Grey priority-setting: an ethnographic study of hospital budgeting in Norway
Year: 2026
Type: article
Abstract: Background Priority-setting at all levels in the health care system implies value trade-offs and tough decisions. When budgeting, hospital leaders distribute substantial proportions of health care funds between the competing claims of clinics and therefore patient groups. However, there is a lack of empirical knowledge on real-life priority-setting at the meso level. This paper aims to document the process of resource allocation between hospital clinics in a Norwegian hospital. Methods This ethnographic study is based on extensive observations of budgeting meetings and in-depth interviews with 12 leaders in a large Norwegian hospital trust during 2022 and 2023. The observational notes and interview transcripts were analysed by drawing on reflexive thematic analysis informed by theories of procedural fairness in health care priority-setting. Results The findings portray how budgeting was divided into three main types of priority-setting decisions: (1) the given priorities imposed on hospital leadership by external factors, (2) the chosen priorities: additional funding explicitly distributed by the hospital leaders and (3) the grey priorities: budgetary cuts imposed by additional funding in other areas, conducted and communicated with very limited openness. Priority-setting discussions were focused on the chosen priorities, with a decoupling between the services and clinics receiving additional and those receiving reductions in funding. Comparisons of possible allocations based on the national priority-setting criteria of severity, health benefit and resource use were extremely uncommon. Conclusions Through the budgeting process, priority-setting decisions were rendered less transparent due to competing rationales in the hospital organisation and a notable lack of comparisons between possible budget allocations. As such, the key concept of opportunity cost was lost from view. The findings enhance our understanding of real-life priority-setting processes and highlight the need for research into the ‘grey box’—the mechanisms through which cuts are made to accommodate new priorities. Clinical trial number Not applicable.
Source: BMC Health Services Research
Authors: Andrea Melberg, Ingrid Miljeteig
Institution: University of Bergen
Language: English
Subfield: General Health Professions
Field: Health Professions
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $3,290
OpenAlex ID: W7212275167
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