Investing and Disinvesting

Health promotion and broader services that promote health need to have realistic starting points. This means better use of existing assets. For example, the OECD report on ‘Wasteful Spending in Health’ presented alarming data on wasted resources with estimations ranging from a conservative 10% up to 34% of expenditures. The COVID-19 pandemic has also shed new lights on the demand for health care treatments, which needs to be further investigated. A reallocation of resources - the freeing of resources and accordingly the reinvestment - is an urgent priority for sustainable and resilient European healthcare systems.


For crossover interventions involving multiple sectors or borders, it means identifying where these assets are and how they are being used within strategic and intervention specific value chains (most valuable areas of activity) and networks. There are different ways to facilitate an adequate process to disinvest to reinvest. To be effective, these processes need to be transparent, systematic and explicit in order to assess the potential for disinvestment in certain interventions and technologies.

Case studies

The Prioritisation Framework (PF) is a priority setting tool for public health investment decisions in England. It provides a platform to aid local authorities to make decisions regarding budget allocations in a structured and transparent manner. This Framework was developed by Public Health England (PHE).

Overview of the prioritisation process


The PF comprises eight essential steps that can take place over several workshops. Those taking part in the workshops would ideally be stakeholders from each of the health programmes under consideration.


Step 1 defines the criteria against which programmes will be evaluated. Operational criteria are selected during this stage of the process, representing key factors of what is to be achieved within each local authority and weights are then applied to each of the criteria in Step 2. The weights that are assigned to each represent the importance of each criteria relative to all others.


Step 3 gathers evidence from each programme area that is relevant to the criteria. The evidence gathered relates to what could potentially be achieved by each programme area against each criterion.


Step 4 rates each of the programmes on a scale of 1 to 5. Higher scores indicates which programme areas have the best potential to achieve positive outcomes.


During Step 5 the weights that were assigned to the criteria and the scores given to the programme areas are combined to calculate an overall score. This final score represents the overall outcome of what could potentially be achieved by each of the programme areas.


Step 6 is used to gather evidence regarding the current expenditure and outcomes of the programme areas. Step 7 assigns scores, with the scoring based on the evidence of the current achievement of the programmes against 3 measures: investment, outcomes, and feasibility. Each programme is given a score from 1 to 5 against each of these measures. Overall, the score gives a clear representation of how the programmes are currently doing in a numerical form.


Finally, in Step 8, the PF produces recommendations on whether to maintain, increase or decrease the current budget allocations. The stakeholders then have the option of following what has been advised or to decide their own actions in the light of other contextual factors.


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In Wales, a national Programme Budgeting and Marginal Analysis (PBMA) exercise was completed by Public Health Wales. The exercise considered public health interventions at a national level, taking into account NHS services and those provided by public and private partners 1Edwards, R. T., Charles, J. M., Thomas, S., Bishop, J., Cohen, D., Groves, S., & Bradley, P. (2014). A national Programme Budgeting and Marginal Analysis (PBMA) of health improvement spending across Wales: disinvestment and reinvestment across the life course. BMC public health, 14(1), 837.. The PBMA can be employed as a means of using expert opinion as a part of evidence-based decision making. It is a process that helps decision-makers maximise the impact of healthcare resources on the health needs of a local population or meet other specified goals such as equity considerations.


Programme budgeting is an appraisal of past resource allocation in specified programmes, with a view to tracking future resource allocation in those same programmes. An expert panel was established with representatives from Public Health Wales, the Welsh Government, NHS Health Boards, the third sector, local government and primary care. The results identified a budget of £15.1 million, spanning 10 Welsh Government priority areas and 6 life course stages. Due to lack of evidence the panel recommended total disinvestment in 7 out of 25 initiatives releasing £1.5 million of resources, and partial disinvestment in a further 3 interventions releasing £7.3 million of resources to be reinvested.