Applied Health Economics and Health Policy

, Volume 15, Issue 6, pp 697–706 | Cite as

Decision Making and Priority Setting: The Evolving Path Towards Universal Health Coverage

  • Francesco Paolucci
  • Ken Redekop
  • Ayman Fouda
  • Gianluca Fiorentini
Current Opinion


Health technology assessment (HTA) is widely viewed as an essential component in good universal health coverage (UHC) decision-making in any country. Various HTA tools and metrics have been developed and refined over the years, including systematic literature reviews (Cochrane), economic modelling, and cost-effectiveness ratios and acceptability curves. However, while the cost-effectiveness ratio is faithfully reported in most full economic evaluations, it is viewed by many as an insufficient basis for reimbursement decisions. Emotional debates about the reimbursement of cancer drugs, orphan drugs, and end-of-life treatments have revealed fundamental disagreements about what should and should not be considered in reimbursement decisions. Part of this disagreement seems related to the equity-efficiency tradeoff, which reflects fundamental differences in priorities. All in all, it is clear that countries aiming to improve UHC policies will have to go beyond the capacity building needed to utilize the available HTA toolbox. Multi-criteria decision analysis (MCDA) offers a more comprehensive tool for reimbursement decisions where different weights of different factors/attributes can give policymakers important insights to consider. Sooner or later, every country will have to develop their own way to carefully combine the results of those tools with their own priorities. In the end, all policymaking is based on a mix of facts and values.


Author Contributions

Francesco Paolucci, Ken Redekop, Ayman Fouda, and Gianluca Fiorentini equally contributed to the conception and development of the theoretical framework, contributed to the writing of the manuscript, and contributed to the editing of the subsequent drafts of the manuscript in light of the comments made by the reviewers for this journal. All authors gave final approval of the version to be submitted.

Compliance with Ethical Standards

Conflict of interest

Francesco Paolucci, Ken Redekop, Ayman Fouda, and Gianluca Fiorentini declare they have no conflicts of interest.


No funding was received for the paper.


