Publications
123 results found
Hauck KD, Thomas R, Smith PC, 2016, Departures from cost-effectiveness recommendations: The impact of health system constraints on priority setting, Health Systems & Reform, Vol: 2, Pages: 61-70, ISSN: 2328-8604
The methods and application of cost-effectiveness analysis have reached an advanced stage of development. Many decision makers consider cost-effectiveness analysis to be a valid and feasible approach towards setting health priorities, and it has been extensively applied in evaluating interventions and developing evidence based clinical guidelines. However, the recommendations arising from cost-effectiveness analysis are often not implemented as intended. A fundamental reason for the failure to implement is that CEA assumes a single constraint, in the form of the budget constraint, whilst in reality decision-makers may be faced with numerous other constraints. The objective of this paper is to develop a typology of constraints that may act as barriers to implementation of cost-effectiveness recommendations. Six categories of constraints are considered: the design of the health system; costs of implementing change; system interactions between interventions; uncertainty in estimates of costs and benefits; weak governance; and political constraints. Where possible -and if applicable- for each class of constraint, the paper discusses ways in which these constraints can be taken into account by a decision maker wishing to pursue the principles of cost-effectiveness.
Hauck KD, Smith PC, 2015, The Politics of Priority Setting in Health: A Political Economy Perspective, Publisher: Center for Global Development
Many health improving interventions in low-income countries are extremely good value for money. So why has it often proven difficult to obtain political backing for apparently common-sense interventions such as vaccinations, treatments against diarrhoeal disease in children, and preventive policies such as improved access to clean water, or policies curtailing tobacco consumption? We use economic models of public choice, supported by examples, to explain how powerful interests groups, politicians or bureaucrats who pursue their own objectives, or voting and institutional arrangements in countries have shaped health priority setting. We show that it may be perfectly rational for policy makers to accommodate these constraints in their decisions, even if it implies departing from welfare maximizing solutions.
Hauck KD, 2015, The Social Determinants of Health: Do the Data support the Rhetoric?, Publisher: Submitted
The WHO Commission on the Social Determinants of Health presented evidence on the importance of a long list of social determinants of health, but policy makers find it difficult to translate the careful work of the Commission into concrete action because it remains unclear what interventions to prioritize. The objective of this paper is to determine a small set of robust social determinants from the large pool of suggested candidates with Extreme Bound Analysis. Panel data models of life expectancy at birth for 54 low-income countries over the years 1990 to 2012 are estimated using the World Bank’s World Development Indicators. For robust determinants the magnitude of association with life expectancy is determined. Up to 14 months longer life expectancy is associated with low HIV prevalence, public health interventions in early childhood, gender equality, agricultural production, good governance, political stability and absence of armed conflict, access to clean water and sanitation, primary school enrolment and its public provision, private health expenditure, traffic accidents, and overseas development assistance. There is no evidence that national income, public spending on healthcare and education, secondary education, terms of trade, employment, debt service, urbanization and environmental degradation are associated with population health. The paper derives empirical evidence on the social determinants of health under high model uncertainty, and the results offer insights that can inform priorities for further, more detailed research, and for policy action.
