Advancing methods for health priority setting practice through the contribution of systems theory: Lessons from a case study in Ethiopia

Accepted Manuscript Advancing methods for health priority setting practice through the contribution of systems theory: Lessons from a case study in Ethiopia Kadia Petricca, Asfaw Bekele, Whitney Berta, Jennifer Gibson, Clare Pain PII:

S0277-9536(17)30739-6

DOI:

10.1016/j.socscimed.2017.12.009

Reference:

SSM 11540

To appear in:

Social Science & Medicine

Received Date: 3 March 2017 Revised Date:

3 December 2017

Accepted Date: 9 December 2017

Please cite this article as: Petricca, K., Bekele, A., Berta, W., Gibson, J., Pain, C., Advancing methods for health priority setting practice through the contribution of systems theory: Lessons from a case study in Ethiopia, Social Science & Medicine (2018), doi: 10.1016/j.socscimed.2017.12.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Advancing methods for health priority setting practice through the contribution of systems theory: Lessons from a case study in Ethiopia Kadia Petricca* MSc PhD, University of Toronto, Institute of Health Policy, Management and Evaluation

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Asfaw Bekele MPH, Senior Health Insurance Specialist, Abt Associates, Addis Ababa Whitney Berta MBA PhD, Associate Professor, University of Toronto, Institute of Health Policy, Management and Evaluation

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Jennifer Gibson PhD, Director, Joint Centre for Bioethics, University of Toronto, Associate Professor, Institute of Health Policy, Management and Evaluation

Clare Pain MSc MD Associate Professor, Department of Psychiatry, University of Toronto, Mount Sinai Hospital

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* (416) 978-4326 ; [email protected] 155 College St, Toronto, ON M5T 3M6

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Abstract

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Setting priorities for health services is a complex and value laden process. Over the past

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twenty years, there has been considerable scholarly attention paid to strengthening

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fairness and legitimacy using the prominent ethical framework, Accountability for

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Reasonableness (A4R). A variety of case studies applying A4R have advanced our

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conceptual understanding of procedural fairness, and have highlighted the significance of

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context through its application. There is a paucity of research, however, that rigorously

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examines how and to what extent context influences health priority setting processes and

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the establishment of procedural fairness. We argue here that to study context rigorously

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requires taking a holistic view of the system by examining the dynamics and

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interrelationships within it. Using the Transformative Systems Change Framework

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(TSCF), this investigation sought to examine the influence of system factors on priority

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setting practice and procedural fairness. A qualitative case study of Ethiopian district

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health planning was undertaken in 2010 and 2011. Methods included 58 qualitative

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interviews with decision makers, participant observation, and document analysis. Data

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analysis followed in three phases: i) an inductive analysis of district health priority setting

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to highlight experiences across each of the three districts selected, ii) deductive analysis

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applying A4R and the TSCF independently; and iii) a synthesis of concepts of priority

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setting practice and procedural fairness within a broader, theoretical understanding of the

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system. Through the application of the TSCF, a nuanced understanding of priority setting

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practice is revealed that situates this process within a system of interdependent

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components that include: norms, operations, regulations, and resources. This paper offers

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a practical guide attuned to system features influencing the design, implementation, and

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sustainability of greater fairness in health priority setting practice.

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Keywords

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District health planning; A4R; Systems theory; Ethiopia; Africa

27 1. Background

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1.1. The significance of context in health priority setting

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Setting priorities among competing health services is both challenging and complex. In

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low-income country contexts, decision-making complexity is further exacerbated by

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resource scarcity, weakened data management systems, and limited institutional and

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individual capacity (Glassman & Chalkidou, 2014). To address challenges in priority

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setting, a variety of approaches have been documented in the literature. In 1998, Soren

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Holm categorized these approaches into two distinct phases. Phase 1 viewed priority

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setting as a technical issue, with an emphasis on developing tools and criteria to guide

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decision makers. It was believed that through the application of tools and evidence,

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decision makers could rationally decide where best to allocate resources and, as a result,

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make well-justified and legitimate decisions.

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However, the concept of devising a ‘simple set of rules’ was recognized as flawed given

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the complexity of the decision-making process. Numerous stakeholder interests, coupled

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with challenges in the use and interpretation of data have been acknowledged as

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additional challenges of decision making. Holm (1998) described this shift towards

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process considerations as phase 2 in priority setting, whereby procedural-based

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approaches aimed to strengthen transparency, stakeholder inclusivity, and fairness.

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During this phase, Accountability for Reasonableness (A4R) became a prominent ethical

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framework that sought to provide guidance in the operationalization of procedural

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fairness. Developed by Daniels and Sabin (1998), A4R outlined four conditions that, if

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met, would constitute legitimate and fair decision-making. These conditions included: (i)

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relevance: if priority setting decisions were based on evidence, reasons, and principles

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accepted as relevant by a wide range of stakeholders; (ii) publicity: if priority setting

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decisions and their rationales were made publicly available to stakeholder groups, so as to

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increase transparency; (iii) appeals and revision: if mechanisms were present for

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stakeholders to dispute decisions and revise them in light of further information; and (iv)

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enforcement: if public or voluntary regulation of the priority setting process was present

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to ensure that the first three conditions were met.

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Since its development, A4R has been widely applied as a normative guide to achieving

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procedural fairness in both high- and low-income country contexts, and at various levels

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of the health system—macro (policy), meso (institutional), or micro (bedside) (Reeleder

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et al., 2006; Jansson, 2007; Schlander, 2007; Walton et al., 2007; Kapiriri et al., 2009;

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Stellan et al., 2013).

