Since January 2018, iDSI has been working closely with the Global Fund to fight against AIDS, TB and Malaria (henceforth the Global Fund), the Kenyan Ministry of Health (National AIDS and STI Control Program -NASCOP- and the National AIDS Control Council -NACC) to assess the impact of implementation of Quality Improvement (QI) in support to differentiated care (DC) models on the quality of HIV care in Kenya. This was a unique project: the topic was scoped through lengthy consultations and was entirely led by local partners, the Global Fund and iDSI providing support on research methods, analysis and write-up. This modality of collaboration ensured that the study focus was aligned with future programming plans and strategic policy interests, and that the overall research being conducted with local ownership throughout.

Why is this important?

The study looks at the use of Quality Improvement to support the roll out of one of the most important changes in HIV/AIDs clinical guidelines in the country of the recent year. In 2016, the Ministry of Health issued comprehensive guidelines on Antiretroviral Therapy (ART), which introduced differentiated care (DC) pathways also known as “the DC ART model”. The DC ART model separated patients into different clinical groups demanding on their clinical needs, with specific differentiated patient pathways for each group so as to easily address their clinical needs. Prior to the introduction of DC, all patients were cared under one clinical pathway, e.g. whether they were stable or unstable (e.g. not virally suppressed or with a history of poor adherence). With the introduction of DC, stable patients (which represent > 75% of all patients) have fewer clinical visits and can pick up ART refills directly from pharmacies; freeing up resources (e.g., clinical staff time) to more intensive care for unstable patients with poor health outcomes.

There is a lot of interest and enthusiasm about DC globally, and it is seen as a means to achieve global HIV targets, especially in resource-constrained high prevalence settings[1]. However, there are anecdotal reports of barriers and challenges in implementation of DC pathways[2], including in Kenya where our study took place. As a result, the Kenya Ministry of Health and the Global Fund piloted early on a QI Program in support of DC implementation (with a focus on facilities where performance along HIV targets was not satisfactory). The intervention was implemented from December 2017 to May 2019, with 70 sites participating across 7 counties in the country. It followed a ‘Plan-Do-Act-Study’ process, whereby facilities diagnosed implementation barriers and developed with the support of NASCOP and other facilities local tailored solutions, testing change in real time. In addition, additional training and coaching on the new ART guidelines (including DC pathways) was provided in intervention facilities. There was some training to control sites, but it was far less intensive than in facilities receiving QI.

This is to our knowledge, the first comprehensive evaluation of a practical support program to DC pathway implementation. The study yields significant learnings for other countries looking to implement DC in their countries.

How was the study conducted?

The study followed a simple yet robust evaluation method relying on a single end-point evaluation between intervention and control facilities, identified through propensity score matching (PSM). PSM utilized data pre-intervention (June 2016) to ensure that intervention and control facilities were comparable prior to the implementation of QI. 70 intervention sites were matched with 193 sites based on facility level, volume of patients on ART, county epidemiological characteristics (e.g., HIV prevalence, population density) and proportion of patients with a viral load test in the last year (as an indicator of ‘performance’). Only the best 15 matches out of the 70 sites were selected for the study, for a final sample of 30 facilities. In all facilities, three survey instruments were used: (i) patient survey (coupled with chart abstraction for viral load and information on ARV regimens, weight, height etc.), (ii) facility costing tools (including time and motion survey administered to a sub-sample of patients) and (iii) provider survey (to measure satisfaction and knowledge of guidelines). Ethical clearance was granted by the Red Cross Ethical Review Committee.

Descriptive statistics were produced (means comparison between the two groups), and significance of the difference in means was tested using t-tests and Chi2 tests.

What have we learned?

Processes of care varied widely between facilities in both control (facilities implementing DC alone) and intervention (facilities implementing both QI and DC) groups. For instance, some facilities applied changes that improved service delivery, e.g. changes in opening times (e.g. ARV pick up organized from 6am) or appointment days (e.g., pediatric ART versus stable patient days) to implement DC pathways. Those innovations helped staff manage more complex care pathways and keep track of patient needs, although it is not clear whether they supported more effective implementation (not within the scope of this study). Another common theme across all sites was long waiting times for clinical appointments, especially in high volume facilities. Patients spent on average 92.8 minutes in facilities, and only 8.1 minutes were spent actively seeking services (e.g. clinical consultation, nutritional support, pharmacy time). Those results also support the overall rationale for DC: patients who were present for ARV pick up spent less than 25mins in total in the facility. This is in line with the global literature showing that DC models utilise health resources more efficiently, but may also align better with patient preferences given the otherwise long waiting times. It should be highlighted that waiting times in intervention facilities was lower than in control facilities.

