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Njie H, Dale E, Gopinathan U. Procedural fairness in decision-making for financing a National Health Insurance Scheme: a case study from The Gambia. Health Policy Plan 2023; 38:i73-i82. [PMID: 37963076 PMCID: PMC10645046 DOI: 10.1093/heapol/czad063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 03/29/2023] [Accepted: 07/27/2023] [Indexed: 11/16/2023] Open
Abstract
Achieving universal health coverage (UHC) involves difficult policy choices, and fair processes are critical for building legitimacy and trust. In 2021, The Gambia passed its National Health Insurance (NHI) Act. We explored decision-making processes shaping the financing of the NHI scheme (NHIS) with respect to procedural fairness criteria. We reviewed policy and strategic documents on The Gambia's UHC reforms to identify key policy choices and interviewed policymakers, technocrats, lawmakers, hospital chief executive officers, private sector representatives and civil society organizations (CSOs) including key CSOs left out of the NHIS discussions. Ministerial budget discussions and virtual proceedings of the National Assembly's debate on the NHI Bill were observed. To enhance public scrutiny, Gambians were encouraged to submit views to the National Assembly's committee; however, the procedures for doing so were unclear, and it was not possible to ascertain how these inputs were used. Despite available funds to undertake countrywide public engagement, the public consultations were mostly limited to government institutions, few trade unions and a handful of urban-based CSOs. While this represented an improved approach to public policy-making, several CSOs representing key constituents and advocating for the expansion of exemption criteria for insurance premiums to include more vulnerable groups felt excluded from the process. Overload of the National Assembly's legislative schedule and lack of National Assembly committee quorum were cited as reasons for not engaging in countrywide consultations. In conclusion, although there was an intent from the Executive and National Assembly to ensure transparent, participatory and inclusive decision-making, the process fell short in these aspects. These observations should be seen in the context of The Gambia's ongoing democratic transition where institutions for procedural fairness are expected to progressively improve. Learning from this experience to enhance the procedural fairness of decision-making can promote inclusiveness, ownership and sustainability of the NHIS in The Gambia.
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Affiliation(s)
- Hassan Njie
- Department of Community Medicine and Global Health, University of Oslo, Postboks 1130 Blindern, Oslo 0318, Norway
| | - Elina Dale
- Cluster for Global Health, Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
| | - Unni Gopinathan
- Cluster for Global Health, Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
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Dale E, Peacocke EF, Movik E, Voorhoeve A, Ottersen T, Kurowski C, Evans DB, Norheim OF, Gopinathan U. Criteria for the procedural fairness of health financing decisions: a scoping review. Health Policy Plan 2023; 38:i13-i35. [PMID: 37963078 PMCID: PMC10645052 DOI: 10.1093/heapol/czad066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 06/19/2023] [Accepted: 08/02/2023] [Indexed: 11/16/2023] Open
Abstract
Due to constraints on institutional capacity and financial resources, the road to universal health coverage (UHC) involves difficult policy choices. To assist with these choices, scholars and policy makers have done extensive work on criteria to assess the substantive fairness of health financing policies: their impact on the distribution of rights, duties, benefits and burdens on the path towards UHC. However, less attention has been paid to the procedural fairness of health financing decisions. The Accountability for Reasonableness Framework (A4R), which is widely applied to assess procedural fairness, has primarily been used in priority-setting for purchasing decisions, with revenue mobilization and pooling receiving limited attention. Furthermore, the sufficiency of the A4R framework's four criteria (publicity, relevance, revisions and appeals, and enforcement) has been questioned. Moreover, research in political theory and public administration (including deliberative democracy), public finance, environmental management, psychology, and health financing has examined the key features of procedural fairness, but these insights have not been synthesized into a comprehensive set of criteria for fair decision-making processes in health financing. A systematic study of how these criteria have been applied in decision-making situations related to health financing and in other areas is also lacking. This paper addresses these gaps through a scoping review. It argues that the literature across many disciplines can be synthesized into 10 core criteria with common philosophical foundations. These go beyond A4R and encompass equality, impartiality, consistency over time, reason-giving, transparency, accuracy of information, participation, inclusiveness, revisability and enforcement. These criteria can be used to evaluate and guide decision-making processes for financing UHC across different country income levels and health financing arrangements. The review also presents examples of how these criteria have been applied to decisions in health financing and other sectors.
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Affiliation(s)
- Elina Dale
- Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
| | | | - Espen Movik
- Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
| | - Alex Voorhoeve
- Philosophy, Logic and Scientific Method, London School of Economics and Political Science (LSE), Houghton Street, London WC2A 2AE, UK
| | - Trygve Ottersen
- Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
| | - Christoph Kurowski
- Health, Nutrition and Population, World Bank Group, 1818 H Street, NW, Washington, DC 20433, USA
| | - David B Evans
- Health, Nutrition and Population, World Bank Group, 1818 H Street, NW, Washington, DC 20433, USA
| | - Ole Frithjof Norheim
- Bergen Centre for Ethics and Priority Setting (BCEPS), University of Bergen, Årstadveien 21, Bergen 5018, Norway
| | - Unni Gopinathan
- Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
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Viriyathorn S, Sachdev S, Suwanwela W, Wangbanjongkun W, Patcharanarumol W, Tangcharoensathien V. Procedural fairness in benefit package design: inclusion of pre-exposure prophylaxis of HIV in Universal Coverage Scheme in Thailand. Health Policy Plan 2023; 38:i36-i48. [PMID: 37963082 PMCID: PMC10645053 DOI: 10.1093/heapol/czad061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 03/09/2023] [Accepted: 07/29/2023] [Indexed: 11/16/2023] Open
Abstract
Since 2002, Thailand's Universal Coverage Scheme (UCS) has adopted a comprehensive benefits package with few exclusions. A positive-list approach has gradually been applied, with pre-exposure prophylaxis (PrEP) of HIV recently being included. Disagreements resulting from competing values and diverging interests necessitate an emphasis on procedural fairness when making any decisions. This qualitative study analyses agenda setting, policy formulation and early implementation of PrEP from a procedural fairness lens. Literature reviews and in-depth interviews with 13 key stakeholders involved in PrEP policy processes were conducted. Civil society organizations (CSOs) and academia piloted PrEP service models and co-produced evidence on programmatic feasibility and outcomes. Through a broad stakeholder representation process, the Department of Disease Control proposed PrEP for inclusion in UCS benefits package in 2017. PrEP was shown to be cost-effective and affordable through rigorous health technology assessment, peer review, use of up-to-date evidence and safe-guards against conflicts of interest. In 2021, Thailand's National Health Security Board decided to include PrEP as a prevention and promotion package, free of charge, for the populations at risk. Favourable conditions for procedural fairness were created by Thailand's legislative provisions that enable responsive governance, notably inclusiveness, transparency, safeguarding public interest and accountable budget allocations; longstanding institutional capacity to generate local evidence; and implementation capacity for realisation of procedural fairness criteria. Multiple stakeholders including CSOs, academia and the government deliberated in the policy process through working groups and sub-committees. However, a key lesson from Thailand's deliberative process concerns a possible 'over interpretation' of conflicts of interest, intended to promote impartial decision-making, which inadvertently limited the voices of key populations represented in the decision processes. Finally, this case study underscores the value of examining the full policy cycle when assessing procedural fairness, since some stages of the process may be more amenable to certain procedural criteria than others.
