Navigating stormy waters in times of fiscal uncertainty: mitigating the challenges

New approaches to resource allocation are providing healthcare managers with ways to meet budget pressures while maximizing benefit to patients and populations. But putting these approaches in place often involves significant organizational change to which some degree of resistance must be expected. The authors have seen seven common objections raised time and again. Here, we offer our best advice on how healthcare leaders can anticipate and respond proactively to these challenges. </jats:p

Managing healthcare budgets in times of austerity: the role of program budgeting and marginal analysis

Given limited resources, priority setting or choice making will remain a reality at all levels of publicly funded healthcare across countries for many years to come. The pressures may well be even more acute as the impact of the economic crisis of 2008 continues to play out but, even as economies begin to turn around, resources within healthcare will be limited, thus some form of rationing will be required. Over the last few decades, research on healthcare priority setting has focused on methods of implementation as well as on the development of approaches related to fairness and legitimacy and on more technical aspects of decision making including the use of multi-criteria decision analysis. Recently, research has led to better understanding of evaluating priority setting activity including defining ‘success’ and articulating key elements for high performance. This body of research, however, often goes untapped by those charged with making challenging decisions and as such, in line with prevailing public sector incentives, decisions are often reliant on historical allocation patterns and/or political negotiation. These archaic and ineffective approaches not only lead to poor decisions in terms of value for money but further do not reflect basic ethical conditions that can lead to fairness in the decision-making process. The purpose of this paper is to outline a comprehensive approach to priority setting and resource allocation that has been used in different contexts across countries. This will provide decision makers with a single point of access for a basic understanding of relevant tools when faced with having to make difficult decisions about what healthcare services to fund and what not to fund. The paper also addresses several key issues related to priority setting including how health technology assessments can be used, how performance can be improved at a practical level, and what ongoing resource management practice should look like. In terms of future research, one of the most important areas of priority setting that needs further attention is how best to engage public members

Health care priority setting: principles, practice and challenges

BACKGROUND: Health organizations the world over are required to set priorities and allocate resources within the constraint of limited funding. However, decision makers may not be well equipped to make explicit rationing decisions and as such often rely on historical or political resource allocation processes. One economic approach to priority setting which has gained momentum in practice over the last three decades is program budgeting and marginal analysis (PBMA). METHODS: This paper presents a detailed step by step guide for carrying out a priority setting process based on the PBMA framework. This guide is based on the authors' experience in using this approach primarily in the UK and Canada, but as well draws on a growing literature of PBMA studies in various countries. RESULTS: At the core of the PBMA approach is an advisory panel charged with making recommendations for resource re-allocation. The process can be supported by a range of 'hard' and 'soft' evidence, and requires that decision making criteria are defined and weighted in an explicit manner. Evaluating the process of PBMA using an ethical framework, and noting important challenges to such activity including that of organizational behavior, are shown to be important aspects of developing a comprehensive approach to priority setting in health care. CONCLUSION: Although not without challenges, international experience with PBMA over the last three decades would indicate that this approach has the potential to make substantial improvement on commonly relied upon historical and political decision making processes. In setting out a step by step guide for PBMA, as is done in this paper, implementation by decision makers should be facilitated

Using Economic Evidence to Set Healthcare Priorities in Low-Income and Lower-Middle-Income Countries: A Systematic Review of Methodological Frameworks.

Policy makers in low-income and lower-middle-income countries (LMICs) are increasingly looking to develop 'evidence-based' frameworks for identifying priority health interventions. This paper synthesises and appraises the literature on methodological frameworks--which incorporate economic evaluation evidence--for the purpose of setting healthcare priorities in LMICs. A systematic search of Embase, MEDLINE, Econlit and PubMed identified 3968 articles with a further 21 articles identified through manual searching. A total of 36 papers were eligible for inclusion. These covered a wide range of health interventions with only two studies including health systems strengthening interventions related to financing, governance and human resources. A little under half of the studies (39%) included multiple criteria for priority setting, most commonly equity, feasibility and disease severity. Most studies (91%) specified a measure of 'efficiency' defined as cost per disability-adjusted life year averted. Ranking of health interventions using multi-criteria decision analysis and generalised cost-effectiveness were the most common frameworks for identifying priority health interventions. Approximately a third of studies discussed the affordability of priority interventions. Only one study identified priority areas for the release or redeployment of resources. The paper concludes by highlighting the need for local capacity to conduct evaluations (including economic analysis) and empowerment of local decision-makers to act on this evidence

Global developments in priority setting in health

Countries around the world are experiencing an ever-increasing need to make choices in investments in health and healthcare. This makes it incumbent upon them to have formal processes in place to optimize the legitimacy of eventual decisions. There is now growing experience among countries of the implementation of stakeholder participation, and a developing convergence of methods to support decision-makers within health authorities in making tough decisions when faced with the stark reality of limited resources. We call for further interaction among health authorities, and the research community to develop best practices in order to confront the difficult choices that need to be made

Coronavirus: Where Has All the Health Economics Gone?

As the coronavirus disease 2019 (COVID-19) pandemic continues to unfold there is an untold number of trade-offs being made in every country around the globe. The experience in the United Kingdom and Canada to date has not seen much uptake of health economics methods. We provide some thoughts on how this could take place, specifically in three areas. Firstly, this can involve understanding the impact of lockdown policies on national productivity. Secondly, there is great importance in studying trade-offs with respect to enhancing health system capacity and the impact of the mix of private-public financing. Finally, there are key trade-offs that will continue to be made both in terms of access to testing and ventilators which would benefit greatly from economic appraisal. In short, health economics could – and we would argue most certainly should – play a much more prominent role in policy-making as it relates to the current as well as future pandemics

Factors influencing application of behavioural science evidence by public health decision-makers and practitioners, and implications for practice

The National Institute of Health and Care Excellence (NICE) in the UK recommends behavioural science evidence underpins public health improvement services. In practice, level of implementation varies. This study is the first to explore factors affecting use of behaviour-specific evidence by public health decision-makers and practitioners for design and delivery of health improvement services. Twenty semi-structured interviews were conducted, along with a review of the commissioning cycle with public health decision-makers and practitioners across a range of health improvement fields (e.g. weight management). Interviews were informed and analysed using the Theoretical Domains Framework (TDF). Limited comprehension of behaviour change, challenges identifying specific behaviour change strategies and translating research into practice were prevalent. Local authority processes encouraged uptake of evidence to justify solutions as opposed to evidence-driven decision-making. Some decision-makers perceived research evidence may stifle innovation and overwhelm practitioners. Potential facilitators of research use included: ensuring uptake and implementation of evidence is compulsory within commissioning and its potential to show value for money. A strong belief in local evidence and achieving outcomes were identified as barriers to research evidence uptake. Social and environmental challenges included cultural, political, and workload pressures and journal article accessibility. Embedding behavioural science systematically into public health practice requires changes throughout the public health system; from priorities set by national public health leaders to the way in which relevant evidence is disseminated. Framing factors affecting use of behavioural science evidence using the TDF is helpful for identifying the range of interventions and support needed to affect change. Keywords: Behaviour change, Behavioural science, Theoretical Domains Framework, Evidence, Public health, Research translatio