iDSI contributed extensively to the 5^th Biennial African Health Economics and Policy Association (AfHEA) conference 2019, including organising 10 sessions and bringing over 30 researchers and experts to the conference, strengthening our collaborations with African partners. The conference occurred as iDSI turns its focus increasingly towards Africa, working to support decision-making and health priority-setting across the continent.

iDSI kicked off the week with a pre-conference session on applying health economics for immunisation, delivered with Teaching Vaccine Economics Everywhere. Through the conference we ran 10 sessions covering a range of topics on how African countries can use clear decision-making processes as they strive towards UHC. These sessions brought practitioners and policymakers together to identify cost-effective pathways towards achieving UHC and primary healthcare (PHC) for all, the theme of the conference.

As importantly, and true to iDSI’s collaborative nature, the conference was a great opportunity for our network to come together. From Australia to Zambia, it was a great chance for us to bring the iDSI family together so that network partners could continue to share knowledge and provide support to policymakers and researchers across the globe.

Key takeaways

• There is a huge momentum towards UHC and PHC for all in Africa. With limited resources and growing pressures on healthcare systems, sound decision-making and effective prioritisation will be crucial.
• Supporting country-owned decision-making in Africa requires understand the priorities and values of decision-makers. iDSI should work to support systems that reflect these local principles. Ethical analysis and explicit consideration of equity concerns can guide such work.
• At present, health technology assessment and appraisal across Africa is fragmented. Often small teams, based in health ministries and without explicit remit, are conducting HTA in an ad hoc way. There is much value in bringing these users and producers of HTA evidence together; and iDSI is keen to collaborate with AfHEA to develop a community of practice to do just that.

More detail on the key messages can be found in this document.

Preconference workshop – Applied Health Economics in Africa Using Examples from Immunization

iDSI’s AfHEA involvement kicked off with a full house at our pre-conference session, delivered together with Teaching Vaccine Economics Everywhere, on applying health economics to vaccines. This session brought together academics, policymakers in health ministries, officials from multilateral organisations, students and others. Opening the session, David Bishai (Johns Hopkins University) spoke passionately about the need to prioritise within available health budgets, emphasising that “saving money is saving lives”.

The session increased understanding of how health economics tools can be used in resource allocation decisions for health technologies including national essential medicines lists and health benefits packages. iDSI’s interactive components brought the session to life and enabled participants to enhance their learning.

• David Bishai: Introduction to Vaccine Economics
• Tommy Wilkinson: Introduction to Priority Setting in Health
• Tommy Wilkinson: Introduction to Economic Evaluation – Using HTA
• Justice Nonvignon: Measuring Costs of Health Interventions
• Ijeoma Edoka: Measuring and Valuing Health Outcomes
• Ijeoma Edoka: Application of Economic Evaluation – Decision Modelling
• David Bishai: TVEE: Creating the Architecture for Sustainable Vaccine Financing

Organised sessions

The iDSI-organised sessions brought together health economics, policy and ethics experts from across the iDSI global network.

• Organised session 1: Sound Decisions Making for UHC
• Organised session 2: Teaching Health Economics – a Low and Middle Income Country Focus
• Organised session 3: Agent Based Modelling
• Organised session 4: Addressing Ethics Considerations
• Organised session 5: Approaches for Achieving UHC – Perspectives from Africa and Asia

Oral sessions

As part of the main conference break-out session, iDSI members presented their work alongside other leading health economists from across Africa.

• Tommy Wilkinson: Approaches for achieving Universal Health Care: Policy Perspectives from Africa and Asia
• Gavin Surgey: Revision of STG and NEMLIT in Tanzania: a mechanism for introducing HTA?
• Maio Buluwayo: The Potential Impact of a 25% Tax on Sugar Sweetened Beverages in Zambia
• Sam Hollingsworth: Health technology assessment capacity at national level in sub-Saharan Africa: a survey of stakeholders
• Kim MacQuilkan: How can HTA improve equity, access and quality of healthcare services?
• Kim MacQuilkan: Strengthening Health Technology Assessment Systems in the Global South

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.

Please click here to download the Job description.

To apply, please forward your CV and a covering letter to llazarus@icon.co.za 

Closing date for applications is Thursday 30 June 2016

iDSI’s mission is to guide decision makers to effective, efficient and ethical healthcare resource allocation strategies for improving people’s health. Since 2014 it has significantly strengthened local capacities for setting health priorities across Indonesia, India, Vietnam, China and South Africa.

