Introduction

Universal health coverage requires everyone to access the quality health services they need without experiencing financial hardship [1]. The development of a health benefits package is central to universal health coverage policy [2]. The health benefits package creates explicit entitlements for the public by prioritizing interventions within resource constraints [3]. Defining an effective yet affordable health benefits package avoids having aspirational "de jure" services that, while available in theory, differ from the "de facto" set of interventions accessed [3]. The program of action for the 1994 Cairo International Conference on Population and Development defined and proposed a package for universal access to sexual and reproductive health services and reproductive rights [4]. In Sub-Saharan Africa, the sexual reproductive health and rights (SRHR) 2005 continental policy framework [5] and its operationalization through the 2016–2030 Maputo action plan [6], reinforced the Cairo program of action aspirations in line with the 2030 sustainable development goals and universal health coverage objectives.

To accelerate global progress towards the program of action aspirations, the 2018 Guttmacher–Lancet Commission proposed that each country adopt the comprehensive definition of SRHR interventions into a health benefits package that should be universally available [7]. The Guttmacher–Lancet Commission’s definition is consistent with the World Health Organisation’s proposed SRHR benefits package [8, 9]. The Guttmacher–Lancet Commission interventions are cost-effective and affordable for most low and middle-income countries [7]. However, health benefits packages in most low and middle-income countries, only include pregnancy-related care, family planning, and HIV/AIDS, from the proposed Guttmacher–Lancet Commission’s SRHR definition. The other Guttmacher–Lancet Commission interventions, notably services on reproductive cancers, infertility, intimate partner and sexual violence, abortion care, comprehensive sexuality education, and sexual health, are seldom included [7, 10]. In most countries, where SRHR services are included, difficulties in public finance, delivery, quality, and access for vulnerable and marginalised populations are widespread [7]. The limited delivery and outright exclusion of some SRHR services in a health benefits package are likely to infringe on people’s right to health, ultimately threatening a country’s UHC objectives [7]. The High-Level Commission on the International Conference on Population and Development 25 years follow-up, identified Sub-Saharan Africa as having made the slowest progress in the world in terms of effective, accelerated implementation and funding of the program of action for the comprehensive SRHR package [11]. Trade-offs are inevitable in SRHR benefits package priority-setting and design and as such the Guttmacher–Lancet Commission recommends transparent and participatory approaches to enhance accountability and legitimacy [7].

To encourage the practical application of evidence-informed, transparent, and inclusive decision-making for benefits package design for universal health coverage, the World Health Assembly also passed Resolution WHA 67.23 on health intervention and technology assessment [12]. Health technology assessment is defined as a "multidisciplinary process that uses explicit methods to determine the value of health technology at different points in its lifecycle. The purpose is to inform decision-making to promote an equitable, efficient, and high-quality health system" [13]. There is increasing use of Health technology assessment to support decision-making for health benefits package design in low and middle-income countries [14]. A growing number of low and middle-income countries are using evidence-informed deliberative processes to advance the use of Health technology assessment for health benefits revision and design [15]. It provides practical steps to legitimize health technology assessment decision-making using six steps: (1) installing an advisory committee, (2) defining decision criteria, (3) identification and selection of health technology, (4) scoping, assessment, and appraisal of evidence, (5) communication and appeal, and (6) monitoring and evaluation [15]. The evidence-informed deliberative processes framework is a practical interpretation of the accountability for reasonableness theory. The accountability for reasonableness theory is a procedural framework on conditions for fair decision-making based on four principles: consideration of all relevant values, transparency, provision of appeal processes and ensuring that all these conditions are met [16].

The evidence-informed deliberative processes framework has been used in countries such as Ghana, Moldova, Pakistan, and Ukraine to support explicit priority-setting processes to define their health benefits design initiatives [15]. In Tanzania, components of the evidence-informed deliberative processes framework were used to elicit the capacity needs of the health technology assessment committee to support universal health coverage policy [17]. The Republic of Kazakhstan applied the evidence-informed deliberative process to prioritise 25 health technologies including HIV in the development of a health benefits package for universal health coverage [18]. Similarly, Indonesia utilised the framework for the prioritisation of HIV control interventions [19]. In addition, the Islamic Republic of Iran applied the framework for the inclusion and appraisal of nine multiple sclerosis services for health insurance benefits package revision [20].

