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In most countries, the demand for integrated care for people with chronic diseases is increasing as the population ages. This demand requires a fundamental shift of health-care systems towards more integrated service delivery models. To achieve this shift in China, the World Health Organization, the World Bank and the Chinese government proposed a tiered health-care delivery system in accordance with a people-centred integrated care model. The approach was pioneered in Luohu district of Shenzhen city from 2015 to 2017 as a template for practice. In September 2017, China's health ministry introduced this approach to people-centred integrated care to the entire country. We describe the features of the Luohu model in relation to the core action areas and implementation strategies proposed and we summarize data from an evaluation of the first two years of the programme. We discuss the challenges faced during implementation and the lessons learnt from it for other health-care systems. We consider how to improve collaboration between institutions, how to change the population's behaviour about using community health services as the first point of contact and how to manage resources effectively to avoid budget deficits. Finally, we outline next steps of the Luohu model and its potential application to strengthen health care in other urban health-care systems.Dans la plupart des pays, la demande de soins integres pour les personnes atteintes de maladies chroniques augmente a mesure que la population vieillit. Cette demande necessite une reorientation majeure des systemes de soins de sante vers des dispositifs de prestation de services plus integres. Pour effectuer cette reorientation en Chine, l'Organisation mondiale de la Sante, la Banque mondlale et le gouvernement chlnois ont propose un systeme de soins de sante a plusieurs niveaux selon un dlspositif de soins integres axes sur 1'etre humain. Cette approche a ete utilisee pour Ia premiere fois dans le distria de Luohu de la ville de Shenzhen de 2015 a 2017 en tant que modele de pratique. En septembre 2017, le ministere chinois de la Sante a applique a l'ensemble du pays ce dispositif de soins integres axes sur l'etre humain. Nous decrivons les caracteristiques du modele de Luohu par rapport aux principaux domaines d'action et aux strategies de mise en ceuvre proposees et nous resumons les donnees extraites d'une evaluation des deux premieres annees du programme. Nous examinons les difficultes rencontrees lors de la mise en ceuvre et les lecons tirees de ees difficultes pour d'autres systemes de soins de sante. Nous reflechissons aux moyens d'ameliorer la collaboration entre les institutions, de changer le comportement de la population concernant l'utilisation des services de sante des collectives comme premier point de contact et de gerer efncacement les ressources pour eviter les deficits budgetaires. Enfin, nous decrivons les prochaines etapes a suivre dans le cadre du modele de Luohu et son application potentielle pour renforcer les soins de sante dans d'autres systemes urbains de soins de sante.En la mayoria de los paises, la demanda de atencion integrada para las personas con enfermedades cronicas aumenta a medida que la poblacion envejece. Esta demanda requiere un cambio fundamental de los sistemas de atencion sanitaria hacia modelos de prestacion de servicios mas integrados. Para lograr este cambio en China, la Organizacion Mundial de la Salud, el Banco Mundial y el gobierno chino propusieron un sistema escalonado de prestacion de servicios sanitarios de acuerdo con un modelo de atencion integrada centrada en las personas. El enfoque se introdujo en el distrito de Luohu de la ciudad de Shenzhen de 2015 a 2017 como modelo para la practica. En septiembre de 2017, el Ministerio de Salud de China introdujo este enfoque de atencion integrada centrada en las personas en todo el pais. Se describen las caracteristicas del modelo de Luohu en relacion con las areas centrales de accion y las estrategias de implementation propuestas y se resumen los datos de una evaluacion de los dos primeros anos del programa. Se exponen los desafios enfrentados durante la implementacion y las lecciones aprendidas de la misma para otros sistemas de atencion sanitaria. Se considera como mejorar la colaboracion entre las instituciones, como cambiar el comportamiento de la poblacion sobre el uso de los servicios sanitarios comunitarios como primer punto de contacto y como gestionar eficazmente los recursos para evitar deficits de presupuesto. Por ultimo, se esbozaron los proximos pasos del modelo de Luohu y su posible aplicacion para fortalecer la atencion sanitaria en otros sistemas urbanos de atencion sanitaria., IntroductionOn 1 September 2017, China's health ministry introduced a new approach to people-centred integrated care to the entire country. (1) Called the Luohu model, the approach was pioneered in Luohu [...]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2005.10.023 Byline: Amiram Gafni, Stephen Birch Keywords: Economic evaluation; Cost-effectiveness analysis; Decision rules; Incremental cost-effectiveness ratio; Health care costs Abstract: Despite the central role of the threshold incremental cost-effectiveness ratio (ICER), or lambda (I'), in the methods and application of cost-effective analysis (CEA), little attention has been given to the determining the value of I'. In this paper we consider 'what explains the silence of the I''? The concept of the threshold ICER is critically appraised. We show that there is 'silence of the I'' with respect to justification of the value of ICER thresholds, their use in decision-making and their relationship to the opportunity cost of marginal resources. Moreover, the 'sound of silence' extends to both 'automatic cut-off' and more sophisticated approaches to the use of I' in determining recommendations about health care programs. We argue that the threshold value provides no useful information for determining the efficiency of using available resources to support new health care programs. On the contrary, the threshold approach has lead to decisions that resulted in increased expenditures on health care programs and concerns about the sustainability of public funding for health care programs without any evidence of increases in total health gains. To improve efficiency in resource allocation, decision-makers need information about the opportunity costs of programs. Author Affiliation: McMaster University, Hamilton, Ont., Canada

