Does the Narrative About the Use of Evidence in Priority Setting Vary Across Health Programs Within the Health Sector: A Case Study of 6 Programs in a Low-Income National Healthcare System

Background: There is a growing body of literature on evidence-informed priority setting. However, the literature on the use of evidence when setting healthcare priorities in low-income countries (LICs), tends to treat the healthcare system (HCS) as a single unit, despite the existence of multiple programs within the HCS, some of which are donor supported.

Objectives: (i) To examine how Ugandan health policy-makers define and attribute value to the different types of evidence; (ii) Based on 6 health programs (HIV, maternal, newborn and child health [MNCH], vaccines, emergencies, health systems, and non- communicable diseases [NCDs]) to discuss the policy-makers’ reported access to and use of evidence in priority setting across the 6 health programs in Uganda; and (iii) To identify the challenges related to the access to and use of evidence.

Methods: This was a qualitative study based on in-depth key informant interviews with 60 national level (working in 6 different health programs) and 27 sub-national (district) level policy-makers. Data were analysed used a modified thematic approach.

Results: While all respondents recognized and endeavored to use evidence when setting healthcare priorities across the 6 programs and in the districts; more national level respondents tended to value quantitative evidence, while more district level respondents tended to value qualitative evidence from the community. Challenges to the use of evidence included access, quality, and competing values. Respondents from highly politicized and donor supported programs such as vaccines, HIV and maternal neonatal and child health were more likely to report that they had access to, and consistently used evidence in priority setting.

Conclusion: This study highlighted differences in the perceptions, access to, and use of evidence in priority setting in the different programs within a single HCS. The strong infrastructure in place to support for the access to and use of evidence in the politicized and donor supported programs should be leveraged to support the availability and use of evidence in the relatively under-resourced programs. Further research could explore the impact of unequal availability of evidence on priority setting between health programs within the HCS.

Application of evidence-informed deliberative processes in health technology assessment in low- and middle-income countries

OBJECTIVES

Evidence-informed deliberative processes (EDPs) were introduced to guide health technology assessment (HTA) agencies to improve their processes toward more legitimate decision making. A survey among members of the International Network of Agencies for HTA (INAHTA) showed that EDPs can also be relevant for countries that have not (yet) established such an agency. Therefore, we explored to what extent low- and middle-income countries (LMIC) applied the steps and elements stipulated in the EDP framework and their need for guidance.

METHODS

The survey among INAHTA members was slightly adapted to address LMIC context and sent to 416 experts identified through several HTA sources. The questions focused on contextual factors and the EDP steps (installation of an appraisal committee, selecting technologies and criteria, assessment, appraisal, communication and appeal). Data collection took place between 21 May and 1 September 2019. Descriptive statistics and qualitative analyses were used to summarize the findings.

RESULTS

We received sixty-six meaningful responses from experts in thirty-two LMIC. We found that contextual factors to support HTA development are overall not present or only present to some extent. Respondents indicated that guidance was needed for specific elements related to selecting technologies and criteria, assessment, appraisal, as well as communication and appeal.

CONCLUSIONS

EDPs have the potential to provide steps for improving HTA processes. The results of this study can serve as a baseline measurement for future monitoring and evaluation of EDP application in the responding LMIC. This could support the countries in improving their processes and enhancing legitimate decision making when using HTA.

Priority setting for health system strengthening in low income countries. A qualitative case study illustrating the complexities

Health systems are critical to the realisation of Universal Health Coverage. There has been insufficient attention to the evaluation of priority setting for health system strengthening within low income countries, including evaluation of the local capacity to implement priorities. This study evaluated the extent to which health system strengthening was prioritized in Uganda. The Kapiriri & Martin framework was used to evaluate health system priority setting from 2005-2015. A document analysis was triangulated with interview data (n = 67) from global, national and subnational stakeholders and analysed using content analysis. Health system strengthening was perceived to be circumvented by a lack of resources as well as influential actors with disease focused, rather than system-oriented, interests. There were defined processes with explicit criteria for identifying priorities and evidence was highly valued. But sub-optimal transparency and weak accountability often compromised the integrity of priority setting and contributed to stalling progress on health system strengthening and achieving health system outcomes. The strengths in the current planning processes should be harnessed. In addition, a systematic approach to priority setting, potentially through the establishment of an independent body, and stronger oversight mechanisms, would strengthen health system planning in this setting.

