Economics and resourcing of complex healthcare systems

With rapid increases in healthcare spending over recent years, health economic evaluation might be thought to be increasing in importance to decision-makers. Such evaluations are designed to inform the efficient management of healthcare resources. However, research into health policy decisions often report, at best, moderate use of economic evaluation information, especially at the local level of administration. Little attention seems to have been given to the question of why economic evaluations have been underused and why they may yield different results in different contexts. There are many barriers to applying economic evaluations in situations which combine complexity with uncertainty. These barriers call for innovative and creative responses to economic evaluation of healthcare interventions. One response is to view economic evaluations in the context of complex adaptive systems theory. Such theory offers a conceptual framework that takes into account contextual factors, multiple input and output, multiple perspectives and uncertainty involved in healthcare interventions. This article illustrates how complexity theory can enrich and broaden policy-makers’ understanding of why economic evaluations have not always been as successful as health economists would have hoped. It argues for health economists to emphasise contextual knowledge and relativist understanding of decision contexts rather than seeking more technically sound evidence-based reviews including economic evaluations. What is known about the topic? Although it is widely acknowledged that economic evaluation, as presently constituted, is underused in its influence on allocation decisions in healthcare, previous research often ignores the ways multiple factors influence economic evaluations at several inter-related levels of the healthcare systems. Our topic is novel in its application of complexity theory to economic evaluation and attempts to show how allocation decisions reflect concern for economic efficiency in complex situations. What does this paper add? This paper shows that, although there has been a dense body of literature on the theoretical use of economic evaluations in allocation decisions around the world, evidence of successful uptake is limited. The paper shows that current economic evaluation practices oversimplify complex allocation decisions. They often ignore, marginalise or devalue the context and modifying conceptual factors that underlie explanation, meaning, sense making and values of real world contingencies. They insufficiently take notice of contextual factors and relationships in multi-objective, multi-stakeholder resource management situations. One approach is to view economic evaluations through the lens of complex adaptive systems theory, which rarely has been informed by current research. This study is innovative in its approach to using complex adaptive systems theory to investigate economic evaluation in a complex environment. The paper describes a vital step for greater acceptance of economic evaluation through understanding the underlying features of complex adaptive systems theory. It supports a shift away from equilibrium and reductionist thinking into the complex behaviour of natural and social systems. It argues for health economists to emphasise contextual knowledge and relativist understanding of the decision contexts, rather than seeking more and more ‘technically sound’ economic evaluations. What are the implications for practitioners? This study should be of interest to a broad readership, including those interested in health economics, public health policy, healthcare delivery, healthcare resource allocation and decision-making. The paper creates a dialogue about how researchers can better respond to the needs of those making resource allocation decisions in healthcare.