Priority-setting of health interventions is one of the most challenging and difficult issues faced by health policy decision-makers around the world. It is a process that is inevitably value-laden and political (Ham 1997; Klein 1998; Buse 1999; Bryant 2000; Goddard et al. 2006), requiring credible evidence, strong and legitimate institutions and fair processes (Daniels & Sabin 1997; Klein & Williams 2000; Cappenlen & Norheim 2006; Norheim 2008).
Priority-setting is especially important in developing countries, where resources are limited and government expenditures on health are less than US$20 per capita per year (World Health Organization 2008). As Kapiriri and Martin (2007) argue, this is further complicated by: (i) the burden of underdevelopment in these countries which increases the gap between the health needs and resources available to respond to them; (ii) the many uncertainties in priority-setting because of lack of dependable information; (iii) the multiple players with various agendas; (iv) few systematic processes for decision-making; and (v) many obstacles to implementation such as political instability, inadequately developed social sectors, weak institutions and marked social inequalities, which make the implementation of systematic priority-setting processes difficult (Bryant 2000). As a result, priority-setting in developing countries is often ad hoc or history-based (Baltussen & Niessen 2006; Kapiriri & Martin 2007).
There have been a number of international efforts to promote rational priority-setting by addressing the information gaps, such as studies on burden of disease (BoD) (Lopez et al. 2006) and cost-effectiveness analysis (CEA) (Jamison et al. 1993;Evans et al. 2005). Many such studies have also been carried out at the national level, e.g. in Mexico, India, and a set of east and northern African countries (Baltussen et al. 2005). Although these initiatives may have improved the evidence-base for priority-setting, it was also observed that the resulting information is only input to complex process of priority-setting and that ‘simple technical solutions’ are insufficient (Naylor 1995; Holm 2000; Haudemaekers & Dekkers 2003; Benatar 2003; Evans et al. 2005; Teerawattananon et al. 2007).
In response to this, a growing number of empirical studies have explored more comprehensive approaches to priority-setting in developing countries in the past decade. For example, researchers have tested different strategies to involve all relevant stakeholders in the priority-setting process (Makundi et al. 2007), or to identify the relative importance of CEA and severity of disease as criteria for priority-setting (Kapiriri et al. 2004). While these studies provide valuable information with potential benefit to policy-makers and researchers, a review is lacking and the options and limitations of the various approaches are difficult to assess.
We reviewed empirical studies on priority-setting of health interventions in developing countries, classified their methodological approaches and defined methodological suggestions for future studies. Thus we aimed at stimulating discussion on the options and limitations of the various approaches. This paper defines priority-setting as the process of rank ordering interventions with the aim of informing decision-makers on the implementation of these interventions.