Abstract
Due to constraints on institutional capacity and financial resources, the road to universal health coverage (UHC) involves difficult policy choices. To assist with these choices, scholars and policy makers have done extensive work on criteria to assess the substantive fairness of health financing policies: their impact on the distribution of rights, duties, benefits and burdens on the path towards UHC. However, less attention has been paid to the procedural fairness of health financing decisions. The Accountability for Reasonableness Framework (A4R), which is widely applied to assess procedural fairness, has primarily been used in priority-setting for purchasing decisions, with revenue mobilization and pooling receiving limited attention. Furthermore, the sufficiency of the A4R framework’s four criteria (publicity, relevance, revisions and appeals, and enforcement) has been questioned. Moreover, research in political theory and public administration (including deliberative democracy), public finance, environmental management, psychology, and health financing has examined the key features of procedural fairness, but these insights have not been synthesized into a comprehensive set of criteria for fair decision-making processes in health financing. A systematic study of how these criteria have been applied in decision-making situations related to health financing and in other areas is also lacking. This paper addresses these gaps through a scoping review. It argues that the literature across many disciplines can be synthesized into 10 core criteria with common philosophical foundations. These go beyond A4R and encompass equality, impartiality, consistency over time, reason-giving, transparency, accuracy of information, participation, inclusiveness, revisability and enforcement. These criteria can be used to evaluate and guide decision-making processes for financing UHC across different country income levels and health financing arrangements. The review also presents examples of how these criteria have been applied to decisions in health financing and other sectors.
Keywords: Health financing, accountability, equity, policy process, participation
Key messages
This scoping review supplements previous substantive accounts of fairness in health financing with a comprehensive procedural account, based on 10 criteria: equality, impartiality, consistency over time, reason-giving, transparency, accuracy of information, participation, inclusiveness, revisability and enforcement.
Procedural fairness can contribute to more equitable outcomes, strengthen the legitimacy of decisions, build public trust and promote the implementation and sustainability of reforms.
Judgements about procedural fairness require examining many different features of decision-making and should not rest solely on the satisfaction of a subset of the proposed criteria or on a narrow focus on one or two aspects, such as participation or transparency.
Health financing represents an area with promising experiments in more open and inclusive decision-making in different contexts and political conditions, offering opportunities for cross-country learning about ways to strengthen procedural fairness.
Introduction
Fairness lies at the heart of discussions about financing universal health coverage (UHC). Substantive fairness involves how rights, duties, benefits and burdens ought to be distributed (Rawls, 1971; Sen, 1992). What constitutes good health financing policies in terms of their impact on the fair and progressive realization of UHC has been given significant attention in recent years. For example, in 2014, the WHO Consultative Group on Equity and Universal Health Coverage proposed criteria for assessing the substantive fairness of the critical choices countries face when seeking to advance UHC along three key dimensions: expanding priority services, including more people, and reducing out-of-pocket payments (World Health Organization, 2014). These criteria included the maximization of aggregate population health, improving the situation of those who are worse off along several dimensions (including the individual burden of disease, income and wealth, and social status), and improving financial risk protection, especially for the poorest. It also argued that some ways of making trade-offs between different people’s interests (and between these dimensions of progress) were incompatible with the fair, progressive realization of UHC (Norheim, 2015). For example, it argued that it was unfair to expand coverage for health services that, given these criteria, should have low- to medium-priority before there is near-universal coverage for high-priority services. In 2018, the World Bank expanded on this work by systematically describing unacceptable ways of making trade-offs across the three health financing functions of revenue mobilization, pooling and purchasing (World Bank, 2018). More recently, the World Bank and the WHO have provided guidance on which policies can fairly improve financial protection through increased domestic revenue mobilization and pooling as well as more efficient use of available resources (World Bank, 2019; Jowett et al., 2020).
Even though these proposed criteria have gained substantial support from countries around the world, there is scope for questioning them (Littlejohns and Chalkidou, 2016; Rumbold and Wilson, 2016; Weale, 2016; Woldemariam, 2016). Moreover, these proposals themselves leave plenty of room for judgement and debate about matters of substantive justice on the path to UHC. For example, even those who accept the Consultative Group’s proposed three core criteria must face the difficulty of specifying how these criteria should be practically applied and arrive at a way of balancing them when they point in opposing directions. Furthermore, the Consultative Group made it clear that further criteria may be relevant depending on country context. There is, in sum, a need for reasoned, open and inclusive debate on how to resolve these questions of substantive fairness, as is demonstrated by several country case studies (Voorhoeve et al., 2016; 2017) and in policy making that was informed by the Consultative Group’s report in Ethiopia and Zanzibar (Eregata et al., 2020; Verguet et al., 2021; Ministry of Health of Zanzibar, 2023). In debating criteria for fairness and in making difficult decisions in light of them, there is an important role for supplementing a substantive account with a procedural account.
Procedural fairness concerns how people are included, informed and treated in the decision-making processes. Our main rationale for being concerned with procedural fairness is fourfold. First, procedural fairness can positively impact the outcomes of a decision-making process: for example, by improving the quality of policies, reducing corruption or improving equity through greater openness and inclusion, especially of poor and marginalized communities (Department of Economic and Social Affairs, 2005; World Bank, 2008; Landemore, 2013; Cabannes, 2014; Akech and Kirya, 2020; Eriksen, 2022b). When decision-makers commit to explaining their decisions to the wider public and there is room for open questioning and exchange of ideas between diverse voices it is more likely that the gross injustices that flow from people’s interests being misrepresented or overlooked can be prevented. Secondly, procedural fairness strengthens the legitimacy of decisions. When decisions are made through procedures where people are treated with respect, have opportunities to participate, and where authorities are perceived as neutral, decisions are more likely to be accepted, even when disagreements persist (Tyler, 2000; Rawls, 2012; Langvatn, 2015). Third, procedural fairness builds trust, because it increases the reliability of the information used, ensures everyone’s interests are considered, and allows citizens and civil society organizations to understand and check decisions (Miller and Listhaug, 1990; OECD, 2017). Fourth, it may promote the sustainability of policy decisions (Raisio, 2010; Chwalisz, 2020a). The public exchange of reasons for and against a policy, which is part of procedural fairness, can generate understanding of a policy’s rationale, which can contribute to enduring support for it. By creating space for voice from all constituencies, including those whose preferred solutions are not ultimately adopted, fair processes also create space for finding common ground, thereby reducing chance that reforms will be undone when power shifts (Daniels, 2008a; Newdemocracy Foundation and The United Nations Democracy Fund, 2019; World Bank, 2023; Norheim et al., 2021; Murphy and Tyler, 2008).
The characteristics of procedural fairness are widely debated. In health, the guiding framework for prioritizing health care resources is Accountability for Reasonableness (A4R) developed by Norman Daniels and Jim Sabin (Daniels and Sabin, 2002). The framework specifies four conditions as core to a fair process: relevance (the evidence and rationales for decisions must be pertinent to meeting population health needs fairly), publicity (the reasons for decisions must be publicly available), appeals and revision (there must be mechanisms to challenge decisions and procedures for revising them in light of new evidence or changes in circumstances) and enforcement (institutions must be set up to ensure the three conditions above are consistently met) (Daniels and Sabin, 2002). Widespread disagreement may exist on the outcomes of priority-setting decisions, such as the inclusion or exclusion of services in a health benefit package. For such cases, A4R advocates argue that when these procedural conditions are met, there will be a greater likelihood that the decisions are accepted as legitimate even by those who preferred a different outcome (Daniels, 2007). However, critics have argued that there is a need to re-evaluate some the proposed criteria or extend A4R’s focus. A key objection is that the framework places insufficient emphasis on the importance of public participation for procedural fairness (Friedman, 2008). Some have also argued that it is unclear how different kinds of arguments come to be seen as relevant for an informed debate (Rid, 2009; Ford, 2015). Daniels himself acknowledges that there is a need for further work to examine what procedural fairness involves for different policy questions or in different settings, for example with respect to the selection and role of stakeholders in a priority-setting process (Daniels, 2009). Together, these different assessments suggest that procedural fairness is determined by a broader set of criteria than those given attention by A4R (Friedman, 2008; Kapiriri et al., 2009; Rid, 2009; Ford, 2015). From a health financing policy perspective, a key gap is the lack of insight on the application of these and other criteria to health financing functions beyond the purchasing function, specifically to revenue generation and pooling (Box 1).
Box 1.
Health financing and its core functions
Health financing refers to mobilization, accumulation and allocation of money to cover people’s needs, individually and collectively (Kutzin, 2001; World Health Organization, 2010; World Bank, 2019). Revenue mobilization is about the way money is raised to pay for health services and the necessary investment in service delivery capacity, core public health functions and system governance. After collection, such funds are accumulated and pooled on behalf of a segment or the whole population. Pooling health funds allows redistribution of prepaid resources to individuals with the greatest health service needs (Mcintyre et al., 2013). This can occur through different types of organizational and governing arrangements, such as health insurance funds, national health ministries and local governments. Purchasing covers the broad question of what to buy and how to pay for these goods and services (World Bank, 2019). Decisions to purchase services from pooled funds include the purchasing of public health functions, such as surveillance systems, screening programmes and the regulation of unhealthy products. A health financing system requires these functions to perform well with scope for adjustments to predictable and less predictable shocks to revenue or those which increase health spending (World Bank, 2019).
