Priority-setting institutions in health: recommendations from a center for global development working group

Was priority setting considered in COVID-19 response planning? A global comparative analysis

Background

The COVID-19 pandemic forced governments across the world to consider how to prioritize resource allocation. Most countries produced pandemic preparedness plans that guide and coordinate healthcare, including how to allocate scarce resources such as ventilators, human resources, and therapeutics. The objective of this study was to compare and contrast the extent to which established parameters for effective priority setting (PS) were incorporated into COVID-19 pandemic response planning in several countries around the world.

Methods

We used the Kapriri and Martin framework for effective priority setting and performed a quantitative descriptive analysis to explore whether and how countries' type of health system, political, and economic contexts impacted the inclusion of those parameters in their COVID-19 pandemic plans. We analyzed 86 country plans across six regions of the World Health Organization.

Results

The countries sampled represent 40% of nations in AFRO, 54.5% of EMRO, 45% of EURO, 46% of PAHO, 64% of SEARO, and 41% of WPRO. They also represent 39% of all HICs in the world, 39% of Upper-Middle, 54% of Lower-Middle, and 48% of LICs. No pattern in attention to parameters of PS emerged by WHO region or country income levels. The parameters: evidence of political will, stakeholder participation, and use of scientific evidence/ adoption of WHO recommendations were each found in over 80% of plans. We identified a description of a specific PS process in 7% of the plans; explicit criteria for PS in 36.5%; inclusion of publicity strategies in 65%; mention of mechanisms for appealing decisions or implementing procedures to improve internal accountability and reduce corruption in 20%; explicit reference to public values in 15%; and a description of means for enhancing compliance with the decisions in 5%.

Conclusion

The findings provide a basis for policymakers to reflect on their prioritization plans and identify areas that need to be strengthened. Overall, there is little consideration for explicit prioritization processes and tools and restricted attention to equity considerations; this may be a starting point for policymakers interested in improving future preparedness and response planning. Although the study focused on the COVID-19 pandemic, priority setting remains one of the policymakers' most prominent challenges. Policymakers should consider integrating systematic priority setting in their routine decision-making processes.

From political priority to service delivery: complexities to real-life priority of abortion services in Ethiopia

Improving access to abortion services has been coined a high priority by the Ethiopian Federal Ministry of Health. Nevertheless, many women are still struggling to access abortion services. The dedicated commitment to expanding abortion services by central authorities and the difficulties in further improving access to the services make for an interesting case to explore the real-life complexities of health priority setting. This article thus explores what it means to make abortion services a priority by drawing on in-depth interviews with healthcare bureaucrats and key stakeholders working closely with abortion service policy and implementation. Data were collected from February to April 2022. Health bureaucrats from 9 of the 12 regional states in Ethiopia and the Federal Ministry of Health were interviewed in addition to key stakeholders from professional organizations and NGOs. The study found that political will and priority to abortion services by central authorities were not necessarily enough to ensure access to the service across the health sector. At the regional and local level, there were considerable challenges with a lack of funding, equipment and human resources for implementing and expanding access to abortion services. The inadequacy of indicators and reporting systems hindered accountability and made it difficult to give priority to abortion services among the series of health programmes and priorities that local health authorities had to implement. The situation was further challenged by the contested nature of the abortion issue itself, both in the general population, but also amongst health bureaucrats and hospital leaders. This study casts a light on the complex and entangled processes of turning national-level priorities into on-the-ground practice and highlights the real-life challenges of setting and implementing health priorities.

How did European countries set health priorities in response to the COVID-19 threat? A comparative document analysis of 24 pandemic preparedness plans across the EURO region

The COVID-19 pandemic has forced governments across the world to consider how to prioritise the allocation of scarce resources. There are many tools and frameworks that have been designed to assist with the challenges of priority setting in health care. The purpose of this study was to examine the extent to which formal priority setting was evident in the pandemic plans produced by countries in the World Health Organisation's EURO region, during the first wave of the COVID-19 pandemic. This compliments analysis of similar plans produced in other regions of the world. Twenty four pandemic preparedness plans were obtained that had been published between March and September 2020. For data extraction, we applied a framework for identifying and assessing the elements of good priority setting to each plan, before conducting comparative analysis across the sample. Our findings suggest that while some pre-requisites for effective priority setting were present in many cases - including political commitment and a recognition of the need for allocation decisions - many other hallmarks were less evident, such as explicit ethical criteria, decision making frameworks, and engagement processes. This study provides a unique insight into the role of priority setting in the European response to the onset of the COVID-19 pandemic.

