Cost analysis for initiating an integrated package of essential non-communicable disease interventions (PEN-Plus) in Kondoa District Hospital, Tanzania: a time-driven activity-based costing (TDABC) study protocol.

INTRODUCTION: Non-communicable diseases (NCDs) constitute approximately 74% of global mortality, with 77% of these deaths occurring in low-income and middle-income countries. Tanzania exemplifies this situation, as the percentage of total disability-adjusted life years attributed to NCDs has doubled over the past 30 years, from 18% to 36%. To mitigate the escalating burden of severe NCDs, the Tanzanian government, in collaboration with local and international partners, seeks to extend the integrated package of essential interventions for severe NCDs (PEN-Plus) to district-level facilities, thereby improving accessibility. This study aims to estimate the cost of initiating PEN-Plus for rheumatic heart disease, sickle cell disease and type 1 diabetes at Kondoa district hospital in Tanzania. METHODS AND ANALYSIS: We will employ time-driven activity-based costing (TDABC) to quantify the capacity cost rates (CCR), and capital and recurrent costs associated with the implementation of PEN-Plus. Data on resource consumption will be collected through direct observations and interviews with nurses, the medical officer in charge and the heads of laboratory and pharmacy units/departments. Data on contact times for targeted NCDs will be collected by observing a sample of patients as they move through the care delivery pathway. Data cleaning and analysis will be done using Microsoft Excel. ETHICS AND DISSEMINATION: Ethical approval to conduct the study has been waived by the Norwegian Regional Ethics Committee and was granted by the Tanzanian National Health Research Ethics Committee NIMR/HQ/R.8a/Vol.IX/4475. A written informed consent will be provided to the study participants. This protocol has been disseminated in the Bergen Centre for Ethics and Priority Setting International Symposium, Norway and the 11th Muhimbili University of Health and Allied Sciences Scientific Conference, Tanzania in 2023. The findings will be published in peer-reviewed journals for use by the academic community, researchers and health practitioners.

Impacts of Norway's extended free choice reform on waiting times and hospital visits.

Norway's extended free choice (EFC) reform extends the patient's choice of publicly funded hospitals for treatment to authorized private institutions (EFC providers). We study the effects of the reform on waiting times, number of visits, and patients' Charlson Comorbidity Index scores in public hospitals. We use a difference-in-differences model to compare changes over time for public hospitals with and without EFC providers in the catchment area. Focusing on five prevalent somatic services, we find that the EFC reform did not exert pressure on public hospitals to stimulate shorter waiting times and more visits. Moreover, we do not find that the sum of public and private visits increased. When we compare patient comorbidity between public hospitals and EFC providers, we find that for non-invasive diagnostic services, patient comorbidity is lower in EFC providers. For surgical services, we detect no difference in patient comorbidities between public and EFC providers.

Emerging integrated care models for children and youth with mental health difficulties in Norway: a horizon scanning study.

BACKGROUND: The implementation of Integrated Care Models (ICMs) represents a strategy for addressing the increasing issues of system fragmentation and improving service customization according to user needs. Available ICMs have been developed for adult populations, and less is known about ICMs specifically designed for children and youth. The study objective was to summarize and assess emerging ICMs for mental health services targeting children and youth in Norway. METHODS: A horizon scanning study was conducted in the field of child and youth mental health. The study encompassed two key components: (i) the identification of ICMs through a review of both scientific and grey literature, as well as input from key informants, and (ii) the evaluation of selected ICMs using semi-structured interviews with key informants. The aim of the interviews was to identify factors that either promote or hinder the successful implementation or scale up of these ICMs. RESULTS: Fourteen ICMs were chosen for analysis. These models encompassed a range of treatment philosophies, spanning from self-care and community care to specialized care. Several models placed emphasis on the referral process, prioritizing low-threshold access, and incorporating other sectors such as housing and child welfare. Four of the selected models included family or parents in their target group and five models extended their services to children and youth beyond the legal age of majority. Nine experts in the field willingly participated in the interview phase of the study. Identified challenges and facilitating factors associated with implementation or scale up of ICMs were related to the Norwegian healthcare system, mental health care delivery, as well as child and youth specific factors. CONCLUSION: Care delivery targeting children and youth's mental health requires further adaptation to accommodate the intricate nature of their lives. ICMs have been identified as a means to address this complexity by offering accessible services and adopting a holistic approach. This study highlights a selection of promising ICMs that appear capable of meeting some of the specific needs of children and youth. However, it is recommended to subject these models to further assessment and refinement to ensure their effectiveness and the fulfilment of their intended outcomes.

Contracts for primary and secondary care physicians and equity-efficiency trade-offs.

