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This systematic review aimed to identify criteria being used for priority setting for resource allocation decisions in low- and middle-income countries (LMICs). Furthermore, the included studies were analyzed from a policy perspective to understand priority setting processes in these countries.
Searches were carried out in PubMed, Embase, Econlit, and Cochrane databases, supplemented with pre-identified Web sites and bibliographic searches of relevant papers. Quality appraisal of included studies was undertaken. The review protocol is registered in International Prospective Register of Systematic Reviews PROSPERO CRD42017068371.
Of 16,412 records screened by title and abstract, 112 papers were identified for full text screening and 44 studies were included in the final analysis. At an overall level, cost-effectiveness 52 percent (n = 22) and health benefits 45 percent (n = 19) were the most cited criteria used for priority setting for public health resource allocation. Inter-region (LMICs) and between various approaches (like health technology assessment, multi-criteria decision analysis (MCDA), accountability for reasonableness (AFR) variations among criteria were also noted. Our review found that MCDA approach was more frequently used in upper middle-income countries and AFR in lower-income countries for priority setting in health. Policy makers were the most frequently consulted stakeholders in all regions.
Conclusions and Recommendations
Priority-setting criteria for health resource allocation decisions in LMICs largely comprised of cost-effectiveness and health benefits criteria at overall level. Other criteria like legal and regulatory framework conducive for implementation, fairness/ethics, and political considerations were infrequently reported and should be considered.
Flower and leaf herbivory might cause relevant and negative impacts on plant fitness. While flower removal or damage by florivores produces direct negative effects on plant fitness, folivores affect plant fitness by reducing resource allocation to reproduction. In this study, we examine the effects of both flower and leaf herbivory by leaf-cutting ants on the reproductive success of the shrub species Miconia nervosa (Smith) Triana (Family Melastomataceae) in a fragment of Atlantic Forest in Northeast Brazil. We conducted a randomized block-designed field experiment with nine replicates (blocks), in which three plants per block were assigned to one of the three following treatments: undamaged plants (ant exclusion), leaf-damaged plants (ant exclusion from reproductive organs, but not from leaves), and flower + leaf-damaged plants (no exclusion of ants). We then measured flower production, fruit set, and fruit production. Our results showed that flower + leaf-damaged plants reduced flower production nearly twofold in relation to undamaged plants, while flower set in leaf-damaged plants remained constant. The number of flowers that turned into fruits (i.e., fruit set), however, increased by 15% in flower + leaf-damaged plants, while it slightly decreased in leaf-damaged compared to undamaged plants. Contrastingly, fruit production was similar between all treatments. Taken together, our results suggest a prominent role of ant floral herbivory across different stages of the reproductive cycle in M. nervosa, with no consequences on final fruit production. The tolerance of M. nervosa to leaf-cutting ant herbivory might explain its high abundance in human-modified landscapes where leaf-cutting ants are hyper-abundant.
In the western Serengeti of Tanzania, African elephant Loxodonta africana populations are increasing, which is rare across the species’ range. Here, conservation objectives come into conflict with competing interests such as agriculture. Elephants regularly damage crops, which threatens livelihoods and undermines local support for conservation. For damage reduction efforts to be successful, limited resources must be used efficiently and strategies for mitigation and prevention should be informed by an understanding of the spatial and temporal distribution of crop damage. We assessed historical records of crop damage by elephants to describe the dynamics and context of damage in the western Serengeti. We used binary data and generalized additive models to predict the probability of crop damage at the village level in relation to landscape features and metrics of human disturbance. During 2012–2014 there were 3,380 reports of crop damage by elephants submitted to authorities in 42 villages. Damage was concentrated in villages adjacent to a reserve boundary and peaked during periods of crop maturity and harvest. The village-level probability of crop damage was negatively associated with distance from a reserve, positively with length of the boundary shared with a reserve, and peaked at moderate levels of indicators of human presence. Spatially aggregated historical records can provide protected area managers and regional government agencies with important insights into the distribution of conflict across the landscape and between seasons, and can guide efforts to optimize resource allocation and future land use planning efforts.
