The session brought together officials from Kenya, Zambia, Indonesia, Eswatini, Rwanda and Malawi representing ministries of health, national health insurers, a Prime Minister’s cabinet and academia to share practical experiences from health financing reforms, with a focus on priority-setting and strategic purchasing.

Dr Velphi Okello: “Weak links between budgets and supply chains often a challenge”

Dr Velphi Okello, Deputy Director of Clinical Health Services at the Eswatini Ministry of Health, shared her knowledge of the design of an essential Health Benefits Package and emphasised the importance of assessing the healthcare provision landscape. Dr Okello stated assessments carried out in 10 rural clinics in Eswatini revealed they were ready to scale up the National Essential Health Care Package (EHCP). However, through assessments at clinics and hospitals, bottlenecks in the supply chain were identified and efforts were made to ensure delivery of EHCP through improvements in the supply chain through budget processes. Political attention was also found to be focusing more on tertiary care than primary care; and there was room for improvement in cross-ministerial relationships. Dr Okello raised the need to mobilise resources to make these health landscapes ready and the need to maximise efficiency opportunities as much as possible.

Dr Solange Hakiba: “Rwanda is continuing to work on educating and engaging patients and the public more to emphasise primary care is just as crucial as tertiary care”

Dr Solange Hakiba, Deputy Director General in charge of Benefits at the Rwanda Social Security Board, highlighted the importance for low and middle-income countries (LMICs) to scope out opportunities to engage the private sector. Dr Hakiba detailed how Rwanda brought the private sector on board to help build infrastructure in partnership with nurses and the District Government, who provided buildings and furniture. Dr Hakiba explained how Rwanda experienced a lack of health workforce following genocide in 1994; as the country recovered its education system this meant more university graduates were coming through, however Rwanda still required non-university educated nurses and community health workers, thus set up ‘Health Posts’ which operate as entry-level clinics in the public sector and provide care for common conditions such as malaria and diarrhoea. Each post is run by an experienced nurse given access to financing and training in business, post-operations and clinical skills. The franchise approach allows the nurse operator to earn a living operating a small business while increasing access to essential medicines and basic healthcare for communities. After a short grace period, the Health Posts begin operating on a self-sustaining basis and can accept reimbursements through Rwanda’s community-based health insurance scheme, the Mutuelle de Sante, which covers approximately 90% of the population. Rwanda is continuing to work on educating and engaging patients and the public more to emphasise that effective and efficient primary care is just as crucial as tertiary care.

Dr Gerald Manthalu: “Multiple sources of funding for health are often not used efficiently as many have different priorities and plans – pooling of funds where possible can help with challenges of fragmentation of financing”

Issues surrounding the fragmentation of financing was raised by Dr Gerald Manthalu, Deputy Director of Planning at Malawi’s Ministry of Health. Dr Manthalu explained how Malawi had over 190 different sources of funding for health, however their use was not always efficient as many had different priorities and plans in place. Dr Manthalu specified Malawi was tackling this specific challenge by aiming to carry out more detailed resource mapping; and encouraging the pooling of funds where possible, especially from donors. Dr Manthalu mentioned the importance of potential revisions of Essential Medicines Lists and also the need to make citizens more aware and encouraging nationwide discussions. The last revision of Malawi’s Essential Medicines List included the addition of antenatal corticosteroids, chlorhexidine, injectable contraceptives and contraceptive implants – increasing commodity access for women and newborns who need lifesaving interventions.

Remaining on the topic of Essential Medicines Lists, Pak Budi Hidayat, Professor of Health Economics and Health Insurance at the University of Indonesia and a member of the national Health Technology Assessment (HTA) Committee, announced at the satellite session the decision by Indonesian authorities to delist certain medicines deemed to be cost-ineffective from the national formulary. Professor Hidayat stated that Badan Penyelenggara Jaminan Sosial, the social insurance agency responsible for administering the Jaminan Kesehatan Nasional (JKN), the world’s largest single national health insurance scheme for Universal Health Coverage, will no longer reimburse cetuximab and bevacizumab for certain colorectal cancers. iDSI core partner HITAP was instrumental in the economic evaluation of the two medicines which led to the policy decision. The costs of these drugs are strikingly high with only marginal benefits for patients, so much so that they are considered poor value for money and not advised as first-line treatment options even in high-income countries.

