Selecting priorities for MCH Use of a prioritization matrix

The process of selecting the appropriate/ key interventions whose voices are heard, whose views prevail and, thus, whose health interests are advanced? (RESEARCH INTO ACTION 1997) Those likely to have the greatest impact in the relevant setting

Learning objectives Based on the situation analysis DCST’s to be able to: Decide the priority maternal and child health problems that will be addressed Guide which interventions will be implemented at community, first level and referral level to address the priority maternal and child health problems Guide which of the identified gaps in health care provision and health care utilisation will be addressed by them

Introduction Prioritising between different health interventions is an important first step to achieving optimal allocation of resources in the health sector. This presentation discusses criteria used to select and prioritise interventions. The best policies and actions to promote and deliver these priority interventions is the subject of a subsequent session

Any process designed to set priorities Any process designed to set priorities ... should not lose sight of the fundamental questions: whose voices are heard, whose views prevail and, thus, whose health interests are advanced? (RESEARCH INTO ACTION 1997)

What is priority setting? Prioritisation is a process whereby all potential options (interventions), that address the problems identified in the situation analysis, are reviewed according to an agreed set of criteria. The aim of this process is to select the key interventions that are likely to have the greatest impact in the relevant setting. Once the appropriate interventions have been selected, suitable strategies can be developed to maximize the effectiveness of the interventions.

What is priority setting? Prioritisation cannot be resolved by purely technical and scientific methods Adequate attention has to be given to other dimensions of priority setting such as: - the political context - the decision-making process - the institutional and management implications, and - the role of community values in the allocation of health resources Priority setting requires more than just drawing up a list of statistics of poor MCH with a statement of determination to address these. It entails making hard decisions about priorities, examining the underlying health system, and ensuring that implementation, monitoring, and accountability processes are in place.

Essential characteristics of a good priority setting process Be adequately informed (by the situational analysis) Achieve balanced participation between different stakeholders - particularly between communities and professionals Encourage a multi-sectoral perspective Encourage integration of activities where feasible Clearly identify the individuals responsible for taking the decisions Be transparent

Essential characteristics of a good priority setting process Use clear and consistent criteria Be timely Be as simple as is consistent with the above points Result in decisions that are consistent with services’ budgetary and implementation abilities Result in aims and objectives that are clear and feasible

KEY CONSIDERATIONS IN PRIORITY SETTING Major causes of maternal and child mortality and morbidity Coverage targets Existing efforts and delivery channels The quality of services and care provided

Summary of steps in a priority setting process Step 1: Determine the aim and scope of the priority setting exercise Step 2: Review the situation analysis and compile a programme budget Step 3: Convene an advisory panel Step 4: Determine locally relevant decision-making criteria Step 5: Identify possible strategy areas (interventions) Step 6: Prioritise strategies and make recommendations Step 7: Consult stakeholders Step 8: Final decision

Summary of steps in a priority setting process Step 1: Determine the aim and scope of the priority setting exercise Step 2: Review the situation analysis and compile a programme budget Step 3: Convene an advisory panel Step 4: Determine locally relevant decision-making criteria Step 5: Identify possible strategy areas (interventions) Step 6: Prioritise strategies and make recommendations Step 7: Consult stakeholders Step 8: Final decision

CRITERIA USED TO PRIORITISE INTERVENTIONS Equity considerations Feasibility Acceptability to community Appropriateness (effectiveness) Cost effectiveness

Equity Equity in health can be defined as “the absence of systematic disparities in health (or in major social determinants of health, including access to health care) between groups with different levels of underlying social advantage or disadvantage.” Because a particular health intervention is used to prevent or treat a disease that is more prevalent among the poor, does not necessarily mean that the poor will be the ones who benefit from increased spending on that intervention

Equity Frequently, health interventions, such as immunisation, do not adequately reach the poor despite being cost-effective and widely promoted. On average, immunization coverage in a developing country's poorest 20% of the population is around 35%-40% (half the level achieved in the richest fifth). Wealth is only one form of inequality. Ethnic, language and other divisions are equally or more significant markers of gaps in maternal and child mortality in many countries. Gender inequity may be critical to child health outcomes.

Feasibility What is feasible varies widely even among low-income countries. An intervention is feasible if there is a consensus that it can be implemented successfully in the local setting despite resource constraints. Feasibility can be viewed as a match between technical complexity and capacity. For example, there is a variety of effective interventions to prevent hypothermia in newborns (i.e. incubators, radiant warmers, wrapping warmly in blankets, kangaroo mother care). However, if a setting lacks regular electricity, kangaroo care is the most feasible (and still effective) intervention to achieve the desired result.

Feasibility The obstacles to intervention delivery include insufficient capacity and resources: not enough money, not enough human resources, not enough managerial skills, not enough information, not enough political will. Availability of skilled human resources is the key constraint While most important prioritisation is among health programmes, also necessary to establish priorities for services. Consider: - Health services: clinics, community health centres, hospitals - Resource management: drugs, laboratory, human resources, transport, etc. - General management: health information, finance, etc.

Acceptability to the community To be sustainable, an intervention must be acceptable to the community. Decision makers must consider the community's culture, traditions and values. Although an intervention may present a new idea to the community, it may be compatible with community norms, and therefore easily accepted. Community members must be seen as full partners who can make recommendations about what is effective and feasible in the local setting

Appropriateness (Effectiveness) Effectiveness refers to whether the intervention has an effect under the “real-life” circumstances faced by health services. Interventions may be effective in one setting but highly dependent on infrastructure and, therefore, not feasible in another setting.   The Bellagio Study Group on Child Survival estimated that with 99% coverage of proven effective interventions, 63% of child mortality would be averted

Cost-effectiveness In simple terms, the methodology for improving health sector spending on health consists of estimating the extent to which populations suffer from disease (the burden of disease) and the costs and effectiveness of curative and preventive health interventions known to reduce this burden.   The burden of disease is estimated in terms of disability adjusted life years (DALYs).

DALYS The DALY expresses years of life lost to premature death and years lived with a disability of specified severity and duration. One DALY is thus one lost year of healthy life. Here, a “premature” death is defined as one that occurs before the age to which the dying person could have expected to survive if they were a member of a standardized model population with a life expectancy at birth equal to that of the world’s longest-surviving population (Japan).

Example - malaria control (cost/daly saved) Improvement in case management (accurate diagnosis, effective treatment) $1-8 Insecticide treatment of existing nets $4-10 Antimalarial prophylaxis for children (assuming an existing delivery system) $3-12 Intermittent antimalarial treatment of pregnant women $4-29 Provision of nets and insecticide treatment $19-85 Residual spraying ­ internal house walls (two rounds per year) $32-58

PRIORITISING TABLE Interven-tion Equity Feasibility Acceptability Effectiveness (Appropriateness) Cost-effectiveness Score 1.   2. 3. 4. 5.

Determining priorities: URGENT NOT URGENT 1 Crises Pressing problems Deadline driven activities 2 Prevention Relationship building Data management Planning Recognising opportunities Recreation 3 Interruptions Some calls, meetings, mail, reports Pressing matters Popular activities 4 Trivia/busy work Some mail/ paper work/ phone calls Time wasters Pleasant activities Not important IMPORTANT

WEIGHTING CRITERIA The assignment of equal or differential weights to the criteria should be carefully deliberated upon by the participants until a consensus is reached on the selected criteria and the weights. For this exercise: weigh each criteria as follows: High (5 points) or +++ Medium (3 points) or ++ Low (1 point) or +

Once a nation is free it must also be free to work ……. A pay cheque maketh a living, BUT work maketh a life. JTibane

INSTRUCTIONS