As universal health coverage becomes the norm in many countries, it is important to determine public priorities regarding benefits to include in health insurance coverage. We report results of ...participation in a decision exercise among residents of Switzerland, a high-income country with a long history of universal health insurance and deliberative democracy.
We adapted the Choosing Healthplans All Together (CHAT) tool, an exercise developed to transform complex healthcare allocation decisions into easily understandable choices, for use in Switzerland. We conducted CHAT exercises in twelve Swiss cities with recruitment from a range of socio-economic backgrounds, taking into account differences in language and culture.
Compared to existing coverage, a majority of 175 participants accepted greater general practice gatekeeping (94%), exclusion of invasive life-sustaining measures in dying patients (80%), longer waiting times for non-urgent episodic care (78%), greater adherence to cost-effectiveness guidelines in chronic care (66%), and lower premium subsidies (51%). Most initially chose greater coverage for dental care (59%), quality of life (57%), and long-term care (90%). During group deliberations, participants increased coverage for out-of-pocket costs (58%) and mental health to current levels (41%) and beyond current levels for rehabilitation (50%), and decreased coverage for quality of life to current levels (74%). Following group deliberation, they tended to change their views back to below current coverage for help with out-of-pocket costs, and back to current levels for rehabilitation. Most participants accepted the plan as appropriate and fair. A significant number would have added nothing.
Swiss participants who have engaged in a priority setting exercise accept complex resource allocation trade-offs in healthcare coverage. Moreover, in the context of a well-funded healthcare system with universal coverage centered on individual choice, at least some of our participants believed a fully sufficient threshold of health insurance coverage was achieved.
Global Developments in Priority Setting in Health Baltussen, Rob; Mitton, Craig; Danis, Marion ...
International journal of health policy and management,
03/2017, Letnik:
6, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Countries around the world are experiencing an ever-increasing need to make choices in investments in health and healthcare. This makes it incumbent upon them to have formal processes in place to ...optimize the legitimacy of eventual decisions. There is now growing experience among countries of the implementation of stakeholder participation, and a developing convergence of methods to support decision-makers within health authorities in making tough decisions when faced with the stark reality of limited resources. We call for further interaction among health authorities, and the research community to develop best practices in order to confront the difficult choices that need to be made.
Current trends in vaccine development have stimulated much commentary on how vaccines deemed to be the safest and most effective should be allocated, both at the global level (to ensure access for ...low-income countries)1 2 and within countries (to prioritise critical personnel and the most vulnerable population groups).3 We recognise the importance of mass vaccination as a public health measure, and the crucial need to promote equity and solidarity across countries.4 5 We also recognise that prioritisation is required within countries so that resources are directed to best protect life, reduce inequities and increase public confidence. Cost analysis should therefore encompass logistical and distribution issues, which are likely to be significant drivers of affordability and influenced by, for example, the requirement for vaccine storage at very low temperatures.6 Vaccine costs and cost-effectiveness should be considered in the wider context of equity of access and outcome, and fair allocation of resources within and across populations.7 8 Though COVID-19 vaccines may initially be funded by donors, all countries will need long-term, mass COVID-19 vaccination strategies to ensure equitable and sustainable practices. Vaccine roll-out, however welcome, is an additional strain not only in LICs but also increasingly in high-income countries.21 22 There is a need to support health systems to sustain routine services—this is more critical for weaker health systems seeking to prevent excessive avoidable mortality.20 Lastly, as countries plan to roll out COVID-19 vaccination, it is important that effective strategies to deal with vaccine hesitancy are developed and implemented.23 24 Conclusions The fundamental tenets of good priority setting include: taking an explicit approach to decision-making; meaningful stakeholder engagement; consideration of public values, ensuring mechanisms for appeals and revisions; and use of relevant evidence.25 26 Furthermore, for priority setting to be impactful, resource allocation should be aligned with set priorities.25 27 In the case of vaccination against COVID-19, such tenets will be crucial, as mismanaged priority setting would have disastrous consequences for health, equity and trust in public health and policymakers. There are no simple decision rules that can be transferred across contexts28 and consistency will best be served by the building of ‘case law’ as a means to inform, defend and refine decisions, and enable constant and careful monitoring and evaluation to ensure the greatest impact.29 In these conditions of uncertainty and occasional conflict, the design of vaccination programmes cannot be a purely technical task, and hence, there is a need for greater participation in decision-making than has been exercised so far with, for example, poor gender and racial representation on COVID-19 planning task forces.30 Successful vaccination programmes will require buy-in from patient groups, local implementers and healthcare professionals (including the largely unpaid community health workers who will be relied on to support vaccination programmes in LICs), as well as major players from industry and
ObjectivePublic engagement in priority setting for health is recognised as a means to ensure more inclusive, fair and legitimate decision making processes, especially in the context of Universal ...Health Coverage where demands outweigh available resources. Deliberative engagement approaches are often viewed as particularly useful in considering social values and balancing trade-offs, however, implementation of these approaches for priority setting is scant, especially in low and middle income settings. In order to address this gap we implemented a context specific public deliberation tool in a rural community in South Africa to determine priorities for a health services package.MethodsQualitative data were analysed from seven group deliberations using the engagement tool. Content analysis was conducted and inductive and deductive coding was used. The analysis focused on understanding the deliberative process, what the participants prioritised, the reasons for these selections and how negotiations took place within the groups.ResultsThe deliberations demonstrated that the groups often prioritised curative services over primary prevention which related to perceived lack of efficacy of existing health education and prevention programmes in leading to behaviour change. The groups engaged deeply with trade-offs between costly treatment options for HIV/AIDS and those for non-communicable disease. Barriers to healthcare access were considered especially important by all groups and some priorities included investing in more mobile clinics.DiscussionSouth Africa is committed to public engagement in priority-setting for health, yet the views of communities are not considered in policy and programme development which largely involves top down decision making. This study demonstrates that deliberative engagement methods can be successful in helping communities balance trade-offs and in eliciting social values around health priorities. The findings from such deliberations, alongside other evidence and broader ethical considerations, have the potential to inform decision-making with regard to health policy design and implementation.
