Priority-Setting Institutions in Health
Andrés Pichon-riviere2012, Global Heart
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Abstract
The rationing problem is common to all health systems--the challenge of managing finite resources to address unlimited demand for services. In most low-and middle-income countries, rationing occurs as an ad hoc, haphazard series of nontransparent choices that reflect the competing interests of governments, donors, and other stakeholders. Yet in a growing number of countries, more explicit processes, with strengths and limitations, are under development that merit better support. Against this background, the purpose of the Center for Global Development Working Group, which is to examine how priorities are set currently, and to propose institutional arrangements that promote country ownership and improve health outcomes by more systematically managing this complex process of politics and economics, is discussed. Current global and national priority-setting practices in low-and middle-income countries, the potential for strengthened national institutions, and increased global support are reviewed. Recommendations for action are provided.
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gINTELLIGENCE RECOMMENDATIONS & G UIDELINES Priority-Setting Institutions in Health Recommendations from a Center for Global Development Working Group
2012
The rationing problem is common to all health systems-the challenge of managing finite resources to address unlimited demand for services. In most low-and middle-income countries, rationing occurs as an ad hoc, haphazard series of nontransparent choices that reflect the competing interests of governments, donors, and other stakeholders. Yet in a growing number of countries, more explicit processes, with strengths and limitations, are under development that merit better support. Against this background, the purpose of the Center for Global Development Working Group, which is to examine how priorities are set currently, and to propose institutional arrangements that promote country ownership and improve health outcomes by more systematically managing this complex process of politics and economics, is discussed. Current global and national priority-setting practices in low-and middle-income countries, the potential for strengthened national institutions, and increased global support are reviewed. Recommendations for action are provided. A fundamental challenge for all health systems is to allocate finite resources across the unlimited demand for health services. This is a rationing problem, regardless of whether it is explicitly addressed as such, because it requires active or passive choices about what services are provided to whom, at what time, and at whose expense. Inevitably, some demand goes unmet, which is a source of the intense pressure to provide more services within any given resource envelope. Efforts to reduce waste, increase quality, and improve efficiency are all responses to this pressure. Expanding healthcare costs are another reflection of the same forces. A recent Organisation for Economic Cooperation and Development (OECD) report [1] found that health spending growth exceeded economic growth in almost all OECD countries over the past 15 years. In the context of worsening fiscal positions in the global recession and greater demand for services because of aging populations, as well as more complex and expensive health technologies, the pressure on OECD health systems to deliver more care with greater efficiency is unprecedented. Policymakers and analysts working in low-and middle-income countries (LMIC) are concerned with the same issues. In many middle-income countries, economic growth is also accompanied by a greater proportion of gross domestic product devoted to health. This has led to a significant increase in health spending, often because of costly technologies of marginal benefit while most of the population remains without access to basic and The authors have reported that they have no relationships relevant to the contents of this article to disclose.
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Social Science & Medicine, 2014
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2021
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Weaknesses in health systems contribute to a failure to improve health outcomes in developing countries, despite increased official development assistance. Changes in the demands on health systems, as well as their scope to respond, mean that the situation is likely to become more problematic in the future. Diverse global initiatives seek to strengthen health systems, but progress will require better coordination between them, use of strategies based on the best available evidence obtained especially from evaluation of large scale programs, and improved global aid architecture that supports these processes. This paper sets out the case for global leadership to support health systems investments and help ensure the synergies between vertical and horizontal programs that are essential for effective functioning of health systems. At national level, it is essential to increase capacity to manage and deliver services, situate interventions firmly within national strategies, ensure effective implementation, and coordinate external support with local resources. Health systems performance should be monitored, with clear lines of accountability, and reforms should build on evidence of what works in what circumstances.