Who is in and who is out? A qualitative analysis of stakeholder participation in priority setting for health in three districts in Uganda

Stakeholder participation is relevant in strengthening priority setting processes for health worldwide, since it allows for inclusion of alternative perspectives and values that can enhance the fairness, legitimacy and acceptability of decisions. Low-income countries operating within decentralized systems recognize the role played by sub-national administrative levels (such as districts) in healthcare priority setting. In Uganda, decentralization is a vehicle for facilitating stakeholder participation. Our objective was to examine district-level decision-makers' perspectives on the participation of different stakeholders, including challenges related to their participation. We further sought to understand the leverages that allow these stakeholders to influence priority setting processes. We used an interpretive description methodology involving qualitative interviews. A total of 27 district-level decision-makers from three districts in Uganda were interviewed. Respondents identified the following stakeholder groups: politicians, technical experts, donors, non-governmental organizations (NGO)/civil society organizations (CSO), cultural and traditional leaders, and the public. Politicians, technical experts and donors are the principal contributors to district-level priority setting and the public is largely excluded. The main leverages for politicians were control over the district budget and support of their electorate. Expertise was a cross-cutting leverage for technical experts, donors and NGO/CSOs, while financial and technical resources were leverages for donors and NGO/CSOs. Cultural and traditional leaders' leverages were cultural knowledge and influence over their followers. The public's leverage was indirect and exerted through electoral power. Respondents made no mention of participation for vulnerable groups. The public, particularly vulnerable groups, are left out of the priority setting process for health at the district. Conflicting priorities, interests and values are the main challenges facing stakeholders engaged in district-level priority setting. Our findings have important implications for understanding how different stakeholder groups shape the prioritization process and whether representation can be an effective mechanism for participation in health-system priority setting.

Applying priority-setting frameworks: A review of public and vulnerable populations' participation in health-system priority setting

BACKGROUND

There is a growing body of literature that describes, applies, and evaluates applications of health-system priority-setting frameworks in different contexts. However, little explicit focus has been given to examining operationalization of the stakeholder participation component of these frameworks. The literature identifies the public as a stakeholder group and recommends their participation when applying the frameworks.

METHODS

We conducted a scoping review to search the PubMed, EMBASE, HealthSTAR, Medline, and PsycINFO databases for cases where priority-setting frameworks were applied (2000-2017). We aimed to synthesize current literature to examine the degree to which the public and vulnerable populations have been engaged through applications of these frameworks FINDINGS: The following stakeholders commonly participated: managers, administrators/coordinators, clinicians/physicians, non-physician health care providers, health economists, academics/researchers, experts, decision-makers, and policy-makers. Few papers reported on public participation, and even fewer identified vulnerable groups that participate. Stakeholders were most commonly reported to participate in identifying areas for prioritization.

CONCLUSIONS

While the frameworks were developed with stakeholder participation in mind, in practice not all stakeholders are participating in priority-setting processes as envisioned by the frameworks. The public and vulnerable groups do not consistently participate, challenging the utility of the participation component of frameworks in guiding stakeholder participation in health-system priority setting. Frameworks can be more explicit about which stakeholders should participate and detailing how their participation should be operationalized.

Priority setting for maternal, newborn and child health in Uganda: a qualitative study evaluating actual practice

Background

Despite continued investment, Maternal, Newborn and Child Health (MNCH) indicators in low and middle income countries have remained relatively poor. This could, in part, be explained by inadequate resources to adequately address these problems, inappropriate allocation of the available resources, or lack of implementation of the most effective interventions. Systematic priority setting and resource allocation could contribute to alleviating these limitations. There is a paucity of literature that follows through MNCH prioritization processes to implementation, making it difficult for policy makers to understand the impact of their decision-making on population health. The overall objective of this paper was to describe and evaluate priority setting for maternal, newborn and child health interventions in Uganda.

