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Background: The value of a life is regularly monetised by government departments for informing resource allocation. Guidance documents indicate how economic evaluation should be conducted, often specifying precise values for different impacts. However, we find different values of life and health are used in analyses by departments within the same government despite commonality in desired outcomes. This creates potential inconsistencies in considering trade-offs within a broader public sector spending budget. We provide evidence to better inform the political process and to raise important issues in assessing the value of public expenditure across different sectors. Methods: Our document analysis identifies thresholds, explicitly or implicitly, as observed in government-related publications in the following public sectors: health, social care, transport, and environment. We include both demand-side and supply-side thresholds, understood as societies' and governments' willingness to pay for health gains. We look at key countries that introduced formal economic evaluation processes early on and have impacted other countries' policy development: Australia, Canada, Japan, New Zealand, the Netherlands, and the United Kingdom. We also present a framework to consider how governments allocate resources across different public services. Results: Our analysis supports that identifying and describing the Value of a Life from disparate public sector activities in a manner that facilitates comparison is theoretically meaningful. The optimal allocation of resources across sectors depends on the relative position of benefits across different attributes, weighted by the social value that society puts on them. The value of a Quality-Adjusted Life Year is generally used as a demand-side threshold by Departments of transport and environment. It exceeds those used in health, often by a large enough proportion to be a multiple thereof. Decisions made across departments are generally based on an unspecified rationing rule. Conclusions: Comparing government expenditure across different public sector departments, in terms of the value of each department outcome, is not only possible but also desirable. It is essential for an optimal resource allocation to identify the relevant social attributes and to quantify the value of these attributes for each department. [ABSTRACT FROM AUTHOR]

Background: Implementing evidence into clinical practice is a key focus of healthcare improvements to reduce unwarranted variation. Dissemination of evidence-based recommendations and knowledge brokering have emerged as potential strategies to achieve evidence implementation by influencing resource allocation decisions. The aim of this study was to determine the effectiveness of these two research implementation strategies to facilitate evidence-informed healthcare management decisions for the provision of inpatient weekend allied health services.Methods and Findings: This multicentre, single-blinded (data collection and analysis), three-group parallel cluster randomised controlled trial with concealed allocation was conducted in Australian and New Zealand hospitals between February 2018 and January 2020. Clustering and randomisation took place at the organisation level where weekend allied health staffing decisions were made (e.g., network of hospitals or single hospital). Hospital wards were nested within these decision-making structures. Three conditions were compared over a 12-month period: (1) usual practice waitlist control; (2) dissemination of written evidence-based practice recommendations; and (3) access to a webinar-based knowledge broker in addition to the recommendations. The primary outcome was the alignment of weekend allied health provision with practice recommendations at the cluster and ward levels, addressing the adoption, penetration, and fidelity to the recommendations. The secondary outcome was mean hospital length of stay at the ward level. Outcomes were collected at baseline and 12 months later. A total of 45 clusters (n = 833 wards) were randomised to either control (n = 15), recommendation (n = 16), or knowledge broker (n = 14) conditions. Four (9%) did not provide follow-up data, and no adverse events were recorded. No significant effect was found with either implementation strategy for the primary outcome at the cluster level (recommendation versus control β 18.11 [95% CI -8,721.81 to 8,758.02] p = 0.997; knowledge broker versus control β 1.24 [95% CI -6,992.60 to 6,995.07] p = 1.000; recommendation versus knowledge broker β -9.12 [95% CI -3,878.39 to 3,860.16] p = 0.996) or ward level (recommendation versus control β 0.01 [95% CI 0.74 to 0.75] p = 0.983; knowledge broker versus control β -0.12 [95% CI -0.54 to 0.30] p = 0.581; recommendation versus knowledge broker β -0.19 [-1.04 to 0.65] p = 0.651). There was no significant effect between strategies for the secondary outcome at ward level (recommendation versus control β 2.19 [95% CI -1.36 to 5.74] p = 0.219; knowledge broker versus control β -0.55 [95% CI -1.16 to 0.06] p = 0.075; recommendation versus knowledge broker β -3.75 [95% CI -8.33 to 0.82] p = 0.102). None of the control or knowledge broker clusters transitioned to partial or full alignment with the recommendations. Three (20%) of the clusters who only received the written recommendations transitioned from nonalignment to partial alignment. Limitations include underpowering at the cluster level sample due to the grouping of multiple geographically distinct hospitals to avoid contamination.Conclusions: Owing to a lack of power at the cluster level, this trial was unable to identify a difference between the knowledge broker strategy and dissemination of recommendations compared with usual practice for the promotion of evidence-informed resource allocation to inpatient weekend allied health services. Future research is needed to determine the interactions between different implementation strategies and healthcare contexts when translating evidence into healthcare practice.Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12618000029291. [ABSTRACT FROM AUTHOR]

Background: Disease surveillance and response are critical components of epidemic preparedness. The disease response, in most cases, is a set of reactive measures that follow the outcomes of the disease surveillance. Hence, timely surveillance is a prerequisite for an effective response. Methodology/principal findings: We apply epidemiological soundness criteria in combination with the Latent Influence Point Process and time-to-event models to construct a disease spread network. The network implicitly quantifies the fertility (whether a case leads to secondary cases) and reproduction (number of secondary cases per infectious case) of the cases as well as the size and generations (of the infection chain) of the outbreaks. We test our approach by applying it to historic dengue case data from Australia. Using the data, we empirically confirm that high morbidity relates positively with delay in disease response. Moreover, we identify what constitutes timely surveillance by applying various thresholds of disease response delay to the network and report their impact on case fertility, reproduction, number of generations and ultimately, outbreak size. We observe that enforcing a response delay threshold of 5 days leads to a large average reduction across all parameters (occurrence 87%, reproduction 83%, outbreak size 80% and outbreak generations 47%), whereas extending the threshold to 10 days, in comparison, significantly limits the effectiveness of the response actions. Lastly, we identify the components of the disease surveillance system that can be calibrated to achieve the identified thresholds. Conclusion: We identify practically achievable, timely surveillance thresholds (on temporal scale) that lead to an effective response and identify how they can be satisfied. Our approach can be utilized to provide guidelines on spatially and demographically targeted resource allocation for public awareness campaigns as well as to improve diagnostic abilities and turn-around times for the doctors and laboratories involved. [ABSTRACT FROM AUTHOR]

