2. Priority Setting and Resource Allocation
Priority Setting and Resource Allocation
CARE Act resources are limited and need is severe. This heightens the responsibility of Title II to use sound information and a rational decision-making process when deciding which services and other program categories are priorities (priority setting) and how much to fund them (resource allocation).
Priority setting and resource allocation (PSRA) is linked to other planning tasks because it draws upon information compiled from those efforts. For example, which needs are higher priorities depends on data compiled through the needs assessment. However, decisions must often be made with incomplete information, such as limited data on the unmet need for services or outcomes evaluation data on the effectiveness of current services. A thorough PSRA process can help address these information gaps when making decisions about what services to fund.
Legislative Background and HAB/DSS Expectations TOP
States are responsible for setting Title II service priorities, determining how best to meet those priorities, and allocating resources to them. Needs assessment and comprehensive planning should be linked to priority setting so that this information can be used to make sound decisions.
Section 2617(b)(4)(A) calls for States to “establish priorities for the allocation of funds within the State based on
“(i) size and demographics of the population of individuals with HIV disease" and “the needs of such population…;
(ii) availability of other governmental and non-governmental resources, including the State medicaid plan under title XIX of the Social Security Act and the State Children’s Health Insurance Program under title XXI of such Act to cover health care costs of eligible individuals and families with HIV disease;
(iii) capacity development needs resulting from disparities in the availability of HIV-related services in historically underserved communities and rural communities; and
(iv) the efficiency of the administrative mechanism of the State for rapidly allocating funds to the areas of greatest need within the State;”
PSRA requires allocating resources across service categories, whether by absolute dollar amounts or as percents of total funds. This requires deciding the amount or proportion of Title II program funds to be allocated to each of the service priorities that is established.
Resource allocation does not mean procurement. In determining how best to meet stated priorities, the priority setting process may stipulate what provider characteristics should be sought in the request for proposals (RFP) process. However, selection of providers is conducted through separate contracting processes.
Priority Setting and Services to Women, Infants, Children, and Youth with HIV Disease
The CARE Act requires that a certain proportion of Title II funds be used for care and support services to women, infants, children, and youth with HIV disease. The percent of the State’s total Title II service funds that go to services for women, infants, children, and youth must not be less than their percent of the total population with AIDS in the State. This provision does not require States to create a special priority for services to these populations. A waiver to this provision can be granted when States can demonstrate that the needs of each population or combination of these populations is being met through other programs such as Medicaid, Children’s Health Insurance Program (CHIP), or other CARE Act titles.
A Model for Priority Setting and Resource Allocation TOP
The following decision-making model is intended to help plan and implement decision-making processes to set CARE Act priorities and allocate resources among service categories and other program-related activities. It suggests steps that use documented needs in making decisions. Examples are provided. The model is designed to meet legislative requirements and address HAB/DSS expectations. Also provided are guidelines and additional considerations for those with more experience, information, and/or resources. The model recognizes that the process used locally may vary, based upon these factors.
This model includes the following assumptions:
The following 15 steps outline how to conduct priority setting and resource allocation and should be carried out over a period of several months, probably by committees and the full planning body.
For purposes of this document, priority setting and resource allocation are described as separate steps, carried out in sequence by a special committee and the full planning body. Two different committees might also be used, or the two processes might be combined. Each planning body should view the steps provided as one example of a sound process and should feel free to adopt or adapt it as appropriate, given their unique circumstances.
Steps in Priority Setting and Resource Allocation
1. Agree on the priority-setting and resource-allocation process and its desired outcomes.
1. Agree on the priority-setting and resource-allocation process and its desired outcome. TOP
First, agree on the specific tasks to be carried out and the expected outcomes. Usually the tasks will be decision making to set priorities and allocate resources to those priorities and provide guidance on how best to meet each priority. Priorities may include Direct Services and Program Support (e.g., capacity development, outcomes evaluation).