Sharma A, Hauck K, Hollingsworth B, et al., 2014, The Effects of Taxing Sugar-Sweetened Beverages across different Income Groups, Health Economics, Vol: 23, Pages: 1159-1184, ISSN: 1099-1050
This paper investigates the impact of sugar-sweetened beverages (SSB) taxes on consumption, bodyweight and tax burden for low-income, middle-income and high-income groups using an Almost Ideal Demand System and 2011 Household level scanner data. A significant contribution of our paper is that we compare two types of SSB taxes recently advocated by policy makers: A 20% flat rate sales (valoric) tax and a 20 cent/L volumetric tax. Censored demand is accounted for using a two-step procedure. We find that the volumetric tax would result in a greater per capita weight loss than the valoric tax (0.41 kg vs. 0.29 kg). The difference between the change in weight is substantial for the target group of heavy purchasers of SSBs in low-income households, with a weight reduction of up to 3.20 kg for the volumetric and 2.06 kg for the valoric tax. The average yearly per capita tax burden on low-income households is $17.87 (0.21% of income) compared with $15.17 for high-income households (0.07% of income) for the valoric tax, and $13.80 (0.15%) and $10.10 (0.04%) for the volumetric tax. Thus, the tax burden is lower, and weight reduction is higher under a volumetric tax
Hayes R, Ayles H, Beyers N, et al., 2014, HPTN 071 (PopART): Rationale and design of a cluster-randomised trial of the population impact of an HIV combination prevention intervention including universal testing and treatment - a study protocol for a cluster randomised trial, Trials, Vol: 15, ISSN: 1745-6215
Background: Effective interventions to reduce HIV incidence in sub-Saharan Africa are urgently needed. Mathematicalmodelling and the HIV Prevention Trials Network (HPTN) 052 trial results suggest that universal HIV testing combinedwith immediate antiretroviral treatment (ART) should substantially reduce incidence and may eliminate HIV as a publichealth problem. We describe the rationale and design of a trial to evaluate this hypothesis.Methods/Design: A rigorously-designed trial of universal testing and treatment (UTT) interventions is needed because:i) it is unknown whether these interventions can be delivered to scale with adequate uptake; ii) there are manyuncertainties in the models such that the population-level impact of these interventions is unknown; and ii) there arepotential adverse effects including sexual risk disinhibition, HIV-related stigma, over-burdening of health systems, pooradherence, toxicity, and drug resistance.In the HPTN 071 (PopART) trial, 21 communities in Zambia and South Africa (total population 1.2 m) will be randomlyallocated to three arms. Arm A will receive the full PopART combination HIV prevention package including annualhome-based HIV testing, promotion of medical male circumcision for HIV-negative men, and offer of immediate ARTfor those testing HIV-positive; Arm B will receive the full package except that ART initiation will follow current nationalguidelines; Arm C will receive standard of care. A Population Cohort of 2,500 adults will be randomly selected in eachcommunity and followed for 3 years to measure the primary outcome of HIV incidence. Based on model projections,the trial will be well-powered to detect predicted effects on HIV incidence and secondary outcomes.Discussion: Trial results, combined with modelling and cost data, will provide short-term and long-term estimates ofcost-effectiveness of UTT interventions. Importantly, the three-arm design will enable assessment of how much couldbe achieved by optimal delivery o
Cori A, Ayles H, Beyers N, et al., 2014, HPTN 071 (PopART): A Cluster-Randomized Trial of the Population Impact of an HIV Combination Prevention Intervention Including Universal Testing and Treatment: Mathematical Model, PLOS ONE, Vol: 9, ISSN: 1932-6203
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- Citations: 81
Hauck KD, Smith PC, 2014, Public choice analysis of public health priority setting, Encyclopaedia of Health Economics, Editors: Culyer, San Diego, Publisher: Elsevier, Pages: 184-193
Many public health interventions are extremely good value for money. So why has it often proven difficult to obtain political backing for apparently common-sense public health interventions such as sewage treatment, vaccinations, or cigarette taxes? We use economic models of public choice, supported by plenty of examples, to explain how powerful interests groups, voting arrangements, and politicians or bureaucrats who pursue their own objectives, have shaped public health priority setting. We show that it may be perfectly rational for policy makers to accommodate these constraints in their decisions, even if it implies departing from welfare maximizing solutions.
