1
|
Ahumada-Canale A, Jeet V, Bilgrami A, Seil E, Gu Y, Cutler H. Barriers and facilitators to implementing priority setting and resource allocation tools in hospital decisions: A systematic review. Soc Sci Med 2023; 322:115790. [PMID: 36913838 DOI: 10.1016/j.socscimed.2023.115790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 01/24/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023]
Abstract
Health care budgets in high-income countries are having issues coping with unsustainable growth in demand, particularly in the hospital setting. Despite this, implementing tools systematising priority setting and resource allocation decisions has been challenging. This study answers two questions: (1) what are the barriers and facilitators to implementing priority setting tools in the hospital setting of high-income countries? and (2) what is their fidelity? A systematic review using the Cochrane methods was conducted including studies of hospital-related priority setting tools reporting barriers or facilitators for implementation, published after the year 2000. Barriers and facilitators were classified using the Consolidated Framework for Implementation Research (CFIR). Fidelity was assessed using priority setting tool's standards. Out of thirty studies, ten reported program budgeting and marginal analysis (PBMA), twelve multi-criteria decision analysis (MCDA), six health technology assessment (HTA) related frameworks, and two, an ad hoc tool. Barriers and facilitators were outlined across all CFIR domains. Implementation factors not frequently observed, such as 'evidence of previous successful tool application', 'knowledge and beliefs about the intervention' or 'external policy and incentives' were reported. Conversely, some constructs did not yield any barrier or facilitator including 'intervention source' or 'peer pressure'. PBMA studies satisfied the fidelity criteria between 86% and 100%, for MCDA it varied between 36% and 100%, and for HTA it was between 27% and 80%. However, fidelity was not related to implementation. This study is the first to use an implementation science approach. Results represent the starting point for organisations wishing to use priority setting tools in the hospital setting by providing an overview of barriers and facilitators. These factors can be used to assess readiness for implementation or to serve as the foundation for process evaluations. Through our findings, we aim to improve the uptake of priority setting tools and support their sustainable use.
Collapse
Affiliation(s)
- Antonio Ahumada-Canale
- Macquarie University Centre for the Health Economy, Macquarie Business School & Australian Institute of Health Innovation, Macquarie University, Level 5, 75 Talavera Rd, Macquarie Park, New South Wales, 2109, Australia.
| | - Varinder Jeet
- Macquarie University Centre for the Health Economy, Macquarie Business School & Australian Institute of Health Innovation, Macquarie University, Level 5, 75 Talavera Rd, Macquarie Park, New South Wales, 2109, Australia.
| | - Anam Bilgrami
- Macquarie University Centre for the Health Economy, Macquarie Business School & Australian Institute of Health Innovation, Macquarie University, Level 5, 75 Talavera Rd, Macquarie Park, New South Wales, 2109, Australia.
| | - Elizabeth Seil
- Macquarie University Centre for the Health Economy, Macquarie Business School & Australian Institute of Health Innovation, Macquarie University, Level 5, 75 Talavera Rd, Macquarie Park, New South Wales, 2109, Australia.
| | - Yuanyuan Gu
- Macquarie University Centre for the Health Economy, Macquarie Business School & Australian Institute of Health Innovation, Macquarie University, Level 5, 75 Talavera Rd, Macquarie Park, New South Wales, 2109, Australia.
| | - Henry Cutler
- Macquarie University Centre for the Health Economy, Macquarie Business School & Australian Institute of Health Innovation, Macquarie University, Level 5, 75 Talavera Rd, Macquarie Park, New South Wales, 2109, Australia.