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Tropical Medicine and Health
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Health policy in less developed countries: Past trends and future directions
Journal of International Development, 1995
Health policies worldwide have changed dramatically in the last few decades. We reflect upon these changes, highlight current trends and identify key issues and challenges as the year 2000 approaches. The article comprises five sections: (i) comments on concepts of health and of policy; (ii) historical developments which have influenced policy; (iii) discussion of the context within which health policies in low income countries are formulated and implemented, including macropolitical and macroeconomic developments, health needs and determinants, financing, approaches to health planning and priority setting, and the key international health policy actors; (iv) an overview of the content of current health policy proposals in less developed countries which considers the financing, organization and management of health systems and (v) a concluding section which identifies key issues for the coming years. The recent World Bank Development Report, Investing in Health (1993) and other health sector reform efforts, form the backdrop for this discussion. 0 1995 by John Wiley & Sons, Ltd. CCC 0954-1748/95/030299-30 300 A. B. Zwiand A . Mills
Facilitating access to healthcare in low-income countries: a contribution to the debate
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Priority setting for maternal, newborn and child health in Uganda: a qualitative study evaluating actual practice
BMC Health Services Research
Background: Despite continued investment, Maternal, Newborn and Child Health (MNCH) indicators in low and middle income countries have remained relatively poor. This could, in part, be explained by inadequate resources to adequately address these problems, inappropriate allocation of the available resources, or lack of implementation of the most effective interventions. Systematic priority setting and resource allocation could contribute to alleviating these limitations. There is a paucity of literature that follows through MNCH prioritization processes to implementation, making it difficult for policy makers to understand the impact of their decision-making on population health. The overall objective of this paper was to describe and evaluate priority setting for maternal, newborn and child health interventions in Uganda. Methods: Fifty-four key informant interviews and a review of policies and media reports were used to describe priority setting for MNCH in Uganda. Kapiriri and Martin's conceptual framework was used to evaluate priority setting for MNCH. Results: There were three main prioritization exercises for maternal, newborn and child health in Uganda. The processes were participatory and were guided by explicit tools, evidence, and criteria, however, the public and the districts were insufficiently involved in the priority setting process. While there were conducive contextual factors including strong political support, implementation was constrained by the presence of competing actors, with varying priorities, an unequal allocation of resources between child health and maternal health interventions, limited financial and human resources, a weak health system and limited institutional capacity. Conclusions: Stronger institutional capacity at the Ministry of Health and equitable engagement of key stakeholders in decision-making processes, especially the public, and implementers, would improve understanding, satisfaction and compliance with the priority setting process. Availability of financial and human resources that are appropriately allocated would facilitate the implementation of well-developed policies.
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Health Care Systems in Low-and Middle- Income Countries
T h e ne w e ngl a nd jou r na l o f m e dicine n engl j med 370;6 nejm.org february 6, 2014 O ver the past 10 years, debates on global health have paid increasing attention to the importance of health care systems, which encompass the institutions, organizations, and resources (physical, financial, and human) assembled to deliver health care services that meet population needs. It has become especially important to emphasize health care systems in low-and middle-income countries because of the substantial external funding provided for disease-specific programs, especially for drugs and medical supplies, and the relative under-funding of the broader health care infrastructures in these countries. 1 A function ing health care system is fundamental to the achievement of universal coverage for health care, which has been the focus of recent statements by advocacy groups and other organizations around the globe, including a declaration by the United Nations in 2012. 2 Recent analyses have drawn attention to the weaknesses of health care systems in low-and middle-income countries. For example, in the 75 countries that account for more than 95% of maternal and child deaths, the median proportion of births attended by a skilled health worker is only 62% (range, 10 to 100%), and women without money or coverage for this service are much less likely to receive it than are women with the means to pay for it. 3 Lack of financial protection for the costs of health care means that approximately 100 million people are pushed below the poverty line each year by payments for health care, 4 and many more will not seek care because they lack the necessary funds. In response to such deficiencies in the health care system, a number of countries and their partners in development have been introducing new approaches to financing , organizing, and delivering health care. This article briefly reviews the main weaknesses of health care systems in low-and middle-income countries, lists the most common responses to those weaknesses, and then presents three of the most popular responses for further review. These responses, which have attracted considerable controversy, involve the questions of whether to pay for health care through general taxation or contributory insurance funds to improve financial protection for specific sections of the population, whether to use financial incentives to increase health care utilization and improve health care quality, and whether to make use of private entities to extend the reach of the health care system. This review draws on what is now quite an extensive literature on the deficiencies of health care systems 1 and on the Health Systems Evidence database. 5 However , the poor quality and uneven coverage of evidence on the strengthening of health care systems means that evidence of deficiencies is stronger than evidence of remedies. Moreover, the specific circumstances of individual countries strongly influence both decisions about which approaches might be relevant and their success , so any generalizations made from health systems research in particular countries must be carefully considered. 6 It is unlikely that there is one single blueprint The New England Journal of Medicine Downloaded from nejm.org at UC SHARED JOURNAL COLLECTION on March 28, 2015. For personal use only. No other uses without permission.