With the funding boost in Phase 2, iDSI will scale up its practical support to countries aspiring to universal health coverage (UHC), both in terms of intensifying and sustaining the institutional impact in the five flagship countries, and broadening its geographic reach particularly into sub-Saharan Africa. iDSI also continues to receive funding support from the UK Department for International Development and the Rockefeller Foundation.

Damian Walker, Deputy Director (Data & Analytics, Global Development) , Bill & Melinda Gates Foundation, said:  “Countries worldwide face life-or-death choices in deciding whom receives what kinds of healthcare at what cost. iDSI will work with national and global decision-makers to help them make better choices, to save as many lives as they can afford and allow as many people as possible to lead healthy and productive lives.”

iDSI is a global network of public bodies, think-tanks, and academics in priority-setting, and comprises core partners NICE International (UK), HITAP (Health Interventions and Technology Assessment Program, Thailand), CGD (Center for Global Development, USA), and PRICELESS SA (Priority Cost Effective Lessons for System Strengthening at the University of Witwatersrand School of Public Health, South Africa), who join as the iDSI regional hub for sub-Saharan Africa. iDSI builds on its core partners’ track records over the past decade in delivering demand-driven practical support to low- and middle-income country governments, and puts into action recommendations from the 2012 CGD Priority-Setting in Health Working Group, which articulated the need for systematic, fair and evidence-informed priority-setting mechanisms in healthcare.

Prof Karen Hofman, Director of PRICELESS SA, said: “The iDSI grant will enable us to continue supporting the Ministry of Health, Treasury and other health policy makers in South Africa on setting evidence-based priorities as the country moves towards National Health Insurance. But more than this, building on successful initiatives in South East Asia we aim to go beyond our borders to share successes and lessons with policymakers in sub-Saharan Africa, as they too move towards UHC.”

“Our ambition for iDSI is that evidence-informed decision making becomes the norm in countries that we work with,” agreed Dr Yot Teerawattananon, Leader of HITAP, “and that these countries begin to contribute to the efforts in developing the capacity of other countries.”

In the era of Sustainable Development Goals and countries transitioning from aid, country policymakers will increasingly be making their own healthcare spending decisions with the goal of UHC. iDSI will provide much needed support for countries, and respond to growing demand for knowledge sharing and capacity building for priority-setting.

“iDSI has the potential to be a major contributor to improved health outcomes and health equity on the African continent,” added Prof Hofman.

We needed to know who were making priority-setting decisions in the respective health systems, how these decisions were being made and financed, what technical capacity countries had to implement HTA processes, as well as the key challenges facing their health systems. But at the time, there was no comprehensive literature covering all of these issues of relevance to priority-setting, within a broad enough geographical scope. Existing surveys on HTA (including those done by NICE International and HITAP) tended to focus narrow on its technical aspects, whereas studies from the health systems research field didn’t go deep enough into the important facets of priority-setting such as who are the stakeholders, what evidence is used, and so on.

With the end goal of selecting a country to offer iDSI practical support that would be feasible, in demand, and generate significant impact, we set out to assess how ready countries were for priority-setting support. We developed a conceptual framework, methods (including a country selection process), qualitative and quantitative indicators, and data collection tools (including questionnaires and interview guides) for priority-setting readiness. The mapping combined published and grey literature, insights from iDSI partners, and primary data collection from in-country key opinion leaders. And thanks to the hard work of iDSI partners worldwide, we successfully completed mapping of 17 countries within the space of 7 months.

Since completing the mapping, we have used it to select Indonesia as our focal country partner, where HITAP, NICE International and PATH are working in collaboration with local decision makers and academics to support HTA development. We have also subsequently secured additional funding to support a Sub-Saharan African regional hub for priority-setting around PRICELESS SA, South Africa.

One year on from the HITA resolution, there has been a proliferation of regional mapping exercises for priority-setting capacity, coinciding with the global momentum to support HITA. These include WHO-led efforts as well as iDSI partnerships with WHO regional initiatives (such as the Asia Pacific Observatory on Health Systems and Policies, and Advance HTA with PAHO). As the global health and political scene is so fast moving, some of the findings in the iDSI mapping report are inevitably already out of date. My hope is that these latest efforts will add to our global knowledge and provide practical insights to international donors and development partners, in order to support country partners in building capacity for better priority-setting in health.

