Setting priorities in health care organizations: criteria, processes, and parameters of success

Background

Hospitals and regional health authorities must set priorities in the face of resource constraints. Decision-makers seek practical ways to set priorities fairly in strategic planning, but find limited guidance from the literature. Very little has been reported from the perspective of Board members and senior managers about what criteria, processes and parameters of success they would use to set priorities fairly.

Discussion

We facilitated workshops for board members and senior leadership at three health care organizations to assist them in developing a strategy for fair priority setting. Workshop participants identified 8 priority setting criteria, 10 key priority setting process elements, and 6 parameters of success that they would use to set priorities in their organizations. Decision-makers in other organizations can draw lessons from these findings to enhance the fairness of their priority setting decision-making.

Summary

Lessons learned in three workshops fill an important gap in the literature about what criteria, processes, and parameters of success Board members and senior managers would use to set priorities fairly.     

Priority setting and economic appraisal: whose priorities--the community or the economist?

Scarce resources for health require a process for setting priorities. The exact mechanism chosen has important implications for the type of priorities and plans set, and in particular their relationship to the principles of primary health care. One technique increasingly advocated as an aid to priority setting is economic appraisal. It is argued however that economic appraisal is likely to reinforce a selective primary health care approach through its espousal of a technocratic medical model and through its hidden but implicit value judgements. It is suggested that urgent attention is needed to develop approaches to priority setting that incorporate the strengths of economic appraisal, but that are consistent with comprehensive primary health care.     

Health research priority setting in selected high income countries: a narrative review of methods used and recommendations for future practice

Research priority setting aims to gain consensus about areas where research effort will have wide benefits to society. While general principles for setting health research priorities have been suggested, there has been no critical review of the different approaches used. This review aims to: (i) examine methods, models and frameworks used to set health research priorities; (ii) identify barriers and facilitators to priority setting processes; and (iii) determine the outcomes of priority setting processes in relation to their objectives and impact on policy and practice.Medline, Cochrane, and PsycINFO databases were searched for relevant peer-reviewed studies published from 1990 to March 2012. A review of grey literature was also conducted. Priority setting exercises that aimed to develop population health and health services research priorities conducted in Australia, New Zealand, North America, Europe and the UK were included. Two authors extracted data from identified studies.Eleven diverse priority setting exercises across a range of health areas were identified. Strategies including calls for submission, stakeholder surveys, questionnaires, interviews, workshops, focus groups, roundtables, the Nominal Group and Delphi technique were used to generate research priorities. Nine priority setting exercises used a core steering or advisory group to oversee and supervise the priority setting process. None of the models conducted a systematic assessment of the outcomes of the priority setting processes, or assessed the impact of the generated priorities on policy or practice. A number of barriers and facilitators to undertaking research priority setting were identified.The methods used to undertake research priority setting should be selected based upon the context of the priority setting process and time and resource constraints. Ideally, priority setting should be overseen by a multi-disciplinary advisory group, involve a broad representation of stakeholders, utilise objective and clearly defined criteria for generating priorities, and be evaluated.     

How should health and healthcare priorities be set and evaluated? Prioritization methods and regional disparities. 2008 SESPAS Report

The conflict between scarce resources and unlimited needs is perhaps more prominent in the healthcare sector than in any other areas. Thus, setting priorities in health care emerges as an unavoidable task. The laudable aim of adopting any health technology that improves the population's health is impossible when confronted by budgetary constraints. Therefore, the outstanding health problems of a society and the most efficient health technologies in terms of their cost-effectiveness must be identified and patients must be prioritized, bearing in mind aspects of equity and efficiency. The present article reviews the issue of setting health care priorities by examining the experiences that have been put into practice in Spain and abroad. The problem is analyzed at three levels: the "macro" level (strategic planning, identification of higher priority areas and the selection of health care interventions); the "meso" level (incorporation of cost-effectiveness analyses into clinical practice guidelines), and the "micro" level (how to design priority systems for patients on waiting lists based on clinical and social criteria). In all these levels, there is substantial heterogeneity between Spanish regional health services, the steps that need to be taken and the ground that needs to be covered. Thus, we suggest that the first steps that some regional health services have made, together with international initiatives, could serve as a reference for the definitive incorporation of new approaches in priority setting in the Spanish health system as a whole.     