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Affiliation(s)
- Shaheda Viriyathorn
- International Health Policy Program (IHPP), Ministry of Public Health, Tiwanon Road, Nonthaburi 11000, Thailand
| | - Saranya Sachdev
- International Health Policy Program (IHPP), Ministry of Public Health, Tiwanon Road, Nonthaburi 11000, Thailand
| | - Waraporn Suwanwela
- National Health Security Office (NHSO), The Government Complex Commemorating His Majesty the King's 80th Birthday Anniversary 5th December, B.E.2550 (2007) Building B 120 Moo 3 Chaengwattana Road, Lak Si District, Bangkok 10210, Thailand
| | - Waritta Wangbanjongkun
- International Health Policy Program (IHPP), Ministry of Public Health, Tiwanon Road, Nonthaburi 11000, Thailand
| | - Walaiporn Patcharanarumol
- International Health Policy Program (IHPP), Ministry of Public Health, Tiwanon Road, Nonthaburi 11000, Thailand
| | - Viroj Tangcharoensathien
- International Health Policy Program (IHPP), Ministry of Public Health, Tiwanon Road, Nonthaburi 11000, Thailand
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Multiple Criteria Decision Analysis (MCDA) for evaluating cancer treatments in hospital-based health technology assessment: The Paraconsistent Value Framework. PLoS One 2022; 17:e0268584. [PMID: 35613115 PMCID: PMC9132343 DOI: 10.1371/journal.pone.0268584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 05/02/2022] [Indexed: 11/19/2022] Open
Abstract
Background In recent years, the potential of multi-criteria decision analysis (MCDA) in the health field has been discussed widely. However, most MCDA methodologies have given little attention to the aggregation of different stakeholder individual perspectives. Objective To illustrate how a paraconsistent theory-based MCDA reusable framework, designed to aid hospital-based Health Technology Assessment (HTA), could be used to aggregate individual expert perspectives when valuing cancer treatments. Methods An MCDA methodological process was adopted based on paraconsistent theory and following ISPOR recommended steps in conducting an MCDA study. A proof-of-concept exercise focusing on identifying and assessing the global value of first-line treatments for metastatic colorectal cancer (mCRC) was conducted to foster the development of the MCDA framework. Results On consultation with hospital-based HTA committee members, 11 perspectives were considered in an expert panel: medical oncology, oncologic surgery, radiotherapy, palliative care, pharmacist, health economist, epidemiologist, public health expert, health media expert, pharmaceutical industry, and patient advocate. The highest weights were assigned to the criteria “overall survival” (mean 0.22), “burden of disease” (mean 0.21) and “adverse events” (mean 0.20), and the lowest weights were given to “progression-free survival” and “cost of treatment” (mean 0.18 for both). FOLFIRI and mFlox scored the highest global value score of 0.75, followed by mFOLFOX6 with a global value score of 0.71. mIFL was ranked last with a global value score of 0.62. The paraconsistent analysis (para-analysis) of 6 first-line treatments for mCRC indicated that FOLFIRI and mFlox were the appropriate options for reimbursement in the context of this study. Conclusion The Paraconsistent Value Framework is proposed as a step beyond the current MCDA practices, in order to improve means of dealing with individual expert perspectives in hospital-based HTA of cancer treatments.
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Kapiriri L, Razavi SD. Equity, justice, and social values in priority setting: a qualitative study of resource allocation criteria for global donor organizations working in low-income countries. Int J Equity Health 2022; 21:17. [PMID: 35135553 PMCID: PMC8822856 DOI: 10.1186/s12939-021-01565-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 10/03/2021] [Indexed: 12/02/2022] Open
Abstract
Background There is increasing acceptance of the importance of social values such as equity and fairness in health care priority setting (PS). However, equity is difficult to define: the term means different things to different people, and the ways it is understood in theory often may not align with how it is operationalized. There is limited literature on how development assistance partner organizations (DAP) conceptualize and operationalize equity in their health care prioritization decisions that affect low-income countries (LIC). This paper explores whether and how equity is a consideration in DAP priority setting processes. Methods This was a qualitative study involving 38 in-depth interviews with DAPs involved in health-system PS for LICs and a review of their respective webpages. Results While several PS criteria were identified, direct articulation of equity as an explicit criterion was lacking. However, the criterion was implied in some of the responses in terms of prioritizing vulnerable populations. Where mentioned, respondents discussed the difficulties of operationalizing equity as a PS criterion since vulnerability is associated with several varying and competing factors including gender, age, geography, and income. Some respondents also suggested that equity could be operationalized in terms of an organization not supporting the pre-existing inequities. Although several organizations’ webpages identify addressing inequities as a guiding principle, there were variations in how they spoke about its operationalization. While intersectionalities in vulnerabilities complicate its operationalization, if organizations explicitly articulate their equity focus the other organizations who also have equity as a guiding principle may, instead of focusing on the same aspect, concentrate on other dimensions of vulnerability. That way, all organizations will contribute to achieving equity in all the relevant dimensions. Conclusions Since most development organizations support some form of equity, this paper highlights a need for an internationally recognized framework that recognizes the intersectionalities of vulnerability, for mainstreaming and operationalizing equity in DAP priority setting and resource allocation. Such a framework will support consistency in the conceptualization of and operationalization of equity in global health programs. There is a need for studies which to assess the degree to which equity is actually integrated in these programs. Equity has become an increasingly important focus in the health and social science literature, however, equity is a contested concept. While development assistance partners supporting health development subscribe to equity as a guiding principle, they struggle with its operationalization. There is need for a general framework that explicitly conceptualizes the operationalization of equity in health development.
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Affiliation(s)
- Lydia Kapiriri
- Department of Health, Aging and Society, McMaster University, 1280 Main street West, Hamilton, Ontario, Canada.
| | - S Donya Razavi
- Department of Health, Aging and Society, McMaster University, 1280 Main street West, Hamilton, Ontario, Canada
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Stratil JM, Voss M, Arnold L. WICID framework version 1.0: criteria and considerations to guide evidence-informed decision-making on non-pharmacological interventions targeting COVID-19. BMJ Glob Health 2020; 5:bmjgh-2020-003699. [PMID: 33234529 PMCID: PMC7688443 DOI: 10.1136/bmjgh-2020-003699] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 01/12/2023] Open
Abstract
Introduction Public health decision-making requires the balancing of numerous, often conflicting factors. However, participatory, evidence-informed decision-making processes to identify and weigh these factors are often not possible- especially, in the context of the SARS-CoV-2 pandemic. While evidence-to-decision frameworks are not able or intended to replace stakeholder participation, they can serve as a tool to approach relevancy and comprehensiveness of the criteria considered. Objective To develop a decision-making framework adapted to the challenges of decision-making on non-pharmacological interventions to contain the global SARS-CoV-2 pandemic. Methods We employed the ‘best fit’ framework synthesis technique and used the WHO-INTEGRATE framework as a starting point. First, we adapted the framework through brainstorming exercises and application to case studies. Next, we conducted a content analysis of comprehensive strategy documents intended to guide policymakers on the phasing out of applied lockdown measures in Germany. Based on factors and criteria identified in this process, we developed the WICID (WHO-INTEGRATE COVID-19) framework version 1.0. Results Twelve comprehensive strategy documents were analysed. The revised framework consists of 11+1 criteria, supported by 48 aspects, and embraces a complex systems perspective. The criteria cover implications for the health of individuals and populations due to and beyond COVID-19, infringement on liberties and fundamental human rights, acceptability and equity considerations, societal, environmental and economic implications, as well as implementation, resource and feasibility considerations. Discussion The proposed framework will be expanded through a comprehensive document analysis focusing on key stakeholder groups across the society. The WICID framework can be a tool to support comprehensive evidence-informed decision-making processes.