Conserving biodiversity and combating ecological hazards require cost‐effective allocation of limited resources among potential management projects. Project priorities, however, can change over time as underlying social‐ecological systems progress, novel priorities emerge, and management capabilities evolve. Thus, reallocation of ongoing investments in response to shifting priorities could improve management outcomes and address urgent demands, especially when additional funding is not available immediately. Resource reallocation, however, could incur transaction costs, require additional monitoring and reassessment, and be constrained by ongoing project commitments. Such complexities may prevent managers from considering potentially beneficial reallocation strategies, reducing long‐term effectiveness. We propose an iterative project prioritization approach, based on marginal return‐on‐investment estimation and portfolio optimization, that guides resource reallocation among ongoing and new projects. Using simulation experiments in 2 case studies, we explored how this approach can improve efficacy under varying reallocation constraints, frequencies, costs, and rates of project portfolio change. Periodic budget reallocation could enhance the management of stochastically emerging invasive weeds in Australia and thus reduce the overall risk by up to 50% compared with a static budget. Reallocation frequency and the rate of new weed incursion synergistically increased the conservation gains achieved by allowing unconstrained reallocation. Conversely, budget reallocation would not improve the International Union for Conservation of Nature conservation status of threatened Australian birds due to slow rates of transition among conservation states; extinction risk could increase if portfolio reassessment is costly. Although other project prioritization studies may recommend periodic reassessment and reallocation, our findings revealed conditions when reallocation is valuable and demonstrated a structured approach that can help conservation agencies schedule and implement iterative budget‐allocation decisions cost‐effectively. Article impact statement: Reallocating funding among conservation projects in response to shifting or emerging priorities may improve outcomes. [ABSTRACT FROM AUTHOR]

Background: Health policy and management decisions rarely reflect research evidence. As part of a broader randomized controlled study exploring implementation science strategies we examined how allied health managers respond to two distinct recommendations and the evidence that supports them. Methods: A qualitative study nested in a larger randomized controlled trial. Allied health managers across Australia and New Zealand who were responsible for weekend allied health resource allocation decisions towards the provision of inpatient service to acute general medical and surgical wards, and subacute rehabilitation wards were eligible for inclusion. Consenting participants were randomized to (1) control group or (2) implementation group 1, which received an evidence-based policy recommendation document guiding weekend allied health resource allocation decisions, or (3) implementation group 2, which received the same policy recommendation document guiding weekend allied health resource allocation decisions with support from a knowledge broker. As part of the trial, serial focus groups were conducted with a sample of over 80 allied health managers recruited to implementation group 2 only. A total 17 health services participated in serial focus groups according to their allocated randomization wave, over a 12-month study period. The primary outcome was participant perceptions and data were analysed using an inductive thematic approach with constant comparison. Thematic saturation was achieved. Results: Five key themes emerged: (1) Local data is more influential than external evidence; (2) How good is the evidence and does it apply to us? (3) It is difficult to change things; (4) Historically that is how we have done things; and (5) What if we get complaints? Conclusions: This study explored implementation of strategies to bridge gaps in evidence-informed decision-making. Results provide insight into barriers, which prevent the implementation of evidence-based practice from fully and successfully occurring, such as attitudes towards evidence, limited skills in critical appraisal, and lack of authority to promote change. In addition, strategies are needed to manage the risk of confirmation biases in decision-making processes. Trial registration This trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) (ACTRN12618000029291). Universal Trial Number (UTN): U1111-1205-2621. [ABSTRACT FROM AUTHOR]

Background: Health policy and management decisions rarely reflect research evidence. As part of a broader randomized controlled study exploring implementation science strategies we examined how allied health managers respond to two distinct recommendations and the evidence that supports them.Methods: A qualitative study nested in a larger randomized controlled trial. Allied health managers across Australia and New Zealand who were responsible for weekend allied health resource allocation decisions towards the provision of inpatient service to acute general medical and surgical wards, and subacute rehabilitation wards were eligible for inclusion. Consenting participants were randomized to (1) control group or (2) implementation group 1, which received an evidence-based policy recommendation document guiding weekend allied health resource allocation decisions, or (3) implementation group 2, which received the same policy recommendation document guiding weekend allied health resource allocation decisions with support from a knowledge broker. As part of the trial, serial focus groups were conducted with a sample of over 80 allied health managers recruited to implementation group 2 only. A total 17 health services participated in serial focus groups according to their allocated randomization wave, over a 12-month study period. The primary outcome was participant perceptions and data were analysed using an inductive thematic approach with constant comparison. Thematic saturation was achieved.Results: Five key themes emerged: (1) Local data is more influential than external evidence; (2) How good is the evidence and does it apply to us? (3) It is difficult to change things; (4) Historically that is how we have done things; and (5) What if we get complaints?Conclusions: This study explored implementation of strategies to bridge gaps in evidence-informed decision-making. Results provide insight into barriers, which prevent the implementation of evidence-based practice from fully and successfully occurring, such as attitudes towards evidence, limited skills in critical appraisal, and lack of authority to promote change. In addition, strategies are needed to manage the risk of confirmation biases in decision-making processes. Trial registration This trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) (ACTRN12618000029291). Universal Trial Number (UTN): U1111-1205-2621. [ABSTRACT FROM AUTHOR]

Background: Matching survival of a donor kidney with that of the recipient (longevity matching), is used in some kidney allocation systems to maximize graft-life years. It is not part of the allocation algorithm for Australia. Given the growing evidence of survival benefit due to longevity matching based allocation algorithms, development of a similar kidney allocation system for Australia is currently underway. The aim of this research is to estimate the impact that changes to costs and health outcomes arising from 'longevity matching' on the Australian healthcare system.Methods: A decision analytic model to estimate cost-effectiveness was developed using a Markov process. Four plausible competing allocation options were compared to the current kidney allocation practice. Models were simulated in one-year cycles for a 20-year time horizon, with transitions through distinct health states relevant to the kidney recipient. Willingness to pay was considered as AUD 28000.Results: Base case analysis indicated that allocating the worst 20% of Kidney Donor Risk Index (KDRI) donor kidneys to the worst 20% of estimated post-transplant survival (EPTS) recipients (option 2) and allocating the oldest 25% of donor kidneys to the oldest 25% of recipients are both cost saving and more effective compared to the current Australian allocation practice. Option 2, returned the lowest costs, greatest health benefits and largest gain to net monetary benefits (NMB). Allocating the best 20% of KDRI donor kidneys to the best 20% of EPTS recipients had the lowest expected incremental NMB.Conclusion: Of the four longevity-based kidney allocation practices considered, transplanting the lowest quality kidneys to the worst kidney recipients (option 2), was estimated to return the best value for money for the Australian health system. [ABSTRACT FROM AUTHOR]

