Reviewer's report
Title:From papers to practices: District level priority setting practices, attitudes
and criteria for family planning, maternal, newborn and child health interventions
in Tanzania
Version: 2Date:13 June 2011
Reviewer: Jens Byskov
Reviewer's report:
'From papers to practices: District level priority setting practices, attitudes and
criteria for family planning, maternal, newborn and child health interventions in
Tanzania'
Dereck Chitama, Rob Baltussen, Evert Ketting, Phares G.M Mujinja, Switbert
Kamazima and Anna Nswilla
BMC Women's Health
Research article
Review done by Jens Byskov
Compulsory revisions
For a paper of this nature that relates to a field of many partly conflicting
concepts, this means either actual revisions or explanation why a revision is not
done.
1. The paper title should better reflect the aim of assessing the adequacy of
FMNCH activities and outcomes in relation its policies and needs. It is really
assessing whether the policy recommendations and priorities are reflected in the
actual practice. Surely the study must have been based on an impression that
they are not and has set out to document that. The methods framework as
expressed already in the title could be more consistent. Practices, attitudes and
criteria are important areas, but are not expressing the actual data, themes, aims
and methodologies, which are explained differently in the text and use different
terms. In the title this could merely be expressed as the priority setting criteria
and processes.
2. The abstract background could be reviewed similarly to focus on criteria and
processes, but expand criteria to be linked to values of different stakeholders.
Sensible priority setting as such stands unexplained and is not clarified later.
Processes also cover a broader range of the priority setting structures, their
involved stakeholders, the way they define criteria (based on explicit or implicit
values) and the information and tools used. This should end with an indication of
the research question, aim or objective of the study.
3. The abstracted methodology could take in the overall approach to the
exploration (based on the background/aim being precise on what is mainly to be
compared. Next to the actual methods and data sources and analyses focused
on the research question.
4. The abstracted results could also be more clearly linked to the priority setting
processes and criteria as suggested to be subdivided as under background.
5. The abstracted conclusions also miss a strict enough focus and use of terms.
As shown in the paper there are may priority setting frameworks around and it
would be sound to make an informed choice of one with the inherent advantages
and disadvantages being discussed. Terms used are legitimacy, which links to
amongst other being transparent and explicit. With the choice of reference 12
(Sibbald) as a key reference I suggest to use and define terminologies in accord
with that paper. E.g. use its term of successful priority setting linked to concepts
of efficiency and fairness as suggested by Gibson. Anyway there are no right or
wrong approaches here internal and well referenced consistency will assist in
arriving at applicable and measurable priority setting interventions. Sensible
priority setting can of course also be used, but must then be defined according to
Gilson.
6. In the same it is excellent to refer to “and other priority interventions” though
this issue is not unpacked in this paper, which is also not venturing into the real
problem of resource constraints and the further challenge of prioritizing between
other programs and towards broad general service capacity. It could be further
stated that this is a limitation, not to the validity of findings, but to the way to act
on them in a way that does not compromise other priorities.
7. Although the paper is soundly based on current state of the art in a range of
relevant publications at its time of implementation, it can be useful here to refer to
findings in the recent interventions studies on priority setting by the REACT
project that also involves Tanzania and where recent key papers are include in
the Tanzanian PhD study: Maluka S. PhD Thesis. Strengthening Fairness,
Transparency and Accountability in Health Care Priority. Setting at District Level
in Tanzania. Opportunities, challenges and the way forward. Umeå University
Medical Dissertation. New Series No 1407 ISSN 0346-6612-1407 ISBN
978-91-7459-155-2. Department of Public Health and Clinical Medicine
Epidemiology and Global Health, Umeå University, SE-901 87 Umeå, Sweden.
2011. Link:
http://umu.diva-portal.org/smash/record.jsf?searchId=1&pid=diva2:399505&rvn=1
8. The above comments to the abstract are based on the full paper, and are not
repeated where the same issues emerge in the full text. They summarize a
number of key issues which authors have to reflect on and where the next
version must bear evidence of such both in the full text and in the abstract - or in
attached comments. The comments are not prescribing exactly how to do this
and better internal consistency is mainly what is looked for.
In the full text they mainly concern:
9. Background para 1: Reference 6 concerning MDGs is of course right. However
the nature of health goals in the MDGs have the fallacy of being used as
arguments for specific action within health and forgetting that they are really
development goals or kind of indicators for relevant broader political, economic
etc, and of course health action. However this is a broader area for conceptual
debate and priority setting, that is beyond the scope of this paper, so a response
to this item is not necessary.
10. Background para 2: to clarify acc. to reference 12. You may also consider a
reference to the more generic evaluation criteria of relevance, effectiveness,
efficiency and sustainability (for the latter refer to other publications by Martin D.
and others).
11. Methods: Here you can clarify in slightly more detail on the abstract
comment.
12. Data analysis: You seem to partly lean on concepts in you reference 12, but
focus on inputs, processes and outputs, which can be a feasible interpretation of
the processes that you have data for. Are you missing an outcome framework?
13. Results: External influences seem to be the broader context that is not (and
cannot be) fully examined, but is rightly recognized. However local cultural and
other social values must be recognized for their influence (and are a reason why
it is necessary to respect community and user views whether well organized
under explicit values and criteria or not. This is illustrative and it is up to the editor
if shortening is necessary. It could be possible.
14. Results subsection on correlation analysis: A main concern is the validity of
using statistics here as much of the explanation could be different group mixes
and differences of individuals (e.g. according to their political, religious and even
personality characteristics. However the views of those currently setting priorities
make sense based on the realization that the CCHP is used to get funds by
predetermined criteria, and it is well known that they do not match local priorities
or are useful for guiding in the face of shifting realities and throughout the year
continuous de facto reprioritization. To me the qualitative assessment of results
remains most important.
15. Discussion, para 1 and 2: Clarify shortfalls or gaps in relation to what e.g. to
clear criteria for successful priority setting.Priority setting skills and practice are a
tricky area in the face of experts developing elaborate conditions and detailed
frameworks that in themselves enstrange the non expert, community or user
influence on priority setting. So it is not only that FMNCH staff is not involved.
Even if they were there would still be the need to open up the priority setting
process further jointly with those who have currently reserved priority setting for
themselves. Great care must be taken not to make popular involvement
conditional to approving a certain level of skills with them. Rather the actual
administrative and technical staff needs to be trained to facilitate social
processes and “equal” partnership with the non technicians (a basic democratic
principle that is not agreed with all priority setting approaches). You write that
other priorities have taken key resources from FMNCH, but you would really
need to make a case that these were less important. However it is OK for you to
explicitly state that you find that to be the likely case based on general
agreement that this is an important areas for both preventive and curative
activities.
16. Discussion para 4: Criteria or values is fine, but you could make sure
throughout of the same logical presentation conceptual hierarchy. One could be
that values influence criteria and define desired information and methods for
setting priorities and making decisions within an existing resource frame.
17. Discussion para 5: Value for money is only one may not be the only criterion
in favour of FMNCH.
18. Conclusions: Finally changes done in the preceding will influence the
wording.
The responses to the above will show if minor essential revisions or discretionary
revisions remain, but I expect that to be quick and limited if responses to the
above are adequate.
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: Yes, but I do not feel adequately qualified to assess the
statistics.
Declaration of competing interests:
I declare that I have no competing interests