Priority Setting in Indigenous Health: Why We Need an Explicit Decision Making Approach


The International Indigenous Policy Journal

Volume 6 | Issue 3 Article 8

June 2015

Priority Setting in Indigenous Health: W hy We
Need an Explicit Decision Making Approach
Michael E. Otim
Australian Catholic University, North Sydney, michael.otim@acu.edu.au

Ranmalie Jayasinha
University of Sydney, Sydney, ranmalie.jayasinha@sydney.edu.au

Margaret Kelaher
University of Melbourne, Melbourne, mkelaher@unimelb.edu.au

Edward Shane Houston
University of Sydney, Sydney, shane.houston@sydney.edu.au

Ian P. Anderson
University of Melbourne, Melbourne, ipa@unimelb.edu.au

See next page for additional authors

Recommended Citation
Otim, M. E. , Jayasinha, R. , Kelaher, M. , Houston, E. S. , Anderson, I. P. , Jan, S. (2015). Priority Setting in Indigenous Health: Why 
We Need an Explicit Decision Making Approach. The International Indigenous Policy Journal, 6(3).
DOI: 10.18584/iipj.2015.6.3.8



Priority Setting in Indigenous Health: W hy We Need an Explicit Decision
Making Approach

Abstract
Indigenous Australians have significantly poorer health outcomes than the non-Indigenous population
worldwide. The Australian government has increased its investment in Indigenous health through the "Closing
the Health Gap" initiative. Deciding where to invest scarce resources so as to maximize health outcomes for
Indigenous peoples may require improved priority setting processes. Current government practice involves a
mix of implicit and explicit processes to varying degrees at the macro and meso decision making levels. In this
article, we argue that explicit priority setting should be emphasized in Indigenous health, as it can ensure that
the decision making process is accountable, systematic, and transparent. Following a review of the literature,
we outline four key issues that need to be considered for explicit priority setting: developing an Indigenous
health "constitution," strengthening the evidence base, selecting mechanisms for priority setting, and
establishing appropriate incentives and institutional structure. We then summarize our findings into a
checklist that can help a decision makers ensure that explicit priority setting is undertaken in Indigenous
health. By addressing these key issues, the benefits of an explicit approach, which include increased efficiency,
equity, and use of evidence, can be realized, thereby maximizing Indigenous health outcomes.

Keywords
Indigenous peoples, Aboriginal people, priority setting, health, decision-making, Australia

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Authors
Michael E. Otim, Ranmalie Jayasinha, Margaret Kelaher, Edward Shane Houston, Ian P. Anderson, and
Stephen Jan

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P r i o r i t y  S e t t i n g  i n  I n d i g e n o u s  H e a l t h :  W h y  W e  N e e d  a n  E x p l i c i t  D e c i s i o n  M a k i n g  
A p p r o a c h  

B a c k g r o u n d  

Indigenous peoples everywhere—including Aboriginal and Torres Strait Islanders in Australia, 
referred to here as Indigenous Australians—have significantly poorer health outcomes compared to 
the general population in their respective countries (Australian Bureau of Statistics [ABS] & 
Australian Institute of Health and Welfare [AIHW], 2010).  Indigenous Australians in particular 
have significantly poorer health outcomes than other Indigenous populations in Canada, USA, and 
New Zealand (ABS & AIHW, 2010; Gracey & King, 2009; Kunitz & Brady, 1995).  This can be 
attributed to socioeconomic status and low utilisation of health care services due to limited access to 
good quality health care services.   Even where quality health care services exist, Indigenous 
peoples—especially Australian ones—face structural problems, culturally inappropriate services, 
and institutional racism (Henry, Houston, & Mooney, 2004).  Further, dispossession and 
colonisation contribute to the poor health status of Indigenous Australia through loss of self-esteem 
and loss of resilience (ABS & AIHW, 2010).  As Archibald Meston (cited in Evans, Saunders, & 
Cronin, 1993) described: 

Never before had I seen aboriginal men living under extraordinary terrorism, many of them 
fine athletic fellows who could in case of a row have settled with their terrorisers in a very 
summary fashion.  But many of them had long been treated as the dogs are treated and were 
scared into a belief that their employers wielded the power of life and death.  (p. 112)  

