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af7dca372431885a71c3cc2056a97b17.pdf
REVIEW
Setting healthcare priorities in hospitals: a review of empirical studies Edwine W Barasa,1,2* Sassy Molyneux,1,3 Mike English1,4 and Susan Cleary2
1 KEMRI Centre for Geographic Medicine Research – Coast, and Wellcome Trust Research Programme, P.O. Box 43640, Nairobi 00100,
Kenya, 2Health Economics Unit, University of Cape Town, Observatory 7975, Cape Town, South Africa, 3Centre for Tropical Medicine, Nuffield Department of Medicine Research Building, University of Oxford, Old Road campus, Roosevelt Drive, Headington, Oxford, OX3 7FZ and 4Nuffield Department of Medicine & Department of Paediatrics, University of Oxford, Old Road Campus, Headington, Oxford OX3 7BN, Oxford, UK
*Corresponding author. Health Services Research Department, KEMRI-Wellcome Trust Research Programme, P O Box 43640-00100, Nairobi, Kenya. E-mail: [email protected]
Accepted 30 January 2014
Priority setting research has focused on the macro (national) and micro (bedside)
level, leaving the meso (institutional, hospital) level relatively neglected. This is
surprising given the key role that hospitals play in the delivery of healthcare services
and the large proportion of health systems resources that they absorb. To explore the
factors that impact upon priority setting at the hospital level, we conducted a
thematic review of empirical studies. A systematic search of PubMed, EBSCOHOST,
Econlit databases and Google scholar was supplemented by a search of key websites
and a manual search of relevant papers’ reference lists. A total of 24 papers were
identified from developed and developing countries. We applied a policy analysis
framework to examine and synthesize the findings of the selected papers. Findings
suggest that priority setting practice in hospitals was influenced by (1) contextual
factors such as decision space, resource availability, financing arrangements,
availability and use of information, organizational culture and leadership, (2)
priority setting processes that depend on the type of priority setting activity, (3)
content factors such as priority setting criteria and (4) actors, their interests and
power relations. We observe that there is need for studies to examine these issues
and the interplay between them in greater depth and propose a conceptual
framework that might be useful in examining priority setting practices in hospitals.
Keywords Priority setting, healthcare rationing, healthcare planning, hospitals
KEY MESSAGES
� There is a dearth of empirical work on hospital level priority setting practices and more so in smaller, rural hospitals in
developing country contexts.
� The majority of empirical papers identified focused on hospital priority setting in larger, often referral hospitals in
developed countries.
� Factors at play in hospital priority setting practices include (1) contextual factors such as decision space, resource availability,
financing arrangements, availability and use of information, organizational culture and leadership, (2) priority setting
processes, (3) content factors such as such as priority setting criteria and (4) actors, their interests and power relations.
� Research that aims to examine priority setting practices in hospitals would benefit from applying a health policy lens to
their analysis.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0/), which permits
unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Published by Oxford University Press in association with The
London School of Hygiene and Tropical Medicine
� The Author 2014; all rights reserved. Advance Access publication 5 March 2014
Health Policy and Planning 2015;30:386–396
doi:10.1093/heapol/czu010
386
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Introduction Priority setting refers to the distribution of resources among
competing programmes and patients or patient groups
(McKneally et al. 1997). Given that healthcare demand outstrips
available resources, the judicial use of resources through
appropriate priority setting has been considered a key deter-
minant of health system performance (Martin 2007). For
example, it has been shown that a reallocation of 50% of the
health budget from interventions that are less cost effective to
those that are more cost effective could result in a 64% increase
in years of life saved in the East African region (Bobadilla et al.
1994). In addition, the ‘Tanzania Essential Health Intervention
Project’ suggested that targeted investments guided by proper
prioritization resulted in a 40% reduction in child mortality
in test districts (De Savigny et al. 2004).
Whereas priority setting occurs in every health system, research
has mainly focused on macro and micro level processes and rarely
on the meso level, particularly hospitals (Martin et al. 2003a). This
is perhaps surprising given the critical role that hospitals play in
the delivery of healthcare services and the observation that they
absorb a significant portion of healthcare resources. For example,
it has been observed that public hospitals absorb 30–50% of
government budgetary allocations to the health sector in both
developed and developing countries (Mills 1990; Martin et al.