Au N, Hauck K, Hollingsworth B, 2013, The relationship between smoking, quitting smoking and obesity in Australia: a seemingly unrelated probit approach., Applied Economics, Vol: 45, Pages: 2191-2199
Smoking and obesity are two leading causes of preventable death. Further understanding of the relationship between these two risk factors can assist in reducing avoidable morbidity and mortality. This study investigates the empirical association between obesity and the propensity to smoke and to quit smoking, using a seemingly unrelated (SUR) probit approach that takes into consideration the potential for reverse causality and unobserved heterogeneity. Using Australian health survey data, this paper demonstrates the usefulness of the SUR probit approach in generating information on the relationship between unobserved factors influencing both smoking behaviour and obesity. Further, it provides estimates of the conditional probabilities of smoking and obesity, which allow predicting the knock-on effects of public health policies targeted at one lifestyle onto the other. The presence, size and direction of correlation between the unobserved factors are found to vary by smoking behaviour and by gender. Estimates of conditional probabilities demonstrate smokers have a lower probability of obesity, particularly among females, and ex-smokers have a higher probability of obesity, particularly among males. We discuss possible sources of unobserved heterogeneity and highlight areas for further research into the relationship between smoking, quitting smoking and obesity.
Zhang X, Hauck K, Zhao X, 2013, Patient Safety in Hospitals – A Bayesian Analysis of Unobservable Hospital and Specialty Level Risk Factors, Health Economics, Vol: 22, Pages: 1158-1174
This paper demonstrates how Bayesian hierarchical modelling can be used to evaluate the performance of hospitals. We estimate a three-level random intercept probit model to attribute unexplained variation in hospital-acquired complications to hospital effects, hospital-specialty effects and remaining random variations, controlling for observable patient complexities. The combined information provided by the posterior means and densities for latent hospital and specialty effects can be used to assess the need and scope for improvements in patient safety at different organizational levels. Information on posterior densities is not usually available from standard approaches for performance assessment, but provides valuable additional guidance to policy makers on what poorly performing hospitals and specialties should be prioritized for policy action. We use surgical patient administrative data for 2005/06 for 16 specialties in 35 public hospitals in Victoria, Australia. We use posterior means for latent hospital and specialty effects to compare hospital performance in patient safety. Posterior densities and variances are also compared for different specialties to identify clinical areas with greatest scope for improvement. We also show that the same hospital may rank markedly differently for different specialties. Further, complexity adjusted complication rates are presented which offer a meaningful measure for comparing performance across hospitals.
Au N, Hauck K, Hollingsworth B, 2013, Employment, work hours and weight gain among middle-aged women, International Journal of Obesity, Vol: 37, Pages: 718-724
Objective: To investigate the influence of employment and work hours on weight gain and weight loss among middle-aged women. Design: Quantile regression techniques were used to estimate the influence of employment and hours worked on percentage weight change over 2 years across the entire distribution of weight change in a cohort of middle-aged women. A range of controls was included in the models to isolate the effect of work status. Subjects: 9 276 women aged 45-50 years at baseline who were present in both the 1996 and 1998 surveys of the Australian Longitudinal Study of Women’s Health (ALSWH). The women were a representative sample of the Australian population. Results: Being out of the labour force or unemployed was associated with lower weight gain and higher weight loss than being employed. The association was stronger at low to moderate levels of weight gain. Among employed women, working regular (35-40), long (41-48) or very long (49+) hours was associated with increasingly higher levels of weight gain compared to working part-time hours. The association was stronger for women with greater weight gain overall. The association between unemployment and weight change became insignificant when health status was controlled for. Conclusions: Employment was associated with more weight gain and less weight loss. Among the employed, working longer hours was associated with more weight gain, especially at the higher levels of weight gain where the health consequences are more serious. These findings suggest that as women work longer hours they are more likely to make lifestyle choices that are associated with weight gain.
