Health Economics and Indigenous Health: measuring value beyond health outcomes

Australia has decades of public policy experience attempting to overcome the disparities in health outcomes facing Aboriginal and Torres Strait Islander (Indigenous) Australians. Significant resources have accompanied these policy initiatives, however, Indigenous Australians continue to bear a heavier burden of death, disease, disability and economic hardship than other Australians. Despite the policy experience of Australia and widespread support for initiatives to overcome Indigenous disadvantage, there is little consensus on the best means to actually do so. Working to ensure that available resources are used in their most effective way possible is vital to improving the health of Australia’s Indigenous populations. At its broadest level, health economics is the study of the choices made in the allocation of scarce resources to improve the health status of populations and service delivery. Notwithstanding the political, moral and economic importance of the issue, there remains limited health economic research in the field of Indigenous health nor is there a developed evidence base to provide guidance to policy-makers looking to invest in cost-effective interventions. Further, health economic methods have been criticised as potentially inappropriate for the area of Indigenous health. Current methods for economic evaluation tend to adopt a reductionist approach based on a cost per health outcome paradigm and are potentially insensitive to the outcomes and processes that Indigenous people see to be of value to their health and health care on three broad and related levels. First, Indigenous conceptions of health have been shown to differ from the biomedical notions which tend to underlie the reductionist approach of health economic evaluations. Second, a central tenet of Indigenous health care is community ownership and control of healthcare services. As such there is value associated with how well services achieve engagement with communities which may also be missed through a reductionist health economic approach. Third, social determinants of health have also been demonstrated to be particularly important to the health outcomes of Indigenous Australians but again have tended to lie outside the domain of traditional economic evaluation methods. Potentially because of these and other difficulties, resource allocation decisions in the field of Indigenous health have been made without a strong economic evidence-base and have instead seemingly relied on rights-based arguments promoting investment based on the sizeable need that these communities face. While there is no denying the stark disadvantage facing Australia’s Indigenous populations, such rights-based arguments provide little guidance on how much to invest or on trade-offs between different policy options or individual service components. Further, the weight attributed to such arguments has tended to vary according to the prevailing political climate. Health economic approaches on the other hand, can provide evidence based on value that can transcend politics and lay the foundation for rational priority-setting that maximises the health of target populations. Ignoring the realities of resource scarcity in the sector will not allow policy interventions to maximise the health outcomes for Australia’s Indigenous communities. Health economic methods such as discrete choice experiments (DCEs) and contingent valuation studies have been used to value factors outside of traditional economic evaluations in other fields yet have been largely untested in Australian Indigenous populations. Such techniques potentially represent a direct means through which to incorporate Indigenous values and preferences into the evaluation and design of health programs and ultimately a mechanism for the sector to demonstrate the value and impact that properly designed services can have. There is limited empirical understanding of the role of culturally-specific healthcare providers in terms of the service use patterns of these communities and overcoming the barriers that face Indigenous Australians attempting to access health services. Examining these issues through an economic lens is likely to provide a level of guidance to policy-makers that is currently absent from Indigenous health policy in Australia. This thesis explores these issues through a mixed-methods approach investigating the application and merits of a variety of health economic methods in these populations. Chapter 1 introduces the major issues in the field and provides an overview of the published literature carried out to date. Chapter 2 presents a more detailed investigation of the economic evaluation literature with a systematic review of published economic evaluations investigating health interventions in Indigenous populations around the world. The review finds relatively limited economic evaluation of health care interventions for Indigenous populations in Australia or globally, however, what has been done has demonstrated the potential for cost-effective interventions in these populations. Almost no consideration of alternative conceptions of health or Indigenous-specific values were found through the review. Chapter 3 examines this issue further, investigating the use of health-related quality of life (HRQoL) instruments in these populations, one of the most direct method to incorporate Indigenous conceptions of health into evaluations of health programs, through a systematic review of the use of these instruments in Indigenous populations around the world. The review found that while HRQoL instruments have been used to elicit the quality of life of Indigenous populations their use was relatively limited, as was evidence of the validation of these instruments in these population groups. The evidence that does exist suggests that some Indigenous populations potentially conceptualise these issues fundamentally differently to populations in which these tools have been designed and validated. Chapter 4 discusses the findings of the reviews presented in Chapters 2 and 3 in light of the Australian policy context. The chapter argues that the policy environment has emphasised rights-based rather than economic arguments in resource allocation decisions that has left room for efficiency and equity improvements in the way that resource allocation decisions are made in the field of Indigenous health. Given this, the chapter calls for further work to investigate the service utilisation of Indigenous populations and the role of culturally-specific healthcare providers and incorporate Indigenous values to value programs to improve Indigenous health including through contingent valuation and discrete choice experiment methodologies. Chapter 5 takes up the first of these issues with an analysis of the healthcare expenditure of a cohort of Indigenous and non-Indigenous Australians at high-risk of cardiovascular disease to investigate the relative service utilisation of the two groups. The analysis finds that when individuals are engaged with care providers, culturally-specific providers were providing equivalent care to mainstream providers in non-remote areas and factors other than patient Aboriginality seem to be more important in determining the healthcare expenditure of these high-risk patients. The chapter also highlights problems with current data collections in the field that acts to obscure analysis of service utilisation patterns of Indigenous Australians, particularly in remote areas, and comparisons between the relative service use of Indigenous and non-Indigenous Australians. Chapter 6 further investigates the role of culturally-specific service providers through a DCE attempting to value the cultural component of a fall-prevention service. The chapter presents the findings of a DCE carried out in a cohort of older Aboriginal people receiving a culturally-specific fall-prevention intervention. The chapter demonstrates that DCEs provide a potential means to incorporate the preferences of Indigenous communities into the design and evaluation of health services. A value for the cultural component of the service was derived through the DCE and the relative importance of different barriers to care to the decision-making of the participants were investigated. Chapter 7 presents the findings of a contingent valuation study investigating the value that the Australian community places on holding a driver licence as an example of a social determinant that has been shown to be associated with positive health outcomes in Indigenous populations. The analysis finds contingent valuation techniques can provide a means to value social determinants of health that lie outside traditional health economic evaluations and to value broader policy interventions to improve living standards. Chapter 8 puts forward the main findings of this thesis arguing that the health economics field has an important role to play in improving the health of Australia’s Indigenous populations. Appropriate targeting of available resources is essential to close the gap in health outcomes between Indigenous and non-Indigenous Australians. Economic research is vital to build an evidence-base for policy makers looking to invest in cost-effective policy options and this needs to be based on factors that Indigenous communities consider important to their health and healthcare. Potential for economic evaluation of programs needs to be a key consideration in resource allocation decisions in the field. These need to be robust enough to incorporate the factors that are important to Indigenous Australians. The role of culturally-specific providers needs to be better understood as do the different components that make up such a service. Finally, incorporating social determinants of health into the health policy environment remains crucial in the field of Indigenous health. Given the political, moral and economic importance of overcoming the disparities faced by Australia’s Aboriginal and Torres Strait Islander communities, the relative lack of health economic research in the sector is a failing of the field in Australia. Building an economic evidence base will assist those working in the sector to demonstrate the value of appropriately designed, culturally acceptable healthcare services and decision-makers in the field to move beyond rights-based arguments for funding decisions. Collectively this will enable a system of rational priority-setting in the sector whereby the health impacts derived from scarce resources are maximised