Patient satisfaction with HIV services overall was high across all facilities. Patients were most satisfied with drug availability, and the least satisfied with waiting times. Intervention sites scored higher than control sites along the following dimensions: waiting times, convenience of the appointment, time spent with the clinician and observation of privacy. It is worth noting that while the intervention involved coaching on DC guidelines, we found no statistical difference in provider knowledge of DC guidelines between control and intervention groups, and patient satisfaction with provider technical skills. However, 82% of providers in intervention sites reported that the intervention helped them improve their knowledge of DC pathways very much. Patients scored also higher in ‘knowledge questions’ in intervention sites compared to controls: for instance, to the question “what do you do if you have forgotten your medication?”, 70.6% of respondents in intervention sites answered correctly compared to 58.7% in control sites.

There were notable differences in patient outcomes between control and intervention sites. Patients cared for in intervention sites reported a lower incidence of opportunistic infections (9% compared to 12% in control), higher rate of viral suppression (92.7% compared to 89.4%) and higher quality of life as measured by EQ5D 5L instrument. All those differences were significant at the 5% level. This points to the fact that DC+QI did improve processes of care at the facility level, which resulted in greater patient health.

All in all, the costs of implementing DC+QI versus DC alone amounted to 516 KES  (or less than 5 dollars) per patient per year (a health systems perspective was adopted for costing). Overall costs varied significantly across facilities (e.g. based on facility size) and across different patient groups (e.g. between stable and unstable patients). Almost half of the DC+QI implementation costs (43%) were spent on organizing and learning sessions. Another 39% was attributed to administration and overheads.

A research collaboration led by local actors

This research was entirely driven by NASCOP and NACC, and the results of the report were used to discuss funding and modalities for scaling up the intervention in other counties. This is an example of a collaboration with academic partners, donors, led by country partners to ensure direct application into decision-making, as well as building awareness and capacity around project evaluation and costing methods.

Read the full report here

[1] El-Sadr WM, Rabkin M, DeCock KM. Population health and individualized care in the global AIDS response: synergy or conflict? AIDS. 2016;30(14):2145–8.

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6738628/

If you are a policy-maker working on the COVID-19 response in your country, we would love to hear about your experience and intention to work with those models, as well as your assessment of the perceived gaps. In addition, we would like to learn from you how models can be best communicated, including what they should report.

Communicating effectively and presenting results clearly is important in order to ensure that results are understood by end-users and appropriately incorporated into policy-making.

The intention of attached survey is to gather your perspective on (1) model outcomes and scenarios and their relevance to your work, (2) presentation of the results, and (3) trust/accountability of results and modellers. This survey is organised around those three sections.

The survey may take 15-20 minutes to complete.

Click here to access the survey or alternatively, use the link below

https://docs.google.com/forms/d/e/1FAIpQLSd-MC15jaUFR0fOkcfJpdDuPhvOB5x8Y-Z1qVMvRjFPB_KFfg/viewform

Should you have any questions, please address queries to ychi@cgdev.org

The grant, which will cover five years, represents a significant uplift to the funding granted to iDSI in 2015 and will allow us to continue working relationships with policymakers and healthcare payers to understand and respond to the challenges they face – whether ensuring the financial sustainability of a health insurance fund or fair access to good quality care across public health facilities.

This next phase of iDSI will see stronger emphasis on Sub-Saharan Africa with iDSI’s flagship countries including Kenya and Ghana, where global health funders will be departing and domestic health care spending is on the rise. Additionally, many Sub-Saharan African countries are currently introducing national health insurance or coverage plans and making important decisions about what health services and technologies should be included in Universal Health Coverage (UHC) offerings, where value for money considerations could make a huge difference in health outcomes.

