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Contents lists available at ScienceDirect

Health Policy
journal homepage: www.elsevier.com/locate/healthpol

Review

How have systematic priority setting approaches inuenced policy

making? A synthesis of the current literature
Lydia Kapiriri a, , Donya Razavi b
a
Department of Health, Aging and Society, McMaster University, 1280 Main St. West, Hamilton, Ontario, L8S 4L8, Canada
b
Centre for Health Policy Analysis, McMaster University, 1280 Main St. West, Hamilton, Ontario, L8S 4L8, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Background: There is a growing body of literature on systematic approaches to healthcare priority setting
Received 13 October 2016 from various countries and different levels of decision making. This paper synthesizes the current litera-
Received in revised form 30 June 2017 ture in order to assess the extent to which program budgeting and marginal analysis (PBMA), burden of
Accepted 3 July 2017
disease & cost-effectiveness analysis (BOD/CEA), multi-criteria decision analysis (MCDA), and account-
ability for reasonableness (A4R), are reported to have been institutionalized and inuenced policy making
Keywords:
and practice.
Systematic approaches
Methods: We searched for English language publications on health care priority setting approaches
Healthcare priority setting
Health policy and practice
(20002017). 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 inuenced 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 identied 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.
2017 Elsevier B.V. All rights reserved.

1. Introduction/Background
Priority setting, (PS), a process involving decision making about
the allocation of resources between the competing claims of differ-
ent services, different patient groups or different elements of care
[1], is one of the most critical health policy challenge because of the
gap between the increasing population health demands and needs
and the resources that should meet them [2]. Several priority set-
ting frameworks have been developed to provide guidance for the
policy makers who have to make these decisions. While theres a
growing body of literature on the application of the frameworks
in various contexts, there is a paucity literature that assesses the
extent to which these frameworks have been institutionalized to
guide routine policy decision making. This paper responds to this
gap.
Corresponding author.
E-mail address: kapirir@mcmaster.ca (L. Kapiriri).
The factors fueling the priority setting challenges vary with the
priority setting context. For example in high income countries,
the aging population and the innovations in treatment options
contribute to people living longer but often with resource inten-
sive health problems. Conversely, low income countries are faced
with extreme lack of resources and an increasing disease burden
which is fueled by the epidemiologic transition. In both contexts,
there is lack of consensus with regards to what should guide the
priority setting processes, highlighting the challenge of priority
setting being an inherently value laded process, whereby even
rational people might disagree on the values that should guide
priority setting. Under such circumstances, decision makers need
clear guidance so as to ensure that their decisions are consistent,
effective, efcient, and fair [3,4].
Frameworks have been developed to provide this much needed
guidance. For example, the Nordic countries, pioneering system-
atic priority setting dened principles and explicit criteria that
should determine what interventions get to be implemented [5].
Subsequently frameworks such as program budgeting & marginal
analysis (PBMA), the burden of disease & cost-effectiveness analy-

http://dx.doi.org/10.1016/j.healthpol.2017.07.003
0168-8510/ 2017 Elsevier B.V. All rights reserved.

