1. Selecting priorities for MCH
Use of a prioritization matrix

2. The process of selecting the appropriate/ key interventions
whose voices are heard,
whose views prevail and, thus,
whose health interests are advanced?
(RESEARCH INTO ACTION 1997)
Those likely to have the greatest impact in the relevant setting

3. Learning objectives
Based on the situation analysis DCST’s to be able to:
Decide the priority maternal and child health problems that will be addressed
Guide which interventions will be implemented at community, first level and referral level to address the priority maternal and child health problems
Guide which of the identified gaps in health care provision and health care utilisation will be addressed by them

4. Introduction
Prioritising between different health interventions is an important first step to achieving optimal allocation of resources in the health sector.
This presentation discusses criteria used to select and prioritise interventions.
The best policies and actions to promote and deliver these priority interventions is the subject of a subsequent session

5. Any process designed to set priorities
Any process designed to set priorities ... should not lose sight of the fundamental questions:
whose voices are heard,
whose views prevail and, thus,
whose health interests are advanced?
(RESEARCH INTO ACTION 1997)

6. What is priority setting?
Prioritisation is a process whereby all potential options (interventions), that address the problems identified in the situation analysis, are reviewed according to an agreed set of criteria.
The aim of this process is to select the key interventions that are likely to have the greatest impact in the relevant setting.
Once the appropriate interventions have been selected, suitable strategies can be developed to maximize the effectiveness of the interventions.

7. What is priority setting?
Prioritisation cannot be resolved by purely technical and scientific methods
Adequate attention has to be given to other dimensions of priority setting such as: the political context the decision-making process the institutional and management implications, and the role of community values in the allocation of health resources
Priority setting requires more than just drawing up a list of statistics of poor MCH with a statement of determination to address these.
It entails making hard decisions about priorities, examining the underlying health system, and ensuring that implementation, monitoring, and accountability processes are in place.

8. Essential characteristics of a good priority setting process
Be adequately informed (by the situational analysis)
Achieve balanced participation between different stakeholders - particularly between communities and professionals
Encourage a multi-sectoral perspective
Encourage integration of activities where feasible
Clearly identify the individuals responsible for taking the decisions
Be transparent

9. Essential characteristics of a good priority setting process
Use clear and consistent criteria
Be timely
Be as simple as is consistent with the above points
Result in decisions that are consistent with services’ budgetary and implementation abilities
Result in aims and objectives that are clear and feasible

10. KEY CONSIDERATIONS IN PRIORITY SETTING
Major causes of maternal and child mortality and morbidity
Coverage targets
Existing efforts and delivery channels
The quality of services and care provided

11. Summary of steps in a priority setting process
Step 1: Determine the aim and scope of the priority setting exercise
Step 2: Review the situation analysis and compile a programme budget
Step 3: Convene an advisory panel
Step 4: Determine locally relevant decision-making criteria
Step 5: Identify possible strategy areas (interventions)
Step 6: Prioritise strategies and make recommendations
Step 7: Consult stakeholders
Step 8: Final decision

12. Summary of steps in a priority setting process
Step 1: Determine the aim and scope of the priority setting exercise
Step 2: Review the situation analysis and compile a programme budget
Step 3: Convene an advisory panel
Step 4: Determine locally relevant decision-making criteria
Step 5: Identify possible strategy areas (interventions)
Step 6: Prioritise strategies and make recommendations
Step 7: Consult stakeholders
Step 8: Final decision

13. CRITERIA USED TO PRIORITISE INTERVENTIONS
Equity considerations
Feasibility
Acceptability to community
Appropriateness (effectiveness)
Cost effectiveness

14. Equity
Equity in health can be defined as “the absence of systematic disparities in health (or in major social determinants of health, including access to health care) between groups with different levels of underlying social advantage or disadvantage.”
Because a particular health intervention is used to prevent or treat a disease that is more prevalent among the poor, does not necessarily mean that the poor will be the ones who benefit from increased spending on that intervention

15. Equity
Frequently, health interventions, such as immunisation, do not adequately reach the poor despite being cost-effective and widely promoted. On average, immunization coverage in a developing country's poorest 20% of the population is around 35%-40% (half the level achieved in the richest fifth).
Wealth is only one form of inequality. Ethnic, language and other divisions are equally or more significant markers of gaps in maternal and child mortality in many countries. Gender inequity may be critical to child health outcomes.

