Priority setting in uhc sep 9 short version

Priority Setting in UHC
The Role of HTA
Alaa Hamed
September 26, 2017
MNA Health Policy Forum

Outline
• Health Technology Assessment in Universal Health
Coverage
• HTA: The Framework for Evidence Informed Priority
Setting
• HTA: The Case for Fairness
• HTA: Defining the Benefit Package
• HTA: Strategic Purchasing – A Missed Focus
• OPTIMA: The New Approach For Evidence Generation
2Alaa Hamed, MNA Health Policy Forum, Sept. 2017

Health
Technology
Assessment in
Universal
Health
Coverage

UHC is the ultimate
expression of fairness
UHC is about ensuring that
everyone can obtain essential
health services of high quality
without suffering financial
hardship

Priority setting is
inevitable on the path
towards UHC
Health needs exceed resource
availability, not setting priorities
may lead to unfairness
Countries experience gap between
their population health needs and
what is economically feasible to
provide
Can priority setting be fair and
ethically acceptable?
Fairness requires unmet health
needs to be addressed, but in a fair
order.

HTA is Part of Priority
Setting Process
It is a critical component of
evidence-based policy decision
making
It is an essential foundation to
secure UHC through the efficient
and equitable allocation of health
care and other resources
It identifies critical inputs for
decision makers’ judgement, such
as balancing uncertainty about
difficult trade-offs, or how best to
proceed when the evidence is
poor or absent.

Priority Setting, The Right
to Health
Most countries have the right to health
in their constitutions
In some cases, country’s judiciary make
decisions on what to be paid for
individual patients, ignoring budgetary
constraints and impact on availability for
rest of the population
Could harm be done by well-meaning
intentions?
Could the presence of legitimate,
transparent and evidence based priority
setting process bring value for money?

Now imagine…
You are a policy
maker in a low or
middle income
country
You are part of a committee deciding what
services — the Health Benefits Package -
should be provided to whom and at what
cost.
You are asked to set priorities within and
across health problems and for different
groups of populations
Now, you are facing PRESSURE and
DEMAND
Doctor and patient requiring best
treatment, disregarding cost
limitations
Media puts pressure, once every new
technology emerges
Industry demands their products
included in benefits package
You need to make a
decision, a complex
one

You are looking for a
Priority Setting Process
Robust process, evidence to decide on
health benefits is needed
Fair, systematic, transparent and
acceptable manner to all
We call this HTA
a ‘‘multidisciplinary policy research, in
generating evidence to inform
prioritization, selection, introduction,
distribution, and management of
interventions for health promotion,
disease prevention, diagnosis and
treatment, and rehabilitation and
palliation’’

Around the world, who is
doing the priority
setting?
England and Wales: National Institute
for Health and Care Excellence, NICE
Canada: Canadian Agency for Drugs and
Technologies in Health, CADTH
Republic of Korea: National Evidence-
based Healthcare Collaborating Agency,
NECA
Thailand: Health Interventions and
Technology Assessment Program, HITAP
Brazil: (National Committee for
Technology Incorporation, CONITEC

These are called
HTAs, but no more
only about
technology
NICE, CADTH, NECA, HITAP, CONITEC are
known as Health Technology Assessment
(HTA) Organizations
They are broader than “Technology”, they
encompass policies and delivery platforms
Their role is about defining benefits
packages, deciding who receives what
healthcare at what cost
But also about services and technologies to
be covered by public budgets, through
explicit lists, including positive lists (e.g.
benefits catalogues), and negative lists (e.g.
technologies not covered)

UHC is the ultimate expression of fairness
HTA is Part of Priority Setting Process for
UHC
HTA is not only about technology, but also
about policies and delivery platforms
Alaa Hamed, MNA Health Policy Forum, Sept. 2017 12

HTA: The
Framework for
Evidence
Informed
Priority Setting

Evidence, Interests,
Values
Global evidence and guidance about
globally cost-effective health
interventions are not sensitive to local
political economy, unlikely to influence
local resources allocation
Priority setting is in reality a value-
laden political process, multiple
criteria beyond cost-effectiveness are
important
Cost-effectiveness is not much used by
countries, economic evidence is down
valued, deprioritized over other
socially acceptable considerations

Research & Data
Analysis
Need In-country expertise for
commissioning, producing and
interpreting local data on costs
and outcomes
This will require support to
technical, institutional and
informational capacity at the local
level.

