How have systematic priority setting approaches influenced policy making? A synthesis of the current literature

doi:10.1016/j.healthpol.2017.07.003

Health Policy

Volume 121, Issue 9, September 2017, Pages 937-946

https://doi.org/10.1016/j.healthpol.2017.07.003 Get rights and content

Highlights

•
Systematic approaches to healthcare priority setting can improve policy making.
•
There is need to assess if the common approaches have impacted policy making.
•
While some have been used, their complexity and resource requirements hamper their institutionalization.

Abstract

Background

There is a growing body of literature on systematic approaches to healthcare priority setting from various countries and different levels of decision making. This paper synthesizes the current literature in order to assess the extent to which program budgeting and marginal analysis (PBMA), burden of disease & cost-effectiveness analysis (BOD/CEA), multi-criteria decision analysis (MCDA), and accountability for reasonableness (A4R), are reported to have been institutionalized and influenced policy making and practice.

Methods

We searched for English language publications on health care priority setting approaches (2000–2017). Our sources of literature included PubMed and Ovid databases (including Embase, Global Health, Medline, PsycINFO, EconLit).

Findings

Of the four approaches PBMA and A4R were commonly applied in high income countries while BOD/CEA was exclusively applied in low income countries. PBMA and BOD/CEA were most commonly reported to have influenced policy making. The explanations for limited adoption of an approach were related to its complexity, poor policy maker understanding and resource requirements.

Conclusions

While systematic approaches have the potential to improve healthcare priority setting; most have not been adopted in routine policy making. The identified barriers call for sustained knowledge exchange between researchers and policy-makers and development of practical guidelines to ensure that these frameworks are more accessible, applicable and sustainable in informing policy making.

Section snippets

Introduction/Background

Priority setting, (PS), a process involving decision making about the allocation of resources between the competing claims of different services, different patient groups or different elements of care [1], is one of the most critical health policy challenge because of the gap between the increasing population health demands and needs and the resources that should meet them [2]. Several priority setting frameworks have been developed to provide guidance for the policy makers who have to make

Methods

This was a scoping literature review. Our sources of literature included PubMed and Ovid databases (including Embase, Global Health, Medline, PsycINFO). We searched for peer-reviewed literature on priority setting in health care published between January 2000 and March 2017. Search terms included “priority setting”, “resource allocation”, “health care”, “health systems”, “health interventions”, “approaches”, “initiatives” and “frameworks”. Subsequent searches involved a combination of the

Data extraction and synthesis

The following steps were followed;

i)
Developing the data extraction tool: LK & SDR developed the data extraction tool based on the relevant themes namely; name of the framework, countries and level of application; priority setting case, health issue or health program; paper type; decision maker satisfaction or perception of the utility of the approach, whether or not the framework/priorities influenced policy making.
ii)
Data extraction: Using the data extraction tool, SDR read through the selected

Results

This section is organised according to the frameworks. For each framework there is a description of the framework and the reported country/region and level of its application, an assessment of ‘decision maker perspectives on its utility, and whether or not the framework is reported to have impacted policy or to have been adopted for routine policy making (Table 4).

Program budgeting and marginal analysis (PBMA)

The program budgeting and marginal analysis (PBMA) approach relies on two fundamental economic principles in its approach to priority setting: opportunity cost and marginal analysis [11]. The notion of opportunity cost implies that if resources are invested in one area, there are benefits that are given up in another area. Marginal analysis is concerned with the last unit of production of any two or more given programs. Marginal analysis allows decision makers to identify the best mix of

Multi-criteria decision analysis (MCDA)

We retrieved and reviewed twenty papers that described the application of the Multi- criteria decision analysis (MCDA) approach. Multi-criteria decision analysis facilitates the use of multiple explicit criteria in priority setting [4]. The process consists of four steps: 1) identifying policy criteria and metrics; 2) identifying a series of alternatives based on various combinations of policy criteria; 3) measuring performance of alternatives by criteria (through discrete choice experiment

Accountability for reasonableness

Accountability for reasonableness (A4R), is an ethics-based, and process-driven framework that focuses on ensuring that the priority setting process is fair [59]. According to this framework, a fair PS process should fulfill four conditions namely: Publicity: both the decisions and rationales of used in PS must be made publicized; Relevance: the rationales that guide the PS process must be considered to be relevance by “fair-minded” people in the context in which the framework is being applied;

Burden of disease and cost-effectiveness analysis (BOD & CEA)

The BOD/CEA approach was first introduced in the World Bank’s World Development Report of 1993, ‘Investing in Health’ [85]. In this approach, effectiveness is evaluated based on both mortality and morbidity data, under a composite measure; the Disability Adjusted Life Year (DALYs) [86]. DALYs are then used in CEA, whereby interventions with the most favorable cost-effectiveness ratio are prioritized. In many contexts, the most cost- effective interventions comprise the essential or basic health

Discussion

While there is a wealth of literature on approaches to priority setting, there is a paucity of synthesizes of the current literature to assesses the degree to which the approaches that have been developed to guide priority setting have influenced policy making and have been institutionalized. This paper filled this gap.

