Maarten Paul Maria Jansen

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.

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.

Time to recognise countries' preferences in HIV control

www.thelancet.com Vol 387 March 12, 2016 1053 thermonebulisation as an attempt to control the adult vector; despite serious concerns regarding Malathion. The Revolving Fund for Strategic Public Health Supplies in the Pan American Health Organization has prioritised the purchase of pesticides. The prescribed model of implementation is centralised, vertical, and does not consider the steep social gradient where clusters of microcephaly areis found in poor outskirts of cities, where sanitary conditions are bad. Although offi cial data point out that 92% of urban households in Brazil were connected to public water in 2010, there are 3 983 329 unserved households, and intermittent water supply, forcing the population to store water for everyday consumption, and favouring mosquito breeding. And only 28% of rural households are connected to public water. The approach applied so far by the Government uses large resources on inefficient or unsafe vector control methods, instead of improving urban infrastructure and environmental sanitation, with a stable supply of potable water. Relying on a chemical war against the vector tends to pacify the population with false security, while a broad programme for better sanitary urban conditions could generate social mobilisation and co-responsibility of the population. Improvement of sanitary conditions is a long-term investment in population health, while pesticide use will have to be repeated. The Brazilian Association of Collective Health calls to stop the use of chemical products against A aegypti, especially in household water reservoirs, and prioritise sanitary measures.

Translating international HIV treatment guidelines into local priorities in Indonesia

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.

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

*Correspondence to: Maarten P. Jansen, Email: maarten.jansen@radboudumc.nl Copyright:

Progressive realisation of universal health coverage: what are the required processes and evidence?

Progressive realisation is invoked as the guiding principle for countries on their own path to universal health coverage (UHC). It refers to the governmental obligations to immediately and progressively move towards the full realisation of UHC. This paper provides procedural guidance for countries, that is, how they can best organise their processes and evidence collection to make decisions on what services to provide first under progressive realisation. We thereby use ‘evidence-informed deliberative processes’, a generic value assessment framework to guide decision making on the choice of health services. We apply this to the concept of progressive realisation of UHC. We reason that countries face two important choices to achieve UHC. First, they need to define which services they consider as high priority, on the basis of their social values, including cost-effectiveness, priority to the worse off and financial risk protection. Second, they need to make tough choices whether they should first include more priority services, first expand coverage of existing priority services or first reduce co-payments of existing priority services. Evidence informed deliberative processes can facilitate these choices for UHC, and are also essential to the progressive realisation of the right to health. The framework informs health authorities on how they can best organise their processes in terms of composition of an appraisal committee including stakeholders, of decision-making criteria, collection of evidence and development of recommendations, including their communication. In conclusion, this paper fills in an important gap in the literature by providing procedural guidance for countries to progressively realise UHC.