16. Feasibility
What is feasible varies widely even among low-income countries.
An intervention is feasible if there is a consensus that it can be implemented successfully in the local setting despite resource constraints.
Feasibility can be viewed as a match between technical complexity and capacity.
For example, there is a variety of effective interventions to prevent hypothermia in newborns (i.e. incubators, radiant warmers, wrapping warmly in blankets, kangaroo mother care). However, if a setting lacks regular electricity, kangaroo care is the most feasible (and still effective) intervention to achieve the desired result.

17. Feasibility
The obstacles to intervention delivery include insufficient capacity and resources: not enough money, not enough human resources, not enough managerial skills, not enough information, not enough political will.
Availability of skilled human resources is the key constraint
While most important prioritisation is among health programmes, also necessary to establish priorities for services. Consider: - Health services: clinics, community health centres, hospitals - Resource management: drugs, laboratory, human resources, transport, etc General management: health information, finance, etc.

18. Acceptability to the community
To be sustainable, an intervention must be acceptable to the community.
Decision makers must consider the community's culture, traditions and values.
Although an intervention may present a new idea to the community, it may be compatible with community norms, and therefore easily accepted.
Community members must be seen as full partners who can make recommendations about what is effective and feasible in the local setting

19. Appropriateness (Effectiveness)
Effectiveness refers to whether the intervention has an effect under the “real-life” circumstances faced by health services.
Interventions may be effective in one setting but highly dependent on infrastructure and, therefore, not feasible in another setting.  
The Bellagio Study Group on Child Survival estimated that with 99% coverage of proven effective interventions, 63% of child mortality would be averted

20. Cost-effectiveness
In simple terms, the methodology for improving health sector spending on health consists of estimating the extent to which populations suffer from disease (the burden of disease) and the costs and effectiveness of curative and preventive health interventions known to reduce this burden.
  The burden of disease is estimated in terms of disability adjusted life years (DALYs).

21. DALYS
The DALY expresses years of life lost to premature death and years lived with a disability of specified severity and duration.
One DALY is thus one lost year of healthy life.
Here, a “premature” death is defined as one that occurs before the age to which the dying person could have expected to survive if they were a member of a standardized model population with a life expectancy at birth equal to that of the world’s longest-surviving population (Japan).

22. Example - malaria control (cost/daly saved)
Improvement in case management (accurate diagnosis, effective treatment) $1-8
Insecticide treatment of existing nets $4-10
Antimalarial prophylaxis for children (assuming an existing delivery system) $3-12
Intermittent antimalarial treatment of pregnant women $4-29
Provision of nets and insecticide treatment $19-85
Residual spraying ­ internal house walls (two rounds per year) $32-58

23. PRIORITISING TABLE Interven-tion Equity Feasibility Acceptability
Effectiveness (Appropriateness)
Cost-effectiveness
Score 1. 2. 3. 4. 5.

24. Determining priorities:
URGENT
NOT URGENT 1
Crises
Pressing problems
Deadline driven activities 2
Prevention
Relationship building
Data management
Planning
Recognising opportunities
Recreation 3
Interruptions
Some calls, meetings, mail, reports
Pressing matters
Popular activities 4
Trivia/busy work
Some mail/ paper work/ phone calls
Time wasters
Pleasant activities
Not important IMPORTANT

25. WEIGHTING CRITERIA
The assignment of equal or differential weights to the criteria should be carefully deliberated upon by the participants until a consensus is reached on the selected criteria and the weights.
For this exercise: weigh each criteria as follows:
High (5 points) or +++
Medium (3 points) or ++
Low (1 point) or +

26. Once a nation is free it must also be free to work …….
A pay cheque maketh a living,
BUT work maketh a life.
JTibane

27. INSTRUCTIONS