Biomedical subjects

Lydia Kapiriri

Publications and source records attributed to Lydia Kapiriri.

11 recordsLinked to original sources

PubMed2006

Priority setting at the micro-, meso- and macro-levels in Canada, Norway and Uganda.

UNLABELLED: 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. METHODS: 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. RESULTS: (i) DESCRIPTION: 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. CONCLUSIONS: 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.

Health Personnel↗

PubMed2006

Priority setting in developing countries health care institutions: the case of a Ugandan hospital.

BACKGROUND: Because the demand for health services outstrips the available resources, priority setting is one of the most difficult issues faced by health policy makers, particularly those in developing countries. However, there is lack of literature that describes and evaluates priority setting in these contexts. The objective of this paper is to describe priority setting in a teaching hospital in Uganda and evaluate the description against an ethical framework for fair priority setting processes--Accountability for Reasonableness. METHODS: A case study in a 1,500 bed national referral hospital receiving 1,320 out patients per day and an average budget of 13.5 million US dollars per year. We reviewed documents and carried out 70 in-depth interviews (14 health planners, 40 doctors, and 16 nurses working at the hospital). Interviews were recorded and transcribed. Data analysis employed the modified thematic approach to describe priority setting, and the description was evaluated using the four conditions of Accountability for Reasonableness: relevance, publicity, revisions and enforcement. RESULTS: Senior managers, guided by the hospital strategic plan make the hospital budget allocation decisions. Frontline practitioners expressed lack of knowledge of the process. RELEVANCE: Priority is given according to a cluster of factors including need, emergencies and patient volume. However, surgical departments and departments whose leaders "make a lot of noise" are also prioritized. Publicity: Decisions, but not reasons, are publicized through general meetings and circulars, but this information does not always reach the frontline practitioners. Publicity to the general public was through ad hoc radio programs and to patients who directly ask. Revisions: There were no formal mechanisms for challenging the reasoning. Enforcement: There were no mechanisms to ensure adherence to the four conditions of a fair process. CONCLUSION: Priority setting decisions at this hospital do not satisfy the conditions of fairness. To improve, the hospital should: (i) engage frontline practitioners, (ii) publicize the reasons for decisions both within the hospital and to the general public, and (iii) develop formal mechanisms for challenging the reasoning. In addition, capacity strengthening is required for senior managers who must accept responsibility for ensuring that the above three conditions are met.

Decision Making, Organizational↗

PubMed2006

The Global Fund Secretariat's suspension of funding to Uganda: how could this have been avoided?

In August 2005, the Global Fund to fight AIDS, Tuberculosis and Malaria (the Global Fund) Secretariat suspended its five grants to Uganda following a PricewaterhouseCoopers audit report that exposed gross mismanagement in the Project Management Unit. How could this have been avoided? How can other countries avoid a similar pitfall? We argue that if a legitimate and fair decision-making process were used, the suspension of funding to Uganda could have been avoided, and that this lesson should be applied to other countries. The "accountability for reasonableness" framework of relevance, publicity, revisions and enforcement would help in implementing legitimate and fair decision-making processes, which would improve effectiveness, accountability and transparency in the implementation of Global Fund programmes, preventing future suspension of funding to any Global Fund projects.

Communicable Disease Control↗

PubMed2005

Health practitioners' and health planners' information needs and seeking behavior for decision making in Uganda.