2003a). Understanding how these hospitals set their priorities
and the factors that influence their allocation of resources is
therefore imperative. We conducted a thematic review of empir-
ical literature on priority setting at the hospital (meso) level with
the aim of describing what is known about priority setting
practices and exploring the factors that influence this practice.
Methods Literature search
We carried out a literature search in December 2012 in
PubMed, EBSCOHOST, Econlit databases, Google scholar and
websites of the World Health Organization, the World Bank,
Management Science for Health, US Agency for International
Development and the Organization for Economic Cooperation
and Development. In a first step, we performed a search using
the following keywords: ‘hospital’ and ‘priority setting’ or
‘rationing’ or ‘healthcare rationing’ or ‘planning’ or ‘decision
making’ or ‘strategic planning’ or ‘resource allocation’ or ‘health
technology assessment’ or ‘budgeting’. Reference lists of
selected papers were also manually searched for relevant
papers. We limited the search to studies published in the
English language that were available from January 1990 to
December 2012. Next, we only included studies in the review if
they reported empirical data on priority setting practice in
hospitals. In this step, we initially screened study abstracts
using these criteria and subsequently obtained full-text formats
for studies deemed relevant. The final inclusion of studies
in the review was based upon a detailed assessment of the
full-text formats (studies for which no full-text format was
available were excluded). All abstracts and full-text formats
were reviewed independently by two authors. We then classi-
fied studies according to five general characteristics: (1) country
(ies) where the studies were conducted, (2) study design, (3)
priority setting activity and (4) study objectives.
Analysis of selected papers
First, we read through the selected papers to familiarize
ourselves with the studies and identify key ideas and themes.
Drawing on the Walt and Gilson policy analysis framework that
focuses on four key domains (content, context, process and
actors) (Walt and Gilson 1994), we identified themes and
concepts that clustered around each of these main domains.
Each of the selected papers was imported to NVIVO version 10
software (QSR International) and coded using this thematic
framework. Data were then lifted from their original context
and rearranged according to the appropriate thematic reference
and summarized in charts. Finally, a synthesis and interpret-
ation of each theme and interrelationships between themes was
conducted.
Results The first step in the literature search resulted in a total of 2659
papers. In total, 2531 studies were excluded on the basis of
their title. The abstracts of the remaining 136 studies were
assessed, and a further 93 papers excluded. Three more papers
were excluded because they were not available online. An
assessment of the full-text formats of the remaining 40 papers
resulted in a further 16 exclusions. A total of 24 studies were
finally included in the review (Table 1). This section will first
present the characteristics of selected studies, their objectives
and methodological approaches. In line with the policy analysis
framework employed in the review, this will then be followed
by findings on the content, context, process and actors of
priority setting processes. Finally, findings on how priority
setting processes were evaluated in the studies are presented.
Further information on these result areas for each of the papers
selected for the review is presented in Supplementary data.
Characteristics of selected studies
Of the 24 papers, 20 were focused on developed country
experiences, while only 5 included developing country contexts.
One of the papers reported a multi-country study that
compared priority setting practices in two developed country
hospitals (Canada and Norway) and one developing country
hospital (Uganda). Ten studies were conducted in Canada,
three each in Australia and the USA, two in Denmark and
Uganda and one each in Argentina, Chile, Norway, Israel,
France and South Africa.
Of the selected papers, 15 included tertiary level hospitals,
13 of which were also teaching hospitals, while 1 study was
conducted in a community hospital. The level and type of
hospital in the remaining eight studies was not clear. Fourteen
studies were conducted in public hospitals, two in faith owned
hospitals and one in a network of private hospitals. Seven
studies were not clear about the ownership of the hospitals
where the study was conducted.