As a result of the renewed funding, iDSI’s global network of expertise is expanding – we’re pleased to report iDSI core partners now include: the Asia Health Technology Assessment consortium which includes the National Health Foundation of Thailand, the Saw Swee Hock School of Public Health, National University of Singapore and Health Intervention and Technology Assessment Program; the Health Economics Research Unit of the KEMRI Wellcome Trust Programme, the Norwegian Institute of Public Health and the Clinton Health Access Initiative, Inc.,in addition to current core partners: the Global Health and Development Group at Imperial College London, the China National Health Development Research Center and the Center for Global Development.

The network endeavours to generate long-term, locally-owned solutions to health care challenges through building capacities for using evidence in policy and clinical decisions. Its impact to date includes influencing policy in eight countries – China, India, Indonesia, Philippines, Vietnam, South Africa, Tanzania, and Ghana – where there has been tangible progress toward national institutions being established to embed value-for-money into decision-making about what medicines, vaccines or other health services should be offered to the population, and how these could be procured in the most cost-effective way. Already iDSI has supported Tanzania to prioritise its Essential Medicines List from 500 to 400 drugs, reducing spending on poor value items and freeing up resources to improve access to the most cost-effective medicines, trained Kenya’s Health Benefits Package Committee on measuring the added value of a new health intervention compared to existing ones, piloted a local quality improvement initiative with hospital staff in Vietnam to reduce inappropriate antibiotic prescribing for pneumonia and brought together more than 100 policy makers, academics and industry representatives working across Sub-Saharan Africa for a special event to share knowledge and best practices.

iDSI Director Kalipso Chalkidou, a Professor of Global Health Practice at Imperial College London who also directs the Global Health program at the Center for Global Development, said: “With government and aid budgets under pressure, many developing countries are facing declines in health funding and are going to have to make difficult choices. Policymakers’ decisions about what health care to make available and at what cost can be a life or death decision for people across the developing world. We will inform these critical decisions with data and evidence that maps out how best to spend limited funds to improve outcomes and save lives.”

Chinese, Thai, Norwegian, and British governments have backed iDSI, which also receives funding from the Department for International Development, the UK government department responsible for administering overseas aid.

Amanda Glassman, Chief Operating Officer at the Center for Global Development, said: “Previous health care decision making in developing countries has too often been driven by inertia and lobbying rather than science, economics, ethics and the public interest. We want to change that.”

Ira C. Magaziner, Chief Executive Officer of the Clinton Health Access Initiative Inc (CHAI), said: “Low- and middle-income countries are set to make great strides toward universal health coverage in the coming years, ensuring that all people have access to affordable and quality care. CHAI works with governments that are implementing health financing and service delivery reforms to meet this goal. We are excited to deepen our collaboration with the iDSI network to help partner governments set health care priorities, drawing on iDSI’s expertise and years of experience across different country settings.”

Trygve Ottersen, Executive Director at the Norwegian Institute of Public Health, said: “Without proper support, it is hard for decision-makers to navigate within the broad and ambitious agenda of the Sustainable Development Goals and to make evidence-informed choices that are both fair and efficient. iDSI serves as a unique platform for supporting the most critical choices on the path to UHC and the Institute is delighted to be part of this partnership.”

Professor Teo Yik Ying, Dean of the Saw Swee Hock School of Public Health at the National University of Singapore, said: “The Saw Swee Hock School of Public Health at the National University of Singapore is delighted to be a contributing partner to iDSI. The mission of iDSI to support evidence-based decision making in global public health is aligned to the mission of the School, with the aim of translating research discoveries to improve the health of global communities.”

Dr Somsak Chunharas, from the National Health Foundation of Thailand, said: “Being an organisation promoting evidence-based policy and system development in Thailand for the last 30 years, the National Health Foundation looks forward to this opportunity to share and learn from various countries’ context in establishing the mechanism and tools for evidence-informed policy.”

iDSI was borne out of the recommendations of the Center for Global Development’s Priority-Setting Institutions for Global Health Working Group in 2012.

A HSR 2018 satellite session, which will focus on health financing towards Universal Health Coverage (UHC), has received funding from Sida, working on behalf of the Swedish Parliament and Government. The full day session is co-hosted by the Clinton Health Access Initiative, Sida and iDSI.

