16 de des. 2018

10 years of The Catalan Institute for the Evaluation of Public Policies (Ivàlua)

The Catalan Institute for the Evaluation of Public Policies (Ivàlua) was created 10 years ago. It's a public institution depending of the Government of Catalonia. The board of trustees is made up of the founding Academic Institutions (UPF), public institutions (Ministry of the Vice-presidency and of the Economy and Finance, DIBA, CTESC, CIC)

Ivalua promotes the evaluation of public policies among the Catalan public administrations, non-profit entities that pursue objectives that are of public interest and among citizens in general,

The evaluation is a tool for improving government performance and democratic accountability. To accomplish its mission, Ivàlua is guided by the following strategic lines:
  • Evaluation of public policies and advisory activities
  • Training and generation of training resources
  • Promotion and dissemination of evaluation
Ivàlua has traditionally and naturally specialised in social policies, employment policies and educational policies (in this field jointly with Fundació Jaume Bofill they are promoting the #WhatWorks in Education movement)

All the activities done during these 10 years have been done with Independence, Technical Rigor to generate evidence and with maximum Transparency at all times. In their website you can download all the Evaluations carried.


photo: Ivalua Team; Marc Balaguer, Mireia Climent, Núria Comas, Marçal Farré, Laura Kirchner, Jordi Miras. Erika Pérez, Ramon Sabes-Figuera, Jordi Sanz, Anna Segura, Federico Todeschini, Frederic Udina.

22 de nov. 2018

think big... or better not: what the evidence says to hospitals' scale?

One important source of potential inefficiency in the hospital sector relates to hospitals’ scale and scope.
  • Big Hospitals: It might make good economic sense to enlarge the size and scope of a hospital to make better use of available expertise, infrastructure and equipment. However, at some point, a hospital departs from its optimal level of efficiency and begins to exhibit diseconomies of scale. Bigger organizations are harder to manage.
  • Small Hospitals: At the other end of the scale, small hospitals might also be inefficient because the fixed infrastructural and administrative costs are shared across too small a caseload, thereby pushing up the cost of an average hospital visit.
Monica Giancotti, Annamaria Guglielmo, and Marianna Mauro did a huge systematic review from the last 50 years (1964-2014) of research "published in peer-reviewed scientific journals" to try to answer some of these questions:
  • Have mergers contributed to enhance hospitals efficiency?
  • Which is the optimal size of hospitals in terms of beds?
  • Which factors influenced the hospitals scale efficiency?
According to the evidence the main conclusions are:
  1. Studies analysed that economies of scale are present for merging hospitals. Results supported the current policy of expanding larger hospitals and restructuring/closing smaller hospitals
  2. In terms of beds, studies reported consistent evidence of economies of scale for hospitals with 200–300 beds. Diseconomies of scale can be expected to occur below 200 beds and above 600 beds.
  3. There is no evidence that the increase in size may lead to outcome improvements.
  4. Teaching activities are an important cost-driving factor,
  5. Hospitals that have a broader range of specialization are relatively more costly.
  6. According to ownership, public hospitals are more efficiently than other types.
  7. According to location, urban hospitals used resources more efficiently.
Access to the Article (free): (2017) Hospital Size: Systematic Review

photo: 1957. Chicago The LIFE Picture Collection

30 de set. 2018

public sector responsiveness

Despite the recent increase of empirical research and conceptual development in transparency and accountability this has been on the side of citizen action, looking at why and how citizens mobilise around accountability demands and at what makes their actions successful.

Comparatively, there has been much less work exploring the state side of the equation – to explain why and how public officials respond (or not) to citizen demands for accountability.

The research brief from Anuradha Joshi, Rhiannon McCluskey Why and how bureaucrats respond to citizen voice (2018) review the relevant literature on public sector responsiveness and they try to answer the other side of the equation.

