What it is
What others have done
How to get started
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What should I know before beginning implementation?

Local priority setting involves two central considerations: the choice of indicators/data for identifying needs and selecting priorities as well as the process for determining, monitoring, and implementing priorities including the necessary stakeholders to conduct these activities.

  • Local priority setting often begins by reviewing the burden and cause of mortality and morbidity in a population. These data should be complemented by social determinants unique to the population. Experience from Uganda found ten criteria that were deemed highly relevant for local priority setting by community stakeholders: 2 

    • Severity of diseases
    • Benefit of intervention
    • Costs of intervention
    • Cost-effectiveness of intervention
    • Quality of data
    • Patient age
    • Place of residence
    • Lifestyle
    • Importance of equity of access
    • Community views

    These findings demonstrate the importance of melding social and lifestyle considerations – such as norms about childbirth/child rearing or preferences for provider gender - with more traditional epidemiological data when setting priorities. At first, indicators may have to be chosen based on available data. Quantitative indicators should also be supplemented with qualitative feedback solicited through active community engagement. Conclusions from these data can then be linked to evidence-based interventions that may be feasible, effective, and acceptable in the given setting. Stakeholders should ensure alignment with existing national or sub-national structures and documents such as the Basic Package of Essential Health Services. Eventually, data management and priority setting should operate in tandem and be informed by larger performance management systems. These systems are discussed in greater detail in performance measurement and management.    

  • The process for determining priorities and setting local agendas presents an opportunity to leverage local knowledge and expertise from communities. The Accountability for Reasonableness (AFR) approach is a framework that focuses on legitimacy and fairness in local priority setting.3 This approach, applied from Kamuzora et al (2013) comprises a four-step framework:

    • Relevance: the rationales for priority setting are based on evidence and are relevant to meeting healthcare needs
    • Publicity: priority-setting decisions are publically accessible and the processes are transparent
    • Appeals and revision: priority setting processes include a mechanism for challenging decisions
    • Monitoring: systems are in place for leaders to ensure that the conditions are being met 4

    Taken together and effectively implemented, these elements can ensure strong, transparent, and well-monitored priority setting activities.

    While not widely tested, a second framework developed in Australia identifies factors that influence effective priority setting:

    • Comparable state-wide and catchment level data
    • Orientation towards social determinants of health
    • Scale of the problem (number of people affected)
    • Impact of a problem (morbidity and mortality)
    • Aligning priority with governments’ priorities and targets
    • Maintaining progress with existing community health plan initiatives
    • Assessment of available resources
    • Values of members of the population
    • Consumer voice and consumer action
    • Assessment of financial cost of not addressing the problem
    • Leveraging concurrent initiatives
    • Potential to produce improvement
    • Strength of evidence base 1

    A common theme across frameworks is the importance of using comparable data between the national and local levels as it can align progress and priorities across districts and increase efficiency through shared and standardized indicators.5 However, comparability should be balanced with quality and relevance to ensure that indicators are actionable. A second theme is the value of transparency and alignment with communities and consumers. Local priority setting presents an opportunity for community engagement where community members and health care users can help determine which services are most needed and valued. When services are tailored to the community that they serve in regard to both clinical need and cultural awareness, health systems can achieve: greater efficiency, improved health status, stronger patient-provider respect and trust and people centeredness, greater equity, more responsive, and better utilization by the community.4

Suggested citation: “Population Health Management: Local Priority Setting.” Improvement Strategies. Primary Health Care Performance Initiative, 2018, https://improvingphc.org/improvement-strategies/population-health-manage.... Accessed [insert date].

What has been done elsewhere to improve local priority setting?

  • Regardless of the process for priority setting, robust local data are crucial for informing these exercises, and thus capacity for data collection, analysis, and use are necessary. In Costa Rica, community health workers regularly collect local data during routine community visits.11 After data are transferred from community health workers to clerks (Registros de Salud or REDES), they are sent to and analyzed by the Costa Rican social security agency (Caja Costarricense de Seguro Social) and eventually returned to the Health Area Teams (akin to district health management teams) where they are used to set priorities for the coming year.7 For a brief time, these data were also used to negotiate bonus compensation for the health area. However, this was system was antithetical to many values held by providers in Costa Rica and was eventually abolished.8 Regardless, this system of data collection and feedback has established a systematic approach to priority setting and re-revaluation of priorities that is grounded by local data collection and supported by functioning analytic systems and clear communication.