1. The satellite session will feature policy makers from Sub Saharan Africa sharing their experiences developing and implementing policies and reforms to make progress towards UHC. What are you hoping will come out of this session?

Low and middle-income countries are facing a very similar set of health financing challenges and implementing related reforms. There are many success stories and practical experiences to be shared from the people currently implementing reforms on the ground.

We are hoping that this session will contribute to strengthening the knowledge exchange between the decisions-makers from Low and middle-income countries in how to best address common challenges and learn from each other.

We will focus on how priority setting, defining basic health services, resource allocation and strategic purchasing can be applied to make progress towards UHC, including essential sexual and reproductive health and rights (SRHR): What do we pay for, which services and for whom, and how do we pay it? How do we make the difficult choice of prioritising certain services above others and how do we ensure that services are delivered in a sustainable and equitable way? How do we ensure key services such as SRHR are included and specific needs of for example adolescents and young women are not left behind.

2. Can you tell us more about the facilitators and panellists that will be part of the satellite session?

We are bringing together leading researchers, government officials and policy representatives from Asia and Sub-Saharan Africa that have on the ground experience in developing and implementing policies.  This includes government representatives from countries Sida is supporting, with technical assistance from the Clinton Health Access Initiative (CHAI) in health financing reforms (Ethiopia, Rwanda, Malawi, South Africa, Eswatini, Zambia).

We believe this mix of people will make for interesting discussions. We will also open up the floor after each sub-session for an audience of international attendees.

3. Investment in sexual and reproductive health and rights in Sub-Saharan Africa is major part of Swedish development cooperation. Can you tell us some more about the work of the regional team based in Lusaka and Sida’s approach?

Sweden has a feminist foreign policy and SRHR is a top priority for Swedish Development Assistance. Approximately 60 per cent of our official development assistance for health is directed towards SRHR. The regional team works on SRHR to advance the continental and regional agenda for sexual and reproductive health and rights through supporting legal and policy reform, expanding access to essential SRH-services, changing social norms around gender and sexuality, as well as advancing accountability for regional commitments. The team has partnerships with regional economic communities such as the Southern African Development Community (SADC) and East African Community, parliamentary fora such as SADC Parliamentary Forum, the UN including the United Nations Population Fund and WHO, research institutes and civil society networks. Our work with CHAI on health financing is an important part in advancing SRHR in sub-Saharan Africa. Access to SRHR services, under a model for UHC, requires a transparent and inclusive discussion on how resources are prioritised and what services to include in basic packages based on the best available evidence. For us, UHC is based on the principle that basic health services should be provided to all. If these principles are adhered to, SRHR services become naturally prioritised.

Sida’s commitment to SRHR is likely to remain for the foreseeable future. Therefore we believe in establishing long-term partnerships with organisations that can contribute to normative change in the region.

4. What do you enjoy most about your role?

My position gives me a good overview of regional SRHR issues and a chance to see how different structures and processes are related. Thanks to that overview, I have a unique opportunity to connect partners and key actors to initiative and networks where synergies can be created. The HSR 2018 satellite sessionis a good example of connecting people to achieve more. Personally, I am very happy to be part of the promotion of SRHR-interventions as a natural and integral part of basic health care packages and UHC since these services respond to common and often recurring needs in the population and therefore must be included in public commitments.

5. If you weren’t in the global health, what would you be doing instead?

Living in Sweden I would probably work for a health provider with Lean production and quality assurance or in a purchaser–provider organisation defining volumes, cost levels and quality standard of health services in assignments to health providers, both public and private. Irrespective of which job, I would make sure I was involved in organisational and operational development since it really matters “how” services are provided and what results you get for your money.

Conference delegates can attend ‘Health financing towards UHC’ from in conference room 13 from 8.30am on Monday 8 October as part of HSR 2018 of which the overaching theme is ‘advancing health systems for all in the Sustainable Development Goals era’. Find out more at www.healthsystemsresearch.org/hsr2018

1. You are a panel member in the sub-session, ‘Design of Health Benefit Packages’ during the HSR 2018 satellite session on Health Financing for Universal Health Coverage (UHC), co-hosted by Clinton Health Access Initiative, the Swedish Government and iDSI. What do you believe your experience will bring to the discussion?