Over the years, there have been several attempts in Australia to improve the health of Indigenous 
peoples through reform of the health system as a means to improve Indigenous peoples’ access to 
health services (Aboriginal & Torres Strait Islander Commission, 1993; S. Richardson, 1997; 
Thomson, 1984).  Most recently, the Australian government pledged in the “Close the Gap” 
initiative to close the gap in life expectancy and social indicators between Indigenous and non-
Indigenous people within two generations (Council of Australian Government [COAG], 2009).   
This was followed by more reforms to the funding and delivery of health care services.  However, 
over the years, these reforms have not been effective at achieving the government’s goals (Aboriginal 
& Torres Strait Islander Social Justice Commissioner, 2006).  This leaves improving the priority 
setting process as the key issue to be addressed in order to ensure that the government’s efforts at 
“Closing the Gap” can be done efficiently.  Priority setting can be defined as a non-market based 
process of making choices in the face of scarcity, which arises from the demand for a good or service.   
Scarcity necessitates making choices, leading to the loss of other opportunities that would have been 
realised if investment had been done elsewhere (Culyer, 2005; Earl-Slater, 1999).  There is therefore 
an urgent need to improve the current priority setting process in Indigenous health so that resource 
allocation ensures maximisation of health outcome.   

In the work we recently published elsewhere (Otim, Kelaher, Anderson, & Doran, 2014), results 
indicated that key decision makers from both government and Indigenous community organisations 
involved in Indigenous-specific health services in the Australian State of Victoria value transparent 
priority setting processes.  Indigenous respondents revealed the need for such an approach if it 
allowed them to shift resources between and within programs, and was accompanied by health gains, 
buy-in from government, and Indigenous community involvement (Otim et al., 2014).  Such an 
approach would encourage accountability and transparency.  Thus, such results would be useful as 
criteria for explicit priority setting (Maynard, 1996; Mooney, Gerard, Donaldson, & Farrar, 1992).   

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Explicit priority setting is when the choices made by decision makers are publicly known and bases 
for such decisions are publicly known too (Earl-Slater, 1999).  However, how to implement explicit 
priority setting in Indigenous settings has not been undertaken.    

The primary aim of this article is therefore to provide a framework for improving priority setting and 
describe how such a framework can be implemented in practice.  We explore the role of criteria or 
principles that guide the health system and associated weights, engagement of the Indigenous 
community, and the role of shifting resources within and across programs to maximise outcomes.   
As one government respondent indicated, it is the burden of disease and its distribution that guides 
his decision making process.  When asked if that is enough for maximising population health (Otim, 
et al., 2014), he said, “for me the most important issues would be equity . . . and the size of the health 
burden would be an issue but not the overriding factor” (Otim, et al. 2014, Perceptions of the 
current process of setting priorities section, para. 3). 

I m p r o v i n g  P r i o r i t y  S e t t i n g :  T h e  R o l e  o f  E x p l i c i t  P r i o r i t y  S e t t i n g  i n   
I n d i g e n o u s  H e a l t h  

Undertaking explicit priority setting to improve decision making in Indigenous health requires 
addressing four key issues, identified from the literature (Carter, et al., 2008; Earl-Slater, 1999; 
Mooney & Wiseman, 1999; Shiell & Mooney, 2002):  

a. The establishment of an Indigenous health constitution;  

b. Strengthening of the Indigenous evidence base for decision making;  

c. The adoption of a decision making mechanism to resource allocation;  

d. The establishment of an appropriate incentive and institutional structure.   

D e v e l o p i n g  a n  I n d i g e n o u s  H e a l t h  C o n s t i t u t i o n  

The development of an Indigenous health constitution involves establishing the broad principles or 
criteria that should guide the health system and the trade-offs that Indigenous people are prepared to 
make (Shiell & Mooney, 2002).  These principles or criteria can be used for determining the extent 
to which programs or interventions should be publicly provided or financed and the relative 
importance of each criterion and therefore their relative weights.  As one Indigenous community 
member expressed her frustration with the way funding agencies allocated resources: “I would be 
happy to know what reasons the funders use to select programs or services to fund.  Most 
importantly, I would like to know the reasons why they have not funded some of our activities” 
(Otim et al., 2014, Assessment of the current priority setting process section, para. 2). 

Different countries use different criteria to guide priority setting (Kapiriri & Norheim, 2004).  Some 
of them publish their criteria and others do not (Table 1).  The publication of Nordic countries’ 
criteria served to address political issues in funding and access to health care services, thus ensuring 
transparency and accountability by these governments.  These criteria also provided guidance to the 
development of the guidelines for assessing the successes of the different priority setting frameworks 
that had been employed (Sabik & Lie, 2008).  The literature suggests that successful processes have 
involved the presence of priority setting commissions (Sabik & Lie, 2008).   

