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This paper compares the relative productive efficiencies of four models of primary care service delivery using the data envelopment analysis method on 130 primary care practices in Ontario, Canada. A quality-controlled measure of output and two input scenarios are employed: one with full-time-equivalent labour inputs and the other with total expenditures. Regression analysis controls for the mix of patients in the practice population. Overall, we find that community health centres fare the worst when it comes to relative efficiency scores.

We take explicit account of the way in which the supply of physicians and patients in the economy affects the design of physician remuneration schemes, highlighting the three-way trade-off between quality of care, access, and cost. Both physicians and patients are heterogeneous. Physicians choose both the number of patients and the quality of care to provide to their patients. When determining physician payment rates, the principal must ensure access to care for all patients. When physicians can adjust the number of patients seen, there is no incentive to over-treat. In contrast, altruistic physicians always quality stint: they prefer to add an additional patient, rather than to increase the quality of service provided. A mixed payment mechanism does not increase the quality of service provided with respect to capitation. Offering a menu of compensation schemes may constitute a cost-effective strategy for inducing physicians to choose a given overall caseload but may also generate difficulties with access to care for frail patients.

Review Suggested citationMilliken OV, Ellis VL, Development of an investment case for obesity prevention and control: perspectives on methodological advancement and evidence. Rev Panam Salud Publica. 2018;42:e62. https://doi.org/10. 26633/RPSP.2018.62 As the obesity epidemic has been spreading rapidly across the Americas, national governments and regional and international organizations have called for action from the whole of society (1-4). To answer these calls, jurisdictions are seeking comprehensive investment cases that would articulate the benefits and costs of an intervention strategy across various economic actors and the factors that could affect its implementation. For example, the United Nations Interagency Task Force on the Prevention and Control of Noncommunicable Diseases has been working with countries around the globe to prepare investment cases for prevention and control of noncommunicable diseases (NCDs) and their risk factors (5).An investment case presents reasoning for an action and includes a strategy to achieve a stated objective. Drawing from recent efforts to formulate investment cases (5-7), we find that a public health investment case generally includes six steps: 1) describing the problem within a given country, including determinants and risk factors and public health and economic impacts; 2) identifying effective, feasible, and locally relevant interventions for analysis; 3) providing analysis of the costs versus benefits of intervening, and identifying synergies among interventions; 4) building a package of interventions based on the second and third steps as well as other criteria such as distributional consequences and acceptability among stakeholders; 5) identifying the funding requirements and finding resources; and 6) developing a detailed plan for implementation and evaluation of results. Figure 1 summarizes this process.The objective of this paper is to discuss how various economic methods for valuing costs and benefits can be applied to obesity-targeted interventions (the third step listed above). The paper also summarizes major evidence towards the development of an investment case for obesity prevention and control in line with the third and fourth steps. ABSTRACT

Obesity is a compelling example of the challenges of championing and mobilizing a response that involves the whole of government and all of society. This paper discusses the need for economic rationales to strengthen the case for government intervention on obesity, with a view to better engaging the expertise and resources of nonhealth sectors. The paper also briefly reviews economic theory and evidence that could support an integrated multisectoral rationale for action, noting opportunities to expand the integration of economic evidence in the Americas.