Please cite this article in press as: Kapiriri L, Razavi D. How have systematic priority setting approaches inuenced policy making? A
synthesis of the current literature. Health Policy (2017), http://dx.doi.org/10.1016/j.healthpol.2017.07.003
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ses (BOD/CEA), the Multi-Criteria Decision Analysis (MCDA), and
procedural justice approaches such as Accountability for Rea-
sonableness (A4R) have been developed and applied in various
contexts. To what extent have these impacted policy and practice?
All the frameworks that have been developed to evaluate suc-
cessful or high performing priority setting and resource allocation
identify the relevance of assessing the impact of priority setting on
policy and practice (in terms of; actual reallocation/dis-investment
of resources, stakeholder endorsement [6,7]; adoption for future
use [8] institutionalization [9]). However, there is a paucity of liter-
ature on the extent to which the common frameworks (that should
guide priority setting) have been adopted for routine use in deci-
sion making, health policy making and practice. To the best of our
knowledge, only one paper did this in 2008. This paper synthesized
the priority setting literature in seven countries and found that the
different principles and approaches had had limited inuence on
policy making [10]. This paper builds on the 2008 synthesis.
This paper synthesizes the current literature in order to assess
the extent to which the most commonly documented system-
atic approaches to priority setting in health care namely; 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 inuenced policy and practice.
2. Methods
This was a scoping literature review. Our sources of litera-
ture included PubMed and Ovid databases (including Embase,
Global Health, Medline, PsycINFO). We searched for peer-reviewed
literature on priority setting in health care published between
January 2000 and March 2017. Search terms included priority set-
ting, resource allocation, health care, health systems, health
interventions, approaches, initiatives and frameworks. Sub-
sequent searches involved a combination of the terms, for example
priority setting and approaches or priority setting and health
interventions. We then grouped the hits from these searches
according to the frameworks (Table 1).
We conducted further searches focusing on the frameworks
with the highest number of hits from the initial literature search
namely: A4R, PBMA, MCDA. While it did not have as many hits, we
deliberately included the BOD/CEA approach in the review because
it had the highest number of most hits for low income countries.
We also included a combination of search words for the different
frameworks; e.g. PBMA & A4R, MCDA & A4R, BOD/CEA & A4R,
PBMA,MCDA & A4R. (Summarised in Table 2)
The second strategy involved reviewing the bibliographies of
the most relevant papers that were retrieved to identify additional
relevant literature which we may have missed in the initial search
strategy. Relevant literature was retrieved.
We reviewed all the abstracts retrieved from the data bases
for relevance (abstracts describing priority setting for health care
interventions which involved a specic framework). Full articles
of the relevant abstracts were retrieved and reviewed. The inclu-
sion and exclusion criteria were: publication period (20002017)
(excluded earlier publications), describes actual PS for health inter-
ventions using either of the four approaches (excluded conceptual
and theoretical papers), discusses the utility of the approach and/or
stakeholder satisfaction, or adoption of framework into routine pol-
icy making (excluded papers were these are not discussed) (Table 3).
We ended up with 84 papers that were included in our study.
3. Data extraction and synthesis
The following steps were followed;
Please cite this article in press as: Kapiriri L, Razavi D. How have systematic priority setting approaches inuenced policy making? A
synthesis of the current literature. Health Policy (2017), http://dx.doi.org/10.1016/j.healthpol.2017.07.003
i) Developing the data extraction tool: LK & SDR developed the data
extraction tool based on the relevant themes namely; name of
the framework, countries and level of application; priority set-
ting case, health issue or health program; paper type; decision
maker satisfaction or perception of the utility of the approach,
whether or not the framework/priorities inuenced policy mak-
ing.
ii) Data extraction: Using the data extraction tool, SDR read through
the selected manuscripts and extracted the information related
to the identied themes. The relevant information was cut and
copied directly into the data extraction tool.
iii) Thematic synthesis: SDR read through and summarized the
information related to the relevant themes (number of relevant
publications, level of application and utility or policy impact),
in the form of a narrative report. LK reviewed the synthesis and
compared it to the original manuscripts, and the data extraction
tool to ensure consistence.
iv) Assessment of reported impact: Both SDR and LK read through the
narrative and assessed impact based on: (i) the reported deci-
sion makers satisfaction and their perspectives on the utility of
the framework whereby positive perspectives were assumed
to be an indication of acceptability and potential for possible
use; (ii) explicit reporting that the framework was adopted for
future use in routine priority setting within the organization or
region, reported use beyond research project, and whether the
priorities identied using the approach were integrated into the
national/organizations policy and practice [8].
4. Results
This section is organised according to the frameworks. For each
framework there is a description of the framework and the reported
country/region and level of its application, an assessment of deci-
sion maker perspectives on its utility, and whether or not the
framework is reported to have impacted policy or to have been
adopted for routine policy making (Table 4).
5. Program budgeting and marginal analysis (PBMA)
The program budgeting and marginal analysis (PBMA) approach
relies on two fundamental economic principles in its approach to
priority setting: opportunity cost and marginal analysis [11]. The
notion of opportunity cost implies that if resources are invested
in one area, there are benets that are given up in another area.
Marginal analysis is concerned with the last unit of production of
any two or more given programs. Marginal analysis allows decision
makers to identify the best mix of services as determined by exam-
ining the relative costs and benets of the various options, at the
margin [12,13].
According to PBMA, the primary goal of priority setting is to
maximize the benets and minimize the opportunity costs. PBMA
involves: 1) determining the aim and scope of the priority setting
exercise; 2) compiling a program budget; 3) forming a marginal
analysis advisory panel; 4) determining locally relevant decision
making criteria; 5) having the advisory panel to identify options; 6)
having the advisory panel to make recommendations; 7) checking
validity with additional stakeholders and nal decisions in order to
inform budget planning process [13,14].
We retrieved and reviewed 32 papers that met our inclusion
criteria.
The papers revealed that PBMA has been applied in different
contexts at various levels of decision making. The majority of the
articles focused on empirical applications of PBMA, in high income
countries; nineteen in Canada, seven in the United Kingdom (UK)
and ve in Australia.
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Table 1
Search Terms and Hits for Preliminary Search and per database identied within the preliminary search for each identied frameworks for priority setting

