Carol Barker

Priority setting and economic appraisal: Whose priorities—the community or the economist?

Scarce resources for health require a process for setting priorities. The exact mechanism chosen has important implications for the type of priorities and plans set, and in particular their relationship to the principles of primary health care. One technique increasingly advocated as an aid to priority setting is economic appraisal. It is argued however that economic appraisal is likely to reinforce a selective primary health care approach through its espousal of a technocratic medical model and through its hidden but implicit value judgements. It is suggested that urgent attention is needed to develop approaches to priority setting that incorporate the strengths of economic appraisal, but that are consistent with comprehensive primary health care.

Research and the health services manager in the developing world

Recent work such as that of the Joint Health Systems Research Project has done a great deal to support and encourage health systems research. Despite that, health service managers in developing countries only rarely regard research as integral to the process of priority setting, planning and management. To some extent, this is because the organisational environment is not supportive of managerial initiatives for research-based change. Furthermore, health-related research tends to support a relatively narrow range of managerial activity. The research process itself militates against those qualitative research methods which would frequently provide the appropriate tools for the study of management problems. Six possible reasons for this are proposed. The first is the expectation of those controlling funding and research, that it should produce generalisations. Second, there is a gap between the biomedical research which tends to get funded, and the problems managers really need to solve. Third, disproportionate attention is given to the evaluation of health status over and above organisational states. Fourth, much health systems research tends to embody a simplistic assumption that the only social function of health services is to improve health. Fifth, much of the research which is done is evaluative, and evaluations are frequently required to tell us whether formal goals have been achieved; this both rules out a learning process approach, and militates against finding out what is actually happening. Sixth, the question is raised that funding agencies may play a major role in limiting the use of qualitative research methods. It is suggested that any such effect may be peculiar to the health sector. As a way ahead, conscious efforts to increase the extent to which the research environment helps managers to develop a problem-solving approach, are needed.

An approach to setting priorities in health planning

This paper describes work undertaken in Pakistan within a project to strengthen the health planning system, aimed at improving the capacity of the planning cells to identify priorities and develop broad strategic guidelines. The work starts from the premise that identification of priorities requires two stages. In the first stage, problems must be structured and defined in a way that is accepted by all major stakeholders in the planning process. In the second stage, a transparent process of decision making must exist which will provide the means for the planning group to establish priorities and time-scales. The tools chosen in this instance were selected in relation to the characteristics of the local environment, and the paper describes these.