Evidence-Based Priority Setting for Health Care and Research: Tools to Support Policy in Maternal, Neonatal, and Child Health in Africa

and Child Health in Africa. PLoS Med 7(7): e1000308. doi:10.1371/journal.pmed.1000308 Evidence-Based Priority Setting for Health Care and Research: Tools to Support Policy in Maternal, Neonatal, and Child Health in Africa Igor Rudan 0 Lydia Kapiriri 0 Mark Tomlinson 0 Manuela Balliet 0 Barney Cohen 0 Mickey Chopra 0 This paper is part of a PLoS Medicine series on maternal 0 neonatal 0 child health in Africa 0 Priority Setting-Implicit or Explicit? 0 0 1 Global Health Academy and Centre for Population Health Sciences, The University of Edinburgh Medical School , Edinburgh, Scotland , United Kingdom , 2 Croatian Centre for Global Health, Faculty of Medicine, University of Split , Soltanska, Split , Croatia , 3 Department of Health, Aging and Society, McMaster University , Hamilton, Ontario , Canada , 4 Department of Psychology, Stellenbosch University , Stellenbosch, South Africa, 5 Committee on Population , United States National Academy of Sciences , Washington, D.C. , United States of America , 6 UNICEF , New York , New York , United States of America - Priority setting is required in every health care system. It guides investments in health care and health research, and respects resource constraints. It happens continuously, with or without appropriate tools or processes. Although priority-setting decisions have been described as difficult, value laden, and political, only a few research groups are focused on advancing the theory of priority setting and the development and validation of priority setting tools [14]. These groups advocate the use of their tools, but their work is often not widely recognized, especially among the policy makers in developing countries, where these tools would be most helpful [2]. Our primary objective in this essay is to present the available tools for priority setting that could be used by policy makers in low-resource settings. We also provide an assessment of the applicability and strengths of different tools in the context of maternal and child health in subSaharan Africa. The analyses of investments in neglected diseases showed that they lack transparent priority-setting processes [2]. This persisting situation results in remarkable levels of inequity between investments in different health priorities [16]. Therefore, our secondary objective is to advocate for the use of the tools that could lead to more rational priority setting in sub-Saharan The Essay section contains opinion pieces on topics of broad interest to a general medical audience. Africa. An optimal tool should be able to draw on the best local evidence and guide policy makers and governments to identify, prioritize, and implement evidencebased health interventions for scale-up and delivery. Priority Setting in LowResource SettingsMixed Evidence Although there is currently insufficient evidence that the use of priority-setting tools improves health outcomes and reverses existing inequities, we have ample evidence that the lack of a rational and transparent process generates inequity and stagnation in mortality levels [5,6]. Recently, Youngkong et al. conducted a systematic review of empirical studies on health care priority setting in low-income countries (Table 1) [7]. The review found that policy makers in developing countries rarely consider using the available prioritysetting tools, but also that the available tools lack credibility for priority setting in low-resource settings [7,8]. This is mainly because it is not easy to validate the tools or to link their output with concrete follow-up actions and policy development [9]. Indeed, it is difficult to prove beyond all doubt that investments in health care or health research are valuable to society when compared to alternative investments such as infrastructure or the economy. However, there are many examples of countries that have reduced their maternal and child disease burden substantially from very high starting levels, and of others that keep failing to achieve progress [10]. We also have strong evidence on the key determinants of those successes, which has been incorporated into various priority-setting tools [1,49]. The few studies that have evaluated processes in lowresource settings not using priority-setting tools found that most of them fell short on all four conditions of the accountability for reasonableness framework that assessed their basic legitimacy and fairness [11,12]. Moreover, there is evidence on the interventions and health research needed to improve maternal and child survival in Competing Interests: IR, LK, MT, and MC have all been involved in the development and implementation of the CHNRI methodology. IR and MC have been consultants of Child Health and Nutrition Research Initiative of the Global Forum of Health Research while developing the CHNRI methodology. The other coauthors have no competing interests to declare. Abbreviations: CAM, Combined Approach Matrix; CHNRI, Child Health and Nutrition Research Initiative; CHOICE, Choosing Interventions that are Cost-Effective; COHRED, Council on Health Research for Development; DALY, disability-adjusted life year; DCPP, Disease Control Priorities Project; EHCP, Essential Health Care Package; ENHR, Essential National Health Research; LiST, Lives Saved Tool; MBB, Marginal Budgeting for Bottlenecks; WHO, World Health organization. Health care/health interventions all low-resource countries (Refs. [13,21,22]) Low-resource globally TE All major diseases DCPP project consensus Low-resource globally TE, PM, OS Primary health care Yes, modified CHNRI Low-resource globally TE, PM, OS Stillbirth prevention Yes, modified CHNRI Health care/health interventions - national or sub-national level (Refs. [7,34,35,37]) Thailand PM, HM, HW, TE Several diseases Yes, through literature review Chile None Health system Yes, through literature review South Africa PM, NGO, TE HIV/AIDS Yes, through literature review Tanzania PM Health system Yes, through group discussions Tanzania PM, HP, GP, PA Health system Not transparent Tanzania PM, HP, GP, PA Several diseases Yes, through literature review Argentina PM (at all levels) Health system Yes, focus group and interviews Nepal PM, HP Yes, literature review and Individual rating group discussions Pakistan PM Yes, in-depth interview Semi-structured Interview Table with choice frequency Secondary data analysis List with ranks for 56 choices Group discussion and interview List with ranks by THREE chosen criteria Group discussion and question. Ranking of criteria by importance PM, HM, TE, NGO Ghana and Mali Focus group and interviews Burkina Faso, Ghana, PM, TE Child mortality Malawi Health research all low-resource countries (Refs. [2329]) Low-resource globally TE, PM, HP, OS Mental health Yes, standard CHNRI Low-resource globally TE, HP Maternal and child survivalNone; collective opinion PM, TE, HP, OS PM, TE, HP, NGO, PSHealth research Child health research Yes, standard CHNRI Not fully transparent Ge (...truncated)