Health priority-setting for official development assistance in low-income and middle-income countries: a Best Fit Framework Synthesis study with primary data from Ethiopia, Nigeria and Tanzania

A Best Fit Framework Synthesis was performed [36], by first building a conceptual framework – the a priori framework - from a scoping review using the Arksey and O’Mally method [37] and then testing it against primary data collected from three case countries.

For the scoping review and framework development, relevant published articles were identified from PubMed, Embase and Web of Science (Thomson) using the following search terms: 1) low- and middle-income countries, 2) external funding and aid, 3) health, and 4) tools and processes. General terms such as “tools” and “processes” were used, instead of “priority setting” or “agenda setting”, to include articles which described the process of using external funding for health but didn’t specifically use the term “priority setting”. Two researchers (XK and YL) independently reviewed the abstracts of the articles retrieved by the search and selected those which were relevant to the research topic and extracted keywords. Differences full-text selection and data extraction were resolved with internal discussions.

Conventional qualitative content analysis and grounded theory method [38‐40] were used to analyze the data extracted from the final selection of articles. Keywords emerged from those articles were compared and synthesized into major thematic categories to develop the final analytical framework.

In parallel to the framework development, primary data were collected from Ethiopia, Nigeria, and Tanzania on decision making in external funding for health to be tested against the a priori framework. The three countries were selected from the seven African country members of the China Harvard Africa Network, namely, Botswana, Ethiopia, Ghana, Nigeria, South Africa, Tanzania, and Uganda, based on existing research collaborations and the willingness of the countries to participate in the study.

The interview guide was developed and validified with each country team, and it included general open questions such as “How is your organization involved in setting agenda and priorities for external funding for health?” and “What are the tools/methods/mechanisms used in the process?”. All interviewers were encouraged to use prompt to probe further for detailed description of these tools, methods, and mechanisms relating to decision making for priority setting and to ascertain the origins of the tools, methods, and mechanisms used.

The interviews were initially conducted with key informants who worked in the main department(s) or organization(s) that managed and oversaw external funds, as decided by the research team in each case country. Snowballing methodology was used to identify and interview additional key informants in all departments and organizations involved in priority setting process. These additional key informants were identified by interviewees of the first round of interviews.

All interviews were conducted in person from February 2018 to April 2019 across the three countries. The interviews in Ethiopia were conducted in Amharic by public health researchers fluent in speaking, reading, and writing in Amharic. The interviews in Nigeria were conducted in English and in Tanzania, Swahili.

For those who consented to audio recording, the recording was transcribed in full text. For those who did not give consent to audio recording, meeting notes were taken contemporaneously by the research team undertaking interviews in the respective country. The research teams in Ethiopia and Tanzania are comprised of members fluent in Amharic and Swahili respectively, and they all participated in the coding and interpretation of the data.

In Nigeria, a state was selected for interviews at sub-national government departments, as the decision-making process in Nigeria for prioritizing ODA was de-centralized to state level, as assessed by the local research team.

A framework was developed by the authors using the results of the scoping literature review. Qualitative data from interviews was coded using the layers and themes presented in the framework following conventional qualitative content analysis [38] method: frequencies of keywords that correspond to each of the layers of themes in the framework, in the format of verbatim quotations from study participants or notes from the interviewers, were documented and the context they appeared in were analyzed and compared across themes, layers and countries to identify strength or weakness areas.

The systematic scoping review yielded 8170 results across three databases (1886 from Pubmed, 197 from Embase, and 6087 from Web of Sciences). The search was completed on September 10th, 2018. After removal of 1310 duplicates, 6860 distinct records were retrieved for review following the criteria specified above and generated 79 articles for full-text review. Data extraction and narrative synthesis was conducted on a final list of 40 articles (Fig. 1).

All 40 articles described the decision making process of an LMIC government agency on the use of external funds and 15 of them also described how they resolved disagreements with ODA donors. Thirty-five (35) of them covered a single LMIC and 5 covered multiple countries. Of the 35 articles that covered single country cases, 25 (71%) of the studies were in Africa, 8 (23%) in Asia and 2(6%) in Latin America.