This article examines the degree to which relationships between social capital and health are embedded in local geographical contexts and influenced by demographic factors, socio-economic status, health behaviours and coping skills. Using data from a telephone survey of a random sample of adults (N = 1504 respondents, response rate = 60%), the article determines if relationships between involvement in voluntary associations and various measures of individual health are associated with neighbourhood of residence in the mid-sized city of Hamilton, Canada. Associational involvement and overweight status (assessed by body-mass score) were weakly but significantly related after controlling for the other variables; involvement had relationships with self-rated health and emotional distress before but not after controlling for socio-economic status, health behaviours and coping skills. Relationships between neighbourhood of residence and two health outcomes, self-rated health and overweight status, were statistically significant before and after controlling for the other characteristics of respondents; neighbourhood of residence was not a significant predictor of number of chronic conditions and emotional distress in multivariate models. The neighbourhood and associational involvement relationships with health were not dependent upon one another, suggesting that neighbourhood of residence did not help to explain the positive health effects of this particular measure of social capital. Keywords: Social capital; Social networks; Neighbourhood; Health behaviours; Coping skills; Canada

Much research has been devoted to handling uncertainty in cost-effectiveness analysis. The current literature suggests summarizing uncertainty in cost-effectiveness analysis using acceptability curves or net health benefits. These approaches, however, focus only on uncertainty associated with costs and effects of the programs under consideration. In the real world, most decision-makers have to fund a portfolio of health care programs. Therefore, a more comprehensive approach would include in the analysis the uncertainty of costs and effects of all programs supported by the fixed budget. This paper extends the decision rule described by Birch and Gafni (J. Health Econ. 11(3) (1992) 279) within the context of a portfolio of programs when costs and effects are uncertain and resources constrained. Keywords: Cost-effectiveness analysis; Uncertainty; Sensitivity analysis; Portfolio; Resource constraints

The application of Sen's notion of capabilities to problems of the allocation of resources to health in the form of an extra-welfarist framework underlies the justification of quality adjusted life years (QALYs) as the method for valuing the benefits of health care. In this paper we critically appraise this application from both conceptual and empirical perspectives. We show that the alleged limitations of the welfarist approach are essentially limitations in its application, not in the capacity of the approach to accommodate the concerns of extra-welfarists. Moreover, the arguments used to justify the application of the extra-welfarist framework are essentially welfarist. We demonstrate that the methods used to measure QALYs share their basic theoretical roots with welfarist valuation methods, such as willingness to pay (WTP). Although QALYs and WTP share many challenges, we argue that WTP provides a method which performs better with respect to those challenges. In the context of evaluating alternative allocations of health care resources we are left asking what is `extra' in extra-welfarism? Keywords: Economic evaluation; Welfarism; Extra-welfarism

