The document discusses three levels of decision making for healthcare resources - macro, intermediate, and micro. It finds that decision making is currently fragmented between these levels, with different decision makers not following common objectives or methods. There is also significant variation between countries. The document identifies some potential policy options to better align decision making across levels, including using a consistent value principle, strengthening intermediate-level decisions, and monitoring data on health and economic impacts. However, more research is needed to develop an integrated decision making framework to reduce inefficiencies in health systems from the misalignment between different decision-making levels.

1. 3.RESULTS
The figure shows that decision making in this way is fragmented, compartmentalised, and doesn’t follow common
objectives. This seems to be the case whether or not structured priority setting processes are used.
We also found substantial between-country variation in priority setting at all levels across LMICs: some countries have
implemented formal processes at the micro level (e.g. Thailand), whilst others have implemented major reforms at the macro
level (e.g. Rwanda). In many other LMICs, priority setting remains informal.
We identified a number of policy options and tools which could be, or have been, used to realign decision making at the
different levels in LMICs. These fall into three main categories:
1. A consistent principle of value being used to inform decision making at all levels;
2. Strengthening decision making at the disease (or intermediate) level;
3. Collecting and monitoring data on health and economic consequences of decisions at all levels.
Building Efficient Healthcare Systems
Through Integrated Health Care Decision
Making in Low and Middle Income Countries
Grace Marsden*, Martina Garau, Adrian Towse
*presenting author; email: gmarsden@ohe.org
1. INTRODUCTION
Acknowledgements
This work was funded by Novartis. The authors would like to thank Christophe Carbonel and the project team at Novartis for their input and feedback,
and thank the global health experts for participating in interviews with us.
2. METHODS
4. CONCLUSION
• Health technology assessment (HTA) and other
tools for decision making are used around the
world to promote efficient resource allocation within
healthcare systems (HCS)
• Resource allocation decisions are made at various
levels (national level or regional level; disease level
or technology level), yet it seems that the
objectives of decision makers at the different levels
do not always align with one another
• We explore whether these inconsistencies exist in
current processes in low and middle income
countries (LMICs), and identify policy options
which could be used to improve the efficiency of
resource allocation processes in these regions.
• Three strands of literature were reviewed:
1. Current approaches for priority setting in
LMICs;
2. Health service delivery and integrated care
(including disease management programmes
(DMPs));
3. Future of healthcare systems.
• Specific case studies illustrating examples of DMPs
and healthcare system reforms implemented in
LMICs were identified.
• Interviews with a set of global health experts
were conducted to gather further information on
existing priority setting processes in LMIC and the
different levels of decision making identified in the
literature review.
Micro decision making
Decision makers: Doctors, HTA
agencies, payers
Methods: HBP, HTA, A4R, MCDA,
value of implementation
Criteria: cost effectiveness, equity
Intermediate decision making
Decision makers: Payers, Providers,
Government
Methods: guidelines, protocols,
incentive schemes
Criteria: clinical outcome improvements
Macro decision making
Decision makers: Government,
insurers
Methods: Budget allocation
Criteria: equity, affordability
Service
delivery
Interventions (medical
products, vaccines and
technologies)
Payment
schemes
Health
workforce
Improved health (level and equity)
Responsiveness
Social and financial risk protection
Improved efficiency
Configuration of
facilities
Disease and
social priorities
Financing
We discuss three key levels of decision making: macro, intermediate and micro level (see figure).
Summary of levels:
different decision
makers at different
levels do not follow
common methods or
criteria
The components of the
health system:
compartmentalised and
planned at different levels
The fragmented
components are expected
to work together to
achieve these system
objectives1
Fragmentation and misalignment between levels of decision making means that decision maker’s objectives are not
consistent, and is highly likely to lead to inefficiencies in health systems.
There are limited policy options and tools available which could be used to align the objectives of decision making throughout
governments and health services. Further research is required to develop an integrated decision making framework that
could align all levels of decision making.
Notes
1The system objectives included in the diagram are those listed in the WHO building blocks framework. Full reference: WHO, 2007. Everybody’s
business: strengthening health systems to improve health outcomes: WHO's framework for action. Geneva: World Health Organization.