1
|
Mbau R, Oliver K, Vassall A, Gilson L, Barasa E. A qualitative evaluation of priority-setting by the Health Benefits Package Advisory Panel in Kenya. Health Policy Plan 2022; 38:49-60. [PMID: 36373870 PMCID: PMC9849713 DOI: 10.1093/heapol/czac099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 09/12/2022] [Accepted: 11/13/2022] [Indexed: 11/16/2022] Open
Abstract
Kenya's Ministry of Health established the Health Benefits Package Advisory Panel (HBPAP) in 2018 to develop a benefits package for universal health coverage. This study evaluated HBPAP's process for developing the benefits package against the normative procedural (acceptable way of doing things) and outcome (acceptable consequences) conditions of an ideal healthcare priority-setting process as outlined in the study's conceptual framework. We conducted a qualitative case study using in-depth interviews with national-level respondents (n = 20) and document reviews. Data were analysed using a thematic approach. HBPAP's process partially fulfilled the procedural and outcome conditions of the study's evaluative framework. Concerning the procedural conditions, transparency and publicity were partially met and were limited by the lack of publication of HBPAP's report. While HBPAP used explicit and evidence-based priority-setting criteria, challenges included lack of primary data and local cost-effectiveness threshold, weak health information systems, short timelines and political interference. While a wide range of stakeholders were engaged, this was limited by short timelines and inadequate financial resources. Empowerment of non-HBPAP members was limited by their inadequate technical knowledge and experience in priority-setting. Finally, appeals and revisions were limited by short timelines and lack of implementation of the proposed benefits package. Concerning the outcome conditions, stakeholder understanding was limited by the technical nature of the process and short timelines, while stakeholder acceptance and satisfaction were limited by lack of transparency. HBPAP's benefits package was not implemented due to stakeholder interests and opposition. Priority-setting processes for benefits package development in Kenya could be improved by publicizing the outcome of the process, allocating adequate time and financial resources, strengthening health information systems, generating local evidence and enhancing stakeholder awareness and engagement to increase their empowerment, understanding and acceptance of the process. Managing politics and stakeholder interests is key in enhancing the success of priority-setting processes.
Collapse
Affiliation(s)
- Rahab Mbau
- *Corresponding author. Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. E-mail:
| | - Kathryn Oliver
- Department of Public Health Environment and Society, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Lucy Gilson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK,Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory 7925, South Africa
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, P.O. BOX 43640-00100, 197 Lenana Place, Nairobi Kenya,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Old Campus, Roosevelt Drive, Oxford OX3 7LG, UK,Institute of Healthcare Management, Strathmore University, Karen Ole Sangale Road, P.O. BOX 59857-00200, Nairobi, Kenya
| |
Collapse
|
2
|
Sakowsky RA. Disentangling the welfarism/extra-welfarism distinction: Towards a more fine-grained categorization. HEALTH ECONOMICS 2021; 30:2307-2311. [PMID: 34216077 DOI: 10.1002/hec.4382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/08/2021] [Accepted: 06/18/2021] [Indexed: 06/13/2023]
Abstract
In health economics, the distinction between welfarism and extra-welfarism has been employed to discuss various epistemological and normative differences between health evaluation approaches. However, a clear consensus on the definition of either welfarism, extra-welfarism, or the differences between the two sets of approaches has not emerged. I propose an alternative set of distinctions that allows for a more fine-grained categorization of health evaluation approaches. This categorization focuses on five dimensions: (1) the maximand of an evaluation approach, (2) its sensitivity toward normative concerns that defy compensation, (3) its position on which groups of individuals or collective entities act as sources of values, (4) its sensitivity to changes of mind, and (5) the inclusion of process-external values.
