Ethics and economics: does programme budgeting and marginal analysis contribute to fair priority setting?

Objective: Limited resources mean that decision-makers must set priorities among competing opportunities. Programme budgeting and marginal analysis (PBMA) is an economic approach that focuses on optimizing benefits with available resources. Accountability for reasonableness ( A4R) is an ethics approach that focuses on ensuring fair priority-setting processes. PBMA and A4R have been used separately to provide decision-makers with advice about how to set priorities within limited resources. The goals of this research were to use the A4R framework to evaluate the fairness of using PBMA for priority setting and to assess how A4R might make PBMA fairer. Methods: Qualitative case studies to describe priority setting using PBMA in the Calgary Health Region (Alberta, Canada) evaluated using A4R as a conceptual framework. Results: The use of PBMA for priority setting was fairer than previous priority setting because of its emphasis on explicit rational decision-making. However, there were opportunities to improve the process, particularly by collecting data related to the decision criteria, by developing a communication plan to engage internal and external stakeholders about priority-setting, and by providing a formal mechanism to review priority-setting decisions and resolve disputes. Conclusions: There is potential for combining A4R and PBMA in a more comprehensive approach to priority setting, which uses a fair priority-setting process to reach decisions aimed at achieving optimal benefits with available resources.