The greatest happiness of the greatest number? Policy actors' perspectives on the limits of economic evaluation as a tool for informing health care coverage decisions in Thailand.(Research article)

Authors: Yot Teerawattananon (corresponding author) [1]; Steve Russell [2]

Background

In all societies health care resources are restricted so that priority setting for health expenditure has to be done either implicitly or explicitly[1]. Health economic evaluation is a method used to analyse the costs and benefits of different health care interventions, and has often been quoted as the most promising tool to assist decision-makers in health care rationing[2, 3]. Cost-utility analysis, which is one type of health economic evaluation, is widely recommended in many official health technology assessment guidelines in many settings [4, 5, 6, 7]. The method assumes that the ultimate goal of the health care system is to maximise health benefits from the finite resources available, regardless of the distribution of these health benefits. To allow comparisons across a broad spectrum of intervention or programme areas, a common health benefit composite indicator, such as the Quality Adjusted Life Year (QALY), has been created and applied to numerous interventions to enable decision makers to decide which health investments maximise health (QALYs)[8, 9]. A QALY measures both the quantity of life generated by an intervention (in years) and the change to quality of life in each of those years.

Although there are several moral and methodological controversies over the use of economic evaluation to guide health resource allocation[3, 10, 11], it is increasingly being used in some industrial countries on the grounds that it can inform more explicit and transparent health care coverage decisions[12]. In low- and middle-income countries the tool has rarely been used to inform decisions about the content of health care benefit packages. However in middle income countries such as Thailand policy-makers are facing growing pressure to justify resource allocation decisions in the health sector, due to increasing resource constraints arising from an epidemiological transition and increases in the availability and cost of new health technologies [13, 14, 15]. In Thailand the Universal Health Insurance Coverage (UC) policy implemented in 2001 offers a package of health care interventions at public facilities to all Thai citizens not covered by other benefit packages[16]. There is growing pressure on the government to clarify and make more transparent the UC benefit package, particularly for high cost interventions that absorb a disproportionate amount of resources[17]. Some high cost interventions are included in the package, others are excluded and some are in a 'grey zone' and provided at the discretion of consultants or hospital directors. A mix of criteria, mainly implicit, have influenced these decisions, for example pre-existing service availability, affordability for the provider and political pressures[18].

This paper presents qualitative findings based on semi-structured face-to-face interviews that explored the acceptability of using only evidence from economic evaluation among different policy actors. A case scenario was constructed using information from two separate economic evaluation studies previously conducted in Thailand. One was an economic evaluation of open versus laparoscopic cholecystectomy for gallbladder stone disease[19] and the other was an economic evaluation of renal dialysis compared to palliative treatment of end-stage renal disease[20]. The interviews sought to explore policy actors' justifications for their decisions on the case scenarios, including the trade-offs they had to make between cost utility criteria founded on the principle of health (QALY) maximisation, and other criteria such as disease severity and overall budget impact[21, 22].

Methods

Respondents

The selection of respondents was purposive to cover four groups of policy actors who play a major role or influence in health resource allocation decisions within the Thai healthcare system. A purposive sampling strategy was used to ensure that a range of policy actors was covered and that, at the highest level, the most important policy actors were selected. The qualitative data generated is not intended to be 'representative' in statistical terms, but the data can be used to build understanding of policy actors' attitudes and positions relating to economic evaluation in decision-making. Depth of understanding rather than sample size was the main concern[23, 24]. However the policy relevance of the findings did rely on ensuring that an appropriate range of policy actors for this particular setting were covered, to enable the capture of a 'typical' range of perspectives[25].

As a result, an invitation letter, research proposal and consent form were sent to each of 38 potential participants including:

* fourteen

policy makers at the national level who were the most senior administrators at the Ministry of Public Health (MOPH) and National Health Security Office (NHSO), which is an autonomous health care institution in Thailand that manages the Universal Health Coverage scheme;

* five

hospital directors who are responsible for allocating resources within Thai healthcare institutions;

* twelve

health professionals (medical specialists) who are responsible for resource allocation decisions at the patient-level, and;

* seven …