University of Toronto, Institute of Health Policy, Management and Evaluation, Canada.
Abt Associates, Addis Ababa, Ethiopia.
Soc Sci Med. 2018 Feb;198:165-174. doi: 10.1016/j.socscimed.2017.12.009. Epub 2017 Dec 9.
Setting priorities for health services is a complex and value laden process. Over the past twenty years, there has been considerable scholarly attention paid to strengthening fairness and legitimacy using the prominent ethical framework, Accountability for Reasonableness (A4R). A variety of case studies applying A4R have advanced our conceptual understanding of procedural fairness, and have highlighted the significance of context through its application. There is a paucity of research, however, that rigorously examines how and to what extent context influences health priority setting processes and the establishment of procedural fairness. We argue here that to study context rigorously requires taking a holistic view of the system by examining the dynamics and interrelationships within it. Using the Transformative Systems Change Framework (TSCF), this investigation sought to examine the influence of system factors on priority setting practice and procedural fairness. A qualitative case study of Ethiopian district health planning was undertaken in 2010 and 2011. Methods included 58 qualitative interviews with decision makers, participant observation, and document analysis. Data analysis followed in three phases: i) an inductive analysis of district health priority setting to highlight experiences across each of the three districts selected, ii) deductive analysis applying A4R and the TSCF independently; and iii) a synthesis of concepts of priority setting practice and procedural fairness within a broader, theoretical understanding of the system. Through the application of the TSCF, a nuanced understanding of priority setting practice is revealed that situates this process within a system of interdependent components that include: norms, operations, regulations, and resources. This paper offers a practical guide attuned to system features influencing the design, implementation, and sustainability of greater fairness in health priority setting practice.
卫生服务的重点排序是一个复杂且充满价值取向的过程。在过去的二十年中，人们对使用突出的伦理框架“合理性问责制（A4R）”来增强公平性和正当性给予了相当多的关注。各种应用 A4R 的案例研究推进了我们对程序公平的概念理解，并通过其应用强调了背景的重要性。但是，很少有研究严格检查背景如何以及在何种程度上影响卫生重点设置过程和程序公平的建立。我们认为，要严格研究背景，需要通过检查系统内部的动态和相互关系，从整体上看待系统。本研究使用变革系统变化框架（TSCF），旨在检查系统因素对重点设置实践和程序公平的影响。2010 年至 2011 年，对埃塞俄比亚地区卫生规划进行了定性案例研究。方法包括与决策者进行 58 次定性访谈、参与观察和文件分析。数据分析分为三个阶段：i）对地区卫生重点设置进行归纳分析，以突出三个选定地区的经验；ii）分别应用 A4R 和 TSCF 进行演绎分析；iii）在对系统的更广泛理论理解的基础上，对重点设置实践和程序公平的概念进行综合。通过应用 TSCF，可以揭示出重点设置实践的细微差别，将这一过程置于一个相互依存的组件系统中，这些组件包括：规范、运作、法规和资源。本文提供了一个注重系统特征的实用指南，这些系统特征影响着在卫生重点设置实践中实现更大公平性的设计、实施和可持续性。
