The 2019 study tour represented another successful collaboration between core iDSI partners to support knowledge strengthening among key policy makers in China through interaction with representatives from UK government agencies, NHS, academic and private sector colleagues involved in healthcare.

The Chinese participants included seven representatives from the National Health Commission, including representation from the Department of Drug Policy and Essential Medicines Systems, and the Department of Healthcare Reform; a representative from the Department of Social Security, Ministry of Finance; and representatives from provincial health authorities, including the health commissions of Liaoning, Jiangsu and Henan. Researchers and policy advisers from CNHDRC and the Shanghai Health and Development Research Center also joined, in addition to colleagues from the academic sector in China, the latter including representation from Peking University, the Beijing Normal University, and the China Pharmaceutical University. Full details of all the participants can be found listed in the agenda.

As in previous years, all 27 delegates received a detailed introduction into the structure and financing of the NHS, including the role of HTA in supporting resource allocation decisions in the UK. In addition, there was a special focus on primary care, led by the Imperial College WHO Collaborating Centre for Public Health Education and Training, and an afternoon workshop hosted by the Centre for Health Economics at the University of York, which explored specific issues relating to the application of economic techniques to inform discussions on evaluating health system performance and efficiency.

For this year’s tour, we also placed a special emphasis on the UK’s approach to cancer care, specifically in relation to the process adopted by the National Institute for Health and Care Excellence (NICE) when evaluating new oncology products. We also explored the importance of considering the value that new innovations could bring within the context of delivering appropriate and timely pathways of care, including radiology, pathology, surgery, and radiotherapy. The UK’s experience in these issues can potentially provide useful insights for the Chinese setting, given that cancer has become a leading cause of mortality in the country. This is being driven by an ageing population and the prevalence of lifestyle factors such as smoking, with lung, stomach and breast being among the most common cancers. Policy makers in China have recognised the need to strengthen systems for assessing the clinical benefit of new cancer medicines, and this will be the focus of planned further collaboration between the Global Health and Development Group at Imperial and CNHDRC.

We would like to thank everyone who attended and contributed to the two-week study tour, with a special thanks to the British Embassy in Beijing, and Professor Kun Zhao and her team at the CNHDRC.

Saw Swee Hock School of Public Health, National University of Singapore, 24-28 June 2019. By invitation only

Universal health coverage (UHC) is not only to be made available but also sustainable and every country is now thinking about how to make both happen. Health technology assessment (HTA) is one of the helping tools, which is increasingly used in both resource-rich and poor settings.

NIHA LDP 2019 is designed for senior policymakers and HTA researchers who would like to know more how to make HTA work better to enhance UHC in their countries. The policymakers and the researchers will be paired to work together not only during the programme period, but also long-term post-programme.

The programme is co-hosted by iDSI and the Access and Delivery Partnership, and will feature iDSI expert speakers including from the
HITAP, Center for Global Development, Imperial College London, and China National Health Development Research Center.

The Health Technology Assessment Toolkit was published in September 2018 following consultation with staff working in health policy around the world who helped develop the content. The end result is a tool detailing the building blocks of a sustainable and locally relevant Health Technology Assessment mechanism for priority-setting. Since its launch, the Health Technology Assessment Toolkit has had over 110 downloads.

iDSI would like to thank reviewers working in ministries of health, health insurers and other health agencies based in: Bhutan, Brunei, China, India, Malaysia, Philippines, Spain, Vietnam, the USA and the UK for their efforts to make the HTA Toolkit a success.

The Health Technology Assessment Toolkit and all other iDSI research and technical outputs can be viewed on the open science publication platform F1000Research. The iDSI Gateway features work developed through iDSI’s core themes: tackling healthcare challenges; strengthening health systems and institutions; generating and using evidence; smart purchasing for Universal Health Coverage; value for money for sustainable development; and measuring impact

All articles on the iDSI Gateway are published in line with F1000Research’s immediate and transparent publication model, regardless of the article size, type, or perceived impact.

Want to know more about how iDSI works to maximise the value of funds and coverage of quality healthcare? Follow a typical iDSI journey which encourages local ownership and capacity towards ensuring policies are evidence informed and fair.

Already applied iDSI’s Health Technology Assessment Toolkit to your work? Send in your experiences, iDSI would be very glad to hear from you. Contact Madeleine Stewart, iDSI Communications Manager, madeleine.stewart@imperial.ac.uk.

The 22 delegates, from both clinical and non-clinical backgrounds, visited London and Cambridge to develop their understanding of the UK healthcare system, including health-related legislation and regulatory mechanisms, policy development and health reforms.