We analyse how payment systems for general practitioners (GPs) and hospital specialists affect inequalities in healthcare treatments, referrals, and patient health. We present a model of contracting with two providers, a GP and a hospital specialist, with patients differing in severity and socioeconomic status, and the GP only receiving an informative signal on severity. We investigate four health system configurations depending on whether the GP refers and the specialist treats only high-severity patients or patients with any severity. We show that an increase in the GP fee, which induces GPs to refer only high-severity patients, increases utilitarian welfare but also increases inequities in access to specialist visits. A reduction in the DRG reimbursement to hospital specialists, which induces specialists to treat only high-severity patients, increases utilitarian welfare but also increases inequities in access to specialist visits when the GP refers only high-severity patients.

Medical leadership development during the COVID-19 pandemic.

BACKGROUND: A leadership development programme (The Health Leadership School) was launched in 2018 for junior doctors and medical students in Norway. OBJECTIVE: To study participants' experiences and self-assessed learning outcomes, and if there were any differences in outcome among participants who met face-to-face versus and those who had to complete half of the programme in a virtual classroom due to the COVID-19 pandemic. METHODS: Participants who completed The Health Leadership School in 2018-2020 were invited to respond to a web-based questionnaire. RESULTS: A total of 33 (83%) out of 40 participants responded. The majority of respondents (97%) somewhat agreed or strongly agreed that they had gained knowledge and skills they did not learn in medical school. Respondents reported a high learning outcome for most competency domains, and there was no difference in outcome when comparing scores of those who met face-to-face versus and those who had to complete half of the programme in a virtual classroom. Among participants who participated in virtual classroom sessions due to the COVID-19 pandemic, the majority agreed that the programme could be run as a combination of face-to-face and virtual sessions. CONCLUSION: This brief report suggests that leadership development programmes for junior doctors and medical students can be run in-part using virtual classroom sessions, but that face-to-face sessions are important to foster relational and teamwork skills.

Learning from the COVID-19 pandemic among migrants: An innovative, system-level, interdisciplinary approach is needed to improve public health.

The effects of the COVID-19 pandemic are amplified among socially vulnerable groups, including international migrants, in terms of both disease transmission and outcomes and the consequences of mitigation measures. Migrants are overrepresented in COVID-19 laboratory-confirmed cases, hospital admissions, intensive care treatment and death statistics in all countries with available data. A syndemic approach has been suggested to understand the excess burden in vulnerable populations. However, this has not stopped the unequal burden of disease in Norway. Initially, the disease was mainly imported by Norwegians returning from skiing holidays in the Alps, and the prevalence of infection among migrants in Norway, defined as people born abroad to foreign parents, was low. Later, confirmed cases in migrants increased and have remained stable at 35-50% - more than twice the proportion of the migrant population (15%). To change this pattern, we need to understand the complex mechanisms underlying inequities in health and their relative and multiplying impacts on disease inequalities and to test the effect of counterfactual policies in order to reduce inequalities in disease burden. Yet, the current paradigm in the field of migration and health research, that is, the theories, research methods and explanatory models commonly applied, fail to fully understand the differences in health outcomes between international migrants and the host population. Here, we use the Norwegian situation as a case to explain the need for an innovative, system-level, interdisciplinary approach at a global level.

Development of voluntary private health insurance in Nordic countries - An exploratory study on country-specific contextual factors.

The Nordic countries are healthcare systems with tax-based financing and ambitions for universal access to comprehensive services. This implies that distribution of healthcare resources should be based on individual needs, not on the ability to pay. Despite this ideological orientation, significant expansion in voluntary private health insurance (VPHI) contracts has occurred in recent decades. The development and role of VPHIs are different across the Nordic countries. Complementary VPHI plays a significant role in Denmark and in Finland. Supplementary VPHI is prominent in Norway and Sweden. The aim of this paper is to explore drivers behind the developments of the VPHI markets in the Nordic countries. We analyze the developments in terms of the following aspects: the performance of the statutory system (real or perceived), lack of coverage in certain areas of healthcare, governmental interventions or inability to reform the system, policy trends and the general socio-cultural environment, and policy responses to voting behavior or lobbying by certain interest groups. It seems that the early developments in VPHI markets have been an answer to the gaps in the national health systems created by institutional contexts, political decisions, and cultural interpretations on the functioning of the system. However, once the market is created it introduces new dynamics that have less to do with gaps and inflexibilities and more with cultural factors.

Social capital and cigarette smoking: New empirics featuring the Norwegian HUNT data.