Objectives and methodological approaches of selected papers
Of the 24 papers, only 2 sought to introduce a priority setting
method, while 22 sought to describe and/or evaluate the
existing priority setting process. Of the latter, 13 sought to
SETTING HEALTHCARE PRIORITIES IN HOSPITALS 387
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388 HEALTH POLICY AND PLANNING
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SETTING HEALTHCARE PRIORITIES IN HOSPITALS 389
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describe and evaluate the priority setting process, 7 sought only
to describe the priority setting process and 2 sought only to
evaluate the priority setting process. Thirteen of the evaluation
studies employed the ethical framework accountability for
reasonableness (AFR) (Daniels 2000), while one evaluated
health technology assessment using an adapted mini-health
technology assessment tool and another using no specific
framework or tool.
The allocation of hospital resources and budgets to depart-
ments and service areas within the hospital was examined in
11 of the selected studies, while the remaining 13 specifically
examined health technology assessment in hospitals. Of these,
three looked at the medicines formulary management process,
two looked at acquisition of surgical technology, while the
remaining eight looked at the technology acquisition process in
general.
Most papers (n¼18) employed case study methodology,
while six employed quantitative survey methodology. Two of
the 18 case studies were interventional, while the rest were
descriptive explanatory, and all were qualitative, with the
exception of one mixed method case study.
Content of priority setting
Criteria used in priority setting
Formal and informal criteria were used to set priorities. Formal
criteria are objective criteria that, at least on paper, hospitals
claim to use in priority setting. These could be classified as
health criteria, economic criteria and administrative criteria, as
illustrated below. Informal criteria refer to subjective consider-
ations that influence priority setting practices in hospitals.
Formal criteria. In allocating budgets to departments and health
services, the main health criteria used were the perceived
medical need in the hospital’s catchment area. For example,
a study in a referral hospital in Uganda showed that disease
prevalence in the hospital’s catchment area was considered in
making decisions about what services to offer (Kapiriri and
Norheim 2004). Burden of disease was also an important
criteria in priority setting in hospitals in Canada (Kapiriri et al.
2007), Norway (Kapiriri et al. 2007), Chile (Valdebenito et al.
2009) and Argentina (Gordon et al. 2009). The rule of rescue
also featured prominently whereby emergencies received high
priority (Kapiriri et al. 2007). For health technology assessments
and medicines selection, medical criteria included effectiveness,
safety, ease of use and capacity of staff to employ the technol-
ogy, patient benefits in terms of health outcomes and the
nature of the technology/medicines. The latter was described in
terms of whether it was a proven, new or investigational
therapy. Proven therapies were often preferred.
Administrative criteria included strategic alignment and
alignment with regional/national priorities, policies and object-
ives. Examples were found in both developed (such us Canada,
Norway and Australia) and developing country (such as
Uganda and Argentina) hospitals (Kapiriri et al. 2007; Gordon
et al. 2009). Priority setting in hospitals in developed countries
was also guided by organizational strategies, goals and vision
(Martin et al. 2003a; Kapiriri et al. 2007). For example, a study
of priority setting in three teaching hospitals in Canada showed
that decisions were made based on local strategic fit, and
academic commitment and research focus (Gibson et al. 2004).
Hospitals also seemed to favour innovation in health technol-
ogies providing perceived competitive advantage over other
hospitals.
Economic criteria included historical budgeting, revenue
generating potential, budget impact and costs to patients.
Cost effectiveness was a criterion considered in only two
studies. Consideration was, however, given to whether the new
interventions were affordable (Madden et al. 2005; Kapiriri et al.
2007; Valdebenito et al. 2009).
Informal criteria. Informally, personal relationships and mutual
benefit, lobbying, level of ambition and bargaining ability of
departmental heads and political interests among actors often
dominated priority setting decisions especially in developing
countries (Kapiriri and Norheim 2004; Gordon et al. 2009).
For example, in a hospital in Argentina, it was reported that
allocations depended on whether the hospital managers and
departmental heads enjoyed good relations and the potential
for mutual benefit between them (Gordon et al. 2009). In
addition, given that decision making was centralized, priorities
were aligned to meet the political goals of local politicians
rather than the health needs of the population (Gordon et al.
2009). In Uganda, even though the formal criteria of need
determined that the paediatric department, which received
almost 40% of the hospital emergencies, is given higher priority,
the surgical department was given greater priority because of its
perceived prestige, and because it had managers who were
better at ‘lobbying, making noise and quickly use up their
resources’ (Kapiriri and Martin 2006).