Barriers to preschool aged children's participation in swimming lessons in New South Wales, Australia

Issue Addressed: To understand barriers to uptake of subsidised swimming lessons by children aged 3–6 years old (‘preschool aged children’), including from priority populations, in New South Wales (NSW). Methods: A thematic analysis of 4191 qualitative responses from parents/carers of preschool aged children describing barriers that resulted in their child's non-participation in subsidised swimming lessons in the past 12 months was conducted. Data, including parent/carer sociodemographic variables, were collected through registrations for the NSW Government's First Lap voucher program. Results: Seven overarching barriers to participation were identified: (1) child's disability or health needs; (2) swimming lesson affordability; (3) family or personal circumstances; (4) lack of or poor availability of swimming lessons; (5) parent/carer availability, including to fulfil participation requirements; (6) COVID-19 and (7) deprioritisation of formal swimming lessons due to parent/carer perceptions relating to its importance. These may limit the uptake of swimming lessons in preschool aged children, particularly those who are Aboriginal and Torres Strait Islander, from culturally and linguistically diverse backgrounds, living with a disability, from low socioeconomic families and living in regional and remote areas. Conclusion: Structural barriers must be addressed to increase uptake of swimming lessons in preschool aged children, particularly in priority populations, to reduce drowning risk. So What? Evidence-based policy initiatives, with robust evaluation, should seek to address the availability and flexibility of swimming lessons, including for priority populations; complexities associated with supervision requirements; poor awareness of parents/carers of the importance of swimming for preschool aged children and the lack of continuity of swimming for children in out of home care

