Priority setting at the micro-, meso- and macro-levels in Canada, Norway and Uganda
Introduction
Priority setting, the allocation of resources between competing demands, occurs in every health system at the macro-level (national, provincial), meso-level (regional, institutional) and micro-level (clinical programs). Priority setting determines the sustainability of any health system, whether primarily publicly or privately financed, and so is one of the greatest challenges faced by policy makers in both developed and developing countries [1], [2].
Developed countries, such as Canada and Norway, face growing challenges because of an aging population, advancements in expensive medical technology and increased demands fuelled by increasing access to information [3], [4]; while developing countries such as Uganda, face growing challenges of an increasing gap between the health needs and the meager resources available to respond to them, underdeveloped capacity for decision-making, and weak institutional infrastructure [5], [6]. Priority setting in developing countries has been said to be ad hoc [7]. Since they differ economically, socially and politically (Table 1), decision makers in these varying contexts have used different approaches to set priorities.
Canada, Norway and Uganda are also different enough with regards to their experiences with priority setting to provide informative comparators. Canada lacks a national level priority-setting process, decisions are decentralized to the provincial governments which have varying priority-setting processes. Furthermore, it has a complex web of interconnected priority-setting processes that vary across contexts. It has been called a laboratory from which lessons can be drawn [8], [9]. Norway, on the other hand, has one of the most responsive health care systems world wide. Although decentralized to the county level, Norway also has a national level priority-setting process. It was among the first countries to attempt to systematise priority setting by setting up a national council for priority setting as early as 1987 [10], [11], [12]. Uganda is the only low-income country among the three. While it also has a decentralized public health care system, similar to Norway, most of the priority setting occurs at the national level and districts follow the national guidelines. Uganda has much experience making difficult priority-setting decisions in the face of insufficient resources, but it has not yet gained as much experience in systematizing its priority setting [13], [14]. Although priority setting in Uganda should be evidence based, it has been said to occur more by chance than choice [15]. A systematic study of priority setting in these three health systems would yield valuable lessons. However, to date, no detailed cross-country comparisons between these diverse contexts exist.
Such comparisons would necessitate using a common lens, such as a conceptual framework, for examining, discussing, or thinking about diverse data. Accountability for reasonableness’ with its four conditions (relevance, publicity, revisions and enforcement) (Box 1) is a leading conceptual framework for evaluating fair priority-setting processes. It has been used by both decision makers and scholars to identify good practices and opportunities for improvement in relation to priority setting [16], [17]. We use this framework in our comparisons.
The objectives of this study were to (1) describe the process of healthcare priority setting in Ontario-Canada, Norway and Uganda at the macro-, meso- and micro-levels; (2) evaluate the description using a common conceptual framework, accountability for reasonableness; (3) identify lessons of good practise.
To the best of our knowledge, this is the first study to describe, evaluate, and compare lessons across different priority-setting contexts in developed and developing countries.
Section snippets
Design
We conducted case studies of priority setting at the micro-, meso- and macro-levels of policy making. A case study is “an empirical” inquiry that investigates a contemporary phenomenon within its real-life context. It is a structured, yet flexible approach to data collection and analysis that has historically been used to describe institutions and their actions [19]. We limited our inquiry to priority setting broadly relating to the hospital sector—in publicly funded health systems, hospital
Results
The results of this study are organized in two sections: first, we describe the priority-setting processes (including the actors, the reasons, how decisions are disseminated and any provisions for revisions) at the three levels in each country. Second, we evaluate the descriptions using accountability for reasonableness. Verbatim quotes are included to illustrate key points. The cross-country lessons are presented in Section 4.
Discussion
In this paper we have described priority setting at the macro-, meso- and micro-levels of policy making, in Ontario, Norway and Uganda, with a specific focus on hospitals, and evaluated the descriptions using a leading conceptual framework ‘accountability for reasonableness’.
To the best of our knowledge this is the first study that compares priority-setting processes between developed and developing countries across the three levels of health policy decision-making. The conceptual framework was
References (41)
- et al.
Adoption of new health care services in Norway (1993–1997): specialists’ self-assessment according to national criteria for priority setting
Health Policy
(2001) - et al.
Using the burden of disease information for health planning in developing countries: experiences from Uganda
Social Science and Medicine
(2003) - et al.
Knowledge management in clinical practice: a systematic review of information seeking behavior in physicians
International Journal of Medical Informatics
(2003) - et al.
Hospital priority setting with an appeals process: a qualitative case study and evaluation
Health Policy
(2005) - et al.
International experience of rationing (or priority setting)
- et al.
Managing scarcity: priority setting and rationing in the National Health Service
(1998) Choices in health care
(1992)Limiting access to health care. A contractualist approach to fair rationing
(1996)Health priority dilemas in developing countries
Public health priorities and the social determinants of ill health
Opportunities for public accountability in priority setting: the case of Uganda
Priority setting and health technology assessment: beyond evidence-based medicine and cost-effectiveness analysis
Canada
Norway
Procedures for priority setting and mechanisms of appeal in the Norwegian health care system
Criteria for priority setting in health care in Uganda: exploration of stakeholders’ values
Bulletin of the World Health Organization
Providing a core set of health interventions for the poor. Towards developing a framework for reviewing and planning—a systemic approach. Background document
Priority setting and hospital strategic planning: a qualitative case study
Journal of Health Services Research and Policy
Cited by (107)
Barriers and facilitators to implementing priority setting and resource allocation tools in hospital decisions: A systematic review
2023, Social Science and MedicineSalient stakeholders: Using the salience stakeholder model to assess stakeholders’ influence in healthcare priority setting
2021, Health Policy OPENCitation Excerpt :Second, contrary to the perception that priority setting decisions are technical, in practice priority setting decisions are both political and value-laden. Hence, involving a varying range of stakeholders enhances accountability and the legitimacy of the priority setting decisions [1,4–8]. In relationship to the politics of priority setting, involving a wide range of stakeholders creates shared decision-making on key policy issues, which supports consensus building around critical decisions and contributes to the resolving of the moral conflicts that are pervasive in pluralistic societies [9,10].
The whole systems energy injustice of four European low-carbon transitions
2019, Global Environmental ChangeCitation Excerpt :By macro, we refer to injustices that occur and circulate at the regional, transnational, and global scale. This micro-meso-macro framing has been used extensively in other fields, notably evolutionary economics (Dopfer et al., 2004), innovation studies and technology analysis (Jamison and Baark, 1990), health studies (Kapiriri et al., 2007), and environmental studies (Liljenstrom and Svedin, 2005), but has not been applied to energy justice analysis. We also draw on the transitions field, recognizing that low carbon transitions are geographically-constituted processes (Bridge et al., 2013), and that there is a need to go beyond nationally bounded case analysis (Raven et al., 2012).
Health systems research in burn care: An evidence gap map
2023, Injury Prevention