BACKGROUND: Access to reliable information is the most cost-effective and achievable strategy for sustainable improvement in health care. While several studies have described practitioners' information seeking behavior in developed countries, literature from developing countries is lacking. The aims of the study were: (i) to determine the most influential type of information for health workers' and planners' decision making; (ii) to establish the practitioners' evaluation of the availability and quality of this important information; and (iii) to establish the most commonly used/accessible sources of the information relevant for decision making in Uganda. METHODS: Self-administered questionnaires were sent to 610 health workers, planners, and administrators at the national, district and health facility levels in four districts in Uganda. Respondents were reminded three times, after which non-response was registered. Data were entered, cleaned and analysed using SPSS version 12.0. Logistic regression analysis was used to test for differences in responses. RESULTS: The response rate was 67.7% (413). The respondents indicated that personal experience (79%), discussion with colleagues (76%) and national policy and treatment guidelines (75%) were most influential when making decisions in health care and planning. They reported that most of the epidemiological information was available and of relatively good quality but there was lack of information about distribution of benefit, segregated demographic data, and social values. The most often used sources of information included; discussions with colleagues (89%), doctors' statements (85%) and text books (77%). The least frequently used sources were the internet and the library. This varied with respondents' designation and region of origin. CONCLUSIONS: Health planners and practitioners lack some of the information relevant for decision making. They tend to rely on the national policy and treatment guidelines, discussion with colleagues, and personal experience. Most frequently used sources of information are similar to previous studies. The variation in the frequency of use of the different sources of research information necessitates research to understand the barriers and careful planning of health information delivery to ensure equitable access.

Access to Information↗

PubMed2004

Criteria for priority-setting in health care in Uganda: exploration of stakeholders' values.

OBJECTIVE: To explore stakeholders' acceptance of criteria for setting priorities for the health care system in Uganda. METHODS: A self-administered questionnaire was used. It was distributed to health workers, planners and administrators working in all levels of the Ugandan health care system. It was also distributed to members of the public. Participants were asked how strongly they agreed or disagreed with 18 criteria that could be used to set priorities for allocating health care. A total of 408 people took part. Data were entered and analysed using SPSS statistical software. Predetermined cut-off points were used to rank the criteria into three different categories: high weight (>66% of respondents agreed), average weight (33-66% of respondents agreed) and low weight (<33% of respondents agreed). We also tested for associations between respondents' characteristics and their degree of agreement with the criteria. FINDINGS: High-weight criteria included severity of disease, benefit of the intervention, cost of the intervention, cost-effectiveness of the intervention, quality of the data on effectiveness, the patients age, place of residence, lifestyle, importance of providing equity of access to health care and the community's views. The average-weight criteria included the patient's social status, mental features, physical capabilities, political views, responsibilities for others and gender. Low-weight criteria included the patient's religion, and power and influence. There were few associations between respondents' characteristics and their preferences. CONCLUSION: There was a high degree of acceptance for commonly used disease-related and society-related criteria. There was less agreement about the patient-related criteria. We propose that average-weight criteria should be debated in Uganda and other countries facing the challenge of distributing scarce health care resources.

Adult↗

PubMed2004

Is cost-effectiveness analysis preferred to severity of disease as the main guiding principle in priority setting in resource poor settings? The case of Uganda.

INTRODUCTION: Several studies carried out to establish the relative preference of cost-effectiveness of interventions and severity of disease as criteria for priority setting in health have shown a strong preference for severity of disease. These preferences may differ in contexts of resource scarcity, as in developing countries, yet information is limited on such preferences in this context. OBJECTIVE: This study was carried out to identify the key players in priority setting in health and explore their relative preference regarding cost-effectiveness of interventions and severity of disease as criteria for setting priorities in Uganda. DESIGN: 610 self-administered questionnaires were sent to respondents at national, district, health sub-district and facility levels. Respondents included mainly health workers. We used three different simulations, assuming same patient characteristics and same treatment outcome but with varying either severity of disease or cost-effectiveness of treatment, to explore respondents' preferences regarding cost-effectiveness and severity. RESULTS: Actual main actors were identified to be health workers, development partners or donors and politicians. This was different from what respondents perceived as ideal. Above 90% of the respondents recognised the importance of both severity of disease and cost-effectiveness of intervention. In the three scenarios where they were made to choose between the two, a majority of the survey respondents assigned highest weight to treating the most severely ill patient with a less cost-effective intervention compared to the one with a more cost-effective intervention for a less severely ill patient. However, international development partners in in-depth interviews preferred the consideration of cost-effectiveness of intervention. CONCLUSIONS: In a survey among health workers and other actors in priority setting in Uganda, we found that donors are considered to have more say than the survey respondents found ideal. Survey respondents considered both severity of disease and cost-effectiveness important criteria for setting priorities, with severity of disease as the leading principle. This pattern of preferences is similar to findings in context with relatively more resources. In-depth interviews with international development partners, showed that this group put relatively more emphasis on cost-effectiveness of interventions compared to severity of disease. These discrepancies in attitudes between national health workers and representatives from the donors require more investigation. The different attitudes should be openly debated to ensure legitimate decisions.