Database Search Terms Total hits

PubMed [Priority setting (title/abstract) OR resource allocation (title/abstract)]; AND [health title/abstract)] 955
AND [initiative (title/abstract) OR approach (title/abstract) OR framework (title/abstract)]; limit
published 2000-current.
Ovida (including Embase, Global [Priority setting (title) OR resource allocation (title)]; AND [health (keyword)] AND [initiative 372
Health, Medline, PsycINFO) (keyword) OR approach (keyword) OR framework (keyword)]; limit published 2000-current
EconLit Priority setting (title) OR resource allocation (title)]; AND [health (keyword)] AND [initiative 44
(keyword) OR approach (keyword) OR framework (keyword)]; limit published 2000-current
a
Ovids duplicate removal tool was applied here.

Table 2
Framework specic search with search terms and hits per framework (limit published 2000-current).

Database Stage 1 Stage 2 Stage 3 Stage 4

Initial search and hits Total Abstract Review Total Full Text Review Total included

Accountability for reasonableness Search terms: health AND (priority setting OR resource allocation) AND (Accountability for
reasonableness OR A4R)
PubMed 90 72 34 22
Ovid 101 83 34 18
EconLit 2 2 2 1
Total (duplicate removed) 26

Program budgeting and marginal analysis Search terms: PBMA OR program budgeting and marginal analysis OR programme
budgeting and marginal analysis
PubMed 148 61 30 21
Ovid 165 53 33 28
EconLit 8 4 4 3
Total (duplicate removed) 32

Multi-criteria decision analysis Search terms: (priority setting OR resource allocation) AND (multi-criteria decision analysis OR
MCDA OR multicriteria decision analysis)
PubMed 172 78 36 16
Ovid 24 16 10 7
EconLit 3 2 2 1
Total (duplicate removed) 20

Burden of disease (BOD) and Cost-effectiveness analysis Search terms: priority setting AND (burden of disease OR BoD OR BOD)
AND (cost effectiveness analysis OR CEA OR DALY OR disability adjusted life year OR disability-adjusted life year) AND health
PubMed 51 40 19 11
Ovid 42 37 12 8
EconLit 4 4 1 0
Bibliography search 10
Total (duplicate removed) 22

Table 3
Inclusion and Exclusion Criteria.

Stage Inclusion Criteria Exclusion Criteria

Stage 1 Peer-reviewed journal articles Gray literature

Articles published between 2000- 2015 articles published prior to January 1st, 2000

English language papers Non-English language papers

Stage 2 Papers describing priority setting for health interventions at different Papers describing priority setting for non-health
levels and in different contexts. interventions or priority setting for health research.

Papers describing the four most commonly published Papers describing any other less published
approach/framework approach/framework

Stage 3 Empirical, review or theoretical papers describing the application of any Papers that did not describe the application of any of the
of the four priority setting approach four approaches

Stage 4 Papers discussing any aspect of: assessment of stakeholder satisfaction Papers that did not discuss any aspects of stakeholder
with the PS approach, or their comments on the approach evaluation of the approach or the application of an
approach in routine decision making.

