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How do government health departments in Australia access health economics advice to inform decisions for health? A survey

How do government health departments in Australia access health economics advice to inform... Background: Government anticipates that health economic analysis will contribute to evidence-based policy development. Early examples in Australia where this expectation has been met include the economic evaluations of breast and cervical screening. However, the level of integration of health economics within health services that require this advice appears uneven. We sought to describe how government health departments in Australia use specialist health economic advice to inform policy and planning and the mechanisms through which they access this advice. Methods: Information describing the arrangements for gaining health economics input into health decision- making was sought through interviews with a purposeful sample of economists and non-economists employed by all departments of health in Australia (state, territories and national). The survey was undertaken in August 2004. To aid interpretation of the results eight health economic functions were identified. As a comparison, four other government departments in NSW provided information about their access to economic advice. Results: All health departments except one reported being current users of health economics expertise. A variety of arrangements were described to source this, from building organisational capacity with self-sufficient in-house units to forging links with external sources. However, specialist positions for economists or health economists employed within health were few. A framework mapping these arrangements for sourcing advice with the eight common health economic functions to be met is presented. All other non-health government departments approached accessed economic advice, with three having in-house units. Discussion: A small health economics capacity in Australia has been established over the past 30 years through a variety of structural and strategic mechanisms. Health departments value health economic advice and use a variety of arrangements to obtain this. These arrangements have strengths and weaknesses depending upon the task to be undertaken. The lack of uniformity of approach suggests that health departments are still seeking the best ways to incorporate this form of specialist advice into mainstream decision-making. Implications: Summarises ways that governments source specialist services. Demonstrates how to describe an organisation's need for specialist services as a set of functions. This approach could be applied to assessing need for other specialist areas of advice. Page 1 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:6 http://www.anzhealthpolicy.com/content/6/1/6 Hepatitis C has also confirmed both the personal- and sys- Background A broad range of information is required to analyse pat- tem-level savings resulting from these policies and under- terns of health and disease, inform health policy, and pinned support for continued action [13,14]. More manage services and programs that treat and prevent ill recently, Australia has led international efforts to improve health. Consequently, health and public health organisa- health systems resource allocation that pioneers the use of tions draw expertise from many disciplines and profes- economic evaluation to guide decisions relating to new sional groups [1]. One such discipline is health pharmaceuticals and new health technologies [15,16]. economics, which applies the principles of economics to decision-making in health care, and in so doing has chal- Nonetheless, despite these successful examples of utilising lenged many of the conventional ways of thinking about health economic expertise, there is the perception that health and the distribution of the finite public resources health economic advice is not always well-matched to the that fund public health services. needs of government policy-makers [17-19]. Further reviews of the public health workforce in Australia since Health economics is a young field. In Australia, the first 1990 continue to acknowledge health economics as a health economics research unit was established in 1978 at public health speciality skill that needs strengthening [20- the Australian National University and was funded by the 22]. National Health and Medical Research Council (NHMRC) [2]. Following Kerr White's review of public To explore this issue, we describe how departments of health research and education in 1985, which encouraged health around Australia, and some other government the development of the capacity for "population-based' departments in New South Wales (NSW), access eco- thinking, a sustained capacity in health economics began nomic advice to inform policy and programs. To identify to be established in the 1990s [3,4]. The NHMRC and the potential strengths and weaknesses of these mecha- VicHealth funded the National Centre for Health Program nisms they are mapped against the common functions Evaluation in Melbourne, and in Sydney, the Centre for that health economics expertise could be anticipated to Health Economics Research and Evaluation was sup- fulfil. ported by the NSW Department of Health, and from 1994, also by the Public Health Education and Research Methods Program (PHERP) as a national specialist centre in health To identify the range of mechanisms that government economics [5,6]. From these beginnings, today there are health departments employ to access economic advice, we number of groups specialising in health economics surveyed a non-random (purposively selected) sample of around the country, usually located within universities. health economists and non-health economists employed by departments of health in all the states and territories of Despite the promise held out by health economics as an Australia and by the Australian Government Department aid to decision-making, policy-makers continue to experi- of Health and Ageing. Initial contacts were identified ence problems accessing economic advice. This need was through the networks of the authors and then by snow- highlighted most notably in the United Kingdom (UK) by balling if necessary [23]. We interviewed people with Derek Wanless in his report to HM Treasury [7]. Wanless knowledge of the health economics capacity within their considered that the information base for public health jurisdiction. generally was poor; and while there was often evidence on the scientific need for action, there was little evidence Semi-structured interviews were conducted by telephone, describing the cost-effectiveness or the outcomes of the where possible, or via e-mail where preferred by respond- implementation of programs. He also noted a relatively ents. All interviews (n = 15) were conducted in August slow acceptance of economic perspectives within public 2004 by one of the authors (LK). Information was sought health. about mechanisms for gaining health economics input into health decision-making in general, not just for public In Australia, health economics has made a contribution to health issues. evidence-based policy development within public health. Early examples include the economic evaluations of The questions asked were: breast and cervical screening that informed national screening policy [8,9]. Estimates of the social