Disinvestments in practice: overcoming resistance to change through a sociotechnical approach with local stakeholders.

For health care, economists have developed cost-effectiveness analysis (CEA) as a "rational," analytic tool to set priorities. Attempts to use CEA to decide how to cut expenditures, however, have been met with stakeholders' resistance. This article presents an illustrative case study of the application of an approach explicitly designed to engage stakeholders with conflicting objectives in confronting tightening budgets. The outcome of this process, which engaged a group of stakeholders including patients, caregivers, clinicians, and managers, was a strategy that reconfigured services to produce more health gain at reduced total cost. I argue that the key factors that led to overcoming resistance to change were (1) the collective character of the deliberations; (2) the analysis of the whole pathway; (3) the presence of patients; and (4) the development of a model based on CEA principles, which provided a credible rationale for difficult decisions.