Journal Article↗

PubMed2004

Can the value choices in DALYs influence global priority-setting?

The "disability adjusted life years" (DALYs) are increasingly used as a tool for decision-making and for describing the distribution of the Global Burden of Disease. The "DALY" combines information about mortality and morbidity, with several value choices such as disability weighting, age-weighting and discounting. These value choices imply that life years are assigned different value, depending on the age and the health state they are in. How robust is the distribution of DALYs to changes in these value choices, and are the choices transparent at the point of use? We calculated the burden attributed to "developmental disability due to malnutrition" and "major depression" with alternative value choices in a simple sensitivity analysis. In particular, we explored the relation between disability weight, health state description and incidence rate. The formulae and information needed was found in the World Health Organisation (WHO) publications using DALYs, and in a survey among international health workers. We found that alternative age-weights, disability weights and discount rate led to an inversion in the ranking of the burden of the two conditions. The DALY loss attributed to "developmental disability due to malnutrition" increased from 14 to 90%, while that of "major depression" sunk from 86 to 10%. The value choices currently used, tend at underestimating the disease burden attributed to young populations and to communicable diseases and this goes against the renewed efforts of the WHO of targeting diseases that are typical of poor populations. While the value choices may be changed, lack of transparency is a more profound problem. At the point of use, the number of DALYs attributed to a condition cannot be fully disaggregated. Hence, one cannot know which part of a DALY loss reflects the age group affected, the prevalence, the mortality rates, the disability weight assigned to it, or to how the condition has been defined. A more transparent and useful approach, we believe, would be to present the years lost due to a disease, and the years lived with a disease separately, without disability weights, age-weights and discounting. This would keep the best of the DALY approach and come closer to the aim of disentangling science from advocacy.

Decision Making, Organizational↗

PubMed2003

The relationship between prevention of mother to child transmission of HIV and stakeholder decision making in Uganda: implications for health policy.

OBJECTIVES: To explore a selection of stakeholders' use of evidence and other reasons in the relative ranking of the prevention of mother to child HIV transmission with nevirapine in a setting of extreme resource scarcity. DESIGN: Group interviews using nominal group technique with provision of evidence. SETTING: One rural and one urban district in Uganda. PARTICIPANTS: People living with HIV/AIDS, people from the general population, planners, health workers and people with hypertension. MAIN OUTCOME MEASURE: relative ranking of prevention of vertical HIV transmission with nevirapine compared to nine other interventions for different conditions and evaluation of participants' use of evidence in the ranking. RESULTS: In the overall final ranking, prevention of vertical HIV transmission with nevirapine was ranked as number five compared to the other eight conditions. Treatment for childhood diseases and highly active anti retroviral treatment (HAART) for HIV/AIDS were ranked higher. Group specific ranking followed the same pattern, although the people living with HIV-group ranked HAART consistently as number one. CONCLUSIONS: Stakeholders seem to rank prevention of vertical HIV transmission lower than treatment for malaria, pneumonia and diarrhoea. Policies considering prevention of vertical transmission of HIV should consider its implications. This study shows that stakeholders are open to considering evidence in assessing the relative priority of different interventions competing for scarce resources. More research is needed to develop methods that can involve representative stakeholders, including the public, in good and legitimate decisions on priorities.