Insights from literatures outside health policy also suggest that a broader range of criteria shape procedural fairness. For example, the literature on public financial management—understood as the institutions, policies and processes that govern the use of public funds—emphasizes features such as stakeholder input and the contestability of policy advice (World Bank, 1998). A concern for procedural fairness also motivates the literature on deliberative democracy, which rests on concepts such as equality of opportunity to participate and equal consideration of interests and viewpoints, respect for different viewpoints, and the value of public justification of policies (Gutmann and Thompson, 1995; 2009; Erman, 2016; Beauvais, 2018). Furthermore, in the extensive literature on participatory budgeting the value of participation is tied to other features of the decision process, such as inclusiveness and an empowered citizenry (Souza, 2001).
While procedural fairness is a theme in these vast literatures, no synthesis exists of the treatment of different criteria across disciplines, which criteria are emphasized and why, and how these criteria are applied to decisions in different sectors. In this paper, we fill this gap. The integrated and interdisciplinary assessment we perform can help policy makers and practitioners in health financing identify the criteria that are given greatest theoretical and empirical attention. This, in turn, can inform future frameworks for examining, building and reforming decision processes in health financing. The primary objective of our scoping review is thus to identify, and to offer an analytical, constructive synthesis of key criteria used to determine the fairness of decision-making processes in resource mobilization and allocation decisions. Its secondary objective is to identify how these criteria have been applied in relevant decision situations in health financing, public finance and environmental management.
Methods
Study design
We considered both a systematic review of qualitative evidence and a scoping review of the literature to pursue our research questions. Our preliminary assessment of the literature identified that relevant theoretical and empirical contributions were made in several disciplines. Investigating our broadly formulated research objectives required mapping key concepts related to procedural fairness, examining their conceptual description and interpretation in different disciplines, and defining their conceptual boundaries. Moreover, we sought to identify a wide range of empirical examples which were analysed from different disciplinary perspectives. Therefore, we deemed that a scoping review of the literature would be most appropriate (Arksey and O'Malley, 2005; Peters et al., 2015; Munn et al., 2018). To increase the reliability and replicability of the review, our approach was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (Tricco et al., 2016). The scoping review protocol is made available on the website of the Open Science Framework (Dale et al., 2023).
Search strategy: theoretical concepts and design
The search strategy was designed in consultation between the review authors and an information specialist. Three electronic databases, MEDLINE, SCOPUS and Epistemonikos, covering literature from the biomedical and social sciences were searched between 3 and 18 June 2021 (Supplementary file S1: Search strategy). Key concepts for the search were derived from the initially identified theoretical perspectives and were used in three combined search strings. The first string focused on financing of health care and wider social welfare arrangements, representing relevant decision situations involving conflicting values and trade-offs where features of procedural fairness were likely to have been studied. The second string aimed to cover terms describing the processes by which financing decisions are made. Accordingly, we included terms such as ‘deliberation’ or ‘budgeting’. Finally, fairness was the focus of the third string. We included values of decision-making that are distinct but tied to fairness, such as ‘accountability’, ‘legitimacy’, ‘public participation’ and ‘transparency’.
We used two additional methods to identify relevant literature. First, we searched for reports and other types of work produced by organizations that (1) support health financing and public finance reforms (e.g. the WHO or World Bank); (2) have produced comprehensive assessments of the defining features of procedural fairness (e.g. the OECD), or (3) have significant work focused on transparency and civil society participation in public budgeting (e.g. the International Budget Partnership). Second, the scoping review is part of a larger project between the authors' institutes which is advised by an international expert group. Suggestions for literature were solicited from members of the expert group, which included researchers and practitioners with backgrounds in philosophy, health financing and law. The latter was deemed necessary because we identified that certain important theoretical contributions, especially from the fields of democratic theory and public finance, were not picked up by our search strategy due to the absence of indexed abstracts or keywords.
Study eligibility criteria
Inclusion criteria were published peer-reviewed articles that:
were theory-driven, or used qualitative methods or mixed-methods including qualitative data;
directly focused on questions about procedural fairness or how decision-making achieves goals tied to procedural fairness (e.g. trust, legitimacy and accountability);
focused on decision situations of interest (health financing, public finance, or environmental management).
Exclusion criteria were:
theses, commentaries and conference abstracts;
studies in languages other than English;
book chapters, apart from widely cited works from leading scholars in the field.
Study screening and selection: machine learning strategy
Two review authors independently assessed the titles and abstracts of the identified records against the eligibility criteria. The priority screening ranking algorithm of EPPI-Reviewer, a web-based software program for managing and analysing data in literature reviews, was used to prioritize studies for review. This machine learning strategy continuously learns from researcher decisions, prioritizing the most relevant studies to be screened first (Gates et al., 2019; Muller et al., 2021). After learning from the independent assessments of ∼1500 titles, abstracts and full-texts, we established a baseline inclusion rate by two people further manually screening and piloting inclusion criteria on a random sample of 200 records. The remaining records were subsequently assigned to 10 bands, based on their probability of being relevant (0–9%, 10–19%, 20–29%, etc.). We reviewed all records from the bands 40–49% and up. In the 30–39% band, we reviewed 10% of the records and found that no new studies needed to be added to the full-text inclusion list, indicating that this band represented titles and abstracts that did not meet the eligibility criteria for the review. Box 2 presents additional details about the machine learning strategy (Thomas et al., 2010; Gates et al., 2019; Muller et al., 2021). Disagreements were resolved and a final decision on inclusion was made through discussion or with the involvement of a third review author.
Box 2.
Machine learning for study screening and selection
Machine learning is increasingly being used by researchers to perform knowledge summaries more efficiently. Web-based software programs like EPPI-reviewer are designed for managing and analysing data in literature reviews, particularly the title and abstract screening stage, which can be time-consuming for reviewers. Machine learning tools have been designed to semi-automate some processes. The EPPI-reviewer learns from a sub-set of the researchers citation screening, and then by following the preferences of the researcher (those articles that are most relevant to their research question), the machine learning tool uses an algorithm to predict the relevance of the remaining records for the review. Reviewers therefore focus their screening time on those articles most relevant to their research.
Data extraction and analysis
The included full texts were distributed among three authors, who independently extracted relevant criteria using a data extraction form that included basic bibliographic data, country setting, objectives of the study, disciplinary domain, procedural criteria studied, main arguments used to support why the criteria mattered for procedural fairness, experiences with mechanisms for implementing the criteria, and a simple assessment and summary of methodological quality. We defined a criterion for procedural fairness to be a standard for evaluating a decision-making process that, if met, was said to positively impact fairness and/or legitimacy. Box 3 explains how fairness and legitimacy represent intersecting values for decision-making processes. To strengthen validity, ∼20% of the included full texts were randomly reviewed by a second author, who assessed data extraction for accuracy and consistency.
Box 3.
Fairness and legitimacy—intersecting values of a decision-making process
There is a tight relationship between fairness and legitimacy when it comes to assessment of decision-making processes. Justifying political power and decisions about laws and policies by public reasons—reasons that are shared by and acceptable to free and equal people—is a key source of normative legitimacy (Cohen, 1989; Rawls, 1997; Freeman, 2003; Peter, 2007). Furthermore, public discussion is central to authority and the reasons supporting a decision have a bearing on its perceived legitimacy (Eriksen, 2022a). In discussions of the A4R framework, procedural fairness and legitimacy is generally discussed together, with the criteria of A4R deemed to promote both procedural fairness and legitimacy (Daniels and Sabin, 1997; 2002).
Our scoping review identified >25 criteria that have been proposed to represent key features of procedural fairness (see Supplementary file S2: Data extraction sheet). We subsequently aimed to narrow down and synthesize these criteria to identify the most critical aspects of procedural fairness and thereby develop a set that could serve as the foundation for an evaluative framework for policy. During the selection process, we consolidated criteria that referred to similar ideas into a single criterion and narrowed down the number of criteria to ten. For example, community participation, citizen input/voice, social participation, stakeholder engagement and collective decision-making can all be interpreted as relating to participation. In other cases, one term, such as ‘participation’ would be used in a study but reading through the text it was clear that it also implied inclusiveness and equality. This process involved iterative discussions among the lead authors, consultation with the broader research team, and engagement with an international expert group.
Quality assessment
We were unable to identify a quality assessment tool that was appropriate for every study, given the heterogenous and interdisciplinary nature of the included literature. The Critical Appraisal Skills Programme (CASP) quality assessment tool for qualitative studies was deemed most closely relevant (Critical Appraisal Skills Programme, 2018) and our quality assessment was guided by this checklist (Supplementary file S2: Data extraction sheet). No quality assessment was performed if the included article was a conceptual contribution or if the article was rooted in a discipline where the use of CASP was deemed not fit for purpose.
Results
Descriptive overview
The PRISMA flow diagram displays the records identified, screened and included (Figure 1). We screened 7760 records, where 2278 records were double screened independently by two researchers and 5482 records were screened using a machine learning strategy. Based on title and abstract screening, 584 papers were identified for full text screening. Of these, 266 records were deemed eligible for data extraction. Key reasons for exclusion during full text screening are presented in Figure 1. Guided by recent methodological reviews of qualitative research for inclusion in systematic reviews, we adopted a purposive sampling approach aiming to draw insights from a diverse range of disciplines and theoretical perspectives rather than aiming to extract information from every eligible study (Booth, 2016). A total of 197 of the included records were subject to data extraction (Supplementary file S2: Data extraction sheet).
Figure 1.
PRISMA flow diagram
Overall, an extensive literature across different disciplines—political theory and public administration (including deliberative democracy), public finance, environmental management, psychology, and health financing—informed the characterization of key features of procedural fairness. Figure 2 presents the quantity of articles categorized according to each discipline.