The benefits of applying transparent and deliberative processes for health technology assessment to support priority-setting and health benefits package design include improved evidence availability [19], stakeholder involvement [19], and legitimacy of the decision-making process [20]. In Malaysia for instance, the involvement of diverse stakeholders in SRHR priority-setting for universal health coverage, increased understanding and buy-in [21], whereas the lack of involvement in Afghanistan, was perceived to favour donor priorities and donor evidence [22]. In Thailand’s introduction of universal health coverage, the success of SRHR integration into the benefits package has been attributed to coordinated government efforts to use stakeholder-acceptable evidence to extend health services to clients and reduce financial barriers to health [23]. In sub-Saharan Africa, two accessible studies have explored the inclusion of Guttmacher–Lancet Commission proposed SRHR interventions in health benefits packages. In the first research, the authors analysed decision-making processes for SRHR and mapped the Guttmacher–Lancet Commission package across health benefits packages of six countries [24]. The authors of the second study expanded the assessment of the Guttmacher–Lancet Commission SRHR package in a health benefits package to thirty-three sub-Saharan African countries and other low-and middle-income [10]. In both studies, the pattern of SRHR intervention inclusion in health benefits packages, as well as the recommendation for stakeholder participation and deliberations, were comparable to those established by the Guttmacher–Lancet Commission.

Recommendations for the adoption of the Guttmacher–Lancet Commission SRHR package and the use of the evidence-informed deliberative processes framework are recent. However, applying the evidence-informed deliberative processes principles on stakeholder participation and deliberations to current and historic decision-making for the Guttmacher–Lancet Commission SRHR proposed interventions, has the potential to provide a forward-looking model to improve legitimacy and accountability. This scoping review aims to synthesise this evidence by mapping literature in sub-Saharan Africa on the use of health technology assessment (in particular assessment and appraisal) of SRHR health technologies for SRHR priority-setting and benefits package design. It describes the policy context of health technology assessment and characterises the evidence-informed deliberative processes principles (stakeholder involvement, use of an explicit set of decision criteria, use of evidence, transparency) and steps (identification and selection, scoping, assessment and appraisal, communication, appeal, monitoring, and evaluation) for SRHR priority-setting and benefits package design in sub-Saharan Africa.

Materials and methods

Study selection and analysis

All duplicates were removed, and WS double-screened prospective papers by title and abstract. WS and JM conducted a full-text screening of the remaining studies. In cases of inclusion uncertainty, KG independently reviewed each case using the deciding criteria that a study should document actual resource allocation decision-making for SRHR. All included studies were imported to Zotero-6.0.13 for reference management. Fig 1 shows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews flow chart, for the search and inclusion process [30]. Deductive thematic analysis responding to the evidence-informed deliberative processes framework was used in the analysis. We did not perform any quality assessments on the included studies because the scoping review was exploratory.

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Fig 1. Study selection process flowchart.

https://doi.org/10.1371/journal.pone.0306042.g001

Results

The flow chart in Fig 1 summarizes the study selection process. A total of 218 studies were identified; 213 from 6 databases and 5 from other sources. There were 31 duplicate studies removed, leaving 187 studies for screening. An additional 143 studies were excluded based on the title and abstract. Of the 44 remaining studies, 30 did not match the selection criteria and were removed after a full screening. As a result, 14 papers were included in the review: 12 from database peer-reviewed searches and 2 from manual searches of grey literature.

Discussion

Sub-Saharan African countries are increasingly implementing health benefits packages to support public resource allocation across health services, including SRHR. However, there is a paucity of information on the inclusion of diverse stakeholders and the quality of decision-making processes to support health technology assessment for a benefits package design for SRHR. This review sought to characterise evidence using the evidence-informed deliberative processes framework in health technology assessment to support decision-making for SRHR program-specific interventions and their inclusion in health benefits packages in sub-Saharan Africa. As this scoping review findings have shown, the environment to support SRHR and broad health benefits package decision-making in sub-Saharan Africa lacks formal health technology assessment institutions, funding, and explicit country policy statements encouraging the use of health technology assessment. Fairer decision-making for SRHR is lacking. Advisory committees to support decision-making do not have clear roles and responsibilities to increase the legitimacy of their decision-making recommendations. Furthermore, the review found that stakeholders included in these committees do not represent diverse social values, including those of the public, patients, industry, and payers. Whereas there are attempts to define decision criteria, there is limited evidence on its use in the assessment and appraisal of SRHR health technology. Additionally, stakeholders were extensively dissatisfied with health technology assessment for SRHR recommendations. The implications of this review’s findings are important to all stakeholders interested in ensuring that decision-making for SRHR accounts for diverse social values fairly and transparently.

