The burden of NCDs remains high in low and middle-income countries (LMICs). Reducing this burden is at the forefront of the global health agenda, but how do countries go about doing this?

HITAP and partners from expert institutions have been commissioned by the Prince Mahidol Award Conference (PMAC); Institute for Population and Social Research; and Mahidol University to develop a book that draws on examples of cost-effective interventions for NCDs, dubbed ‘best buys’; cost-ineffective interventions for NCDs (‘wasted buys’) and controversies that can often proliferate both. We are delighted to have this work supported by the Thai Health Promotion Foundation and iDSI and hope the end product will capture what good investments have been for NCD prevention, whilst at the same time detailing obstacles policy makers must navigate, such as public opinion; commercial and trade interest; and unique health system challenges.

The project team are looking forward to launching the book as an ‘evidence package’ that will draw upon examples where lessons can be learned; and provide readers with the tools to review the evidence available.

Chapter authors and co-investigators met at the Center for Global Development Europe in London last month to review preliminary findings and decide on next steps for the project. One of the key points raised was the unavoidable, harsh reality that there is not just a dichotomy between ‘best buys’ and ‘wasted buys’. What may be a best buy in one setting can be wasted in another; and evidence on effectiveness can be weak or absent altogether in certain settings. Authors agreed that addressing uncertainties needs to be at the core of this project.

As well as raising local contextual questions, the project team agree the books content needs to highlight the monitoring and evaluation of interventions once implemented – effectiveness is not static and a ‘best buy’ can soon become a ‘wasted buy’.

Public health specialist and policy advocator Dr Suwit Wibulpolprasert, from Thailand’s Ministry of Public Health, said: “This is a dynamic research project that should not limit itself to a book but rather a continuous evidence-based social movement.”

We still have a year to go until the launch of the evidence package on UHC Day 2019 (12 December), in the meantime the project team can be found presenting preliminary findings at PMAC 2019. We will be at the PS2.5 session on Saturday 2 February 2019, 10.30am-12.30pm. Hope to see you there!

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.

Following approval by the Technical Appraisal Committee, this pioneering study will inform the ophthalmology surgical packages reimbursable under the new National Health Protection Scheme (NHPS), which is set to provide healthcare coverage for over 500 million Indian citizens.

The study identified phacoemulsification with foldable lenses as the most cost-effective intervention for lens replacement for cataracts in India compared to other available options such as small incision surgery, with an incremental cost effectiveness ratio of 3862.79 rupees per quality adjusted life year (QALY) gained. Cataracts account for ~70% of all blindness in India, so enhancing cost-effective management of the disease in the country will have a positive impact on many millions of Indian citizens.

iDSI partners Imperial College London and HITAP Thailand provided technical assistance to the HTAIN by providing hands-on training and practical skill building workshops, technical advice and assistance, and guidance in aspects such as how to identify and engage with stakeholders.

The intraocular lens HTA in India is a significant step forward for evidence-informed priority setting in India; and sets a strong example for other countries in the region to follow. Indeed, where it took 15 years to link HTA to prospective payment for secondary care in the UK under the National Health Service, the Government of India have seamlessly bridged the translation of HTA evidence into policy in one fell swoop. By using this kind of information to update and refine the benefit package offered under the NHPS, the Government can be assured of enhancing value for money of every rupee spent on the scheme – setting a strong precedent for scale and diffusion from the Centre for State governments to follow.

Many congratulations to the HTAIN team and all those involved in the study – a truly impressive feat!

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

To address this and improve the access and uptake of health care services, the Ministry of Health (MoH) of Zambia have embarked on a project to strengthen their basic health care services management (BHC for UHC Project), with the help of the Japan International Cooperation Agency (JICA). The project has identified that being able to effectively set priorities, such as which diseases to focus on and how best to allocate resources, is key to achieving UHC. The NHCP is currently under review in Zambia, so the need for evidence to inform any revisions and costing is greater than ever. JICA and the MoH are keen to learn from other countries that have successfully implemented an evidence-based policy formulation process.

Thailand is one of the earliest countries to have achieved UHC among the low and middle-income countries (LMICs) and through institutions such as the iDSI partner PRICELESS SA, visited the HITAP offices in July this year for a session focused on using HTA to provide evidence to inform the NHCP revision process.

