Within the eligibility and graduation debates, a major touchstone is whether health aid recipients, as they get richer and graduate, are going to pick up essential health services currently funded by aid such as immunizations or antiretrovirals. And, if not, why not and what should donors do about it?

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Although the Thai Universal Healthcare Coverage (UHC) excluded ART for HIV/AIDS when it was introduced in 2002, it included ART for all eligible patients the following year due to the Prime Minister’s announcement during the World AIDS Conference in Bangkok. Whether this inclusion was based on evidence, careful consideration, or political bravery, it has 070-667 been considered as another success story by champions for HIV and the story was used to inspire other low- and middle-income countries (LMICs) to follow the path of providing universal access to ART.

Until March 2014, almost 300,000 HIV-infected persons received ART. The current ART guidelines indicate that HIV-infected persons with CD4 lower than 350 cells/mm³ are eligible. This change two years ago in the CD4 threshold from 250 cells/mm³ was the result of a long standing debate between two opposing groups: One opposed the change because they estimated that almost 33,000 patients with CD4 lower than 250 cells/mm³ were not able to access ART due to several reasons, including unknown HIV status. The other supported the change because scientific evidence proved a greater health benefit of HIV patients. The central theme of the debate surrounded the issue of whether Thailand should devote their limited resources to patients who could not access ART by identifying unknown HIV infections versus giving the benefits to those who already knew of their HIV status but did not qualify for the CD4 threshold.

On 31 July 2013, the national AIDS committee approved an ‘end AIDS’ policy, with the ultimate goal of zero mother-to-child HIV transmissions, reducing new
070-684 HIV infections to less than 1000 persons/year or 10% of the current statistic, and providing ART to all known HIV-infections. A key strategy of this policy is to provide ART regardless of CD4 levels. Although there is no evidence to support the benefit of ART for HIV patients at CD4 above 500 cells/mm³, a study in Africa showed that early ART can reduce HIV transmission. So ART at an early stage is mainly for the benefit of society and perhaps at the cost of the patients’ health due to potential adverse reactions and drug resistance. Surprisingly, there is not much debate at this time, which may be due to the previous painful debate.

The national AIDS committee produced a report indicating that the policy was based on economic evidence, produced by overseas AIDS experts. The evidence suggests that expanding or scaling up ART to all HIV-infected individuals would offer good economic return to the country: spending USD $95 million over 10 years would result in a return of investment amounting to over USD $300 million. In other words, the benefit to cost ratio of the scale up is equivalent to 3:1.

HITAP was requested by the National Health Security Office (NHSO) to assess the feasibility of this policy because the NHSO needs to be responsible for financing major activities of this end AIDS policy. HITAP carefully examined the evidence presented by the AIDS committee and the respective national plan proposed by the public authorities responsible for policy implementation. Two obvious issues arose from the review. First, the report provided an optimistic estimate of the effectiveness of HIV screening, which is a crucial success factor of the end AIDS policy. It suggests that 1 new HIV case would be detected for every 26 screened. This is in contrast to the empirical evidence in Thailand, showing that scaling up HIV screening would significantly increase the number of screenings needed to identify a new HIV case to more than 200. Secondly, the bigger issue is that the report informs us that the USD $95 million needed for the policy is of a net present value (discounting all future investments in the current value of money). This figure was referred to by the AIDS committee and used as an absolute number, saying that the policy needs USD $100 million of investments over 10 years or an additional USD $10 million per annum on top of the current HIV budget. HITAP’s estimation is that if the net present value is converted to an absolute number, the policy will require USD $380 million or an average of USD $38 million per annum.

The review results were presented in a stakeholder consultation meeting last month and created debate about the financial sustainability of this policy and feasibility of devoting human resources for HIV screening and early ART, especially in making asymptomatic patients adhere to the treatment in order to prevent the development of drug resistance in patients with poor ART adherence. Drug resistance would lead to a higher burden of finances and human resources in offering more expensive second-, third-, and fourth-line ART drugs, which is not properly incorporated in the economic analysis.

It remains to be seen how the NHSO will decide on this case, but one thing is certain: this circumstance illustrates the benefits of having evidence-based policy decisions. All decisions are made based on publicly available evidence for all stakeholders to carefully consider and discuss. However, it also shows that making evidence available for policy decisions is not enough. Decision makers and other stakeholders need to be empowered to access and appropriately interpret the available evidence to be able to claim that policy decisions are well-informed by evidence. This showcase is very much in line with the scope of iDSI in which we try to build up local capacity of researchers and decision makers to be able to generate and make use of evidence appropriately, across health problems as opposed to specific diseases or technologies. The process takes time, effort, and compassion but leads to sustainable health development.

