**4. Discussion**

In this report we have described a structured process to adapt the template of a validated international multiple-criteria scoring decision format to the specific setting of making performance-based decisions for public purchasing in Thai hospitals. The involvement of a broad stakeholder group in the design process is critical for the acceptance and subsequent implementation of the methodology. In this workshop, there were 37 participants who represented the user perspectives as well as the administrative or regulatory perspectives, the academic expertise and the perspectives of the pharmacist profession through PAT and of the industry by representation of the Pharmaceutical Research and Manufacturers Association (PReMA, http://www.prema.or.th).

Although using a standardized process for the workshop and a previously designed Excel-based model template [13], the participants were involved in each step of designing the specific Thai decision tool during a 1-day workshop. Continuing the participatory process by involving the important purchasing stakeholders in the pilots and the evaluation will further foster full transparency and improvement through user feedback, and, finally, it should support endorsement of the process in the specific Thai hospital bidding decision context. The participants agreed to the approach and considered the resulting MCDA tool to be suitable to improve the transparency and consistency of decision-making for multisource pharmaceuticals in Thai hospitals.

The MCDA model is a living instrument which can be revised when the priorities and needs in the healthcare system and policies change. Therefore, criteria can be included, excluded, or adapted at a later stage once a new consensus on the importance and the transparent measures for qualification is reached among the users of the instrument due to new developments and experiences. For example, it has been proposed by some participants that some flexibility might be advisable for the weighting of the price criterion when evaluating a specific type of product such as lifesaving medicines or a stricter scoring of the quality criteria when it comes to narrow therapeutic window drugs. An adaptation of the price weight depending on such considerations is possible on the hospital level if required. Another point for reconsideration after testing the tool in the real-life situation resulted from the discussion of the criterion of the "Certificate of Analysis for the finished product": in the final model, the scoring was determined as either complying with the specifications (=100%) or not complying (exclusion). Thus, this criterion may be considered as another prerequisite to enter the bidding instead of a MCDA decision criterion.

The final list of criteria selected in this initial workshop for the resulting MCDA model shows some deviations from the criteria which were previously suggested by an international expert group [2] and which were selected in other countries which adapted the tool to their settings [13]. This reflects the active engagement and contribution of the participants who critically questioned and deliberated each of the proposed criteria in comparison to their current decision processes.

After successful piloting, evaluation, and refinement of the model based on the real-life experience, a roadmap for further dissemination and implementation should be developed.

The process presented here for the adaption of a multiple-criteria scoring format to the specific decision problem in Thailand follows the general process as suggested by the ISPOR task force [5, 6]. The core elements in this process were addressed with a group of Thai stakeholders in the hospital purchasing processes, who represented a range of hospitals.

While the selection of criteria, the ranking, and the weighting require adaptation to the specific decision problem and policy framework, the process itself can be generalized and transferred to other countries or organizations. The foundation for the course of work steps in preparation of the workshop, conduct of the workshop, and follow-up has been formed through the experience from three countries, Indonesia, Kazakhstan, and Vietnam [13, 14]. In each of these countries, different types of purchasing or tender decision problems (national purchasing, public tender) had been addressed. In this book, another example is presented, where the process was followed to develop a decision analysis tool to help provincial policy makers with the comparison of alternative insurance policies in China [15]. For that, a new set of decision criteria had to be compiled, which reflected the needs to be addressed by a policy change from the stakeholder perspective. However, despite that the objective to select the optimal future insurance policy is very different from the objective which guided the Thai initiative, the same process was followed in China: preparation with desk research and discussions with local stakeholders, workshop with consensus on the purpose of the tool, selection of the criteria, prioritization and ranking of the criteria, and follow-up with testing and piloting. The most important element is the engagement with and of those stakeholders who are concerned by the decision. How each of the procedural elements is shaped in the specific local application will strongly depend on the local preferences and needs. If the participating stakeholders are already familiar with the principles of MCDA, such as in Thailand, a 1-day workshop format may suffice. In Indonesia and Kazakhstan, a 2-day format was preferred which allowed for more presentation of the technical and methodological information before entering the interactive workshop parts. In all cases, we saw that the discussion at each step throughout the workshop is essential for building consensus.

Another important consideration should be that the current values and daily routines are considered when selecting the criteria. For example, the original list of internationally validated criteria was modulated in Thailand to satisfy the

### *Weighing Price and Performance for Decisions for Multisource Pharmaceutical Bidding in Public… DOI: http://dx.doi.org/10.5772/intechopen.83823*

traditionally high use of specific quality measures. If the MCDA process shall be used for tender decisions, it will be important to train the users who may previously only have used the price or a very limited amount of information to select the winning bid. A standard template for dossier submission may facilitate the targeted supply of data and information for the manufacturers, a standard template for data as has been proposed by Brixner et al. in consequence of the experiences in the previous workshops [16]. Increasing experience with the implementation for further applications in CEHCs and ongoing evaluation and communication will help in the efficient implementation of new initiatives.

A limitation of the approach presented here for developing a MCDA tool to be used for hospital purchasing may be that the initial design is limited to the number of participants and the breadth of stakeholder groups involved in the design workshop. However, further involvement will be achieved throughout the piloting through communication of the experiences after each step of the process and through updating of the tool based on the practical experience.