Priority Setting,
Role of Experts
Standardized cost-effectiveness is for
global guidance, avoid one-size fit all
Respect local context related to
demographics, disease burden, equity
Respect local judgements about
acceptability, feasibility, manageability,
and speed of implementation in policy
and practice
Caution to distort local spending,
consider local cost of interventions
Advise national processes to guide
subnational decisions, define scope of
local discretion, resolve differences

Priority Setting,
Context-based
Evidence for Better
Decisions
A deliberative process taking into
account local values and evidence is
the path for country empowerment
and UHC sustainability for better
spending outcomes in health
This will include consultation,
transparency, and guarding against
vested interests, parallelly
generating needed economic
evidence to influence resource
allocation.

Priority Setting, Takes
Time and Costs Money
Creating a deliberative process
takes time
Generate technocratic evidence
from a small unit in a relevant
organization (ministry of health,
social health insurance, ministry
of finance) to influence budgets
and investment providing
evidence of trade-offs to decision
makers

Priority setting is a value-laden political
process, multiple criteria beyond cost-
effectiveness are important
Priority Setting, Context-based Evidence
for Better Decisions
Priority Setting, Takes Time and Costs
Money

HTA: The Case
of Fairness

• Scope of interventions (prevention
strategies, health delivery systems)
• Objectives of health (changes in
the distribution of health or in
distribution of burden of cost)
Measuring the distributional effects of
technology adoption and
quantifying the value society places
on these effects; however a
challenge
Possible to weight costs and benefits
differentially according to the
distributional value one wishes to
embody, dropping the assumption
“all DALYs are equal”.
HTA, A Broader View

Combine equity and
efficiency in a
deliberative process
rather than a
mathematical algorithm
Transparency
Independence from vested
interests
Stakeholder consultations

A fair health
system will
Expand coverage for
cost-effective
services
Give priority to those
benefiting the worse
off
Provide high
financial risk
protection
Acceptable Criteria Unacceptable
Criteria
Contested Criteria
Cost-effectiveness Place of
residence
Size of the
population
affected (rarity)
Priority to the
worse-off
Race/ Ethnicity Size of the benefit
(very small
benefits are
irrelevant)
Financial risk
protection
Occupation Age
Gender Responsibility of
own health
Religion Co-morbidity
Education
Socioeconomic
status
Social Capital
Equity is context-dependent

The aim is to
ensure
selection,
distribution of
services is FAIR
Understanding determinants of health, Examining
social inequities and policies maintaining them.
Determining mix of economic, environmental,
social, and health care programs and policies that
will enhance both health and health equity.
Two principles:
Interventions aimed at changing the entire
population’s incidence of disease are likely to have
a greater impact than interventions aimed at
preventing individual cases of disease.
Health is unevenly distributed in the population, with
a gradient in health from the most socially
disadvantaged to the most privileged and
advantaged members of society, where the most
disadvantaged have the worst health.

How to ensure
that
interventions
benefit the
disadvantaged?
Need interventions aimed at improving
population health
Assess impact of interventions on health
inequalities
Beware
Policies/ programs aimed at improving
population health risk benefiting the more
privileged/ better-off without improving the
health of the disadvantaged
If they increase the gap between rich and
poor, or across any other social group, they
become ineffective

Equity-effectiveness
loop: a framework for
evaluating impact on
health equity

Measure risk (burden of disease) and
response (effectiveness) across
socioeconomic factors in which disadvantage
exist; translate knowledge into interventions
to improve population health.
Assess potential for inequity at each step,
likelihood of intervention to benefit the
disadvantaged.
Coverage/access, diagnostic accuracy,
provider compliance, consumer compliance
maybe lower in disadvantaged groups,
creating staircase effect further
disadvantaging the disadvantaged.
Introduced
interventions need to
benefit the
disadvantaged

