The Need for Global Application of the Accountability for Reasonableness Approach to Support Sustainable Outcomes Comment on "Expanded HTA: Enhancing Fairness and Legitimacy"

Public legitimacy of healthcare resource allocation committees: lessons learned from assessing an Israeli case study

Background

The National Health Insurance Law enacted in 1995 stipulates a list of health services to which all Israeli residents are entitled. For the past 20 years, the list has been updated annually, as a function of a predetermined budget, according to recommendations from the Public National Advisory Committee (PNAC), which evaluates and prioritizes candidate technologies. We assessed the legitimacy of this resource-allocation process as reflected in Israeli public discourse and its congruence with the accountability for reasonableness (A4R) framework.

Methods

A qualitative analysis of public discourse documents (articles in the print media, court rulings and parliamentary debates (N = 119) was conducted to assess the perceived legitimacy by the Israeli public of the PNAC. Further content analysis of these documents and semi-structured interviews with stakeholders (N = 70) revealed the mainstays and threats to its legitimacy. Based on these data sources, on governmental documents specifying PNAC's procedures, and on data from participant observations, we assessed its congruence with A4R’s four conditions: publicity, relevance, revision and appeals, regulation.

Results

The PNAC enjoys ongoing support for its legitimacy in Israeli public discourse, which stem from its perceived professional focus and transparency. These strengths are consistent with the A4R’s emphasis on the publicity and the relevance conditions. The three major threats to PNAC's legitimacy pertain to: (1) the composition of the committee; (2) its operating procedures; (3) its guiding principles. These perceived shortcomings are also consistent with incongruencies between PNAC's work model and A4R. These findings thus further support the empirical validity of the A4R.

Conclusion

The analysis of the fit between the PNAC and A4R points to refinements in all four conditions that could make the A4R a more precise evaluative framework. Concurrently, it highlights areas that the PNAC should improve to increase its legitimacy, such as incorporating cost-effectiveness analyses and including patient representatives in the decision-making process.

Hebrew and Arabic abstracts for this article are available as an additional file.

A systems perspective on the importance of global health strategy developments for accomplishing today's Sustainable Development Goals

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.

Ethics in HTA: Examining the "Need for Expansion"

The article by Daniels and colleagues on expanding the scope of health technology assessment (HTA) to embrace ethical analysis has received endorsement and criticism from commentators in this journal. Referring to this debate, we examine in this article the extent and locus of ethical analysis in HTA processes. An expansion/no-expansion framing of HTA is, in our view, not very fruitful. We argue that meaningfulness and relevance to the needs of the population are what should determine the extent of ethics in HTA. Once ‘relevance’ is the guiding principle, engaging in ethical analysis becomes inevitable as values are all over the place in HTA, also in how assessors frame research questions. We also challenge dividing the locus of ethical analysis into assessment and appraisal as this would detach HTA from its purpose, ie, supporting legitimate decision-making. Ethical analysis should therefore be considered integral to the HTA process.