Figure 2.
Articles reviewed by discipline (n = 197)
The data extraction and analysis process identified 10 distinct criteria: equality, impartiality, consistency over time, reason-giving, transparency, accuracy of information, participation, inclusiveness, revisability and enforcement. Table 1 summarizes the main disciplinary areas informing the assessment of these criteria and the principal arguments for their importance for procedural fairness. Other criteria, such as ‘listening to each other’ and ‘time for deliberation’, were interpreted to be characteristics of robust public participation and were incorporated in the discussion of that criterion (Chwalisz, 2020b). Another criterion—‘accountability’—is widely applied (Fletcher, 2007; Cornwall and Shankland, 2008; Clark et al., 2012). During the analytical process, the concept of accountability was interpreted to encompass two distinct aspects discussed below: reason-giving and enforcement (Gutmann and Thompson, 2004b; Ringold et al., 2012).
Table 1.
Summary of criteria for procedural fairness as identified by the review
| Criterion | Main disciplinary areas informing the assessment | Key arguments presented for the criterion’s importance | Proposed policy-oriented definition | Studies contributing to criterion summarya |
|---|---|---|---|---|
| 1. Equality | Health financing, public finance, political theory, social psychology |
|
Equality demands that, in the deliberative and decision-making process, there is equal representation regardless of social status, gender, ethnicity, religion, or power. People should have equal opportunity to access information and articulate their views, and their views should be considered with equal respect. | Bachtiger et al., 2018, Barasa et al., 2016, Beauvais, 2018, Ford, 2015, Fletcher, 2007, Friedman, 2008, Gutmann and Thompson, 2004b, Gibson et al., 2005, Kantamaturapoj et al., 2020a, Kapiriri et al., 2009, Leventhal et al., 1980, Lukasiewicz and Baldwin, 2017, Mansbridge et al., 2012, Norheim et al., 2021, O’Hagan et al., 2020, Peacock et al., 2009, |
| 2. Impartiality | Health financing, political theory, social psychology |
|
Impartiality requires decision-makers to produce an unbiased assessment. Their decisions should not be driven by self-interest or unduly influenced by stakeholders with vested interests. | Afsahi, 2022, Bertram et al., 2021, Ford, 2015, European Network For Health Technology Assessment, 2021, Fletcher, 2007, Gibson et al., 2005, Johnson, 2009, Leventhal et al., 1980, Mansbridge et al., 2010, Murphy, 2005, Norheim et al., 2021, Prichard et al., 2019, Rid, 2009, Twea et al., 2020 |
| 3. Consistency over time | Health financing, social psychology |
|
Consistency over time requires that decision procedures are stable and predictable, especially over the short term, to foster acceptance and trust. Changes to decision-making procedures should be explained and justified. | Baltussen et al., 2017a, Charlton, 2020, Ford, 2015, Friedman, 2008, Kapiriri et al., 2009, Leventhal et al., 1980, Peacock et al., 2009 |
| 4. Reason-giving | Health financing, political theory |
|
Reason-giving involves addressing moral disagreements through public reasoning where reasons are exchanged, listened to, and accepted (or rejected) by free and equal persons. | Bachtiger et al., 2018, Badano, 2018, Baltussen et al., 2017a, Baltussen et al., 2017b, Bukachi et al., 2014, Byskov et al., 2014, Chambers, 2018, Gutmann and Thompson, 2004b, Daniels, 2008b, Ford, 2015, Friedman, 2008, Hasman and Holm, 2005, Johnson, 2009, Kantamaturapoj et al., 2020b, Lakin, 2018, Maluka et al., 2010a, Rawls, 2005, Rid, 2009, Zulu et al., 2014 |
| 5. Transparency | Political theory, public finance, health financing, environmental management |
|
Transparency is about making information accessible to the public. This includes information on the decision-making process itself (e.g. steps in the budget cycle), justifications during deliberations on the issue at hand (e.g. reasons for a proposed budget, any alternatives, and discussions around these), and reasoning on the decisions taken (e.g. why this particular budget is adopted), as well as the output of the decision itself (e.g. a budgetary document with actual figures in it). | Bachtiger et al., 2018, Berggren, 2018, Bukachi et al., 2014, Daniels, 2008a, Daniels, 2008b, Gallego et al., 2007, Garrett and Vermeule, 2008, Gutmann and Thompson, 2004b, Harrison and Sayogo, 2014, International Budget Partnership, 2022, Isaksen et al., 2007, Lakin and Nyagaka, 2016, Maluka et al., 2010b, Menon et al., 2007, Mukhopadhyay, 2017, PEFA, 2019, PEFA, 2022, Timmis et al., 2017, World Bank, 2021 |
| 6. Accuracy of Information | Health financing, political theory, public finance, social psychology environmental management |
|
Decisions must be based on accurate information and on high-quality, informed opinion, representing the full breadth and diversity of views. | Bachtiger et al., 2018, Baltussen et al., 2013, Baltussen et al., 2017a, Bentley et al., 2019, Bijlmakers et al., 2020, Gordon et al., 2009, Gutmann and Thompson, 2004b, Hysing, 2015, Jansson, 2007, Kantamaturapoj et al., 2020b, Kapiriri et al., 2003, Leventhal et al., 1980, Martinez and Kohler, 2016, Petricca and Bekele, 2018, Rajan et al., 2019, Wagner et al., 2019, Simcock, 2016, Waithaka et al., 2018a, Williamson and Scicchitano, 2014 |
| 7. Public participation | Health financing, political theory, environmental management |
|
Public participation is about enabling members of the public to access information and express their opinions, engaging people as agents in the decision-making process. Public participation also requires the engagement of those who are indirectly affected and are therefore unlikely to participate directly in the decision in question. | Abelson et al., 2002, Barasa et al., 2015, Byskov et al., 2014, Castillo, 2015, Calisto Friant, 2019, , Chwalisz, 2020b , Daniels and Sabin, 1998, Daniels, 2007, De Santo, 2016, Eriksen, 2022b, Eriksen, 2022a, Essue and Kapiriri, 2020, Firestone et al., 2020, Gilman, 2016, Gutmann and Thompson, 2004a, Gutmann and Thompson, 2004b, Hunter et al., 2016, Hysing, 2015, Jansen et al., 2018, Maluka et al., 2010b, Maluka et al., 2010a, Maluka et al., 2011, Maluka, 2011, Martinez and Kohler, 2016, Mitton et al., 2009, Rid, 2009, Russell and Jovanovic, 2020, Sintomer et al., 2008, Struić and Bratić, 2018, Tugendhaft et al., 2021, Weale et al., 2016a, Williamson and Scicchitano, 2014 |
| 8. Inclusiveness | Health financing, public finance, environmental management |
|
Inclusiveness is about the range of views and concerns represented and considered in a decision-making process. It requires mechanisms for bringing in people who typically would not contribute to public policy and decision making. Inclusiveness goes beyond ‘counting heads’ to securing the inclusion of various perspectives and arguments in the process. | Begg, 2018, 2020a Chwalisz, 2020b, Dalton, 2005, Dryzek and Niemeyer, 2008, Dryzek, 2009, Erman, 2016, Mansbridge et al., 2012, Milewa, 2008, Oh et al., 2015, Parkinson, 2012, Rajan et al., 2019, Smith and Mcdonough, 2001, Tugendhaft et al., 2022 |
| 9. Revisability | Health financing, political theory, public finance, social psychology |
|
Revisability means accepting that new reasons—such as new evidence and new understandings of the issue at hand—can be given greater weight in the future, and therefore justify revised decisions. Mechanisms must therefore exist for those who disagree with the decision to challenge it and for decision-makers to respond to reasons and to consider revising the original decision. | Barasa et al., 2017, Daniels and Sabin, 1998, Ford, 2015, Gibson et al., 2004, Gutmann and Thompson, 1995, Gutmann and Thompson, 2004b, Hofmann, 2013, Hunter et al., 2016, Leventhal et al., 1980, Lukasiewicz and Baldwin, 2017, Maluka et al., 2010b, National Institute For Health And Care Excellence, 2014, Petricca et al., 2018, Rumbold et al., 2017, Syrett, 2011, Tuba et al., 2010, Waithaka et al., 2018a, Williams-Jones and Burgess, 2004, World Bank, 1998, Wagner et al., 2019, Zulu et al., 2014 |
| 10. Enforcement | Health financing, political theory, public finance, environmental management |
|
There are two aspects to enforcement. One aspect, emphasized in frameworks such as the Accountability Reasonableness (A4R), is about the presence of mechanisms to ensure that the criteria for procedural fairness are upheld. The second aspect pertains to the outcomes of the decision-making process and having laws, regulations and oversight mechanisms in place to ensure that outcomes are implemented. | Chwalisz, 2020a, Daniels, 2008a, Gutmann and Thompson, 2004b, Petricca et al., 2018, PEFA, 2019, Isaksen et al., 2007, Lukasiewicz and Baldwin, 2017, Lo et al., 2013, Simcock, 2016, Smith and Mcdonough, 2001, Syrett, 2011, Waithaka et al., 2018a, Williamson and Scicchitano, 2014 |
See Supplementary file S2 for all records that identified the specific criteria.
