Session 3
Priority Setting
Building on M1S2, the purpose of this session is to continue learning how to set priorities, for considering some of the recognised practical frameworks for achieving this in different healthcare contexts.
Activity 1.4.1: Mapping out Job Opportunities
The paper highlights the inherent complexity and political nature of priority setting in health care, driven by diverse social values and interests. It criticizes current HTA frameworks for failing to adequately capture this complexity, leading to legitimacy issues and challenges to decisions.
Proposed Framework: The authors propose "evidence-informed deliberative processes," which integrate MCDA and A4R to address the limitations of current frameworks. This new approach emphasizes early and continuous stakeholder deliberation and structured, evidence-informed decision-making.”Complexity of Priority Setting: Health care priority setting is complex and involves diverse social values and interests. Current HTA frameworks, which often rely on predefined principles like "cost-effectiveness," fail to capture this diversity, leading to legitimacy issues.
Inadequacy of Current Frameworks: Present HTA frameworks do not adequately address the range of stakeholder values, leading to ethical issues and challenges to HTA decisions, as seen in countries like Brazil, Mexico, and Thailand.
Proposed Framework: The paper proposes "evidence-informed deliberative processes" as an alternative framework. This combines the structured decision-making of multicriteria decision analysis (MCDA) with the fair process focus of accountability for reasonableness (A4R).
Stakeholder Involvement: The new framework emphasizes early and ongoing stakeholder deliberation to identify and evaluate relevant/mutual social values. This helps in making more legitimate and accepted HTA recommendations.
Integration of Phases: HTA processes should integrate assessment and appraisal phases to gather and consider relevant evidence in a timely manner, enhancing the comprehensiveness and legitimacy of recommendations.
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Criteria Specification: HTA agencies should publicly scrutinize and justify their decision-making criteria, ensuring they reflect a broad range of stakeholder values and are contextually relevant.
Recommendation Development: Recommendations should be developed through a balanced consideration of quantitative and qualitative information, with clear argumentation on how each criterion affects the decision.
Communication and Appeal: Agencies should transparently communicate their reasoning and provide mechanisms for appeal, ensuring ongoing stakeholder engagement and adaptation to new evidence or societal changes
What is the Combined Approach Matrix Framework:
The Combined Approach Matrix (CAM) framework is a strategic tool used in project management, risk assessment and decision-making to integrate various perspectives and methodologies for a comprehensive analysis. This framework aims to enhance the quality of decisions by combining multiple approaches, often from different disciplines and areas of expertise. It combines aspects of two popular decision matrices: the Risk Assessment Matrix (RAM) and the Decision Matrix.
Briefly, the Risk Assessment Matrix (RAM) is a tool used to evaluate and prioritise risks based on their likelihood and impact. It helps in identifying, assessing, and managing risks effectively. Whereas the Decision Matrix, also known as a Multi-Criteria Decision Analysis (MCDA), is a tool used to evaluate and prioritise different options based on multiple criteria. It provides a systematic approach for comparing alternatives and making informed decisions. When incorporated into the Combined Approach Matrix (CAM) framework, the Decision Matrix enhances the decision-making process by offering a structured method to assess and weigh various factors and RAM enhances the overall analysis to handle uncertainties and potential negative outcomes.
The CAM framework brings together different analytical and strategic approaches to address complex issues. These approaches can include Qualitative and Quantitative Analysis, Systems thinking and Scenario planning. The framework takes the form of a matrix. The characteristic matrix structure is utilised to organise and compare. It goes further as to identify key variables, compare how different methodologies will essentially address the identified key variables. CAM also highlights interdependencies. It shows how different factors and potential approaches influence each other.
The CAM framework is versatile and can be applied in various fields such as business strategy, project management and public policy.
The Combined Approach Matrix framework is a powerful tool for integrating multiple perspectives and methodologies to achieve comprehensive and effective decision-making. Its structured yet flexible nature allows it to be tailored to various contexts and fields, making it an asset in strategic planning and analysis.
Priority Setting
The Combined Approach Matrix (CAM) framework is an effective tool for priority setting, allowing organisations to integrate multiple perspectives and methodologies to systematically evaluate and rank priorities.
The process begins with clearly defining the objectives and scope of the priority-setting exercise, including the goals, desired outcomes, and any constraints. Next, all possible projects, initiatives, or tasks are identified, along with the criteria for their evaluation, such as cost, impact, feasibility, risk, time to completion, and alignment with strategic goals. Each criterion is then weighted according to its relative importance, often determined through stakeholder surveys or expert input. Relevant data is collected for each option, and scores are assigned based on how well each option meets the criteria. These scores are then multiplied by the corresponding weights, and a matrix is constructed to display the weighted scores, which are summed to provide a total score for each option.
The options are ranked based on these total weighted scores, and a sensitivity analysis is conducted to ensure robustness. Stakeholders review and validate the rankings to ensure alignment with strategic goals, and any necessary adjustments are made. Finally, an action plan is developed for implementing the prioritised options, with assigned responsibilities, allocated resources, and set timelines. The process concludes with continuous monitoring and adjustments as needed to stay aligned with changing circumstances.
