On Friday 4th October 2019, members of the International Decision Support initiative (iDSI) were invited to the Ministerial Inauguration meeting of Ghana’s first National Health Technology Assessment (HTA) steering and technical committees for HTA. The invitation acknowledged iDSI’s 11 years of active involvement in the country advocating for prioritising evidence-informed decision making in Ghana

The honourable Kwaku Agemang-Manu, Minister of Health in Ghana started the event with an announcement of the launch of a steering and technical committee to institutionalise HTA in Ghana.

This new National Steering Committee, with representatives from the public and private sectors, as well as development partners, aims to set the HTA agenda. The National Steering Committee will also oversee HTA activities in the country, and provide advice on governance and structuring process and methods for assessments and decision making to ensure the nationwide HTA function is sustainable.

This step comes as the Ministry of Health reinforces its commitment to attaining Universal Health Coverage (UHC) through effective resources allocation within the Ghanaian healthcare system. According to the Ministry of Health, the technical committee will play a technical supporting role for evidence generation and supporting the steering committee in preparation of the tools needed to support and operationalise HTA activities as envisioned by the main stakeholders in the country. Both committees are expected to be coordinated and run by a Ministerial Secretariat, which was assembled and trained since 2016, and continues to receive extensive support from the iDSI network

Leading directors from the Ministry of Health, including Ms Martha Gyansa-Lutterodt, Director–Technical Coordination Unit and iDSI advisory board member, Ms Joycelyn Azeez, Director–Pharmacy Unit and Mr Hamidu Adakurugu, Director of Administration attended the meeting. In addition, other national executives, such as Lydia Dsane- Selby, Chief Executive Officer–National Health Insurance Authority, attended the event. They have been working closely with our network on technical assistance projects, most recent of which was an HTA study on hypertension in Ghana, which informed price negotiations and the 2017 update on standard treatment for hypertension.

As a global network of health, policy and economic experts, supporting countries to achieve UHC and Sustainable Development Goal 3 (SDG 3), iDSI has been fully committed to supporting the development of tailored institutional capacity for HTA in Ghana across all government, academia, and private entities. We have been working to foster collaboration nationally and internationally, emphasising country ownership and local mandate, so countries can lead their own progress towards UHC with support from international partners.

Ghana has achieved critical milestones for developing HTA capacity through recent achievements with iDSI support and ministerial leadership, such as:

• Ghana’s first national economic evaluation on hypertension management. This work informed price negotiation, procurement, and changes to the standard treatment guidelines.
• Practical learning and knowledge mobilisation, using the hypertension project as a case study to raise awareness and build practical experiences around conduction economic evaluations for HTA in Ghana.
• Ghanaian stakeholders attending bespoke iDSI trainings that address differential needs across various Ghanaian stakeholders aimed to develop the necessary capacities in-country.
• Developing a country strategy for HTA institutionalisation and laying foundations for assembling HTA committees by sharing global experiences of process and methods deployed for similar activities internationally.

To formalise our relationship and commitment, iDSI are in the process of signing a Memorandum of Understanding (MOU) between the Ministry of Health, the University of Ghana and Kwame Nkrumah University of Science and Technology (KNUST). This will be instrumental in harmonizing all national and international efforts.

We are eager to continue our longstanding collaboration in Ghana to help the county realise its vision for HTA institutionalisation. Our cross-country team, made up of members of the Ministry of Health secretariat, are expected to fully carry out the operations of the announced committee, will be meeting this week in Oslo, Norway to discuss the outcomes of this inauguration meeting and organise a plan of action for iDSI activities going forward.

Within the next few years, Ghana can be an African leader in HTA institutionalisation, which will in turn help expand activities beyond Ghana, situating the country as a regional hub to mobilise knowledge and capacities in other African countries. Ghana is already a leading member state in the West African Health Organisation (WAHO) and can play a leading role to strengthen south-south collaboration, drawing on its rich experience in the field of HTA. A great example to follow is the achievement of Health Intervention and Technology Assessment Program (HITAP) in Thailand, which emerged as a major regional hub extending support to Asian and African countries’ efforts, to achieve HTA institutionalisation.

As the Minister of Health accurately described, Ghana has positioned itself to institutionalise HTA. However, the main bulk of work is still yet to come, and as we look forward to our next phase of work in Ghana, we call on all involved parties to engage with each other and keep effective communication strategy. We also invite the Ghanaian government to continue leading the way by mobilising essential domestic resources to self-sustain and steer future developments in this new dynamic age of healthcare in Ghana.

Congratulations to all involved in this important development.