Along with visits to St Thomas’ Hospital, Boots Pharmacy’s corporate office and AstraZeneca, the group received talks on the role and function of National Institute for Health and Care Excellence and the Medicines and Healthcare Products Regulatory Agency in protecting and improving public health; the pricing of branded and generic pharmaceuticals in the UK; vaccine evaluation; the development of evidence-based clinical pathways and integrated care pathways; and how to best to make use of electronic health record systems.

Members of the delegation from China with iDSI staff in Queen’s Gate

Yu Ou’yang from the Division of Medical Administration within the Hunan Provincial Health Commission in China said: “Over the last two weeks we have had presentations from almost 30 experts, even though the context of the UK and China is very different there has been so much for us to learn here. During the study tour I have realised healthcare management and delivery in the UK is very detailed and precise to ensure all goes as smoothly as possible, the UK also takes into account the balance between cost and effectiveness in healthcare which is extremely important. It has been great to learn more about standardised operations such as Clinical Commissioning Groups and NICE and their responsibilities. I would like to extend my thanks to all the presenters and those that facilitated our practical days.”

Ying Peng, who is based in Beijing but also carrying out a PhD in Health Economics at the University of Sheffield, said: “The range of presentations we received will really help my own PhD studies, I’ve definitely developed my understanding of how new interventions are appraised in the UK and how evidence is the pinnacle of decision-making. It was really important for me to learn more about the UK health system, which organisations underpin it and how this could be adapted for China.”

The group was made up of officials from iDSI core partner the China National Health and Development Research Center (CNHDRC) and the Chinese Ministry of Health (National Health Commission); along with policy makers and academics from Huazong, Beijing and Shanghai universities.

Liu Jianan, from the Division of the Essential Medicines List, within China’s National Health Commission, said: “Our delegation is diverse but between us all we have rich experience and knowledge. Our learning over the last two weeks has been delivered in such a systematic way; there is still much more we can learn from the UK healthcare system however for now I am pleased we will all be able to bring back our experiences from this trip, especially for matters such as pricing for medicines, which is of broad and current interest in China.”

Chen Bo, a PhD student from Peking University’s School of Public Health, said: “I feel very lucky to be here. The talks have inspired me a lot, particularly as my current area of study is public hospital reform at county-level in China. For me the most valuable part of the study tour has been expanding my knowledge of the ways in which hospital reforms could be made more efficient; and learning so much about Cost Effective Analysis exercises and ways we could push forward with this in China.”

Francis Ruiz, iDSI Senior Advisor, said: “The Global Health & Development Team at Imperial and iDSI have been delighted to organise study tours to the UK for senior Chinese officials since 2014. The talks from various presenters, including representatives from The Nuffield Trust, NHS England, NHS Benchmarking and feedback on their own workstreams from the delegates themselves has been a fantastic complement to off-site days where the group observed the delivery of health care first-hand and attended a workshop focused on primary care. We hope the visit was valuable and will have positive impact on them as individuals; and help develop the UK-China partnership in Health Technology Assessment.”

The workshop was attended by 23 delegates representing NACC and NASCOP, as well partners from the Global Fund to fight against AIDS, Tuberculosis and Malaria; the Centre for Disease Control; USAID, Kenya Institute for Public Policy Research and Analysis; and the National Treasury.

The first day kicked off with presentations and case study exercises by the iDSI team, including an introduction to economic evaluation and to fundamentals of costing; as well as a session on valuing and measuring costs. The HIV programmes in the country highlighted the need to develop a standard framework for costing work in Kenya, given that several costing studies are on-going in the country.

Participants spent the morning of day two discussing the evidence needs for the HIV programme. NASCOP presented the on-going work on the piloting of differentiated care pathways coupled with a quality improvement intervention (DCM+QI) in seven counties. DCM+QI recognises that the change from a single guideline to a differentiated pathways requires up-front investment and training to support providers. As a result, NASCOP has worked for almost two years with facilities in the intervention counties to develop locally relevant solutions to support DCM implementation.

In-country partners, the Global Fund and iDSI, will form a technical working group to support NASCOP and NACC in generating the evidence relating to the pilot. This workshop demonstrated the importance of consultation, especially between external partners and local partners working on the ground in Kenya.

The workshop was the first in a series that are designed to help build capacity for undertaking HTA in India; and come as the Global Health and Development team at Imperial College London have signed a Letter of Understanding with the Department of Health Research (DHR) within the Government of India, who are leading on an exciting initiative to institutionalise HTA.

Over 30 attendees gathered in Delhi for the workshop which focused on introducing participants to the key concepts of evidence-based priority setting and HTA, how to frame an economic evaluation, and how to identify key stakeholders for consultation throughout the HTA process.

