Brazil is a high middle income country where health inequities persist across two systems of health care financing and delivery. The publicly financed system (SUS) is one of the world’s largest health organizations, which is charged with the constitutional mandate to provide comprehensive health care coverage to over 190 million citizens. National Health Conferences (CNS), the core forum for societal participation in health policy making for the SUS, occur every four years. Yet, managers and councillors struggle to decide on how to allocate resources to meet competing populational health needs and demands, and to comply with the directives of the SUS. The purpose of my research is to describe the three most recent CNS, based on a scoping literature review, to evaluate the ethical account of these decision making processes, and to provide recommendations for improving priority setting for health resource allocation for the SUS according to the ethical analysis.

Brazil is a high middle income country where health inequities persist across two systems of health care financing and delivery. The publicly financed system (SUS) is one of the world’s largest health organizations, which is charged with the constitutional mandate to provide comprehensive health care coverage to over 190 million citizens. National Health Conferences (CNS), the core forum for societal participation in health policy making for the SUS, occur every four years. Yet, managers and councillors struggle to decide on how to allocate resources to meet competing populational health needs and demands, and to comply with the directives of the SUS. The purpose of my research is to describe the three most recent CNS, based on a scoping literature review, to evaluate the ethical account of these decision making processes, and to provide recommendations for improving priority setting for health resource allocation for the SUS according to the ethical analysis.

Research Question: This research adapted, tested, and evaluated a methodology to set priorities for systematic reviews topics within the Cochrane Collaboration that is sustainable and incorporates the social determinants of health and health equity into the analysis. Background: In 2008 a study was conducted to review, evaluate and compare the methods for prioritization used across the Cochrane Collaboration. Two key findings from that study were: 1) the methods were not sustainable and 2) health equity represented a gap in the process. To address these key findings, the objective of this research was to produce and test a method that is sustainable and incorporates the social determinants of health and health equity into the decision making process. As part of this research, the methods were evaluated to determine the level of success. Methodology: With assistance from experts in the field, a comparative analysis of existing priority setting methods was conducted. The Global Evidence Mapping (GEM) method was selected to be adapted to meet our research objectives. The adapted method was tested with assistance of the Cochrane Musculoskeletal Group in identifying priorities for Osteoarthritis. The results of the process and the outcomes were evaluated by applying the “Framework for Successful Priority Setting”. Results: This research found that the priority setting method developed is sustainable. Also, the methods succeeded in incorporating the social determinants of health and health equity into the analysis. A key strength of the study was the ability to incorporate the patients’ perspective in setting priorities for review topics. The lack of involvement of disadvantaged groups of the population was identified as a key limitation. Recommendations were put forward to incorporate the strengths of the study into future priority setting exercises within Cochrane and to address the limitations.

A growing demand for services and expensive innovative technologies is threatening the sustainability of healthcare systems worldwide. Decision makers in this environment struggle to set priorities appropriately, particularly because they lack consensus about which values should guide their decisions; this is because there is no agreement on best practices in priority setting. Decision makers (or ‘leaders’) who want to evaluate priority setting have little guidance to let them know if their efforts were successful t. While approaches exist that are grounded in different disciplines, there is no way to know whether these approaches lead to successful priority setting. The purpose of this thesis is to present a conceptual framework and an evaluation tool for successful priority setting. The conceptual framework is the result of the synthesis of three empirical studies into a framework of ten separate but interconnected elements germane to successful priority setting: stakeholder understanding, shifted priorities/reallocation of resources, decision making quality, stakeholder acceptance and satisfaction, positive externalities, stakeholder engagement, use of explicit process, information management, consideration of values and context, and revision or appeals mechanism. The elements specify both quantitative and qualitative dimensions of priority setting and relate to both process and outcome aspects. The evaluation tool is made up of three parts: a survey, interviews, and document analysis, and specifies both quantitative and qualitative dimensions and relates to both procedural and substantive dimensions of priority setting. The framework and the tool were piloted in a meso-level urban hospital. The pilot test confirmed the usability of the tool as well as face and content validity (i.e., the tool measured relevant features of success identified in the conceptual framework). The tool can be used by leaders to evaluate and improve priority setting.

In Ontario, access to publicly funded home care services is managed by Community Care Access Centres (CCACs). CCAC case managers are responsible for assessing all potential clients and prioritizing the allocation of services. The objectives of this thesis were to: 1) describe the types of decisions made by CCAC organizations and by individual case managers concerning the allocation of nursing, personal support and homemaking services to long-term adult clients with no mental health issues; and 2) to describe and assess the factors and values that influence these decisions. We conducted two case studies in which qualitative data were collected through 39 semi-structured interviews and a review of relevant documents from an urban and a rural area CCAC. A modified thematic analysis was used to identify themes related to the types of priority setting decisions and the associated factors and values. An internet-based survey was then designed based on these results and answered by 177 case managers from 8 of the 14 CCACs. The survey contained discrete choice experiments to examine the relative importance of client attributes and values to prioritization choices related to personal support and homemaking services, as well as questions that examined case managers’ attitudes towards priority setting. We found that both the rural and the urban CCACs utilized similar forms of priority setting and that case managers made the majority of these decisions during their daily interactions with clients. Numerous client, CCAC, and external factors related to the values of safety, independence and client-focused care were considered by case managers during needs assessment and service plan development. The relative importance of the selected client attributes in defining need for personal support and homemaking services was tested and found to be significantly affected by the location of the case manager (rural or urban area), years of experience in home care, and recent experience providing informal care. Case managers allocated services in the spirit of equal service for equal need and in consideration of operational efficiency. We also identified a number of case manager-related, client-related and external factors that interfered with the achievement of horizontal equity.