Introduction: The objective was to compare the diagnostic accuracy of the decision tree analysis prediction model P1, which incorporates the human chorionic gonadotropin (hCG) ratio (hCG 48 hours/hCG 0 hour), and risk prediction model M4 in the management of women with pregnancy of unknown location (PUL).Material and Methods: A retrospective diagnostic accuracy study was performed on PUL data collected between August 2011 and September 2018. Women with a PUL were prospectively managed according to the P1 prediction model, which utilizes the hCG ratio and, if necessary, a day (D) 7 hCG. We compared the performance of P1 with the M4 model, a logistic regression mathematical model using initial hCG and hCG ratio, to classify PULs as low risk (failed PUL [failed] or intrauterine pregnancy) or high risk (ectopic pregnancy or persistent PUL). The reference standard was defined as the final PUL outcome.Results: Transvaginal ultrasound was done in 3847 consecutive women for early pregnancy complications, 437 (11.3%) of whom were classified as PUL. Final analysis comprised 413 cases with complete data. Final PUL clinical outcomes were: 247 (59.8%) failed PUL, 94 (22.7%) intrauterine pregnancy, 49 (11.8%) ectopic pregnancy and 23 (5.5%) persistent PUL. The sensitivity of P1 and M4 in predicting high-risk PUL were 81.9% (95% confidence interval [CI] 71.1-90.0) and 80.6% (95% CI 69.5-88.9), respectively. The specificities were 74.5% (95% CI 69.5-79.1) and 75.6% (95% CI 70.7-80.1), respectively.Conclusions: P1 and M4 performed similarly with respect to diagnostic accuracy in predicting PUL outcome. P1 needs to be externally validated. [ABSTRACT FROM AUTHOR]

Background Clinical frailty scales (CFS) predict hospital-related outcomes. Frailty is more common in areas of higher socioeconomic disadvantage, but no studies exclusively report on the impact of CFS on hospital-related outcomes in areas of known socioeconomic disadvantage. Aims To evaluate the association of the CFS with hospital-related outcomes. Design Retrospective observational study in a community hospital within a disadvantaged area in Australia (Social Economic Index for Areas = 0.1%). Methods The CFS was used in the emergency department (ED) for people aged ≥ 75 years. Frailty was defined as a score of ≥4. Associations between the CFS and mortality, admission rates, ED presentations and length of stay (LOS) were analysed using regression analyses. Results Between 11 July 2017 and 31 March 2018, there were 5151 ED presentations involving 3258 patients aged ≥ 75 years. Frail persons were significantly more likely to be older, represent to the ED and have delirium compared with non-frail persons. CFS was independently associated with 28-day mortality, with odds of mortality increasing by 1.5 times per unit increase in CFS (95% CI: 1.3–1.7). Frail persons with CFS 4–6 were more likely to be admitted (OR: 1.2; 95% CI: 1.0–1.5), have higher geometric mean LOS (1.43; 95% CI 1.15-1.77 days) and higher rates of ED presentations (IRR: 1.12; 95% CI 1.04–1.21) compared with non-frail persons. Conclusions The CFS predicts community hospital-related outcomes in frail persons within a socioeconomic disadvantage area. Future intervention and allocation of resources could consider focusing on CFS 4–6 as a priority for frail persons within a community hospital setting. [ABSTRACT FROM AUTHOR]

Introduction: The detection of harmful alcohol use and the delivery of brief advice in primary care are less than optimal. Given limited health care resources, deciding where best to allocate funding to optimize health outcomes is imperative. A simple data-based tool could be useful when access to specialist health economic advice is unavailable. This study aimed to examine the utility of a simple data-based calculator to facilitate priority setting in general practice for reducing alcohol-related harm.Methods: A simple algorithm was developed within Microsoft Excel to allow comparison of hypothetical intervention scenarios that aimed to increase detection and brief advice for harmful alcohol use in general practice. The calculator accommodated varying implementation costs, size of effect and reach for each scenario created. The incremental costs of the intervention scenarios, the incremental number of successes (i.e. abstinence or drinking at safe levels) and the incremental costs-effectiveness ratio (ICER) were calculated for each hypothetical scenario and compared with a usual care scenario.Results: In the hypothetical scenarios modelled, increasing both the detection of harmful alcohol consumption and the provision of brief advice produced the greatest number of incremental successes above baseline. Increasing detection alone produced fewer incremental successes but was the most cost-effective approach, as indicated by the lowest ICER.Discussion: The data-based calculator provides a simple method of exploring reach and cost-effectiveness outcomes without the need for any specific skills. Although this approach has limitations, the calculator can be used by decision makers to guide intervention planning. [ABSTRACT FROM AUTHOR]

Pyrocumulonimbus (pyroCb) wildfires cause devastation in many regions globally. Given that fire‐atmosphere coupling is associated with pyroCbs, future changes in coincident high index values of atmospheric instability and dryness (C‐Haines) and near‐surface fire weather are assessed for southeastern Australia using a regional climate projection ensemble. We show that observed pyroCb events occur predominantly on forested, rugged landscapes during extreme C‐Haines conditions, but over a wide range of surface fire weather conditions. Statistically significant increases in the number of days where both C‐Haines and near‐surface fire weather values are conducive to pyroCb development are projected across southeastern Australia, predominantly for November (spring), and less strongly for December (summer) in 2060‐2079 versus 1990‐2009, with future C‐Haines increases linked to increased 850‐hPa dewpoint depression. The increased future occurrence of conditions conducive to pyroCb development and their extension into spring have implications for mitigating these dangerous wildfires and urbanizing fire‐prone landscapes. Plain Language Summary: Pyrocumulonimbus wildfires (pyroCb) are extreme wildfires. They involve a coupling between the fire and the atmosphere, which drives dangerous fire conditions that result in fatalities and considerable damage. Climate change could amplify the conditions associated with pyroCb development. We use high‐resolution regional climate projection data to assess future changes in the risk of pyroCb occurrence for southeastern Australia. We demonstrate that atmospheric instability and dryness is a better indicator of pyroCb development than surface fire weather conditions, with topographic roughness and vegetation type also playing roles. Coincidences of high index values of atmospheric conditions (tropospheric instability and dryness) and surface fire weather conditions (temperature, humidity, wind speed, and precipitation) associated with pyroCb development are projected to increase in frequency predominantly for November (spring) in 2060‐2079 versus 1990‐2009, but less so for summer. The extension of the season conducive to pyroCbs into spring is important because Australian pyroCbs are typically summer phenomena. A change in seasonality has implications for resource allocations by fire agencies. Projected changes in the conditions conducive to pyroCbs are primarily associated with increased dryness at 1.5‐km altitude. These findings are relevant to the mitigation of pyroCbs, and they have implications for continued urban expansion on fire‐prone landscapes. Key Points: Significant increases in the frequency of conditions conducive to pyrocumulonimbus fires occur in November (Spring) 2060‐2079 versus 1990‐2009Atmospheric instability and dryness are better indicators of pyrocumulonimbus fire development than surface fire weatherLocations in southeast Australia where these changes are projected to occur are identified [ABSTRACT FROM AUTHOR]