Methods

Fifty-four key informant interviews and a review of policies and media reports were used to describe priority setting for MNCH in Uganda. Kapiriri and Martin’s conceptual framework was used to evaluate priority setting for MNCH.

Results

There were three main prioritization exercises for maternal, newborn and child health in Uganda. The processes were participatory and were guided by explicit tools, evidence, and criteria, however, the public and the districts were insufficiently involved in the priority setting process. While there were conducive contextual factors including strong political support, implementation was constrained by the presence of competing actors, with varying priorities, an unequal allocation of resources between child health and maternal health interventions, limited financial and human resources, a weak health system and limited institutional capacity.

Conclusions

Stronger institutional capacity at the Ministry of Health and equitable engagement of key stakeholders in decision-making processes, especially the public, and implementers, would improve understanding, satisfaction and compliance with the priority setting process. Availability of financial and human resources that are appropriately allocated would facilitate the implementation of well-developed policies.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4170-6) contains supplementary material, which is available to authorized users.

Beyond cost-effectiveness, morbidity and mortality: a comprehensive evaluation of priority setting for HIV programming in Uganda

BACKGROUND

While there has been progress in controlling the HIV epidemic, HIV still remains a disease of global concern. Some of the progress has been attributed to increased public awareness and uptake of public health interventions, as well as increased access to anti- retroviral treatment and the prevention of vertical HIV transmission. These interventions would not have been possible without substantial investments in HIV programs. However, donor fatigue introduces the need for low income countries to maximize the benefits of the available resources. This necessitates identification of priorities that should be funded. Evaluating prioritization processes would enable decision makers to assess the effectiveness of their processes, thereby designing intervention strategies. To date most evaluations have focused on cost-benefit analyses, which overlooks additional critical impacts of priority setting decisions. Kapiriri & Martin (2010) developed and validated a comprehensive framework for evaluating PS in low income countries. The objective of this paper report findings from a comprehensive evaluation of priority setting for HIV in Uganda, using the framework; and to identify lessons of good practice and areas for improvement.

METHODS

This was a qualitative study based on forty interviews with decision makers and policy document review. Data were analysed using INVIVO 10, and based on the parameters in Kapiriri et al's evaluation framework.

RESULTS

We found that HIV enjoys political support, which contributes to the availability of resources, strong planning institutions, and participatory prioritization process based on some criteria. Some of the identified limitations included; undue donor and political influence, priorities not being publicized, and lack of mechanisms for appealing the decisions. HIV prioritization had both positive and negative impacts on the health system.

CONCLUSIONS

The framework facilitated a more comprehensive evaluation of HIV priority setting. While there were successful areas, the process could be strengthened by minimizing undue influence of external actors, and support the legitimate institutions to set priorities and implement them. These should also institute mechanisms for publicizing the decisions, appeals and increased accountability. While this paper looked at HIV, the framework is flexible enough to be used in evaluating priority setting for other health programs within similar context.

Evaluating health research priority-setting in low-income countries: a case study of health research priority-setting in Zambia

Priority-setting (PS) for health research presents an opportunity for the relevant stakeholders to identify and create a list of priorities that reflects the country's knowledge needs. Zambia has conducted several health research prioritisation exercises that have never been evaluated. Evaluation would facilitate gleaning of lessons of good practices that can be shared as well as the identification of areas of improvement. This paper describes and evaluates health research PS in Zambia from the perspectives of key stakeholders using an internationally validated evaluation framework.

METHODS

This was a qualitative study based on 28 in-depth interviews with stakeholders who had participated in the PS exercises. An interview guide was employed. Data were analysed using NVIVO 10. Emerging themes were, in turn, compared to the framework parameters.

RESULTS

Respondents reported that, while the Zambian political, economic, social and cultural context was conducive, there was a lack of co-ordination of funding sources, partners and research priorities. Although participatory, the process lacked community involvement, dissemination strategies and appeals mechanisms. Limited funding hampered implementation, monitoring and evaluation. Research was largely driven by the research funders.