Priority setting for expensive biopharmaceuticals is one of the most important challenges for publicly funded health systems. One of the drivers of rising healthcare expenditures is pharmaceuticals (i.e., drugs). Moreover, people are living longer and their expectation of, and demand for, health care, drugs, and services are continually increasing. The overall aim of this research was to describe and evaluate reimbursement decisions for six expensive biopharmaceuticals across five countries in order to ascertain if the processes were legitimate and fair. I conducted qualitative case studies of six expensive biopharmaceuticals in order to describe and evaluate the priority setting activities of eight committees across five countries, including Canada, England and Wales, Australia, Israel and the United States. Data sources included: 1) 32 documents and 2) 56 interviews with informants. The recommendations process of each committee partially met the four conditions of ‘accountability for reasonableness’. My main finding is that, while a number of values were considered by committees when making reimbursement decisions, committees tended to focus on values of evidence, effectiveness and efficiency, but not the full range of relevant values. Thus, these contexts did not fully meet the conditions of legitimacy and fairness. I have provided an in-depth description of the eight committees’ priority setting activities regarding the study drugs, as well as committee members’, patients’ and industry representatives’ views regarding the process. I developed practical guidance for leaders for improving reimbursement decisions for expensive biopharmaceuticals, the implementation of which would enhance the fairness and legitimacy of priority setting. This study has demonstrated that in order to create a fair and legitimate drug reimbursement process, we need to ensure the incorporation of a wide range of values, and the involvement of multiple stakeholder groups within the deliberative and appeals/revisions processes.

Research Question: This research adapted, tested, and evaluated a methodology to set priorities for systematic reviews topics within the Cochrane Collaboration that is sustainable and incorporates the social determinants of health and health equity into the analysis. Background: In 2008 a study was conducted to review, evaluate and compare the methods for prioritization used across the Cochrane Collaboration. Two key findings from that study were: 1) the methods were not sustainable and 2) health equity represented a gap in the process. To address these key findings, the objective of this research was to produce and test a method that is sustainable and incorporates the social determinants of health and health equity into the decision making process. As part of this research, the methods were evaluated to determine the level of success. Methodology: With assistance from experts in the field, a comparative analysis of existing priority setting methods was conducted. The Global Evidence Mapping (GEM) method was selected to be adapted to meet our research objectives. The adapted method was tested with assistance of the Cochrane Musculoskeletal Group in identifying priorities for Osteoarthritis. The results of the process and the outcomes were evaluated by applying the “Framework for Successful Priority Setting”. Results: This research found that the priority setting method developed is sustainable. Also, the methods succeeded in incorporating the social determinants of health and health equity into the analysis. A key strength of the study was the ability to incorporate the patients’ perspective in setting priorities for review topics. The lack of involvement of disadvantaged groups of the population was identified as a key limitation. Recommendations were put forward to incorporate the strengths of the study into future priority setting exercises within Cochrane and to address the limitations.

In 2003 national heads of African states, including Zambia, met in Maputo and pledged to increase financial resources to the agriculture sector, up to 10 % of their national budgets, in order to meet growth targets. Given the need to increase investments in agriculture, it follows that impact assessment studies have become handy as funding agencies demand better accountability and empirical justification for further investment. However, experts have reasoned that the quantity of resources is as important as the quality of spending in that, if resources are allocated efficiently, more could be achieved with the same level of resources. The lack of an effective strategy and basis upon which investments in agriculture crop research ought to be prioritised in order to improve agricultural productivity is the main concern in Zambia. This study sought to illustrate the use of the Dynamic Research Evaluation for Management (DREAM) model to assess the economic returns of investing in agriculture technologies and to set priorities for crop-based research activities in Zambia. The study hypothesised that the financial outlay allocated to agricultural crop research is not efficiently allocated so as to achieve the nation’s agricultural production potential, and that agricultural crop research investment influences the distribution of welfare effects on producers and consumers. The DREAM model is conceptually based on the economic surplus theory and is designed for research priority setting and ex ante evaluations. It computes the net present value (NPV) of benefits for both producers and consumers as a result of investing in agriculture technology. The findings from this study reveal that investment in agriculture crop research in Zambia is worthwhile as positive net present values were obtained for all crops under consideration in this study. Maize research gives the highest return to both large-scale and smallholder producers. Maize also yielded the highest returns for consumers in Zambia. In order of priority, maize is followed by soya bean, groundnuts, cotton, millet, sunflower and sorghum. In spite of this, the order of priority in terms of financial expenditure on crop research is maize, cotton, sorghum, soya bean, groundnuts, sunflower and millet. Therefore, the allocation of financial resources towards crop research is not efficient for all crops except maize since some crops such as sorghum receiving high financial expenditure in research did not necessarily generate high returns. This is because the Government still conducts the bulk of research in Zambia, and as such, other social objectives such as equity and food security considerations play a major role in determining investment patterns. The study further establishes that the choice of crop research expenditure influences the distribution of welfare benefits on different producer groups; and that smallholder farmers in Central, Eastern and Southern province are among the group that received the highest proportion of benefits even for crops such as maize for which financial resources were efficiently allocated. Therefore, the efficiency objective may not necessarily leave smallholder farmers worse off as long as they have access to complementary infrastructure and institutions for agriculture production and marketing. As such the study recommends that the Government, private sector and other development partners must focus on raising agriculture productivity by expanding investments in crop science-based technologies; and also recommends re-allocation of financial resources between crops in favour of crops with high returns because this benefits both large scale and smallholder farmers. This must be accompanied by further investment in complementary infrastructure and good governance. Copyright / Dissertation (MScAgric)--University of Pretoria, 2010. / Agricultural Economics, Extension and Rural Development / unrestricted