Senior Scientist Dr Kavitha Rajsekar discussed the importance of HTA for India and gave an update on the latest developments on HTA in India. Ensuring that an evidence-based, inclusive, and transparent system is put in place via the HTAIN will aid health resource allocation decisions across the country.

Associate Prof Shankar Prinja presented the results of the cost effectiveness of auto disposable syringes, one of the first studies to be approved by the HTAIN Technical Appraisal Committee which has resulted in the government of Andra Pradesh using results to inform their decision to invest in autodisposible syringes to reduce rates of infection due to needle re-use in the state.

Alex Winch discussed what UHC means for India and how establishing fully functioning HTAIN centers will provide a sound basis upon which health resource allocation decisions can be made in India, to ensure that every rupee spent buys the maximum health possible.

Dr Laura Downey and Dr Pankaj Bhaguna outlined what evidence is required to undertake HTA analyses, drawing from their own experience of conducting HTA in India; and their recent publication on identifying publicly available data sources for HTA in India.

Dr Oshima Sachin presented on how evidence for health costs is being collected by the HTAIN and a network of partners from across India to form a common costing database, which iDSI is providing technical advice and assistance with.
Dr Aamir Sohail introduced the concept of equity and ethics in informing HTA in India; and shared his experience of conducting a literature review on equity to inform the intraocular lens HTA undertaken by the HTAIN secretariat at DHR.

Juliet Eames and Saudamini Dabak of HITAP Thailand introduced the concept burden of disease and measuring quality of life to estimate Quality Adjusted Life Years (QALYs), as well as Disability Adjusted Life years (DALYs).
The presentations stimulated lengthy discussions amongst participants as to the challenges of conducing HTA in India, when such evidence is often not available and not routinely collected.

A follow up workshop will be held in three months’ time and iDSI is pleased to report feedback received from participants to this workshop was overwhelmingly positive, with 75% of participants reporting they plan to use the skills and knowledge that they had learned during the course towards undertaking a policy-relevant HTA study.

This year I attended because I was representing a collaboration between iDSI and the World Health Organisation (WHO). The first meeting held in July 2016 aimed to develop a guidance document informing countries of methods to set up Health Technology Assessment (HTA) mechanisms for reimbursement purposes. Building on this initial meeting and the consecutive guidance document development, we led a session titled ‘Using HTA to inform country specific reimbursement’ at this year’s conference.

The panel was held on Tuesday afternoon and my fellow panel members included Tessa Tan-Torres Edejer (WHO), Shankar Prinja (Post-Graduate Institute of Medical Education and Research, PGIMER), John Wong (EpiMetrics). Setting the scene, I started by providing a general overview of capacity building needs when looking to establish a HTA mechanism, linked to a paper published by Dr Li of iDSI. Shankar and John provided country examples of capacity building and the development of HTA mechanisms in India and the Philippines respectively. These countries are both in very different stages of the development, however their talks highlighted both the similarities and differences when setting out to develop a HTA mechanism. Tessa spoke about the development and need for the guidance document, which is still in its early development stages though a first draft is due to be published later this year. Watch this space!

The three day conference brought me a huge range of new information and contacts in the Global Health scene which left me with a thirst to explore the field of priority setting even further!  All-in-all, this first experience of a major conference was a memorable one – and not just because of the delicious pasta and gelato in Rome!

Last month Laura Downey, GHD, convened a panel at

The panel was chaired by Kalipso Chalkidou, GHD, and speakers alongside Laura included representatives from the Department of Health Research (DHR), Ministry of Health and Family Welfare, Government of India and the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

We had some questions for Laura about the panel session and the supporting BMJ paper that was recently published:

What is meant by ‘Institutionalizing HTA’?

Essentially what we mean by this is moving towards a health system where Indian policy makers use evidence generated through HTA to inform their decisions for how health resources are allocated. In order for this to reach the point of “institutionalization”, we would hope that such evidence-informed decision making would be diffused widely. This would be at both the National, or Union, level, as well as at the level of the States, where health is a State-lead subject in India. There’s a long way to go before the country comes close to reaching this point. However, the DHR is taking active measures to bring the HTA message to policymakers across the country in an effort to lay the foundation to effectively bridge the gap between evidence and policy.

How do you build national capacity?

It’s important to define here what we mean by “HTA capacity”, as there are a number of areas for which building up local skills and knowledge is necessary to effectively support the HTA ecosystem.