Hauck K, Jackson T, Zhao X, 2012, Adverse event rates as measures of hospital performance-A chance for organizational learning In reply to "'Adverse event rates as measures of hospital performance'-Conflation and confusion with the use of the complications code", HEALTH POLICY, Vol: 105, Pages: 319-320, ISSN: 0168-8510
Hauck K, Zhao X, Jackson T, 2012, Adverse event rates as measures of hospital performance, Health Policy, Vol: 104, Pages: 146-154
Objectives: Adverse events, complications or medical errors are increasingly advocated as measures of hospital quality and performance. Objective of this study is to analyse patient-complexity adjusted adverse events rates to compare the performance of hospitals in Victoria, Australia. We use a unique hospital dataset that routinely records adverse events which arise during the admission. We identify hospitals with below or above average performance in comparison to their peers, and show for which types of hospitals risk adjusting makes biggest difference.Methods: We estimate adverse event rates for 87,790 elective and 43,771 emergency episodes in 34 public hospitals over the financial year 2005/06 with a complementary log-log model, using patient level administrative hospital data and controlling for patient complexity with a range of covariates. Results: Teaching hospitals have average risk-adjusted adverse event rates of 24.3% for elective and 19.7% for emergency surgical patients. Suburban and rural hospitals have lower rates of 17.4% and 17%, and 16.1% and 15.7%, respectively. Selected non-teaching hospitals have relatively high rates, in particular hospitals in rural and socially disadvantaged areas. Risk adjustment makes a significant difference to some, but not all hospitals. Conclusion: We find comparably high adverse events rates for surgical patients in Australian hospitals, possibly because our data allow identification of a larger number of adverse events than data used in previous studies. There are marked variations in adverse event rates across hospitals in Victoria, even after risk adjusting. We discuss various ways that policy makers could improve quality of care in Australian hospitals.
Au N, Hauck K, Hollingsworth B, 2012, Employment, work hours and weight gain among middle-aged women, International Journal of Obesity, revised and resubmitted
Objective: To investigate the influence of employment and work hours on weight gain and weight loss among middle-aged women.Design: Quantile regression techniques were used to estimate the influence of employment and hours worked on percentage weight change over 2 years across the entire distribution of weight change in a cohort of middle-aged women. A range of controls was included in the models to isolate the effect of work status.Subjects: 9 276 women aged 45-50 years at baseline who were present in both the 1996 and 1998 surveys of the Australian Longitudinal Study of Women’s Health (ALSWH). The women were a representative sample of the Australian population.Results: Being out of the labour force or unemployed was associated with lower weight gain and higher weight loss than being employed. The association was stronger at low to moderate levels of weight gain. Among employed women, working regular (35-40), long (41-48) or very long (49+) hours was associated with increasingly higher levels of weight gain compared to working part-time hours. The association was stronger for women with greater weight gain overall. The association between unemployment and weight change became insignificant when health status was controlled for.Conclusions: Employment was associated with more weight gain and less weight loss. Among the employed, working longer hours was associated with more weight gain, especially at the higher levels of weight gain where the health consequences are more serious. These findings suggest that as women work longer hours they are more likely to make lifestyle choices that are associated with weight gain.
Hauck K, Zhao X, 2011, How Dangerous is a Day in Hospital? <i>A Model of Adverse Events and Length of Stay for Medical Inpatients</i>, MEDICAL CARE, Vol: 49, Pages: 1068-1075, ISSN: 0025-7079
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Hauck K, Hollingsworth B, 2011, Health dynamics, adaptation to illness and resource allocation, Applied Economics Letters, Pages: 1545-1548
The increased availability of panel data has made it possible to estimate and measure health dynamics for population subgroups who may have systematically different levels of dynamics. We use a straightforward hypothetical example to investigate the implications of different levels of health dynamics on health outcomes, considering in addition the effects of adaptation to illness over time. The results demonstrate implications for the assessment of health technologies.
Hauck K, Tsuchiya A, 2011, Health dynamics: implications for efficiency and equity in priority setting, Value in Health, forthcoming
Hauck K, Tsuchiya A, 2011, Health dynamics: implications for efficiency and equity in priority setting, Value in Health, Vol: 14, Pages: 387-389
Health dynamics are intertemporal fluctuations in health status of an individual or a group of individuals. It has been found in empirical studies of health inequalities that health dynamics can differ systematically across subgroups, even if prevalence measured at one point in time is the same. We explore the relevance of the concept of health dynamics in the context of cost-effectiveness analysis (CEA). While economic evaluation takes health dynamics into account where they matter in terms of efficiency, we find that it fails to take into account the equity dimensions of health dynamics. In addition, the political implications of health dynamics may influence resource allocation decisions, possibly in opposing directions.
