Priority Setting


Below is a highly selective list of helpful resources related to priority setting. Note there is a balance (of sorts) here between priority-setting for healthcare institutions (which is typically used to prioritize service delivery packages or interventions) and priority-setting for research (e.g. on a health-systems level, setting a broader research agenda, or as a function within the national health research system).

For all material here, PS = priority setting. PSP = priority-setting process. PSE = priority-setting exercise.

The pdf for every article can be accessed at the end of the citation <pdf>. Note I have put little commentary here and inserted instead what I felt to be sound quotations from the article.

Campbell S. “Deliberative Priority Setting for Research”. Chapter 3 in Graham ID et al, Eds. Turning Knowledge into Action: Practical Guidance on how to do Integrated Knowledge Translation. Lippincott-Joanna Briggs Institute Synthesis Science in Healthcare Series: Book 21. 2014. Forthcoming.

Campbell S. “Priority Setting”. Module 3 in the Knowledge Translation Curriculum. Ottawa: Canadian Coalition for Global Health Research, 2012.

Campbell, S. Deliberative Priority Setting. A CIHR Knowledge Translation Module. Ottawa: Canadian Institutes for Health Research. June 2010. Available from CIHR here.

If we conceptualize knowledge translation (KT) as an ever-turning cycle of policy-informed research leading to evidence-informed policy, then priority setting is where this cycle often begins to move. A singular KT tool in identifying policy needs and research options, deliberative priority setting selects the right people to brainstorm on the right issues to determine what a society's, a system's, or an institution's priorities are. Exactly how we determine the "right people," select the "right issues," and arrive at a set of fair and inclusive priorities is the subject of this Module.

Alliance for Health Policy and Systems Research. Priority Setting for Health Policy and Systems Research. Briefing Note #3. Alliance for Health Policy and Systems Research, Geneva. 2009. <pdf>. Note that I was contracted by the Alliance to write this.

“How can LMICs increasingly identify their own health policy and systems research priorities? How might funders start developing priority-setting processes within the LMICs they support?As importantly,how might evidence needs articulated by LMIC policy-makers start to drive global priorities? This brief:

  1. 1.•Discusses the fundamental concepts of priority setting exercises;

  2. 2.•Explores the priority-setting dynamic between the national and global levels; 

  3. 3.•Describes priority setting exercises specific to health policy and systems research;

  4. 4.•Details the work of the AHPSR in driving global priorities based upon the evidence needs of LMIC policy-makers through a three-step approach;

  5. 5.•Concludes with recommendations for how researchers, LMIC policy-makers and the global community might increasingly promote, fund and convene priority-setting exercises in health policy and systems research.

Sibbald SL, Singer PA, Upshur R, Martin DK. Priority setting: what constitutes success? A conceptual framework for successful priority setting. BMC Health Services Research. 9:43, 2009. <pdf>.

•“there is no agreed-upon definition for successful PS, so there is no way of knowing if an organization achieves it. PS is extremely complex – choosing between competing ethical values makes PS fundamentally an ethical issue. Different disciplines offer their own perspective on how PS ‘ought’ to be done, defining ‘good’ (or successful) PS through values such as efficiency, equity, or justice. Discipline-specific approaches and PS frameworks can help decision-makers with PS: health economics encourages a focus on efficiency, policy approaches focus on legitimacy, evidence-based medicine looks to effectiveness. Daniels and Sabin created Accountability for Reasonableness (A4R) with legitimacy and fairness as two key goals of PS. Interdisciplinary approaches are also available such as PBMA, HTA. Menon et al described PS in four steps: 1) identification of health care needs; 2) allocation of resources; 3) communication of decisions to stakeholders; and 4) management of feedback from them. Still, there is no consensus that any one framework provides the ‘correct’ or ‘best’ comprehensive definition of successful PS.