In setting the tasks and desired outcomes, agree on a format and level of detail for the completed priorities and resource allocations. In doing so, look back to the previous year and identify any changes or improvements needed in the service categories to be considered or the level of detail to be specified. For example, the following specific outcomes might be selected:
Each step in the planning and decision-making process should be documented. Use the following outline as a starting point. Such documentation will make it clear at the end of the process how decisions were made.
Documenting the Decision-making Process:
A. The Task and Desired Outcomes: Service Priorities and Resource Allocations
II. FACTORS IN DECISION MAKING
A. Committee Structure
III. THE DECISION-MAKING PROCESS
A. Ground Rules and Overall Approach
A. Chart of Service Priorities and Resource Allocations
2. Agree on responsibilities for carrying out the decision-making process. TOP
Next, decide who will be responsible for carrying out various steps. While final decisions should be made by the State or its designee (e.g., a full planning body), preliminary work can be delegated to a special committee If a committee approach is chosen, ensure that the committee:
Is large and diverse enough to reflect the various population groups and types of technical skills and experience needed for an inclusive and sound process (a committee of 11-15 people is typical)
Documents its work and brings process decisions such as proposed procedures and criteria for decision making to the full planning body for review and approval (see below), and
Returns to the entire planning body for review of its preliminary work and receives participation from the entire planning body in determining priorities and/or resource allocations.
A useful activity is to identify the "stakeholders" who should be involved in priority setting and resource allocation, such as:
If a committee is used to coordinate decision making, consider including representatives of these stakeholders as members. It may be useful and is entirely appropriate to involve in committee work individuals who are not members of the overall planning body. Where funds or volunteer services are available, consider using the services of a professional facilitator for this committee.
3. Review relevant legislative requirements and guidances. TOP
The group responsible for coordinating the priority setting and resource allocations process should review legislative requirements and HAB/DSS guidances to ensure that the decision-making process is compatible with them. For example, the process needs to:
Because CARE Act policies may change over time, planning bodies should consult the most recent application guidances from HAB/DSS to identify other legislative factors and HAB/DSS expectations. Information obtained should be summarized in writing and used in deciding on a decision-making process and criteria.
4. Determine and obtain available information "inputs," including comprehensive plans and needs assessments. TOP
Ideally, most or all of the information listed in the table below will be available as “inputs” to decision making. This information will help in making decisions about service priorities and resource allocations. HAB/DSS does not expect all of these data components to be used, but many States have found that using a combination of data provides the best results.
Checklist of Data/Information for Priority Setting and Resource Allocation
Data/Information Used for Priority Setting and Allocation of Funds
|Trends/changes in HIV incidence and/or prevalence|
|Trends/changes in AIDS incidence and/or prevalence|
|Changes in the demographics of HIV/AIDS cases in relation to the total population as a measure of disproportionate impact on specific populations|
|Information regarding populations with special needs, including barriers to care and other access issues|
|Quantitative data regarding persons living in the area who know they have HIV but are not receiving HIV/AIDS primary medical care|
|Outcomes Evaluation Data (e.g., effects on clients receiving specific services)|
|Client-level health status outcomes – primary medical care|
|Other health status outcomes|
|System-level health status outcomes|
|Service Utilization Data|
|Numbers of unduplicated clients; numbers of units of service provided|
|Demographic information regarding who is and is not accessing care|
|Service Cost Data|
|Unit costs for each service, known or estimated|
|Cost-effectiveness data, if available|
|Qualitative and Needs Assessment Data|
|Focus group findings|
|Client Survey results|
|Key informant interview findings|
|Estimates of unmet need among clients in the service area’s continuum of HIV/AIDS care|
|Estimates of unmet need among clients not in the service area’s continuum of HIV/AIDS care|
|Other Relevant Data|
|Co-morbidity, poverty, insurance status data|
|Information on other funding streams|
Identify missing information before priority setting begins to avoid conflict over any limitations in the process caused by a lack of data. Identifying information gaps will also help to improve the information inputs for next year's decision making.