Understanding community health worker employment preferences in Malang district, Indonesia using a discrete choice experiment

BACKGROUND: Community health workers (CHWs) play a critical role in supporting health systems, and in improving accessibility to primary healthcare. In many settings CHW programmes do not have formalised employment models and face issues of high attrition and poor performance. This study aims to determine the employment preferences of CHWs in Malang district, Indonesia, to inform policy interventions. METHODS: A discrete choice experiment was conducted with 471 CHWs across 28 villages. Attributes relevant to CHW employment were identified through a multistage process including literature review, focus group discussions and expert consultation. Respondents’ choices were analysed with a mixed multinomial logit model and latent class analyses. RESULTS: Five attributes were identified: (1) supervision; (2) training; (3) monthly financial benefit; (4) recognition; and (5) employment structure. The most important influence on choice of job was a low monthly financial benefit (US$~2) (β=0.53, 95$~20) was most unappealing to respondents (β=−0.13, 95% CI=−0.23 to −0.03). Latent class analysis identified two groups of CHWs who differed in their willingness to accept either job presented and preferences over specific attributes. Preferences diverged based on respondent characteristics including experience, hours’ worked per week and income. CONCLUSION: CHWs in Malang district, Indonesia, favour a small monthly financial benefit which likely reflects the unique cultural values underpinning the programme and a desire for remuneration that is commensurate with the limited number of hours worked. CHWs also desire enhanced methods of performance feedback and greater structure around training and their rights and responsibilities. Fulfilling these conditions may become increasingly important should CHWs work longer hours

Re-aligning Incentives to Address Informal Payments in Tanzania Public Health Facilities: A Discrete Choice Experiment

Background: Informal payments for healthcare are typically regressive and limit access to quality healthcare while increasing risk of catastrophic health expenditure, especially in developing countries. Different responses have been proposed, but little is known about how they influence the incentives driving this behaviour. We therefore identified providers’ preferences for policy interventions to overcome informal payments in Tanzania. Methods: We undertook a discrete choice experiment (DCE) to elicit preferences over various policy options with 432 health providers in 42 public health facilities in Pwani and Dar es Salaam region. DCE attributes were derived from a multi-stage process including a literature review, qualitative interviews with key informants, a workshop with health stakeholders, expert opinions, and a pilot test. Each respondent received 12 unlabelled choice sets describing two hypothetical job-settings that varied across 6-attributes: mode of payment, supervision at facility, opportunity for private practice, awareness and monitoring, measures against informal payments, and incentive payments to encourage noninfraction. Mixed multinomial logit (MMNL) models were used for estimation. Results: All attributes, apart from supervision at facility, significantly influenced providers’ choices (P<.001). Health providers strongly and significantly preferred incentive payments for non-infraction and opportunities for private practice, but significantly disliked disciplinary measures at district level. Preferences varied across the sample, although all groups significantly preferred the opportunity to practice privately and cashless payment. Disciplinary measures at district level were significantly disliked by unit in-charges, those who never engaged in informal payments, and who were not absent from work for official trip. 10% salary top-up were preferred incentive by all, except those who engaged in informal payments and absent from work for official trip. Conclusion: Better working conditions, with improved earnings and career paths, were strongly preferred by all, different respondents groups had distinct preferences according to their characteristics, suggesting the need for adoption of tailored packages of interventions

Generating sustainable collective action: Models of community control and governance of alcohol supply in Indigenous minority populations