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Affiliation(s)
- Jan M Stratil
- Institute for Medical Informatics, Biometry and Epidemiology - IBE and Pettenkofer School of Public Health, LMU Munich, Munich, Bavaria, Germany
| | - Maike Voss
- Global Issues Division, German Institute for International and Security Affairs, Berlin, Germany
| | - Laura Arnold
- Epidemiology and Health Reporting, Academy of Public Health Services, Duesseldorf, North Rhine-Westphalia, Germany
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Laba TL, Jiwani B, Crossland R, Mitton C. Can multi-criteria decision analysis (MCDA) be implemented into real-world drug decision-making processes? A Canadian provincial experience. Int J Technol Assess Health Care 2020; 36:1-6. [PMID: 32762789 DOI: 10.1017/s0266462320000525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To describe the implementation of multi-criteria decision analysis (MCDA) into a Canadian public drug reimbursement decision-making process, identifying the aspects of the MCDA approach, and the context that promoted uptake. METHODS Narrative summary of case study describing the how, when, and why of implementing MCDA. RESULTS Faced with a fixed budget, a pipeline of expensive but potentially valuable drugs, and potential delays to drug decision making, the Ministry of Health (i.e., decision makers) and its independent expert advisory committee (IAB) sought alternative values-based decision processes. MCDA was considered highly compatible with current processes, but the ability as a stand-alone intervention to address issues of opportunity cost was unclear. The IAB nevertheless collaboratively voted to implement an externally developed MCDA with support from decision makers. After several months of engagement and piloting, implementation was rapid and leveraged strong pre-existing formal and informal communication networks. The IAB as a whole rates new submissions which serves as an input into the deliberative process. CONCLUSIONS MCDA can be a highly adaptable approach that can be implemented into a functioning drug reimbursement setting when facilitated by (i) a truly limited budget; (ii) a shared vision for change by end-users and decision makers; (iii) using pre-existing deliberative processes; and (iv) viewing the approach as a decision framework rather than the decision (when appropriate). Given the current limitations of MCDA, implementing an academically imperfect tool first and evaluating later reflects a practical solution to real-time fiscal constraints and impending delays to drug approvals that may be faced by decision makers.
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Affiliation(s)
- Tracey-Lea Laba
- The University of British Columbia, Centre for Clinical Epidemiology and Evaluation, Vancouver, Canada
- The Centre for Health Economics Research and Evaluation, Business School, The University of Technology, Sydney, Australia
| | - Bashir Jiwani
- Fraser Health, Ethics and Diversity Services, Surrey, Canada
| | | | - Craig Mitton
- The University of British Columbia, Centre for Clinical Epidemiology and Evaluation, Vancouver, Canada
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Byskov J, Maluka S, Marchal B, Shayo EH, Blystad A, Bukachi S, Zulu JM, Michelo C, Hurtig AK, Bloch P. A systems perspective on the importance of global health strategy developments for accomplishing today's Sustainable Development Goals. Health Policy Plan 2019; 34:635-645. [PMID: 31363736 PMCID: PMC6880334 DOI: 10.1093/heapol/czz042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2019] [Indexed: 12/01/2022] Open
Abstract
Priority setting within health systems has not led to accountable, fair and sustainable solutions to improving population health. Providers, users and other stakeholders each have their own health and service priorities based on selected evidence, own values, expertise and preferences. Based on a historical account, this article analyses if contemporary health systems are appropriate to optimize population health within the framework of cross cutting targets of the Sustainable Development Goals (SDGs). We applied a scoping review approach to identify and review literature of scientific databases and other programmatic web and library-based documents on historical and contemporary health systems policies and strategies at the global level. Early literature supported the 1977 launching of the global target of Health for All by the year 2000. Reviewed literature was used to provide a historical overview of systems components of global health strategies through describing the conceptualizations of health determinants, user involvement and mechanisms of priority setting over time, and analysing the importance of historical developments on barriers and opportunities to accomplish the SDGs. Definitions, scope and application of health systems-associated priority setting fluctuated and main health determinants and user influence on global health systems and priority setting remained limited. In exploring reasons for the identified lack of SDG-associated health systems and priority setting processes, we discuss issues of accountability, vested interests, ethics and democratic legitimacy as conditional for future sustainability of population health. To accomplish the SDGs health systems must engage beyond their own sector boundary. New approaches to Health in All Policies and One Health may be conducive for scaling up more democratic and inclusive priority setting processes based on proper process guidelines from successful pilots. Sustainable development depends on population preferences supported by technical and managerial expertise.
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Affiliation(s)
- Jens Byskov
- Research and Health Systems Advisor, School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Stephen Maluka
- Institute of Development Studies, University of Dar Es Salaam, Tanzania
| | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Nationalestraat 155, B Antwerpen, Belgium
| | - Elizabeth H Shayo
- National Institute for Medical Research (NIMR), Dar Es Salaam, Tanzania
| | - Astrid Blystad
- Department of Global Health and Primary Care, University of Bergen, Norway
| | - Salome Bukachi
- Institute of Anthropology, Gender and African Studies University of Nairobi, Nairobi, Kenya
| | - Joseph M Zulu
- School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Charles Michelo
- School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Anna-Karin Hurtig
- Department of Epidemiology and Global Health, Umeå University, SE, Umea, Sweden
| | - Paul Bloch
- Steno Diabetes Center Copenhagen, Niels Steensens Vej 6, DK Gentofte, Denmark
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Baltussen R, Jansen M, Bijlmakers L. Stakeholder participation on the path to universal health coverage: the use of evidence-informed deliberative processes. Trop Med Int Health 2018; 23:1071-1074. [PMID: 30112816 DOI: 10.1111/tmi.13138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Rob Baltussen
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherland
| | - Maarten Jansen
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherland
| | - Leon Bijlmakers
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherland
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Tromp N, Prawiranegara R, Siregar A, Wisaksana R, Pinxten L, Pinxten J, Lesmana Putra A, Kurnia Sunjaya D, Jansen M, Hontelez J, Maurits S, Maharani F, Bijlmakers L, Baltussen R. Translating international HIV treatment guidelines into local priorities in Indonesia. Trop Med Int Health 2018; 23:279-294. [PMID: 29327397 DOI: 10.1111/tmi.13031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE International guidelines recommend countries to expand antiretroviral therapy (ART) to all HIV-infected individuals and establish local-level priorities in relation to other treatment, prevention and mitigation interventions through fair processes. However, no practical guidance is provided for such priority-setting processes. Evidence-informed deliberative processes (EDPs) fill this gap and combine stakeholder deliberation to incorporate relevant social values with rational decision-making informed by evidence on these values. This study reports on the first-time implementation and evaluation of an EDP in HIV control, organised to support the AIDS Commission in West Java province, Indonesia, in the development of its strategic plan for 2014-2018. METHODS Under the responsibility of the provincial AIDS Commission, an EDP was implemented to select priority interventions using six steps: (i) situational analysis; (ii) formation of a multistakeholder Consultation Panel; (iii) selection of criteria; (iv) identification and assessment of interventions' performance; (v) deliberation; and (vi) selection of funding and implementing institutions. An independent researcher conducted in-depth interviews (n = 21) with panel members to evaluate the process. RESULTS The Consultation Panel included 23 stakeholders. They identified 50 interventions and these were evaluated against four criteria: impact on the epidemic, stigma reduction, cost-effectiveness and universal coverage. After a deliberative discussion, the Consultation Panel prioritised a combination of several treatment, prevention and mitigation interventions. CONCLUSION The EDP improved both stakeholder involvement and the evidence base for the strategic planning process. EDPs fill an important gap which international guidelines and current tools for strategic planning in HIV control leave unaddressed.