costs of 1. What health economics capacity does your health smoking and the social benefits of reducing the number of department have in-house? people who smoke have provided support for effective anti-smoking policies and interventions in NSW [10,11] 2. How do you gain health economics advice to and nationally [12]. The evaluation of Australia's invest- inform decision-making? ment in the prevention and treatment of HIV/AIDS and Page 2 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:6 http://www.anzhealthpolicy.com/content/6/1/6 3. What avenues are open to you to gain such advice? each function, illustrative questions or situations are pro- vided in the table. In addition, to provide a point of comparison, informa- tion about arrangements used by four other government All survey participants indicated that economics and departments in NSW to obtain economic advice was health economics have the potential to contribute con- obtained through an examination of websites or by tele- cepts and techniques to address a wide range of issues phone interview. faced by health system decision-makers. All but one of the departments of health we surveyed reported currently To describe common health economics functions we making use of health economics expertise to inform deci- examined the Health Economics Competency Area devel- sion-making. Mechanisms used to secure this advice var- oped for the competency framework that underpins deliv- ied among the departments of health, over time and with ery of the NSW Public Health Officer Training Program, the type of task, with most organisations using a mixture and the self-assessment questions developed by the Cana- of in-house and external sources (Table 2). The range of dian Health Services Research Foundation for use by deci- options seen in practice extended from sourcing services sion-makers to assess their organisation's capacity to use from external groups (n = 2) to well- structured, specialist research (or other specialised expertise) [24,25]. The units within the health department (n = 3). Most depart- organisational mechanisms identified by the survey were ments used more than one mechanism at any time. In then mapped against these functions to determine the general, however, the number of in-house positions for potential utility of the various mechanisms to obtain health economists (or economists) was few. Two depart- health economics advice. ments had developed specialist training programs to train health economists–only one of which continues today. Results Both these programs offered a combination of a university The set of eight health economic functions identified are qualification in health economics and a period of work- presented in Table 1. To make explicit what is meant by based learning. Table 1: Eight common health economics functions and examples of the types of situation in which they might be useful or types of questions that might be answered using this function Function Types of questions/situation in which this function would be applied 1. Appreciation of how economics fits into multi-disciplinary analysis of Does this problem have an economic aspect? Would it benefit from an public health problems economic perspective? 2. Advanced appreciation of economic concepts and frameworks, able Problem has an economic aspect that can be framed i.e., the person is to frame issues, formulate questions and obtain advice able to formulate an economic question in an appropriate way as part of a proposal. 3. Economic analysis of simple problems and issues, requiring literature Able to read and interpret the economic literature and think from an searches, appraisal, synthesis and interpretation economic perspective. 4. A capacity to respond quickly to emerging and emergency issues An economic surge capacity exists. 5. Conducting economic evaluations and other studies, with appropriate Able to answer questions about performing economic analysis for methods example: when is the right time; how should it be done; what level of complexity is required; do we have the necessary skills and experience required, or do we know who has the necessary skills? 6. Application of economic findings to priority settings, emerging issues Able to apply priority setting techniques and able to factor in issues such and decision-making as equity. 7. A priority-driven, policy relevant research program Not reactive but anticipates need. Is able to formulate research questions, develop a proposal to answer those questions and execute the study. 8. An investigator-led research program Not reactive – sees gaps in the available knowledge and tools, is able to develop a research plan to fill these gaps and secure funding to support the research agenda. Page 3 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:6 http://www.anzhealthpolicy.com/content/6/1/6 Table 2: Description of organisational mechanisms, both internal and external to the organisation, used to meet health economics needs by departments of health in Australia, 2004. Organisational mechanism Description Internal Position descriptions require qualifications that include an appreciation Many position descriptions in health require a qualification that includes of economics or health economics in the coursework some introduction to economics or health economics eg Masters of Public Health or Masters of Health Administration. Staff training (e.g., the NSW Public Health Officer Training Program) Short courses in health economics of varying duration and intensity, with or without final assessment of participants or accreditation of the courses. Generalist staff with economic qualifications Staff have a degree in economics but are not specialist health economists nor does their position require this qualification. Specialist health economics training programs Structured training programs to develop specialist health economists. Health economist positions Position description requires a qualification in health economics. Health economics units A team of health economists (with or without other disciplines) of varying size with well developed roles and functions to support decision making. External Consultancy for services Services of a scale that do not require contracted arrangements, usually for specific tasks, where expertise was sought through professional and personal networks. Contract research Contracts whose size does not warrant a competitive tendering process sometimes met by a preferred provider. Contract research by tender Contracts developed and let by competitive tender, usually filled by private providers or the academic sector. Collaborative research centres University professorial chairs or research centres established with funding that secures the focus of the work in whole or part to meet health service needs. Three of the four other government departments Discussion approached in NSW had internal economics units. One Our survey revealed a wide range of organisational mech- department had developed guidelines to support their anisms that have been used to secure health economics staff to collaborate effectively with their economics unit, and economics advice by Australian governments. It also and these guidelines were accompanied by workshops linked these mechanisms with the type of health eco- and training sessions. These departments supplemented nomic functions that governments require to inform deci- this internal capacity with