Priority setting, the distribution of resources among competing services, patients, and patient groups, remains a fundamental challenge for health system managers.

In Kenya’s county hospitals, the process of setting healthcare priorities is made especially difficult due to highly constrained budgets and unpredictable funding.

Researchers at KEMRI-Wellcome Trust have conducted qualitative case studies of two county hospitals in Coastal Kenya to describe and evaluate priority setting processes in these hospitals. The research reveals that priority setting practices in Kenyan hospital are ad hoc rather than systematic. The research also reveals that priority setting processes in Kenyan hospitals do not use explicit priority setting criteria. 

Describing the priority setting process: key findings

The budgeting and planning process in the case hospitals was not aligned

While it would be expected that hospital budgeting and planning processes are linked, in practice, there was no alignment between plans and budgets. Hospital budgets were developed every quarter, whilst annual plans were developed 3-4 months later, hence hospital budgets did not reflect the priorities included in the plans.

Use of inappropriate priority setting criteria

While some appropriate criteria such as healthcare need and affordability were used to set priorities, hospitals also used inappropriate criteria including revenue generation and lobbying to make decisions. In both hospitals, the main factor in determining allocations was the potential of departments and service areas to generate money. This behaviour was driven by hospitals’ heavy dependence on user fees, which accounted for up to 90% of their cash budgets. As a consequence, departments or patients that did not generate money, such as children under 5 who are exempt from fees, were overlooked in allocations.

Evaluating the priority setting process: key findings

To evaluate the priority setting processes in the case hospitals, the researchers used an evaluative framework that recommends that both the outcomes and processes of priority setting practices are considered (Barasa et al. 2015). The figure below outlines the components of the evaluative framework with priority setting outcomes listed in column one and processes listed in column two.

With regard to priority setting outcomes, the researchers found that priority setting decisions in Kenyan hospitals did not incorporate equity and efficiency considerations, although the use of affordability criteria could be seen as an attempt to incorporate efficiency considerations. Priority setting decisions were also found to be based on historical allocations, and hence were static rather than responsive to the changing dynamics of resource needs.

With regard to priority setting processes, the researchers found that key stakeholders were not included in hospital priority setting processes. In both hospitals clinicians and the community were not empowered to contribute to decision making, while in one hospital, only senior managers contributed to decision making. Further, hospital priority setting processes did not have a provision for a formal appeals and revisions process. This meant that decisions, once made, could not be changed even in the face of new circumstances. In both hospitals, community views were rarely incorporated in decision making. Even though channels for community inputs such as suggestion boxes and a hospital management community that comprised of community representatives existed, these avenues were found to be weak.

The need to strengthen hospital priority setting processes

Public hospitals in Kenya could improve their priority setting processes by harmonizing the budgeting and planning processes, using explicit appropriate priority-setting criteria, and incorporating both outcomes (efficiency, equity, stakeholder satisfaction and understanding, shifted priorities, implementation of decisions), and processes (stakeholder engagement and empowerment, transparency, use of evidence, revisions, enforcement, and incorporating community values) conditions. 

Dr. Edwine W. Barasa is a health economist and health systems researcher at the KEMRI-Wellcome Trust Research programme, Kenya