Rationing in Health Systems a Critical Review- Ncbi- Nih
Med J Islam Repub Iran. 2017; 31: 47.
Rationing in health systems: A critical review
Iman Keliddar
1 Tehran University of Medical Sciences, Tehran, Iran.
Ali Mohammad Mosadeghrad
ii School of Public Health, Tehran University of Medical Sciences, Tehran, Islamic republic of iran.
Mehdi Jafari–Sirizi
3 School of Health Management and Data Sciences, Iran University of Medical Sciences, Tehran, Islamic republic of iran.
Abstract
Groundwork: It is difficult to provide wellness care services to all those in demand of such services due to limited resources and unlimited demands. Thus, priority setting and rationing accept to exist practical. This written report aimed at critically examining the concept of rationing in health sector and identifying its purposes, influencing factors, mechanisms, and outcomes.
Methods: The critical interpretive synthesis methodology was used in this written report. PubMed, Cochrane, and Proquest databases were searched using the related key words to find related documents published between 1970 and 2015. In total, 161 published reports were reviewed and included in the study. Thematic content analysis was applied for data analysis.
Results: Health services rationing means restricting the access of some people to useful or potentially useful health services due to budgetary limitation. The inherent features of the health market place and health services, limited resource, and unlimited needs necessitate wellness services rationing. Rationing tin can exist applied in 4 levels: wellness care policy- makers, health care managers, health care providers, and patients. Health care rationing tin exist accomplished through fixed budget, benefit packet, payment mechanisms, queuing, copayments, and deductibles.
Conclusion: This paper enriched our understanding of wellness services rationing and its mechanisms at diverse levels and contributed to the literature by broadly conceptualizing health services rationing.
Keywords: Wellness system, Wellness Intendance Rationing, Health resource, Patient pick, Critical review
↑ What is "already known" in this topic:
Despite the importance of rationing in the health sector as a prerequisite to universal health coverage, there is little consensus nigh its meaning and practical mechanisms in the literature.
→ What this commodity adds:
This study further developed the concept and theory of health services rationing through identifying its purposes, influencing factors, mechanisms, and outcomes. Furthermore, a systemic model of rationing in health systems was developed.
Introduction
The Globe Health Arrangement defined health as a land of complete physical, mental, and social well-being and not merely the absence of illness or infirmity (1). Accordingly, governments should institute robust wellness systems to promote the health status of their nations. Every man being has the right to have admission to the highest attainable standards of health without distinction of gender, race, religion, belief, income, or social class (1). Providing high quality, accessible, and affordable wellness services should be the main goal of health intendance organizations (ii).
Health care organizations are facing several challenges such every bit unlimited demands, increasing costs, and resource shortage (3-4). During the last 15 years, the rate of wellness expenditure growth exceeded the charge per unit of economical growth (five). However, money, especially in developing countries, is disproportionately spent on those health services that have a low impact on people'due south health, and mainly benefit the rich (vi). Inefficiencies in the delivery of wellness care services, variable providers' payment systems, supplier induced need, and inappropriate use of expensive technologies are the main causes of escalating health intendance costs (7). For instance, in some OECD countries, and the US, new advanced technologies with less marginal effectiveness were sometimes used instead of alternative and less expensive existing procedures (8). Redirecting even a fraction of that money could expand useful health care coverage, enhance quality of care, and improve patient satisfaction.
It is highly important to get the best value for money due to the shortage of health care resources. Thus, health care policy makers and administrators take to apply strategies like priority setting and rationing and should invest more than in affordable, constructive, patient-centered, and safe services that deliver the best wellness outcomes (nine). Particularly, the situation worsens for health intendance organizations during the economic recession and public spending cuts.
The World Wellness Organization (2013) highlighted the importance of rationing as a prerequisite to universal health coverage (10). Despite the importance of rationing in health systems for universal health coverage, at that place is fiddling consensus about its significant and applied mechanisms in the literature. This study aimed at critically examining the concept and theory of health services rationing to contribute to a better agreement of its concept and related policy bug past addressing some key questions such as "what is wellness services rationing?", and "why, how and by whom are wellness services rationed?" We besides provided a brief overview of the development of rationing concept in health sector and some of its policy implications.
Methods
Health care rationing literature is big, complex, and various. Thus, we decided to use critical interpretive synthesis (CIS), instead of conventional systematic review methodology, to achieve the aims of this study. Critical interpretive synthesis enables researchers to critically synthesize a diverse body of evidences and studies in a given field and generate theories. While conventional systematic review aims to test theories through searching for, appraising, and synthesizing the findings of the primary studies (aggregative syntheses) in a fixed process of predefined sequence, critical interpretive synthesis aims to generate a theory by including many unlike forms of bear witness (Interpretive syntheses) through iterative, dynamic, interactive, and recursive processes of question conception, searching for, data extraction, critique, and synthesis (11).