Background: This is the seventh in a series of papers reporting Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The SHARE Program was a systematic, integrated, evidence-based program for resource allocation within a large Australian health service. It aimed to facilitate proactive use of evidence from research and local data; evidence-based decision-making for resource allocation including disinvestment; and development, implementation and evaluation of disinvestment projects. From the literature and responses of local stakeholders it was clear that provision of expertise and education, training and support of health service staff would be required to achieve these aims. Four support services were proposed. This paper is a detailed case report of the development, implementation and evaluation of a Data Service, Capacity Building Service and Project Support Service. An Evidence Service is reported separately.Methods: Literature reviews, surveys, interviews, consultation and workshops were used to capture and process the relevant information. Existing theoretical frameworks were adapted for evaluation and explication of processes and outcomes.Results: Surveys and interviews identified current practice in use of evidence in decision-making, implementation and evaluation; staff needs for evidence-based practice; nature, type and availability of local health service data; and preferred formats for education and training. The Capacity Building and Project Support Services were successful in achieving short term objectives; but long term outcomes were not evaluated due to reduced funding. The Data Service was not implemented at all. Factors influencing the processes and outcomes are discussed.Conclusion: Health service staff need access to education, training, expertise and support to enable evidence-based decision-making and to implement and evaluate the changes arising from those decisions. Three support services were proposed based on research evidence and local findings. Local factors, some unanticipated and some unavoidable, were the main barriers to successful implementation. All three proposed support services hold promise as facilitators of EBP in the local healthcare setting. The findings from this study will inform further exploration. [ABSTRACT FROM AUTHOR]

Background: This is the fifth in a series of papers reporting Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. This paper synthesises the findings from Phase One of the SHARE Program and presents a model to be implemented and evaluated in Phase Two. Monash Health, a large healthcare network in Melbourne Australia, sought to establish an organisation-wide systematic evidence-based program for disinvestment. In the absence of guidance from the literature, the Centre for Clinical Effectiveness, an in-house 'Evidence Based Practice Support Unit', was asked to explore concepts and practices related to disinvestment, consider the implications for a local health service and identify potential settings and methods for decision-making.Methods: Mixed methods were used to capture the relevant information. These included literature reviews; online questionnaire, interviews and structured workshops with a range of stakeholders; and consultation with experts in disinvestment, health economics and health program evaluation. Using the principles of evidence-based change, the project team worked with health service staff, consumers and external experts to synthesise the findings from published literature and local research and develop proposals, frameworks and plans.Results: Multiple influencing factors were extracted from these findings. The implications were both positive and negative and addressed aspects of the internal and external environments, human factors, empirical decision-making, and practical applications. These factors were considered in establishment of the new program; decisions reached through consultation with stakeholders were used to define four program components, their aims and objectives, relationships between components, principles that underpin the program, implementation and evaluation plans, and preconditions for success and sustainability. The components were Systems and processes, Disinvestment projects, Support services, and Program evaluation and research. A model for a systematic approach to evidence-based resource allocation in a local health service was developed.Conclusion: A robust evidence-based investigation of the research literature and local knowledge with a range of stakeholders resulted in rich information with strong consistent messages. At the completion of Phase One, synthesis of the findings enabled development of frameworks and plans and all preconditions for exploration of the four main aims in Phase Two were met. [ABSTRACT FROM AUTHOR]

Background: This is the third in a series of papers reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. Leaders in a large Australian health service planned to establish an organisation-wide, systematic, integrated, evidence-based approach to disinvestment. In order to introduce new systems and processes for disinvestment into existing decision-making infrastructure, we aimed to understand where, how and by whom resource allocation decisions were made, implemented and evaluated. We also sought the knowledge and experience of staff regarding previous disinvestment activities.Methods: Structured interviews, workshops and document analysis were used to collect information from multiple sources in an environmental scan of decision-making systems and processes. Findings were synthesised using a theoretical framework.Results: Sixty-eight respondents participated in interviews and workshops. Eight components in the process of resource allocation were identified: Governance, Administration, Stakeholder engagement, Resources, Decision-making, Implementation, Evaluation and, where appropriate, Reinvestment of savings. Elements of structure and practice for each component are described and a new framework was developed to capture the relationships between them. A range of decision-makers, decision-making settings, type and scope of decisions, criteria used, and strengths, weaknesses, barriers and enablers are outlined. The term 'disinvestment' was not used in health service decision-making. Previous projects that involved removal, reduction or restriction of current practices were driven by quality and safety issues, evidence-based practice or a need to find resource savings and not by initiatives where the primary aim was to disinvest. Measuring resource savings is difficult, in some situations impossible. Savings are often only theoretical as resources released may be utilised immediately by patients waiting for beds, clinic appointments or surgery. Decision-making systems and processes for resource allocation are more complex than assumed in previous studies.Conclusion: There is a wide range of decision-makers, settings, scope and type of decisions, and criteria used for allocating resources within a single institution. To our knowledge, this is the first paper to report this level of detail and to introduce eight components of the resource allocation process identified within a local health service. [ABSTRACT FROM AUTHOR]

