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5.1 wrap up (t)
5.1 wrap up (t)
5.1 wrap up (t)
5.1 wrap up (t)
5.1 wrap up (t)
5.1 wrap up (t)
5.1 wrap up (t)
5.1 wrap up (t)
5.1 wrap up (t)
5.1 wrap up (t)
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5.1 wrap up (t)
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5.1 wrap up (t)
5.1 wrap up (t)
5.1 wrap up (t)
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5.1 wrap up (t)
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5.1 wrap up (t)

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  • 1. Workshop wrap-up Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 1
  • 2. Summary of the situationregarding resource allocation in health care Some challenging issues exist: widespread perception amongst decision makers that there are not enough resources (very commonly there is not sufficient resources to carry on with current services as they are and add new services) and amongst the public that major changes are needed And there is uncertainty on the part of decision makers on how to address this need for changes Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 2
  • 3. The goal in resource allocationDecision-makers need to determine: what health care services to provide for whom to provide services how to provide services where services should be provided… in order to meet local and/ or system levelobjectives including access, health gain… Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 3
  • 4. How is that typically done?Resource allocation decisions are typically based on: Historical patterns with incremental adjustment Politics and the ‘squeaky wheel’ Needs assessment Core services economic evaluation (limited) Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 4
  • 5. What is required?A pragmatic decision-making approach that….– Aligns resources strategically with system goals and community needs– Leads to publicly defensible decisions based on available evidence and community values– Facilitates stakeholder engagement around improving benefit with limited resources– Supports the public accountability of health care decision-makersHow do we move in this direction? Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 5
  • 6. Elements of the solutionWe need to draw from: Medicine Economics Ethics Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 6
  • 7. MedicineEpidemiological informationInformation on interventions’ effectivenessSystem objectives Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 7
  • 8. Economics: Relevant Economic Principles• Opportunity cost – every time we choose to use resources to meet one need we give up the "opportunity" to use those resources to meet some other need – aim of economics is to ensure that we undertake activities where benefits outweigh opportunity cost• The Margin – Marginal Cost = cost of one more unit of output/consumption – Marginal Benefit = benefit from one more unit of output/ consumption Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 8
  • 9. Ethics: Role of ethicsProvides moral compass to guide difficultvalue-based decisions about limited resources Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 9
  • 10. Goals of legitimacy and fairnessExperience shows difficulty of agreeing on whatdecisions should be made Competing goals/ mandates Incomplete data and information Conflicting stakeholder interests/valuesIt is more likely agreement can be reached on howdecisions should be madeSocial acceptability rests on real/ perceivedlegitimacy & fairness of decision process Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 10
  • 11. How do we put all this together: a framework such as Program Budgeting and Marginal Analysis (PBMA) PBMA is a formal framework to assist decision- makers in making resource allocations decisions Combines medicine, economics and ethics Used since the 1970’s in health care Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 11
  • 12. PBMA: Practical StepsDetermine aim and scope of activityIdentify and map resource useForm an advisory panelDefine and weight decision making criteriaIdentify options for service growth and resource releaseEvaluate proposed investments and disinvestmentValidate results, recommendations for (re)-allocation,communicate decisionsEvaluation, refinement and ongoing revision Peacock et al. 2006 Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 12
  • 13. Critical success factorsStrong leadership and Board endorsementSolid project managementInternal and external buy-inPhysician involvement/ ownershipClear objectives and alignment with strategic goalsClear roles and responsibilitiesClear institutional boundariesExplicit, validated criteriaTraining and two way exchange of informationChange management processes – credible commitmentCommitment to evaluation and improvementPolitical overlay and expectation management Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 13
  • 14. Benefits of PBMAPrimary benefit: implementation Achieving resource allocation shifts that are consistent withstrategic decision-making objectivesSecondary benefits Evidence driven decisions Ownership of planning process Transparent and defensible decision making Clinician engagement and partnership Gibson et al. JHSRP 2006 Ruta et al. BMJ 2005 Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 14
  • 15. What about values? Best outcomes vs. fair chances? How much priority to Individual choice vs. disease prevention? collective good? Resource allocation decisions = value-based decisionsModest benefits for many vs. Urgent vs. likelihoodsignificant benefits for a few? of success? Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 15
  • 16. How are values integrated inresource allocation decisions? Priority setting processes (such as PBMA) are based on formal comparisons of possible courses of action e.g. investments or disinvestments These comparisons involve the application of evaluation criteria It is in the selection of these criteria and of their weights that values are reflected Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 16
  • 17. What about Economic Evaluation as a resource allocation framework?Economic evaluation is a set of scientificmethods to assist decision-makers in makingchoices between alternative interventionsConcerned with efficiency not justeffectivenessBased on principles of welfare economics maximise the well-being of the community ‘Fair’ choices require a systematic comparison of costs (resources) and consequences (outcomes or benefits) of alternative health programs Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 17
  • 18. Limitations of Economic evaluationSome technical limitations:• Potential challenges to validity• Does a low ICER mean that the new drug/ technology is ‘cost-effective’?• What does an ICER actually mean in terms of budget impact?Key issue:• What about other factors affecting the decision, i.e. how do we integrate ethical considerations and multiple system objectivesBecause of this issue, while in some cases, CEA is an ideal tool, in the broadercontext of typical resource allocation decisions, it plays a role but it is usually notsufficient, which brings us back to frameworks such as PBMA Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 18
  • 19. ConclusionIrrespective of the specific framework adopted,proper prioritization requires: Alignment with multiple organizational objectives Explicit recognition of the role of evidence and values Engagement of stakeholders Public accountability Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 19

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