This study has experimented with the use of MCDA to guide the priority setting of HIV/AIDS interventions in Thailand, on the basis of consultations with the relevant stakeholders through a deliberative process.
This study revealed the importance of five criteria included in the DCE (i.e. target groups of interventions, gender of target groups, type of interventions, effectiveness, and quality of evidence on effectiveness), and a number of additional criteria raised during the deliberative process (i.e. ethical and social concerns, cost-effectiveness, (non)availability of alternatives; number of beneficiaries; and inappropriate use or abuse of interventions). This reflects that stakeholders consider multiple criteria in prioritising interventions.
The abovementioned results highlight that MCDA has good potential to be used for the making of explicit prioritisation decisions. Also, we observed that the group of policy makers and VHVs - although not PLWHA respondents - applauded the systematic approach for priority setting, including the development of relevant criteria, the presentation of the performance of interventions against these criteria, and the deliberative process. Although MCDA seems difficult for PLWHA as they may not be familiar or comfortable to make trade-off decisions, the considerable overlap of the rank ordering before and upon deliberation in the group of policy makers and VHVs indicates that the quantifiable criteria used in the DCE partly reflect the concerns that stakeholders have in their intervention priorities. We believe that, through its explicit approach, MCDA contributes to the transparency and accountability of the priority setting process. Moreover, the provision of the DCE ranking reduces the stream of information that stakeholders need to absorb when prioritising many interventions simultaneously. We therefore advocate that the identification and weighing of quantifiable criteria (whether through DCE or any other technique) should also be considered as an integrated MCDA component.
The present application of MCDA seems especially useful for policy planning in the long run as it can set priorities among a large set of interventions without defining the allocation of resources in a precise fashion. This use, also labeled generalized priority setting, can have far-reaching and constructive influences on policy formulation in the long term . In contrast, the use of MCDA as presented in this study may not be useful for guiding highly contextualized decisions on the implementation of a single intervention, since this requires a higher level of detail in terms of financial and budgeting considerations.
This study has experimented with the inclusion of a process of deliberation in MCDA in a research environment. As of now, Thailand is stepping towards a routine application of MCDA to define its universal coverage benefit package. Observations of that process reveal that the inclusion of all relevant stakeholders right from the beginning of the MCDA process is imperative to its success .
Yet, we also observed a number of shortcomings in the use of MCDA in this study. First, DCE are cognitive demanding and may not be appropriate for all stakeholders. Most notably, PLWHA had difficulties in completing the DCE survey and interpreting the DCE findings. Further research is needed on the use of less cognitive demanding techniques than DCE that serve the same goal . Second, our intervention set was relatively homogeneous in terms of the criteria covered in the DCE (e.g. effectiveness; quality of evidence on effectiveness; type of intervention), and this resulted in low variation in the probabilities of inclusion. The application of DCE across different health conditions [15–19] is, in that respect, more powerful. Third, we did not engage all stakeholders in a single deliberative process to arrive at a consensus on the rank ordering of interventions, an adaption which would represent the final stage of a successful priority setting process. However, the findings in this study can serve as a reflection of other stakeholders' preferences for policy decision making that may lead to greater acceptance of priority setting decisions. Moreover, this study can be considered a lesson learned process for other stakeholders, especially the general population who have never been involved in health policy decision-making, and can help them to understand how to set priorities for health interventions. In future priority setting research, it would therefore be valuable to incorporate these public perspectives.
Although the set of criteria for MCDA may vary by country and health system context, the approach is generalizable to other settings. Furthermore, the MCDA criteria may be different if priority setting is required across different health problems e.g. infectious diseases, cardiovascular conditions, and mental health problems. Therefore, further exploration is warranted.