Criterion 1: equality
Theoretical description
Equality is a foundational concept for procedural fairness. A comprehensive treatment of equality and its relationship to procedural fairness is found in the literature on deliberative democracy, in seminal books and peer-reviewed articles (Gutmann and Thompson, 2004b; Mansbridge et al., 2012; Bachtiger et al., 2018). The key proposition of deliberative democracy is that genuine deliberation is only possible if participants view each other as equals and with mutual respect (Gutmann and Thompson, 2004b; Bachtiger et al., 2018). In this literature, the concept of equality has evolved. A key shift is from a focus on ‘equal influence’, which implies that each participant has ‘an equal effect on the deliberative outcome’, to ‘equal opportunity to influence’, with the latter being determined not only by material resources but also by people’s equal capacity to articulate themselves (Bachtiger et al., 2018). The literature on deliberative democracy acknowledges that these forms of equality are aspirational and difficult to achieve. However, inequality is a matter of degree, and certain processes for making decisions are better suited to ameliorating the impact of social and economic inequalities on people’s opportunities to influence decisions. This view resonates with the literature on stakeholder representation in environmental management (Fletcher, 2007) and participatory budgeting (O’Hagan et al., 2020), where well-designed participatory mechanisms can mitigate pre-existing societal inequalities. It also resonates with the health literature on citizen voice that emphasizes the need to alleviate the impact of socio-economic inequalities and power differences on priority-setting decisions (Gibson et al., 2005; Barasa et al., 2016; Kantamaturapoj et al., 2020a).
In psychology, the concept of consistency across persons, which requires that similar rules and procedures should be applied to all participants of the process, is closely related with the concept of equal consideration (Leventhal et al., 1980). It also features in examples from health (Friedman, 2008; Kapiriri et al., 2009; Peacock et al., 2009; Ford, 2015; Norheim et al., 2021) and environmental management (Lukasiewicz and Baldwin, 2017).
Illustration of empirical application
Equality is supported through legal frameworks that recognizes and protects civil rights, through an independent and diverse mass media protected from monopolistic or oligopolistic market forces or political influence, and through civic fora providing spaces in which otherwise disempowered groups can be given an equal chance to participate, deliberate and voice their views (Beauvais, 2018). In the included empirical literature, equality was most frequently discussed in relation to barriers to participation and inclusiveness. Empirical applications are therefore provided as part of the discussion of these two criteria.
Criterion 2: impartiality
Theoretical description
Literature from psychology and health emphasizes the importance of impartiality for procedural fairness. In psychology, Leventhal et al.’s seminal contribution on the defining features of procedural fairness in allocative decisions uses the term ‘bias suppression’, which is defined as: ‘suppression of personal self-interest and suppression of blind allegiance to narrow preconceptions at all points in the allocative process’ (Leventhal et al., 1980). Furthermore, the bias suppression criteria prescribes that no person should serve as a judge in a case where they have a conflict of interest. Influenced by this work, impartiality is viewed as a necessary addition to the A4R framework (Rid, 2009; Ford, 2015) and is highlighted in a recent report on how to engage in open and inclusive deliberation about trade-offs during a pandemic (Norheim et al., 2021).
Our review found several reasons for endorsing impartiality. The literature on tax compliance establishes a connection between perceived impartiality and trust: tax authorities that are perceived as even-handed and seen to rely on facts and not personal opinions are more likely to build trust among taxpayers, contributing positively to compliance (Murphy, 2005; Prichard et al., 2019). Theories of deliberative democracy have, in the past, emphasized that the exclusion of self-interest from the deliberative process facilitates the identification of the best possible solutions based on reasons (Mansbridge et al., 2010; Afsahi, 2022). However, recent accounts of deliberative democracy have questioned whether absolute impartiality is a reasonable requirement on all forms of participation. It is increasingly acknowledged in these theories that the common good is made up of individual goods, which may include material self-interest. Accordingly, these self-interests should be taken into account when considering the common good (Mansbridge et al., 2010). Moreover, for groups that traditionally have faced barriers to expressing their voice, it can be important to have participants articulate their interests in their own words (Mansbridge et al., 2010). Viewed this way, impartiality is about constraining self-interest, rather than totally excluding it. The expression and pursuit of self-interest can be constrained to a certain extent by principles of good deliberative behaviour. Moreover, adherence to these constraints can be in the interest of each participant, if they can be assured that others will abide by them too, and if they see the value of a fair deliberative process (Afsahi, 2022). In addition, other criteria on procedural fairness, such as equality, reason-giving, transparency and inclusiveness play an important role in ensuring that self-interest of the powerful does not dominate the decision-making process (Gibson et al., 2005; Johnson, 2009; Mansbridge et al., 2010).
Illustration of empirical application
In health financing, health technology assessment (HTA) procedures are concerned with ensuring that decisions are neither biased nor designed to promote self-serving interests (Bertram et al., 2021). Guidance documents on HTA therefore emphasize prevention and management of conflicts of interest (Bertram et al., 2021; European Network For Health Technology Assessment, 2021). Impartiality appears implicit in how HTA bodies should function, with few concrete descriptions of how it has been applied. In Malawi, impartiality was a guiding principle when revising the criteria used for allocating central funds for health to subnational units (Twea et al., 2020). An inclusive revision process was adopted in developing the allocation formula, with inputs from district health offices and district councils. However, since revisions would inevitably result in ‘winners’ and ‘losers’, inputs from affected stakeholders risked being biased. To promote an impartial process, allocative units were anonymized when presenting budget impact analyses of the new resource allocation formula. The importance of impartiality can also be illustrated by what may happen when it is called into question. In an example from environmental management, dependence on funding from a few donors undermined the perception of impartiality in the decision-making process about coastal management (Fletcher, 2007).
Criterion 3: consistency over time
Theoretical description
Consistency over time is one of the five criteria for shaping procedural fairness in the widely cited contribution in social psychology by Leventhal et al. (1980). The criterion prescribes that decision-making procedures should be stable, at least over the short term, and not deviate from procedures that people expect. In health financing, it has been proposed as a criterion that would strengthen the A4R framework (Friedman, 2008; Kapiriri et al., 2009; Ford, 2015), with a focus on the ‘consistent use of set rules, guidelines and procedures’ (Kapiriri et al., 2009, p. 770). Seen together with reason-giving, participation and inclusiveness, it also implies that substantial changes to decision-making procedures require consultations across various branches and levels of the government, civil society and the wider public.
Illustration of empirical application
In priority-setting decisions that involve HTA, consistency brings structure to the process, both with respect to how information is presented and to how it is used. An important feature of HTA is the use of formalized and consistent decision rules, such as those discussed in works by Baltussen et al. on evidence-informed deliberative processes in health service prioritization (Baltussen et al., 2017a). These features form part of the motivation for applying Multi-Criteria Decision Analysis (MCDA) to ensure systematic and consistent prioritization processes (Peacock et al., 2009).
Kapiriri et al. identify consistency to be a criterion frequently mentioned among 184 decision-makers involved in priority-setting at micro-, meso- and macro-levels of policy making in Canada, Uganda and Norway who were interviewed about elements of fairness (Kapiriri et al., 2009). Related to consistency, they also found that decision-makers emphasized well-organized and impartial processes: a fair process was equated with the consistent use of well-defined procedures and structures that prevent the influence of favouritism (Kapiriri et al., 2009).
The literature does note one drawback of pursuing consistency through formal decision-making rules, however. Charlton examines the increasing formalization of the HTA approach used by the National Institute for Health and Care Excellence (NICE), with detailed manuals stipulating decision rules, including the threshold for defining cost-effectiveness. The author highlights that this significantly restricts committees’ freedom to exercise judgement by defining and limiting the relevant ways in which cases can differ and the appropriate response to these differences and argues that ‘in seeking to secure fairness through formalisation, the benefits of consistency must be balanced against the harms of insensitivity’ (Charlton, 2020).
Criterion 4: reason-giving
Theoretical description
Reason-giving is discussed thoroughly in the literature on deliberative democracy (Gutmann and Thompson, 2004b; Rawls, 2005; Bachtiger et al., 2018). The idea is that decision-makers must attempt to justify decisions to those affected by them if they expect others to accept and follow them willingly rather than merely because of coercion or material incentives (Gutmann and Thompson, 2004b). Such justification takes the form of offering for consideration the proposed reasons for the decision, which can include the factual evidence as well as the normative (value-based) reasons that, on balance, support the decision. Ideally, reason-giving is not unidirectional but part of a deliberation in which participants with differing points of view articulate and discuss their differences in a sincere attempt to consider other views and find common ground where possible. A common idea is that ‘reason-giving is a form of respect’ (Chambers, 2018), where respect involves recognizing each other as ‘reasonable and rational’ agents with a sense of justice (Rawls, 2005). Accordingly, people can form and revise their factual and normative opinions in light of evidence and argument, are willing to propose and deliberate about fair terms of social cooperation, and will accept them if others are willing to do so too. A further idea is that only when citizens treat each other respectfully will justifications be sincere and not manipulative (Johnson, 2009).
In the health financing literature, the term ‘relevance’ from A4R is closely connected with the idea of reason-giving. In this framework, relevance requires that ‘reasonable’ explanations are provided to support how decision-makers, such as insurers, prove value for money when making limit-setting decisions (Daniels, 2008b). As such, it is construed more narrowly than in the literature on deliberative democracy (Hasman and Holm, 2005; Friedman, 2008; Rid, 2009; Ford, 2015; Badano, 2018), although other interpretations emphasize the need to implement deliberative processes that take into account a broader set of social values (Baltussen et al., 2017a; 2017b).
