Funding Envelope Research Articles

Rationing Rotational Magnet Cochlear Implant Technology in a Single Payer Healthcare System.

In a publicly funded health care system, fiscally responsible management of any program is required. This is especially pertinent as evolving technology and associated incremental costs, places pressure on device availability within a fixed funding envelope. The application of rotational magnet technology and associated escalating surgical wait times must be justified to patients and the single-payer system. We present a single cochlear implant center's attempt at a rationing schema for magnetic resonance compatible cochlear implantation. Contrasting approaches to rationing care are evaluated and deliberated. Based on a comparison of magnetic resonance imaging (MRI) rates within the general population to our cochlear implant (CI) cohort, we attempt the development of a decision-making schema that maximizes the number of patients to receive a CI while rationing the distribution of a rotational magnet technology to similarly situated individuals most likely to benefit. We elect to provide rotational magnet technology to select patient cohorts. This is based on the dominant imaging needs of these populations and the probability of requiring recurrent imaging studies. We consider this an ethical approach grounded in the egalitarian principle of equality of opportunity within cohorts of patients. Given finite resources, increasing per unit cost will unavoidably extend wait times for adult patients. Our approach does not afford similar implant devices for all patients, but rather all similarly situated individuals. Therefore, access to a scare medical resource requires program rigor and a formalized policy around candidacy for emergent technology.

Too Many Cooks in the Kitchen? The Division of Financing in World Bank Projects and Project Performance

The total funding envelope for World Bank projects is often divided among various state and non-state actors, each of which can have competing ideas about or interests in the project. How does the division of financing relate to overall project effectiveness? I argue that too many funding streams in a project can reduce project effectiveness by creating delays, increasing transaction costs, and blurring lines of accountability. I combine original data on the number and concentration of financial collaborators in World Bank projects with the World Bank’s ratings of project performance, looking at within-country variation across projects to explore whether or not there is evidence of reduced aid effectiveness in projects with more participants. The results suggest that projects with significant cofinancing receive somewhat worse project ratings.

Growing research in geriatric medicine

Academic geriatric medicine activity lags behind the scale of clinical activity in the specialty. A meeting of UK academic geriatricians was convened in March 2018 to consider causes and solutions to this problem. The meeting highlighted a lack of research-active clinicians, a perception that research is not central to the practice of geriatric medicine and a failure to translate discovery science to clinical studies. Solutions proposed included better support for early-career clinical researchers, schemes to encourage non-University clinicians to be research-active, wider collaboration with organ specialists to broaden the funding envelope, and the need to co-produce research programmes with end-users. Solutions to grow academic geriatric medicine are essential if we are to provide the best care for the growing older population.

Cancro de Mama: Valor em Saúde, Custos e Financiamento

Breast cancer is the second most common oncological disease worldwide. To analyse the new disease specific funding programme (breast cancer) implemented at the Francisco Gentil Portuguese Institute of Oncology, Lisbon Center (Instituto Português de Oncologia de Lisboa Francisco Gentil), the actual costs of the patients were examined using activity-based costing as a costing methodology. This study addresses the following question: "How much does it cost to treat breast cancer per 'patient-month' compared to the monthly fixed 'funding envelope'?". The study cohort consisted of 807 patients, corresponding to all the patients eligible for the new disease specific funding programme and who were enrolled during the first year of implementation. Activity-based costing was used to calculate the total real costs per stage of disease and per 'patient-month' as well as the deviation from the monthly fixed 'funding envelope'. The total costs were 6.6 M€, whereas the total funding was 5.2 M€ for a total of 5648 'patient-months'. In 2014, the balance difference between the funding obtained and the actual costs was -1.4 €M for the cohort of 807 patients. The extreme cases of differences in cost per 'patient-month' compared to the monthly fixed 'funding envelope' were (i) stage 0/Tis, with higher funding at 415.23 € per 'patient-month', and (ii) stage IIIC, with lower funding at 1062.79 € per 'patient-month'. The 'patient-month' cost, regardless of disease stage was 1170.29 €. The median deviation per 'patient-month' was negative (241.21 €) compared to the monthly fixed 'funding envelope' of 929.08 € in the first year. Establishing activity-based costing - funding models will be crucial for the future sustainability of the healthcare sector.

