Placing the Evolution of HTA In Emerging Markets in Context of Health System Development


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These slides were presented by Professor Adrian Towse at the 9th World Congress of the International Health Economics Association in July 2013. The presentation examined how the development of health care systems affect the evolution of the use of health technology assessment. Three countries provide case studies: Brazil, China and Taiwan.

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Placing the Evolution of HTA In Emerging Markets in Context of Health System Development

  1. 1. Placing the Evolution of HTA in Emerging Market Health Care Systems in the Context of Health System Development: Approach and Findings Professor Adrian Towse Office of Health Economics International Health Economics Association 9th World Congress • Sydney • 7-10 July 2013
  2. 2. Acknowledgements • This project has been led by Adrian Towse, Nancy Devlin, and Emma Hawe at the Office of Health Economics (OHE) with the assistance of Professor Lou Garrison and his colleagues at Veritech Consulting and the University of Washington, Seattle • Local researchers Michael Qin, Vanessa Teich, and Ivy Tsai have undertaken research and interviews in China, Brazil, and Taiwan respectively • The study was funded by the Pharmaceutical Research and Manufacturers Association
  3. 3. The Objectives of the Study • To develop a categorisation of health care systems (HCS) • To develop a categorisation of types of HTA using definitions recognised by practitioners in the field. Inevitably these are based on the experiences of high income countries, but can be expressed in a form that can fit into policy development in relation to the current and future health care systems of low and middle income countries. • To combine these two strands (HCS and HTA) to examine the role for HTA in a health care system dependent on development stage and structure of that health care system • To set out these findings in a way that is helpful to understanding the potential role of HTA processes – using three jurisdictions for illustration: Brazil, China and Taiwan.
  4. 4. • More countries seeking to achieve one or more of:  Universal coverage of a minimum benefit package for their citizens  Adding to existing coverage by increasing the numbers of services included in the benefit package (for example by including outpatient services including drugs)  Reducing the amount of co-payment faced by patients on services that are included in the benefit package. • Ageing populations and growth in the disease burden • An increased range of potential health technologies • Economic pressures, with recent and projected economic growth rates in many countries below historical levels Trends in health care
  5. 5. The Four Functions of Health Care Systems Source: Murray and Frenk, 2002
  6. 6. Six Building Blocks of a Health System Source: WHO, 2010
  7. 7. Input-Output Model of the Health Care System Source: Garrido et al, 2010
  8. 8. Definitions of Health Technology and HTA • A health technology is defined by HTAi as An intervention that may be used to promote health, to prevent, diagnose or treat acute or chronic disease, or for rehabilitation. Health technologies include pharmaceuticals, devices, procedures and organizational systems used in health care. • Health technology assessment (HTA) is defined in the HTAi mission statement as A scientifically based and multidisciplinary means of informing decision making regarding the introduction of effective innovations and the efficient use of resources in health care.
  9. 9. What Exactly Is HTA? • We can categorise HTA into three types:  HTA aimed at appraisal of individual technologies, or groups of closely related technologies  HTA aimed at developing clinical practice guidelines or the way in which individual technologies are combined with and within a delivery system to manage patient clinical pathways efficiently  HTA that is about the efficiency of the organizational systems or architecture of the health care system
  10. 10. Specific technology (tool) Area Type Aspirin, lipid-lowering drugs, ACE inhibitors Intervention provided in health-care services Drug Stent/stenting Coronary artery bypass grafting (CABG) Intervention provided in health-care services Device/procedure Rehabilitation programme Educational interventions Intervention provided in health-care services Multifaceted intervention Disease management programme for CVD Intervention applied to the health- care system (organization of service provision) Multifaceted intervention Pay for performance (e.g. targeting higher prescription of aspirin for CVD) Intervention applied to the health- care system (payment of providers) Policy Smoking ban Intervention outside health-care system Policy Examples of Technologies at Different Levels Source: Garrido et al, 2008
  11. 11. • HTA is one tool for improving health system performance. • Considering how to use and improve the use of HTA needs to be put in the context of other tools and of the strengths and weaknesses of the health care system. • Focus of use of HTA often is on informing decisions about the use of individual technologies, notably about inclusion in a benefit package. • Important, however, that context is borne in mind--or efficient HTA for individual technologies may not result in optimal use of those technologies within the health care system because of problems elsewhere in the system. • HTA aimed at developing clinical practice guidelines or HTA that is about the efficiency of the organizational systems or architecture of the health care system may be more important. Role of HTA
  12. 12. The “Natural” History of HTA Development Emergence Consolidation Expansion Why? • Convergence of needs, demands, and supply • Key individuals are “champions” of HTA • Receptive policy/political environment • Early successes attract interest of more decision makers • Expansion of demand for HTA products • Formalized priority settings process • HTA as part of official political discourse • Increased demand for diversified products What? • Narrow interpretation of health technology • Focus on high intensity technology (e.g., imaging) • Exclusion of pharmaceuticals • Broadening of scope of HTA • Possible addition of pharmaceuticals • Shift from specific technologies to care processes for the management of health conditions • Further broadening of scope of HTA (pharmaceuticals, public health, delivery models, social services) • Existing practices and new interventions How? • Modest resources, at times project or deliverables specific • Minimal scientific capacity • Expansion of scientific team • Modest addition of resources • Research partnerships sought • Significant increase in resources • Expansion of scientific team and partnerships • Diversification of products • Clinical practice guidelines And, Then What? • Knowledge translation minimal • Efforts directed to policy makers, often by means of personal communication • Progression of knowledge translation efforts • Broadening of targets audiences • Consolidation of multiple target audiences • Specialization of KT instruments • Increased proportion of resources to KTSource: Battista and Hodge, 2009