| |
Collapse
|
2
|
Tetui M, Zulu JM, Hurtig AK, Ekirapa-Kiracho E, Kiwanuka SN, Coe AB. Elements for harnessing participatory action research to strengthen health managers' capacity: a critical interpretative synthesis. Health Res Policy Syst 2018; 16:33. [PMID: 29673346 PMCID: PMC5907405 DOI: 10.1186/s12961-018-0306-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 04/02/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Health managers play a key role in ensuring that health services are responsive to the needs of the population. Participatory action research (PAR) is one of the approaches that have been used to strengthen managers' capacity. However, collated knowledge on elements for harnessing PAR to strengthen managers' capacity is missing. This paper bridges this gap by reviewing existing literature on the subject matter. METHODS A critical interpretive synthesis method was used to interrogate eight selected articles. These articles reported the use of PAR to strengthen health managers' capacity. The critical interpretive synthesis method's approach to analysis guided the synthesis. Here, the authors interpretively made connections and linkages between different elements identified in the literature. Finally, the Atun et al. (Heal Pol Plann, 25:104-111, 2010) framework on integration was used to model the elements synthesised in the literature into five main domains. RESULTS Five elements with intricate bi-directional interactions were identified in the literature reviewed. These included a shared purpose, skilled facilitation and psychological safety, activity integration into organisational procedures, organisational support, and external supportive monitoring. A shared purpose of the managers' capacity strengthening initiative created commitment and motivation to learn. This purpose was built upon a set of facilitation skills that included promoting participation, self-efficacy and reflection, thereby creating a safe psychological space within which the managers interacted and learnt from each other and their actions. Additionally, an integrated intervention strengthened local capacity and harnessed organisational support for learning. Finally, supportive monitoring from external partners, such as researchers, ensured quality, building of local capacity and professional safety networks essential for continued learning. CONCLUSIONS The five elements identified in this synthesis provide a basis upon which the use of PAR can be harnessed, not only to strengthen health managers' capacity, but also to foster other health systems strengthening initiatives involving implementation research. In addition, the findings demonstrated the intricate and complex relations between the elements, which further affirms the need for a systems thinking approach to tackling health systems challenges.
Collapse
Affiliation(s)
- Moses Tetui
- Makerere University College of Health Sciences, School of Public Health (MakCHS-SPH), New Mulago Complex, P.O. B0X 7072, Kampala, Uganda
- Epidemiology and Global Health Unit, Department of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Joseph Mumba Zulu
- School of Public Health, University of Zambia, P.O. Box 50110, Lusaka, Zambia
| | - Anna-Karin Hurtig
- Epidemiology and Global Health Unit, Department of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Elizabeth Ekirapa-Kiracho
- Makerere University College of Health Sciences, School of Public Health (MakCHS-SPH), New Mulago Complex, P.O. B0X 7072, Kampala, Uganda
| | - Suzanne N. Kiwanuka
- Makerere University College of Health Sciences, School of Public Health (MakCHS-SPH), New Mulago Complex, P.O. B0X 7072, Kampala, Uganda
| | - Anna-Britt Coe
- Sociology Department, Umeå University, 901 87 Umeå, Sweden
| |
Collapse
|
3
|
Manafò E, Petermann L, Vandall-Walker V, Mason-Lai P. Patient and public engagement in priority setting: A systematic rapid review of the literature. PLoS One 2018; 13:e0193579. [PMID: 29499043 PMCID: PMC5834195 DOI: 10.1371/journal.pone.0193579] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 02/14/2018] [Indexed: 11/25/2022] Open
Abstract
Background Current research suggests that while patients are becoming more engaged across the health delivery spectrum, this involvement occurs most often at the pre-preparation stage to identify ‘high-level’ priorities in health ecosystem priority setting, and at the preparation phase for health research. Objective The purpose of this systematic rapid review of the literature is to describe the evidence that does exist in relation to patient and public engagement priority setting in both health ecosystem and health research. Data sources HealthStar (via OVID); CINAHL; Proquest Databases; and Scholar’s Portal. Study eligibility criteria i) published in English; ii) published within the timeframe of 2007—Current (10 years) unless the report/article was formative in synthesizing key considerations of patient engagement in health ecosystem and health research priority setting; iii) conducted in Canada, the US, Europe, UK, Australia/New Zealand, or Scandinavian countries. Study appraisal and synthesis i) Is the research valid, sound, and applicable?; ii) what outcomes can we potentially expect if we implement the findings from this research?; iii) will the target population (i.e., health researchers and practitioners) be able to use this research?. A summary of findings from each of the respective processes was synthesized to highlight key information that would support decision-making for researchers when determining the best priority setting process to apply for their specific patient-oriented research. Results Seventy articles from the UK, US, Canada, Netherlands and Australia were selected for review. Results were organized into two tiers of public and patient engagement in prioritization: Tier 1—Deliberative and Tier 2—Consultative. Highly structured patient and public engagement planning activities include the James Lind Alliance Priority Setting Partnerships (UK), Dialogue Method (Netherlands), Global Evidence Mapping (Australia), and the Deep Inclusion Method/CHoosing All Together (US). Limitations The critical study limitations include challenges in comprehensively identifying the patient engagement literature for review, bias in article selection due to the identified scope, missed information due to a more limited use of exhaustive search strategies (e.g., in-depth hand searching), and the heterogeneity of reported study findings. Conclusion The four public and patient engagement priority setting processes identified were successful in setting priorities that are inclusive and objectively based, specific to the priorities of stakeholders engaged in the process. The processes were robust, strategic and aimed to promote equity in patient voices. Key limitations identified a lack of evaluation data on the success and extent in which patients were engaged. Issues pertaining to feasibility of stakeholder engagement, coordination, communication and limited resources were also considered.
