Priority setting in developing countries health care institutions: the case of a Ugandan hospital

BACKGROUND: Because the demand for health services outstrips the available resources, priority setting is one of the most difficult issues faced by health policy makers, particularly those in developing countries. However, there is lack of literature that describes and evaluates priority setting in these contexts. The objective of this paper is to describe priority setting in a teaching hospital in Uganda and evaluate the description against an ethical framework for fair priority setting processes – Accountability for Reasonableness. METHODS: A case study in a 1,500 bed national referral hospital receiving 1,320 out patients per day and an average budget of US$ 13.5 million per year. We reviewed documents and carried out 70 in-depth interviews (14 health planners, 40 doctors, and 16 nurses working at the hospital). Interviews were recorded and transcribed. Data analysis employed the modified thematic approach to describe priority setting, and the description was evaluated using the four conditions of Accountability for Reasonableness: relevance, publicity, revisions and enforcement. RESULTS: Senior managers, guided by the hospital strategic plan make the hospital budget allocation decisions. Frontline practitioners expressed lack of knowledge of the process. Relevance: Priority is given according to a cluster of factors including need, emergencies and patient volume. However, surgical departments and departments whose leaders "make a lot of noise" are also prioritized. Publicity: Decisions, but not reasons, are publicized through general meetings and circulars, but this information does not always reach the frontline practitioners. Publicity to the general public was through ad hoc radio programs and to patients who directly ask. Revisions: There were no formal mechanisms for challenging the reasoning. Enforcement: There were no mechanisms to ensure adherence to the four conditions of a fair process. CONCLUSION: Priority setting decisions at this hospital do not satisfy the conditions of fairness. To improve, the hospital should: (i) engage frontline practitioners, (ii) publicize the reasons for decisions both within the hospital and to the general public, and (iii) develop formal mechanisms for challenging the reasoning. In addition, capacity strengthening is required for senior managers who must accept responsibility for ensuring that the above three conditions are met

Evidence-Based Priority Setting for Health Care and Research: Tools to Support Policy in Maternal, Neonatal, and Child Health in Africa

As part of a series on maternal, neonatal, and child health in sub-Saharan Africa, Igor Rudan and colleagues discuss various priority-setting tools for health care and research that can help develop evidence-based policy

A review of selected research priority setting processes at national level in low and middle income countries: towards fair and legitimate priority setting

<p>Abstract</p> <p>Background</p> <p>It is estimated that more than $130 billion is invested globally into health research each year. Increasingly, there is a need to set priorities in health research investments in a fair and legitimate way, using a sound and transparent methodology. In this paper we review selected priority setting processes at national level in low and middle income countries. We outline a set of criteria to assess the process of research priority setting and use these to describe and evaluate priority setting exercises that have taken place at country level. Based on these insights, recommendations are made regarding the constituents of a good priority setting process.</p> <p>Methods</p> <p>Data were gathered from presentations at a meeting held at the World Health Organization (WHO) in 2008 and a web-based search. Based on this literature review a number of criteria were developed to evaluate the priority setting processes.</p> <p>Results</p> <p>Across the countries surveyed there was a relative lack of genuine stakeholder engagement; countries varied markedly in the extent to which the priority setting processes were documented; none of the countries surveyed had a systematic or operational appeals process for outlined priorities; and in all countries (except South Africa) the priorities that were outlined described broad disease categories rather than specific research questions.</p> <p>Conclusions</p> <p>Country level priority setting processes differed significantly in terms of the methods used. We argue that priority setting processes must have in-built mechanisms for publicizing results, effective procedures to enforce decisions as well as processes to ensure that the revision of priorities happens in practice.</p

Strengthening fairness, transparency and accountability in health care priority setting at district level in Tanzania

Health care systems are faced with the challenge of resource scarcity and have insufficient resources to respond to all health problems and target groups simultaneously. Hence, priority setting is an inevitable aspect of every health system. However, priority setting is complex and difficult because the process is frequently influenced by political, institutional and managerial factors that are not considered by conventional priority-setting tools. In a five-year EU-supported project, which started in 2006, ways of strengthening fairness and accountability in priority setting in district health management were studied. This review is based on a PhD thesis that aimed to analyse health care organisation and management systems, and explore the potential and challenges of implementing Accountability for Reasonableness (A4R) approach to priority setting in Tanzania. A qualitative case study in Mbarali district formed the basis of exploring the sociopolitical and institutional contexts within which health care decision making takes place. The study also explores how the A4R intervention was shaped, enabled and constrained by the contexts. Key informant interviews were conducted. Relevant documents were also gathered and group priority-setting processes in the district were observed. The study revealed that, despite the obvious national rhetoric on decentralisation, actual practice in the district involved little community participation. The assumption that devolution to local government promotes transparency, accountability and community participation, is far from reality. The study also found that while the A4R approach was perceived to be helpful in strengthening transparency, accountability and stakeholder engagement, integrating the innovation into the district health system was challenging. This study underscores the idea that greater involvement and accountability among local actors may increase the legitimacy and fairness of priority-setting decisions. A broader and more detailed analysis of health system elements, and socio-cultural context is imperative in fostering sustainability. Additionally, the study stresses the need to deal with power asymmetries among various actors in priority-setting contexts

