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Parent with Three Children
You see a parent. He has diabetes for which he takes medicines, on a diet, and exercise. He works at an office (junior management) and is the sole earning member of the family. They three children: one suffers from Chronic Asthma and needs regular medication, the secod has a congenital heart disease and will need surgery soon, and the third just got diagnosed with tonsillitis and the doctor wants him operated urgently.
What will be your advice to the parent to manage this?
X has set up a clinic around Avonhead (an upscale yet recent immigrant dense neighbourhood). The population that the clinic serves is aging (60% above 65 years and 40% are young families (35 years average age with two kids). X wants to set up a suite of services to offer to this community but has resource limitations. What mix of services you will advise him?
The average age of the population is about 55 years. what kind of services would you advise Y to plan for? . most are locally based farmers. or have work with farming machineries. With Limited Budget. or work in sheep shearing sheds.Range of Services Y is a consultant and wants to work in areas of public health and preventive health services at a rural township where a large farming community exists.
How to Play God Z is a venture capitalist and just got an offer from the Bill and Melinda Gates foundation that he has 5 million dollars to spend but has to pick ONLY two disease control/prevention/public health issues in Canterbury. What will you advise Z? . Z comes to you for advice.
Approaches and Frameworks • Discuss How to Identify Who Lost • Revisit the Issues .Sequence of This Presentation • The Problem • Describe Priority Setting in Healthcare • Outline How Priority Setting in Healthcare Adds Value • Outline the Challenges of Priority Setting in Healthcare • Discuss the Processes.
overall cost $1000 out of your pocket You need to get a root canal treatment done for a cavity in your tooth Cosmetic surgery (skin grafting) to cover an old burn scar .Dilemma • Imagine you have only $1000 to spare to pay for treatment • Who will get treatment? $1000 to Spend Child with appendicitis needs an urgent surgery.
Sustainability of healthcare systems is threatened by a growing demand for services and availability of expensive innovative technologies. .
How do We Find a Middle Path? .
• Complex calculations are complex and • Often fraught with controversies . and cost effectiveness of interventions. • Based on their relative contribution to quality of life.What is Priority Setting? • Process of assigning rank orders • Individual disease or health states and interventions or approaches • To mitigate specific health situations.
Priority Setting — Concepts • Precedence. • Establishment of the order of precedence • Rationing and Resource Allocation • Rationing . money) invested systematically . established by order of importance or urgency.Taking care of existing demands when the supply of resources constrained • Resource allocation — Limited resources (time.
Levels Where Priorities are Set Individuals (Micro) Health Agencies (Meso ) System Level (Macro) .
Nature of Prioritization Exercises • Core Issues are Political and Ethical • How Resources. • Political considerations underpin why implement validated technical interventions are difficult . Rights. and Responsibilities are distributed.
Politics & Priority Setting • Ever-expanding waiting lists for treatment —> political pressure for a system to prioritize patients on waiting lists (Norway) • Press and Media as Watchdogs on cases where patients were denied services (UK) • Reports of differential access in different parts of the country (UK) • New legislation regarding health insurance created a need to decide what services should be provided (Holland. Israel) .
Trip Up Points • Multiplicity of priorities and • Lack of institutional mechanisms to rationalize services and spending often results in • Poor overall system performance. • Low coverage for highly cost-effective health technologies .
Alternatives to Prioritization • Add More Resources • Take out Services .
Why Prioritize When Adding Resources Might Work? • Assure donors to maintain or increase the flow of funds • Prioritization can itself increase resources • Prioritization is needed if we are to know that prioritization is insufficient • Most important when there is little money • Risk of Spending Too Much on Tertiary Care: Poor Spending Pattern • Unfunded Primary Care —> Lethal in the poorest countries .
Challenges of Prioritization • Resources are limited • Impossible to provide everyone with every effective intervention • Limited resources and unlimited demands • Justice and efficiency • Lack of Consensus • Little interaction about priority setting among decision makers .
and at “What Cost” • Donors want to see their investments incorporated into public budgets • No simple or purely technical answers • Uncertainties around which values should guide decisions about Prioritization . “How Much”. What. “When”.Controversies of Prioritization • Process Affects Who.