In order to provide a platform for South African policymakers to engage with local and international experts around this area, a Policy Dialogue was organised in South Africa by iDSI partners in March 2017. The Policy Dialogue followed a workshop entitled “Designing and Adjusting the Health Services Package for Universal Health Coverage in South Africa”.  Representatives from the South African Treasury and the NDoH engaged with experts from South Africa, the United Kingdom and Thailand to discuss topics related to a Health Services Package (HSP).

After a discussion of key challenges, the participants agreed upon some important next steps to address these. Firstly, clarity on the budget envelope and financing of NHI in the context of the relationship between national and provincial-level decision making and resource allocation (fiscal federalism) is required. Due to the large variability of quality, transparency and availability of clinical guidelines, there is a need for a dedicated unit responsible for coordinating clinical guidelines. It is also important to build understanding of and commitment to evidence-based medicine especially amongst clinicians, and to strengthen the local ownership of clinical guidelines. Clear criteria need to be developed for ‘value for money’ such as a cost-effectiveness threshold. Establishing a national health technology assessment (HTA) unit will provide the technical and analytic input required to inform evidence based decision making for the NHI and HSP. Furthermore, priority topics for HTA need to be identified. Lastly, formal public engagement processes and collaboration with a wide range of stakeholders is important for the successful and appropriate implementation of an HSP.

To read the full report click here.

The white paper was revised and gazetted as the National Health Insurance Policy in June of this year. You can access the policy document here.

Just days ago, Bill Gates had visited the country to meet with prime minister Nadendra Modi, where the multibillion dollar philanthropist commended the PM on his efforts to improve the country’s population health. Indeed, Gates followed up his visit with a guest editorial in the Times of India, reflecting on his week of meetings in the capital and history of collaboration in India, stating that “With the right investment in India’s economy and India’s people, what lies ahead will be even more impressive”. Is it a coincidence that the PM waited until Gates had left the country before announcing cuts to the country’s largest public health program? I think not.

Reuters further reports that ‘officials familiar with the plan said the finance ministry reduced planned funding because of other spending priorities and because of state governments’ poor track record of spending the health budgets they’ve been allotted in the past’. This news is not new, and indeed an analysis by India Spend of 2017 Reserve Bank of India data on state budgets released in July this year, reported that nine of India’s poorest states spent less money than was allocated to them, and that these same states had the poorest performance indicators in the country.

I wrote a blog when the India Spend analysis was released in July this year, titled ‘More money does not mean more health’. In this blog I highlighted that system inefficiencies needed to be effectively addressed if countries, and states in the case of India, are to adequately utilise resources to improve health outcomes. While few would argue against the notion that India will not come close to achieving its ambition of achieving universal health coverage (UHC) with the current health spend of 1.4%GDP, one of the lowest spends globally, the notion that more money does not guarantee more health may come as a surprise to some.

We know from global surveillance data that health expenditure is rising in most countries across the world, yet figures released by the OECD reveal that a considerable proportion of this expenditure has little to no impact on improving people’s health. This is consistent with a 2010 WHO analysis which concluded that 20-40% of healthcare spending globally is wasted. This tells us that when the right systems are not in place to spend money wisely, effectively implement policy decisions, and govern their deployment.

So is the government of India justified in not increasing the budget allocated for health and raising the expenditure from the current 1.4% GDP? The answer is no. Unless more money is invested into the Indian health system to meet the growing demands of the 1.3bn strong population, the country will never realise its ambition of providing UHC. Consider the counterfactual – if investment in health stays stable or drops, are the population health indicators likely to improve? The latest Human Development Index, released in 2016 saw India slip to a rank of 131 out of a possible 188 countries in the world, behind neighbours Sri Lanka and the Maldives. If drastic action to rectify falling health indicators is not taken, evidenced by a stronger financial and practical commitment to health, the wellbeing of the population will continue to slide backwards.

Strong strategic planning and support should be undertaken to complement increased spending to ensure that additional funds are adequately absorbed and spent wisely. Such planning to not only spend more money, but spend it better is essential to maximise the value of every rupee spent, and ultimately improve the health of the population.

The key messages outlined in the earlier blog are highlighted here again, as follows:

• An important determinant of success or failure of Indian states to improve their health indicators will be the strength of system-wide mechanisms to engage in effective priority setting of resources and govern their deployment.
• Effective uptake of resource allocation decisions requires a system able to deliver and strong governance mechanisms to ensure that policies are properly implemented.
• Evidence-based priority setting of resources is important to maximise health gains made within the constraints of a finite budget.
• Without robust surveillance and governance mechanisms, the value of effective priority setting is severely diminished.
• Ensuring an adequate number of well-trained and reasonably paid health professionals with access to necessary equipment and infrastructure is critical to ensure a fit for purpose delivery system and address supply-side inefficiencies.

