HTA in Sub-Saharan Africa meeting: Use of HTA in Health Systems strengthening, Cape Town, Oct 4, 2014

1. Incorporating
HTA into
Health
Systems
Reiner Banken M.D. M. SC.
Advisor to the CEO, Alliances and Networks
reiner.banken@inesss.qc.ca
Cape Town, Oct 4, 2014
HTA in Sub-Saharan
Africa meeting: Use of
HTA in Health Systems
strengthening

2. 2
Objectives of the presentation
• Understanding
– the objectives for introducing HTA
– the evolution of HTA in Health Systems
– the human resources and instutional arrangements
necessary for effective HTA

3. 3
Outline
• Why should Health Systems use HTA ?
• Messages from high income countries
• From HTA to action: Context, policy tools and
governance
• Resources needed
• Conclusion

4. 4
Why should Health Systems
use HTA ?
 Improve the quest for clinical excellence
 Support the efficient use of health technologies
 Inform the formulation of safe, effective, sustainable
decision-making in health systems that is patient-focused and
seeks to achieve best value
 Favor consensus between clinicians and managers
 Define benefit packages for health care
 Provide evidence for the development of clinical practice
guidelines
Increase the transparency of decision-making
All of the above and more

5. Evidence for informing decision-making
+Evidence
Intuitive
Decision-making
Technological,
Organisational,
Ethical,
Legislative
Conditions
Political, Social,
Economic
Conditions

6. 6
Why should you support the
development of HTA?
Decision-makers in all Health Systems are being
held accountable for not meeting the rising
expectations of patients, clinicians and the public.
HTA can partially solve this
unsolvable problem.
HTA makes your life easier

7. 7
The price to be paid….
HTA as a service for the health system
cannot work without rigor, independence
and transparency.

8. 8
The “natural history” of health
technology assessment: emergence,
consolidation, and expansion.
• Emergence: need expressed by decision-makers in a context
of depoliticizing allocation decisions in times of increasing
resource constraints, importance of leaders, development of
the scientific know-how, high cost medical device focused,
little stakeholder involvement,
• Consolidation: more structured organizational HTA systems,
priority setting, enlargement of scope of technologies,
increased stakeholder involvement
• Expansion: multiple disciplines, multiple products, political
recognition, HTA system, strong stakeholder involvement,
investment into Knowledge translation
Battista RN, Hodge MJ . Int J Technol Assess Health Care.
2009 Jul;25 Suppl 1:281-4.

9. 9
INESSS – 40 years of science
advice for decision-making
1972 1991
1996
Conseil d’évaluation des
technologies de la santé
(1988)
Réseau de revue
d’utilisation des
médicaments
January, 19,
Agences d’évaluation
des technologies et
des modes d’intervention
en santé
Comité de revue
de l’utilisation des
médicaments
2000
Conseil consultatif
de pharmacologie
Conseil du
médicament
2003
2003
Institut national
d’excellence
en santé et en
services sociaux
Social Services
Clinical Practice
Guidelines
2009
2011
1988
2011
Medical Biology
Lab tests

10. 10
HTA in the 21 century – A
perspective from Political Science
• HTA has developed in a relatively depoliticized environment … buffered
from the capricious impacts of electoral politics.
• HTA in all the countries began with relatively politically innocuous studies
of technologies recognized to be of major import to national health
systems or researcher-initiated studies.
• However, with increased focus in health systems on explicit determination
of health benefits baskets, the role of HTA has become more high profile.
This means that political accountability for the entire HTA process will
increase.
• The implication is that future management of HTA programs will require
self-conscious attention to the building of institutions capable of handling
the delicate process of integrating science and politics in health policy.
Citation from the abstract of Chinitz. Health technology
assessment in four countries: response from political science.
IJTAHC 20:1 (2004), 55–60

11. 11
Messages from the evolution of
HTA
1. The use of HTA in Health Systems is evolving over time.
2. Institutions (rules, organisations, legal frameworks) are
important and should enable HTA to evolve.
3. Mature HTA systems include a wide range of health
technologies and interventions to be assessed, strong
stakeholder involvement and knowledge mobilisation
activities.
4. The development of HTA takes place in a political arena; the
objectives and processes have to clear from the start.

12. 12
Reasoning in HTA
Implementation
Appropriateness
Effectiveness
and safeness
How should we do
it here?
Should we
do it here?
Can it
work
here?
(here=context
of decision-making)
Theoretical
safety and
Can it work? efficacy
Research
Translational research
Adapted from Health technology assessment of medical devices. WHO Medical device technical series,
2011. Available at: http://whqlibdoc.who.int/publications/2011/9789241501361_eng.pdf

13. 13
Context is essential for evidence-informed
decision making
There are decisions that…
take good
evidence …
… and use it
well
in context
w i t h o u t c o n t e x t
i n c o n t e x t
poor evidence … and use it poorly
…
without context
Adapted from Shaxson, L 2004: Evidence-based policy making: if it exists
what makes it robust? Available at http://bit.ly/hIsNC

14. 14
On Context
1. Stakeholder involvement is an important element
of scoping and contextualizing HTA.
2. Health Service Research and Implementation
Science are important for providing a perspective of
health systems context.
3. The capacity of health information systems to
provide contextual data is very useful for
supporting the context aspect of the HTA
knowledge synthesis

15. 15
Health Technology Assessment for
Improving Health Systems and
Health
Governance
Health Technology
Efficient Health Systems
Improving population
health
Appropriate
Use
Decisions
Policy Tools
HTA