Adjudication in the Context of Prioritization Exercises • • • • Every Disease Condition is a Priority Governments Cannot set policies in vacuum. Between many relevant values and that People (and disciplines) disagree which values should dominate • There is no agreed upon normative approach .
to create a package of services .How to Conduct Priority Setting Exercises • Collect information on the costs and benefits of all the interventions to be considered —> creating a common currency for measuring and comparing the benefits • Use models and assessments. such as the burden of disease and cost-effectiveness.
Factors Considered for Priority Setting Exercises • • • • • Burden of Disease Cost effectiveness of Interventions Equity Existing Capacity to Deliver Risk Pooling .
Risk Pooling • Some health conditions are rare and too costly for most uninsured individuals to pay out-of-pocket .
Approaches to Priority Setting • Using Formulae or Models • Using Guidelines or Technology Assessments • Utilize Explicit Criteria (NZ early 90s. public health considerations • Basic package of services is provided or financed based on an agreed criteria list • Social preferences can influence how the different benefits are combined and valued . community preferences. Oregon) • Include community needs. UK. economic evaluations of cost-effectiveness. Holland.
Frameworks • • • • Frameworks Are Necessary Explicit Processes != Haphazard Rationing Ethical Issues Can be Addressed Inevitable Policy and Implementation Issues localized • Helps to Choose Among Alternative Treatments .
Available Frameworks • • • • A4R Framework PBMA Framework Sibbald‟s Framework “7+7 framework” seven principles and processes .
Accountability for Reasonableness Framework (A4R) • Decision procedures for Rationing must have general features if they are to qualify as legitimate and fair • They must provide publicly available rationale • Decisions about coverage of new technologies must be publicly available • The rationale must follow a reasonable argument as to how to meet the medical needs of a covered population • There must be mechanisms for considering challenges to the decisions that are made • There should be voluntary or public regulation to see that the above conditions are met .
decision making should explicitly consider opportunity cost and „the margin‟. considering both opportunity cost and resource shifts „at the margin‟ . economic tools and thinking have much to offer. In particular.PBMA Framework • Program budgeting and marginal analysis (PBMA) is an economic framework specifically designed to help local decision makers set health service priorities • While making decisions between competing claims on scarce health service resources. Recent evidence shows that decision makers both understand these economic principles and would like to use economic tools in setting priorities • The intent of PBMA is to assist local decision makers in directing resources to maximize benefits from health services.
and potentially changes to legislations or practice . peeremulation or health sector recognition (e. social learning.Sibbald’s Framework • • • • • • • • Explicit Process Consideration of Context and Values Stakeholder Engagement Transparency Effective and Efficient Information Management Revision or Appeals Mechanism Positive Externalities Externalities may include positive media coverage (which can contribute to public dialogue.g. accreditation bodies. changes in policies. by other health care organizations. etc). and improved decision making in subsequent iterations of priority setting).
and Evaluation • Conduct Cost Effectiveness • Use Deliberative Processes • Decide Consistently . contestable. • Standardize Registration • Select and Scope Topics based on Evidence • Assess Budget Impacts • Allow for Appeals. consistent. timely. Tracking. independent from vested interests. transparent.7 by 7 Framework • Priority setting should be scientifically rigorous. and enforceable.
Best Practices • Use recent data • Analysis should be country specific • Be based on a well functioning and representative set of information systems • Rank Order by Burden and by population subgroup in order to provide useful advocacy information for the different groups • Build Flexibility in Budget • Build Linkages across services • Ensure Sufficient time and resources to deliver the interventions .
Role of Losers • Group of people that inevitably will get less. • Those segments of society that have the least “voice” or political influence are likely to be the ones that receive the least attention . than others • Policy Attention Usually paid to the groups in society that make the loudest noise about their perceived needs. in terms of benefits or services.
How to Identify the Losers in the System? • • • • Conduct a Benefit Incidence Assessment Need Detailed household survey data Identify Who are using the services Estimate cost to the Payors of making the services available • Assess Unit cost to the Payors .
Multiply the net unit cost by the group service use to determine group benefit . Subtract the out-of-pocket fees from cost 5. Determine service use by group 3. Group users by socioeconomic category 2. Calculate the unit cost for the service 4.Steps of Benefit Incidence Analysis • • • • • 1.
Conclusions and Comments • Priority Setting As Balance Between Resources and Demands • Necessary for Best Allocation of Resources • Frameworks Provide Good Structures to Achieve Prioritization • Class Exercise • Discussions and Comments? .
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