Activity-based costing of health-care delivery, Haiti

Abstract Objective: To evaluate the implementation of a time-driven activity-based costing analysis at five community health facilities in Haiti. Methods: Together with stakeholders, the project team decided that health-care providers should enter start and end times of the patient encounter in every fifth patient’s medical dossier. We trained one data collector per facility, who manually entered the time recordings and patient characteristics in a database and submitted the data to a cloud-based data warehouse each week. We calculated the capacity cost per minute for each resource used. An automated web-based platform multiplied reported time with capacity cost rate and provided the information to health-facilities administrators. Findings: Between March 2014 and June 2015, the project tracked the clinical services for 7162 outpatients. The cost of care for specific conditions varied widely across the five facilities, due to heterogeneity in staffing and resources. For example, the average cost of a first antenatal-care visit ranged from 6.87 United States dollars (US$) at a low-level facility to US$ 25.06 at a high-level facility. Within facilities, we observed similarly variation in costs, due to factors such as patient comorbidities, patient arrival time, stocking of supplies at facilities and type of visit. Conclusion: Time-driven activity-based costing can be implemented in low-resource settings to guide resource allocation decisions. However, the extent to which this information will drive observable changes at patient, provider and institutional levels depends on several contextual factors, including budget constraints, management, policies and the political economy in which the health system is situated

Economic Analysis of Knowledge: The History of Thought and the Central Themes

Following the development of knowledge economies, there has been a rapid expansion of economic analysis of knowledge, both in the context of technological knowledge in particular and the decision theory in general. This paper surveys this literature by identifying the main themes and contributions and outlines the future prospects of the discipline. The wide scope of knowledge related questions in terms of applicability and alternative approaches has led to the fragmentation of research. Nevertheless, one can identify a continuing tradition which analyses various aspects of the generation, dissemination and use of knowledge in the economy

Patient and public involvement: ethical justifications, expert knowledge, and deliberative democracy

Across many countries worldwide, support for patient and public involvement (PPI) in health care has grown significantly over the last two decades. Calls to democratize the health care system have resulted in a system where patients are increasingly involved in the design of medical research and members of the public have been called upon to help make decisions concerning various elements of national, regional, and local health care policy. In some countries, like the UK, laws on the books now mandate that health care institutions meet certain benchmarks in PPI in order to be eligible for national funding. Though many scholars have sought to understand how society can make PPI efforts more "effective," they have largely neglected to provide an overarching justification for involvement in the first place. This thesis seeks to understand whether such a justification exists. I examine two sets of arguments in support of PPI: one that maintains PPI simply improves the quality, relevance, or effectiveness of medical research and health care provision (the outcomes-based argument) and one that appeals to notions of democratic legitimacy and representation. I argue that the outcome-centered argument wrongly presupposes an agreement on which outcomes should be prioritized while the democratic legitimacy argument fails to adequately identify the relationship between PPI and greater transparency, accountability, or reasonability. Since supporters of PPI often use the framework of deliberative democracy as support for the democratic legitimacy argument, I use it as well as a starting point for analysis. In short, though PPI may appeal to certain democratic intuitions, there is little reason to think that in practice it has strengthened bonds of democratic legitimacy. I conclude by suggesting ways in which those core democratic virtues might be strengthened outside the realm of PPI. Despite increased patient involvement, the processes of resource allocation (rationing) in health care remain opaque in many countries. In addition, there exist few mechanisms for individual appeal of an unjust decision, a feature that most deliberative democrats consider essential to a just system of resource allocation. Ultimately, I contend that a greater focus on the processes that facilitate transparency and accountability will better serve citizens and their health care systems

Patient and public involvement: ethical justifications, expert knowledge, and deliberative democracy