CONCLUSIONS

Although there is apparent commitment to health research in Zambia, health research PS is limited by lack of funding, and consistently used explicit and fair processes. The designated national research organisation and the availability of tools that have been validated and pilot tested within Zambia provide an opportunity for focused capacity strengthening for systematic prioritisation, monitoring and evaluation. The utility of the evaluation framework in Zambia could indicate potential usefulness in similar low-income countries.

Stakeholder involvement in health research priority setting in low income countries: the case of Zambia

SUMMARY

While there is increasing recognition of the importance of stakeholder involvement in health research priority setting there is a paucity of literature reporting on stakeholder involvement in health research priority setting in low income countries. This paper fills this gap by identifying and discussing the roles and legitimacy of different stakeholders (including the public and patients) involved in the health research priority setting process in Zambia; identifying the barriers to public participation and proposing improvement strategies.We interviewed 28 policy makers and practitioners who had participated in the national level health research priority setting in Zambia. Reported participants in health research priority setting included research users, researchers, research funders and the community/ public. Research funders were thought to have undue influence while the public and patients were not effectively involved. This could be due to the public's lack of education, lack of resources to facilitate public involvement and limited skills to meaningfully engage the public. Participation of people from rural areas, women and young professionals was also limited.While there is a commitment to broad stakeholder involvement in health research priority setting, there's limited public/patient involvement. Public education, availing more resources, and skills to meaningfully engage the public need to be explored. The undue influence of research funders should be mitigated and incentives availed to ensure that they align their research funding with the national priorities. These efforts would strengthen meaningful stakeholder engagement in health research prioritization within Zambia and other similar contexts.

ABSTRACT

Background Stakeholder involvement in health research priority setting contributes to the legitimacy and acceptability of the priorities. Hence legitimate priority setting should involve a broad representation of stakeholders including the public. While there is a growing body of literature on health research prioritization in low income countries, there is a paucity of literature reporting on stakeholder involvement in the process. The objectives of this paper are to; 1) identify the stakeholders who were involved in the health research priority setting process in Zambia; 2) discuss the roles and perceived legitimacy of the stakeholders and analyze the degree to which patients/ public was involved; 3) To discuss some of the barriers to stakeholder participation in Zambia and similar contexts and to propose improvement strategies.Methods This was a qualitative study involving 28 in-depth interviews with stakeholders who had participated in the national level health research priority setting exercises in Zambia. An interview guide was used. Audio recorded interviews were transcribed and analyzed using INVIVO 10. Analysis of the Stakeholders' theme involved identifying the different dimensions of stakeholder involvement as discussed in the interviews.Results Identified stakeholders included; research users, researchers, research funders and the community/ public. We found that health research priority setting involved research users, researchers, research funders and the community/ public. However, research funders were thought to have undue influence while the public and patients were not effectively involved. While the respondents recognized the advantages of involving the public and patients, they were not effectively involved. This could be due to the public's limited understanding of the technicalities of priority setting, lack of resources to facilitate public involvement and limited skills to meaningfully engage the public. Participation from rural areas, women, and young professionals was also limited.Conclusions While there is a commitment to broad stakeholder involvement in health research priority setting, the public is left out. Efforts such as public education, availing more resources, and skills to meaningfully engage the public need to be explored. The undue influence of research funders should be mitigated through their direct involvement in the prioritization process and incentives to ensure that they align their research funding with the national priorities. These efforts would strengthen meaningful stakeholder engagement in health research prioritization within Zambia and other similar contexts.

The Politics of Disease Epidemics: a Comparative Analysis of the SARS, Zika, and Ebola Outbreaks

Over the past few decades, disease outbreaks have become increasingly frequent and widespread. The epicenters of these outbreaks have differed, and could be linked to different economic contexts. Arguably, the responses to these outbreaks have been "political" and inherently burdensome to marginalized populations. Key lessons can be learned from exploring the narratives about the different epidemics in varying income settings. Based on a review of the published medical, social, and political literature, which was accessed using four electronic databases-PubMed, Sociological Abstracts, Scholars Portal, and Web of Science, the overall objective of this paper discuss scholars' narratives on the "politics" of Ebola in a low-income setting, Zika virus in a middle-income setting, and SARS in a high-income setting. Various themes of the politics of epidemics were prominent in the literature. The narratives demonstrated the influence of power in whose narratives and what narratives are presented in the literature. While marginalized populations were reported to have borne the brunt of all disease outbreaks in the different contexts, the prevalence of their narratives within the reviewed literature was limited. Regardless of income setting, there is a need to give voice to the most marginalized communities during an epidemic. The experiences and narratives of those most vulnerable to an epidemic-specifically poor communities-need to be represented in the literature. This could contribute to mitigating some of the negative impact of the politics in epidemics.

