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.”

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

At the end of March 2017, Professor Jo Lord, Director of the Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, and Dr Kalipso Chalkidou travelled to Accra, Ghana to meet with colleagues and follow up on latest developments. iDSI is co-producing with our Ghanaian partners a full report on the technical and data aspects of the model, discussing the likely characteristics of a Ghana-specific Reference Case for economic evaluation and setting out specific policy angles of interest to Ghanaian policy makers, including the potential linkage between HTA and reimbursement. We aim to set out a vision for joint working over the next 2-3 years, based on the country’s priorities and commitment to building the needed capacities for effectively using economic and clinical evidence of comparative effectiveness to inform spending decisions. The report will offer robust estimates of savings from shifts in current practice, from changes in prescribing behaviour to reductions in prices and population level prevention and screening initiatives, to inform Ghanaian policy makers about resources that can be released to expand the breadth and depth of coverage, without harming quality. We hope to do more such analyses on NCDs, including diabetes and end stage kidney disease as well as mental health, as we continue our joint efforts.

At a time where Ghana is transitioning away from aid whilst striving to expand and ensure the financial sustainability of its health insurance scheme, transparency and accountability when it comes to important investment decisions, become even more important. Building on strong institutional structures for multi-stakeholder engagement and evidence informed policy such as the Essential Medicines List and the Standard Treatment Guidelines and the recently formed HTA Working Group, and on existing academic groups with a track record in the field of HTA at Kumasi (KNUST) and Accra (School of Public Health) this is an opportunity to help build a Ghanaian HTA system better to control escalating costs and inform future investment and disinvestment decisions.

A case for further investment in health cannot be made unless systems are in place to ensure good value for money for every Cedi spent. Identifying, in an evidence informed way, opportunities for releasing resources for reinvestment to expand coverage whilst ensuring health outcomes remain the same or improve, is a powerful argument for more and better spending in health. Our report will go some way towards making the case for an HTA mechanism for strengthening the handle of the Ghanaian authorities over its own budget through tackling a specific cased of high spending and high burden, namely hypertension management. Using Ghanaian data and making all assumptions explicit, the analysis will point to areas for improved spending, quantifies potential savings and health gains from reallocation and make a case for an institutionalised approach to HTA in Ghana, as an important tool for transitioning away from aid and towards sustainable and affordable Universal Healthcare Coverage.

Health Technology Assessment offers a framework for decision making though multi-stakeholder processes and a multidisciplinary approach which aims to incorporate evidence and values, locally relevant, to drive better decisions. But it relies heavily on implementation levers such as provider payment, contracting, patient and professional education and strong regulation to make a difference.

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.

In a recent policy brief, Oxford Policy Management and the International Decision Support Initiative (iDSI) have asked “would the VfM analysis that the UK’s Department for International Development conduct on their programme expenditure be more useful if lessons were learnt from the iDSI Reference Case for Economic Evaluation?”. It is argued that significant methodological improvements are available to DFID – which could make the information they generate more useful for their decision makers. These recommendations are also applicable to other donors who follow similar guidelines for monitoring their VfM.

Alex Jones’ blog post exploring some of the issues raised in the brief is available on the Oxford Policy Management website.

NICE International Director Kalipso Chalkidou offered an overview of NICE and its core principles and practices. During this she emphasised how important it is to not only measure the cost-effectiveness of a particular drug or intervention, but then comparing it to the existing standard practice. Economic evaluations of these sorts are what the delegation is keen to bring to the Vietnamese health system.

The following presentation was probably of the most interest, both to the delegation and to me, as it outlined the nature of and the methods underlying Health Technology Assessment (HTA). NICE International’s Tommy Wilkinson went into detail on a plethora of topics encompassing: HTA and its workings, from assessment to technology appraisal, and then subsequently to recommendations; regulatory approval, oversight and accountability; the two drug pricing mechanisms in the UK; the Patient Access Scheme (PAS) and reference pricing; pharmacist’s pay; medical device pricing and procurement; deliberate misalignment of the main stakeholders’ incentives; and the Incremental cost-effectiveness ratio (ICER) and QALYs. Predictably, after covering so many areas, the delegation had numerous questions, especially seeing as economic evaluation has great significance to the Vietnamese setting as with many health systems in emerging economies. For someone who is about to study Economics at university these discussions really captured my attention; most significantly how QALYs and the ICER allow for multiple health interventions to be simultaneously compared and graphically illustrated in terms of both health gain and economic impact. This can help decision makers make a better, more informed healthcare decision for the population.