Hauck K, Hollingsworth B, Lawrie M, 2011, BMI differences in 1st and 2nd generation immigrants of Asian and European origin to Australia, Health & Place, Vol: 17, Pages: 78-85
We estimate assimilation of immigrants' body mass index (BMI) to the host population of Australia over one generation, conducting separate analyses for immigrants from 7 regions of Europe and Asia. We use quantile regressions to allow for differing impact of generational status across 19 quantiles of BMI from under-weight to morbidly obese individuals. We find that 1st generation South European immigrants have higher, and South and East Asian immigrants have lower BMI than Australians, but have assimilated to the BMI of their hosts in the 2nd generation. There are no or only small BMI differences between Australians and 1st and 2nd generation immigrants from East Europe, North-West Europe, Middle East and Pacific regions. We conclude that both upward and downward assimilation in some immigrant groups is most likely caused by factors which can change over one generation (such as acculturation), and not factors which would take longer to change (such as genetics). Our results suggest that public health policies targeting the lifestyles of well educated Asian immigrants may be effective in preventing BMI increase in this subgroup.
Hollingsworth B, Hauck K, 2010, Translational research in the area of inequalities in health related to obesity in Australia
Health inequalities are a fundamental policy issue. However despite various policy initiatives in this area inequality persists, and in fact may be on the increase. Effective policy requires an understanding of the causes of inequalities. Health economics has developed tools and theories purported to be useful in measuring and identifying inequalities. We question current economic theories in the area of obesity, an important, if not the most important, public health concern of the future. We summarise economic work in this area, suggesting a different economic perspective to that of rational choice, and go on to present some preliminary results of quantitative analysis of Australian data to support our theories, before mapping out possible areas for future research. This paper asks more questions as it answers, aiming to set a framework for a dialogue which may ultimately help translate research findings into useable evidence for policy makers.
Hauck K, Hollingsworth B, 2010, The impact of severe obesity on hospital length of stay, Medical Care, Vol: 48, Pages: 335-340
Background: The excess health care costs caused by obesity are a concern in many countries, yet little is known about the additional resources required to treat obese patients in hospitals.Objective: To estimate differences in hospital resource use, measured by length of stay, between severely obese and other patients, conditioning on a range of patient and hospital characteristics.Research Design: Administrative patient-level hospital data for 122 Australian public hospitals over the financial year 2005/06 (Victorian Admitted Episodes Data).Subjects: Episodes (435,147) for patients above 17 years of age and with a stay of one night or more.Measures: Quantile Regression analysis is used to generate 19 estimates of the difference between severely obese and other patients across the whole range of length of stay, from very short to very long staying patients. Separate estimates for 17 hospital specialties and for medically and surgically treated patients are generated.Results: There are significant differences in average length of stay for almost all specialties. For some, differences are less than 1 day, but for others, severely obese patients stay up to 4 days longer. For a number of specialties, obese patients have significantly shorter length of stay. Overall, medically managed obese patients stay longer, whereas surgically treated patients stay shorter than other patients. Differences tend to increase with length of stay.Conclusions: Differences in length of stay may arise because severely obese patients are medically more complex. The observed shorter stays for obese patients in some specialties may result from their observed greater likelihood of being transferred to another hospital.(C) 2010 Lippincott Williams & Wilkins, Inc.
Hauck K, Hollingsworth B, 2009, Do obese patients stay longer in hospital? Estimating the health care costs of obesity.
