Mapping Priority Setting in Health in 17 Countries Across Asia, Latin America, and sub-Saharan Africa

Figures & data

Table 1. Factors Used for the Rapid Assessment of Priority Setting and How These Map Out onto Kingdon and Thurber's¹² MST. MST, multiple streams theory; NICE, National Institute for Health and Care Excellence; HITAP, Health Intervention and Technology Assessment Program

Politics Stream	Policy Stream	Problem Stream
1. Political commitmentNational health strategyCentralization of policy-making power	3. InstitutionsInstitutional capacity for explicit prioritysetting (policy-making and technical levels)Governance in health resources allocation	2. Current position on UHC journeyAccess and qualityFinancial protection and distributionalissues
	4. Health system financingFinancial sustainability of the health systemPresence of other donors/developmentagencies
Policy Entrepreneurs5. Economies of scale (iDSI related)Geographic scope Existing support from NICE and HITAP

Table 2. Quantitative Factors and Indicators Used in the Rapid Assessment of Priority Setting (Continued)

Political will and influence
National health strategy calls for rational priority setting and HTA	Sponsor of World Health Assembly Resolution on “Health Interventions and Technology Assessment in Support of Universal Health Coverage”
Potential to benefit given current position along the UHC journey
Health indicators of current position along the UHC journey	Millennium Development Goals IndicatorsProportion of one-year-old children immunized against measles^29,30 Proportion of births attended by skilled health personnel^a^,^23 Maternal mortality ratio^b^,^23 NCD Indicators Prevalence of smoking in adults (females and males)^c^,^29 Percentage of all NCD deaths occurring under age of 70 (females and males).^31 Effective cervical cancer screening coverage for women^32
	General availability of breast^d/bowel^e cancer screening at the primary health care level^33 Probability of premature death from cardiovascular disease, cancer, diabetes, and chronic respiratory disease^f^,^34
Financial protection and distributional issues	Gini coefficient^g^,^23 Out-of-pocket expenditure as percentage of total health expenditure^h^,^23 Incidence of catastrophic health expenditure due to out-of-pocket payments^i^,^35
Institutions
Identified institutional capacity for priority setting at policy maker level	Presence of essential drugs lists^36 Presence of national clinical guidelines:  National treatment guidelines for adult and pediatric treatment of HIV (year of the first record in the AIDSTAR-One database)^37  Standard treatment guidelines, national and regional osteoporosis guidelines (year of the first record in the International Osteoporosis Foundation database)^38 Political stability and absence of violence/terrorism (2012)^j^,^39
Identified institutional capacity for priority setting at technical level	Researchers, headcounts/million population (2012)^k^,^40 QS World University Rankings, average score top three (2012)^l^,^40University/industry research collaboration (2012)^m^,^40 Statistical capacity scientific and technical journal articles (per 100,000 people) (2009)^n^,^41Scientific and technical journal articles (per 100,000 people) (2009)^o^,^23
Governance in health resource allocation	Corruption perception index^p^,^42Government effectiveness (2012)^q^,^39Performance of grants by component: tuberculosis, malaria, and HIV^r
Health system financing
Financial sustainability of the health system, considering projected growth and government spending	Growth in health expenditure per capita (estimation based on the World Bank data regarding health expenditure per capita^23)Public expenditure as percentage of total health expenditure^s^,^23
Significant presence of other donors/development agencies in health care	Disbursements to recipient countries for health (per capita, constant 2009 USD)^t^,^43 External resources as percentage of total health expenditure (2011)^u^,^44

HTA = health technology assessment, UHC = universal health coverage, NCDs = noncommunicable diseases.

^a Percentage of deliveries attended by personnel trained to give the necessary supervision, care, and advice to women during pregnancy, labor, and the postpartum period; to conduct deliveries on their own; and to care for newborns.²³

^b Maternal mortality ratio is the number of women who die during pregnancy and childbirth, per 100,000 live births. The data are estimated with a regression model using information on fertility, birth attendants, and HIV prevalence.²³

^c Prevalence of smoking any tobacco product among adults aged ≥15 years (%): Smoking of any form of tobacco, including cigarettes, cigars, pipes, bidis, etc., and excluding smokeless tobacco. Age-standardized prevalence rates for smoking tobacco.²⁹

^d Whether the country has breast cancer screening (by palpation or mammogram) generally available at the primary health care level.³³

^e Whether the country has bowel cancer screening (by digital exam or colonoscopy) generally available at the primary health care level.³³

^f Percentage of 30-year-old people who would die before their 70th birthday from any of cardiovascular disease, cancer, diabetes, or chronic respiratory disease, assuming that she or he would experience current mortality rates at every age and she or he would not die from any other cause of death (e.g., injuries or HIV/AIDS).³⁴

^g The Gini index measures the extent to which the distribution of income or consumption expenditure among individuals or households within an economy deviates from a perfectly equal distribution. A Gini index of 0 represents perfect equality, and an index of 100 represents perfect inequality.²³

^h Any direct outlay by households, including gratuities and in-kind payments, to health practitioners and suppliers of pharmaceuticals, therapeutic appliances, and other goods and services whose primary intent is to contribute to the restoration or enhancement of the health status of individuals or population groups²³

ⁱ The measure of financial burden and catastrophic health expenditure from out-of-pocket expenditure is based on the concept of health spending relative to household nonsubsistence expenditure (or household capacity to pay). The latter was defined on the basis on food expenditure, whereby all household expenditure exceeding a particular food expenditure threshold was considered to be nonsubsistence expenditure. Out-of-pocket expenditure is presented as a share of household capacity to pay. Additionally, a household is defined as facing catastrophic health expenditure if its health spending exceeds 40% of its capacity to pay.³⁵