Person Centred Planning within the NDIS: Current Limitations—Prospective Opportunities

The National Disability Insurance Scheme (NDIS) has been a universally accepted initiative. It represents a very significant policy in terms of numbers of people prospectively impacted (about 460,000 at full roll out), in terms of complexity, and in terms of the cost (the current funding envelope is set at $22 billion). Adding to this complexity, the roll out of the scheme is intended to be implemented over a relatively brief period ending in 2020 so that the risk related to the establishment of the NDIS is increased as a result. Because a central tenet of the scheme is for participants (service users) to have choice and control over the services they receive, Person Centred Planning (PCP) is a core element of the NDIS. Every person deemed eligible for support is intended to have a plan that outlines the goals to be achieved, defines the “reasonable and necessary” supports to which they are entitled and which are funded by the NDIS, together with the total amount of funding allocated to spend on those supports. The PCP is then implemented by the participant’s preferred provider. Notwithstanding their considerable experience and capacity, the National Disability Insurance Agency (NDIA) prevents service providers undertaking the planning process and so most plans are completed by NDIA personnel. There is concern that providers might focus on developing plans that are more financially rewarding or more aligned with their service provision systems than aligned with the goals of the participant. The NDIA is also seen to have a potential conflict in that scheme sustainability is central to that agency’s responsibility and the PCP process is one way the NDIA can maintain control of costs because the plan sets out the funded services amongst other things. However, significant concerns have been raised with respect to the PCP process suggesting that, because of the sheer size of the scheme and the shortage of appropriately qualified and experienced NDIA planners, amongst other things, the process results in: (1) poor quality plans being developed; (2) delays in services being provided; and (3) for participant health and welfare to be put at risk. It is also an expensive process with $1.76 billion being allocated to this process for the roll out period and an ongoing cost of between $900 million and $1 billion being the ongoing expected annual cost. These costs are increased when plans need to be rectified. This report results from a project examining the anecdotal concerns raised by all stakeholders involved in the service provision process—NDIA, peak bodies and service providers—via semi-structured interviews and evidence evaluation processes. The project considered the evidence and put to stakeholders three alternate options that could be used to support the PCP process: (1) the status quo; (2) a risk-based proportionate response allowing for both provider and NDIA planning activities but focused on ensuring regulatory resources were applied where the level of risk warranted them; and (3) a model including providers as planners for all situations and with the NDIA providing assurance over the plans developed. We identified that there is support for the development of a risk-based approach to the planning process (i.e. option 2) so that service providers can assist in planning where appropriate and so that the NDIS only applies its scarce resources to supervise, regulate and/or plan where appropriate in order to reduce the average cost of a plan. Such a strategy is likely to mitigate the perceived problems associated with conflict of interest or bias, increase the quality and timeliness of plans and reduce the costs of the PCP process to the NDIA. Indeed, potentially, costs may be reduced to the NDIS by around $400 million, which can be applied to service delivery.

