Stakeholder Participation for Legitimate Priority Setting: A Checklist.

Accountable decision-makers are required to legitimize their priority setting decisions in health to members of society. In this perspective we stress the point that fair, legitimate processes should reflect efforts of authorities to treat all stakeholders as moral equals in terms of providing all people with well-justified, reasonable reasons to endorse the decisions. We argue there is a special moral concern for being accountable to those who are potentially adversely affected by decisions. Health authorities need to operationalize this requirement into real world action. In this perspective, we operationalize five key steps in doing so, in terms of (i) proactively identifying potentially adversely affected stakeholders; (ii) comprehensively including them in the decision-making process; (iii) ensuring meaningful participation; (iv) communication of recommendations or decisions; and (v) the organization of evaluation and appeal mechanisms. Health authorities are advised to use a checklist in the form of 29 reflective questions, aligned with these five key steps, to assist them in the practical organization of legitimate priority setting in healthcare.

Evidence for scaling up HIV treatment in sub-Saharan Africa: A call for incorporating health system constraints.

Jan Hontelez and colleagues argue that the cost-effectiveness studies of HIV treatment scale-up need to include health system constraints to be more informative.

Fair Processes for Priority Setting: Putting Theory into Practice Comment on "Expanded HTA: Enhancing Fairness and Legitimacy".

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.

Priority Setting for Universal Health Coverage: We Need Evidence-Informed Deliberative Processes, Not Just More Evidence on Cost-Effectiveness.

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.