Maternal health care

Universal Healthcare Coverage (UHC) is a basic human right but is something that a great deal of the world’s population doesn’t have access to. Goal 3 of the sustainable development goals is to “ensure healthy lives and promote well-being for all at all ages” and has a set date to be achieved by 2030. The UN has set thirteen targets to achieve UHC including reducing the global maternal mortality ratio to less than 70 per 100,000 live births, to end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases, combat hepatitis, water-borne diseases and other communicable diseases. These goals whilst fully achievable with the correct support, almost all apply to the poorest parts of the world in Sub-Saharan Africa and Southern Asia.

These regions also present persistent problems with gender equality and women’s rights: a contributing factor to high rates of infant mortality. Goal 5 of the sustainable development goals is to “Achieve gender equality and empower all women and girls” – which at first may seem unrelated, is entwined with Goal 3. Empowering women and giving them equal rights to education can reduce the number of forced marriages of girls under the age of 18, as girls in education wait longer to marry and then have children. By implementing programmes to inform and educate adolescents and parents in sexual health and the advantages of education for girls, countries can move towards gender equality. This in turn can help a country progress towards achieving health lives for all of its population, as education is likely to reduce adolescent pregnancies and therefore potentially reduce the number of deaths due to child birth. iDSI has carried out work on maternal care and reducing mortality rates due to child birth in Kerala, India which can be found on the iDSI Knowledge Gateway here.

Linking sustainable development goals

Improvements have been made and are continuing to be made by local governments, for example in Southern Asia in 1990 only 74 girls were enrolled in primary school for every 100 boys. However, in 2012, the enrolment ratios were the same for both boys and girls[1]. With the help and funding of more developed countries like the UK more advanced programmes can be implemented to help achieve these basic human rights. Dr. Tedros WHO Director-General is championing women’s equality and healthcare “we must not only place the well-being of women, children and adolescents at the centre of global health and development, but also position health at the centre of the gender equality agenda”.[2] Following this thinking, the large overlap between Goal 3 and Goal 5 regarding maternal care and support should link them together enough for governments to work on achieving them both at the same time. Funders and development partners should be asking: does improving prospects for women reduce the spending required in maternal care? What are the downstream and cross sector effects of complex interventions in particular sectors? If education could lead to reduced cost of maternal healthcare, where could these resources be reallocated to, in order to achieve universal health coverage? A recent iDSI article “We need a NICE for global development spending” looks at the principles of resource allocation and value for money and how evidence based decisions can help funders and recipient countries decide how to best use their resources to achieve the most health for their population.

[1] www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20Summary%20web_english.pdf

[2]  www.who.int/dg/speeches/2017/every-woman-every-child/en/

According to the WHO report, public expenditure in health decreases as a percentage of total public expenditure in the presence of donor aid, and does not increase in line with fiscal growth. But what does this mean in relation to improving population health and economic productivity? This answer to this question is not easily extracted from the report. In fact, the single methods page gives little detail as to data provenance and how it was analysed – necessary requisites of any academic paper submitted for peer-reviewed publication. The document also reports patterns of spending as proportional to total investment, which in the absence of absolute figures can be misleading, though the authors do recognise this as a caveat within the report. The underlying assumption here seems to be the myopic belief that the healthcare sector should be taking up an ever-greater share of public expenditure in all circumstances. But what does analysing and tracking percentage of public expenditure on health really tell us about whether monies are allocated appropriately and systems are operating efficiently?

The WHO report focuses heavily on the question of fungibility and whether development assistance crowds out domestic funding for the healthcare sector. However, an argument can be made that investing in areas such as infrastructure, sanitation, or education may be an even better use of scarce country resources than healthcare, since it has a direct impact on alleviation from poverty and an indirect positive impact on health. There is perhaps some value in a country trying to ensure access to safe drinking water and adequate sanitation before investing in the rotavirus vaccine for all its children. Indeed, a recent study examining the fungibility of development assistance in Tanzania found that fungibility of external funds was in fact beneficial to the country’s development, with evidence suggesting that the ‘displaced’ funds were reallocated towards education. It is obvious that the opportunity cost of spending finite, scare resources in LMIC unwisely has implications beyond health, so fiscal elasticity in this context is not necessarily detrimental, but potentially beneficial.

In recent years, a number of econometric studies have been carried out to address the question of the fungibility of development assistance. However, results of these analyses have been shown to be highly sensitive to the methods used, and are usually based on weak and divergent data sources.