 

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T a b l e  1 .  E x a m p l e s  o f  C r i t e r i a  f o r  P r i o r i t y  S e t t i n g  f r o m  S e l e c t e d  C o u n t r i e s  
C o u n t r y  o r  

R e g i o n  C r i t e r i a  S o u r c e  
Oregon Cost-effectiveness; then equity (Oberlander & Marmor, 2001) 

Netherlands 
(filter mode) 

Service necessity; effectiveness; efficiency; 
and personal responsibility 

(Government Committee on 
Choices in Health Care, 1992) 

Sweden Human dignity; equal rights; need; 
solidarity; and cost-efficiency  

(Health Care and Medical Priorities 
Commission, 1993) 

Denmark Equality, solidarity, security, and autonomy (Danish Council of Ethics, 1997) 

New Zealand 
(Maori) 

Efficiency; effectiveness; equity; 
acceptability; and Maori health principles 

(Ashton, Cumming, & Devlin, 2000; 
Tito & Kavanagh, 2004) 

Uganda  Efficiency/ accountability; effectiveness/ 
quality care; 
equity/fairness/justice/ethics; and 
national solidarity/cultural practices 

(Kapiriri & Norheim, 2004) 

Canada Maximisation; egalitarianism; claims such 
as severity, human rights, etc.   

(Shiell & Mooney, 2002) 

West Australia Need; socioeconomic disadvantage; access (Mitton & Prout, 2004) 

Torres Strait, 
Queensland 

Public outrage; burden of disease; cost; 
preventability; national priorities 

(McDermott & Mills, 2004) 

 

 

Indeed, lessons from previous studies such as those identified above suggest that a set of criteria 
ought to be culturally or system specific (Otim et al., 2014; Shiell & Mooney, 2002).  Whilst useful 
in conceptualising possible criteria, these may be divergent from the experiences of Indigenous 
peoples.    

In recognition of Indigenous values, there have been a few attempts in Australia at identifying 
principles that should guide priority setting and/or resource allocation in Indigenous health and 
research (Monk, Rowley, & Anderson, 2009; National Aboriginal and Torres Strait Islander Health 
Council [ NATSIHC], 2003; National Health and Medical Research Council [NHMRC], 1993, 
2003; Otim et al., 2014).  Results indicate that the key principles include cultural respect, 
community control, and capacity building within the Indigenous community controlled health 
sector, provider collaboration, localised decision making, accountability, justice, quality of life, and 
social worth.  Such criteria highlight the importance that Indigenous peoples and decision makers 
attach to the role of evidence, such as economic evaluation.  Having an Indigenous health 
constitution would inform the debate on the appropriateness of the criteria and their relative weights 
for decision making in Indigenous health.   

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S t r e n g t h e n i n g  t h e  E v i d e n c e  B a s e   

The second step in the development of explicit priority setting is the strengthening of the evidence 
base in Indigenous health that can be used to guide the process of setting priorities.  This is part of 
the “evidence based policy making” discussion, which has been around for a long time and may be 
linked to evidence-based clinical decision making.  However, several key issues have been identified 
to explain why policy makers fail to use evidence and why researchers fail to produce useful evidence 
(Banks, 2009; Otim, et al., 2014; Ross, 1995).   These issues include the complex processes involved 
in policy processes; lack of relevant and timely evidence, such as economic evaluation and 
epidemiological evidence for decision making; necessary improvement in the quality and the 
measurement rigour of such evidence; and the need for a holistic approach to Indigenous health 
policy.    

Furthermore, the criteria for assessing the quality of evidence might need to be widened and 
strengthened.  Widening the evidence base to guide decision making ought to include a combination 
of technical rigour and value judgments about what constitutes benefits or costs (Mooney, 2006).  
Technical judgements may rely on the availability and quality of data and technical methods for 
making decisions.    

Value judgements rely on the principles and values of the decision makers and the Indigenous 
population. When data are not readily available, value judgements may be used in the process of 
assessing the quality of evidence in Indigenous health, which would ensure that interventions 
targeting Indigenous health are not penalised for lack of high quality evidence (Rychetnyk, 
Frommer, Hawe, & Shiell, 2002; Sibthorpe et al., 2002).    