Often, the information listed will be available but not in an easily usable form. For example, the needs assessment may be quite lengthy. An important task is to determine the kinds of information needed from each of these inputs and prepare summaries in narrative or chart form for use in decision making. For example:
5. Identify a list of service categories for consideration, including definitions, components, and how best to deliver each service. TOP
HAB/DSS provides a list of HIV-related service categories and definitions that indicate what services may be funded under specific titles of the CARE Act. Prioritized services should be consistent with this list. Those that fall outside these areas (in cases where the State has other service lists and definitions) may be included, provided they are in compliance with existing HAB/DSS policies on allowable services.
Because different terms are sometimes used to describe similar services, and certain activities can be provided in more than one service category, a consistent listing can greatly simplify discussions about needs and priorities. For example, in some service areas, client advocacy is considered a part of case management, while in other locations it is a separate service category or is included in various program areas (e.g., housing services staff provide client advocacy on housing services, while personnel within medical clinics provide client advocacy on health care).
Following are helpful steps in defining the service categories:
Remember that the service categories should be listed so they illustrate options for consideration in meeting documented needs. For each HIV health care need identified, choose the service interventions that work best in your area. For example, your needs assessment might indicate that PLWH need to have their care coordinated. This might be accomplished through case management or through some other service intervention. Once a list of service categories and interventions is developed, the committee should provide it to the full planning body for review and approval. The box suggests two ways to approach defining service categories.
Two Models for Developing Service Categories
Model A. A service priority may be specified as a broad service category with several "subcategories" within it, such as:
Model B. Services for specific populations or geographic areas, or using different types of interventions, may be specified as separate priorities. For example, a planning body might specify several different priorities that involve case management services for different groups of clients, different geographic areas, or different service models, such as:
6. Agree on principles to be applied in decision making. TOP
Sound priority setting must be based on principles and criteria for decision making, which must be clearly stated and consistently applied. A first step is to identify—and obtain any needed review and approval of—the principles that will be used in guiding the decision-making process (see examples below.) Often, such principles have been discussed and reflected in the area's comprehensive HIV services plan. In making decisions about priorities, the decision-making body should consider whether proposed priorities are consistent with these principles.
Sometimes documentation may not exist to apply all these principles. For example, cost-effectiveness and outcome-effectiveness data may not be available. Note how the lack of information limits the quality of decision making and specify additional information needed in future years.
Possible Principles to Guide Decision Making
1. Decisions must be based on documented needs.
2. Services must be responsive to the epidemiology of HIV/AIDS in this service area.
3. Priorities should contribute to strengthening the agreed-upon continuum of care, including providing primary health care, limiting duplication of services, and minimizing the need for hospitalization.
4. Decisions are expected to address overall needs within the service area, not narrow advocacy concerns.
5. Services must be culturally appropriate.
6. Services should focus on the needs of low-income, underserved, and severe needs populations.
7. Equitable access to services should be provided across geographic areas and subpopulations.
8. Services should meet Public Health Service treatment guidelines and other standards of care and be of demonstrated quality and effectiveness.
7. Determine the criteria to be used in priority setting. TOP
In addition to principles, agree on the criteria to be used in setting priorities. These criteria should be "weighted" to determine which ones are most important in making decisions. Suggest a limited number of criteria and indicate which are most important. The box below provides sample criteria.
Sample Criteria for Priority Setting
1. Documented need, based on:
2. Quality, cost effectiveness, and outcome effectiveness of services, as measured through outcomes evaluation, quality management programs, client surveys, and other evaluation methods.
3. Consumer preferences or priorities, including services and interventions for particular populations, especially those with severe need, historically underserved communities, and individuals who know their status but are not in care.
4. Consistency with the continuum of care, and its underlying priorities, such as ensuring access to basic health care, minimizing the need for hospitalization, and eliminating duplication of services.
5. Balance between ongoing service needs and emerging needs, reflecting the changing local epidemiology of HIV disease.
An experienced planning body with extensive information "inputs" may want to add more criteria, based on the principles agreed upon in Step 6. The criteria and their relative weight should be discussed and agreed upon by the full planning body.