Dr Henry Kansembe: “G2G funding can result in one strategic plan and a country’s strategic purchasing formula can be applied to a larger amount”

Chief Planner at Zambia’s Ministry of Health (MoH) Dr Henry Kansembe gave examples of how strategic thinking can improve health indicators in a space where fiscal expansion is limited. Dr Kansembe explained how Zambia’s MoH were aware they would unlikely get increased funding from their country’s treasury, so created incentives for providers to perform better. Results-based financing was on five key performance indicators and led to 30% of the allocation being invested more strategically. Zambia has also explored ‘G2G’ funding, where government funds are pooled with donor funds – meaning one strategic plan can be put together and a country’s strategic purchasing formula can be applied to a larger amount of funding.

Practicalities surrounding health financing towards UHC discussed ranged from data constraints to political challenges, such as how to engage civil society. Professor Tony Culyer highlighted the importance of the education of and understanding from all stakeholders, including the public; and used examples of where blood pressure control methods had received public ‘buy in’ after they were successfully communicated, by both health ministries/departments and the media.

Professor Kalipso Chalkidou emphasised the need for LMICs to have more access to data on costs/prices of essential medicines, as high mark-ups are often charged on medicines in LMICs. This could be due to historical practices, or a result of public services buying medicines in the private sector. Professor Chalkidou used the Congo as an example, where the cost of essential medicines is four times higher than the international average; and stressed that the impact is often on individuals, given the high percentage of out-of-pocket payments in LMICs.

The need for integration and transparency with regards to priority-setting; and ensuring policy-makers are on the same page as academics was also high on the agenda during the session.  All agreed academics are habitually signed up to the process of priority-setting for decision making. Decision making however doesn’t always follow through with the priority-setting process. Being transparent when engaging with stakeholders and citing what options were and who was consulted was highlighted as the only way to defend difficult decisions. The value of having a legal and governance framework to link priority-setting and decision making was a theme that was frequently raised throughout the session.

On the topic of Health Technology Assessment (HTA) infrastructure, the UK and Sweden were hailed as success stories, as a drug is not approved for reimbursement before the HTA process (including health economic analyses) has occurred. In contrast, the HTA process happens far too infrequently in LMICs. All concurred it could be challenging to replicate the same structure the UK and Sweden has elsewhere, however a strategy to collaborate internationally – such as via universities’ economics departments – could be a promising way forward to foster HTA within LMICs.

The satellite session received funding from the Swedish International Development Cooperation Agency (Sida), working on behalf of the Swedish Parliament and Government; and was co-hosted by the Clinton Health Access Initiative, Sida and iDSI. We have made all presentations from the session available for download.

 Ahead of the event iDSI caught up with Patric Landin, regional advisor for Sida’s Sexual and Reproductive Health and Rights team; and Dr Yogan Pillay, Deputy Director-General for Communicable and Non-communicable Disease, Prevention, Treatment and Rehabilitation in the National Department of Health in South Africa.

 Read our 60 seconds interview with Patric Landin here.

Read our 60 seconds interview with Yogan Pillay here.

As part of a satellite session iDSI hosted with CHAI and Sida, ‘Health financing towards UHC’, Pak Budi Hidayat, Professor of Health Economics and Health Insurance at the University of Indonesia and a member of the national Health Technology Assessment (HTA) Committee, announced the decision by Indonesian authorities to delist certain medicines deemed to be cost-ineffective from the national formulary.

Badan Penyelenggara Jaminan Sosial (BPJS), the social insurance agency responsible for administering the Jaminan Kesehatan Nasional (JKN), the world’s largest single national health insurance scheme for Universal Health Coverage, will no longer reimburse cetuximab and bevacizumab for certain colorectal cancers.

iDSI core partner HITAP was instrumental in the economic evaluation of the two medicines which led to the policy decision. The costs of these drugs are strikingly high with only marginal benefits for patients, so much so that they are considered poor value for money and not advised as first-line treatment options even in high-income countries.