In this review, which was conducted during the summer of 2015, PubMed, Cochrane, and Proquest databases were searched to detect published English literature in wellness services rationing from 1970 to 2015. Keywords were rationing health*, priority setting health*, setting priority* and wellness*, using a combination of Medline subject headings (Mesh) and text words (tw). The reference lists of the retrieved articles were also reviewed for finding additional studies.
A data extraction form was developed co-ordinate to the main objectives of the study to examine the concept and theory of rationing in the wellness sector and its purposes, influencing factors, processes, mechanisms, and outcomes. All retrieved studies were initially screened on championship and abstract past ane of the report members (IK). Relevance and contribution to theory development were the main criteria for appraising the quality of the papers in the interpretive review (12). Only fatally flawed papers were excluded using the criteria stated in Table 1. The retrieved articles were reviewed critically and categorized using the information extraction course. Justification well-nigh each selected papers was done by consensus.
Table 1
Criteria for quality appraisal of the papers
• Are the research goals and objectives clearly specified?
• Is the enquiry design clearly specified and is information technology suitable for achieving research goals?
• Is the research process conspicuously explained?
• Are plenty data displayed to support inquiry interpretations and conclusions?
• Is the assay method advisable and fairly explained?
Results
In this report, 11 668 records were retrieved, of which 8097 were excluded past title/abstract screening. After retrieving the total texts, we plant that 161 studies met the quality appraisal criteria. Studies were conducted in a wide range of countries, and near of the studies were done in adult countries in Europe and America.
The synthesis of the literature was organized into 6 sections. In the first and second sections, the concept of rationing and its necessity in health sector were discussed. The 3rd part was devoted to the trends of rationing in the wellness sector. So, the levels of applying health care rationing were examined. Finally, the mechanisms for rationing health services were described.
What is health services rationing?
There is no universal definition of the word 'rationing'. Fourteen definitions of rationing were elicited from the literature (Table 2). The word 'rationing' has derived from the Latin 'ration', meaning 'to apply limitation in usage' (13). In economic science, rationing refers to decision-making the distribution of scarce resource and services among a population (xiv). Oxford Lexicon defines rationing as 'allowing each person to have just a stock-still amount of a commodity' (15).
Tabular array ii
The Definitions of Health Services Rationing
| Author (s) | Definition |
| Aaron and Schwartz (1990) | "The deliberate and systematic deprival of sure types of services, even when they are known to be benign, because they are deemed too expensive." ( p.418) (19) |
| Asch and Ubel (1997) | "Non to provide some beneficial health care services, which are simply too expensive" (p.1668) (20). |
| Baily (2003) | "To limit the beneficial wellness care an private receives by whatsoever means – price or non-price, direct or indirect, explicit or implicit" (p.35) (21). |
| Bennett and Chanfreau (2005) | "The controlled distribution of scarce goods or services" (p. 542) (22). |
| Brown (1991) | "The deliberate, systematic withholding of beneficial appurtenances or services from some elements of the population on the grounds that society cannot beget to extend them." (p.30) (18) |
| Dougherty (1991) | "The deprival of services that are potentially beneficial to some people because of limitations on the resource available for health care" (p.3) (23) |
| Goldbeck-Forest (1997) | "Withholding a beneficial treatment because of its costs" (p.146 ) (24) |
| Fleck (1992) | "The denial of life-sustaining medical intendance on the basis of an arbitrary monetary limit" (p.1605) (25). |
| Hadorn and Brook (1991) | "The withholding of necessary services and societal toleration of caitiff access (for example, based on ability to pay) to services best-selling beingness necessary by reference to necessary care guidelines." (p.3331) (26) |
| Hurst and Danis (2007) | "Whatsoever clinical decision to place or to take a limit on benefits for a patient" (p.248) (27) |
| Maynard (1999) | "An individual is deprived of care which is of do good (in improving wellness status, or the length and quality of life), which is desired by the patient." (p.half dozen) (28) |
| Ole Frithjof (1999) | "The withholding of potentially benign health care through financial or organizational features of the health intendance system in question." (p.1426) (29) |
| Pickard and Sheaff (1999) | "Restricting access to health intendance for nonclinical reasons such as price command" (p.38) (30). |
| Ubel (2001) | "Whatsoever implicit or explicit mechanism that allows people to go without beneficial services" (p.35) (sixteen). |
Ubel defines rationing as "any implicit or explicit mechanisms that allow people to become without beneficial services" (16). Russell (2002) defined rationing as "someone or some institution's deliberate decision to distribute a scarce good among competing persons" (17). According to Brown (1991), rationing is the "deliberate and systematic withholding of beneficial goods or services from some elements of the population on the grounds that the society cannot afford to extend them" (18).