Their main conclusions are:

Whether public officials respond to citizen demands depends on several sources of pressure upon them including organisational, professional, elites and citizens. With respect to citizens, the key to whether demands translate into effective pressure is the way in which public officials perceive citizens and their claims:
  • The legitimacy of their claims. Regarding legitimacy, there is a higher likelihood of eliciting responsiveness from public officials if claims relate to existing entitlements in law or policy, as well as if claims are broad and inclusive, rather than narrow.
  • The credibility of who makes the claims. Ensuring that civil society organisations are neutral in respect to political parties might strengthen their credibility. Also, the degree to which they genuinely represent marginalised groups allows for perceptive public officials to take them more seriously.
  • The level of trust between public officials and citizens. Engagement with citizens can transform public officials’ perceptions of citizens’ claims and their legitimacy. Through repeated interactions that demonstrate integrity, they can earn each other’s trust. If this trust exists, public officials will be more willing to ‘stick their neck out’ for citizens.
photo: (*) Photosolde Tanqueu totes les portes

25 de jul. 2018

Back to basics: the 7 enemies of evidence-based policy

Evidence-based policy is focused on research-based evidence to inform policymakers about “what works” and thereby produce better policy outcomes.

Graham Leicester in his 20th century article - 1999- brings us a number of factors that he suggests inhibits the adoption of the evidence based policy

What we could do against them?
  1. Recognise that these enemies are everywhere not only in the governing machine. In the universities, research centres, ... 
  2. We live in a risk society and the whole society is a laboratory. All the things that happen are real life experiences with risky technologies, not experiments conducted in laboratory controlled conditions. That means that when they go wrong—and it is axiomatic in the scientific model that they must go wrong if progress is to be made—they do so for real. There needs to be a much closer relationship therefore between government and research evidence. 
  3. The political management of the evidence in our ‘risk society’ is even more important than the evidence itself. Researches have an obligation not only to be as rigorous as possible, but also to recognise that their research has a political dimension. What they choose to investigate, how and when they present the findings are part of the risk management process. They are all agents of change.
  4. Technological advance is giving a new opportunities to get to grips with complexity. The increase in processing capacity makes all sorts of things possible in the management of complex systems. There is now a capacity for instant information gathering and analysis which makes all policy into a continuous real-time experiment. The researcher’s role will be to monitor, evaluate and adjust continuously. 
  5. We must work harder to develop better data, and true indicators of what really matters to us as a society. We need data that answers the question ‘why’ as well as ‘how much’ or ‘how many’? We need indicators which can stand proxy for the general health of society, measures of the vital signs.
It is important for researchers not only to gather the evidence to describe what is happening and how society is changing, but to provide explanations about why these changes are occurring, and then ideally to suggest things that might be done to adjust the system accordingly.

As a Citizens we want evidence-based policy NOT "policy-based evidence": where evidence is typically used as a weapon — mangled and used selectively in order to claim that it supports a politician’s predetermined position

Acces to the article (restricted): The seven enemies (1999)

photo: Game of Thrones. Jon Snow: You know nothing and Book

27 de maig 2018

are you free to speak up in your team?

I would like to show you “Freedom to Speak Up”, the review chaired by Sir Robert Francis QC. The purpose of the review published in 2015 was to provide independent advice and recommendations on creating a more open and honest reporting culture in the NHS.

The review followed on from the Public Inquiry, also chaired by Sir Robert, into the Mid Staffordshire NHS Foundation Trust which exposed unacceptable levels of patient care and a staff culture that deterred staff from raising concerns.