Editorial: The NPS MedicineWise vision for Australian Prescriber

Australian Prescriber is much loved by you, its readers, and justifiably so. You have said in many readership surveys over the years that you value the quality of the content and the concise easy-to-read format. I know that you appreciate the ‘without fear or favour’ approach the journal takes, on both clinical and policy matters. Some 53 000 health professionals receive Australian Prescriber including about 12 000 GPs, 9000 medical specialists and 14 000 pharmacists. It is popular internationally and the website has had a high rate of hits. So why has NPS MedicineWise decided to make changes to this icon of Australian medical publishing and why now? It could be seen as a contentious decision and requires scrutiny because the future of Australian Prescriber is something we all care about. NPS MedicineWise has been the custodian of the journal since 2002 and we know it is one of our most valuable products. At 40 years old, the journal remains as vital and effective as at inception. It has retained its relevance over the years by being connected with the readers, adapting to change and regularly introducing innovations. Australian Prescriber was one of the first Australian medical journals to go online. It was early to introduce mobile access and last year it produced its first app, The Doctor’s Bag. Australian Prescriber is run very efficiently by a small team of passionate and talented people. It has a thorough editorial process that adds tremendous value to the articles it commissions. It has strong and enduring relationships with some of the best medical and pharmacy minds in the country. I believe these three key components are critical to the quality, credibility and utility of Australian Prescriber. These are the things that I trust will never be compromised. However, maintenance of these critical features of Australian Prescriber’s operations sits on a background of gradually increasing costs and a slightly smaller funding envelope for NPS MedicineWise in the coming years. We want to continue to innovate, grow the readership and keep pace with changes in medical publishing, and to succeed we need to reallocate resources. On this basis, I have taken the decision to cease print publication and distribution. While I know many readers will miss the hard copy, I encourage you to tell us what formats will work best for you in a digital world. In 2012, doctors were spending an average of six hours per week online and had high levels of access to computers, tablets and smart phones.1 An NPS MedicineWise survey in 2012 found that 55% of GPs prefer to do self-education online.2 More recent data from the wider community would lead us to believe this connectivity has increased. A Nielson poll in December 2015 reported that over 18 million Australians use the internet. They spend 30 hours on average per week online and the growing areas of use are mobile phones and tablets, now making up 69% of all use.3 The future for Australian Prescriber is bright. It will remain an important medical journal here and internationally. One of the early challenges will be to increase email subscriptions to reach existing readers and also find new readers. For example, our circulation numbers show that not all GPs have signed up to receive Australian Prescriber in print. I hope we can move towards 100% of GPs reading the journal online. Making the journal available when and how readers find most convenient is likely to mean expanding to some new media formats. The Australian Prescriber team will be undertaking evaluation to learn more about the best ways to bring digital content to you, whatever your needs. There will be opportunities to bring articles together to support students and practitioners with particular questions or needs. The journal will also be looking for ways to support new prescribers, whatever their profession. Australian Prescriber will continue to be essential reading for everyone wanting to stay up to date with drugs and therapeutics.

Feasibility of Budget for Acquisition of Two Joint Support Ships

The mandate of the Parliamentary Budget Officer is to provide independent analysis to Parliament on the state of the nation's finances, the government's estimates, and trends in the Canadian economy, and, upon request from a committee or parliamentarian, to estimate the financial cost of any proposal for matters over which Parliament has jurisdiction. The PBO received requests from the Member from St John's East and the Member from Scarborough-Guildwood to undertake an independent cost assessment of the Joint Support Ship project. This report assesses the feasibility of replacing Canada's current Auxiliary Oiler Replenishment ships with two Joint Support Ships within the allocated funding envelope. The cost estimates and observations presented in this report represent a preliminary set of data for discussion and may change subject to the provision of detailed financial and non-financial data to the Parliamentary Budget Officer by the Department of National Defence, Public Works, and Government Services Ca...

Ontario primary care reform and quality improvement activities: an environmental scan.

BackgroundQuality improvement is attracting the attention of the primary health care system as a means by which to achieve higher quality patient care. Ontario, Canada has demonstrated leadership in terms of its improvement in healthcare, but the province lacks a structured framework by which it can consistently evaluate its quality improvement initiatives specific to the primary healthcare system. The intent of this research was to complete an environmental scan and capacity map of quality improvement activities being built in and by the primary healthcare sector (QI-PHC) in Ontario as a first step to developing a coordinated and sustainable framework of primary healthcare for the province.MethodsData were collected between January and July 2011 in collaboration with an advisory group of stakeholder representatives and quality improvement leaders in primary health care. Twenty participants were interviewed by telephone, followed by review of relevant websites and documents identified in the interviews. Data were systematically examined using Framework Analysis augmented by Prior’s approach to document analysis in an iterative process.ResultsThe environmental scan identified many activities (n = 43) designed to strategically build QI-PHC capacity, identify promising QI-PHC practices and outcomes, scale up quality improvement-informed primary healthcare practice changes, and make quality improvement a core organizational strategy in health care delivery, which were grouped into clusters. Cluster 1 was composed of initiatives in the form of on-going programs that deliberately incorporated long-term quality improvement capacity building through province-wide reach. Cluster 2 represented activities that were time-limited (research, pilot, or demonstration projects) with the primary aim of research production. The activities of most primary health care practitioners, managers, stakeholder organizations and researchers involved in this scan demonstrated a shared vision of QI-PHC in Ontario. However, this vision was not necessarily collaboratively developed nor were activities necessarily strategically linked.ConclusionsWithin the scope of this research, the scan affirmed that there is currently no province-wide, integrated, and measured quality improvement program for the primary healthcare sector in Ontario. This could be improved by the development of a coordinated plan, an accompanying accountability framework, and an appropriate sustainable funding envelope for QI-PHC at the provincial level.

Is Ontario medicine asleep at the switch?

