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ISDS Annual Conference Proceedings 2012. This is an Open Access article distributed under the terms of the Creative Commons Attribution-
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ISDS 2012 Conference Abstracts

Multi-dimensional Problems in Health Settings: 
A Review of Approaches to Decision Making
Victor J. Del Rio Vilas*1, Gilberto Montibeller2, L. Alberto Franco3 and Willy Aspinall4

1PAHO, Rio de Janeiro, Brazil; 2London School of Economics, London, United Kingdom; 3University of Hull, Hull, United Kingdom;
4University of Bristol, Bristol, United Kingdom

Introduction
There appears to be a growing number of prioritization exercises,

for example of diseases, in health related settings (1). The decision
process around these exercises involves comparing competing alter-
natives, i.e. diseases, and irreducible objectives. In addition to the
multi-dimensional nature of the problem, the lack of reliable data,
group dynamics associated to the involvement of experts, and the
multiplicity of stakeholders, among other contextual factors, add
complexity to the decision process. Here we review trends in such
prioritization exercises and applications in different settings and for
different events of interest, for example the management of emerging
risks. Based on our findings, we discuss a conceptual framework
based on multi-attribute utility theory presented to the World Organ-
ization for Animal Health (OIE) for the modification of its qualitative
assessment of veterinary services performance into a quantifiable de-
cision support system.

Methods
We searched PubMed for articles containing the key words ‘multi-

criteria’, ‘multi-attribute’, ‘multi-objective’, ‘prioritization’, ‘deci-
sion making’ and their variations (e.g. without hyphenation) for the
period 1990 to 2011 for human and veterinary medicine. We focused
on prioritization methodologies and their sound application.

Results
A large number of prioritization efforts in health settings aim to

produce a rank order of diseases to help allocation of scarce surveil-
lance and disease control budgets. A number of applications target
the prioritization of competing health interventions against specific
diseases. Fewer target different events, for example emerging threats.
Common mistakes found in multi-attribute prioritization approaches
reported in the social sciences (2) appear also in public and animal
health settings. In particular, the application of linear additive mod-
els to non-preferentially independent evaluation criteria, the poor de-
sign of attributes to assess the decision alternatives, the failure to
define suitable criteria scales, and mistakes in defining trade-off
weights were prevalent. In addition, most decision support tools tend
to be overly complex. This not only compromises their acceptability
and long-term sustainability but also increases the likelihood of
methodological mistakes in their design and regular application. For
example, the failure to properly identify and separate ‘ends’ objec-
tives, such as the improvement of a country’s health, from ‘means’
objectives, i.e. required resources, in the definition of the fundamen-
tal drivers in any decision process.

Conclusions
Our findings, and experience in the practical application of formal

prioritization methodologies (3), informed our advice to the OIE for
the quantification of its tools for the assessment of veterinary services
performance. The current framework used by the OIE produces a
purely qualitative output with ordinal scales. The suggested quantita-
tive extension allows additional outputs not available in their current
form, for example, the aggregation of assessment scores at any level
within the framework to produce a country’s overall score. It also per-
mits the assessment of marginal performance improvements for every
criterion and the consideration of trade-offs among the different cri-
teria. The final output of our extension is the identification of the best
portfolio of actions that will maximize the overall capability of na-
tional veterinary services given available resources. Quantification of
the existing tool will deliver obvious benefits such as enhanced ac-
countability and transparency in the decision making process, and will
allow the historical analysis of a country’s veterinary services per-
formance. The approach suggested to the OIE is adaptable to similar
decision problems, such as monitoring the implementation of the In-
ternational Health Regulations in a given country.

Keywords
Prioritisation; Multi-attribute utility theory; Decision support

References

1. Krause G., 2008. Prioritisation of infectious diseases in public health
– call for comments. Euro Surveillance 13, 40. 

2. Keeney R.L. (2002). Common Mistakes in Making Value Trade-Offs.
Operations Research, 50, 6, 935–945.

3. Del Rio Vilas V.J., Voller F., Montibeller G., Franco A., Sribhashyam
S., Watson E., Hartley M., Gibbens J. An integrated process and man-
agement tools for ranking multiple emerging threats to animal health.
Preventive Veterinary Medicine (in press).

*Victor J. Del Rio Vilas
E-mail: vdelriovilas@yahoo.co.uk

Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * 5(1):e117, 2013