Using a rich Norwegian longitudinal data set, this study explores the effects of different social capital variables on the probability of cigarette smoking. There are four social capital variables available in two waves of our data set. Our results based on probit (and OLS) analyses (with municipality fixed-effects) show that the likelihood of smoking participation is negatively and significantly associated with social capital attributes, namely, community trust (-0.017), participation in organizational activities (-0.032), and cohabitation (-0.045). Significant negative associations were also observed in panel data, pooled OLS, and random effects models for community trust (-0.024; -0.010) and cohabitation (-0.040; -0.032). Fixed-effects models also showed significant negative effects for cohabitation (-0.018). Estimates of alternative instrumental variables (IV) based on recursive bivariate probit and IV-GMM models also confirmed negative and significant effects for three of its characteristics: cohabitation (-0.030; -0.046), community trust (-0.065; -0.075), and participation in organizational activities (-0.035; -0.046). The limitations of our conclusions are discussed, and the significance of our study for the field of social capital and health is described, along with suggested avenues for future research.

How do Hospitals Respond to Price Changes? Evidence from Norway.

Many publicly funded health systems use activity-based financing to increase hospital production and efficiency. The aim of this study is to investigate whether price changes for different treatments affect the number of patients treated and the mix of activity provided by hospitals. We exploit the variations in prices created by the changes in the national average treatment cost per diagnosis-related group (DRG) offered to Norwegian hospitals over a period of 5 years (2003-2007). We use the data from Norwegian Patient Register, containing individual-level information on age, gender, type of treatment, diagnosis, number of co-morbidities and the national average treatment costs per DRG. We employ fixed-effect models to examine the changes in the number of patients treated within the DRGs over time. The results suggest that a 10% increase in price leads to about 0.8-1.3% increase in the number of patients treated for DRGs, which are medical (for both emergency and elective patients). In contrast, we find no price effect for DRGs that are surgical (for both emergency and elective patients). Moreover, we find evidence of upcoding. A 10% increase in the ratio of prices between patients with and without complications increases the proportion of patients coded with complications by 0.3-0.4 percentage points.

The relationship between educational attainment and waiting time among the elderly in Norway.

We investigate whether educational attainment affects waiting time of elderly patients in somatic hospitals. We consider three distinct pathways; that patients with different educational attainment have different disease patterns, that patients with different levels of education receive treatments at different hospitals, and that patient choice and supply of local health services within hospital catchment areas explain unequal waiting time of different educational groups. We find evidence of an educational gradient in waiting time for male patients, but not for female patients. Conditional on age, male patients with tertiary education wait 45% shorter than male patients with secondary or primary education. The first pathway is not quantitatively important as controlling for disease patters has little effect on relative waiting times. The second pathway is important. Relative to patients with primary education, variation in waiting time and education level across local hospitals contributes to higher waiting time for male patients with secondary education and female patients with secondary or tertiary education and lower waiting time for male patients with tertiary education. These effects are in the order of 15-20%. The third pathway is also quantitatively important. The educational gradients within catchment areas disappear when we control for travel distance and supply of private specialists.

Waiting times and socioeconomic status. Evidence from Norway.

We investigate whether socioeconomic status, measured by income and education, affects waiting time when controls for severity and hospital-specific conditions are included. We also examine which aspects of the hospital supply (attachment to local hospital, traveling time, or choice of hospital) matter most for unequal treatment of different socioeconomic groups. The study uses administrative data from all elective inpatient and outpatient stays in somatic hospitals in Norway. The main results are that we find very little indication of discrimination with regard to income and education when both severity and aspects of hospital supply are controlled for. This result holds for both men and women.

The impact of different prioritisation policies on waiting times: case studies of Norway and Scotland.

We investigate the distributional consequences of two different waiting times initiatives, one in Norway, and one in Scotland. The primary focus of Scotland's recent waiting time reforms, introduced in 2003, and modified in 2005 and 2007, has been on reducing maximum waiting times through the imposition of high profile national targets accompanied by increases in resources. In Norway, the focus of the reform introduced in September 2004, has been on assigning patients referred to hospital a maximum waiting time based on disease severity, the expected benefit and the cost-effectiveness of the treatment. We use large, national administrative datasets from before and after each of these reforms and assign priority groups based on the maximum waiting times stipulated in medical guidelines. The analysis shows that the lowest priority patients benefited most from both reforms. This was at the cost of longer waiting times for patients that should have been given higher priority in Norway, while Scotland's high priority patients remained unaffected.

Monitoring prioritisation in the public health-care sector by use of medical guidelines. The case of Norway.

This paper presents a new way to monitor priority settings in public health-care systems. We take departure in medical guidelines prescribing acceptable waiting times for different medical descriptions. Allocating ICD10 codes to the medical descriptions, we are able to compare actual waiting times to the recommended maximum waiting times. This way we use the medical guidelines as a tool for monitoring prioritisation in the health sector. In an application, using data from the Norwegian Patient Register, we test statistically for compliance with the guidelines. The results indicate that patients suffering from the most severe conditions are receiving too low priority in the Norwegian health-care sector relative to patients of lower priority.