Paper discussing application of an approach in routine policy making

Please cite this article in press as: Kapiriri L, Razavi D. How have systematic priority setting approaches inuenced policy making? A
synthesis of the current literature. Health Policy (2017), http://dx.doi.org/10.1016/j.healthpol.2017.07.003
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Table 4
Overview of the common approaches by region, and levels of application and number of papers reporting stakeholder assessment of approaches utility in policy making.a
Approach Predominant region where the
approach was most applied
Program Budgeting and High income countries
Marginal Analysis (PBMA)
Multi-Criteria Decision Both high and low income
Analysis (MCDA) countries
Accountability for Predominantly high income
Reasonableness (A4R) with a few applications in low
income countries
Burden of Disease & Exclusively low income
Cost-effectiveness Analysis countries
(BOD & CEA)
a
Columns 4 & 5 include only papers that addressed stakeholder satisfaction and/or use in policy making.
Of the nineteen papers that reported PBMA application within
Canada, most were implemented at the regional level e.g. nine in
Alberta [1119], ve in British Colombia [2024], one in Ontario (at
an urban community hospital) [25], and two in Nova Scotia [26,27].
Of the seven papers that discussed the application of PBMA in
the UK, two studies were based in hospitals in Scotland [28] and
in Wales [29] ve were based at the regional level within differ-
ent institutions; one at the Ministry for Health & Social Care in
Wales [30], two regional studies conducted as a part of the National
Health Service (NHS) [31,32] and two in Primary Care Trusts (PCTs)
in England [32,33].
Of the ve papers that discussed the application of PBMA in
Australia, three reported ndings from studies at the regional level
[20,34,35], and one from the district [36] and one from the hospi-
tal [37]. Two studies reported regional PBMA application in New
Zealand [35,38].
Only one paper described PBMA application in a low income
country, namely Ghana [35].
5.1. Decision maker perspectives on the utility of PBMA
Twenty three papers discussed decision-maker perspectives
on the utility of the PBMA framework in setting health prior-
ities. According to these publications, decision-makers agreed
that PBMA was a valuable and pragmatic tool for priority
setting and that it positively contributed to decision making
[11,1424,26,3032,3440]. Seven papers reported ndings from
direct discussions with stakeholders who had participated in
the PBMA priority setting who were asked about whether they
would recommend its use in future priority setting initiatives
[11,14,19,27,29,32,37]. For example, in Wales there were consider-
ations to extend the use of PBMA across a health board [29] PBMA
was also endorsed by the Department of Human Services (DHA) in
South Australia and considered successful by decision-makers in
two regional health authorities in Australia [38].
Some of the literature reported that stakeholders found general
difculties with understanding the framework due to its complex-
ity. They also thought it to be cumbersome, with the potential to be
time consuming and increase the planners workload [34,40]. Fur-
thermore, the perceived complexity may have contributed to the
Please cite this article in press as: Kapiriri L, Razavi D. How have systematic priority setting approaches inuenced policy making? A
synthesis of the current literature. Health Policy (2017), http://dx.doi.org/10.1016/j.healthpol.2017.07.003
Examples of levels where Number of papers reporting Number of papers
approach was most applied stakeholder evaluation of reporting explicit use of the
approachs utility approach in policy making
Regional (24) 23 11
District (1)
Hospital (2)
National (12) 10 2
Provincial (2)
Local (2)
National (2) 12 3
Provincial (4)
Regional (3)
District (7)
Hospital (8)
Global (4) 4 9
National (14)
District (4)
reported requirement for educating stakeholders involved in the
process (about priority setting and PBMA) before it is used in prior-
ity setting [23,24]. To some, this would have an impact on the effort
and resources (especially time) that would need to be invested in
the planning processes [32].
5.2. PBMA use in policymaking
Very few papers reported on the future use or adoption of PBMA.
Since PBMA is reported to have been repeatedly used in about 45
cases and over the years in Calgary, peer reviewed literature may
not be a good reection of actual adoption [8]. However, based on
this literature, eleven papers explicitly discussed ways in which
PBMA had inuenced policymaking. Most of these papers were
based at the regional level within Canada. According to this liter-
ature, Calgary Regional Health Authority (CRHA) and Headwaters
Health Authority (HHA) reallocated their resources to meet the rec-
ommendations resulting from the PBMA process [11,15]; the CRHA
adopted PBMA as their organizational approach to priority setting
[14]. In this case, the managers and clinicians in the CRHA indicated
their willingness to use PBMA when setting operational priorities
[12]. In British Colombia, PBMA was used in the development of the
annual operating budget (20072008) for home and Community
Care (HCC) of the Northern Health Authority [41]. While is Australia,
the framework was adopted by the Womens and Childrens Hos-
pital in Adelaide, for use in future priority setting initiatives [37].
Overall, most of the reviewed literature reported that PBMA
was perceived as a useful tool for PS and was viewed favourably
by decision-makers. Only three papers reported otherwise. One
paper reported that while the Interior Health Authority (IHA) of
Central Okanagan Local Health Area (LHA), attempted to use PBMA
to set priorities for the 20072008 and 20082009 budgets, par-
ticipants found it difcult and remained concerned about the time
and effort it would take to engage in PBMA [19]. Similar concerns
were reported when PBMA was used in Community care settings
[40]. In both cases, the use of the PMBA approach was discontin-
ued [19,23,40]. In the UK, Miller and Vale found that although there
was a general belief that PBMA could make positive contributions
to the priority setting process within the NHS, the commissioning
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environment and organizational structures hindered its adoption before its application [39]. This could potentially hinder its use in
[31]. routine decision making [58].