  1. 1.
    Colombo F, Tapay N. Private health insurance in OECD countries: the benefits and costs for individuals and health systems. OECD Health Working Papers. 2004;15:265–319.Google Scholar
  2. 2.
    Cutler DM. Equality, efficiency, and market fundamentals: the dynamics of international medical-care reform. J Econ Lit. 2002;40(3):881–906.CrossRefGoogle Scholar
  3. 3.
    Hurst J. The reform of health care systems in seven OECD countries. Paper presented at the Second World Congress of Health Economics, Zurich (Switzerland). OECD; 1990 September.Google Scholar
  4. 4.
    OECD. Health at a glance 2013: OECD indicators. OECD Publishing; 2013. p. 153–66.Google Scholar
  5. 5.
    Kotlikoff LJ, Hagist C. Who’s going broke? Comparing growth in healthcare costs in ten OECD countries. NBER Working Paper 2005(w11833)Google Scholar
  6. 6.
    Kanters TA, Hakkaart L, Rutten-van Mölken MP, Redekop WK. Access to orphan drugs in western Europe: can more systematic policymaking really help to avoid different decisions about the same drug? Expert Rev Pharmacoecon Outcomes Res. 2015;15(4):557–9.CrossRefPubMedGoogle Scholar
  7. 7.
    EUnetHTA Work Package 8. EUnetHTA Handbook on Health Technology Assessment Capacity Building. Barcelona (Spain): Catalan Agency for Health Technology Assessment and Research. Catalan Health Service. Department of Health Autonomous Government of Catalonia; 2008. Google Scholar
  8. 8.
    Luce BR, Drummond M, Jönsson B, Neumann PJ, Schwartz JS, Siebert U, Sullivan SD. EBM, HTA, and CER: Clearing the confusion. Milbank Quarter. 2010;88(2):256–76. doi: 10.1111/j.1468-0009.2010.00598.CrossRefGoogle Scholar
  9. 9.
    Shah KK, Cookson R, Culyer AJ, Lettlejohns P. NICE’s social value judgements about equity in health and health care. Health Econ Policy Law. 2013;8(2):145–65.CrossRefPubMedGoogle Scholar
  10. 10.
    Beattie A, Yates R, Noble DJ. Accelerating progress towards universal health coverage in asia and pacific: Improving the future for women and children. BMJ Glob Health. 2016;1(Suppl 2):i12–8.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Paolucci F. Economic rationales for the design of health care financing schemes. In: Health care financing and insurance: options for design. Berlin: Springer; 2011. p. 13–32.Google Scholar
  12. 12.
    Stolk E, Busschbach J. Cost effectiveness of sildenafil calls for political discussion. Br Med J. 2000;321:510.CrossRefGoogle Scholar
  13. 13.
    Stolk EA, van Donselaar G, Brouwer WB, Busschbach JJ. Reconciliation of economic concerns and health policy: illustration of an equity adjustment procedure using proportional shortfall. Pharmacoeconomics. 2004;22(17):1097–107.CrossRefPubMedGoogle Scholar
  14. 14.
    Aizuddin AN, Sulong S, Aljunid SM. Factors influencing willingness to pay for healthcare. BMC Public Health. 2012;12(Suppl 2):A37.CrossRefGoogle Scholar
  15. 15.
    Paolucci F, Schut E, van de Ven, WPMM. Economic rationales for the design of health care financing schemes. iHEA 2007 6th World Congress: Explorations in Health Economics Paper; 2007.Google Scholar
  16. 16.
    Cutler DM, Zeckhauser RJ. The anatomy of health insurance. In: Culyer AJ, Newhouse JP, editors. Handbook of health economics, vol. 1A. Elsevier: Amsterdam; 2000. p. 563–644.Google Scholar
  17. 17.
    Baltussen R, Niessen L. Priority setting of health interventions: the need for multi-criteria decision analysis. Cost Eff Resour Alloc. 2006;4:14. doi: 10.1186/1478-7547-4-14.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Marsh K, Lanitis T, Neasham D, Orfanos P, Caro J. Assessing the value of healthcare interventions using multi-criteria decision analysis: A review of the literature. Pharmacoeconomics. 2014;32(4):345–65.CrossRefPubMedGoogle Scholar
  19. 19.
    Mühlbacher AC, Kaczynski A. Making good decisions in healthcare with multi-criteria decision analysis: the use, current research and future development of MCDA. Appl Health Econ Health Policy. 2016;14(1):29–40.CrossRefPubMedGoogle Scholar
  20. 20.
    Angelis A, Kanavos P. Value-Based assessment of new medical technologies: towards a robust methodological framework for the application of multiple criteria decision analysis in the context of health technology assessment. Pharmacoeconomics. 2016;34(5):435–46.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Thokala P, Duenas A. Multiple criteria decision analysis for health technology assessment. Value Health. 2012;15(8):1172–81.CrossRefPubMedGoogle Scholar
  22. 22.
    Mirelman A, Mentzakis E, Kinter E, Paolucci F, Fordham R, Ozawa S, Ferraz M, Baltussen R, Niessen L. Decision-making criteria among national policymakers in five countries: a discrete choice experiment eliciting relative preferences for equity and efficiency. Val Health. 2012;15(3):534–9.CrossRefGoogle Scholar
  23. 23.
    Paolucci F, Mentzakis E, Defechereux T, Niessen LW. Equity and efficiency preferences of health policy makers in China—a stated preference analysis. Health Policy Plan. 2015;30(8):1059–66.CrossRefPubMedGoogle Scholar
  24. 24.
    Keane MP, Wasi N. The structure of consumer taste heterogeneity in revealed vs. stated preference data. Economics Papers 2013-W10. Economics Group, Nuffield College, University of Oxford; 2013.Google Scholar
  25. 25.
    Schroeder DA. Discrete choice models. In: Accounting and causal effects: econometric challenges. New York: Springer; 2010. p. 77–95.Google Scholar
  26. 26.
    Colapinto C, Jayaraman R, Marsiglio S. Multi-criteria decision analysis with goal programming in engineering, management and social sciences: a state-of-the art review. Ann Oper Res. 2017;251(1–2):7–40.CrossRefGoogle Scholar
  27. 27.
    Neumann PJ, Sanders GD, Russell LB, Siegel JE, Ganiats TG. Cost-effectiveness in health and medicine. 2nd ed. Oxford: Oxford University Press; 2016.CrossRefGoogle Scholar
  28. 28.
    Dakin H, Devlin N, Feng Y, Rice N, ONeill P, Parkin D. The influence of cost-effectiveness and other factors on NICE decisions. HERC research paper 01/13. Health Economics Research Centre, University of Oxford; 2014.Google Scholar
  29. 29.
    de Groot S, Rijnsburger AJ, Versteegh MM, Heymans JM, Kleijnen S, Redekop WK, Verstijnen IM. Which factors may determine the necessary and feasible type of effectiveness evidence? A mixed methods approach to develop an instrument to help coverage decision-makers. BMJ Open. 2015;5(7):e007241.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Piniazhkho O, Németh B. An analysis of the criteria used in existing or proposed MCDA models PRM202. ISPOR 21st Annual International Meeting. May 2016.Google Scholar
  31. 31.
    Defechereux T, Paolucci F, Mirelman A, Youngkong S, Botten G, Hagen TP, Niessen LW. Health care priority setting in Norway: a multicriteria decision analysis. BMC Health Serv Res. 2012;12:39.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Redekop WK. Navigating the waters of economic evaluations of medical devices. ISPOR. Presentation at the annual meeting of the International Society of Pharmacoeconomics and Outcomes Research, Dublin, November 2013.Google Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • Francesco Paolucci
    • 1
    • 2
  • Ken Redekop
    • 3
    • 4
  • Ayman Fouda
    • 2
    • 4
  • Gianluca Fiorentini
    • 2
  1. 1.Murdoch UniversityPerthAustralia
  2. 2.University of BolognaBolognaItaly
  3. 3.National University of SingaporeSingaporeSingapore
  4. 4.Erasmus University RotterdamRotterdamThe Netherlands

Personalised recommendations