Health Service Resource Allocation Research Articles

Will urban scale affect health services inequity? The empirical evidence from cities in China.

The equity of public resources triggered by city shrinkage is a global challenge. Significantly, the impact of city shrinkage on the allocation of health service resources needs to be better understood. This study explores the impact of population change on government investment and health service delivery in shrinking cities. Using data from China's Urban Statistical Yearbook (2010-2020), we employ regression discontinuity (RD) and fixed-effect models to examine the causal relationship between city shrinkage and health service provision. Shrinking cities show significant disparities in health resources, particularly in bed numbers (-1,167.58, p < 0.05) and doctor availability (-538.54, p < 0.05). Economic development (p < 0.01) and financial autonomy (p < 0.01) influence hospital bed distribution. Investments in public services (primary schools and teachers, p < 0.01) affect health resource delivery. Robustness tests support our results. This study reveals how city shrinkage disrupts health service provision and equity, establishing a causal relationship between city shrinkage/expansion and health resource allocation, emphasizing the imbalance caused by urban population changes. City expansion intensifies competition for health resources, while shrinking cities struggle to provide adequate resources due to government reluctance. Policymakers should adapt health resource allocation strategies to meet patient demands in changing urban landscapes.

Health anxiety, coping mechanisms and COVID 19: An Indian community sample at week 1 of lockdown.

It is critical to gain an understanding of the impact of the COVID 19 pandemic and the associated lockdown restrictions on the psychological, social and behavioural functioning of the general public, in order to inform public health promotion and future health service resource allocation. This cross-sectional study, completed during week 1 of lockdown in India, reports on data from 234 participants using an online survey. Data regarding health anxiety, coping mechanisms and locus of control was collected. Structural equation modelling was used to assess the relationship between locus of control, coping mechanisms, health anxiety and age. Age related differences in both locus of control and coping strategies were found. Younger people experienced more health-related anxiety and were more likely to engage with social media as a coping mechanism. Mindfulness-based strategies may reduce health anxiety by increasing tolerance of uncertainty experienced during the COVID 19 pandemic.

The impact of a change in referral pathway on a paediatric short-stay ward in Cape Town, South Africa

Background. The opening of the new Khayelitsha District Hospital in April 2012 coincided with a change in referral pathway to Tygerberg Hospital (TBH) for children requiring specialist care. Objective. To determine the disease burden impact of the referral pathway change on paediatric short-stay ward admissions at TBH. Methods. A retrospective cohort study, analysing routine health information as captured in ward admissions registers over two similar seasonal periods: 1 April - 30 September 2011 (prior to referral change) and 1 April - 30 September 2012 (post referral change). Results. Paediatric short-stay ward admissions remained similar, but a statistically significant increase in the number of admissions from Khayelitsha sub-district (SD) ( p <0.001) was seen. The median age was 13 months over the two time periods. Children from Khayelitsha (median age 9.49 months for 2011 and 5.2 months for 2012) were, however, significantly younger than those from other SDs (median age 26.31 months in 2011 and 26.44 months in 2012) ( p =0.001). Khayelitsha children were more likely to require admission to a TBH paediatric ward ( p <0.001, adjusted odds ratio (aOR) 0.57), while children from other SDs were more likely to be discharged home or transferred to a district hospital ( p <0.001, aOR 1.75). Respiratory illnesses accounted for the majority of admissions during both time periods (54% in 2011 and 51% in 2012). Conclusion. Children from Khayelitsha were significantly younger and more likely to be admitted to a TBH inpatient ward compared with other SDs. These findings necessitate a review of current health service resource allocation.

Derivation of indices of socioeconomic status for health services research in Asia

BackgroundEnvironmental contexts have been shown to predict health behaviours and outcomes either directly or via interaction with individual risk factors. In this paper, we created indexes of socioeconomic disadvantage (SEDI) and socioeconomic advantage (SAI) in Singapore to test the applicability of these concepts in an Asian context. These indices can be used for health service resource allocation, research and advocacy. MethodsWe used principal component analysis (PCA) to create SEDI and SAI using a structured and iterative process to identify and include influential variables in the final index. Data at the master plan geographical level was obtained from the most recent Singapore census 2010. ResultsThe 3 areas with highest SEDI scores were Outram (120.1), followed by Rochor (111.0) and Downtown Core (110.4). The areas with highest SAI scores were Tanglin, River Valley and Newton. The SAI had 89.6% of variation explained by the final model, as compared to 67.1% for SEDI, and we recommend using both indices in any analysis. ConclusionThese indices may prove useful for policy-makers to identify spatially varying risk factors, and in turn help identify geographically targeted intervention programs, which can be more cost effective to conduct.