6. Multi-criteria decision analysis (MCDA)

7. Accountability for reasonableness
We retrieved and reviewed twenty papers that described
Accountability for reasonableness (A4R), is an ethics-based, and
the application of the Multi- criteria decision analysis (MCDA)
process-driven framework that focuses on ensuring that the prior-
approach. Multi-criteria decision analysis facilitates the use of mul-
ity setting process is fair [59]. According to this framework, a fair
tiple explicit criteria in priority setting [4]. The process consists
PS process should fulll four conditions namely: Publicity: both
of four steps: 1) identifying policy criteria and metrics; 2) iden-
the decisions and rationales of used in PS must be made publi-
tifying a series of alternatives based on various combinations of
cized; Relevance: the rationales that guide the PS process must be
policy criteria; 3) measuring performance of alternatives by criteria
considered to be relevance by fair-minded people in the context
(through discrete choice experiment (DCE); 4) determining pref-
in which the framework is being applied; Revisions/appeals: there
erences through scoring of the intervention options against those
must be mechanisms of appeal and/or the ability to revise the deci-
criteria [42]. Commonly used criteria include evidence on effective-
sions made in priorities setting processes as well as the reasons
ness, burden of disease, cost effectiveness and equity [4,42].
and rationales used to come to those decisions, and lastly Enforce-
The retrieved literature revealed that MCDA has been applied in
ment: there should be voluntary or public regulatory mechanisms
both high-income countries (e.g. four in Canada [39,4345], two in
to ensure that the rst three conditions are met [59]. We retrieved
Norway [42,46], one in Germany [47] and one in the UK [48]) and
and reviewed twenty six papers that described the application of
low and middle income countries (e.g. two in South Africa [49,50],
A4R.
two in Thailand [51,52], Ghana [53], Cote dIvoire [54], Brazil, Cuba,
Our review revealed that A4R has been applied in both HIC and
Nepal & Uganda [46], and Palestine, Syria, Tunisia and Turkey [55]).
LMICs. In HICs, there were 14 papers describing its application of
Most of the papers reported MCDA application at the national
which eight were based at national and sub-national levels in the
level, with only a couple reporting its application at the sub-
Netherlands [60], Sweden [61] and Canada [18,6266], and three
regional and clinic level. Sixteen papers reported empirical
described A4R application at the hospital level in Canada [63,67,68],
applications while four were theoretical papers [46,49,56,57]).
Norway [63] and Australia [69].
Thirteen papers described the application of A4R framework
6.1. Decision maker perspectives on the utility of MCDA
in LMICs: one paper reported national level application [63], two
reported sub- national and national level applications (in Mexico
Ten of the 20 papers we included in this review reported deci-
[70] and Indonesia [71]) seven reported district level applications
sion maker perspectives on the utility of the framework. In a study
(in Kenya, Tanzania and Zambia [7278]); and three reported hos-
in South Africa, MCDA was thought to have the potential to improve
pital level applications (in Uganda and South Africa [63,79,80]).
the stakeholder acceptability since it facilitated transparency in the
Most of the reviewed papers reported that A4R was used to
decision-making process [50]. A study in Thailand reported that
evaluate the fairness of PS processes. For example, Walton et al.
the policy makers were satised with the systematic nature of the
used A4R to evaluate priority setting in cardiac surgery in Toronto,
MCDA approach to priority setting [52]. Studies in both Canada
Canada at three cardiac surgery centers that are afliated with the
(when applied at the provincial level in priority setting for coverage
University of Toronto [81]. Furthermore, Kapiriri et al. used the A4R
for new drugs) and the UK (when applied by NICE to prioritize pre-
approach to evaluate fair priority setting at the decision-making
ventative health interventions), found that MCDA was acceptable
levels across 3 countries (Canada, Norway and Uganda) [82], Tromp
to the decision makers [45,48]. Similar results were documented
et al. and Moosa et al. used A4R to evaluate priority setting for
in studies conducted in Brazil, Cuba, Nepal, Norway, and Uganda,
HIV in Thailand and within a nephrology clinic in South Africa,
mainly because of its ability to concurrently consider and weigh
respectively [71,80].
different criteria and the perceptions that it was transparent, struc-
A couple of papers described how A4R was used to enhance
tured and systematic [39,46,50,51].
fairness of priority setting processes. For example in a ve year
research project in East Africa, A4R was used as a tool to improve
6.2. MCDA use in policymaking
district level priority setting in Tanzania, Kenya and Zambia [74,83].
In Mexico, A4R is reported to have been used to guide decision
Very few papers reported on the future use or adoption of MCDA.
making when setting priorities interventions to include in their
This may be a reection of what is published as opposed to actual
essential health care package [70]. Daniels recommended that A4R
adoption into policy making since this information may in more
be used in the 3by5 WHO initiative to determine who should have
likely to be presented in policy documents [8]. However, based
access to anti-retroviral HIV treatment [84].
on the published literature, only two papers reported cases where
MCDA had explicitly inuenced policy making. A study from Ghana
reported that policy makers had adopted MCDA as an approach 7.1. Decision maker perspectives on the utility of A4R
to guide the ministry of health when identifying the priorities
to be included in their Five Year Programme of Work (POW) for Twelve out of the twenty-six papers we reviewed discussed
(20012006), and (20072011) [53]. While in Thailand, MCDA is decision maker perspectives on the utility of A4R. Most of these
reported to have been used when identifying priority interven- reported that policy makers considered A4R to be useful because it
tions to include in their Universal Coverage scheme health benet was structured, has explicit conditions that can be used to evaluate
package in 20092010 [52]. the fairness of a PS process and improve transparency. For example
Overall, most of the reviewed literature reported that MCDA was a study in a hospital network in Canada reported that stakeholders
perceived as a useful tool for PS and was viewed favourably by thought that A4R facilitated participatory and systematic decision
decision-makers. However, one study that explored its application making., and specically the appeals condition was thought to have
in priority setting for physiotherapy services in Canada reported contributed to improving the fairness of the process [67]. Further-
that the users perception was that the approach was technically more, a study in local integration networks reported that staff from
challenging to implement and would require some basic training the various LHINs perceived the approach as useful for provid-