The study tour comprised a four-day workshop and a day field trip to local health facilities and covered a range of topic areas including UHC and HTA development in Thailand, the role of HTA in various aspects of policy formulation and the process of developing the benefits package using a HTA approach. Further sessions were allocated for delegates from PRICELESS and the MoH Zambia to exchange ideas and explore potential areas for future collaborations.

The entire program was highly commended by the Zambian delegates. They were impressed with learning about the home-grown experience of Thailand in achieving UHC and institutionalizing HTA in the decision-making process. It was acknowledged that reviewing and costing of the NHCP, amongst others, would serve as a good starting point in introducing the concept of HTA to Zambia. Developing a policy brief on HTA was recommended as one of top priorities to gain stakeholders’ engagement in pushing the HTA agenda forward. The delegates were motivated by the potential role HTA could play in the quest towards achieving UHC in Zambia.

You know that the solution is ‘evidence-informed decision making’ but you also know that you and your colleagues have very limited capacity in this field. Is this situation familiar to you? Or, is it you?

HITAP International Internship Program might just be what you are looking for.

The Health Intervention and Technology Assessment Program (HITAP) plays a vital advisory role in Thailand in providing rigorous scientific evidence through Health Technology Assessments (HTA) for healthcare decision making to achieve Universal Health Coverage. Hitap provides evidence from a broad range of research activities, i.e.  economic evaluation and modeling studies, rapid and systematic reviews of literature, feasibility studies, ex-post and ex-ante studies, as well as system-wide studies. The organization also functions as a secretariat to the Health Economics working group for the National List of Essential Medicines, which oversees the HTA process from topic nomination and prioritization, results appraisal to generating evidence for price negotiations with industry players.

HITAP is continuously growing and it established its international units (HIU) to provide intensive technical and institutional support primarily to countries in Asia with nascent and emerging HTA systems.

The unit works closely with local partners to:

– conduct collaborative research;

– build HTA capacity of researchers in training sessions, conferences, and study visits;

– provide guidance on establishing an HTA agency (looking at governance, committee protocols, and hta processes);

– formulate HTA tools (e.g. economic evaluation guidelines, eq-5d-5l datasets, threshold studies);

– as well as support the linking of hta studies to policy.

This year HITAP will be providing international internship opportunities funded by the Thai Research Fund which is also known as the Senior Research Scholarship (SRS).

This internship program will fund three researchers from low-middle income countries (LMICs) to pursue their own proposed topic for HTA research, under a HITAP supervisor for a maximum duration of 9 months. It will be a tailor-made program based on the needs of the applicants. HITAP and HIU’s work for conducting and incorporating HTA for use in policy making both nationally and internationally will be used for mentorship in this program.

The potential areas include health economics, economic modeling, literature review, feasibility, health system and policy research or one proposed by the applicant!

Researchers at all levels are encouraged to apply, to find out more about the application criteria and process, visit HITAP’s website here.

Thai efforts to help Indonesia take efficient steps towards UHC

Jakarta: As we fly over the clear blue Java Sea, I notice the sand from a few scattered islands sloping into the clear waters. I glance again towards my right shoulder at the travel pack I have been reading, containing Indonesia’s country progress report and the objectives of our collaborative activities. I am part of a 9-member strong HITAP team approaching this mesmerizing Indonesian archipelago, containing islands said to be anywhere between 13 to 18 000. Indonesia is the fourth most populated country in the world with approximately 900 islands known to have a permanent human settlement. Its main island Java houses half of the 257.6 million people, while the other half of the population inhabit other islands in pockets. This certainly poses a veritable challenge for the provision of universal health coverage (UHC).

iDSI partners) will be shared in this three-day interaction with our collaborators from: Centre for Healthcare Financing under the Ministry of Health; the Healthcare Social Security Agency or the BPJS; the University of Indonesia; the Gadjah Mada University; members of the Health Technology Assessment Committee (HTAC); and, international partners such as PATH. HITAP aims to help the local research teams finalize four proposals of HTAs that will be conducted to improve Indonesia’s pharmaceutical reimbursement list.