S e l e c t i n g  M e c h a n i s m s  f o r  P r i o r i t y  S e t t i n g  

The third issue involves the need for practical decision making mechanisms to ensure that resource 
allocation decisions are consistent with the principles embodied in the Indigenous health 
constitution and trade-offs can be undertaken.  In practice, decision making happens at the margin; 
small incremental adjustments to an existing plan of action, in accordance with the concept of 
marginal analysis (Mooney, 2002).  Knowing that marginal analysis is a tool for estimating efficiency 
of government actions, it is important that a clear specification of the objectives being pursued is 
made so that an appropriate framework that can address such objectives can be selected.  An ideal 
priority setting framework should be able to shift resources matched with health gain, and be able to 
have an impact on the health of Indigenous peoples (Otim et al., 2014).  Further, such an approach 
ought to be able to use both technical evidence and due process, which may require resources and 
structures for collating such evidence and expertise.  First, the decision makers have to buy-in to the 
idea of implementing a priority setting model that has potential to maximise health outcomes.   

P u t t i n g  A p p r o p r i a t e  I n c e n t i v e s  a n d  I n s t i t u t i o n a l  S t r u c t u r e  i n  P l a c e  

Buy-in by funding agencies is important since Indigenous providers are already overbudened by 
limited funding, as well as administrative and multiple accounting requirements from the funding 
agencies (Dwyer, O'Donnell, Lavoie, Marlina, & Sullivan, 2009).  This would ensure that the 
priorities identified are acted upon and staff are trained in the chosen priority setting framework to 
ensure its adoption as a routine decision making tool (Shiell & Mooney, 2002).  Thus, funding 
agencies would need to put in place incentives and institutional structures for Indigenous providers.   

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Incentives can be put in place by funding agencies to encourage Indigenous community providers to 
use the chosen approaches for routine decision making.  Other requirements would involve ensuring 
Indigenous ownership of the process and the results, organisational stability of Aboriginal 
Community Controlled Health Services (ACCHS), and organisational decision making culture to 
focus on the costs and benefits.  It is therefore imperative for the funding agencies to financially 
support the implementation of a new way of priority setting in ACCHS.  Thus, for Indigenous health 
providers to be able to adopt explicit priority setting, appropriate incentives, and institutional 
structures would need to be established.  The key challenge is how all the above issues can be 
translated into practice to ensure the implementation of the explicit priority setting in Indigenous 
health.  Thus, there is a need to invest in the establishment of the institutional structures that are 
needed to support a systematic approach to priority setting (Ham & Coulter, 2000).    

I m p l e m e n t i n g  E x p l i c i t  P r i o r i t y  S e t t i n g :  P r a c t i c a l  I s s u e s  i n  I n d i g e n o u s  H e a l t h  

In the following section, we consider some of the challenges that ought to be addressed in order to 
allow explicit priority setting processes to be implemented in Indigenous health.  A checklist is later 
developed to guide such a process and it is summarised in Table 2.   

I d e n t i f y i n g  t h e  G o a l  t h a t  i s  B e i n g  P u r s u e d   

The first task is to specify what goal is being pursued explicitly, and within a specific context.  This 
will enable priority setting to occur within a pre-defined framework.  Under economic theory, for 
example, maximising health should be one of the key objectives, and, under non-economic theories, 
other objectives exist such as equity, equality, fairness, and need (Otim et al., 2014).  Thus, 
optimising or maximising health, and improving access and equity, while ensuring Indigenous 
engagement in the process, could be the key goals.    

The challenge, however, is how to make the objectives as discrete as possible due to the potential for 
overlap in certain areas, especially in cases where more than one objective may be stated.  For 
example, “equality of health” overlaps with “equality of outcomes” or “equality of use,” but differs 
significantly.  The similarities and differences ought to be reflected and captured in the priority 
setting approach used for the maximisation of health.  Thus, the objectives have to be as clearly 
stated as possible and framed in an answerable manner.   