external expertise. sion-making for policy and planning purposes. Our findings suggest that while health economics is estab- Table 3 describes the potential links between the mecha- lished as part of the specialist public health workforce, the nisms and the functions they fulfil as seen by the authors. role is perhaps not as well-integrated into public health as The first row presents the mechanisms, with the internal other specialist areas, such as biostatistics. As further evi- (in-house) arrangements to the left and the external (out- dence of this, health economics was again raised in the of-house) sources of support to the right. The left-hand most recent review of PHERP as a specialty area that still column presents the eight health economic functions, requires development [22]. arranged in increasing order of technical complexity from top to bottom. Shaded boxes denote the functions that are Depending upon the type of health economic task at best met by each particular mechanism. hand, health agencies use a number of different arrange- Page 4 of 7 (page number not for citation purposes) Table 3: Organisational mechanisms used by departments of health in Australia in 2004 to secure health economics advice and the economic functions that these mechanisms might serve. Internal Mechanisms External Mechanisms Organisational Qualification s Staff training/ Staff with Specialist H/E Health Health Consultancy Contracted Contracted Collaborative mechanism Function include NSW Public economic training economist economics for service advice advice by research appreciation of Health Officer qualifications programs position units tender centres economics or Training health Program economics in coursework. 1. Appreciation of how Y Y YY YY economics fits into multi- disciplinary analysis of public health problems 2. Advanced appreciation of Y YY YYY economics concepts and methods, able to frame issues, formulate questions and obtain advice 3. Economic analysis of Y YY YYYYY (simple) problems and issues, requiring literature searches, appraisal, synthesis and interpretation. 4. A capacity to respond YY Y quickly to emerging and emergency issues 5. Conducting economics YY YYYYYY evaluations and other studies, with appropriate methods 6. Application of economic YYYYYY findings to priority setting, emerging issues and decision- making 7. A priority- driven, policy YY YYY relevant research program 8. An investigator-led Y research program Australia and New Zealand Health Policy 2009, 6:6 http://www.anzhealthpolicy.com/content/6/1/6 Page 5 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:6 http://www.anzhealthpolicy.com/content/6/1/6 ments to meet that need. However, as observed by survey to ensure that cost-effectiveness questions are approached participants, not all the mechanisms will meet a given in a systematic way [27]. Bringing health service staff in need equally well. Some questions that are commonly contact with health economists also potentially builds raised by government–for example, the cost and likely informal collegial networks. The importance of these effect of interventions being implemented locally–can be kinds of networks to building links between policy and difficult for external groups to answer, as much of the evidence were described by Nutbeam [1]. Personal net- information required is held within the organisation. Fur- works were described in one jurisdiction as enabling some ther, government seeks answers to very practical questions staff to access advice from outside the organisation on a and this may not readily correspond to the interests or pro bono basis. expertise of external groups. None of the external mecha- nisms and very few of the internal mechanisms identified The mixture of structure and strategy points to important offer health services a true 'surge capacity' of health eco- complementarities that exist among the mechanisms nomics skills. Surge capacity can be required to provide, identified. One example of this is the provision of training for example, advice on options for outbreak control [26] programs–which requires access to competent trainers– or to respond to urgent requests for budgeting options. who may also be the providers of high-level external There would be merit in investigating how well each of expertise and advice to health departments. the mechanisms addresses different needs and to intro- duce a grading of usefulness to the responses. The investigators are aware of at least two mechanisms for obtaining advice that were not described by participants. Health departments varied also in the ease with which These were both external mechanisms. The first is where a they were able to employ each mechanism. For example, formal agreement ensures that a quantum of advice is successfully sourcing health economics capacity through available on demand, provided either by an expert or a external mechanisms is dependent upon suitable provid- group of experts working either pro-bono or for a nominal ers being identified and available. One jurisdiction noted fee. This is the mechanism that the NHMRC employs with that there were few local external providers from whom its working groups and advisory groups. The second they could purchase these services. Establishing contract- mechanism is where an external economist is retained to ing arrangements through tender also takes time, and provide an agreed number of days' service. often advice is required quickly. Consequently, to stream- line the process of contracting research, two jurisdictions A recent systematic review of the use of health economics had used 'preferred providers'; that is, small panels of pre- by health authorities in the UK has questioned the capac- identified experts who were available to provide advice in ity of health economics to assist government and con- areas of specialist knowledge. Membership of these panels cluded that more needed to be done '... to ensure was established through tendering processes. alignment between the objectives assumed in economic analyses and the objectives facing decision-makers in real- We see in the mechanisms that have been identified both ity'[18]. This need highlights another gap revealed by structures, such as position descriptions and contracting Table 3, that few mechanisms allowed health economics with experienced economists located in external centres, to continue to develop as a field through methodological and strategies such as training. Structures ensure that peo- research. This function is most likely to be met through ple with the right skills are in place and are accessible, specialist research centres and unlikely to be supported while strategies such as professional development provide through funding that is limited to answering specific serv- opportunity for the development of skills required by the ice-based questions. Consequently, health departments organisation for future capacity. need to be aware of the other objectives of external research groups lest the sustainability and utility of these Training is also being used to ensure that staff responsible groups and their capacity to meet more immediate, pol- for accessing health economics expertise are efficient com- icy-relevant needs is diminished. missioners and users of that expertise, whether in-house or external. This was illustrated by a non-health depart- In conclusion, the potential offered by health economics ment in NSW that