Scarcity, resource constraint, and exclusion are 3 of import notions that found the definition of health care rationing. Therefore, we ascertain health services rationing as "restricting the access of some people to useful or potentially useful wellness services due to budgetary limitation".
Why health services must be rationed?
Products or services should accept iii features to be rationed. These features are scarcity, value, and controllability (17). All these features are inherent in health care services, which make rationing a necessity. First, health care is a deficient commodity. The resource shortage for health services commitment is particularly noticeable in the developing countries, where a smaller share of resources is allocated to the health sector (31). The problem would be worse during the economic recession. For instance, health spending vicious in half of the EU countries between 2009 and 2012, following the economic crunch. As a issue, health expenditure declined by 0.6% annually, compared with an almanac growth of 4.seven% between 2000 and 2009 (32). In addition, the homo resource needed for wellness care organizations are decreasing due to the crumbling societies and a rise in the need for health care services in Europe (33).
Second, wellness is a valuable good and has the value of life principle; and life itself is inseparable from health. Without some degree of good for you functionality, the living whole would not be. Thus, people may have the willingness to give their assets abroad in return of getting their health dorsum. Thus, access to adequate health care is considered as a key homo correct in many countries. Finally, the wellness services are controllable and tin can be refused to provide to some people and reserved to meet more urgent and immediate demands. Therefore, wellness service is one of the cases which demands rationing.
The goal of rationing is to supply rational, equitable, and price-constructive health services while reducing expenditure (34). Moreover, the inherent characteristics of the wellness market as well make it necessary to employ rationing (Table iii). Characteristics such as information disproportion and heterogeneity make the use of rationing inevitable. The data asymmetry between patients and physicians may increase supplier induced need (35). On the other mitt, health care professionals deliver the services to patients differently (36,37). Variations in medical practices raise questions about the equity, quality, and efficiency of wellness care services (38). Limited health care resources suggest applying rationing mechanisms such as evidence-based guidelines and protocols to evangelize but effective intendance to patients. Equally a result, induced demand and medical practice variations can be reduced.
Table 3
Determinants of rationing wellness services
| Determinants of rationing | Features |
| Characteristics of health services | • Value of health services • Scarcity of health services • Controllability of wellness services |
| Characteristics of wellness market | • Information asymmetry • Heterogeneity |
What is the trend of health services rationing?
The notion of rationing has evolved gradually from an "implicit" and "hidden nonsystematic" to an "explicit and open systematic" style (39). Implicit rationing relies on hidden norms and rules mainly defined by health intendance providers such equally physicians. In contrast, explicit rationing is based on clearly defined indicators such as patient historic period, gender, financial status, and clinical condition.
Traditionally, an private or groups of doctors decide near who and when gets treated in an uncoordinated manner (40). The public is not involved in the rationing decisions in a "hidden nonsystematic approach. Hence, medical doctors within the given budget limit, allocate resources based on clinical priorities and inter-specialty bargaining power. For instance, they may deny dialysis to patients over the age of 55 years co-ordinate to an unwritten rule due to limited budgets.
In the 1980s, rationing decisions were started to carry out co-ordinate to systematic well-divers efficiency considerations. The aim was to maximize the amount of health for a population for a given budget without involving the public in the rationing decisions (41). Doctors had a limited power in determining rationing principles and their applications in practice. Using relatively high deductibles and copayments to discourage people from using expensive health services is an example of hidden systematic rationing.
Finally, open up systematic rationing has been used since 1990s in some developed countries such every bit United kingdom of great britain and northern ireland (42), where a public recognition was happening. In some countries, a minimum health intendance package was introduced to ensure people's access to those services, and wellness services exterior of this package were not guaranteed to the population.
Who does health services rationing?
Health services rationing decisions could be taken past various organizations, groups, and individuals in unlike levels of a health system. Mechanic (1997) argues that decisions near health services rationing are normally made at three levels: wellness systems, intermediate, and clinical levels (34). At the health care systems level, governments, health government, or wellness insurance companies determine the total health care spending levels, the types of health services to be covered, the extent of technological development, the location of health care facilities, and the extent of patient cost sharing. At the intermediate level, subunits such as hospitals determine the number and mix of various providers, the extent of direct access, schedules, and waiting times for various health care services. Finally, at the clinical level, clinicians decide about treatment priorities considering types of patients, varying weather condition, and treatment approaches.