•these normative approaches are necessary because they help identify important values and underlying assumptions in PS, however alone they are insufficient and provide only a piece of a definition of successful PS. The problem that remains is: PS involves the adjudication between many different relevant values and that people (and disciplines) will disagree about which values should dominate in any specific PS context and that there is no agreed-upon normative approach for resolving the disagreement. When relevant values conflict, decision-makers must rely on developing context-specific agreement in order to achieve PS success.

The authors outline 10 elements crucial to successful PS, broken into two categories (process and outcomes). Process: stakeholder engagement; explicit process; information management; consideration of context and values; revision or appeals mechanism. Outcomes: stakeholder understanding; shifted priorities/reallocation of resources; improved decision-making quality; stakeholder acceptance  and satisfaction; positive externalities.

Listening for Direction - Canadian Health Services Research Foundation website.

The website provides details on the three different rounds of the Listening for Direction process, including final reports and papers.

“The primary aim of Listening for Direction is to identify areas where investments in research are most likely to help to improve system-level decision-making. The process requires the significant involvement of HC managers and policy-makers in the consultation meetings to identify and prioritize current and longer-term issues. The process also requires the involvement of lead researchers to help translate decision-makers’ needs for information into researchable questions. Listening for Direction is based on the principle of ‘linkage and exchange’ whereby funders, researchers and research-users are brought together in the interests of promoting the production of timely, relevant evidence to inform healthcare decision-making.”

“The Listening for Direction model builds on the respective areas of expertise of research funders, researchers and research-users. All groups participate in the process with varying degrees of intensity throughout its various phases. Representatives from the partner organizations (primarily research funders whose roles include knowledge transfer and research use) oversee the consultation process, listen to the discussions and, with the aid of expert researchers, use the concerns identified by decision-makers and other research-users to derive research questions. During the consultation workshops, research-users identify priority issues that would benefit from being informed by research. Researchers ‘translate’ those priority issues and concerns into research questions that are likely to provide evidence to help address those issues.”

Lomas J et al. On being a good listener: setting priorities for applied health services research.The Milbank Quarterly. 81:3, 2003. <pdf>

This published piece outlines the Listening for Direction model in loose academic style.

“...the listening model [is] interpretive, based on the principle of linkage and exchange between research funders and researchers on the one hand and the research’s potential users on the other. We contend that both sides need to listen to each other in order to arrive at research priorities that are relevant to decision-makers, feasible within the research community, and eventually incorporated into practice. This listening model has six steps:

•identify the stakeholders to participate in the consultation. A group of experts determine the desired mix of key stakeholders who should be consulted. Most of the participants should represent potential users of research, since the main objective of the consultation is to identify the priorities of these potential users.

•identify and assemble any data needed for the consultation. Data, such as on current system problems or existing research priorities, are collected to help inform participants’ discussions during the consultation and help them build on existing knowledge during their exchanges

•Design and complete the consultation with the stakeholders to identify those issues likely to be a priority over the next three to five years. The consultation should be designed to ensure that stakeholders are consulted on issues they feel will remain priorities in the long term, that is, for the next three-to-five years. This period takes into account the time needed for the design, conduct, and completion of primary resaerch studies. Stakeholders also could be consulted on shorter-term priorities that, if data are available, would help create a secondary research agenda for exercises such as synthesis or meta-analysis. This, however, means another step in the process to determine whether an adequate number of primary studies are, indeed, available for synthesis

•validate the identified priority issues against similar exercises. Validating the results of the consultation against other sources of similar information helps ensure that the priorities are generalizable and not artifactual to the particular process or people involved.

•translate priority issues into priority research themes. The priority issues uncovered through the consultation need to be ‘translated’ by research experts from pressing issues into prioritiy areas in which it is possible and/or feasible to do research

•validate the priority research themes with stakeholders. A validity check with the consulted stakeholders is needed to guarantee that the final research priorities truly reflect their expressed views.

Rudan I et al. Setting priorities in global child health research investments: universal challenges and conceptual framework. Croatian Medical Journal. 49, 2008. <pdf>

Excellent piece outlining some core issues.

