title: Disinvestment policy and the public funding of assisted reproductive technologies: outcomes of deliberative engagements with three key stakeholder groups.
abstract: BACKGROUND
  Measures to improve the quality and sustainability of healthcare practice and provision have become a policy concern. In addition, the involvement of stakeholders in health policy decision-making has been advocated, as complex questions arise around the structure of funding arrangements in a context of limited resources. Using a case study of assisted reproductive technologies (ART), deliberative engagements with a range of stakeholder groups were held on the topic of how best to structure the distribution of Australian public funding in this domain.
  
  
  METHODS
  Deliberative engagements were carried out with groups of ART consumers, clinicians and community members. The forums were informed by a systematic review of ART treatment safety and effectiveness (focusing, in particular, on maternal age and number of treatment cycles), as well as by international policy comparisons, and ethical and cost analyses. Forum discussions were transcribed and subject to thematic analysis.
  
  
  RESULTS
  Each forum demonstrated stakeholders' capacity to understand concepts of choice under resource scarcity and disinvestment, and to countenance options for ART funding not always aligned with their interests. Deliberations in each engagement identified concerns around 'equity' and 'patient responsibility', culminating in a broad preference for (potential) ART subsidy restrictions to be based upon individual factors rather than maternal age or number of treatment cycles. Community participants were open to restrictions based upon measures of body mass index (BMI) and smoking status, while consumers and clinicians saw support to improve these factors as part of an ART treatment program, as distinct from a funding criterion. All groups advocated continued patient co-payments, with measures in place to provide treatment access to those unable to pay (namely, equity of access).
  
  
  CONCLUSIONS
  Deliberations yielded qualitative, socially-negotiated evidence required to inform ethical, accountable policy decisions in the specific area of ART and health care more broadly. Notably, reductionist, deterministic characterizations of stakeholder 'self-interest' proved unfounded as each group sought to prioritise universal values (in particular, 'equity' and 'responsibility') over specific, within-group concerns. Our results--from an emotive case study in ART--highlight that evidence-informed disinvestment decision-making is feasible, and potentially less controversial than often presumed.
authors.forename: Katherine
authors.initials: K
authors.lastname: Hodgetts
authors.forename: Janet E
authors.initials: JE
authors.lastname: Hiller
authors.forename: Jackie M
authors.initials: JM
authors.lastname: Street
authors.forename: Drew
authors.initials: D
authors.lastname: Carter
authors.forename: Annette J
authors.initials: AJ
authors.lastname: Braunack-Mayer
authors.forename: Amber M
authors.initials: AM
authors.lastname: Watt
authors.forename: John R
authors.initials: JR
authors.lastname: Moss
authors.affiliation: Menzies Centre for Health Policy, Sydney School of Public Health, Sydney Medical School, The University of Sydney, Coppleson Building D02, Sydney, NSW 2006, Australia. elshaug@sydney.edu.au.
authors.forename: Adam G
authors.initials: AG
authors.lastname: Elshaug
mesh_terms: D001315:Australia; D003362:Cost-Benefit Analysis; D019317:Evidence-Based Medicine; D005260:Female; D005380:Financing, Government; D006291:Health Policy; D006801:Humans; D011050:Policy Making; D036301:Qualitative Research; D027724:Reproductive Techniques, Assisted / Q000191:economics*