^j Reflects perceptions of the likelihood that the government will be destabilized or overthrown by unconstitutional or violent means, including politically motivated violence and terrorism. Estimate of governance ranges from approximately −2.5 (weak governance performance) to +2.5 (strong governance performance).³⁹

^k Researchers per million population, headcounts. Researchers in research and development are professionals engaged in the conception or creation of new knowledge, products, processes, methods, or systems and in the management of the projects concerned. Postgraduate PhD students (International Standard Classification of Education, 1997, level 6) engaged in research and development are included.⁴⁰

^l Average score of the top three universities at the QS world university ranking per country. If fewer than three universities are listed in the QS ranking of the global top 700 universities, the sum of the scores of the listed universities is divided by three, thus implying a score of zero for the nonlisted universities⁴⁰

^m Average answer to the survey question: To what extent do business and universities collaborate on research and development in your country? (1 = do not collaborate at all; 7 = collaborate extensively).⁴⁰

ⁿ Statistical capacity indicator provides an overview of the statistical capacity of developing countries. It is based on a diagnostic framework developed with a view to assessing the capacity of statistical systems. The framework consists of three assessment areas: methodology, data sources, and periodicity and timeliness (institutional framework has not been included in score calculation).⁴¹

^o Scientific and technical journal articles refer to the number of scientific and engineering articles published in the following fields: physics, biology, chemistry, mathematics, clinical medicine, biomedical research, engineering and technology, and earth and space sciences.²³

^p The Corruption Perceptions Index ranks countries and territories based on how corrupt their public sector is perceived to be. A country or territory's score indicates the perceived level of public sector corruption on a scale of 0–100, where 0 means that a country is perceived as highly corrupt and 100 means that it is perceived as very clean.⁴²

^q Reflects perceptions of the quality of public services, the quality of the civil service and the degree of its independence from political pressures, the quality of policy formulation and implementation, and the credibility of the government's commitment to such policies. Ranges from approximately −2.5 (weak governance performance) to +2.5 (strong governance performance).³⁹

^r Based on The Global Fund database. The grant portfolio includes more than 1,000 programs across more than 140 countries. Grants are measured and rated against country-owned targets at each periodic disbursement of funding. Only in the case of Chile are there no registered programs related to HIV, tuberculosis, and/or malaria,⁴⁵

^s Public health expenditure consists of recurrent and capital spending from government (central and local) budgets, external borrowings and grants (including donations from international agencies and nongovernmental organizations), and social (or compulsory) health insurance funds. Total health expenditure is the sum of public and private health expenditure. It covers the provision of health services (preventive and curative), family planning activities, nutrition activities, and emergency aid designated for health but does not include provision of water and sanitation.²³

^t The amount of disbursements of official development assistance for health, from donor(s) to recipient(s). A disbursement is the release of funds to or the purchase of goods or services for a recipient and, by extension, the amount thus spent. Disbursements record the actual international transfer of financial resources or of goods or services valued at the cost to the donor.⁴³

^u External resources for health are funds or services in kind that are provided by entities not part of the country in question. The resources may come from international organizations, other countries through bilateral arrangements, or foreign nongovernmental organizations. These resources are part of total health expenditure.⁴⁵

Table 3. General Characteristics of Sampled Countries

Region	Country (Classification by Income)^a	Population in Millions (2012)	Gross Domestic Product per Capita (Current USD) (2013)	Health Expenditure per Capita (Current USD) (2011)	Cause of Death by Communicable Diseases^b (% of Total) (2008)	Infant Mortality Rate^c (2008)	Life Expectancy at Birth, Female (Years) (2011)	Life Expectancy at Birth, Male (Years) (2011)
Latin America and the Caribbean	Brazil (UMI)	198.66	11,340	1,120.6	14	14	77	70
	Chile (HI)	17.46	15,452	1,074.5	9	8	82	76
	Colombia (UMI)	47.70	7,748	432.0	13	15	77	70
	Mexico (UMI)	120.85	9,749	619.6	12	13	79	75
	Uruguay (HI)	3.40	14,703	1,104.9	8	9	80	73
Sub-Saharan Africa	Ghana (LMI)	25.37	1,605	75.0	53	3	62	60
	Kenya (LI)	43.18	943	36.2	63	48	62	59
	Malawi (LI)	15.91	268	30.9	63	53	54	54
	South Africa (UMI)	52.27	7,508	689.3	67	35	57	53
	Uganda (LI)	36.35	547	42.4	65	58	59	57
Asia Pacific	China (UMI)	1,350.70	6,091	278.0	7	13	76	74
	India (LMI)	1,236.69	1,489	59.1	37	47	68	64
	Indonesia (LMI)	246.86	3,557	95.0	28	25	72	68
	Myanmar (LI)	52.80	1,144	22.5	33	48	67	63
	The Philippines (LMI)	96.71	2,587	96.5	31	20	72	65
	Thailand (UMI)	66.79	5,480	201.8	17	11	77	71
	Vietnam (LMI)	88.77	1,755	94.8	16	17	80	71

UMI = upper-middle-income economies (4,086 USD to 12,615 USD), HI = high-income economies (12,616 USD or more), LMI = lower-middle-income economies (1,036 USD to 4,085 USD), LI = low-income economies (1,035 USD or less).

^a Country groups by income according with The World Bank classification²⁴: The split is based on 2012 gross national income per capita.

^b Cause of death by communicable diseases and maternal, prenatal, and nutritional conditions.

^c Probability of dying by age one per 1,000 live births.

Source: Data extracted from data.worldbank.org.²⁴ The gross domestic product for Myanmar was extracted from data.un.org.⁴⁶

Figure 1. Flow of Country Shortlisting Process

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