However, HTA methods obviously cannot be taught solely through a short study tour, which raises the question: how much can the delegates take from this? This, in my opinion, is a greater understanding of the fundamental benefits of HTA and possessing an evidence-based policy making ethos. Therefore, Francoise Cluzeau and Ryan Li referenced NICE International’s work in Vietnam itself developing Quality Standards for the Hospital Management of Acute Stroke, demonstrating the application of HTA in that setting. They drew in many features of the project, including identification of problems, creation of innovative, evidence-based solutions, the systematic implementation of the quality standards and their impact on health outcomes. This was well received by the delegation, yet what became evident was how their understanding developed most when explanations were applicable to a familiar setting. Despite being a highly distilled version of the projects, simply referring to a practical real-life example made HTA more relatable to the delegates. This was the most valuable lesson I drew: that clear explanation is vital, but making what you are saying applicable to the audience is even more so. In this case NICE International’s previous work in Vietnam enabled an easier explanation to the Vietnamese delegation

The last presentation came from Steven Edwards representing the British Medical Journal Technology Assessment Group (BMJ-TAG), which is one of the organisations who conduct HTAs for NICE. A much deeper understanding of what is practically involved with doing frequent and large HTAs for NICE was provided, and – coming from an external source – was couched in different terms, creating a good balance. This covered the different types of HTA, the time constraints and the significant work put into analysing manufacturers submissions. The delegates’ questions seemed to focus on identifying where accountability lay, and how legal issues relating to malpractice are handled. Admittedly a sensitive topic, it was clearly important to members of the delegation.

Events were preceded by a one-to-one discussion between Professor Phạm Lê Tuấn and Kalipso Chalkidou. Apparently productive, it felt like it set the tone and thrust of the rest of the day, as well as providing an agreement for NICE International to continue its collaboration with Vietnam under the international Decision Support Initiative (iDSI), specifically developing Quality Standards on Antimicrobial Resistance. For NICE International and the Vietnamese delegation this was considered a productive event, but it was also personally valuable to me, as I am now considering a career in health economics!

Therefore, difficult decisions on healthcare prioritisation are constantly being made by governments and aid organisations, with an increasing focus on allocative efficiency to achieve greater returns on investment. The World Health Organisation (WHO) has identified substantial inefficiencies in healthcare financing, amounting to between 20% and 40% of total spending. These inefficiencies have several sources, from allocation decisions based on poor cost-benefit analyses to losses in the supply chain. Aid allocation decisions are often based on non-objective criteria, such as shifting political priorities in aid-giving governments or geopolitical factors. Aid financing can also go “missing” as a result of poor governance, or be consumed by the high running costs of organisations.

This report, commissioned by the International Decision Support Initiative (iDSI) and written by the Economist Intelligence Unit (EIU), reviews the current research and methodologies used to analyse resource allocation and identifies gaps that could be bridged to improve health outcomes. To reduce waste and improve efficiency, the report then seeks to lay the groundwork for developing an index—a multidimensional measurement framework—that will evaluate the “enabling environments for health aid effectiveness”. Such a tool could, in our view, become a powerful resource for quantifying how effectively the healthcare sector works in low- and middle-income countries.

The report can be found here.

Simply complete the questionnaire (which should take less than 15-20 minutes) here. Thank you!
https://www.surveymonkey.com/r/ResearchMethodsEE

This survey is part of an iDSI research project, to help our academic and country policymaker partners in prioritising methodological issues for future research. This will hopefully address the major concerns of researchers supporting priority-setting in LMICs.

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Update (7 Sep 2015): The paper by Hauck & Smith is now published in the iDSI Knowledge Library.

Why study the political economy of priority-setting in health?

The global health agenda aims to reach universal health coverage (UHC)—which the WHO defines as providing “access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost.” Though UHC may be in the far future for many countries, priority-setting is needed to use resources efficiently, and the reality is that there are many objectives and interests competing for limited resources. In many low- and middle-income countries (LMIC), ad hoc processes drive choices that can result in low value and inequitable resource allocation.

iDSI provides LMIC governments with practical support and knowledge products so countries can create institutions that lead to better decisions and ultimately better health. We aim to increase goal-consequent resource allocation, not only to maximize health but also to consider equity, financial protection, and other values.