The first two proposals are economic evaluations for targeted treatments cetuximab for metastatic colorectal cancer and bevacizumab for colon cancer. They are discussed together as they have comparable research objectives. The costs of these two interventions are strikingly high, so much so that they are not advised as first-line treatment options even in high-income countries like the UK. In the UK, cetuximab in combination with chemotherapy is only recommended for untreated metastatic cancer. In Thailand, both drugs are not recommended at all under their UHC. After cetuximab was included in the Indonesian national formulary in 2014 (until June-2016), it has already accounted for 6.5 billion IDR (O.5 Million USD) in treating only 32 patients.  Bevacizumab is similarly expensive and costs IDR 4.8 million/vial (100 mg in 4 ml) about 400 USD, that’s more than a return ticket from Jakarta to Biak, one of the furthest regions in Indonesia. The comparison here is made to appreciate not only the high cost of the intervention but also the need to address barriers to uptake. Distances between islands can be measured in many nautical miles and access is certainly a major barrier for this intervention with only 6 hospitals, located primarily in Java, having the capacity to diagnose and give treatment. Since targeted treatment for metastatic colon cancer prolongs life by a year and given the side effects from treatment and the debilitating effects of the disease, reflections were made on the utility a patient struggling with access is willing to make for an additional life year under targeted treatment. Therefore, the importance of using other less expensive strategies with lower side effects such as palliative care as comparators were emphasized in the study. This would give the study a holistic depth and an advantage to policy makers to deliberate all policy angles. Key emphasis was also made by HITAP for collecting data from the Indonesian nationals or from studies in comparable settings to add weight to findings in pushing for policy actions.

The third proposal is on Nilotinib, Imatinib and Hydroxy urea as possible first line therapy for Chronic Myeloid Leukaemia (CML).  The study proposes Dasatinib in combination with Nilotinib and Imatinib for second line therapy. Nilotinib and Imatinib are among the top 5 medicines with highest financial burden in the claims department. And though practice guidelines specify Imatinib as the first line medicine, the use of Nilotinib is currently higher. Over the course of discussions, the CML team opted for a mixed method study instead of an economic evaluation to: understand the process of approving Nilotinib use in Indonesia in comparison with other countries; evaluate factors influencing its prescription; and, identify any gaps in the reimbursement process which may lead to its overutilization.

Due to Indonesia’s high burden of type 2 diabetes (with a prevalence rate of 6.9 % among patients aged 15 years and above), the fourth study looks at insulin analog compared to more traditional human insulin. Insulin analogs priced 160,000 IDR or 12 USD per vial and are more widely available, with 96% of patients receiving insulin analogs, even though they are almost twice the price of human insulin (at 90,000 IDR or 6 USD per vial). The study aims to explore evidence for human insulin benefits to support scaling up its availability and prescription.

The three-day knowledge sharing and consultation process saw several key issues were identified and addressed, with consultation meetings including key comments from clinicians. The proposals had also evolved, with the focus shifting from purely economic evaluations to more need-based studies. HITAP teams also presented study risk evaluations to keep the studies on course.  The aim was not only to bring technical and knowledge skills but more so to focus on developing a well-designed study to help sound decision making for the benefit of patients in the largest economy in South East Asia.

This cross-country collaboration, with two countries openly sharing HTA knowledge and skills with each other, is perhaps a salient message not only for this region but for the global community. Thailand is taking a step further in Universal Health Coverage – towards compassion for other countries making efforts in UHC. Ironically, an advertisement for a major brand in Thamrin Street went that in the fashion industry there are no boundaries or borders, only ‘access.’ This resonates with me during our visit: the importance to involve compassion for countries committed to UHC especially those that may be facing either economic or technical hardships or both.

1- Dissemination Meeting on Developing Evidence-based Care Pathways for Chronic Disease in China
February 17th – Morning

National Developments showcase & providing means for utilising UK expertise

Following successful launch of this UK supported Prosperity Fund project on July 28th 2016, the dissemination meeting had the key aim of communicating progress in establishing a standardised approach to clinical guidelines development, and in applying them to update existing care pathways in China. The topic areas selected for the pilot were on priority chronic disease areas namely hypertension and diabetes that were currently in use in Xiamen and Qingdao cities.

A representative on the behalf of CNHDRC Director General- Ms Wei Fu gave an opening speech where he provided an overview of the burden of chronic diseases in China. He described China’s aging population as a critical high priority issue, highlighting the estimated 220 million people aged above 60 in China, added to by about 8 million people per year. He emphasized the significance of establishing a ‘tiered healthcare system’ in China utilizing UK NHS expertise and experience to support the local development of standardised care pathways. He concluded by inviting the audience of about 50 in number consisting of senior officials from Xiamen Health and Qingdao Health authorities, representatives from tertiary and secondary hospitals, nurses, local administrative officials and clinicians- to share the results of the preliminary version of the guidelines handbook, and encouraged feedback and discussion among attendees.

