Evaluating healthcare priority setting at the meso level: A thematic review of empirical literature

Abstract

Background: Decentralization of health systems has made sub-national/regional healthcare systems the backbone of healthcare delivery. These regions are tasked with the difficult responsibility of determining healthcare priorities and resource allocation amidst scarce resources. We aimed to review empirical literature that evaluated priority setting practice at the meso level of health systems. Methods: We systematically searched PubMed, ScienceDirect and Google scholar databases and supplemented these with manual searching for relevant studies, based on the reference list of selected papers. We only included empirical studies that described and evaluated, or those that only evaluated priority setting practice at the meso-level. A total of 16 papers were identified from LMICs and HICs. We analyzed data from the selected papers by thematic review. Results: Few studies used systematic priority setting processes, and all but one were from HICs. Both formal and informal criteria are used in priority-setting, however, informal criteria appear to be more perverse in LMICs compared to HICs. The priority setting process at the meso-level is a top-down approach with minimal involvement of the community. Accountability for reasonableness was the most common evaluative framework as it was used in 12 of the 16 studies. Efficiency, reallocation of resources and options for service delivery redesign were the most common outcome measures used to evaluate priority setting. Limitations: Our study was limited by the fact that there are very few empirical studies that have evaluated priority setting at the meso-level and there is likelihood that we did not capture all the studies. Conclusions: Improving priority setting practices at the meso level is crucial to strengthening health systems. This can be achieved through incorporating and adapting systematic priority setting processes and frameworks to the context where used, and making considerations of both process and outcome measures during priority setting and resource allocation.

Development of the WHO-INTEGRATE evidence-to-decision framework: an overview of systematic reviews of decision criteria for health decision-making

“…distribution of adverse events across all those affected by the intervention) or as an outcome (e.g. reduced health inequity several years Uptake of intervention [15,20,34,35] Magnitude of benefit/effect/impact [2,4,11,14,18,31,33,36] Additional or indirect effects [2,6,33,34] Type and composition of effect/ benefit/impact [2] Impact on mortality, survival, longevity and life expectancy [1, 2, 4, 11, 16, 19, 21, 24-26, 28, 34-36] Last chance therapies [23,24] Impact on morbidity and disability [1,2,16,35] Potential changes in health consequences [24,25] Impact on (health-related) quality of life [2,8,11,12,14,19,20,22,25,26,28,29,31,33,35,36] Impact on patient-reported outcomes [2,12,16,21,26]…”

“…Size of affected population and number of potential beneficiaries [1, 2, 4, 5, 8, 10, 11, 13-17, 20-26, 28, 31-34, 36] Maximum potential for disease burden reduction [10] Severity of disease/condition: in general [1, 2, 4, 5, 9-12, 14, 16-19, 21-26, 28, 29, 31, 33-36] Severity of disease/condition: long term outcomes [34,35] Severity of disease/condition: life threatening disease/condition and prognosis without treatment [1,5,11,16,21,28,29,34] Severity of disease/condition: late stage or end-of life status of disease/condition [5,21,24,25,28,29,36] Outbreaks and epidemic potential [15,34] Urgency and emergencies [1,2,13,25] Human and individual rights…”

“…Human rights considerations [2,11,12,20,36] Autonomy and informed consent [2,11,35] Privacy and confidentiality [26,35] Intrusiveness of intervention [22] Acceptability considerations…”

“…Perceived priority of the problem Public perception of disease burden, disease risk or severity [15,34,35] Acceptability Acceptability in general [2,4,6,14,15,24,26,27,[34][35][36] Acceptability of cost and financial outcomes [2,14,25,26,34] Acceptability by beneficiaries Acceptability by beneficiaries: in general [2,6,8,11,15,16,26,35] Comfort, convenience and user experience [2, 11, 12, 14, 15, 20, 24-26, 31, 33, 35] Acceptability by those providing intervention Acceptability by those providing intervention [15,16,34,35] Social and cultural acceptability Social and cultural acceptability [2,4,8,9,11,15,18,21,22,25,26,[31][32][33][34]36] Ethical...…”

“…Other reviews have explored the criteria employed in the context of health technology assessments (HTA), which intend to examine social, economic, organizational and ethical considerations in relation to health technologies in a comprehensive manner [30]; these covered both the criteria to inform decisions about health technologies by national or sub-national HTA institutions [19,[31][32][33], and the criteria used for selecting the technologies or interventions a HTA is to be conducted on [8,34]. In general, reviews have addressed criteria used for making decisions on funding or implementing health interventions or technologies [9,10,22,[35][36][37][38], prioritizing research topics [39][40][41] or coverage decisions [7,12,42,43]. Reviews include criteria used on various levels of decision making (national, regional, or local), in different contexts (e.g.…”