had developed guidelines and training. was first recognised more than 30 years ago. Since then, Creating 'informed consumers' of health economics infor- the need for health managers to be informed by a wide mation is also an objective of the health economics mod- range of skills including economics has been emphasised ule in the NSW Public Health Officer Training Program. and re-emphasised [1,22]. Most recently, Prime Minister This requires trainees to demonstrate a level of compe- Rudd, in an address to his heads of department and senior tence in health economics. We see similar developments bureaucrats, stated: 'Policy innovation and evidence- internationally. For example, the National Institute of based policy-making is at the heart of being a reformist Health and Clinical Excellence in the UK has developed government.' To achieve this end one of the seven ele- guidelines and frameworks for use by non-economist staff ments of his government's vision for the Australian public Page 6 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:6 http://www.anzhealthpolicy.com/content/6/1/6 NSW – Mortality, Morbidity and Economic Impact. Sydney: service is developing evidence-based policy-making proc- NSW Department of Health; 2007. esses [28]. It is encouraging therefore that departments of 14. Health Outcomes International Pty Ltd, National Centre for HIV Epi- health across Australia are looking to engage with health demiology and Clinical Research, Drummond M: Return on invest- ment in needle and syringe programs in Australia. Canberra: economics and have a variety of means of doing so avail- Australian Government Department of Health and Ageing; 2002. able to them. We have also demonstrated that it is possi- 15. Drummond M: Basing prescription drug payment on eco- nomic analysis: The case of Australia. Health Affairs 1992, ble to describe an organisation's need for specialist 11:191-196. services as a set of functions or competencies and then 16. Drummond M: Economic evaluation in health care: Is it really identify the range of mechanisms through which those useful or are we just kidding ourselves? Australian Econ Rev 2004, 37:3-11. functions were met. 17. Ross J: The use of economic evaluation in health care: Aus- tralian decision makers' perceptions. Health Policy 1995, Competing interests 31:103-110. 18. Williams I, McIver S, Moore D, Bryan S: The use of economic eval- The authors declare that they have no competing interests. uations in NHS decision-making: A review and empirical investigation. Health Technol Assess 2008:12 [http:// www.hta.nhs.uk/fullmono/mon1207.pdf]. Authors' contributions 19. Mooney G, Wiseman V: Listening to the bureaucrats to estab- The study was originally conceived by LM in consultation lish principles for priority setting. Sydney: SPHERe, University of with LK and AS. Study design was agreed by all three Sydney; 1999. 20. Public Health Association of Australia: Workforce issues for pub- authors. Interviews and initial analysis were completed by lic health. The report of the Workforce Study 1990. Can- LK, with comments and contributions from LM and AS. berra: Public Health Association of Australia; 1990. 21. Salmond GC: Independent review of the Public Health Educa- First draft of the manuscript was completed by LM based tion and Research Program in Australia: Report to the Hon. on a report compiled by LK. All authors contributed to the B. Howe MP. Canberra: Department of Health and Aged Care re-writing of the manuscript. Services; 1992. 22. Durham G, Plant A: PHERP The Public Health Education and Research Program review 2005: Strengthening workforce Acknowledgements capacity for population health. 2005 [http://www.health.gov.au/ The authors would like to thank the following colleagues for their help: internet/wcms/publishing.nsf/Content/pherp-review-pdfreview- report-cnt.htm/$FILE/pherp_report.pdf]. Canberra: Commonwealth Michelle Haby, Brian Harrison, Pauline Ireland, Michael Kissane, Angela of Australia McKinnon, Jason Micallef, Jim Pearse, Myra Navarro-Mukii, Bruce Swanson, 23. Patton M: Qualitative evaluation and research methods Newbury Park, Sean Terry, James White, Susan White, Eugene Zhao. CA: Sage Publications; 1990. 24. Public Health Training and Development Unit: Informing public health practice – competencies of the graduate diploma of References aplied eidemiology. Sydney: NSW Department of Health; 2000. 1. Nutbeam D: How does evidence influence public health pol- 25. Judd M, McAuley L, Villenevue J, Lomas J: Is research working for icy? Tackling health inequalities in England. Health Promot J Aust you? A self-assessment tool and discussion guide for health 2003, 14:154-8. services management and policy organizations. Paper pre- 2. Deeble J: Twenty-five years of Australian health economics. sented to the annual conference of the Canadian Association of Health Address to the annual conference dinner. In Aust Econ Rev Vol- Services and Policy Research 2006. ume 37. Australian Health Economics Society; 2003:1-2. 26. 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Centre for Health Economics Research and Evaluation: 1998 Annual Clinical Excellence; 2004. Report. [http://www.chere.uts.edu.au/pdf/ar98.pdf]. 28. Gittins R: Rudd's vision: Get the bureaucrats to say what 7. Wanless D: Securing good health for the whole population – needs reforming. Monday Comment Sydney Morning Herald Final report. London: HM Treasury; 2004. 2008:19-20. 8. Australian Health Ministers' Advisory Council, Cervical Cancer Screening Evaluation Committee: Cervical cancer screening in Australia: Options for change. Canberra: Australian Govern- ment Printing Service; 1991. Publish with Bio Med Central and every 9. Australian Institute of Health and Welfare: Breast cancer screen- scientist can read your work free of charge ing in Australia: Future directions. Canberra: Australian Insti- "BioMed Central will be the most significant development for tute of Health and Welfare; 1990. 10. Junor W, Collins DJ, Lapsley HM: The macroeconomic and dis- disseminating the results of biomedical researc h in our lifetime." tributional effects of reduced smoking prevalence in New Sir Paul Nurse, Cancer Research UK South Wales. Sydney: The Cancer Council of New South Wales; Your research papers will be: 11. Collins DJ, Lapsley HM: Counting the costs of tobacco and the available free of charge to the entire biomedical community benefits of reducing smoking prevalence in NSW. Sydney: NSW Department of Health; 2005. peer reviewed and published immediately upon acceptance 12. Applied Economics: Returns on investment in public health: An cited in PubMed and archived on PubMed Central epidemiological and economic analysis. Canberra: Department yours — you keep the copyright of Health and Ageing; 2002. 13. Health Outcomes International Pty Ltd, National Centre in HIV Epi- BioMedcentral Submit your manuscript here: demiology and Clinical Research: The Impact of HIV/AIDS in http://www.biomedcentral.com/info/publishing_adv.asp Page 7 of 7 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australia and New Zealand Health Policy Springer Journals

How do government health departments in Australia access health economics advice to inform decisions for health? A survey

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Springer Journals
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Copyright © 2009 by Madden et al; licensee BioMed Central Ltd.
