ABSTRACT
Priority setting during public health emergencies presents an enormous challenge for federal and state decision makers in the U.S. Objectives We describe the degree to which U.S. priority setting adheres to established quality indicators and explore relationships between such indicators and states' demographic characteristics. Methods Data includes the U.S. COVID-19 preparedness and response plan of January 2021 and individual state plans. Purposive sampling of 22 states from multiple geographic regions considered total population,% rural residents, income per capita, health ranking, and political leanings. State plans were sought online and using multiple contacts with state health and emergency preparedness departments. We analyzed plans using a tool based on an established framework of quality indicators to evaluate priority setting, for example principles and criteria, stakeholder and public participation, publicity and accountability. Results The national plan included 7 of 20 quality parameters, including attention to at-risk populations, a comprehensive list of resources and interventions to which priority setting would apply, publicity, and the use of (and efforts to improve) evidence for priority setting decisions. The US plan describes the importance of 'engag[ing] the American people' and various stakeholders to inform the federal response. Enforcement, accountability, incentives, and assessment of impact were not identified in the plan. We obtained pandemic plans from 4 states and documents from 6 states that, while not explicitly labelled as pandemic plans, include priority setting. Analysis is in process;we expect to present results for 4-10 states. Discussion The US plan's consideration of various scarce resources, public engagement, and equity concerns recognizes the disproportionate impact of COVID-19 among racial and ethnic minorities and low-income communities. However, its lack of accountability and assessment of impact on outcomes may hinder achievement of goals. Difficulty finding and obtaining state plans suggests a lack of publicity and transparency.
ABSTRACT
Background The COVID-19 pandemic has significantly disrupted health systems in the Eastern Mediterranean Region (WHO-EMRO), where over half of the countries are affected by armed conflict. Active humanitarian and refugee crises have led to mass population displacement and increased health system fragility. This has exacerbated pre-existing resource gaps and increased competition for meager resources. With large proportions of vulnerable populations - refugees, migrants, and internally displaced people (IDPs) - their explicit consideration in planning documents is critical if equitable priority setting is to be realized during the pandemic. We examine what and how priority setting (PS) was included in national COVID-19 pandemic plans within the region. Methods An analysis of COVID-19 pandemic response and preparedness planning documents from a sample of twelve purposively selected countries in WHO-EMRO. We assessed the degree to which documented PS processes adhere to twenty established quality indicators of effective PS from Kapiriri & Martin's framework. Results While all reviewed plans addressed some aspect of PS, none included all quality parameters. Yemen's plan included the most quality parameters (12), while Egypt's addressed the least (4). Publicity of priorities was common to all plans. The next mostly commonly identified parameter was use of evidence to guide planning and PS. When considering equity as a PS criterion, despite the high concentration of refugees, migrant, and IDPs in the region, only a quarter of the plans prioritized these populations. Discussion When setting priorities in health emergencies, context is paramount. In areas experiencing conflict and crisis, PS can be an undemocratic and challenging process. Health system fragmentation is key contributor to COVID-19 inequities experienced across the EMRO region. Limited prioritization of vulnerable groups like refugees, migrant, and IDPs in planning documents, will have long-term health implications and exacerbate the disproportionate burden of COVID illness and death for these groups.