Whole of government approaches to accelerate adolescent success: efficiency and financing considerations

The multiple domains of development covered by the Sustainable Development Goals (SDGs) present a practical challenge for governments. This is particularly acute in highly resource-constrained settings which use a sector-by-sector approach to structure financing and prioritization. One potentially under-prioritized solution is to implement interventions with the potential to simultaneously improve multiple outcomes across sectors, what United Nations Development Programme refer to as development 'accelerators'. An increasing number of accelerators are being identified in the literature. There are, however, challenges associated with the evaluation and implementation of accelerators. First, as accelerators have multiple benefits, possibly in different sectors, they will be undervalued if the priority setting is conducted sector-by-sector. Second, even if their value is recognized, accelerators may not be adopted if doing so clashes with any of the multiple competing interests policymakers consider, of which efficiency/social desirability is but one. To illustrate the first challenge, and outline a possible solution, we conduct a cost-effectiveness analysis comparing the implementation of three sector-specific interventions to an accelerator, first using a sector-by-sector planning perspective, then a whole of government approach. The case study demonstrates how evaluating the cost-effectiveness of interventions sector-by-sector can lead to suboptimal efficiency rankings and overlook interventions that are efficient from a whole of government perspective. We then examine why recommendations based on a whole of government approach to evaluation are unlikely to be heeded. To overcome this second challenge, we outline a menu of existing and novel financing mechanisms that aim to address the mismatch between political incentives and logistical constraints in the priority setting and the economic evaluation evidence for cost-effective accelerators. These approaches to financing accelerators have the potential to improve efficiency, and in doing so, progress towards the SDGs, by aligning political incentives more closely with recommendations based on efficiency rankings.

A global comparative analysis of the criteria and equity considerations included in eighty-six national COVID-19 plans

Systematic priority setting (PS), based on explicit criteria, is thought to improve the quality and consistency of the PS decisions. Among the PS criteria, there is increased focus on the importance of equity considerations and vulnerable populations. This paper discusses the PS criteria that were included in the national COVID-19 pandemic plans, with specific focus on equity and on the vulnerable populations considered. Secondary synthesis of data, from a global comparative study that examined the degree to which the COVID-19 plans included PS, was conducted. Only 32 % of the plans identified explicit criteria. Severity of the disease and/or disease burden were the commonly mentioned criteria. With regards to equity considerations and prioritizing vulnerable populations, 22 countries identified people with co-morbidities others mentioned children, women etc. Low social-economic status and internally displaced population were not identified in any of the reviewed national plans. The limited inclusion of explicit criteria and equity considerations highlight a need for policy makers, in all contexts, to consider instituting and equipping PS institutions who can engage diverse stakeholders in identifying the relevant PS criteria during the post pandemic period. While vulnerability will vary with the type of health emergency- awareness of this and having mechanisms for identifying and prioritizing the most vulnerable will support equitable pandemic responses.

Health technology assessment (HTA) readiness in Uganda: stakeholder's perceptions on the potential application of HTA to support national universal health coverage efforts

INTRODUCTION

Health technology assessment (HTA) is an area that remains less implemented in low- and lower middle-income countries. The aim of the study is to understand the perceptions of stakeholders in Uganda toward HTA and its role in decision making, in order to inform its potential implementation in the country.

METHODS

The study takes a cross-sectional mixed methods approach, utilizing an adapted version of the International Decision Support Initiative questionnaire with both semi-structured and open-ended questions. We interviewed thirty key informants from different stakeholder institutions in Uganda that support policy and decision making in the health sector.