While there is a large and growing literature investigating the relationship between an individual's employment status and health, considerably less is known about the effect on this relationship of the context in which unemployment occurs. The aim of this paper is test for the presence and nature of contextual effects in the ways unemployment and health are related, based on a simple underlying model of stress, social support and health using a large population health survey. An individual's health can be influenced directly by own exposure to unemployment and by exposure to unemployment in the individual's context, and indirectly by the effects these exposures have on the relationship between other health determinants and health. Based on this conceptualization an empirical model, using multi-level analysis, is formulated that identifies a five-stage process for exploring these complex pathways through which unemployment affects health. Results showed that the association of individual unemployment with perceived health is statistically significant. Nevertheless, this study did not provide evidence to support the hypothesis that the association of unemployment with health status depends upon whether the experience of unemployment is shared with people living in the same environment. Above all, this study demonstrates both the subtlety and complexity of individual- and contextual-level influences on the health of individuals. Our results caution against simplistic interpretations of the unemployment-health relationship and reinforce the importance of using multi-level statistical methods for investigation of it. Keywords: Unemployment; Population health; Contextual effect; Multi-level models; Survey data set; Census data set; Canada

Systematic variations in health and illness among social groups have persisted and, in some cases increased, in many countries in spite of improvements in the availability of, and access to, health care services. Health policy makers have responded by showing increasing interest in non-clinical determinants of health as a way of explaining the observed systematic variations in health and illness. Yet health care and non-health care 'factors' are often seen as competing for society's scarce resources in the production of health. The purpose of this paper is to augment this traditional approach to understanding the determinants of health in populations by exploring heterogeneity in the smoking-health relationship between social groups. Logistic regression analyses were performed using data from the 1992-93 Sante Quebec survey, a weighted random sample of the non-institutionalized population of the province of Quebec, Canada (N = 23,564). The findings suggest that the likelihood of reporting health as poor or fair was greater for smokers than non-smokers. However, the difference between smokers and non-smokers was significantly greater among groups of the population with low incomes and without employment, but significantly less among sub-groups with lower levels of education. These findings suggest that the identification, evaluation and implementation of health care programmes need to pay greater attention to the interface between social, behavioural and clinical determinants of health.

We evaluated objective criteria for defining points for needle insertion prior to conducting a multisite clinical trial of auricular acupuncture for cocaine addiction. Thirty-four cocaine-abusing subjects participated in a study in which the trial's active zones (Shenmen, Liver, Lung, and Sympathetic) and control zones (located on the ear helix) were divided into quadrants and assessed along four dimensions: electrical resistance, skin discoloration, skin topography, and tenderness. Acute effects of needles inserted into points of low electrical resistance in one ear and high electrical resistance in the other were also assessed. Results showed that the active zones had lower overall electrical resistance and more subcutaneous ridges than control zones. Zones did not possess significant variability along any single dimension. Acute effects of needling high and low resistance points were similar, differing only for 'fullness.' Based on these findings, and in view of the difficulty of accurately measuring electrical resistance at ear points, we do not recommend the use of electrical devices for point determination in the multisite study. At present, there seems to be little scientific basis for the preselection of specific points for needle insertion within auricular zones. Needle placement should be based upon clinical judgement. Keywords - acupuncture; cocaine; addiction; methadone.

In recent years considerable attention has been given to the effects of universal, first-dollar coverage for health care services as provided under Canada's health care system. However, no consideration has been given to the stability of these effects through periods of changing economic climate. In this paper we consider the extent to which the achievements of the Canadian approach to health care funding have been maintained in the presence of increasing attention to cost containment. Multivariate analyses are used to (a) explain variations in utilization of family physician services among the population and (b) explore the relationship between utilization and need for periods of differing economic circumstances. We observe that the relative importance of differences in need in explaining variations in use among the population was less in the period when cost containment was of greater concern. These findings indicate that policymakers cannot assume that removing financial barriers to access to service, although important in achieving a more equitable distribution of service utilization, may be sufficient to sustain such distributions during time of constraint.

Geographically decentralized planning and management is an emerging theme within the health sector in many OECD countries. Advocates of decentralization argue that providing greater authority to local decision-making bodies can improve both the technical and allocative efficiency with which health care systems operate. Using concepts drawn from organizational theory and the economics of organizations, we examine the potential of centralized and decentralized planning and management structures to be efficient in light of the informational problems that must be overcome to allocate resources efficiently. We focus in particular on the need to integrate information regarding: (1) the effectiveness and efficiency of alternative clinical interventions and of alternative ways organize the delivery of health care; (2) the needs, values, and preferences in the population; and (3) local circumstances that affect delivery of care across regions. Informational concerns suggest that decentralized structures have greater potential to be efficient. We then briefly discuss some principles for the design of decentralized structures to aid in realizing these potential efficiency gains. Key words - decentralized planning, information, efficiency