Quantifying interconnected performances of the modules in a colonial organism (feeding, sexual reproduction, rejuvenation, dormancy) into an integral picture enables studying functional dynamics and resource allocation at different levels – from module to population. Testing this approach on the common boreal-Arctic bryozoan Cribrilina annulata in the White Sea, we describe its life history, comparing colonies on two algal substrates with contrasting size and lifespan. Colonies living on kelps were much larger and had a higher proportion of dormant zooids, whereas the percentage of reproducing, feeding and rejuvenating zooids was higher in colonies on red algae (with the colonies also exhibiting longer reproductive period). Colony lifespan was dependent both on substrate type and on time of colony establishment, lasting from 4–5 to up to 17 months on kelps and 14–18 months on red algae. During the reproductive season (May–September) the C. annulata population consisted of colonies of three cohorts on both substrata: overwintered and two summer generations that behaved differently. Whereas overwintered and summer colonies established in June–early August produced larvae, most of the colonies established after mid-summer were preparing for hibernation and postponed reproduction until next spring. Moreover, young reproducing colonies formed brooding hermaphrodite zooids of ordinary size, whereas overwintered colonies budded smaller-sized basal and frontal (dwarf) hermaphrodites. Finally, overall zooidal performance in co-existing colonies of the overwintered and young generations was different on kelps, but similar on red algae. Altogether our findings indicate that the life histories of colonial epibionts are much more complex and evolutionarily flexible than generally acknowledged.
As referrals to specialist palliative care (PC) grow in volume and diversity, an evidence-based triage method is needed to enable services to manage waiting lists in a transparent, efficient, and equitable manner. Discrete choice experiments (DCEs) have not to date been used among PC clinicians, but may serve as a rigorous and efficient method to explore and inform the complex decision-making involved in PC triage. This article presents the protocol for a novel application of an international DCE as part of a mixed-method research program, ultimately aiming to develop a clinical decision-making tool for PC triage.
Five stages of protocol development were undertaken: (1) identification of attributes of interest; (2) creation and (3) execution of a pilot DCE; and (4) refinement and (5) planned execution of the final DCE.
Six attributes of interest to PC triage were identified and included in a DCE that was piloted with 10 palliative care practitioners. The pilot was found to be feasible, with an acceptable cognitive burden, but refinements were made, including the creation of an additional attribute to allow independent analysis of concepts involved. Strategies for recruitment, data collection, analysis, and modeling were confirmed for the final planned DCE.
Significance of results
This DCE protocol serves as an example of how the sophisticated DCE methodology can be applied to health services research in PC. Discussion of key elements that improved the utility, integrity, and feasibility of the DCE provide valuable insights.
Research suggests that a significant minority of hospital in-patients could be more appropriately supported in the community if enhanced services were available. However, little is known about these individuals or the services they require.
To identify which individuals require what services, at what cost.
A ‘balance of care’ (BoC) study was undertaken in northern England. Drawing on routine electronic data about 315 admissions categorised into patient groups, frontline practitioners identified patients whose needs could be met in alternative settings and specified the services they required, using a modified nominal group approach. Costing employed a public-sector approach.
Community care was deemed appropriate for approximately a quarter of admissions including people with mild-moderate depression, an eating disorder or personality disorder, and some people with schizophrenia. Proposed community alternatives drew heavily on carer support services, community mental health teams and consultants, and there was widespread consensus on the need to increase out-of-hours community services. The costs of the proposed community care were relatively modest compared with hospital admission. On average social care costs increased by approximately £60 per week, but total costs fell by £1626 per week.
The findings raise strategic issues for both national policymakers and local service planners. Patients who could be managed at home can be characterised by diagnosis. Although potential financial savings were identified, the reported cost differences do not directly equate to cost savings. It is not clear whether in-patient beds could be reduced. However, existing beds could be more efficiently used.