    Learn more about Costa Rica in our Promising Practice and a longer, comprehensive case study developed by Ariadne Labs. 

  • The Response to Accountable Priority Setting for Trust in health systems (REACT) initiative in Tanzania brought together community members and medical professionals to determine priorities and establish a system for implementing the Accountability for Reasonableness (AFR) framework in Tanzania with mixed results.4 The decentralized nature of the health system in Tanzania was a significant enabler of implementation during this project. Pre-existing Council Health Management Teams (CHMTs) were responsible for planning and budgeting and formed the foundation of the AFR intervention. The CHMTs collaborated with research teams to conduct participatory research evaluating the existing priority-setting practices, training for CHMT to restructure priority setting, and development of strategies to address AFR. The CHMT was ultimately responsible for spreading AFR values throughout the district.4 There was initial resistance to the inclusion of special interest groups and community members in the CHMT despite community engagement and transparency being a central component of AFR. Critics felt that community members often did not have adequate knowledge or skills to contribute to these exercises. After a few years, the CHMTs acclimated to the inclusion of special groups and recruited community members into their planning and budgeting process. Thus, the evaluation found that successful integration of community perspectives in priority setting required external support to sensitize health professionals towards the utility of community input, an important consideration for health systems seeking to integrate community members into priority setting exercises.4

    The program experienced some logistical challenges that should be considered by others attempting to replicate this process, including lack of financial support to effectively carry out roles and insufficient time for pre-planning, discussion of priorities, and meeting preparation. Thus, countries working towards incorporating community voices and values in priority setting should ensure that they devote adequate time and financial resources to community engagement during planning. Despite these shortcomings, this approach was successful at improving health outcomes, including marginalized groups, and appropriately orienting priorities to local needs. The process resulted in better identification of needs and priorities, increased community knowledge about priority setting, greater transparency, improved trust, and improved perceived accessibility of services.4

  • Mothers groups are a common structure for integrating local priority setting and community engagement. Inspired by a design that had been used successfully in Bolivia, the MIRA Makwanpur trial was established in Nepal to test the impact of a women’s group on neonatal mortality.9 Trained and remunerated local women led each meeting and worked with community volunteer to organize the logistics of the meetings. Facilitators used meeting manuals to guide the group through planning activities. Women’s groups identified problems in the communities as well as ideas for addressing them using local resources. Afterwards, the whole community was invited to discuss and plan strategies. A randomized controlled trial of this program found a 30% reduction in neonatal mortality over the first 30 months of the program.9 Women’s groups may be an effective strategy for building community and trust for the purpose of receiving feedback and identifying opportunities for growth and interventions within the health system.

Suggested citation: “Population Health Management: Local Priority Setting.” Improvement Strategies. Primary Health Care Performance Initiative, 2018, https://improvingphc.org/improvement-strategies/population-health-manage.... Accessed [insert date].

What questions should be considered to begin improvements?

The questions below may be a useful starting place for determining whether local priority setting is an appropriate area of focus for a given context and how one might begin to plan and enact reforms:

How are national priorities determined, and what is the system for reporting on benchmarks?

Understanding existing systems for national priorities will influence the indicators or systems used to set local priorities and can reduce redundancy and increase efficiency in data collection and reporting. Note that national priorities, while an important consideration for local priority setting, are only one element to be considered. Local priority setting also relies heavily upon community engagement and local data.

What, if any, systems are in place for setting local priorities, including informal ones?

Before implementing new systems for local priority settings, first explore what formal or informal system are already in place. For instance, there may be community feedback forms or conversations that occur with existing regional or district health teams that contribute to decisions about local priorities and these could be evaluated for effectiveness and formalized or integrated into new systems.

What local data on demographics and health status exist and how often are they collected?

Because local priority setting should be informed by data, it is crucial to identify the relevant data sources and data collection systems within the community. If these do not exist or are not reliable, stakeholder may choose to focus on strengthening them while also engaging with community members on their needs and priorities. Stakeholders within the health system must also have the capacity to store, analyze, and share data.