SOCIETAL VIEWS ON NICE, CANCER DRUGS FUND AND VALUE‐BASED PRICING CRITERIA FOR PRIORITISING MEDICINES: A CROSS‐SECTIONAL SURVEY OF 4118 ADULTS IN GREAT BRITAIN

The criteria used by the National Institute for Health and Clinical Excellence (NICE) for accepting higher incremental cost-effectiveness ratios for some medicines over others, and the recent introduction of the Cancer Drugs Fund (CDF) in England, are assumed to reflect societal preferences for National Health Service resource allocation. Robust empirical evidence to this effect is lacking. To explore societal preferences for these and other criteria, including those proposed for rewarding new medicines under the future value-based pricing (VBP) system, we conducted a choice-based experiment in 4118 UK adults via web-based surveys. Preferences were determined by asking respondents to allocate fixed funds between different patient and disease types reflecting nine specific prioritisation criteria. Respondents supported the criteria proposed under the VBP system (for severe diseases, address unmet needs, are innovative--provided they offered substantial health benefits, and have wider societal benefits) but did not support the end-of-life premium or the prioritisation of children or disadvantaged populations as specified by NICE, nor the special funding status for treatments of rare diseases, nor the CDF. Policies introduced on the basis of perceived--and not actual--societal values may lead to inappropriate resource allocation decisions with the potential for significant population health and economic consequences.

Economic evaluation of nuclear medicine procedures

Healthcare regulators anxious to contain spiralling healthcare costs have started to look hard at the area of medical imaging, alarmed by its rapid expansion. However, although it may be tempting to spend less on medical imaging in an attempt to cut costs, in many settings increasing medical imaging would actually reduce healthcare costs, and also improve patient outcomes [1]. So-called health economic evaluations are studies that consider the costs and outcomes of given diagnostic procedures and interventions, aiming to optimise the allocation of health service resources and thereby maximise the level of health in the population of interest. There are three main types of evaluation: cost-effectiveness analysis (CEA), cost-utility analysis (CUA), and cost-benefit analysis (CBA) [2]. The CEA takes a common effectiveness measure (e.g. cost per accurately diagnosed patient or per life year gained) and uses it to compare alternative interventions, also taking into account their relative costs. The incremental cost-effectiveness ratio (ICER) is a parameter calculated in order to effect these comparisons, whose results may, for example, be stated in terms of costs per life year gained. The ICER highlights the additional costs generated by the implementation of a new diagnostic test or intervention and relates them to the health outcome: ICER=(costsnew test— costsstandard test)/( life years gainednew test—life years gainedstandard test). Acceptable ICER thresholds (maximum ICERs)—i.e., the levels at which the funding of health interventions is deemed justified on the basis of the benefit to the population—differ between countries according to wealth and societal preferences. For instance, the UK National Institute for Health and Clinical Excellence (NICE) defines a threshold of £30,000 per additional life year gained as acceptable. The advantages of the CEA are its simplicity and its costs, which are usually lower than those incurred by the CUA and the CBA. In fact, whereas CEAs usually measure effectiveness in daily, routine care or in clinical trials, in CUAs and CBAs patients have to be specially interviewed [2]. Cost-effectiveness analyses usually measure health outcome in terms of life years gained, but in some cases it is necessary to consider not only the “quantity” of life gained but also the “quality” of life (as in the case of palliative care, for example). In such cases, the unit of measure normally used is defined “quality-adjusted life year” (QALY) and the CUA “Focus on...” abridgements aim to highlight papers published within the past year and draw extensively on the texts and summaries of the articles referenced. Less recent citations are also included when deemed useful to provide background information on the topic reviewed.

Beyond reproduction: Women's health in today's developing world

The concept of women's health is tethered strongly to reproductive health. At present, international attention and resources are focused on obstetric events and, recently, HIV/AIDS because of the significance of these problems in the least developed nations. This limited concept of women's health, however, is decreasingly relevant to the global community, and needs to be revisited in the light of decreasing fertility and increasing life expectancy in many countries where it was previously applicable. It should be expanded to embrace the full spectrum of health experienced by women, and preventive and remedial approaches to the major conditions that afflict women. Allocation of health service resources should be aligned with the epidemiological realities of these threats to women's health. Cause of death data for women aged 15-34 years and 35-44 years were examined for nine less developed countries. Deaths associated with pregnancy and child birth, and HIV were compared with deaths due to three chronic disease categories (cancer, cardiovascular disease, and diabetes). The women's health research literature for developing countries appearing in the American Journal of Public Health and British Medical Journal was also examined. In seven out of the nine countries, among women aged 15-34 years, chronic diseases caused over 20% of deaths, while reproductive causes and HIV together accounted for approximately 10% of deaths, in all countries except in India. Among women aged 35-44 years, in all but India, chronic diseases accounted for over four times the deaths attributable to reproductive causes and HIV. The causes of death were not related to the level of development in these countries as measured by GNI PPP. Papers pertaining to women's health published in public health and medical research journals focused principally on reproduction. Extending the definition of women's health to include a concern for chronic diseases is critical if the needs of women in less developed nations are to be met. In less developed countries, chronic disease is the most important cause of female death even during childbearing years and for women with young families. Development agencies and private philanthropy must begin to fund the studies that will further refine our understanding of the role of chronic diseases in women's health in the developing world.

