Priority Setting and Sequencing

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Priority Setting and Sequencing

• Thomas Bossert, Ph.D.
• Harvard School of Public Health

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Priority Setting and Strategic Planning

• How to prioritize as part of strategic planning
• Strategic Planning as process
• Emphasizes interactive involvement
• Gaining information and buy-in
• Priority setting is only part of that process
• Priority Setting
• logic of evidenced based decision making

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Steps in Priority Setting and Sequencing

• Problem Identification by Assessing Current
  Status of HRH Indicators against Benchmarks
• Develop Criteria for Prioritizing HRH Problems
• Choose HRH Reform Policies
• Sequencing of HRH Reform Policies
• Assess Political Feasibility of HRH Reform
  Policies

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Step 1 Assessing Current HRH Status

• Collect the best data you have for the WHO tool
• HR Status densities and distribution
• Cross Cutting Issues
• Financing
• Education
• Management
• Develop means of estimating when you do not have
  the data

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Densities and Distribution

• How do HRH densities for each HRH categories
  compare to benchmarks? Which HRH categories are
  more understaffed than others?
• Are there significant regional differences in
  staffing? How do these compare to benchmarks?
• Use methods to do projections of HR stock and
  future needs

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Cross Cutting Issues

• Are there retention/migration problems and
  shortages in qualified candidates for key
  categories? How do these problems compare to
  benchmarks?
• Are there absentee/ghost worker problems? How do
  these problems compare to benchmarks?
• Are there multiple job holding problems? How do
  these problems compare to benchmarks?

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Financing Capacity Problems

• Does the health sector have adequate funding? How
  does your country compare to benchmarks?
• Is HRH financing efficient? Compare allocations
  and bang for the buck indicators to benchmarks.
• Is HRH funding equally distributed across
  geographical regions?
• Are salaries low and incentives inadequate?
• Is there sufficient funding for training
  capacities?
• Are there incentives to work in rural areas and
  emerging regions.

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Education Capacity Problems

• Is the current education output sufficient to
  increase and in the medium term - maintain HRH
  densities?
• Is the pool of potential applicants for HRH
  education from secondary education adequate for
  expanded HRH in specific categories?
• Is the distribution of HRH education capacity and
  output across geographical regions equitable?
• Is there sufficient management training?

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Management Capacity Problems

• Is there adequate information for policy and
  decision making (e.g. HMIS)?
• Does the amount of autonomy (decision space)
  conform to decision making capacity at each level
  of the system?
• Does the national level have leadership capacity
  to lead HR reforms?
• Is there sufficient management training for
  managers at all levels?

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Management Capacity Problems (2)

• Are good HRH core administrative techniques
  used at all levels of the system
• Is there leadership and effective organizational
  culture at facility-level?
• Are general working conditions adequate?
• Is the private sector adequately engaged?

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Step 2. Criteria for Prioritizing HRH Problems

• Priority Setting is partly technical (evidence
  based) but has to be embedded in national and
  stakeholder values
• Identify National priorities for HRH appropriate
  to health status problems (i.e. MDGs)
• National priorities for HRH responsive to popular
  and patient satisfaction and financial security
• Current HRH initiatives (civil service reform,
  private sector training, etc.)

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Technical Quality Criteria

• National level capacity in the Ministry of Health
  (and Ministry of Education if appropriate) to
  make policy decisions based on evidence
• Quality of training be sufficient to provide
  adequately trained HRH in the appropriate
  categories
• Working conditions, career paths and salary and
  other incentives are sufficient for attracting
  and retaining quality staff

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Step 3. Strategic Planning Process for Choosing
HRH Reform Policies

• Fishbone Diagram
• Causes
• Problem

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Diagnostic Tree Analysis

• Diagnostic Tree from Problems to Causes to
  Control Knobs or Policy Levers
• Ask Why Five Times

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Example High Maternal Mortality
Unhealthy/high-risk behavior(s)
Performance problem

• High Maternal Mortality

Inadequate health care
Chronic diseases
Broad Cause(s)
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Broad Cause of High Maternal MortalityInadequate
Health Care

• Inadequate health care

Poor clinical quality of care
Insufficient quantity of services consumed
Broad Cause
Next linked cause(s)
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Next Linked Causes Poor Clinical Quality of Care
Inadequate skill or decision making

• Poor clinical quality of care

Lack of equipment and supplies
Organization of services
Next linked cause
Further linked problems and causes
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Further Linked Problems and Causes
Poor Training

Inadequate skill or decision making
Lack of Motivation
Insufficient total resources
Lack of equipment and supplies
Inappropriate allocation of resources
Institutional incentives
Organization of services
Poor Management
Organizational Design
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Select Control Knobs

• Policy levers that can change the causes of the
  problems
• Financing changes increase in funding?
• Payment changes incentives?
• Education system changes?
• Management and organizational changes?

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Think about Innovations for Control Knobs

• Family medicine?
• Medical Officers/Assistants?
• Nurses and community workers?
• Incentives for improving satisfaction and
  motivation?
• Leadership and Change Management techniques?

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Guidance on the Process

• Work backwards
• Do not jump to conclusions
• Be scientific
• Respect data
• Be specific
• Look for causes you can fix

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Prioritizing Reform Options

• Are some control knobs more likely to achieve
  objectives than others?
• Family medicine or more nurses?
• Incentives for rural practice or incentives to
  reduce migration?
• Do you have to tradeoff some objectives for
  others?
• Improve efficiency before equity?
• Improve motivation before equity?

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Preliminary Political Feasibility Assessment

• Stakeholder analysis and initial political map of
  supporters and opponents
• Consider modification in the planned reform to
  reduce opposition and increase support

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Step 4. Sequencing of HRH Reform Policies

• Similar to prioritizing but temporal criteria
• Is there a logical temporal sequence?
• Expand training facilities before training
  begins?
• Train trainers?
• Pilot test before scaling up?
• Improve management training before granting
  autonomy?
• Incremental steps vs. big bang reforms
• Low cost solutions before high cost solutions?

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Step 5. Assess Political Feasibility of HRH
Reform Policies

• Are there current initiatives in HR capacity
  building?
• Are key stakeholders interested?
• Donors?
• Ministry of Finance?
• Ministry of Health?
• Associations and Unions?
• Can you change the current political situation in
  your favor?