This is the first in a series of papers reporting Sustainability in Health care by Allocating Resources Effectively (SHARE). The SHARE Program is an investigation of concepts, opportunities, methods and implications for evidence-based investment and disinvestment in health technologies and clinical practices in a local healthcare setting. The papers in this series are targeted at clinicians, managers, policy makers, health service researchers and implementation scientists working in this context. This paper presents an overview of the organisation-wide, systematic, integrated, evidence-based approach taken by one Australian healthcare network and provides an introduction and guide to the suite of papers reporting the experiences and outcomes. [ABSTRACT FROM AUTHOR]

Background: Technological advances in clinical data capturing and storage systems have led to recent attempts at disease surveillance and region specific population health planning through regularly collected primary care administrative clinical data. However the accuracy and comprehensiveness of primary care health records remain questionable. Methods: We aimed to explore the perceptions and experiences of general practice staff in maintaining accurate patient health data within clinical software used in primary care settings of regional NSW. Focus groups were conducted with general practitioners, practice nurses and practice administrative staff from 17 practices in the Illawarra-Shoalhaven region of the state of New South Wales (NSW) in Australia that had participated in the Sentinel Practices Data Sourcing (SPDS) project - a general practice based chronic disease surveillance and data quality improvement study. A total of 25 respondents that included 12 general practitioners (GPs) and 13 practice staff participated in the 6 focus groups. Focus groups were audio-recorded and transcribed verbatim. Thematic analysis of the data was undertaken. Results: Five key themes emerged from the data. Firstly, the theme of resourcing data management raised issues of time constraints, the lack of a dedicated data management role and the importance of multidisciplinary involvement, including a data champion. The need for incentives was identified as being important to motivate ongoing commitment to maintaining data quality. However, quality of software packages, including coding issues and software limitations and information technology skills were seen as key barriers. The final theme provided insight into the lessons learnt from the project and the increased awareness of the importance of data quality amongst practice staff. Conclusion: The move towards electronic methods of maintaining general practice patient records offers significant potential benefits in terms of both patient care and monitoring of health status and health needs within the community. However, this study has reinforced the importance of human factors in the maintenance of such datasets. To achieve optimal benefits of electronic health and medical records for patient care and for population health planning purposes, it is extremely essential to address the barriers that clinicians and other staff face in maintaining complete and correct primary care patient electronic health and medical information. [ABSTRACT FROM AUTHOR]

Background: Antibiotic treatment options for common infections are diminishing due to the proliferation of antimicrobial resistance (AMR). The impact of Antimicrobial Stewardship (AMS) programs seeking to preserve viable antibiotic drugs by governing their use in hospitals has hitherto been limited. Pharmacists have been delegated a critical role in antibiotic governance in AMS teams within hospitals but the experience of pharmacists in influencing antibiotic use has received limited attention. In this study we explore the experiences of pharmacists in antibiotic decision-making in two Australian hospitals.Methods: We conducted 19 semi-structured interviews to explore hospital-based pharmacists' perceptions and experiences of antibiotic use and governance. The analysis was conducted with NVivo10 software, utilising the framework approach.Results: Three major themes emerged in the pharmacist interviews including (1) the responsibilities of pharmacy in optimising antibiotic use and the interprofessional challenges therein; (2) the importance of antibiotic streamlining and the constraints placed on pharmacists in achieving this; and (3) the potential, but often under-utilised expertise, pharmacists bring to antibiotic optimisation.Conclusions: Pharmacists have a critical role in AMS teams but their capacity to enact change is limited by entrenched interprofessional dynamics. Identifying how hospital pharmacy's antibiotic gatekeeping is embedded in the interprofessional nature of clinical decision-making and limited by organisational environment has important implications for the implementation of hospital policies seeking to streamline antibiotic use. Resource constraints (i.e. time limitation and task prioritisation) in particular limit the capacity of pharmacists to overcome the interprofessional barriers through development of stronger collaborative relationships. The results of this study suggest that to enact change in antibiotic use in hospitals, pharmacists must be supported in their negotiations with doctors, have increased presence on hospital wards, and must be given opportunities to pass on specialist knowledge within multidisciplinary clinical teams. [ABSTRACT FROM AUTHOR]

Introduction: Australians in rural and remote areas experience poorer health status compared with many metropolitan residents, due partly to inequitable access to primary health care (PHC) services. Building on recent research that identified PHC services which all Australians should be able to access regardless of where they live, this paper aims to define the population thresholds governing which PHC services would be best provided by a resident health worker, and to outline attendant implementation issues. Methods: A Delphi method comprising panellists with expertise in rural, remote and/or Indigenous PHC was used. Five population thresholds reflecting Australia's diverse rural and remote geography were devised. Panellists participated in two electronic surveys. Using a Likert scale, they were asked at what population threshold each PHC service should be provided by a resident health worker. A follow-up focus group identified important underlying principles which guided the consensus process. Results: Response rates were high. The population thresholds for core PHC services provided by a resident worker were less in remote communities compared with rural communities. For example, the population threshold for 'care of the sick and injured,' was ≤ 100 for remote compared with 101-500 for rural communities. For 'mental health', 'maternal/ child health', 'sexual health' and 'public health' services in remote communities the population threshold was 101-500, compared to 501-1000 for rural communities. Principles underpinning implementation included the fundamental importance of equity; consideration of social determinants of health; flexibility, effective expenditure of resources, tailoring services to ensure consumer acceptability, prioritising services according to need, and providing services as close to home as possible. Conclusion: This research can assist policy makers and service planners to determine the population thresholds at which PHC services should be delivered by a resident health worker, to allocate resources and provide services more equitably, and inform consumers about PHC services they can reasonably expect to access in their community. This framework assists in developing a systematic approach to strategies seeking to address existing rural-urban health workforce maldistribution, including the training of generalists as opposed to specialists, and providing necessary infrastructure in communities most in need. [ABSTRACT FROM AUTHOR]

