TY - JOUR
T1 - Advancing the application of systems thinking in health
T2 - Why cure crowds out prevention
AU - Bishai, David
AU - Paina, Ligia
AU - Li, Qingfeng
AU - Peters, David H.
AU - Hyder, Adnan A.
N1 - Funding Information:
Generous support provided by Bloomberg Philanthropies Global Road Safety Program and the Alliance for Health Policy and Systems Research. Support also provided by Future Health Systems a research policy consortium of DFID. This paper is part of the Thematic Series entitled: “Advancing the application of systems thinking in health”. The Series was coordinated by the Alliance for Health Policy and Systems research, World Health Organization. The publication of the Series and the associated capacity building and dissemination activities were carried out with the aid of a grant from the International Development Research Centre, Ottawa, Canada.
PY - 2014/6/16
Y1 - 2014/6/16
N2 - Introduction: This paper presents a system dynamics computer simulation model to illustrate unintended consequences of apparently rational allocations to curative and preventive services.Methods: A modeled population is subject to only two diseases. Disease A is a curable disease that can be shortened by curative care. Disease B is an instantly fatal but preventable disease. Curative care workers are financed by public spending and private fees to cure disease A. Non-personal, preventive services are delivered by public health workers supported solely by public spending to prevent disease B. Each type of worker tries to tilt the balance of government spending towards their interests. Their influence on the government is proportional to their accumulated revenue.Results: The model demonstrates effects on lost disability-adjusted life years and costs over the course of several epidemics of each disease. Policy interventions are tested including: i) an outside donor rationally donates extra money to each type of disease precisely in proportion to the size of epidemics of each disease; ii) lobbying is eliminated; iii) fees for personal health services are eliminated; iv) the government continually rebalances the funding for prevention by ring-fencing it to protect it from lobbying.The model exhibits a " spend more get less" equilibrium in which higher revenue by the curative sector is used to influence government allocations away from prevention towards cure. Spending more on curing disease A leads paradoxically to a higher overall disease burden of unprevented cases of disease B. This paradoxical behavior of the model can be stopped by eliminating lobbying, eliminating fees for curative services, and ring-fencing public health funding.Conclusions: We have created an artificial system as a laboratory to gain insights about the trade-offs between curative and preventive health allocations, and the effect of indicative policy interventions. The underlying dynamics of this artificial system resemble features of modern health systems where a self-perpetuating industry has grown up around disease-specific curative programs like HIV/AIDS or malaria. The model shows how the growth of curative care services can crowd both fiscal and policy space for the practice of population level prevention work, requiring dramatic interventions to overcome these trends.
AB - Introduction: This paper presents a system dynamics computer simulation model to illustrate unintended consequences of apparently rational allocations to curative and preventive services.Methods: A modeled population is subject to only two diseases. Disease A is a curable disease that can be shortened by curative care. Disease B is an instantly fatal but preventable disease. Curative care workers are financed by public spending and private fees to cure disease A. Non-personal, preventive services are delivered by public health workers supported solely by public spending to prevent disease B. Each type of worker tries to tilt the balance of government spending towards their interests. Their influence on the government is proportional to their accumulated revenue.Results: The model demonstrates effects on lost disability-adjusted life years and costs over the course of several epidemics of each disease. Policy interventions are tested including: i) an outside donor rationally donates extra money to each type of disease precisely in proportion to the size of epidemics of each disease; ii) lobbying is eliminated; iii) fees for personal health services are eliminated; iv) the government continually rebalances the funding for prevention by ring-fencing it to protect it from lobbying.The model exhibits a " spend more get less" equilibrium in which higher revenue by the curative sector is used to influence government allocations away from prevention towards cure. Spending more on curing disease A leads paradoxically to a higher overall disease burden of unprevented cases of disease B. This paradoxical behavior of the model can be stopped by eliminating lobbying, eliminating fees for curative services, and ring-fencing public health funding.Conclusions: We have created an artificial system as a laboratory to gain insights about the trade-offs between curative and preventive health allocations, and the effect of indicative policy interventions. The underlying dynamics of this artificial system resemble features of modern health systems where a self-perpetuating industry has grown up around disease-specific curative programs like HIV/AIDS or malaria. The model shows how the growth of curative care services can crowd both fiscal and policy space for the practice of population level prevention work, requiring dramatic interventions to overcome these trends.
UR - http://www.scopus.com/inward/record.url?scp=84903457221&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=84903457221&partnerID=8YFLogxK
U2 - 10.1186/1478-4505-12-28
DO - 10.1186/1478-4505-12-28
M3 - Article
C2 - 24935344
AN - SCOPUS:84903457221
SN - 1478-4505
VL - 12
JO - Health Research Policy and Systems
JF - Health Research Policy and Systems
IS - 1
M1 - 28
ER -