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Over the past decade, a growing number of case studies have acknowledged the influence

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of context in shaping both priority-setting practice as well as the potential for fair and

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legitimate processes of decision-making (Mitton and Donaldson, 2003; Mitton & Prout,

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2004; Kapiriri & Martin, 2007; Balabanova et al., 2010; Maluka et al., 2011). Gibson and

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colleagues (2005), for instance, highlighted that while improved stakeholder inclusivity

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and participatory dialogue were important features of procedural fairness, power

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differentials among stakeholders also required consideration given their influence on

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limiting active stakeholder participation. This acknowledgment of a wider contextual

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feature revealed a conceptual limitation in A4R that led to the proposal of a fifth A4R

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condition: empowerment. Through the empowerment condition, a decision-making

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process is believed to uphold fairness and legitimacy if mechanisms are in place to

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minimize power differentials across stakeholders by encouraging active participation.

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Given the importance of empowerment within all priority-setting processes that seek to

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promote stakeholder inclusivity, we modified A4R for this study to include the

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empowerment condition.

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In addition to the influence of context noted above, the REACT study (REsponse to

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ACcountable priority setting for Trust in health systems) further revealed the significance

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of context through the practical application of A4R principles in three low-income

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country contexts: Zambia, Tanzania, and Kenya (Byskov et al., 2009; Bukachi et al.,

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2013). While findings suggested conceptual resonance between the principles of A4R and

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cultural values in support of greater transparency and fairness in planning, decision

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makers also viewed A4R as conceptually technical and complicated to operationalize in

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practice. Stakeholders questioned, for instance, if the application of A4R would result in

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increased tension between planners and politicians at different levels of government

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(Mshana et al., 2007; Maluka et al., 2010)—a valid concern in contexts where power

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differentials have historically played a significant role in decision-making dynamics

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(Szeftel, 1998).

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Such findings reinforce the need for sensitivity to contextual factors when seeking to

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strengthen fair processes of health decision making. Presently, attention to context is not

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a feature acknowledged in A4R. It is a process-driven, normative framework that does

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not reflect on the socio-cultural features that may have a significant bearing on how

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procedural fairness manifests, unfolds, and can be sustained. Although A4R was not

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developed to directly incorporate these wider contextual features, we argue that greater

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attention to context can facilitate a more nuanced understanding of the priority-setting

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process that will, in turn, support the implementation of priority setting methods with

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greater fidelity.

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1.2. The potential for systems theory to advance priority setting approaches

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While greater attention to context has emerged from a variety of case studies, scant in the

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literature has been an examination of how the context itself is shaped and exerts such

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influence. In recent years, systems theory has emerged as an analytical lens for gathering

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insight into how a system is shaped and functions. In 2009, the World Health

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Organization report, Systems Thinking for Health Systems Strengthening, revealed an

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approach to understanding context as part of a wider dynamic of system interactions (de

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Savigny & Adam, 2009). To approach context rigorously requires taking a holistic view

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of the system by examining the dynamics and interrelationships between its component

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parts.

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As governments and organizations implement policies that seek to improve processes for

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more streamlined health planning, whole systems change theory emerges as a valuable

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frame through which to view the change process (Foster-Fishman et al., 2007). Systems

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change theory treats modern health systems as complex adaptive systems; whereby a

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strategy, policy, or intervention is viewed as a perturbation of a complex system that

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requires a process of learning and adaptation by organizational decision-makers (Edwards

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et al., 2007: 2). Drawing from lessons of what comprises effective systems change,

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Foster-Fishman, Nowell and Yang (2007) conceptualized the Transformative Systems

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Change Framework (TSCF) to guide an understanding of the fundamental system parts

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that can explain how a system functions and highlight the barriers and facilitators needed

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for systems change. The TSCF is comprised of four stages, which include: Stage 1,

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binding the system or identifying the problem and, Stage 2, understanding the systems

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structure or fundamental system parts. Once a holistic picture is captured of the system’s

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structure, system interactions are conceptualized (Stage 3) to offer insights where change

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can be leveraged across its parts or interactions (Stage 4).

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Although the application of the TSCF is limited to date, a number of lessons derived from

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the systems change literature more broadly have been documented. Edwards et al. (2007),

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for instance, have consolidated common barriers and facilitators to system change across

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the literature. Key facilitators of systems change included: (i) ongoing stakeholder

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consultation (Daniels, et al., 2005); (ii) consensus building among stakeholders

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(Nyonator, et al., 2005); (iii) clarity of stakeholder roles, authority, and accountability

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(Neville et al., 2005); and (v) adequate human resources and technical capacity to

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accommodate the transition (Pariyo et al., 2005).

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Barriers, on the other hand, included: (i) limited organizational capacity to implement

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lessons learned (Markoff et al., 2005); (ii) unclear authority and accountability structures

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(Hasselback et al., 2003); (iii) on-going financial restraints (Neville et al., 2005); and (v)

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high staff turnover and uncoordinated transitioning towards the change efforts (Huicho et

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al., 2005).

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145 In this paper, we apply systems theory to the problem of district health priority setting

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and view the system—under which priority-setting methods are applied as complex and

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adaptive. Such a lens is particularly relevant in the field of health priority setting,

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whereby methods, approaches, and processes enter within a system, and must adapt to

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accommodate such new procedures and processes.

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2. Methods

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153 2.1. Case study research design

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A qualitative case study of the Ethiopian district health planning and priority setting

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process was undertaken with three key objectives. The first objective sought to describe

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the district planning process. Using this descriptive analysis, the second objective sought

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to analyze district health planning and priority setting through the theoretical lens of A4R

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(to provide insight to procedural fairness within the Ethiopian context) and the TSCF (to

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provide insight to the systemic factors influencing district health planning and priority

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setting processes). The third objective sought to advance our understanding of priority

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setting methods by integrating conceptual and pragmatic considerations of district health

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planning, priority setting, and procedural fairness against an understanding of system

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factors.