The 20 principles to create “an open and honest reporting culture in the NHS were:
  1. Culture of safety: Every organisation involved in providing NHS health care, should actively foster a culture of safety and learning, in which all staff feel safe to raise concerns.
  2. Culture of raising concerns: Raising concerns should be part of the normal routine business of any well-led NHS organisation.
  3. Culture free from bullying: Freedom to speak up about concerns depends on staff being able to work in a culture which is free from bullying and other oppressive behaviours. 
  4. Culture of visible leadership: All employers of NHS staff should demonstrate, through visible leadership at all levels in the organisation, that they welcome and encourage the raising of concerns by staff. 
  5. Culture of valuing staff: Employers should show that they value staff who raise concerns, and celebrate the benefits for patients and the public from the improvements made in response to the issues identified. 
  6. Culture of reflective practice: There should be opportunities for all staff to engage in regular reflection of concerns in their work. 
  7. Raising and reporting concerns: All NHS organisations should have structures to facilitate both informal and formal raising and resolution of concerns. 
  8. Investigations: When a formal concern has been raised, there should be prompt, swift, proportionate, fair and blame-free investigations to establish the facts. 
  9. Mediation and dispute resolution: Consideration should be given at an early stage to the use of expert interventions to resolve conflicts, rebuild trust or support staff who have raised concerns. 
  10. Training: Every member of staff should receive training in their organisation’s approach to raising concerns and in receiving and acting on them. 
  11. Support: All NHS organisations should ensure that there is a range of persons to whom concerns can be reported easily and without formality. They should also provide staff who raise concerns with ready access to mentoring, advocacy, advice and counselling.  
  12. Support to find alternative employment in the NHS: Where a NHS worker who has raised a concern cannot, as a result, continue in their current employment, the NHS should fulfil its moral obligation to offer support. 
  13. Transparency: All NHS organisations should be transparent in the way they exercise their responsibilities in relation to the raising of concerns, including the use of settlement agreements. 
  14. Accountability: Everyone should expect to be held accountable for adopting fair, honest and open behaviours and practices when raising or receiving and handling concerns. There should be personal and organisational accountability for:  a) poor practice in relation to encouraging the raising of concerns and responding to them; b) the victimisation of workers for making public interest disclosures; c) raising false concerns in bad faith or for personal benefit; d) acting with disrespect or other unreasonable behaviour when raising or responding to concerns; e) inappropriate use of confidentiality clauses.
  15. External Review: There should be an Independent National Officer (INO) resourced jointly by national systems regulators and oversight bodies and authorised by them to carry out the functions described in this Report, namely: a) review the handling of concerns raised by NHS workers and/or the treatment of the person or people who spoke up, where there is cause for believing that this has not been in accordance with good practice; b) advise NHS organisations to take appropriate action where they have failed to follow good practice, or advise the relevant systems regulator to make a direction to that effect; c) act as a support for Freedom to Speak Up Guardians;provide national leadership on issues relating to raising concerns by NHS workers; d) offer guidance on good practice about handling concerns;publish reports on the activities of this office.
  16. Coordinated Regulatory Action: There should be coordinated action by national systems and professional regulators to enhance the protection of NHS workers making protected disclosures and of the public interest in the proper handling of concerns.
  17. Recognition of organisations: Care Quality Commission (CQC) should recognise NHS organisations which show they have adopted and apply good practice in the support and protection of workers who raise concerns. 
  18. Students and Trainees: All principles in this report should be applied with necessary adaptations to education and training settings for students and trainees working towards a career in healthcare. 
  19. Primary Care: All principles in this report should apply with necessary adaptations in primary care.
  20. Legal protection should be enhanced 
Acces to the report: Freedom to Speak up
National Guardians Office: Web Access

photo: (*) Photosolde.
Lita Cabellut

6 de maig 2018

breaking the hospital model

The hospitals have to move from the concept of “repair shop” function to a "hub" in their community: providing social services, improving education and becoming aware of their significant economic role in communities. Hospitals have the potential to affect the economic model and the social determinants of health by leveraging their hiring, purchasing, investing, and other operational assets more intentionally.
  • HUB means an organization or institution that is a focal point in a community and helps blend together a range of stakeholders and services that improve the health and economic mobility of residents. It does not necessarily lead activities or function as the sole focal point—often it is a partner with other institutions. But through partnerships and its own services it enables organizations and people with particular skills, assets, and connections to work more effectively together to improve the neighborhood.
Some recomendations to promote a Hub:

Improve the collection, use, and sharing of data among sectors to facilitate partnerships. Hospitals as data warehouses centers for the community, assuring interoperability and data governance including detailed demographic data, and other information to build a picture of the community.

