Healthcare Priority Setting In Kenya: A Gap Analysis Applying The Accountability For Reasonableness Framework

Abstract

In resource-poor settings, the accountability for reasonableness (A4R) has been identified asan important advance in priority setting that helps to operationalize fair priority setting inspecific contexts. The four conditions of A4R are backed by theory, not evidence,that conformance with them improves the priority setting decisions. This paper describesthe healthcare priority setting processes in Malindi district, Kenya, prior to the implementationof A4R in 2008 and evaluates the process for its conformance with the conditions for A4R.In-depth interviews and focus group discussions with key players in the Malindi district healthsystem and a review of key policy documents and national guidelines show that the prioritysetting process in the district relies heavily on guidelines from the national level, making itmore of a vertical, top-down orientation. Multilateral and donor agencies, national government,budgetary requirements, traditions and local culture influence the process. The four conditionsof A4R are present within the priority setting process, albeit to varying degrees and referred toby different terms. There exists an opportunity for A4R to provide a guiding approach withinwhich its four conditions can be strengthened and assessed to establish whether conformancehelps improve on the priority setting process. Copyright © 2013 John Wiley & Sons, Ltd.KEY WORDS: priority setting; accountability for reasonableness; healthcare; Kenya