Clinical and translational science is vitally dependent on the nation’s underlying health-care policies and programs. In a reciprocal fashion, data generated by clinical and translational research can inform both health policy and health-care delivery. It is important, therefore, to rate health reform proposals comprehensively on a set of criteria that reflect the broad goals of reform, including the potential impact on clinical and translational science and medical education. I propose that the criteria include achieving universal coverage, reducing administrative costs, retaining one’s chosen primary care physician, encouraging care coordination, empowering physicians, freeing industry from choosing and administering health plans, providing choice of specialists and hospitals, providing patient education, preventing patient overuse of services, rationalizing resource allocation, encouraging competition, limiting government’s role, supporting medical education, training, and research, and freeing industry to make personnel decisions based on business criteria rather than the impact on health-care costs to the company. I discuss the rationale for each element and offer a rating of current proposals relative to a proposal previously made.
Explanations of the state of ‘crisis’ in the English National Health Service (NHS) generally focus on the overall level of health care funding rather than the way in which funding is distributed. Describing systematic patterns in the way different areas are experiencing crisis, this paper suggests that NHS organisations in older, rural and particularly coastal areas are more likely to be ‘failing’ and that this is due to the historic underfunding of such areas. This partly reflects methodological and technical shortcomings in NHS resource allocation formulae. It is also the outcome of a philosophical shift from horizontal (equal access for equal needs) to vertical (unequal access to equalise health outcomes) principles of equity. Insofar as health inequalities are determined by factors well beyond health care, we argue that this is an ineffective approach to addressing health inequalities. Moreover, it sacrifices equity in access to health care by failing to adequately fund the health care needs of older populations. The prioritisation of vertical over horizontal equity also conflicts with public perspectives on the NHS. Against this background, we ask whether the time has come to reassert the moral and philosophical case for the principle of equal access for equal health care need.
Introduction: Resource allocation planning (RAP) for emergency medical services (EMS) systems determines optimal resources for patient needs in order to minimize morbidity and mortality. The British Columbia Emergency Health Services developed a new RAP using an evidenced informed methodology, statistical analysis of outcomes and with further clinical input from EMS physicians, paramedics and allied EMS providers. The revised RAP was implemented on a pan provincial basis in fall of 2013. It is unknown how the modifications will affect outcomes of EMS cases. Population-based analysis was used to determine the effect of a comprehensive RAP changes by comparing 24-hour mortality before and after province-wide implementation of the revised RAP. Methods: The primary outcome, 24-hour mortality, was obtained through linked provincial health administrative data. All adult cases with evaluable outcome data were included in the analysis. A pre and post methodology was used to evaluate the effect of post-RAP revision (post-RAP-revision) on 24-hour mortality compared to pre-RAP revision (pre-RAP-revision). Multivariable logistic regression was used to adjust for variations in other significant factors associated with 24-hour mortality. The interrupted time series (ITS) estimated any immediate changes in the level or trend of outcome after the start of the revised RAP implementation (fall of 2013), while simultaneously controlling for pre-existing trends. Results: The cohort is comprised of 562,546 cases (April 2012 March 2015). In the multivariate model, adjusted for age, sex, urban/metro region, season, day hour, and MPDS determinant, the probability of dying within 24 hours of EMS call was 7% lower in the post-RAP-revision cohort (OR=0.936; 95% CI: 0.886 - 0.989; P=0.018). A sub-group analysis of immediately life-threatening cases demonstrated similar effect (OR=0.890; 95% CI: 0.808 - 0.981; P=0.019) Conclusion: Our results demonstrate that a comprehensive, evidence informed reconstruction of a provincial EMS RAP is feasible. Despite considerable change in crew level response and resource allocation, there was significant decrease in 24 hour mortality in a large pan-provincial population based patient cohort.