I have been coordinating the process to define benefit packages in preparation for implementation of National Health Insurance (NHI) in South Africa for the past two years. NHI is our version of UHC and aims to address historical inequalities by bringing the public and private sector into a unified national health system. As I have been responsible for health programmes in South Africa for the past 10 years this was a good fit. I think I will benefit as much from the discussion as I think I can contribute based on our experiences in trying to design benefits in a rather complex environment – with a large private health sector and many medical insurance companies and administrators.

2. What are Health Benefits Plans and why are they important?

Health benefit plans define the services that will be available within a health system and should cover all levels of care, from community based services through to highly specialised care. This is important for at least two reasons: (a) certainty on what services are offered; and (b) ensuring that these services are funded.

3. What have been the challenges in development of the benefits package in South Africa?

An initial challenge has been the wide range in standards and guidelines relating to service delivery in South Africa not just across the public and private sector, but also across disease areas. We are addressing this as a priority to ensure a common understanding of acceptable quality of care prior to costing. Other challenges include: (a) availability of data, including epidemiological data, (b) limited or fragmented health technology assessment capacity in the country; (b) political pressure to include all services currently available – even in the context of limited resources; (c) and the designing of a transparent process by which to prioritise services and revise the package over time.

4. If you weren’t in the healthcare field, what would you be doing instead?

Human rights lawyer!
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Conference delegates can attend the session, called ‘Health financing towards UHC’ from in conference room 13 from 8.30am on Monday 8 October as part of HSR 2018 of which the overaching theme is ‘advancing health systems for all in the Sustainable Development Goals era’.

Find out more at www.healthsystemsresearch.org/hsr2018

1. The poor are the primary beneficiaries of this scheme

Modicare’ s predecessor, the government-run health insurance programme Rashtriya Swasthya Bima Yojana (RSBY), covered only those identified in the national census as below the World Bank-defined ‘poverty line’ of $1.90 per day. Under Modicare, coverage criteria will expand to include identified occupational categories of urban workers’ and their families.

2. The scheme covers secondary and tertiary care only

There are approximately 1,500 secondary and tertiary care procedures nominated in the package of services covered under the scheme.

3. Responsibility for financing the scheme will be shared between the Central and the State governments

Purchasing will occur through a State-run trust fund or a market-driven tendering process. The States will be given flexibility over the financial administration of the scheme. 

4. Beneficiaries can avail benefits in both public and empanelled private facilities

States will be given flexibility over choice of care providers and means of purchasing and procurement.

5. The Scheme will pioneer the use of a novel digital information capture system

Utilising India’s biometric ID scheme, ‘Aadhar’ identification cards will be used to capture details of enrolment, claims and reimbursement activity in each State.

The rollout of such an ambitious scheme in a country as large and diverse as India faces challenges, including the identification of and outreach to beneficiaries; putting in place adequate governance and regulatory mechanisms to reduce fraud and low value care; and making sure finances allocated to provide for the scheme match local need.

Ensuring the delivery of high quality of care will perhaps be the most important challenge to address, given India’s recent ranking in terms of quality and accessibility of healthcare in the Lancets’ Global Burden of Disease study.

Nevertheless, Modicare represents a unique opportunity to provide access to healthcare to a population that sorely needs it, moving India one step closer to Universal Health Coverage and bridging economic, gender and social divides.

The scheme is due to launch next week on 25 September.

The ‘setting priorities fairly’ event is the first of its kind for Sub Saharan Africa (SSA), with the main event opened by Ghana’s Minister for Health, Kwaku Agyemang-Manu. How important is it for representatives from SSA to share knowledge to optimise the impact of health spending?

The prospect of HTA in SSA is promising, with an increasing number of countries planning to use HTA as a priority-setting tool to promote Universal Health Coverage (UHC). In the light of this, it is crucial that SSA countries share experiences (however little) to learn from each other.

What can attendees to your workshop session on case studies of how Health Technology Assessment can inform decisions on cost-effectiveness expect?

Attendees can expect to learn what has been done already, especially in the case of Ghana and how that applies to their specific country context.

