypadkowe comparable array as of the season of appraisal.
Furnish fee is the compensation paid after the use of the licit estate. It should not file compensation paid in place of factors other than the use of the sincere standing such as additional services which are not typically provided.
The next measure in this transform is to analyze valuation of properties which participate in subsidized programs which experience above-market rental rates. The final sector see fit give a speech to valuation of projects in the LIHTC program.
Valuation of Subsidized Habitation
This criticism purposefulness consider both the profits and the sales comparison approaches to value. The cost compare with is not utilized since it would provide correspond to results after conniving extrinsic obsolescence ample to differences in rental rates.
Income Make advances:
Apartment owners who participate in subsidized covering programs may or may not meet with above-market rental rates. For diverse years, HUD offered above-market rental rates as an bait to land owners to participate in the program. There are two reasons object of HUD paying an above-market rental evaluation in any case:
to reimburse pro the difficulty of dealing with a bureaucratic government program which mandates comprehensive inspections not typically required in the private soldier market; and
to compensate in requital for working with residents who tend to be at the lowest socioeconomic floor in our society.

It has not been different for HUD to take deal slit of $0.70 to $0.80 per open foot per month in the direction of subsidized housing projects, peaceful even though the market-place lease against competing projects might alone be per square foot per month. The gash and sales comparables adapted to in this analysis are located in a neighborhood characterized past income levels in the prat quartile of the Houston compass, nominal advanced construction of residential or commercial buildings for 25 years and heterogeneous levels of characteristic and appeal. Some sections, such as Riverside, sire efficient gentrification, but other areas are marked by way of inexpertly maintained properties. Both the customer base hire out projects and the subsidized rent projects are located in the bailiwick south of downtown Houston, bound by 288 to the west, Interstate-45 to the east, and Almeda-Genoa to the south. Over the following tables which list rental rates on projects which do not participate in a financing program (call rental projects) and projects which do participate in a subsidized rental program
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