Accounting for reasonableness: Exploring the personal internal framework affecting decisions about cancer drug funding

OBJECTIVES: Drug decision-makers are involved in developing and implementing policy, procedure and processes to support health resource allocation regarding drug treatment formularies. A variety of approaches to decision-making, including formal decision-making frameworks, have been developed to support transparent and fair priority setting. Recently, a decision tool, 'The 6-STEPPPs Tool', was developed to assist in making decisions about new cancer drugs within the public health care system. METHODS: We conducted a qualitative study, utilizing focus groups and participant observation, in order to investigate the internal frameworks that supported and challenged individual participants as they applied this decision tool within a multi-stakeholder decision process. RESULTS: We discovered that health care resource allocation engaged not only the minds of decision-makers but profoundly called on the often conflicting values of the heart. CONCLUSIONS: Objective decision-making frameworks for new drug therapies need to consider the subjective internal frameworks of decision-makers that affect decisions. Understanding the very human, internal turmoil experienced by individuals involved in health care resource allocation, sheds additional insight into how to account for reasonableness and how to better support difficult decisions through transparent, values-based resource allocation policy, procedures and processes.     

A linear programming model for allocating HIV prevention funds with state agencies: a pilot study

Given the initiatives to improve resource allocation decisions for HIV prevention activities, a linear programming model was designed specifically for use by state and local decision-makers. A pilot study using information from the state of Florida was conducted and studied under a series of scenarios depicting the impact of common resource allocation constraints. Improvements over the past allocation strategy in the number of potential infections averted were observed in all scenarios with a maximal improvement of 73%. When allocating limited resources, policymakers must balance efficiency and equity. In this pilot study, the optimal allocation (i.e., most-efficient strategy) would not distribute resources in an equitable manner. Instead, only 12% of at-risk people would receive prevention funds. We find that less efficient strategies, where 58% fewer infections are averted, result in significantly more equitable allocations. This tool serves as a guide for allocating funds for prevention activities. Funding: This research was supported by Cooperative Agreement Number R18/CCR420943 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent official views of the CDC.     

Decentralization and equity of resource allocation: evidence from Colombia and Chile

OBJECTIVE: To investigate the relation between decentralization and equity of resource allocation in Colombia and Chile. METHODS: The "decision space" approach and analysis of expenditures and utilization rates were used to provide a comparative analysis of decentralization of the health systems of Colombia and Chile. FINDINGS: Evidence from Colombia and Chile suggests that decentralization, under certain conditions and with some specific policy mechanisms, can improve equity of resource allocation. In these countries, equitable levels of per capita financial allocations at the municipal level were achieved through different forms of decentralization--the use of allocation formulae, adequate local funding choices and horizontal equity funds. Findings on equity of utilization of services were less consistent, but they did show that increased levels of funding were associated with increased utilization. This suggests that improved equity of funding over time might reduce inequities of service utilization. CONCLUSION: Decentralization can contribute to, or at least maintain, equitable allocation of health resources among municipalities of different incomes.     

Equity in resource allocation in the Irish health service. A policy Delphi study

Resource allocation in the Irish health service, based on historical allocations with incremental increases, is widely believed to be inequitable. Using a three-round policy Delphi survey, which seeks to explore both consensus and disagreement surrounding policy issues, the views of 52 senior health service personnel were sought in order to determine ways to improve equity in resource allocation. Panelists provided several reasons why the current method of resource allocation is inequitable and several suggestions for improving equity. The level of consensus on views was determined by calculating the percentage of ratings in each category based on a series of rating scales. The main suggestion centred around the development and implementation of a needs based resource allocation formula. Panelists reached a high consensus in favour of this but only reached a low consensus as to its feasibility. Potential obstacles identified included methodological difficulties, insufficient resources and resistance from potential losers. These findings highlight concerns about the lack of transparency in the resource allocation process and openness to the development of a more equitable needs based resource allocation model, a move which is becoming more common internationally. Feasibility concerns should not preclude an attempt to begin this process.     