Collapse
Affiliation(s)
- Ruben Andreas Sakowsky
- Department of Medical Ethics and History of Medicine, University Medical Center Göttingen, Göttingen, Germany
| |
Collapse
|
3
|
Fattore G, Federici C, Drummond M, Mazzocchi M, Detzel P, Hutton ZV, Shankar B. Economic evaluation of nutrition interventions: Does one size fit all? Health Policy 2021; 125:1238-1246. [PMID: 34243979 DOI: 10.1016/j.healthpol.2021.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 06/14/2021] [Accepted: 06/24/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Nutrition interventions have specific features that might warrant modifications to the methods used for economic evaluations of healthcare interventions. AIM The aim of the article is to identify these features and when they challenge the use of cost-utility analysis (CUA). METHODS A critical review of the literature is conducted and a 2 by 2 classification matrix for nutrition interventions is proposed based on 1) who the main party responsible for the implementation and funding of the intervention is; and 2) who the target recipient of the intervention is. The challenges of conducting economic evaluations for each group of nutrition interventions are then analysed according to four main aspects: attribution of effects, measuring and valuing outcomes, inter-sectorial costs and consequences and equity considerations. RESULTS AND CONCLUSIONS CUA is appropriate for nutrition interventions when they are funded from the healthcare sector, have no (or modest) spill-overs to other sectors of the economy and have only (or mainly) health consequences. For other interventions, typically involving different government agencies, with cost implications for the private sector, with important wellbeing consequences outside health and with heterogeneous welfare effects across socio-economic groups, other economic evaluation methods need to be developed in order to offer valid guidance to policy making. For these interventions, checklists for critical appraisal of economic evaluations may require some substantial changes.
Collapse
Affiliation(s)
- Giovanni Fattore
- CeRGAS-SDA, Università Bocconi, Milano, Italy; Department of Social and Political Sciences, Università Bocconi, Milano, Italy.
| | - Carlo Federici
- Department of Social and Political Sciences, Università Bocconi, Milano, Italy
| | - Michael Drummond
- Department of Social and Political Sciences, Università Bocconi, Milano, Italy; Centre for Health Economics, York University, United Kingdom
| | - Mario Mazzocchi
- Department of Statistical Sciences, Bologna University, Bologna, Italy
| | | | | | - Bhavani Shankar
- Institute of Sustainable Food and Department of Geography, Sheffield University, United Kingdom
| |
Collapse
|
4
|
Value-based healthcare: Il nuovo approccio di AIFA alla determinazione multidimensionale del valore. GLOBAL & REGIONAL HEALTH TECHNOLOGY ASSESSMENT 2020; 7:9-13. [PMID: 36627957 PMCID: PMC9677615 DOI: 10.33393/grhta.2020.2102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 04/08/2020] [Indexed: 01/13/2023] Open
Abstract
In this viewpoint, we discuss the approach promoted by the Italian Drug Agency (AIFA) to the assessment of the value of new pharmaceuticals in the Italian Healthcare Service. On top of traditionally acknowledged components, such as quality adjusted life years gained and net costs, the overall value framework might include other elements such as productivity and adherence, equity, severity of disease, reduction in uncertainty, spillover effects. There is a residual dimension in the value framework that may capture the option value or reduction in fear of contagion for infectious disease treatments. We debate measurement issues on these elements of value and discuss open issues from a methodological and policy standpoint.
Collapse
|
5
|
Criteria Used for Priority-Setting for Public Health Resource Allocation in Low- and Middle-Income Countries: A Systematic Review. Int J Technol Assess Health Care 2019; 35:474-483. [PMID: 31307561 DOI: 10.1017/s0266462319000473] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES This systematic review aimed to identify criteria being used for priority setting for resource allocation decisions in low- and middle-income countries (LMICs). Furthermore, the included studies were analyzed from a policy perspective to understand priority setting processes in these countries. METHODS Searches were carried out in PubMed, Embase, Econlit, and Cochrane databases, supplemented with pre-identified Web sites and bibliographic searches of relevant papers. Quality appraisal of included studies was undertaken. The review protocol is registered in International Prospective Register of Systematic Reviews PROSPERO CRD42017068371. RESULTS Of 16,412 records screened by title and abstract, 112 papers were identified for full text screening and 44 studies were included in the final analysis. At an overall level, cost-effectiveness 52 percent (n = 22) and health benefits 45 percent (n = 19) were the most cited criteria used for priority setting for public health resource allocation. Inter-region (LMICs) and between various approaches (like health technology assessment, multi-criteria decision analysis (MCDA), accountability for reasonableness (AFR) variations among criteria were also noted. Our review found that MCDA approach was more frequently used in upper middle-income countries and AFR in lower-income countries for priority setting in health. Policy makers were the most frequently consulted stakeholders in all regions. CONCLUSIONS AND RECOMMENDATIONS Priority-setting criteria for health resource allocation decisions in LMICs largely comprised of cost-effectiveness and health benefits criteria at overall level. Other criteria like legal and regulatory framework conducive for implementation, fairness/ethics, and political considerations were infrequently reported and should be considered.