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2.2. Research setting and data collection

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Given the paucity of priority setting research documented in Ethiopia, this setting was

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selected to fill this empirical gap. Ethiopia is located in the horn of Africa and is

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ethnically divided into nine regions. Over the past twenty years, health planning has been

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decentralized from the Regional Health Bureaus (RHBs) to the District Health Offices

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(DHOs). In 2007, the Ethiopian government sought to strengthen decentralized health

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planning through the implementation of the Woreda (district)-based Health Sector

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Planning (WBHSP) strategy. Key goals of the strategy were to strengthen coordination

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between national and district planning, the management of health information; and

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channels of communication across all levels.

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To explore district health planning procedures, district selection was guided by the

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following criteria: (i) no travel advisories; (ii) RHB approval; and (iii) the support of the

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DHO. Three districts in Ethiopia were selected for inclusion (each from a separate

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region), including: Lume district (Oromia region), Shebedino district (SNNP region), and

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Hintalo-Wajerat district (Tigray region).

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Data collection took place in two phases. Phase 1 during the planning process of the 2010

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district annual plan, and Phase 2 involved follow-up and supplementary data collection

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during the 2011 district annual plan. Three primary sources of data were collected that

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included qualitative interviews, document analysis, and participant observation.

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2.2.1. Qualitative interviews

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In-depth key informant interviews were undertaken with district, regional, zonal, and

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national health planners, members of the district cabinet and finance office, and non-

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governmental organizations (NGOs). A purposive sampling strategy guided the selection

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of participants with knowledge and involvement in the district health planning process.

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Sampled participants were provided with a translated consent form to ensure an

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understanding of the study objectives, the selection process, risks and benefits associated

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with participation, and confidentiality.

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196 Interview questions aimed to capture how district health planning procedures unfolded

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during the planning cycle. Questions were derived from both the A4R framework, and

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the TSCF. For instance, to assess fairness and legitimacy of district health priority setting

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against each A4R condition, questions included: Who was involved in this planning

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process? Who leads the planning of the annual plan? What happens if and, when,

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someone disagrees with a decision? In addition, tailored questions from the TSCF

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included: Have there been any major inconsistencies with what is written in the WBHSP

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document and what can be implemented? How has WBHSP altered decision-making

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structures and power dynamics across stakeholders?

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Interview guides were translated into Afan Oromo, Tigrigna, and Amharic. Two local

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data collectors were hired from each region and trained by the primary investigator

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(‘acronym anonymous’) to conduct all interviews. After each day of interviews,

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‘acronym anonymous’ met with each pair of data collectors for a 1-2 hour debriefing to

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discuss questions, concerns, and emergent key themes. Interviews were audio tape-

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recorded from Shebedino and Lume districts. In Hintalo-Wajerat district, data collectors

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believed that study participants would not feel comfortable with their interviews

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recorded. The data collectors therefore opted to conduct interviews in pairs to ensure a

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thorough manual collection of interview material.

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All interview transcripts were translated into English. Further, to support the authenticity

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of transcribed material, an external Ethiopian reviewer validated the content of five

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random tape recordings. In total, fifty-two participants were interviewed spanning

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national (n=3), regional (n=12), zonal (n=2), and district (n=35) levels. Additionally, five

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district-level NGO counterparts were interviewed. Participant representation across all

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three districts was relatively equal.

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Pertinent health planning policies, reports and strategic documents were analyzed to

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provide insight into the Ethiopian health planning context and process. In total, four key

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documents were analyzed. These documents included the Health Sector Development

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Program (HSDP) policies I-IV, which have been classified as the “centerpiece of

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[Ethiopia’s] health policy” (FMOH, 2007: 14), the HSDP Harmonization Manual

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(HHM), the WBHSP Training manual, and the Ethiopian Constitutional Health Policy.

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During our data collection phase, Ethiopian decision makers identified these documents

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as pertinent to understanding existing governance and health system structures as well as

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health policy goals. All documents were analyzed for information related to how

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decisions are to be made, what structures are to be in place, who is to be included in the

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planning process, how district health planning procedures are to be disseminated, and

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what overall values may guide decision-making.

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2.2.3. Participant observation

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Participant observation was undertaken during the five-day planning workshop in

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Shebedino district to provide a richer understanding of the health planning experience

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and to triangulate findings with those drawn from qualitative interviews and document

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analysis.

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All interview transcripts, document analysis data, and participant observation notes were

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imported into NVivo software for data management and analysis. Analysis was

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undertaken in three phases: i) an inductive analysis of district health priority setting, ii)

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analysis using A4R and the TSCF independently; and iii) a conceptual synthesis of

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priority setting practice and procedural fairness within a broader, theoretical

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understanding of the system.

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2.3.1. Inductive thematic analysis

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As it applied to objective 1, thematic coding was undertaken to derive common themes

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experienced across all three districts included in this study. This step was completed to

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generate an overall narrative that spoke to the complexities and successes experienced

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across participants. To guide inductive thematic coding, interview manuscripts were first

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reviewed via a conceptualization technique for the first level of coding abstraction. Data

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from interview manuscripts, documents, and participant observation notes were reviewed

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in NVivo and interatively analyzed by identifying themes and sub-themes that related to a

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particular concept or idea.

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2.3.2. Framework Analysis

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As it applied to Objective 2, pooled data across all three sources were deductively coded

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against each of the two frameworks—A4R and the TSCF—to gain deeper insight into

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elements of procedural fairness and systemic impacts noted during the planning process.

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266 i. Accountability for Reasonableness

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To draw inferences related to procedural fairness, data were analyzed through the four

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A4R conditions proposed by Daniels and Sabin (1998) and the fifth condition of

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empowerment proposed by Gibson and colleagues (2005). It was concluded that a

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condition was satisfied if measures existed in support of each of the following

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characteristics.