Note that these sample criteria do not include financial considerations, such as availability of other funding streams or unmet demand. This priority-setting model assumes that priorities will reflect judgment concerning needed services to provide a continuum of care, regardless of how these services are being funded and the extent of unmet demand for these services. Funding availability and unmet needs associated with these service priorities are considered in Step 12, as part of the resource allocation process.
In establishing service priorities, consideration of the availability of other funding and the extent of unmet service needs is required. Review suggested procedures and charts in Step 12 before deciding on the criteria to be used in priority setting.
8. Determine the decision-making process to be used. TOP
Once all the prior steps have been completed, principles and criteria for decision making will have been adopted, and arrangements will have been made to obtain summaries of available information "inputs" for review during the decision-making process.
The recommended decision making-process should be reviewed and revised as needed. There is no one decision-making process or method for priority setting. However, the considerations described below, reflecting the experience of several planning bodies, can help develop a practical method.
As noted earlier, some planning bodies may want to combine the priority setting and resource allocation processes. However, if a committee is doing the preliminary work, it is generally better for the entire planning body to review and approve the service priorities before the committee begins to allocate resources to them. This ensures careful planning body attention to both responsibilities and prevents the committee from having to redo the allocations process if the planning body makes significant changes to the service priorities.
Issues to Consider in Defining the Priority-Setting Process
Consider the following issues in defining a decision-making process:
Methods for Decision Making
9. Implement the process: set service priorities, including how best to meet them. TOP
Once the planning body has adopted a priority-setting process, including an agreed-upon method to make decisions, implement the priority-setting process, with staff support where available. Following is a detailed case study example of how one planning body carries out the decision-making meetings and follow up, involving both a preliminary priority-setting meeting of a committee and a final priority-setting meeting of the full planning body.
Example of a Preliminary
1. A roll call ensures that committee members present represent the diversity necessary for an informed priority-setting process.
2. To address conflict of interest concerns, the chair asks members of the committee to disclose any relationships with current and potential CARE Act service providers (e.g., employment, board membership, spouse/partner employment or board membership, financial relationship) and indicate the kinds of HIV/AIDS-related services these providers offer. Two provider representatives disclose that they are the only provider in the service area that delivers a particular type of service. Because the priority-setting process does not involve decisions to fund particular providers, all committee members are permitted to participate in discussion and voting.
3. The chair reads the principles and criteria that have been adopted to guide the priority-setting process, and asks whether they are clear and understandable to all members. The chair also reminds the committee that they are expected to represent the interests of all PLWH in the service area when they set service priorities.
4. Several members of the committee and planning body staff (previously assigned this responsibility) present summary information on documented need—including the needs of individuals who know their status but are not in care—as well as service quality and outcomes and consumer preferences. All members receive handouts summarizing this information in narrative or chart form. Included is a chart showing the number of people with HIV disease in the service area, by stage of illness. These data are presented by population (e.g., women, racial/ethnic minorities, homeless, substance abusers) where available.
5. The committee reviews the list of essential services (the core continuum of care) as agreed upon by the planning body.
6. The committee reviews the agreed-upon list of service categories, with reference to priorities established last year.
7. The committee discusses how best to meet each identified need in terms of specific service interventions and the service categories through which they might be provided. Specific components or interventions are specified within service categories, populations and geographic areas of focus identified, and service categories added to the list where needed. To generate this information about needed services, the committee uses a "nominal group process," writing down individual lists, and then sharing their responses using a "round robin" process, until all contributions have been presented and recorded on an easel pad or whiteboard. Responses are clarified as needed. The group attempts to reach consensus around the scope and components of each service category and identifies areas of disagreement for presentation to the full planning body.
8. Committee members present their recommendations for service priorities through a structured discussion, with time limits enforced by the chair.
9. During the discussion, all committee members are expected to base their recommendations on the agreed-upon principles and criteria, which should include the use of evidence as a basis of recommendations. If a recommendation violates the principles or does not reflect the criteria, other members take responsibility for pointing this out and challenging the member to meet these requirements.
10. Once the discussion period has been completed, the chair restates the principles and criteria to be used in decision making. Then each committee member is asked to individually rank the service categories, using prepared sheets.