Context of priority setting
Decision space
Decision space refers to the range of effective choices or
discretion that local authorities or institutions are allowed by
central authorities (Bossert 1998; Bossert and Beauvais 2002).
This space can be formal (as defined by policies and regula-
tions) and informal (choices exercised in practice but not
formally defined) (Bossert 1998; Bossert and Beauvais 2002).
The decision space for hospital level priority setting was
influenced by the structure of the health system and the
nature of the priority setting activity. For example, in countries
such as Canada and Norway where the health system was
significantly decentralized, hospitals had greater decision-
making latitude (Kapiriri et al. 2007), while in Chile, a country
with a less decentralized health system, priority setting at the
hospital level was predominantly guided by national decisions
with little discretion at the hospital level (Valdebenito et al.
2009). Hospitals generally had most discretion over decisions
about medicines formularies and adopting new technologies
compared to decisions about choice of programmes and
allocations across programmes and departments.
Resource gap
The reality of constrained resources compelled decision makers
to tackle the issue of healthcare rationing (Bochner et al. 1994;
Martin et al. 2003a,b; Gallego et al. 2007). In Australia, for
example, shrinking healthcare resources resulted in vigorous
debate about the need for, ethics of and possible methods for
cost containment and rationing of health services (Gallego et al.
2007). Increasing demand and reduced revenues also
390 HEALTH POLICY AND PLANNING
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influenced the financing arrangements in hospitals. In Uganda,
for example, an increasing budget deficit led to the capping of
budgets and introduction of line budgeting which reduced
the flexibility of priority setting (Kapiriri and Martin 2006).
Budget caps for new medicines were also implemented in an
Australian hospital to contain costs in the face of reducing
resources (Bochner et al. 1994).
Financing arrangements
Hospital financing arrangements also played a key role in
determining priority setting practices in hospitals. This influ-
ence appeared to be in two forms (1) through the conditions
associated with the financing sources and (2) through the
incentives engendered by financing arrangements. For example,
given that Chile has a mixed publicly and privately financed
healthcare system, hospitals were required to employ guidelines
that aligned their priorities to those prescribed by both systems
(Valdebenito et al. 2009). Funding arrangements also generated
incentives that influenced priority setting practice. Hospitals
which were funded by a global budget were less willing to fund
incremental use of new technology compared to hospitals
funded under different models, such as fee for service (Sharma
et al. 2006; Danjoux et al. 2007). Operating under line budgets
reduced the flexibility of hospitals in choosing priorities and
allocating resources across them (Kapiriri and Martin 2006).
The introduction of budget caps also discouraged the adoption
of new technologies as it required cutting allocations to hospital
services (Sharma et al. 2006).
Organizational culture
Two important aspects of culture seemed crucial enablers of
systematic priority setting processes, namely the importance
attached to the use of evidence and the openness to consulta-
tive and deliberative processes (Astley and Wake-Dyster 2001;
Madden et al. 2005; Danjoux et al. 2007). For example, in Chile,
a country with a history of dictatorship and military rule, a
government culture that discourages disagreement impeded the
implementation of an appeals and revisions process
(Valdebenito et al. 2009). Specifically for technology adoption,
cultural drivers for technology assessment and acquisition
included a proactive approach to seeking new technology,
having an organizational commitment to innovation and
placing high importance on integration of technology planning
with the mission and strategic plan of the organization (Astley
and Wake-Dyster 2001; Danjoux et al. 2007; Haselkorn et al.
2007).
Leadership
Within hospitals, leadership emerged as one of the key factors
influencing the process of priority setting. A study on the role
of leadership in priority setting reported that leaders are
expected to foster goals and a vision for the hospital; create
alignment between goals, vision, resources and skills, actors
and processes; develop and maintain relationships among
actors; embody and promote desired values and establish an
effective process for priority setting (Reeleder et al. 2006). The
commitment of hospital leaders to implementing a fair and
legitimate process was considered crucial to meeting the
conditions of the ethical priority setting framework, AFR (Bell
et al. 2004; Madden et al. 2005; Reeleder et al. 2005; Kapiriri and
Martin 2006; Kapiriri et al. 2007; Gordon et al. 2009, Valdebenito
et al. 2009). Within this framework the role of leadership seems
to hinge on two points. First, the enforcement condition of A4R
suggests that good leadership involves attention to the ethical
aspects of priority setting. Second, leadership approaches
describe a variety of values and behaviours which align with,
and can be viewed as enablers for, A4R.
