On the Unfairness of the 'Fair-share Principle' for Health Research.

How ought scarce health research resources be allocated, where health research spans basic, translational, clinical, health systems and public health research? In this article, I first outline a previously suggested answer to this question: the 'fair-share principle' stipulates that total health research funding ought to be allocated in direct proportion with suffering caused by each disease. Second, I highlight a variety of problems the fair-share principle faces. Like other resource allocation frameworks, the principle needs to address the aggregation and distribution of harms and consider cost-effectiveness. Moreover, to make resource allocation recommendations, the principle has to be used in conjunction with real-world estimates of 'suffering', usually provided by the Global Burden of Disease Study. These estimates are disease-centric and only take 'proximal' causes of health loss into account. Applying the principle based on such estimates disregards 'distal' causes, including social determinants of health, thus skewing resource allocation towards biomedical research and away from public health research. Since public health research aims at improving population health while reducing health inequalities, the principle leads to inequitable priority-setting. The fair-share principle can only become equitable when due consideration is also given to 'distal' causes that are amenable to public health research and interventions.