Krizova and Simek (2002) believe that rationing occurs at political and clinical levels (43). Wellness intendance politicians, wellness insurance companies, and infirmary executives set up an external economic framework for clinical piece of work. At the clinical level, physicians and medical professionals are responsible for quality of care and bear out the rationing. Klein (1997) suggests that rationing could occur at macro, meso- and micro- levels (44). The macro- level rationing refers to decisions about how much funding should exist allocated to health services birthday. Resource allotment of resources betwixt particular services and localities occur at the meso- level. Finally, rationing at the micro- level deals with decisions on treating private patients. Coast et al. (1996) suggest 4 levels for rationing health services: (a) beyond whole services, (b) across treatments within services, (c) within treatments, and (d) betwixt individual patients (45).
Therefore, considering the complex nature of health care organizations, rationing could be practiced at 4 levels: patient, provider, manager, and policymaker (Fig. i). The individual patient's needs and preferences may lead to cocky-rationing. A sick person without a health insurance plan makes the decision to seek intendance by comparison the costs and benefits of receiving the care. South/he might pass up to proceed to get the services if could not afford it or see the costs more than than the benefits. Toll-based cocky-rationing leads to underutilization of wellness care services. The health care team consists of the individual physicians and intendance providers. Basically, rationing decisions are made according to the clinical interactions between physicians and patients. Despite a commitment to ration wellness care services openly in theory, clinicians use more implicit methods in exercise.
Health organization rationing levels
The third level of the health services rationing occurs at the organizational level (due east.1000, hospital, clinic, and nursing home) that provide infrastructure and needed resources to support wellness care providers. Managers are responsible for allocating resources among various health care providers and may ration some health services.
Finally, politicians, policymakers and wellness insurance companies at the macro- level set up some rules and regulations almost the allocated health care budget, services coverage, and price sharing mechanisms considering political, economic, social, and technological factors. The comparing between different levels of health services rationing proposed by dissimilar scholars and this written report is demonstrated in Table iv.
Tabular array 4
Levels of Health Services Rationing in Health Systems
| Klein (1992) | Mechanic (1997) | Krizova & Simek (2002) | Coast et al.(1996) | This study |
| Macro level | Health care organization level | Political level | Across whole services | Policy makers |
| Meso level | Intermediate level | - | Across whole services, Across treatments within services | Managers |
| Micro level | Clinical level | Clinical level | Within treatments, Between individual patients | Providers |
| - | - | - | - | Patients |
Health care rationing too depends on the financing sources of a health system. While in tax-based wellness systems, the authorities regime could go on the responsibleness for wellness care rationing, in payroll and premium-based health systems, social or individual insurance companies deal with the responsibleness. Finally, in an out of pocket-based health system, wellness care institutes' managers, clinicians, and even patients themselves brand the decisions for rationing health intendance services.
Rationing can be applied in all 4 functions of the health systems including governance, financing, resources generation, and health services provision. At the macro- level, politicians and health care regime, equally the stewards of the national resource, plan and directly rationing wellness intendance services to plant the fairest possible health arrangement, to make the best possible use of limited resources, and to deliver the best health outcomes. The government and Ministry of Health should regulate and balance rationing at meso- and micro- levels to maximize the probability of success in health services rationing. A lack of rationing health care services policy at the political level may lead to uncontrolled medical professionals' ability of decision-making.
How practise ration health services?
Health is a correct and health services should exist deservedly accessible to all. Thus, health care services should exist rationally distributed to fit the needs of the people who need them. To exercise and so, it is sometimes necessary to limit the access of less needy people to some health care services to provide them to more urgent needs. Several mechanisms could exist used for health intendance rationing, which is classified as supply and demand side mechanisms.
Policymakers and government at macro- level can use methods such equally upkeep, benefit package, and payment mechanisms to control the behavior of health intendance managers and providers and restrict providing a broad variety of inappropriate health services. Budget influences the behavior of providers and leads them to reallocate health care resources or even ration some wellness care services. This method was used in the UK between the 1950s and early on 1980s. Budget may fifty-fifty lead to covert rationing. For example, tight budgets in the UK resulted in the deprival of dialysis and some forms of heart surgery to patients over the age of 55 years (v).
Health services coverage is sometimes limited through the specification of a carte du jour of core health care services (minimum health intendance package) to exist fabricated available for the public. Accordingly, certain health care services outside of this package volition be unavailable to all patients (46). Practitioners tin can employ clinical guidelines for requesting advisable constructive health care services for patients. Clinical guidelines assist practitioners on which diagnostic tests to order, how to provide surgical, medical, and nursing services and how long patients should stay in the hospital (47). In addition, policymakers use toll-benefit and cost-effectiveness analyses to finalize the benefit parcel (minimum health care package).
