Priority Setting for Universal Health Coverage: We Need to Focus Both on Substance and on Process Comment on "Priority Setting for Universal Health Coverage: We Need Evidence-Informed Deliberative Processes, not Just More Evidence on Cost-Effectiveness"

Abstract

In an editorial published in this journal, Baltussen et al argue that information on cost-effectiveness is not sufficient for priority setting for universal health coverage (UHC), a claim which is correct as far as it goes. However, their focus on the procedural legitimacy of ‘micro’ priority setting processes (eg, decisions concerning the reimbursement of specific interventions), and their related assumption that values for priority setting are determined only at this level, leads them to ignore the relevance of higher level, ‘macro’ priority setting processes, for example, consultations held by World Health Organization (WHO) Member States and other global stakeholders that have resulted in widespread consensus on the principles of UHC. Priority setting is not merely about discrete choices, nor should the focus be exclusively (or even mainly) on improving the procedural elements of micro priority setting processes. Systemic activities that shape the health system environment, such as strategic planning, as well as the substantive content of global policy instruments, are critical elements for priority setting for UHC.

Evidence-Informed Deliberative Processes – Early Dialogue, Broad Focus and Relevance: A Response to Recent Commentaries

“…We agree with Gopinathan and Ottersen that the “focus of such processes [to support priority setting for UHC] should go beyond clinical services to accommodate also public health interventions.” 4 We also concur with Lauer et al that priority setting should take into account higher level, systemic activities that can strengthen progression towards UHC such as ‘improving health-system governance,’ ‘ensuring equitable access to quality services,’ ‘separating prescribing from dispensing,’ or ‘setting up a pooled funding mechanism to purchase services.’ 5 Moreover, EDPs “should adapt to a diverse set of factors shaping the relationship between evidence and policy.” 4 Ideally, EDPs are initiated at an early stage, as policy-relevant evidence can still be commissioned or searched for during this stage, and there is still time to reflect on input or ideas put forward by stakeholders. As Gopinathan and Ottersen point out, this requires involvement of the right stakeholders, including non-health stakeholders where relevant.…”

“…As Gopinathan and Ottersen point out, this requires involvement of the right stakeholders, including non-health stakeholders where relevant. 4 At the same time, Lauer et al raise the question “who should be invited to the deliberative dialogue?” 5 We argue that those affected by decisions should at least be provided the opportunity to participate and provide relevant reasons or evidence 3 – and we acknowledge that it is hard to determine who the relevant stakeholders are, and that standardized approaches are required to identify and engage relevant stakeholders. The description by Gopinathan and Ottersen of the complex relationship between evidence and policy further demonstrates the challenge of knowledge translation and how evidence can eventually be presented so as to facilitate its uptake and inclusion in policy formulation or revision.…”

“…5 Universal goals do need to be aligned with local context and priorities. We also recognize the point made by Lauer et al that EDPs, generic as they are, are already in place to a certain degree at the country level and are supported by the WHO Secretariat, 5 in the form of consultative groups, and part of health-sector reviews and strategic planning and budgeting.…”

“…5 Universal goals do need to be aligned with local context and priorities. We also recognize the point made by Lauer et al that EDPs, generic as they are, are already in place to a certain degree at the country level and are supported by the WHO Secretariat, 5 in the form of consultative groups, and part of health-sector reviews and strategic planning and budgeting. Likewise, as Chalkidou et al point out, the International Decision Support Initiative () has been established to strengthen in-country institutional and technical capacity together with open participative processes for evidence-informed policy-making.…”

“…5,7 On the contrary, evidence on the cost-effectiveness of a clinical or public health intervention provides relevant information on the opportunity costs of alternative investments that are foregone. Hence we do not oppose, but instead welcome efforts to integrate evidence on multiple criteria as is the case in the extended cost-effectiveness analysis approach.…”