Collapse
Affiliation(s)
- Elizabeth Manafò
- Patient Engagement Platform, Alberta SPOR SUPPORT Unit, Edomonton, Alberta, Canada
- * E-mail:
| | - Lisa Petermann
- Patient Engagement Platform, Alberta SPOR SUPPORT Unit, Edomonton, Alberta, Canada
| | | | - Ping Mason-Lai
- Patient Engagement Platform, Alberta SPOR SUPPORT Unit, Edomonton, Alberta, Canada
| |
Collapse
|
4
|
KIM JS, YOON SY, CHO SY, KIM SK, CHUNG IS, SHIN HS. Effectiveness of participatory training for the promotion of work-related health and safety among Korean farmers. INDUSTRIAL HEALTH 2017; 55:391-401. [PMID: 28484146 PMCID: PMC5546848 DOI: 10.2486/indhealth.2017-0015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 05/02/2017] [Indexed: 06/07/2023]
Abstract
This study was conducted to explore the effectiveness of participatory training for promoting farmer's health and reducing agricultural work-related injuries. Candidates for this study included 595 farmers in 8 rural villages of South Korea. The one-day course participatory training was administered to 217 (36.5%) farmers and included an action-checklist, a good example presentation, and group discussion. The follow-up visit to participants' houses and farms was performed after 1 to 3 months. A direct interview survey was administered pre- and post-trainings. The total number of proposed action plans for the improvement of working condition was 620. It was observed that 61.5% of action plans (72.2% of short term and 41.3% of long term plans) were completely implemented. In regards to health and safety indices, the proportion of current smokers was reduced from 29.8% to 25.3% in the group that underwent training. The pesticide intoxication was reduced from 16.1% to 4.8% in participants that underwent training. However, the agricultural injury rate was unchanged in both groups. This study reports significant beneficial effects of participatory training in the agriculture sector in Korea.
Collapse
Affiliation(s)
- Jin-Seok KIM
- Division of Occupational and Environmental Medicine, School of Medicine, Soonchunhyang University, Korea
| | - Seong-Yong YOON
- Division of Occupational and Environmental Medicine, School of Medicine, Soonchunhyang University, Korea
| | - Seong-Yong CHO
- Division of Occupational and Environmental Medicine, School of Medicine, Soonchunhyang University, Korea
| | - Sang-Kyu KIM
- Department of Preventive Medicine, Dongkook University, Korea
| | - In-Sung CHUNG
- Division of Occupational and Environmental Medicine, School of Medicine, Keimyung University, Korea
| | - Hyeong-Soo SHIN
- Department of Physical Therapy, College of Health and Welfare, KyungWoon University, Korea
| |
Collapse
|
5
|
Tautolo ES, Wrapson W, Paterson J, Clair VWS, Neville S, Dewes O, Iusitini L. Healthy Pacific grandparents: a participatory action research project exploring ageing well among Pacific people in New Zealand. ACTA ACUST UNITED AC 2017. [DOI: 10.1080/03060497.2017.1334973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- El-Shadan Tautolo
- Centre for Pacific Health & Development Research, Auckland University of Technology, Auckland, New Zealand
| | - Wendy Wrapson
- Centre for Pacific Health & Development Research, Auckland University of Technology, Auckland, New Zealand
| | - Janis Paterson
- Centre for Pacific Health & Development Research, Auckland University of Technology, Auckland, New Zealand
| | | | - Stephen Neville
- Centre for Active Ageing, Auckland University of Technology, Auckland, New Zealand
| | - Ofa Dewes
- School of Nursing and Maurice Wilkins Centre for Molecular Discovery, Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
| | - Leon Iusitini
- Centre for Pacific Health & Development Research, Auckland University of Technology, Auckland, New Zealand
| |
Collapse
|
6
|