Guidance on stakeholder engagement practices to inform the development of areawide vector control methods

This is the final version. Available from the publisher via the DOI in this record.British Academ

From papers to practices: district level priority setting processes and criteria for family planning, maternal, newborn and child health interventions in Tanzania

Contains fulltext : 97928.pdf (publisher's version ) (Open Access)ABSTRACT: BACKGROUND: Successful priority setting is increasingly known to be an important aspect in achieving better family planning, maternal, newborn and child health (FMNCH) outcomes in developing countries. However, far too little attention has been paid to capturing and analysing the priority setting processes and criteria for FMNCH at district level. This paper seeks to capture and analyse the priority setting processes and criteria for FMNCH at district level in Tanzania. Specifically, we assess the FMNCH actor's engagement and understanding, the criteria used in decision making and the way criteria are identified, the information or evidence and tools used to prioritize FMNCH interventions at district level in Tanzania. METHODS: We conducted an exploratory study mixing both qualitative and quantitative methods to capture and analyse the priority setting for FMNCH at district level, and identify the criteria for priority setting. We purposively sampled the participants to be included in the study. We collected the data using the nominal group technique (NGT), in-depth interviews (IDIs) with key informants and documentary review. We analysed the collected data using both content analysis for qualitative data and correlation analysis for quantitative data. RESULTS: We found a number of shortfalls in the district's priority setting processes and criteria which may lead to inefficient and unfair priority setting decisions in FMNCH. In addition, participants identified the priority setting criteria and established the perceived relative importance of the identified criteria. However, we noted differences exist in judging the relative importance attached to the criteria by different stakeholders in the districts. CONCLUSIONS: In Tanzania, FMNCH contents in both general development policies and sector policies are well articulated. However, the current priority setting process for FMNCH at district levels are wanting in several aspects rendering the priority setting process for FMNCH inefficient and unfair (or unsuccessful). To improve district level priority setting process for the FMNCH interventions, we recommend a fundamental revision of the current FMNCH interventions priority setting process. The improvement strategy should utilize rigorous research methods combining both normative and empirical methods to further analyze and correct past problems at the same time use the good practices to improve the current priority setting process for FMNCH interventions. The suggested improvements might give room for efficient and fair (or successful) priority setting process for FMNCH interventions

Operational research in low-income countries: what, why, and how?

Operational research is increasingly being discussed at institutional meetings, donor forums, and scientific conferences, but limited published information exists on its role from a disease-control and programme perspective. We suggest a definition of operational research, clarify its relevance to infectious-disease control programmes, and describe some of the enabling factors and challenges for its integration into programme settings. Particularly in areas where the disease burden is high and resources and time are limited, investment in operational research and promotion of a culture of inquiry are needed so that health care can become more efficient. Thus, research capacity needs to be developed, specific resources allocated, and different stakeholders (academic institutions, national programme managers, and non-governmental organisations) brought together in promoting operational research

Strategies to Avoid the Loss of Developmental Potential in More than 200 Million Children in the Developing World

This paper is the third in the Child Development Series. The first paper showed that more than 200 million children under 5 years of age in developing countries do not reach their developmental potential. The second paper identified four well-documented risks: stunting, iodine deficiency, iron deficiency anaemia, and inadequate cognitive stimulation, plus four potential risks based on epidemiological evidence: maternal depression, violence exposure, environmental contamination, and malaria. This paper assesses strategies to promote child development and to prevent or ameliorate the loss of developmental potential. The most effective early child development programmes provide direct learning experiences to children and families, are targeted toward younger and disadvantaged children, are of longer duration, high quality, and high intensity, and are integrated with family support, health, nutrition, or educational systems and services. Despite convincing evidence, programme coverage is low. To achieve the Millennium Development Goals of reducing poverty and ensuring primary school completion for both girls and boys, governments and civil society should consider expanding high quality, cost-effective early child development programmes

Priority setting in primary health care - dilemmas and opportunities: a focus group study

<p>Abstract</p> <p>Background</p> <p>Swedish health care authorities use three key criteria to produce national guidelines for local priority setting: severity of the health condition, expected patient benefit, and cost-effectiveness of medical intervention. Priority setting in primary health care (PHC) has significant implications for health costs and outcomes in the health care system. Nevertheless, these guidelines have been implemented to a very limited degree in PHC. The objective of the study was to qualitatively assess how general practitioners (GPs) and nurses perceive the application of the three key priority-setting criteria.</p> <p>Methods</p> <p>Focus groups were held with GPs and nurses at primary health care centres, where the staff had a short period of experience in using the criteria for prioritising in their daily work.</p> <p>Results</p> <p>The staff found the three key priority-setting criteria (severity, patient benefit, and cost-effectiveness) to be valuable for priority setting in PHC. However, when the criteria were applied in PHC, three additional dimensions were identified: 1) viewpoint (medical or patient's), 2) timeframe (now or later), and 3) evidence level (group or individual).</p> <p>Conclusions</p> <p>The three key priority-setting criteria were useful. Considering the three additional dimensions might enhance implementation of national guidelines in PHC and is probably a prerequisite for the criteria to be useful in priority setting for individual patients.</p