Priority setting for disease outbreaks in Uganda: A case study evaluating the process

Priority setting (PS) and resource allocation during health emergencies are key factors influencing an effective response. However, there is limited understanding of how priorities and resource allocation during disease outbreaks occur and the extent to which these processes are successful. This paper, based on 23 in-depth interviews with policy makers and a review of policy and emergency preparedness documents, used a PS evaluation framework to evaluate PS for disease outbreaks in Uganda. With regard to PS for disease outbreaks in Uganda, we identified a conducive socio-political-economical context, credible institutions, formal participatory prioritisation processes, evidence informed the processes, demonstrated implementation capacity, institutional strengthening and positive health outcomes. Factors that compromised the success of PS included limited resources - especially in between disease outbreaks and unfair processes. Investment in sustaining the established prioritisation infrastructure to oversee preparedness activities between the outbreaks would strengthen the prioritisation process. This should be supported with health system strengthening. The framework enabled us to evaluate some aspects of PS during disease outbreaks. The framework's inability to evaluate all aspects, and reported as opposed to actual PS calls for the integration of evaluation throughout the planning and implementation process to ensure validity and continuous implementation of improvement strategies.

Past, present and future challenges in health care priority setting

Purpose Current conditions have intensified the need for health systems to engage in the difficult task of priority setting. As the search for a "magic bullet" is replaced by an appreciation for the interplay between evidence, interests, culture, and outcomes, progress in relation to these dimensions requires assessment of achievements to date and identification of areas where knowledge and practice require attention most urgently. The paper aims to discuss these issues. Design/methodology/approach An international survey was administered to experts in the area of priority setting. The survey consisted of open-ended questions focusing on notable achievements, policy and practice challenges, and areas for future research in the discipline of priority setting. It was administered online between February and March of 2015. Findings "Decision-making frameworks" and "Engagement" were the two most frequently mentioned notable achievements. "Priority setting in practice" and "Awareness and education" were the two most frequently mentioned policy and practical challenges. "Priority setting in practice" and "Engagement" were the two most frequently mentioned areas in need of future research. Research limitations/implications Sampling bias toward more developed countries. Future study could use findings to create a more concise version to distribute more broadly. Practical implications Globally, these findings could be used as a platform for discussion and decision making related to policy, practice, and research in this area. Originality/value Whilst this study reaffirmed the continued importance of many longstanding themes in the priority setting literature, it is possible to also discern clear shifts in emphasis as the discipline progresses in response to new challenges.

The unfunded priorities: an evaluation of priority setting for noncommunicable disease control in Uganda

BACKGROUND

The double burden of infectious diseases coupled with noncommunicable diseases poses unique challenges for priority setting and for achieving equitable action to address the major causes of disease burden in health systems already impacted by limited resources. Noncommunicable disease control is an important global health and development priority. However, there are challenges for translating this global priority into local priorities and action. The aim of this study was to evaluate the influence of national, sub-national and global factors on priority setting for noncommunicable disease control in Uganda and examine the extent to which priority setting was successful.

METHODS

A mixed methods design that used the Kapiriri & Martin framework for evaluating priority setting in low income countries. The evaluation period was 2005-2015. Data collection included a document review (policy documents (n = 19); meeting minutes (n = 28)), media analysis (n = 114) and stakeholder interviews (n = 9). Data were analysed according to the Kapiriri & Martin (2010) framework.

