**1.3 A format to facilitate policy decisions**

In China, the responsibility for transferring nationally formulated policy objectives into the provinces is decentralized and lies with the provincial administration. There are many options on how the provincial policies can be formulated and applied. Alignment of the overall central policy is important to ensure consistency and equity in health-care access for the Chinese population. However, new policies are in the responsibility of the provincial insurance authorities, and therefore, the policy decision has to be made in each province under consideration of the national policy priorities and the provincial political and health-care context. In such complex situations, decision support tools may help the provincial authorities to prioritize possible insurance options.

Among the plethora of decision support tools, multiple criteria decision analysis (MCDA) was chosen because this method can help to assess multiple, and sometimes conflicting, criteria to evaluate alternatives [14–16]. It originates from operational research supporting single decision-makers [17] but is increasingly also used to structure decision alternatives, to prognose their consequences, and to facilitate dialog on the benefits and harms of decisions in a multistakeholder context in order to enhance procedural quality in the decision-making process [18]. MCDA methods are used across many branches of science and policy-making including environmental, infrastructural, and health-care policies, prioritization, and planning [15, 19, 20].

Next to MCDA, other methods are existing to inform strategic decisions between alternative option and much can be learned from the world of business management [21]. Some of these lead to increasing complexity such as strategic options development and analysis (SODA), a comprehensive cognitive mapping of individual stakeholder views. Others, such as a "strengths, weakness, opportunity, and threat" (SWOT) analysis, structure the thinking and accumulate facts and data, but the interpretation and weighing is left to the decision-makers. Pure deliberation of the alternatives in the discussion among decision-makers and experts often lead to decisions of low transparency and may lack consistency. Simulating the impact of a new policy in a health economic models or trade-off models would limit the factors to be considered.

MCDA is an umbrella term for decision support tools which can be used in situations like presented here for the Chinese insurance policies, where (1) there are one or several clearly stated objectives that stakeholders groups and/or decisionmakers value differently [20], (2) there are several alternative options how to fully or partially reach these objectives, and (3) there multiple criteria, which can be integrated into a calculable composite measure of the benefit or worth of the various alternatives [21]. Among the MCDA methods are the analytic hierarchy process, weighed sum and weighed product models, or ranking and simple multiattribute rating techniques (SMART) as described below [22, 23].

A taskforce of the International Society of Pharmacoeconomics and Outcomes Research (ISPOR) has described the MCDA process for the use in health-care decisions [24, 25]. Generally, the process includes six steps, and is adapted based on the specific decision problem, objective, and context. The definition of the decision problem is the first step. Subsequently, agreement needs to be reached among the stakeholders to determine which criteria are useful to determine the alternative option that will best solve the decision problem. If the importance of these defined criteria differs, the stakeholders also should agree on the weight (relative importance) of each criterion in the assessment of the alternative options.

Finally, in the assessment of the alternatives, each criterion is scored separately and contributes with the predetermined weight, to the composite score that reflects the overall performance of each alternative. As decisions in healthcare often impact a wide range of stakeholders, the criteria may also be chosen to accommodate different stakeholder perspectives [26]. MCDA is being used widely across health-care systems to inform decision-making in healthcare, including benefit-risk assessment of medicines, formulary listings, purchasing, or reimbursement decisions [25, 27–29]. MCDA has specifically been suggested as an evidence-based health technology assessment (HTA) tool for evaluating off-patent pharmaceuticals in developing countries [30]. Examples for using MCDA in decision-making for off-patent medicines in developing countries are emerging in several countries such as China, Thailand, Indonesia, or Egypt [31–34].

A short explanation of MCDA in lay language (English) can be viewed in the online material to this book and via the Internet (https://www.youtube.com/ watch?v=7OoKJHvsUbo).

## **1.4 Policy initiative in China**

The objective of this initiative was to collaborate among provincial insurance policy leaders in China to create an MCDA tool to evaluate insurance policy options across China. This collaborative process was intended to provide a transparent prioritization of insurance models to guide provinces in the decision process. A secondary objective was to adapt a globally validated MCDA in a local environment to address a specific decision problem.