With Indonesia the fourth most populated country in the world, running a large-scale health insurance scheme is complicated and there is mounting financial pressure on BPJS. Pak Budi said: “With 200 million citizens in the scheme, BPJS needs to be a more strategic purchaser. There is a real need to be an active purchaser, rather than a passive purchaser; and determine whether to pay for the things we have to pay, or what providers are asking to be paid.”

Pak Budi Hidayat at the Fifth Global Symposium on Health Systems Research

Technical assistance from HITAP to the Indonesian health ministry (including the HTA Committee), the national health insurer and universities began in 2013. In 2017, HITAP provided intense capacity-building support to local research teams on four HTA studies, all of which were commissioned and funded by BPJS, on some of the highest cost items reimbursed by the JKN.

Two of the studies, by the University of Indonesia and the University of Gadjah Mada, respectively focused on the value of cetuximab and bevacizumab as first-line treatment options for metastatic colorectal cancer. The announcement to delist the two medicines marks significant policy impact of iDSI’s engagement in Indonesia; and more importantly tangible institutional progress in the use of health economic evidence to inform policy.

Cetuximab was included in the Indonesian national formulary in 2014. iDSI analysis revealed that treatment for 32 patients in Indonesia came at a cost of IDR 6.5 billion (USD $500,000). Bevacizumab was also shown to be high-priced, with costs of IDR 4.8 million (USD $400) per vial.

HITAP’s work with the Indonesian health ministry considered not only cost effectiveness analyses, but also the barriers to uptake. Only six hospitals, all located on Indonesia’ main island Java, have the capacity to diagnose and treat metastatic colorectal cancer. Although Java is home to 257.6 million people, the other half of the population inhabit other islands, up to many hundreds of miles away. Targeted treatment for metastatic colon cancer prolongs life by one year on average. With substantial distance between some the Indonesian islands and Java, the team also considered the strain on cancer patients who may struggle to access treatment centres without difficulty. As a result, the importance of using other less expensive strategies with lower side effects, such as palliative care, as comparators were emphasised in the HTA study. HITAP accentuated this would add a holistic viewpoint and a chance for policy-makers to deliberate all policy angles.

With cancer drugs accounting for the lion’s share of global drug spending, it’s crucial HTA studies are carried out to ensure costs translate into outcomes which make a difference to patients and thereby ensure long-term financial sustainability of national UHC schemes like JKN. Furthermore, HTA processes need to be institutionally embedded into drug reimbursement policies. iDSI’s engagement with Indonesia, via HITAP, continues and policy briefs describing the study findings are due to be published on the iDSI Gateway by the end of 2018.

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

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.

So, what are off-label medicines?

Off-label use of medications involves “prescribing currently available and marketed medications but for an indication (e.g., a disease or a symptom) that has not been approved by a country’s drug administration”. The term can also apply to the use of a marketed medication in a patient population (e.g., pediatric), dosage, or dosage form that does not have a country formal approval.”[1] It can be common practice in countries, especially amongst patient populations that are less likely to be included in clinical trials, such as pregnant women, children, extremely elderly and mental health patients. Medicines may also be registered for a certain indication in some countries but not in others, which begs the question on their registration and availability in countries that may have more stringent regulations on off-label medicines. They can be controversial because they have not undergone a rigorous assessment process to ensure safety and clinical benefit. Nevertheless, obtaining approval for a new medical indication can be resource and time consuming and industry players are not willing to invest, especially when medicines are not patented.