Objectives: In recent years, numerous frameworks have been developed to enhance the legitimacy of health technology assessment processes. Despite efforts to implement these “legitimacy frameworks,” medicines funding decisions can still be perceived as lacking in legitimacy. We, therefore, sought to examine stakeholder views on factors that they think should be considered when making decisions about the funding of high-cost breast cancer therapies, focusing on those that are not included in current frameworks and processes.
Methods: We analyzed published discourse on the funding of high-cost breast-cancer therapies. Relevant materials were identified by searching the databases Google, Google Scholar, and Factiva in August 2014 and July 2016 and these were analyzed thematically.
Results: We analyzed fifty published materials and found that stakeholders, for the most part, want to be able to access medicines more quickly and at the same time as other patients and for decision makers to be more flexible with regards to evidence requirements and to use a wider range of criteria when evaluating therapies. Many also advocated for existing process to be accelerated or bypassed to improve access to therapies.
Conclusions: Our results illustrate that a stakeholder-derived conceptualization of legitimacy emphasizes principles of accelerated access and is not fully accounted for by existing frameworks and processes aimed at promoting legitimacy. However, further research examining the ethical, political, and clinical implications of the stakeholder claims raised here is needed before firm policy recommendations can be made.
The availability of resources including energy, nutrients and (developmental) time has a crucial impact on productivity of farm animals. Availability of energy and nutrients depends on voluntary feed intake and intestinal digestive and absorptive capacity at optimal feeding conditions. Availability of time is provided by the management in animal production. According to the resource allocation theory, resources have to be allocated between maintenance, ontogenic growth, production and reproduction during lifetime. Priorities for these processes are mainly determined by the genetic background, the rearing system and the feeding regimen. Aim of this review was to re-discuss the impact of a proper resource allocation for a long and healthy life span in farm animals. Using the barrel model of resource allocation, resource fluxes were explained and were implemented to specific productive life conditions of different farm animal species, dairy cows, sows and poultry. Hypothetically, resource allocation mismatch neglecting maintenance is a central process, which might be associated with morphological constraints of extracellular matrix components; evidence for that was found in the literature. A potential consequence of this limitation is a phenomenon called disproportionate growth, which counteracts the genetically determined scaling rules for body and organ proportions and could have a strong impact on farm animal health and production.
Vertically transmitted parasites (VTPs) such as Wolbachia are expected not only to minimize the damage they inflict on their hosts, but also to protect their hosts against the damaging effects of coinfecting parasites. By modifying the fitness costs of the infection, VTPs can therefore play an important role in the evolution and epidemiology of infectious diseases.
Using a natural system, we explore the effects of a Wolbachia–Plasmodium co-infection on mosquito fecundity. While Plasmodium is known to frequently express its virulence by partially castrating its mosquito vectors, the effects of Wolbachia infections on mosquito fecundity are, in contrast, highly variable. Here, we show that Plasmodium drastically decreases the fecundity of mosquitoes by ca. 20%, and we provide the first evidence that this decrease is independent of the parasite's burden. Wolbachia, on the other hand, increases fecundity by roughly 10%, but does not alter the tolerance (fecundity–burden relationship) of mosquitoes to Plasmodium infection.
Although Wolbachia-infected mosquitoes fare overall better than uninfected ones, Wolbachia does not confer a sufficiently high reproductive boost to mosquitoes to compensate for the reproductive losses inflicted by Plasmodium. We discuss the potential mechanisms and implications underlying the conflicting effects of these two parasites on mosquito reproduction.
Objectives: The aim of this study was to examine submissions made to the Pharmaceutical Benefits Advisory Committee (PBAC) and assess whether the predicted financial impact was associated with a recommendation. The second objective was to assess whether the financial and utilization estimates for listing the proposed medicine were reliable.
