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. 6 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 7
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 4
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. 8 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. 7