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      Don’t Discount Societal Value in Cost-Effectiveness : Comment on "Priority Setting for Universal Health Coverage: We Need Evidence-Informed Deliberative Processes, Not Just More Evidence on Cost-Effectiveness"

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          Abstract

          As healthcare resources become increasingly scarce due to growing demand and stagnating budgets, the need for effective priority setting and resource allocation will become ever more critical to providing sustainable care to patients. While societal values should certainly play a part in guiding these processes, the methodology used to capture these values need not necessarily be limited to multi-criterion decision analysis (MCDA)-based processes including ‘evidence-informed deliberative processes.’ However, if decision-makers intend to not only incorporates the values of the public they serve into decisions but have the decisions enacted as well, consideration should be given to more direct involvement of stakeholders. Based on the examples provided by Baltussen et al, MCDA-based processes like ‘evidence-informed deliberative processes’ could be one way of achieving this laudable goal.

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          Most cited references15

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          Welfarism vs. extra-welfarism.

          'Extra-welfarism' has received some attention in health economics, yet there is little consensus on what distinguishes it from more conventional 'welfarist economics'. In this paper, we seek to identify the characteristics of each in order to make a systematic comparison of the ways in which they evaluate alternative social states. The focus, though this is not intended to be exclusive, is on health. Specifically, we highlight four areas in which the two schools differ: (i) the outcomes considered relevant in an evaluation; (ii) the sources of valuation of the relevant outcomes; (iii) the basis of weighting of relevant outcomes and (iv) interpersonal comparisons. We conclude that these differences are substantive.
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            Intergenerational equity: an exploration of the 'fair innings' argument.

            Many different equity principles may need to be traded off against efficiency when prioritizing health care. This paper explores one of them: the concept of a 'fair innings'. It reflects the feeling that everyone is entitled to some 'normal' span of health (usually expressed in life years, e.g. 'three score years and ten') and anyone failing to achieve this has been cheated, whilst anyone getting more than this is 'living on borrowed time'. Four important characteristics of the 'fair innings' notion are worth noting: firstly, it is outcome based, not process-based or resource-based; secondly, it is about a person's whole life-time experience, not about their state at any particular point in time; thirdly, it reflects an aversion to inequality; and fourthly, it is quantifiable. Even in common parlance it is usually expressed in numerical terms: death at 25 is viewed very differently from death at 85. But age at death should be no more than a first approximation, because the quality of a person's life is important as well as its length. The analysis suggests that this notion of intergenerational equity requires greater discrimination against the elderly than would be dictated simply by efficiency objectives.
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              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.
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                Author and article information

                Journal
                Int J Health Policy Manag
                Int J Health Policy Manag
                Kerman University of Medical Sciences
                Int J Health Policy Manag
                International Journal of Health Policy and Management
                Kerman University of Medical Sciences
                2322-5939
                September 2017
                14 January 2017
                : 6
                : 9
                : 543-545
                Affiliations
                Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.
                Author notes
                [* ] Correspondence to: William Hall will.hall50@ 123456gmail.com
                Article
                10.15171/ijhpm.2017.03
                5582442
                d4bd5b02-05bc-48a5-a11b-e4aeb408997b
                © 2017 The Author(s); Published by Kerman University of Medical Sciences

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 14 November 2016
                : 08 January 2017
                Page count
                References: 28, Pages: 3
                Categories
                Commentary

                cost-effectiveness,priority setting,resource allocation,multi-criterion decision analysis (mcda),deliberative processes

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