Cumming JM. Priority Setting Meets Multiple Streams: A Match to Be Further Examined? Comment on "Introducing New Priority Setting and Resource Allocation Processes in a Canadian Healthcare Organization: A Case Study Analysis Informed by Multiple Streams Theory. Int J Health Policy Manag 2016; 5:497-499. [PMID: 27694663 DOI: 10.15171/ijhpm.2016.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 05/09/2016] [Indexed: 11/09/2022] Open
Abstract
With demand for health services continuing to grow as populations age and new technologies emerge to meet health needs, healthcare policy-makers are under constant pressure to set priorities, ie, to make choices about the health services that can and cannot be funded within available resources. In a recent paper, Smith et al apply an influential policy studies framework - Kingdon's multiple streams approach (MSA) - to explore the factors that explain why one health service delivery organization adopted a formal priority setting framework (in the form of programme budgeting and marginal analysis [PBMA]) to assist it in making priority setting decisions. MSA is a theory of agenda-setting, ie, how it is that different issues do or do not reach a decision-making point. In this paper, I reflect on the use of the MSA framework to explore priority setting processes and how the framework might be applied to similar cases in future.
Collapse
|
7
|
Gagliardi AR, Berta W, Kothari A, Boyko J, Urquhart R. Integrated knowledge translation (IKT) in health care: a scoping review. Implement Sci 2016; 11:38. [PMID: 26988000 PMCID: PMC4797171 DOI: 10.1186/s13012-016-0399-1] [Citation(s) in RCA: 312] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 03/05/2016] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Integrated knowledge translation (IKT) refers to collaboration between researchers and decision-makers. While advocated as an approach for enhancing the relevance and use of research, IKT is challenging and inconsistently applied. This study sought to inform future IKT practice and research by synthesizing studies that empirically evaluated IKT and identifying knowledge gaps. METHODS We performed a scoping review. We searched MEDLINE, EMBASE, and the Cochrane Library from 2005 to 2014 for English language studies that evaluated IKT interventions involving researchers and organizational or policy-level decision-makers. Data were extracted on study characteristics, IKT intervention (theory, content, mode, duration, frequency, personnel, participants, timing from initiation, initiator, source of funding, decision-maker involvement), and enablers, barriers, and outcomes reported by studies. We performed content analysis and reported summary statistics. RESULTS Thirteen studies were eligible after screening 14,754 titles and reviewing 106 full-text studies. Details about IKT activities were poorly reported, and none were formally based on theory. Studies varied in the number and type of interactions between researchers and decision-makers; meetings were the most common format. All studies reported barriers and facilitators. Studies reported a range of positive and sub-optimal outcomes. Outcomes did not appear to be associated with initiator of the partnership, dedicated funding, partnership maturity, nature of decision-maker involvement, presence or absence of enablers or barriers, or the number of different IKT activities. CONCLUSIONS The IKT strategies that achieve beneficial outcomes remain unknown. We generated a summary of IKT approaches, enablers, barriers, conditions, and outcomes that can serve as the basis for a future review or for planning ongoing primary research. Future research can contribute to three identified knowledge gaps by examining (1) how different IKT strategies influence outcomes, (2) the relationship between the logic or theory underlying IKT interventions and beneficial outcomes, and (3) when and how decision-makers should be involved in the research process. Future IKT initiatives should more systematically plan and document their design and implementation, and evaluations should report the findings with sufficient detail to reveal how IKT was associated with outcomes.