Payment mechanisms as incentives influence the behavior of health care professionals to decrease or increase the number of patients (through capitation), the number of visits (through salary or fee-for-service), the blazon and quality of services (through fee for services), and the referral of patients to other wellness care facilities (through salary, fee-for-service) (48).
Some mechanisms such as queuing, copayments, and deductibles tin can be used at macro-, meso- and micro- levels to limit access to wellness intendance services at individual, household, or customs levels and control the demands for wellness care services. Queuing gives some patients a higher priority than others in accessing health care services, which may exist explicit by using divers indicators of severity of the patient's clinical condition, or may exist implicit based upon doc's referral practices (49). Copayments and deductibles influence the beliefs of the receiver of the health services. High copayments and deductibles discourage but non cease patients from using expensive health care services (5).
Word
Health service rationing is a mechanism that could aid clinch disinterestedness (fifty). Health services rationing is a key issue in wellness systems' policymaking. Most studies on health services rationing focus on its specific levels. To the best of our knowledge, this was one of the get-go studies that offered a theoretical conceptualization of health services rationing through analyzing its whole moving-picture show in health systems.
Wellness services rationing was defined in this written report as "to restrict some people'due south admission to useful or potentially useful health services due to budgetary limitation". Health care rationing means denying patients the potentially beneficial health care services. Such a definition integrates both clinical and political levels in health rationing. Rationing is most applying price and non-cost, directly or indirect, and open or hidden mechanisms to restrict access to the required wellness care services. These health intendance services should be provided according to people's health needs.
Those decisions that limit access to health services based on nonfinancial reasons (eastward.one thousand., medical reasons) or focus on reducing wastage and administrative costs in health intendance are not considered as rationing decisions. Just those decisions that cause behavioral changes in unlike health arrangement actors and consequently limit admission to wellness services can be considered every bit rationing.
Rationing in health systems is a multi-dimensional field of activeness. Nosotros proposed a model of rationing in health systems based on the system theory (Fig. 2). The health services rationing system is concerned with deciding which appurtenances or services must exist restricted and which patients should be given limited access to such services. The principal components of this model are input, process, output, and feedback. At the first step, a condition occurs in which the demand exceeds the supply of wellness resource. This gap is made due to a force per unit area of the environment. The resources shortages and the right to high quality and affordable health services (inputs) feed into the rationing system. Therefore, health system stewardship decides to restrict some people to access health services (procedure), and this is done through using demand-side and supply-side rationing strategies (outputs). Rationing health services leads to rational utilization of health services (outcome). The impact of health services rationing depends on its effects on the equity of health and efficiency of health services. The information well-nigh reactions to health services rationing operation in each stage should be used for improvement.
A model for health services rationing
The methodology of this report benefits from the comprehensiveness and theory generated nature. The product of the synthesis is non aggregations of data, just a theory grounded in the studies included in the review. The terminal proposed conceptual model breaks down the whole picture of rationing in the health organisation into discrete stages. The model tin can be applied to all health systems. Even so, this study had a limitation. The model placed as well little emphasis on what is happening inside the health services rationing process at micro- levels, and it just provided a big picture of wellness care rationing at the macro- level of a health organization.
Determination
Developing countries such as Iran confront serious challenges in the express resource and unlimited needs. These issues bear on the effectiveness, efficiency, and equity of wellness intendance services provided to the lodge. This newspaper helps policymakers and managers empathize the necessity of wellness services rationing and its mechanisms at diverse levels. Health services rationing could improve the utilization of health services and move toward universal health coverage. The stewardship of the wellness care system should regulate and balance rationing to control the behavior of the managers, wellness care providers (supply- side- rationing), and patients (demand- side- rationing).
Acknowledgements
This study was part of a PhD thesis supported by Tehran University of Medical Sciences (TUMS). The authors would like to thank the anonymous reviewers for their valuable comments on the earlier draft of the paper.
Conflict of Interests
The authors declare that they have no competing interests.
Notes
Cite this commodity as: Keliddar I, Mosadeghrad AM, Jafari Sirizi M. Rationing in health systems: A critical review. Med J Islam Repub Iran. 2017 (27 Aug);31:47. https://doi.org/ten.14196/mjiri.31.47
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Manufactures from Medical Journal of the Islamic Republic of Iran are provided here courtesy of Iran University of Medical Sciences
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5804460/
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