Health services reform in Poland: issues in recent developments

After ten years of debate and discussion, the political situation within Poland finally allows the possibility to implement basic reforms in the health care system. Parallel development of the political and technical aspects of the reform has now lead to a final proposal for fundamental reforms in health system responsibility, financing and management. This article describes the current conceptual developments and the political and social context for these final reform proposals at the time of their submission to the government. The primary changes suggested are aimed at increasing the awareness of local, regional and national administrations, health care professionals and the general public that health care has a cost, and that resources must be used carefully if they are to cover health needs. In addition, 'health care' as a term must be extended to include factors and activities besides direct medical services. Such factors as air and water quality, diet, smoking and alcohol consumptions are examples of matters which will also be included in the focus of health system planners. A key element of the organisational reforms is decentralisation of responsibility for health care planning and administration within the framework of nationally set standards and priorities. Based on local decisions, the current basic organisation unit of health care delivery, the ZOZ or integrated health care units, will be redefined and either decomposed into their component services or receive newly defined responsibilities more adapted to the local realities of available manpower and medical facilities. In addition, the development of a private health care sector complementing and even competing with the public services sector will be actively encouraged.     

Citizens and rationing: analysis of a European survey

While many studies have reviewed the issues involved in rationing and priority setting within health care services, few studies have comprehensively analysed the views and attitudes of a significant stakeholder in the debate - the public. The aims of this paper are to discuss the issues involved in involving the public in rationing and priority setting decision-making; and to analyse data pertaining to citizen's attitudes towards rationing and priority setting. The data analysed were taken from the 1998 Eurobarometer Survey, with specific questions pertaining to rationing and priority setting asked in six countries within the European Union: Germany; France; Italy; the Netherlands; Britain and Sweden. The review of previous studies and the analysis of the Eurobarometer data, focus on issues relating to funding for health care; the need to set limits in health coverage; the role of stakeholders in setting priorities; and the use of age, and other factors, as a criteria for setting priorities.     

Priority setting in Ontario's LHINs: ethics and economics in action

Healthcare organizations the world over are faced with having to set priorities and allocate resources within the constraint of a fixed envelope of funding. Drawing on economic principles of value for money and ethical principles of fair process, a priority setting framework was developed for Ontario's local health integration networks (LHINs) in late 2007 and early 2008. Subsequently, over an 18-month period, the framework was piloted in three LHINs. In this article, the framework and pilot implementations are described, results from a formal evaluation are outlined and recommendations for future use are highlighted.     

The public and professional interface with priority setting in the National Health Service

The agenda of purchasers of health care in the National Health Service (NHS) is increasingly dominated by the issue of priority setting. This is a consequence of the interplay of limited budgets, increasing demands on health care services and a contracting process that makes explicit resource decisions that were previously implicit through clinical discretion. Purchasers are increasingly concerned to show that their decisions are rationally informed and embody a professional and public consensus. This paper examines literature that suggests variables, other than rational determinants, play a part in the process of priority setting at the purchaser and provider level. The interface of public, political and professional agendas in this process help explain the lack of national uniformity in both setting priorities and their translation into practice. Consequently, there is a need for more comprehensive exploration of the relationship between the setting of priorities and their effect on practice.     

A Strategy to Improve Priority Setting in Developing Countries

Because the demand for health services outstrips the available resources, priority setting is one of the most difficult issues faced by health policy makers, particularly those in developing countries. Priority setting in developing countries is fraught with uncertainty due to lack of credible information, weak priority setting institutions, and unclear priority setting processes. Efforts to improve priority setting in these contexts have focused on providing information and tools. In this paper we argue that priority setting is a value laden and political process, and although important, the available information and tools are not sufficient to address the priority setting challenges in developing countries. Additional complementary efforts are required. Hence, a strategy to improve priority setting in developing countries should also include: (i) capturing current priority setting practices, (ii) improving the legitimacy and capacity of institutions that set priorities, and (iii) developing fair priority setting processes.     

