Integrated care in a Beveridge system: experiences from England and Denmark.

Health systems internationally face demands to deliver care that is better coordinated and integrated. The health system financing and delivery model may go some, but not all the way in explaining health system fragmentation. In this paper, we consider the road to care integration in two countries with Beveridge style health systems, England and Denmark, that are both ranked as highly Integrated systems in Toth's health integration index. We use the SELFIE framework to compare the policies and reforms that have affected care integration over the past 30 years in the two countries. The countries both started their reform path by reforming to introduce choice and competition, but did so in different ways that set them on different pathways. Nevertheless, after two decades, the countries ended the period with largely similar structures that emphasised the creation of a cross-sectoral governance structure. In the relatively centralised England, by introducing decentralised Integrated Care Systems, and in the relatively decentralised Denmark with a centralising element in the form of new Health Clusters.

The Use of Multicriteria Decision Analysis to Support Decision Making in Healthcare: An Updated Systematic Literature Review.

OBJECTIVES: Multicriteria decision analysis (MCDA) is increasingly used for decision making in healthcare. However, its application in different decision-making contexts is still unclear. This study aimed to provide a comprehensive review of MCDA studies performed to inform decisions in healthcare and to summarize its application in different decision contexts. METHODS: We updated a systematic review conducted in 2013 by searching Embase, MEDLINE, and Google Scholar for MCDA studies in healthcare, published in English between August 2013 and November 2020. We also expanded the search by reviewing grey literature found via Trip Medical Database and Google, published between January 1990 and November 2020. A comprehensive template was developed to extract information about the decision context, criteria, methods, stakeholders involved, and sensitivity analyses conducted. RESULTS: From the 4295 identified studies, 473 studies were eligible for full-text review after assessing titles and abstracts. Of those, 228 studies met the inclusion criteria and underwent data extraction. The use of MCDA continues to grow in healthcare literature, with most of the studies (49%) informing priority-setting decisions. Safety, cost, and quality of care delivery are the most frequently used criteria, although there are considerable differences across decision contexts. Almost half of the MCDA studies used the linear additive model whereas scales and the analytical hierarchy process were the most used techniques for scoring and weighting, respectively. Not all studies report on each one of the MCDA steps, consider axiomatic properties, or justify the methods used. CONCLUSIONS: A guide on how to conduct and report MCDA that acknowledges the particularities of the different decision contexts and methods needs to be developed.

Harnessing Health Technology Assessment in Latin America and the Caribbean: Keeping the Region on Course.

Latin America and the Caribbean has made significant progress toward universal health coverage (UHC), but health spending efficiency, equity, and sustainability remain major challenges-and progress is hindered by the difficult macroeconomic context. Health technology assessment (HTA) can make resource allocation more efficient and equitable when systematically used to inform coverage decisions. We highlight five considerations that need to be taken into account to realize the full potential of HTA in the LAC region: i) explicitly link HTA to decision-making and anchor it in legal frameworks, ii) systematically incorporate the opportunity cost as a core principle into HTA activities informing coverage decisions, iii) make the internationally available evidence more fit for purpose for low- and middle-income countries (LMICs), iv) incorporate pragmatism as a key principle of HTA activities in the region, and v) institutionalize the monitoring of HTA processes and results.

Commissioning [Integrated] Care in England: An Analysis of the Current Decision Context.

Background: The emergence of Integrated Care Systems (ICSs) across England poses an additional challenge and responsibility for local commissioners to accelerate the implementation of integrated care programmes and improve the overall efficiency across the system. To do this, ICS healthcare commissioners could learn from the experience of the former local commissioning structures and identify areas of improvement in the commissioning process. This study describes the investment decision process in integrated care amid the transition toward ICSs, highlights challenges, and provides recommendations to inform ICSs in their healthcare commissioning role. Methods: Twenty-six semi-structured interviews were conducted with local commissioners and other relevant stakeholders in South East England in 2021. Interviews were supplemented with literature. Results: England's local healthcare commissioning has made the transition towards a new organisational architecture, with some integrated care programmes running, and a dual top-down and bottom-up prioritisation process in place. The commissioning and consequent development of integrated care programmes have been hindered by various barriers, including difficulties in accessing and using information, operational challenges, and resource constraints. Investment decisions have mainly been driven by national directives and budget considerations, with a mixture of subjective and objective approaches. A systematic and data-driven framework could replace this ad-hoc prioritisation of integrated care and contribute to a more rational and transparent commissioning process. Conclusion: The emerging ICSs seem to open an opportunity for local commissioners to strengthen the commissioning process of integrated care with evidence-based priority-setting approaches similar to the well-established health technology assessment framework at the national level.

Income inequality and self-rated health status in Colombia.

BACKGROUND: The negative association between income inequality and health has been known in the literature as the Income Inequality Hypothesis (IIH). Despite the multiple studies examining the validity of this hypothesis, evidence is still inconclusive, and the debate remains unsolved. In addition, relatively few studies have focused their attention on developing or emerging economies, where levels of inequality tend to be the highest in the world. This work examines the statistical association between income inequality and self-rated health status in Colombia, a highly unequal Latin American country. METHODS: To explore whether this association is present in the general population or whether it is only confined to the bottom of the income distribution, we use data from the 2011-2019 National Quality of Life Survey. Multiple probit estimations are considered for testing the robustness of the IIH. RESULTS: Evidence favouring the IIH was found, even after controlling for individual income levels, average regional income, and socioeconomic characteristics. The link between income inequality and the probability of reporting poor health seems to be present across all income quintiles. However, the magnitude of such association is considerably smaller when using inequality measures with relatively greater sensitivity to income differences among the rich. CONCLUSIONS: The association between regional income inequality and individual's self-rated health status in Colombia is not only confined to low-income individuals but extends across all socioeconomic strata. This association is robust to the income inequality measure implemented, the income-unit of analysis, and changes in the sample. It is suggested that reducing income disparities can potentially contribute to improving individual's health.