Please cite this article in press as: Kapiriri L, Razavi D. How have systematic priority setting approaches inuenced policy making? A
synthesis of the current literature. Health Policy (2017), http://dx.doi.org/10.1016/j.healthpol.2017.07.003
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ing explicit criteria and improving transparency [65]. Two papers;
one from Canada [66] and one Sweden [61] reported that decision
makers found the approach to be acceptable. The four conditions
resonated with the stakeholders institution values.
7.2. A4R use in policymaking
While A4R has been used repeatedly on its own, or in con-
junction with other approaches, only a few papers reported on
its adoption for future use, which may be a reection of what
is published [8]. The framework is reported to have contributed
to improving participation and the fairness of district level prior-
ity setting in Zambia, Kenya and Tanzania [77]. In Mexico where
it was also applied as a part of the new national health reform,
government ofcials are reported to have approved the institution-
alization of A4R for use in national level priority setting [70]. A4R
has also been repeatedly used in various provinces within Canada
[8].
Only one paper reported on the limitations to the institutional-
ization of A4R. In the Netherlands where the framework was used
by the Dutch reimbursement system to examine the National Reg-
istry of Growth Hormone Treatment (LRG), using A4R is reported to
have resulted in decisions that contradicted the national guidelines.
This impacted its acceptability [60].
7.3. Multi-approach applications
It is important to note that more recent applications of these
frameworks has involved two or more approaches. For example,
A4R has been used alongside the economic frameworks as a strat-
egy to improve procedural fairness in economic priority setting
approaches, and MCDA has been used together with PBMA. How-
ever, most of these papers, e.g. Gibson et al. are theoretical and
were not included in this review [18]. A few reported on the actual
implementation. For example; A4R was used with PBMA in both
Home, Community and tertiary Care institutions in Canada [27,41].
It was used alongside MCDA when developing the National Uni-
versal Health Coverage Benet Package in Thailand [52]. These are
included.
8. Burden of disease and cost-effectiveness analysis (BOD &
CEA)
The BOD/CEA approach was rst introduced in the World Banks
World Development Report of 1993, Investing in Health [85]. In
this approach, effectiveness is evaluated based on both mortal-
ity and morbidity data, under a composite measure; the Disability
Adjusted Life Year (DALYs) [86]. DALYs are then used in CEA,
whereby interventions with the most favorable cost-effectiveness
ratio are prioritized. In many contexts, the most cost- effective
interventions comprise the essential or basic health care packages
[87].
This scoping review found twenty two papers that documented
the use of the BOD/CEA approach. Most of these were based in low
or middle income countries including Afghanistan, Thailand, Korea,
Ghana, Zimbabwe, South Africa, Tanzania, Uganda, Mexico, Nigeria,
Malawi, Bangladesh and Democratic Republic of Congo. Fourteen
papers reported empirical applications of BOD & CEA [88101],
the rest were either review, conceptual or descriptive-reporting
ndings from Global Burden of Disease Studies (GBDS) [102108].
Of the conceptual papers one focused on explicit priorities set-
ting within Mexicos System of Social Protection in Health [108],
and two illustrated how the Ugandan Essential Health Care Pack-
age (EHP) dened using the BOD & CEA approach have not been
effectively applied [87,109].
Please cite this article in press as: Kapiriri L, Razavi D. How have systematic priority setting approaches inuenced policy making? A
synthesis of the current literature. Health Policy (2017), http://dx.doi.org/10.1016/j.healthpol.2017.07.003
8.1. Decision maker perspectives on the utility of the BOD/CEA
approach
Four papers discussed decision makers perspectives on the util-
ity of the BOD/CEA approach. Three of these papers were based in
Uganda and one in Tanzania. Kapiriri et al. reported ndings from
a Uganda study where national and district level decision makers
perceived the approach favourably by virtue of its being systematic
and evidence based. Furthermore, the numerical ranking of the pri-
orities was found to be handy when advocating for more resources
from politicians [95]. This paper also reports that the BOD/CEA sup-
ported decision makers to focus on the key health problems, and to
maximize the use of their resources. Similar ndings were reported
by Jeppsson et al. who explored district managers perceptions [90].
However, the same studies report that the same decision makers
found the approach to be technically complex and resource inten-
sive. The evidence requirements (which is often lacking) were also
thought to be prohibitive. A few policy makers are also reported to
have been dissatised with the value choices made in the approach