The Ontario government has recently instituted several shocking policies for health care. A particularly surprising one was the recent rollback of pinpointed particular fee codes. This was also accompanied by a relative decrease in the funding envelope for salaries by way of a freeze in overall budget in the face of a growing number of physicians. Many of us looked at the pointed attack on certain radiology, cardiology and ophthalmology fees with the opinion that it was justified in some ways. Certainly every surgeon has considered cataract fees to be a little out of line. The Ontario government has responded to these perceived overpaid or misused fees and rolled them back. They moved unilaterally, without approval from the Ontario Medical Association with what looks like insider information. This sets a dangerous precedent. The physician management groups in each province have been in charge of fee codes in the past. Each province’s physicians are supposed to prioritize and ensure equitable health care costs and salaries for their particular region. We are doing a poor job of policing our own codes if the government is able to identify outliers better than we can. The government, emboldened by the use of the power to affect individual fee codes, may or may not make appropriate decisions in the future. The fee codes in orthopedics targeted by the Ontario Ministry of Health and Long-Term Care are after-hour codes — a decision where the government has definitely overstepped the realms of good patient care. If there is anything that should continue to be remunerated adequately, it is after-hour work. This is a good investment to ensure adequate patient care. Despite whether there is any wisdom in the singling out of fee codes for change by the government, these choices must be judged separately from any overall decision on physician pay envelope. Certainly this is a period of austerity in the country, but as goes the pay structure in Ontario, the most physician-populated province, so goes the rest of the country. Quebec has tied its salary structure to that of Ontario through Canadian average values. Any change in the pay envelope in Ontario will be reflected in that of other provinces. Since the Ontario restrictions, the British Columbia government has recently brought down fee increases of 0.5% over the next 2 years.1 Certainly this is a de facto fee reduction, as it does not even match inflation. We know there is a shortage of physicians overall in Canada. Even more important, resources are also limited — largely by the provincial/territorial governments. The combination of inferior working conditions and decreasing salary scales will make the greener pastures of the United States a more alluring place to work. We have been through previous physician exodus periods — it is not good for Canadian patients. The Ontario situation represents a thin opening wedge that merits a reaction that the rest of Canada awaits in anticipation. Would someone in Ontario please wake up?

Implementing the Global Plan to Stop TB, 2011–2015 – Optimizing Allocations and the Global Fund’s Contribution: A Scenario Projections Study

BackgroundThe Global Plan to Stop TB estimates funding required in low- and middle-income countries to achieve TB control targets set by the Stop TB Partnership within the context of the Millennium Development Goals. We estimate the contribution and impact of Global Fund investments under various scenarios of allocations across interventions and regions.Methodology/Principal FindingsUsing Global Plan assumptions on expected cases and mortality, we estimate treatment costs and mortality impact for diagnosis and treatment for drug-sensitive and multidrug-resistant TB (MDR-TB), including antiretroviral treatment (ART) during DOTS for HIV-co-infected patients, for four country groups, overall and for the Global Fund investments. In 2015, China and India account for 24% of funding need, Eastern Europe and Central Asia (EECA) for 33%, sub-Saharan Africa (SSA) for 20%, and other low- and middle-income countries for 24%. Scale-up of MDR-TB treatment, especially in EECA, drives an increasing global TB funding need – an essential investment to contain the mortality burden associated with MDR-TB and future disease costs. Funding needs rise fastest in SSA, reflecting increasing coverage need of improved TB/HIV management, which saves most lives per dollar spent in the short term. The Global Fund is expected to finance 8–12% of Global Plan implementation costs annually. Lives saved through Global Fund TB support within the available funding envelope could increase 37% if allocations shifted from current regional demand patterns to a prioritized scale-up of improved TB/HIV treatment and secondly DOTS, both mainly in Africa − with EECA region, which has disproportionately high per-patient costs, funded from alternative resources.Conclusions/SignificanceThese findings, alongside country funding gaps, domestic funding and implementation capacity and equity considerations, should inform strategies and policies for international donors, national governments and disease control programs to implement a more optimal investment approach focusing on highest-impact populations and interventions.