Ghana was the first Sub Saharan African country to introduce a National Health Insurance Scheme (NHIS) and has long standing commitment towards achieving UHC, of course, there is no “one-size-fits-all” approach to UHC, but what is on Ghana’s agenda?

Ghana’s road to UHC through the NHIS has been brave and bumpy, with key challenges relating to financial sustainability. However, given the political support – from all sides of the political divide – the future of the NHIS is bright. A key approach is expanding enrolment through innovative strategies including group enrolment, enrolment of prison inmates etc. In addition, there are efforts to boost the financial status of the NHIS while removing other bottlenecks to promote UHC. A key way forward is re-visiting the Primary Health Care agenda to strengthen close-to-client services and implement provider payment mechanisms that reduce overall service costs and enhance sustainability of the scheme. The overall improvements in the economy could boost fiscal space for health and fast-track attainment of UHC.

You have led on a number of research projects on health economics and policy in Ghana, Botwsana, Kenya, Malawi and Nigeria – what has been your biggest achievement?

My joyous moments (which I see as achievements) are when I see that recommendations from a previous study I was involved in are evaluated and implemented. A typical example was when the Ministry of Health and World Health Organization in Botswana accepted the findings and recommendations of our study on efficiency and begun planning to implement.

What do you enjoy most about your role?

I enjoy seeing my former students in decision-making roles, applying some of the things they learnt. I also enjoy being involved in discussions and networking (with networks such as the platform that iDSI provides) that are directly relevant for evidence-informed policy making in low- and middle-income countries, particularly efforts that benefit Ministries of Health.

If you weren’t a health economist, what would you be doing instead?

I would have been a geomorphologist, studying earth formations.

Registered delegates can attend the workshop Justice will feature in, ‘Introduction to Health Technology Assessment’, from 1pm on 26 September 2018, as part of Setting priorities fairly: sustainable policies for effective resource allocation in Africa.

The US capital was the setting for three days of meetings and events to mark UHC Day and the release of ‘What’s In, What’s Out: Designing Benefits for Universal Health Coverage’.

IDSI’s time in DC kicked off with a Global Health Initiatives meeting attended by representatives from the Gates Foundation, World Bank, Givewell, the Center for Global Development (CGD), PRICELESS South Africa, the UK Department for International Development (DFID), Clinton Health Access Initiative (CHAI), Japan International Cooperation Agency (JICA), the Joint Learning Network (JLN), Tufts Medical, Disease Control Priorities (DCP), the Health Intervention and Technology Assessment Program (HITAP), the Norwegian Institute of Public Health (NIPH) and Gavi the Vaccine Alliance.

During the meeting iDSI, CHAI, JLN, NIPH and Tufts Medical Centre showcased their initiatives and the concentration of their work including their successes, focus countries and potential future opportunities.

Amanda Glassman

Attendees then heard from Global Development Funders’ representatives: David Wilson from the Gates Foundation, Julia Watson from DFID, James Snowden from GiveWell, Adrien de Chaisemartin from Gavi, Naina Ahluwalia and Somil Nagpal from World Bank and Yosuke Kobayashi from JICA; with all agreeing each partner group is carrying out valuable efforts in the bid to expand and improve healthcare globally.

Tuesday 12 December was the celebration of UHC Day around the world. A sold-out event at the CGD offices saw presentations from iDSI Director Professor Kalipso Chalkidou, CGD Chief Operating Officer Amanda Glassman, Professor Karen Hofman from PRICELESS, Waranya Rattanavipapong from HITAP, iDSI Board chair Professor Tony Culyer and a keynote speech by Dr Mark McClellan.

Copies of ‘What’s In, What’s Out’ were available for attendees to take away and Amanda Glassman explained how the creation of an explicit health benefits plan is an essential element in creating a sustainable system of UHC. With limited healthcare budgets comes tough decisions for policymakers, along with the many facets of governance, institutions, methods, political economy and ethics that are needed to decide what’s in and what’s out in a way that is fair, evidence-based, and sustainable over time.

Dr Mark McClellan

At the heart of Dr Mark McClellan’s keynote address was opportunities for greater value for healthcare spending – specifically, the ‘accountable care’ model, which sees providers held jointly accountable for the cost and quality of care for a defined population of patients.