and its failure to consider equity [95,110]. Some of the litera-
ture discussed the limitations associated with the tendency for the
approach to use global level data which may not be context specic
[111].
8.2. Use of BOD/CEA in policymaking
There are 50 national applications of BOD [8] especially in low
income countries who are reported to have adopted this approach
in their national health policies and health sector strategic plan
development (For example Uganda, Kenya, Tanzania, Ethiopia,
Sierra Leone; to name but a few) [95]. However, since policy docu-
ments were not included in this review, subsequent discussion will
focus on the ndings from the systematic review.
Of the 22 articles, nine referred to the use of BOD &
CEA in guiding policy decision making and practice. Seven
reported on the implementation of the approach to policy mak-
ing in Uganda, Malawi, Bangladesh, and South Africa respectively
[87,90,95,97,100,109,110]. Specically, in Uganda, Bangladesh and
Tanzania, the approach is reported to have inuenced the realloca-
tion of resources from tertiary level services to primary level units
[90,100,101]. In an international organization, DALYS were used
as a basis for identifying targeted strategies and greater program
diversication [88].
A couple of papers identied some challenges that were associ-
ated with using the approach in policy making. These were mainly
related to the technical difculties and limited local capacity, which
would necessitate technical support. This would, inevitably, impact
the potential for its institutionalization [87,89,97,109].
9. Discussion
While there is a wealth of literature on approaches to priority
setting, there is a paucity of synthesizes of the current literature to
assesses the degree to which the approaches that have been devel-
oped to guide priority setting have inuenced policy making and
have been institutionalized. This paper lled this gap.
There were relatively limited peer review publications reporting
on the degree to which all the approaches have inuenced policy
making and have been institutionalized. Although consistent with
some of the literature, this was surprising given the reported appli-
cations of the frameworks by leading global researchers [58]. Lack
of reporting on the frameworks utility in peer review literature
does not reect the degree to which the different frameworks have
been adopted by policy makers but could be attributed to practical
constraints and stringent journal requirements which make it dif-
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L. Kapiriri, D. Razavi / Health Policy xxx (2017) xxxxxx
cult to publish case studies in policy implementation [8]. However,
within the limited published literature, there seemed to be a link
between the presence of a researcher champion and the number of
peer review publications. Most of the publications were linked to
research projects e.g. PBMA and A4R.
Furthermore, we found that different approaches had been
applied in particular contexts as opposed to other contexts or lev-
els. PBMA was almost exclusively applied in high income countries
while BOD/CEA was almost exclusively applied in low income coun-
tries. Both MCDA and A4R have been applied in both high and
low income countries. With regards to the level of application,
all frameworks were reported to have been applied mainly at the
national and sub- national levels and within health authorities.
There were only a couple of reported applications within health
facilities (mainly for A4R). While the other frameworks were mainly
applied at the formative stages; with the exception of (some cases
in) Canada, Mexico and Tanzania, Kenya and Zambia project, A4R
was commonly reported to have been used to evaluate fairness of
processes which after the fact. While this may be a reection of the
most appropriate levels (and contexts) of application, it could also
be a reection of what was feasible for the researchers, since most
of the applications were in the context of research programs (for
example; 1618, 4245, 6165).
Relatively few papers reported on policy makers perceptions
about the different approaches. We hypothesized that their per-
ceptions, if positive, would be an indication of their willingness to
adopt the approach into their routine priority setting [8]. All the
approaches had both positive and negative evaluations. Consistent
with the literature, factors that contributed to positive percep-
tions included stakeholder understanding of- and ease of use of
the approach, similarities in values and being systematic [6,27].
Challenges to adoption were also consistent with the literature and
included the perceived technical difculties associated with imple-
menting the approach, the time and resources it would take to
implement and the need for prior training, or an expert in using the
approach [58]. It is hence, not surprising that in many cases where
for example BOD/CEA, PBMA, and MCDA were applied the lead
researchers were on hand to facilitate the process. Of course this