The Privatization of the Canadian Military

Since the end of the Cold War, nonstate actors have become increasingly important players in the security field, challenging the state's traditional monopoly over the use of legitimate force. Although nonstate actors have participated historically in conflict, in the modern era these groups and individuals have played only a marginal role in warfare. Mercenaries, for instance, have generally been individual combatants or informal groups of former soldiers selling their services to the highest bidder. In contrast, the world has recently witnessed the emergence of a new breed of private actors who represent the modern, corporate evolution of mercenary forces. These private military firms are profit-driven corporations that trade in professional services intricately linked to warfare and that work for international organizations, humanitarian groups, multinational corporations, and national governments.' Employing former soldiers and police officers from around the world, these firms offer their clients a wide range of services including both armed and unarmed support of military operations, military training and advice, and logistics support.In the early 1990s, firms such as the now defunct Executive Outcomes played crucial roles in several developing world conflicts, working on behalf of weak governments to defeat rebel insurgencies. Western militaries have also employed these firms, contracting out training and base support services, and have increasingly used them to augment military capabilities on international operations. Western militaries are now employing the full range of private military services in combat operations, a practice once reserved for African despots. The American military has been the leader in this regard, contracting logistics, intelligence, site security, and convoy security services in Iraq and Afghanistan. Many other western militaries have followed suit.2The Canadian military has followed this trend of privatizing military functions. Since the 1990s, the Canadian forces have come to rely heavily on contracted services, ranging from logistics support to strategic lift, primarily to alleviate the stress experienced by key forces' occupations that are repeatedly deployed abroad. Although the forces have been using private military services in international operations for several years, past employment of private firms by the Canadian military was restricted to the relatively safe environments of peace-support operations. Moreover, the Canadian military did not use private firms in all expeditionary operations. Rather, decisions to employ private contractors were made on an ad hoc basis contingent upon the specific operating conditions of each mission.The precedent set by Canada's use of private firms in Afghanistan, and the funding envelope and policy guidelines established by the 2008 Canada defence strategy, however, will make the future use of private firms by the Canadian forces a virtual certainty. To prepare for this eventuality, the Canadian government must ensure the proper coordination and control of Canadian contracted firms, carefully control the management and oversight of all contracts, and develop a policy framework to properly integrate these firms with Canadian military personnel.This article addresses the Canadian military's use of private firms in international operations. The first section provides a brief overview of Canada's historical use of private firms to demonstrate how the forces' employment of contractors has evolved during operations in Afghanistan. The article goes on to argue that current Canadian defence policy ensures that private firms will be used by the Canadian military in all future international operations. This is followed by an examination of some of the key challenges posed by the forces' use of private military services. The article concludes by making recommendations for future government action.THE PRIVATIZATION OF THE CANADIAN FORCESIn the wake of the defence spending cuts introduced by the Liberal government of Jean Chretien in the 1990s, the Canadian forces began exploring private-sector delivery of defence functions as a means of saving budgetary resources through the alternative service delivery program. …

Cost Analysis of Public Health Influenza Vaccine Clinics in Ontario

Public health in Ontario delivers, promotes and provides each fall the universal influenza immunization program. This paper addresses the question of whether Ontario public health agencies are able to provide the influenza immunization program within the Ministry of Health fiscal funding envelope of $5 per dose. Actual program delivery data from the 2006 influenza season of Wellington-Dufferin-Guelph Public Health (WDGPH) were used to create a model template for influenza clinics capturing all variable costs. Promotional and administrative costs were separated from clinic costs. Maximum staff workloads were estimated. Vaccine clinics were delivered by public health staff in accordance with standard vaccine administration practices. The most significant economic variables for influenza clinics are labour costs and number of vaccines given per nurse per hour. The cost of facility rental was the only other significant cost driver. The ability of influenza clinics to break even depended on the ability to manage these cost drivers. At WDGPH, weekday flu clinics required the number of vaccines per nurse per hour to exceed 15, and for weekend flu clinics this number was greater than 21. We estimate that 20 vaccines per hour is at the limit of a safe workload over several hours. Managing cost then depends on minimizing hourly labour costs. The results of this analysis suggest that by managing the labour costs along with planning the volume of patients and avoiding expensive facilities, flu clinics can just break even. However, any increased costs, including negotiated wage increases or the move to safety needles, with a fixed revenue of $5.00 per dose will negate this conclusion.

Alternative Funding Plans and Alternative Relationship Plans: Saviours of Academic Medicine or Just the Last Gasp?