RESULTS

All participants perceived HTA as an important tool for decision making. Allocative efficiency was regarded as the most important use of HTA receiving the highest average score (8.8 out of 10), followed by quality of healthcare (7.8/10), transparency (7.6/10), budget control (7.5/10), and equity (6.5/10). There was concern that some of the uses of HTA may not be achieved in reality if there was political interference during the HTA process. The study participants identified development partners as the most likely potential users of HTA (66.7 percent of participants), followed by Ministry of Health (43.3 percent).

CONCLUSION

Interviewed stakeholders in Uganda viewed the role of HTA positively, suggesting that there exists a promising environment for the establishment and operationalization of HTA as a tool for decision making within the health sector. However, sustainable development and application of HTA in Uganda will require adequate capacity both to undertake HTAs and to support their use and uptake.

Economic evaluations of non-communicable diseases conducted in Sub-Saharan Africa: a critical review of data sources

BACKGROUND

Policymakers in sub-Saharan Africa (SSA) face challenging decisions regarding the allocation of health resources. Economic evaluations can help decision makers to determine which health interventions should be funded and or included in their benefits package. A major problem is whether the evaluations incorporated data from sources that are reliable and relevant to the country of interest. We aimed to review the quality of the data sources used in all published economic evaluations for cardiovascular disease and diabetes in SSA.

METHODS

We systematically searched selected databases for all published economic evaluations for CVD and diabetes in SSA. We modified a hierarchy of data sources and used a reference case to measure the adherence to reporting and methodological characteristics, and descriptively analysed author statements.

RESULTS

From 7,297 articles retrieved from the search, we selected 35 for study inclusion. Most were modelled evaluations and almost all focused on pharmacological interventions. The studies adhered to the reporting standards but were less adherent to the methodological standards. The quality of data sources varied. The quality level of evidence in the data domains of resource use and costs were generally considered of high quality, with studies often sourcing information from reliable databases within the same jurisdiction. The authors of most studies referred to data sources in the discussion section of the publications highlighting the challenges of obtaining good quality and locally relevant data.

CONCLUSIONS

The data sources in some domains are considered high quality but there remains a need to make substantial improvements in the methodological adherence and overall quality of data sources to provide evidence that is sufficiently robust to support decision making in SSA within the context of UHC and health benefits plans. Many SSA governments will need to strengthen and build their capacity to conduct economic evaluations of interventions and health technology assessment for improved priority setting. This capacity building includes enhancing local infrastructures for routine data production and management. If many of the policy makers are using economic evaluations to guide resource allocation, it is imperative that the evidence used is of the feasibly highest quality.

Evaluation framework study assessing the role, applicability and adherence to good practice of planning support tools for allocation of development aid for health in low-income and middle-income countries

OBJECTIVES

Allocation of development aid for health is controversial and challenging. In recent years, several planning-software tools have promised to help decision-makers align resource allocation with their objectives, more clearly connect prioritisation to evidence and local circumstances, and increase transparency and comparability. We aim to explore these tools to provide insight into their fitness for purpose and suggest future directions to fulfil that promise.

DESIGN

We identified seven tools that met the inclusion criteria and developed an evaluation framework to compare them along two dimensions for assessing fitness for purpose: ability to produce analyses adhering to principles laid out in the International Decisions Support Initiative (iDSI) Reference Case for health economic evaluations; and resources required, including expertise and time. We extracted information from documentation and tool use and sent this information to tool developers for confirmation.

RESULTS

We categorise the tools into evidence-generating ones, evidence-syntheses ones and process support ones. Tools' fitness for purpose varies by the context, technical capacity and time limitation. The tools adhere to several reference case principles but often not to all of them. The source and underlying assumptions of prepopulated data are often opaque. Comparing vertical interventions across diseases and health system strengthening ones remains challenging.

CONCLUSIONS

The plethora of tools that aid priority setting in different ways is encouraging. Developers and users should place further emphasis on their ability to produce analyses that adhere to prioritisation principles. Opportunities for further development include using evidence-generating tools and multicriteria decision analysis approaches complimentarily. However, maintaining tool simplicity should also be considered to allow wider access.