E n g a g i n g  t h e  I n d i g e n o u s  C o m m u n i t y   

The second task is how to engage the Indigenous community in the decision making process in a 
meaningful manner.  That is, the Indigenous community should be involved in the formulation of 
the objectives, identification of the priorities, and their implementation.  To identify priorities and 
criteria to be used in priority setting, the key findings of the Harvard Project, for example, indicate 
that sovereignty matters in the Native American lands development (Jorgensen & Taylor 2000).   
Further, good governance, cultural issues, and institutions are important pillars for development and 
sustainability (Cornell 2002; Dodson & Smith 2003).  Therefore, an approach that ensures the 
above issues are incorporated in the decision making process can ensure that the Indigenous 
community is likely to accept and/or embrace the choices made by decision makers, and will ensure 
ownership and sustainability of the selected services or strategies.  Several authors argue that 
Indigenous Australian communities are in crisis and this is widely acknowledged in the literature 
(Dodson 2003; Sutton 2001).  This crisis is mainly one of governance.  From whichever perspective 
this crisis is viewed, be it anthropological or economic analysis, what matters most is that the health 

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outcomes of Indigenous peoples must improve to a level that is comparable to the rest of the non-
Indigenous population.  Such an improvement can only be achieved with good governance and 
institutions that are influenced by cultural issues.  In Australia, several comprehensive primary health 
care services are Aboriginal community controlled.  This allows control and engagement of the 
community in the decision making process.    

Thus, the governance process that allows and incorporates Indigenous cultural and other values in 
the setting of priorities, and aids Indigenous institutions to choose and implement those strategies is 
likely to maximise health gain.  From an economic perspective, Indigenous values can be 
incorporated into the health system through empirical ethics (J. Richardson, 2000) or a 
communitarian approach, which emphasises the need to use the preferences of that marginalised 
group to address their disadvantage (Mooney, 1998).  This approach classifies reasons for a person’s 
claim for a good into two groups: “communitarian claims” and “other reasons” (Mooney, 1998).   
To understand individuals in society, especially when undertaking priority setting, one must look at 
the community from where the individual comes and their communal relationships (Avineri & de-
Shalit, 1992).  Thus, this requires the promotion of community control and self-determination in 
priority setting.  For example, Indigenous Australian management structures could provide a 
mechanism for the engagement of the Indigenous community in the decision making process.  In a 
study of decision makers from both government and Indigenous communities that we undertook, 
respondents identified cultural security, individual health gain, community gain, and access as 
important key outcomes of any allocation of resources especially in health (Otim et al., 2014).   
Knowing that Indigenous peoples everywhere are not a homogenous group, it is important to 
undertake empirical studies to elicit the broad principles from Indigenous peoples and communities 
that should guide the priority setting process and what weights should be attached to those criteria.   

E m p i r i c a l  E l i c i t a t i o n  o f  C r i t e r i a  t o  E s t a b l i s h  I n d i g e n o u s  H e a l t h  C o n s t i t u t i o n  

The next task involves how to elicit the broad criteria that should guide the priority setting process 
and the associated weights to be attached to these criteria.  In essence, these criteria should include 
the Indigenous values and aspirations (Mooney, 2000, 2002, 2003, 2010; Mooney & Houston, 
2004; Mooney & Wiseman, 1999; Shiell & Mooney, 2002).   Eliciting such criteria can be done 
using empirical ethics (J. Richardson, 2000) or communitarian claims approach (Mooney, 2002, 
2010).  These approaches can also elicit preferences for weighting the criteria for their relative 
importance.  Publishing such criteria and the associated weights can allow the public to have a 
debate on the appropriateness and acceptability of each.    

J. Richardson (2000) argued that social ethics ought to guide the decision-maker’s health policy 
objectives, and these ethical issues should be captured using the “empirical ethics” approach.  This 
would involve ethical values being subjectively derived from a sample of Indigenous individuals 
within the population and these values being subjected to ethical analysis and criticism.  These 
values can then be quantified and converted into a scale that can be used to weight the importance of 
decision criteria or health outcomes (J. Richardson, 2000).  In the event that the social values are 
shown to lead to abhorrent outcomes, such as racism, sexism, or discrimination, then preferences 
should be “laundered,” and an iterative process undertaken between the ethicist and the public.   
However, this approach has not yet been applied in Indigenous health.   

The communitarianism claims approach advocates for the use of community preferences as the basis 
for criteria, and argues that these same members are the most appropriate to determine what weights 
to attach to these preferences (Mooney & Russell, 2003).  These criteria would be elicited using 

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citizenry workshops (Mooney, 2010) and used to inform the selection of the options for change, the 
weighting of the scores, and interpretation of the findings.  Thus, the use of ethical values or 
principles that are carefully inferred from the respondents, and together with evidence, is likely to 
lead to desirable outcomes from the priority setting process.   

