Academic journal article Bulletin of the World Health Organization

Intervention Complexity-A Conceptual Framework to Inform Priority-Setting in Health

Academic journal article Bulletin of the World Health Organization

Intervention Complexity-A Conceptual Framework to Inform Priority-Setting in Health

Article excerpt

Introduction

Determining priorities and planning the implementation of health interventions in resource-poor countries is difficult and uncertain, due to lack of dependable evidence, analytical methods for identifying priority options and coherent processes for decision-making which take difficulties in implementation into account (1). The analytical tools currently available for evidence-based health planning and priority-setting are economic evaluation and burden of disease assessment. However, there is no analytical tool to assess the technical feasibility of an intervention according to its complexity. Different health interventions differ considerably in the degree of effort required to implement them. To some extent this is apparent in their financial cost, but in general cost is not a very effective proxy for the degree of effort or the nature of the resources required. For example, in some contexts the availability of skilled human resources may be a much greater constraint than financial resources. The main reason why the technical complexity of an intervention is not well reflected in its cost is because, in the short term, a lack of human resources or other shortcomings in capacity cannot easily be compensated for with money. Hence, non-financial resources are potential constraints to scaling up, and additional financial resources are not the solution in the short to medium term.

We define intervention complexity as the quality and quantity of non-financial resources required to implement and sustain an intervention. A close link exists between intervention complexity and capacity to implement the intervention. Assessing technical complexity is the first step in evaluating technical feasibility. Feasibility can be seen as the match between technical complexity and capacity. If complexity exceeds capacity, there is a capacity gap. Hence, technical feasibility is not ensured and the country faces a constraint to scaling up. This capacity gap can be closed either by increasing technical capacity or by decreasing the complexity of the intervention. Intervention complexity thus complements the notion of institutional capacity.

In this article we propose a conceptual framework for systematically analysing the importance of intervention complexity in expanding access to, and utilization of, health interventions. We see four potential applications for this framework in health policy decision-making, planning and programme management.

* To assess the technical complexity of an intervention as a first step in evaluating technical feasibility, i.e. to assess the capacity gap.

* To identify the most significant supply- and demand-side constraints to scaling up, i.e. to answer the question of how to close the capacity gap.

* To identify intervention designs that lend themselves to scaling up in the short-term as opposed to intervention designs that require significant implementation constraints to be overcome, i.e. to use for operational priority-setting. This has two types of application:

--to compare different modes of delivery for the same intervention, e.g. comparing tuberculosis treatment with hospitalization to directly-observed treatment; and

--to compare different interventions in terms of their technical complexity, e.g. antiretroviral therapy versus treatment of malaria.

* To indicate research and development priorities in order to simplify interventions, i.e. for use in setting priorities for research.

Using the dimensions proposed in the conceptual framework, an intervention-specific capacity profile can be drawn up to highlight particular constraints and priority areas. If interventions can be made very simple--whether in terms of "hardware" (e.g. vaccines) or "software" (e.g. guidelines on use)--and inexpensive, then they lend themselves to widespread use through all delivery channels and may also be deliverable through alternative channels such as nongovernmental organizations (NGOs), community-based arrangements or the retail sector. …

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