title: How countries cope with competing demands and expectations: perspectives of different stakeholders on priority setting and resource allocation for health in the era of HIV and AIDS.
abstract: BACKGROUND
  Health systems have experienced unprecedented stress in recent years, and as yet no consensus has emerged as to how to deal with the multiple burden of disease in the context of HIV and AIDS and other competing health priorities. Priority setting is essential, yet this is a complex, multifaceted process. Drawing on a study conducted in five African countries, this paper explores different stakeholders' perceptions of health priorities, how priorities are defined in practice, the process of resource allocation for HIV and Health and how different stakeholders perceive this.
  
  
  METHODS
  A sub-analysis was conducted of selected data from a wider qualitative study that explored the interactions between health systems and HIV and AIDS responses in five sub-Saharan countries (Burkina Faso, the Democratic Republic of Congo, Ghana, Madagascar and Malawi). Key background documents were analysed and semi-structured interviews (n = 258) and focus group discussions (n = 45) were held with representatives of communities, health personnel, decision makers, civil society representatives and development partners at both national and district level.
  
  
  RESULTS
  Health priorities were expressed either in terms of specific health problems and diseases or gaps in service delivery requiring a strengthening of the overall health system. In all five countries study respondents (with the exception of community members in Ghana) identified malaria and HIV as the two top health priorities. Community representatives were more likely to report concerns about accessibility of services and quality of care. National level respondents often referred to wider systemic challenges in relation to achieving the Millennium Development Goals (MDGs). Indeed, actual priority setting was heavily influenced by international agendas (e.g. MDGs) and by the ways in which development partners were supporting national strategic planning processes. At the same time, multi-stakeholder processes were increasingly used to identify priorities and inform sector-wide planning, whereby health service statistics were used to rank the burden of disease. However, many respondents remarked that health system challenges are not captured by such statistics.In all countries funding for health was reported to fall short of requirements and a need for further priority setting to match actual resource availability was identified. Pooled health sector funds have been established to some extent, but development partners' lack of flexibility in the allocation of funds according to country-generated priorities was identified as a major constraint.
  
  
  CONCLUSIONS
  Although we found consensus on health priorities across all levels in the study countries, current funding falls short of addressing these identified areas. The nature of external funding, as well as programme-specific investment, was found to distort priority setting. There are signs that existing interventions have had limited effects beyond meeting the needs of disease-specific programmes. A need for more comprehensive health system strengthening (HSS) was identified, which requires a strong vision as to what the term means, coupled with a clear strategy and commitment from national and international decision makers in order to achieve stated goals. Prospective studies and action research, accompanied by pilot programmes, are recommended as deliberate strategies for HSS.
authors.affiliation: Royal Tropical Institute, Amsterdam, The Netherlands.
authors.forename: Françoise
authors.initials: F
authors.lastname: Jenniskens
authors.forename: Georges
authors.initials: G
authors.lastname: Tiendrebeogo
authors.forename: Anne
authors.initials: A
authors.lastname: Coolen
authors.forename: Lucie
authors.initials: L
authors.lastname: Blok
authors.forename: Seni
authors.initials: S
authors.lastname: Kouanda
authors.forename: Fuseini
authors.initials: F
authors.lastname: Sataru
authors.forename: Andriamampianina
authors.initials: A
authors.lastname: Ralisimalala
authors.forename: Victor
authors.initials: V
authors.lastname: Mwapasa
authors.forename: Mbela
authors.initials: M
authors.lastname: Kiyombo
authors.forename: David
authors.initials: D
authors.lastname: Plummer
mesh_terms: D017954:Africa South of the Sahara; D017144:Focus Groups; D015658:HIV Infections / Q000628:therapy*; D015276:Health Care Rationing / Q000458:organization & administration*; D006292:Health Priorities / Q000458:organization & administration*; D006301:Health Services Needs and Demand; D006801:Humans; D036301:Qualitative Research