Interviewee

Dr Lydia Kapiriri, Research Co-ordinator, Global Priority Setting Research Network, Joint Centre for Bioethics, University of Toronto, Toronto Canada

Article

Kapiriri, L., & Martin, K. (2006) Priority setting in developing countries health care institutions: the case of a Ugandan hospital. BMC Health Services Research, 6:127

Summary

Hamish Holewa talks with Dr Lydia Kapiriri about her research on priority setting in developing country health care institutions, which was conducted within a Ugandan hospital. Lydia talks about the varied ethical and priority setting concepts documented by the study and how the findings of this research can be translated into practice.

Transcript

Hamish Holewa: Hi and welcome to IPP-SHR Podcasts, I’m Hamish Holewa and today I’m speaking with Dr. Lydia Kapiriri from The Joint Center of Bioethics, University of Toronto, Canada. Lydia has just recently published an article in the BMC Health Service Research titled, ‘Priority Setting in Developing Countries’ Healthcare Institutions: The Case of a Ugandan Hospital’, which she co-authored with Dr. Douglas Martin. Right Lydia, thanks for speaking with us today. Your article explains a process of priority setting in the Ugandan hospital, do you want to talk about what that process actually is? Lydia Kapiriri: What we wanted to describe was what really goes on so we sought to describe the state of priority setting in that hospital. In our interviews, what we asked people was really to tell us their experience of priority setting. So we probed for who is involved in the priority setting process, we looked specifically for both health manager, practitioner, but also members of the public because we think that members of the public are legitimate stakeholders who should have a say in the decisions that are made in the hospital. The other thing that we were addressing was, we were asking our respondents to describe with regards to the priority setting process, is what is considered and with this we wanted to get an understanding of what are the reasons behind the decisions. So we got the criteria that was used, they told us things about the hospital formula, they told us the fact that emergencies are considered over programs which are not dealing with emergencies. Interestingly, they told us that surgical disciplines are prioritized over non-surgical disciplines. They told us that programs that attend to very many patients, that receive very many patients are prioritized over programs that – departments that don’t attend to so many patients. However, this was refuted by the department of pediatrics because they were complaining and saying that that criteria exists on paper but actually practiced, which was very interesting because the managers would tell us what is in the political planning, what is in the strategic plan but when we talked to the practitioners they would tell us how they experience of the implementation of the strategic plan. And then the other thing that we probed for in the description of the priority setting process was, what happens if someone does not agree with a decision and this kind of reflects the appeals condition in the framework that we used in that there should be mechanisms for revisiting decisions that are made, especially if there is credible evidence to force people to look at decisions in a different way. And it was interesting that the informal mechanisms seemed like they got results as opposed to the formal mechanisms. So the interplay was very interesting. Hamish Holewa: Also in your article you talk about the framework for analyzing priority setting using the ethical notion of accountability of reasonableness. Do you want to explain what that concept is for our listeners? Lydia Kapiriri: [Norman Daniel’s] Accountability for reasonableness says that instead of focusing on explicit criteria it may be better to focus on the priority setting process in that if the priority setting process is fair then eventually the priority setting decisions will be fair. There are four conditions and they include relevance, whereby he says that the rationale for priority setting decisions should rest on reason, that stakeholders in the priority setting process agree a reasonable. The other condition that the framework talks about is the condition of publicity, where he says that in fairness, justice does not dwell behind closed doors. And for us, when we’re operationalising this in our study we thought that yes, many times people print out very technical information and they throw it out there for the public to see and of course, yes it’s out there but it’s really not accessible because the public can not understand it and they cannot engage with discussing that information which is so abstract. The other condition is revision or appeal, where he says that there should be mechanisms for challenging decisions that are made. If someone feels that the decision is not fair and they have corresponding evidence to show that actually a decision is not fair there should be mechanisms for that person to appeal a decision and there should also be possibilities for revising that decision. And of course the last condition he talks about is enforcement, whereby he says there should be either a voluntary external or internal public regulatory process where the first three conditions of relevance, publicity and revision are met and I think this is just a caveat to make sure because if you just throw out those conditions and there are no mechanisms making sure people are actually accountable to fulfill those conditions then nothing will happen. Hamish Holewa: And has this ethical framework of accountability of reasonableness for priority setting been translated into practice at the hospital? Lydia Kapiriri: I wouldn’t say it has been but we are working on it. I presented them with the four conditions of accountability for reasonableness and explained it to them and asked them, how does this resonate with you, you think this is something that can work. They said, you know what, it’s something that we need. For various reasons, they were saying they were struggling so much with allocation resources, there is lack of transparency and they lack processes to ensure that there is transparency and there is accountability. Of course I want to go back to the hospital and sit with the managers and try to work with them and see that we apply some of these principles in the decision making. Hamish Holewa: Sure and did the process of qualitative research provide a catalyst for reflection there? Lydia Kapiriri: Yes it was. For example when I was talking to the clinicians especially. So I talked to both health manager, heads of departments and clinicians who make decisions at the bedside. As we were talking they were like, no-one has ever asked me how I decide what patients to see first. No-one has ever asked me how I decide which patient to give the meager resources, the few drugs that I have. The managers read memos and they post them on bulletins in the ward. Clinicians don’t read bulletins so they really don’t have access to the decisions. Clinicians don’t attend meetings and there was a discordance between the reasons why clinicians didn’t attend meetings. The managers thought the clinicians were not interested and they did not have time but the clinicians said no, we are interested, actually we have important information that would help the managers make their decisions because we work with the patients but they don’t talk to us. They go there and present their needs and present their disagreements but because the hospital hands are tied they don’t have the resources to respond to the needs. The practitioners get frustrated so they feel like it is a waste of their time to go and attend meetings where they complain and so there was kind of a lack of communication between the two because when I was talking to the practitioners and I was telling them that actually the managers hands are tied because there is no budget, the hospital budget has been cut. So there was really kind of - it was an educational process. Hamish Holewa: Well I know that your study is not just limited to Uganda and hopefully we’ll get a chance to explore those similarities and differences between countries in another podcast but for now, thanks for speaking with us and we hope to talk to you soon. Lydia Kapiriri: Thank-you too.