Priority setting in health authorities: a novel approach to a historical activity

As resources in health care are scarce, health authorities and other health organizations are charged with determining how best to spend limited resources. While a number of formal approaches to priority setting within health authorities have been used internationally, there has been limited success with such activity, particularly across major service portfolios. This participatory action research project instituted a novel priority setting framework, coined macro-marginal analysis (MMA), in a fully integrated urban health region in Alberta, Canada. The focus of MMA is on identifying areas for service growth and areas for resource release, then determining, based on pre-defined, locally generated criteria, if actual shifts or re-allocation of resources should occur. For fiscal year 2002/03, the Calgary Health Region identified over 40 M dollars in resource releases (approximately 3% of the total budget), which were made available for servicing the deficit, and more importantly for our purposes, re-investing in service growth areas. The MMA framework is pragmatic in nature and has the ability to incorporate relevant evidence directly into the decision-making process. This work constitutes a significant advancement in health economics, and responds where previous priority setting approaches have failed in that it allows decision-makers to achieve genuine re-allocation of resources with the aim of improving population health or better meeting other important criteria.     

Injury morbidity in an urban and a rural area in Tanzania: an epidemiological survey

Background  

Injuries are becoming a major health problem in developing countries. Few population based studies have been carried out in African countries. We examined the pattern of nonfatal injuries and associated risk factors in an urban and rural setting of Tanzania.     

Fostering an Internet-based work group in community health through action research

In this article, we describe an action research study to foster an Internet-based work group as part of a two-year community health research training program in Alberta, Canada. The objectives of our study were to incorporate Internet-based technology into the program, establish a distributed work group over time, and reflect on the lessons learned. The participants represented seventeen health regions. There were thirty-five instructors and expert resource persons (varied over time), two training coordinators, four support staff, a program coordinator, two action researchers, and two independent consultants. The data collected included program documents, phone interviews, online surveys, meeting notes, online discussions, computer usage log, site visits, keystroke entry logs, help desk logs, and program evaluation reports. Content analysis was conducted with NUD*IST to identify concepts and themes from the data. Our findings suggest that role clarification, facilitative support, network linkages, and workplace learning are important aspects of fostering Internet-based work groups in a health setting, where members strive to establish themselves, seek meaning in their work, support each other, and add value to their organizations.     

基于知识的专家系统在产前诊断应用的设想

作为人工智能的重要分支，基于知识的专家系统目前在医疗行业得到了广泛的应用，但一般停留在中医诊断等，我们设想在西医中开发一套集诊断、健康生活指导、饮食营养建议、健康宣教等一体的专家系统，选择了产前诊断专家系统作一个探索，本文详述了系统结构、工作流程和开发思路，并分析了该系统对临床医护人员、孕妇和政府的意义，展示了其光辉的前景。     

兰州市自来水局部苯指标超标事件应急处置分析

目的 通过对兰州自来水局部苯指标超标事件的卫生应急处置工作进行分析,系统分析其应急处理方法、流程与效果,为政府、卫生和疾控等相关部门制定相应应急对策提供科学依据,对应急工作中采取的诸多应急处置措施进行归纳总结,分析应急处置工作取得的成效和存在的主要问题及建议.方法 收集兰州市政府、兰州威立雅水务集团公司及兰州市疾控中心统计数据、公告、报表和会议纪要等,采用描述分析应急处置措施、处置效果和存在问题及建议.结果 此次自来水局部苯指标超标事件,造成饮用水危机,兰州市政府采取了应急措施,及时公开信息、免费限量供应成品饮用水和治理污染,动态监测水质、实时公开检测结果,经过紧急处置,饮用水各项指标符合国家标准,解除应急状态.结论 有效的多部门联动机制和开展动态监测、信息实时公开和共享,多途径采取应急处置措施可有效、迅速控制饮用水污染事件.     

