Evaluation criteria

Rational decision-making requires systematic evaluation of alternative ways to achieve defined objectives. Given the condition of “scarcity” or, more generally, resource constraints, these objectives determine the appropriate evaluation criteria.

These criteria exceed the traditional set of medical parameters, usually centered on clinical efficacy, safety, and quality:

1. A Prior Normative Commitment, determining boundaries for a federal HTA framework

Empirical preferences (neither individual nor social ones, see below) alone do not form a sufficient basis for decision-making; Swiss HTA Consensus states they need to be embedded in the context of a prior normative commitment. This commitment is derived from constitutional provisions as well as the principled, rights-based legal tradition of Switzerland. Non-discrimination, including that of persons with disabilities, special protection of the autonomy and the development opportunities of children, and procedural justice, have all been part of that tradition. Equal access to appropriate health care, effectively maintaining or restoring health-related quality of life, functioning and capabilities, should primarily protect individuals’ normal range of opportunities to pursue their plans of life in autonomy. The Swiss health care legislation has been dominated by a focus on solidarity and the provision of support for those in greatest need.

2. Social Preferences, a major input to an externally valid HTA framework

Within the boundaries of the prior normative commitment, the expectations (“social preferences”) of the Swiss population for a specific allocation of jointly funded health care resources should guide the decision-making process.  Beyond pure efficiency goals, these generally include fairness objectives and equal access, preferences for reciprocity and altruistic motives. This best corresponds to the proposed concept of an “empirical ethics” with health care resource allocation being directed to best meet the expectations and the needs of the insured, which are believed to specifically include a priority for those worst off and for fair chances of access to effective health care, including access to innovative interventions. Swiss HTA Consensus recognizes the need for, and hence encourages, the conduct of further research and methods development in this respect.

3. Swiss “WZW” Criteria, explicit recognition of multiple criteria for decision making

Decisions about the allocation of health care resources in Switzerland have to comply with the so called “WZW” criteria stipulated by the Swiss Health Insurance Act (Krankenversicherungsgesetz, KVG). In line with the aforementioned considerations, Swiss HTA Consensus proposes a revised interpretation of these criteria as follows:

  1. W (Wirksamkeit: “effectiveness”), as the additional health related benefits conferred by a technology in comparison to the existing standard of care in Switzerland, which especially in case of subsequent economic evaluation may also comprise valuation (e.g., “utility”) from an individual perspective;
  2. Z (Zweckmässigkeit: “appropriateness”), as the ability of a technology to promote the purpose and objectives of the Swiss statutory health insurance system as defined by the social preferences of the Swiss population (i.e., “social desirability”), constrained by the prior normative commitment;
  3. W (Wirtschaftlichkeit: “economic viability”), as the economic impact of funding a health technology within the Swiss statutory health insurance system (opportunity cost; budget impact; efficiency).