CHAT SA: Modification of a Public Engagement Tool for Priority Setting for a South African Rural Context

Document Type: Original Article

Authors

1 SAMRC/Wits Centre for Health Economics and Decision Science - PRICELESS, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa

2 Department of Bioethics, National Institutes of Health, Bethesda, MD, USA

3 School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

4 MRC/Wits Rural Public Health and Health Transitions Research Unit - Agincourt, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

5 New York Academy of Medicine, New York City, NY, USA

Abstract

Background
Globally, as countries move towards universal health coverage (UHC), public participation in decision-making is particularly valuable to inform difficult decisions about priority setting and resource allocation. In South Africa (SA), which is moving towards UHC, public participation in decision-making is entrenched in policy documents yet practical applications are lacking. Engagement methods that are deliberative could be useful in ensuring the public participates in the priority setting process that is evidence-based, ethical, legitimate, sustainable and inclusive. Methods modified for the country context may be more relevant and effective. To prepare for such a deliberative process in SA, we aimed to modify a specific deliberative engagement tool – the CHAT (Choosing All Together) tool for use in a rural setting.
 
Methods
Desktop review of published literature and policy documents, as well as 3 focus groups and modified Delphi method were conducted to identify health topics/issues and related interventions appropriate for a rural setting in SA. Our approach involved a high degree of community and policy-maker/expert participation. Qualitative data were analysed thematically. Cost information was drawn from various national sources and an existing actuarial model used in previous CHAT exercises was employed to create the board.
 
Results
Based on the outcomes, 7 health topics/issues and related interventions specific for a rural context were identified and costed for inclusion. These include maternal, new-born and reproductive health; child health; woman and child abuse; HIV/AIDS and tuberculosis (TB); lifestyle diseases; access; and malaria. There were variations in priorities between the 3 stakeholder groups, with community-based groups emphasizing issues of access. Violence against women and children and malaria were considered important in the rural context.
 
Conclusion
The CHAT SA board reflects health topics/issues specific for a rural setting in SA and demonstrates some of the context-specific coverage decisions that will need to be made. Methodologies that include participatory principles are useful for the modification of engagement tools like CHAT and can be applied in different country contexts in order to ensure these tools are relevant and acceptable. This could in turn impact the success of the implementation, ultimately ensuring more effective priority setting approaches.

Highlights

 

Supplementary File 1 (Download)

Supplementary File 2 (Download)

Supplementary File 3 (Download)

 

