Table 1 Accountability for reasonableness framework

Publicity

Decisions regarding both direct and indirect limits to care and their rationales must be publicly accessible. The process of priority setting must be open and transparent and consultations and public hearings should be held. Publicity and involvement of key stakeholders are particularly important in contexts where policy and programmatic decisions occur in a multi-actor environment and affect large parts of the population.

Relevance

The rationales for priority-setting decisions should aim to provide a reasonable explanation of how organisations and health providers seek to meet the health needs of a population under reasonable resource constraints. Specifically, a rationale will be reasonable if it appeals to evidence, reasons, and principles that are accepted as relevant by fair-minded people who are disposed to finding mutually justifiable terms of cooperation. By 'fair-minded' people, we do not simply mean our friends or people who just happen to agree with us.

Appeals and revision

There must be mechanisms for challenge and dispute resolutions regarding priority-setting decisions, and, more broadly, opportunities for revision and improvement of policies in the light of new evidence or arguments.

Enforcement

There must either be a voluntary or public regulation of the process to ensure the first three conditions are met.