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To assess relevance, data were analyzed to uncover the rationale, principles and/or

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reasoning underpinning health priority setting. To assess publicity, data were analyzed for

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various opportunities for public disclosure of decision rationale and decisions. To assess

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revisions and appeals, data were analyzed for any mechanisms that incorporated

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opportunities for iterative review of decisions, and if there had been mechanisms to

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develop a formal decision-review process based on explicit decision-review criteria. To

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assess enforcement, data were analyzed to ascertain the enforcement /leadership

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mechanisms in place during the priority setting process and how this feature was

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upholding the aforementioned conditions. To evaluate empowerment, data were analyzed

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to assess the presence of power differentials during decision-making procedures and, if

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any efforts existed to support leadership development and to minimize power

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differentials.

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ii. Transformative Systems Change Framework

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To acquire an understanding of the system, deductive analysis was undertaken using an

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adapted list of open-ended questions from the TSCF. To bind the system in Stage 1, data

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from Phase 1 qualitative interviews were used to draw inferences from questions

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capturing participant experiences with the WBHSP strategy. Through document analysis

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and analysis of interview data, this stage also included the identification of system layers

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to outline pertinent actors, levels, and organizations deemed significant to WBHSP

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implementation. The identification of system layers served to ensure that no key

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stakeholders, meetings, or levels were missed during phase 2 interviews.

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Stage 2 sought to provide a greater understanding of the four system components: (1)

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system norms (including attitudes, values and beliefs); (2) system regulations (such as

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policies and procedures, roles, and responsibilities); (3) system resources (such as

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available resources such as human and social capital); and (4) system operations (such as

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power and control structures).

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2.3.3. Conceptual Synthesis

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A concept synthesis was undertaken to apply the empirical findings emergent from

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inductive thematic coding (Objective 1) and framework analysis (Objective 2). Walker

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and Avant describe a concept synthesis as a process “to extract or pull together concept(s)

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or a set of observations (2004: 32). For this study, the conceptual synthesis facilitated a

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wider reflection on the dimensions of procedural fairness (as viewed through the ethical

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framework A4R) and systems theory (as viewed through the lens of the TSCF).

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3. Findings

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The following findings present the data emergent from the first two study objectives that

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included: i) an inductive analysis of the Ethiopian district health planning process; and ii)

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a deductive analysis using A4R and the TSCF.

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3.1. Inductive analysis of Ethiopian district health planning

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Participant observation and in-depth interviews revealed that overall, the district health

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planning process aligned quite closely in practice with the vision and principles set out by

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the government. The majority of participants emphasized that since the adoption of

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WBHSP, “health decision-making has become a much more structured process that

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aligns with democratic, evidence-based, and seemingly more accountable processes”

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(Member, RHB).

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In addition, the WBHSP strategy appeared to reaffirm the importance of both technical

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and procedural approaches when setting priorities. This observation was apparent through

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the implementation of the criteria-based Evidence-Based Planning and Budgeting

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(EBPB) tool, and the five-day planning meeting; both of which are core components of

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the WBHSP strategy. To guide the analysis of district health data during the meeting, the

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World Bank, UNICEF, and the Ethiopian Ministry of Health collaborated to develop the

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EBPB tool—an automated Excel-based tool that guides district planners in identifying,

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costing, and budgeting interventions specific to their district need. A defining

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characteristic of the EBPB tool is the embedded Marginal Budgeting for Bottlenecks

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(MBB) analysis that is contextually adapted to ensure that target areas within the HSDP

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are accounted for at the district level. Through this analysis, decision makers are able to

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assess the allocative and input efficiency of various health resource utilization scenarios

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and are provided with a menu of evidence-based high impact interventions to guide

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prioritization. For example, under the EPBP tool heading Strengthen Hygiene and

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Environmental Health Services—acknowledged as an HSDP health goal—district health

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planners are provided with various interventions options such as, increase latrine

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coverage, which further outlines associated indicators such as proportion of households

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with a latrine in their data assessments. Other intervention examples may include

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prevention and control of malaria, TB, and leprosy, and associated indicators to capture

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incidence and prevalence data. Given the tools complexity, district-level training to

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navigate and complete the tool is facilitated by the presence of trainers from the regional

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and zonal health bureaus during the five-day meeting.

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During key informant interviews, the majority of study participants described the EBPB

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tool as effective in standardizing priority setting procedures in a manner that would now

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directly align district health priorities with both national and international health

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priorities. One member from the RHB commented that, “since the start of the EBPB tool,

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it is providing guidance from the bottom up and all workers at all levels are now able to

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talk the same language” (Member, RHB). In addition to the tool, study participants also

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validated the importance of the five-day district-planning meeting, as providing

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stakeholders with the opportunity to collectively discuss district health priorities in a

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transparent fashion. As a result, participants believed they were in a better position to

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communicate and explain the rationale for district health priorities to their various

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constituencies, such as during the Woreda Administrative Council (WAC) meeting.

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3.1.1. The significance of context

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While the majority of study participants held positive views towards WBHSP

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implementation, they also spoke to a number of contextual factors that limited the

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implementation of the tool and the planning meeting. Figure 1 summarizes three

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emergent themes of contextual factors, which were categorized as: organizational

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(including factors related to limitations to managerial capacity, organizational

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empowerment, and leadership; technical capacity to manage the tool; and insufficient

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time allocated to complete the plan); infrastructural (including factors related to the

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presence of required material resources; timely and complete data; and an adequate

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budget to support planning activities); and socio-cultural (including factors related to the

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decision-making milieu supportive and inclusive of multi-stakeholder engagement and

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stakeholder inclusivity).

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In addition to contextual features, Figure 1 further highlights thematic outcomes (positive

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and negative) related to WBHSP implementation. Many positive outcomes focused on

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improvements to multi-stakeholder engagement and overall participation; improved data

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usage through the EBPB tool; improved harmonized planning standardized throughout

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the country; and, as a result, reduced planning subjectivity. However, unintended

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negative outcomes were also described. Many participants articulated feeling discouraged

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when using the EBPB tool, for they did not feel adequately trained. Further, as

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summarized by one DHO member, “once the planning meeting is completed, there is no

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support outside of this meeting. No materials, or additional training meeting are provided

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and, so, maintenance and retention are difficult (Member, DHO).” Some participants also

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emphasized feelings of disempowerment when planning in an environment of fiscal

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uncertainty. Such unintended negative outcomes appeared to manifest when the

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aspirations of the strategy were at odds with the existing resource and technical capacity

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of the context in which it was being implemented.