Process of priority setting
The process of priority setting in hospitals was dependant on
the priority setting activity (Figure 1). For hospital budget
allocations to departments and service areas, at least on paper,
the priority setting process began with frontline staff (clinical
and non-clinical staff within all the departments of the
hospital) submitting their wish lists to their departmental
heads (Kapiriri and Martin 2006; Kapiriri et al. 2007; Gordon
et al. 2009). In practice, the departmental heads compiled
departmental wish lists and submitted them to the hospital
management without consulting frontline staff (Kapiriri and
Martin 2006; Valdebenito et al. 2009). Departmental priorities
were compiled to form hospital priorities by a hospital man-
agement committee whose membership comprised of all or
Figure 1 Hospital priority setting processes.
SETTING HEALTHCARE PRIORITIES IN HOSPITALS 391
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some of the departmental heads and the executive hospital
management. These hospital priorities/budget allocations were
thereafter submitted to a hospital management board, whose
membership included external stakeholders such as the com-
munity, for approval (Kapiriri and Martin 2006; Kapiriri et al.
2007; Gordon et al. 2009). Thereafter, plans were submitted to
the regional or national health authorities/ministries for final
approval.
Decision making for new technologies and medicines often
began with clinician interest and initiative (Bochner et al. 1994;
Martin et al. 2003b; Sharma et al. 2006; Danjoux et al. 2007;
Gallego et al. 2007). Suggestions for new technologies and
medicines were thereafter processed through three possible
channels (Figure 1). For medicines, often these suggestions
were presented to an assessment committee which employed
selection criteria to make decisions about their selection and
inclusion in the hospital formulary (Bochner et al. 1994; Martin
et al. 2003b; Gallego et al. 2007). This committee goes under
different names such as the medicines and therapeutics
committee, or pharmacy and therapeutics committee. For
other technology such as surgical technology, decision making
depended on the level of capital investment required (Sharma
et al. 2006; Danjoux et al. 2007). For technology that required
a low capital investment, decision making for adoption was
made by departmental heads. When a proposed technology
was associated with significant capital investment, final adop-
tion decisions were made by the hospital manager/Chief
Executive Officer (Greenberg et al. 2005). In some hospitals,
technology assessment committees had the responsibility of
evaluating and making decisions about the adoption of new
technologies (Greenberg et al. 2005).
Availability and use of information
The availability and quality of information for decision making
had a significant influence on priority setting practice. The lack
of information was the most frequent priority setting obstacle
identified by the studies in the review. Hospital decision makers
generally lacked sufficient and reliable information for decision
making (Gordon et al. 2009; Greenberg et al. 2009). The absence
of quality data provided loopholes for the use of informal/
subjective considerations in the priority setting process (Gordon
et al. 2009). Lack of information also resulted in assessments
being conducted after technologies had been adopted and
widely used (Greenberg et al. 2009). Decision makers felt
that the availability of quality information would improve
the priority setting process (Martin et al. 2003a,b; Madden et al.
2005; Reeleder et al. 2005).
Actors, their power and interests
Whereas the different actors and their influence permeate
through all the other themes, we discuss here some specific
observations. Actors (stakeholders) in the priority setting
process included national and regional health policy makers
and planners, local politicians, donor organizations, community
members, patients, hospital administrators/executives, hospital
department heads and frontline practitioners (non-managerial
clinical and non-clinical staff working directly with clients). The
involvement of national and regional health policy makers was
dependent on where the policy making authority was vested.
In high-income countries such as Canada, where regional
health authorities made policy, hospitals aligned their priorities
with those of the regional health authorities (Kapiriri et al.
2007). In low- and middle-income countries such as Uganda
and Chile, where policy making was done at the national level,
the hospital priorities were aligned with national priorities
(Kapiriri and Martin 2006; Valdebenito et al. 2009). Donor
organizations influenced decision making in Uganda, a de-
veloping country setting, where resource scarcity was extreme
(Kapiriri and Martin 2006).