Illustration of empirical application
Empirical applications of the reason-giving concept feature heavily in applications of A4R in a wide range of settings. They are mostly centred around the extent of stakeholder involvement in the priority-setting process. Among the most widely cited empirical contributions are those deriving from the five-year Response to Accountable Priority-Setting for Trust in Health Systems (REACT) project, which implemented and studied the A4R framework in districts in Tanzania, Kenya and Zambia (Maluka et al., 2010a; Bukachi et al., 2014; Byskov et al., 2014; Zulu et al., 2014). Going beyond A4R, authors from Thailand have emphasized the reason-giving aspect of joint decision-making in the context of Thailand’s Annual Public Hearings, which is a mechanism for participatory health policymaking involving national and sub-national government representatives, producers of knowledge and the public (Kantamaturapoj et al., 2020b).
In public finance, there is widespread acceptance of the principle of providing public justification for budget allocations (Lakin, 2018). A study by Lakin, which assessed the quality of reasons in budgetary documents, such as why health spending deviated from what was budgeted, identified that a diverse set of countries, including Afghanistan, Chile, Costa Rica, the Dominican Republic, Jordan, New Zealand, Nicaragua, Philippines, South Africa and the United Kingdom provide such explanations. However, the quality of these explanations varies. The quality of reason-giving was insufficient even in countries with relatively good transparency or extensive documentation accompanying budget proposals. The paper suggests that developing ‘a set of criteria for evaluating the adequacy of such public reasons’ would make reason-giving more meaningful (Lakin, 2018).
Criterion 5: transparency
Theoretical description
Conceptual discussions of what transparency implies and its links to legitimacy, trust, good governance and procedural fairness appear in contributions to deliberative democracy, public finance, health financing and environmental management. Transparency is viewed as a pre-condition for meaningful participation: without disclosure of information, public participation has limited value (Harrison and Sayogo, 2014; Lakin and Nyagaka, 2016; Mukhopadhyay, 2017). In public financial management, disclosing information to the public is also seen as crucial to preventing rent-seeking activities and corrupt behaviour among people in positions of power (Isaksen et al., 2007). In a World Bank report on the role of public finance in post-pandemic recovery (World Bank, 2021), transparency is regarded as vital for ensuring legitimacy and people’s trust.
The deliberative democracy and health financing literatures emphasize the central role that transparency plays in public justification. Accordingly, the goal of reason-giving sets a minimum standard for transparency: the reasons underlying views and decisions should be explicit and public to allow others to judge the adequacy of justifications (Gutmann and Thompson, 2004b; Bachtiger et al., 2018). In A4R, transparency is described under the concept ‘publicity’ and requires that the rationale for arriving at priority-setting decisions is accessible to providers, patients and others affected (Daniels, 2008a). It is also seen as contributing to the quality of decision-making: when a decision-maker is forced to make their reasoning open to general scrutiny, the use of evidence in the process is likely to be more diligent (Daniels, 2008b).
In public finance, Garrett and Vermeule distinguish between transparency of the budgetary process—how budgets are negotiated and agreed as well as how inputs are provided during the budget preparation process—and transparency of the output—the actual budget documents (Garrett and Vermeule, 2008). This distinction is reflected in how transparency is measured, with analysts placing increasing emphasis on the process through which public budgets are formulated, negotiated and approved, including allowing sufficient time for various actors to provide inputs on the budget (International Budget Partnership, 2022). Similarly, a study on vaccine decision-making also distinguishes between transparency about the decision-making process, which includes the recording and real-time reporting of proceedings and interim stages of decision-making and transparency in the rationales for decisions, which involves the public disclosure of information and reasons for preferring one option over another (Timmis et al., 2017).
While transparency is seen to have many benefits, theoretical and empirical contributions also indicate the need to strike a balance between optimizing transparency and optimizing conditions for high quality and equitable deliberation, because a deluge of information can affect the quality of deliberations (Bachtiger et al., 2018; Berggren, 2018) and because some forms of transparency can disproportionately aid those with more resources and power (Garrett and Vermeule, 2008).
Illustration of empirical application
In public finance, measures of transparency are part of well-developed frameworks. The Public Expenditure and Financial Accountability (PEFA) framework, with 11 pillars, is one of the main frameworks for analysing the integrity of a country’s Public Financial Management system (PEFA, 2019), and has been applied in countries with different income levels around the world (PEFA, 2022). The transparency indicators focus on whether the budget and fiscal risk oversight are comprehensive and whether fiscal and budget information is accessible to the public.
Transparency, referred to as publicity, is widely applied by those using the A4R framework to analyse procedural fairness in priority-setting across different income settings and health systems. For example, Maluka et al. who applied the A4R framework at the sub-national level in Tanzania, found that district officials used letters to inform stakeholders about decisions taken without providing a rationale for these decisions, with no mechanisms for promoting true publicity (Maluka et al., 2010b). Similarly, at district level in Kenya, the priority-setting process fell short with regard to publicity due to ‘ineffective formal mechanisms of disseminating priority setting decisions (Bukachi et al., 2014). Given the conceptualization of publicity in the A4R framework, these applications focus on public justification more than the transparency in process as described by Timmis et al. (2017).
All countries, regardless of their income level, encounter difficulties in effectively implementing transparency. In Alberta, Canada, a study found that while all regional health authorities used various means for communicating decisions to the public, only some consistently revealed the underlying reasons for them (Menon et al., 2007). In a study of the High Cost Drug Sub-Committee in an Australian public hospital, Gallego et al. also highlight constraints on publicity posed by factors such as the need to keep commercial information confidential due to conditions imposed by pharmaceutical companies (Gallego et al., 2007).
Criterion 6: accuracy of information
Theoretical description
The concept of accuracy of information is described in the literature in many disciplines. Its motivating idea is the value of evidence and well-informed participants in a decision-making process. In Leventhal et al.’s work on the defining features of procedural fairness, accuracy of information is framed in these terms: ‘allocations should be based on as much good information and informed opinion as possible’ (Leventhal et al., 1980). In the health financing literature, the relevance criterion of the A4R framework emphasizes the crucial role of robust information and evidence. This interpretation has provided grounds for work combining A4R and MCDA with a strong emphasis on the use of quantitative, verifiable data in identifying high-priority services (Baltussen et al., 2013; 2017a). In deliberative democratic theory, the importance of accuracy of information is implied in the discussion of reciprocity: if participants in a decision-making process expect others to accept their reasons, they should make a good-faith effort to ensure that these are based on accurate information because they would expect the same in return (Gutmann and Thompson, 2004b). Moreover, those engaged in mutually respectful deliberations should avoid manipulation, including manipulation of information (Bachtiger et al., 2018).
Illustration of empirical application
In the health financing literature, information is often discussed in conjunction with participation (Kapiriri et al., 2003; Martinez and Kohler, 2016; Bentley et al., 2019; Rajan et al., 2019; Bijlmakers et al., 2020; Kantamaturapoj et al., 2020b). For example, in Thailand, adequacy of information is emphasized for ensuring effective participation in annual public hearings (Kantamaturapoj et al., 2020b). According to the study, while the organizers provided information, the participants felt that this provision did not go far enough. For example, participants felt that information should be provided well in advance to allow them to process and use it to make meaningful inputs during the hearings. They also desired more substantive information. This is echoed in studies in public budgeting (Williamson and Scicchitano, 2014) and environmental policy (Hysing, 2015; Simcock, 2016) where accurate information—provided in a way that enables participants to engage with it—is discussed as an important enabler for meaningful participatory processes.
Studies on applying A4R and the framework for evidence-informed deliberative processes also offer examples of the application of the accuracy of information criterion (Jansson, 2007; Gordon et al., 2009; Baltussen et al., 2017a; Petricca and Bekele, 2018; Waithaka et al., 2018a; Wagner et al., 2019). However, these studies interpret accuracy of information more broadly and tie it to reason-giving and the inclusive representation of stakeholder views.
Criterion 7: public participation
Theoretical description
The scoping review identified many different accounts of public participation. Here, the discussion is focused on the relationship between participation and perceptions of fairness and legitimacy as well as its relationship with other procedural criteria. ‘Public involvement’, ‘public engagement’, ‘stakeholder engagement’ and ‘stakeholder participation’ are other commonly used terms (De Santo, 2016; Martinez and Kohler, 2016; Hunter et al., 2016; Jansen et al., 2018; Essue and Kapiriri, 2020; Firestone et al., 2020).
Public participation implies creating opportunities for direct democratic involvement and voice. It is described as improving the openness of policy discussions, bringing epistemic benefits for participants, enabling decision-makers to connect with public values, and strengthening accountability and legitimacy (Mitton et al., 2009; Rid, 2009; Hysing, 2015; Hunter et al., 2016; Weale et al., 2016; Chwalisz, 2020b). In A4R, the operationalization of the relevance condition often rests on mechanisms for stakeholder involvement (Maluka et al., 2010a; 2010b; 2011; Maluka, 2011; Byskov et al., 2014). However, it is worth noting that its original proponents do not regard stakeholder involvement as a necessary or sufficient condition for A4R (Daniels and Sabin, 1998; Daniels, 2007).
Many articles highlight the constrained nature of conventional mechanisms for public participation and the risk of participatory mechanisms involving tokenism and manipulative practices (Barasa et al., 2015; Weale et al., 2016; Hunter et al., 2016). When allocating limited health resources, participatory processes need to adjudicate competing interests and build consensus (Barasa et al., 2015; Tugendhaft et al., 2021). The value of participatory mechanisms, from a procedural point of view, is therefore tied to the extent to which these achieve inclusiveness and reason-giving in a decision-making process (Williamson and Scicchitano, 2014). Meaningful engagement with the public therefore requires fora that provide for equal opportunities to be heard, that secure mutual respect and that provide space for those making decisions to defend their arguments, respond to objections and revise their decisions (Barasa et al., 2015; Eriksen, 2022b). Moreover, social, political and economic factors in society that create power imbalances in participatory spaces must be mitigated to create an environment that supports respectful deliberation (Gutmann and Thompson, 2004a).