运用爱国卫生工作方法渐进式推进健康村工程——南海区建设健康村的主要做法

佛山市南海区在政府领导和专家指导下,创造性地运用爱国卫生工作的方式进行健康村建设的积极探索,选取试点后,通过制定健康村指标以及评估体系、大力宣传和动员全民参与、严格落实指标执行、专家评估的方式和做法,在实践中渐进推行健康村工程,为如何进一步提高农村卫生、居民健康水平和推进农村卫生事业发展积累了极为宝贵的经验。     

发展城市社区卫生服务的思考

社区卫生服务是城市卫生工作的重要组成部分,目前我国在发展社区卫生服务的进程中仍然存在卫生资源配置不合理、人才缺乏、政策落实不到位、双向转诊存在障碍等问题。为了进一步促进社区卫生服务的发展,作者提出了如下对策:优化卫生资源配置、加大对社区卫生事业资源投入;建立人才保障机制;强化政府职能,因地制宜,落实好各项政策;加强机构建设,完善双向转诊制度等。     

Resource Allocation in Health Care: Health Economics and Beyond

As resources in health care are scarce, managers and clinicians must make difficult choices about what to fund and what not to fund. At the level of a regional health authority, limited approaches to aid decision makers in shifting resources across major service portfolios exist. A participatory action research project was conducted in the Calgary Health Region. Throughfive phases of action, including observation of senior management meetings, as well as two sets of one-on-one interviews and two focus groups, an approach to priority setting at the macro level within the health region was developed and implemented. The resulting macro level approach builds on the program budgeting and marginal analysis (PBMA)framework. Using a multi-disciplinary expert panel, about dollar 45M (CAN) was released for the 2002/03 fiscal year and made available for re-allocation to service growth areas and the deficit. Important qualitative themes from the managers and clinicians informed both process development and refinement. The approach developed here not only facilitated re-allocation of resources, but also drew in both clinicians and managers to work together on this challenging task. The approach is pragmatic, transparent and evidence based, and should have application elsewhere.     

发展城市社区卫生服务的思考

社区卫生服务是城市卫生工作的重要组成部分,目前我国在发展社区卫生服务的进程中仍然存在卫生资源配置不合理、人才缺乏、政策落实不到位、双向转诊存在障碍等问题。为了进一步促进社区卫生服务的发展,作者提出了如下对策：优化卫生资源配置、加大对社区卫生事业资源投入;建立人才保障机制;强化政府职能,因地制宜,落实好各项政策;加强机构建设,完善双向转诊制度等。     

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.     

云南省农村社区卫生工作的做法及体会

云南省卫生厅与加拿大国际发展署在云南省的 10个县开展了建立自我依靠思想、依靠社区资源解决社区妇女、儿童健康问题的社区卫生工作为主的妇幼保健合作项目。项目实施后 ,社区妇幼卫生工作者服务能力不断提高、妇幼保健服务不断完善、社区参与意识不断增强、群众开始关注自己的健康 ,孕产妇死亡率及婴儿死亡率呈逐年下降趋势。云南省农村社区卫生工作模式的探索及经验 ,为边远、贫困地区在有限资源的情况下 ,依靠社区力量解决社区卫生问题 ,促进妇幼保健工作持续发展提供了一种很好的思路     

Making choices in healthcare: the reality of scarcity

Processes are required to aid decision-makers in better managing existing resources in healthcare. To date, limited research has informed priority setting at the macro level, across broad service areas, within health organizations. As part of a participatory action research project, a macro-level resource allocation framework was developed and implemented in the Calgary Health Region (CHR). The approach relies on an expert panel of managers and clinicians who are charged with identifying, on the basis of evidence and local information, how resources might be reallocated to improve population well-being. The framework developed was seen as an improvement over historical allocation processes.     

