Better policymaking for universal health coverage (UHC) requires different actors in the health system to have the right capacities to generate and use evidence. Led by HITAP, in Vietnam iDSI has been supporting the Health Strategy and Policy Institute (HSPI), a technical unit under the Ministry of Health, to build capacity for generating policy-relevant health economic evidence. Through 2016 we have supported HSPI to provide advice to Ministry of Health on reviewing its Basic Health Services Package, identifying high-cost interventions that are inappropriate or poor value for money among the 17,000 drugs and services currently reimbursed by Vietnam Social Security (VSS), the implementing agency for Vietnam’s social health insurance scheme.

As this work draws to a close in January 2017, HITAP and Imperial College visited Hanoi to plan the next phase of iDSI activities with HSPI. iDSI is now also engaging with VSS to explore practical ways of issuing a revised benefit package (based on both clinical and cost-effectiveness evidence) as a national healthcare payer, in order to achieve efficient, fair and high quality UHC.

Dr Netnapis Suchonwanich, Adviser, HITAP (former Deputy Secretary General of National Health Security Office) shares the Thai experience of implementing efficient UHC

April 2015

NICE International coordinated two events in Hanoi on health benefits package design in partnership with the Health Strategy and Policy Institute and the Vietnamese Health Economics Association.

A health benefits package is the range of technologies and services that are available at a free or subsidised rate to the insured population, and the methods, processes and policies that contribute to its design and inclusions or exclusions are central to achieving and maintaining universal health insurance coverage. The events included a meeting to share international experiences of decision making for health entitlements and benefits package design, and a workshop focusing on the status and future direction for benefits package design in Vietnam.

The events were opened by Professor Pharm Le Tuan, Deputy Minister of Health who advised of the importance of the role of a high quality, nationally accessible and affordable benefits package as Vietnam moves towards Universal Health Coverage. Dr Tran Thi Mai Oanh, Director of the Health Strategy and Policy Institute and Dr Kalipso Chalkidou, Director of NICE International endorsed the Deputy Minister’s comments and highlighted the beneficial role of continuing partnership and joint working between Vietnamese institutions and iDSI

Sir Andrew Dillon of NICE, UK and Dr Yot Teerawattananon of the Health Intervention and Technology Assessment Programme (HITAP), Thailand shared the experience of their country’s approach to determining access to technologies and services.  They were joined by Ursula Giedeon of the Inter-American Development Bank on an international panel who discussed initiatives in different South American countries to establish explicit benefits packages.

Attendees also benefited from hearing experience from Dr Sastroasmoro and Dr Gyansa-Lutterodt who shared early experiences of health technology assessment and benefits package design in Indonesia and Ghana.

At the workshop Amanda Glassman of the Center for Global Development presented a comprehensive overview of key themes in benefits package design and explained how a methodological and strategic approach can optimise health outcomes from within limited resources available for health. The diversity of international experiences provided useful insight into potential opportunities and challenges facing policy makers in Vietnam and was a valuable input to the strategic direction of the Vietnamese benefits package.

Developing capacity for HTA and quality improvement initiatives are key areas where NICE International and HITAP are working with colleagues in the Ministry of Health and supporting institutions in Vietnam.  The benefits package workshop showcased pilot HTAs conducted by technical teams, showing how the information produced through HTA can be a valuable input to benefits package design. Highlighting the importance of the quality component to services patients receive as part of a benefits package, recent work to adapt Quality Standards used in the English National Health Service to the Vietnamese context were also presented and discussed.

Importantly, the events facilitated discussion by local policy makers and stakeholders on the institutional arrangements and strategic direction for benefits package design. Presentations from the Department of Planning and Finance in the Ministry of Health and Vietnamese Social Security in addition to an overview of the status of social health insurance by the World Bank Vietnam office provided a comprehensive overview of the underlying needs and current status of benefits package design and enabled attendees to generate key areas of recommendation for work going forward. Recommendation areas included the need for analytical and administrative capacity development, established process and evidence generation and use, and a focus on communication and implementation activities. Dr Duong Huy Lieu, Chairman of the Vietnamese Health Economics Association closed the events reiterating the importance maintaining the momentum for benefits package reform in Vietnam and continuing dialogue between all major stakeholders.

The meeting and workshop brought together departments of the Vietnamese Ministry of Health, Vietnamese Social Security (the state insurer), local clinicians and academic institutions, policy makers from around the world and international experts in benefits package design.

The events were supported by the Rockefeller Foundation and were part of NICE International’s long-term partnership with the Ministry of Health of Vietnam on their journey towards achieving Universal Health Coverage (UHC).

NICE International supports Vietnamese colleagues in Health Technology Assessment capacity building

July 2014

NICE International staff joined the Health Intervention and Technology Assessment Program (HITAP), Thailand, in the delivery of a week-long training course on health technology assessment in Hanoi, Vietnam. The in depth course covered fundamental aspects of the conduct of health technology assessment including searching for and synthesising evidence, health state evaluation, costing methods and decision rules. The course participants were from the various institutions in Hanoi that are currently engaged in some form of economic evaluation and is part of a wider Rockefeller Foundation-funded initiative to use the results of health technology assessment to informing priority setting and health policy in Vietnam.

Support for basic package design

November 2013

NICE International completed the first phase of its programme to support the design of the basic package of healthcare subsidised at Vietnamese health facilities. This included interviews and group discussions to outline current mechanisms for basic package design and targeted training events in collaboration with the Health Interventions and Technology Assessment Program (HITAP), Thailand.

The “Principles of HTA” training event, held at Hanoi Medical University, targeted researchers and policymakers who will be conducting economic evaluations. The event attracted 40 attendees from universities, the Ministry of Health, and affiliated research institutions. 80% of attendees felt confident or very confident that they could apply the training to their current work.

The “HTA in Policy” training event was held at Hanoi School of Public Health, and primarily targeted policymakers interested in how HTA can inform priority-setting decisions in health. This event featured theoretical approaches to basic package design, and experiences of how HTA is used for priority-setting in the UK and Thailand

HTA in Vietnam conference

Hanoi Medical University and VHEA hosted a conference on HTA in Hanoi on 15 – 16 November. The conference provided a forum for senior Ministry of Health policymakers , healthcare professionals and researchers from across Vietnam, and international partners to discuss current research and HTA developments in Vietnam. NICE International and partners delivered presentations on experiences from the Technology Appraisals programme and incorporation of health economic evidence in NICE Clinical Guidelines, and chaired panels on addressing the challenges to institutionalising HTA in Vietnam.

 Groundwork project

for more information on the Groundwork project, please click here

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.