贵州省县级疾控机构人力资源现状及公平性分析

目的 分析贵州省县级疾控中心（以下简称“县级疾控”）现有人力资源现状及公平性,为疾控人才队伍建设提供参考依据。方法 采用多阶段分层随机抽样的方法,抽取贵州省18所县级疾控,通过调查表收集机构编制和人员数量、职称、学历等情况,用构成比对卫生资源配置情况进行描述性分析;运用洛伦兹曲线和基尼系数从人口/面积/经济维度对卫生资源配置的公平性进行分析。结果 贵州省被调查县级疾控每万人实有编制0.97个;每万人常住人口拥有在编疾控人员0.84人;学历以本科为主（43.71%）;职称以初级及以下职称为主（71.01%）;不同地区间人员在编情况（χ²= 30.143,P＜0.001）、性别（χ²= 24.248,P＜0.001）、年龄（χ²= 25.896,P = 0.004）、职称（χ² = 26.952,P = 0.001）、学历（χ²= 32.874,P＜0.001）和专业（χ²= 109.208,P＜0.001）分布差异有统计学意义（P＜0.05）。编制、在职人员及在编人员按人口、面积配置公平性相对较好,按经济配置公平性有待进一步提高。结论 政府应加大对疾控的经费和政策支持,完善人才准入机制和培养机制,提高疾控人员待遇;在进行疾控人力资源配置时,应综合考虑人口、地理面积和经济3个方面,以促进疾控人员配置更加公平和合理。     

基于集聚度和差别指数的东北三省疾控中心人力资源配置公平性分析

目的 对我国东北三省（黑龙江省、吉林省、辽宁省）疾控中心人力资源配置公平性进行分析,比较与全国水平差异及其省间差异,为人力资源合理配置提供参考。方法 收集2015—2019年东北三省及全国人口和地理因素、疾控中心人力资源资料,计算卫生资源集聚度（Health Resource Agglomeration Degree, HRAD）、人口集聚度（Population Agglomeration Degree,PAD）、HRAD-PAD值和差别指数（Index of Dissimilarity,ID）,分析我国东北三省疾控中心人力资源配置公平性及其变化趋势。结果 2015—2019年间东北三省疾控中心人员总数减少了16.0%,从18 754人减少至15 756人,减少率明显高于全国（1.8%）。在单位面积人力资源占有量上,黑龙江省（0.012~0.014人/平方千米）低于全国平均水平（0.020人/平方千米）。三省HRAD和HRAD-PAD值均逐年降低;三省资源按地理面积分布上的差异（ID:0.140~0.301）明显高于按人口数量分布上的差异（ID:0.003~0.105）（P<0.001）。结论 东北三省疾控中心人力资源流失情况较为严重,建议应加强疾控队伍建设,优化我国疾控中心人力资源结构、完善激励机制,吸引人才,提升疾控人力资源配置的公平性。     

Protecting resources for primary health care under fiscal federalism: options for resource allocation

The introduction of fiscal federalism or decentralization of functions to lower levels of government is a reform not done primarily with health sector concerns. A major concern for the health sector is that devolution of expenditure responsibilities to sub-national levels of government can adversely affect the equitable distribution of financial resources across local jurisdictions. Since the adoption of fiscal federalism in South Africa, progress towards achieving a more equitable distribution of public sector health resources (financial) has slowed down considerably. This study attempts to identify appropriate resource allocation mechanisms under the current South African fiscal federal system that could be employed to promote equity in primary health care (PHC) allocations across provinces and districts. The study uses data from interviews with government officials involved in the budgeting and resource allocation process for PHC, literature on fiscal federalism and literature on international experience to inform analysis and recommendations. The results from the study identify historical incremental budgeting, weak managerial capacity at lower levels of government, poor accounting of PHC expenditure, and lack of protection for PHC funds as constraints to the realization of a more equitable distribution of PHC allocations. Based on interview data, no one resource allocation mechanism received unanimous support from stakeholders. However, the study highlights the particularly high level of autonomy enjoyed by provincial governments with regards to decision making for allocations to health and PHC services as the major constraint to achieving a more equitable distribution of PHC resources. The national government needs to have more involvement in decision making for resource allocation to PHC services if significant progress towards equity is to be achieved.     

Outcome based state budget allocation for diabetes prevention programs using multi-criteria optimization with robust weights

We consider the problem of outcomes based budget allocations to chronic disease prevention programs across the United States (US) to achieve greater geographical healthcare equity. We use Diabetes Prevention and Control Programs (DPCP) by the Center for Disease Control and Prevention (CDC) as an example. We present a multi-criteria robust weighted sum model for such multi-criteria decision making in a group decision setting. The principal component analysis and an inverse linear programming techniques are presented and used to study the actual 2009 budget allocation by CDC. Our results show that the CDC budget allocation process for the DPCPs is not likely model based. In our empirical study, the relative weights for different prevalence and comorbidity factors and the corresponding budgets obtained under different weight regions are discussed. Parametric analysis suggests that money should be allocated to states to promote diabetes education and to increase patient-healthcare provider interactions to reduce disparity across the US.     