How Least Developed to Lower-Middle Income Countries Use Health Technology Assessment: A Scoping Review

Health Technology Assessment (HTA) is a multidisciplinary tool to inform healthcare decision-making. HTA has been implemented in high-income countries (HIC) for several decades but has only recently seen a growing investment in low- and middle-income countries. A scoping review was undertaken to define and compare the role of HTA in least developed and lower middle-income countries (LLMIC). MEDLINE and EMBASE databases were searched from January 2015 to August 2021. A matrix comprising categories on HTA objectives, methods, geographies, and partnerships was used for data extraction and synthesis to present our findings. The review identified 50 relevant articles. The matrix was populated and sub-divided into further categories as appropriate. We highlight topical aspects of HTA, including initiatives to overcome well-documented challenges around data and capacity development, and identify gaps in the research for consideration. Those areas we found to be under-studied or under-utilized included disinvestment, early HTA/implementation, system-level interventions, and cross-sectoral partnerships. We consider broad practical implications for decision-makers and researchers aiming to achieve greater interconnectedness between HTA and health systems and generate recommendations that LLMIC can use for HTA implementation. Whilst HIC may have led the way, LLMIC are increasingly beginning to develop HTA processes to assist in their healthcare decision-making. This review provides a forward-looking model that LLMIC can point to as a reference for their own implementation. We hope this can be seen as timely and useful contributions to optimize the impact of HTA in an era of investment and expansion and to encourage debate and implementation.

Prioritization and Resource Allocation in Academic Global Health Partnerships

OBJECTIVE

US-based academic institutions involved in global health (GH) partnerships can have a positive impact on health care systems in low/middle-income countries but lack a consistent approach. Existing priority setting and resource allocation (PSRA) frameworks do not adequately capture the interpersonal and sociopolitical complexity of decision-making in GH work. The authors explored how US-based GH practitioners prioritize and allocate resources for different types of support in academic GH partnerships.

METHOD

In 2020 to 2021, the authors invited 36 US-based GH practitioners from the 2015 Pediatric GH Leadership Conference to participate in individual 1-hour semi-structured interviews. Using an iterative and inductive grounded theory approach, the study team analyzed interview transcripts through the lens of Heyse's framework on decision-making in humanitarian aid.

RESULTS

The authors interviewed 20 GH practitioners and reached thematic sufficiency. A descriptive conceptual framework, capturing 18 distinct themes in 4 major categories, emerged from the data. In this framework, categories included: 1) stakeholders: those who influence and are influenced by the partnership; 2) goals: vision, mission, aims, and scope of the partnership; 3) implementation strategy: approach to accomplishing goals, categorized as relationship-oriented, task-oriented, context-oriented, or nonprescriptive; and 4) approach to conflict: response when goals and strategies do not align among stakeholders.

CONCLUSION

Themes revealed a dynamic process for PSRA. Using our study findings, and building on existing literature, our framework highlights the complex interpersonal relationships, resource limitations, and sociopolitical and economic constraints that affect PSRA in GH partnerships. Finally, themes point to the field's evolution toward a more decolonized approach to GH.

What are the impacts of increasing cost-effectiveness Threshold? a protocol on an empirical study based on economic evaluations conducted in Thailand

Background

Economic evaluations have been widely used to inform and guide policy-making process in healthcare resources allocation as a part of an evidence package. An intervention is considered cost-effective if an ICER is less than a cost-effectiveness threshold (CET), where a CET represents the acceptable price for a unit of additional health gain which a decision-maker is willing to pay. There has been discussion to increase a CET in many settings such as the United Kingdom and Thailand. To the best of our knowledge, Thailand is the only country that has an explicit CET and has revised their CET, not once but twice. Hence, the situation in Thailand provides a unique opportunity for evaluating the impact of changing CET on healthcare expenditure and manufacturers’ behaviours in the real-world setting. Before we decide whether a CET should be increased, information on what happened after the CET was increased in the past could be informative and helpful.

