Elsevier

Health Policy

Volume 82, Issue 1, June 2007, Pages 78-94
Health Policy

Priority setting at the micro-, meso- and macro-levels in Canada, Norway and Uganda

https://doi.org/10.1016/j.healthpol.2006.09.001Get rights and content

Abstract

The objectives of this study were (1) to describe the process of healthcare priority setting in Ontario-Canada, Norway and Uganda at the three levels of decision-making; (2) to evaluate the description using the framework for fair priority setting, accountability for reasonableness; so as to identify lessons of good practices.

Methods

We carried out case studies involving key informant interviews, with 184 health practitioners and health planners from the macro-level, meso-level and micro-level from Canada-Ontario, Norway and Uganda (selected by virtue of their varying experiences in priority setting). Interviews were audio-recorded, transcribed and analyzed using a modified thematic approach. The descriptions were evaluated against the four conditions of “accountability for reasonableness”, relevance, publicity, revisions and enforcement. Areas of adherence to these conditions were identified as lessons of good practices; areas of non-adherence were identified as opportunities for improvement.

Results

(i) Description: at the macro-level, in all three countries, cabinet makes most of the macro-level resource allocation decisions and they are influenced by politics, public pressure, and advocacy. Decisions within the ministries of health are based on objective formulae and evidence. International priorities influenced decisions in Uganda. Some priority-setting reasons are publicized through circulars, printed documents and the Internet in Canada and Norway. At the meso-level, hospital priority-setting decisions were made by the hospital managers and were based on national priorities, guidelines, and evidence. Hospital departments that handle emergencies, such as surgery, were prioritized. Some of the reasons are available on the hospital intranet or presented at meetings. Micro-level practitioners considered medical and social worth criteria. These reasons are not publicized. Many practitioners lacked knowledge of the macro- and meso-level priority-setting processes. (ii) Evaluationrelevance: medical evidence and economic criteria were thought to be relevant, but lobbying was thought to be irrelevant. Publicity: all cases lacked clear and effective mechanisms for publicity. Revisions: formal mechanisms, following the planning hierarchy, were considered less effective, informal political mechanisms were considered more effective. Canada and Norway had patients’ relations officers to deal with patients’ dissensions; however, revisions were more difficult in Uganda. Enforcement: leadership for ensuring decision-making fairness was not apparent.

Conclusions

The different levels of priority setting in the three countries fulfilled varying conditions of accountability for reasonableness, none satisfied all the four conditions. To improve, decision makers at the three levels in all three cases should engage frontline practitioners, develop more effectively publicized reasons, and develop formal mechanisms for challenging and revising decisions.

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

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