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Affiliation(s)
- Noor Tromp
- Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,KIT (Royal Tropical Institute), Amsterdam, The Netherlands
| | - Rozar Prawiranegara
- Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Faculty of Medicine, Padjadjaran University, Bandung, Indonesia
| | - Adiatma Siregar
- Faculty Economics and Business, Padjadjaran University, Bandung, Indonesia
| | - Rudi Wisaksana
- Faculty of Medicine, Padjadjaran University, Bandung, Indonesia
| | - Lucas Pinxten
- Nijmegen Institute for Scientist-Practitioners in Addiction, Radboud University, Nijmegen, The Netherlands.,Faculty of Psychology and Neuroscience, Department of Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
| | - Juul Pinxten
- Social Protection and Jobs Global Practice, World Bank, Jarkarta, Indonesia
| | - Arry Lesmana Putra
- United Nations Development Programme Indonesia, Jakarta, Indonesia.,West Java Provincial AIDS commission, Bandung, Indonesia
| | | | - Maarten Jansen
- Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan Hontelez
- Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Heidelberg Institute of Public Health, Faculty of Medicine, Heidelberg University, Heidelberg, Germany
| | - Scott Maurits
- Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Leon Bijlmakers
- Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rob Baltussen
- Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Dukhanin V, Searle A, Zwerling A, Dowdy DW, Taylor HA, Merritt MW. Integrating social justice concerns into economic evaluation for healthcare and public health: A systematic review. Soc Sci Med 2018; 198:27-35. [PMID: 29274616 PMCID: PMC6545595 DOI: 10.1016/j.socscimed.2017.12.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 12/06/2017] [Accepted: 12/11/2017] [Indexed: 11/21/2022]
Abstract
Social justice is the moral imperative to avoid and remediate unfair distributions of societal disadvantage. In priority setting in healthcare and public health, social justice reaches beyond fairness in the distribution of health outcomes and economic impacts to encompass fairness in the distribution of policy impacts upon other dimensions of well-being. There is an emerging awareness of the need for economic evaluation to integrate all such concerns. We performed a systematic review (1) to describe methodological solutions suitable for integrating social justice concerns into economic evaluation, and (2) to describe the challenges that those solutions face. To be included, publications must have captured fairness considerations that (a) involve cross-dimensional subjective personal life experience and (b) can be manifested at the level of subpopulations. We identified relevant publications using an electronic search in EMBASE, PubMed, EconLit, PsycInfo, Philosopher's Index, and Scopus, including publications available in English in the past 20 years. Two reviewers independently appraised candidate publications, extracted data, and synthesized findings in narrative form. Out of 2388 publications reviewed, 26 were included. Solutions sought either to incorporate relevant fairness considerations directly into economic evaluation or to report them alongside cost-effectiveness measures. The majority of reviewed solutions, if adapted to integrate social justice concerns, would require their explicit quantification. Four broad challenges related to the implementation of these solutions were identified: clarifying the normative basis; measuring and determining the relative importance of criteria representing that basis; combining the criteria; and evaluating trade-offs. All included solutions must grapple with an inherent tension: they must either face the normative and operational challenges of quantifying social justice concerns or accede to offering incomplete policy guidance. Interdisciplinary research and broader collaborations are crucial to address these challenges and to support due attention to social justice in priority setting.
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Affiliation(s)
- Vadim Dukhanin
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alexandra Searle
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alice Zwerling
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; School of Epidemiology, Public Health & Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Holly A Taylor
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA
| | - Maria W Merritt
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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12
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Safarnejad A, Pavlova M, Son VH, Phuong HL, Groot W. Criteria for prioritization of HIV programs in Viet Nam: a discrete choice experiment. BMC Health Serv Res 2017; 17:719. [PMID: 29132355 PMCID: PMC5683339 DOI: 10.1186/s12913-017-2679-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 11/03/2017] [Indexed: 11/21/2022] Open
Abstract
Background With the decline in funding for Viet Nam’s response to the HIV epidemic, there is a need for evidence on the criteria to guide the prioritization of HIV programs. There is a gap in the research on the relative importance of multiple criteria for prioritizing a package of interventions. This study elicits preferences and the trade-offs made between different HIV programs by relevant stakeholders and decision-makers in Viet Nam. It also pays attention to how differences in social and professional characteristics of stakeholders and their agency affiliations shape preferences for HIV program criteria in Viet Nam. Methods This study uses self-explicated ranking and discrete choice experiments to determine the relative importance of five criteria - effectiveness, feasibility, cost-effectiveness, rate of investment and prevention/treatment investment ratio - to stakeholders when they evaluate and select hypothetical HIV programs. The study includes 69 participants from government, civil society, and international development partners. Results Results of the discrete choice experiment show that overall the feasibility criterion is ranked highest in importance to the participants when choosing a hypothetical HIV program, followed by sustainability, treatment to prevention spending ratio, and effectiveness. The participant’s work in management, programming, or decision-making has a significant effect on the importance of some criteria to the participant. In the self-explicated ranking effectiveness is the most important criterion and the cost-effectiveness criterion ranks low in importance across all groups. Conclusions This study has shown that the preferred HIV program in Viet Nam is feasible, front-loaded for sustainability, has a higher proportion of investment on prevention, saves more lives and prevents more infections. Similarities in government and civil society rankings of criteria can create common grounds for future policy dialogues between stakeholders. Innovative models of planning should be utilized to allow inputs of informed stakeholders at relevant stages of the HIV program planning process. Electronic supplementary material The online version of this article (10.1186/s12913-017-2679-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ali Safarnejad
- Maastricht Graduate School of Governance, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, Netherlands.
| | - Milena Pavlova
- Department of Health Services Research; CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Vo Hai Son
- Viet Nam Authority of HIV/AIDS Control (VAAC), Ministry of Health, Hanoi, Vietnam
| | - Huynh Lan Phuong
- The Joint United Nations Programme on HIV/AIDS (UNAIDS), Hanoi, Vietnam
| | - Wim Groot
- Department of Health Services Research; CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
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13
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Harris C, Green S, Elshaug AG. Sustainability in Health care by Allocating Resources Effectively (SHARE) 10: operationalising disinvestment in a conceptual framework for resource allocation. BMC Health Serv Res 2017; 17:632. [PMID: 28886740 PMCID: PMC5590199 DOI: 10.1186/s12913-017-2506-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 08/03/2017] [Indexed: 11/15/2022] Open
Abstract
Background This is the tenth in a series of papers reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. After more than a decade of research, there is little published evidence of active and successful disinvestment. The paucity of frameworks, methods and tools is reported to be a factor in the lack of success. However there are clear and consistent messages in the literature that can be used to inform development of a framework for operationalising disinvestment. This paper, along with the conceptual review of disinvestment in Paper 9 of this series, aims to integrate the findings of the SHARE Program with the existing disinvestment literature to address the lack of information regarding systematic organisation-wide approaches to disinvestment at the local health service level. Discussion A framework for disinvestment in a local healthcare setting is proposed. Definitions for essential terms and key concepts underpinning the framework have been made explicit to address the lack of consistent terminology. Given the negative connotations of the word ‘disinvestment’ and the problems inherent in considering disinvestment in isolation, the basis for the proposed framework is ‘resource allocation’ to address the spectrum of decision-making from investment to disinvestment. The focus is positive: optimising healthcare, improving health outcomes, using resources effectively. The framework is based on three components: a program for decision-making, projects to implement decisions and evaluate outcomes, and research to understand and improve the program and project activities. The program consists of principles for decision-making and settings that provide opportunities to introduce systematic prompts and triggers to initiate disinvestment. The projects follow the steps in the disinvestment process. Potential methods and tools are presented, however the framework does not stipulate project design or conduct; allowing application of any theories, methods or tools at each step. Barriers are discussed and examples illustrating constituent elements are provided. Conclusions The framework can be employed at network, institutional, departmental, ward or committee level. It is proposed as an organisation-wide application, embedded within existing systems and processes, which can be responsive to needs and priorities at the level of implementation. It can be used in policy, management or clinical contexts. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2506-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Claire Harris
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia. .,Centre for Clinical Effectiveness, Monash Health, Melbourne, Victoria, Australia.