•Universal challenges in setting priorities in health research investments identified by Child HElth and Nutrition Research Institute (CHNRI) experts:

1.Deciding who should be involved in the process of setting research priorities

2.Defining what constitutes a health research investment option opportunity

3.Defining what constitutes the expected ‘return’ on the investment

4.Defining what constitutes a potential ‘risk’ in the investment

5.Finding a way of dealing with uncertainty of health research outcomes

6.Defining health research, its boundaries, and its levels of ‘depth’

7.Systematic listing of many competing research investment options

8.Defining what is meant by ‘priority setting’ in the context of health research

9.Defining criteria relevant to PS in health research investments

10.Comparing different domains of health research using the same criteria

11.Development of a simple quantitative way to rank competing research options

12.Limiting the potential of personal biases to substantially influence the outcome

13.ensuring the PSP is fully transparent

14.Ensuring that it can be repeated and validated

15. Ensuring that it is flexible and adjustable to all contexts and levels of application

16.Ensuring that it is iterative with a feedback loop, instead of a one-way process

17.Ensuring that it is perceived by the users as legitimate and fair

18.Ensuring that it is simple and intuitive enough to become popular among users

19.Linking quantitative ranks of research options with specific investment decisions

20.Involving stakeholders from the wider community into the process.

•“criteria that can be used to discriminate between any two health research options that compete for investments in order to set research priorities:

•Acceptability: how likely is the proposed research to be approved, taking into account any possible resistance based on ethical or political grounds and public opinion?

•Affordability: how likely is it that the results will improve affordability of existing policies and programs?

•Answerability: how likely is it that the objectives will be met given the current state of science and the size of the gap in knowledge?

•Applicability: how likely is it that the results will be immediately applicable for guiding policies and programs?

•Deliverability: how likely is it that the results will improve the delivery of existing policies and programs?

•Equity: how likely is it that the proposed research will benefit those who are most vulnerable to poor child development?

•Feasibility: how likely is it that the cost of the proposed research will be a feasible investment?

•Potential effect on disease burden: how likely is the proposed research to lead to significant improvement in disease burden reduction?

•Sustainability: how likely is it that the results will improve sustainability of existing policies and programs?

•Usefulness: given the quality of existing evidence, how likely is it that the proposed research will fill a critical gap in knowledge?

•Existing research capacity: how likely is it that the objectives will be met given existing research capacity?

•Alignment with other policies: how well are the objectives aligned with other existing policies in society?

•Generation of commercial products: how likely is it that the proposed research will lead to patents and generate commercial products?

•Competitiveness and publication impact: how likely is it that the results of the research will be seen as competitive against other ongoing work and be accepted for publication in the journals with the highest impact factor?

•the variety of contexts in which PS occurs and ‘returns’ on investments expected by different donors are so large, that we believe it would not be possible to develop a ‘one-size-fits-all method with a fixed set of criteria and processes. the successful method that will have a chance to become accepted and popular will need to show very large flexibility in design to be readily tailored to different contexts and purposes. PS is a ‘science’ intending to serve the needs of a community or a society at a specific point in time, within given policy, context, time limit, and financial constraints. It is value-driven and there are many interested stakeholders who will necessarily promote a diverse set of opinions and values. There are also many possible criteria according to which priorities could be set, some of them conflicting each other.

Smith N et al. Identifying research priorities for health care priority setting: a collaborative effort between managers and researchers. BMC Health Services Research. 9:165, 2009. <pdf>

Article provides good details on an actual priority-setting process in British Columbia. Quotations:

•“for priority-setting decisions in a broader context: how can formal PS processes best align with and complement other decision-making processes? what consequential and reactive impacts result in the implementation of PS approaches? can we improve the measurement of costs and benefits to account for the full range of organizational impacts? can we assess the relative merits of implementing formal PS as a small-scale pilot or an organization-wide mandate?”