Dr McClellan, a doctor and economist, said: “There is more healthcare can do than ever before, however this means rising costs in healthcare. The value of healthcare can be improved by developing and implementing evidence-based policy solutions.”

The importance of sharing data and creating interoperability to understand health outcomes within an accountable care system was also put forward by Dr McClellan, who provided Nepal as an example of success in utilising remote personal health tools, telemedicine and lower-cost sites of care: “In Nepal a simple process of patients’ texting in information can result in a visit to their homes by community care workers and a potential prescription of antibiotics. Investment in these modest but effective interventions can also gather useful metrics in the form of electronic health records. We need to move from ‘siloed’ data to data that provides intelligence about our populations.”

Waranya Rattanavipapong

HITAP’s Waranya Rattanavipapong presented on building research capacity for UHC in Southeast Asia and told of how analysis by HITAP revealed Indonesia could save 90% of its insulin budget. Waranya said: “Indonesia has a current budget of $18 million per year for insulin. Tens of millions more than necessary is being spent on modern insulins to treat diabetes despite evidence cheaper products work just as well. Our analysis revealed switching from insulin analogue to human insulin and negotiating to Thai prices ($2 for human insulin and $9 for insulin analogue, compared to $20 for human insulin and $22 for insulin analogue in Indonesia) could save 90% of the budget.”

Professor Karen Hofman detailed the strides South Africa has taken towards promoting the health of the population by passing a bill to implement a tax on sugar-sweetened beverages. Professor Hofman, who proudly sported an ‘I am #sweetenough’ t-shirt supporting the sugar tax, focused on fiscal levers in South Africa and the positive impact they have had in the past: “After the increase in the excise tax on cigarettes, sales reduced between 1993-2009 by one third and per capita consumption decreased by 50%. With 25% of teenage girls in rural areas overweight in South Africa, the time is now for translating evidence on sugar to policy. There will inevitably be push-back from various sources but the passing of the bill, which will be implemented in April 2018, is a powerful step forward.”

Professor Karen Hofman

Professor Tony Culyer rounded up the event and took to the stage to emphasise iDSI’s objectives to help low- and middle-income countries to transition from aid, develop skills to spend smarter and to increase access to quality healthcare so they can achieve UHC: “Our aim is to give LMICs capacity to produce policies that will have an impact of health. We wish to leave behind an endowment of expertise for LMICs to build better worlds for themselves.”

A recording of the ‘Better Decisions, Better Health: Practical Experiences Supporting UHC from around the World’ event is available on the CGD website (1 hour 32 minutes).

UHC Day, commemorated each 12 December, is the anniversary of the first unanimous United Nations resolution calling for countries to provide affordable, quality healthcare to every person, everywhere. The United Nations Sustainable Development Goals, that all UN Member States have agreed to, try to achieve UHC by 2030. This includes financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

Professor Tony Culyer

Key features of the policy include the establishment of the HTA unit in the Department of Health (DOH), a description of the principles, criteria and process, as well as the composition and qualifications of the appraisal body. These provisions strengthen existing policies related to HTA, such as the Philippine National Formulary System (PNFS) in DOH and the Priority Setting Process in PhilHealth. The bill is a legislative priority of the current administration so we are hopeful that it receives substantial support from the upper house. We recognise HTA as a key tool to achieve universal health coverage in the country as per the HITAP sponsored World Health Assembly 2014 HTA Resolution, especially since service coverage remains fragmented and out-of-pocket payments are still high at 53.7% of total health expenditure (2014), despite 92% of the population having health insurance.

Global collaboration

iDSI, has provided support to the Philippines during the PNFS’ early stages. In 2011, NICE International started work with the MoH under The Rockefeller Foundation support, and in 2012, the National Center for Pharmaceutical Access and Management (NCPAM) (now called the Pharmaceutical Division in DOH) together with HITAP, conducted two policy relevant evaluations on the PCV and HPV vaccine. This project enabled NCPAM staff to visit HITAP and publish articles in international peer-reviewed journals, some articles can be viewed here and here. Two of the DOH staff are now back in Thailand pursuing a postgraduate programme in HTA at Mahidol University under iDSI scholarships.