The Open Peer Commentaries on “The Emergence of Clinical Research Ethics Consultation: Insights from a National Collaborative201D highlight the many ways in which the practice of ethics consultation ...for clinical research can be further advanced. We respond here to a number of key considerations highlighted by commentators, including the role and scope of research ethics consultation (REC), relationships with other institutional services and programs, efforts to ensure the quality of consultations provided, and the feasibility of widespread REC services.
The problems of racism and racially motivated violence in predominantly African American communities in the United States are complex, multifactorial, and historically rooted. While these problems ...are also deeply morally troubling, bioethicists have not contributed substantially to addressing them. Concern for justice has been one of the core commitments of bioethics. For this and other reasons, bioethicists should contribute to addressing these problems. We consider how bioethicists can offer meaningful contributions to the public discourse, research, teaching, training, policy development, and academic scholarship in response to the alarming and persistent patterns of racism and implicit biases associated with it. To make any useful contribution, bioethicists will require preparation and should expect to play a significant role through collaborative action with others.
Intersectionality has become a significant intellectual approach for those thinking about the ways that race, gender, and other social identities converge in order to create unique forms of ...oppression. Although the initial work on intersectionality addressed the unique position of black women relative to both black men and white women, the concept has since been expanded to address a range of social identities. Here we consider how to apply some of the theoretical tools provided by intersectionality to the clinical context. We begin with a brief discussion of intersectionality and how it might be useful in a clinical context. We then discuss two clinical scenarios that highlight how we think considering intersectionality could lead to more successful patient-clinician interactions. Finally, we extrapolate general strategies for applying intersectionality to the clinical context before considering objections and replies.
Active and engaged patients seek the understanding, knowledge, and skills to promote their own health. Efforts to promote such patient activation and engagement are ethically justified because they ...are consonant with the well-established principle of respect for persons and, as the evidence shows, because they are likely to produce better outcomes for patients. Yet patient activation and engagement can also go ethically awry if, for example, nonadherent patients are abandoned or are unduly disadvantaged by punitive policies and practices, or if the conditions for successful activation and engagement are missing. In this article we discuss the ethical issues and responsibilities that pertain to patients, clinicians, health care organizations, delivery systems, insurers, payers, and communities. For example, physicians or payers could hold patients blameworthy for not following recommendations, but we suggest that a better approach would be for providers and payers to empower patients to effectively share responsibility for defining goals and achieving them. An ethical approach to patient activation and engagement should place obligations not only on patients but also on clinicians, health care organizations and delivery systems, insurers, and communities.
This study used "Choosing All Together" (CHAT), a deliberative engagement tool to prioritise nutrition interventions and to understand reasons for intervention choices of a rural community in ...northern Ghana. The study took an exploratory cross-sectional design and used a mixed method approach to collect data between December 2020 and February 2021. Eleven nutrition interventions were identified through policy reviews, interaction with different stakeholders and focus group discussions with community members. These interventions were costed for a modified CHAT tool-a board-like game with interventions represented by colour coded pies and the cost of the interventions represented by sticker holes. Supported by trained facilitators, six community groups used the tool to prioritise interventions. Discussions were audio-recoded, transcribed and thematically analysed. The participants prioritised both nutrition-sensitive and nutrition-specific interventions, reflecting the extent of poverty in the study districts and the direct and immediate benefits derived from nutrition-specific interventions. The prioritised interventions involved livelihood empowerment, because they would create an enabling environment for all-year-round agricultural output, leading to improved food security and income for farmers. Another nutrition-sensitive, education-related priority intervention was male involvement in food and nutrition practices; as heads of household and main decision makers, men were believed to be in a position to optimise maternal and child nutrition. The prioritised nutrition-specific intervention was micronutrient supplementation. Despite low literacy, participants were able to use CHAT materials and work collectively to prioritize interventions. In conclusion, it is feasible to modify and use the CHAT tool in public deliberations to prioritize nutrition interventions in rural settings with low levels of literacy. These communities prioritised both nutrition-sensitive and nutrition-specific interventions. Attending to community derived nutrition priorities may improve the relevance and effectiveness of nutrition health policy, since these priorities reflect the context in which such policy is implemented.
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