THE STANDARD OF CARE DEBATE: CONCEPTUAL CLARIFICATIONS

In the June issue of the Journal, Wendler et al. discuss the standard of care for research in developing countries and propose a valuable set of criteria.1 However, there are conceptual issues with important implications for this debate that require clarification. Wendler et al. assert that “inequalities in health care have contributed to significant inequalities in health.”1 Lack of access to and poor quality of health care are neither the most important nor the primary reasons for health inequalities. The social determinants of health, including poverty, status of women, and social vulnerability, are more important.2 This premise is critical, as it frames the context within which people live in the developing world. The authors propose focusing on “methods that communities can implement, if proved successful.”1 This concept has been debated within health systems and health research.3 What information is required to determine which intervention can be implemented? What level of evidence should be required from researchers? Wendler et al. do not operationalize this concept, leaving it a theoretical construct—which does not further the debate from previous discussions. The example of the Glaser Foundation is misplaced, since health care allocations are fundamentally different from decisions within health research. The foundation was maximizing benefit per unit of investment—one rational way of resource allocation for health services. The same type of clinical example for research appears in Wendler et al.’s discussion of Niverapine.1 Health research does not (and should not) have a primary aim of provision of health services, and thus cannot be held to principles of health care distribution. Wendler et al. define a ceiling by calling for defense of any standard of care less than the best in the world. A complementary approach is needed to define the floor, by proposing national standards as the minimum for research studies, even if they can defend the use of a standard less than the world’s best. This would prevent the exploitation of the most disadvantaged groups within developing countries (the worst off). Wendler et al.’s article has important implications for ethics committees in the developing world, in terms of their strengthening and their dialogue with those in the developed world.4 For example, what are the competencies required for making such decisions in institutional review boards? In externally funded projects, which committee has precedence—sponsoring country or host country? Finally, there is a need for greater participation of developing-country researchers, ethicists, and health professionals in this debate.

Socio-economic inequalities in diabetes complications, control, attitudes and health service use: a cross-sectional study.

To investigate socio-economic inequalities in diabetes complications, and to examine factors that may explain these differences. Cross-sectional questionnaire survey of 770 individuals with diabetes among 40 general practices in Avon and Somerset. General practice, optometrist and eye hospital records over time (median 7 years) were analysed. Slope indices of inequality, odds ratios and incidence rate ratios were calculated to estimate the magnitude of inequality between the most and least educated, and the highest and lowest earning patients, adjusted for age, sex and type of diabetes, and clustering of outcomes within practices. The least educated patients were more likely than the most educated patients to have diabetic retinopathy [adjusted odds ratio (OR) 4.3; 95% confidence interval 0.8, 23.7] and heart disease (adjusted OR 3.6; 1.1, 11.8), had higher HbA1c levels (adjusted slope index of inequality 0.9; 0.3, 1.5), felt that diabetes more adversely affected their social and personal lives (adjusted slope index of inequality 0.8; 0.5, 1.1 Diabetes Care Profile units), were more likely to be recorded as non-compliant by their health professionals, and had lower rates of hospital attendance (adjusted rate ratio 0.43; 0.26, 0.71). However, they did not see themselves as less compliant, and had higher general practice attendance rates (adjusted rate ratio 1.5; 1.1, 2.2). Less educated and lower earning individuals with diabetes bear a larger burden of morbidity but use hospital care less. Health service resource allocation should reflect the distribution of chronic illness.

Funding a primary care led NHS: achieving a model for more equitable allocation of healthcare resources at a sub-district level.

Current resource allocation for health services have developed in a haphazard and inequitable way. This project aimed to determine a fairer and more rational way to distribute health authority's (HA's) money to general practitioners (GPs). A dataset was developed to examine the way resources were spent on patients at the level of general practice. Important managerial aspects of the project were addressed. This involved the establishment of the 'Equity Group' of GPs to work with the HA. The group sought a measure of health need that was rigorous and scientifically based but was also practical and politically acceptable to GPs and the HA. The York Relative Needs Index (RNI) was chosen, and applied to populations at practice level. An implementation plan was then developed by the Equity Group. Results demonstrated considerable inequalities between practices in age-adjusted use of healthcare resources. There was low correlation between the level of need in practices and the per capita expenditure. Applying the York RNI to practice populations indicated current practice allocations were within the range 82-126 per cent of their needs-based target. The managerial implications of the proposed changes are described. The new methods for resource allocation appear to be an advance on the unplanned methods which have evolved. Full evaluation of the long-term results of redistributing health resources will be needed. Important aspects of this project were the participation of GPs and general development of the concept of equity in North Derbyshire.