– See more at: https://www.ohe.org/news/international-decision-support-initiative-idsi-mapping-priority-setting-health-17-low-and#sthash.lz3LaQkb.dpuf

Cuba’s reputation for producing dedicated health workers who are prepared to work in difficult or remote health contexts is well known and was profiled by Jose Luis de Fabio, Director of the Pan American Health Organisation in Cuba. Since the 1970s Cuba has been a major producer of health workers with a commitment to international solidarity in health and provides doctors to countries facing severe shortages of health workers. The selection process for entry to Cuban medical education focuses on social skills and competencies as much as academic ability which has helped overcome the mal-distribution of health workers, common in most countries, which leave major  gaps in service provision for poor and marginalised populations.

But perhaps the Cuban experience is not all it seems.  Jimmy Volmink, Dean of the Medical School of Stellenbosch University in South Africa laid out the advantages and disadvantages of a long-standing scheme that trains African students in Cuba with the aim of providing doctors for rural areas. Volmink highlighted the culture shock that awaits rural black African students in Cuba, the language problems, the lack of internet to enable easy communication with relatives back home, and problems of re-integration with South African trained students when they return home for ‘top-up’ courses on malaria,   HIV/AIDS, neonatal infections – preventable diseases that are not common in Cuba.  One returning student said: “if you buy a cat, don’t expect it to bark!”  The culture shock and the process of adaptation experienced by these students may be essential components that makes the Cuban approach so powerful.  Incubating Cuban approaches within Africa – a potentially more logical and less disruptive plan – but without the experience in Cuba may not work so well.

These optimistic and pessimistic views of the transferability and utility of Cuban medical education arise because of different contexts and ways of implementing the Cuban approach – which is very flexible and is modifiable depending on the resources available.  All systems of medical education produce ‘pluri-potential’ doctors who may become family doctors, eye surgeons or psychiatrists. So the cat-dog analogy doesn’t work for me.  Neil Squires, Deputy Director, Public Health England, asked whether the global shortage of family doctors and an imperative for universal health care, would leverage medical schools to focus their core curriculum on graduating functional family doctors.  John Ashton, President of the Faculty of Public Health, described such a scheme operating in the rural mid-west states of USA.

Jim Campbell, Director of WHO’s Health Workforce Department, described the WHO Initiative on transforming and scaling up health professionals’ education and training which has compiled regional case studies.  These provide a substantial evidence base from which to work.  WHO’s commitment to universal health coverage and the new sustainability development goals that will do away with targets, replacing them, for example, with zero acceptance of neonatal and maternal deaths and 100% access to primary care provide compelling reasons for solving the primary care workforce crisis.  The massive growth in health care in high income countries is likely to suck markedly large flows of doctors from low income countries.[Crisp & Chen, 2014] Global action to create primary care doctors and community health workers on an industrial scale is needed now to offset workforce crises in primary care, which in turn provide fertile soil for epidemics of preventable communicable and chronic diseases.

Evaluations of the Cuban model have been conducted in the past but questions of selection of students, training of faculty, competences at graduation, impact on distribution and retention of doctors in disadvantaged and rural communities need to be answered to provide better evidence for policy making.  A DfID funded policy programme grant has been awarded to support Cuban, African and UK collaborative research on the Cuban approach.  In the UK, NICE International, Public Health England and LSHTM are involved.  The research aims to answer these questions:

• Does the Cuban system of medical education result in more equitable distributions of doctors? And in stronger retention of doctors in rural and disadvantaged communities?
• Are doctors trained in the Cuban model equipped with an appropriate set of skills and competencies for primary care? Are they better equipped than doctors trained in conventional ways?
• What lessons can we learn for health professional capacity building from a development perspective? And what can we learn for the NHS here in England?

Medical schools should be capable of assimilating and retaining the lessons learned over the last 40 years: redesigning selection processes to improve access for disadvantaged students; early and long-term contact with patients and their families; shifting teaching into primary care; integrated core training of doctors, nurses and other health professionals. [Frenk et al, 2010]  General Medical Councils may make accreditation more difficult for highly innovative education but they are not the barrier.  Deans of medical schools have more room for initiating change as demonstrated by the Training for Health Equity network (THEnet) and other networks, one of them arising in Africa,  the Consortium of New Southern African Medical Schools.  Once again we have to “turn the world upside down”, asking rich countries to learn these lessons from Cuban medical schools which show how doctors with vision, resilience, relevant competencies and the motivation to work with the most disadvantaged people can be created.

