1KEMRI Centre for Geographic Medicine Research – Coast, and Welcome Trust Research Programme, Nairobi, Kenya
2Health Economics Unit, University of Cape Town, Cape Town, South Africa
3Centre for Tropical Medicine, University of Oxford, Oxford, UK
4Department of Paediatrics, University of Oxford, Oxford, UK
Background Priority setting in healthcare is a key determinant of health system performance. However, there is no widely accepted priority setting evaluation framework. We reviewed literature with the aim of developing and proposing a framework for the evaluation of macro and meso level healthcare priority setting practices.
Methods We systematically searched Econlit, PubMed, CINAHL, and EBSCOhost databases and supplemented this with searches in Google Scholar, relevant websites and reference lists of relevant papers. A total of 31 papers on evaluation of priority setting were identified. These were supplemented by broader theoretical literature related to evaluation of priority setting. A conceptual review of selected papers was undertaken.
Results Based on a synthesis of the selected literature, we propose an evaluative framework that requires that priority setting practices at the macro and meso levels of the health system meet the following conditions: (1) Priority setting decisions should incorporate both efficiency and equity considerations as well as the following outcomes; (a) Stakeholder satisfaction, (b) Stakeholder understanding, (c) Shifted priorities (reallocation of resources), and (d) Implementation of decisions. (2) Priority setting processes should also meet the procedural conditions of (a) Stakeholder engagement, (b) Stakeholder empowerment, (c) Transparency, (d) Use of evidence, (e) Revisions, (f) Enforcement, and (g) Being grounded on community values.
Conclusion Available frameworks for the evaluation of priority setting are mostly grounded on procedural requirements, while few have included outcome requirements. There is, however, increasing recognition of the need to incorporate both consequential and procedural considerations in priority setting practices. In this review, we adapt an integrative approach to develop and propose a framework for the evaluation of priority setting practices at the macro and meso levels that draws from these complementary schools of thought.
Holm S. The second phase of priority setting. Goodbye to simple solutions. BMJ. 2000;317;1000-1002.
Coulter A, Ham C. International experiences of rationing (or priority setting). In: Coulter A, Ham C, eds. The Global Challenge of Healthcare Rationing. Buckingham, Philadelphia: Open University Press; 2000.
Martin D, Singer P. A strategy to improve priority setting in health care institutions. Health Care Anal. 2003;11(1):59-68. doi:10.1007/s10728-006-0037-1
Kapiriri L, Martin DK. A Strategy to Improve Priority Setting in Developing Countries. Health Care Anal. 2007;15(3):159-167. doi:10.1007/s10728-006-0037-1
Smith N. Using evaluation theory in priority setting and resource allocation. J Health Organ Manag. 2012;26(5):655-671. doi:10.1108/14777261211256963
Kapiriri L, Martin D. Successful Priority Setting in Low and Middle Income Countries: A Framework for Evaluation. Health Care Anal. 2010;18(2):129-147. doi:10.1007/s10728-009-0115-2
Sibbald SL, Singer PA, Upshur R, Martin DK. Priority setting : what constitutes success? A conceptual framework for successful priority setting. BMC Health ServRes. 2009;9;43. doi:10.1186/1472-6963-9-43
Sibbald SL, Gibson JL, Singer PA, Upshur R, Martin DK. Evaluating priority setting success in healthcare: a pilot study. BMC Health ServRes. 2010;10:31. doi:10.1186/1472-6963-10-131
Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8:45. doi:10.1186/1471-2288-8-45
Dixon-Woods M, Agarwal S, Jones D, Young B, Sutton A. Synthesising qualitative and quantitative evidence: a review of possible methods. J Health Serv Res Policy. 2005;10(1):45-53. doi:10.1258/1355819052801804
Dixon-Woods M, Cavers D, Agarwal S, et al. Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups. BMC Med Res Methodol. 2006;6:35. doi:10.1186/1471-2288-6-35
Noblit G, Hare R. Meta-Ethnography: Synthesising Qualitative Studies. Newbury Park, California: Sage Publications; 1988.
Jan S. Proceduralism and its role in economic evaluation and priority setting in health. Soc Sci Med. 2014;108:257-261. doi:10.1016/j.socscimed.2014.01.029
Norheim OF, Cavallero E, Segall S. The ethics of priority setting in health: a review of principles, criteria and procedures we can all agree about. Bergen; 2007.
Brock D, Wikler D. Ethical Issues in Resource Allocation, Research, and New Product Development. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, eds. Disease Control Priorities in Developing Countries. 2nd ed. New York: Oxford University Press and The World Bank; 2006.
Drummond M. Output measurement for resource allocation decisions in health care. In: McGuire A, Fenn P, Mayhew K, eds. Providing Health Care. The Economics of Alternative Systems of Finance and Delivery. Oxford: Oxford University Press; 1991.
Baerøe K. Priority-setting in healthcare: a framework for reasonable clinical judgements. J Med Ethics. 2009;35(8):488-496. doi:10.1136/jme.2007.022285
Bell JA, Hyland S, DePellegrin T, Upshur RE, Bernstein M, Martin DK. SARS and hospital priority setting: a qualitative case study and evaluation. BMC Health Serv Res. 2004;4(1):36.
