International Decision Support Initiative: Mapping of Priority-Setting in Health for 17 Low and Middle Countries Across Asia, Latin America and Africa

Abstract

Background: The objective of this paper was to assess the characteristics of a sample of low and middle income countries (LMICs), in order to select a shortlist of countries in which an international Decision Support Initiative (iDSI) practical support project could have the maximum likelihood of success and possible impact. The practical support project would take place between end 2014 until end 2015, and support one country in building institutional and technical capacity in priority -setting for universal health coverage (UHC).Candidate countries should provide for a strong likelihood of success for the iDSI practical support project with traction among policymakers (“feasibility”), aligned with the strategic objectives of iDSI (“wants”), and which could generate impact within the country and across neigbouring countries, as well as other countries with similar economic, socio-cultural or political characteristics (“needs”).Method: We identified a long list of 17 LMICs across three regions, with a broad mix of geographical representation, population size and economic performance:o Latin America and Caribbean (LAC): Brazil, Chile, Colombia, Mexico and Uruguayo Sub-Saharan Africa (SSA): Ghana, Kenya, Malawi, South Africa and Ugandao South Asia and Asia Pacific: China, India, Indonesia, Myanmar, Philippines, Thailand and Vietnam.In order to assess priority-setting readiness in each country, we developed a set of qualitative and quantitative indicators covering: political will, current position along the UHC journey, institutional and technical capacity, health system financing characteristics, and potential economies of scale in priority-setting.Adopting a pragmatic, mixed-methods approach, we gathered and synthesised data up to May 2014 on countries’ priority-setting readiness from various sources, including literature review, key opinion leader questionnaires and in-depth interviews. In shortlisting candidate countries for the iDSI practical support project, we excluded: (1) countries that have already established a dedicated, centralised priority-setting institution (reflecting lower need), (2) countries that have not articulated a political commitment to priority-setting for UHC (reflecting lower wants), and (3) countries where iDSI partners may be limited in their ability to gain traction (reflecting lower feasibility). For the remaining countries (the “shortlist”), we sought statements of intention from in-country policymakers, and described potential entry points for iDSI support.Key findings from long list of countries: Countries that had clearly articulated political will for priority-setting and some existing unstructured HTA activities (South Africa, India, Indonesia and Myanmar), could benefit from consolidation and institutionalisation of such activities within a broader context of priority-setting for UHC.Many of the SSA and Asian countries were committed to UHC, and faced current challenges in at least one health indicator for Millennium Development Goals (MDGs) or non-communicable diseases (NCDs). Therefore, they could benefit from more robust priority-setting mechanisms, to ensure that higher quality healthcare reaches the most vulnerable population groups.External donors accounted for high proportions of total health expenditure in the SSA countries (except South Africa) and in Myanmar. Robust country-led priority-setting mechanisms could help donors and policymakers make healthcare investments that are cost-effective, equitable and responsive to local needs.Shortlist of candidate countries: We applied our exclusion criteria and identified a shortlist of four countries: Indonesia, Myanmar, South Africa and Ghana. An iDSI practical support project in any of these countries would likely be feasible, have impact through strengthening or consolidating priority-setting capacity, and be well-aligned with the strategic priorities of Bill & Melinda Gates Foundation (BMGF), UK Department for International Development (DFID) and high-level decision makers in those countries. Conclusion: All four shortlisted countries (Indonesia, Myanmar, South Africa, Ghana) share a common vision of increased public financing and provision of healthcare, with explicit priority-setting recognised as a crucial means of ensuring sustainable UHC. Leaders in all four countries have expressed a strong interest in working with iDSI in their effort to introduce UHC.In all four countries, an iDSI practical support project would be highly likely to generate economies of scale within and across regions.iDSI could support institutional and technical capacity building for priority-setting and add significant value for each of these countries in different ways.Given the strong traction on the part of key decision makers, clearly identified and articulated need for priority-setting for UHC, and the backing of BMGF and DFID, any one of these countries would be a viable option for an iDSI practical support project.