Anti-HIV Agents↗

PubMed2003

Using burden of disease information for health planning in developing countries: the experience from Uganda.

Given the growing interest in both the use of evidence in planning and in using the burden of disease measure (BOD) and cost-effectiveness analysis, we explored health planners' perception of the usefulness of the BOD in priority setting and planning in developing countries, using Uganda as an example. An exploratory qualitative approach involving in-depth interviews with key policy makers in health at district and national levels was employed. Interviews were supplemented with a review of relevant documents. Analysis involved identification of key concepts from the interviews. Concepts were grouped into categories, namely, the appeal of quantitative data, data limitations, opaque methodology, planning as a political process and opportunity costs. These form the basis of this article. We found that the BOD study results have been used as the basis for the national health policy and in defining the contents of the national essential health care package. The quantification and ranking of disease burden is appreciated by politicians and used for advocacy, resource mobilization and re-allocation. The results have also provided information for priority setting and strategic planning. Limitations to its use included poor understanding of the methodology, poor quality of data in-puts, low involvement of stakeholders, inability of the methodology to capture key non-economic issues, and the costs of carrying out the study. There is commitment, by Ugandan planners to using evidence in priority setting. Since this was an exploratory study, there is a need for more studies in developing countries to document their experiences with the use of evidence, and specifically, the BOD approach in planning and priority setting. Such information would contribute to further synthesis of the approach.

Cost of Illness↗

PubMed2003

Public participation in health planning and priority setting at the district level in Uganda.

OBJECTIVE: To explore the experiences of the public and leaders with participatory planning and priority setting in health, in a decentralized district in Uganda. METHODOLOGY: An exploratory qualitative approach, involving in-depth interviews with health planners at the national, district and community levels (n = 12), and five group discussions at community level with women (two groups), men, youths and adolescents (n = 51). The analysis adapted some principles from grounded theory. The five levels of the participation framework by Rifkin (1991) were used to assess the actual level of participation in the study population. RESULTS: Uganda has established structures for participatory planning. Within this context, district level respondents reported to have gained decision-making powers, but were concerned about the degree of financial independence they had. The national level respondents were concerned about the capacity of the districts to absorb their new roles. Actual involvement of the public in priority setting and poor communication between the different levels of the decentralization system, despite the existing structures, were additional concerns. Public participation is mainly through representatives. Majority participation is mainly at health benefits and programme activity levels. Decision-making, monitoring and evaluation, and implementation are still dominated by the locally elected leaders due to reported economic, social and cultural barriers that hinder the participation of the rest of the public.

Community Health Planning↗

PubMed2002

Whose priorities count? Comparison of community-identified health problems and Burden-of-Disease-assessed health priorities in a district in Uganda.

OBJECTIVES: The aim of the study was to compare health problems as defined quantitatively by the Burden of Disease study to those defined by the community. The secondary aim was to explore the potential for using qualitative participatory methodologies as tools for planing and priority setting. DESIGN: Interviews and group discussions with a purposely sampled set of community members (n = 51) and community leaders(n = 6). The Nominal group technique, as well as in-depth interviews, were used to identify major health problems - as perceived by the community. Epidemiological data on the major health problems were derived from the national Burden of Disease study. RESULTS: Community perceived health problems were similar to those identified by the burden of disease study. Reasons given for the ranking included prevalence, fatality, social and cultural stigma. Social stigma and cultural values were not considered in the burden of disease studies. However, socially stigmatized diseases were considered to be more serious compared to non-stigmatised conditions, in spite of their low prevalence. Poverty and lack of knowledge were the perceived major causes of ill-health in the community. CONCLUSIONS: Qualitative approaches like the nominal group technique may be useful in eliciting community values that could supplement quantitative information like that elicited by the Burden of Disease study. Such a mixed approach would capture both epidemiologicaly assessed and community felt needs in the priority setting process.

Adolescent↗