Prioritization of Investments in Reproductive, Women’s and Children’s Health
Evidence-based Recommendations for Low and Middle Income Countries in Asia and the Pacific – a Subnational Focus
In the pursuit to take forward the Global Strategy for Women’s and Children’s Health and accelerate progress toward Millennium Development Goals 4 and 5 in Asia and the Pacific, there is ample evidence on what should be done and why investments in Reproductive, Maternal, Neonatal and Child Health (RMNCH) are, or should be, national priorities. However, there is scant evidence on best practice approaches to prioritizing the investment in RMNCH, and implementation of health system strategies to improve the health of women and children, which remains a challenge for many countries in the region.
In decentralized systems, which make up the vast majority in the region, prioritization usually takes place at different levels. Decision-making on the content of the benefits package, that is, which health interventions may be financed with public monies are usually taken by national authorities (macro-level or national priority setting). The difficult task of deciding how to deliver the benefits package, that is, the actual mix of providers (public and private), programs, resources, and strategies, usually rests on the shoulders of state, provincial and even district authorities (meso-level or subnational priority setting). Evidence-based recommendations were recently made for low and middle income countries (LMICs) to improve the process of prioritizing health interventions at national level (Glassman et al., 2012). However, scarce evidence exists to guide subnational authorities in their prioritization exercises.
The primary aim of this exercise is therefore to provide evidence-based recommendations to inform decisions by subnational authorities on how to prioritize service delivery investments in RMNCH in Asia and the Pacific. For this purpose we undertook a review of the available evidence on priority setting for health in both the published and the grey literature during the last 10 years. Although our primary focus was on priority setting at the subnational level, we also examined the more extensive literature on macro-level priority setting to identify lessons learned.
The literature review revealed the following:
- Available evidence for how to effectively conduct priority setting for women’s and children’s health and health in general is scarce. Very few priority setting approaches have been documented and even less formally evaluated in either high- middle-, or low-income countries.
- Purely technical approaches have limited impact on actual budget allocation or policy implementation. Priority setting is a political issue and highly context specific and evidence is only one of the factors that policy-makers need to consider in this process.
- The challenges posed for priority setting at the subnational -level are common to all approaches. They include systemic issues such as funding constraints, low capacity for planning and budgeting at the subnational level and low quality information systems. Unless these issues are rectified, evidence-based health priorities will fail to get adequately funded and implemented.
From our review we conclude that we cannot recommend any single evidence-based approach to priority setting. However, we should not abandon efforts to bridge the gap between evidence and the process of making decisions for allocation in health. Good priority-setting is even more important now with an increasing focus on achieving value for money, or more health for the money. This is particularly the case for many lower and middle income countries negotiating the epidemiologic transition and the so-called double burden of disease(Abegunde et al., 2007), and for subnational authorities determining whether and how to implement new solutions for a new constellation of issues.
Therefore we propose a roadmap to help governments interested in improving their priority setting process. This roadmap takes into consideration the various issues identified in the literature, acknowledging the importance of political and contextual issues. The roadmap is adapted from Martin and Singer (2003) but has been re-designed into the following categories: A) Assess current health priority setting process (situation analysis); B) Decide whether improvement in the current health priority setting process is needed and/or viable; C) Improve current health priority setting process; D) Evaluate health priority setting process.
The roadmap does not assume that improving priority setting is feasible in every location. It is not possible to implement programs, however strongly prioritised, unless known problems with the health system are rectified. In some instances, the prioritisation exercise itself would be useful in examining those systemic issues (i.e. human resources) and the strategies and associated investments required to effectively address them. However, in other cases, barriers to successful priority setting will be interlinked with barriers to implementing new programs. For example delays in funding flows not only prevent implementation, but also discourage efforts to improve budgets. The decision to improve priority-setting processes linked to planning and budgeting should thus follow a pragmatic consideration about the extent to which such process has the potential to accelerate the scale-up of health services in the given context.
For governments who have made a decision to improve their priority setting processes for RMNCH (C above), in Chapter 3 we also present ten elements to consider in the process. The recommended elements are drawn from the approaches in the reviewed literature. They aim to illustrate the scope of activities involved in adopting a systematic approach to prioritize investments in RMNCH. Although our focus is on the type of decisions usually made by sub-national authorities in decentralised systems, they are also applicable to national level exercises aimed to informing such decisions on how to deliver health services. . They are not intended to be prescriptive and should be adapted to the individual country situation and the specific approach adopted.
- Setting up a multi-stakeholder advisory group
- to help advise on all aspects of the priority-setting process
- Choosing a direction - deciding on the objectives
- to identify the objectives for priority-setting in relation to women’s and children’s health for instance selecting low-cost strategies for scale up or identify under-invested RMNCH programmes
- Choosing a priority setting approach
- Using and adapting an approach from the literature that fits in with the identified objectives for priority-setting
- Deciding on criteria to inform the selection of priorities
- Criteria will be closely related to the objectives and approach that is chosen for priority-setting and may include both quantitative (e.g. costs) and qualitative (e.g. cultural acceptability of interventions)
- Organizing, collecting and validating information
- A number of frameworks exist to help in organising data. Some approaches to priority-setting use particular frameworks
- Choosing WHICH health services to scale-up
- From a list of 56 interventions known to be cost-effective and feasible to implement in low income settings, choose the interventions most likely to reduce deaths in mothers and children in a particular location
- Choosing HOW to scale-up health services
- Identifying the problems to health service delivery and developing locally relevant strategies/investment scenarios to address these problems and increase coverage of critical RMNCH interventions
- Costing the investment scenarios
- Which package of strategies/investment scenarios best meets the identified criteria for priority-setting?
- Deciding between investment scenarios
- Which package of strategies/investment scenarios best meets the identified criteria for priority-setting
- Evaluating and feeding back into priority-setting
- Involves continuous improvement for priority-setting and evidence needed on what works and does not work
One of the major constraints to priority-setting in resource-poor settings is the lack of evidence on what has worked and not worked. Once a process for priority-setting has been implemented in a particular setting, financial and human resources should be allocated to monitoring of both the process (to see whether it is actually being implemented in the way envisaged) and outcomes (whether it is shifting allocation of resources towards identified priorities and in the longer term whether these changes are translating into better health outcomes for women and children). It is important that the results of the monitoring and evaluation process are documented. Such information can be used in the location where the priority-setting is being implemented, to continually hone and improve the methods. It should also be widely disseminated in the Asia-Pacific region so it can contribute to the scarce literature on the use of different priority-setting approaches in Low and Middle Income Country settings.