•“for PS implementation: report on typical criteria used in formal PS studies and guidance about how to draft locally relevant measures for assessing spending options; understand the different ways in which decision-makers understand and apply the concept of disinvestment; explore the rhetorical and tactical choices made in ‘bundling’ spending options and how these affect the results of formal PS; identify the personal, social and organizational dimensions of how decision-makers manage conflicting role loyalties in PS; improve the quality and accessibility of relevant data; identify the skills and capacities needed for effectively using formal PS methods, as well as the related education and training requirements; provide guidance about why, when and how to engage the public in PS and resource allocation decisions.

Ranson MK, Bennett SC. Priority setting and health policy and systems research. Health Research Policy and Systems. 7:27, 2009. <pdf>

This provides a good overview of different PS approaches, highlighting attention to:

•level: they may aim to set research priorities at global, national, sub-national or institutional levels

•comprehensiveness: some PSPs focus on relatively narrow sub-sets of research questions (what are the key research questions in the field of malaria control, or health workforce for example), whereas others aim to set research priorities for the whole of the health sector, others still may situate health research priorities within the broader context of scientific investment and research priorities in other fields.

•the balance between technical vs. interpretive approaches: PSPs within the health sector may be predominantly technical in nature, dominated by quantifiable epidemiologic or other needs and costs data, or more interpretive assessments, dominated by the consensus views of informed participants.

•stakeholders: those included in consultative process may be primarily researchers, or include a broader audience of research funders, research users and communities.

The authors state that further thought is needed on:

•development of mechanisms to determine the relative importance of research priorities established through different types of PSEs. The use of separate processes to identify health policy and systems research (HPSR) priorities and disease-specific priorities creates difficulties for research funders in terms of determining the relative weight to assign to disease-specific vs. HPSR.

•systematic investigation and development of guidance on how stakeholder engagement affects research priorities identification… the relationship between stakeholder involvement and the type of priorities identified has not been well documented. The relative weight or priority placed upon the viewpoints of different stakeholders can be adjusted according to the objective of the exercise and whose voice needs to be heard, but there is no clear set of principles guiding how best to do this. Finally, the outcome of an interpretive research priority setting exercise will depend also on whether data on health system performance (and constraints) is used as part of the process and if so how this is incorporated and weighted relative to the judgment of participants.

•information needs of target audiences… there is no mapping of, or systematic enquiry into how research funders would like to see research priorities presented.

•understanding the implications of HPSR capacity constraints for the identification of research priorities… good analyses are needed of how limited research capacity shapes the nature of research priorities, and how HPSR PS could also address capacity strengthening so as to strike a balance between investments in direct research funding and in capacity development.

Martin D, Abelson J, Singer P. Participation in health care priority-setting through the eyes of the participants. Journal of Health Services Research & Policy. 7:4, 2002. <pdf>

•the literature on participation in PS has three key gaps. First, techniques for obtaining public input into PS, such as surveys or citizens’ juries, are consultative mechanisms and do not involve the public directly in decision-making. Second, the lit is focused primarily on the public’s role in PS, not on all potential participants. Third, although there are a few studies of PS decision-making, we are unaware of any descriptions of the full range of roles various participants plan in groups making PS decisions.

Through their case study, the authors note six specific roles that can be very important in a PSE:

committee chair helps ensure that the committee adheres to fair procedures

administrators contribute to discussions of costs and goals and strategies

medical specialists contribute to discussions of disease conditions and treatment benefits

medical generalists contribute to discussions of evidence and alternatives

public representatives contribute to discussions of fair process, access and equity

patient representatives contribute discussions of patients’ needs and the impact of treatments on patients.

A good quote from a participant: “you don’t want the person who has the most expertise to shut up. And yet, you don’t want the committee to be over-influenced by, quote, an expert”.

•“in this paper we have described contributions that members of the public and patients can make to PS, and can feel comfortable making, such as discussions of fair process, access and equity, and the impact of treatment on patients. Focusing on these contributions may ease the trepidation some may feel towards participating in health care PS, particularly those who feel unqualified to evaluate complicated medical or economic evidence.

