Session 7.1 – Different Actors in Priority Setting

Friday October 31 11:00-12:30

Look Before You Leap: A Critical Analysis of the Use of Competitive Contracts to Enact Priority Setting in Primary Health Care

(Abstract 0033)

Judith Smith1, Helen Parker2
1Victoria University of Wellington, New Zealand, 2University of Birmingham, United Kingdom

Background: Primary care trusts (PCTs) in England are responsible for needs assessment, priority setting and the purchasing of health services for their local population. The PCT’s role as a purchaser of primary health services is increasingly being viewed by policy makers as one where competition and contracting should be employed as a way of ensuring a better fit between local priorities, available funding, and the delivery of services to meet the needs of specific population groups.

Learning Objectives: In this paper, international research evidence from New Zealand, Australia and Canada is used to analyse the policy of using competitive contracting in primary and community care in England, with a particular focus on how far such an approach can serve the needs of marginalised communities. The paper seeks to:

• describe how competitive contracts are being used by PCTs to try and connect health needs, national/local priorities, and available funding;
• use international research evidence to explore the risks and opportunities entailed in using competitive contracts to try and meet the primary health care needs of marginalised populations;
• consider the potential implications for NGO primary care providers of the use by PCTs of competitive contracts;
• use international comparative research to suggest that a shift from competitive to relational contracting may be more appropriate for PCTs as they seek to develop services to meet the needs of marginalised populations.

Local Participation in Foreign Aid Administration in the Health Sector, The Case of Ethiopia: Lessons for developing countries

(Abstract 0127)

Simon Molla
MoFED, Ethiopia

Background: Does scarcity of resources really explicate the immense problems in the health sector and is this explanation satisfactory to all stakeholders including the public? This research is an attempt to give some radiance toward these issues.

Objectives: 1. Analyze the level of people’s participation, transparency and accountability in foreign aid administration in the health sector.  2. Assess health sector development and the quality of health service in the past 10 years.

Methods: Primary data were collected using surveys and in-depth interviews mainly from three target groups, namely a) health personnel b) workers of kebeles (the lowest government administrative unit), c) “Edir” (CBO) leaders in the case study area.

Results:

• Proper management of resources is not distinguished as an indispensable priority area.
• Low initiative and commitment on the part of the government to efficiently administer resources.
• Mal-administration of foreign aid in the health sector, which is evidenced from the existence of corruption in the health sector.
• Low coordination with donors and lack of proper utilization of donated drugs and medical equipments.
• Under utilization of the available foreign aid.
• Policy Implications & recommendations.
• Proper management of resources should be set as the earliest priority in health sector.
• It must be made imperative for lowest administrative units to at least post their budgets on visible places.
• The high turnover of health personnel should be reduced by increasing their benefits based on need-assessment.
• MOH and Health Bureaus should reconsider their improper imposition of drugs and medical equipments on health centers.

Guidance for Decision Makers? What Does the International Literature Tell Us About Public Engagement for Health Care Priority Setting?

(Abstract 0039)

Neale Smith1, Craig Mitton1, Stuart Peacock2, Brian Evoy3, Julia Abelson4
1UBC Okanagan, Canada, 2BC Cancer Agency, Canada, 3Vancouver Coastal Health Authority, Canada, 4McMaster University, Canada

Health system decision makers face many pressures to increase the extent of meaningful public engagement in priority setting and resource allocation. We conducted a Scoping Review in order to summarize the substantial literature of the past quarter century. This involved systematic search and assessment of both peer reviewed and grey literatures, drawing from both the health sector and other fields such as urban planning or environmental conservation. Results were obtained from a broad range of empirical studies in a variety of countries and at all levels of government.

We identified promising directions including:

• Governments appear to recognize the benefits of consulting multiple publics using a range of methods. There have been advances in new deliberative models, though traditional approaches like public hearings or opinion surveys continue to be most commonly employed.
• Public engagement is mainly sought in establishing broad strategic directions and the allocation of resources to programs or sites, and less frequently for guidelines for individual treatment or program evaluation.
• Consultation exercises tend to be one-off rather than on going, though further development of on-going methods would seem to be of great promise.

Major gaps in the literature include the lack of evaluation of public engagement, and practical guidance on how to integrate public input with other sources of evidence in decision-making. This research provides a critical starting point for the development of guidelines to assist decision makers in determining effective engagement methods fit for their contextual circumstances and decision needs.

“I Can See Where They're Coming From, but When You're on the End of It … You Just Want to get the Money and the Drug”: Explaining Reactions to Explicit Healthcare Rationing.

(Abstract 0090)

Amanda Owen-Smith1, Joanna Coast2, Jenny Donovan1
1University of Bristol, United Kingdom, 2University of Birmingham, United Kingdom

The traditional pattern of implicit and unacknowledged rationing in the UK NHS is beginning to change. The advent of NICE, widespread use of the Internet, and the media interest in healthcare rationing means that patients are increasingly likely to learn that certain treatments are not available for financial reasons. However, a lack of direct empirical research in this area means that how patients react to explicit rationing is unknown, and thus its implications are largely the matter of conjecture. This paper presents results from a qualitative interview study with NHS managers, clinicians, and patients who have experienced rationing associated with their morbid obesity or breast cancer care (n=52). Patients had a choice whether to accept explicit rationing decisions, protest against them, or pay for private care. However, there was a discrepancy between how many patients said they would react to rationing in theory, and how they actually reacted when faced with shortages themselves. A number of factors affected how patients reacted to rationing, among the most important being their sense of entitlement to NHS care, and the attitude of their clinical team. The findings suggest that research with patients directly affected is the most informative means to understand the implications of explicit rationing, that to preserve the legitimacy of decision-making both the basis and the process of decision-making needs to be seen as fair, and that all patients need to be provided with sufficient information and support to make an informed decision following the revelation of rationing.