Priority setting methods for health care decision-makers

Programme budgeting and marginal analysis (PBMA) is as an explicit, robust, and practical tool to assist decision-makers in setting priorities in health care. The PBMA framework has been used in at least 70 health service organisations across the UK, Australia, and Canada over the last 25 years. In this paper, we synthesise experiences from these countries in both developing the PBMA framework and implementing the results of PBMA exercises. In particular, we have found the methods used in PBMA are now less mechanistic than they have been in the past, recognising the need to balance pragmatic and ethical considerations with economic rationality. We identify and discuss international challenges and advances in the application of the PBMA framework in local health service organisations. Finally, we describe a framework for pragmatic study design in PBMA studies, based on lessons learnt from the practical application of PBMA, including institutional and managerial challenges in health systems.