3.RESULTS

The figure shows that decision making in this way is fragmented, compartmentalised, and doesn’t follow common objectives. This seems to be the case whether or not structured priority setting processes are used. We also found substantial between-country variation in priority setting at all levels across LMICs: some countries have implemented formal processes at the micro level (e.g. Thailand), whilst others have implemented major reforms at the macro level (e.g. Rwanda). In many other LMICs, priority setting remains informal.We identified a number of policy options and tools which could be, or have been, used to realign decision making at the different levels in LMICs. These fall into three main categories:

1. A consistent principle of value being used to inform decision making at all levels; 2. Strengthening decision making at the disease (or intermediate) level;3. Collecting and monitoring data on health and economic consequences of decisions at all levels.

Building Efficient Healthcare Systems Through Integrated Health Care Decision

Making in Low and Middle Income CountriesGrace Marsden*, Martina Garau, Adrian Towse

*presenting author; email: gmarsden@ohe.org

1. INTRODUCTION

AcknowledgementsThis work was funded by Novartis. The authors would like to thank Christophe Carbonel and the project team at Novartis for their input and feedback, and thank the global health experts for participating in interviews with us.

2. METHODS

4. CONCLUSION

• Health technology assessment (HTA) and other tools for decision making are used around the world to promote efficient resource allocation within healthcare systems (HCS)

• Resource allocation decisions are made at various levels (national level or regional level; disease level or technology level), yet it seems that the objectives of decision makers at the different levels do not always align with one another

• We explore whether these inconsistencies exist in current processes in low and middle income countries (LMICs), and identify policy options which could be used to improve the efficiency of resource allocation processes in these regions.

• Three strands of literature were reviewed:1. Current approaches for priority setting in LMICs; 2. Health service delivery and integrated care

(including disease management programmes (DMPs));

3. Future of healthcare systems.• Specific case studies illustrating examples of DMPs

and healthcare system reforms implemented in LMICs were identified.

• Interviews with a set of global health experts were conducted to gather further information on existing priority setting processes in LMIC and the different levels of decision making identified in the literature review.

Micro decision makingDecision makers: Doctors, HTA agencies, payersMethods: HBP, HTA, A4R, MCDA, value of implementationCriteria: cost effectiveness, equity

Intermediate decision makingDecision makers: Payers, Providers, Government Methods: guidelines, protocols, incentive schemesCriteria: clinical outcome improvements

Macro decision makingDecision makers: Government, insurersMethods: Budget allocationCriteria: equity, affordability

Service delivery

Interventions (medical products, vaccines and technologies)

Payment schemes

Health workforce

Improved health (level and equity)Responsiveness

Social and financial risk protectionImproved efficiency

Configuration of facilities

Disease and social priorities

Financing

We discuss three key levels of decision making: macro, intermediate and micro level (see figure).

Summary of levels: different decision

makers at different levels do not follow

common methods or criteria

The components of the health system:

compartmentalised and planned at different levels

The fragmented components are expected

to work together to achieve these system

objectives1

Fragmentation and misalignment between levels of decision making means that decision maker’s objectives are not consistent, and is highly likely to lead to inefficiencies in health systems.

There are limited policy options and tools available which could be used to align the objectives of decision making throughout governments and health services. Further research is required to develop an integrated decision making framework that could align all levels of decision making.

Notes1The system objectives included in the diagram are those listed in the WHO building blocks framework. Full reference: WHO, 2007. Everybody’s business: strengthening health systems to improve health outcomes: WHO's framework for action. Geneva: World Health Organization.