I n v e s t m e n t  i n  S t r e n g t h e n i n g  E v i d e n c e  

Developing a strong evidence base is another key aspect of explicit decision making, which promotes 
the systematic collection of data relating to the costs and benefits of interventions or programs.   
This evidence may be in the form of epidemiology data, economic evaluation evidence, or political 
incentives.  Evidence gathered from economic evaluation, for example, ensures that maximising 
outcomes for a given budget can be achieved (Feldman & Serrano, 2006; Tsuchiya & Williams, 
2001).    

In practice, the number of economic evaluation studies has been increasing worldwide since the 
1970s (Gerard & Mooney, 1993).  In Australia, an increasing number of economic evaluations 
studies have been adopted for policy purposes.  For example, the Australian government uses 
economic evaluation to make choices on what pharmaceutical products or medical devices and 
procedures it subsidises.  This evidence has also been used in other areas such as, breast and cervical 
cancer screening, organ transplantation, co-ordinated care trials, the Cancer Council National 
Strategy, and the National Tobacco Control strategy.  However, very few such studies have been 
done specifically in Indigenous health and hence the uptake of economic evaluation evidence in 
priority setting is not known.    

Alternatively, epidemiologically based studies may include the burden of disease studies, community 
surveys, and setting goals and targets to be achieved either at an individual or a societal level.   
However, these data can fail to capture equity and other social justice issues in Indigenous health, 
unless guided by objectives that explicitly promote these principles.  Whilst each source of data has 
its own challenges, explicitly accounting for these issues and choosing an appropriate method is 
important to ensuring the results are relevant to the intervention to be implemented.   

D e c i s i o n  M a k i n g  M e c h a n i s m s   

There are several frameworks for priority setting from both non-economic and economic disciplines.   
Examples of economic-based approaches include the league table approach, the Health Sector-Wide 
(HSW) model (Segal & Mortimer, 2006), Health Benefit Groups/Health Resources Groups 
(HBG/HRG) (Beaver, Williams, Zhao, & Weeramanthari, 1999; McDermott, 2004; McDermott & 
Mills, 2004), and Program Budgeting and Marginal Analysis (PBMA) (Gruskin & Daniels, 2008).   

Whereas, non-economic frameworks include historically based allocations, needs assessments 
(burden of disease, cost of illness, community surveys, goals and targets), and clinical guidelines and 
protocols (defining core services, best practice guidelines, and shared protocols) (Carter, et al., 
2008; Mitton & Donaldson, 2004; Segal & Mortimer, 2006).  Non-economic based approaches 
emphasise the explicitness of the values and criteria that ought to guide priority setting, and the 
active involvement of the Indigenous stakeholders in the process.  For example, ethically based 
approaches such as the accountability for reasonableness approach and a human rights-based 
approach have potential to improve priority setting (Daniels, 2000; Gruskin & Daniels, 2008; 
Kapiriri, Norheim, & Martin, 2007; Martin, Giacomini, & Singer, 2002; Mitton & Donaldson, 

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2004).  However, these approaches do not have decision making mechanisms that can be used to 
maximise health gain.   

E s t a b l i s h m e n t  o f  I n c e n t i v e s  a n d  I n s t i t u t i o n a l  S u p p o r t  

It is vital that the funding bodies create environments that promote the ACCHS use of priority 
setting methods if the funders hope to see service providers use formal methods to set priorities 
(Peacock, 1998; Shiell & Mooney, 2002).  This would legitimise the decisions made and increase 
the potential acceptance and adoption of the results.  Additionally, buy-in by funders is needed to 
fund project support.    

The Australian government is increasingly concerned with ensuring the risk management by 
ACCHS.  Dwyer and colleagues (2009) have proposed that long-term contracting for core primary 
health care services should be the basis for the funder–provider relationship.  This would allow 
flexibility for local priority setting, in accordance with agreed plans, and subsequently reduce 
transaction costs.  The funders would therefore need to establish appropriate incentives and 
structures within their funding guidelines to ensure that the priorities identified by the organisations 
are acted upon, the chosen priority setting framework is adopted as routine decision making tool, 
and such a tool is not a burden to community-based organisations.  Furthermore, integrating the 
values of the community and decision makers into the program design and delivery may further 
support their buy-in to the priority setting process.    

