The results section is organized in two subsections: First we describe priority setting according to the themes that emerged from our case study: Second, we evaluate the description using the accountability for reasonableness framework.
The need for priority setting
Decisions makers in the study hospital encountered priority setting challenges everyday due to policy decisions at the national level which resulted in the hospital having a perpetual shortage of funds. For example, this financial year (2006/2007) the hospital submitted a budget estimate of 60 billion Shillings (US$ 32.4 Million), yet received Uganda shillings 25 billion (US$ 13.5 Million) which is approximately 30% of its budget estimates .
"... I think the problem is the shortage of funds from Finance...there is never enough money, so even though the directorate makes its budget, when the hospital gets it funds, there is always much less than what they require..."
According to our respondents, in previous years the hospital would spend beyond its budgetary limits and the Ministry of Finance would pay the deficits. However, in order to curb the national budget deficits, Ministry of Finance introduced budget ceilings beyond which the hospital cannot be funded; and line item financing as opposed to global funding which constrains the degree of flexibility in priority setting at the hospital management level.
Participants in priority setting
In the past, the hospital director and senior accountant submitted their budget directly to the Ministry of Finance. However, the introduction of Sector Wide Approaches (SWAP) – whereby donors support the health sector as opposed to vertical programs or institutions – has meant reduction in these direct negotiations. At the time of our study, all hospitals' budget negotiations occurred through the ministry of health.
Within the hospital, hospital managers have attempted to decentralized priority setting to directorates. However, due to various reasons (presented later in this paper) this has not been very successful and current priority setting still involves mainly the members of the senior management committee. The committee receives advice from the interim hospital board. They also receive input from the leaders of the directorates who should involve the frontline practitioners in identifying priorities within their departments. However the hospital managers felt that practitioners were reluctant to participate due to either time constraints, lack of interest, or power struggles.
"... But often you will find that it (involvement of frontline practitioners) doesn't happen like that, that's my disappointment as a manager. Because it involves letting go of power people don't want to let go, and actually even at the operational level also the head of the directorate doesn't want to let go. And at the departmental level, that head also doesn't want to let go to get his colleagues to bring their inputs."
This was corroborated by frontline practitioners who reported that they were not involved in the priority setting process. This lack of involvement contributed to their lack of knowledge of the priority setting process at the hospital management level. However, since they are daily confronted with patients and bear the direct consequences of the priority setting decisions, most of the frontline respondents thought they should be more involved in informing the hospital priority setting decisions.
Some of the departmental leaders that were involved in the process reported frustration since their concerns are often not addressed. For example, respondents from the department of pediatrics reported that they have repeatedly requested for cephalosporins – a broad-spectrum antibiotic, which is effective in treating most of the aggressive infections affecting their patients, but this has not been addressed due to lack of funds.
"...The problem is that sometimes you submit a proposal or a budget..., but not everything you have asked for are you able to get and sometimes what you have even put in the budget is not what is allocated to you. So, it can be frustrating..."
Participants reported that the public is involved through representation on the hospital board. One of the mandates of the board is to provide a link between the community and the hospital, however, since the board had not been officially instituted (at the time of the study), their effectiveness as representatives of the public could not be assessed.
What is considered?
Priority setting in the hospital occurs within the framework of the hospital strategic plan. Formally, there are pre-determined budget proportions whereby 50% of the budget is allocated to drugs, 30% to sundries, 10% to reagents and 10% to X-ray. These proportions are then further allocated according to a formula that is based on evidence and need (need was defined in terms of the number of beds per directorate, medical emergencies, and the patient load). The members of the senior hospital management team developed this formula, with input from the different departments.
However, respondents from the department of pediatrics and general medicine felt there was lack of adherence to this formula. They argued that according to the formula and the 'need' criterion, the department of pediatrics deserved to be prioritized since they receive almost 40% of the hospital emergencies. Since the department was not prioritized, these respondents thought that informal factors significantly influenced priority setting. They thought that departments whose leaders knew how to "lobby", "make noise", " quickly use up their resources", "make their case" are usually prioritized. As such, surgical departments seemed to receive disproportionately high priority.
"... You know resource allocation is political with a small " p". So sometimes you get departments or directorates which are either very vocal, and can argue their case very vehemently or very organized, in that once the money is available they know what exactly to do with it and they finish their part of the money and are ready to take the money from those who are not organized..."
"...You see, as I told you that sometimes I may be getting things because I put a little bit of pressure on people, and I only leave when I have got what I want..."
Communication of decisions
Various strategies are used to communicate priority setting decisions to staff members including meetings, circulars and an annual general meeting. The leaders of the various departments who are members of and should participate in the senior management meetings, are expected to communicate the decisions to the members of their departments. However, hospital managers doubted the effectiveness of this mode of communication, since many leaders fail to attend the meetings and those who attend did not communicate the decisions to their staff. In particular, departmental leaders with a dual role (of university professor and hospital manager) tended to value their roles and duties with the university more than their managerial roles at the hospital. This manifested as apathy in attending management meetings, with subsequent lack of understanding of the hospital planning management system, and lack of knowledge of the priority setting processes and decisions – which they should be communicating to their staff members.