Community involvement was in theory effected through
representation in hospital management boards. In one study,
community and patient involvement was effected through
surveys of community and patient views (Astley and Wake-
Dyster 2001). The minimal involvement of the community and
patients was attributed to, among others, the perception that
the community and patients lack understanding of medical
issues and would represent a biased opinion by solely arguing
for the merit of the particular interventions for which they were
concerned (Martin et al. 2003b). Within the hospital, priority
setting was dominated by hospital administrators/managers,
with some settings reporting minimal involvement of frontline
practitioners (Kapiriri and Martin 2006; Kapiriri et al. 2007).
Reasons for the minimal involvement of practitioners included
time constraints, and lack of interest (Kapiriri and Martin
2006). Power struggles between practitioners and managers
who were reluctant to share decision-making power, and
frustration by practitioners when their concerns were not
addressed, also contributed to the non-participation of practi-
tioners (Kapiriri and Martin 2006).
Other than the range of stakeholders involved, the power
differences between these stakeholders had a major influence
in the priority setting process in hospitals (Gibson et al. 2005).
Power differences exist when some actors in the priority setting
process have the capacity to influence priority setting outcomes
more than others. This occurs given that hospital decision-
making environments tend to be hierarchical and politically
complex (Gibson et al. 2005). Power was derived from several
sources. For example, actors with control over the budget had
more power and hence influence over priority setting decisions
(Gordon et al. 2009). The senior hospital managers exercised
more power over decisions compared with other hospital
managers and frontline practitioners by virtue of their position
as senior managers (Gibson et al. 2005). For example, the
hospital executive in a hospital in Argentina indicated that they
did not need to consult the hospital management committee
when requesting additional staff allocations (Gordon et al.
2009). A study of a hospital in Uganda reported power struggles
between management and frontline workers, with managers
reluctant to share decision-making responsibility. Actor power
derived from possession of specialized skills and certain
personal characteristics were also exercised (Gibson et al.
2005). For example, a study of decision making for a new
surgical technology in Canada reported conflict between
surgeons and radiologists over leadership of the process.
There was also conflict between professional groups in hospitals
(Astley and Wake-Dyster 2001; Haselkorn et al. 2007) leading to
competitive and defensive rather than collaborative behaviour.
A study in Canada reported that actors with greater persuasive
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skills had greater power to influence the planning process
(Gibson et al. 2005).
Different actors often had varying values and hence depend-
ing on the power they possess, influence priority setting in line
with their values. For example, two decision-making systems
were in conflict in hospitals namely the ‘medical-individualistic’
decision system and the ‘fiscal-managerial’ decision system
(Greer 1985). While clinicians, who subscribe to the ‘medical-
individualistic’ decision system, were concerned with individual
patient outcomes, administrators/managers, who subscribe to
the ‘fiscal-managerial’ decision system, were concerned with
the implications of decisions on the budget (Danjoux et al.
2007; Gordon et al. 2009). This conflict was more evident in
scenarios where decisions affected identifiable patients such as
medicines selection processes (Gallego et al. 2007).
Evaluation of priority setting process
The dominant priority setting framework used in evaluation
was AFR. AFR proposes that a legitimate and fair priority
setting process should meet the following four conditions:
(1) publicity, (2) relevance, (3) revisions and (4) enforcement
(Daniels and Sabin 2002).
All the studies that evaluated priority setting using the AFR
framework reported that the relevance condition was not met.
While there were some formal reasons, often informal reasons
were also considered. These included political reasons and actor
interests, persuasion skills of actors and relationships between
the actors. The lack of evidence or information to support
formal reasons is also seen as a barrier by decision makers.
Given that frontline staff and the public were often excluded,
not all the relevant actors participated in the process. It was
generally observed that the publicity condition was not met
because while decisions were communicated, this communica-
tion was often only for the people that took part in decision
making, thereby excluding other stakeholders such as frontline
workers and/or the public. In addition, reasons/rationales for
the decisions were not communicated. Of the 12 studies, only 4
reported the presence of a formal appeals mechanism, while the
other 8 reported the presence of informal mechanisms where
dissatisfied staff would seek redress directly with the hospital
chief executive. There was generally no mechanism for en-
forcement of a fair and legitimate process other than in four
studies.