Health care priority setting: principles, practice and challenges

BACKGROUND: Health organizations the world over are required to set priorities and allocate resources within the constraint of limited funding. However, decision makers may not be well equipped to make explicit rationing decisions and as such often rely on historical or political resource allocation processes. One economic approach to priority setting which has gained momentum in practice over the last three decades is program budgeting and marginal analysis (PBMA). METHODS: This paper presents a detailed step by step guide for carrying out a priority setting process based on the PBMA framework. This guide is based on the authors' experience in using this approach primarily in the UK and Canada, but as well draws on a growing literature of PBMA studies in various countries. RESULTS: At the core of the PBMA approach is an advisory panel charged with making recommendations for resource re-allocation. The process can be supported by a range of 'hard' and 'soft' evidence, and requires that decision making criteria are defined and weighted in an explicit manner. Evaluating the process of PBMA using an ethical framework, and noting important challenges to such activity including that of organizational behavior, are shown to be important aspects of developing a comprehensive approach to priority setting in health care. CONCLUSION: Although not without challenges, international experience with PBMA over the last three decades would indicate that this approach has the potential to make substantial improvement on commonly relied upon historical and political decision making processes. In setting out a step by step guide for PBMA, as is done in this paper, implementation by decision makers should be facilitated.     

The use of nominal group technique in identifying community health priorities in Moshi rural district, northern Tanzania

This article highlights issues pertaining to identification of community health priorities in a resource poor setting. Community involvement is discussed by drawing experience of involving lay people in identifying priorities in health care through the use of Nominal Group Technique. The identified health problems are compared using four selected village communities of Moshi district in Kilimanjaro region, Tanzania. We conducted this study to trace the experience and knowledge of lay people as a supplement to using 'health experts' in priority setting using malaria as a tracer condition. The patients/caregivers, women's group representatives, youth leaders, religious leaders and community leaders/elders constituted the principal subjects. Emphasis was on providing qualitative data, which are of vital consideration in multi-disciplinary oriented studies, and not on quantitative information from larger samples. We found a high level of agreement across groups, that malaria remains the leading health problem in Moshi rural district in Tanzania both in the highland and lowland areas. Our findings also indicate that 'non-medical' issues including lack of water, hunger and poverty heralded priority in the list implying that priorities should not only be focused on diseases, but should also include health services and social cultural issues. Indeed, methods which are easily understood and applied thus able to give results close to those provided by the burden of disease approaches should be adopted. It is the provision of ownership of the derived health priorities to partners including the community that enhances research utilization of the end results. In addition to disease-based methods, the Nominal Group Technique is being proposed as an important research tool for involving the non-experts in priority setting in Tanzania.     

The Evolution of PBMA: Towards a Macro-Level Priority Setting Framework for Health Regions

To date, relatively little work on priority setting has been carried out at a macro-level across major portfolios within integrated health care organizations. This paper describes a macro marginal analysis (MMA) process for setting priorities and allocating resources in health authorities, based on work carried out in a major urban health region in Alberta, Canada. MMA centers around an expert working group of managers and clinicians who are charged with identifying areas for resource re-allocation on an ongoing basis. Trade-offs between services are based on locally defined criteria and are informed by multiple inputs such as evidence from the literature and local expert opinion. The approach is put forth as a significant improvement on historical resource allocation patterns.     

Priority dilemmas in psoriasis care and visions of a future care in a group of administrators, politicians and professionals in northern Sweden

During the 1990s priority discussions were actualized in Sweden due to increased demands on health care and limited resources. In the county of V?sterbotten in northern Sweden, with large rural areas, the decision makers faced special challenges due to distances and cost. Despite discussions striving for fairness in priorities, decision makers are still dealing with limited resources and difficult priority decisions regarding different diseases and treatments. In this study we aimed at describing views on priorities in public psoriasis care and visions of a future care among politicians, administrators and professionals in the county of V?sterbottten in northern Sweden. Qualitative research interviews were performed with 23 key-persons. The findings revealed priority dilemmas about issues on organization, accessibility and ethics. Visions of a future care appeared as ambitions of a more effective care with good accessibility, continued research, information and a holistic approach in priorities. We conclude that dilemmas revealed in this study were a reflection of a gap between intentions and practice. In efforts to reduce these dilemmas we suggest methods with fairness in economic planning and priority setting, with concrete, official statements about the dominating views on which the priorities are based, and public information about these statements.     