The hospital management also tries to send circulars about key issues to all relevant departments. These are received and read by the frontline practitioners. However, several respondents expressed frustration since this form of communication is one way and provides no opportunity for feedback and dialogue.
The annual general meeting is convened for all the hospital staff. The hospital managers thought that this would provide an opportunity for staff and management to engage in direct dialogue over issues of interest. They, however, noted that attendance was still very disappointingly poor.
"...During the annual assembly information is given to the staff about how much money the hospital got, what the demands are, the priority areas of the hospital, this is to give them a general view. However the assemblies are very poorly attended by staff members. People don't seem to be interested..."
Mechanisms for communication of decisions and reasons to the public were less clear. The radio is occasionally used in response to crises, but it is not often used because of the costs involved. Respondents expressed mixed feelings about availing information about priority setting decisions to the public. Some respondents were weary of publicity and feared that the information, being too technical, would be misinterpreted by the public who may become more demanding. Others, however, felt that communication of decisions and reasons to the public-especially with regards to the resource constraints the hospital faces – would enable the public to have realistic expectations from the hospital and therefore deter the public from blaming the hospital management for the shortages of supplies within the hospital.
"...this information is not available to the general public. I must say that the public I think is fairly ignorant about the financial situation in the hospital. You know, there's a lot of blame placed squarely on foot of management for some of these things. But once somebody gets to what the facts on the ground are, people begin to change their perception about what they thought was a management fault..."
Dealing with disagreements
Frontline practitioners reported that they often disagreed with the priority setting decisions made at the hospital level, but were not aware of any formal mechanisms for challenging the decisions. In case of disagreements, practitioners usually write to, or verbally present their complaints to the senior management committee either directly or through the leaders of their departments. However, since they found that the management committee handled too many varying hospital related issues to address directorate specific complaints; practitioners often used the direct approach. They complained directly to the director of the hospital or his deputy who maintain an "open door" policy and could be accessed directly.
"... I actually often appeal through letters, directly to the Director, and you know, the Director then handles this on an individual basis, but I think it would be nice if there was a formal mechanism, or maybe if the formal mechanism exists, at least, for me to get to know it. I think it would improve also the running of the directorates if this actually happened on a regular basis, rather than when there was a crisis..."
Revisions of the priority setting decisions only occasionally occur, and are commonly in response to emergencies or crises. Usually this involves re-allocation of resources from one program to another, and is not popular. This lack of revision led people to question the usefulness of attending these meetings.
"...So there is that forum to which is the management committee and the all leaders of department are supposed to bring their comments.... In a way it could be like an appeal or a forum but you see what happens, if you come and complain, nothing is done, next month you come and complain... people lose morale they even cease to come. They just look at it as time wasting forum..."
Resource allocation decisions were based on a complex cluster of both formal and informal factors. The formal factors identified in this study such as the strategic plan and the hospital's management formula, have been documented in other settings . Informal factors, such as lobbying, exerting pressure on management, and reacting to crises, also played a role. Although respondents agreed on the relevance of the formal factors, there was lack of agreement about the relevance of the informal factors. Respondents who got what they wanted base on informal factors and mechanisms such as lobbying thought these should be considered relevant. This was because the director of the hospital, who makes the final priority setting decisions, maintained an open door policy, which meant that anyone who was dissatisfied with the priority setting decision had an equal opportunity to directly argue their case. However, since achieving the desired results depended on individual characteristics, such as one's ability to present a good case, those respondents who did not have the lobbying and advocacy skills felt that priority setting would be fairer if only the formal factors (and mechanisms) such as the strategic plan, evidence and need were the relevant reasons.
There were attempts to communicate the decisions but not the rationales, to the hospital staff through meetings, and circulars, but these were not functioning well. In particular there was a breech in the flow of information from the management to the rest of the hospital staff.
The hospital lacked systematic mechanisms for publicizing priority setting decisions and the rationales to the general public. Publicity to the general public was through the radio and newspapers. However, because of the costs involved, this was ad hoc and often in response to crises. Some respondents thought it would benefit the hospital if the public had access to information about priority setting.
There were no formal mechanisms for appealing the priority setting reasoning. The senior management meeting, which was thought to be the formal institution for appealing, was said to be less effective in revising the decisions once made. Some practitioners found that the informal mechanisms, such as complaining directly to the hospital director instead of going to the senior management committee, were more effective in getting them what they wanted. However, revisions to priority setting decisions was generally hampered by lack of resources and this failure to revise priority setting decisions by the management team was a source of frustration for front-line practitioners who often reacted by refusing to participate in the decision making processes. Respondents expressed the need for fair, clear, explicit, and more responsive mechanisms for appeals and revisions.
There was no mention by participants of any system to ensure that the above three conditions were satisfied. Mechanisms to ensure adherence to set criteria, follow up of the implementation of the decisions and evaluation of the impact of the decisions were also lacking.