Prof Shah Ebrahim, Honorary Professor of Public Health at LSHTM, is collaborating with NICE International, Public Health England, PAHO and the Cuban Ministry of Health on the DfID-supported project on Cuban medical education model for Africa.

References

Nigel Crisp, Lincoln Chen. Global supply of Health Professionals. N Engl J Med 2014;370:950-7

Julio Frenk, Lincoln Chen, Zulfiqar A Bhutta, Jordan Cohen, Nigel Crisp et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923–58

Our healthcare budget, similar to healthcare budgets around the world, is not infinite. This means every rand spent on one intervention is a rand not spent on another. Trade-offs are inevitable. How we prioritise our resources in a fair and equitable manner must be based on evidence of what really works and at what cost. This will ensure that the population receives good value for its healthcare rand.

These factors are pertinent today as we mark the first Universal Health Coverage Day, an initiative endorsed by over 500 organisations globally, including the World Bank and the World Health Organisation, and sponsored by The Rockefeller Foundation. This day highlights the need for countries, including SA, to provide access for all their citizens to quality health services without incurring financial hardship.

Priority-setting for health in SA has to date largely been influenced by expert opinion and often by who shouts the loudest. While our combined public and private investment in health ranks relatively high compared to that of emerging economies, our maternal and child health indicators have not met national targets and our rates of obesity and related non-communicable diseases such as high blood pressure and diabetes are skyrocketing.

We propose a more systematic approach for gathering evidence and call for economic evaluations to be conducted as part of the priority-setting process. This will enable us to understand how to scale up the most cost-effective interventions, and will assist policymakers in weighing the costs and benefits of different clinical and public health interventions leading to better health.

At the 2014 World Health Assembly in Geneva, a resolution was adopted for incorporating health intervention and technology assessment to support universal health coverage. This resolution calls on all member states to develop and strengthen priority-setting capacity. A growing number of countries, especially those that have already implemented universal health coverage, or are in the process of doing so, have priority-setting agencies in place.

For SA to reach its goal of universal health coverage, there are several agencies that will be needed. The establishment of the Office of Health Standards Compliance to monitor compliance with norms and standards for quality healthcare delivery is an important first step on the road to universal health coverage, but little attention has been focused on the establishment of a formal priority-setting agency.

One potentially good model for SA is the Thai Health Intervention and Technology Assessment Programme. Its mission is to inform rational health allocation decisions that have an impact on population health. Similarly, in the UK, the National Institute for Health and Care Excellence plays an important role in advising the National Health Service. In SA, an entity of this nature would commission research to identify cost-effective interventions and would be expected to process the evidence in a transparent fashion. In this way, policymakers would be supported to identify where health gaps can be addressed to save the most lives at a reasonable cost.

Cost-effective health interventions would include drugs, devices and treatment guidelines, but would extend beyond this to include health promotion and prevention. A broad range of stakeholders, including policymakers, practitioners, industry and, most important the public, would need to be engaged to understand the process by which these estimates are reached.

The Department of Health is increasingly aware of the need for evidence-based priority-setting and is supportive of work to generate evidence for best buys for health in SA. The National Strategic Plan for the Prevention and Control of Non-Communicable Diseases, for example, lists several cost-effective interventions to achieve its targets.

We do not advocate a “one size fits all” approach to priority-setting, as this would be ineffective in addressing equity gaps. Understanding what is needed in each province and district is essential.

Reaching sustainable health targets is a matter of urgency. A priority-setting agency will be key to ensuring that the public purse is used effectively, efficiently and equitably to get a “good bang for our (health) buck”.

Between 2012 and 2014, the Rockefeller Foundation funded NICE International to support a series of initiatives with the Ministry of Health and associated agencies, including The National Health Insurance Agency (NHIA), The Ghana Health Service (GHS, the largest provider agency) and the Ghana National Drugs Programme. The key objective of this cooperation was to raise awareness among stakeholders in Ghana on the role and value of using evidence-based approaches in healthcare decision making and priority setting, including performance monitoring. See below for further information on this earlier work and

Study visit to the UK