Bruni, RA, Laupacis A, Martin DK. Public engagement in setting priorities in health care.Canadian Medical Association Journal. 179:1, 2008. <pdf>

•“there are at least four reasons for believing that public engagement in setting health care priorities has value. First, because the public funds and uses the health care system, citizens are the most important stakeholders of the health care system. Thus, legitimacy and fairness demand that they be at the priority-setting table. Second, greater involvement of the public in policy-making is in keeping with the principles of democracy. Third, empowering people to provide input in decisions that affect their lives encourages support for those decisions, which in turn improves the public’s trust and confidence in the health care system. Fourth, public involvement provides a crucial perspective about the values and priorities of the community, which should lead to higher quality, or at least greater acceptance of, PS decisions.”

The public can be involved in a few ways:

as representatives on PS committees

as representatives on executive committees and boards (i.e. hospital boards and regional health authorities).

as members of citizens’ councils to provide ongoing advice on specific matters

as participates of surveys, citizens’ juries, community meetings, focus groups and the like, to provide feedback on all elements of PS.

Kapiriri L, Martin DK. A strategy to improve priority setting in developing countries. Health Care Analysis 15, 2007. <pdf>

•“the meager literature on PS in developing countries identified four major challenges: i) lack of information; ii) overcoming the disconnection between who is setting priorities in developing countries and who should be; iii) overcoming the disconnection between the values that are driving PS decisions in developing countries and the values that should be; and (iv) the weak institutions and meager capacity available to make PS decisions.

•the authors argue that “improvements in PS may not be realized unless there are corresponding efforts to: capture and share current PS practices; strengthen the legitimacy and capacity of PS institutions, and develop fair PSPs.”

•developing fair PSPs requires that the current practices are well aligned with the four conditions of AFR by ensuring that PS involves legitimate stakeholders, eliciting and defining a core set of values to guide PS, publicizing the decisions and reasons behind the PS decisions, and that some stakeholders ensure adherence to the three conditions. If not aligned - context-specific legitimate leaders would need training in order to enhance their capacity to implement fair PSPs. Where external illegitimate influences exist, these should be mitigated.

Gibson JL, Martin DK, Singer PA. Setting priorities in health care organizations: criteria, processes, and parameters of success. BMC Health Services Research. 4:25, 2004. <pdf>

•“parameters of success: outcome parameters - effect on organizational priorities and budget: priorities change; resources shift; SP supported/enhanced; conditions for growth created/enhanced; budget balanced; - effect on staff: staff satisfaction neutral or positive; retention/recruitment neutral or positive; organizational understanding improved; - effect on community: public media recognition neutral or positive; public acceptance or community support improved; public perception of institutional accountability improved; health care integration through partnerships increased; education/research peer recognition enhanced; emulated by other organizations.”

•“parameters of success: process parameters - efficiency of PSP: increased ease in allocating resources; improved capacity for making PS decisions; perceived return on time invested; - fairness: stakeholders understand the process; feel engaged; priorities are justified and seen to be reasonable; process is perceived to be consistent and fair; winners/losers issue well-managed.”

Peacock S, Ruta D, Mitton C, Donaldson C, Bate A, Murtagh M. Using economics to set pragmatic and ethical priorities. BMJ. Vol 332 25 February 2006. <pdf>

The authors outline the 7 stages of PS using program budgeting and marginal analsyis (PBMA):

“1. Determine the aim and scope of the PSE - will the analysis examine changes in service within a given program or between programs?

2. Compile a program budget - the resources and costs of programs combined with activity information

3. Form a marginal analysis advisory panel - the panel should include key stakeholders (managers, clinicians, consumers, etc) in the PSP

4. Determine locally relevant decision-making criteria - the advisory panel determines local priorities (maximizing benefits, improving access and equity, reducing waiting times, etc) with reference to national, regional and local objectives

5. Identify where services could grow and where resources could be released through improved efficiency or scaling back or stopping some services - the panel uses the program budget along with information on decision-making objectives, evidence on benefits from service, changes in local healthcare needs, and policy guidance to highlight options for investment and disinvestment.

