Implementing priority setting frameworks: Insights from leading researchers.

In spite of a substantial literature developing frameworks for policymakers to use in resource allocation decisions in healthcare, there remains limited published work reporting on the implementation or evaluation of such frameworks in practice. This paper presents findings of a targeted survey of 18 leading researchers around the implementation and evaluation of priority-setting exercises. Approximately one third of respondents knew of situations where recommendations of priority-setting exercises had been implemented, one third knew that recommendations had not been implemented and the final third responded that they did not know whether recommendations had been adopted. The lack of evidence linking the implementation of priority-setting recommendations to equity and efficiency outcomes was highlighted by all respondents. Features identified as facilitating successful implementation of priority-setting recommendations included having a climate ready to accept priority-setting, good leadership or a 'champion' for the priority-setting process and having a health economist to guide the process. Successful disinvestment was very uncommon in the experience of the researchers surveyed. Recommendations emerging from Program Budgeting and Marginal Analysis exercises appeared to be more widely implemented than those coming from alternative processes. Identifying if the process was repeated following the initial process was suggested as a means to measure success.

Aspectos econômicos da equidade em saúde / Economic aspects of health equity

As contribuições para este livro fazem um exame crítico de alguns desafios a enfrentarmos nos campos da equidade em saúde e nos sistemas de saúde. Ao mesmo tempo em que fornece uma visão resumida dos problemas da desigualdade em saúde em uma perspectiva global, reflete sobre a importância de examinar a comunidade e a cultura, particularmente a cultura nativa, na busca pela equidade. Também compara e contrasta abordagens neoliberais e igualitárias e o que elas significam para os sistemas de saúde. Explora as diferentes dimensões do acesso aos serviços de saúde e, no tocante à prestação desses serviços, analisa a disponibilidade de recursos humanos e a necessidade de redistribuí-los no nível global. Discute, ainda, desafios e alternativas do financiamento à saúde, sobretudo no contexto dos substanciais setores privados que existem em muitos países. Um dos capítulos aborda a equidade na assistência à saúde brasileira, explicando por que - e como - ela pode melhorar ainda mais. "Todos os autores oferecem sugestões de como a equidade em saúde poderá testemunhar um futuro mais positivo. Há esperança", destacam os organizadores.

Africanizing the social determinants of health: embedded structural inequalities and current health outcomes in sub-Saharan Africa.

There is a growing interest in health policy in the social determinants of health. This has increased the demand for a paradigm shift within the discipline of health economics from health care economics to health economics. While the former involves what is essentially a medical model that emphasizes the maximization of individual health outcomes and considers the social organization of the health system as merely instrumental, the latter emphasizes that health and its distribution result from political, social, economic, and cultural structures. The discipline of health economics needs to refocus its energy on the social determinants of health but, in doing so, must dig deeper into the reasons for structurally embedded inequalities that give rise to inequalities in health outcomes. Especially is this the case in Africa and other low- and middle-income regions. This article seeks to provide empirical evidence from sub-Saharan Africa, including Ghana and Nigeria, on why such inequalities exist, arguing that these are in large part a product of hangovers from historically entrenched institutions. It argues that there is a need for research in health economics to embrace the social determinants of health, especially inequality, and to move away from its current mono-cultural focus.

Neoliberalism is bad for our health.

This paper examines some of the concerns that arise from the impact of neoliberalism on health and health care. It also examines the way that global institutions such as the World Health Organization and the World Trade Organization, having been captured by neoliberalism, fail to act decisively to reduce poverty and inequality and thereby do all too little to promote population health at a global level. The paper argues for a greater community focus, with health care systems being seen more as social institutions and placing more power over decision making in the hands of a critically-informed citizenry.

People's policies for the health of the poor globally.

In this paper, we argue that the dominant role played by governments of the developed countries in global health policies is a critical but often an ignored factor in contributing to the lack of progress in global health. The solution to this challenge lies in efforts to 'democratise' global decision making and to argue for a greater say of the poor globally in policies affecting them. Although there are potentially many ways to achieve this, the paper proposes 'communitarian claims' as one way to have the voice of people globally involved and to make decisions about how best to allocate resources globally. It is argued that such claims can be advanced at a practical level through 'citizens' juries' as evident from the experience in Australia. That experience and with increasing evidence from elsewhere, there is a strong indication from communities of desires for a very different set of values to underpin healthcare than the Australian and other governments, in partnership with global institutions, deliver.