From the technical perspective, it’s important to build capacity for undertaking economic analyses and developing a robust methodological guide for the conduct of analysis, or what we call a Reference Case. We recently ran a training workshop on economic analyses for HTA in Kerala, which was delivered collectively by experts from Imperial College London, HITAP Thailand, and PGIMER. PGIMER has also developed a series of online modules for studying HTA, which will ensure wider-reach of building skills in this area across the country.

From the wider policy perspective, capacity needs to be built for the policymakers and their health system colleagues to be able to understand and use the HTA results to their advantage. iDSI recently facilitated a study trip for Indian policymakers and academics to Thailand to learn from Thai policymakers on how they have been able to use HTA to achieve UHC.

Capacity-building through education and engagement is also taking place with the stakeholder community. Stakeholders refer to all those with an interest in the analysis, such as the patients themselves who are the ultimate beneficiaries of the policy decisions, as well as civil society organizations, industry bodies, non-government groups, and the clinical and allied health community. Through education stakeholders are empowered to take an active role in how the HTA research questions are shaped, and inform the decisions that are made. iDSI recently co-facilitated a stakeholder consultation event on HTA with the Indian Council of Medical Research and DHR, which brought together academics and policymakers to discuss HTA, its need in India, and the establishment of the MTAB. Further stakeholder engagement meetings are planned to take place in the coming months.

What are the next steps?

There is a long way to go before HTA will be effectively “institutionalised” in India, but the MTAB team at DHR are laying strong foundations for taking the program of work forward. Robust methods and process guidelines are being drafted to guide technically rigorous and uniform analyses. Training to build skills for economic analysis will continue to be delivered; technical exercises to pilot the methods, processes, and technical skills will be undertaken; and the political and stakeholder economy will be addressed along the way through active engagement, advocacy, and education.

iDSI will continue to support this incredible National effort, which represents not only an international collaboration, but a collaboration between complex networks of institutions from all over India.  In a country as large as this, where the population is now said to have surpassed that of China, institutionalising the highly complex process of using HTA evidence to inform policy decisions is a formidable task. However, the herculean efforts already shown by the government of India, led by DHR and the MTAB team, and their technical partners from across the country is nothing short of incredible.

Writing from London on the 1 year anniversary of Brexit where political parlance continues in an unending circular discourse devoid of any discernible path forward, I think we can all learn a lesson from our Indian colleagues.

In the space of less than 1 year, the Government of India have achieved more than most countries would hope to have achieved in 5.

Never more did Ghandi’s words “be the change” ring true, as our colleagues at DHR and the MTAB have shown us. It is a true privilege to be part of this great change in the Indian health system.

This was one of the key take-home messages from the first in a series of workshops designed to build capacity for undertaking HTA analyses in India.

Participants from technical institutions across the country travelled to Thiruvananthapuram in Kerala to join this workshop. The workshop focused on supporting India in the transition towards a formalized system of using evidence to inform health resource allocation. The Department of Health Research, Government of India are leading on this by establishing a medical technology assessment board (MTAB). Building capacity to undertake health economic analyses in India will be an imperative foundation for the success of the HTA program under MTAB.

Key take-home messages from the workshop:

HTA is an important tool for prioritizing health resources in India’s journey towards UHC: Dr Soumya Swaminathan, Secretary DHR and Director General of the Indian Council of Medical Research (ICMR) discussed the importance of HTA for India. Ensuring that an evidence-based, inclusive, and transparent system is put in place via the MTAB will aid health resource allocation decisions. As a result, healthcare decisions will be made on the basis of best value for money for the Indian people.

Sri Rajeev Sadanandan, Principle Secretary for the State of Kerala, further reiterated this sentiment and expressed his commitment to establishing a center for HTA in Kerala.

Dr Laura Downey lead a discussion on what UHC means for India, and how establishing a fully functioning MTAB centers on utilizing the best available evidence. This will provide a sound basis upon which health resource allocation decisions can be made in India, to ensure that every rupee spent buys the maximum health possible.

Economic analysis requires a lot of evidence, some of which isn’t always easily available: Discussions relating to evidence were a common theme throughout the workshop. Dr Miqdad Asaria outlined the kinds of evidence that is required to undertake a HTA analyses. Dr Akashdeep Chauhan presented on how evidence for health costs is being collected from across India to form a common costing database. Dr Laura Downey also introduced the concept of utility tariffs for measuring quality of life to estimate Quality Adjusted Life Years (QALYs) or Disability Adjusted Life years. Together these presentations stimulated lengthy discussions amongst participants as to the difficulties of conducing HTA in India, when such evidence is often not available and not routinely collected.