Reasonable constraints on the extent of public participation are another key aspect. For example, it might not be a good use of the public’s time to participate extensively in every decision. Therefore, public officials may reasonably abridge or omit direct public participation in some decisions (Gutmann and Thompson, 2004b). However, determining the circumstances requiring participation should itself be done through public involvement and deliberation to ensure the reasons for constraining participation are accepted by the public. This should be supplemented through strengthening other procedural aspects, such as accuracy of information, transparency, reason-giving and opportunities to appeal the decision (Eriksen, 2022a; 2022b).
Illustration of empirical application
The wide range of national and sub-national mechanisms for public participation that have been implemented and empirically studied in health financing highlight the contextual factors that shape the effectiveness of these participatory mechanisms and the costs and benefits involved. At the sub-national level, facility-level committees, health councils and other similar mechanisms have facilitated the inclusion of civil society. However, empirical studies reinforce the extent to which contextual factors shape their effectiveness. For example, a study of Health Councils in Brazil found that public members of these councils can be reluctant to engage in open discussion for fear of government retaliation (Martinez and Kohler, 2016). Studies on participatory budgeting provide insight into how best to organize and engage the public (Sintomer et al., 2008; Castillo, 2015; Gilman, 2016; Struić and Bratić, 2018; Russell and Jovanovic, 2020). These highlight that creating conditions for effective deliberation requires investments of time and in capacity-building, including training and incentivizing participants, dedicating staff to manage the process and creating an environment for an empowered, diverse and vibrant civil society (Calisto Friant, 2019).
The health financing literature provides some promising participatory mechanisms implemented primarily in the context of benefit design decision processes (Table 2) as well as assessments of why conventional methods, such as public consultations organized by political authorities, fall short. For example, Tugendhaft et al. examine deliberative engagement methods in South Africa and describe how parliamentary processes with public consultations and local mechanisms, such as community health committees, fall short of standards for procedural fairness (Tugendhaft et al., 2021).
Table 2.
Participatory mechanisms implemented in the context of benefit design decisions
| Mechanism/country | Summary of key aspects |
|---|---|
| National Health Conferences (CNS) in Brazil |
Basis: Legally mandated Decision: Benefit design Participant selection method: Unclear from the article Additional information: Held every 4 years and organized in three stages: Municipal, State and Federal. Each jurisdictional health council is required to elect an ad hoc committee and produce a priority-setting report for health policies on a core subject predetermined by the CNS committee. The reports are then compiled further and sent upwards. Eventually, policies receiving a certain proportion of votes are then compiled into a final document defining priorities for the SUS for the following four years. In 2007, 50% of participants were users of SUS—the national universal health care system. The CNS also included elected representatives of health professionals (25%) and elected representatives of management of health service providers (25%) (Ferri-De-Barros et al., 2009). |
| Citizen committee for participation in the Republic of Korea |
Basis: Legally mandated Decision: Decision-making for the benefit coverage under National Health Insurance Participant selection method: Random within a larger pool of applicants with clear exclusion criteria in support of the impartiality principle Additional information: It appears that over the years, some of the same citizens participate continuously, raising questions about inclusiveness and the extent to which they truly represent citizens’ perspectives or are functioning as part of the health care system (Oh et al., 2015). |
| Annual public hearings in Thailand |
Basis: Legally mandated Decision: Services offered under the Universal Health Coverage Scheme (UCS), which is the largest public insurance scheme covering ∼75% of the population Participant selection method: By invitation through CSOs; in some regions, organizers use personal relationships to invite participants they know to ensure representation in the forum, diminishing diversity because the same persons are invited every year Additional information: Each region manages public hearings differently and according to the capacity of the organizers at regional level. In some, there is more bottom-up participation with meetings at provincial level before a large regional meeting (Kantamaturapoj et al., 2020b, Rajan et al., 2019). |
| Citizen representatives in the National Health Security Board (NHSB) in Thailand |
Basis: Legally mandated Decision: The board directs and oversees the performance of the management and the operation of the UCS, including the standards and scope of health services, appointment of the secretary general, the effective implementation the scheme, regulations and approval of administrative policies, financial plans, annual budget ceiling and other relevant governance matters. Participant selection method: Citizens are selected from the nine civil society organization (CSO) constituencies registered with the Ministry of Interior whose activities are related to (1) children and adolescents; (2) women; (3) the elderly; (4) disabled and mentally ill patients; (5) patients with HIV and chronic disease; (6) labour unions; (7) slum dwellers; (8) agricultural workers; and (9) minorities. Additional information: Each board member is allocated one vote, with decisions made by majority, providing citizens with 17% (5 out of 30) of the board’s voting power (Marshall et al., 2021). |
| Town hall meetings in the State of Oregon, USA |
Basis: Legally mandated Decision: Determining the list of priority services to be used by the Health Services Commission in its deliberations of the Oregon Health Plan Participant selection method: Self-selection. Additional information: Town hall meeting discussions and the whole consultative process on the Oregon Health Plan was facilitated by a grassroots bioethics organization. Therefore, unlike many other similar mechanisms of town hall meetings, these were professionally facilitated and therefore may have had higher quality deliberations (Kitzhaber, 1993). |
| Health care priority-setting exercise in South Africa |
Basis: Experiment Decision: Determining the list of priority services using Choosing All Together (CHAT) tool, a game-like exercise, which aims to facilitate a deliberative and interactive process to understand trade-offs and come to a decision as a group. Participant selection method: A total of 63 participants were recruited through a purposive sampling to include participants from a range of villages with various characteristics and to ensure a gender and age mix. Additional information: Participants were divided into seven groups with a professional facilitator. The entire exercise took half a day (Tugendhaft et al., 2021). |
As with transparency, the benefits of public participation depend on its implementation. For example, in assessing the experience with public involvement at the regional health system in Canada, Abelson et al. identify that participatory processes were used by stakeholders with vested interests to dominate the process and that health planners and policy makers used such processes to gain purported legitimacy for pre-determined policy options (Abelson et al., 2002). In such cases, public participation serves as ‘window dressing’ rather than a pathway for genuine deliberation.
Criterion 8: inclusiveness
Theoretical description
Inclusiveness is widely discussed in the literature concerning deliberative democracy, priority-setting in health, psychology, participatory budgeting and environmental management. Another frequently used term is ‘representativeness’. The main concern is that all perspectives and interests that are affected by the decision should be included in the decision-making process (Dryzek and Niemeyer, 2008; Dryzek, 2009; Mansbridge et al., 2012; Begg, 2018; Rajan et al., 2019). Special attention is paid to equal opportunities for participation and the removal of barriers to participation for populations who often are not represented (Smith and Mcdonough, 2001; Begg, 2018).
Inclusiveness is a fundamental value for deliberative democracy and is deeply tied to the idea of political equality: that anyone affected by the decision, regardless of social, economic or political status, should have a say in the decision-making process and that their arguments should be given equal consideration (Parkinson, 2012; Erman, 2016). It is also the primary motivation for promoting more ambitious approaches to participation during policy-making, such as citizen assemblies formed through random sampling (Chwalisz, 2020b).
Inclusiveness is concerned with securing representation of a diversity of views and concerns in a decision-making process (Dryzek and Niemeyer, 2008; Milewa, 2008; Rajan et al., 2019). To this end, democratic theorists advance the notion of ‘discursive representation’, which is about securing representation of relevant discourses, including interests, identities and values (Dryzek and Niemeyer, 2008). The focus on discourses ensures that inclusiveness cannot be reduced to focusing on direct participation of stakeholders in a process.
Illustration of empirical application
Empirical examples highlight the investments in time and resources, and the social, economic and educational barriers that need to be addressed to make participatory mechanisms more inclusive. For example, Rajan et al. (2019) examine Thailand’s National Health Assembly. They find that the health assembly has motivated coordination among community groups and civil society and thereby promoted more inclusive participation (Rajan et al., 2019). At the same time, they find that people with lower income, lower educational levels and less free time were dependent on active outreach by local CSO networks to ensure their voice was represented (Rajan et al., 2019).
To promote greater inclusiveness, tools and methods for public deliberation may need adaptation. For example, Tugendhaft et al. report experiences from adapting the Choosing All Together (CHAT) tool for rural South Africa. The study used an iterative participatory process involving rural community members and policy makers, thereby achieving locally responsive deliberation about health care priorities (Tugendhaft et al., 2022).
In an example from environmental management, Dalton examines public involvement in the context of determining marine protected areas and highlights that the value of public involvement for conservation decisions should be carefully considered, given its resource-intensive nature (Dalton, 2005). The most ambitious approach for strengthening inclusiveness, motivated by the ideas of deliberative democracy, involves mechanisms for random recruitment to a deliberative process, such as citizen panels. Promoted in recent works by the OECD (Chwalisz, 2020a), it has been implemented in South Korea for questions about setting health insurance premiums and potential benefit expansion (Oh et al., 2015).
