How to Improve Efficiency through Systematic Priority Setting

JLN Network Manager

This post was originally published on the World Bank’s Investing in Health blog.

On March 1-2, 2019, the Efficiency collaborative co-located with the Domestic Resource Mobilization collaborative in Delhi, India. This fourth in-person collaborative meeting focused on two workstreams: systematic priority setting and measurement and information.

Systematic Priority Setting Workstream

The first day and a half focused on systematic priority setting, which aims to generate a database of resource allocation frameworks for health, as well as a comprehensive guide.

The database will provide an accessible taxonomy of decision-making practices across countries. The group reviewed preliminary themes emerging from the database, which was populated through a questionnaire administered to twelve JLN countries.

Countries revisited the guide to review content and share experiences on institutions, data and tools, and political economy around priority setting. This guide will build on resources like What’s in What’s Out on designing health benefits packages and the iDSI Health Technology Assessment (HTA) Toolkit.

Key Take-aways

All priority setting exercises are not equal. Undertaking HTA and establishing benefits packages represent “gold standard” exercises for priority setting; however, in many countries, even where there is a costed benefits package and/or institutionalized HTA, priorities may not be budgeted for. Additionally, some disease programs may have more developed priority setting practices than others. Priority setting occurs in different ways across settings and in many places the process varies from the ideal.

Priority setting is not just collecting the ‘right’ data or generating the ‘right’ evidence. Countries have a wealth of local, regional and global data at their disposal. However, there are limiting factors for the use of data including low capacity, historical budgeting, and inflexible rules for allocation and expenditure. Priority setting should make controversial decisions easier to defend and increase accountability when budget holders deviate from norms.

Donor financing can distort priority setting. Having visibility into donor funding streams is critical for governments to understand how they should invest their limited resources, especially as countries are expected to co-finance or take over programs traditionally financed through external funds.

Political factors can impact the success of priority setting efforts. When times get hard, HTA programs risk getting cut or dismantled. Several countries highlighted challenges associated with fiscal decentralization including lack of policy alignment across levels. Understanding political factors at play during priority setting is critical to ensure that both priorities and the agencies that set them remain high on the agenda.

Measurement and Information Workstream

The last half day focused on measurement and information, which will produce a practical resource guide and visualized fact sheets on indicators for how to measure efficiency.

This session presented a framework for identifying and measuring efficiency in healthcare. The group then reviewed progress on the resource guide and indicator fact sheets including feedback from “self-pilots” that applied these indicators. Participants conducted group work aimed at building an understanding of the need to think beyond indicators to action planning and embedding data collection and use of evidence into broader processes.

Key Take-aways

There isn’t one indicator that measures the efficiency of a health system. While measuring efficiency is typically a process of assessing whether outcomes have been maximized per input, service delivery can be a complex “black box” that reduces visibility into this process.

Process flow of assessing the maximization of inputs.

This makes it hard to say whether any dollar spent was truly “efficient”. Practitioners need to look at not one, but a series of indicators along the results chain in order to pinpoint inefficiencies.

When it comes to indicators, less can be more. Most countries find it useful to use no more than 10 routine indicators as larger numbers can be difficult to interpret. The prioritized indicators should be viewed as a menu to choose from based on priorities. As issues are identified, a deeper-dive may be necessary to pinpoint areas for improvement.

Measuring efficiency is part of a process, not a one-off exercise. Once inefficiencies have been identified, countries need an action plan to move forward. This requires having clear processes in place that institutionalize data use. For instance, tools like dashboards, yearbooks, budget reviews and Public Expenditure Reviews are only valuable if the data is used.

What now?

In all, the meeting was a successful event that benefited from the participation of both efficiency and DRM collaborative members. The facilitation team is consolidating information to inform the final products. The database will be re-organized around a clear taxonomy. The guide will be re-oriented as a reference to existing tools and resources, including country experience. The measurement and information stream will finalize the fact sheets and resource guide. The products will be ready by late summer/early fall.

This post is a joint product of the authors and a broader facilitation team including Amanda Glassman, Carleigh Krubiner, Francoise Cluzeau, Kalipso Chalkidou, Lydia Ndebele, Somil Nagpal, and Y Ling Chi.