11. Individual rankings are tabulated and an aggregate listing of service priorities is generated. The committee reviews these priorities and makes needed adjustments, by consensus in most cases, and by vote in two situations where consensus was not possible. Areas of disagreement are recorded for presentation to the full planning body.
12. The committee identifies Planning Body Support and Program Support activities that are expected to require resources during the program year. Examples include: planning body staffing, an updated needs assessment to gather data about the needs of PLWH who know their status but are not in care, an updated comprehensive plan, and evaluation of cost effectiveness and outcome effectiveness. A "nominal group process" is used to add to the list of possible Program Support activities. Then the committee conducts a preliminary vote to select the top three priorities. Activities not among the aggregate top three are listed as "low priority" but retained for full planning body review. Remaining activities are then ranked in priority order through a tabulation of individual committee member rankings, for presentation to the full planning body.
13. Selected committee members and/or staff document the process and recommendations for use in the presentation to the planning body.
Example of a Planning Body Meeting
1. Prior to the meeting, the planning body receives the following:
2. At the beginning of the meeting, the planning body chair addresses possible conflict-of-interest concerns by asking members to disclose any relationships with current and potential CARE Act service providers and indicate the kinds of AIDS-related services these providers offer. Provider staff, board members, and volunteers provide these disclosures, as does the partner of a provider director. Several provider representatives also disclose that they are the only providers of certain services; they agree to respond to questions about those services but not to serve as their primary advocates. Because the priority-setting process does not involve decisions to fund particular providers, all committee members are permitted to participate in discussion and voting.
3. The chair reads the principles and criteria adopted to guide the priority-setting process and ensures that all members understand them. The chair also reminds the committee members that they are expected to represent the interests of all PLWH in the service area when they set service priorities.
4. Committee representatives present the recommended list of service priorities, including specific components, populations, and geographic areas identified within service categories. Priorities are justified in the context of documented need (with special attention to historically underserved communities and the needs of individuals who know their status but are not in care), consumer preferences, and evaluation data. Areas of consensus and disagreement are identified.
5. Planning body members raise issues and concerns, and committee members justify their recommendations by explaining how they reflect the decision-making criteria and principles.
6. Planning body members suggest refinements to the priorities. They are asked to justify their recommendations through the agreed-upon criteria. Most changes are made by consensus.
7. Several areas remain where consensus is not possible, so the planning body members are asked to individually rank these possible service priorities using a scoring sheet. Results are tabulated, and the revised priorities are reviewed and further refined where necessary. The chair indicates that if one-third or more of members feel further refinement is needed, time-limited discussion will be permitted and members will be asked to vote on the ranking of specific categories about which there is no consensus. Because there is a lack of consensus about the relative ranking of two service categories, voting is used for these service categories. The results of the vote generate a final list of service priorities, which is approved by consensus.
8. The planning body ensures adequate written documentation throughout the process, including specific notation of areas for possible improvement, such as missing or incomplete information. Follow-up discussion is planned to be sure that these needs are adequately recognized in the resource allocations process, to improve the amount and quality of information available for the following year's priority-setting process.
10. Define the scope of the resource-allocation process. TOP
If the planning body is responsible for resource allocations as well as priority setting, it should now define the scope of this activity. The extent of the effort depends upon the planning body's scope of responsibility. Some planning bodies are responsible for allocating funds from one CARE Act title, while other handle multiple sources, such as Title I, Title II, and HOPWA (Housing Opportunities for People With AIDS) funds.
Step 1 identified typical outcomes for the priority-setting and resource-allocation task. The desired outcome of the resource-allocation process is typically a chart showing the percent or dollars to be allocated to each service category or subcategory. To reach this outcome, the resource-allocation process typically requires the following activities:
Present the results of the resource allocations task in summary form. This might mean preparing a chart indicating service priorities and resource allocations to each of those services—in terms of dollars or percent of funds—with a separate column for each funding stream for which the planning body is responsible. The format for presenting the completed task might be as shown in the sample Priorities and Resource-Allocations Chart at the end of Step 13. Additional columns would be needed for each additional funding source. An additional column might also be used to show the dollars allocated to each service category and subcategory, in addition to the percent of funds.