Close to 20 sub-themes were identified from the analysis of data emerging from the review relating to elements and actions that influenced decision making for priority setting for ODA. These sub-themes included “data”, “evidence”, “successes from pilot projects”, “consultation of external experts”, “the top leader’s will” and etc. Following the review of the emerging sub-themes, the team categorized them further into four higher themes, namely, Principles, Players, Processes, and Products, each relating to the process of priority setting. Based on the layers of themes identified, we developed a framework for analyzing the priority setting process in LMICs. The framework consists of four inter-related elements: 1) Principles, which shape the global, regional and local contexts (such as Paris Principles, Accra Agenda for Action, and IHP+ which has informed the development of country compacts), 2) Players, which refer to all the entities and individuals who contribute to the decisions made, 3) Processes, which describe the different channels and approaches those players take in exerting their decision making or advisory power, and 4) Products, which represent a variety of tools and instruments developed over the past years that are used by players to shape priority setting process and channeling of funds, such as SWAPs, Sector Investment Plans (SIPs), Budget Support, National Health Plans, National Strategies, disease specific plans, international evidence, and among others, analytic tools, for example One Health Tool (see Fig. 2).

A total of 21 in-depth interviews were conducted (6 in Ethiopia, 10 in Nigeria and 5 in Tanzania), with participants who were holding key positions in different institutions involved in the decision-making process at the time of the interview.

The three countries varied substantially in their economic and demographic status, as well as their levels of reliance on external funding for health. Tanzania has the highest percentage of current health expenditure financed from external sources (32%), followed by Ethiopia (22%) and then Nigeria (8%), see Table 1.

Each of the 4 layers of framework - principles, players, processes, and products – informs the analysis of the priority setting process from a different angle. Keywords deemed relevant to each theme were used to search through the transcripts or interview notes. The context, where the keywords were mentioned was analyzed to identify how and where in the decision-making process a particular theme played a role.

Table 2 illustrates how each layer of the framework played a role in the priority setting process. Factors with major influence were marked in green, while factors with minor or no influence were marked in red.

Limited data emerged from the interviews conducted in Tanzania relating to the analysis of principles. Richer data enabled a comparison of Ethiopia and Nigeria on the principles that were used in the priority setting process for ODA. Analysis revealed that International agreements, including Paris Declaration and Accra Agenda, as well as International Health Partnership country compact played important roles in the priority setting process in Ethiopia:

“…Based on different international declaration such as the Paris and Accra declarations the government negotiates by prioritizing the national interest.” (one government official from Ministry of Finance and Economic Development (MoFED), Ethiopia)

“Since different agreements are signed between the funder and the government, disagreements are less to happen.” (one government official from MoFED, Ethiopia)

By contrast, none of those principles were mentioned by interviewees in Nigeria. Instead, different officials agreed that attending international conferences was a way for them to perceive ideas for priority setting, as well as reading guidelines established by international organizations:

“The federal ministry of women affairs normally organizes council meetings, in that place we prepare a lot of proposals and prepare for what we'll do the coming year. Aside from that, every March, they normally attend the U.N status of women in New York. So, they come with new things by that time based on global focus.” (one government official from the Ministry of Women Affairs and Social Development, Nigeria)

“Another thing is we can look at the WHO guideline and seek for approval along with this guideline that is if the policy is domesticated and accepted in Nigeria” (one government official in charge of Communicable Diseases, HIV/AIDS, and TB [tuberculosis], Nigeria)

The most frequently mentioned players in Ethiopia and Tanzania were bilateral agencies: “donor(s)” or “development partner(s)”, followed by government departments/ministries. The context in which bilateral agencies were mentioned depicts a spectrum of roles these agencies were playing in priority setting. In most cases, they were mentioned together with other stakeholders as a member of the collaborative planning process:

“…Based on the revised policy the government sets sector-based plans and in consultation with different stakeholders including donors.” (one government official from MoFED, Ethiopia)

“HSHSP [Health Sector HIV and AIDS Strategic Plan] IV includes both GOT [Government of Tanzania] and donor priorities as it is developed in a participatory manner.” (one government official from Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC), Tanzania)

In other cases, bilateral aid agencies acted alone, but were also following the national plan of local governments:

“So based on our Growth and Transformation Plan, donors will provide support by aligning with the nationally set priorities and local agendas.” (one government official from MoFED, Ethiopia)

A few scenarios were mentioned when conflicts arose between local governments and donor organizations:

“the donor may request to use its own consultant to work different activities while the Ministry can do it with the available staff, this causes a conflict of interest between the two.” (one government official from MoFED, Ethiopia)

In Nigeria, however, top leaders were mentioned with unusually high frequency. Specific leader positions were mentioned, such as “directors/directorate”, “governor”, and “commissioners”. In Tanzania, top leaders, represented by Presidents Office Regional Administration and Local Government (PORALG), also played an important role in the priority setting process:

“But, in the Ministry of Health which happens to be the mother of all related agencies, so, it is the Director of Administration and Supplies, they are saddled with that exercise. He is the one that will write a memo regarding that and make a request.” (one government official from Oyo State Ministry of Health, Nigeria)

“For instance, the Ministry of Health has been able to convince the permanent secretary and the commissioner for health that we need this much resources to do something.” (one government official from the Malaria Program, Nigeria)

Hospitals in Nigeria were much more involved in priority setting than other organizations. Regular visits and frequent meetings were scheduled with doctors and administrators from hospitals to hear their recommendations on what is needed:

“Not only that, but we also meet with our doctors in our various hospitals once every month, first Friday to be precise. It is a technical meeting where they give us a report of what has happened in the various hospitals in the last month. They help us know the disease pattern, know the area we need to focus and give us the ability to compare the hospitals or facilities where there’s health insurance with facilities or hospitals where there is no health insurance.” (one staff from Oyo State Health Insurance Agency)

Donor organizations were identified as important stakeholders in Nigeria, such as the United States Agency for International Development (USAID), in the priority setting process but to a much lesser extent compared to Ethiopia and Tanzania.

Interview findings from all three country cases indicated that non-governmental organizations (NGOs) and multilateral agencies had little direct influence over the priority setting process. However, they could influence other elements of the framework, for example the Processes utilized and the Products used, as described below.

In Ethiopia, Nigeria, and Tanzania “collaborative planning” was the most frequently mentioned process in priority-setting, and involved multiple stakeholders, each of which played a relatively equal role in decision making:

“All of the mentioned stakeholders will also participate in decision making and agenda prioritization but the main role in agenda-setting is led by FMOH.” (one government official from Federal Ministry of Health (FMoH), Policy and Planning, Ethiopia)

“They always bring their work plan which at times may not suit our challenges. But this time around, both of us will sit down and look at their work plan and look at our work plan and we merged them.” (one government official from Oyo State Ministry of Health, Nigeria)

“Annual stakeholders meeting is a forum for all partners, implementers and beneficiaries to discuss issues related to TB and Leprosy including the sharing of annual operational plans.” (one government official from National TB and Leprosy Programme (NTLP)-MOHCDGEC, Tanzania)

“Political dialogue and “coordination/consultation” initiated by local governments were also quite commonly used processes in all the three countries studied. In Ethiopia, political dialogue usually took the form of negotiation, while in Nigeria, it was mentioned as meetings and discussions, and in Tanzania, as discussions and negotiations:

“During setting priorities, the government takes the lead however consultations are commonly requested from different stakeholders to finalize and approve priorities.” (one government official from MoFED, Ethiopia)

“…the major problem is the vacuum called ‘meeting, discussion’ before the final approval of the project.” (one government official from the Ministry of Women Affairs and Social Development, Nigeria)

“MOHCDGEC and PORALG had different views on this issue and through dialogue, a consensus was reached.” (one government official from Directorate of Policy and Planning (DPP)-MOHCDGEC, Tanzania)

“Dialogue is the approach used to address any disagreements. A good example is when the PORALG wanted to use the balance from unused HBF [Health Basket Funds] funds for upgrading or putting up a new infrastructure for health facilities. The Sector ministry and Donors had a different opinion, but after repeated dialogue, all parties agreed to use the funds for an infrastructure upgrade. (one government official from PORALG, Tanzania)

Political power was also used in the priority setting process. It included diplomatic power, as well as power to influence higher levels of government hierarchy and judiciary power that imposed legal constraints on certain behaviors:

Conflicts that arise mostly due to implementation (if the project implementation deviates from the directive and proclamation), are primarily resolved by negotiation. If the dispute is not resolved by negotiation, then it will be referred to be handled by the federal court. (one official from the Social Charity organizations, Ethiopia)

“Conditioned financial support” was mentioned in all three cases, suggesting that donor influence through funding was still very prevalent:

“The first word I will say that he who has the piper dictates the tune. No matter what your priorities are, by the time someone is bringing money to help you, but then these are the ways at which you can go, the best you can do is to see how well their most mode of operation will end up suiting your own expectation.” (one government official from Oyo State Ministry of Health, Nigeria)

“Partners would in many cases come up with innovations that are not included in HSHSP IV and would like to fund pilots.” (one government official from National AIDS Control Program-MOHCDGEC, Tanzania)