Social health insurance: to each according to his needs; from each according to his means--but what might that mean?

Despite the substantial literature on the financing and benefit incidence of social health insurance, the principles underlying such schemes are little debated. This article examines one of these key principles: to each according to his needs; from each according to his means. The authors discuss both sides of this principle at a conceptual level. On the needs side, they examine the issue of vertical equity. The approach of "communitarian claims" is proposed, both for eliciting the components of need and for determining the relative weights to be attached to the vertical dimensions of equity in health service delivery. On the means side, the authors also look to communitarian claims to assist in determining who should bear what burden in paying for social health insurance. They argue that with respect to the concept of "from each according to his means," it is useful to incorporate an element of willingness to pay, but meaning here the community's willingness to pay.

Claims on health care: a decision-making framework for equity, with application to treatment for HIV/AIDS in South Africa.

Trying to determine how best to allocate resources in health care is especially difficult when resources are severely constrained, as is the case in all developing countries. This is particularly true in South Africa currently where the HIV epidemic adds significantly to a health service already overstretched by the demands made upon it. This paper proposes a framework for determining how best to allocate scarce health care resources in such circumstances. This is based on communitarian claims. The basis of possible claims considered include: the need for health care, specified both as illness and capacity to benefit; whether or not claimants have personal responsibility in the conditions that have generated their health care need; relative deprivation or disadvantage; and the impact of services on the health of society and on the social fabric. Ways of determining these different claims in practice and the weights to be attached to them are also discussed. The implications for the treatment of HIV/AIDS in South Africa are spelt out.

A communitarian approach to public health.

This paper argues that there is a need to move yet further than has already been suggested by some from the individual to the collective as a base for public health. A communitarian approach is one way to achieve this. This has the advantage of allowing not only the community's voice to have a say in setting the values for public health but also more formally the development of a constitution on which public health might then be built. It also sees public health as a social institution which can be valued in its own right.

Prevention before profits: a levy on food and alcohol advertising.

The recent interest in health promotion and disease prevention has drawn attention to the role of the alcohol and junk-food industries. Companies supplying, producing, advertising or selling alcohol or junk food (ie, foods with a high content of fat, sugar or salt) do so to generate profits. Even companies marketing "low-carbohydrate" beers, "mild" cigarettes, or "high-fibre" sugary cereals are not primarily concerned about population health, more so increased sales and profits. In a competitive market, it is assumed that consumers make fully informed choices about costs and benefits before purchasing. However, consumers are not being fully informed of the implications of their junk-food and alcohol choices, as advertising of these products carries little information on the health consequences of consumption. We propose that there should be a levy on advertising expenditure for junk food and alcoholic beverages to provide an incentive for industry to promote healthier products. Proceeds of the levy could be used to provide consumers with more complete and balanced information on the healthy and harmful impacts of food and alcohol choices. Our proposal addresses two of the greatest challenges facing Australia's preventable disease epidemic - the imbalance between the promotion of healthier and unhealthy products, and securing funds to empower consumer choice.

Equity and efficiency in HIV-treatment in South Africa: the contribution of mathematical programming to priority setting.

The HIV-epidemic is one of the greatest public health crises to face South Africa. A health care response to the treatment needs of HIV-positive people is a prime example of the desirability of an economic, rational approach to resource allocation in the face of scarcity. Despite this, almost no input based on economic analysis is currently used in national strategic planning. While cost-utility analysis is theoretically able to establish technical efficiency, in practice this is accomplished by comparing an intervention's ICER to a threshold level representing society's maximum willingness to pay to avoid death and improve health-related quality of life. Such an approach has been criticised for a number of reasons, including that it is inconsistent with a fixed budget for health care and that equity is not taken into account. It is also impractical if no national policy on the threshold exists. As an alternative, this paper proposes a mathematical programming approach that is capable of highlighting technical efficiency, equity, the equity/efficiency trade-off and the affordability of alternative HIV-treatment interventions. Government could use this information to plan an HIV-treatment strategy that best meets equity and efficiency objectives within budget constraints.