Discussion We set out to review empirical studies of meso level priority
setting in hospitals. To our knowledge this is the first review of
empirical studies on hospital level priority setting. Our review
confirms that there is limited research attention given to
priority setting at this level. Given that hospitals consume a
significant proportion of health system resources, and act as
avenues for delivery of key healthcare interventions, under-
standing how and where they put their resources is an
important research and practice question. Another key obser-
vation is that most studies of priority setting in hospitals
focused on developed country settings with few being con-
ducted in developing countries. Most of the studies were
conducted in tertiary, often teaching hospitals. Such hospitals
are relatively large and act as referral hospitals. These hospitals
are often semi-autonomous institutions whose management
structures, operations, resources and target users are very
different from lower level hospitals. There is, therefore, a gap in
understanding how smaller, non-referral hospitals set their
priorities and allocate their resources.
Most of the studies in this review employed qualitative case
study methodology. The use of this approach allowed for an in-
depth exploration of not just the what, but how and why of
priority setting practices in these hospitals. Where case study
methodology was not employed, quantitative surveys were
used. These surveys were often limited to reporting frequencies
against selected characteristics of priority setting and were
unable to explore how and why the different aspects of priority
setting interact and affect each other. There is perhaps a need
to develop and employ mixed method approaches in the study
of priority setting. For example, while qualitative methods were
particularly good at eliciting the criteria used in setting
priorities, they were unable to determine the relative import-
ance of these criteria. Application of priority setting criteria
implies trade-offs between competing criteria. Determining the
relative importance of priority setting criteria is, therefore, an
important ingredient in systematic priority setting processes.
There are a number of quantitative methodologies that can be
employed to elicit preferences for priority setting criteria,
ranging from simple rating and ranking scales, self-explication
methodology and choice experiments, to more complex discrete
choice experiments (Ryan et al. 2001; Pavlova et al. 2003;
Baltussen and Niessen 2006).
All but one of the studies that sought to evaluate priority
setting employed the AFR framework. This is an ethical
framework developed by Daniels and Sabin that aims to be ‘a
practical, yet theoretically defensible, account of how societies
should set limits to and priorities for health care’ (Eddy 1991).
The framework argues for a focus on the ‘process’, rather than
the ‘outcome’ of priority setting, given the lack of consensus
about universal criteria. AFR proposes that the goal of priority
setting should be fairness and legitimacy. The studies captured
in this review, therefore, endeavoured to evaluate priority
setting processes against the four conditions of AFR such as
relevance, publicity, appeals and revision and enforcement. The
‘publicity’ criterion holds that resource allocation decisions
must be public, including the grounds for making them. The
criteria for ‘relevance’ require that the basis on which allocative
decisions are made must be ones that ‘fair-minded people can
agree are relevant to meeting the healthcare needs fairly under
reasonable constraint’ (Daniels and Sabin 1997). Arguments
should rest on scientific evidence, though not necessarily a
specific kind of evidence (Daniels and Sabin 1998). The
‘revisions and appeals’ process criterion requires that there is
an institutional mechanism that provides for channels for
appeals to decisions and subsequent revisions of decisions in
light of further arguments. The ‘enforcement’ criterion requires
that some form of regulation exists to make sure that the first
three conditions are met (Daniels 2008). While a focus on the
fairness and legitimacy of priority setting processes is indisput-
ably important, understanding what substantive principles are
employed in priority setting and how they are operationalized
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in local context is equally important. For example, do hospitals
allocate their resources across services according to severity of
disease or efficiency? And how do they define and specify these
principles? While this distinction between substantive and
procedural approaches to priority setting suggests that the two
are incompatible, there is increasing consensus on the need to
combine these approaches (Ham and Coulter 2000; Ruger 2004;
Kamm 2005). There is, therefore, a need to develop approaches
that combine the use of substantive principles that are widely
accepted with fair processes.