Restrictions on the supply of alcohol are amongst the most effective and cost effective interventions to address harmful use. However, despite international human rights bodies recognising that self determination must be pre-eminent in efforts to improve Indigenous health, little is known about the role of Indigenous communities in designing and implementing alcohol controls as well as the degree to which government resourcing and/or regulation is utilised. This commentary explores Australian examples of the governance models used to ensure Indigenous participation and leadership when developing regulatory interventions for alcohol control within communities. We identify four models of Indigenous governance: alcohol control interventions that were community conceived and implemented, government-facilitated community-led, community coalitions backed by government intervention and government initiated community partnerships. Each model is underpinned by specific governance arrangements which incorporate rules and processes that determine authority, accountability and Indigenous participation in decision-making. The aim of this paper is to benchmark these models of governance along a spectrum of community engagement beginning with forms of non-participation and ending with full citizen control. In addition, we put forward recommendations for governments at all levels to facilitate culturally acceptable and robust models of Indigenous governance that have the potential to improve health and social outcomes

Who Is Most Likely to Experience Corruption When Seeking Health Care in Nigerian Healthcare Facilities?

Background: Experiencing corruption when seeking health services remains a significant problem in Nigeria. An effective response requires knowledge of the individual characteristics of those impacted by corruption when seeking healthcare. This study examined the prevalence of corruption among those seeking health services in Nigeria’s public healthcare facilities and how it varies among different user groups. Methods: We used a pre-tested interviewer-administered questionnaire to collect data from 1659 individuals randomly selected from households in two Nigerian states. We collected data on respondents’ socio-demographic characteristics and experiences of corrupt practices. We undertook descriptive and binomial logistic regression analyses. Results: Approximately 50% (823) of respondents experienced corrupt practices, such as using connections for faster treatment and bribery when seeking health services. 446 (27%) respondents bribed or made so-called ‘unapproved’ payments to health providers to obtain health services. Gender was a strong predictor, with male healthcare service users being more likely to experience corrupt practices (%point risk difference=24; 95% CI= 20, 29) and bribe or make an unapproved payment to obtain healthcare (%point risk difference=20; 95% CI= 15, 25). Residents in the northern state were (%point risk difference=30; 95% CI= 26, 35) more likely to experience corrupt practices than residents in the eastern state. People seeking healthcare in urban (%point risk difference=09; 95% CI= -05, 08) and semi-urban (%point risk difference=12; 95% CI= 05, 19) locations were more likely to have bribed or made ‘unapproved’ payments to healthcare providers compared to rural residents. Conclusion: Health sector corruption, in its various forms, is frequently reported in both northern and southern Nigeria. However, user experience of corruption varies according to socio-demographic characteristics, and this is often insufficiently acknowledged. To combat corrupt practices in both health sectors, anti-corruption initiatives must be tailored to particular groups and settings, addressing specific disadvantages at individual and community levels

Scoping Review of Economic Analyses of Rare Kidney Diseases

INTRODUCTION: Rare kidney diseases (RKDs) place a substantial economic burden on patients and health systems, the extent of which is unknown and may be systematically underestimated by health economic techniques. We aimed to investigate the economic burden and cost-effectiveness evidence base for RKDs. METHODS: We conducted a systematic scoping review to identify economic evaluations, health technology assessments, and cost-of-illness studies relating to RKDs, published since 2012. RESULTS: A total of 161 published studies, including 66 cost-of-illness studies and 95 economic evaluations; 72 grey literature reports were also included. Most published literature originated from high-income nations, particularly the USA (81 studies), and focused on a handful of diseases, notably renal cell carcinomas (70) and systemic lupus erythematosus (36). Limited evidence was identified from lower-income settings and there were few studies of genetic conditions, which make up most RKDs. Some studies demonstrated the cost-effectiveness of existing treatments; however, there were limited considerations of broader economic impacts on patients that may be important to those with RKDs. Included health technology assessments highlighted difficulties in obtaining high-quality clinical evidence for treatments in very small patient populations, and often considered equity issues and other patient impacts qualitatively alongside clinical and economic evidence in their recommendations. CONCLUSION: We found large gaps in the economic evidence base for RKDs and limited adaptation of methods to account for the uniqueness of these diseases. There may be significant scope for innovation in building an investment case for RKD treatments, as well as in decision-making processes to inform investment decisions