RESULTS

Priority setting for noncommunicable diseases was not entirely fair nor successful. While there were explicit processes that incorporated relevant criteria, evidence and wide stakeholder involvement, these criteria were not used systematically or consistently in the contemplation of noncommunicable diseases. There were insufficient resources for noncommunicable diseases, despite being a priority area. There were weaknesses in the priority setting institutions, and insufficient mechanisms to ensure accountability for decision-making. Priority setting was influenced by the priorities of major stakeholders (i.e. development assistance partners) which were not always aligned with national priorities. There were major delays in the implementation of noncommunicable disease-related priorities and in many cases, a failure to implement.

CONCLUSIONS

This evaluation revealed the challenges that low income countries are grappling with in prioritizing noncommunicable diseases in the context of a double disease burden with limited resources. Strengthening local capacity for priority setting would help to support the development of sustainable and implementable noncommunicable disease-related priorities. Global support (i.e. aid) to low income countries for noncommunicable diseases must also catch up to align with NCDs as a global health priority.

The quest for a framework for sustainable and institutionalised priority-setting for health research in a low-resource setting: the case of Zambia

Background

Priority-setting for health research in low-income countries remains a major challenge. While there have been efforts to systematise and improve the processes, most of the initiatives have ended up being a one-off exercise and are yet to be institutionalised. This could, in part, be attributed to the limited capacity for the priority-setting institutions to identify and fund their own research priorities, since most of the priority-setting initiatives are driven by experts. This paper reports findings from a pilot project whose aim was to develop a systematic process to identify components of a locally desirable and feasible health research priority-setting approach and to contribute to capacity strengthening for the Zambia National Health Research Authority.

Methods

Synthesis of the current literature on the approaches to health research prioritisations. The results of the synthesis were presented and discussed with a sample of Zambian researchers and decision-makers who are involved in health research priority-setting. The ultimate aim was for them to explore the different approaches available for guiding health research priority-setting and to identify an approach that would be relevant and feasible to implement and sustain within the Zambian context.

Results

Based on the evidence that was presented, the participants were unable to identify one approach that met the criteria. They identified attributes from the different approaches that they thought would be most appropriate and proposed a process that they deemed feasible within the Zambian context.

Conclusion

While it is easier to implement prioritisation based on one approach that the initiator might be interested in, researchers interested in capacity-building for health research priority-setting organisations should expose the low-income country participants to all approaches. Researchers ought to be aware that sometimes one shoe may not fit all, as in the case of Zambia, instead of choosing one approach, the stakeholders may select desirable attributes from the different approaches and piece together an approach that would be feasible and acceptable within their context. An approach that builds on the decision-makers’ understanding of their contexts and their input to its development would foster local ownership and has a greater potential for sustainability.

Electronic supplementary material

The online version of this article (10.1186/s12961-017-0268-7) contains supplementary material, which is available to authorized users.

International validation of quality indicators for evaluating priority setting in low income countries: process and key lessons

Background

While there have been efforts to develop frameworks to guide healthcare priority setting; there has been limited focus on evaluation frameworks. Moreover, while the few frameworks identify quality indicators for successful priority setting, they do not provide the users with strategies to verify these indicators. Kapiriri and Martin (Health Care Anal 18:129-147, 2010) developed a framework for evaluating priority setting in low and middle income countries. This framework provides BOTH parameters for successful priority setting and proposes means of their verification. Before its use in real life contexts, this paper presents results from a validation process of the framework.

Methods

The framework validation involved 53 policy makers and priority setting researchers at the global, national and sub-national levels (in Uganda). They were requested to indicate the relative importance of the proposed parameters as well as the feasibility of obtaining the related information. We also pilot tested the proposed means of verification.

Results

Almost all the respondents evaluated all the parameters, including the contextual factors, as ‘very important’. However, some respondents at the global level thought ‘presence of incentives to comply’, ‘reduced disagreements’, ‘increased public understanding,’ ‘improved institutional accountability’ and ‘meeting the ministry of health objectives’, which could be a reflection of their levels of decision making. All the proposed means of verification were assessed as feasible with the exception of meeting observations which would require an insider. These findings results were consistent with those obtained from the pilot testing.

