About STP
Scenarios
Background
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They have to combine a proactive approach to priority setting (e.g. what priority should an issue be given in a national strategic plan for the health sector?) together with a reactive approach that can respond to the pressing issues of the day (e.g. what priority should an issue receive when it appears on the front page of a newspaper or is discussed in the legislature?). A priority-setting approach needs to contribute to future plans while responding to existing potentially difficult circumstances
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Policymakers have to balance a disease or illness orientation (e.g. what priority should be given to HIV/AIDS or diabetes?), a programme, service and drug orientation (e.g. what priority should be given to a screening programme, a counselling service or a new class of drugs?), and a health system arrangements orientation (e.g. what priority should be given to a regulatory change in the scope of the practice of nurses, or to a change in the financial arrangements that determine how doctors are paid, or to a change in the delivery arrangements that determine whether some forms of care are provided only in high-volume facilities?). A priority-setting approach needs to function with multiple, often interacting, orientations at the same time
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They have to balance shorter-term confidentiality issues with longer-term commitments to transparency and public accountability. This is particularly true for policymakers who typically rely heavily on civil servants to assess issues for them. Strict confidentiality provisions are often set to ensure that issues are not discussed before they have been vetted by policymakers. This is important given that policymakers are accountable in a very public way (through periodic elections) for the decisions they make. A priority-setting approach – at least one based within government – needs to accommodate a mix of confidentiality and transparency provisions
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Most tools and resources focus on how to prioritise programmes, services and drugs that are targeted at illnesses and injuries, or at ill health more generally. Many of these tools and resources focus both on data on prevalence or incidence, and on research evidence about the effectiveness or cost-effectiveness of prevention and treatment options [11‐13]. Few deal with a broader set of criteria or have a more holistic approach to setting priorities [14‐16]
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Almost no tools and resources address the issue of how to prioritise health system arrangements (or changes to health system arrangements) that support the provision of cost-effective programmes, services and drugs, [17] or how to prioritise actions to address the social determinants of health
A number of different types of organisations have emerged to support evidence-informed policymaking. For example: • The Strategic Policy Unit, based within the United Kingdom’s Department of Health, was set up to examine high-priority issues that need to be addressed within a timeline of weeks to months • The Canadian Agency for Drugs and Therapeutics in Healthcare (http://www.cadth.ca), a national government-funded agency, provides a rapid-response function (called the Health Technology Inquiry Service) to Provincial Ministries of Health seeking input about which health technologies to introduce, cover or fund. Timelines range from 1-30 days • An Evidence-Informed Policy Network (http://www.evipnet.org) in Vietnam has obtained funding to produce two policy briefs and convene two policy dialogues in the coming year to respond to the priorities of policymakers and stakeholders • The European Observatory on Health Systems and Policies (http://www.euro.who.int/observatory) convenes a range of policy dialogues, including ‘rapid reaction seminars’ which can be organised at very short notice. The On-call Facility for International Healthcare Comparisons (http://www.lshtm.ac.uk/ihc/index.html), located within the London School of Hygiene and Tropical Medicine, responds to direct requests from the United Kingdom’s Department of Health about how health systems in other high-income countries are addressing particular issues [29] Each of these organisations must, implicitly or explicitly, have timelines within which they are prepared to work. They also need criteria to decide which issues warrant significant periods of their time and which issues warrant less, or even none at all. Processes to make these decisions are also required. |
Questions to consider
1. Does the approach to prioritisation make clear the timelines that have been set for addressing high-priority issues in different ways?