Generally, resource allocations will need to be completed before final figures are available on funding. Therefore, allocations can be based on various funding assumptions, such as:
Or, allocations can be based on an expected minimum level of funding, with information about how additional funds will be allocated, as in the first scenario described in Step 13.
11. Agree on the principles, criteria, decision-making process, and methods to be used in allocating funds to service categories. TOP
Factors to use in resource allocation are usually similar to those used for priority setting, with some refinements. The principles and criteria used for priority setting should modified as needed for use in the allocations process. If a committee is delegated responsibility for recommending resource allocations to the full planning body, the committee should recommend, and the planning body should review and approve, these factors.
Regarding principles, the planning body might want to add the following, which reflect CARE Act requirements:
Regarding criteria, the planning body might want to add the following:
Regarding the decision-making process, many issues need to be considered. If the planning body uses a committee process to set priorities, it can use the same committee to do the resource allocations, including the same attention to scheduling and publicizing meetings and ensuring open forums. The complexity of the resource-allocation process makes especially important a committee process—supported by staff work and followed by review and decision making at a full planning body meeting.
As with priority setting, the committee should recommend the process to the planning body, and the planning body should review and approve it. Many of the considerations are identical to those identified in Step 8; some additional considerations are described below.
Additional Issues to Consider in Defining the Resource-Allocation Process
12. Estimate needs by service category. TOP
Thoughtful resource allocations depends upon the amount and quality of information available on:
As explained in Step 7, some planning bodies consider unmet service needs, including financial requirements to meet these needs, in setting their priorities. If your planning body uses this approach, you may already have compiled the information described below by the time you begin the resource-allocation process. If so, make sure the materials described below are available for review as you determine resource allocations.
Several of your analyses will require an inventory of the sources and levels of other governmental and nongovernmental resources available to support AIDS services in your community. Such information is also necessary to assess and, to the extent possible, quantify gaps in services. This inventory may be a part of your needs assessment.
The planning body should gather available information by service category. If information is available only for some types of services, use what is available and identify information gaps. It is particularly helpful to prepare charts that list service priorities in order and provide information needed for the allocations process. Examples of particularly useful analyses and charts follow.
Prepare a comparison of the service priorities for the upcoming year with the priorities and allocations identified for the current year.
The chart format might look like this:
Service Priorities Comparison
|Ambulatory Medical Care|
|Drug Reimbursement (ADAP)|
|Emergency Financial Assistance|
Food and Nutrition Services
|[List other priorities]|
Obtain information on the units of service provided and the costs per unit of service or per client for the service categories or components within them. The most easily obtainable information might be the number of clients served in a year and the estimated costs per client per year. Your chart might look like this:
Services and Costs
No. of Clients Served Per Week
Average Cost Per Client Per Year
Funding for Current Year
Ambulatory Medical Care
• City X
|AIDS Drug Assistance Program (ADAP)|
|Emergency Financial Assistance|
Food and Nutrition Services
• Home-Delivered Meals
• Spanish-speaking/Latino clients
|<<th scope="row" width="54%">[List other priorities]|
If available, provide a more extensive analysis of your current year funding levels. For example, did funds for certain services (e.g., emergency financial assistance) run out before the end of the year, or were funds reallocated because of under-expenditure or low demand? Obtain the grantee’s or administrative agent's projection of unspent funds for each service category. If this information is available, make it a separate column on your chart.