Across many countries worldwide, support for patient and public involvement (PPI) in health care has grown significantly over the last two decades. Calls to democratize the health care system have resulted in a system where patients are increasingly involved in the design of medical research and members of the public have been called upon to help make decisions concerning various elements of national, regional, and local health care policy. In some countries, like the UK, laws on the books now mandate that health care institutions meet certain benchmarks in PPI in order to be eligible for national funding. Though many scholars have sought to understand how society can make PPI efforts more "effective," they have largely neglected to provide an overarching justification for involvement in the first place. This thesis seeks to understand whether such a justification exists. I examine two sets of arguments in support of PPI: one that maintains PPI simply improves the quality, relevance, or effectiveness of medical research and health care provision (the outcomes-based argument) and one that appeals to notions of democratic legitimacy and representation. I argue that the outcome-centered argument wrongly presupposes an agreement on which outcomes should be prioritized while the democratic legitimacy argument fails to adequately identify the relationship between PPI and greater transparency, accountability, or reasonability. Since supporters of PPI often use the framework of deliberative democracy as support for the democratic legitimacy argument, I use it as well as a starting point for analysis. In short, though PPI may appeal to certain democratic intuitions, there is little reason to think that in practice it has strengthened bonds of democratic legitimacy. I conclude by suggesting ways in which those core democratic virtues might be strengthened outside the realm of PPI. Despite increased patient involvement, the processes of resource allocation (rationing) in health care remain opaque in many countries. In addition, there exist few mechanisms for individual appeal of an unjust decision, a feature that most deliberative democrats consider essential to a just system of resource allocation. Ultimately, I contend that a greater focus on the processes that facilitate transparency and accountability will better serve citizens and their health care systems.</p

Patient and public involvement: ethical justifications, expert knowledge, and deliberative democracy

Across many countries worldwide, support for patient and public involvement (PPI) in health care has grown significantly over the last two decades. Calls to democratize the health care system have resulted in a system where patients are increasingly involved in the design of medical research and members of the public have been called upon to help make decisions concerning various elements of national, regional, and local health care policy. In some countries, like the UK, laws on the books now mandate that health care institutions meet certain benchmarks in PPI in order to be eligible for national funding. Though many scholars have sought to understand how society can make PPI efforts more "effective," they have largely neglected to provide an overarching justification for involvement in the first place. This thesis seeks to understand whether such a justification exists. I examine two sets of arguments in support of PPI: one that maintains PPI simply improves the quality, relevance, or effectiveness of medical research and health care provision (the outcomes-based argument) and one that appeals to notions of democratic legitimacy and representation. I argue that the outcome-centered argument wrongly presupposes an agreement on which outcomes should be prioritized while the democratic legitimacy argument fails to adequately identify the relationship between PPI and greater transparency, accountability, or reasonability. Since supporters of PPI often use the framework of deliberative democracy as support for the democratic legitimacy argument, I use it as well as a starting point for analysis. In short, though PPI may appeal to certain democratic intuitions, there is little reason to think that in practice it has strengthened bonds of democratic legitimacy. I conclude by suggesting ways in which those core democratic virtues might be strengthened outside the realm of PPI. Despite increased patient involvement, the processes of resource allocation (rationing) in health care remain opaque in many countries. In addition, there exist few mechanisms for individual appeal of an unjust decision, a feature that most deliberative democrats consider essential to a just system of resource allocation. Ultimately, I contend that a greater focus on the processes that facilitate transparency and accountability will better serve citizens and their health care systems.</p

Rethinking the cost of healthcare in low-resource settings: the value of time-driven activity-based costing

Low-income and middle-income countries account for over 80% of the world's infectious disease burden, but <20% of global expenditures on health. In this context, judicious resource allocation can mean the difference between life and death, not just for individual patients, but entire patient populations. Understanding the cost of healthcare delivery is a prerequisite for allocating health resources, such as staff and medicines, in a way that is effective, efficient, just and fair. Nevertheless, health costs are often poorly understood, undermining effectiveness and efficiency of service delivery. We outline shortcomings, and consequences, of common approaches to estimating the cost of healthcare in low-resource settings, as well as advantages of a newly introduced approach in healthcare known as time-driven activity-based costing (TDABC). TDABC is a patient-centred approach to cost analysis, meaning that it begins by studying the flow of individual patients through the health system, and measuring the human, equipment and facility resources used to treat the patients. The benefits of this approach are numerous: fewer assumptions need to be made, heterogeneity in expenditures can be studied, service delivery can be modelled and streamlined and stronger linkages can be established between resource allocation and health outcomes. TDABC has demonstrated significant benefits for improving health service delivery in high-income countries but has yet to be adopted in resource-limited settings. We provide an illustrative case study of its application throughout a network of hospitals in Haiti, as well as a simplified framework for policymakers to apply this approach in low-resource settings around the world