We sought to answer three research questions in this study. The first was ‘What is the decision-making process for HIV/AIDS resource allocation?’ Our analysis revealed several important insights. For governmental organizations and international or national NGOs, the resource allocation process begins with the selection of HIV/AIDS programmes and is based on available data. Once the programmes are selected, they use further techniques to determine the funding level for each programme. For local community-based organizations or NGOs, the selection of HIV/AIDS programmes is driven by their experiences in the field; they then submit proposals to identify funding sources. Governmental organizations and large NGOs tend to use more formal techniques, while local community-based organizations and FBOs tend to be less formal and more opportunistic. Also, initial planning efforts tended to be more thorough than subsequent planning efforts, which were often based on historical spending trends. In local community-based organizations and FBOs, allocation decisions tend to be made internally by the organization’s director aided, where applicable, by finance and programme managers. At the local government level in KwaDukuza, hospital and clinic managers are the main decision-makers; they are influenced in part by donors and by meeting their portion of the district’s target levels. Albeit ad hoc, there is an attempt to coordinate HIV/AIDS services between health-care facilities and community-based organizations.
The second question was ‘What factors influence the resource allocation process?’ We found that external individuals and organizations, as well as a number of intangible factors, have a strong influence on decision-making. In many instances their influence was stronger than that of the formal planning exercises undertaken by decision-makers and placed constraints on the types of decision that could be made.
The third question was ‘How are decision-making support tools or frameworks used in HIV/AIDS resource allocation?’ No respondents representing small organizations or local level decision-making mentioned the use of such formal techniques. The one respondent who did indicate the use of rational economic models was from a national level organization. This respondent used epidemiological and cost-effectiveness models but did not use other methods including operations research techniques or other frameworks.
We conducted a search in PubMed using the search terms ‘resource allocation’, ‘model’ and ‘HIV’. We found 29 references containing all three terms detailing mathematical models intended to be useful for decision-making. However, only one of the references consider the factors identified in this study and these are clearly important to decision-making (Lasry et al. 2008
). The factors and processes uncovered in this research may lead to improved methods of resource allocation. Resource allocation methods that include a thorough understanding of the current allocation process, the stakeholders involved and their influence on the allocation are likely to yield recommendations that are useful and attuned to the context within which resource allocation decisions are made. The current allocation of resources in KwaDukuza and the results of an improved allocation are discussed elsewhere (Lasry et al. 2008
). In general, a cost-effectiveness-based approach applied in KwaDukuza would encourage increasing the allocation to condom distribution and treatment of sexually transmitted infections (Lasry et al. 2008
As with all case study research, our results are limited to the setting in which they were conducted. However, we believe that they are likely applicable to other municipalities in South Africa given the similarity in backgrounds. Our results are similar to those of Bollinger and Stover (2000
), who interviewed the National AIDS Control Programme managers of 14 countries, including South Africa. Both studies demonstrate that donors exert a strong influence on the decision-making process for HIV/AIDS resources, that past allocations are an indicator of current allocations and that legal, political and ethical considerations are determinants of HIV/AIDS resource allocation patterns (Bollinger and Stover 2000
Further, our results are consistent with other descriptive studies of health-care priority setting. In an evaluation of priority setting for reproductive health in Ghana, researchers concluded that political attention trumped available scientific and economic evidence in terms of the priority given to breast cancer over cervical cancer (Reichenbach 2002
). Reichenbach determined that leadership, advocacy, media attention, culture and political issues affect priority setting (Reichenbach 2002
). An analysis of health-care priority setting in Canada, Norway and Uganda determined that, in all three countries, previous allocations, advocacy, external pressures and, in the case of Uganda, international development organizations, are among salient considerations in the priority-setting process (Kapiriri et al. 2007
). Though costs and efficiency are used to create guidelines, these are often overridden by public pressures and lobbying (Kapiriri et al. 2007
). In addition, priority-setting decisions are disseminated to the public, but the reasons behind the decisions are not provided (Kapiriri et al. 2007
Our study has limitations. Our method of sampling interview respondents may have resulted in a non-representative sample. However, due to the nature of the information sought, we could not draft an exhaustive list of potential interview respondents from which to draw a random sample. We did not have access to decision-makers at privately owned and managed health-care institutions. Therefore, they were excluded from our study. However, there are few privately managed medical clinics in KwaDukuza and the vast majority of the population in KwaDukuza does not have private medical insurance.
Our study contributes to the identification of important factors that are an integral part of the decision-making process for resource allocation. By highlighting these factors, we expose the gap between the state of the art in resource allocation modelling and the realities that decision-makers are faced with in their actual decision-making processes. Without a thorough understanding of existing decision-making processes, it is unlikely that formal resource allocation models can be made easily portable to any real decision-making situation.
In this study, we explored the decision-making process for allocating HIV resources in KwaDukuza. We observed that in addition to formal resource allocation techniques, many political, social and ethical factors as well as players such as donors, media and community groups have a strong influence on the allocation of HIV funds. If models are to be used, they should account for the influence of external factors; we recommend resource allocation methods that take into consideration both principles of efficient resource allocation and the role of non-quantifiable influences on the decision-making process. We refer the reader to the description of a rational economic model for resource allocation embedded in a decision-support framework that includes an analysis of the external factors that influence the process (Lasry et al. 2008
). We believe that an understanding of the influencing factors highlighted in this study can lead to improved allocation decisions.