Collapse
|
8
|
Smith N, Mitton C, Dowling L, Hiltz MA, Campbell M, Gujar SA. Introducing New Priority Setting and Resource Allocation Processes in a Canadian Healthcare Organization: A Case Study Analysis Informed by Multiple Streams Theory. Int J Health Policy Manag 2015; 5:23-31. [PMID: 26673646 DOI: 10.15171/ijhpm.2015.169] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 09/14/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND In this article, we analyze one case instance of how proposals for change to the priority setting and resource allocation (PSRA) processes at a Canadian healthcare institution reached the decision agenda of the organization's senior leadership. We adopt key concepts from an established policy studies framework - Kingdon's multiple streams theory - to inform our analysis. METHODS Twenty-six individual interviews were conducted at the IWK Health Centre in Halifax, NS, Canada. Participants were asked to reflect upon the reasons leading up to the implementation of a formal priority setting process - Program Budgeting and Marginal Analysis (PBMA) - in the 2012/2013 fiscal year. Responses were analyzed qualitatively using Kingdon's model as a template. RESULTS The introduction of PBMA can be understood as the opening of a policy window. A problem stream - defined as lack of broad engagement and information sharing across service lines in past practice - converged with a known policy solution, PBMA, which addressed the identified problems and was perceived as easy to use and with an evidence-base from past applications across Canada and elsewhere. Conditions in the political realm allowed for this intervention to proceed, but also constrained its potential outcomes. CONCLUSION Understanding in a theoretically-informed way how change occurs in healthcare management practices can provide useful lessons to researchers and decision-makers whose aim is to help health systems achieve the most effective use of available financial resources.
Collapse
Affiliation(s)
- Neale Smith
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Craig Mitton
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | | | - Mary-Ann Hiltz
- Strategy and Organizational Performance, IWK Health Centre, Halifax, NS, Canada
| | - Matthew Campbell
- Strategy and Organizational Performance, IWK Health Centre, Halifax, NS, Canada
| | - Shashi Ashok Gujar
- Strategy and Organizational Performance, IWK Health Centre, Halifax, NS, Canada.,Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| |
Collapse
|
9
|
Font JC, Forns JR, Sato A. Eliciting health care priorities in developing countries: experimental evidence from Guatemala. Health Policy Plan 2015; 31:67-74. [PMID: 25841770 DOI: 10.1093/heapol/czv022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2015] [Indexed: 11/13/2022] Open
Abstract
Although some methods for eliciting preferences to assist participatory priority setting in health care in developed countries are available, the same is not true for poor communities in developing countries whose preferences are neglected in health policy making. Existing methods grounded on self-interested, monetary valuations that may be inappropriate for developing country settings where community care is provided through 'social allocation' mechanisms. This paper proposes and examines an alternative methodology for eliciting preferences for health care programmes specifically catered for rural and less literate populations but which is still applicable in urban communities. Specifically, the method simulates a realistic collective budget allocation experiment, to be implemented in both rural and urban communities in Guatemala. We report evidence revealing that participatory budget-like experiments are incentive compatible mechanisms suitable for revealing collective preferences, while simultaneously having the advantage of involving communities in health care reform processes.
Collapse
Affiliation(s)
- Joan Costa Font
- Department of Social Policy, London School of Economics and Political Science (LSE), London UK and
| | - Joan Rovira Forns
- Department of Economic Theory, University of Barcelona, Diagonal 690, Barcelona, Catalonia, Spain
| | - Azusa Sato
- Department of Social Policy, London School of Economics and Political Science (LSE), London UK and
| |
Collapse
|
10
|
Health sector priority setting at meso-level in lower and middle income countries: lessons learned, available options and suggested steps. Soc Sci Med 2013; 102:190-200. [PMID: 24565157 DOI: 10.1016/j.socscimed.2013.11.056] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 11/25/2013] [Accepted: 11/29/2013] [Indexed: 11/23/2022]
Abstract
Setting priority for health programming and budget allocation is an important issue, but there is little consensus on related processes. It is particularly relevant in low resource settings and at province- and district- or "meso-level", where contextual influences may be greater, information scarce and capacity lower. Although recent changes in disease epidemiology and health financing suggest even greater need to allocate resources effectively, the literature is relatively silent on evidence-based priority-setting in low and middle income countries (LMICs). We conducted a comprehensive review of the peer-reviewed and grey literature on health resource priority-setting in LMICs, focussing on meso-level and the evidence-based priority-setting processes (PSPs) piloted or suggested there. Our objective was to assess PSPs according to whether they have influenced resource allocation and impacted the outcome indicators prioritised. An exhaustive search of the peer-reviewed and grey literature published in the last decade yielded 57 background articles and 75 reports related to priority-setting at meso-level in LMICs. Although proponents of certain PSPs still advocate their use, other experts instead suggest broader elements to guide priority-setting. We conclude that currently no process can be confidently recommended for such settings. We also assessed the common reasons for failure at all levels of priority-setting and concluded further that local authorities should additionally consider contextual and systems limitations likely to prevent a satisfactory process and outcomes, particularly at meso-level. Recent literature proposes a list of related attributes and warning signs, and facilitated our preparation of a simple decision-tree or roadmap to help determine whether or not health systems issues should be improved in parallel to support for needed priority-setting; what elements of the PSP need improving; monitoring, and evaluation. Health priority-setting at meso-level in LMICs can involve common processes, but will often require additional attention to local health systems.
