Implementing priority setting frameworks: Insights from leading researchers

Priority setting for non-communicable disease prevention - Co-producing a regulatory agenda informing novel codes of practice in Australia

There are a range of priority setting methods for non-communicable disease (NCDs) prevention. However, existing methods are often designed without detailed consideration of local context and political economy- critical success factors for implementation. In Australia, codes of practice under state government Public Health Acts could be used for NCD prevention. To inform the potential development of codes of practice under Public Health Acts, this study aimed to co-create a priority setting framework that accounts for local context and the prevailing regulatory agenda. A priority setting framework was co-produced by a multidisciplinary technical advisory group consisting of government representatives, public health lawyers and academic experts. It incorporated general prioritisation criteria (evidence, cost-effectiveness, equity, burden of disease) and local contextual criteria (legal compatibility, unmet-needs, political acceptability, structural and technical feasibility, community support). The framework was then applied in practice through surveys and policy dialogue workshops to discuss political economy factors. Policies were limited to nutrition, alcohol and physical activity risk factors. Through the prioritisation process, the most impactful, feasible and acceptable policies for NCD prevention via state government codes of practice were: restrictions on in-store placement of unhealthy products, enhancing data systems and capabilities for health surveillance and implementation monitoring, removal of unhealthy foods and drinks sold and supplied in public institutions, prohibition of marketing of unhealthy foods and drinks on assets controlled by government, and implementation of subsidies or grants to increase fruit and vegetable intake. The process illustrated that explicit consideration of local context, legal compatibility and the political economy had a substantial influence on the prioritised list of actions. The proposed priority setting framework is designed to be flexible and adaptable to varying contexts, can be embedded in government processes or utilised by researchers and practitioners to co-produce a regulatory agenda that is locally relevant.

The sociology of rationing: Towards increased interdisciplinary dialogue - A critical interpretive literature review

Since the 1990s, the sociology of rationing has developed in explicit opposition to health economic and bioethical approaches to healthcare rationing. This implies a limited engagement with other disciplines and a limited impact on political debates. To bring the sociology of rationing into an interdisciplinary dialogue, it is important to understand the disciplines' analytical differences and similarities. Based on a critical interpretive literature synthesis, this article examines four disciplinary perspectives on healthcare rationing and priority setting: (1) Health economics, which seeks to develop decision models to provide for more rational resource allocation; (2) Bioethics, which seeks to develop normative principles and procedures to facilitate a just allocation of resources; (3) Health policy studies, which focus on issues of legitimacy and implementation of decision models; and lastly (4) Sociology, which analyses the uncertainty of rationing and the resulting value conflicts and negotiations. The article provides an analytical overview and suggestions on how to advance the impact of sociological arguments in future rationing debates: Firstly, we discuss how to develop the concepts and assumptions of the sociology of rationing. Secondly, we identify specific themes relevant for sociological inquiry, including the recurring problem of how to translate administrative priority setting decisions into clinical practice.

How have systematic priority setting approaches influenced policy making? A synthesis of the current literature

BACKGROUND

There is a growing body of literature on systematic approaches to healthcare priority setting from various countries and different levels of decision making. This paper synthesizes the current literature in order to assess the extent to which program budgeting and marginal analysis (PBMA), burden of disease & cost-effectiveness analysis (BOD/CEA), multi-criteria decision analysis (MCDA), and accountability for reasonableness (A4R), are reported to have been institutionalized and influenced policy making and practice.

METHODS

We searched for English language publications on health care priority setting approaches (2000-2017). Our sources of literature included PubMed and Ovid databases (including Embase, Global Health, Medline, PsycINFO, EconLit).

FINDINGS

Of the four approaches PBMA and A4R were commonly applied in high income countries while BOD/CEA was exclusively applied in low income countries. PBMA and BOD/CEA were most commonly reported to have influenced policy making. The explanations for limited adoption of an approach were related to its complexity, poor policy maker understanding and resource requirements.

CONCLUSIONS

While systematic approaches have the potential to improve healthcare priority setting; most have not been adopted in routine policy making. The identified barriers call for sustained knowledge exchange between researchers and policy-makers and development of practical guidelines to ensure that these frameworks are more accessible, applicable and sustainable in informing policy making.