In any country, healthcare resource allocation decisions are complex and involve assessment of the available scientific evidence, clarification of priorities, value judgments and ethical considerations [1, 2]. In developing countries, which are generally low-resource settings, priority setting for healthcare becomes even more important. Not only are resources limited, but there are also other factors such as poor information, lack of policy, barriers to implementation, and political agendas, to name but a few . The result is that priority setting is inconsistent and unstructured . Transparent and explicit approaches to decisionmaking help produce decisions that are sound and acceptable to stakeholders [4–7].
In the healthcare sector of South Africa, current decisionmaking approaches are centered around evidence-based medicine, affordability and, where available, cost-effectiveness/costutility analysis (CEA/CUA) . Increasingly CEA/CUA is being used for priority setting at all levels: the patient; the healthcare service; and within populations. This is evident in the field of HIV/AIDS where cost-effectiveness analyses of antiretroviral (ARV) medicines has enhanced access to treatment and reduced drug prices [9, 10]. In many instances, a simple cost-minimization approach is all that is attempted. However, this approach has shortcomings, as there are a number of additional important dimensions, such as budget impact, equity, availability of alternatives, disease severity, etc. [11, 12], that are not incorporated. Where these are taken into consideration, they are often assessed in an ad hoc manner and there is a lack of transparency as to how they impact the final decision .
Thus, there is a need for a process that supports consideration of all dimensions impacting a decision in a systematic and explicit fashion, and increases transparency and access to the evidence upon which decisions are based. Multi-criteria decision analysis (MCDA) is a tool to support complex decisionmaking which allows a structured, objective consideration of factors that are both measurable and value-based in an open and transparent manner [1, 13, 14].
While MCDA has been used historically in sectors such as transport or agriculture, there is a growing interest in using and applying the principles of MCDA, and similar approaches based on multiple decision criteria, to resource allocation decisionmaking in health care [15–21]. The EVIDEM framework has been developed to bring together Health Technology Assessment (HTA) and MCDA by proposing a comprehensive set of decision criteria together with standardized processes/methods to develop HTA reports that are structured on these criteria . The aims of the framework are to facilitate concurrent consideration of multiple decision criteria, to stimulate reflection on priorities and values, and to promote transparency and communication within the decisionmaking committee as well as with outside stakeholders. The application of the EVIDEM framework is postulated to be wide ranging from decisionmaking by the healthcare provider, to coverage decisions by the funders or government policy setting.
A proof-of-concept study of the EVIDEM framework was performed in Canada involving a diverse panel of stakeholders appraising 10 medicines . The core framework was also further developed to include standardized contextual criteria and tested for clinical decisionmaking by a panel of pediatric endocrinologists and other stakeholders who applied it to appraise growth hormone for children with Turner syndrome in Canada . The framework was also tested as a support for drug formulary decisionmaking by a public healthcare payer in Canada .
The objective of the current study was to expand the scope of field testing both geographically and with respect to type of intervention: i.e., to field test the framework as a support for coverage decisionmaking on a cervical cancer screening test (liquid-based cytology, LBC) by a private health plan in South Africa.
The healthcare system in South Africa is dichotomous with a small (approximately 7 million lives) but resource-rich private healthcare sector and a growing (approximately 45 million lives) resource-scarce public sector. The private healthcare sector is largely funded by medical insurance companies (health plans), while the public sector is currently funded out-of-pocket or by the government. With respect to cervical cancer screening, the Department of Health guidelines stipulate that all women should be screened three times in their lifetime from the age of 30 years . In the private healthcare sector, cervical cancer screening is often recommended and carried out on an annual basis. Screening uptake is low in South Africa with poor accessibility to healthcare facilities, poorly trained staff, long turnaround times between laboratory and healthcare facility, as well as lack of education cited as some of the reasons . LBC for cervical cancer screening was selected by the health plan as a relevant case study due to its recent introduction as an alternative to conventional Pap smears.