Local prioritisation work in health care--assessment of an implementation process

Political, horizontal prioritisation requires knowledge on local health care resource use on unit or patient group level. This in turn requires unit level structures (meeting forums) and processes for creation of knowledge and continuous, open decision-making on prioritisation. Ideally, for decisions to be legitimate, such procedures should meet the "Accountability for reasonableness"-criteria of Daniels and Sabin [Daniels N. Accountability for reasonableness. Establishing a fair process for priority setting is easier than agreeing on principles. British Medical Journal 2000;321:1300-1]. A strategy, aiming at shaping such an organisational culture, was developed and set to work within a regional health care organisation, responsible for around 250000 inhabitants. This pilot study regarding topic and methodology assesses the changes of knowledge in open prioritisation as well as structures, processes for and results of such work on unit level in that organisation 1998 through early 2005. Initial interviews and two consecutive surveys were analysed. Results indicate that only early adopters respond to the surveys and among them a growing knowledge in priority setting, acceptance of personal leadership for local priority setting work and recognition of a need for adequate structures and processes. Among respondents, one could note a development: A tentative model expressing different positions towards prioritisation was developed.     

Ethische Grundlagen der Priorisierung im Gesundheitswesen

The debate about priorities in healthcare has also started in Germany. Because of the special moral significance of health and healthcare, priority setting in healthcare also involves ethical issues. After clarifying the relationship between priority setting and rationing, I first discuss whether it is ethically acceptable or even mandated to set priorities in healthcare. If this first question is answered with “yes”, the following question is how the priorities can be determined in an ethically defensible way. I will try to show that it is impossible to justify priorities in healthcare within a liberal theory of justice that is neutral towards substantive conceptions of the good life. We rather need a deliberative decision process about how we want to live in the face of illness, suffering, and death. Only by reference to a substantial concept of a good life is it possible to define and justify healthcare priorities. A national priority-setting commission could play an important role in stimulating this deliberation and developing general recommendations according to which criteria and procedures priorities should be set in the German healthcare system. The application of this general framework requires the cooperation of medical scientific and physician organizations.     

Incorporating Ethics in Priority Setting: A Case Study of a Regional Health Board in Canada

The authors were involved in developing an ethical framework to assist the Queens Region Board (Prince Edward Island, Canada) set priorities in health and health care. Two and one half years after the adoption of this framework, the authors undertook an evaluation of the framework. This paper will discuss: a) the historical background of regionalization in Canada, and in particular the circumstances leading up to the institution of regional boards in Prince Edward Island; b) the sorts of ethical issues facing the Queens Regional Board; c) issues arising in connection with the use and development of ethics frameworks for managing ethical issues in priority setting; d) the framework adopted by the Queens Board and the process that led to its development; e) issues arising as concerns implementation of the framework; f) questions and issues pertinent to other boards and bodies considering similar initiatives. This revised version was published online in August 2006 with corrections to the Cover Date.     

Gesundheitsziele – Das Beispiel des Landes Nordrhein-Westfalen

In 1995, the State Health Conference of North Rhine-Westphalia (LGK NRW) adopted ten priority health targets for NRW. In this context, actors of the health care system committed themselves to implementing the targets on a joint basis.The process of developing targets is part of an overall system of health conferences, health targets,and health reporting, which has systematically been set up in NRW.North Rhine-Westphalia is thus one of the first federal states to embark on a comprehensive, participationoriented target development process.NRW's targets are modelled on the 38 WHO targets (1985).Their contents cover a) selected disease patterns, reduction of cardiovascular diseases, controlling cancer, measures against addiction and drugs, b) various health care sectors, health promotion, primary care, health care in hospitals, community-based services, as well as c) important methods and instruments, research and development, health information. The target program is rendered more concrete through implementation concepts in which subtargets, strategies, and measures are defined and assigned to the corresponding actors.Implementation concepts are available in particular for targets 2 (controlling cancer) and 4 (tobacco, alcohol, and psychoactive substances).Further concepts are in preparation.Numerous isolated measures from the overall target catalogue have meanwhile been implemented. A first 10-year period has been fixed for the 1995–2005 interval. An infrastructure for the development and implementation of targetoriented health programs has also been developed at the local level in NRW.Here the local health conferences, which have been set up throughout NRW,develop and realize their priority local recommendations for inclusion into the local health policy.Through the joint setting of priorities, the process of developing targets has great opportunities for achieving more rationality and transparency of actions as well as more efficient use of the resources employed in a pluralistic health care system.     