In global health, we don’t have full understanding of what prevents a government from making goal-consequent resource allocation decisions[1] that use technical information such as cost-effectiveness analysis. The study of politics and political economy, which is fundamentally concerned with conflict of interest, is one lens through which to gain greater understanding of these issues. With a clearer picture, perhaps we can work with governments to formulate strategies to manage competing objectives, demands, and interests—and give donors greater visibility into government processes and preferences so they can better align their decisions with those of government.

Existing literature

Unpacking the complexities of political economy of priority-setting in health is important, but how do people currently study this topic? As part of the iDSI’s work, Jesse Bump and Angela Chang are developing a framework to help analysts and policymakers better understand, predict, and manage the political and economic forces that shape priority-setting. Bump and Chang reviewed syllabi related to health policy and political economy from leading graduate programs in health systems. Though theories with potential explanatory power to analyze the design of priority-setting tools (in particular, health benefits plans), do exist, Bump and Chang have found that at the moment, there is no defined framework or method of study.

In motivating a forthcoming paper, “Departures from cost-effectiveness recommendations: The impact of health system constraints on priority setting,”[2] Katharina Hauck and Peter Smith similarly find little research investigating the political economy of the health sector. Hauck and Smith examine models of political economy and public choice and describe how decision makers react to political realities.

While available literature may not provide a specific framework of analysis, a number of related and overlapping literature does exist and provides an important starting point for discussion. For instance, some of this literature addresses how agencies and actors do and don’t affect decision making in health policy. In a systematic review, Parkhurst and colleagues (2013) found the need to address political and institutional factors affecting the use of evidence in health policy.[3]  Walt and Gilson (1994) argue the need for health policy to focus on the actors involved in policy reform over the content of reform.[4] Reich (1995), through examination of pharmaceutical policy reform, and Lakin (2010), through examination of Mexico’s Seguro Popular, argue that a successful health reform requires analysis of political conditions and factors.[5]^,[6] The references discussed are just a subset of available literature by the mentioned authors and others—and relevant literature outside of the health sector may apply in some instances.

The existing and ongoing research of the political economy of priority-setting in health provides a platform to consider future investigations.

Questions for further study

A body of literature related to the political economy of priority-setting in health does currently exist, but many questions remain unanswered—and these questions provide great opportunities for future study to inform more effective policies.

A set of questions center around the politics of implementation of priority-setting tools and their processes: these questions are listed in the table below. The questions begin with the start-up of a priority-setting mechanism (i.e., what leads a county to want to set up processes for priority-setting?), and also include the role of politics in deciding what technologies or interventions get evaluated, invested, and disinvested—as well as in the reversal of certain decisions.

Another set of questions examine the priority-setting process at a higher level, such as its evolution, “success or failure,” and influence.

Next steps

Many study questions remained unanswered, and the iDSI’s currently planned political economy work will only address a small part of it. Moving forward, the paper by Bump and Chang will study: What are management strategies that enable effective use of technical information on adoption decisions? The research will be limited to countries with well-established formal priority-setting / HTA processes and institutions. In addition, a research team will conduct two country case studies with country qualities similar to those considered in the framework paper. Tentatively, the two countries will be Thailand and South Korea. We look forward to continuing to share knowledge and work in this space.

[1] Meaning resource allocation consistent with a country’s health system goals, whether they be health maximization, greater equity, enhanced financial protection, greater responsiveness or other.

[2] A chapter of broader political constraints work for iDSI by K Hauck, R Thomas, and PC Smith

[3] M Liverani, B Hawkins, and J Parkhurst (2013) “Political and Institutional Influences on the Use of Evidence in Public Health Policy. A Systematic Review.” PLoS ONE 8(10):e77404.

[4] G Walt and L Gilson (1994) “Reforming the health sector in developing countries: the central role of policy analysis.” Health Policy and Planning 9(4): 353-370.

[5] M Reich (1995) “The politics of health sector reform in developing countries: three cases of pharmaceutical policy.” Health Policy 32(1-3):47-77.

[6] J Lakin (2010) “The End of Insurance? Mexico’s Seguro Popular, 2001–2007.” Journal of Health Politics, Policy and Law 35(3):313-352.