Estimate current service gaps in terms of unmet service need by priority. For example, given the current funding situation, estimate the number of PLWH who are not receiving primary care, case management, etc., and are in need of such services. If possible, provide this information by service priority, and estimate the costs for meeting that need. Review unit costs for the past year, and modify as needed to project for next year. Use a format such as the following:
Unmet Service Needs and Cost Estimates
Unmet Service Need
Estimated Number of Persons Needing But Not Receiving Service
Estimated Additional Cost of Meeting Need (Above Current Funding)
|Drug Reimbursement (ADAP)|
|Viral Load Testing|
|Substance Abuse Treatment -|
|Case Management - Family-Centered; for|
|Ambulatory Medical Care in Outlying County X|
|[List other unmet service needs]|
Prepare a combined chart of estimated total needs by service priority, both met and unmet, and available funding. Using the format shown in the chart below, include the following:
Estimated Service Needs
Total Need Per Year (Number of Clients)
Average Cost Per Client Per Year
Total Funds Required to Meet Need
Other Available Funds
Unmet Need or Service Gap
|Ambulatory Medical Care|
|AIDS Drug Assistance Program (ADAP)|
|Emergency Financial Assistance|
(break out by Food,
Food and Nutrition Services
|[List other service categories]|
Once you have prepared this information, you are ready to carry out your agreed-upon resource-allocation process.
13. Allocate resources to service categories. TOP
To allocate resources to established priorities, you will probably need one or two meetings to agree upon and review the principles, criteria, and processes described in Step 11, and to develop and review the information described in Step 12. The allocations process might then proceed to the development of alternative scenarios or funding formulas. Based on the Step 12 information charts, you can develop alternative scenarios or allocation formulas for the committee's review. Following are four possible resource-allocation scenarios:
Sample Scenarios for Use in Resource Allocations
Divide priorities into tiers of services and other activities, as follows:
Determine what is likely to be the minimum amount of funding received. First allocate the funds needed to ensure continuation of first-tier services at the same funding level as the current year, if continued funding is needed. Once these core services have received level funding, allocate a specified proportion of additional expected funds (e.g., 60 percent) to all second-tier categories, so that they all receive the same percentage of the previous year's funding level. Use the remaining proportion of funds (e.g., 40 percent) to expand funding for first-tier categories towards the estimated total need. If funding is higher than projected, use the same allocations procedure (e.g., 60-40) to fund first-tier and second-tier categories.
Continue to fund all existing services but at a specified percent reduction (e.g., 11 percent cuts across the board) to generate a pool of $X dollars for allocation to new service priorities (e.g., drug reimbursements, viral load testing, substance abuse treatment for women, and family-centered case management for Spanish-speaking PLWH). If next year's funding level were higher or lower than expected, increased funds might be allocated proportionately to current and new services, or cuts applied equally to all services.
Continue to fund at the same level those services with high priority rankings, or those identified in the continuum of care as essential to life or essential to providing access to care. Cut other services by a specified percent (e.g., 3 percent; use the pool of funds created by the cuts to fund new priorities or unmet components of high-priority service categories (e.g., substance abuse treatment services for women, case management services for Spanish-speaking PLWH, ambulatory medical care in an outlying county). If the funding level is higher than expected, a set percentage of increased funds might go to new services, high-priority existing services, and lower-priority existing services. If the funding level is lower, a set percentage in cuts might be applied across all services.
Divide services into tiers as in Scenario #1. Continue to fund existing services in first and second tier but decrease funding levels for second-tier services. Base these reductions on a careful review to identify services that are lower in priority, level of unmet need, and/or availability of other resources. Make sufficient cuts to generate a pool of $X dollars to allocate to new service priorities and to increase allocations to specific components within high-priority services which have high levels of unmet need and low availability of other resources.
In all these scenarios, because the planning body does not consider resource availability in the priority-setting process, the highest-priority service within the EMA is not always the service that receives the highest allocation of resources. The highest-priority service may cost less than other services and/or other non-CARE Act resources may be available to fund it. A planning body might, for example, identify outpatient primary health care as its top service priority, but allocate little or no CARE Act funding to the service category if funds were available from other sources. Similarly, a service category that was relatively lower priority but was not funded through other available funding streams might be allocated a large proportion of CARE Act funds. This approach to priority setting and resource allocation has the advantage that it applies regardless of changes in other funding streams. For example, if severe cuts were to occur in funding for outpatient primary health care, the planning body might want to reallocate some of its resources, but would not need to change its priorities. Similarly, if the demand for medications grew beyond the State ADAP’s capacity to meet it, a planning body might choose to allocate additional funds for medications rather than other services.