There were relatively limited peer review publications reporting on the degree to which all the approaches have influenced policy making and have been institutionalized. Although

Conclusion

This review found that while the intention of developing the priority setting approaches is for them to eventually be used to guide routine policy making, to date, not many have been integrated into routine practice. Sited limitations included technical complexity of the approaches and the resource requirements. Conversely, although some approaches, e.g. BOD/CEA, were perceived to be complex by some stakeholders, they have been integrated into routine policy making. This could be explained by

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71 national plans were readily accessible while 43 were not. There were no systematic differences between the countries whose plans were readily available and those whose plans were ‘missing’. However, most of the countries with ‘missing’ plans tended to have a low transparency index. The framework was adapted to the pandemic context by adding a parameter on the need to plan for continuity of priority routine services. While document review may be the most feasible and appropriate approach to conducting policy analysis during health emergencies, interviews and follow up document review would assess policy implementation.
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Systematic priority setting (PS), based on explicit criteria, is thought to improve the quality and consistency of the PS decisions. Among the PS criteria, there is increased focus on the importance of equity considerations and vulnerable populations. This paper discusses the PS criteria that were included in the national COVID-19 pandemic plans, with specific focus on equity and on the vulnerable populations considered. Secondary synthesis of data, from a global comparative study that examined the degree to which the COVID-19 plans included PS, was conducted. Only 32 % of the plans identified explicit criteria. Severity of the disease and/or disease burden were the commonly mentioned criteria. With regards to equity considerations and prioritizing vulnerable populations, 22 countries identified people with co-morbidities others mentioned children, women etc. Low social-economic status and internally displaced population were not identified in any of the reviewed national plans. The limited inclusion of explicit criteria and equity considerations highlight a need for policy makers, in all contexts, to consider instituting and equipping PS institutions who can engage diverse stakeholders in identifying the relevant PS criteria during the post pandemic period. While vulnerability will vary with the type of health emergency- awareness of this and having mechanisms for identifying and prioritizing the most vulnerable will support equitable pandemic responses.
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Health care budgets in high-income countries are having issues coping with unsustainable growth in demand, particularly in the hospital setting. Despite this, implementing tools systematising priority setting and resource allocation decisions has been challenging. This study answers two questions: (1) what are the barriers and facilitators to implementing priority setting tools in the hospital setting of high-income countries? and (2) what is their fidelity? A systematic review using the Cochrane methods was conducted including studies of hospital-related priority setting tools reporting barriers or facilitators for implementation, published after the year 2000. Barriers and facilitators were classified using the Consolidated Framework for Implementation Research (CFIR). Fidelity was assessed using priority setting tool's standards. Out of thirty studies, ten reported program budgeting and marginal analysis (PBMA), twelve multi-criteria decision analysis (MCDA), six health technology assessment (HTA) related frameworks, and two, an ad hoc tool. Barriers and facilitators were outlined across all CFIR domains. Implementation factors not frequently observed, such as ‘evidence of previous successful tool application’, ‘knowledge and beliefs about the intervention’ or ‘external policy and incentives’ were reported. Conversely, some constructs did not yield any barrier or facilitator including ‘intervention source’ or ‘peer pressure’. PBMA studies satisfied the fidelity criteria between 86% and 100%, for MCDA it varied between 36% and 100%, and for HTA it was between 27% and 80%. However, fidelity was not related to implementation. This study is the first to use an implementation science approach. Results represent the starting point for organisations wishing to use priority setting tools in the hospital setting by providing an overview of barriers and facilitators. These factors can be used to assess readiness for implementation or to serve as the foundation for process evaluations. Through our findings, we aim to improve the uptake of priority setting tools and support their sustainable use.
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The initial goal should be to address the needs of the disadvantaged in sustainable and scalable ways. Priority setting is inherently a value-laden process, and cannot be whittled down to technical considerations of clinical or cost-effectiveness alone; diverse frameworks therefore increasingly are being used simultaneously.81,82 Evidence is needed to feed into the deliberative process, but interpretation of the evidence requires a broad perspective and consideration of multiple ethical principles and values, with a willingness to learn and adapt such that decision making can be optimized in an iterative fashion.83
Summary: Priority-setting dilemmas arise when trade-offs must be made regarding the kinds of services that should be provided and to whom, thereby withholding other services from individuals or groups that could benefit from them. Currently, it is practically impossible for lower-income countries to provide dialysis for all patients with kidney failure; however, the fundamental premise of the human right to health, while acknowledging the current resource constraints, is the progressive realization of access to care for all. In this article we outline the rationale for priority setting, starting with the global goal of achieving universal health coverage, the prerequisites for fair and transparent priority setting, and discuss how these may apply to expensive care such as dialysis. Priority is inherently a value-laden process, and cannot be whittled down to technical considerations of clinical or cost effectiveness alone. Fair and transparent priority setting should originate from population health needs, be based on evidence, and be associated with ethical values or principles. This requires effective engagement with relevant stakeholders. Once policies are developed and implemented, good oversight is crucial to ensure accountability and to provide iterative feedback such that the goals of universal health coverage may be progressively realized.
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The fact that the stipulations of the frameworks are not being followed may reflect that many of the included studies were research projects. Feasibility of comprehensive stakeholder participation that includes not only the powerful stakeholders, but also publics and vulnerable groups, can be limited in the context of a research project rather than implementation of the frameworks in actual policymaking contexts [18,23]. Disconnects between the foundational papers and applications of the frameworks may also point to some practical limitations of public participation.
There is a growing body of literature that describes, applies, and evaluates applications of health-system priority-setting frameworks in different contexts. However, little explicit focus has been given to examining operationalization of the stakeholder participation component of these frameworks. The literature identifies the public as a stakeholder group and recommends their participation when applying the frameworks.
We conducted a scoping review to search the PubMed, EMBASE, HealthSTAR, Medline, and PsycINFO databases for cases where priority-setting frameworks were applied (2000–2017). We aimed to synthesize current literature to examine the degree to which the public and vulnerable populations have been engaged through applications of these frameworks
The following stakeholders commonly participated: managers, administrators/coordinators, clinicians/physicians, non-physician health care providers, health economists, academics/researchers, experts, decision-makers, and policy-makers. Few papers reported on public participation, and even fewer identified vulnerable groups that participate. Stakeholders were most commonly reported to participate in identifying areas for prioritization.
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ReviewHow have systematic priority setting approaches influenced policy making? A synthesis of the current literature