Bruni RA, Laupacis A, Levinson W, Martin DK. Public involvement in the priority setting activities of a wait time management initiative : a qualitative case study. BMC Health Serv Res. 2007;7:186.
Danjoux NM, Martin DK, Lehoux PN, et al. Adoption of an innovation to repair aortic aneurysms at a Canadian hospital: a qualitative case study and evaluation. BMC Health Serv Res. 2007;7:182. doi:10.1186/1472-6963-7-182
Dolan P, Edlin R, Tsuchiya A, Wailoo A. It ain’t what you do, it's the way that you do it: Characteristics of procedural justice and their importance in social decision-making. J Econ Behav Organ. 2007;64(1):157-170. doi:10.1016/j.jebo.2006.07.004
Gallego G, Taylor SJ, Brien JA. Priority setting for high cost medications (HCMs) in public hospitals in Australia: a case study. Health Policy. 2007;84(1):58-77. doi:10.1016/j.healthpol.2007.05.008
Gibson JL, Martin DK, Singer PA. Setting priorities in health care organizations: criteria, processes, and parameters of success. BMC Health Serv Res. 2004;4(1):25. doi:10.1186/1472-6963-4-25
Gibson JL, Martin DK, Singer PA. Priority setting in hospitals: fairness, inclusiveness, and the problem of institutional power differences. Soc Sci Med. 2005;61(11):2355-2362. doi:10.1016/j.socscimed.2005.04.037
Gibson J, Mitton C, Martin D, Donaldson C, Singer P. Ethics and economics: does programme budgeting and marginal analysis contribute to fair priority setting? J Health Serv Res Policy. 2006;11(1):32-37. doi:10.1258/135581906775094280
Gordon H, Kapiriri L, Martin DK. Priority setting in an acute care hospital in Argentina : A qualitative case study. Acta Bioethica. 2009;15(2):184-192. doi:10.4067/s1726-569x2009000200009
Greenberg D, Peterburg Y, Vekstein D, Pliskin JS. Decisions to adopt new technologies at the hospital level: insights from Israeli medical centers. Int J Technol Assess Health Care. 2005;21(2):219-227.
Kapiriri L, Martin DK. Priority setting in developing countries health care institutions : the case of a Ugandan hospital. 2006;9:1-9. doi:10.1186/1472-6963-6-127
Kapiriri L, Norheim OF, Martin DK. Priority setting at the micro- , meso- and macro-levels in Canada , Norway and Uganda. Health Policy (New York). 2007;82:78-94. doi:10.1016/j.healthpol.2006.09.001
Madden S, Martin DK, Downey D, Singer PA. Hospital priority setting with an appeals process: a qualitative case study and evaluation. Health Policy. 2005;73(1):10-20.
Maluka S, Kamuzora P, San M, et al. Decentralized health care priority-setting in Tanzania: evaluating against the accountability for reasonableness framework. Soc Sci Med. 2010;71(4):751-756. doi:10.1016/j.socscimed.2010.04.035
Martin DK, Giacomini M, Singer PA. Fairness, accountability for reasonableness, and the views of priority setting decision-makers. Health Policy. 2002;61(3):279-290.
Martin DK, Hollenberg D, Macrae S, Madden S, Singer P. Priority setting in a hospital drug formulary: a qualitative case study and evaluation. Health Policy. 2003;66:295-303. doi:10.1016/s0168-8510(03)00063-0
Martin DK, Shulman K, Santiago-Sorrell P, Singer P. Priority-setting and hospital strategic planning: a qualitative case study. J Health Serv Res Policy. 2003;8(4):197-201. doi:10.1258/135581903322403254
Mitton CR, Donaldson C. Setting priorities and allocating resources in health regions: lessons from a project evaluating program budgeting and marginal analysis (PBMA). Health Policy. 2003;64(3):335-348. doi:10.1016/s0168-8510(02)00198-7
Mitton C, Donaldson C, Shellian B, Pagenkopf C. Priority setting in a Canadian surgical department; a case study using program budgeting and marginal analysis. Can J Surg. 2003;46(1):23-29.
Mori AT, Kaale EA. Priority setting for the implementation of artemisinin-based combination therapy policy in Tanzania: evaluation against the accountability for reasonableness framework. Implement Sci. 2012;7:18. doi:10.1186/1748-5908-7-18
Peacock S, Ruta D, Mitton C, Donaldson C, Bate A, Murtagh M. Using economics to set pragmatic and ethical priorities. BMJ. 2006;332(7539):482-485. doi:10.1136/bmj.332.7539.482
Reeleder D, Martin DK, Keresztes C, Singer PA. What do hospital decision-makers in Ontario, Canada, have to say about the fairness of priority setting in their institutions? BMC Health Serv Res. 2005;5(1):8.