Scoping Review of Economic Analyses of Rare Kidney Diseases

Introduction: Rare kidney diseases (RKDs) place a substantial economic burden on patients and health systems, the extent of which is unknown and may be systematically underestimated by health economic techniques. We aimed to investigate the economic burden and cost-effectiveness evidence base for RKDs. Methods: We conducted a systematic scoping review to identify economic evaluations, health technology assessments, and cost-of-illness studies relating to RKDs, published since 2012. Results: A total of 161 published studies, including 66 cost-of-illness studies and 95 economic evaluations; 72 grey literature reports were also included. Most published literature originated from high-income nations, particularly the USA (81 studies), and focused on a handful of diseases, notably renal cell carcinomas (70) and systemic lupus erythematosus (36). Limited evidence was identified from lower-income settings and there were few studies of genetic conditions, which make up most RKDs. Some studies demonstrated the cost-effectiveness of existing treatments; however, there were limited considerations of broader economic impacts on patients that may be important to those with RKDs. Included health technology assessments highlighted difficulties in obtaining high-quality clinical evidence for treatments in very small patient populations, and often considered equity issues and other patient impacts qualitatively alongside clinical and economic evidence in their recommendations. Conclusion: We found large gaps in the economic evidence base for RKDs and limited adaptation of methods to account for the uniqueness of these diseases. There may be significant scope for innovation in building an investment case for RKD treatments, as well as in decision-making processes to inform investment decisions

The Winter Strategy – a Multifaceted Integrated Care Intervention to Support People with Chronic and Complex Care Needs during the Australian Winter Period

Introduction: Health care demands increase over the winter period, especially for people with chronic diseases. Hospital avoidance programs have potential to address seasonal surges. Methods: An integrated care intervention was provided to patients at high risk of hospitalisation during the 2017 and 2018 winters in Northern New South Wales, Australia. Patients received increased support including general practice sick day action plans, automated admission notifications to the general practitioner, and care coordination services. Outcomes were provider and patient experience and preventable hospitalisation rates. Results: The program enrolled 1244 participating patients from 37 general practices with at least 12 months follow-up. It was associated with marked improvements in provider and patient experience. However, when compared to a propensity score matched control group there was no difference in hospital utilisation or emergency presentation rates. Discussion and Conclusion: An integrated care strategy to address chronic care needs of patients in winter was well received by practitioners and patients, but did not translate to changes in hospital utilisation or emergency presentation rates. Areas for improvement include: strengthening inter-professional engagement between hospital, specialists and primary care providers, more tailored support services for patients with complex health needs, and a more expansive set of process measures beyond hospital and emergency utilisation to assess impact

Health Worker Absenteeism in Selected Health Facilities in Enugu State:Do Internal and External Supervision Matter?

Background: Absenteeism is widespread in Nigerian health facilities and is a major barrier to achievement of effective Universal Health Coverage. We have examined the role of internal (by managerial staff within facilities) and external (by managers at a higher level) supervision arrangements on health worker absenteeism. Specifically, we sought to determine whether these forms of supervision have any role to play in reducing health worker absenteeism in health facilities in Enugu State Nigeria. Methods: We conducted interviews with 412 health workers in urban and rural areas of Enugu State, in South-Eastern Nigeria. We used binary logistic regression to estimate the role of different types of supervision on health worker absenteeism in selected health facilities in Enugu State. Results: Internal supervision arrangements significantly reduce health worker absenteeism (odds ratio = 0.516, p = 0.03). In contrast, existing external supervision arrangements were associated with a small but significant increase in absenteeism (OR = 1.02, 0.043). Those reporting a better financial situation were more likely to report being absent (OR = 1.36, p < 0.01) but there was no association with age and marital status of respondents. Our findings also pointed to the potential for alternative forms of supervision, provided in a supportive rather than punitive way, for example by community groups monitoring the activities of health workers but trying to understand what support these workers may need, within or beyond the work environment. Conclusion: The existing system of external supervision of absenteeism in health facilities in Nigeria is not working but alternatives that take a more holistic approach to the lived experiences of health workers might offer an alternative