More recently, the DOH also arranged a visiting scholarship of the HTA team lead to the Global Health and Development Group (GHD) at Imperial College London (the successor to NICE International), where they received guidance on: developing the country’s HTA roadmap, the revised process guidelines, and on economic evaluation for COPD drugs. It was also through the participation in knowledge sharing activities and international conferences that HTA was brought back on the policy agenda last year. Philippine policy makers and researchers participation in the Prince Mahidol Award Conference 2016 (co-hosted by HITAP, NICE international, and others) re-ignited the policy discussions and research on HTA and priority setting in PhilHealth and DOH.

HTA as a tool to achieve universal health coverage

Under the current bill’s whole system, society, & government approach, the vision is that the country coordinates a multisectoral approach, inclusive of all stakeholders, which looks at each component and function of the health system to realise UHC. This entails establishing a single institution that sets actionable (i.e. reimbursable) priorities for payers of healthcare. However, much capacity building is needed in terms of individual research skills, as well as sectoral capacity to manage and implement such processes. There is also a need to enhance policy makers’ understanding of what HTA is, how it is done, when and where it should be done, as HTA is not the answer to all policy questions. For example, the legislation specifies the use of HTA as an input in revising the Health Benefits Package. Another use could be in pricing discussions with manufacturers. Further, effective HTA has to accommodate existing health system features, including the interplay of different financing agents, private and public healthcare providers, and other stakeholders.

Despite these challenges, we believe that as a country, we have made significant progress towards building our national HTA institution. Last July, a HTA study group was established in the Health Research Division of the Health Policy Development and Planning Bureau in the DOH. The team has full-time researchers in charge of coordinating and implementing HTA related research activities. The DOH also just approved a revised process guideline for HTA, which expands the scope to cover all interventions (not just drugs), uses explicit decision criteria, and a multi-stakeholder process from topic selection, to assessment and appraisal. These achievements would not have been possible without international collaboration with universities, development agencies, and other HTA institutions outside the country, all of which will be featured on the bureau’s website as soon as it is up and running.

While we are still quite a way from having a NICE or HITAP counterpart in the country, the path towards institutionalisation is much clearer now that there is political support, and as we are slowly developing capacity. The DOH is set to scale-up HTA implementation by hiring more full time staff in the coming months, and investing in capacity building programmes. Collaboration with international partners such as iDSI must be fostered in order to sustain momentum. A Letter of Intent for Cooperation between the Philippine Department of Health, HITAP and the Imperial team was recently signed paving the way for further collaboration in the future.

Our Impact

The second feature of the new website that we would like to introduce is the ‘Our Impact’ section of the site – which focuses on country specific work that ranges from developing quality standards to building capacity for health technology assessments.

Use the interactive map to explore the in-country projects that we are supporting – clicking on the country will take you to a page that highlights what work is being conducted and who we are partnering with to enable better healthcare decisions.

Click on South Africa and you will see we are working with our core partner PRICELESS SA (Priority Cost Effective Lessons for System Strengthening South Africa) a research unit based at Wits University School of Public Health, to develop capacity to undertake and use evidence provided by Health Technology Assessments to better inform government decisions on healthcare.

We’ve been working in South-East Asia for a number of years to bring about improvements to healthcare systems and policies. iDSI core partner HITAP (Health Intervention and Technology Assessment Programme) who are based in Thailand lead on much of this work. Our involvement in Vietnam has helped to to embed HTA evidence into designing a safer public health care system, and to improve hospital quality in key disease areas.

“The collaboration with iDSI has led to policy change and has been of great value to us in Vietnam. I appreciate the commitment shown by iDSI in supporting Vietnam to use evidence to inform decision-making in health.”

– Prof Pham Le Tuan, Vice Minister of Health in Vietnam

Find out more about our work in low and middle income countries by exploring the map here.

iDSI Knowledge Gateway

You can also search the iDSI Knowledge Gateway for specific country work using the ‘country focus’ search filter. For example you can view the documents related to our work in Thailand here. The iDSI Knowledge Gateway is an Open Access platform: providing decision makers within health on a global scale with free access to the tools and information they need to make better informed decisions to improve healthcare.

Stay up to date as we post about more of the new features on the website: follow us at @idsihealth and sign up for our newsletter using the form in the right hand side bar.