Over the last 20 years, there has been considerable scholarly attention paid to developing priority setting methods with an emphasis on improving the evidence base of priority setting decisions, the use of explicit decision criteria, and the fairness of decision-making processes. Case studies of priority setting in health institutions and systems internationally have identified a variety of factors in practice that influence the effectiveness of these methods. There is a paucity of research, however, that empirically examines how these factors operate and to what extent they comprise enablers or barriers to fair priority setting. The purpose of this dissertation is to advance priority-setting methods by examining how systems theory may inform our understanding of priority setting through a case study of district health planning in Ethiopia.
To fulfill this purpose, three objectives were undertaken. The first objective sought to describe the district health planning and priority setting process in Ethiopia. A qualitative case study of Ethiopian district health planning was undertaken in 2010 and 2011. Methods included 57 in-depth key informant interviews with decision makers, participant observation, and document analysis. The second objective sought to analyze this description through the theoretical lens of Accountability for Reasonableness (A4R) and the Transformative Systems Change Framework (TSCF). The third objective sought to conceptually synthesize these findings by situating priority setting practice and procedural fairness within a robust understanding of the system. The study findings reaffirm priority setting is a highly complex process that is value laden and influenced by a multiplicity of system-level factors. Through the application of the TSCF, a nuanced understanding of priority setting practice is understood that situates this process within a system of influencing components that include: norms, operations, regulations, and resources. Analysis reveals a number of system barriers and facilitators that impact not only the implementation of district health planning, but also the degree to which elements of procedural fairness are upheld. In light of these findings, I propose the introduction of a third phase in the priority setting discourse that emphasizes the need for methods and approaches inclusive of system-level considerations. I conclude with the development of a series of practical questions to guide practitioners in the design and implementation of their priority setting methods.