Historically, the majority of health systems have been single-payer or multipayer public/private systems. However, these systems are increasingly being characterized as "pluralistic." This means that there are many payers with different needs, data requirements and objectives and therefore the conduct and use of HTA/HEOR is likely to be more complex.
Medical pluralism is a key analytical framework for understanding the diverse and competing ways that people engage with health resources and practices. It was developed in the second half of the twentieth century to examine local medical traditions (what is variously called 'traditional medicine' or 'alternative medicine') and their relationship to biomedicine.
The most well-known example of a pluralistic healthcare system is the United States, which has a multipayer private system alongside a public system. Other examples include multipayer systems serving particular population groups, such as military veterans.
There are many reasons why healthcare systems may not be able to produce timely HTAs in these environments, including the fact that payers will make adoption decisions when it suits their own needs rather than waiting for the HTA report to be completed. Moreover, in decentralized and parallel healthcare systems, there are often differences in the willingness to pay for new technologies between regions or population groups, which can make it difficult to obtain accurate cost and epidemiological data to support an HTA.
As a result, it is necessary to take into account the local epistemic expertise of nonbiomedical health-care providers and to develop local cost and epidemiological databases for use in HTAs. This will help to respect the capacity of individuals and communities for self-care and to recognize the value that these communities can add to UHC.