Disinvestment initiatives in healthcare

Kamaruzaman, Hanin Farhana (2025) Disinvestment initiatives in healthcare. PhD thesis, University of Glasgow.

Abstract

Background:
Health systems worldwide are increasingly adopting disinvestment initiatives to enhance care quality and maximize value by eliminating ineffective and obsolete interventions. However, removing low-value care (LVC) is challenging and complex, as many were adopted without rigorous evidence of clinical or cost-effectiveness, as well as resistance from healthcare stakeholders due to uncertainty in the outcomes of disinvestment. Inconsistent systems for identifying such technologies exacerbate this issue, along with unclear methodologies to assess these LVC. Existing disinvestment efforts have achieved mixed success, highlighting a critical need for structured, inclusive, and evidence-based approaches to address these gaps and enhance the implementation of the initiatives.

Methods:
This multi-method study included a scoping review of healthcare disinvestment initiatives, a mixed-method study integrating an online survey and key informant interviews with Malaysian healthcare stakeholders, and triangulation of findings to inform the development of a decision-making framework. Two case studies were conducted to assess LVC candidates, and the proposed framework was pilot-tested in a stakeholder workshop.

Results:
Stakeholder engagement emerged as pivotal for the success of disinvestment initiatives. Through stakeholder engagement, scoping review, and consultation with experts, this thesis introduces a novel decision-making framework based on the value of de-implementation concept, which incorporates five key domains: health impact, equity considerations, enablers for disinvestment, system readiness, and economic impact. Pilot-testing with Malaysian stakeholders demonstrated the framework’s feasibility and acceptance, supporting its role in promoting a systematic, transparent, and inclusive approach to disinvestment.

Implications:
Implementing healthcare disinvestment as a policy-driven initiative requires a complex approach of stakeholder engagement and empowerment, as well as systematic and comprehensive methodology. This process is heavily dependent on reliable data and evidence to support the assessment and decision-making process, availability of guidance or framework for decision-making, as well as leadership commitment and resources to ensure the sustainability of the effort. Future work should aim to integrate public and patient perspectives into the decision-making process, with opportunities to refine, evaluate, and validate the proposed framework. Further research is needed in assessing the impact of disinvestment decisions and recommendations, especially in optimising value in health service delivery and transition to higher-value strategies as a result of de-implementing LVC.

• Item Type: Thesis (PhD)
• Qualification Level: Doctoral
• Subjects: R Medicine > RA Public aspects of medicine
• Colleges/Schools: College of Medical Veterinary and Life Sciences > School of Health & Wellbeing > Health Economics and Health Technology Assessment
• Supervisor's Name: Wu, Professor Olivia and Grieve, Dr. Eleanor
• Date of Award: 2025
• Depositing User: Theses Team
• Unique ID: glathesis:2025-85143
• Copyright: Copyright of this thesis is held by the author.
• Date Deposited: 02 Jun 2025 08:51
• Last Modified: 02 Dec 2025 11:31
• Thesis DOI: 10.5525/gla.thesis.85143
• URI: https://theses.gla.ac.uk/id/eprint/85143

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