Objectives

This study protocol describes a proposed plan to investigate the impact of increased cost-effectiveness threshold using Thailand as a case study. Specifically, we will examine the impact of increasing CET on the drug prices submitted by pharmaceutical companies to the National List of Essential Medicine (NLEM), the decision to include or exclude medications in the NLEM, and the overall budget impact.

Materials and designs

Retrospective data analysis of the impact of increased CET on national drug committee decisions in Thailand (an upper middle-income country) will be conducted and included data from various sources such as literature, local organizations (e.g. Thai Food and Drug Administration), and inputs from stakeholder consultation meetings. The outcomes include: (1) drug price submitted by the manufacturers and final drug price included in the NLEM if available; (2) decisions about whether the drug was included in the NLEM for reimbursement; and (3) budget impact. The independent variables include a CET, the variable of interest, which can take values of THB100,000, THB120,000, or THB160,000, and potential confounders such as whether this drug was for a chronic disease, market size, and primary endpoint. We will conduct separate multivariable regression analysis for each outcome specified above.

Discussion

Understanding the impact of increasing the CET would be helpful in assisting the decision to use and develop an appropriate threshold for one’s own setting. Due to the nature of the study design, the findings will be prone to confounding effect and biases; therefore, the analyses will be adjusted for potential confounders and statistical methods will be explored to minimize biases. Knowledge gained from the study will be conveyed to the public through various disseminations such as reports, policy briefs, academic journals, and presentations.

Designing and Implementing Deliberative Processes for Health Technology Assessment: A Good Practices Report of a Joint HTAi/ISPOR Task Force

Objectives

Deliberative processes for health technology assessment (HTA) are intended to facilitate participatory decision making, using discussion and open dialogue between stake-holders. Increasing attention is being given to deliberative processes, but guidance is lacking for those who wish to design or use them. Health Technology Assessment International (HTAi) and ISPOR—The Professional Society for Health Economics and Outcomes Research initiated a joint Task Force to address this gap.

Methods

The joint Task Force consisted of fifteen members with different backgrounds, perspectives, and expertise relevant to the field. It developed guidance and a checklist for deliberative processes for HTA. The guidance builds upon the few, existing initiatives in the field, as well as input from the HTA community following an established consultation plan. In addition, the guidance was subject to two rounds of peer review.

Results

A deliberative process for HTA consists of procedures, activities, and events that support the informed and critical examination of an issue and the weighing of arguments and evidence to guide a subsequent decision. Guidance and an accompanying checklist are provided for (i) developing the governance and structure of an HTA program and (ii) informing how the various stages of an HTA process might be managed using deliberation.

Conclusions

The guidance and the checklist contain a series of questions, grouped by six phases of a model deliberative process. They are offered as practical tools for those wishing to establish or improve deliberative processes for HTA that are fit for local contexts. The tools can also be used for independent scrutiny of deliberative processes.

Designing and Implementing Deliberative Processes for Health Technology Assessment: A Good Practices Report of a Joint HTAi/ISPOR Task Force

OBJECTIVES

Deliberative processes for health technology assessment (HTA) are intended to facilitate participatory decision making, using discussion and open dialogue between stakeholders. Increasing attention is being given to deliberative processes, but guidance is lacking for those who wish to design or use them. Health Technology Assessment International (HTAi) and ISPOR-The Professional Society for Health Economics and Outcomes Research initiated a joint Task Force to address this gap.

METHODS

The joint Task Force consisted of 15 members with different backgrounds, perspectives, and expertise relevant to the field. It developed guidance and a checklist for deliberative processes for HTA. The guidance builds upon the few, existing initiatives in the field, as well as input from the HTA community following an established consultation plan. In addition, the guidance was subject to 2 rounds of peer review.

RESULTS

A deliberative process for HTA consists of procedures, activities, and events that support the informed and critical examination of an issue and the weighing of arguments and evidence to guide a subsequent decision. Guidance and an accompanying checklist are provided for (i) developing the governance and structure of an HTA program and (ii) informing how the various stages of an HTA process might be managed using deliberation.