In all three cases, national or sector-specific development/strategic plans were the most frequently used product in guiding the priority setting process. These products were variously called “Growth and Transformation Plan (GTP)” and “(5- year) Health Sector Transformation Plan (HSTP)” in Ethiopia, “5-year National Development/Strategic Plans” in Nigeria, and “Health Sector Strategic Plan (HSSP)” in Tanzania:

“Currently there are around 28 United Nations (UN) agencies. These agencies have a framework for budgeting and implementing planned activities. United Nations Development Assistant Framework (UNDAF) is a framework which will be signed by all UN agencies and all are under this document. Using this framework country-specific projects will be designed for five years based on the sector plan or GTP, for UNICEF the plan will be following the HSTP.” (one government official from Multilateral collaboration, MoFED, Ethiopia)

“there must be a memorandum of understanding, this MOU is review by the desk officer to see if it goes with what is (in) the strategic plan.” (one government official in charge of Communicable Diseases, including HIV/AIDS, TB, Nigeria)

“The HSSP guide the sector and all stakeholders. It is a promise to the public by the Government.” (Notes from a policy consultant with the Government of Tanzania for the interview with a government official from DPP-MOHCDGEC, Tanzania)

In Ethiopia, priority setting took a “cascade”-like hierarchical process, where each level of priority needed to be set based on or following the agreement or principles finalized by upper-level government bodies:

“Five-year strategic plan is set and prioritized issues including resource gaps are addressed in the strategic plan. The mother document is the GTP and every other thing evolved from this document.” (one official from FMoH, Ethiopia)

Data analytics and Experiences were also frequently mentioned in both Ethiopia and Nigeria, which included epidemiological data, demographic data, and among others, economic analysis:

“Disease burden is reviewed during planning, including mortality, morbidity, impact on the economy and also human right issues, then alternative interventions will be proposed and finally will be prioritized.” (One government official from FMoH, Resource mobilization, Ethiopia)

“Zamfara may tell you they have understood there are seasonal variations… I cannot attempt that in Oyo State. Because I know malaria in my state is year-round.” (one government official from the Malaria Program, Nigeria)

In Tanzania, SWAPs were mentioned multiple times by government officials as a useful international instrument for facilitating dialogues between governments and donors:

“Tanzania has a functioning SWAP dialogue structure that puts in use the above.” (one government official from DPP-MOHCDGEC)

Cross country analysis revealed similarities as well as differences relating to Principles guiding priority setting decisions, the Players involved, the Processes utilized, and the Products used.

First, there was noticeable variation in the Principles used and Players involved in the priority-setting process in Nigeria, a lower-middle-income country where external funding accounted for less than 10% of the current total health expenditure, as compared with Ethiopia and Tanzania, both low-income countries, where external funding accounted for 22 and 32% of the total health expenditures respectively.

In Nigeria, Principles appeared in more informal ways, for example the principles garnered from attending international conferences. While in Ethiopia, formal principles, such as the Paris Declaration, the Millennium Development Goals, or the Sustainable Development Goals, as well as signed agreements under the International Health Partnership were mentioned as their guiding principles. In Nigeria, local government, especially the top leaders took a more direct role in setting priorities in the health sector. However, in both Tanzania and Ethiopia, bilateral aid agencies were mentioned most frequently when asked to describe the priority setting process. Non-governmental organizations remained as very marginalized players in decision-making related to resource allocation in health.

In all the three countries there was more convergence with Processes and Products. Across the three study countries: 1) collaborative planning was the most commonly used process, and 2) the Health Sector or National Strategic Plan were the most commonly utilized products in the priority-setting process.

The findings suggest that multiple stakeholders working around one national plan was how priorities were established in these countries. Political dialogue was also frequently used by all three countries as a process to reach an agreement with other stakeholders and/or to resolve an existing conflict of ideas. This took the form of discussions, meetings, and negotiations.

In addition to Health Sector Plans of Strategies, evidence and experiences were two other products used in setting health priorities, more prominently in Ethiopia and Nigeria than that in Tanzania.

There were minor differences in the processes and products used across the three case countries: consultation and coordination were mentioned more often in Ethiopia, where the government assumed a more leading role were mentioned, than in Nigeria and Tanzania. In Ethiopia, there were also other products mentioned as useful tools: “United Nations Development Assistant Framework”, “One Health Tool” and “Marginal Budget Bottlenecks”. In Tanzania, Sector Wide Approaches were mentioned multiple times.