Criterion 9: revisability
Theoretical description
Revisability, also referred to as correctability of decisions in social psychology (Leventhal et al., 1980), revision and appeals in A4R (Daniels and Sabin, 1998) and contestability of policy advice in public financial management (World Bank, 1998), is seen as a core characteristic of a fair process in deliberative democracy (Gutmann and Thompson, 2004b). It implies that a decision-making process should be open to challenge and to revisiting previous justifications (Gutmann and Thompson, 1995; 2004b). Similarly, Daniels and Sabin emphasize the need for mechanisms for ‘challenge and dispute resolution regarding limit-setting decisions, including the opportunity for revising decisions in light of further evidence or arguments’ (Daniels and Sabin, 1998). While A4R focuses on priority-setting, revisability can be applied more broadly as requiring mechanisms for challenging and modifying decisions on taxes or methods for paying providers for health services.
Illustration of empirical application
Revisability has been examined in health financing studies in a variety of settings, including Ethiopia (Petricca et al., 2018), Tanzania (Maluka et al., 2010b), Kenya (Barasa et al., 2017; Waithaka et al., 2018b), Scandinavian countries (Hofmann, 2013), Canada (Gibson et al., 2004; Williams-Jones and Burgess, 2004) and England (Syrett, 2011; Ford, 2015; Rumbold et al., 2017) and in budgeting processes at sub-national levels in Kenya (Barasa et al., 2017).
Appeals mechanisms for decisions on what personal services are specified in the guaranteed set of entitlements can range from courts (Syrett, 2011; Hunter et al., 2016) to special bodies set up as part of HTA agencies (National Institute for Health and Care Excellence, 2014).
In some cases, such as Australia, England and Wales, and New Zealand, both courts and internal appeals mechanisms play a role (Syrett, 2011). Importantly, courts are meant to enforce the process, but not to review the substance of the decisions reached. Appeals and revision mechanisms seem to be weak in general, but particularly at the sub-national level (Waithaka et al., 2018a) and in low- and middle-income settings (Tuba et al., 2010; Maluka et al., 2010b; Zulu et al., 2014). In an explorative case of how appeals and revisions might be applied in rare diseases and regenerative therapies, an expert panel recommended explicit decision rules for appeals during a HTA committee’s proceedings and creating explicit pathways for dissenting voices, such as allowing minority views to be represented in a separate report (Wagner et al., 2019). The panel also recommended clear rules on what qualifies as ‘new evidence’ and clear communication that decisions are subject to revisions given new evidence (Wagner et al., 2019).
Outside health, we found few empirical examples. In environmental management, one study, drawing on Leventhal’s work, examines experiences of different stakeholder groups in making their voices heard during water reform processes in Australia and proposes ‘correctability of errors’ among its nine criteria (Lukasiewicz and Baldwin, 2017).
Criterion 10: enforcement
Theoretical description
Enforcement is taken to refer both to the idea that the outcome of a deliberative procedure is binding on decision-makers and that the process by which decisions are made is suitably regulated and implemented. These two aspects are given different emphasis in the principal theories on deliberative democracy and health. In their seminal work on deliberative democracy, Gutmann and Thompson emphasize that decisions must be binding, at least for some period of time, because participants in the process ‘do not argue for argument’s sake… they intend their discussion to influence a decision the government will make’ (Gutmann and Thompson, 2004b). The importance of deliberation having influence on decisions is also echoed in environmental management (Smith and Mcdonough, 2001; Lo et al., 2013; Simcock, 2016; Lukasiewicz and Baldwin, 2017) as well as in public finance studies (Williamson and Scicchitano, 2014). A recent OECD report on new democratic institutions also emphasizes a commitment from the decision-making authorities to implement and monitor recommendations made as part of the deliberative process (Chwalisz, 2020a). Ensuring that agreed decisions are carried out plays a key role in perceptions of the legitimacy of the process and hence in public trust (Williamson and Scicchitano, 2014). In A4R, where enforcement is referred to as ‘the regulative condition’, the emphasis is on execution of the process, and more specifically, the implementation of the other criteria of the framework (relevance, publicity, and revision and appeal) (Daniels, 2008a).
Illustration of empirical application
In health, empirical studies suggest that enforcement of the criteria for a fair process at sub-national level is weak. In a review of 12 studies of healthcare priority-setting in Canada, England, Kenya, Tanzania and Zambia, none met the enforcement criterion (Waithaka et al., 2018a). Regardless of income level, it seemed that at sub-national levels, insufficient technical capacity and autonomy were major barriers for the enforcement of other procedural fairness criteria. In some cases, such as Tanzania, this was worsened by lack of funding. While a study on district health priority-setting in Ethiopia yields a more positive assessment (Petricca et al., 2018), the study does not provide sufficient details to understand factors shaping the positive experience.
A study on the role of courts in enforcement of the process in Australia, England and Wales, and New Zealand finds that the process of judicial review of administrative actions fulfils the intention of the enforcement criterion (Syrett, 2011). Moreover, such judicial review ensures that public agencies do not overreach their decision-making authority, apply the law correctly, and have processes for decision-making that meet standards for fairness. However, this role is limited partly because courts are not mandated to review the adequacy of reasons or justification given by the bodies responsible for HTAs (Syrett, 2011).
In public finance, particularly in budgeting, the importance of ensuring that decisions are followed through is embodied in monitoring of budget execution (PEFA, 2019). In the PEFA framework, the first pillar is budget reliability. Reliability is achieved if ‘the government budget is realistic and is implemented as intended’, which is measured by comparing actual revenues and expenditures with the original approved budget (PEFA, 2019). Enforcement of a fair process is also emphasized in public finance through monitoring indicators on legislative scrutiny of budgets, including the extent to which procedures for scrutiny are established and adhered to (Isaksen et al., 2007; PEFA, 2019).
Discussion
This scoping review has identified an extensive literature across health financing, environmental management, political theory and public administration (including deliberative democracy), public finance, and social psychology that characterizes key features of procedural fairness. It has also uncovered a rich set of examples of their empirical application across different countries.
By synthesizing insights from these literatures, identifying shared theoretical foundations and demonstrating convergence towards key criteria, this review can contribute to a better understanding of the concept of procedural fairness among policy makers, public officials, researchers and civil society organizations. In clarifying the reasons for pursuing it, it also strengthens the case for attention to procedural fairness in health financing decisions. This review’s focus on criteria and their application can facilitate the uptake of the proposed criteria among policy makers and potential participants in deliberative processes. For example, its findings form the basis of an evaluative framework for open and inclusive processes (World Bank, 2023), which can support efforts to build, examine and reform fair processes for decision-making in health financing for UHC. This contribution responds to the growing global recognition among multilateral institutions and national decision-makers of the importance of procedural fairness (World Health Organization, 2021; World Health Organization South-East Asia Regional Committee, 2022; Chwalisz, 2020a).
The 10 criteria proposed in this review amount to an adjustment to A4R, which has been the dominant framework for procedural fairness in health care priority-setting. In debates about the value of A4R, key objections have been the uncertainty about how the relevance condition should be operationalized and the inadequate attention given to procedural criteria like equality, impartiality, participation and inclusiveness during priority-setting decisions (Gibson et al., 2005; Friedman, 2008; Rid, 2009). Our synthesis of insights from empirical examples across different sectors and decision situations, especially from participatory budgeting, public finance and environmental management, provides support for these additional criteria. Crucial to procedural fairness is how decision-making processes are constructed to create an even playing field, since revenue generation, pooling and purchasing decision situations are rife with power differences and vulnerable to domination by vested interests (Gibson et al., 2005; Smith et al., 2014; Barasa et al., 2016). For policy makers and civil society to respond to this challenge, guiding frameworks need to go beyond A4R and pay greater attention to criteria that promote equality and voice.
Another theme in our review is how strongly procedural fairness is tied to the concept of reason-giving and the importance of examining other criteria, especially transparency, participation and inclusiveness, in terms of that concept. For example, when transparency is interpreted as merely conveying a decision or output of a process (e.g. the budget), but not the underlying reasoning for the decision, the implementation of transparency falls short of meeting the reason-giving requirement of procedural fairness (Gallego et al., 2007; Menon et al., 2007; Lakin, 2018). Similarly, from a procedural point of view, the value of participatory mechanisms is tied to the extent to which these achieve reason-giving in a decision-making process (Williamson and Scicchitano, 2014; Eriksen, 2022b). This emphasis on reason-giving also explains why inclusiveness has value that is independent of participation. In the absence of mechanisms for direct participation, for example due to lack of time or resources, the inclusion of diverse sets of experiences and viewpoints through other means should still form a key part of the reasoning supporting a decision, so that these experiences can be considered and these viewpoints can be addressed (Eriksen, 2022b).
A focus on reason-giving can also strengthen the acceptance of technically driven decisions, which are prevalent in health financing. Health financing policy options across revenue mobilization, pooling and purchasing can be very technical and in certain cases, it may be justified that these policy deliberations and decisions are delegated to technocrats with limited public involvement (Gutmann and Thompson, 2004b; Eriksen, 2022a; World Bank, 2023). For example, decisions such as designing provider payment methods or the specification of services within a broader benefit package are often delegated to an expert-driven process. They are also the types of decisions which can be enacted through secondary or subsidiary laws. This was the case for example in Ukraine prior to the Russian invasion of 2022 (Bredenkamp et al., 2022), but also in a number of other European countries (Schreyögg et al., 2005) and Tunisia (Ben Mesmia et al., 2022). The scope for effective public participation in such decisions can be limited. In such cases, the legitimacy of these decisions depends heavily on the quality of public reasoning, i.e. the ability of these expert groups to communicate the reasons for their decisions and the public’s acceptance of this justification (Eriksen, 2022a). At the same time, even decisions that may be labelled as technical can imply major value judgements, and therefore, there is reason to make them through a more deliberative participatory process. There is evidence that with sufficient facilitation and time, citizens can be a source of valuable expertise (Landemore, 2013; Lever, 2023).