Collapse
|
6
|
Waithaka D, Tsofa B, Barasa E. Evaluating healthcare priority setting at the meso level: A thematic review of empirical literature. Wellcome Open Res 2018. [DOI: 10.12688/wellcomeopenres.13393.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Decentralization of health systems has made sub-national/regional healthcare systems the backbone of healthcare delivery. These regions are tasked with the difficult responsibility of determining healthcare priorities and resource allocation amidst scarce resources. We aimed to review empirical literature that evaluated priority setting practice at the meso level of health systems. Methods: We systematically searched PubMed, ScienceDirect and Google scholar databases and supplemented these with manual searching for relevant studies, based on the reference list of selected papers. We only included empirical studies that described and evaluated, or those that only evaluated priority setting practice at the meso-level. A total of 16 papers were identified from LMICs and HICs. We analyzed data from the selected papers by thematic review. Results: Few studies used systematic priority setting processes, and all but one were from HICs. Both formal and informal criteria are used in priority-setting, however, informal criteria appear to be more perverse in LMICs compared to HICs. The priority setting process at the meso-level is a top-down approach with minimal involvement of the community. Accountability for reasonableness was the most common evaluative framework as it was used in 12 of the 16 studies. Efficiency, reallocation of resources and options for service delivery redesign were the most common outcome measures used to evaluate priority setting. Limitations: Our study was limited by the fact that there are very few empirical studies that have evaluated priority setting at the meso-level and there is likelihood that we did not capture all the studies. Conclusions: Improving priority setting practices at the meso level is crucial to strengthening health systems. This can be achieved through incorporating and adapting systematic priority setting processes and frameworks to the context where used, and making considerations of both process and outcome measures during priority setting and resource allocation.
Collapse
|
7
|
Waithaka D, Tsofa B, Barasa E. Evaluating healthcare priority setting at the meso level: A thematic review of empirical literature. Wellcome Open Res 2018; 3:2. [PMID: 29511741 PMCID: PMC5814743 DOI: 10.12688/wellcomeopenres.13393.2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2018] [Indexed: 01/08/2023] Open
Abstract
Background: Decentralization of health systems has made sub-national/regional healthcare systems the backbone of healthcare delivery. These regions are tasked with the difficult responsibility of determining healthcare priorities and resource allocation amidst scarce resources. We aimed to review empirical literature that evaluated priority setting practice at the meso level of health systems. Methods: We systematically searched PubMed, ScienceDirect and Google scholar databases and supplemented these with manual searching for relevant studies, based on the reference list of selected papers. We only included empirical studies that described and evaluated, or those that only evaluated priority setting practice at the meso-level. A total of 16 papers were identified from LMICs and HICs. We analyzed data from the selected papers by thematic review. Results: Few studies used systematic priority setting processes, and all but one were from HICs. Both formal and informal criteria are used in priority-setting, however, informal criteria appear to be more perverse in LMICs compared to HICs. The priority setting process at the meso-level is a top-down approach with minimal involvement of the community. Accountability for reasonableness was the most common evaluative framework as it was used in 12 of the 16 studies. Efficiency, reallocation of resources and options for service delivery redesign were the most common outcome measures used to evaluate priority setting. Limitations: Our study was limited by the fact that there are very few empirical studies that have evaluated priority setting at the meso-level and there is likelihood that we did not capture all the studies. Conclusions: Improving priority setting practices at the meso level is crucial to strengthening health systems. This can be achieved through incorporating and adapting systematic priority setting processes and frameworks to the context where used, and making considerations of both process and outcome measures during priority setting and resource allocation.