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Medicine & Public Health; Public Health; Social Policy
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1743-8462
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10.1186/1743-8462-6-6
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19358711
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Abstract

Background: Government anticipates that health economic analysis will contribute to evidence-based policy development. Early examples in Australia where this expectation has been met include the economic evaluations of breast and cervical screening. However, the level of integration of health economics within health services that require this advice appears uneven. We sought to describe how government health departments in Australia use specialist health economic advice to inform policy and planning and the mechanisms through which they access this advice. Methods: Information describing the arrangements for gaining health economics input into health decision- making was sought through interviews with a purposeful sample of economists and non-economists employed by all departments of health in Australia (state, territories and national). The survey was undertaken in August 2004. To aid interpretation of the results eight health economic functions were identified. As a comparison, four other government departments in NSW provided information about their access to economic advice. Results: All health departments except one reported being current users of health economics expertise. A variety of arrangements were described to source this, from building organisational capacity with self-sufficient in-house units to forging links with external sources. However, specialist positions for economists or health economists employed within health were few. A framework mapping these arrangements for sourcing advice with the eight common health economic functions to be met is presented. All other non-health government departments approached accessed economic advice, with three having in-house units. Discussion: A small health economics capacity in Australia has been established over the past 30 years through a variety of structural and strategic mechanisms. Health departments value health economic advice and use a variety of arrangements to obtain this. These arrangements have strengths and weaknesses depending upon the task to be undertaken. The lack of uniformity of approach suggests that health departments are still seeking the best ways to incorporate this form of specialist advice into mainstream decision-making. Implications: Summarises ways that governments source specialist services. Demonstrates how to describe an organisation's need for specialist services as a set of functions. This approach could be applied to assessing need for other specialist areas of advice. Page 1 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:6 http://www.anzhealthpolicy.com/content/6/1/6 Hepatitis C has also confirmed both the personal- and sys- Background A broad range of information is required to analyse pat- tem-level savings resulting from these policies and under- terns of health and disease, inform health policy, and pinned support for continued action [13,14]. More manage services and programs that treat and prevent ill recently, Australia has led international efforts to improve health. Consequently, health and public health organisa- health systems resource allocation that pioneers the use of tions draw expertise from many disciplines and profes- economic evaluation to guide decisions relating to new sional groups [1]. One such discipline is health pharmaceuticals and new health technologies [15,16]. economics, which applies the principles of economics to decision-making in health care, and in so doing has chal- Nonetheless, despite these successful examples of utilising lenged many of the conventional ways of thinking about health economic expertise, there is the perception that health and the distribution of the finite public resources health economic advice is not always well-matched to the that fund public health services. needs of government policy-makers [17-19]. Further reviews of the public health workforce in Australia since Health economics is a young field. In Australia, the first 1990 continue to acknowledge health economics as a health economics research unit was established in 1978 at public health speciality skill that needs strengthening [20- the Australian National University and was funded by the 22]. National Health and Medical Research Council (NHMRC) [2]. Following Kerr White's review of public To explore this issue, we describe how departments of health research and education in 1985, which encouraged health around Australia, and some other government the development of the capacity for "population-based' departments in New South Wales (NSW), access eco- thinking, a sustained capacity in health economics began nomic advice to inform policy and programs. To identify to be established in the 1990s [3,4]. The NHMRC and the potential strengths and weaknesses of these mecha- VicHealth funded the National Centre for Health Program nisms they are mapped against the common functions Evaluation in Melbourne, and in Sydney, the Centre for that health economics expertise could be anticipated to Health Economics Research and Evaluation was sup- fulfil. ported by the NSW Department of Health, and from 1994, also by the Public Health Education and Research Methods Program (PHERP) as a national specialist centre in health To identify the range of mechanisms that government economics [5,6]. From these beginnings, today there are health departments employ to access economic advice, we number of groups specialising in health economics surveyed a non-random (purposively selected) sample of around the country, usually located within universities. health economists and non-health economists employed by departments of health in all the states and territories of Despite the promise held out by health economics as an Australia and by the Australian Government Department aid to decision-making, policy-makers continue to experi- of Health and Ageing. Initial contacts were identified ence problems accessing economic advice. This need was through the networks of the authors and then by snow- highlighted most notably in the United Kingdom (UK) by balling if necessary [23]. We interviewed people with Derek Wanless in his report to HM Treasury [7]. Wanless knowledge of the health economics capacity within their considered that the information base for public health jurisdiction. generally was poor; and while there was often evidence on the scientific need for action, there was little evidence Semi-structured