6. Evaluate investments and disinvestments - evaluate the costs and benefits for each option and make recommendations for change

7. Validate results and reallocate resources - re-examine and validate evidence and judgments used in the process and reallocate resources according to cost-benefit ratios and other decision-making criteria.”

Daniels, N. Accountability for Reasonableness. BMJ. 321, 2000. <pdf>

A short, philosophical piece, outlining what has become good evaluation criteria for a PSP.

•“In pluralist societies we are likely to find reasonable disagreement about principles that should govern priority setting. For example, some will want to give more priority to the worst off, some less; some will be willing to aggregate benefits in ways that others are not. In the absence of consensus on principles, a fair process allows us to agree on what is legitimate and fair. Key elements of fair process will involve transparency about the grounds for decisions; appeals to rationales that all can accept as relevant to meeting health needs fairly; and procedures for revising decisions in light of challenges to them. Together these elements assure ‘accountability for reasonableness’.”

Teng F, Mitton C, MacKenzie J. Priority setting in the provincial health services authority: survey of key decision makers. BMC Health Services Research. 7:84, 2007. <pdf>

•“the process of PS is largely based on ‘the squeaky wheel getting the grease,’ and suggested that resources tend to go to ‘whoever yells the loudest’.”

•good quote from a decision-maker: “It’s a squeaky wheel process. Whoever is able to more clearly articulate their problem, or lobby for their group or, through some other form of power and influence, impact whatever process is in place that year will come out with some outcome.”

•“the majority of decision-makers felt that the ideal role of physicians would be to bring clinical evidence to the table.”

The Working Group on Priority Setting. Priority setting for health research: lessons from developing countries. Health Policy and Planning. 15:2, 2000. <pdf>

•countries that have used ENHR strategies have identified four general categories of participants: researchers, decision-makers at different levels, health service providers, and communities. However, the country experiences also suggest the need for stronger representation from the private sector (eg professional health associations, the pharmaceutical industry), parliamentarians and potential donors and international agencies.”

•“research priorities will depend on a two-step process of, first, selecting criteria for PS and, second, selecting research topics from among identified priority problem areas. The countries in this review used one or more criteria from the following categories:

magnitude and urgency of the problem, as suggested from quant and qual data in the requisite situation analysis;

extent of previous research and the potential contribution of research in discovering, developing or evaluating new interventions;

feasibility of carrying out the research in terms of the technical, economic, political, socio-cultural and ethical aspects;

expected impact of the research, considering both direct and indirect efforts, short- and long-term benefits, as well as its implications on issues of affordability, efficacy, equity and coverage.”

--“best buys” for global R&D according to WHO Ad Hoc Committee: “the magnitude of the problem; the reasons for the persistence of the problem; the current knowledge base; the cost-effectiveness of potential interventions; and the current level of effort.”

Wait S, Nolte E. Public involvement policies in health: exploring their conceptual basis. Health Economics, Policy and Law. 1, 2006. <pdf>

•“the incorporation of public views into policy making is perceived as a means to restore trust, improve accountability, and secure ‘cost-effective decision making’ within HC systems. Yet the evidence to support these assumptions remains scarce, partly because many of the current public participation initiatives in place are fairly recent. Also, their objectives and rationale are rarely stated.”

•“public involvement is a central theme of health policy reforms in many countries. Despite its obvious appeal, it is important to keep a clear and honest perspective of what public involvement policies aim to achieve and what health system changes may be needed to allow for their full implementation.”

•“Lomas et al (2003) suggest that one of the greatest challenges to involving the public in PS exercises is to ensure that the process for gathering public input is transparent, impartial, and truly reflects the values of users. There is substantial debate about the appropriate methods for eliciting preferences from the public to involve them in PS decisions. Some authors suggest that indirect input (via mediating institutions) is more feasible and appropriate than direct public input, which may result in hyper-democratic questioning of a wide range of stakeholders. In any case, the chosen approach for eliciting public input will inevitably involve a compromise between transparency of process and complexity and richness of the information gathered.”