Collapse
Affiliation(s)
| | | | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
8
|
Coast J. A history that goes hand in hand: Reflections on the development of health economics and the role played by Social Science & Medicine, 1967-2017. Soc Sci Med 2017; 196:227-232. [PMID: 29132835 DOI: 10.1016/j.socscimed.2017.10.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 10/16/2017] [Accepted: 10/30/2017] [Indexed: 01/05/2023]
Affiliation(s)
- Joanna Coast
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom.
| |
Collapse
|
9
|
Seixas BV. Welfarism and extra-welfarism: a critical overview. CAD SAUDE PUBLICA 2017; 33:e00014317. [PMID: 28832769 DOI: 10.1590/0102-311x00014317] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 06/27/2017] [Indexed: 11/22/2022] Open
Abstract
Rules and principles for guiding decision-making in the health care sector have been debated for decades. Here, we present a critical appraisal of the two most important paradigms in this respect: welfarism and extra-welfarism. While the former deals with the maximization of the overall sum of individual utilities as its primary outcome, the latter has been focusing on the maximization of the overall health status. We argue that welfarism has three main problems: (1) its central idea of overall sum of individual utilities does not capture societal values decisively relevant in the context of health; (2) the use of the Potential Pareto Improvement brings an unresolvable separation between efficiency and equity; and (3) individual utility may not be a good measure in the health sector, given that individuals might value things that diminish their overall health. In turn, the extra-welfarist approach is criticized regarding four main limitations: (1) the advocated expansion of the evaluative space, moving from utility to health, may have represented in reality a narrowing of it; (2) it operates using non-explicit considerations of equity; (3) it still holds the issue of "inability to desire" of unprivileged people being considered the best judges of weighing the criteria used to building the health measures; and (4) there is controversial empirical evidence about society members' values that support its assumptions. Overall, both paradigms show significant weaknesses, but the debate has still been within the realm of welfare economics, and even the new approaches to resource allocation in health care systems appear to be unable to escape from these boundaries.
Collapse
|
10
|
Barasa EW, Molyneux S, English M, Cleary S. Setting Healthcare Priorities at the Macro and Meso Levels: A Framework for Evaluation. Int J Health Policy Manag 2015; 4:719-32. [PMID: 26673332 DOI: 10.15171/ijhpm.2015.167] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 09/08/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Priority setting in healthcare is a key determinant of health system performance. However, there is no widely accepted priority setting evaluation framework. We reviewed literature with the aim of developing and proposing a framework for the evaluation of macro and meso level healthcare priority setting practices. METHODS We systematically searched Econlit, PubMed, CINAHL, and EBSCOhost databases and supplemented this with searches in Google Scholar, relevant websites and reference lists of relevant papers. A total of 31 papers on evaluation of priority setting were identified. These were supplemented by broader theoretical literature related to evaluation of priority setting. A conceptual review of selected papers was undertaken. RESULTS Based on a synthesis of the selected literature, we propose an evaluative framework that requires that priority setting practices at the macro and meso levels of the health system meet the following conditions: (1) Priority setting decisions should incorporate both efficiency and equity considerations as well as the following outcomes; (a) Stakeholder satisfaction, (b) Stakeholder understanding, (c) Shifted priorities (reallocation of resources), and (d) Implementation of decisions. (2) Priority setting processes should also meet the procedural conditions of (a) Stakeholder engagement, (b) Stakeholder empowerment, (c) Transparency, (d) Use of evidence, (e) Revisions, (f) Enforcement, and (g) Being grounded on community values. CONCLUSION Available frameworks for the evaluation of priority setting are mostly grounded on procedural requirements, while few have included outcome requirements. There is, however, increasing recognition of the need to incorporate both consequential and procedural considerations in priority setting practices. In this review, we adapt an integrative approach to develop and propose a framework for the evaluation of priority setting practices at the macro and meso levels that draws from these complementary schools of thought.
Collapse
Affiliation(s)
- Edwine W Barasa
- KEMRI Centre for Geographic Medicine Research - Coast, and Welcome Trust Research Programme, Nairobi, Kenya.,Health Economics Unit, University of Cape Town, Cape Town, South Africa
| | - Sassy Molyneux
- KEMRI Centre for Geographic Medicine Research - Coast, and Welcome Trust Research Programme, Nairobi, Kenya.,Centre for Tropical Medicine, University of Oxford, Oxford, UK
| | - Mike English
- KEMRI Centre for Geographic Medicine Research - Coast, and Welcome Trust Research Programme, Nairobi, Kenya.,Department of Paediatrics, University of Oxford, Oxford, UK
| | - Susan Cleary
- Health Economics Unit, University of Cape Town, Cape Town, South Africa
| |
Collapse
|