CONCLUSIONS

The guidance and the checklist contain a series of questions, grouped by 6 phases of a model deliberative process. They are offered as practical tools for those wishing to establish or improve deliberative processes for HTA that are fit for local contexts. The tools can also be used for independent scrutiny of deliberative processes.

What is the value of explicit priority setting for health interventions? A simulation study

Many countries seek to secure efficiency in health spending through establishing explicit priority setting institutions (PSIs). Since such institutions divert resources from frontline services which benefit patients directly, it is legitimate and reasonable to ask whether they are worth the money. We address this question by comparing, through simulation, the health benefits and costs from implementing two alternative funding approaches – one scenario in which an active PSI enables cost-effectiveness-threshold based funding decisions, and a counterfactual scenario where there is no PSI. We present indicative results for one dataset from the United Kingdom (published in 2015) and one from Malawi (published in 2018), which show that the threshold rule reliably resulted in decreased health system costs, improved health benefits, or both. Our model is implemented in Microsoft Excel and designed to be user-friendly, and both the model and a user guide are made publicly available, in order to enable others to parameterise the model based on the local setting. Although inevitably stylised, we believe that our modelling and results offer a valid perspective on the added value of explicit PSIs.

The political economy of priority-setting for health in South Sudan: a case study of the health pooled fund

BACKGROUND

In fragile and conflict affected settings (FCAS) such as South Sudan, where health needs are immense, resources are scarce, health infrastructure is rudimentary or damaged, and government stewardship is weak, adequate health intervention priority-setting is especially important. There is a scarcity of research examining priority-setting in FCAS and the related political economy. Yet, capturing these dynamics is important to develop context-specific guidance for priority-setting. The objective of this study is to analyze the priority-setting practices in the Health Pooled Fund (HPF), a multi-donor fund that supports service delivery in South Sudan, using a political economy perspective.

METHODS

A multi-method study was conducted combining document review, 30 stakeholder interviews, and an examination of service delivery. An adapted version of the Walt and Gilson policy analysis triangle guided the study's design and analysis.

RESULTS

Priority-setting in HPF occurs in a context of immense fragility where health needs are vast, service delivery remains weak, and external funding is essential. HPF's service package gives priority to the health of mothers and children, gender-sensitive programming, immunization services, and a community health initiative. HPF is structured by a web of actors at national and local levels with pronounced power asymmetries and differing vested interests and ideas about HPF's role. Priority-setting takes place throughout program design, implementing partner (IP) contract negotiation, and implementation of the service package. In practice the BPHNS does not provide adequate guidance for priority-setting because it is too expansive and unrealistic given financial and health system constraints. At the local level, IPs must manage the competing interests of the HPF program and local health authorities as well as challenging contextual factors, including conflict and shortages of qualified health workers, which affect service provision. The resulting priority-setting process remains implicit, scarcely documented, and primarily driven by donors' interests.

CONCLUSION

This study highlights power asymmetries between donors and national health authorities within a FCAS context, which drive a priority-setting process that is dominated by donor agendas and leave little room for government ownership. These findings emphasize the importance of paying attention to the influence of stakeholders and their interests on the priority-setting process in FCAS.

Public participation: healthcare rationing in the newspaper media

Background

It is impossible to meet all healthcare demands, but an open and fair rationing process may improve the public acceptability of priority setting in healthcare. Decision-making is subject to scrutiny by newspaper media, an important public institution and information source for discussions about rationing. In Norway, healthcare rationing has been subject to public debate both before and after the establishment of “The National System for Managed Introduction of New Health Technologies within the Specialist Health Service” (New Methods) in 2013.

Aim

To describe and assess the development of the public debate on Norwegian healthcare rationing through three cases in print media.

Methods

We purposively sampled Norwegian newspaper articles between 2012 and 2018 concerning three reimbursement decisions in the Norwegian system. The reimbursement decisions were ipilimumab (Yervoy, n = 45) against metastatic melanoma, nivolumab (Opdivo, n = 23) against non-small cell lung cancer, and nusinersen (Spinraza, n = 68) against spinal muscular atrophy. Cases were analysed separately using the qualitative method of systematic text condensation.