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3.2. District health priority setting through the lens of A4R

390

A4R was applied to advance an understanding of fairness and legitimacy within

391

Ethiopian district health priority setting process. Through this analysis, it was evident that

392

the WBHSP strategy had facilitated the establishment of a few key organizational

393

structures and processes that supported opportunities for meeting the relevance, publicity,

394

appeals and revision, and empowerment conditions, albeit to varying degrees.

M AN U

SC

389

TE D

395 3.2.1. Relevance

397

For one, the establishment of the five-day planning meeting acted as an effective forum

398

to promote discussion and gather various stakeholder views in the decision-making

399

process. Similarly, the adoption of the EBPB tool fostered greater stakeholder dialogue in

400

order to complete it, and ensured that decisions were consistently based on relevant data

401

and criteria. These features of WBHSP supported mechanisms toward strengthening the

402

reasonableness of district health plans and priorities in keeping with the relevance

403

condition of A4R.

AC C

EP

396

404 405

3.2.2. Publicity

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Related to the publicity condition, the presence of the WAC Review Board also acted as a

407

procedural forum for stakeholders to review, appraise, and disseminate the plan.

408

Although it was unclear the degree to which rationales underpinning decisions were

409

communicated—since data collection methods were not conducted at the level of the

410

WAC Review meeting—participant accounts did suggest that the use of the EBPB tool

411

ensured that the rationales underpinning decisions were more firmly grounded in

412

evidence; thus serving as an appropriate and acknowledged rationale among decision

413

makers.

SC

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406

M AN U

414 3.2.3. Revision and Appeals

416

The flexibility principle of the WBHSP strategy served as an important policy step to

417

formalize the necessity for greater flexibility and amendment in health planning.

418

Although the presence of an aspirational commitment to an appeals process was noted,

419

there did not appear to be any formal appeal procedures described in policy on how to

420

resolve disagreements, should they arise. Had disagreements arisen, the extent to which

421

appeals were made during the review process remains unclear. Many participants

422

highlighted that in some cases, as a result of fiscal constraints, a re-prioritization of the

423

plan would occur, and that during this process, the DHO planners would consider criteria

424

that included multiple stakeholder views, majority consensus, and evidence in support of

425

highest burden of disease or urgent health priorities of the community.

EP

AC C

426

TE D

415

427

3.2.4. Empowerment

428

While multi-stakeholder inclusivity was highlighted by participants as crucial for

429

planning, and noted as a key feature of decision-making in both the HSDP policy and the

18

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WBHSP strategy, mechanisms to ensure active participation across all participants were

431

less apparent in practice. This phenomenon speaks to the importance of an A4R condition

432

that acknowledges the presence of directives that encourage active stakeholder

433

participation.

RI PT

430

434 3.2.5. Enforcement

436

Finally, analysis of the enforcement condition demonstrated that a variety of policy

437

directives and regulations documented in the HSDP, HHM, and WBHSP had

438

institutionalized various elements of each A4R condition. In particular, the strategic

439

objectives outlined in the HSDP and WBHSP revealed the presence of an aspirational

440

commitment towards strengthening clarity around evidence-based planning and criteria

441

for setting health priorities. Similarly, the strategic objectives and the establishment of

442

forums for stakeholder engagement further sought to institutionalize processes for

443

increased multi-stakeholder engagement. The acknowledgment of such mechanisms for

444

priority setting were an essential underlying feature to the fulfillment of enforcement

445

mechanisms in support of procedural fairness. To strengthen priority-setting measures in

446

support of enforcement, opportunities for improvement should focus on enhancing

447

explicit directives to regulate, for instance, the roles and responsibilities of stakeholders

448

within the planning process, and the processes for disseminating the plan and the

449

rationales underpinning the decisions made.

M AN U

TE D

EP

AC C

450

SC

435

451

3.2.6. The significance of context

452

While a commitment in policy was apparent in support of the principles underpinning

453

each condition, contextual factors appeared to limit the degree to which these

19

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commitments could be realized. For instance, there did not appear to be standardized

455

directives to guide stakeholders on how decisions and their rationales would be reviewed

456

and disseminated. Further, the degree to which it was intended for the community to be

457

engaged was also unclear, as study participants spoke of sign postings on the gate of the

458

DHO to disseminate district health decisions. Moreover, while flexibility in planning was

459

valued in policy, there was a lack of clear and standardized mechanisms for challenging

460

and revising decisions.

SC

RI PT

454

461

Although procedures established by WBHSP supported relevance in planning,

463

participants described that previous data collection methods under the Health

464

Management Information System did not align with the data needs of the EBPB tool.

465

Further, while multiple stakeholder engagement was acknowledged as significant to

466

improving transparency and engagement, structural delays in sending invitations, and

467

conflicting schedules of stakeholders appeared to hinder full stakeholder participation.

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M AN U

462

468

3.3. District health priority setting through the lens of the TSCF

470

To explore these contextual features in greater depth, the TSCF was selected to examine

471

system factors influencing the Ethiopian district health planning and priority setting

472

process.

AC C

473

EP

469

474

3.3.1. System Norms

475

Through an examination of system norms, Ethiopian social values and cultural beliefs

476

appeared to play a significant role in shaping how priority setting transpired. Our findings

477

revealed that the implementation of WBHSP was facilitated by an alignment between the

20

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apparent system norms and its overarching principles. Participant accounts revealed that

479

strong values in support of increased harmonization, evidence-based practice,

480

participatory dialogue and greater transparency in health planning fostered a facilitating

481

environment for the implementation of WBHSP. Further, the presence of stakeholder

482

values in support of multi-stakeholder engagement and evidence-based planning,

483

appeared essential to cultivating patterns of behaviour among stakeholders that facilitated

484

these features in the planning process.