Keywords


  1. Florin D, Dixon J. Public involvement in health care. BMJ. 2004;328(7432):159-161. doi:10.1136/bmj.328.7432.159
  2. Bolsewicz Alderman K, Hipgrave D, Jimenez-Soto E. Public engagement in health priority setting in low- and middle-income countries: current trends and considerations for policy. PLoS Med. 2013;10:e1001495. doi:10.1371/journal.pmed.1001495
  3. Childress JF, Faden RR, Gaare RD, et al. Public health ethics: mapping the terrain. J Law Med Ethics. 2002;30(2):170-178.
  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. Daniels N. Accountability for reasonableness. BMJ. 2000;321(7272):1300-1301. doi:10.1136/bmj.321.7272.1300
  6. Sibbald SL, Singer PA, Upshur R, Martin DK. Priority setting: what constitutes success? A conceptual framework for successful priority setting. BMC Health Serv Res. 2009;9:43. doi:10.1186/1472-6963-9-43
  7. Scuffham PA, Ratcliffe J, Kendall E, et al. Engaging the public in healthcare decision-making: quantifying preferences for healthcare through citizens' juries. BMJ Open. 2014;4(5):e005437. doi:10.1136/bmjopen-2014-005437
  8. Caddy J VC. Citizens as partners: information, consultation and public participation in policy-making. Paris: Organisation for Economic Cooperation and Development; 2001.
  9. World Health Organisation (WHO). Making fair choices on the path to universal health coverage: Final report of the WHO Consultative Group on Equity and Universal Health Coverage. WHO; 2014.
  10. Weale A, Kieslich K, Littlejohns P, et al. Introduction: priority setting, equitable access and public involvement in health care. J Health Organ Manag. 2016;30(5):736-750. doi:10.1108/jhom-03-2016-0036
  11. Kapiriri L NO, Heggenhougen K.  Public participation in health planning and priority setting at the district level in Uganda. Health Policy Plan. 2003;18:205-213. doi:10.1093/heapol/czg025
  12. Bolsewicz Alderman K, Hipgrave D, Jimenez-Soto E. Public Engagement in Health Priority Setting in Low- and Middle-Income Countries: Current Trends and Considerations for Policy. PLOS Medicine. 2013;10(8):e1001495. doi:10.1371/journal.pmed.1001495
  13. Kamuzora P, Maluka S, Ndawi B, Byskov J,  Hurtig AK. Promoting community participation in priority setting in district health systems: experiences from Mbarali district, Tanzania. Global Health Action. 2013;6(22669). doi:10.3402/gha.v6i0.22669
  14. 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. doi:10.1016/s0277-9536(02)00343-x
  15. Abelson J, Blacksher E, Li K, Boesveld S, Goold S. Public Deliberation in Health Policy and Bioethics:  Mapping an emerging, interdisciplinary field. Journal of Public Deliberation. 2013;9:5.  
  16. Slutsky J, Tumilty E, Max C, et al. Patterns of public participation. J Health Organ Manag. 2016;30(5):751-768. doi:10.1108/jhom-03-2016-0037
  17. American Institute for Research. Public Deliberation: Bringing Common Sense to Complex Health Policy Issues. AIR; 2015.
  18. Carman KL, Heil SKR, Garfinkel S, et al.  The Use of Public Deliberation in Eliciting Public Input: Findings from a Literature Review. Rockville, MD: Agency for Healthcare Research and Quality, Effective Healthcare Program; 2013.
  19. Goold SD, Biddle AK, Klipp G, Hall CN, Danis M. Choosing Healthplans All Together: a deliberative exercise for allocating limited health care resources. J Health Polit Policy Law. 2005;30(4):563-601. doi:10.1215/03616878-30-4-563
  20. Danis M, Ginsburg M, Goold S. Experience in the United States with public deliberation about health insurance benefits using the small group decision exercise, CHAT. J Ambul Care Manage. 2010;33(3):205-214. doi:10.1097/JAC.0b013e3181e56340
  21. Ginsburg M, Goold SD, Danis M. (De)constructing 'basic' benefits: citizens define the limits of coverage. Health Aff (Millwood). 2006;25(6):1648-1655. doi:10.1377/hlthaff.25.6.1648
  22. Danis M, Abernethy AP, Zafar SY, et al. A decision exercise to engage cancer patients and families in deliberation about Medicare coverage for advanced cancer care. BMC Health Serv Res. 2014;14:315. doi:10.1186/1472-6963-14-315
  23. Danis M, Goold SD, Parise C, Ginsburg M. Enhancing employee capacity to prioritize health insurance benefits. Health Expect. 2007;10(3):236-247. doi:10.1111/j.1369-7625.2007.00442.x
