Increased fairness in priority setting processes within the health sector: the case of Kapiri-Mposhi District, Zambia

Background The challenge of priority setting (PS) in health care within contexts of severe resource limitations has continued to receive attention. Accountability for Reasonableness (AFR) has emerged as a useful framework to guide the implementation of PS processes. In 2006, the AFR approach to enhance legitimate and fair PS was introduced by researchers and decision makers within the health sector in the EU funded research project entitled ‘Response to Accountable priority setting for Trust in health systems’ (REACT). The project aimed to strengthen fairness and accountability in the PS processes of health systems at district level in Zambia, Tanzania and Kenya. This paper focuses on local perceptions and practices of fair PS (baseline study) as well as at the evolution of such perceptions and practices in PS following an AFR based intervention (evaluation study), carried out at district level in Kapiri-Mposhi District in Zambia. Methods Data was collected using in depth interviews (IDIs), focus group discussions (FGDs) and review of documents from national to district level. The study population for this paper consisted of health related stakeholders employed in the district administration, in non-governmental organizations (NGO) and in health facilities. Results During the baseline study, concepts of legitimacy and fairness in PS processes were found to be grounded in local values of equity and impartiality. Government and other organizational strategies strongly supported devolution of PS and decision making procedures. However, important gaps were identified in terms of experiences of stakeholder involvement and fairness in PS processes in practice. The evaluation study revealed that a transformation of the views and methods regarding fairness in PS processes was ongoing in the study district, which was partly attributed to the AFR based intervention. Conclusions The study findings suggest that increased attention was given to fairness in PS processes at district level. The changes were linked to a number of simultaneous factors among them the concepts introduced by the present project with its emphasis on fairness and enhanced participation. A responsive leadership that was increasingly accountable to its operational staff and communities emerged as one of the key elements in driving the processes forward.

Bolded questions are suggested as main questions, to be ensured asked during the interview. Transparency Do you think the process of setting priorities described in A is transparent? Explain How do you ensure that the process of priority setting is transparent?

Relevance
What is your understanding of relevance? Do you think it is relevant in setting priorities? Explain Do you think the process you have described in A takes relevance into account? Explain Specific questions: Information gathering What kind of information is presented for priority setting?

How is communication with the recipients of the priorities set conducted?
How do you communicate with the policy makers and those setting priorities?
Transparency Do you think the process of setting priorities described in A is transparent?

Relevance
What is your understanding of relevance? Do you think it is relevant in setting priorities? Explain Do you think the process you have described in A takes relevance into account? Explain Roles and Responsibilities How would you describe the transparency of roles and responsibilities in the priority setting process? (E.g. are they clear, are they known) How would you describe the effectiveness of the roles and responsibilities in the priority setting process? (E.g. do leaders take responsibility and perform their roles)

Skills
How would you describe the skills of the leadership on decision making processes creating the inventory (services, activities and resources) resource shift and allocation?

End of interview
Thank the interviewee for their time and willingness to answer the questions and inform them of the future plans and intentions of the project. Inform the participants of the anonymity and confidentiality of the information provided Inform the participants of the right to abstain from answering and from participating should he/she wish to do so Ensure that if willing to participate he/she signs the consent form.

Basic overview of priority setting processes E) Process of setting priorities
In reality, who is involved in the PS process? a. How is the membership of those involved in PS process determined? i. Probe: for age, gender, sector for consideration in determining membership for involvement in PS process

What factors/values/criteria are taken into account when identifying priorities ? (record values)
Who decides on the factors to be taken into account?

G) Evaluation
How do you evaluate your priority setting and does it lead to change of priorities? (record meanings related to the 4 conditions)

H) Implementation
What are the challenges of implementing the priorities identified?
Now tell the interviewee that we wish to ask for his/her understanding and opinions about the main concepts involved in the Accountability for Reasonableness framework. Start with the general question on fairness:

Relevance
Do you think the priority setting process in your district is relevant to your needs and challenges? Explain (Beware that this could lead to a long discussion on needs and leave less time on the priority setting process. Focus discussion to priority setting process)

Specific questions
Values and other criteria:

Do you think the priority setting process in your district takes on board the values and other criteria you mentioned? Explain
Publicity Do you think the priority process and the reasons are widely made known and publiciced to the public and relevant stakeholders? E.g. communities, beneficiaries, patients, medical personnel, Explain

Specific question
Transparency: Do you think the priority process in your district is transparent? To what extent and how is it or is it not transparent?

Appeals / Revision
Are you able to appeal and ask for revision if the priorities are not relevant to your values, needs and challenges? Note: If In-depth interviews reveal that there are no such mechanisms skip this question.

Consensus:
How do you resolve disagreements on a priority?

Leadership and Enforcement
Explain initiatives undertaken by leaders to ensure implementation of the priorities identified? (Probe for Publicity, Relevance and Appeal mechanism efforts)