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.

The recent report by the International Decision Support Initiative (iDSI) goes some way towards making the case for Health Technology Assessment (HTA) mechanisms in SSA to support more effective resource allocation when tackling this double burden. Hypertension was chosen as the case study, given its relatively high and growing prevalence in Ghana reaching up to 48% . An economic evaluation was undertaken based on an adaptation of a model developed for the 2006 update of the NICE guideline on hypertension management.

Seven key messages arise from this analysis, which made use of local Ghanaian data and policy-maker engagement:

1. Within the Ghanaian National Health Insurance remit, prescribing diuretics is estimated to cost an additional GH¢642 per DALY averted compared to no intervention.
2. Incremental cost per DALY avoided for Calcium Channel Blockers compared with diuretics is GH¢32,482.

Over the next 5 years Ghanaian authorities can

3. Save up to GH¢ 25,000,000, if they negotiate only a 10% reduction in average drug prices.
4. Save up to GH¢ 18,000,000 by encouraging only a 10% prescription shift from Calcium Channel Blockers to Diuretics, where clinically appropriate.
5. Save up to GH¢ 5,000,000 by encouraging a 10% shift from other drug classes to diuretics, where clinically appropriate.
6. Provide diuretic treatment to all patients with diagnosed but untreated hypertension using only a fraction of savings above (GH¢ 5,900,000) and can generate a net gain of 46,000 extra DALYs averted

Last but not least…

7. This report is an example of the value of being able to share HTA knowledge more freely, specifically executable economic models that can be adapted to local contexts. It demonstrates the positive impact of having open access sources for HTA knowledge dissemination on major health policy challenges worldwide.

To view the details of iDSI Ghana work including analytics, assumptions, and the data behind these key messages, download the report or view it here.

The workshop narrative derived from the global need to develop UHC as a way to improve health, expressed in the SDG 3.8 “achieve universal health coverage (UHC), including financial risk protection, access to quality essential health services and access to safe, effective, quality and affordable essential medicines and vaccines for all”. The basis for the workshop was a document published by CGD on priority setting in health (1).

This 3 day workshop had the overall objective of scope out the content and process for developing guidance on HTA as a tool for reimbursement decisions. A specific deliverable at the end of the workshop was a document outlining:

1. Key issues that need to be tackled in the guidance
2. Insights and learnings from participants that can inform each of these issues, including where possible, identification of  “landmark”  documents and  countries examples of good/bad practice
3. Recommendations for research or data collection on information gaps.

The participants were invited based on their involvement in the Health Technology Assessment (HTA)/priority setting process in their respective countries, and a distinction was made between countries in different levels of development of HTA/priority-setting system (established or working towards UHC). There were representatives from South Africa, Chile, Thailand, the UK, the United States, the Philippines, Croatia, Norway, Switzerland, and other countries. The participants present worked in a wide range of organisation: HTA research – University of Wits and Indonesia, HTA agencies – NICE and HITAP, the Ministry of Health – Zambia, Chile and Vietnam, regional HTA networks EUnetHTA and HTAi, and global funders – BMGF, the UK DFID, GAVI and the Global Fund.

Over the three days, the participants listened to, participated in and prepared sessions on: the scope of work of an HTA mechanism; how are countries setting up HTA mechanisms; legal frameworks for HTA mechanisms; minimum capacities for HTA mechanisms; the role of regional and global partners and networks; criteria to be used at different stages of the HTA process and monitoring the effectiveness of HTA mechanisms. Alongside these sessions, breakout groups discussed questions as: steps and principles for HTA processes; what are the main considerations in landscape/context/mandate analysis and criteria and negative/positive lists of implementing HTA.

The workshop was a success, with a strong interest from the WHO to collaborate with iDSI in future work. IDSI and the WHO are discussing next steps, and there has been a strong interest from the participants to participate in the development of this document.

The agenda for the workshop is here

Universal health coverage (UHC) is now firmly on the global health agenda, and carries with it the ambitious goal of providing “access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost.”  So where do we start?  A critical first step to delivering on the aspirations of UHC is deciding which services and policies to prioritize and make available.  While resources for health care are growing, they are not infinite and hard choices must be made.  

Priority-setting processes for health spending specify at least a certain set of policies, services and technologies that will be financed and made available under UHC.  Some will also indicate which services or technologies will not be funded and provided.  Ideally, the design of a priority setting process is fair, transparent, inclusive and deliberative.  And in the best cases, the selection of these services is based on cost-effectiveness and accounts for equity, financial protection and social values in a systematic way.

When priority-setting processes aren’t in place – that is, when resource allocation decisions are made based on past budgets or under pressure from interest group – less health is provided for every dollar spent. Evidence of suboptimal allocation abounds; India subsidizes open heart surgery while child vaccination rates remain low; Colombia purchases more analogous insulins per diabetic than any country in Latin America while diabetes prevention and management programs remain underfunded; and Egypt spent a fifth of its public spending on health to send a few fortunate people overseas for health treatments while a fifth of their children were stunted.  (for more examples, see our report on priority-setting institutions here)

Under UHC, it will ultimately be up to countries to set their own priorities for health spending.  And that’s great – reallocating a portion of public and donor monies toward the most cost-effective health interventions would save more lives and promote health equity. But too many low- and middle-income countries lack the fair and evidence-based processes and institutions needed to adequately inform funding decisions.

With that in mind, the Center for Global Development ran a working group on priority-setting institutions during 2011/12, recommending the creation and development of national and global systems to more rationally set priorities for public spending on health. The group called for an interim secretariat to incubate a global facility designed to help governments develop national systems and donors get greater value for money in their grants.

So we’re delighted to announce a new platform that does just that — the international Decision Support Initiative (iDSI).  Recently launched by NICE International, the iDSI will support low and middle income governments, and perhaps donors, in making resource allocation decisions for healthcare.  Specifically, the initiative will share experiences, showcase lessons learned and identify practical ways to scale technical support for more systematic, fair and evidence informed priority setting processes. In strengthening priority-setting institutions, the iDSI will be a tool to both improve access to effective health interventions and the quality and efficiency of health care delivery. And importantly, it will help elevate the value of priority setting as a necessary, if not sufficient, condition for attaining and sustaining UHC.

The full announcement from NICE International on the iDSI can be found here and the strategic overview here. For more information on CGD’s work on Priority-Setting, see the report’s brief here and a wonkcast on the topic, here.

Source: Center for Global Health Development