Ashwini Kirchner, Head of Health and Social Care at the British Embassy in Beijing highlighted the importance of bilateral commitment between the UK and China, to learn from one another. She stated that healthcare is a key point of interest between the two countries. Kirchner highlighted the aims of Prosperity Fund Project in providing cutting edge policy in an area where the UK can offer expertise, and to give way for a real impact on the ground.

Kun Zhao, Division Director in CNHDRC, described the status quo and progress of Chinese guidelines development. She compared UK and Chinese guidelines, and provided recommendations for realizing the project aims. She linked the importance of robust guidelines development with the considerable uncertainty around the effectiveness of most of new technologies in China, and the absence of economic and equity perspective in setting hospital treatment standards in different regions in China.

The preliminary version of the Chinese guidelines handbook received strong positive feedback from the audience. Changqin Liu, Vice President of the first affiliated hospital of Xiamen University noted the professionalism underpinning the handbook and described it as a first of its kind to be developed in China.

“This guidelines handbook is very comprehensive…It is first time where we can align with UK Clinical Guidelines principles….I learned a lot”
Fusong Liu- Cardiology department Director of The Third People’s hospital of Qingdao.

Professor Mike Roberts of UCL Partners concluded the meeting by giving a brief presentation on new models of care in the UK, such as ‘Integrated Care Pioneers’ and ‘Vanguard sites’. His presentation can be found here.

2- Leadership & Change Management training
February 17th – Afternoon

Leading Change: New guidelines, new approach..

The afternoon session was dedicated to a training workshop that builds on the introduction of the new guidelines in Xiamen and Qingdao hospitals. According to Mike Roberts, the implementation of new guidelines depends on a number of factors, the most important of which are understanding and managing the change process involved, and developing effective leadership among the interdisciplinary teams adopting the new hypertension and diabetes clinical guidelines.

The training workshop took place over 3 hours and involved presentations on change management by Reetan Patel, effective team leadership by Mike Roberts, combined with an interactive discussion and group work scenarios. The group work emphasised the experience of trying to implement a new set of clinical guidelines and how they may be understood from different perspectives among the stakeholders affected such as management, clinicians and other various implementing teams. The audience were mainly senior officials from Xiamen and Qingdao health authorities, representatives from tertiary and secondary hospitals, nurses, local administrative officials and clinicians.

3- iDSI HTA workshop: knowledge sharing event to support newly launched China HTA network
February 20th – 21st

The role of HTA in international development & National Regulatory Authority strengthening

The iDSI HTA workshop in Xiamen builds on the MOU supporting informed implementation framework for HTA between GHD and CNHDRC. The two-day workshop revolved around 6 main themes: standardised methods for economic evaluation, non-budget constraints and health system strengthening, measuring HTA impact and return on investment, HTA and medical devices, economic evaluation modelling and public health, and adapting HTA to the Chinese context.

The workshop commenced with an opening statement by a representative of CNHDRC on the behalf of Deputy Director Hongwei Yang, who emphasized that the current leadership in China is very supportive of HTA capacity building especially in light of major technology transformation in China.

Kalipso Chalkidou gave an overview of the objectives of the HTA workshop including outlining the role of iDSI HTA hubs for supporting national and regional HTA related activities. Kun Zhao introduced the China HTA network, which is a network of 29 institutions and hospitals backed with a great amount of support by the Chinese healthcare authorities (the presentation can be found here). Tony Culyer briefly introduced the iDSI Reference Case, what it is and how it can be adapted to China context (see his presentation here).

Professor Pete Smith of Imperial College London delivered a presentation on developing a framework for evaluating interventions aimed at health system strengthening. Eleanor Grieve of University of Glasgow talked about developing a theoretical framework for assessing the impact of HTA and the return on investment. Professor Klim McPherson of Oxford University provided a presentation on role of epidemiological modelling to support decisions in public health, and Anastasia Chalkidou and Naomi Herz of KiTEC talked about assessing medical devices and the challenge of incorporating economic evaluations in that field (their presentations can be found here).

Chinese academics linked with the new HTA network also spoke about the role of HTA in China in line with the themes of the workshop. There were presentations on: Standards and procedures of HTA in China by Haiyin Wang, Division Director of Shanghai Health Development Research Center, Performance evaluation on public health system in China by Professor Zhachun of Tongji University, Outcome Evaluation of the Tiered healthcare system in China by Rui Zhao of CNHDRC, Rapid HTA on Proton and Heavy Ion radiotherapy by Michelle Li of CNHDRC; Economic Evaluation of hepatitis B management strategy in China by Steven Qiu of CNHDRC; and finally, a talk by Jenny Sui of CNHDRC on using international evidence to assess cellular immunotherapy.