A Fair Health System Will Expand Coverage for
Cost Effective Services, Prioritize the
Disadvantaged, Provide Financial Protection
Selection and Distribution of Services Need to be
Fair
Selected Interventions Need to Benefit the
Disadvantaged

HTA: Defining
the Benefit
Package

HTA: The Tool to
Define the People’s
Benefit Package
The establishment of an HTA unit will
save more lives, ensure a sustainable
and equitable benefit package
Prioritizing interventions with the highest
value and quality
Reducing wasteful expensive,
unnecessary and unsafe care
Realizing resources, through improving
efficiency to enable the benefit package
to reach more people while ensuring
greater equity

Impacts on Individual
Wellbeing
What positive impacts
does the intervention
provide to those who
receive it?
What negative
outcomes may occur
if this intervention is
not covered?

Population Health
Gains
How well does this
intervention support
high-priority public
health goals and
objectives?
Equity
How well does this
intervention align
with equity
objectives?

Impact on Providers
How might restricting
coverage of this
intervention negatively
affect care providers’
ability to exercise their
discretion in delivering
appropriate care?
Does the community
of practice (e.g.,
medical associations,
international and
national clinical
guidelines) support
adoption of this
intervention?

Evidence-informed
decision-making and
evidence generation
What evidence exists
to inform assessment
for each of these
considerations?
Fair Processes and
Procedures
Whose interests are
most affected by the
decision to include or
exclude this
intervention?

HTA: Strategic
Purchasing – A
Missed Focus

OPTIMA: The
New Approach
For Evidence
Generation

The Optima approach
An allocative
efficiency
analysis tool for
use in informing
public health
investment
choices, as well
as for academic
research.

Mathematical model of disease
transmission and progression
integrated with an economic and
financial analysis framework and a
formal mathematical optimization
routine
Flexible, can accommodate public
health programs and sub-populations
specific to each country
Open-access, cloud-based
Used via a web interface, use Google
Chrome.

Assess the burden of disease over time and
for each disease state (through data
synthesis and epidemiological modeling);
Specify the efficacy and effectiveness of
interventions (for different technologies and
delivery modes) which may reduce disease
burden (and costs of service delivery);
Define strategic objectives and national
priority targets – as well as the logistic,
ethical and/or political constraints around
achieving these objectives;
Use a formal mathematical optimization
algorithm to assess the optimal allocation of
resources to best achieve the objectives.

Optimize to calculate optimal
allocation of resources to different
program areas to address the specific
objectives of either
• reducing new infections, or
disease-related deaths, or
disability-adjusted life years,
or a combination thereof; or
• minimizing costs required to
achieve specific targets.
Build scenarios linked to achieving specific
targets
• Coverage scenarios of core public
health programs to assesses the
impact of such investments.
• Impact targets scenarios to determine
the cost of achieving specific
reductions in incidence and deaths.
• Compare different scenarios to
determine which is most appropriate
given the country context.

References
• Int J Health Policy Management. Health Technology Assessment: Global Advocacy and Local
Realities. Commentary. 2017, 6 (4), 233-236
• The BMJ. Role of Priority Setting in Implementing Universal Health Coverage. 2016; 352:i244
• BMC Medicine. Ethical Priority Setting for Universal Health Coverage: Challenges in Deciding Upon
Fair Distribution of Health Services. Commentary. 2016 14:75
• Pharmacoeconomics. Health Technology Assessment as a Priority-Setting Tool for Universal Health
Coverage: The Call for Global Action at the Prince Mahidol Award Conference 2016. 2016. 34:1-3
• The Lancet. Health Technology Assessment in Universal Health Coverage. December 2013.
• Salud publica. The Equity-effectiveness loop as a Tool for Evaluating Population Health Interventions.
2008. 10 sup (1) 83-96.
• Mohamed Gad, Evidence for Decisions on Health Benefits, Role of HTA, May 2017
• http://optimamodel.com/

Priority setting in uhc sep 9 short version

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