Background
Methods
The conceptual framework
Parameters of Successful Priority Setting | Objectively Verifiable Indicators (OVI) | Means of Verification (MOV) |
---|---|---|
Contextual Factors | ||
Conducive political, economic, social and cultural context | Relevant contextual factors that may impact priority setting | Follow up intermittent interviews with local stakeholders, systematic longitudinal observations, relevant reports, media |
Pre-requisites | ||
Political will | Degree to which politicians support the set priorities | Follow up intermittent interviews with local stakeholders, systematic longitudinal observations, relevant reports, media |
Resources
| Budgetary and human resource allocation to the health sector | National budget documents |
Legitimate and credible priority-setting institutions
| Degree to which the priority setting institution can set priorities; public confidence in the institution | Stakeholder and public interviews |
Incentives | Material and financial incentives | National budget documents |
The Priority Setting Process | ||
Stakeholder participation | Number of stakeholders participating, number of opportunities each stakeholder expresses opinion | Observations/minutes at meetings, media reports, special reports |
Use of clear priority setting process/tool/methods | Documented priority setting process and/or use of priority setting framework | Observation/minutes at meetings, media reports, special reports |
Use of explicit relevant priority setting criteria | Documented/articulated criteria | Observations/minutes at meetings, media reports, special reports |
Use of evidence
| Number of times available data is resourced/number of studies commissioned/strategies to collect relevant data | Observations/minutes at meetings, media reports, special reports |
Reflection of public values
Publicity of priorities and criteria Functional mechanisms for appealing the decisions | Number and type of members from the general public represented, how they are selected, number of times they get to express their opinion, proportion of decisions reflecting public values, documented strategy to enlist public values, number of studies commissioned to elicit public values Number of times decisions and rationales appear in public documents Number of decisions appealed, number of decisions revised | Observations/minutes at meetings, study reports, meeting minutes and strategic plans Media reports Observations/minutes at meetings, media reports, special reports |
Functional mechanisms for enforcement | Number of cases of failure to adhere to priority-setting process reported | Observations/minutes at meetings, media reports, special reports |
Efficiency of the priority-setting process | Proportion of meeting time spent on priority setting, number of decisions made on time | Observations/minutes at meetings, annual budget documents, health system reports |
Implementation | ||
Decreased dissentions | Number of complaints from stakeholders | Meeting minutes, media reports |
Allocation of resources according to priorities
| Degree of alignment of resource allocation and agreed upon priorities, times budget is re-allocated from less prioritized to high prioritized areas, stakeholder satisfaction with decisions | Annual budget reports, evaluation documents |
Decreased resource wastage | Proportion of budget unused, drug stock-outs | Budget documents, evaluation reports |
Increased stakeholder understanding, satisfaction and compliance with the priority setting process | Number of stakeholders attending meetings, number of complaints from stakeholders, % stakeholders that can articulate the concepts used in priority setting and appreciate the need for priority setting | Observations/minutes at meetings, special reports, SH satisfaction survey, media reports, stakeholder interviews, evaluation reports |
Improved internal accountability/reduced corruption
| Number of publicized resource allocation decisions | Evaluation reports, stakeholder interviews, media reports |
Strengthening of the priority setting institution | Indicators of increased efficiency, use of data, quality of decisions, appropriate resource allocation, % stakeholders with the capacity to set priorities | Training reports, evaluation reports, budget documents |
Impact on institutional goals and objectives | % of institutional objectives met that are attributed to the priority setting process | Evaluation reports, special studies |
Outcome/Impact | ||
Impact on health policy and practice
| Changes in health policy to reflect identified priorities | Policy documents |
Achievement of health system goals
| % reduction in DALYs, % reduction of the gap between the lower and upper quintiles, % of poor populations spending more than 50% of their income on health care, % users who report satisfaction with the healthcare system | Ministry of Health documents, Demographic and Health Surveys, commissioned studies |
Improved financial and political accountability
| Number of publicized financial resource allocation decisions, number of corruption instances reported, % of the public reporting satisfaction with the process | Reports, media reports, interviews with stakeholders |
Increased investment in the health sector and strengthening of the health care system | Proportion increase in the health budget, proportion increase in the retention of health workers, % of the public reporting satisfaction with the health care system | National budget allocation documents, human resources survey reports, interviews with stakeholders, media reports |
Data collection
Interviews
Respondent Type | Number of Respondents |
---|---|
National development Agencies
| 13 |
National Government
| 11 |
District Government
| 16 |
Total
| 40 |
Data collection
Document review
Data analysis
Results
Parameters of Successful Priority Setting | HIV Case Study |
---|---|
Contextual factors | |
Conducive political, economic, social, cultural context | Political: Political stability positively impacted priority setting and implementation. Economic: Disagreements between DAPs and Ugandan government (homosexuality bill) led funds to be reduced temporarily, this impacted implementation, for instance, by reducing the availability of ARVs. Global contraction in funds impacted the health sector and HIV programs Sociocultural: Disagreements between DAPs and Ugandan government over the Homosexuality Act reduced funds for implementation temporarily. Cultural and religious beliefs posed implementation challenges for priorities such as family planning and male circumcision; low education levels and stigma and discrimination were barriers to prevention and treatment Legal: Prevention and Control Act increased discrimination and stigma |