There is a growing body of literature about public participation in health-system priority setting in different contexts and levels of governance, however, explicit focus on vulnerable populations’ participation is lacking. This dissertation incorporated a mix of methodological approaches to address this gap. First, a scoping review was used to synthesize the literature on priority-setting frameworks to understand whether and how applications of the frameworks involve the public and vulnerable populations in different contexts. Second, an interpretive description study was used to examine stakeholder participation at the district level in a low-income country, Uganda. Third, a qualitative description study design was used to qualitatively assess vulnerable women’s participation in health-system priority setting within a district in Uganda, from the perspectives of both vulnerable women and decision-makers. The research chapters complement and build on one another to make substantive, methodological, and theoretical contributions. Specifically, insights gained from the scoping review demonstrate that while priority-setting frameworks may require participation of all stakeholders, in practice certain stakeholder groups, namely the public and especially vulnerable populations, are not consistently integrated into priority-setting processes. The empirical research provides a rich understanding of the roles of different stakeholders in the priority-setting process and provides explanations about why vulnerable women, as a subset of the public, are not participating. This adds to the evidence base that policy-makers can access to guide future attempts to engage publics in health-system priority setting. These studies collectively contribute to a wider understanding of public’s and vulnerable populations’ participation in health-system priority setting in low-income contexts where health disparities are pronounced, and health resources are especially scarce. Policy-makers should aim to support vulnerable populations’ participation in health-system priority setting. Clear articulation of which vulnerable populations should participate and how they should participate can facilitate priority-setting processes. Co-developing participatory methods, frameworks, and guides with vulnerable populations can reinforce their participation and lead to mechanisms of participation that are more responsive to their needs. / Thesis / Doctor of Philosophy (PhD) / Public participation is often considered a cornerstone of fair and legitimate priority setting. Yet, little is known about whether and how the participation of vulnerable populations is operationalized in the field of health-system priority setting. An in-depth understanding of who participates and who does not, and how participation is enabled and/or hindered is essential to ensure that policy-makers can support participation. This dissertation addresses gaps in knowledge through: 1) a literature synthesis examining the operationalization of stakeholder participation within priority-setting frameworks, with specific attention to the publics’ and vulnerable populations’ participation, in cases where the frameworks have been applied to health-system priority setting; 2) supportive qualitative evidence on the roles, leverages, and challenges of different stakeholders’ participation in district-level health-system priority setting in Uganda; and 3) examining vulnerable women’s participation within one Ugandan district, specifically outlining barriers to their participation, and solutions to address these barriers and support vulnerable women’s participation in health-system priority setting. Collectively these studies can inform policy-making and development of public participation strategies that specifically target vulnerable populations for participation in health-system priority setting.

This thesis examined factors that influence three Canadian Nursing Associations’ priority setting and policy advocacy for community environmental health (CEH). The research questions that guided the study were: (a) how do the nature and scope of nursing organizations’ engagement for CEH policies differ according to provincial and federal contexts? and (b) how do nursing organizational factors and external system factors influence the priority-setting and policy advocacy choices for CEH policy? To answer these questions I undertook a qualitative comparative case study. The research was guided by epistemological and methodological principles of interpretative description and informed by whole-systems socio-ecological theory and institutional theory. Data were collected through participant interviews (n=41) and document review. Guided by framework analysis and the use of descriptive and conceptually-oriented matrices, cases were analyzed using an iterative and inductive approach to identify case patterns. These case patterns were then compared to identify cross-cutting factors that influence the Nursing Associations’ priority setting and policy advocacy for CEH. Key findings are represented in an integrated conceptual framework. Nursing Associations’ priority setting and policy advocacy are embedded in a dynamic policy field whereby structures and institutional pressure both create opportunities and narrow the Nursing Associations’ options for engaged CEH advocacy. The findings lead to recommendations for practice, policy, and research that have relevance for the profession, nursing associations, and policy decision-makers.