What are the existing systems and opportunities for community engagement within local priority setting?

Community members should be actively engaged in local priority setting, particularly in determining how services are delivered. There are a number of different ways to solicit input from communities including community committees, conversations with community members during outreach, and engagement with specific special interest groups. More information on community engagement can be found in the Community Engagement module.

Which community groups are invited to engage in local priority setting activities?

Given the numerous ways to engage communities, it is important to ensure that all segments of the population are given a voice in local priority setting, particularly those who may be historically under-represented or marginalized.

Suggested citation: “Population Health Management: Local Priority Setting.” Improvement Strategies. Primary Health Care Performance Initiative, 2018, https://improvingphc.org/improvement-strategies/population-health-manage.... Accessed [insert date].

What elements should be in place to support effective improvements?

In order for interventions aimed at improving empanelment to be most successful, the following elements of the PHCPI Conceptual Framework should be in place or pursued simultaneously:

  • While many aspects of population health management depend on local or clinic-level decisions and resources, national policies that are supportive of a population health management approach will aid decision making and service delivery. For instance, national priority setting exercises that allow flexibility and encourage adaptation at a local level will better serve the needs of heterogeneous populations within a given country.

  • Successful local priority setting depends on information systems with broad, fundamental capacities to collect and track indicators that influence adaptation to local priorities. For instance, during monthly household visits, community health agents in Brazil collect individual and household-level data to keep updated vital registers and data on burden of disease and health needs.10 Similarly, in Costa Rica, data feedback loops and efficient communication of information enable the development of targeted action plans and management contracts, targeting the specific health needs of the population.7

Suggested citation: “Population Health Management: Local Priority Setting.” Improvement Strategies. Primary Health Care Performance Initiative, 2018, https://improvingphc.org/improvement-strategies/population-health-manage.... Accessed [insert date].

References:

  1. Mcdonald J, Ollerenshaw A. Priority setting in primary health care: A framework for local catchments. Rural Remote Health. 2011;11(2):1–11.
  2. Kapiriri L, Norheim O. Criteria for priority setting in health interventions in Uganda. exploration of stakeholders’ values. Bull World Heal Organ. 2004;82(03):172–9.
  3. Mshana S, Shemilu H, Ndawi B, Momburi R, Olsen OE, Byskov J, et al. What do District Health Planners in Tanzania think about improving priority setting using “Accountability for Reasonableness”? BMC Health Serv Res [Internet]. 2007;7(1):180. Available from: http://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-7-180
  4. Kamuzora P, Maluka S, Ndawi B, Byskov J, Hurtig AK. Promoting community participation in priority setting in district health systems: experiences from Mbarali district, Tanzania. Glob Health Action. 2013;6:22669.
  5. Kapiriri L, Norheim OF, Heggenhougen K. Using burden of disease information for health planning in developing countries: the experience from Uganda. Soc Sci Med. 2003;56(12):2433–41.
  6. Fausto MCR, Giovanella L, de Mendonca MHM, de Almeida PF, Escorel S, de Andrade CLT, et al. The work of community health workers in major cities in Brazil: mediation, community action, and health care. J Ambul Care Manage. 2011;34(4):339–53.
  7. Pesec M, Ratcliffe HL, Karlage A, Hirschhorn LR, Gawande A, Bitton A. Primary Health Care That Works: The Costa Rican Experience. Health Aff (Millwood). 2017 Mar;36(3):531–8.
  8. Pesec M, Ratcliffe HL, Karlage A, Hirschhorn LR, Gawande A, Bitton A. Primary health care that works: The Costa Rican experience. Health Aff. 2017;36(3):531–8.
  9. Morrison J, Tamang S, Mesko N, Osrin D, Shrestha B, Manandhar M, et al. Women’s health groups to improve perinatal care in rural Nepal. BMC Pregnancy Childbirth [Internet]. 2005;5(1):6. Available from: http://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-5-6
  10. Macinko J, Harris MJ. Brazil’s family health strategy--delivering community-based primary care in a universal health system. N Engl J Med. 2015 Jun;372(23):2177–81.