Results

Our analysis highlighted four common themes—money, rationales, patient stories, and process—and a unique theme for each case. Ipilimumab was uniquely themed by rationing rejection, nivolumab by healthcare two-tiering, and Spinraza by patients’ rights. We found wide media deliberation among a multitude of stakeholders in all cases. Perceptions of rationing were found to be chiefly aligned with previous empirical research. We found that the media reported more frequently on opposition to rationing compared to findings from previous studies on Norwegian healthcare decision-making attitudes. We think this was influenced by our selection of cases receiving extraordinary media attention, and from media sources being subject to political communication from special interest groups.

Conclusion

We observed that the introduction of New Methods institutionalised Norwegian healthcare rationing and isolated the public debate into conversations between stakeholders and decision makers outside the political sphere. The findings from these three extraordinary debates are not generalisable and should be seen as a stakeholder learning opportunity regarding media coverage and engagement with expensive specialist healthcare decision-making in Norway.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07786-w.

Exploring facilitators and barriers to introducing health technology assessment: a systematic review

Objective

This study aims to identify and codify the facilitators and barriers to help implementing partners institutionalize health technology assessment (HTA) successfully and navigate complex systems for health-related policy making.

Methods

We searched for peer-reviewed and gray literature articles examining HTA programs globally using six databases. Keywords used as a guide for capturing articles included “health technology assessment,” “barrier,” and “facilitator” and their synonyms. Search results were scrutinized for duplicates and screened through a review of titles and abstracts. A full-text review was conducted exploring articles’ coverage of twenty-seven evaluation criteria across four primary areas of interest: barriers/facilitators, motivations, guidelines, and institutional frameworks.

Results

A total of 18,599 records were identified for duplication check, title, and abstract review. A total of 1,594 articles underwent full-text review, leading to a final synthesis of 262 studies. We found that ninety-seven articles discussed barriers/facilitators, with fifty-three of those discussing local capacity and unavailable human resources. Out of the sixty-six articles discussing motivations, forty-two cited the interest in supporting the decision-making process for, and promoting, appropriate resource allocation. Of the sixty-one articles that discussed guidelines and institutional framework, twenty-one articles described HTA as an independent national unit, and sixteen described their HTA unit as a unit within the Ministry of Health (MOH).

Conclusions

This systematic review unpacks the dynamic and relevant contexts for understanding the HTA institutionalization process to help policy makers and practitioners achieve tangible progress in confronting the most critical issues facing priority setting and HTA institutionalization.

Health technology assessment capacity at national level in sub-Saharan Africa: an initial survey of stakeholders

Background: Health technology assessment (HTA) is an effective tool for supporting priority setting (PS) in health. Stakeholder groups need to understand HTA appropriate to their role and to interpret and critique the evidence produced. We aimed to rapidly assess current health system priorities and policy areas of demand for HTA in Sub-Saharan Africa, and identify key gaps in data and skills to inform targeted capacity building.

Methods: We revised an existing survey, delivered it to 357 participants, then analysed responses and explored key themes.

Results: There were 51 respondents (14%, 30 full completions) across 14 countries. HTA was considered an important and valuable PS tool with a key role in the design of health benefits packages, clinical guideline development, and service improvement. Medicines were identified as a technology type that would especially benefit from the application of HTA. Using HTA to address safety issues (e.g. low-quality medicines) and value for money concerns was particularly highlighted. The perceived availability and accessibility of suitable local data to support HTA varied widely but was mostly considered inadequate and limited. Respondents also noted a need for training support in research methodology and data gathering.

Conclusions: While important in raising awareness of HTA as a tool for PS, this study had a low response rate, and that respondents were self-selected. A more refined survey will be developed to support engagement strategies and capacity building.