Multi-tasking, quality and pay for performance.

We present a model of optimal contracting between a purchaser and a provider of health services when quality has two dimensions. We assume that: (i) the provider is (at least to some extent) altruistic; (ii) one dimension of quality is verifiable (dimension 1) and one dimension is not verifiable (dimension 2); (iii) the two quality dimensions can be either substitutes or complements. Our main result is that setting the price equal to the marginal benefit of the verifiable quality dimension can be optimal even if the two quality dimensions are substitutes.

Norwegian priority guidelines: estimating the distributional implications across age, gender and SES.

OBJECTIVE: Targeting hospital treatment at patients with high priority would seem to be a natural policy response to the growing gap between what can be done and what can be financed in the specialist health care sector. The paper examines the distributional consequences of this policy. METHOD: 450000 elective patients are allocated to priority groups on the basis of medical guidelines developed by one of the regional health authorities in Norway. Probit models are estimated explaining priority status as a function of age, gender and socioeconomic status. RESULTS: Women and older people are overrepresented among patients with low priority. Conditional on age, women with low priority have lower income and less education than women with high priority. Among men below 50 years, patients with low priority have less education than patients with high priority. CONCLUSION: Targeting hospital treatment at patients with high priority, though sensible from a pure medical perspective, may have undesirable distributional consequences.

Prioritization and patients' rights: analysing the effect of a reform in the Norwegian hospital sector.

The right to equal treatment, irrespective of age, gender, ethnicity, socio-economic status and place of residence, is an important principle for several health care systems. A reform of the Norwegian hospital sector of 2002 may be used as a relevant experiment for investigating whether centralization of ownership and management structures will lead to more equal prioritization practices over geographical regions. One concern was variation in waiting times across the country. The reform was followed up in subsequent years by some other policy initiatives that also aimed at reducing waiting lists. We measure prioritization practice by a method that takes departure in recommended maximum waiting times from medical guidelines. We merge the information from the guidelines with individual patient data on actual waiting times for the period 1999-2005. This way we can monitor whether each patient in the available register of actual hospital visits has waited shorter or longer than what is considered medically acceptable by the guideline. The results indicate no equalization between the five new health regions, but we find evidence of more equal prioritization within four of the health regions. Our method of measuring prioritizations allows us to analyse how prioritization practice evolved over time after the reform, thus covering some further initiatives with the same objective. The results indicate that an observed reduction in waiting times after the reform have favoured patients of lower prioritization status, something we interpret as a general worsening of prioritization practices over time.

[More adequate use of laboratory services--economical aspects]. / Riktigere bruk av laboratorietjenester--økonomiske aspekter.

BACKGROUND: There has been a substantial increase in reimbursement for outpatient laboratory services in recent years. This article gives an overview of the use of such laboratory services and discusses measures for improved efficiency. MATERIAL AND METHODS: We have analysed reimbursement to the specialist health care for the period 2002-04. RESULTS: In the period 2002-04 the reimbursement to public laboratories increased by 42%. There has been a substantial growth in all reimbursements groups, especially for "General analysis for molecular biological methods" (236%). Reimbursement to private laboratories have increased by 24%, similar to the increase in general clinical chemistry. There has been a trend towards using the expensive reimbursement groups more often, especially for public laboratories. There is substantial variation in the use of laboratory services between the health regions. DISCUSSION: Our results indicate that the growth and variation in the use of laboratory services cannot be explained by deteriorated health or more illness in the population. The variation indicates that the use of laboratory services is not optimal. Establishment of a national laboratory system within specialized health care may contribute to a more knowledge-based use of laboratory services.

[Appropriate use of laboratory tests--medical aspects]. / Riktigere bruk av laboratorietjenester--medisinske aspekter.

BACKGROUND: There has been a large increase in the use and costs of laboratory tests during recent years. Several reports have indicated excessive and inappropriate use. The purpose of this study was to assess the use of public laboratory services within clinical chemistry in two Norwegian health regions. MATERIAL AND METHODS: Production statistics for 2004 were obtained through a questionnaire sent to all public clinical chemistry hospital laboratories in northern and western Norway. Additional detailed production statistics were obtained from Haukeland University Hospital for 2002-04. RESULTS: We observed differences in the absolute frequency of requested tests and a marked variation in relative ratios (ratio between related tests) between the laboratories in northern and western Norway. Data from Haukeland University Hospital showed a mean increase of 12% (range: -24-54%) in the number of ordered tests between 2002-04. INTERPRETATION: There are no known differences in morbidity between the northern and western health regions that can explain the observed variations in the use of laboratory tests. Our observations indicate a need for a thorough investigation of current utilisation of laboratory tests. Initiatives should be taken on a national basis to improve appropriate use.