Rising incidence of type 1 diabetes in Scottish children, 1984–93

OBJECTIVESTo calculate the incidence of type 1 diabetes in Scottish children aged less than 15 years between 1984 and 1993; to examine changes in incidence; and to calculate the prevalence...

Vertical equity: weighting outcomes? or establishing procedures?

Considerations of equity in the health policy literature have in the main focussed on horizontal equity (the equal treatment of equals) and as a consequence have tended to overlook vertical equity (the unequal, but equitable, treatment of unequals). There is evidence from earlier, if preliminary, work carried out by the authors and a colleague that health care decision makers may well want to embrace concerns for vertical equity in the allocation of health service resources. This paper examines some possibilities for incorporating vertical equity into health care policy through distributive and/or procedural justice. While no firm solutions are offered, it is suggested that the idea of fitting John Broome's notion of ‘claims’ within a communitarian framework holds promise.

Neuropsychiatric Syndromes in Neurodegenerative Disease: Frequency and Signficance.

Neurodegenerative diseases have neuropsychological, neuropsychiatric, and neurological effects manifested as cognitive, emotional, and physical alterations. These primary effects have secondary consequences on activities of daily living, patient and caregiver distress, and quality of life. Neuropsychiatric manifestations are products of brain dysfunction that are associated with institutionalization, vulnerability to abuse by the caregiver, and use of medications and restraints. Behavioral alterations can often be ameliorated by psychotropic drugs, and the effects of medications contribute to understanding the mechanisms of behavioral changes. Allocation of health service resources for dementia patients is partially determined by the neuropsychiatric dimension of these diseases, and the importance of the neuropsychiatric aspects of degenerative disorders has been underemphasized.

Application of goal programming to improve resource allocation for health services in Papua New Guinea

AbstractThis paper describes exploratory work on two allocation models for policy makers in Papua New Guinea using goal programming. The first model allocates national financial resources for health among the 19 provinces. Determinants of the model include health status, population, manpower, and access provisions and previous resource distribution. The second model utilizes the results from the first model to allocate resources among different health activities within each province. Determinants of the model include major health problems of each province and available health resources. The paper concludes with a dicsussion on the use and implications of the model in the Papua New Guinean situation.

Should QALYs be programme-specific?

One reason for the development of quality adjusted life years (QALYs) is to facilitate comparison across health care programmes in terms of productivity per unit of expenditure. However, some approaches to QALY measurement have also been developed using ‘programme-specific’ dimensions of quality of life. Using data, from a longitudinal trial of long-term care for elderly people, it is shown in this paper that an ‘across-programme’ method of quality of life measurement is less sensitive to changes in elderly people's health states than programme-specific methods more commonly used in the field of evaluating long-term care. It is argued that the same problem is likely to arise in evaluating care for other common chronic conditions like mental handicap, chronic conditions of childhood and terminal cancer. It is concluded that more work should be carried out comparing across-programme and programme-specific measures of quality of life, otherwise it will be difficult to determine whether certain groups in society are being discriminated against in health service resource allocation due to an insensitive across-programme measure of outcome.

QALYS and long-term care for elderly people in the UK: scales for assessment of quality of life.

QALYs have developed in the UK as a tool for comparing the outcome of health care procedures in a single index over time. This tool can then be used, along with information on costs of procedures, in decision-making about health service resource allocation. It is shown that the attributes of disability and distress, on which QALYs are presently based in the UK, are insensitive to changes in the health status of elderly people in long-term care when compared to other measures of quality of life which are frequently used in studies of older people. Thus, if the use of QALYs increases, they should be based on attributes appropriate to the groups studied, otherwise certain groups may be discriminated against in health service resource allocation owing to the use of an insensitive measure of outcome.

The rhetoric and reality of an accounting change: A study of resource allocation

This paper presents a case study of health service resource allocation as a basis for exploring how organizational members come to understand the meanings and implications of accounting change within the enterprise. The analysis describes how the significance of a new calculative process emerges over time, during which accounting both shapes and is in turn shaped by organizational reality. The paper concludes with a discussion of the interplay between the rhetoric and reality of accounting, reviewing the ways in which, as an expressive order, accounting provides a language for discourse, rules for guiding action and a way of establishing legitimacy in an institutionalised organization.