SC

RI PT

478

485

Conversely, study findings revealed that the health planning process was impeded when

487

system norms were at odds with the goals of WBHSP. Although decentralization sought

488

to encourage greater authority for planning at the district-level, the historical hierarchical

489

political structure appeared to limit district health planner empowerment to both fully

490

lead the planning process, and raise relevant issues at the district level. Both findings

491

suggest that the degree of alignment between system norms and the change effort plays

492

an important role in the implementation of a systems change intervention.

TE D

EP

493

M AN U

486

3.3.2. System Operations

495

An analysis of system operations acknowledged the dominance of central authority and,

496

from a systems perspective, underscored the importance of understanding how power,

497

and authority among different stakeholders may influence patterns of communication and

498

information flow prior to and during the planning process. Although the HSDP

499

acknowledged a role for NGO partners in the planning process (this directive categorized

500

as formal authority in the TSCF), their absence from the planning meeting—whether

501

through delayed invitation, or by choice—suggests that, in practice, the role of ‘external’

AC C

494

21

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502

stakeholders in matters of district health decision-making is unclear and requires greater

503

reflection as to the structures and mechanisms needed to strengthen their participation.

504 3.3.3. System Regulations

506

The above finding further revealed the salience of the systems regulation component of

507

the TSCF. Policy directives, guided by the HSDP, HHM, and District Level

508

Decentralization Program (DLDP) policies, supported the implementation of the WBHSP

509

process through a delineation of authoritative roles and responsibilities. In particular, they

510

played a regulative role in shaping how processes should transpire and how stakeholders

511

should interact. The presence of the DLDP, for one, was intended to strengthen the

512

decentralization of health decision-making to district health planners. These regulative

513

efforts to strengthen district governance forged a political climate where the roles and

514

responsibilities of decision makers had already become relatively clearer through the

515

HSDP policy. Similarly, the HHM strategy fostered regulative structures to commence

516

the process of harmonization and alignment—two concepts foundational to the core of

517

the “One Plan, One Budget, One Report” within the WBHSP strategy.

SC

M AN U

TE D

EP

518

RI PT

505

From a regulative standpoint, formalizing who should attend various meeting forums

520

provided guidance regarding which health system actors had a role and were accountable

521

in the district health planning process. Although these stakeholders were identified in

522

policy, study participants spoke to a lack of clear directives on the scope of their roles

523

and an existing lack of accountability structures. These findings emphasize the

524

importance of clarity in scope of role, particularly in light of organizational expectations

525

of stakeholders during the policy reform process.

AC C

519

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526 3.3.4. System Resources

528

Finally, through an analysis of system resources, it was apparent that the presence of

529

human resources, technical capacity and skills to apply new procedures, and fiscal

530

resources to support a variety of organizational requirements were essential to facilitate

531

district health planning. For instance, having the right mix of expertise was noted as a key

532

facilitator of district priority setting. This expertise included the presence of pertinent

533

stakeholders from all levels of the health system who were required to complete the

534

technical components of the EBPB tool. It appeared, however, that the district health

535

planners, to whom this authority was being ceded, felt inadequately equipped with the

536

skills to manipulate the sophisticated EBPB tool, as described by participants.

M AN U

SC

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527

537 4. Discussion

539

This case study of Ethiopian district health planning and priority setting adds to a small,

540

but growing number of case studies of district health planning from African countries,

541

including Tanzania, Uganda, Zambia, and Kenya (de Savigny et al., 2004; Kapiriri &

542

Norheim, 2004; Maluka et al., 2011; Bukachi et al., 2013; Zulu et al., 2014). In line with

543

objective one, an inductive analysis of district health planning and priority setting

544

revealed that participants believed WBHSP strengthened overall district priority setting

545

procedures. The presence of the EBPB tool, as well as the five-day stakeholder planning

546

meeting were key steps to enhance evidence-based and transparent priority setting.

AC C

EP

TE D

538

547 548

The influence of context detailed in this Ethiopian case study augments previous findings

549

in the priority setting literature that highlight organizational and socio-cultural factors

23

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influencing the implementation of priority setting processes (Mitton & Prout, 2004; Teng

551

et al., 2007; Maluka et al., 2010). For example, Mitton and Donaldson (2003) have

552

argued, “understanding of the context in which the application of […] any explicit,

553

evidence-based decision-making framework takes places is required in order for the

554

exercise to have a chance at being successful” (335-348). In their research on priority

555

setting in low- and middle-income countries, Kapiriri and Martin (2007) identified: (i) the

556

capacity and credibility of institutions; and (ii) the political, economic and social/cultural

557

contexts in which priority setting takes place as important contextual influencers. Further,

558

they argued that an understanding of these contextual influencers is necessary for

559

“context sensitive improvement strategies” (145).

M AN U

SC

RI PT

550

560

4.1. Contribution of systems theory to advance our understanding of procedural

562

fairness

563

To date, no application of the TSCF has been reported in the literature with a particular

564

focus on understanding system influences related to district health planning and priority

565

setting. In this study, the TSCF was applied as a conceptual framework to understand the

566

system-level factors influencing both the implementation of the Ethiopian WBHSP

567

process as well as the manifestation of procedural fairness.

EP

AC C

568

TE D

561

569

At the time of this investigation, Ethiopia was undergoing a major systems change

570

endeavour with the implementation of the WBHSP strategy. To assess system factors

571

influencing this process, the TSCF was a relevant analytical guide given its attention to

572

four key system components, which provided a thorough reflection on the how and, why,

24

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573

of specific contextual elements and mechanisms influencing the district health planning

574

and priority setting.

