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Tugendhaft A, Christofides N, Stacey N, Kahn K, Erzse A, Danis M, Gold M, Hofman K. Moving towards social inclusion: Engaging rural voices in priority setting for health. Health Expect 2023; 27:e13895. [PMID: 37882224 PMCID: PMC10726206 DOI: 10.1111/hex.13895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 10/06/2023] [Accepted: 10/10/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Achieving universal health coverage (UHC) in the context of limited resources will require prioritising the most vulnerable and ensuring health policies and services are responsive to their needs. One way of addressing this is through the engagement of marginalised voices in the priority setting process. Public engagement approaches that enable group level deliberation as well as individual level preference capturing might be valuable in this regard, but there are limited examples of their practical application, and gaps in understanding their outcomes, especially with rural populations. OBJECTIVE To address this gap, we implemented a modified priority setting tool (Choosing All Together-CHAT) that enables individuals and groups to make trade-offs to demonstrate the type of health services packages that may be acceptable to a rural population. The paper presents the findings from the individual choices as compared to the group choices, as well as the differences among the individual choices using this tool. METHODS Participants worked in groups and as individuals to allocate stickers representing the available budget to different health topics and interventions using the CHAT tool. The allocations were recorded at each stage of the study. We calculated the median and interquartile range across study participants for the topic totals. To examine differences in individual choices, we performed Wilcoxon rank sum tests. RESULTS The results show that individual interests were mostly aligned with societal ones, and there were no statistically significant differences between the individual and group choices. However, there were some statistically significant differences between individual priorities based on demographic characteristics like age. DISCUSSION The study demonstrates that giving individuals greater control and agency in designing health services packages can increase their participation in the priority setting process, align individual and community priorities, and potentially enhance the legitimacy and acceptability of priority setting. Methods that enable group level deliberation and individual level priority setting may be necessary to reconcile plurality. The paper also highlights the importance of capturing the details of public engagement processes and transparently reporting on these details to ensure valuable outcomes. PUBLIC CONTRIBUTION The facilitator of the CHAT groups was a member from the community and underwent training from the research team. The fieldworkers were also from the community and were trained and paid to capture the data. The participants were all members of the rural community- the study represents their priorities.
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Affiliation(s)
- Aviva Tugendhaft
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SASchool of Public Health, Faculty of Health Sciences, University of WitwatersrandJohannesburgSouth Africa
| | - Nicola Christofides
- School of Public HealthFaculty of Health Sciences, University of the WitwatersrandJohannesburgSouth Africa
| | - Nicholas Stacey
- Department of Health PolicyLondon School of EconomicsLondonUK
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit—AgincourtSchool of Public Health, Faculty of Health Sciences, University of the WitwatersrandJohannesburgSouth Africa
| | - Agnes Erzse
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SASchool of Public Health, Faculty of Health Sciences, University of WitwatersrandJohannesburgSouth Africa
| | - Marion Danis
- Department of BioethicsNational Institutes of HealthBethesdaMarylandUSA
| | - Marthe Gold
- New York Academy of MedicineNew York CityNew YorkUSA
| | - Karen Hofman
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SASchool of Public Health, Faculty of Health Sciences, University of WitwatersrandJohannesburgSouth Africa
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Hurst SA, Schindler M, Goold SD, Danis M. Swiss-CHAT: Citizens Discuss Priorities for Swiss Health Insurance Coverage. Int J Health Policy Manag 2018; 7:746-754. [PMID: 30078295 PMCID: PMC6077280 DOI: 10.15171/ijhpm.2018.15] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 02/12/2018] [Indexed: 11/12/2022] Open
Abstract
Background: 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.
Methods: 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.
Results: 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.
Conclusion: 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.
