Table 3.
Evaluating priority setting for HIV in Uganda using the parameters of successful priority setting
| Parameters of Successful Priority Setting | HIV Case Study |
|---|---|
| Contextual factors | |
| Conducive political, economic, social, cultural context |
Political: Political stability positively impacted priority setting and implementation. Economic: Disagreements between DAPs and Ugandan government (homosexuality bill) led funds to be reduced temporarily, this impacted implementation, for instance, by reducing the availability of ARVs. Global contraction in funds impacted the health sector and HIV programs Sociocultural: Disagreements between DAPs and Ugandan government over the Homosexuality Act reduced funds for implementation temporarily. Cultural and religious beliefs posed implementation challenges for priorities such as family planning and male circumcision; low education levels and stigma and discrimination were barriers to prevention and treatment Legal: Prevention and Control Act increased discrimination and stigma |
| Prerequisites | |
| Political will | Strong political commitment from key politicians such as the President. |
| Resources | Small MOH budget for health; decreased level of funding from DAPs was also observed, although overall, they continued to invest large amounts of funding for HIV. |
| Legitimate and credible priority-setting institutions | UAC has technical expertise and their political appointment, however, their role is sometimes undermined (UAC, 2016). |
| Incentives | None discussed |
| Prioritization process | |
| Stakeholder participation | PS is participatory and involves representatives from the districts, CSOs, FBOs, DAPs, politicians and the private sector; DAPs sometimes negatively influence the agenda; CSOs, as community representatives lack capacity to participate |
| Use of clear priority setting process/tool/method | None reported aside from BOD/CEA |
| Use of explicit/relevant priority setting criteria | Epidemiological evidence, cost-effectiveness, local context, resource availability, alignment with national priorities, alignment with international declarations, accountability, politics, equity, and value added. |
| Use of evidence | Epidemiological evidence, evidence of cost effectiveness, beneficiary assessment data |
| Reflection of public values | The public was directly involved via consultations and annual district partnership meetings |
| Publicity of priorities and criteria | Some government priorities were discussed. Rationales for prioritization inconsistently discussed |
| Functional mechanisms for appealing the decisions | None reported. Complaints channeled through the media |
| Functional mechanisms for enforcement | None reported |
| Efficiency of the priority setting process | PS process reportedly efficient; delays in implementation including slowness in procuring and releasing funds |
| Implementation | |
| Allocation of resources according to priorities | More resources allocated to curative care rather than prevention. Majority of prevention budget funded externally, however donor funds may have negatively impacted the implementation of national priorities. |
| Decreased resource wastage | Expiry of ARVs in clinics and national medical stores |
| Improved internal accountability/reduced corruption | Off-budget system makes funding difficult to track; two cases of possible corruption – the Global Fund and OPM scandals – were reported |
| Increased stakeholder understanding, satisfaction and compliance with the priority setting process | Satisfaction with identified prevention priorities and level of external funding, however, sense that DAPs did not comply with national priorities, as in the case of circumcision |
| Decreased dissentions | Dissentions over the government’s prioritization of treatment while inadequately focusing on prevention strategies and the negative impact of the HIV Prevention and Control Bill. Some members of the public disagreed with male circumcision as a prevention strategy |
| Impact and Outcomes | |
| Strengthening of the priority setting institution | ACP and UAC may have been strengthened in terms of capacity and financial resources |
| Impact on PS Institution goals and objectives | Goals of ACP and UAC to contribute to HIV control were achieved, to some extent |
| Impact on Health Policy and Practice | Some policy changes, such as the prioritization of male circumcision as a preventative strategy occurred |
| Achievement of Health System Goals |
Improvement of population health: Notable improvements, including declining transmission and increased access to ARVs Fairness in financial contribution: Although public funding for the HIV response increased during the period, out of pocket contributions were still high, especially for vulnerable groups Responding to the public’s expectations: Not reported |
| Improved financial and political accountability | Deliberate reduction in funding from donors due to issues with poor financial accountability in 2006 and 2012, as discussed above. |
| Increased investment in the health sector and strengthening of the health care system | Despite increases in funding, gaps in funding, as well as concerns about sustainability and predictability of donor spending and the impact of vertical funding on the health system were reported |