Sharma B, Danjoux NM, Harnish JL, Urbach DR. How are decisions to introduce new surgical technologies made? Advanced laparoscopic surgery at a Canadian community hospital: A qualitative case study and evaluation. Surg Innov. 2006;13(4):250-256. doi:10.1177/1553350606296341
Shayo EH, Norheim OF, Mboera LE, et al. Challenges to fair decision-making processes in the context of health care services: a qualitative assessment from Tanzania. Int J Equity Health. 2012;11(1):30. doi:10.1186/1475-9276-11-30
Valdebenito C, Kapiriri L, Martin DK. Hospital priority setting in a mixed public/private health system: a case study of a Chilean hospital. 2009;15(2):193-201.
Wailoo A, Anand P. The nature of procedural preferences for health-care rationing decisions. Soc Sci Med. 2005;60(2):223-236.
Mitton C, Donaldson C. Tools of the trade: a comparative analysis of approaches to priority setting in healthcare. Heal Serv Manag Res. 2003;16:96-105. doi:10.1258/095148403321591410
Mitton C, Peacock S, Donaldson C, Bate A. Using PBMA in health care priority setting: description, challenges and experience. Appl Health Econ Health Policy. 2003;2(3):121-127.
Baltussen R, Brouwer W, Niessen L. Cost-effectiveness analysis for priority setting in health: penny-wise but pound-foolish. Int J Technol Assess Heal Care. 2005;21(4):532-534. doi:10.1017/s0266462305050750
Tsourapas A, Frew E. Evaluating ‘success’ in programme budgeting and marginal analysis: a literature review. J Health Serv Res Policy. 2011;16(3):177-183. doi:10.1258/jhsrp.2010.009053
Hardon D. Setting health care priorities in Oregon. Cost-Effectiveness meets the rule of rescue. J Am Med Assoc. 1991;265:2218-2225.
Wagstaff A, Van Doorslaer E. Equity in the finance and delivery of health care: concepts and definitions. In: Van Doorslaer E, Wagstaff A, Rutten F, eds. Equity in the Finance and Delivery of Health Care: An International Perspective. New York: Oxford University Press; 1993.
Elster J. Deliberative Democracy. Cambridge: Cambridge University Press; 1998.
Habermas J. The Theory of Communicative Action. Boston: Beacon Press; 1984.
Webler T. “Right” discourse in citizen participation: an evaluative yardstick. In: Renn NO, Wiedelmann P, eds. Fairness and Competence in Citizen Participation: Evaluating Models for Environmental Discourse. Boston, Ma: Kluwer Academic Press; 1995.
Beierle T, Cayford J. Democracy in Practice: Public Participation in Environmental Decisions. Washington DC: Routledge; 2002.
Abelson J, Forest PG, Eyles J, Smith P, Martin E, Gauvin FP. Deliberations about deliberative methods: issues in the design and evaluation of public participation processes. Soc Sci Med. 2003;57(2):239-251. doi:10.1016/s0277-9536(02)00343-x
Pratchett L. New fashions in public participation: Towards greater democracy? Parliam Aff. 1999;52:617-633.
Crosby N. Citizens’ juries: One solution for difficult environmental questions. In: Renn NO, Wiedelmann P, eds. Fairness and Competence in Citizen Participation: Evaluating Models for Environmental Discourse. Boston, Ma: Kluwer Academic Press; 1995.
Gutmann A, Thompson D. Why Deliberative Democracy. Princeton, New Jersey: Princeton Universiy Press; 2004.
Maluka S, Kamuzora P, Sansebastián M, et al. Implementing accountability for reasonableness framework at district level in Tanzania : a realist evaluation. Implement Sci. 2011;6:11. doi:10.1186/1748-5908-6-11
Daniels N, Sabin J. Setting Limits Fairly: Can We Learn to Share Medical Resources? New York: Oxford University Press; 2002.
Mitton C, Smith N, Peacock S, Evoy B, Abelson J. Public participation in health care priority setting: a scoping review. Health Policy. 2009;91(3):219-228. doi:10.1016/j.healthpol.2009.01.005
Mooney G. Communitarian claims’ as an ethical basis for allocating health care resources. Soc Sci Med. 1998;47(9):1171-1180. doi:10.1016/s0277-9536(98)00189-0
Mooney G. Challenging Health Economics. Oxford: Oxford University Press; 2009.
Mooney GH, Blackwell SH. Whose health service is it anyway? Community values in healthcare. Med J Aust. 2004;180(2):76-78.
Mooney G. Communitarian claims and community capabilities: furthering priority setting? Soc Sci Med. 2005;60(2):247-255. doi:10.1016/j.socscimed.2004.04.033
Rowe G, Frewer J. Public participation methods: a framework for evaluation. Sci Technol Hum Values. 2000;25(1):3-29. doi:10.1177/016224390002500101
Sepehri A, Pettigrew J. Primary health care, community participation and community-financing: experiences of two middle hill villages in Nepal. Health PolicyPlan. 1996;11(1):93-100. doi:10.1093/heapol/11.1.93
Lenaghan J. Involving the public in rationing decisions. The experience of citizens juries. Health Policy 1999;49:45-61. doi:10.1016/s0168-8510(99)00042-1