Collapse
|
11
|
|
12
|
Baltussen R, Mikkelsen E, Tromp N, Hurtig A, Byskov J, Olsen Ø, Bærøe K, Hontelez JA, Singh J, Norheim OF. Balancing efficiency, equity and feasibility of HIV treatment in South Africa - development of programmatic guidance. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2013; 11:26. [PMID: 24107435 PMCID: PMC3851565 DOI: 10.1186/1478-7547-11-26] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 08/20/2013] [Indexed: 12/31/2022] Open
Abstract
South Africa, the country with the largest HIV epidemic worldwide, has been scaling up treatment since 2003 and is rapidly expanding its eligibility criteria. The HIV treatment programme has achieved significant results, and had 1.8 million people on treatment per 2011. Despite these achievements, it is now facing major concerns regarding (i) efficiency: alternative treatment policies may save more lives for the same budget; (ii) equity: there are large inequalities in who receives treatment; (iii) feasibility: still only 52% of the eligible population receives treatment.Hence, decisions on the design of the present HIV treatment programme in South Africa can be considered suboptimal. We argue there are two fundamental reasons to this. First, while there is a rapidly growing evidence-base to guide priority setting decisions on HIV treatment, its included studies typically consider only one criterion at a time and thus fail to capture the broad range of values that stakeholders have. Second, priority setting on HIV treatment is a highly political process but it seems no adequate participatory processes are in place to incorporate stakeholders' views and evidences of all sorts.We propose an alternative approach that provides a better evidence base and outlines a fair policy process to improve priority setting in HIV treatment. The approach integrates two increasingly important frameworks on health care priority setting: accountability for reasonableness (A4R) to foster procedural fairness, and multi-criteria decision analysis (MCDA) to construct an evidence-base on the feasibility, efficiency, and equity of programme options including trade-offs. The approach provides programmatic guidance on the choice of treatment strategies at various decisions levels based on a sound conceptual framework, and holds large potential to improve HIV priority setting in South Africa.
Collapse
Affiliation(s)
- Rob Baltussen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Evelinn Mikkelsen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Noor Tromp
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - AnneKarin Hurtig
- Deparment of Public Health and Clinical Medicine Umeå University, Umeå International School of Public Health, Umeå, Sweden
| | - Jens Byskov
- Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Øystein Olsen
- Department of Global Public Health and Primary Care University of Bergen, Bergen, Norway
| | - Kristine Bærøe
- Department of Global Public Health and Primary Care University of Bergen, Bergen, Norway
| | - Jan A Hontelez
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
| | - Jerome Singh
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Department of Public Health Sciences and Joint Centre for Bioethics, University of Toronto, Toronto, Canada
- Howard College School of Law, University of KwaZulu-Natal, Durban, South Africa
| | - Ole F Norheim
- Department of Global Public Health and Primary Care University of Bergen, Bergen, Norway
| |
Collapse
|
13
|
Goodwin E, Frew EJ. Using programme budgeting and marginal analysis (PBMA) to set priorities: reflections from a qualitative assessment in an English Primary Care Trust. Soc Sci Med 2013; 98:162-8. [PMID: 24331895 DOI: 10.1016/j.socscimed.2013.09.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 08/22/2013] [Accepted: 09/23/2013] [Indexed: 10/26/2022]
Abstract