Most of the studies were inspired by a framework proposed
by Martin and Singer (2003) which recommends a strategy for
improving priority setting that involves (1) describing priority
setting in the context where it occurs, (2) evaluating the
description using an ethical framework and (3) improving
priority setting based on the evaluation. In elaborating this
approach, they argue that any sustainable strategy to improve
priority setting must be built on a continuous learning platform
that, at the very least, captures how priority setting decisions
are actually made (Martin and Singer 2003). This, they argue
would necessitate a description of the priority setting contexts,
processes and actors involved. Our review highlights a range of
factors influencing priority setting in these institutions regard-
ing context (e.g. financing arrangements, leadership, organiza-
tional culture, level of resourcing and demand for health care),
process (e.g. procedures and tools used) and content (e.g.
guidelines and criteria of priority setting) as well as the
importance of the interests and influence of the key actors
involved in the process. Some critical aspects of priority setting
appear to have been neglected by the studies reviewed,
however. For example, while contextual issues such as
financing arrangements and decision-making capacity of man-
agers are arguably important in priority setting processes, these
were at best minimally explored. Also given that priority setting
is a social process with a range of actors, the power relation-
ships between these actors and how these influence the process
warrant a more in-depth examination.
Given the difficulty in comparing and analysing studies with
different objectives, approaches and methods, we found it
useful to apply an a priori framework (Walt and Gilson policy
analysis framework) to examine the selected studies. This made
it easier to determine what to look for in the papers, organize
the extracted data and structure the synthesis of findings.
On the basis of the review and drawing on policy analysis
frameworks (Walt and Gilson 1994; Buse 2007; Gilson and
Raphaely 2008), we propose that studies that aim to analyse
priority setting practices use a health policy lens. Future
research that aims to examine priority setting would benefit
from carefully considering four interrelated areas (Figure 2):
� Context: What contextual issues influence the priority
setting processes? This would include issues such as health
system structure, political arrangements, financial and eco-
nomic factors, capacity of decision makers, nature and level
of demand for healthcare services, decision space and
organizational culture.
� Content: What priority setting guidelines are in place, and
what criteria are used to allocate resources?
� Process: What are the procedures and tools hospitals should
use to set priorities? Are these procedures and tools used?
If not why?
Figure 2 Framework for examining priority setting practice in hospitals.
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� Actors: Who are the relevant internal and external actors
involved in the priority setting process? What are their roles,
interests, level of influence and power relations? How does
this influence priority setting practice?
Conclusion Hospitals are a major sector within most health systems
consuming considerable resources. There is, however, a dearth
of literature on priority setting in hospitals in developing
countries and in particular little attention has been paid to
lower level hospitals as opposed to larger, referral hospitals.
Most priority setting studies employed a qualitative case study
methodology, a suitable approach for examining complex social
phenomena that are often highly embedded in context.
However, broader approaches that include mixed methods
should also be considered. Our review identified a range of
factors that affect priority setting practice in hospitals. These
factors provide potential policy levers that could be used to
influence priority setting processes. We have also proposed a
framework that, in our view, could be useful in examining
priority setting processes and potentially informing the design
of system interventions to influence priority setting at the meso
level in hospitals. In increasingly devolved systems greater
attention to the practice and consequences of priority setting
are required to promote accountability, efficiency, effectiveness
and equity.
Supplementary Data Supplementary data are available at HEAPOL online.
Acknowledgements This work is published with the permission of the Director of
Kenya Medical Research Institute (KEMRI). The idea for the
study and its design were conceived by all authors, E.W.B. was
responsible for the literature search, E.W.B. and S.C. were
responsible for the selection of papers for inclusion in the
review and synthesis of the results. E.W.B. was responsible for
the preparation of the initial draft manuscript. All authors
reviewed the draft manuscript and provided input to prepar-
ation of and approval for the final version of the report.
Funding Funds from a Wellcome Trust Strategic Award (#084538) and a
Wellcome Trust core grant awarded to the KEMRI-Wellcome
Trust Research Programme (#092654) made this work possible.
Mike English is supported by a Wellcome Trust Senior
Fellowship awarded to ME (#097170) while Sassy Molyneux
is supported by a Wellcome Trust Career Development
Fellowship to SM (WT 085418). The funders had no role in
the design, conduct, analyses or writing of this study or in the
decision to submit for publication.
Conflict of interest statement: None declared.
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