A Resource Allocations Committee Meeting
1. The chair makes sure that the committee members present provide the diversity needed for the resource-allocation process.
2. The chair describes the task to be completed, and reads the principles and criteria adopted to guide the process. S/he also reviews the planning body's agreed-upon continuum of care to be sure everyone is familiar with it.
3. Committee members are asked to disclose any possible conflict of interest, and any relationship to providers offering services that are among the priority categories. A decision is made that all members may participate in discussion and/or voting but must refrain from voting on those categories in which they have a conflict of interest.
4. The committee members and staff who prepared the charts estimating service needs present their findings and analysis. They provide available information to address each of the criteria, such as information on service quality, outcomes effectiveness, and consumer preferences. Committee members ask questions and obtain clarification of available information and information gaps.
5. The committee discusses the information, with emphasis on unmet needs, the costs of meeting unmet needs, and the availability of other resources. New service priorities and components are highlighted, and the committee reviews the comparison between the new service priorities and those of the previous year.
6. There is discussion regarding the need to provide resource allocations for specific service components, populations, and geographic areas.
7. The alternative scenarios are presented and discussed. Staff have prepared charts showing what the allocations would be under each scenario. As agreed in Step 11 when the planning body determined the decision-making method to be used, committee members discuss and vote on which scenario to use. This scenario reflects what they feel best reflects the overall approach that should be used in allocating resources to the service categories. They pick Scenario #1.
8. Once the outline of a scenario is agreed upon:
9. The recommended allocations are summarized in several charts based on level funding and assumptions of increased and decreased funding, and staff document the committee process for presentation to the full planning body.
Resource allocations are finalized at a full planning body meeting. As with the draft service priorities, the committee presents and justifies recommended resource allocations at an open meeting. Principles, criteria, needs and resource data, and the selected scenario are also presented and discussed. The full planning body reviews the entire process, especially the selected scenario and its rationale, and suggests modifications if needed, based on the criteria and the needs and resource information. The planning body either reaches consensus on the resource allocations, or adopts them through a formal vote.
Staff document the resource-allocation process along with the priority-setting process and results (See Step 1 for a sample format for documentation). Once this process is completed, the results of priorities and funding allocations are summarized, as in the table below.
Service Priorities and Funding Allocations
Service Category and Description
Percent of Funds
Primary Medical Care
• City X
|Medications/Drug Reimbursement (ADAP)|
Emergency Financial Assistance
Food and Nutrition Services
• Home-Delivered Meals
• City X [includes women-centered services; services for gay men of color, Latinos/Spanish speakers and African Americans]
• City X
Mental Health Care
• City X [Includes culturally appropriate services for Spanish speakers and African Americans]
Substance Abuse Treatment
• City X [includes women-centered services; services for gay men of color, Latinos/Spanish speakers and African Americans]
|Planning Body Support|
Home Health Care
• Paraprofessional Home Health Aide Care
|Capacity-Building Assistance to Community-Based Service Providers|
(Residential and Home)
• Housing Assistance
These priority-setting and resource-allocation decisions are reported to the community. The planning body publicizes its decisions through public hearings or meetings in several locations.
14. Provide decisions to the grantee or administrative agent for use in procurement. TOP
The planning body must provide the grantee or administrative agent with the results of the priority-setting and resource-allocation process as a basis for the selection of providers (the procurement process). The planning body's priorities will reflect specific population groups, geographic areas, and service delivery mechanisms.
15. Identify areas of uncertainty and needed improvement. TOP
Once the entire process has been completed for the year, the committee and the full planning body should review the experience and identify ways to improve the process in future years. A designated group should:
This chapter is an update of Priority Setting and Resource Allocation, a HAB/DSS technical assistance guide published in 1998.
 See the Appendix for a list of service categories that may be funded under Title II.
 For more information on decision-making methods, see the Training Guide: Preparing Planning Body Members.
 See Conflict of Interest and Planning Body Duties chapters in this manual.
 See also the section on Planning Body Duties in this manual.