Kapiriri Lydia, Norheim Ole Frithjof, Martin Douglas K
University of Toronto Joint Centre for Bioethics, Toronto, Ontario, Canada.
Health Policy. 2007 Jun;82(1):78-94. doi: 10.1016/j.healthpol.2006.09.001. Epub 2006 Oct 10.
The objectives of this study were (1) to describe the process of healthcare priority setting in Ontario-Canada, Norway and Uganda at the three levels of decision-making; (2) to evaluate the description using the framework for fair priority setting, accountability for reasonableness; so as to identify lessons of good practices.
We carried out case studies involving key informant interviews, with 184 health practitioners and health planners from the macro-level, meso-level and micro-level from Canada-Ontario, Norway and Uganda (selected by virtue of their varying experiences in priority setting). Interviews were audio-recorded, transcribed and analyzed using a modified thematic approach. The descriptions were evaluated against the four conditions of "accountability for reasonableness", relevance, publicity, revisions and enforcement. Areas of adherence to these conditions were identified as lessons of good practices; areas of non-adherence were identified as opportunities for improvement.
(i)
at the macro-level, in all three countries, cabinet makes most of the macro-level resource allocation decisions and they are influenced by politics, public pressure, and advocacy. Decisions within the ministries of health are based on objective formulae and evidence. International priorities influenced decisions in Uganda. Some priority-setting reasons are publicized through circulars, printed documents and the Internet in Canada and Norway. At the meso-level, hospital priority-setting decisions were made by the hospital managers and were based on national priorities, guidelines, and evidence. Hospital departments that handle emergencies, such as surgery, were prioritized. Some of the reasons are available on the hospital intranet or presented at meetings. Micro-level practitioners considered medical and social worth criteria. These reasons are not publicized. Many practitioners lacked knowledge of the macro- and meso-level priority-setting processes. (ii) Evaluation-relevance: medical evidence and economic criteria were thought to be relevant, but lobbying was thought to be irrelevant. Publicity: all cases lacked clear and effective mechanisms for publicity. REVISIONS: formal mechanisms, following the planning hierarchy, were considered less effective, informal political mechanisms were considered more effective. Canada and Norway had patients' relations officers to deal with patients' dissensions; however, revisions were more difficult in Uganda. Enforcement: leadership for ensuring decision-making fairness was not apparent.
The different levels of priority setting in the three countries fulfilled varying conditions of accountability for reasonableness, none satisfied all the four conditions. To improve, decision makers at the three levels in all three cases should engage frontline practitioners, develop more effectively publicized reasons, and develop formal mechanisms for challenging and revising decisions.
本研究的目的是：（1）描述加拿大安大略省、挪威和乌干达在三个决策层面上确定医疗保健优先事项的过程；（2）使用公平优先事项设定框架（合理性问责制）对该描述进行评估，以确定良好做法的经验教训。
我们开展了案例研究，涉及对关键信息提供者的访谈，访谈对象包括来自加拿大安大略省、挪威和乌干达宏观、中观和微观层面的184名卫生从业人员和卫生规划者（根据他们在确定优先事项方面的不同经验进行选择）。访谈进行了录音、转录，并采用改良的主题方法进行分析。根据“合理性问责制”的四个条件（相关性、公开性、修订和执行）对描述进行评估。符合这些条件的领域被确定为良好做法的经验教训；不符合的领域被确定为改进的机会。
（i）描述：在宏观层面，在所有三个国家，内阁做出大多数宏观层面的资源分配决策，这些决策受到政治、公众压力和宣传活动的影响。卫生部内部的决策基于客观公式和证据。国际优先事项影响了乌干达的决策。在加拿大和挪威，一些确定优先事项的理由通过通知、印刷文件和互联网进行了公布。在中观层面，医院的优先事项设定决策由医院管理人员做出，基于国家优先事项、指南和证据。处理急诊的医院科室（如外科）被列为优先。一些理由可在医院内部网获取或在会议上公布。微观层面的从业人员考虑医疗和社会价值标准。这些理由没有公布。许多从业人员对宏观和中观层面的优先事项设定过程缺乏了解。（ii）评估——相关性：医学证据和经济标准被认为是相关的，但游说被认为是不相关的。公开性：所有案例都缺乏明确有效的公开机制。修订：遵循规划层级的正式机制被认为效果较差，非正式的政治机制被认为效果更好。加拿大和挪威有患者关系官员处理患者的纠纷；然而，在乌干达进行修订更加困难。执行：确保决策公平的领导力不明显。
三个国家不同层面的优先事项设定满足了不同的合理性问责条件，没有一个国家满足所有四个条件。为了改进，所有三个案例中三个层面的决策者都应让一线从业人员参与进来，制定更有效的公开理由，并建立质疑和修订决策的正式机制。