The iDSI HTA workshop provided an opportunity for new collaborations between Chinese HTA specialists, UK researchers, and colleagues from neighbouring countries. During the second day of the workshop, a roundtable discussion involving health officials and academics from Indonesia, Cambodia and China highlighted the interest in engaging in mutual cooperation, and the opportunity offered by the Chinese HTA network in providing regional support. The rise of China’s HTA capacity comes at a pivotal timing given the upcoming BRICS Summit scheduled to take place in Xiamen next September. The five key priority areas for BRICS collaboration are: deepening cooperation, strengthening global governance, making institutional improvements and building broader partnerships. Within this context, HTA capacity buidling and wider heathcare refirm offers one important route to achieve these aims. The Goa declaration highlights the importance of BRICS cooperation in the area of healthcare regulation.

“We will seek to identify possibilities for cooperation among our health and/or regulatory authorities, with a view to share best practices and discuss challenges, as well as identifying potential areas for convergence”
8^th BRICS Summit- Goa Declaration October 2016.

China’s role in international support has been given added impetus by a number of initiatives including the recent “One Belt One Road” strategy. Such initiatives can provide important opportunities for sustainable development in countries along the Silk Road Economic Belt, and will be crucial in supporting the spread of evidence informed healthcare decision making in LMICs, a key objective of iDSI.

The objective of the study trip was to understand the Health Technology Assessment (HTA) system in Thailand. Specifically:

o   The mandate, roles and responsibilities of HITAP within the Thai health system

o   The relationships between HITAP and technical partners

o   The roles and responsibilities of committees, advisory bodies and workflow of HTA processes

o   The resources required for conducting HTA

The following participants from India attended the study tour, representing the Ministry of Health and Family Welfare, Indian academia, and the Ministry’s implementation body, the National Health Systems Resource Centre: Shri V.K. Gauba, Join Secretary, Department of Health Research (DHR), Ministry of Health & Family Welfare (MoH&FW), Government of India; Dr. Shankar Prinja, Associate Professor, Post Graduate Institute of Medical Education and Research (PGIMER), India;   Dr. Mohammad Ameel, Advisor, National Health Systems Resource Centre (NHSRC), India; Dr. Kavitha Rajsekar, Scientist E, Department of Health Research (DHR), Ministry of Health & Family Welfare (MoH&FW), Government of India

Day 1 started with opening remarks by Dr. Yot Teerawattananon, Founding Leader, HiTAP, Thailand and focused on the objectives, overview of the three day workshop. Ms.Netnapis Suchonwanich of HITAP, Thailand, and former Deputy Secretary-general at National Health Security Office highlighted about the Universal Health Coverage in Thailand. Ms. Waranya Rattanavipapong gave a detailed Introduction to HITAP, an associate organization with the Bureau of Health Policy and Strategy, Ministry of Public Health, Thailand and gave an overview about the capacity of resource persons available and HiTAP strategies for policy implementation. Dr. Yot Teerawattananong gave the complete Historical development of HTA in Thailand  and methodology involved in Topic Selection for HTA in Thailand. Ms. Alia Luz briefed on all the Conducive Factors responsible for development of HTA in Asia.

Day 2 focused on benefit packages under the Universal Coverage scheme  in Thailand, National Health Security Board structure and function by Danai Chinnacom. Ms. Pattara Leelahavarong briefed on the Coverage decision for development of National List of Essential Medicines (NLEM) in Thailand. The Indian delegation attended the Sub-committee for the development of National List of Essential Medicine (NLEM) to observe and get hands on experience about Thai HTA system.

Day 3 focused on Development of Infrastructure for HTA in Thailand by Dr.Sitapore from Mahidol University. Mrs. Netnapis Suchonwanich gave a detailed presentation on the Implementation of HTA Results in Thailand. An Elaborate discussion was undertaken by the Indian Delegation with Dr. Yot Teerawattananon on HTA Development in India.

This trip was very useful to give a background to how HITAP was started and the way in which HTA is used to inform decision making in health in Thailand. We plan to take this new knowledge and use it to help in planning towards the establishment of the Medical Technology Advisory Board (MTAB) and using HTA evidence to inform decision making in India.

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