Using off-label medicines for benefits packages is an unexplored area for healthcare priority setting, though it can have a significant positive or negative effect to health outcomes and efficiency of healthcare systems. Countries may have regulations to manage off-label medicines use; however, the full understanding of its current situation is not often evaluated. To address this, two academic teams in Indonesia and Thailand explored the laws, regulations, and use of off-label medicines in Australia, Indonesia, Singapore, Thailand, and the United Kingdom as well as interviewed stakeholders and conducted focus group discussions (in Indonesia) to understand the political economy of off-label prescription and identify policy solutions for Indonesia and other countries that may have legal constraints regarding the use of off-label medicines. They found that these countries, except Indonesia, legally allow for the use of off-label medicines in their public health insurance schemes given their potential benefits. To mitigate the risk, Australia and the UK developed a clear process and rigorous mechanism for priority-setting of off-label medicines, while Singapore and Thailand apply general approaches of health technology assessments (HTA)[2] to consider inclusion of off-label medicines in their medicines formulary.

These results were presented to Indonesian policymakers and stakeholders on March 17, 2017, in Jakarta, Indonesia. Several policy recommendations for relevant actors were put forward based off the results of the studies, such as recommending healthcare authorities and payers to: fund the use of off-label medicines with strong scientific evidence for the benefits package; control the marketing and use of off-label medicines with no evidence of clinical benefit and safety, or, if there is clear evidence of harm; provide incentives (e.g. limit the cost and effort required) for industry to register medicines for off-label medicine indications; and, implement national guidelines on the use of off-label medicines at the policy level and for individual physicians. While this issue is still emerging in Indonesia and other countries, this policy forum shows that the movement is starting.

[1] Ten Common Questions (and Their Answers) About Off-label Drug Use. Christopher M. Wittich, MD, PharmD; Christopher M. Burkle, MD, JD;and William L. Lanier, MD

[2] Health technology assessment (HTA) refers to the systematic evaluation of properties, effects, and/or impacts of health technology. It is a multidisciplinary process to evaluate the social, economic, organizational and ethical issues of a health intervention or health technology. The main purpose of conducting an assessment is to inform a policy decision making.http://www.who.int/medical_devices/assessment/en/

However, universal access to RRT is a challenge for low- and middle-income countries due to their high cost. Of the three types, kidney transplantation is the most expensive, given that transplantation services are not widely available in resource-limited settings and as such will require high, intensive capital investment, human resource development, and organ supply, storage, and other related costs. Haemodialysis comes in second for similar reasons – capital investment in machines and human resource development are costly. In addition, physicians have financial incentives to promote this treatment since it will ensure that patients return to clinics or hospitals for treatments several times a week, which may drive up costs if implemented in government-supported facilities.

The last type of RRT, Peritoneal dialysis, has been found cost-effective and has better health outcomes for resource-limited settings (Teerawattananon et al 2016). It also answers unique healthcare challenges in these settings – for example, peritoneal dialysis units can be sent to remote areas that have limited access to healthcare facilities. Thailand has implemented peritoneal dialysis as the first-line treatment to ESRD. This means that patients covered under the universal healthcare scheme will receive peritoneal dialysis as their treatment under public hospitals, with haemodialysis as the secondary treatment in case of contraindications. The country significantly invested and promoted this policy, providing capital investment for PD providers, free training for health professionals, infrastructure development, and a professional fee for health professionals in providing PD services.

On October 13-14 during the International Conference: PD First Policy-Onsite Study, other countries considering their policy for RRT visited Thailand to understand how this policy was enacted and the components of its implementation. The program of activities included a forum that explained the economic and clinical evidence to support peritoneal dialysis for Thailand, the implementation, and the continued management and evaluation of the program. Participants also visited peritoneal dialysis patients and clinics to see first-hand the patient experience on the program. This is particularly important for countries that will be using this information to inform policy on broader level such as Indonesia, which is already implementing pilot programs for RRT and considering scaling them up to the national level.