Health sector reform and reproductive health in Latin America and the Caribbean: strengthening the links

Many countries in Latin America and the Caribbean (LAC) are currently reforming their national health sectors and also implementing a comprehensive approach to reproductive health care. Three regional workshops to explore how health sector reform could improve reproductive health services have revealed the inherently complex, competing, and political nature of health sector reform and reproductive health. The objectives of reproductive health care can run parallel to those of health sector reform in that both are concerned with promoting equitable access to high quality care by means of integrated approaches to primary health care, and by the involvement of the public in setting health sector priorities. However, there is a serious risk that health reforms will be driven mainly by financial and/or political considerations and not by the need to improve the quality of health services as a basic human right. With only limited changes to the health systems in many Latin American and Caribbean countries and a handful of examples of positive progress resulting from reforms, the gap between rhetoric and practice remains wide.     

Budget- and Priority-Setting Criteria at State Health Agencies in Times of Austerity: A Mixed-Methods Study

Objectives. We examined critical budget and priority criteria for state health agencies to identify likely decision-making factors, pressures, and opportunities in times of austerity.Methods. We have presented findings from a 2-stage, mixed-methods study with state public health leaders regarding public health budget- and priority-setting processes. In stage 1, we conducted hour-long interviews in 2011 with 45 health agency executive and division or bureau leaders from 6 states. Stage 2 was an online survey of 207 executive and division or bureau leaders from all state health agencies (66% response rate).Results. Respondents identified 5 key criteria: whether a program was viewed as “mission critical,” the seriousness of the consequences of not funding the program, financing considerations, external directives and mandates, and the magnitude of the problem the program addressed.Conclusions. We have presented empirical findings on criteria used in state health agency budgetary decision-making. These criteria suggested a focus and interest on core public health and the largest public health problems with the most serious ramifications.The governmental public health enterprise continues to face myriad financial and other challenges, including eroding infrastructure, lack of political support, and increasing health problems associated with behavioral health. Since the 2008 economic downturn, thousands of public health jobs have been eliminated, growth has been stifled, and the public health workforce has continued to shrink because of attrition and retirement.1,2 During times of scarcity, the means of allocating resources is of particular interest and importance. However, the characterization and study of resource allocation decision-making is more common in health care compared with public health, where knowledge is limited, especially among national health care systems in developed nations.3–8 Globally, there is a growing interest in the systematic setting of priorities in health care and public health in developing countries, where funds are in shorter supply.4,9–18 A much greater proportion of total health dollars in the United States are spent on health care compared with public health, which is about 3% of total health spending by some estimates.19 This emphasis on spending for health care has created a dearth in research on setting of priorities and budgets in public health; we are not aware of any studies that have examined criteria use in public health priority setting at state health agencies (SHAs), although a few have examined priority setting in local health departments (LHDs). Two studies in particular indicated that the most important priority-setting criteria employed in LHDs were funding availability, mandates, being the sole provider, the size and scope of consequences, politics, and public interest or acceptability.20,21 In 2011, the Association of State and Territorial Health Officials (ASTHO) released their Profile of State Public Health, Volume 2, providing the first collection of revenue and expenditure data that allowed for meaningful comparisons of public health spending across SHAs. These were the first data available in recent years regarding actual spending by SHAs, but these data sets did not capture processes: how SHAs set budgets and why they give priority to the areas they do. We focused on 1 particular component of the priority-setting process—criteria use—because of the critical role criteria were found to play in setting budgets and priorities more broadly in the course of this study, and as reported elsewhere.22