Priority-setting for healthcare: who, how, and is it fair?

INTRODUCTION: In recent years, heightened public awareness of new medical advances that offer improved therapeutic and diagnostic options coupled with increased fiscal pressure on health care systems to deliver both equitable and efficient care have magnified the need to examine carefully how and by whom health care priorities are set.
OBJECTIVE: To assess processes for setting health care priorities in Alberta, Canada.
METHODS: A demographically representative sample of senior management within Regional Health Authorities (RHAs) and specialized provincial boards was selected to participate in key informant interviews. The interviews, which were audio-taped and transcribed, comprised open-ended questions addressing priority-setting approaches employed and the extent to which the public was involved. Through a series of iterations, transcripts were analyzed using content analytic techniques.
RESULTS: In general, priority-setting was found to involve four steps: (1) identification of health care needs, (2) allocation of resources, (3) communication of decisions to stakeholders, and (4) management of feedback from them. While approaches to accomplishing each step varied across RHAs and specialized provincial bodies, public involvement did not. In all cases, mechanisms for engaging them in priority-setting focused almost exclusively on the first step. From an "accountability for reasonableness" perspective, none of the organizations surveyed had established processes that met all four principles.