Dr Yot Teerawattanon shared his experience from Thailand, where HITAP conducted primary research to fill these gaps to inform Thai analyses. This included collecting an EQ5D dataset to build a Thai value set for quality of life utility tariffs. Dr Kavitha Rajshekar from DHR highlighted that in order to address some of these data gaps in India, the MTAB will collaborate with the National Institute of Medical Statistics (NIMS) to build a National data repository to inform HTA analyses.

A mechanism for identifying and addressing data gaps will also be put into place through capitalizing on the partnership between the DHR (government policy-making body) and the ICMR (a scientific primary medical research body).

A reference case for economic evaluation is essential to guide structured, transparent, and technically sound analysis: The necessity for a reference case for Indian health technology assessment was highlighted throughout the workshop.

Dr Deepshikha Sharma lead a discussion regarding the different dimensions a reference case must cover, such as whether DALY or QALY should be used, and at what level a threshold for cost effectiveness must be set.

Dr Miqdad Asaria lead further discussion regarding the importance of setting a threshold at the right level for India to limit the opportunity cost of where resources could potentially be better spent.

Dr Laura Downey and Dr Kavitha Rajshekar shared plans for the development of the Indian reference case under MTAB. They explained that a reference case for economic evaluation will be collaboratively developed, and that all technical institutions whom undertake HTA as part of the MTAB program of work will be required to follow this guide.

Want to know more about HTA?

Health Technology Assessment in Universal Health Coverage

WHO resolution on Health Technology Assessment

National Institute of Health: “HTA 101”

Organizer’s information:

iDSI

The Department of Health Research Government of India

The Post Graduate Institute of Medical Education and Research Chandigarh

The Sree Chitra Tirunal Institute for Medical Sciences and Technology

Useful links:

iDSI reference case for economic evaluation

Informing global health decision making: Cost per DALY thresholds and health opportunity costs

Country-level cost effectiveness thresholds : Initial estimates and need for further research

The first day started with the dissemination meeting of a project supported by the UK Prosperity Fund. The project, led by CNHDRC, focused on utilising UK expertise to support the development of standardised methods to generate evidence-based care pathways for chronic disease in China. The division director of CNHDRC, Prof Kun Zhao, outlines the aim of developing a standardized approach to developing and updating clinical guidelines in China, with a practical application to existing care pathways and guidelines in hypertension and diabetes, currently in use in Xiamen and Qingdao.

The meeting continued with an overview by experts from Xiamen and Qingdao on the ongoing efforts to improve the management of patients with chronic diseases. At the end of the meeting Prof Mike Roberts from UCL Partners shared some experiences on transforming health care towards evidence-based practices and current thinking on new integrated care models in the UK. He emphasized the importance of establishing standardised guidelines to provide high quality and equitable care for the whole Chinese population.

During the afternoon of the 17th, a leadership training workshop was delivered. At the beginning of the workshop, participants were familiarized by the theory on how to implement change and introduce new guidelines into clinical practice.  Later on, effective team leadership strategies in implementing change were discussed.  The training was attended by senior officials from Xiamen Health Bureau and Qingdao Health Bureau, representatives from tertiary and secondary hospitals, nurses, local administrative officials as well as clinicians. The knowledge gained from the workshop is expected to help local stakeholders build effective clinical teams to implement the new guidelines in an efficient manner.

The following week, a workshop was held over two days on ‘Health Policy Evaluation and Technology Assessment Knowledge Sharing’. This workshop was organised in order to help support the momentum generated by the newly launched China Health Policy and Technology Assessment Network, with CNHDRC in the role of focal point of the network (the iDSI China HTA hub).  The workshop was opened by Hongwei Yang, the deputy Director General of CNHDRC, Prof Kun Zhao and Dr Kalipso Chalkidou, Director of the GHD. The aims, objectives and structure of the nascent China HTA network were introduced. In addition, the workshop explored a number of topics considered highly relevant for HTA development in China. These include the role of the iDSI Reference Case and how it may be adapted for a Chinese context; evaluating non-budgetary constraints; health system strengthening; measuring HTA impact; economic evaluation and public health; adapting HTAs; and HTA and medical devices.  For each thematic area there were presentations from UK-based academics and Chinese researchers, as well as experts from the Thai HTA agency, HITAP. HITAP colleagues shared their experiences of how HTA was used to inform UHC policy in Thailand. The workshop concluded with reflections on the working plan for the China network as an iDSI HTA hub, and exploring new collaborations and next steps.

In terms of next steps, it was highlighted that a key objective should be to increase the number of members of the China Health Policy and Technology Assessment Network and on standardising the methodology used in developing clinical guidelines, especially for chronic diseases in China.