575 Through a reflection on the presence and sustainability of procedural fairness via the

577

A4R lens, the TSCF provides greater insight to understanding various system elements

578

required to support the manifestation of each condition. System norms have a significant

579

bearing on how new processes and procedures can and will manifest within a given

580

setting. Stamper, Liu, Hafkamp, and Ades (2000), for one, maintain that understanding

581

social norms creates a conduit to understanding organizational change and how actors

582

within the system operate and interact with each other. The findings from this case study

583

provided a descriptive understanding of the normative dimensions of Ethiopian health

584

planning by identifying additional norms that can limit the fulfillment of district health

585

planning procedures, as they were intended. For instance, the high-level of respect for

586

authority and centralized guidance in the health decision-making process, as described by

587

participants, appeared to be at odds with promoting greater district autonomy; a goal of

588

the WBHSP strategy. Therefore, when the principles of a policy have greater congruency

589

with the social and cultural values within a health system, effective implementation is

590

more likely to occur (Municipal Research and Services Center, 1999).

SC

M AN U

TE D

EP

AC C

591

RI PT

576

592

Petricca and Bekele (2017) further illustrate the relevance of socio-cultural belief systems

593

through an analysis of how fairness is conceptualized among Ethiopian health planners.

594

Here, they reveal that while Ethiopians do value process considerations in their

595

conceptualization of fairness, they also go beyond a purely procedural conception,

596

valuing both principles of distributive and organizational justice. Such reflection

25

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597

generates greater insight into the applicability and manifestation of priority setting

598

methods.

599 Furthermore, the TSCF enhances our understanding of how stakeholders organize,

601

convene, interact, communicate, and collectively make decisions. In particular, through

602

systems operations, we are able to recognize how amenable a system is to support the

603

principles and operational needs of a specific priority setting procedure given formal

604

regulative structures, while paying attention to the hidden power dynamics also at play

605

within the decision-making process. Vaughan and Tronvoll (2003) describe power as a

606

“function of the whole social system [… and] the interaction of the collectivity of

607

individuals, who are themselves also all positioned in and, constitutive of, the structure”

608

(30). In regards to Ethiopia, they apply an understanding of power that captures the

609

positions of individuals and groups of actors by means of their relations with others.

610

Through such an analytical lens, they argue, “state power [in Ethiopia] is not an attribute

611

of the state machinery as such, but a product of the interaction between the state’s ruling

612

elite and all of its citizens. The state “influence[s] the structure of power in so far as it is

613

influential in dictating the social distribution of knowledge” (31). This assertion

614

acknowledges the dominance of central authority and, from a systems perspective,

615

underscores the importance of understanding how power and authority across different

616

stakeholders may influence patterns of communication and information flow prior to and,

617

during, the planning process.

AC C

EP

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M AN U

SC

RI PT

600

618 619

Additionally, the TSCF instructs us that an analysis of system resources provides an

620

important understanding of resource constraints or facilitators that underlie how priority-

26

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setting procedures may unfold. It further emphasizes the criticality of resource

622

commitment from three angles of analysis—human, social, and economic—that were

623

important to the operationalization of WBHSP. Our findings revealed that the presence of

624

human capacity such as, accommodating new technical skill requirements, played a

625

significant role in the uptake and implementation of the EBPB tool. In seeking to support

626

greater procedural fairness, a description of system resources would offer critical

627

reflection as to the resource needs required to maintain and support the fulfillment of

628

each condition, such as the presence of resources to support outlets for promoting

629

transparency and public engagement.

M AN U

SC

RI PT

621

630

By viewing district health planning and priority setting through the TSCF, one can begin

632

to understand various dimensions and structures within a system that may influence the

633

implementation success of new methods and processes. Ford (2007) acknowledges that

634

whole systems change deals with two aspects of organizational culture: i) the apparent (or

635

visible) organization that shapes the formal structure (i.e., policies and standards, official

636

roles, and resources used), and ii) the below the surface (or hidden) organization, which

637

highlights less visible characteristics, such as the values of its leaders, organizational

638

norms and history.

EP

AC C

639

TE D

631

640

The proposal of the empowerment condition by Gibson and colleagues (2005) was

641

seminal in identifying the need for a greater contextual understanding of how

642

stakeholders interact during a health priority setting process that seeks to meet standards

643

of fairness and legitimacy. We believe that the TSCF further enhances this understanding

644

by accentuating the social norms and hidden system politics (operations) that shape how

27

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645

organizational processes may in reality transpire. This phenomenon was observed in this

646

study, whereby power and authority played an important role in shaping whether and how

647

stakeholders convened and interacted.

RI PT

648 Figure 2 highlights an apparent complementarity between the TSCF and A4R and

650

embeds this complementarity within the conceptual organizational construct proposed by

651

Ford (2007). The visual representation presented here illustrates important areas of

652

overlap between these two frameworks—A4R and the TSCF— that supports why and

653

how they may be used synergistically to guide priority setting in a manner that neither

654

framework in isolation can achieve towards more contextually fair and legitimate health

655

priority setting.

M AN U

SC

649

656

658



TE D

657

4.2. A third phase in the priority setting discourse

660

As district health planners and researchers strive to improve the procedural fairness of

661

their health priority setting, and design more rational processes, a deeper understanding

662

of the system is therefore essential. The TSCF complements the A4R framework, and

663

helps us to understand the key system factors that may facilitate and/or constrain the

664

implementation of fair processes predicated on the A4R principles. The TCSF also guides

665

us in understanding how and why other priority setting processes unfold in the ways that

666

they did in the Ethiopian context, and the critical role that the system may play in

667

influencing district planning and priority setting efforts in other low-income countries.

668

Systems thinking therefore, contributes to the priority setting discourse by facilitating a

AC C

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659

28

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669

more in-depth reflection on the influence of systems norms, regulations, operations, and

670

resources.

