The COVID-19 pandemic constrained social, economic and health care systems globally. The acute and intense demand on health system resources led to a mismatch between what was available and the varied public health needs. Under such conditions, effective priority setting, can support fair resource allocation decisions and the achievement of equitable outcomes, as seen in many settings during usual, non-emergency times.

Effective priority setting is often implemented by a legitimate committee/organization that has the capacity to set priorities and supported with adequate human and financial resources to set and implement the identified priorities; it includes (dis)incentives to ensure that these priorities are implemented. This should be based on a systematic approach, using evidence, explicit criteria and a fair process. Fairness in priority setting aims to uphold principles of justice, ensuring that scarce resources are distributed fairly among individuals and populations, regardless of socioeconomic status, ethnicity, or other factors. [1] While the importance of priority setting in healthcare to support fair resource allocation has been widely discussed in the literature prior to the COVID-19 pandemic, [2], [3], [4] there was limited literature on priority setting and resource allocation during emergency contexts and in times of crisis.

Fair priority setting processes are crucial during health emergencies to ensure that resources are allocated equitably and efficiently, and ideally, maximize their impact while minimizing harm. This promotes social cohesion and trust in the health system. Explicit priority setting processes can also enhance public accountability in practice by transparently articulating the criteria and rationale behind resource allocation decisions [5]. This fosters public trust and confidence in authorities' handling of the crisis. Additionally, prioritizing interventions based on evidence of effectiveness, potential to save lives or reduce suffering optimizes the use of limited resources, maximizing the overall health impact of emergency responses [6]. Moreover, fair priority setting processes mitigate the risk of exacerbating existing health disparities and inequities, ensuring that vulnerable and marginalized populations receive adequate support and protection during emergencies. Overall, these processes can uphold ethical principles, promote public trust, optimize resource allocation, and safeguard vulnerable populations, highlighting the value of explicit priority setting during health emergencies [7,8].

This Special Issue (SI) presents a series of papers on “The inclusion of systematic priority setting in the initial national COVID-19 plans”. This work, supported by McMaster University COVID-19 fund, was led by Lydia Kapiriri and Beverley Essue with an international team of collaborators from Canada, Chile, Uganda, the USA, and Zambia. Based on a review of 86 national pandemic plans representing the six World Health Organization (WHO) regions, the study assessed the degree to which the initial national COVID-19 plans included different aspects of effective priority setting.

Several assumptions guided this document analysis:

As policy documents indicate national commitment to implementation, we assumed that including aspects of priority setting in a national COVID-19 pandemic plan signaled policy-makers’ willingness and commitment to including systematic priority setting and resource allocation in their pandemic response.

Most of the literature on transparency links it to democratic political systems. Hence, there was an expectation that countries with democratic political systems involved a wide range of stakeholders in developing their pandemic plans, and publicized their plans.

It was logical to assume that countries that had instituted systematic priority setting prior to the pandemic would include priority setting in their initial national pandemic plans, as priority setting would have been established as routine practice.

The inclusion of systematic priority setting was also assumed to have been associated with experiences with disease epidemics based on the premise that all outbreaks exert exponential demands on the available resources, necessitating prioritization. Countries with prior pandemic experiences, or other emergency ‘shocks’ to their health systems would be expected to have some experiences with grappling with priority setting and resource allocation within the context of disease outbreaks.

There was an assumption that the inclusion of priority setting would vary according to countries’ socioeconomic status and organization of the health care system. The latter was assessed through the WHO regional analysis.

In addition to the general assessment of the inclusion of priority setting, the literature discusses several parameters of fair priority setting such as wide stakeholder involvement, consideration of explicit criteria, and including equity considerations. The importance of these parameters became increasingly apparent during the pandemic as in most instances, there was limited stakeholder engagement. In particular, while WHO and other scholarly guidance called for the engagement of those populations who were most affected by the pandemic, limited engagement was observed. Furthermore, both stakeholder engagement and explicit criteria and equity considerations have been more often discussed during normal times. The urgency, politics and the pressure to make decisions urgently may have impacted the inclusion of these parameters in the decision making. However, it is important to note that the exclusion of these parameters would impact the quality and legitimacy of the prioritization decisions; both of which are critical to effective priority setting.