Make greater use of intermediaries. Hospitals, are often seen by many community organizations as remote yet powerful institutions, and a lack of trust arising from little or no history of partnerships. Hospitals has to build trust inside their community. Intermediaries are organizations or individuals that provide specialized skills or “connecting” functions that facilitate partnerships,

Widen the skill sets of hospital leaders and key staff. Train the leaders and the staff. The full potential of hospitals as hubs requires leaders in these institutions to have a broad vision and set of skills, to manage the delivery of less traditional services, and to work with partners and intermediaries.

Essay and error

Government has to increase the promotion of the pilot projects and programs in different communities and encourage the impact evaluation. Also, they should give more flexibility in the hospital's payment systems being less oriented to outputs and more to outcomes. Take steps to facilitate the braiding and blending of public and private resources from multiple sectors and sources.

Access to the article: Hospitals and Schools as a Hubs (2016)
Authors: Stuart Butler and Carmen Diaz

photo: Third and Colectivo Rua

2 d’abr. 2018

wrong pockets problem and pay for success

The wrong pockets problem: a situation in which we would have better outcomes if one institution or sector invested money, but because the primary benefit accrues to another institution or sector there is no incentive to make that investment. This problem describes a situation where the entity that bears the cost of implementing a practice including an evidence based best practice does not receive a commensurate benefit. Because the costs outweigh the benefits for that implementing governmental actor, projects in the public interest do not receive sufficient resources. Thus, project investment is suboptimal, and overall social welfare is in equilibrium suboptimal. Sustained inefficiency is the norm.

This wrong pockets problem particularly affects prevention programs, whether they are behavior modification programs, public health programs, structural prevention programs, or broad policy changes. Despite a growing body of empirical evidence rigorously demonstrating the effectiveness of many programs across numerous social services, advances in the implementation of evidence-based practices has been slow.

Pay for success (PFS) tries to solve the worng pockets problem: It is an innovative financing mechanism that shifts financial risk from a traditional funder—usually government—to a new investor, who provides up-front capital to scale an evidence-based social program to improve outcomes for a vulnerable population. If an independent evaluation shows that the program achieved agreed-upon outcomes, then the investment is repaid by the traditional funder. If not, the investor takes the loss.

Key drivers of the model:
  • Pay for outcomes: With PFS, the government only pays for new programs if they meet agreed-upon results, shifting away from traditional outputs-focused funding that does not account for whether a program is having the intended impact;
  • Scale evidence-based policymaking: PFS funds tests of potential social programs, amplifies the evidence-base around promising programs, and scales proven programs with a strong evidence base, allowing governments to invest in what is working;
  • Shifts risk to new actors: Setting up a new program is risky for governments, both financially and politically. PFS shifts that risk to an outside funder and bypasses typical bureaucratic challenges.
Examples of pay for success financing: The Social impact bonds (SIBs)

Some interesting articles by Urban institute:
Social impact bons in health:
photo: LIFE; Peter Stackpole (1958)

16 de març 2018

International women's day: Women on Boards

Some research and data related to women on Boards.

Why the Influence of Women on Boards Still Lags
Almost all Fortune 500 executive boards now include at least one woman (and many have two or three). Female board members have doubled since 2006, and while these gains are promising, they are slowing. Research indicates women aren’t making more rapid inroads on corporate boards because very few have been promoted to a post that would give them influence beyond their seat at the table

Authors: Kimberly A. Whitler and Deborah A. Henretta

Slow Progress for Women on Spanish Board
Women's representation on the boards of Spain's listed companies climbed by 15 percent during the year 2017. That increase brought the total to 258 female directors, who now occupy just over 19 percent of 1,347 board seats.

While significant ground was gained, the current situation still falls short of the 30 percent representation recommended by the Good Governance Code of Spain's National Securities Market Commission (CNMV) for the year 2020.