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A search for systematic reviews that address an issue
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A summary of the take-home messages from quality-appraised systematic reviews addressing many facets of an issue, or
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A comprehensive assessment of the research evidence available that will clarify a problem, frame options to address it, and address how an option will be implemented (i.e. a policy brief, as described in Article 13 [2])
A Ministry’s decision-support unit offers the following range of supports to other Ministry staff: 1. A search for systematic reviews that address an issue (Timeline: 1 day; Number that can be provided per quarter: 24) 2. A summary of the take-home messages from quality-appraised systematic reviews addressing many facets of an issue (Timeline: 1 week; Number that can be provided per quarter: 12), and 3. A comprehensive assessment of the research evidence available to clarify a problem, frame options for addressing it, and address how an option will be implemented (Timeline: 1 month; Number that can be provided per quarter: 3) The unit maintains an inventory of requests, in which each request is allocated a score of between 0 and 56. On receipt, a request is reviewed by two unit staff who assign it a rating of between 1 and 7 points (where a rating of 1 indicates ‘strongly disagree’ and 7 is ‘strongly agree’) for each of the following three criteria: • The underlying problem(s), if properly addressed, could lead to health benefits, improvements in health equity or other positive impacts now or in the future, • Viable options, if properly implemented, could affect the underlying problem(s), and hence lead to health benefits, improvements in health equity or other positive impacts, or could lead to reductions in harms, cost savings or increased value for money, and • Political events could open (or political events may already have opened) windows of opportunity for change The individual scores for the third criterion are doubled, as this is deemed to be twice as important as the other two (as a way of ensuring that the Minister’s priorities are given adequate consideration). A maximum of 14 points can be assigned to criterion 1, 14 points to criterion 2, and 28 point to criterion 3. One of the two unit staff will note the nature of the support requested (support types 1, 2 or 3 above). The basis for these assessments is the request description and justification submitted by other Ministry staff (after approval from their respective divisional director). The request must address each of the three criteria using available data and evidence (when available) and a discussion about the application of explicit criteria to the issues that are considered for prioritisation At the beginning of each week, the unit manager, together with all divisional directors, reviews the rank-ordered list of priorities for each of support types 1, 2 and 3. Collectively, they confirm that the top two requests for support type 1 will proceed that week and that the top request for support type 2 will proceed. They also confirm that the top request for support type 3 is on track and that preparations are being made to begin a new assessment for the second-ranked request type 3 as soon as the current assessment is completed. The unit manager (who has training in health policy research) facilitates the meeting, taking care to elicit the rationale for any ranking changes and to ensure that any requests for comprehensive assessments are well thought through in terms of the provisional problem clarification, options framing, and implementation considerations. The unit manager then posts the decisions and rankings on the Ministry’s intranet and directs Ministry staff whose requests have not been addressed within one month of submission to submit an updated request. Once a month, the unit manager reviews the unit’s monitoring data with the divisional directors. The monitoring data includes the number of appeals submitted by Ministry staff and their resolution. Once every year, the unit re-evaluates the scale of its outputs to determine if it can provide more support within shorter time frames. Once every three years, the unit commissions an evaluation of its impacts on the policymaking process. |
2. Does the process incorporate explicit criteria for determining priorities?
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The underlying problem(s), if properly addressed, could lead to health benefits, improvements in health equity or other positive impacts, now or in the future
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Viable options, if properly implemented, could affect the underlying problem(s), and hence lead to health benefits, improvements in health equity or other positive impacts, or could lead to reductions in harms, cost savings or increased value for money, and
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Political events could open (or political events may already have opened) ‘windows of opportunity’ for change. For example, in 1993 Taiwan’s President submitted a national health insurance bill to Parliament in order to pre-empt a challenge by an opposition party [25]. The pending challenge opened a significant window of opportunity for change, and for finding and using research evidence to support policymaking about national health insurance
3. Does the process incorporate an explicit process for determining priorities?
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It is informed by a pre-circulated summary of available data and evidence and by a discussion about the application of explicit criteria to issues that are considered for prioritisation
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It ensures fair representation of those involved in, or affected by, future decisions about the issues that are considered for prioritisation
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A facilitator is engaged who uses well-constructed questions to elicit views about the priority that should be accorded to issues as well as the rationale for their prioritisation, and
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An experienced team of policymakers and researchers is engaged to turn high-priority issues into clearly defined problem(s) and viable options that will be the focus of more detailed assessments
4. Does the process incorporate a communications strategy and a monitoring and evaluation plan?
Conclusion
Resources
Useful documents and further reading
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Healy J, Maxwell J, Hong PK, Lin V: Responding to Requests for Information on Health Systems from Policy Makers in Asian Countries. Geneva, Switzerland: Alliance for Health Policy and Systems Research, World Health Organization; 2007 [28]. – Source of lessons learned about organisations that support evidence-informed policymaking, but with little attention given to how priorities are set by these organisations (http://www.who.int/alliance-hpsr/RespondingRequests_HS_AsianCountries_Healy.pdf)
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Nolte E, Ettelt S, Thomson S, Mays N: Learning from other countries: An on-call facility for health care policy. Journal of Health Services Research and Policy 2008, 13 (supp 2): 58-64 [29]. – Source of lessons learned by an independent organisation that supports evidence-informed policymaking, with some attention given to how priorities are set by the organisation
Links to websites
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Global burden of disease: http://www.who.int/topics/global_burden_of_disease/en – Source of data and research evidence about the global burden of disease. This information can be one input among many in priority setting for evidence-informed policymaking.
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Disease Control Priorities Project: http://www.dcp2.org/main/Home.html – Source of research evidence and recommendations about the programmes, services and drugs that should be prioritised in different types of countries. This information can be one input among many in priority setting for evidence-informed policymaking.
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CHOosing Interventions that are Cost-Effective (CHOICE): http://www.who.int/choice/en – Source of data, research evidence and a tool about the programmes, services and drugs that should be prioritised in different regions and countries. This information can be one input among many in priority setting for evidence-informed policymaking.
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Canadian Priority Setting Research Network: http://www.canadianprioritysetting.ca – Source of published articles about priority-setting in healthcare, which may provide lessons for priority setting for evidence-informed policymaking.