Optimal incentives for allocating HIV/AIDS prevention resources among multiple populations

Many agencies, such as the United Nations Program on HIV/AIDS (UNAIDS), the World Health Organization (WHO), the World Bank, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), and the Global Fund to Fight AIDS, Tuberculosis and Malaria, provide funding to prevent HIV/AIDS infections worldwide. These funds are allocated at multiple levels, resulting in a highly complicated distribution process. An oversight agency allocates funds to various national-level decision-makers who then allocate funds to regional-level decision-makers who in turn distribute the monies to local organizations, programs, or risk groups. Simple allocation techniques are often preferred by the decision-makers at each administrative level, but such methods can lead to sub-optimal allocation of funds. Thus, incentives could be provided to decisionmakers in order to encourage optimal allocation of HIV/AIDS prevention resources. We formulate an incentive-based resource allocation model that takes into consideration strategic interactions between decision-makers in a multiple-level resource-allocation process. We analyze each decision-maker's behavior at the equilibrium and summarize the results that characterize the optimal solution to the resource-allocation problem. Our intended audiences are technical experts, decision-makers, and policy-makers in governments who can make use of incentives to encourage effective decisions regarding HIV/AIDS policy modeling and budget allocation at local levels.     

Recommendations for increasing the use of HIV/AIDS resource allocation models

Background

Resource allocation models have not had a substantial impact on HIV/AIDS resource allocation decisions in spite of the important, additional insights they may provide. In this paper, we highlight six difficulties often encountered in attempts to implement such models in policy settings; these are: model complexity, data requirements, multiple stakeholders, funding issues, and political and ethical considerations. We then make recommendations as to how each of these difficulties may be overcome.

Results

To ensure that models can inform the actual decision, modellers should understand the environment in which decision-makers operate, including full knowledge of the stakeholders' key issues and requirements. HIV/AIDS resource allocation model formulations should be contextualized and sensitive to societal concerns and decision-makers' realities. Modellers should provide the required education and training materials in order for decision-makers to be reasonably well versed in understanding the capabilities, power and limitations of the model.

Conclusion

This paper addresses the issue of knowledge translation from the established resource allocation modelling expertise in the academic realm to that of policymaking.

     

Public health equity in refugee situations

Addressing increasing concerns about public health equity in the context of violent conflict and the consequent forced displacement of populations is complex. Important operational questions now faced by humanitarian agencies can to some extent be clarified by reference to relevant ethical theory. Priorities of service delivery, the allocation choices, and the processes by which they are arrived at are now coming under renewed scrutiny in the light of the estimated two million refugees who fled from Iraq since 2003. Operational questions that need to be addressed include health as a relative priority, allocations between and within different populations, and transition and exit strategies. Public health equity issues faced by the humanitarian community can be framed as issues of resource allocation and issues of decision-making. The ethical approach to resource allocation in health requires taking adequate steps to reduce suffering and promote wellbeing, with the upper bound being to avoid harming those at the lower end of the welfare continuum. Deliberations in the realm of international justice have not provided a legal or implementation platform for reducing health disparities across the world, although norms and expectations, including within the humanitarian community, may be moving in that direction. Despite the limitations of applying ethical theory in the fluid, complex and highly political environment of refugee settings, this article explores how this theory could be used in these contexts and provides practical examples. The intent is to encourage professionals in the field, such as aid workers, health care providers, policy makers, and academics, to consider these ethical principles when making decisions.     

社区卫生资源配置现状及公平性研究

[目的]探讨江苏苏省F市社区卫生资源配置现状及公平性程度,在逐步城乡一体化的背景下,为F市卫生行政部门优化社区卫生资源配置提供政策依据.[方法]采用描述性分析、Lorenz曲线和Gini系数等方法对2006年江苏省F市社区卫生资源配置的合理性及人口和地理的公平性进行分析和评价.[结果]F市社区卫生机构中管理及工勤人员偏多,护理人员、医技人员及中高级职称人员数量有待提高.2006年F市11个乡镇卫生技术人员数、医生数、护士数、政府投入社区卫生经费、卫生机构数、社区卫生服务机构效、业务用房面积、万元以上设备台数、医疗机构床位数在人口配置上,Gini系数分别为0.35、0.32、0.49、0.10、0.23、0.23、0.45、0.57、0.43;在地理配置上.Gini 系数分别为0.51、0.44、0.65、0.23、0.23、0.16、0.60、0.72、0.59.[结论]F市卫生资源配置不尽合理,卫生资源配置的人口公平性和地理公平性都需要提高,对卫生资源配置,政府需要进一步加强政策引导.     

