Naar een rationele allocatie van overheidsmiddelen vanuit een welvaartstheoretisch perspectief

In sommige delen van de overheid speelt de vraag of de verdeling van middelen binnen de overheid wel optimaal is. Investeringen in het onderwijs bijvoorbeeld leveren zowel individueel als maatschappelijk rendement op. Als een land investeert in onderwijs kan dat besparingen opleveren in de bestrijding van criminaliteit, in de uitgaven aan sociale zekerheid en in de uitgaven aan gezondheidszorg. Indien dergelijke positieve externe effecten van een investering in onderwijs niet of onvoldoende worden betrokken bij de beoordeling van verschillende beleidsinterventies, ongeacht om welk beleidsveld het gaat, dan zal dat leiden tot onderinvestering in onderwijs en bijbehorende suboptimale welvaart. In dit discussiedocument doen we een voorstel voor een rationeel allocatiemodel (HALY) dat gebaseerd is op de vergelijking van kosten en effecten of kosten en baten van overheidinvesteringen. Om de werking van het allocatiemodel te laten zien, werken wij een hypothetische toepassing van dit model uit. Hier worden een onderwijsinterventie (onderwijs aan 3-jarigen met taalachterstand) en een justitie-interventie (begeleiding jeugdcriminelen) met elkaar vergeleken. Verder selecteren wij delen van de begroting van andere ministeries met doelen die overeenkomen met onderwijs en laten wij de bijbehorende uitgaven zien.govermental means; allocation; HALY; education; innovation

The Effect of Growth and Inequality in Incomes on Health Inequality: Theory and Empirical Evidence from the European Panel

Europe aims at combining income growth with improvements in social cohesion as measured by income and health inequalities. We show that, theoretically, both aims can be reconciled only under very specific conditions concerning the type of growth and the income responsiveness of health. We investigate whether these conditions held in Europe in the nineties using panel data from the European Community Household Panel surveys. We use pooled interval regressions and inequality decompositions to demonstrate that (i) in all countries except Austria, the income elasticity of health is positive and increases with income, and (ii) that income growth was not pro-rich in most EU countries, resulting in little or no reductions in income inequality and modest increases in income-related health inequality in the majority of countries

Dear Policymaker: Have you made up your mind?

Objectives: To get insight in what criteria as presented in Health Technology Assessment (HTA) studies are important for decision makers in health care priority setting. Methods: We performed a discrete choice experiment (DCE) among Dutch health care professionals (policymakers, HTA experts, advanced HTA students). In 27 choice sets, we asked respondents to elect reimbursement of one of two different health care interventions, which represented unlabeled, curative treatments. Both treatments were incrementally compared to usual care. The results of the interventions were normal outputs of HTA studies with a societal perspective. Results were analysed using a multinomial logistic regression model. Upon completion of the questionnaire we discussed the exercise with policymakers. Results: Severity of disease, costs per QALY gained, individual health gain, and the budget impact were the most decisive decision criteria. A program targeting more severe diseases increased the probability of reimbursement dramatically. Uncertainty related to cost-effectiveness was also important. Respondents preferred health gains that include quality of life improvements over extension of life without improved quality of life. Savings in productivity costs were not crucial in decision making, although these are to be included in Dutch reimbursement dossiers for new drugs. Regarding subgroups, we found that policymakers attached relatively more weight to disease severity than others but less to uncertainty. Conclusions: Dutch policymakers and other health care professionals seem to have reasonably well articulated preferences: six of seven attributes were significant. Disease severity, budget impact, and cost-effectiveness were very important. The results are comparable to international studies, but reveal a larger set of important decision criteria

Socio-economic status and self-reported tuberculosis: A multilevel analysis in a low-income township in the eastern cape, South Africa

Few studies have investigated the interplay of multiple factors affecting the prevalence of tuberculosis in developing countries. The compositional and contextual factors that affect health and disease patterns must be fully understood to successfully control tuberculosis. Experience with tuberculosis in South Africa was examined at the household level (overcrowding, a leaky roof, social capital, unemployment, income) and at the neighbourhood level (Gini coefficient of inequality, unemployment rate, headcount poverty rate). A hierarchical random-effects model was used to assess household-level and neighbourhoodlevel effects on self-reported tuberculosis experience. Every tenth household in each of the 20 Rhini neighbourhoods was selected for inclusion in the sample. Eligible respondents were at least 18 years of age and had been residents of Rhini for at least six months of the previous year. A Kish grid was used to select one respondent from each targeted household, to ensure that all eligible persons in the household stood an equal chance of being included in the survey. We included 1,020 households within 20 neighbourhoods of Rhini, a suburb of Grahamstown in the Eastern Cape, South Africa. About one-third of respondents (n=329; 32%) reported that there had been a tuberculosis case within the household. Analyses revealed that overcrowding (P≤0.05) and roof leakage (P≤0.05) contributed significantly to the probability of a household tuberculosis experience experience, whereas higher social capital (P≤0.01) significantly reduced this probability. Overcrowding, roof leakage and the social environment affected tuberculosis prevalence in this economically disadvantaged community. Policy makers should consider the possible benefits of programs that deal with housing and social environments when addressing the spread of tuberculosis in economically poor districts