16. 16
Science, decisions and policy
tools for pharmaceuticals
Governance Current tools in Québec
Knowledge
Uncertainties
Drug
Reimbursement
Decision
Policy
Tool
•Regular list
•« Médicament d’exception »
•Refusal
Other possible tools,
currently not available
•CED
•Risk sharing
•Limited to specific
settings
•…

17. 17
Impact of HTA depends on links to
policy instruments
In some countries there are specific mechanisms that lead to the
incorporation into policy instruments of research such as Health
Technology Assessments (HTAs) ….no direct link between the
amount of money spent on HTA and its impact on the decision-making
process. Indeed, they suggest that small programmes
can be involved in the core of the policy-making structure whilst
larger HTA programmes have difficulty in demonstrating
impact….It seems clear that HTAs have had most impact in
those situations where there are specific mechanisms in place
that require research evidence to support well-defined policy
decisions on provision, coverage or reimbursement.
Citation from Hanney et al. The utilisation of health research in policy-making:
concepts, examples and methods of assessment. Health
Research Policy and Systems 2003, 1:2

18. 18
How to start the process and
make it last?
“Start small, have a clear
audience and scope, and address
important questions”
(Lavis et al 2008, Synthesis of findings from a
multi-method study of organizations that
support the use of research evidence)

19. 19
Dedicated resources for HTA
1-2 persons
HTA Knowledge
Mobilizer
Putting HTA
into Context
HTA Unit/
Agency
4-5 persons
>9 persons
Dedicated
Resources
HTA
Committee
HTA
System

20. 20
Human resources and objectives
1-2 persons
4-5 persons
>9 persons
Team with health
economist, librarian and
social scientist.
Translation of HTA
knowledge produced
elsewhere into the local
decision-making context.
Clinician champion with
scientific background in
knowledge synthesis. Receptor
for HTA knowledge produced
elsewhere. Second person could
act as an HTA Knowledge
mobilizer and support an HTA
Committee.
Multidisciplinary team
for HTA Knowledge
Synthesis and Knowledge
Mobilisation

21. 21
Guiding principles
• If you do not have the human resources to do scientific
knowledge synthesis, you cannot do HTA.
• If you do not have good links to decision-making, you
can do HTA, but it will not be effective.
• If you do not have strong stakeholder participation and
health systems governance, HTA will not be effective
for Universal Health Coverage.

22. 22
Spectrum of HTA implementations
• Level of governance: HTA for hospital based decision-making,
for health system level decision-making, for decision-making
by health insurances Multi-jurisdictional HTA, HTA for
international decision-making ??? (WHO, World Bank,
international development, …)
• Objects and objectives: selected non pharmaceutical
technologies, wide range of technologies including care
processes, health care delivery models, health benefit
baskets, Universal Health Coverage.
• Dedicated resources: HTA receptor, small unit, full blown
HTA agency, networked HTA (crowdsourcing ?)

23. Agenda setting- the policy context in Colombia
Problem
stream
Policy
stream
Politics
stream
Policy
window of
opportunity
2
2004 inflationary costs
and raising exceptions,
government starts
considering HTA
processes
2008 Constitutional
court´s mandate to
amend structural
factors
2008 National
methods
guidelines
Early 2009 crisis
within the health
system threatening
sustainability
Policy
window of
opportunity
Mid 2009
increased
interest in NICE
methods and
processes,
government´s
official request
for technical
advice
Late 2009
controversial
law of social
emergency by
former
president
1
2007 Decision
making body
created not an
HTA agency
2011 HTA
agency
(IETS)
enacted by
law
2012 HTA
agency
(IETS) starts
operations
Late 2010
New
government
Early 2010 law of
social emergency
declared
unenforceable
04 05 06 07 2008 2009 2010 11
Source: Based on Kingdon model- 1984 by Castro HE, 2013 work in progress
12
2012 Decision
making body
abolished lack of
legitimacy
2013 POS
content
updated
using HTA by
IETS
13
Hector Castro, IETS, Columbia. From presentation at EMRO First Intercountry HTA Meeting,
November 2013, used with permission.

24. 24
HTA as a service for the health system
cannot work without rigor,
independence and transparency
The strategies of influence entail a number of risks that may undermine the
scientific evaluation of drugs. Some outcomes of drug evaluation may favour
the interests of multinational drug companies over those of the public payer.
We suggest that the risks involved in drug evaluation might be mitigated
through (1) professionalization of health technology assessment; (2)
restriction of job seeking and post public-payer employment; (3) disclosure
and management of experts’ conflicts of interest; (4) institutionalisation
of patient and public involvement; and (5) increased institutional
separation of the AHTAPol from political elites.
Citation from the abstract of Ozieranski et al. The politics of health
technology assessment in Poland. Health Policy 108 (2012) 178–193

25. 25
Strategies for Africa
• Developping scientific capacity for knowledge synthesis in
collaboration with universities, the Cochrane Collaboration,
EVIPNet Africa, and other Health Systems Research initiatives.
• Capacity building with existing HTA networks, such as
INAHTA.
• Using country or region specific Policy Windows.
• Regional communities of practice in HTA.
• Promoting the need for HTA with policy makers and funding
agencies , but also the necessary conditions of rigor,
independence and transparency
• Linking HTA to collaborations in regulation for
pharmaceuticals and devices (NEPAD ?, ECOWAS ?,…)

26. 26
Conclusion
• HTA as a service for the health system cannot work
without rigor, independence and transparency.
• HTA should be implemented gradually, starting with
scientific human resources.
• HTA Systems need institutions (organisations, legal
frameworks, dedicated resources)
• HTA relies on strong stakeholder participation and
health systems governance in order to contribute
significantly to Universal Health Coverage.