Reference: Economic Evaluation of Palliative Management versus Peritoneal Dialysis and Hemodialysis for End-Stage Renal Disease: Evidence for Coverage Decisions in Thailand

Link: http://www.valueinhealthjournal.com/article/S1098-3015(10)60455-X/abstract?_returnURL=http%3A%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS109830151060455X%3Fshowall%3Dtrue

Work on developing the tariff was led by researchers based at Padjadjaran University in Bandung, Indonesia and Erasmus University, Netherlands, with support from the EuroQol group. Fredrick Purba (Faculty of Psychology, Padjadjaran University, and Department of Psychiatry, Erasmus Medical Center Rotterdam) was the lead researcher on the project, and during the symposium he outlined the methods and findings to an audience that included academics from a variety of Indonesian institutions, and representatives from HITAP, WHO and the Indonesian MoH.

Given the importance of this work in supporting the development of HTA in Indonesia, Francis Ruiz (Global Health and Development Group at Imperial College) aimed to contextualize the research by highlighting its role in facilitating in the context of supporting evidence-based coverage decisions, and the broader requirements for successful HTA with a focus on the Asia Pacific region. Drg. Armansyah of the Centre for Health Financing and Health Insurance (Pusat Pembiayaan dan Jaminan Kesehatan, PPJK), the HTA secretariat at the MOH, provided a background to HTA in Indonesia and the latest developments in process and methods. In 2013, iDSI through one of its core partners, the Thai HTA body HITAP, began its engagement with Indonesian authorities with the aim of strengthening its nascent HTA programme, and since then has seen the production of several HTAs. Next steps in the engagement will include continuing to support the Indonesian authorities in refining its methods and processes for HTA, including developing a framework for how any outputs from HTA could be implemented in the system. In addition, colleagues from the Global Health Team at the University of York have embarked on a project to estimate an Indonesian relevant cost-effectiveness threshold that could inform decision rules for HTA-informed policy making. Indonesia’s recent health reforms have provided a rich source of accessible data that can be can be exploited in ways suitable for the purpose of within-country threshold estimation.

In a follow-up newsletter, the chair of QOLMARI, Prof Jan Passchier, discussed the seminar, as well as future plans. The newsletter can be found here.

Incidentally, the drug sildenafil, originally tested for heart problems on the basis of its vasodilatory effects (which widens the blood vessels), can become a treatment for PAH patients. Despite its original intentions, in its first decade (1998-2008), the focus of the drug shifted from treating angina (chest pain), of which the treatment outcome was not satisfactory, to treating erectile dysfunction. As such, it became one of the most commercially successful drugs in the world. Its commercial successes did not incentivize companies to also register it for the indication to treat PAH despite many subsequent experiments, studies, randomized controlled trials, and clinician reports that say the little blue pill may actually be a good if not better treatment for PAH relative to other drugs.

In the case of Indonesia, an estimated number of 500 cases of PAH were reported in 2015. Currently, beraprost is the only available treatment approved for PAH by Indonesia’s national formulary. Local clinicians regard sildenafil as clinically more effective than beraprost. However, sildenafil is not listed in the national drugs formulary due to pharmaceutical companies’ non-registration of the product for the PAH indication. Some doses of sildenafil, e.g. 20 mg, for PAH indication is also not available in Indonesia Additionally, it is not included in the Indonesian benefits package of Jaminan Kasehatan Nasional (JKN).

To investigate its practical use in the Indonesian context, Indonesia’s Health Technology Assessment (HTA) Committee had commissioned a team to conduct a model-based economic evaluation and a budget impact analysis for using sildenafil as a first line treatment for PAH patients. This study was completed in the last quarter of 2015. There are reports that the government is considering allowing access to sildenafil for PAH through a Special Access Scheme.

In this effort, the Health Intervention and Technology Assessment Project (HITAP) Thailand, on behalf of the International Decision Support Initiative (iDSI) provided technical support to the team conducting the study. By embarking on this study, there is hope to providing better access to medicines in the country. We would like to acknowledge the Access and Delivery Partnership (ADP) for their support.

The workshop is free to attend. Participants will be selected by Indonesia’s HTA Committee and the WHO from select universities and relevant units within the Ministry of Health. Although the workshop has a targeted audience, anyone interested in learning more about the workshop or HTA in Indonesia can contact Dr Dewi Indriani by emailing indrianid@who.int. The event flyer is available here.

We look forward seeing you there!