Stakeholder Participation for Legitimate Priority Setting: A Checklist

Document Type : Perspective


1 Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands

2 Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway


Accountable decision-makers are required to legitimize their priority setting decisions in health to members of society. In this perspective we stress the point that fair, legitimate processes should reflect efforts of authorities to treat all stakeholders as moral equals in terms of providing all people with well-justified, reasonable reasons to endorse the decisions. We argue there is a special moral concern for being accountable to those who are potentially adversely affected by decisions. Health authorities need to operationalize this requirement into real world action. In this perspective, we operationalize five key steps in doing so, in terms of (i) proactively identifying potentially adversely affected stakeholders; (ii) comprehensively including them in the decision-making process; (iii) ensuring meaningful participation; (iv) communication of recommendations or decisions; and (v) the organization of evaluation and appeal mechanisms. Health authorities are advised to use a checklist in the form of 29 reflective questions, aligned with these five key steps, to assist them in the practical organization of legitimate priority setting in healthcare.


Main Subjects

  1. Degeling C, Carter SM, Rychetnik L. Which public and why deliberate? A scoping review of public deliberation in public health and health policy research. Soc Sci  Med. 2015;131: 114-121. doi:10.1016/j.socscimed.2015.03.009
  2. Abelson J, Wagner F, DeJean D, et al. Public and patient involvement in health technology assessment: a framework for action. Int J Technol Assess Health Care. 2016;32(4):256-264. Doi:10.1017/S0266462316000362
  3. Kahane D, Loptson K, Herriman J, Hardy M. Stakeholder and Citizen Roles in Public Deliberation. Journal of Public Deliberation. 2013;9(2):2.
  4. Clark S, Weale A. Social values in health priority setting: a conceptual framework. J Health Organ Manag. 2012;26(3):293-316. doi:10.1108/14777261211238954
  5. Bærøe K, Baltussen R. Legitimate healthcare limit setting in a real-world setting: integrating accountability for reasonableness and multi-criteria decision analysis. Public Health Ethics. 2014;7(2):98-111.
  6. Peter F. Political legitimacy 2010. Accessed November 30, 2016. First published April 29, 2010.
  7. Holm S. The second phase of priority setting. Goodbye to the simple solutions: the second phase of priority setting in health care. BMJ. 1998;317(7164):1000-1002.
  8. Mitton C, Donaldson C. Health care priority setting: principles, practice and challenges. Cost Eff Resour Alloc. 2004; 2: 3. doi:10.1186/1478-7547-2-3
  9. Kapiriri L, Martin DK. A strategy to improve priority setting in developing countries. Health care analysis. Health Care Anal. 2007;15(3):159-167. doi:10.1007/s10728-006-0037-1
  10. Daniels N. Accountability for reasonableness. BMJ. 2000;321(7272):1300-1301.
  11. Baltussen R, Jansen MP, Mikkelsen E, et al. Priority setting for universal health coverage: we need evidence-informed deliberative processes, not just more evidence on cost-effectiveness. Int J Health Policy Manag. 2016;5(11):615-618. doi:10.15171/ijhpm.2016.83
  12. Abelson J, Giacomini M, Lehoux P, Gauvin FP. Bringing 'the public' into health technology assessment and coverage policy decisions: from principles to practice. Health Policy. 2007;82(1):37-50. doi:10.1016/j.healthpol.2006.07.009
  13. Daniels N, van der Wilt GJ. Health technology assessment, deliberative process, and ethically contested issues. Int J Technol Assess Health Care. 2016;32(1-2):10-15. doi:10.1017/S0266462316000155
  14. Tromp N, Baltussen R. Mapping of multiple criteria for priority setting of health interventions: an aid for decision makers. BMC Health Serv Res. 2012;12:454. doi:10.1186/1472-6963-12-454
  15. EUnetHTA Joint Action 2 WP. HTA Core Model® version 3.0. Published 2016.
  16. Goetghebeur MM, Wagner M, Khoury H, Levitt RJ, Erickson LJ, Rindress D. Evidence and Value: Impact on DEcisionMaking--the EVIDEM framework and potential applications. BMC Health Serv Res. 2008;8:270. doi:10.1186/1472-6963-8-270
  17. Daniels N. Just Health: Meeting Health Needs Fairly. New York: Cambridge University Press; 2007.
  18. Tyler TR. Psychological perspectives on legitimacy and legitimation. Annu Rev Psychol. 2006;57:375-400.
  19. Nedlund A-C, Bærøe K. Legitimate policymaking: the importance of including health-care workers in limit-setting decisions in health care. Public Health Ethics. 2014;7(2):123-133.
  20. Daniels N, Sabin J. Setting Limits Fairly: Learning to Share Resources for Health. 2nd ed. New York: Oxford University Press; 2008.
  21. Maluka SO. Strengthening fairness, transparency and accountability in health care priority setting at district level in Tanzania. Glob Health Action. 2011;4. doi:10.3402/gha.v4i0.7829
  22. Friedman A. Beyond accountability for reasonableness. Bioethics. 2008;22(2):101-112.
  23. Jansen MP, Helderman JK, Boer B, Baltussen R. Fair processes for priority setting: putting theory into practice. Int J Health Policy Manag. 2017;6(1):43-47.
  24. Rohrer K, Rajan D. Population consultation on needs and expectations. In: Schmets G, Rajan D, Kadandale S, eds. Srategizing National Health in the 21st Century: A Handbook. Geneva: World Health Organization; 2016.
  25. Abelson J, Forest PG, Eyles J, Smith P, Martin E, Gauvin FP. Deliberations about deliberative methods: issues in the design and evaluation of public participation processes. Soc Sci Med. 2003;57(2):239-251.
  26. van der Wilt GJ. Healthcare Technology Assessment. In: Have HT, ed. Encyclopedia of Global Bioethics. Dordrecht: Springer; 2015:1-13. doi:10.1007/978-3-319-05544-2_416-1
  27. van der Wilt GJ, Reuzel RP, Grin J. Technology, design, and human values in healthcare. In: Hoven J, Vermaas PE, Poel I, eds. Handbook of Ethics, Values, and Technological Design. Dordrecht: Springer; 2014:717-738. doi:10.1007/978-94-007- 6994-6_36-1
Volume 7, Issue 11
November 2018
Pages 973-976
  • Receive Date: 15 March 2018
  • Revise Date: 15 June 2018
  • Accept Date: 17 June 2018
  • First Publish Date: 01 November 2018