The main objective of this paper is to determine whether the distribution of hospital service utilization corresponds to the distribution of needs within Canada. This is accomplished by identifying the factors affecting the relationship between the incidence and quantity of hospital services and self-assessed need for such care in Canada. The data were derived from the General Social Survey (Statistics Canada, 1987) which is a weighted random sample of the Canadian population aged 15 and over. Employing methodological extensions over previous studies, the results indicate that although variation in quantity of hospital use is largely independent of income, household income has a significant positive effect on the incidence of hospital utilization. Additionally, variations in both incidence and quantity of use of hospital services are associated with variations in need and other factors within the model. Key words - utilization, need, equity, hospital services, Canada

In this paper we critically appraise the appropriateness and validity from an economic perspective of alternative preference-based approaches to measuring outcomes in economic evaluations of health care interventions. We describe the properties of an outcome measure for economic evaluation to make it compatible with the principles of economics when applied to the problem of resource allocation. We also describe the difference and similarities between the psychometric and the economic approaches for the measurement of outcome. Using these properties we critically appraise the use of QALY and HYE methods of measuring individual and social preferences for health outcome. We argue that the most advanced measure currently available that meets these required properties is the HYE. Because the HYE, unlike the QALY, has its foundations in utility theory under uncertainty, it neither assumes particular formulations of the individual utility function, nor is it incompatible with the principles of economics. As such it represents a further stage in the continuing development of methods for economic evaluation of health care programmes. Key words - economic evaluation, cost utility analysis, QALYs, utility theory

The effects of regular and frequent increases in charges for health care on patient utilisation are analysed using monthly data on National Health Service (NHS) prescribed drugs in England for the period 1979-1985. Using a partial adjustment model a utilisation equation of prescribed drugs is estimated for the adult non-elderly population that is subject to the NHS prescription charge. The maximum likelihood estimates of the coefficients of the equation imply that the charges policy followed in the U.K. has led to a significant reduction in utilisation among non-exempt patients. The short-run price elasticity of utlisation is -0.109 and the long-run elasticity is -0.09, while exempt utilisation is unaffected. Although the policy has generated a reduction in the central Government expenditure for prescribed drugs, on the basis of these estimates around 66% of these savings arise from the reduction in service use as opposed to the increased revenue per item of drugs.

Bridges and Terris (Soc. Sci. Med. (2004)) critique our paper on the alternative decision rule of economic evaluation in the presence of uncertainty and constrained resources within the context of a portfolio of health care programs (Sendi et al. Soc. Sci. Med. 57 (2003) 2207). They argue that by not adopting a formal portfolio theory approach we overlook the optimal solution. We show that these arguments stem from a fundamental misunderstanding of the alternative decision rule of economic evaluation. In particular, the portfolio theory approach advocated by Bridges and Terris is based on the same theoretical assumptions that the alternative decision rule set out to relax. Moreover, Bridges and Terris acknowledge that the proposed portfolio theory approach may not identify the optimal solution to resource allocation problems. Hence, it provides neither theoretical nor practical improvements to the proposed alternative decision rule. Keywords: Cost-effectiveness analysis; Uncertainty; Portfolio theory

The levels and types of oral health problems occurring in populations change over time, while advances in technology change the way oral health problems are addressed and the ways care is delivered. These rapid changes have major implications for the size and mix of the oral health workforce, yet the methods used to plan the oral health workforce have remained rigid and isolated from planning of oral healthcare services and healthcare expenditures. In this paper, we argue that the innovation culture that has driven major developments in content and delivery of oral health care must also be applied to planning the oral health workforce if we are to develop 'fit for purpose' healthcare systems that meet the needs of populations in the 21st century. An innovative framework for workforce planning is presented focussed on responding to changes in population needs, service developments for meeting those needs and optimal models of care delivery. [ABSTRACT FROM AUTHOR]

Models for projecting the demand for and supply of health care workers are generally based on objectives of meeting demands for health care and assumptions of status quo in all but the demographic characteristics of populations. These models fail to recognise that public intervention in health care systems arises from market failure in health care and the absence of an independent demand for health care. Hence projections of demand perpetuate inefficiencies in the form of overutilisation of services on the one hand and unmet needs for care on the other. In this paper the problems with basing workforce policy on projected demand are identified and the consequences for health care system sustainability explored. Integrated needs-based models are offered as alternative approaches that relate directly to the goals of publicly funded health care systems and represent an important element of promoting sustainability in those systems. [ABSTRACT FROM AUTHOR]

The editor of Social Science and Medicine gives prospective authors advice on what kinds of topics the journal will consider publishing. The focus is on articles about health economics, which can provide unique insights on the identification and solution of problems in the healthcare industry.