In England from 2002 to 2013, Primary Care Trusts (PCTs) were responsible for commissioning healthcare for their local populations. The NHS has recently undergone rapid organisational change whereby clinicians have assumed responsibility for local commissioning decisions. This change in commissioning arrangements alongside the current financial pressures facing the NHS provides an impetus for considering the use of technical prioritisation methods to enable the identification of savings without having a detrimental effect on the health of the population. This paper reports on the design and implementation of a technical prioritisation method termed PBMA applied within NHS Plymouth, an English PCT responsible for commissioning services for a population of approximately 270,000. We evaluated the effectiveness of the process, the extent to which it was appropriate for local healthcare commissioning and whether it identified budget savings. Using qualitative research methodology, we found the process produced clear strategic and operational priorities for 2010/11, providing staff with focus and structure, and delivered a substantial planned reduction in hospital activity levels. Participants expressed satisfaction with the process. NHS Plymouth adhered to the PBMA process, although concerns were raised about the evidence for some priorities, decibel rationing, and a lack of robust challenge at priority-setting meetings. Further work is required to enhance participants' understanding of marginal analysis. Participants highlighted several external benefits, particularly in terms of cultural change, and felt the process should encompass the whole local health and social care community. This evaluation indicates that the prioritisation method was effective in producing priorities for NHS Plymouth, and that PBMA provides an appropriate method for allocating resources at a local level. In order for PBMA to identify savings, cultural and structural barriers to disinvestment must be addressed. These findings will interest other healthcare commissioners in developing their own approaches to priority-setting.
Collapse
Affiliation(s)
- Elizabeth Goodwin
- NHS Plymouth (Plymouth Primary Care Trust), Building One, Brest Road, Plymouth PL6 5QZ, UK.
| | - Emma J Frew
- Health Economics Unit, Public Health Building, University of Birmingham, B15 2TT, UK
| |
Collapse
|
14
|
Smith N, Mitton C, Bryan S, Davidson A, Urquhart B, Gibson JL, Peacock S, Donaldson C. Decision maker perceptions of resource allocation processes in Canadian health care organizations: a national survey. BMC Health Serv Res 2013; 13:247. [PMID: 23819598 PMCID: PMC3750381 DOI: 10.1186/1472-6963-13-247] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 06/06/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Resource allocation is a key challenge for healthcare decision makers. While several case studies of organizational practice exist, there have been few large-scale cross-organization comparisons. METHODS Between January and April 2011, we conducted an on-line survey of senior decision makers within regional health authorities (and closely equivalent organizations) across all Canadian provinces and territories. We received returns from 92 individual managers, from 60 out of 89 organizations in total. The survey inquired about structures, process features, and behaviours related to organization-wide resource allocation decisions. We focus here on three main aspects: type of process, perceived fairness, and overall rating. RESULTS About one-half of respondents indicated that their organization used a formal process for resource allocation, while the others reported that political or historical factors were predominant. Seventy percent (70%) of respondents self-reported that their resource allocation process was fair and just over one-half assessed their process as 'good' or 'very good'. This paper explores these findings in greater detail and assesses them in context of the larger literature. CONCLUSION Data from this large-scale cross-jurisdictional survey helps to illustrate common challenges and areas of positive performance among Canada's health system leadership teams.
Collapse
Affiliation(s)
- Neale Smith
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, 7th floor, 828 W 10 Avenue, V5Z1M9, Vancouver, BC, Canada.