The clubhouse as an empowering setting

Attention to psychosocial rehabilitation (PSR) practice has expanded in recent years. However, social work research studies on PSR are not numerous. This study focuses on operational characteristics of clubhouses, a major PSR program model, and the organizational attributes (including resource levels) that predict the extent to which the clubhouse constitutes an empowering setting. The authors present data from a statewide sample of 30 clubhouses, annually serving nearly 4,000 consumers (adults with serious mental illnesses), based on interviews of clubhouse directors, on-site observations, and government information sources. Results indicate that users were predominantly male, white, and middle age; about one-third had a major functional disability. There were wide variations in member characteristics as well as in resource levels. In terms of empowerment, this sample of clubs averaged rather low levels of member involvement in governance and operations but seemed to provide members with opportunities and assistance in making their own decisions. The empowerment variables had different predictors, including client characteristics, urban-related characteristics, staffing, and resource levels. Implications for social work practice in PSR settings are discussed.     

A paradox in healthcare service development: Professionalization of service users

Policy makers increasingly regard user involvement as an important dimension of service development. However, research suggests user involvement is often unrepresentative and tokenistic. Drawing on an in-depth case study in mental health carried out in 2008–2012, we examine the processes that give rise to unrepresentative service user involvement. We show that through a combination of self-selection by those wanting to be involved, and professionals actively selecting, educating and socializing certain users, unrepresentative involvement occurs. The selected users tend to be more articulate and able to work with professionals, and are complicit in the processes which give rise to unrepresentative involvement. They pursue their own professional status by delineating a distinctive body of ‘expert’ management knowledge that bounds their jurisdiction, and from which they can exclude those they perceive as ‘less expert’ users.     

Process of construction of an educational booklet for health promotion of pregnant women

This study aimed to describe the production process of an educational booklet focusing on health promotion of pregnant women. The action research method was used in this process composed of the following steps: choice of the content based on the needs of pregnant women, creation of illustrations, content preparation based on scientific literature, validation of the material by experts and pregnant women. This work resulted in the final version of the booklet, which was entitled "Celebrating life: our commitment with the health promotion of pregnant women". Active participation of health professionals and pregnant women through dialogue and collective strategy permeated the process of development of the booklet. The opinions of pregnant women and experts who considered the booklet enriching and enlightening justify the use of it as an additional resource of educational activities carried out during the prenatal care.     

Setting health care capitations through diagnosis-based risk adjustment: a suitable model for the English NHS?

The English system of health resource allocation has been described as the apotheosis of the area-level approach to setting health care capitations. However, recent policy developments have changed the scale at which commissioning decisions are made (and budgets allocated) with important implications for resource allocation. Doubts concerning the legitimacy of applying area-based formulae used to distribute resources between Primary Care Trusts (PCTs) to the much smaller scale required by Practice Based Commissioning (PBC) led the English Department of Health (DH) to introduce a new approach to setting health care budgets. To this end, practice-level allocations for acute services are now calculated using a diagnosis-based capitation model of the kind used in the United States and several other systems of competitive social health insurance. The new Coalition Government has proposed that these budgets are directly allocated to GP ‘consortia’, the new commissioning bodies in the NHS.This paper questions whether this is an appropriate development for a health system in which the major objective of resource allocation is to promote equal opportunity of access for equal needs. The chief reservation raised is that of circularity and the perpetuation of resource bias, the concern being that an existing social, demographic and geographical bias in the use of health care resources will be reinforced through the use of historic utilisation data. Demonstrating that there are legitimate reasons to suspect that this will be the case, the paper poses the question whether health systems internationally should more openly address the key limitations of empirical methods that select risk adjusters on the basis of existing patterns of health service utilisation.     

Expertising according to the federal German social welfare legislation and child and adolescent welfare laws by public health offices--results of an inquiry

Between December 2000 and February 2001 a survey among public health offices was conducted on the practice of expert reports on recipients of income support. More than 50 % (232) of the German public health offices participated; they carried out 164.000 of these reports in 1999. The analysis of the data shows considerable differences between the states (Bundesl?nder) concerning reasons and practice of expert reports which cannot be explained by a different social structure of population but indicate that quality of orders from Social Services and the work process in Public Health Offices may be inadequate. The findings result in recommendations for social services and public health offices to develop standards and improve quality, which can help to achieve greater equality.     