This SI focuses on the inclusion of priority setting in national COVID-19 pandemic plans. The section addresses the degree to which the parameters of effective priority setting were and could be integrated in national policy-making and pandemic planning. Since policy-makers across the world were faced with the priority setting challenge, the regional and global nature of these papers make them relevant to policy-makers across the globe.

This SI presents findings from a subset of our global analysis of priority setting for the initial stages of the COVID-19 pandemic. In the first three papers, Kapiriri et al., Williams et al., and Essue et al. describe and evaluate the parameters of effective priority setting included in the national plans from Canada, the European Region and the Western Pacific Region respectively. These papers analyze if and how the inclusion of priority setting in the national plans varied between the sub-regions/countries based on different political systems, health systems, socio-economic status and experiences with priority setting and previous disease epidemics. A common finding from this research was that while all reviewed plans included aspects of priority setting, they did not include all parameters of effective priority setting [9], [10], [11].

Two papers focus on common conditions recognized for effective and systematic priority setting, namely stakeholder involvement and the inclusion of explicit criteria and equity considerations. Aguilera et al.’s paper assess the degree to which stakeholders were included in the plans’ development, as well as identifying the stakeholders who were identified in the plans [12]. Kapiriri et al. evaluate the criteria that were identified in the 86 plans and critique the emphasis given to equity considerations within the plans [13]. These papers, in addition to identifying the stakeholders, criteria and equity considerations within the national plans, also discuss the complexities of practically considering the various parameters within contexts that require quick decision making. The balance between legitimacy and quality, and timely decision making can be treacherous and is discussed in these papers.

The methodology that anchors this research was published as a standalone paper to guide future research and priority setting evaluation in this area [14]. Table 1 details the papers published in this SI.

A further six aligned papers were published elsewhere and describe priority setting during the initial phases of the pandemic in the remaining WHO regions: African Region, [15] Eastern Mediterranean Region [16], South East Asia Region [17] and in Latin America and the Caribbean [18] complementing the global analysis of priority setting during pandemics that is advanced through this research.

The key lessons relate to the methods employed- including the framework, and the study findings.

The study methods focused on a rapid document review study which relied on the availability of the documents. This approach was appropriate and enabled us to obtain some of the relevant documents. However, several countries were left out since their plans were not accessible. Furthermore, new documents were developed as the pandemic evolved – these were not reviewed. Hence, since the availability of policy documents can be an indicator of the nation's transparency, it is important that the pandemic planning documents are openly available. While the document review is a reasonable and appropriate start for conducting policy research during a pandemic, it should be complimented with interviews and a review of any emerging documents.

The framework of effective priority setting was robust enough to guide the systematic abstraction of the parameters of effective priority setting included in the pandemic plans. It also provided a standard approach to the cross-country and cross-region comparison. However, this is only one of the many frameworks which can be used (based on the objectives of the assessment). Furthermore, it may not be feasible to use all (over 20) of the current framework's parameters within the context of the pandemic: it may be more realistic for decision makers identify a subset of the key parameters they want to include in their policy documents

The study findings show that most of the reviewed pandemic plans across the six WHO regions, had evidence of political will, stakeholder participation, use of evidence. However, very few included the other parameters of effective priority setting. The inclusion of the parameters did not consistently vary according to the countries’ income level, type of health system or political regime, experience with disease pandemics or priority setting. Although it is possible that as the pandemic evolved and countries learned from each other they may have included these parameters in the follow up documents, these findings highlight the potential difficulties in incorporating parameters of effective priority setting in the initial planning documents. However, since priority setting emerged as a critical consideration during the pandemic, it is important that the parameters of effective priority setting are considered in tandem with the development of any policy document.