Nuyens Y. Setting priorities for health research: lessons from low- and middle-income countries.Bulletin of the World Health Organization. 85:4, 2007. <pdf>

•“the process cannot function without proper tools, and the tools require a well-defined process.”

•“the recognition that the mix of stakeholders participating in PS is a key determinant of the selection of research and development practices has significantly influenced practices.”

•“despite countries’ related efforts to involve all stakeholders, the strategies and methods necessary to achieve a participatory process have not been developed or implemented systematically. There is no body of knowledge about how and when various stakeholders should be involved or what their functions and responsibilities should be.”

•“PS has often been handled as an isolated, one-off event that has little impact on, or relation to, other essential components used to construct a health research system.”

•“while most countries have recognized that PS needs to be an iterative process, few have made this process a cyclical, continual one. There are two common discontinuities. First, it is often not clear if or how the outcome of a national PS event will be fed back to the subnational level, nor how this level will adapt national priorities to its specific priority needs. Also, there is scant evidence about the implementation of health research priorities and its impact on producers (do they effectively produce prioritized research?) and users (do they effectively use the prioritized research?). Both discontinuities occurs in the implementation phase of the PSP, which is poorly documented and inadequately analyzed. The scientific community is therefore challenged to evaluate this process systematically and comprehensively.”

Peacock S et al. Overcoming barriers to priority setting using interdisciplinary methods. Health Policy. 92, 2009. <pdf>

Good overview of different PSP methods.

•to develop rational, fair and legitimate PSPs, “researchers and decision-makers need to adopt an interdisciplinary and collaborative approach to PS.”

•“understanding organizational culture and determining procedures to work through barriers are clear pre-requisites for any PSP. An understanding of the ‘antecedent conditions’ that exist in a given health organization must be obtained and used to plan whether the time and setting are most receptive to explicit PS activity. There must be one person with overall ‘change’ responsibility armed with an actionable plan for dissemination and implementation, and there must be an environment where learning and innovation are key pursuits. Strong leadership is critical, combined with buy-in from other stakeholders. Such commitment may be absent if the process itself is not perceived to be ‘fair and legitimate’. Finally, organizations typically consider multiple and potentially conflicting criteria (eg effectiveness, equity and budget impact) when making resource allocation decisions. Relevant decision-making criteria for the organization should be established at the outset of any PSE.”

Baltussen R, Niessen L. Priority setting of health interventions: the need for multi-criteria decision analysis. Cost Effectiveness and Resource Allocation. 4:14, 2006. <pdf>

•“a first, and probably most important, criterion is the societal wish to maximize general population health. This has indeed been the basis of many national disease programs in the past century. A second set of criteria relates to the distribution of health in the population. Societies may give high priority to interventions that target vulnerable population groups such as the poor, the severely ill, or children or women of reproductive age, because they are more deserving of health care than others. Also, societies may give high priority to the economically productive people to stimulate economic growth, or low priority to people who require health care as a result from irresponsible behaviour (Eg smoking). A third set of criteria responds to specific societal preferences, eg for acute care in life-threatening situations, or for curative over preventive services.”

•“A fourth set of criteria relates to the budgetary and practical constraints that policy-makers face when implementing interventions, including costs and availability of trained health workers, and may take these into account when choosing between interventions. Fifthly, political criteria may play an important role. Policy-Makers may not always be benevolent maximizers of social welfare, but may also act out of own (political) self-interest. Interest groups in societies exercise their influence on policy-makers to prioritize interventions according to their objectives, and policy-makers may be sensitive to this in their efforts to maximize political support. For example, health expenditures in many developing countries are often focused on services for richer areas or groups at the expense of the poor, even when the latter offers greater scope for cost-effective healthcare. Also, policy-makers may follow funding preferences of (international) organizations, which may not always cohere with national priorities.”

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