Methods: Data were extracted from public summary documents of major submissions considered by the PBAC from 2012 to 2014. Information collected included whether submissions were accepted, rejected, or deferred; estimated use; and financial impact. For those submissions that were recommended in 2012 and listed on the Pharmaceutical Benefits Scheme (PBS) by January 2014, a comparison was made between predicted and actual use and cost in 2014, based on PBS utilization.
Results: In 2012 to 2014, the PBAC considered 142 unique major submissions; of those, 65 were recommended for listing. A higher financial cost to the government was a statistically significant factor in predicting rejection (p = .004 for cost > AUD 30 million Australian dollars [20.7 million Euros] compared with cost-saving). Of the submissions that were recommended in 2012 and listed by 2014, the actual use was higher than predicted for 5/19 medications. The estimated cost was outside the predicted bracket of cost for 10/19 medications, with 8/19 medications having threefold underestimated expenditure, and 2/19 items having lower than predicted expenditure.
Conclusions: This study highlights that the predicted financial impact of a medication to the PBS budget is associated with a PBAC recommendation and also highlights that predicted use may not reflect actual prescribing practices.
We consider a server with large capacity delivering video files encoded in various resolutions. We assume that the system is under saturation in the sense that the total demand exceeds the server capacity C. In such a case, requests may be rejected. For the policies considered in this paper, instead of rejecting a video request, it is downgraded. When the occupancy of the server is above some value C0 < C, the server delivers the video at a minimal bit rate. The quantity C0 is the bit rate adaptation threshold. For these policies, request blocking is thus replaced with bit rate adaptation. Under the assumptions of Poisson request arrivals and exponential service times, we show that, by rescaling the system, a process associated with the occupancy of the server converges to some limiting process whose invariant distribution is computed explicitly. This allows us to derive an asymptotic expression of the key performance measure of such a policy, namely the equilibrium probability that a request is transmitted at requested bitrate. Numerical applications of these results are presented.
Objectives: We developed specific evaluation criteria to assess patient and public involvement in resource allocation decisions in health care.
Methods: We reviewed the literature from health and other sectors relevant to stakeholder involvement and conducted twenty-seven key informant interviews with stakeholders knowledgeable about patient and public involvement in Canadian drug resource allocation decisions. We used an inductive qualitative thematic approach to analyze the interviews with codes and categories developed directly from individuals’ interview transcripts.
Results: Integrating respondents’ comments and the literature review, we identified nine evaluation criteria of patient and the public involvement in healthcare resource allocation decision making: clarity regarding rationale and roles of patient and public members, sufficient support, adequate representation of relevant views, fair decision-making processes, legitimacy of committee processes, adequate opportunity for participation, meaningful degree of participation, noticeable effect on decisions, and considerations of the efficiency of patient and public involvement.
Conclusions: Our results will help to develop methods to evaluate patient and public involvement in healthcare decision making.
Introduction/Innovation Concept: University Departments of Emergency Medicine are responsible for the supervision of research and other scholarly projects for fellows, residents and students, though often lack resources to provide adequate input and oversight. Many departments cover large geographical areas and several programs. We piloted new research committee structures and processes to improve oversight and output of research projects. Methods: We created an interactive group supervision tool based around formation of a collaborative research committee, with rotating chairs from each program, to provide supervision and face to face interaction, and direction for research learners. Included were all Dalhousie University adult and pediatric emergency medicine residency and fellowship programs, as well as trauma and EMS programs across Nova Scotia, New Brunswick, and Prince Edward Island. In addition to providing expertise in clinical trial coordination, database management, research administration, grant applications and Research Ethics Board submissions, we have completed a 2-year pilot of our interactive group supervision tool for research projects. Curriculum, Tool, or Material: The interactive tool consists of a structured PICOD form; allocation of topic and research mentors; standardized yearly milestones from project development through presentation and publication; and regular video-conferenced and in-person interactive group sessions involving several project leads, as well as program research directors, researchers, and co-ordinators. To date, all participating program learners have engaged with the tool, with positive feedback from learners, supervisors and program directors. Conclusion: We report our development of a regional collaborative interactive group supervision tool, that maximizes expert resources in the provision of research and scholarly project supervision.