Our motivation for undertaking this scoping review was a concern for procedural fairness in health financing and the processes by which UHC is pursued. The nature of different health financing decisions will differ, and such differences will shape how criteria can be practically applied. For example, impartiality is one of the key principles in the way HTA bodies function for benefit design decisions. In comparison, impartiality is more difficult to operationalize when applied to broader decisions, such as the merging of health financing pools. For example, many low- and middle-income countries have separate pools for civil servants with a relatively generous set of guaranteed health services compared to the minimally funded schemes for the informal sector and the poor (Kutzin et al., 2016; Mathauer et al., 2019). During decision-making processes about pooling, civil servants driving the decision-making process will clearly have a bias towards protecting their interests and the benefits they enjoy in the status quo. However, using the impartiality criterion to demand their recusal from the decision-making process seems inappropriate and impractical. After all, the interests of all civil servants are affected, so that representation of their collective voice, alongside others who are more supportive of merged health insurance pools, seem reasonable from a procedural fairness point of view (Mansbridge et al., 2010; Sparkes et al., 2019; Tangcharoensathien et al., 2019). This example illustrates a key trade-off between a strict interpretation of impartiality and relaxing it to allow for greater inclusion of various stakeholder interests, at least in ensuring their views are heard and given due consideration.
Similarly, the application of transparency needs to be evaluated in terms of its benefits and costs—both with respect to the intrinsic value of procedural fairness and the instrumental value for policy outcomes. In health, this question has recently been raised with respect to decisions about vaccination policies and the processes of the Joint Committee on Vaccination and Immunization (JCVI) in the UK (Dawson, 2009; Joint Committee on Vaccination and Immunisation, 2021; Mahase, 2021; The Independent Scientific Advisory Group For Emergencies (Sage), 2021). Dawson makes an argument, similar to Garrett and Vermeule (2008), that with open discussions, particularly for sensitive issues like vaccines, the deliberation of committee members may be constrained, which risks decisions that are less technically sound than if experts deliberated behind closed doors. Accordingly, output transparency, including giving reasons for decisions, can be a reasonable alternative to perfect process transparency (Dawson, 2009).
A further contribution is establishing that procedural fairness demands a comprehensive approach. Previous reviews have had a greater focus on public participation (Street et al., 2014; Oh et al., 2015; Abelson et al., 2020; World Health Organization, 2021). In contrast, our study shows that one should not base judgements about procedural fairness solely on a subset of the proposed 10 criteria. Instead, it requires examining all fairness-relevant features of decision-making in concert. Moreover, as the example of the UK JCVI indicates, in some cases, it may be permissible to satisfy some of the criteria to a lesser degree (e.g. participation) if one can thereby invest attention in strengthening other criteria (e.g. accuracy of information and reason-giving).
Finally, our review highlights that a great deal of experimentation is taking place across settings with different value systems and political conditions, particularly around transparency, participation and inclusiveness in health financing decisions. This experimentation offers opportunities for cross-country learning.
Limitations
Our search strategy was geared towards identifying empirical studies of procedural fairness for resource allocation decision situations. While we included many theoretical contributions, including from social science journals, a key limitation is that the keywords associated with articles and how these are indexed meant that our search did not necessarily capture all the contributions that ought to be considered. However, a scoping review is not necessarily meant to cover all the literature on the themes in focus. Rather, it is intended to map the academic disciplines contributing to the question and point the reader in the direction of relevant contributions.
We used a machine learning strategy to efficiently screen titles and abstracts. While the measurement of the strategy’s performance indicated high coverage of relevant articles, we cannot exclude the possibility that relevant articles were omitted. However, the data extraction and analysis process reached a stage where additional articles reinforced the findings and did not introduce new insights.
A majority of included studies (147 of 197) focused on country applications; among these, 42% (n = 62) included data collection in low- or middle-income countries. Most of the studies we found focused on examining procedural fairness criteria in the context of health financing decisions (Figure 2). This is likely due to our search strategy and the databases we used, which primarily focused on identifying literature related to health financing. Moreover, a limitation of the search was that articles addressing other themes, like public finance or environmental management, were included only if they were indexed in a manner that made them discoverable through our search.
Since the research objective was to investigate the different features of procedural fairness, it was necessary to survey a vast literature covering the different criteria, at the expense of providing in depth assessments of a smaller set. Each of the proposed 10 criteria are subject to deep scholarly attention (Street et al., 2014; Weale et al., 2016; Beauvais, 2018; Abelson et al., 2020). It is therefore unlikely that this review provides a complete overview of all the different aspects to evaluate when considering a specific criterion.
Finally, to make the review manageable, only records in English were included. This carries the risk that valuable perspectives described in other languages have been missed. This shortcoming is partially addressed by the geographic coverage of included articles, which spans every region of the world.
Conclusion
This paper reviews a vast theoretical and empirical literature on procedural fairness from a variety of disciplines, including democratic theory, social psychology, health financing, public administration and finance, and environmental management. Despite disciplinary differences, it argues that the literature can be interpreted as converging on 10 criteria with common philosophical foundations. It provides a statement of these criteria and examples of attempts to implement them in practice. In so doing, this review provides support for a broader and more holistic conception of procedural fairness than some existing frameworks, which focus on a sub-set of the criteria advanced.
This review also highlights how these criteria have been applied in relevant decision-making situations in health financing and beyond, highlighting how they have been interpreted in different contexts as well as some of the challenges in implementing them effectively. It provides evidence that procedural fairness, defined through the 10 criteria described here, can contribute to substantive equity, improve the collective understanding of policy aims and benefits and thereby strengthen the legitimacy of decisions, build public trust, and promote the implementation and sustainability of reforms Together, the proposed criteria can serve as a guide for decision-making processes for financing UHC across different country income levels and health financing arrangements.
Supplementary Material
Acknowledgements
The authors would like to thank colleagues at the Norwegian Institute of Public Health for their contributions: Marit Johansen who played a vital role in developing and conducting the literature search, and Christine Hillestad Hestevik who helped in setting up the review in the EPPI Reviewer—without this step this scoping review would have been hardly possible. The team also expresses its gratitude to Zak Ghouze from the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI Centre) at the Institute of Education, University of London, for valuable support in using the EPPI Reviewer.
Contributor Information
Elina Dale, Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway.
Elizabeth F Peacocke, Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway.
Espen Movik, Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway.
Alex Voorhoeve, Philosophy, Logic and Scientific Method, London School of Economics and Political Science (LSE), Houghton Street, London WC2A 2AE, UK.
Trygve Ottersen, Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway.
Christoph Kurowski, Health, Nutrition and Population, World Bank Group, 1818 H Street, NW, Washington, DC 20433, USA.
David B Evans, Health, Nutrition and Population, World Bank Group, 1818 H Street, NW, Washington, DC 20433, USA.
Ole Frithjof Norheim, Bergen Centre for Ethics and Priority Setting (BCEPS), University of Bergen, Årstadveien 21, Bergen 5018, Norway.
Unni Gopinathan, Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway.
Supplementary data
Supplementary data is available at Heath Policy and Planning online.
Funding
This work was supported with funds from the Norwegian Agency for Development Cooperation (Norad) provided to the University of Bergen and the Norwegian Institute of Public Health under the programme ‘Decision support for universal health coverage’ (Grant No. RAF-18/0009).
Author contributions
Conception of the work: Unni Gopinathan, Trygve Ottersen, Elina Dale, Ole Frithjof Norheim, David Evans and Christoph Kurowski.
Data collection: Elina Dale, Espen Movik, Elizabeth Fleur Peacocke and Unni Gopinathan.
Data analysis and interpretation: Unni Gopinathan and Elina Dale with critical inputs from Trygve Ottersen, David Evans and Ole Frithjof Norheim.
Drafting of article: Elina Dale, Elizabeth Fleur Peacocke and Unni Gopinathan.
Critical revision: Alex Voorhoeve with inputs from all authors.
All named authors approved the paper prior to submission.
Reflexivity statement
This reflexivity statement is provided to clarify factors that can have influenced our interpretation and understanding of issues raised in the included literature. The literature addressed by the review cut across different academic disciplines. The research team benefited from professional backgrounds and expertise in health financing and public finance, health policy and health services research, ethics and political philosophy and institutional backgrounds in national public health institutes, academic institutions and multilateral organizations. It also benefited from a concurrent international expert group process and from engaging with country case study authors who examined the empirical application of the concepts identified by this review in health financing decisions in their settings. The research process and the treatment and synthesis of the key concepts of the review also benefited from consulting with three experts on deliberative democracy, which involved sharing the draft manuscript and discussing it with them during 1-hour digital sessions. However, it should be noted that none of the authors are experts on participatory budgeting and environmental management—two major areas informing the findings of this review. The writing of the paper was led by two female authors, one being from a lower-middle income country. However, this topic merits greater representation of different regions and settings from different income levels in the research team. The key strategy for responding to this shortcoming was to submit this scoping review alongside country case studies, led by country experts from LMICs, who have undertaken in-depth studies of the procedural principles and criteria proposed by this review in their respective settings. This scoping review should therefore ideally be read together with these LMIC-led empirical studies.
Ethical approval
Ethical approval for this type of study is not required by our institute.
Conflict of interest statement
The authors declare that they have no conflict of interest to declare.
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