Priority Setting And Resource Allocation

Question 1

Learning Objectives

Answer 1

To understand towards
- Towards Universal Health Coverage
- Mechanisms for public funding of care
- Prioritisation and resource allocation
- Changing expectations of health systems
- The search for greater efficiency
- Factors affecting access to health care

Question 2

Define Universal Health Coverage

Answer 2

• Ensure that people have equal access to quality health services and financial protection:
• Coverage with health services (prevention, promotion,
  treatment and rehabilitation);
• Coverage with financial risk protection.

Question 3

What are the available mechanisms for the public funding of care?

Answer 3

• “Single payer” tax-based general revenues-provide care directly through state-owned and run facilities e.g. the UK, Canada
• Possibility of earmarked (hypothecated) health tax
• Social insurance financing e.g. Germany, France,
• Individually based insurance e.g. United States (refined by the Affordable Care Act)
• Support health care consumers directly through “vouchers”
• Health savings accounts plus catastrophic insurance

Question 4

Define priority setting in health

Answer 4

The task of determining the priority to be assigned to a service, a service development or an individual patient at a given point in time

Question 5

Why do we need to set priorities?

Answer 5

• To optimize the allocation of resources to best meet the health care needs of a population
• Lack of priorities can distort a national health system’s ability to progress towards UHC.
• Needs and demands on healthcare resources are greater than the resources available, making some form of rationing inevitable
• Because no or ad-hoc priority-setting approaches can disproportionately impact the least well-off
• To increase efficiency and equity of health funding.

Question 6

Why is resource allocation important?

Answer 6

• Resources allocated to meet the health needs of the population
• Normative approaches based on societies’ goals and values
• Outcome based approaches
• Community approaches based on stakeholder engagement

Question 7

What is the criteria for resource allocation?

Answer 7

• Effectiveness and efficiency
• Cost effectiveness-may include monetary costs, effectiveness and efficiency, patient safety and quality of life measures
• Equity-with focus on UHC and reduction of health inequalities and inequities
• Quality of care-difficulties in agreeing definitions and devising measurements

Question 8

What are the explicit priority settings?

Answer 8

• Era of clinical autonomy and decision making ended in 1990s
• Different country approaches
• E.g. include solidarity, liberalism and pluralism-France
• E.g. independent advisory commissions-Norway, Netherlands, Sweden, Denmark
• UK-criteria include necessity, effectiveness, efficiency, personal responsibility, human dignity, human need, equity, comprehensiveness, accountability
• E.g. Oregon health insurance experiment-bundled Medicaid “Health Plan” with bundled elements decided by public consultation. Led to controversy and in 2003 the establishment of expert commission
• E.g. citizens forums- Netherlands

Question 9

What are the changing expectations of health systems-pressures for reform

Answer 9

• Demography-the increasing proportion of the old and the very old
• Co-morbidities amongst the old
• Technological advances-diagnostic, therapeutic, pharmaceutical
• Raising population expectations for quality care
• Litigation pressures
• The increasing involvement of public institutions and financing
• Pressures for quality, efficiency and cost-control

Question 10

What does the search for greater efficiency demand side measures consist of?

Answer 10

• Increased insurance payments
• Increased out of pocket payments
• Increased deductibles and co-payments
• Cost sharing with patients
• Excess charges e.g. hospital day charges
• Such measures may delay diagnosis and treatment, paradoxically leading to increased costs later

Question 11

What does the search for greater efficiency supply side measures consist of?

Answer 11

• Better information about quality care
• Greater transaction visibility, including care outcome measurements
• Better coordination of hospitals and physicians
• Better and more “person-centered” integrated care
• More extensive and binding budgeting
• Greater price competition amongst providers
• Centralised budgeting and cost control, and cash limited budgets
• Changing the pattern of care e.g. increasing health promotion and disease prevention, extending primary health care, increasing day surgery,

Question 12

Conclusions

Answer 12

• Priority setting is a complex, political and “messy” process
• Goal is that intentions meet the reality of advancing towards UHC
• Various tools for priority setting.
• Priority setting often translates into definition of a benefit package.
• The benefit package should be constructed based in the local context, with explicit prioritization criteria and accountability
• Number of available mechanisms for public funding of care, necessary to achieve UHC
• The poor avoid care they cannot afford