Authors: IESE and Atrevia 

Still looking for room at the top: Ten years of research on women in the workplace
In 2017, on average, women accounted for 17 percent of corporate-board members and 12 percent of executive-committee members in the top 50 listed G-20 companies. Even more worrying, perhaps, is that many people are content with the status quo. According to Women in the Workplace 2017 study, almost 50 percent of men think that it is sufficient when just one in ten senior leaders in their company is a woman. One-third of women agree.

Authors: McKinsey and Company

photo: (*) Photosolde.

24 de febr. 2018

Performance culture in hospitals: if you are good in one dimension you'll probably will be good in the rest

Nils Gutacker and Andrew Street using a sample of 95955 patients treated in 252 hospitals during  april 2009 and march 2012 on hip replacement surgery in the English National Health Service, explored the performance of the hospitals. They use four performance indicators: 1) Post operative health status (post OHS); 2) Length of stay (LOS); 3) Waiting time >18 weeks; 4) 28-day emergency readmission.

Using a multidimensional model and a dominance criteria they show us that there are a significance correlation between them.

  • Hospitals with shorter LOS also realise better post operative health status (the fast track or enhanced recovery).
  • Hospitals that have a lower proportion of patients waiting more than 18 weeks to be admitted also have a shorter LOS
  • Hospitals with better post OHS also tend to have a lower proportion of patients waiting for more 18 weeks
  • The emergency readmission within 28 days has a negative impact on health status
They also classified the hospitals in three categories: dominant (perform well), dominated (perform poorly) and non-comparable in overall performance effects: All dominant hospitals are private Independent Sector Treatment Centres (ISTCs), and all dominated hospitals are public NHS.
  • Volume outcome are not important in explaining overall performance differences between them. 
  • Dominant providers operates in a more competitive markets (in a quality competition in-price regulated market). 
  • Dominant providers have economies of scope. Good overall performance is associated with more concentrated delivery system. 
  • ISTCs don't cherry pick healthier cases to treat or “dump” complex cases back into the NHS.
Providers to perform better in one dimension have an excellent performance on another. This means that some providers have a better performance culture than others and this are better for patients.

Access to the article (pdf): Multidimensional performance assessment of public sector organisations using dominance criteria (Health Economics 2017)

photo: Light: (*) Photosolde.

11 de febr. 2018

Alan Maynard arrived at York when I was born

Alan Maynard was the greatest influencer in the field of health economics.

Alan arrived at York as a graduate student in economics in 1967, when I was born. In 1978 he created York’s MSc in health economics, and in 1983 he founded the Centre for Health Economics (CHE), where he was Director until 1995. CHE has had a major influence on health policy and the development of health economics, and continues to flourish.

He was founding editor of Health Economics, now a leading journal in the field, and later had a hand in creating two other thriving institutions: the York Health Economics Consortium and the Centre for Reviews and Dissemination.

Maynard matters. Critical thinking on health policy
This edited volume is a book with two parts:

Part One of the book consists of a set of short pieces written by Alan’s colleagues, celebrating his contributions to different areas of academic and public life. Part Two contains a selection of Alan’s work.
As Tony Culyer says you will meet seven Maynards in these pages:

  1. The health economics pioneer: cost-effectiveness studies, health service inequalities and economics of mental health, an analytical approach to health service design and management.
  2. The high class journalist: Innumerable think pieces in the Health Service Journal. Often scathing, often ironic, often right, NEVER dull.
  3. The high class academic: Founding editor of a great journal: Health Economics.
  4. The policy wonk: His impact on family doctor fund-holding, the creation of NICE, workforce contracting.
  5. The academic manager: Founding director of the Centre for Health Economics
  6. The teacher: Insightful, amusing (often hilarious) but wise and caring too. Never without a box of Kleenex for those who found the going tough.
  7. The NHS chair: York Hospital NHS Foundation Trust for 12 years, Vale of York NHS Commissioning Group 2012-15.

photos: York daffodils. Heslington Hall by W. Monkhouse (1860)