P r a c t i c a l  C h e c k l i s t  f o r  E x p l i c i t  P r i o r i t y  S e t t i n g  

The ideal explicit priority setting framework should be able to shift resources matched with health 
gain, and should be able to engage Indigenous peoples in the process to ensure self-determination.   
In Table 2, we have summarised the key issues for consideration when undertaking explicit priority 
setting in Indigenous health and presented them as brief checklist.  The checklist provided is not 
intended to be exhaustive; rather, it should be viewed as a starting point for considering how an 
explicit priority setting can be adopted.  We recommend that the checklist be modified based on the 
context of the organisation, so that explicit priority setting can be harnessed appropriately and 
effectively to meet the goals and objectives of government and Indigenous organisations.     

C o n c l u s i o n  

Explicit priority setting is not necessarily and universally more valid and reliable than implicit 
judgement.  However, we argue that it makes use of both technical information and due process, and 
has the potential to engage Indigenous people for three reasons.  First, decisions and the criteria 
behind decisions will be transparent.  Second, evidence, such as economic evaluation, is important in 
assisting decision makers with the selection of interventions that work and also offer value for 
money.  Third, in line with the Indigenous principle of self-determination, due process enables 
engagement of Indigenous people in the decision making process.  This helps to ensure that 
Indigenous values are incorporated in the choices, and that Indigenous ownership of the process and 
the results is achieved.  As such, the openness and accountability of the decision making process can 
be ensured.   

  

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T a b l e  2 .  C h e c k l i s t  f o r  P r i o r i t y  S e t t i n g  i n  I n d i g e n o u s  H e a l t h  
S t e p  1  I d e n t i f y i n g  a  w e l l - s p e c i f i e d  a n d  a n s w e r a b l e  g o a l  

• Are the objectives of the exercise clearly specified? 
• Are comparators specified? 
• Is the perspective for decision making specified? 

 
S t e p  2  E s t a b l i s h i n g  t h e  I n d i g e n o u s  h e a l t h  c o n s t i t u t i o n  

• Are criteria for making decisions clearly stated and ranked for relative 
important? 

• Does the framework recognise access issues to culturally appropriate and 
effective heath care? 

• Are Indigenous values embodied in the framework as guiding principles? 
• Does the framework address issues of fairness or equity? 

 
S t e p  3  C h o o s i n g  a  d e c i s i o n  m a k i n g  f r a m e w o r k  

• Is the framework appropriate to the question and context that is specified? 
• Does the framework allow for a fair and open process to priority setting? 
• Is efficiency and equity an integral rule for making judgment?  
 

S t e p  4  S t r e n g t h e n i n g  t h e  e v i d e n c e  b a s e  
• Is expert advice used where data may not be available or of poor quality?  
• Is marginal analysis an integral component of the framework? 
• Are the data needs manageable or tractable? 

 
S t e p  5  P r o m o t i n g  c o m m u n i t y  i n v o l v e m e n t  

• Is the right of Indigenous people to control their health care being respected? 
• Are the Indigenous community’s decision making, participation and control 

supported? 
• Are there effective structures and processes to ensure effective Indigenous 

participation?  
 

S t e p  6  E n s u r i n g  i n c e n t i v e s  a n d  i n s t i t u t i o n a l  s u p p o r t  
• Does the framework contribute to capacity building in Indigenous health 

services?  
• Is the role of judgment recognised in the specification and interpretation of 

the results?  
• Is there capacity for the implementation of the results? 

 
 

 

 

 

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We argued that a key challenge is how to translate an explicit approach to priority setting into 
practice in Indigenous health.  From normative economic and social justice perspectives, this can be 
done by using a clearly specified criteria; frameworks that allow maximisation of health outcomes; 
use of evidence, incentives, and institutional support; and effectively involving Indigenous peoples in 
the process.  Accounting for these considerations will ensure that the choices made reflect 
Indigenous values and aspirations, and offer value for money; thereby, maximising the health of 
Indigenous Australians.   

  

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	The International Indigenous Policy Journal
	June 2015

	Priority Setting in Indigenous Health: Why We Need an Explicit Decision Making Approach
	Michael E. Otim
	Ranmalie Jayasinha
	Margaret Kelaher
	Edward Shane Houston
	Ian P. Anderson
	See next page for additional authors
	Recommended Citation

	Priority Setting in Indigenous Health: Why We Need an Explicit Decision Making Approach
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	Priority Setting in Indigenous Health: Why We Need an Explicit Decision Making Approach