| | - Sally Green
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Adam G Elshaug
- Menzies Centre for Health Policy, Sydney School of Public Health, University of Sydney, Sydney, Australia.,Lown Institute, Brookline, Massachusetts, USA
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14
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Harris C, Allen K, Brooke V, Dyer T, Waller C, King R, Ramsey W, Mortimer D. Sustainability in Health care by Allocating Resources Effectively (SHARE) 6: investigating methods to identify, prioritise, implement and evaluate disinvestment projects in a local healthcare setting. BMC Health Serv Res 2017; 17:370. [PMID: 28545430 PMCID: PMC5445482 DOI: 10.1186/s12913-017-2269-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 04/26/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This is the sixth in a series of papers reporting Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The SHARE program was established to investigate a systematic, integrated, evidence-based approach to disinvestment within a large Australian health service. This paper describes the methods employed in undertaking pilot disinvestment projects. It draws a number of lessons regarding the strengths and weaknesses of these methods; particularly regarding the crucial first step of identifying targets for disinvestment. METHODS Literature reviews, survey, interviews, consultation and workshops were used to capture and process the relevant information. A theoretical framework was adapted for evaluation and explication of disinvestment projects, including a taxonomy for the determinants of effectiveness, process of change and outcome measures. Implementation, evaluation and costing plans were developed. RESULTS Four literature reviews were completed, surveys were received from 15 external experts, 65 interviews were conducted, 18 senior decision-makers attended a data gathering workshop, 22 experts and local informants were consulted, and four decision-making workshops were undertaken. Mechanisms to identify disinvestment targets and criteria for prioritisation and decision-making were investigated. A catalogue containing 184 evidence-based opportunities for disinvestment and an algorithm to identify disinvestment projects were developed. An Expression of Interest process identified two potential disinvestment projects. Seventeen additional projects were proposed through a non-systematic nomination process. Four of the 19 proposals were selected as pilot projects but only one reached the implementation stage. Factors with potential influence on the outcomes of disinvestment projects are discussed and barriers and enablers in the pilot projects are summarised. CONCLUSION This study provides an in-depth insight into the experience of disinvestment in one local healthcare service. To our knowledge, this is the first paper to report the process of disinvestment from identification, through prioritisation and decision-making, to implementation and evaluation, and finally explication of the processes and outcomes.
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Affiliation(s)
- Claire Harris
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia. .,Centre for Clinical Effectiveness, Monash Health, Melbourne, VIC, Australia.
| | - Kelly Allen
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Centre for Clinical Effectiveness, Monash Health, Melbourne, VIC, Australia
| | - Vanessa Brooke
- Centre for Clinical Effectiveness, Monash Health, Melbourne, VIC, Australia
| | - Tim Dyer
- Centre for Clinical Effectiveness, Monash Health, Melbourne, VIC, Australia
| | - Cara Waller
- Centre for Clinical Effectiveness, Monash Health, Melbourne, VIC, Australia
| | - Richard King
- Medicine Program, Monash Health, Melbourne, VIC, Australia
| | - Wayne Ramsey
- Medical Services and Quality, Monash Health, Melbourne, VIC, Australia
| | - Duncan Mortimer
- Centre for Health Economics, Monash University, Melbourne, VIC, Australia
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15
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Schey C, Krabbe PFM, Postma MJ, Connolly MP. Multi-criteria decision analysis (MCDA): testing a proposed MCDA framework for orphan drugs. Orphanet J Rare Dis 2017; 12:10. [PMID: 28095876 PMCID: PMC5240262 DOI: 10.1186/s13023-016-0555-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 12/14/2016] [Indexed: 11/10/2022] Open
Abstract
Background Since the introduction of the orphan drugs legislation in Europe, it has been suggested that the general method of assessing drugs for reimbursement is not necessarily suitable for orphan drugs. The National Institute for Health and Clinical Excellence indicated that several criteria other than cost and efficacy could be considered in reimbursement decisions for orphan drugs. This study sought to explore the multi-criteria decision analysis (MCDA) framework proposed by (Orphanet J Rare Dis 7:74, 2012) to a range of orphan drugs, with a view to comparing the aggregate scores to the average annual cost per patient for each product, and thus establishing the merit of MCDA as a tool for assessing the value of orphan drugs in relation to their pricings. Methods An MCDA framework was developed using the nine criteria proposed by (Orphanet J Rare Dis 7:74, 2012) for the evaluation of orphan drugs, using the suggested numerical scoring system on a scale of 1 to 3 for each criterion. Correlations between the average annual cost of the drugs and aggregate MCDA scores were tested and plotted graphically. Different weightings for each of the attributes were also tested. A further analysis was conducted to test the impact of including the drug cost as an attribute in the aggregate index scores. Results In the drugs studied, the R2, that statistically measures how close the data are to the fitted regression line was 0.79 suggesting a strong correlation between the drug scores and the average annual cost per patient. Conclusion Despite several limitations of the proposed model, this quantitative study provided insight into using MCDA and its relationship to the average annual costs of the products.
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Affiliation(s)
- C Schey
- Unit of PharmacoEpidemiology & PharmacoEconomics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands. .,Global Market Access Solutions (GMAS), St-Prex, Switzerland.
| | - P F M Krabbe
- Department of Epidemiology, (UMCG), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M J Postma
- Unit of PharmacoEpidemiology & PharmacoEconomics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands.,Department of Epidemiology, (UMCG), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Institute for Science in Healthy Aging & healthcaRE (SHARE), UMCg, University of Groningen, Groningen, The Netherlands
| | - M P Connolly
- Unit of PharmacoEpidemiology & PharmacoEconomics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands.,Global Market Access Solutions (GMAS), St-Prex, Switzerland
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16
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Jansen MP, Helderman JK, Boer B, Baltussen R. Fair Processes for Priority Setting: Putting Theory into Practice Comment on "Expanded HTA: Enhancing Fairness and Legitimacy". Int J Health Policy Manag 2017; 6:43-47. [PMID: 28005541 PMCID: PMC5193505 DOI: 10.15171/ijhpm.2016.85] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 06/22/2016] [Indexed: 11/28/2022] Open
Abstract
Embedding health technology assessment (HTA) in a fair process has great potential to capture societal values relevant to public reimbursement decisions on health technologies. However, the development of such processes for priority setting has largely been theoretical. In this paper, we provide further practical lead ways on how these processes can be implemented. We first present the misconception about the relation between facts and values that is since long misleading the conduct of HTA and underlies the current assessment-appraisal split. We then argue that HTA should instead be explicitly organized as an ongoing evidence-informed deliberative process, that facilitates learning among stakeholders. This has important consequences for whose values to consider, how to deal with vested interests, how to consider all values in the decision-making process, and how to communicate decisions. This is in stark contrast to how HTA processes are implemented now. It is time to set the stage for HTA as learning.
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Affiliation(s)
- Maarten P. Jansen
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan-Kees Helderman
- Institute for Management Research, Radboud University, Nijmegen, The Netherlands
| | - Bert Boer
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Rob Baltussen
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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17
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Abstract
Objectives: This study describes the views of various stakeholders on the
importance of different criteria for priority setting of HIV/AIDS interventions in
Indonesia. Methods: Based on a general list of criteria and a focus group discussion
with stakeholders (n = 6), a list was developed of thirty-two criteria
that play a role in priority setting in HIV/AIDS control in West-Java province. Criteria
were categorized according to the World Health Organization's health system goals and
building block frameworks. People living with HIV/AIDS (n = 49),
healthcare workers (HCW) (n = 41), the general population
(n = 43), and policy makers (n = 22) rated the
importance of thirty-two criteria on a 5-point Likert-scale. Thereafter, respondents
ranked the highest rated criteria to express more detailed preferences. Results: Stakeholders valued the following criteria as most important for
the priority setting of HIV/AIDS interventions: an intervention's impact on the HIV/AIDS
epidemic, reduction of stigma, quality of care, effectiveness on individual level, and
feasibility in terms of current capacity of the health system (i.e., HCW, product,
information, and service requirements), financial sustainability, and acceptance by
donors. Overall, stakeholders’ preferences for the importance of criteria are similar. Conclusions: Our study design outlines an approach for other settings to
identify which criteria are important for priority setting of health interventions. For
Indonesia, these study results may be used in priority setting processes for HIV/AIDS
control and may contribute to more transparent and systematic allocation of resources.
