Twenty-five years of programme budgeting and marginal analysis in the health sector, 1974-1999

Programme budgeting and marginal analysis (PBMA) is a priority setting framework that has been used over the last 25 years in the health sector. To date, no formal evaluation of this framework has been conducted. The aims of this study were to categorize previous PBMA exercises systematically and determine the impact of PBMA in regional health authorities (RHAs) internationally.

Thirty authors of grey literature and published papers on PBMA, and an additional six economists with research interests in PBMA, were surveyed with a mailed questionnaire. Previous exercises were categorized and details of the short- and long-term impacts of the framework were obtained. Descriptive statistics and content analysis were used.

The PBMA framework was identified as having been used 78 times in 59 RHAs. For the exercises where longer-term impact was known, the approach was viewed as having had a positive impact, as defined by the setting of priorities or shifting of resources, in 59% of cases and continued to be used in at least 52% of the RHAs. The primary reasons why PBMA was discontinued included personnel changes and lack of internal 'champions'.

Contrary to popular perception, there has been widespread diffusion of PBMA in RHAs internationally and, overall, the impact of this approach has been positive. Although there is general agreement on the validity of the economic principles underlying PBMA, addressing managerial issues would seem to be central to successful implementation in a given region.