To begin, the review has identified challenges in the policy context for sub-Saharan African countries with implications on the use of health technology assessment for SRHR priority-setting and benefits package decision-making, such as budgets, institutional ability to perform health technology assessment, and its use. A recent study by Hollingworth and others exploring health technology assessment institutionalisation in low-and middle-income countries also found that activities are uncoordinated and disconnected from policy [46]. The authors characterised the challenges as poor awareness of the relevance of health technology assessment to assist decision-making, as well as limited health technology assessment institutional and regulatory development, which was worsened by low health technology assessment skill levels and insufficient use of evidence for policy. Similar evidence was also synthesised elsewhere [14, 47]. According to Falkowski and others, a lack of specific health technology assessment units within low and middle-income countries governments contributes to the low financing for health technology assessment initiatives [46]. The foregoing raises a need for guidance to support health technology assessment [48]. Furthermore, in studies identified and included by this scoping review, the Ministry of Health initiated the creation of advisory committees. However, the reasons for the process, inclusion, and roles of specific stakeholders and their veto powers, were unclear. In addition, our study found that SRHR health technology assessment advisory panels mostly comprise researchers, development assistance organizations, and policymakers, while other stakeholders such as patients, the general public, payers, purchasers, and industry are frequently excluded. This worrying trend was also revealed in a recent literature review where authors identified the inclusion of public and vulnerable populations as lacking in priority-setting processes [49]. Their study recommended that priority-setting processes should be explicit on how these marginalised groups should be included and how the participation process should be administered. As encouraged by Kapiriri using the priority-setting case of Uganda, fostering legitimate priority-setting processes requires that government and development assistance partners work together with wider stakeholders to balance decision-making powers [50].

As seen in our review, while most included studies expressed a wish to employ decision criteria for priority-setting, this was seldom implemented. Disease burden, cost-effectiveness, equity, and budget impact were the most sought-after decision criteria, whereas public acceptability, quality disease severity, and safety were the least sought-after. These results closely resemble those identified by Kaur and others [51]. In their research, however, the decision criteria were employed to enhance priority-setting procedures, which was seldom the case in our findings. In our review, there were limited efforts to operationalise the sought-after decision criteria for SRHR decision-making.

The role of development assistance partners in benefits package decision-making is critical. In our study, the identification of SRHR health technologies as potential candidates for selection into the evidence synthesis stage mainly followed the priorities for development assistance partners. As demonstrated by Kapiriri using the instance of Uganda, the perceived role of development assistance partners in the priority-setting process is to direct how their funds should be used for their established priorities [50]. Their research, however, contends that there must be a fair and acceptable balance between national priorities and those of development aid partners [50]. One way to achieve this as shown in our study is through stakeholder capacity development and collaborations using development assistance networks and academia. Countries can leverage decision-support networks such as the international decision-support initiative and the newly formed Health Economics Program at Africa Center for Disease Control, in addition to academia to steer capacity development efforts in sub-Saharan Africa [14].

In our review of the appraisal stage of the studies identified, most data did not correspond to the objectives set at the scoping stage. Whereas there was a measure of tools used for the assessment stage, the use of tools at the appraisal stage was predominantly absent across most studies. These mismatches resulted from data unavailability, lack of clear objectives at the scoping stage, and influence from development assistance partners. For example, the Department for International Development’s business case was used in South Sudan, because the priority-setting process was steered by Department for International Development [36]. Firstly, the unavailability of health and economics data and assessment tools to support health technology assessment priority-setting has been widely discussed elsewhere [14, 46, 47]. This could be because some social value dimensions are difficult to quantify and there are no systems to periodically collect the needed data [46]. Secondly, as shown in the literature, frameworks such as the Integrated health technology assessment for the evaluation of complex technologies, guidance on priority-setting in health care, World Health Organisation’s choosing cost-effective Interventions, and the health technology assessment core model by EUnetHTA could provide additional resources to guide scoping objectives, assessment, and appraisal [47, 52–54].

Appeal processes provide opportunities to improve the quality of the decision-making process [15]. Across all included studies, there were no available avenues for the appeal of the SRHR priority-setting decisions. In fact, in 11 of the 14 included studies, stakeholders were unhappy with the recommendations. As an example of why appeals are important, although not in sub-Saharan Africa, the re-appeals at the National Institute of Health and Care Excellence in the United Kingdom, have a 54% favourable outcome for organizations objecting to an initial decision [55].