This structured approach and versatility of the CAM framework ensures comprehensive evaluation, transparency, stakeholder engagement, and flexibility, leading to well-informed and balanced decisions that align with organisational objectives and resources.
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Strengths and Limitations
Using the Combined Approach Matrix (CAM) framework for priority setting offers several strengths and limitations. However, it is important to consider both to make an informed decision. The strengths include comprehensive evaluation, as the CAM framework integrates various analytical approaches, ensuring a thorough and multi-faceted evaluation of options. The structured decision-making process provides a systematic and organised approach, making prioritisation clear and justified. The transparency of the CAM framework, through documented methodology and stakeholder involvement, builds trust and ensures alignment with strategic goals. The inclusive process of stakeholder engagement ensures diverse perspectives are considered, leading to more widely accepted decisions. The CAM framework is adaptable and scalable, making it versatile for various contexts.
In contrast, the complexity of the framework can be a significant limitation, as the process of defining criteria, collecting data, and scoring options can be time-consuming and resource intensive. The subjectivity involved in assigning weights and scores can introduce biases. Data quality and availability remain potential challenges that can impact the reliability of the outcomes. Additionally, the CAM framework may not fully account for rapidly changing conditions. Therefore, implementing the prioritised decisions may face resistance and execution risks.
The Combined Approach Matrix (CAM) framework provides a structured, transparent, and comprehensive method for priority setting, making it a valuable tool for informed decision-making. However, its complexity, potential for subjectivity, data challenges, sensitivity to changing environments, and implementation difficulties must be carefully managed to ensure effective outcomes. Balancing these strengths and limitations can help organisations leverage the CAM framework to make strategic and well-supported decisions.
How it Works in the South African Context
When it comes to healthcare financing in South Africa, the system is heavily burdened by a dual structure, where a small wealthier portion of the population accesses private healthcare through medical schemes and out-of-pocket, while 83% of the population relies on an underfunded, understaffed and overstretched public healthcare sector (Ngobeni et al., 2020). This disparity leads to significant inequities in health service access and quality.
The public sector is known for inefficient resource allocation and pervasive corruption, which further exacerbate poor service delivery (Maphumulo & Bhengu, 2019). Additionally, there is a lack of implementation analysis framework to guide effective policy making and resource distribution (Campos & Reich, 2019). The introduction of the National Health Insurance (NHI) aims to address these disparities, but its implementation is not without challenges. This ranges from financial sustainability given NHI will be funded by progressive taxation in a country with the highest unemployment rate globally, administrative capacity and stakeholder resistance (Hlayisi, 2022: Maphumulo & Bhengu, 2019). These issues collectively hinder the ability to achieve a universally accessible, equitable and efficient healthcare system in South Africa at the moment.
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What are the important dimensions of the framework?
Legitimacy in this framework refers to reasonableness, or fairness of recommendations (social values) as perceived by concerned stakeholders. Establishing this legitimacy is a crucial prerequisite for broad societal support of these recommendations.
The framework integrates two increasingly popular and complementary frameworks: The Multicriteria Decision Analysis (MCDA) framework, and the Accountability for Reasonableness (A4R) framework. The MCDA determines the general value of interventions based on a set of multiple explicit criteria. While the MCDA is recognised for its “rational pursuit”, it falls short by being technocratic and lacking an element that addresses deliberation involving stakeholders. This shortfall is filled by the A4R framework as it recognises that stakeholder understandably disagree about significance of specific social values when setting priorities and argues that priorities are more likely to be accepted by stakeholders if they emerge from a fair process. The overall aim of this process is to establish a shared basis for decision-making among stakeholders. This should not be mistaken for seeking consensus. Policymakers hold the final authority on all decisions.
The proposed Evidence-informed deliberative processes combines the structured decision-making of the MCDA framework. The processes in this framework hinge on “early, continued deliberation among stakeholders to identify, reflect, and learn about the meaning and importance of relevant social values”. Secondly, they are based on “structured and rational decision-making—through evidence-informed evaluation of the identified values where possible”. Evidence-informed evaluations refers to a balance of stakeholder’s contributions from their clinical experience as well as their judgement when stronger evidence is not available.
The guiding ideal and aspirational goal of this framework is that stakeholders must be able to draw legitimacy from recommendations.
The key dimensions of this framework is an incremental process that transforms stakeholder deliberation into learning, and the transformation of values (stakeholder’s preferences) into criteria – a more formal version of values that can be used in real-world settings.
Stakeholder deliberation has three objectives: Firstly, it should identify the full range of values that a society bears in relation to a specific recommendation. Secondly, deliberation should result in stakeholders understanding each other’s values. Thirdly, it should attain maximum coherence among stakeholders in their argumentation of a recommendation. These three objectives contribute to enhanced legitimacy and thus a recommendation is considered more reasonable.
Deep-engagement (through explicating their underlying assumptions and preferences) is essential to this deliberation process and is most likely in a diverse group of stakeholders