The real problem with the question of fungibility and how to capture and analyse it, is that we’re asking the wrong questions. What we should be asking is not where the money is going, but instead ‘are those monies allocated appropriately and spent efficiently to maximise value?’, where allocative efficiency is dependent on the presence of effective priority setting and governance. Answering this question involves looking beyond the expenditure databases at priority setting mechanisms within particular countries and what financing and governance models can be made to work best for donors and, more importantly, for countries, in their quest to improve health and wellbeing for their populations. Indeed, the emergence of pay for performance incentive schemes and Development Impact Bonds is evidence of a growing trend towards results-based health financing (for more information, see Centre for Global Development’s extensive literature on the potential and pitfalls of these kinds of financing models).

Aside from the substantial technical, statistical, and data quality issues of fungibility-focused econometric studies, it is very difficult to extract the answer to the ‘So what?’ question of how to make things better. One way to address this question experimentally is to design a well-structured, responsive, and flexible co-financing system which facilitates a shift of focus on fungibility to productivity gains. Such a system was recently put forward by Morton and Colleagues, which is founded in the assumption that a list of ‘best buys’ can be relatively easily generated for countries. These high-benefit and low cost interventions could be paid for by the country and more costly interventions higher up the list could be paid for by donors, either in full or as part of a cross-subsidy agreement. The question is then targeted at the point at which an intervention becomes cost effective, within the confines of the domestic budget, and whether donors should subsidise up to this point at the assumption (or agreement) that local policymakers will pay for interventions at the point at which they become cost effective for them. This kind of alignment of donor and local priorities has also proved successful in the form of sector wide approach to payments (SWAp), where recent analyses suggest that $0.52 more cents of domestic government revenues is spent in the health sector when health aid is channelled to settings where there is a SWAp in place. Such co-payment mechanisms focus more on a reciprocal relationship and open conversations between donors and local governments to enter into mutually beneficial contractual arrangements, which significantly reduces the importance of fungibility. To take the argument one step further, we should aspire towards non-siloed donor budgets which can look not only beyond vertical programs, but also beyond health towards pan social-sector relevance – then fungibility loses its meaning entirely.

As countries progress they should be establishing robust mechanisms for evidence-based priority setting to ensure that value is maximised for every rupee, peso or rand spent. Whether health spending as a share of public spending increases or decreases is of secondary importance to the question of whether money is spent wisely. In the context of a rapidly changing development assistance landscape, policymakers and donors alike should be focussing on the ‘so what’ question – what will the transition from external to domestic financing mean for health outcomes? How can donors and policymakers work together to facilitate a smooth transition? And how can domestic resources be most effectively prioritised to ensure best value health buys? The global health community needs to rise to the challenge and support policymakers across the world to spend their money better, and ensure that adequate governance mechanisms are in place to protect these finite resources against waste.

Laura Downey¹, Alec Morton², Kalipso Chalkidou^1,3

1 – Global Health and Development, Institute of Global Health Innovation, Imperial College London, London UK
2 – Strathclyde Business School, University of Strathclyde, Strathclyde UK
3 – Global Health and Policy, Centre for Global Development, London UK

In a recent policy brief, Oxford Policy Management and the International Decision Support Initiative (iDSI) have asked “would the VfM analysis that the UK’s Department for International Development conduct on their programme expenditure be more useful if lessons were learnt from the iDSI Reference Case for Economic Evaluation?”. It is argued that significant methodological improvements are available to DFID – which could make the information they generate more useful for their decision makers. These recommendations are also applicable to other donors who follow similar guidelines for monitoring their VfM.

Alex Jones’ blog post exploring some of the issues raised in the brief is available on the Oxford Policy Management website.

Therefore, difficult decisions on healthcare prioritisation are constantly being made by governments and aid organisations, with an increasing focus on allocative efficiency to achieve greater returns on investment. The World Health Organisation (WHO) has identified substantial inefficiencies in healthcare financing, amounting to between 20% and 40% of total spending. These inefficiencies have several sources, from allocation decisions based on poor cost-benefit analyses to losses in the supply chain. Aid allocation decisions are often based on non-objective criteria, such as shifting political priorities in aid-giving governments or geopolitical factors. Aid financing can also go “missing” as a result of poor governance, or be consumed by the high running costs of organisations.

This report, commissioned by the International Decision Support Initiative (iDSI) and written by the Economist Intelligence Unit (EIU), reviews the current research and methodologies used to analyse resource allocation and identifies gaps that could be bridged to improve health outcomes. To reduce waste and improve efficiency, the report then seeks to lay the groundwork for developing an index—a multidimensional measurement framework—that will evaluate the “enabling environments for health aid effectiveness”. Such a tool could, in our view, become a powerful resource for quantifying how effectively the healthcare sector works in low- and middle-income countries.

The report can be found here.