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iDSI aims to help policymakers in low and middle income countries in building capacity for active priority-setting, such that they can spend limited health budgets in a more efficient and equitable way, and achieve sustainable universal health coverage (UHC). In order to help achieve iDSI this aim, we at NICE International have developed a questionnaire to assess countries’ ‘priority-setting readiness’. We believe this is the first published questionnaire that comprehensively captures priority-setting readiness at a health systems level, beyond the technical dimension of health technology assessment (HTA).

We are now making this questionnaire freely available as a global public good, and we hope it will be useful to policymakers, global health funders, academics and international development partners.

Download iDSI Priority-setting Questionnaire v1.0 – Jun 2014

Our questionnaire builds on an earlier questionnaire developed jointly with HITAP for the purposes of a training workshop in Hanoi, Vietnam (Situation analysis of HTA Introduction at national level, version 2.0, October 2013; for non-commercial use only).

Priority-setting is not a merely technocratic exercise. Thus priority-setting readiness comprises more than just technical capacity; it also encapsulates institutional capacity, the political appetite for priority-setting, as well as the potential for the country to benefit from improved priority-setting processes. In May 2014, we saw the adoption of the World Health Assembly Resolution on Health Interventions and Technology Assessment for UHC. The principles behind this Resolution are in line with the objectives of iDSI, and we believe that our questionnaire can be a useful needs assessment tool for countries committed to UHC.

We have designed the questionnaire with flexibility in mind. For instance, we piloted this questionnaire as a supervised teaching tool at the recent AfHEA conference, to help delegates understand and think through the opportunities and challenges for priority-setting in their respective countries. And as part of a comprehensive priority-setting mapping exercise of 17 low and middle income countries for iDSI, we have obtained useful data from asking key opinion leaders to self-complete this questionnaire, and using the responses to guide more in-depth discussion.

iDSI’s global public good offerings will evolve and improve with time. We are always striving to produce something that will be useful in helping people make decisions, and we would very much appreciate your feedback to make this questionnaire a more useful product.

Preferred citation: NICE International (2014) Mapping of priority-setting and HTA: Questionnaire. Version 1.0. NICE: London.

Cost-effectiveness studies compare the costs and benefits of different interventions with the aim of improving decisions on the allocation of scarce resources for health.  Or, put simply, they allow policy-makers to set priorities for health spending and consider how the next dollar available can get more health for the money. 

The Bill & Melinda Gates Foundation (BMGF) funds about a fifth of all published cost-effectiveness studies on interventions to address AIDS, tuberculosis, malaria, and vaccine-preventable diseases in low- and middle-income countries. BMGF also plays a high-profile role in promoting the concept of cost effectiveness as a criterion for global health decision making and spending.

But for cost-effectiveness studies to actually improve decisions, methods must be appropriate and reporting must be clear and accurate. If not done well, these analyses can be difficult to interpret and can lead to suboptimal or even incorrect decisions.

So BMGF recently commissioned NICE International, the University of York, and the Health Intervention and Technology Appraisal Program (Thailand) to develop the Gates Reference Case, a principle-based standardized methodology for economic evaluation in developing countries. The principles are described in detail here, and cover issues of transparency, comparators, better use of evidence, and measures of outcomes, among others.  Using these principles, they also assess retrospectively how published BMGF-funded studies have fared since 2000.

The results of the study were disappointing.  Paraphrasing the report:

“Most studies provided insufficient information about currency conversions and/or methods for adjusting costs to account for temporal disparities. Where information was provided, crude exchange rates were frequently used to convert unit costs drawn from other settings (often high-income countries). There was poor adherence to the three key methodological specifications for DALY estimation, raising significant concerns as variant approaches to DALY calculation limit comparability between studies. Although widely considered as the most comprehensive method of dealing with the various sources of uncertainty in economic evaluations, few studies presented probabilistic sensitivity analyses. Generalizability and transferability of results and equity implications of evaluated interventions were discussed in less than one-third of all reviewed studies. Only 35% of studies discussed the affordability of the interventions being assessed, despite these studies being undertaken in very resource-limited settings.”

Bottom line: it is tough to use this body of evidence to make better decisions.

Reference cases have been in the public domain for some time, and have been adopted by the US Panel on Cost-Effectiveness in Health and Medicine, the World Health Organization, and NICE itself, as a means to improve quality and comparability in the conduct and reporting of cost-effectiveness analyses. BMGF adoption could greatly improve the quality of economic evaluation for global health, particularly if the case is used as a condition for funding and a criterion for a specialized peer review as part of the commissioning and oversight of cost-effectiveness studies.

At the recent launch of the Reference Case, the Foundation announced plans to create incentives for researchers to adhere more closely to the best practice principles laid out in the Reference Case. Other cost-effectiveness analysis funders should follow suit; Wellcome Trust/MRC, DFID, USAID, and others could use the same standards and even the same peer review mechanism. Widespread use could enable more meaningful and explicit comparison of analyses and findings across multiple studies, which in turn will allow cost-effectiveness analyses to better guide health care spending decisions in developing countries.