Is cost-effectiveness analysis preferred to severity of disease as the main guiding principle in priority setting in resource poor settings? The case of Uganda

INTRODUCTION: Several studies carried out to establish the relative preference of cost-effectiveness of interventions and severity of disease as criteria for priority setting in health have shown a strong preference for severity of disease. These preferences may differ in contexts of resource scarcity, as in developing countries, yet information is limited on such preferences in this context. OBJECTIVE: This study was carried out to identify the key players in priority setting in health and explore their relative preference regarding cost-effectiveness of interventions and severity of disease as criteria for setting priorities in Uganda. DESIGN: 610 self-administered questionnaires were sent to respondents at national, district, health sub-district and facility levels. Respondents included mainly health workers. We used three different simulations, assuming same patient characteristics and same treatment outcome but with varying either severity of disease or cost-effectiveness of treatment, to explore respondents' preferences regarding cost-effectiveness and severity. RESULTS: Actual main actors were identified to be health workers, development partners or donors and politicians. This was different from what respondents perceived as ideal. Above 90% of the respondents recognised the importance of both severity of disease and cost-effectiveness of intervention. In the three scenarios where they were made to choose between the two, a majority of the survey respondents assigned highest weight to treating the most severely ill patient with a less cost-effective intervention compared to the one with a more cost-effective intervention for a less severely ill patient. However, international development partners in in-depth interviews preferred the consideration of cost-effectiveness of intervention. CONCLUSIONS: In a survey among health workers and other actors in priority setting in Uganda, we found that donors are considered to have more say than the survey respondents found ideal. Survey respondents considered both severity of disease and cost-effectiveness important criteria for setting priorities, with severity of disease as the leading principle. This pattern of preferences is similar to findings in context with relatively more resources. In-depth interviews with international development partners, showed that this group put relatively more emphasis on cost-effectiveness of interventions compared to severity of disease. These discrepancies in attitudes between national health workers and representatives from the donors require more investigation. The different attitudes should be openly debated to ensure legitimate decisions.     

云南省曲靖市临床医师配置标准测算及制定方法研究

[目的]测算曲靖市医疗卫生人力资源配置标准,为当地政府制定卫生规划提供理论依据。[方法]统计描述曲靖市2005-2010年医疗卫生人员千人口拥有量;分别采用卫生服务需求法、人口比值法和专家咨询法三种方法各自测算出一个医疗医师的配置标准,再将上述三种方法分别按40%、40%和20%的权重比例后计算出一个综合标准。[结果]2005-2010年,曲靖市千人口卫生技术人员数由1.53上升到2.10;执业(助理)医师数由0.54上升到0.93;注册护士由0.40上升到0.74;卫生服务需求法配置标准为每千人口2.18人,人口比值法为1.40人,专家咨询法为1.79~2.23人,综合配置标准为1.79~1.88人/千人口。[结论]本研究制定的曲靖市医疗医师配置标准具有科学性,并符合当地实际发展需要。     

老年人数字健康素养评价指标体系构建研究

目的 构建老年人数字健康素养评估指标体系,为评价老年人数字健康素养提供参考。方法 2021年12月—2022年5月,采用文献研究法、焦点小组讨论法、德尔菲专家函询法筛选评估指标,运用层次分析法确定指标权重,建立老年人数字健康素养评价指标体系。结果 共开展3轮专家函询。函询问卷回收率为100%、100%、93.4%,专家权威系数为0.82、0.82、0.83,肯德尔和谐系数为0.095～0.211、0.095～0.149、0.159～0.200。所有专家的所有判断矩阵的一致性比例均小于0.1。最终确立老年人数字健康素养评价指标,共包括一级指标6个,二级指标21个,三级指标39 个。结论 构建的老年人数字健康素养的评价指标专家咨询意见趋于一致,内容科学、合理,今后需进一步在老年人群中开展实证工作。