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18
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Baltussen R, Jansen MP, Mikkelsen E, Tromp N, Hontelez J, Bijlmakers L, Van der Wilt GJ. Priority Setting for Universal Health Coverage: We Need Evidence-Informed Deliberative Processes, Not Just More Evidence on Cost-Effectiveness. Int J Health Policy Manag 2016; 5:615-618. [PMID: 27801355 PMCID: PMC5088720 DOI: 10.15171/ijhpm.2016.83] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 06/18/2016] [Indexed: 11/09/2022] Open
Abstract
Priority setting of health interventions is generally considered as a valuable approach to support low- and middle-income countries (LMICs) in their strive for universal health coverage (UHC). However, present initiatives on priority setting are mainly geared towards the development of more cost-effectiveness information, and this evidence does not sufficiently support countries to make optimal choices. The reason is that priority setting is in reality a value-laden political process in which multiple criteria beyond cost-effectiveness are important, and stakeholders often justifiably disagree about the relative importance of these criteria. Here, we propose the use of 'evidence-informed deliberative processes' as an approach that does explicitly recognise priority setting as a political process and an intrinsically complex task. In these processes, deliberation between stakeholders is crucial to identify, reflect and learn about the meaning and importance of values, informed by evidence on these values. Such processes then result in the use of a broader range of explicit criteria that can be seen as the product of both international learning ('core' criteria, which include eg, cost-effectiveness, priority to the worse off, and financial protection) and learning among local stakeholders ('contextual' criteria). We believe that, with these evidence-informed deliberative processes in place, priority setting can provide a more meaningful contribution to achieving UHC.
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Affiliation(s)
- Rob Baltussen
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maarten P Jansen
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Evelinn Mikkelsen
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Noor Tromp
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan Hontelez
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA.,Africa Centre for Population Health, Mtubatuba, South Africa
| | - Leon Bijlmakers
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gert Jan Van der Wilt
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Hontelez JAC, Tanser FC, Naidu KK, Pillay D, Bärnighausen T. The Effect of Antiretroviral Treatment on Health Care Utilization in Rural South Africa: A Population-Based Cohort Study. PLoS One 2016; 11:e0158015. [PMID: 27384178 PMCID: PMC4934780 DOI: 10.1371/journal.pone.0158015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 06/08/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The effect of the rapid scale-up of vertical antiretroviral treatment (ART) programs for HIV in sub-Saharan Africa on the overall health system is under intense debate. Some have argued that these programs have reduced access for people suffering from diseases unrelated to HIV because ART programs have drained human and physical resources from other parts of the health system; others have claimed that the investments through ART programs have strengthened the general health system and the population health impacts of ART have freed up health care capacity for the treatment of diseases that are not related to HIV. To establish the population-level impact of ART programs on health care utilization in the public-sector health system, we compared trends in health care utilization among HIV-infected people receiving and not receiving ART with HIV-uninfected people during a period of rapid ART scale-up. METHODS AND FINDINGS We used data from the Wellcome Trust Africa Centre for Population Health, which annually elicited information on health care utilization from all surveillance participants over the period 2009-2012 (N = 32,319). We determined trends in hospitalization, and public-sector and private-sector primary health care (PHC) clinic visits for HIV-infected and -uninfected people over a time period of rapid ART scale-up (2009-2012) in this community. We regressed health care utilization on HIV status and ART status in different calendar years, controlling for sex, age, and area of residence. The proportion of people who reported to have visited a public-sector primary health care (PHC) clinic in the last 6 months increased significantly over the period 2009-2012, for both HIV-infected people (from 59% to 67%; p<0.001), and HIV-uninfected people (from 41% to 47%; p<0.001). In contrast, the proportion of HIV-infected people visiting a private-sector PHC clinic declined from 22% to 12% (p<0.001) and hospitalization rates declined from 128 to 82 per 1000 PY (p<0.001). For HIV-uninfected people, the proportion visiting a private-sector PHC clinic declined from 16% to 9%, and hospitalization rates declined from 78 to 44 per 1000 PY (p<0.001). After controlling for potential confounding factors, all trends remained of similar magnitude and significance. CONCLUSIONS Our results indicate that the ART scale-up in this high HIV prevalence community has shifted health care utilization from hospitals and private-sector primary care to public-sector primary care. Remarkably, this shift is observed for both HIV-infected and -uninfected populations, supporting and extending hypotheses of 'therapeutic citizenship' whereby HIV-infected patients receiving ART facilitate primary care access for family and community members. One explanation of our findings is that ART has improved the capacity or quality of primary care in this community and, as a consequence, increasingly met overall health care needs at the primary care level rather than at the secondary level. Future research needs to confirm this causal interpretation of our findings using qualitative work to understand causal mechanisms or quasi-experimental quantitative studies to increase the strength of causal inference.
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Affiliation(s)
- Jan A. C. Hontelez
- Wellcome Trust Africa Centre for Population Health, University of KwaZulu-Natal, Mtubatuba, South Africa
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, United States of America
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Frank C. Tanser
- Wellcome Trust Africa Centre for Population Health, University of KwaZulu-Natal, Mtubatuba, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Kevindra K. Naidu
- Wellcome Trust Africa Centre for Population Health, University of KwaZulu-Natal, Mtubatuba, South Africa
| | - Deenan Pillay
- Wellcome Trust Africa Centre for Population Health, University of KwaZulu-Natal, Mtubatuba, South Africa
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Till Bärnighausen
- Wellcome Trust Africa Centre for Population Health, University of KwaZulu-Natal, Mtubatuba, South Africa
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, United States of America
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20
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Bermudez LG, Jennings L, Ssewamala FM, Nabunya P, Mellins C, McKay M. Equity in adherence to antiretroviral therapy among economically vulnerable adolescents living with HIV in Uganda. AIDS Care 2016; 28 Suppl 2:83-91. [PMID: 27392003 PMCID: PMC4940111 DOI: 10.1080/09540121.2016.1176681] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/23/2016] [Indexed: 11/24/2022]
Abstract
Studies from sub-Saharan Africa indicate that children made vulnerable by poverty have been disproportionately affected by HIV with many exposed via mother-to-child transmission. For youth living with HIV, adherence to life-saving treatment regimens are likely to be affected by the complex set of economic and social circumstances that challenge their families and also exacerbate health problems. Using baseline data from the National Institute of Child and Human Development (NICHD) funded Suubi+Adherence study, we examined the extent to which individual and composite measures of equity predict self-reported adherence among Ugandan adolescents aged 10-16 (n = 702) living with HIV. Results showed that greater asset ownership, specifically familial possession of seven or more tangible assets, was associated with greater odds of self-reported adherence (OR 1.69, 95% CI: 1.00-2.85). Our analyses also indicated that distance to the nearest health clinic impacts youth's adherence to an ARV regimen. Youth who reported living nearest to a clinic were significantly more likely to report optimal adherence (OR 1.49, 95% CI: 0.92-2.40). Moreover, applying the composite equity scores, we found that adolescents with greater economic advantage in ownership of household assets, financial savings, and caregiver employment had higher odds of adherence by a factor of 1.70 (95% CI: 1.07-2.70). These findings suggest that interventions addressing economic and social inequities may be beneficial to increase antiretroviral therapy (ART) uptake among economically vulnerable youth, especially in sub-Saharan Africa. This is one of the first studies to address the question of equity in adherence to ART among economically vulnerable youth with HIV.
