Developing and piloting a context-specified ethics framework for health technology assessment: the South African Values and Ethics for Universal Health Coverage approach

Abstract

Objectives: While ethics has been identified as a core component of health technology assessment (HTA), there are few examples of practical, systematic inclusion of ethics analysis in HTA. Some attribute the scarcity of ethics analysis in HTA to debates about appropriate methodology and the need for ethics frameworks that are relevant to local social values. The "South African Values and Ethics for Universal Health Coverage" (SAVE-UHC) project models an approach that countries can use to develop HTA ethics frameworks that are specific to their national contexts. Methods: The SAVE-UHC approach consisted of two phases. In Phase I, the research team convened and facilitated a national multistakeholder working group to develop a provisional ethics framework through a collaborative, engagement-driven process. In Phase II, the research team refined the model framework by piloting it through three simulated HTA appraisal committee meetings. Each simulated committee reviewed two case studies of sample health interventions: opioid substitution therapy and either a novel contraceptive implant or seasonal influenza immunization for children under five. Results: The methodology was fit-for-purpose, resulting in a context-specified ethics framework and producing relevant findings to inform application of the framework for the given HTA context. Conclusions: The SAVE-UHC approach provides a model for developing, piloting, and refining an ethics framework for health priority-setting that is responsive to national social values. This approach also helps identify key facilitators and challenges for integrating ethics analysis into HTA processes.Priority-setting on the path to Universal Health Coverage (UHC) is morally complex with unavoidable trade-offs, especially in resource-constrained settings. Over the past few decades, there has been increasing interest in health technology assessment (HTA) to support national health decision-making in countries pursuing UHC policies (1). HTA has been defined as a process for systematically evaluating the properties, effects, impacts, and overall value of a health intervention in order to inform decision-making in support of an equitable, efficient, and highquality health system (2). While ethics has long been articulated as central to HTA-alongside clinical effectiveness, safety, costs, and economics-there are still few examples of practical, systematic inclusion of broader ethics analysis in HTA processes (3-7). Lack of consensus about how to conduct ethics analyses, approaches to ethics analysis being ill-suited to those without philosophy backgrounds, and existing frameworks not being adequately specified or responsive to particular social contexts have all been cited as reasons why ethics has lagged behind the other core components of HTA (4;[8][9][10][11]. South Africa's ongoing process to introduce National Health Insurance (NHI) presented an opportunity to develop a methodological approach for early integration of nationally relevant ethics analysis into priority-setting (12;13). Th...

Universal Health Coverage, National Health Insurance, and Sustainable Workforce

“…The South African Values and Ethics for Universal Health Coverage (SAVE-UHC) Working Group has developed a framework to use in South Africa for health priority-setting (Blaauw et al, 2022;Krubiner et al, 2022). There are 12 domains in the framework of which the first four are commonly used in health priority-setting, namely burden of disease, expected health benefits and harms, cost-effectiveness analysis, and budget impact.…”

Conducting a health technology assessment in the West Bank, occupied Palestinian territory: lessons from a feasibility project

“…There is a growing demand for the institutionalization of evidence-informed priority setting (EIPS) in low- and middle-income countries (LMICs), to support the efficient and fair allocation of healthcare resources (1–3). EIPS is being championed as a means to achieving universal health coverage (UHC), because it requires the use of inclusive and transparent deliberative processes for supporting decision making (4;5). In many LMICs, healthcare resources and services are often not adequately available or accessible to a significant proportion of the population, due to supply and demand constraints, such as limited infrastructure, insufficient health personnel, and poor health-seeking behavior (6).…”