| | | | | | | | | | | | | | | |
Collapse
|
15
|
Bosio C, Graffigna G, Scaratti G. Knowing, learning and acting in health care organizations and services. QUALITATIVE RESEARCH IN ORGANIZATIONS AND MANAGEMENT 2012. [DOI: 10.1108/17465641211279743] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
16
|
Nugus P, Greenfield D, Travaglia J, Braithwaite J. The politics of action research: "if you don't like the way things are going, get off the bus". Soc Sci Med 2012; 75:1946-53. [PMID: 22910192 DOI: 10.1016/j.socscimed.2012.06.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 04/04/2012] [Accepted: 06/27/2012] [Indexed: 10/28/2022]
Abstract
Participatory action research is lauded for its emancipatory potential and practice relevance. Little research has focused on the ethical and political dimensions of power relations between management gatekeepers and staff in large organizations in the negotiation of action research. To illuminate the dynamics of this engagement, this paper is informed by Aristotle's practical ethics of phronesis, arguing that ethics emerge through human interaction. The paper reports on a multi-method study and intervention in inter-professional learning and collaboration, conducted between 2008 and 2010, across an Australian health system. It draws on results from researchers' progress notes, 139 semi-structured interviews and focus groups (492 participants), more than 200 h of organizational document analysis, and more than 200 h of ethnographic observation. From conventional thematic analysis, we note that the project had considerable support from senior managers who were gatekeepers for the research. Such support stemmed from managerialist tendencies, with senior managers explicitly aligning inter-professionalism with prospective health reforms and improvements to quality of care and patient safety. Senior managers were also enthusiastic about standardized processes. Many frontline staff were less supportive, and some were suspicious of or hostile towards management-led processes to improve and evaluate care. Some senior managers' self perceived alignment with and support for the research process changed to resistance once this finding was presented. This paradox in the interplay of research findings and research process evinces the inherent tension between organizational politics and conducting action research that reflexive researchers need to negotiate in knowledge translation, exchange or mobilization exercises.
Collapse
Affiliation(s)
- Peter Nugus
- Centre for Clinical Governance Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Australia.
| | | | | | | |
Collapse
|
17
|
Smith N, Mitton C, Peacock S. Qualitative methodologies in health-care priority setting research. HEALTH ECONOMICS 2009; 18:1163-1175. [PMID: 18972324 DOI: 10.1002/hec.1419] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Priority setting research in health economics has traditionally employed quantitative methodologies and been informed by post-positivist philosophical assumptions about the world and the nature of knowledge. These approaches have been rewarded with well-developed and validated tools. However, it is now commonly noted that there has been limited uptake of economic analysis into actual priority setting and resource allocation decisions made by health-care systems. There seem to be substantial organizational and political barriers. The authors argue in this paper that understanding and addressing these barriers will depend upon the application of qualitative research methodologies. Some efforts in this direction have been attempted; however these are theoretically under-developed and seldom rooted in any of the established qualitative research traditions. Two such approaches - narrative inquiry and discourse analysis - are highlighted here. These are illustrated with examples drawn from a real-world priority setting study. The examples demonstrate how such conceptually powerful qualitative traditions produce distinctive findings that offer unique insight into organizational contexts and decision-maker behavior. We argue that such investigations offer untapped benefits for the study of organizational priority setting and thus should be pursued more frequently by the health economics research community.
Collapse
Affiliation(s)
- Neale Smith
- Faculty of Health and Social Development, University of British Columbia Okanagan, BC, Canada
| | | | | |
Collapse
|
18
|
Peacock S, Mitton C, Bate A, McCoy B, Donaldson C. Overcoming barriers to priority setting using interdisciplinary methods. Health Policy 2009; 92:124-32. [PMID: 19346024 DOI: 10.1016/j.healthpol.2009.02.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2008] [Revised: 02/13/2009] [Accepted: 02/14/2009] [Indexed: 10/20/2022]
Abstract
Ten years ago, Holm's highly influential paper "Goodbye to the simple solutions: the second phase of priority setting" was published [Holm S. Goodbye to the simple solutions: the second phase of priority setting in health care. British Medical Journal 1998;317:1000-7]. Whilst attending the 2nd International Conference on Priorities in Health Care in London, Holm argued that the search for a rational set of decision-making rules was no longer adequate. Instead, the priority setting process itself was now thought to be more complex. Ten years later, the Conference returns to the UK for the first time, and it is timely to describe some new tools intended to assist both researchers and decision-makers seeking to develop both rational and fair and legitimate priority setting processes. In this paper we argue that to do so, researchers and decision-makers need to adopt an interdisciplinary and collaborative approach to priority setting. We focus on program budgeting and marginal analysis (PBMA) and bring together three hitherto separate interdisciplinary strands of the PBMA literature. Our aim is to assist researchers and decision-makers seeking to effectively develop and implement PBMA in practice. Specifically, we focus on the use of multi-criteria decision analysis, participatory action research, and accountability for reasonableness, drawn from the disciplines of decision analysis, sociology, and ethics respectively.
Collapse
Affiliation(s)
- Stuart Peacock
- Centre for Health Economics in Cancer, British Columbia Cancer Agency, Canada.
| | | | | | | | | |
Collapse
|