Coping with uncertainty: decisions and resources within health authorities

Summary This article reports on a two-year study which looked at decision-making in two Scottish health boards. The study, which focused on the allocation of development funds (growth monies), is about understanding and not about reform. It was prompted by: (1) a dearth of knowledge concerning the dynamics of decision-making in the National Health Service (NHS) at local level, especially since the 1974 reorganisation of the Service; and (2) a desire to understand the factors at local level which might help to explain the persistence of resource imbalances between different sectors of health care despite successive attempts by central government to remove them. The study suggests that, contrary to much popular opinion, decision-making in the NHS is decentralised - the two health boards featured in the research possessed a large measure of influence over the services they provided. Aside from rational and incremental theories of decision-making which were of value in compre-hending the decision process observed, the notion of puzzlement as a factor determining decision outcomes was found to be of particular value in the context of the allocation of development funds. The main study findings were: (1) that a policy of appeasing competing, and equally demanding, interests rendered change exceptional although not impossible, as was shown by the emphasis placed upon community health services; (2) that various constraints, both internal and external, operated on decision-makers; and (3) that a number of coping strategies were adopted by decision-makers in order to structure their uncertain and unpredictable environment and to manage the constraints on them.     

Accounting for the increase in NSAID expenditure: substitution or leakage?

Priority setting of health interventions is often ad-hoc and resources are not used to an optimal extent. Underlying problem is that multiple criteria play a role and decisions are complex. Interventions may be chosen to maximize general population health, to reduce health inequalities of disadvantaged or vulnerable groups, ad/or to respond to life-threatening situations, all with respect to practical and budgetary constraints. This is the type of problem that policy makers are typically bad at solving rationally, unaided. They tend to use heuristic or intuitive approaches to simplify complexity, and in the process, important information is ignored. Next, policy makers may select interventions for only political motives. This indicates the need for rational and transparent approaches to priority setting. Over the past decades, a number of approaches have been developed, including evidence-based medicine, burden of disease analyses, cost-effectiveness analyses, and equity analyses. However, these approaches concentrate on single criteria only, whereas in reality, policy makers need to make choices taking into account multiple criteria simultaneously. Moreover, they do not cover all criteria that are relevant to policy makers. Therefore, the development of a multi-criteria approach to priority setting is necessary, and this has indeed recently been identified as one of the most important issues in health system research. In other scientific disciplines, multi-criteria decision analysis is well developed, has gained widespread acceptance and is routinely used. This paper presents the main principles of multi-criteria decision analysis. There are only a very few applications to guide resource allocation decisions in health. We call for a shift away from present priority setting tools in health – that tend to focus on single criteria – towards transparent and systematic approaches that take into account all relevant criteria simultaneously.     

Clarifying Efficiency-Equity Tradeoffs Through Explicit Criteria,With a Focus on Developing Countries

Expenditures on health in many developing countries are being disproportionately spent on health services that have a low overall health impact, and that disproportionately benefit the rich. Without explicit consideration of priority setting, this situation is likely to remain unchanged: resource allocation is too often dictated by historical patterns, and maintains vested interests. This paper explores how prioritization between different health interventions can be rationalised by the use of clearly defined criteria. A number of key efficiency and equity criteria are examined, in particular analysing how potential tradeoffs could be incorporated into the decision making process.     

四川省中药房资源配置的公平性及效率研究

目的 以市（州）为单位,对四川省医院中药房资源配置的公平性及效率进行分析。方法 采用分层抽样,将四川省21个市（州）按经济水平及地理分布进行分层,抽取了其中17个市（州）。应用集聚度分析17个市（州）中药房资源配置的公平性;采用数据包络分析（data envelopment analysis,DEA）方法,测量中药房的客观效率值。结果 在17个市（州）34组数据中,中药房和执业医师HRAD值大于相应HRAD/PAD比值的有22组,因此四川省医院中药房资源按地理位置配置的公平性优于按人口配置的公平性。阿坝州中药房及执业医师的比值分别为43.171、27.261,远大于其他市,所以阿坝州按人口配置的公平性远高于其他市。泸州市、德阳市、绵阳市、乐山市、宜宾市和达州市无论是在地理位置还是人口分布上,中药房资源配置公平性都达到了较高（中药房和执业医师集聚度和比值均大于1）,其余市（州）并未达到绝对公平。各市（州）的医院中药房综合技术效率较低,均低于0.400。总体的综合技术效率值为0.167,为弱有效。结论 应强化四川省医院中药房资源的配置公平性,缩小地域差异,同时注重提升医院中药房的效率。     