Summary Data on National Health Service (NHS) dental care utilization by the elderly are analysed to consider the distribution of dental care according to the charge status of the patient. Considerable and significant differences are observed in the type and amount of dental care provided to elderly patients exempt and not exempt from patient charges. Consideration is given to alternative explanations of the observed distribution and the implications for the performance of the NHS with regard to objectives.

Rationale, aims and objectives Allocating resources on the basis of population need is a health care policy goal in many countries. Thus, resources must be allocated in accordance with need if stakeholders are to achieve policy goals. Small area methods have been presented as a means for revealing important information that can assist stakeholders in meeting policy goals. The purpose of this review is to examine the extent to which small area methods provide information relevant to meeting the goals of a needs-based health care policy. Methods We present a conceptual framework explaining the terms 'demand', 'need', 'use' and 'supply', as commonly used in the literature. We critically review the literature on small area methods through the lens of this framework. Results 'Use' cannot be used as a proxy or surrogate of 'need'. Thus, if the goal of health care policy is to provide equal access for equal need, then traditional small area methods are inadequate because they measure small area variations in use of services in different populations, independent of the levels of need in those populations. Conclusions Small area methods can be modified by incorporating direct measures of relative population need from population health surveys or by adjusting population size for levels of health risks in populations such as the prevalence of smoking and low birth weight. This might improve what can be learned from studies employing small area methods if they are to inform needs-based health care policies. [ABSTRACT FROM AUTHOR]

Cost-effectiveness analysis has been advocated in the health economics methods literature and adopted in a growing number of jurisdictions as an evidence base for decision makers charged with maximising health gains from available resources. This paper critically appraises the information generated by cost-effectiveness analysis, in particular the incremental cost-effectiveness ratio (ICER). It is shown that this ratio is used as comparative information on what are non-comparable options and hence evades the reality of the decision-maker's problem. The theoretical basis for the ICER approach is the simplification of theoretical assumptions that have no relevance to the decision maker's context. Although alternative, well established methods can be used for addressing the decision maker's problem, faced with the increasing evidence of the theoretical and empirical failures of the cost-effectiveness approach, some proponents of the approach now propose changing the research question to suit the approach as opposed to adopting a more appropriate method for the prevailing and continuing problem. As long as decision makers are concerned with making the best use of available healthcare resources, cost-effectiveness analysis and the ICER should not be where we look for answers. [ABSTRACT FROM AUTHOR]

The application of Sen''s notion of capabilities to problems of the allocation of resources to health in the form of an extra-welfarist framework underlies the justification of quality adjusted life years (QALYs) as the method for valuing the benefits of health care. In this paper we critically appraise this application from both conceptual and empirical perspectives. We show that the alleged limitations of the welfarist approach are essentially limitations in its application, not in the capacity of the approach to accommodate the concerns of extra-welfarists. Moreover, the arguments used to justify the application of the extra-welfarist framework are essentially welfarist. We demonstrate that the methods used to measure QALYs share their basic theoretical roots with welfarist valuation methods, such as willingness to pay (WTP). Although QALYs and WTP share many challenges, we argue that WTP provides a method which performs better with respect to those challenges. In the context of evaluating alternative allocations of health care resources we are left asking what is ‘extra’ in extra-welfarism? [Copyright &y& Elsevier]

The article reports that much attention has been given to the critical appraisal of the healthy years equivalent (HYE) concept as an alternative and superior approach to the measurement of preferences over probabilistic health states compared to quality-adjusted life year (QALY). The debate about relative merits of the HYE and the QALY has clarified some things but left many questions unanswered. Measuring HYE is likely to involve greater respondent burden mainly in terms of the number of questions being asked. In terms of the conceptual limitations of the HYE, it is noted that HYE definition imposes same restrictions as the QALY in terms of underlying assumptions of utility independence between health and other commodities in an individual's utility function. The HYE-QALY debate has demonstrated the need to understand clearly the nature of the problem and the objective being pursued in attempting to solve the problem of measurement of preference.