1. Selecting priorities for MNCH Prioritizing activities of identified problems or challenges

3. 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. Select the key interventions that are likely to have the greatest impact in the relevant setting. Develop suitable strategies to maximize the effectiveness of the interventions.

4. 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

5. The rate of antenatal clients initiated on HAART of 45.5% is lower than the 51.2% of 2010/11 and is the lowest in the province and also well below the 2011/12 national average of 80.4%. Namakwa The under-1 facility mortality rate increased from 5.9% in 2010/11 to 7.4% and is also higher than the national average of 6.8%. Pixley The stillbirth rate was 27.5 per 1 000 births, above the national average of 22.5. Still births

6. The under-1 facility mortality rate was an alarming 31.5%, fourfold higher than the provincial (8.0%) and national (6.8%) averages JTG The 54.3% rate of antenatal clients initiated on HAART is slightly below the provincial (55.3%) and considerably below the national (80.4%) rates of initiation onto HAART. Siyanda

7. Essential characteristics of a good priority setting process 1.Be adequately informed (by the situational analysis) 2.Achieve balanced participation between different stakeholders - particularly between communities and professionals 3.Encourage a multi-sectoral perspective 4.Encourage integration of activities where feasible 5.Clearly identify the individuals responsible for taking the decisions 6.Be transparent

8. Essential characteristics of a good priority setting process 7.Use clear and consistent criteria 8.Be timely 9.Be as simple as is consistent with the above points 10.Result in decisions that are consistent with services’ budgetary and implementation abilities 11.Result in aims and objectives that are clear and feasible

9. 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

10. Criteria used to prioritise interventions Equity considerations Feasibility Acceptability to community Appropriateness (effectiveness) Cost effectiveness

11. 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.”

12. Feasibility An intervention is feasible if there is a consensus that it can be implemented successfully in the local setting despite resource constraints. It is a match between technical complexity and capacity. For example, there is a variety of effective interventions to prevent hypothermia in new-borns (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. Look beyond health programmes or services eg drugs, laboratory, transport, general management: health information, finance, etc.

13. Acceptability to the community Consider the community's culture, traditions and values. Community members must be seen as full partners who can make recommendations about what is effective and feasible in the local setting

14. 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.

15. Cost-effectiveness Is the intervention going to give value for money spent: 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).

16. 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).

17. 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

18. Instructions Use table 1& 2 from handout Select 2-3 maternal & child health problems Feedback What are your maternal & child health priority problems Why did your team prioritize these

19. Prioritizing table Interven- tion EquityFeasibilityAccepta bility Effectiven ess (Appropri ateness) Cost- effectiven ess Score 1. 2. 3. 4. 5.

20. 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 +