interviews were conducted by telephone, describing the cost-effectiveness or the outcomes of the where possible, or via e-mail where preferred by respond- implementation of programs. He also noted a relatively ents. All interviews (n = 15) were conducted in August slow acceptance of economic perspectives within public 2004 by one of the authors (LK). Information was sought health. about mechanisms for gaining health economics input into health decision-making in general, not just for public In Australia, health economics has made a contribution to health issues. evidence-based policy development within public health. Early examples include the economic evaluations of The questions asked were: breast and cervical screening that informed national screening policy [8,9]. Estimates of the social costs of 1. What health economics capacity does your health smoking and the social benefits of reducing the number of department have in-house? people who smoke have provided support for effective anti-smoking policies and interventions in NSW [10,11] 2. How do you gain health economics advice to and nationally [12]. The evaluation of Australia's invest- inform decision-making? ment in the prevention and treatment of HIV/AIDS and Page 2 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:6 http://www.anzhealthpolicy.com/content/6/1/6 3. What avenues are open to you to gain such advice? each function, illustrative questions or situations are pro- vided in the table. In addition, to provide a point of comparison, informa- tion about arrangements used by four other government All survey participants indicated that economics and departments in NSW to obtain economic advice was health economics have the potential to contribute con- obtained through an examination of websites or by tele- cepts and techniques to address a wide range of issues phone interview. faced by health system decision-makers. All but one of the departments of health we surveyed reported currently To describe common health economics functions we making use of health economics expertise to inform deci- examined the Health Economics Competency Area devel- sion-making. Mechanisms used to secure this advice var- oped for the competency framework that underpins deliv- ied among the departments of health, over time and with ery of the NSW Public Health Officer Training Program, the type of task, with most organisations using a mixture and the self-assessment questions developed by the Cana- of in-house and external sources (Table 2). The range of dian Health Services Research Foundation for use by deci- options seen in practice extended from sourcing services sion-makers to assess their organisation's capacity to use from external groups (n = 2) to well- structured, specialist research (or other specialised expertise) [24,25]. The units within the health department (n = 3). Most depart- organisational mechanisms identified by the survey were ments used more than one mechanism at any time. In then mapped against these functions to determine the general, however, the number of in-house positions for potential utility of the various mechanisms to obtain health economists (or economists) was few. Two depart- health economics advice. ments had developed specialist training programs to train health economists–only one of which continues today. Results Both these programs offered a combination of a university The set of eight health economic functions identified are qualification in health economics and a period of work- presented in Table 1. To make explicit what is meant by based learning. Table 1: Eight common health economics functions and examples of the types of situation in which they might be useful or types of questions that might be answered using this function Function Types of questions/situation in which this function would be applied 1. Appreciation of how economics fits into multi-disciplinary analysis of Does this problem have an economic aspect? Would it benefit from an public health problems economic perspective? 2. Advanced appreciation of economic concepts and frameworks, able Problem has an economic aspect that can be framed i.e., the person is to frame issues, formulate questions and obtain advice able to formulate an economic question in an appropriate way as part of a proposal. 3. Economic analysis of simple problems and issues, requiring literature Able to read and interpret the economic literature and think from an searches, appraisal, synthesis and interpretation economic perspective. 4. A capacity to respond quickly to emerging and emergency issues An economic surge capacity exists. 5. Conducting economic evaluations and other studies, with appropriate Able to answer questions about performing economic analysis for methods example: when is the right time; how should it be done; what level of complexity is required; do we have the necessary skills and experience required, or do we know who has the necessary skills? 6. Application of economic findings to priority settings, emerging issues Able to apply priority setting techniques and able to factor in issues such and decision-making as equity. 7. A priority-driven, policy relevant research program Not reactive but anticipates need. Is able to formulate research questions, develop a proposal to answer those questions and execute the study. 8. An investigator-led research program Not reactive – sees gaps in the available knowledge and tools, is able to develop a research plan to fill these gaps and secure funding to support the research agenda. Page 3 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:6 http://www.anzhealthpolicy.com/content/6/1/6 Table 2: Description of organisational mechanisms, both internal and external to the organisation, used to meet health economics needs by departments of health in Australia, 2004. Organisational mechanism Description Internal Position descriptions require qualifications that include an appreciation Many position descriptions in health require a qualification that includes of economics or health economics in the coursework some introduction to economics or health economics eg Masters of Public Health or Masters of Health Administration. Staff training (e.g., the NSW Public Health Officer Training Program) Short courses in health economics of varying duration and intensity, with or without final assessment of participants or accreditation of the courses. Generalist staff with economic qualifications Staff have a degree in economics but are not specialist health economists nor does their position require this qualification. Specialist health economics training programs Structured training programs to develop specialist health economists. Health economist positions Position description requires a