  24. Dror DM, Koren R, Ost A, Binnendijk E, Vellakkal S, Danis M. Health insurance benefit packages prioritized by low-income clients in India: three criteria to estimate effectiveness of choice. Soc Sci Med. 2007;64(4):884-896. doi:10.1016/j.socscimed.2006.10.032
  25. Danis M, Lovett F, Sabik L, Adikes K, Cheng G, Aomo T. Low-income employees' choices regarding employment benefits aimed at improving the socioeconomic determinants of health. Am J Public Health. 2007;97(9):1650-1657. doi:10.2105/ajph.2006.091033
  26. Goold SD, Myers CD, Danis M, et al. Members of Minority and Underserved Communities Set Priorities for Health Research. Milbank Q. 2018;96(4):675-705. doi:10.1111/1468-0009.12354
  27. Danis M, Kotwani N, Garrett J, Rivera I, Davies-Cole J, Carter-Nolan P. Priorities of low-income urban residents for interventions to address the socio-economic determinants of health. J Health Care Poor Underserved. 2010;21(4):1318-1339. doi:10.1353/hpu.2010.0929
  28. Hurst SA, Schindler M, Goold SD, Danis M. Swiss-CHAT: Citizens Discuss Priorities for Swiss Health Insurance Coverage. Int J Health Policy Manag. 2018;7(8):746-754. doi:10.15171/ijhpm.2018.15
  29. Schindler M, Danis M, Goold SD, Hurst SA. Solidarity and cost management: Swiss citizens' reasons for priorities regarding health insurance coverage. Health Expect. 2018;21(5):858-869. doi:10.1111/hex.12680
  30. Dror I. Demystifying Micro Health Insurance Package Design - Choosing Healthplans All Together (Chat). Microfinance Insights. 2007;4:17-19.
  31. National Department of Health. National Health Act. Vol 61. Republic of South Africa: National Department of Health; 2003.
  32. Padarath A, Friedman I. The Status of Clinic Committees in Primary Level Public Health Sector Facilities in South Africa. Durban: Health Systems Trust; 2008.
  33. Haricharan HJ. Extending Participation: Challenges of Health Committees as Meaningful Structures for Community Participation: A study of health committees. Cape Town Metropole: Human Rights Division, School of Public Health, University of Cape Town and The Learning Network on Health and Human Rights; 2010.
  34. Hofman KJ, McGee S, Chalkidou K, Tantivess S, Culyer AJ. National Health Insurance in South Africa: Relevance of a national priority-setting agency. S Afr Med J. 2015;105(9):739-740. doi:10.7196/SAMJnew.8584
  35. National Department of Health. National Health Insurance Bill. Republic of South Africa: Government Gazette; 2019:42598.
  36. Kahn K, Collinson MA, Gomez-Olive FX, et al. Profile: Agincourt health and socio-demographic surveillance system. Int J Epidemiol. 2012;41(4):988-1001. doi:10.1093/ije/dys115
  37. Wariri O, D'Ambruoso L, Twine R, et al. Initiating a participatory action research process in the Agincourt health and socio-demographic surveillance site. J Glob Health. 2017;7(1):010413. doi:10.7189/jogh.07.010413
  38. Twine R, Kahn K, Scholtz A, Norris SA. Involvement of stakeholders in determining health priorities of adolescents in rural South Africa. Glob Health Action. 2016;9:29162. doi:10.3402/gha.v9.29162
  39. Kabudula CW, Houle B, Collinson MA, et al. Socioeconomic differences in mortality in the antiretroviral therapy era in Agincourt, rural South Africa, 2001-13: a population surveillance analysis. Lancet Glob Health. 2017;5(9):e924-e935. doi:10.1016/s2214-109x(17)30297-8
  40. O'Leary DF, Casey M, O'Connor L, et al. Using rapid reviews: an example from a study conducted to inform policy-making. J Adv Nurs. 2017;73(3):742-752. doi:10.1111/jan.13231
  41. Africa Department of Health. White Paper on National Health Insurance In. Pretoria, South Africa: DOH; 2015.
  42. Van Newenhizen J. The Borda method is most likely to respect the Condorcet principle. Econ Theory. 1992;2:69. doi:10.1007/BF01213253
  43. Mitton C, Smith N, Peacock S, Evoy B, Abelson J. Public participation in health care priority setting: A scoping review. Health Policy. 2009;91(3):219-228. doi:10.1016/j.healthpol.2009.01.005
  44. Stats SA. Mortality and causes of death in South Africa, 2016: Findings from death notification. Pretoria: STATISTICS South Africa; 2018.