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Affiliation(s)
- Samia A Hurst
- Institute for Ethics, History, and the Humanities, Geneva University Medical School, Geneva, Switzerland
| | - Mélinée Schindler
- Institute for Ethics, History, and the Humanities, Geneva University Medical School, Geneva, Switzerland
| | - Susan D Goold
- Department of General Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Marion Danis
- Department of Bioethics, National Institutes of Health, Bethesda, MD, USA
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Obse A, Hailemariam D, Normand C. Knowledge of and preferences for health insurance among formal sector employees in Addis Ababa: a qualitative study. BMC Health Serv Res 2015; 15:318. [PMID: 26260445 PMCID: PMC4532245 DOI: 10.1186/s12913-015-0988-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 08/05/2015] [Indexed: 11/28/2022] Open
Abstract
Background The Ethiopian health system has been undergoing through reforms. One of the reforms stipulated in policy documents is the introduction of health insurance at national level. Having the majority of the population without any experience of health insurance, investigating preferences and knowledge of the essence of health insurance among potential enrolees will provide vital information for policy makers. This formative study seeks to explore the knowledge and the preference for health insurance among formal sector employees in Addis Ababa. Methods Six focus group discussions with formal sector employees and five key informant interviews were conducted in Addis Ababa. A thematic analysis is used to analyse the results. Results The findings suggest that there is little knowledge about the concept and elements of health insurance. Some concepts such as, risk pooling and sharing are not well understood. The participants of the study considered health insurance as only a prepayment mechanism without risk sharing among members of the scheme. Regarding preference for health insurance, they have revealed quality of care as the most important factor. Comprehensiveness of benefit packages and the amount of premium level are also found to be concerns related to health insurance. However, a trade-off is also observed among premium level, comprehensive benefit packages, and healthcare facilities. Conclusions Improvements on availability and quality of services need to precede the introduction of social health insurance. There is also a need to work on awareness creation regarding concepts of health insurance. Further studies may explore if the knowledge gap is real or appeared due to reservations of the participants on the introduction of health insurance.
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Affiliation(s)
- Amarech Obse
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethopia.
| | - Damen Hailemariam
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethopia.
| | - Charles Normand
- Centre for Global Health, Trinity College Dublin, 3-4 Foster Place, Dublin 2, Ireland.
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Carman KL, Mallery C, Maurer M, Wang G, Garfinkel S, Yang M, Gilmore D, Windham A, Ginsburg M, Sofaer S, Gold M, Pathak-Sen E, Davies T, Siegel J, Mangrum R, Fernandez J, Richmond J, Fishkin J, Siu Chao A. Effectiveness of public deliberation methods for gathering input on issues in healthcare: Results from a randomized trial. Soc Sci Med 2015; 133:11-20. [PMID: 25828260 DOI: 10.1016/j.socscimed.2015.03.024] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
UNLABELLED Public deliberation elicits informed perspectives on complex issues that are values-laden and lack technical solutions. This Deliberative Methods Demonstration examined the effectiveness of public deliberation for obtaining informed public input regarding the role of medical evidence in U.S. healthcare. We conducted a 5-arm randomized controlled trial, assigning participants to one of four deliberative methods or to a reading materials only (RMO) control group. The four deliberative methods reflected important differences in implementation, including length of the deliberative process and mode of interaction. The project convened 76 groups between August and November 2012 in four U.S. LOCATIONS Chicago, IL; Sacramento, CA; Silver Spring, MD; and Durham, NC, capturing a sociodemographically diverse sample with specific attention to ensuring inclusion of Hispanic, African-American, and elderly participants. Of 1774 people recruited, 75% participated: 961 took part in a deliberative method and 377 participants comprised the RMO control group. To assess effectiveness of the deliberative methods overall and of individual methods, we evaluated whether mean pre-post changes on a knowledge and attitude survey were statistically different from the RMO control using ANCOVA. In addition, we calculated mean scores capturing participant views of the impact and value of deliberation. Participating in deliberation increased participants' knowledge of evidence and comparative effectiveness research and shifted participants' attitudes regarding the role of evidence in decision-making. When comparing each deliberative method to the RMO control group, all four deliberative methods resulted in statistically significant change on at least one knowledge or attitude measure. These findings were underscored by self-reports that the experience affected participants' opinions. Public deliberation offers unique potential for those seeking informed input on complex, values-laden topics affecting broad public constituencies.