Prerequisites | |
Political will | Strong political commitment from key politicians such as the President. |
Resources | Small MOH budget for health; decreased level of funding from DAPs was also observed, although overall, they continued to invest large amounts of funding for HIV. |
Legitimate and credible priority-setting institutions | UAC has technical expertise and their political appointment, however, their role is sometimes undermined (UAC, 2016). |
Incentives | None discussed |
Prioritization process | |
Stakeholder participation | PS is participatory and involves representatives from the districts, CSOs, FBOs, DAPs, politicians and the private sector; DAPs sometimes negatively influence the agenda; CSOs, as community representatives lack capacity to participate |
Use of clear priority setting process/tool/method | None reported aside from BOD/CEA |
Use of explicit/relevant priority setting criteria | Epidemiological evidence, cost-effectiveness, local context, resource availability, alignment with national priorities, alignment with international declarations, accountability, politics, equity, and value added. |
Use of evidence | Epidemiological evidence, evidence of cost effectiveness, beneficiary assessment data |
Reflection of public values | The public was directly involved via consultations and annual district partnership meetings |
Publicity of priorities and criteria | Some government priorities were discussed. Rationales for prioritization inconsistently discussed |
Functional mechanisms for appealing the decisions | None reported. Complaints channeled through the media |
Functional mechanisms for enforcement | None reported |
Efficiency of the priority setting process | PS process reportedly efficient; delays in implementation including slowness in procuring and releasing funds |
Implementation | |
Allocation of resources according to priorities | More resources allocated to curative care rather than prevention. Majority of prevention budget funded externally, however donor funds may have negatively impacted the implementation of national priorities. |
Decreased resource wastage | Expiry of ARVs in clinics and national medical stores |
Improved internal accountability/reduced corruption | Off-budget system makes funding difficult to track; two cases of possible corruption – the Global Fund and OPM scandals – were reported |
Increased stakeholder understanding, satisfaction and compliance with the priority setting process | Satisfaction with identified prevention priorities and level of external funding, however, sense that DAPs did not comply with national priorities, as in the case of circumcision |
Decreased dissentions | Dissentions over the government’s prioritization of treatment while inadequately focusing on prevention strategies and the negative impact of the HIV Prevention and Control Bill. Some members of the public disagreed with male circumcision as a prevention strategy |
Impact and Outcomes | |
Strengthening of the priority setting institution | ACP and UAC may have been strengthened in terms of capacity and financial resources |
Impact on PS Institution goals and objectives | Goals of ACP and UAC to contribute to HIV control were achieved, to some extent |
Impact on Health Policy and Practice | Some policy changes, such as the prioritization of male circumcision as a preventative strategy occurred |
Achievement of Health System Goals | Improvement of population health: Notable improvements, including declining transmission and increased access to ARVs Fairness in financial contribution: Although public funding for the HIV response increased during the period, out of pocket contributions were still high, especially for vulnerable groups Responding to the public’s expectations: Not reported |
Improved financial and political accountability | Deliberate reduction in funding from donors due to issues with poor financial accountability in 2006 and 2012, as discussed above. |
Increased investment in the health sector and strengthening of the health care system | Despite increases in funding, gaps in funding, as well as concerns about sustainability and predictability of donor spending and the impact of vertical funding on the health system were reported |
The priority setting context
Economic context
Political context
2011/12 | 2012/13 | 2013/14 | 2014/15 | |
---|---|---|---|---|
Private | 0a | 0 | 0 | 1 |
Other Donors | 7 | 7 | 6 | 6 |
Multi-lateral donors | 5 | 5 | 4 | 3 |
Global fund | 10 | 10 | 13 | 19 |
Bilateral donors | 4 | 5 | 4 | 4 |
PEPFAR | 61 | 60 | 59 | 55 |
Public | 13 | 14 | 14 | 12 |
Total funding in US$ millions | 425 | 411 | 470 | 551 |
Sociocultural context
Legal environment
Prerequisites
Political will
Resources
Legitimate and credible PS institutions
Incentives
The priority setting process
Stakeholder participation
Use of clear priority setting process/tools/methods
Use of explicit relevant priority setting criteria
Use of evidence
Reflection of public values
Publicity of priorities and criteria
Functional mechanisms for appealing the decisions
Functional mechanisms for enforcement
Efficiency of the priority setting process
Implementation
Allocation of resources according to priorities
Decreased resource wastage
Improved internal and external accountability/reduction of corruption
Increased stakeholder understanding, satisfaction, and compliance with the PS process
Decreased dissentions
Impact and outcomes
Strengthening of the priority setting institution
Impact on the priority setting institutional goals and objectives
Indicator | 2011a M/F% | 2012a M/F% | 2013a M/F% | 2014 M/F% | 2015b M/F% |
---|---|---|---|---|---|
Pregnant women on PMTCT | 49 | 87 | 82 | > 95 | 97% |
Knowledge of HIV | 39.3/38 | 36.9/ 29.6 | 40.3/ 33.1 | 42.3/35.7 | – |
Male circumcision | 26.4 | 31.4 | 35.8 | 40 | – |
- > PLHIV receiving ART | 25%b | 33%b | 43%b | 53%b | 57% |
AIDS-related deaths | – | – | 63,000 | 31,000b | 28,000 |
New infections (adults) | 162,294 | 150,000 | 140,000 | 95,000 | 79,777 |
New infections (children) | 31,000a | – | 12,000b | 52,000b | 3500 |