A cost-based equity weight for use in the economic evaluation of primary health care interventions: case study of the Australian Indigenous population

Background

Efficiency and equity are both important policy objectives in resource allocation. The discipline of health economics has traditionally focused on maximising efficiency, however addressing inequities in health also requires consideration. Methods to incorporate equity within economic evaluation techniques range from qualitative judgements to quantitative outcomes-based equity weights. Yet, due to definitional uncertainties and other inherent limitations, no method has been universally adopted to date. This paper proposes an alternative cost-based equity weight for use in the economic evaluation of interventions delivered from primary health care services.

Methods

Equity is defined in terms of 'access' to health services, with the vertical equity objective to achieve 'equitable access for unequal need'. Using the Australian Indigenous population as an illustrative case study, the magnitude of the equity weight is constructed using the ratio of the costs of providing specific interventions via Indigenous primary health care services compared with the costs of the same interventions delivered via mainstream services. Applying this weight to the costs of subsequent interventions deflates the costs of provision via Indigenous health services, and thus makes comparisons with mainstream more equitable when applied during economic evaluation.

Results

Based on achieving 'equitable access', existing measures of health inequity are suitable for establishing 'need', however the magnitude of health inequity is not necessarily proportional to the magnitude of resources required to redress it. Rather, equitable access may be better measured using appropriate methods of health service delivery for the target group. 'Equity of access' also suggests a focus on the processes of providing equitable health care rather than on outcomes, and therefore supports application of equity weights to the cost side rather than the outcomes side of the economic equation.

Conclusion

Cost-based weights have the potential to provide a pragmatic method of equity weight construction which is both understandable to policy makers and sensitive to the needs of target groups. It could improve the evidence base for resource allocation decisions, and be generalised to other disadvantaged groups who share similar concepts of equity. Development of this decision-making tool represents a potentially important avenue for further health economics research.     

A spatial decision support tool for estimating population catchments to aid rural and remote health service allocation planning

There is mounting pressure on healthcare planners to manage and contain costs. In rural regions, there is a particular need to rationalize health service allocation to ensure the best possible coverage for a dispersed population. Rural health administrators need to be able to quantify the population affected by their allocation decisions and, therefore, need the capacity to incorporate spatial analyses into their decision-making process. Spatial decision support systems (SDSS) can provide this capability. In this article, we combine geographical information systems (GIS) with a web-based graphical user interface (webGUI) in a SDSS tool that enables rural decision-makers charged with service allocation, to estimate population catchments around specific health services in rural and remote areas. Using this tool, health-care planners can model multiple scenarios to determine the optimal location for health services, as well as the number of people served in each instance.     

Equity considerations in health care: the relevance of claims

The general issues of equity and efficiency are central to the analysis of resource allocation problems in health care. We examine them using axiomatic bargaining theory. We study different solutions that have been proposed and relate them to previous literature on health care allocation. In particular, we focus on the solutions based on axiomatic bargaining with claims, and show that they are appealing as distributive criteria in health policy. Finally, we present the results of a survey that tries to elicit moral intuitions of people about resource allocation problems and their different solutions.     

大型医用设备地理分布公平性的评估方法研究

该研究的目的是探索一种评价大型医用设备配置公平性的方法,为区域卫生规划工作和卫生资源的合理配置提供分析工具。方法：劳伦兹曲线和基尼系数是经济学中评价收入公平性的良好方法,作者依据其原理提出可以利用基尼系数评价大型设备配置的公平性,并利用一个省大型医用设备调查的数据绘制了设备配置的劳伦兹曲线,计算了相应的基尼系数。结果：大型医用设备配置的基尼系数为0．366,CT配置的基尼系数为0.245,CT配置的公平程度要稍好于大型医用设备的总体情况。结论：大型医用设备在配置规划上要多向配置水平较低的地区倾斜,以改善公平性。劳伦兹曲线和基尼系数也可用于卫生资源配置公平性评价的其他方面,如医师和护士的配置以及床位资源的配置。可以为区域卫生规划工作提供决策参考依据。