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Affiliation(s)
- Kristin L Carman
- American Institutes for Research, 1000 Thomas Jefferson Street, NW, Washington, DC 20007, USA.
| | - Coretta Mallery
- American Institutes for Research, 1000 Thomas Jefferson Street, NW, Washington, DC 20007, USA
| | - Maureen Maurer
- American Institutes for Research, 1000 Thomas Jefferson Street, NW, Washington, DC 20007, USA
| | - Grace Wang
- American Institutes for Research, 1000 Thomas Jefferson Street, NW, Washington, DC 20007, USA
| | - Steve Garfinkel
- American Institutes for Research, 1000 Thomas Jefferson Street, NW, Washington, DC 20007, USA
| | - Manshu Yang
- American Institutes for Research, 1000 Thomas Jefferson Street, NW, Washington, DC 20007, USA
| | - Dierdre Gilmore
- American Institutes for Research, 1000 Thomas Jefferson Street, NW, Washington, DC 20007, USA
| | - Amy Windham
- American Institutes for Research, 1000 Thomas Jefferson Street, NW, Washington, DC 20007, USA
| | - Marjorie Ginsburg
- Center for Healthcare Decisions, 955 University Avenue, Suite C, Sacramento, CA 95825, USA
| | - Shoshanna Sofaer
- American Institutes for Research, 1000 Thomas Jefferson Street, NW, Washington, DC 20007, USA
| | - Marthe Gold
- City College of New York, The Graduate Center, CUNY, 365 Fifth Avenue, New York, NY 10016, USA
| | - Ela Pathak-Sen
- Commotion, Nishana Enterprises Ltd, Culvert Cottage, Kingsmill Lane, Painswick GL6 6RT, UK
| | - Todd Davies
- Center for the Study of Language and Information, Stanford University, CSLI, Cordura Hall, 210 Panama Street, Stanford, CA 94305, USA
| | - Joanna Siegel
- Center for Outcomes and Evidence, Agency for Healthcare Research and Quality, 540 Gaither Road, Suite 2000, Rockville, MD 20850, USA
| | - Rikki Mangrum
- American Institutes for Research, 1000 Thomas Jefferson Street, NW, Washington, DC 20007, USA
| | - Jessica Fernandez
- American Institutes for Research, 1000 Thomas Jefferson Street, NW, Washington, DC 20007, USA
| | - Jennifer Richmond
- American Institutes for Research, 1000 Thomas Jefferson Street, NW, Washington, DC 20007, USA
| | - James Fishkin
- Center for Deliberative Democracy, Stanford University, Dept. of Communication, 450 Serra Mall, Bldg 120, Stanford, CA 94305, USA
| | - Alice Siu Chao
- Center for Deliberative Democracy, Stanford University, Dept. of Communication, 450 Serra Mall, Bldg 120, Stanford, CA 94305, USA
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Sommers R, Goold SD, McGlynn EA, Pearson SD, Danis M. Focus groups highlight that many patients object to clinicians' focusing on costs. Health Aff (Millwood) 2013; 32:338-46. [PMID: 23381527 DOI: 10.1377/hlthaff.2012.0686] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Having patients weigh costs when making medical decisions has been proposed as a way to rein in health care spending. We convened twenty-two focus groups of people with insurance to examine their willingness to discuss health care costs with clinicians and consider costs when deciding among nearly comparable clinical options. We identified the following four barriers to patients' taking cost into account: a preference for what they perceive as the best care, regardless of expense; inexperience with making trade-offs between health and money; a lack of interest in costs borne by insurers and society as a whole; and noncooperative behavior characteristic of a "commons dilemma," in which people act in their own self-interest although they recognize that by doing so, they are depleting limited resources. Surmounting these barriers will require new research in patient education, comprehensive efforts to shift public attitudes about health care costs, and training to prepare clinicians to discuss costs with their patients.
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Evans-Lacko SE, Baum N, Danis M, Biddle A, Goold S. Laypersons' choices and deliberations for mental health coverage. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2012; 39:158-69. [PMID: 21452017 DOI: 10.1007/s10488-011-0341-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Insurance coverage for mental health services has historically lagged behind other types of health services. We used a simulation exercise in which groups of laypersons deliberate about healthcare tradeoffs. Groups deciding for their "community" were more likely to select mental health coverage than individuals. Individual prioritization of mental health coverage, however, increased after group discussion. Participants discussed: value, cost and perceived need for mental health coverage, moral hazard and community benefit. A deliberative exercise in priority-setting led a significant proportion of persons to reconsider decisions about coverage for mental health services. Deliberations illustrated public-spiritedness, stigma and significant polarity of views.
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Affiliation(s)
- Sara E Evans-Lacko
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, De Crespigny Park, London, UK.
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