An analysis of policy and funding priorities of global actors regarding noncommunicable disease in low-and middle-income countries
Background: Noncommunicable diseases (NCDs), including mental health, have become a major concern in lowand middle-income countries. Despite increased attention to them over the past decade, progress toward addressing NCDs has been slow. A lack of bold policy commitments has been suggested as one of the contributors to limited progress in NCD prevention and management. However, the policies of key global actors (bilateral, multilateral, and not-for-profit organisations) have been understudied. Methods: This study aimed to map the key global actors investing in action regarding NCDs and review their policies to examine the articulation of priorities regarding NCDs. Narrative synthesis of 70 documents and 31 policy papers was completed, and related to data collated from the Global Health Data Visualisation Tool. Results: In 2019 41% of development assistance for health committed to NCDs came from private philanthropies, while that for other global health priorities from this source was just 20%. Through a range of channels, bilateral donors were the other major source of NCD funding (contributing 41% of NCD funding). The UK and the US were the largest bilateral investors in NCDs, each contributing 8%. However, NCDs are still under-prioritised within bilateral portfoliosreceiving just 0.48% of US funding and 1.66% of the UK. NGOs were the key channels of funding for NCDs, spending 48% of the funds from donors in 2019. The reviewed literature generally focused on NCD policies of WHO, with policies of multilateral and bilateral donors given limited attention. The analysis of policies indicated a limited prioritisation of NCDs in policy documents. NCDs are framed in the policies as a barrier to economic growth, poverty reduction, and health system sustainability. Bilateral donors prioritise prevention, while multilateral actors offer policy options for NCD prevention and care. Even where stated as a priority, however, funding allocations are not aligned. Conclusion: The growing threat of NCDs and their drivers are increasingly recognised. However, global actors' policy priorities and funding allocations need to align better to address these NCD threats. Given the level of their investment and engagement, more research is needed into the role of private philanthropies and NGOs in this area.
The process of prioritization of non-communicable diseases in the global health policy arena
Although non-communicable diseases (NCDs) are the leading cause of morbidity and mortality worldwide , the global policy response has not been commensurate with their health, economic and social burden. This study examined factors facilitating and hampering the prioritization of NCDs on the United Nations (UN) health agenda. Shiffman and Smith's (Generation of political priority for global health initiatives: a framework and case study of maternal mortality. The Lancet 370: 1370-9.) political priority framework served as a structure for analysis of a review of NCD policy documents identified through the World Health Organization's (WHO) NCD Global Action Plan 2013-20, and complemented by 11 semi-structured interviews with key informants from different sectors. The results show that a cohesive policy community exists, and leaders are present, however, actor power does not extend beyond the health sector and the role of guiding institutions and civil society have only recently gained momentum. The framing of NCDs as four risk factors and four diseases does not necessarily resonate with experts from the larger policy community, but the economic argument seems to have enabled some traction to be gained. While many policy windows have occurred, their impact has been limited by the institutional constraints of the WHO. Credible indicators and effective interventions exist, but their applicability globally, especially in low-and middle-income countries, is questionable. To be effective , the NCD movement needs to expand beyond global health experts, foster civil society and develop a broader and more inclusive global governance structure. Applying the Shiffman and Smith framework for NCDs enabled different elements of how NCDs were able to get on the UN policy agenda to be disentangled. Much work has been done to frame the challenges and solutions, but implementation processes and their applicability remain challenging globally. NCD responses need to be adapted to local contexts, focus sufficiently on both prevention and management of disease, and have a stronger global governance structure.
What can global health institutions do to help strengthen health systems in low income countries?
2010
Weaknesses in health systems contribute to a failure to improve health outcomes in developing countries, despite increased official development assistance. Changes in the demands on health systems, as well as their scope to respond, mean that the situation is likely to become more problematic in the future. Diverse global initiatives seek to strengthen health systems, but progress will require better coordination between them, use of strategies based on the best available evidence obtained especially from evaluation of large scale programs, and improved global aid architecture that supports these processes. This paper sets out the case for global leadership to support health systems investments and help ensure the synergies between vertical and horizontal programs that are essential for effective functioning of health systems. At national level, it is essential to increase capacity to manage and deliver services, situate interventions firmly within national strategies, ensure effective implementation, and co-ordinate external support with local resources. Health systems performance should be monitored, with clear lines of accountability, and reforms should build on evidence of what works in what circumstances.
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