This study explores relationships between spiritual resources, job resources, and work engagement among 496 Australian religious workers at three time points over a period of 18 months. Drawing on the Conservation of Resources theory and Job Demands-Resources model, spiritual resources are conceptualized as a distinct category of personal resources significant for this occupational cohort. Results of structural equation modelling analysis did not support the hypothesis of reciprocal relationships between spiritual and job resources and work engagement. Instead, spiritual resources had a positive cross-lagged effect on work engagement, and work engagement had a positive cross-lagged effect on job resources. When the high stability of spiritual resources over time was accounted for, work engagement had a negative indirect effect on spiritual resources over time mediated by a negative effect of job resources on spiritual resources (suppression effect). Spiritual resources emerge as an important category of antecedent resources for work engagement among religious workers. However, it appears that motivated religious workers may prioritize energy investments into increasing job resources at the expense of maintaining and developing spiritual resources. Practically, this research provides evidence for the promotion of initiatives to foster spiritual resources that enhance resilience and well-being among religious workers. Practitioner points Spiritual resources are an under-researched category of personal resources that positively predict work engagement among religious workers., Religious organizations and individual religious workers need to invest energy in the ongoing development of spiritual resources to maintain motivation for this unique type of work., Managers need to be aware that a focus on enhancing job resources and work engagement can have deleterious effects on religious workers' spiritual resources and so threaten their ongoing work engagement. [ABSTRACT FROM AUTHOR]

Abstract: Environmental policy instruments generate transaction costs to public and private parties. There is a growing literature reporting on the size of transaction costs produced by environmental policy instruments. This paper extends that literature through an analysis of the factors that influence transaction costs in environmental policy and how this influence occurs. The theory based factors that influence transaction costs are categorised as: 1) transaction characteristics; 2) transactor characteristics; 3) nature of the institutional environment; and 4) nature of the institutional arrangements. We examined how these factors influenced transaction costs through the analysis of two Australian-based development offset schemes with different policy designs. We found evidence of all four theory-based categories of influence in the policy case studies. The degree of influence and how each factor influenced transaction costs varies across the two policies and between parties. Policy design as a component of the institutional environment had a particularly large bearing on transaction costs of offset buyers and the policy administrator. An important contribution to transaction cost theory assumes the institutional environment as given. [Copyright &y& Elsevier]

Abstract: This study employs a comparative analysis of the transaction costs of alternative policy instruments. The institutional approach to the allocation of resources is emerging to supplement traditional analyses of market and government failures. The causes of these failures are many, but often point to high transaction costs that result largely from institutional impediments. Effective institutions can help reduce transaction costs through more effective signals and incentives, including information generation, to help markets function more efficiently and policies to be delivered more successfully. The study, which contributes to transaction costs measurement, finds that the magnitudes and types of transaction costs associated with setting up and implementing three greenhouse gas reduction policy programs in Australia are substantial and different. The estimated transaction costs of the Tradable Permit and Fee System are relatively high compared to those of the mandatory Fuel Label Program and the voluntary Fuel Efficiency Program, which supports the view that market-based policies can also be costly to deliver. Notwithstanding, transaction costs have frequently been ignored in cost–benefit analyses. It is concluded that transaction costs need to be considered alongside other costs and benefits in the assessment of policies. [Copyright &y& Elsevier]

Background: Health economics is increasingly used to inform resource allocation decision-making, however, there is comparatively little evidence relevant to minority groups. In part, this is due to lack of cost and effectiveness data specific to these groups upon which economic evaluations can be based. Consequently, resource allocation decisions often rely on mainstream evidence which may not be representative, resulting in inequitable funding decisions. This paper describes a method to overcome this deficiency for Australia's Indigenous population. A template has been developed which can adapt mainstream health intervention data to the Indigenous setting. Methods: The 'Indigenous Health Service Delivery Template' has been constructed using mixed methods, which include literature review, stakeholder discussions and key informant interviews. The template quantifies the differences in intervention delivery between best practice primary health care for the Indigenous population via Aboriginal Community Controlled Health Services (ACCHSs), and mainstream general practitioner (GP) practices. Differences in costs and outcomes have been identified, measured and valued. This template can then be used to adapt mainstream health intervention data to allow its economic evaluation as if delivered from an ACCHS. Results: The template indicates that more resources are required in the delivery of health interventions via ACCHSs, due to their comprehensive nature. As a result, the costs of such interventions are greater, however this is accompanied by greater benefits due to improved health service access. In the example case of the polypill intervention, 58% more costs were involved in delivery via ACCHSs, with 50% more benefits. Cost-effectiveness ratios were also altered accordingly. Conclusions: The Indigenous Health Service Delivery Template reveals significant differences in the way health interventions are delivered from ACCHSs compared to mainstream GP practices. It is important that these differences are included in the conduct of economic evaluations to ensure results are relevant to Indigenous Australians. Similar techniques would be generalisable to other disadvantaged minority populations. This will allow resource allocation decision-makers access to economic evidence that more accurately represents the needs and context of disadvantaged groups, which is particularly important if addressing health inequities is a stated goal. [ABSTRACT FROM AUTHOR]

This paper describes a decision support model for allocating financial resources amongst multiple user groups in environmental management problems. The model is based on the multiple criteria analysis (MCA) method of compromise programming. It was used to inform the allocation of Natural Heritage Trust funds across 14 regions in Queensland, Australia. The model targets funding to those regions with greater natural resource management needs. Need is determined by 19 weighted criteria relating to natural resource assets and threats. The model was accepted by the Australian Government, Queensland Government and regional groups as an appropriate means for allocating program funds; first in 2005 and then again, with improvements, in 2007. This paper shows that an MCA model can improve the transparency, auditability and acceptance of allocation decisions which would otherwise be heavily politicised. [Copyright &y& Elsevier]

Plant defense theories predict that relatively resource-rich environments (those with more fertile soil) will support a greater abundance of plants with nitrogen-based chemical defense, but this has yet to be adequately tested. We tested this prediction by measuring the diversity and contribution to total biomass of cyanogenic plants (those that release hydrogen cyanide from endogenous cyanide-containing compounds) in the Australian tropical rain forest. We examined 401 species in thirty 200-m² plots, six at each of five sites, for cyanogenesis. In upland/highland rain forest, two pairs of sites similar in rainfall and altitude, but differing in soil nutrients, were selected, as well as one site in lowland rain forest. Sites differed markedly in species composition and foliar N was positively related to soil fertility. Holding altitude constant, we did not detect significant differences in the proportion of cyanogenic species with soil fertility, nor did we consistently detect significant increases in the contribution of cyanogenic species to total biomass on higher nutrient sites. Thus we found no clear evidence that soil fertility affects the distribution and prevalence of species investing in a constitutive N-based defense at the community level. [ABSTRACT FROM AUTHOR]