The rapid decline of clinician-scientists in all facets of medicine, including gastroenterology, has been well documented. Many groups have also been severely challenged by the inability of their fee-for-service billings to enable them to meet their rapidly expanding educational commitments in addition to sustaining their research programs. Together, these trends have threatened the core academic mission at many Canadian institutions. In the late 1980s, the concept of a provincial government global funding envelope in place of fee-for-service billings was introduced in response to these challenges, and in 1990 the first Alternative Funding Plan (AFP) appeared in the Department of Paediatrics at the Hospital for Sick Children in Toronto, Ontario. We now have four additional AFPs or Alternative Relationship Plans (ARPs) in place, one each at Dalhousie Universtiy (Halifax, Nova Scotia), Queen’s University (Kingston, Ontario), the University of Calgary (Calgary, Alberta) and the University of Alberta (Edmonton, Alberta). Moreover, AFPs are currently being negotiated at all the remaining academic centres in Ontario and are being considered elsewhere in Canada. The existing programs are at various stages of maturity and a number have been renegotiated one or more times with their respective provincial governments and medical associations. In this interview, I have communicated with three heads of gastroenterology (GI) divisions: Dr Ron Bridges (University of Calgary); Dr Des Leddin (Dalhousie University); and Dr William Paterson (Queen’s University). I have also communicated with a previous Chair of Paediatrics, Dr Hugh O’Brodovich (the Hospital for Sick Children), as well as a department head, Dr Jon Meddings (University of Alberta), to gain their insights into whether they believe these funding plans will be the ultimate saviours of academic medicine and what experience and advice they have to offer to those who are considering joining similar programs.

European Regional Policy and Backward Regions: Implications Towards EU Enlargement

In this paper we show that the success of the EU Regional Policy, in terms of boosting growth in objective 1 regions, will mean a big opportunity for Central and Eastern European Countries (CEECs) and hence the increases in competition arising from an enlarged European market combined with a suitable regional development policy should in the future boost the growth of those countries. In the last part of the paper we made a simulation for the funding envelope from 2007, based on the 2000‐2006 budget. We show that the figures of the Agenda 2000 provide enough financial support for 90% of the total CEEC population and for 75% of “current” objective 1 population.

Listening to the Decision Makers

Decision makers within the Calgary Health Region adopted and applied programme budgeting and marginal analysis (PBMA) for priority-setting activity across major service portfolios within the Region. Seventeen in-depth qualitative interviews were conducted with senior managers and clinicians to gain a user perspective and identify specific areas for process refinement. Data were thematically coded and categorised into relevant themes. Key strengths included a culture shift in thinking about the need to reallocate resources within a fixed funding envelope, whereas a key challenge identified was in putting forth genuine disinvestment options. Areas suggested for improvement included evoking an incentive system for stakeholder engagement and having a mechanism for tracking the effect of resource reallocations. Both an evidence-based approach to priority setting, as well as a way of thinking around managing resource scarcity, can be integrated into organisational processes. Findings reported in this article will influence further application in Calgary and should provide insight for those attempting such activity elsewhere.

Priority Setting in a Canadian Long-Term Care Setting: A Case Study Using Program Budgeting and Marginal Analysis

ABSTRACTCanadian health regions are required to set priorities and allocate resources within a limited funding envelope. Program budgeting and marginal analysis (PBMA) was piloted in continuing care in Claresholm, Alberta, with the aim of improving overall benefit from available resources. A marginal-analysis expert panel was used to assess options for continuing-care delivery. Inputs into the decision-making process included evidence from the literature, regional and provincial reports, program budgeting information, and local knowledge. Recommendations included implementing adult, day-and-night support programs and converting long-term beds to convalescent beds. Changes were funded through allocating provincial Broda funding and altering nursing assistant and physiotherapy activity. PBMA was demonstrated to be an effective framework in aiding decision makers with redesigning services in Claresholm. This case study is one of several which indicate PBMA to be a valuable aid to priority setting in health care service provision.

Setting Priorities and Allocating Resources in Regional Health Authorities: A Report from Two Pilot Exercises Using Program Budgeting and Marginal Analysis

A significant mandate of Canadian regional health authorities is to set priorities and allocate resources within a limited funding envelope. Program budgeting and marginal analysis is a priority-setting framework used in the health sector. This article discusses the application of the framework in two regional health authorities in Alberta. The framework was demonstrated to be effective in aiding decision makers to set priorities, and wider application of the framework in these health authorities is planned.