How Is Equity Considered Within National Healthcare Priority Setting? A Qualitative Study of Australian Health Technology Assessment Actors' Perspectives

INTRODUCTION: Equity is recognised in the decision-making within Australian health technology assessment (HTA), although limited studies describe how these considerations are operationalised in practice. We aimed to explore the experiences and views of a range of HTA actors, to understand how equity is considered in HTA processes. METHODS: Semi-structured interviews were conducted with 21 participants including sponsors, members of patient or consumer representative groups, non-government organisations and interest groups, economists preparing or assessing HTA submissions and people in government-appointed roles, including HTA committee members. Interview transcripts were analysed using reflexive thematic analysis. RESULTS: Reflexive thematic analysis produced three overarching themes. Firstly, equity can be considered in decision-making, but its role is not transparent, and equity meaningfully impacts decision-making in few circumstances. Secondly, there are institutional, ideological and methodological challenges that impede the consideration of equity in HTA. Ambiguous guidance and public summary documents mean the inclusion, evaluation and appraisal of equity-relevant information depends on the individual, creating inconsistency. In the absence of a clear equity definition, HTA actors frame equity in ways that serve their own purposes, creating confusion and tension within a reactive process. Decision-makers face a dilemma between evidence-based medicine paradigms, which predominate, and patient or lived experience evidence. Limited knowledge of public values on equity priorities constrains decision-maker ability to integrate equity concerns into recommendations. Thirdly, HTA actors express a preference for incremental and pragmatic HTA reform. They wish to maintain a deliberative approach to decision-making with qualitative equity information but see scope to adopt strategies such as Citizens' juries or case studies trialling the use of equity-informed economic evaluations. CONCLUSIONS: This study constructed a detailed understanding of how equity is considered by HTA actors, the challenges faced, and generated potential strategies to better consider equity in Australian HTA.