ObjectiveTo determine if obese patients have longer average length of stay once they are admitted to hospital, across a range of specialties. This contributes to measuring the impact of obesity on health care resource use.Data Sources/Study Setting Administrative hospital data are used for the financial year 2005/06 covering all episodes of patient care (1.3 million) in 122 public hospitals in the state of Victoria, Australia. The data are collected as part of Diagnosis Related Group (DRG) case mix funding arrangements by the state government. Study Design Statistical analysis are undertaken using quantile regression analysis to determine differences in average length of stay within different specialties for two groups of patients, those classified as obese, and those not classified as obese. Quantile regression allows a comparison of differences between the length of stay of obese and non-obese patients across the whole distribution of length of stay of inpatients, in contrast to more commonly used statistical methods which use only the mean. We condition on a range of patient and hospital characteristics such as age, sex, socioeconomic status, medical complexity of patients, teaching status, size and location of hospitals. Data Collection/Extraction Methods Data on inpatient episodes with at least one overnight stay in hospital are used. We exclude episodes with missing information on one or more of the explanatory variables and we exclude specialties with less than 50 reported obese inpatients per financial year. The final sample consists of just over 460,000 observations. Principal Findings Large and significant differences in average length of stay are found between obese and non-obese patients for nearly all specialties. In some specialties, obese patients can stay up to 4 days longer. However, obesity does not necessarily lead to longer hospital stays. In a range of specialties, obese patients have shorter length of stay on average. In general, di
Hauck K, Street A, 2007, Do targets matter? A comparison of English and Welsh National Health priorities, Health Economics, Vol: 16, Pages: 275-290, ISSN: 1099-1050
National priorities and performance management regimes in the National Health Services of England and Wales diverged following devolution, most notably with respect to the use of waiting time targets, which have been progressively strengthened in England but were abandoned in Wales in the immediate post-devolution period. We analyse routine data collected over a six-year period from three English and one Welsh hospital trust close to the English–Welsh border to ascertain whether: (a) there is evidence of differential performance over time that relates to the country where the hospital is located; (b) within each hospital, there is evidence that English and Welsh patients faced different waiting times. Over the period the English hospitals recorded increased levels of activity, undertook proportionately more day case activity, and mortality rates fell. Activity levels remained constant in Wales, the proportion of day case activity fell, proportionately more non-elective patients were admitted, and mortality rates rose. There is partial evidence that English patients faced lower waiting times than their Welsh counterparts and were more likely to be admitted within a target waiting period. The stronger performance management regime operating in England appears to have contributed to higher levels of performance in the English hospitals over the period. Copyright © 2006 John Wiley & Sons, Ltd.
Goddard M, Hauck K, Smith PC, 2006, Priority setting in health-a political economy perspective, Health Economics, Policy and Law, Vol: 1, Pages: 79-90, ISSN: 1744-1331
Most countries face high demands on their health care systems and have limited resources with which to meet them. Priority setting seeks to address these problems by proposing rules to decide which groups of patients or disease areas should secure favoured access to limited health care resources. The economic approach towards priority setting, particularly in the form of cost-effectiveness analysis, is commonly advocated. However, despite many decades of refinement of the technical and methodological issues arising from the use of economic evaluation in priority setting, decision makers continue to diverge frequently from the principles of economic evaluation. Our approach in this paper is to highlight the potential contribution of models of political economy to understanding what constitutes rational behaviour when agents operate within political and institutional constraints. We argue that there may be potentially greater benefits to be gained from exploration and analysis of priority setting using models based on concepts such as median voter and competing interest groups, than from further efforts to refine the techniques of economic evaluation.(Published Online December 2 2005)
Hauck K, Street A, 2006, Performance assessment in the context of multiple objectives: A multivariate multilevel analysis, Journal of Health Economics, Vol: 25, Pages: 1029-1048
The pursuit of multiple objectives by public sector organisations makes it difficult to assess and compare their performance. Considering objectives in isolation ignores the possibility of correlations between objectives, and a single index of performance requires subjective judgements to be made about the relative value of each objective. An alternative approach is to estimate a multivariate system of equations in which objectives are analysed individually but correlations across objectives are considered explicitly. We analyse the performance of English health authorities against 13 objectives using hierarchical data for electoral wards that are nested within health authorities. We find evidence of correlation across objectives, suggesting that some are complementary and others subject to trade-off. The estimates generated when assessing performance with multivariate multilevel models as compared to ordinary least squares or multilevel models differ, with the magnitudes varying by objective and health authority.