Highlights

Abstract

Background

Methods

Findings

Conclusions

Section snippets

Introduction/Background

Methods

Data extraction and synthesis

Results

Program budgeting and marginal analysis (PBMA)

Multi-criteria decision analysis (MCDA)

Accountability for reasonableness

Burden of disease and cost-effectiveness analysis (BOD & CEA)

Discussion

Conclusion

Rationing in the fiscal ice age

Health Economics, Policy and Law

Public participation in health care priority setting: a scoping review

Health Policy (New York)

“Rationing” health care: not all definitions are created equal

Archives of Internal Medicine

Priority setting of health interventions: the need for multi-criteria decision analysis

Cost Effectiveness and Resource Allocation [Internet]

International experience of rationing

Introducing new priority setting and resource allocation processes in a Canadian Healthcare Organization: a case study analysis informed by multiple streams theory

Kerman University of Medical Sciences [Internet]

Priority setting: what constitutes success? A conceptual framework for successful priority setting

BMC Health Services Research [Internet]

Evaluating “success” in programme budgeting and marginal analysis: a literature review

Journal of Health Services Research & Policy

Successful priority setting in low and middle income countries: a framework for evaluation

Health Care Analysis

Priority setting in health care: lessons from the experiences of eight countries

International Journal for Equity in Health [Internet]

Setting priorities and allocating resources in health regions: lessons from a project evaluating program budgeting and marginal analysis (PBMA)

Health Policy (New York)

Listening to the decision makers: sustainability of PBMA in Alberta

Applied Health Economics and Health Policy

A priority-setting framework for Canadian regional health authorities

Healthcare Management Forum [Internet]

The evolution of PBMA: towards a macro-level priority setting framework for health regions

Health Care Management Science

Resource allocation in health care: health economics and beyond

Health Care Analysis

Setting priorities in Canadian regional health authorities: a survey of key decision makers

Health Policy (New York)

From the trenches: views from decision-makers on health services priority setting

Health Services Management Research

Ethics and economics: does programme budgeting and marginal analysis contribute to fair priority setting?

Journal of Health Services Research & Policy

Priority setting in a Canadian surgical department: a case study using program budgeting and marginal analysis

Canadian Journal of Surgery

Introducing priority setting and resource allocation in home and community care programs

Journal of Health Services Research & Policy

Evaluation of the impact of program budgeting and marginal analysis in Vancouver Island Health Authority

Journal of Health Services Research & Policy

Difficult decisions in times of constraint: criteria based resource allocation in the Vancouver coastal health authority

BMC Health Services Research [Internet]

Changing priority setting practice: the role of implementation in practice change

Health Policy (New York) [Internet]

Determining and broadening the definition of impact from implementing a rational priority setting approach in a healthcare organization

Social Science & Medicine [Internet]

Evaluating priority setting success in healthcare: a pilot study

BMC Health Services Research [Internet]

Allocating limited resources in a time of fiscal constraints: a priority setting case study from Dalhousie University faculty of medicine

Academic Medicine

A qualitative evaluation of program budgeting and marginal analysis in a Canadian Pediatric Tertiary Care Institution

Applied Health Economics and Health Policy

The costs of caring for stroke patients in a GP-led community hospital: an application of programme budgeting and marginal analysis

Health & Social Care in the Community

Use of programme budgeting and marginal analysis as a framework for resource reallocation in respiratory care in North Wales, UK

Journal of Public Health (Oxford)

A national Programme Budgeting and Marginal Analysis (PBMA) of health improvement spending across Wales: disinvestment and reinvestment across the life course

BMC Public Health

Programme approach to managing informed commissioning

Health Services Management Research

Using programme budgeting and marginal analysis (PBMA) to set priorities: reflections from a qualitative assessment in an english primary care trust

Review
How have systematic priority setting approaches influenced policy making? A synthesis of the current literature