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Affiliation(s)
- Laura Gauer Bermudez
- Columbia University School of Social Work, International Center for Child Health and Asset Development, New York, NY, USA
| | - Larissa Jennings
- Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Fred M. Ssewamala
- Columbia University School of Social Work, International Center for Child Health and Asset Development, New York, NY, USA
| | - Proscovia Nabunya
- School of Social Service Administration, University of Chicago, Chicago, IL, USA
| | - Claude Mellins
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University Medical Center, New York, NY, USA
| | - Mary McKay
- McSilver Institute for Poverty Policy and Research, Silver School of Social Work, New York University, New York, NY, USA
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21
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Valentijn PP, Vrijhoef HJM, Ruwaard D, Boesveld I, Arends RY, Bruijnzeels MA. Towards an international taxonomy of integrated primary care: a Delphi consensus approach. BMC FAMILY PRACTICE 2015; 16:64. [PMID: 25998142 PMCID: PMC4446832 DOI: 10.1186/s12875-015-0278-x] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 05/06/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND Developing integrated service models in a primary care setting is considered an essential strategy for establishing a sustainable and affordable health care system. The Rainbow Model of Integrated Care (RMIC) describes the theoretical foundations of integrated primary care. The aim of this study is to refine the RMIC by developing a consensus-based taxonomy of key features. METHODS First, the appropriateness of previously identified key features was retested by conducting an international Delphi study that was built on the results of a previous national Delphi study. Second, categorisation of the features among the RMIC integrated care domains was assessed in a second international Delphi study. Finally, a taxonomy was constructed by the researchers based on the results of the three Delphi studies. RESULTS The final taxonomy consists of 21 key features distributed over eight integration domains which are organised into three main categories: scope (person-focused vs. population-based), type (clinical, professional, organisational and system) and enablers (functional vs. normative) of an integrated primary care service model. CONCLUSIONS The taxonomy provides a crucial differentiation that clarifies and supports implementation, policy formulation and research regarding the organisation of integrated primary care. Further research is needed to develop instruments based on the taxonomy that can reveal the realm of integrated primary care in practice.
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Affiliation(s)
- Pim P Valentijn
- Jan van Es Institute, Netherlands Expert Centre Integrated Primary Care, Wisselweg 33, CB 1314, Almere, The Netherlands.
- Scientific Centre for Care and Welfare (Tranzo), Tilburg University, Tilburg, The Netherlands.
| | - Hubertus J M Vrijhoef
- Scientific Centre for Care and Welfare (Tranzo), Tilburg University, Tilburg, The Netherlands.
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.
- Department of Patient and Care, University Hospital Maastricht, Maastricht, The Netherlands.
| | - Dirk Ruwaard
- Department of Health Services Research, School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | - Inge Boesveld
- Jan van Es Institute, Netherlands Expert Centre Integrated Primary Care, Wisselweg 33, CB 1314, Almere, The Netherlands.
| | - Rosa Y Arends
- Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands.
| | - Marc A Bruijnzeels
- Jan van Es Institute, Netherlands Expert Centre Integrated Primary Care, Wisselweg 33, CB 1314, Almere, The Netherlands.
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Norheim OF, Baltussen R, Johri M, Chisholm D, Nord E, Brock D, Carlsson P, Cookson R, Daniels N, Danis M, Fleurbaey M, Johansson KA, Kapiriri L, Littlejohns P, Mbeeli T, Rao KD, Edejer TTT, Wikler D. Guidance on priority setting in health care (GPS-Health): the inclusion of equity criteria not captured by cost-effectiveness analysis. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2014; 12:18. [PMID: 25246855 PMCID: PMC4171087 DOI: 10.1186/1478-7547-12-18] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 07/18/2014] [Indexed: 11/10/2022] Open
Abstract
This Guidance for Priority Setting in Health Care (GPS-Health), initiated by the World Health Organization, offers a comprehensive map of equity criteria that are relevant to health care priority setting and should be considered in addition to cost-effectiveness analysis. The guidance, in the form of a checklist, is especially targeted at decision makers who set priorities at national and sub-national levels, and those who interpret findings from cost-effectiveness analysis. It is also targeted at researchers conducting cost-effectiveness analysis to improve reporting of their results in the light of these other criteria. THE GUIDANCE WAS DEVELOP THROUGH A SERIES OF EXPERT CONSULTATION MEETINGS AND INVOLVED THREE STEPS: i) methods and normative concepts were identified through a systematic review; ii) the review findings were critically assessed in the expert consultation meetings which resulted in a draft checklist of normative criteria; iii) the checklist was validated though an extensive hearing process with input from a range of relevant stakeholders. The GPS-Health incorporates criteria related to the disease an intervention targets (severity of disease, capacity to benefit, and past health loss); characteristics of social groups an intervention targets (socioeconomic status, area of living, gender; race, ethnicity, religion and sexual orientation); and non-health consequences of an intervention (financial protection, economic productivity, and care for others).
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Affiliation(s)
- Ole F Norheim
- Department of Global Public Health and Primary Care, University of Bergen, PB 7800, 5020 Bergen, Norway
| | - Rob Baltussen
- Nijmegen International Centre for Health Systems Research and Education (NICHE), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Mira Johri
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Québec, Canada
| | - Dan Chisholm
- Department of Health Systems Financing, World Health Organization, Geneva, Switzerland
| | - Erik Nord
- Norwegian Institute of Public Health, Oslo, Norway
| | - DanW Brock
- Harvard Medical School, Harvard University, Cambridge, USA
| | - Per Carlsson
- National Centre for Priority Setting in Health Care, Linköping University, Linköping, Sweden
| | | | - Norman Daniels
- Harvard School of Public Health, Harvard University, Cambridge, USA
| | - Marion Danis
- Section on Ethics and Health Policy, NIH Clinical Centre, Bethesda, USA
| | - Marc Fleurbaey
- Woodrow Wilson School of Public and International Affairs, Princeton University, Princeton, USA
| | - Kjell A Johansson
- Department of Global Public Health and Primary Care, University of Bergen, PB 7800, 5020 Bergen, Norway
| | - Lydia Kapiriri
- Department of Health, Aging, and Society, McMaster University, Hamilton, Canada
| | - Peter Littlejohns
- Department of Primary Care and Public Health Sciences, Division of Health and Social Care Research, King’s College London, Previous affiliation the National Institute for Health and Care Excellence (NICE), London, England, UK
| | - Thomas Mbeeli
- Ministry of Health and Social Services, Windhoek, Namibia
| | | | - Tessa Tan-Torres Edejer
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Québec, Canada
| | - Dan Wikler
- Harvard School of Public Health, Harvard University, Cambridge, USA
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23
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Byskov J, Marchal B, Maluka S, Zulu JM, Bukachi SA, Hurtig AK, Blystad A, Kamuzora P, Michelo C, Nyandieka LN, Ndawi B, Bloch P, Olsen ØE. The accountability for reasonableness approach to guide priority setting in health systems within limited resources--findings from action research at district level in Kenya, Tanzania, and Zambia. Health Res Policy Syst 2014; 12:49. [PMID: 25142148 PMCID: PMC4237792 DOI: 10.1186/1478-4505-12-49] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 08/03/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Priority-setting decisions are based on an important, but not sufficient set of values and thus lead to disagreement on priorities. Accountability for Reasonableness (AFR) is an ethics-based approach to a legitimate and fair priority-setting process that builds upon four conditions: relevance, publicity, appeals, and enforcement, which facilitate agreement on priority-setting decisions and gain support for their implementation. This paper focuses on the assessment of AFR within the project REsponse to ACcountable priority setting for Trust in health systems (REACT). METHODS This intervention study applied an action research methodology to assess implementation of AFR in one district in Kenya, Tanzania, and Zambia, respectively. The assessments focused on selected disease, program, and managerial areas. An implementing action research team of core health team members and supporting researchers was formed to implement, and continually assess and improve the application of the four conditions. Researchers evaluated the intervention using qualitative and quantitative data collection and analysis methods. RESULTS The values underlying the AFR approach were in all three districts well-aligned with general values expressed by both service providers and community representatives. There was some variation in the interpretations and actual use of the AFR in the decision-making processes in the three districts, and its effect ranged from an increase in awareness of the importance of fairness to a broadened engagement of health team members and other stakeholders in priority setting and other decision-making processes. CONCLUSIONS District stakeholders were able to take greater charge of closing the gap between nationally set planning and the local realities and demands of the served communities within the limited resources at hand. This study thus indicates that the operationalization of the four broadly defined and linked conditions is both possible and seems to be responding to an actual demand. This provides arguments for the continued application and further assessment of the potential of AFR in supporting priority-setting and other decision-making processes in health systems to achieve better agreed and more sustainable health improvements linked to a mutual democratic learning with potential wider implications.