qualification in health economics. Health economics units A team of health economists (with or without other disciplines) of varying size with well developed roles and functions to support decision making. External Consultancy for services Services of a scale that do not require contracted arrangements, usually for specific tasks, where expertise was sought through professional and personal networks. Contract research Contracts whose size does not warrant a competitive tendering process sometimes met by a preferred provider. Contract research by tender Contracts developed and let by competitive tender, usually filled by private providers or the academic sector. Collaborative research centres University professorial chairs or research centres established with funding that secures the focus of the work in whole or part to meet health service needs. Three of the four other government departments Discussion approached in NSW had internal economics units. One Our survey revealed a wide range of organisational mech- department had developed guidelines to support their anisms that have been used to secure health economics staff to collaborate effectively with their economics unit, and economics advice by Australian governments. It also and these guidelines were accompanied by workshops linked these mechanisms with the type of health eco- and training sessions. These departments supplemented nomic functions that governments require to inform deci- this internal capacity with external expertise. sion-making for policy and planning purposes. Our findings suggest that while health economics is estab- Table 3 describes the potential links between the mecha- lished as part of the specialist public health workforce, the nisms and the functions they fulfil as seen by the authors. role is perhaps not as well-integrated into public health as The first row presents the mechanisms, with the internal other specialist areas, such as biostatistics. As further evi- (in-house) arrangements to the left and the external (out- dence of this, health economics was again raised in the of-house) sources of support to the right. The left-hand most recent review of PHERP as a specialty area that still column presents the eight health economic functions, requires development [22]. arranged in increasing order of technical complexity from top to bottom. Shaded boxes denote the functions that are Depending upon the type of health economic task at best met by each particular mechanism. hand, health agencies use a number of different arrange- Page 4 of 7 (page number not for citation purposes) Table 3: Organisational mechanisms used by departments of health in Australia in 2004 to secure health economics advice and the economic functions that these mechanisms might serve. Internal Mechanisms External Mechanisms Organisational Qualification s Staff training/ Staff with Specialist H/E Health Health Consultancy Contracted Contracted Collaborative mechanism Function include NSW Public economic training economist economics for service advice advice by research appreciation of Health Officer qualifications programs position units tender centres economics or Training health Program economics in coursework. 1. Appreciation of how Y Y YY YY economics fits into multi- disciplinary analysis of public health problems 2. Advanced appreciation of Y YY YYY economics concepts and methods, able to frame issues, formulate questions and obtain advice 3. Economic analysis of Y YY YYYYY (simple) problems and issues, requiring literature searches, appraisal, synthesis and interpretation. 4. A capacity to respond YY Y quickly to emerging and emergency issues 5. Conducting economics YY YYYYYY evaluations and other studies, with appropriate methods 6. Application of economic YYYYYY findings to priority setting, emerging issues and decision- making 7. A priority- driven, policy YY YYY relevant research program 8. An investigator-led Y research program Australia and New Zealand Health Policy 2009, 6:6 http://www.anzhealthpolicy.com/content/6/1/6 Page 5 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:6 http://www.anzhealthpolicy.com/content/6/1/6 ments to meet that need. However, as observed by survey to ensure that cost-effectiveness questions are approached participants, not all the mechanisms will meet a given in a systematic way [27]. Bringing health service staff in need equally well. Some questions that are commonly contact with health economists also potentially builds raised by government–for example, the cost and likely informal collegial networks. The importance of these effect of interventions being implemented locally–can be kinds of networks to building links between policy and difficult for external groups to answer, as much of the evidence were described by Nutbeam [1]. Personal net- information required is held within the organisation. Fur- works were described in one jurisdiction as enabling some ther, government seeks answers to very practical questions staff to access advice from outside the organisation on a and this may not readily correspond to the interests or pro bono basis. expertise of external groups. None of the external mecha- nisms and very few of the internal mechanisms identified The mixture of structure and strategy points to important offer health services a true 'surge capacity' of health eco- complementarities that exist among the mechanisms nomics skills. Surge capacity can be required to provide, identified. One example of this is the provision of training for example, advice on options for outbreak control [26] programs–which requires access to competent trainers– or to respond to urgent requests for budgeting options. who may also be the providers of high-level external There would be merit in investigating how well each of expertise and advice to health departments. the mechanisms addresses different needs and to intro- duce a grading of usefulness to the responses. The investigators are aware of at least two mechanisms for obtaining advice that were not described by participants. Health departments varied also in the ease with which These were both external mechanisms. The first is where a they were able to employ each mechanism. For example, formal agreement ensures that a quantum of advice is successfully sourcing health economics capacity through available on demand, provided either by an expert or a external mechanisms is dependent upon suitable provid- group of experts working either pro-bono or for a nominal ers being identified and available. One jurisdiction noted fee. This is the mechanism that the NHMRC employs with that there were few local external providers from whom its working groups and advisory groups. The second they could purchase these services. Establishing