671 To engage in any efforts to strengthen priority setting in isolation of this precursory

673

analysis sets researchers and practitioners up for a ‘business as usual’ model of priority

674

setting practice that may hinder progress towards the desired outcomes sought. Through

675

these findings, we propose that the increasing significance of context in the health

676

priority setting process heralds a third phase in the priority setting discourse, which

677

emphasizes the need for methods and approaches that are inclusive of wider system-level

678

considerations (Figure 3).

679 680



TE D

681

M AN U

SC

RI PT

672

4.3. System considerations to guide priority setting implementation

683

To practically guide the design and implementation of priority setting initiatives, Figure 4

684

summarizes the systemic considerations that may be associated with the implementation

685

of a change initiative to alter health priority setting procedures and/or processes. A series

686

of guiding questions are offered around each of the four system components that were

687

derived from the analysis of the TSCF and A4R on Ethiopian district health planning.

688

These reflective questions can either be used as a prospective tool to guide planners in the

689

identification of key system components prior to the implementation of a priority setting

690

process, or as a retrospective tool to reflect on the key system components to identify

691

barriers to and/or facilitators of implementation. Decision makers and researchers may

692

also view this analytical process iteratively, whereby prospective and retrospective

AC C

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693

application of these questions may facilitate ongoing learning that may advance more

694

effective implementation and system change in relation to health priority setting practice.

695

RI PT

696 697

4.4. Study limitations

699

District selection for inclusion in this study was limited to those districts selected and

700

approved by the RHBs. As a result, remote districts were not included in this study,

701

which may have limited the inclusion of other contextual challenges or successes

702

experienced under different geographical settings. In addition, although analyzing power

703

dynamics is an important component of the TSCF, capturing accurate portrayals of power

704

can be challenging for any cross-cultural researcher. While methodological attempts were

705

made to derive claims from the participant accounts, constructs of power and governance

706

are complex and inherently embedded within a nexus of political history, ethnic

707

federalism, and power relations.

708

EP

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698

5. Conclusions

710

Our study findings reaffirm that district health planning and priority-setting processes are

711

influenced by a multiplicity of system-level factors. They provide a nuanced conceptual

712

understanding of applying A4R, a prominent framework to improve the fairness of

713

priority-setting practice, by reflecting on the systemic influences through the TSCF. The

714

experience of health planning reform in Ethiopia offers a unique opportunity to not only

715

advance our understanding of how the district health planning process transpires in

716

practice, but also enhances our conceptual and pragmatic understanding of procedural

AC C

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717

fairness, and the systemic factors that impact both policy implementation and district

718

health planning practice.

719 Whether improving the evidence-base through explicit tools, or strengthening the fairness

721

and legitimacy of the priority setting process, it is evident that the system in which the

722

process is embedded plays a critical role in shaping how tools may be used and processes

723

may transpire. The third phase in the priority setting discourse that we propose

724

acknowledges the salience of the system and calls for greater recognition in developing

725

tools that can provide deeper and more meaningful insight into these processes.

726 727 728

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Acknowledgments This research was undertaken as part of the lead author’s doctoral dissertation and funded through the Canadian Institutes for Health Research fellowship. She and the collaborating authors extend their heartfelt gratitude to the Ethiopian government and Ministry of Health, as well as to all participants who took the time from their busy schedule to share their health planning experiences.

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Figure 1. Summary of contextual factors influencing the process and outcomes of WBHSP implementation

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Figure 2. Complementarity between the TSCF and A4R in acknowledging the importance of hidden norms and system politics

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Figure 3. Arguments informing the debate on priority setting: Proposing Phase 3 (modified from Holm, 1998, p. 1000) Phase 1

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There is a principled way of making priority decisions, and it is possible to devise a rational priority setting system. Decisions made by applying the appropriate tools to priority setting are thereby legitimate. Phase 2

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There is reasonable disagreement about what priorities should be set, so it is not possible to devise a rational priority setting system based on technocratic considerations alone. Decisions made through a fair priority setting process are thereby legitimate.

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The fair priority setting process is characterized by transparency and accountability— this seems to limited a definition of such a process. Phase 3*

A fair and legitimate priority setting process is influenced by a system that values transparency and accountability and supports their attainment.

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A system is characterized by four key components—norms, regulations, operations, and resources—that will uncover system patterns and dynamics influencing priority setting practice.

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* Signifies our conceptual addition to the priority setting debate proposed by Holm (1998)

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Figure 4. Pertinent system considerations to guide the implementation of priority setting procedures and processes

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System Operations Clear directives on the roles and responsibilities of system members and clear pathways for communication are facilitative

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System Regulations Alignment of the new priority setting process with existing policies and procedures of the system are facilitative

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Do the principles of the priority setting initiative align with the goals and values of the system and its members? Are there any system values or socio-cultural views that may impede the implementation of the new priority setting practices or procedures? What are existing patterns of interaction for system members? Which stakeholders in the system will require ongoing interaction in light of changes to priority setting procedures? Do system members have a clear understanding of their roles and the roles of other system members? What changes in the patterns of communication are required to facilitate priority setting practice? Who are the key system members assigned with responsibility for priority setting? Do existing directive exist that outline how processes and procedures are to transpire? What are the existing procedures that may align or conflict with the priority setting procedures?

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• System Norms Alignment between system norms and the principles of the priority setting initiative are facilitative

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System Resources The presence of human capacity, social structures for conveying system members, and financial resources are facilitative to successful priority setting practice

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• What are the existing skills of the system members to accommodate the imposition of new priority setting procedures and practice? • What financial resources are currently allocated to support existing priority setting procedures? • How will imposing priority setting procedures affect existing resource demands?

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The following 5 bullets list the research highlights and unique contribution of this paper (85 characters): •Provides an undocumented account of health priority setting processes in Ethiopia.

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•Applies the Transformative Systems Change Framework scant in the literature. •Reveals key system factors impacting policy implementation and procedural fairness.

•Proposes a third phase in priority setting that acknowledges the system’s role.

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•Offers a contextually sensitive guide to strengthen fairness in priority setting.