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Affiliation(s)
- Jens Byskov
- DBL – Centre for Health Research and Development, Faculty of Health and Medical Sciences, University of Copenhagen, Thorvaldsensvej 57, DK 1871 Frederiksberg, Denmark
| | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, B 2000 Antwerpen, Belgium
| | - Stephen Maluka
- Institute of Development Studies, University of Dar Es Salaam, PO Box 35169, Dar Es Salaam, Tanzania
| | - Joseph M Zulu
- Department of Public Health, School of Medicine, University of Zambia, PO Box 50110, Lusaka, Zambia
| | - Salome A Bukachi
- Institute of Anthropology, Gender and African Studies University of Nairobi, PO Box 30197, Nairobi 00100, Kenya
| | - Anna-Karin Hurtig
- Umeå International School of Public Health, Umeå University, SE 90185 Umea, Sweden
| | - Astrid Blystad
- Department of Public Health and Primary Health Care, University of Bergen, PO Box 7804, 5020 Bergen, Norway
| | - Peter Kamuzora
- Institute of Development Studies, University of Dar Es Salaam, PO Box 35169, Dar Es Salaam, Tanzania
| | - Charles Michelo
- Department of Public Health, School of Medicine, University of Zambia, PO Box 50110, Lusaka, Zambia
| | - Lillian N Nyandieka
- Centre for Public Health Research, Kenya Medical Research Institute (KEMRI), PO Box 20752, Nairobi 00202, Kenya
| | - Benedict Ndawi
- Primary Health Care Institute, PO Box 235, Iringa, Tanzania
| | - Paul Bloch
- Steno Health Promotion Center, Steno Diabetes Center, Niels Steensens Vej 8, DK-2820 Gentofte, Denmark
| | - Øystein E Olsen
- Affiliated to Centre for International Health, University of Bergen, Årstadveien 21 5th floor, N-5009 Bergen, Norway
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24
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Venhorst K, Zelle SG, Tromp N, Lauer JA. Multi-criteria decision analysis of breast cancer control in low- and middle- income countries: development of a rating tool for policy makers. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2014; 12:13. [PMID: 24855456 PMCID: PMC4031156 DOI: 10.1186/1478-7547-12-13] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 05/02/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objective of this study was to develop a rating tool for policy makers to prioritize breast cancer interventions in low- and middle- income countries (LMICs), based on a simple multi-criteria decision analysis (MCDA) approach. The definition and identification of criteria play a key role in MCDA, and our rating tool could be used as part of a broader priority setting exercise in a local setting. This tool may contribute to a more transparent priority-setting process and fairer decision-making in future breast cancer policy development. METHODS First, an expert panel (n = 5) discussed key considerations for tool development. A literature review followed to inventory all relevant criteria and construct an initial set of criteria. A Delphi study was then performed and questionnaires used to discuss a final list of criteria with clear definitions and potential scoring scales. For this Delphi study, multiple breast cancer policy and priority-setting experts from different LMICs were selected and invited by the World Health Organization. Fifteen international experts participated in all three Delphi rounds to assess and evaluate each criterion. RESULTS This study resulted in a preliminary rating tool for assessing breast cancer interventions in LMICs. The tool consists of 10 carefully crafted criteria (effectiveness, quality of the evidence, magnitude of individual health impact, acceptability, cost-effectiveness, technical complexity, affordability, safety, geographical coverage, and accessibility), with clear definitions and potential scoring scales. CONCLUSIONS This study describes the development of a rating tool to assess breast cancer interventions in LMICs. Our tool can offer supporting knowledge for the use or development of rating tools as part of a broader (MCDA based) priority setting exercise in local settings. Further steps for improving the tool are proposed and should lead to its useful adoption in LMICs.
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Affiliation(s)
- Kristie Venhorst
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
- Knowledge Institute of Medical Specialists, Utrecht, The Netherlands
| | - Sten G Zelle
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Noor Tromp
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeremy A Lauer
- Costs, Effectiveness, Expenditure and Priority Setting, World Health Organization, Geneva, Switzerland
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25
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Marsh K, Chapman R, Baggaley RF, Largeron N, Bresse X. Mind the gaps: what's missing from current economic evaluations of universal HPV vaccination? Vaccine 2014; 32:3732-9. [PMID: 24837538 DOI: 10.1016/j.vaccine.2014.05.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 04/24/2014] [Accepted: 05/01/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Since the original licensing of human papilloma virus (HPV) vaccination for women, evidence is accumulating of its effectiveness in preventing HPV-related conditions in men, and universal vaccination (vaccinating men and women) is now recommended in some countries. Several models of the cost-effectiveness of universal HPV vaccination have been published, but results have been mixed. This article assesses the extent to which economic studies have captured the range of values associated with universal HPV vaccination, and how this influences estimates of its cost-effectiveness. METHODS Eight published economic evaluations of universal HPV vaccination were reviewed to identify which of the values associated with universal HPV vaccination were included in each analysis. RESULTS Studies of the cost-effectiveness of universal HPV vaccination capture only a fraction of the values generated. Most studies focused on impacts on health and health system cost, and only captured these partially. A range of values is excluded from most studies, including impacts on productivity, patient time and costs, carers and family costs, and broader social values such as the right to access treatment. Further, those studies that attempted to capture these values only did so partially. DISCUSSION Decisions to invest in universal HPV vaccination need to be based on a complete assessment of the value that it generates. This is not provided by existing economic evaluations. Further work is required to understand this value. First, research is required to understand how HPV-related health outcomes impact on society including, for instance, their impact on productivity. Second, consideration should be given to alternative approaches to capture this broader set of values in a manner useful to decisions-makers, such as multi-criteria decision analysis.
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Affiliation(s)
- Kevin Marsh
- Evidera, Metro Building, 6th Floor, 1 Butterwick, London W6 8DL, United Kingdom
| | - Ruth Chapman
- Evidera, Metro Building, 6th Floor, 1 Butterwick, London W6 8DL, United Kingdom
| | - Rebecca F Baggaley
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E HT, United Kingdom
| | | | - Xavier Bresse
- Sanofi Pasteur MSD, 8, rue Jonas Salk, 69367 Lyon Cedex 07, France
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Tromp N, Prawiranegara R, Subhan Riparev H, Siregar A, Sunjaya D, Baltussen R. Priority setting in HIV/AIDS control in West Java Indonesia: an evaluation based on the accountability for reasonableness framework. Health Policy Plan 2014; 30:345-55. [DOI: 10.1093/heapol/czu020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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