raises concerns about the potential for sustainability and institu-
tionalization. It is not surprising that policy makers within contexts
of limited expertise, resort to using outdated information as basis
for their decision making [87], or stop implementing the approach-
once the experts leave [40]. These ndings point to the need
for capacity building to enable decision makers to apply these
approaches [27,112]. Researcher/policy maker collaboration would
also ensure that the concepts included in the approaches are easily
understood by the potential users. Furthermore, practical guide-
lines and toolkits, as have been developed for PBMA and A4R, may
be a critical piece in ensuring sustainable use of rather technically
challenging approaches [113,114].
9.1. Reection on the search strategies and study limitations
While this paper provides insight with regards to the use of
the different PS approaches in policy decision making, there were
some limitations to our approach. First, we found that the liter-
ature used many terms (for example framework, approach,
initiative, tool, model or guide), (Table 1) interchangeably
when discussing the PS approaches. While there are differences
between these in the policy literature [115], we had to use them
interchangeably as long as they referred to any of the PS approach
of interest.
Second, we are aware that there are other approaches to priority
setting which are not included in this review. This was a deliberate
choice intended to make the project manageable. By focusing on
the most commonly documented approaches, we maintain that the
Please cite this article in press as: Kapiriri L, Razavi D. How have systematic priority setting approaches inuenced policy making? A
synthesis of the current literature. Health Policy (2017), http://dx.doi.org/10.1016/j.healthpol.2017.07.003
7
paper makes meaningful contribution to the current literature on
the utility of priority setting approaches.
Third, we focused on only the published literature. Since policy
makers were not interviewed, we can only discuss the reported and
not the actual adaption of the various approaches. Furthermore,
by excluding unpublished literature, we may have missed more
information on the application of the different approaches [33].
While this is a limitation, it also highlights the need for the stake-
holders introducing a new strategy, such as those discussed in this
paper, to routinely integrate systematic evaluation of these policy
experiments. Concurrently, journal requirements may need to be
adjusted to facilitate the publication of such unique case studies.
Given the investments (nancial and human resource) required to
implement these approaches; systematic evaluation and publica-
tion of their application would be a valuable resource for policy
makers who may be interested in using these approaches.
10. Conclusion
This review found that while the intention of developing the
priority setting approaches is for them to eventually be used to
guide routine policy making, to date, not many have been inte-
grated into routine practice. Sited limitations included technical
complexity of the approaches and the resource requirements. Con-
versely, although some approaches, e.g. BOD/CEA, were perceived
to be complex by some stakeholders, they have been integrated into
routine policy making. This could be explained by the approaches
having powerful stakeholders who encourage and advocate for
their integration into routine policy making, or introducing prac-
tical guidelines which make them accessible to decision makers.
Furthermore, approaches that were introduced by researchers
were more likely to be systematically evaluated and their impact
published. There is therefore a need for all stakeholders: the devel-
opers, researchers, policy makers and health system funders to
work collectively in the development, application and evaluation
of the different approaches in order to increase their potential for
adoption into policy making.
The divisions of where different approaches have been pre-
dominantly applied calls for a webpage or workbook devoted
to introducing the policy makers in the different regions of the
world to the different priority setting approaches; summarizing the
strengths and limitations of each approach. Such a resource would
not only facilitate capacity building but will also ensure that policy
makers make informed choices with regard to the approach that
would be most suited for their context.
While not exhaustive, this paper provides an initial insight into
the sustainability of the different systematic approaches to health
care priority setting. The relatively limited literature assessing the
extent to which the different approaches have been institutional-
ized calls for empirical research (involving interviews with relevant
policy makers and reviewing of policy documents) that system-
atically evaluates the degree to which the approaches have been
integrated into routine priority setting.
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