In our study, there was no evidence of deliberate use of monitoring and evaluation for SRHR health technology assessment. However, there were benefits to the use of health technology assessment processes with important implications for policy and practice. The study findings indicate accrued benefits as a result of increased transparency, effective inclusion of stakeholders’ preferences, and value for money in decisions made [44]. A South African study on the application of context-specific ethics frameworks in decision-making revealed that deliberations enhanced appraisal quality and transparency [56]. The impact of implementing health technology assessment decision recommendations on SRHR included workforce strengthening and improved service delivery. However, the non-use of systematic approaches to SRHR resource allocation resulted in inequalities in healthcare access and poor implementation. There is evidence that monitoring and evaluation approaches introduced by research institutions within the advisory committees are likely to be adopted in priority-setting [57].

This review’s novelty of applying the evidence-informed deliberative processes framework on health technology assessment for SRHR priority-setting and benefits package design has limitations, including missing data on key thematic areas for the framework. It’s worth noting that just 6 of the 14 included studies were carried out after the evidence-informed deliberative processes framework was formulated. While it is unlikely that they would have followed the evidence-informed deliberative processes step by step, they would have followed its principles, which have long been established in stakeholder involvement and deliberative processes. In our contextual review of health technology assessment in each study, we did not independently verify with literature or use our prior knowledge of included countries to triangulate any information. As a consequence of the foregoing, the unit of study was each included article and not the country the article was carried in. The study used the face value for the included studies. Furthermore, although desirable, following the evidence-informed deliberative processes framework, this review could not conclusively characterise the performance of SRHR decisions as part of general health benefit package decisions versus specific SHRH package decisions. As a consequence, evidence from this study cannot characterise if there are specific procedural requirements, that SRHR decisions should meet given the characteristics of the interventions, the stakeholders affected by these and the influence of values. Additional limitations include the absence of a quality assessment of the included studies and the use of a single reviewer for the title and abstract screening stage.

Conclusion

This review has shown potential benefits accrued in applying the evidence-informed deliberative processes framework for health technology assessment to improve stakeholder involvement and deliberations in SRHR priority-setting and benefits package design. The implications of the study findings for policy and practice highlight the need for policymakers and healthcare professionals to prioritise evidence-informed deliberative processes in the design of benefits packages for SRHR in sub-Saharan Africa. The use of the evidence-informed deliberative processes framework for priority-setting is particularly important in SRHR programming and benefits package design to promote equity, efficiency, and legitimacy, as diverse stakeholders with multiple social values are likely to affect the legitimacy of decision recommendations. To the best of our knowledge, this is the first review to systematically evaluate the use of a deliberative framework for health technology assessment in SRHR benefits package design across sub-Saharan Africa.

As a policy recommendation, sub-Saharan African Governments could consider moving towards institutionalizing health technology assessment and generating explicit policy statements and sufficient yearly budgets for its use. There must be deliberate efforts to enhance health technology assessment networking and support for stakeholder capacity strengthening. Specifically, there is a need for enhanced involvement of stakeholders with diverse backgrounds for SRHR benefits package design. Initiating an advisory committee for each decision-making process, including benefits package design and revision and SRHR program-specific interventions, should follow transparent recruitment processes, with clearly defined roles and voting responsibilities. Consensus-building techniques, as identified by the recent deliberation guidance by the Professional Society for Health Economics and Outcomes Research, and Health Technology Assessment International [58], are seen as good practice.

In-country decision criteria for the selection and reimbursement of health technology should be in place to guide the selection of technologies for assessment following the identification and appraisal stages. Furthermore, Identification, selection, scoping, assessment, appraisal, and appeal of SRHR health technologies should follow exhaustive stakeholder involvement within the advisory group and wider population. Guidelines for economic evaluations, socio-cultural, ethics, equity, legal, effectiveness, quality, and safety should be established to support SRHR health technology assessment. There must be an explicit channel to support stakeholder appeals for decision recommendations. As an implication for further research, there is a need to quantify the return on investment for the use of deliberative processes in health technology assessment for SRHR benefits designs. This would require appropriate tools for health technology assessment inputs, outputs, outcomes, and impacts [59]. Development assistance partners should work closely with other stakeholders, including the government, and advance more research and practices to strengthen the legitimacy, accountability, and transparency of these processes.

Supporting information

Acknowledgments

The authors express their gratitude to the anonymous reviewers for their feedback.