Hauck K, Shaw R, Smith PC, 2005, Formula funding of health purchasers: towards a fairer distribution?, Health Policy and Economics: Opportunities and Challenges, Editors: Smith, Ginnelly, Sculpher, Maidenhead, Publisher: Open University Press
Hauck K, Smith PC, Goddard M, 2005, What to buy? Revisiting priority setting in health care, Spending wisely: buying health services for the poor, Editors: Preker, Langenbrunner, Washington DC, Publisher: World Bank
Hauck K, Smith PC, Goddard M, 2004, The Economics of Priority Setting for Health Care: A Literature Review, Health, Nutrition and Population Discussion Paper, Washington DC, Publisher: World Bank
Hauck K, Rice N, 2004, A longitudinal analysis of mental health mobility in Britain, Health Economics, Vol: 13, Pages: 981-1001, ISSN: 1099-1050
This paper is concerned with quantifying the level of mental health mobility in the British Household Panel Survey (BHPS). We investigate whether the extent of intertemporal fluctuations in mental health is different across categories of socio-economic group such as income quintiles, educational attainment and social class. Our measure of mental health is the 12-item version of the General Health Questionnaire (GHQ) that serves as a self-administered screening test aimed at detecting psychiatric disorders. Using 11 waves of the BHPS and a variety of methods we show there is much mobility in mental health from one wave to the next. Further the extent of mobility varies across socio-economic categories with greatest persistence observed in more disadvantaged groups. In general, these groups suffer poorer mental health and experience more periods of ill-health. Our results have implications for the design of appropriate prevention policies targeting mental illness within different risk groups, and also for the measurement of long-term inequalities in mental health across socioeconomic groups.Copyright © 2004 John Wiley & Sons, Ltd.
Hauck K, Rice N, Smith P, 2003, The influence of health care organisations on health system performance, Journal of Health Services Research and Policy, Vol: 8, Pages: 68-74
Objectives: The governments of many countries are undertaking initiatives to assess the extent to which health care organisations fulfil important objectives of health care, such as health improvement, fair access and efficiency. However, the extent to which these health care organisations can influence these objectives is unclear. The purpose of this study is to examine the potential influence of English National Health Service territorial health authorities on 14 indicators of system performance. Methods: The study uses performance data relating to approximately 5000 small geographical areas with average populations of 10 000. Multi-level statistical models are used to attribute variation in the indicators to three hierarchical levels - small areas, district health authorities and regional health authorities - after controlling for socio-demographic characteristics. Variations in indicators attributable to district or regional level give an indication of the extent to which health authorities may influence performance. Results: After adjusting for socio-demographic characteristics, the proportion of variation in performance attributable to district health authorities varies from about 8% (for standardised mortality ratios) to about 76% (for waiting time for elective surgery). Variation at the regional level is smaller than at the district level. Conclusions: There appear to be very large variations between indicators in the extent to which health care organisations can influence health system performance. Choice of performance indicators and the managerial incentive regime based on the indicators should recognise this variability, as it is highly dysfunctional to hold managers accountable for measures of performance that are beyond their control.
Hauck K, Shaw R, Smith PC, 2002, Reducing avoidable inequalities in health: a new criterion for setting health care capitation payments, Health Economics, Vol: 11, Pages: 667-677, ISSN: 1099-1050
Traditionally, most health care systems which pretend to any sort of rationality and cost control have sought to allocate their limited funds in order to secure equal opportunity of access for equal need. The UK government is implementing a fundamental change of resource allocation philosophy towards ‘contributing to the reduction of avoidable health inequalities’. The purpose of this essay is to explore some of the economic issues that arise when seeking to allocate health care resources according to the new criterion. It indicates that health inequalities might arise because of variations in the quality of health services, variations in access to those services, or variations in the way people produce health, and that the resource allocation consequences differ depending on which source is being addressed. The paper shows that an objective of reducing health inequalities is not necessarily compatible with an objective of equity of access, nor with the objective of maximising health gain. The results have profound consequences for approaches towards economic evaluation, the role of clinical guidelines and performance management, as well as for resource allocation methods.Copyright © 2002 John Wiley & Sons, Ltd.
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