  13. 13. Health Care System Typology: Two Key Attributes/Variables and Levels LEVEL OF SPEND What quantity of resources are available? • Low spend per capita • Medium spend per capita • High spend per capita DEGREE OF CENTRALISATION Who makes decisions about what health care is funded? • Out-of-pocket spend dominant • Emergence of insurance or collective funding; decisions localised • Active third party purchasing
  14. 14. HTA Typology: Key HTA System Attributes/Variables And Levels FOCUS OF HTA What is appraisal concerned with? • Efficacy/safety • Relative effectiveness • Cost-effectiveness (C-E) • C-E and broader issues BREADTH OF HTA Which health services appraised? • Basic preventative services and minimum care packages • New technologies • All technologies/services
  15. 15. Evolution of HTA • HTA has to be linked to the evolution of health care systems • Limited role for HTA in a self-pay market • As public insurance funding develops, it is in governments’ interests to ensure that claims on those funds are justified • Yet HTA can be a “product” without a customer • Initially the insurer is typically just “paying the bills” • The initial focus of HTA may therefore be on the highest cost services • Over time, however, more active purchasing is likely to evolve • HTA is often initially introduced as a “black box” with little thought given to appropriate processes to involve stakeholders • Ultimately, all services will be seen as candidates for HTA • Key aspects of system architecture such as payment mechanisms and incentives will also come under scrutiny
  16. 16. Observations • Observation 1: Incomes are growing in emerging markets, but resulting increases in funding for health care are likely to be outpaced by rising demands and expectations. HTA has a role in assisting health care system reconcile rapidly expanding demand with more slowly expanding resources. HTA can provide a potential means of handling this in a more explicit and transparent way, and in promoting public debate about priorities. • Observation 2: HTA of individual technologies is not a substitute for the reform of health care systems. Where health care systems create obviously bad incentives, this type of micro HTA is unlikely to compensate for these failings. • Observation 3: “One size fits all” HTA processes and methods are unlikely to be appropriate for emerging markets. There needs to be clarity over the purpose of HTA – and the methods and processes that are adopted need to be fit for purpose. • Observation 4: HTA and pricing regulations work hand in hand: the approach to HTA should be appropriate to, and work sensibly in combination with, the particular approach to pricing technologies.
  17. 17. Particular Issues in Brazil • In Brazil, CITEC worked slowly and appeared to be under- resourced. This has the effect, intentional or otherwise, or delaying reviews of, and decisions on, access to new technologies. CONITEC has been set up in part to address these issues. • It is unclear how the role of CONITEC fits alongside a constitutional right of access to healthcare (which is clearly not consistent with the levels of funding available) and regulation by the ANS of the minimum requirements of the private insurance package.
  18. 18. Particular Issues in China • In China, there are a number of reforms to health system architecture underway and others are needed. • Where HTA seems to be emerging as important is in the key area of clinical practice guidelines. The initiative with the UK’s NICE International is aimed to be targeted at generating evidence-based clinical practice guidelines linked to incentives to deliver these evidence based clinical pathways. • HTA in the sense of appraising the cost-effectiveness of individual drugs is not used. There is interest in the possible use of HTA in drug assessment in all three Ministries (MoH, MoHRSS, NRDC) and leading academics continue to promote dialogue on guidelines for good practice. • Arguably the biggest issue in drug procurement is improving the working of the generic market where HTA in the narrow use of the term has no role. • There is some use of HTA for other individual technologies outside of drugs, led by the China National Health Development Research Center (CNHDRC)
  19. 19. Particular Issues in Taiwan • HTA applied to drugs was first established in 2008 as a pilot project. It is unclear how it fits logically alongside an international reference price system. • There are also some issues around the “black box” nature of the process:  the degree of transparency of the assessment;  the relationship between the assessment and the drug licensing process, given that expertise for pharmacoeconomic assessments is drawn from the licensing body. • Beginning in 2013, as part of Second Generation National Health Insurance reform, the pilot project is being replaced by a new agency unit for HTA. This is intended to address a number of issues with the pilot project. • The role of HTA appears to be exclusively in the area of drug reimbursement; • Some other elements impacting on cost and prices, such as incentives to prescribe and trading margins are also being addressed in the Second Generation reform.
  20. 20. • Battista, R.N. and Hodge, M.J. (2009) The “natural” history of health technology assessment. International Journal of Technology Assessment in Health Care. 25(suppl.1), 281-284. • Garrido, M.V., Zentner, A. and Busse, R. (2008) Health Systems, health policy and health technology assessment. In Garrido et al, eds. Health technology assessment and health policy-making in Europe. Observatory Studies Series No. 14. Copenhagen: WHO Regional Office for Europe. • Garrido, M.V., Gerhardus, A., Rottingen, J-A. and Busse, R (2010). Developing health technology assessment to address health care system needs. Health Policy. 94(3), 196-20. • Murray, C. and Frenk, J. (2002) A WHO framework for health system performance assessment. Available at [Accessed 29 July 2013]. • Towse et al. (2011). The evolution of HTA in emerging market health care systems: Analysis to support a policy response. Consulting Report. London: Office of Health Economics. Available at • WHO (World Health Organisation). (2010) Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. Geneva: WHO. References
  21. 21. To enquire about additional information and analyses, please contact Adrian Towse at To keep up with the latest news and research, subscribe to our blog, OHE News. Follow us on Twitter @OHENews, LinkedIn and SlideShare. Office of Health Economics (OHE) Southside, 7th Floor 105 Victoria Street London SW1E 6QT United Kingdom +44 20 7747 8850 OHE’s publications may be downloaded free of charge for registered users of its website. ©2013 OHE The Office of Health Economics is a research and consulting organisation that has been providing specialised research, analysis and expertise on a range of health care and life sciences issues and topics for over 50 years.