Conclusions

These findings are relevant to policy makers and researchers involved in priority setting in low and middle income countries. To the best of our knowledge, this is one of the few initiatives that has involved potential users of a framework (at the global and in a Low Income Country) in its validation. The favorable validation of all the parameters at the national and sub-national levels implies that the framework has potential usefulness at those levels, as is. The parameters that were disputed at the global level necessitate further discussion when using the framework at that level. The next step is to use the validated framework in evaluating actual priority setting at the different levels.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2360-7) contains supplementary material, which is available to authorized users.

How acceptable is it for HIV positive African, Caribbean and Black women to provide breast milk/fluid samples for research purposes?

Background

The African, Caribbean and Black communities have been found to be reluctant to participate in health research in North America. This is partly attributed to historical experiences as well as their cultural beliefs. Cultural beliefs about the uses of breast milk/fluids could further hinder the participation of African, Caribbean, and Black communities in research involving the collection of breast milk/fluids samples.

Methods

We conducted 17 in-depth interviews and three group interviews (n = 10) with HIV+ African, Caribbean and Black women living in Ontario, Canada to explore their cultural beliefs about breast milk/fluids and their acceptance of participating in research that involves the provision of breast fluid samples.

Study design

Qualitative study involving in-depth interviews.

Results

Our respondents believed that breast milk/fluids should be used for infant feeding and for curative purposes for a variety of children’s health ailments as well as ailments experienced by other family members. The cultural belief that breast milk/fluids could be used to bewitch the baby and mother and the perception that it is intrusive (equating breast milk/fluids research to DNA testing), could prevent African, Caribbean and Black women from participating in research involving the collection of breast milk/fluids. Despite these fears, some respondents expressed that they would participate if the research results would benefit them directly, for example, by finding a cure for HIV, enabling HIV+ mothers to breastfeed, or contributing to developing new drugs or vaccines for HIV. Women’s recommendations to facilitate successful recruitment included giving incentives to participants, and employing a recruiter who was trustworthy, informed, and culturally sensitive.

Conclusion

Cultural beliefs could present barriers to recruitment and participation of Africa, Caribbean and Black communities in health research involving breast milk/fluid samples. Successful recruitment for future studies would necessitate researchers to be culturally aware of the beliefs held by African, Caribbean and Black women, to build trust, and use an appropriate recruiter. While the findings relate to breast milk/fluids, the suggested recommendations for facilitating recruitment of research participants from these communities may be useful to consider when recruiting ethnically and culturally similar participants for research involving biological samples.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-016-2326-6) contains supplementary material, which is available to authorized users.

Three Case Studies in Making Fair Choices on the Path to Universal Health Coverage

The goal of achieving Universal Health Coverage (UHC) can generally be realized only in stages. Moreover, resource, capacity, and political constraints mean governments often face difficult trade-offs on the path to UHC. In a 2014 report, Making fair choices on the path to UHC, the WHO Consultative Group on Equity and Universal Health Coverage articulated principles for making such trade-offs in an equitable manner. We present three case studies which illustrate how these principles can guide practical decision-making. These case studies show how progressive realization of the right to health can be effectively guided by priority-setting principles, including generating the greatest total health gain, priority for those who are worse off in a number of dimensions (including health, access to health services, and social and economic status), and financial risk protection. They also demonstrate the value of a fair and accountable process of priority setting.

Health research priority setting in Zambia: a stock taking of approaches conducted from 1998 to 2015

Background

Priority setting in health research is an emerging field. In Zambia, like many other African countries, various priority setting activities have been undertaken with a view to identify research activities to which the available resources can be targeted while at the same time maximising the health impact for resource allocation to support evidence-based decision-making. The aim of this paper is to document the key elements of the various priority setting activities that have been conducted since 1998, identifying the key lessons and providing recommendations to improve the process.

Methods

A comprehensive review of the previous priority setting activities and processes in Zambia was conducted. Both published and unpublished reports were reviewed in order to identify any research priority setting processes that have been undertaken in Zambia. We developed a framework, based on the priority setting literature, to guide our abstraction and synthesis of the literature.

