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Article

Marissa Collins, Neil McHugh, Rachel Baker, Alec Morton, Lucy Frith, Keith Syrett, and Cam Donaldson

Health and social care organizations work within the context of limited resources. Different techniques to aid resource allocation and decision-making exist and are important as scarcity of resources in health and social care is inescapable. Healthcare systems, regardless of how they are organized, must decide what services to provide given the resources available. This is particularly clear in systems funded by taxation, which have limited budgets and other limited resources (staff, skills, facilities, etc.) and in which the claims on these resources outstrip supply. Healthcare spending in many countries is not expected to increase over the short or medium term. Therefore, frameworks to set priorities are increasingly required. Four disciplines provide perspectives on priority setting: economics, decision analysis, ethics, and law. Although there is overlap amongst these perspectives, they are underpinned by different principles and processes for priority setting. As the values and viewpoints of those involved in priority setting in health and social care will differ, it is important to consider how these could be included to inform a priority setting process. It is proposed that these perspectives and the consideration of values and viewpoints could be brought together in a combined priority setting framework for use within local health and social care organizations.

Article

In order to secure effective service access, coverage, and impact, it is increasingly recognized that the introduction of novel health technologies such as diagnostics, drugs, and vaccines may require additional investment to address the constraints under which many health systems operate. Health-system constraints include a shortage of health workers, ineffective supply chains, or inadequate information systems, or organizational constraints such as weak incentives and poor service integration. Decision makers may be faced with the question of whether to invest in a new technology, including the specific health system strengthening needed to ensure effective implementation; or they may be seeking to optimize resource allocation across a range of interventions including investment in broad health system functions or platforms. Investment in measures to address health-system constraints therefore increasingly need to undergo economic evaluation, but this poses several methodological challenges for health economists, particularly in the context of low- and middle-income countries. Designing the appropriate analysis to inform investment decisions concerning new technologies incorporating health systems investment can be broken down into several steps. First, the analysis needs to comprehensively outline the interface between the new intervention and the system through which it is to be delivered, in order to identify the relevant constraints and the measures needed to relax them. Second, the analysis needs to be rooted in a theoretical approach to appropriately characterize constraints and consider joint investment in the health system and technology. Third, the analysis needs to consider how the overarching priority- setting process influences the scope and output of the analysis informing the way in which complex evidence is used to support the decision, including how to represent and manage system wide trade-offs. Finally, there are several ways in which decision analytical models can be structured, and parameterized, in a context of data scarcity around constraints. This article draws together current approaches to health system thinking with the emerging literature on analytical approaches to integrating health-system constraints into economic evaluation to guide economists through these four issues. It aims to contribute to a more health-system-informed approach to both appraising the cost-effectiveness of new technologies and setting priorities across a range of program activities.

Article

End-of-life spending is commonly defined as all health costs in the 12 months before death. Typically, the costs represent about 10% of all health expenses in many countries, and there is a large debate about the effectiveness of the spending and whether it should be increased or decreased. Assuming that health spending is effective in improving health, and using a wide definition of benefits from end-of-life spending, several economists have argued for increased spending in the last years of life. Others remain skeptical about the effectiveness of such spending based on both experimental evidence and the observation that geographic within-country variations in spending are not correlated with variations in mortality.