Allocating money for species conservation on the basis of threatened species listings is not the most cost-effective way of promoting recovery or minimizing extinction rates. Using ecological and social factors in addition to threat categories, we designed a decision-support process to assist policy makers in their allocation of resources for the management of native wildlife and to clarify the considerations leading to a priority listing. Each species is scored on three criteria at the scale of the relevant jurisdiction: (1) threat category, (2) consequences of extinction, and (3) potential for successful recovery. This approach provides opportunity for independent input by policy makers and other stakeholders (who weight the relative importance of the criteria) and scientists (who score the species against the criteria). Thus the process explicitly separates societal values from the technical aspects of the decision-making process while acknowledging the legitimacy of both inputs. We applied our technique to two Australian case studies at different spatial scales: the frogs of Queensland (1,728,000 km2; 116 species) and the mammals of the Wet Tropics bioregion (18,500 km2; 96 species). We identified 7 frog and 10 mammal species as priorities for conservation. The frogs included 1 of the 9 species classified as endangered under Queensland legislation, 3 of the 10 species classified as vulnerable, 2 of the 22 species classified as rare, and 1 of the 75 species classified as least concern. The mammals identified included 3 of the 6 species classified as endangered, 1 of the 4 species classified as vulnerable, 5 of the 11 species classified as rare, and 1 of the 75 species classified as least concern. The methods we used to identify species were robust to comparisons across the two taxonomic groups. We concluded that (1) our process facilitates comparisons of data required to make transparent, cost-effective, and strategic management decisions across taxonomic groups and (2) the process should be used to short-list species for further discussion rather than for allocating resources per se. [ABSTRACT FROM AUTHOR]

Tobacco is the main cause of preventable mortality among Aboriginal and Torres Strait Islander Australians. The article focuses on the mortality and morbidity rates from conditions related to tobacco in Aboriginal and Torres Strait, Australia. It also describes the cultural, historical and political factors leading to the high prevalence of smoking among Aboriginal and Torres Strait Islander people. It outlines and discusses intervention efforts undertaken so far and consider their merits and weaknesses, paying particular attention to resource allocation issues. Finally, it considers priorities for future programme delivery that would be most likely to result in reduced tobacco use among this population.

Examines the consequences of introducing trade and allocating water for environmental use in the Border Rivers region of Queensland. Estimation of the extractive demand for water in the region; Evaluation of the differences between extractive and environmental flow regimes; Consequences of decreasing the announced allocation.

Patients have a right to refuse medical treatment. But what should happen after a patient has refused recommended treatment? In many cases, patients receive alternative forms of treatment. These forms of care may be less cost-effective. Does respect for autonomy extend to providing these alternatives? How for does justice constrain autonomy? I begin by providing three arguments that such alternatives should not be offered to those who refuse treatment. I argue that the best argument which refusers can appeal to is based on the egalitarian principle of equality of outcome. However, this principle does not ultimately support a right to less cost-effective alternatives. I focus on Jehovah's Witnesses refusing blood and requesting alternative treatments. However, the point applies to many patients who refuse cost-effective medical care. [ABSTRACT FROM AUTHOR]

The article focuses on the Australian Living Standards Study of 5000 families in 12 rural and urban areas of Australia. The survey covered a host of issues associated with living standards and the contribution that service provision makes to family well-being. The study showed that the middle urban areas had a lower problem profile than other geographic areas in the study, as far as providers and parents were concerned, and the two outer urban areas of Campbell town and Elizabeth/Munno-Para featured among the top areas in many of the issues mentioned. In a needs-based allocation of resources, the funding of services for marital problems might therefore need a slightly different geographic formula from the allocation for child abuse, if the responses of providers are anything to go by. Those differences may not be major, but they do ensure that we cannot assume that outer areas are significantly more disadvantaged than other urban areas in all issues. They also indicate that problems can vary across the rural sector, sometimes mire roring urban trends but at other times not.

This study examines the carbon capture, utilization, and storage research performance of 31 countries from the knowledge spillover perspective. Knowledge spillover efficiency—operationally defined as the level of academic and practical influence of research and development outputs—is measured using the output-oriented constant return to scale, variable returns to scale, and super efficiency models using data envelopment analysis. We consider the number of patents and research articles from 2000 to 2016 as input variables, while the number of research article citations, patent citations, and registration of triadic patent families as of 2017 are the three output variables. The samples for measuring efficiency were obtained by collecting patents and research articles using Wintelips and Scopus database, respectively. The results of the super-efficiency data envelopment analysis were used to examine each country's position in terms of knowledge spillover. More specifically, the US, European countries, Japan, Australia, and New Zealand showed relatively high efficiency, which might be characteristic of their R&D policies and environmental factors. Moreover, the returns to scale analysis provide implications for R&D resource allocation as to whether to encourage the quantitative or qualitative expansion of R&D outputs to improve efficiency. This study can provide meaningful information to policymakers to identify ex post R&D activities and planning. • Examines carbon capture, utilization, and storage (CCUS) technology knowledge spillover efficiency. • Employs data envelopment analysis (DEA) methods to compare countries' knowledge spillover efficiency. • The US, European countries, Japan, Australia, and New Zealand show relatively high knowledge spillover efficiency. • Returns to scale (RTS) analysis provides implications for R&D resource allocation. • Provides meaningful information to policymakers to determine CCUS R&D strategies. [ABSTRACT FROM AUTHOR]

As with most governments worldwide, Australian governments list threatened species and proffer commitments to recovering them. Yet most of Australia's imperiled species continue to decline or go extinct and a contributing cause is inadequate investment in conservation management. However, this has been difficult to evaluate because the extent of funding committed to such recovery in Australia, like in many nations, is opaque. Here, by collating disparate published budget figures of Australian governments, we show that annual spending on targeted threatened species recovery is around U.S.$92m (AU$122m) which is around one tenth of that spent by the U.S. endangered species recovery program, and about 15% of what is needed to avoid extinctions and recover threatened species. Our approach to estimating funding needs for species recovery could be applied in any jurisdiction and could be scaled up to calculate what is needed to achieve international goals for ending the species extinction crisis. [ABSTRACT FROM AUTHOR]