contract- mechanism is where an external economist is retained to ing arrangements through tender also takes time, and provide an agreed number of days' service. often advice is required quickly. Consequently, to stream- line the process of contracting research, two jurisdictions A recent systematic review of the use of health economics had used 'preferred providers'; that is, small panels of pre- by health authorities in the UK has questioned the capac- identified experts who were available to provide advice in ity of health economics to assist government and con- areas of specialist knowledge. Membership of these panels cluded that more needed to be done '... to ensure was established through tendering processes. alignment between the objectives assumed in economic analyses and the objectives facing decision-makers in real- We see in the mechanisms that have been identified both ity'[18]. This need highlights another gap revealed by structures, such as position descriptions and contracting Table 3, that few mechanisms allowed health economics with experienced economists located in external centres, to continue to develop as a field through methodological and strategies such as training. Structures ensure that peo- research. This function is most likely to be met through ple with the right skills are in place and are accessible, specialist research centres and unlikely to be supported while strategies such as professional development provide through funding that is limited to answering specific serv- opportunity for the development of skills required by the ice-based questions. Consequently, health departments organisation for future capacity. need to be aware of the other objectives of external research groups lest the sustainability and utility of these Training is also being used to ensure that staff responsible groups and their capacity to meet more immediate, pol- for accessing health economics expertise are efficient com- icy-relevant needs is diminished. missioners and users of that expertise, whether in-house or external. This was illustrated by a non-health depart- In conclusion, the potential offered by health economics ment in NSW that had developed guidelines and training. was first recognised more than 30 years ago. Since then, Creating 'informed consumers' of health economics infor- the need for health managers to be informed by a wide mation is also an objective of the health economics mod- range of skills including economics has been emphasised ule in the NSW Public Health Officer Training Program. and re-emphasised [1,22]. Most recently, Prime Minister This requires trainees to demonstrate a level of compe- Rudd, in an address to his heads of department and senior tence in health economics. We see similar developments bureaucrats, stated: 'Policy innovation and evidence- internationally. For example, the National Institute of based policy-making is at the heart of being a reformist Health and Clinical Excellence in the UK has developed government.' To achieve this end one of the seven ele- guidelines and frameworks for use by non-economist staff ments of his government's vision for the Australian public Page 6 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:6 http://www.anzhealthpolicy.com/content/6/1/6 NSW – Mortality, Morbidity and Economic Impact. Sydney: service is developing evidence-based policy-making proc- NSW Department of Health; 2007. esses [28]. It is encouraging therefore that departments of 14. Health Outcomes International Pty Ltd, National Centre for HIV Epi- health across Australia are looking to engage with health demiology and Clinical Research, Drummond M: Return on invest- ment in needle and syringe programs in Australia. Canberra: economics and have a variety of means of doing so avail- Australian Government Department of Health and Ageing; 2002. able to them. We have also demonstrated that it is possi- 15. Drummond M: Basing prescription drug payment on eco- nomic analysis: The case of Australia. Health Affairs 1992, ble to describe an organisation's need for specialist 11:191-196. services as a set of functions or competencies and then 16. Drummond M: Economic evaluation in health care: Is it really identify the range of mechanisms through which those useful or are we just kidding ourselves? Australian Econ Rev 2004, 37:3-11. functions were met. 17. Ross J: The use of economic evaluation in health care: Aus- tralian decision makers' perceptions. Health Policy 1995, Competing interests 31:103-110. 18. Williams I, McIver S, Moore D, Bryan S: The use of economic eval- The authors declare that they have no competing interests. uations in NHS decision-making: A review and empirical investigation. Health Technol Assess 2008:12 [http:// www.hta.nhs.uk/fullmono/mon1207.pdf]. Authors' contributions 19. Mooney G, Wiseman V: Listening to the bureaucrats to estab- The study was originally conceived by LM in consultation lish principles for priority setting. Sydney: SPHERe, University of with LK and AS. Study design was agreed by all three Sydney; 1999. 20. Public Health Association of Australia: Workforce issues for pub- authors. Interviews and initial analysis were completed by lic health. The report of the Workforce Study 1990. Can- LK, with comments and contributions from LM and AS. berra: Public Health Association of Australia; 1990. 21. Salmond GC: Independent review of the Public Health Educa- First draft of the manuscript was completed by LM based tion and Research Program in Australia: Report to the Hon. on a report compiled by LK. All authors contributed to the B. Howe MP. Canberra: Department of Health and Aged Care re-writing of the manuscript. Services; 1992. 22. Durham G, Plant A: PHERP The Public Health Education and Research Program review 2005: Strengthening workforce Acknowledgements capacity for population health. 2005 [http://www.health.gov.au/ The authors would like to thank the following colleagues for their help: internet/wcms/publishing.nsf/Content/pherp-review-pdfreview- report-cnt.htm/$FILE/pherp_report.pdf]. Canberra: Commonwealth Michelle Haby, Brian Harrison, Pauline Ireland, Michael Kissane, Angela of Australia McKinnon, Jason Micallef, Jim Pearse, Myra Navarro-Mukii, Bruce Swanson, 23. 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Health Outcomes International Pty Ltd, National Centre in HIV Epi- BioMedcentral Submit your manuscript here: demiology and Clinical Research: The Impact of HIV/AIDS in http://www.biomedcentral.com/info/publishing_adv.asp Page 7 of 7 (page number not for citation purposes)

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Australia and New Zealand Health PolicySpringer Journals

Published: Apr 9, 2009

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