Result

The earliest record of priority setting was conducted in 1998. Various priority setting approaches have been implemented in Zambia; ranging from externally driven, once-off activities to locally (in country) initiated comprehensive processes. However, there has been no systematic national process for priority setting. These priority setting processes in Zambia were characterised by limited stakeholder buy-in of the resulting national research or programmatic research agenda. Most striking was the lack of linkages between the different initiatives. There seems to have been no conscious recognition and building on previous priority-setting experiences of previous initiatives.

Conclusion

There were gaps in the priority setting processes, stakeholder engagement and application of a defined criterion. There is a need for a priority setting framework coupled with local capacity developed across a range of stakeholders.

Bedside Rationing by Health Practitioners: A Case Study in a Ugandan Hospital

Purpose. The purpose of this study was to describe bedside rationing by health practitioners in a teaching hospital in Uganda.

Methods. This was a case study involving in-depth interviews. A modified thematic approach was used in data analysis. Types of decisions, the decision-making process, key players, and hospital-, medical-, and patient-related considerations in the process were identified. Klein’s 6 forms of rationing were used to identify the forms of rationing used. The setting was a tertiary hospital in Uganda. Theoretical sampling was used to identify 40 doctors and 16 nurses from the Departments of Medicine, Surgery, Paediatrics, and Obstetric and Gynaecology.

Results. Four types of bedside rationing decisions were identified: 1) which patients are seen first, 2) which treatment the patients receive, 3) which patients are admitted, and 4) which patients are taken to the operating theatre first. Hospital-related considerations regarding bedside rationing included the hospital budget and number of beds; medical-related considerations included the patient’s diagnosis and effectiveness of treatment; and patient-related considerations included poverty, social status, and age. All forms of rationing (denial, dilution, deflection, deterrence, delay, and termination) were practiced.

Conclusion. Although bedside rationing decisions in the study hospital seem somewhat similar to that in developed countries, the rationing of 1st-line drugs by health practitioners in Uganda is complex, difficult, and different from what has been described in industrialized countries. The complexity and severity of the consequences of the bedside decisions necessitate the development of resource-sensitive clinical guidelines and transparent decision-making processes to foster patients’ understanding of the reasons and the procedures and to ensure fair decision-making processes.

' … They should understand why … ' The knowledge, attitudes and impact of the HIV criminalisation law on a sample of HIV+ women living in Ontario

Over 60 countries criminalise 'the "willful" transmission of HIV'. Such a law has the potential to hinder public health interventions. There is limited literature discussing the perceptions of this law and the impact, it has had on HIV-positive women. This paper describes the knowledge of and attitudes of this law by HIV-positive women living in Ontario; and their experiences with its application. Three group discussions (n = 10) and 17 in-depth interviews with HIV-positive women age: 21-56 years. Data were analysed using a modified thematic approach. Most of the respondents knew about the law with regard to adult HIV transmission. However, very few knew about any laws related to mother to child HIV transmission, although some reported having had their children taken away because of breastfeeding. Respondents felt that the law could be fair and protective if there were means of providing a priori support to those women who have been disadvantaged social-culturally and structurally. Without this support, the law could potentially lead HIV-positive women into hiding and not accessing services that could help them. There is need for the law implementers to consider these findings if they are to support the public health efforts to control HIV.

The experiences of making infant feeding choices by African, Caribbean and Black HIV-positive mothers in Ontario, Canada

Mothers in HIV-endemic countries are advised to exclusively breastfeed their babies until six months because of lack of resources and better chances for child survival, while in developed countries, replacement feeding is advised. What are the experiences of HIV-positive women who migrate from HIV-endemic countries to developed countries, when making infant feeding choices?

METHODS

In-depth interviews and focus group discussions with a total of 25 women living with HIV in Toronto and Hamilton, Ontario.

RESULTS

Free infant formula alleviates the practical constraints in making infant feeding choices. However, cultural beliefs and social expectations constrain HIV-positive mothers' decision not to breastfeed. This is further complicated by the different policies. Service providers should understand the psychological and emotional experiences of the mothers in order to provide the appropriate support. Peers could be potential sources of support. The differences in policies are issues of global justice that need to be addressed.