Background: Physical inactivity is a global public health problem, partly due to urbanization and increased use of passive modes of transport such as private motor vehicles. Improving accessibility to public transport could be an effective policy for Governments to promote equity and efficiency within transportation systems, increase population levels of physical activity and reduce the negative externalities of motor vehicle use. Quantitative estimates of the health impacts of improvements to public transport accessibility may be useful for resource allocation and priority-setting, however few studies have been published to inform this decision-making. This paper aims to estimate the physical activity, obesity, injury, health and healthcare cost-saving outcomes of scenario-based improvements to public transport accessibility in Melbourne, Australia. Methods: Baseline and two hypothetical future scenario estimates of improved public transport accessibility for Melbourne, Australia, were derived using a spatial planning and decision tool designed to simulate accessibility performance (the Spatial Network Analysis for Multimodal Urban Transport Systems (SNAMUTS)). Public transport related physical activity was quantified by strata of age group and sex from Melbourne travel survey data (VISTA survey) and used with the SNAMUTS Composite Index to estimate input data for health impact modelling for the Melbourne population aged 20–74 years. A proportional multi-state, multiple cohort lifetable Markov model quantified the potential health gains and healthcare cost-savings from estimated changes in physical activity, body weight and injuries related to walking to access/egress public transport under two scenarios: (S1) public transport accessibility under current policy directions, and (S2) multi-directional, high-frequency network improvements. Results: Multi-directional, high-frequency improvements to the public transport network (S2) resulted in significantly greater health and economic gains than current policy directions (S1) in relation to physical activity (mean 6.4 more MET minutes/week), body weight (mean 0.05 kg differential), health-adjusted life years gained (absolute difference of 4878 HALYs gained) and healthcare cost-savings (absolute difference of AUD43M), as compared to business as usual under both scenarios (n = 2,832,241 adults, over the lifecourse). Conclusions: Based on our conservative analyses, improving accessibility to public transport will improve population health by facilitating physical activity and lead to healthcare cost savings compared with business-as-usual. These wider health benefits should be better considered in transport planning and policy decisions. [ABSTRACT FROM AUTHOR]

Background: This is the eighth in a series of papers reporting Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The SHARE Program was a systematic, integrated, evidence-based program for disinvestment within a large Australian health service. One of the aims was to explore methods to deliver existing high quality synthesised evidence directly to decision-makers to drive decision-making proactively. An Evidence Dissemination Service (EDS) was proposed. While this was conceived as a method to identify disinvestment opportunities, it became clear that it could also be a way to review all practices for consistency with current evidence. This paper reports the development, implementation and evaluation of two models of an in-house EDS.Methods: Frameworks for development of complex interventions, implementation of evidence-based change, and evaluation and explication of processes and outcomes were adapted and/or applied. Mixed methods including a literature review, surveys, interviews, workshops, audits, document analysis and action research were used to capture barriers, enablers and local needs; identify effective strategies; develop and refine proposals; ascertain feedback and measure outcomes.Results: Methods to identify, capture, classify, store, repackage, disseminate and facilitate use of synthesised research evidence were investigated. In Model 1, emails containing links to multiple publications were sent to all self-selected participants who were asked to determine whether they were the relevant decision-maker for any of the topics presented, whether change was required, and to take the relevant action. This voluntary framework did not achieve the aim of ensuring practice was consistent with current evidence. In Model 2, the need for change was established prior to dissemination, then a summary of the evidence was sent to the decision-maker responsible for practice in the relevant area who was required to take appropriate action and report the outcome. This mandatory governance framework was successful. The factors influencing decisions, processes and outcomes were identified.Conclusion: An in-house EDS holds promise as a method of identifying disinvestment opportunities and/or reviewing local practice for consistency with current evidence. The resource-intensive nature of delivery of the EDS is a potential barrier. The findings from this study will inform further exploration. [ABSTRACT FROM AUTHOR]

The author discusses the effect of the Pharmaceutical Benefits Scheme (PBS) on the pharmaceutical industry in Australia. He explains that PBS aims to recover the cost of services provided and encourage efficient allocation of resources in which lodgement fee us needed to support functions of the Pharmaceutical Benefits Pricing Authority (PBCA). He states that PBS may contribute to the lower profit already carried by the industry and may compromise PBAC's independence.

The article offers information on the 2014 International AIDS Conference held in Melbourne, Australia. Topics of the conference include former U.S. President Bill Clinton's views on people with HIV/AIDS, improvement in access to affordable HIV medicines that proved useful to millions of HIV/AIDS patients and efforts of North American and European conference-goers to hold this conference.

Introduction The situation in Tasmania represents a unique perspective. Within the public system, the entire patient population is available for examination in a linked and costed dataset covering the past 10 years. This dataset provides the opportunity to examine the effect of high levels of comorbidity on patient-care pathways, as well as the associated cost estimates. Methods For the present analysis, a subset of the existing casemix dataset - encompassing admitted and emergency department care - was examined. An approach to identifying multi-morbidity cases was created based on the occurrence of distinct conditions in the coded dataset. A further analysis of PCCL scores was made by using a modified version of the AR_DRG-V5.1 grouper. Results The primary dataset comprised 191,000 individuals with 433,000 episodes of admitted data over a four-year period. The 3,376 individuals having multi-morbidity were identified. These individuals encompass nearly 48,000 episodes with 1,550 deaths. Conclusion The paper outlines an approach to identifying these individuals, and analyzing some aspects in terms of occurrence, cost, and outcome. It builds on work already undertaken in identifying the impact of tertiary care using Australian and European data. The high level of disease burden, and disproportionate use of hospital resources, requires that this analysis be undertaken to identify the scope for improvement in the care of these individuals, as well as creating a model for a better allocation of resources. [ABSTRACT FROM AUTHOR]

The article focuses on various issues discussed in the Australian Living Standards Study of 5000 families in 12 rural and urban areas of Australia. The major issues affecting service delivery for outer urban areas were high number of low income families, high cost of travel to work for residents, absence of important facilities from the area, difficulty of attracting services to the area and high number of non-English-speaking residents. The major issues affecting service delivery for middle urban areas were high number of non-English-speaking residents, high number of low income families, and scarcity and high cost of available land. The major issues affecting service delivery for inner urban areas were high number of low income families, high number of non-English-speaking residents, high number of Aboriginal residents, scarcity and cost of available land, high cost of living, and absence of important facilities. The major issues affecting service delivery for rural-remote areas were high number of low income families, difficulty of attracting services to the area, high cost of transporting goods to the area, high cost of travel, high cost of living in the area, absence of important facilities, and the distance from other services and facilities.