Objectives: In 2012, Colombia experienced an important institutional transformation after the establishment of the Health Technology Assessment Institute (IETS), the disbandment of the Regulatory Commission for Health and the reassignment of reimbursement decision-making powers to the Ministry of Health and Social Protection (MoHSP). These dynamic changes provided the opportunity to test Multi-Criteria Decision Analysis (MCDA) for systematic and more transparent resource-allocation decision-making.
Methods: During 2012 and 2013, the MCDA framework Evidence and Value: Impact on Decision Making (EVIDEM) was tested in Colombia. This consisted of a preparatory stage in which the investigators conducted literature searches and produced HTA reports for four interventions of interest, followed by a panel session with decision makers. This method was contrasted with a current approach used in Colombia for updating the publicly financed benefits package (POS), where narrative health technology assessment (HTA) reports are presented alongside comprehensive budget impact analyses (BIAs).
Results: Disease severity, size of population, and efficacy ranked at the top among fifteen preselected relevant criteria. MCDA estimates of technologies of interest ranged between 71 to 90 percent of maximum value. The ranking of technologies was sensitive to the methods used. Participants considered that a two-step approach including an MCDA template, complemented by a detailed BIA would be the best approach to assist decision-making in this context. Participants agreed that systematic priority setting should take place in Colombia.
Conclusions: This work may serve as the basis to the MoHSP on its interest of setting up a systematic and more transparent process for resource-allocation decision-making.
Misallocation of resources across firms leads to lower aggregate productivity. In this paper, we provide new estimates of manufacturing productivity differences across countries and establish by how much they would be reduced if such misallocation were eliminated. Using World Bank survey data for formal manufacturing firms in 52 low- and middle-income countries, we show that manufacturing productivity would increase by an average of 62%, but productivity gaps relative to the United States would remain large. We also find that lower-income countries do not have more to gain from reducing misallocation, as efficiency of resource allocation is uncorrelated with income levels.
Objectives: Many of the currently used health technologies have never been systematically assessed or are misused, overused or superseded. Therefore, they may be ineffective. Active identification of ineffectiveness in health care is gaining importance to facilitate best care for patients and optimal use of limited resources. The present research analyzed processes and experiences of programs for identifying ineffective health technologies. The goal of this study was to elucidate factors that facilitate implementation.
Methods: Based on an overview article, a systematic literature search and unsystematic hand-search were conducted. Further information was gained from international experts.
Results: Seven programs were identified that include identification, prioritization and assessment of ineffective health technologies and dissemination of recommendations. The programs are quite similar regarding their goals, target groups and criteria for identification and prioritization. Outputs, mainly HTA reports or lists, are mostly disseminated by means of the internet. Top–down and bottom–up programs both have benefits in terms of implementation of recommendations, either as binding guidelines and decisions or as nonbinding information for physicians and other stakeholders. Crucial facilitators of implementation are political will, transparent processes and broad stakeholder involvement focusing on physicians.
Conclusions: All programs can improve the quality of health care and enable cost reduction in supportive surrounding conditions. Physicians and patients must be continuously involved in the process of evaluating health technologies. Additionally, decision makers must support programs and translate recommendations into concrete actions.
The treatment of rare and expensive medical conditions is one of the defining qualities of paediatric cardiology and congenital heart surgery. Increasing concerns over healthcare resource allocation are challenging the merits of treating more expensive forms of congenital heart disease, and this trend will almost certainly continue. In this manuscript, the problems of resource allocation for rare and expensive medical conditions are described from philosophical and economic perspectives. The argument is made that current economic models are limited in the ability to assess the value of treating expensive and rare forms of congenital heart disease. Further, multi-disciplinary approaches are necessary to best determine the merits of treating a patient population such as those with significant congenital heart disease that sometimes requires enormous healthcare resources.