Using health technology assessment to set priority, inform target product profiles, and design clinical study for health innovation

Early health technology assessment (early HTA) is a useful tool in guiding the innovation development process in medical technology development. However, the application of early HTA is sub-optimal amongst research and development (R&D) communities due to several challenges. In this paper, we presented a case study of application of early HTA by drawing on the experience from a workshop conducted for the Singapore government's medical technology innovation agency. The framework developed can help maximise the chance of the newly developed technology being accepted and widely used. By providing step-by-step guidance, this work aims to translate early HTA into a practical tool and promote the application of early HTA amongst R&D communities.

SMART Vaccines 2.0 decision-support platform: a tool to facilitate and promote priority setting for sustainable vaccination in resource-limited settings

In resource-constrained environments, priority setting is critical to making sustainable decisions for introducing new and underused vaccines and choosing among vaccine products. Donor organisations and national governments in low-income and middle-income countries (LMICs) recognise the need to support prioritisation of vaccine decisions driven by local health system capacity, epidemiology and financial sustainability.

Successful efforts have supported the establishment of National Immunisation Technical Advisory Groups (NITAGs) to undertake evidence-informed decision making (EIDM) in LMICs. Now, attention is increasingly focused on supporting their function to leverage local expertise and priorities. EIDM and priority-setting functions are complex and dynamic processes. Here, we report a pilot of a web-based decision-support tool. Applying tenets of multicriteria decision analysis, SMART Vaccines 2.0 supported transparent, reproducible and evidence-informed priority setting with an easy-to-use interface and shareable outputs.

The pilot was run by the Uganda NITAG who were requested by the Ministry of Health (MOH) in 2016 to produce recommendations on the prioritised introduction of five new vaccines. The tool was acceptable to the NITAG and supported their recommendations to the MOH. The tool highlighted sensitivity in the prioritisation process to the inherent biases of different stakeholders. This feature also enabled examination of the implications of data uncertainty. Feedback from users identified areas where the tool could more explicitly support evidence-to-recommendation frameworks, ultimately informing the next generation of the platform, PriorityVax.

Country ownership and priority setting in vaccine decisions are central to sustainability. PriorityVax promotes auditable and rigorous deliberations; enables and captures the decision matrix of users; and generates shareable documentation of the process.

Addressing Challenges in Health Technology Assessment Institutionalization for Furtherance of Universal Health Coverage Through South-South Knowledge Exchange: Lessons From Bhutan, Kenya, Thailand, and Zambia

Health Technology Assessment (HTA), a tool for priority setting, has emerged as a means of ensuring the sustainability of a Universal Health Coverage (UHC) system. However, setting up an effective HTA system poses multiple challenges and knowledge exchange can play a crucial role in helping countries achieve their UHC targets. This article reports the results of the discussion during a preconference session at the 2019 HTAsiaLink Conference, an annual gathering of HTA agencies in Asia, which supports knowledge transfer and exchange among HTA practitioners. As part of this discourse, 3 main HTA challenges were identified based on experiences of selected countries in Asia and Africa, namely Bhutan, Kenya, Thailand, and Zambia: availability of funding, building technical capacity, and achieving buy-in among stakeholders for successful translation of HTA research into UHC policy. The potential solutions identified through this South-South engagement included establishing a legal mandate for HTA, building local technical capacity through partnerships and enhancing strategic communication with stakeholders to increase awareness, among others. South-South Knowledge Exchange can therefore be instrumental in sharing lessons learned from common challenges and offer potential solutions to address capacity building initiatives for HTA in LMICs.

Investigating public values in health care priority - Chileans´ preference for national health care

BACKGROUND

This study aims to assess preferences and values for priority setting in healthcare in Chile through an original and innovative survey method. Based on the answers from a previous survey that look into the barriers the Chilean population face, this study considers the preferences of the communities overcoming those barriers. As a result six programs were identified: (1) new infrastructure, (2) better healthcare coverage, (3) increasing physicians/specialists, (4) new informatics systems, (5) new awareness healthcare programs, and (6) improving availability of drugs.

METHODS

We applied an innovative survey method developed for this study to sample subjects to prioritize these programs by their opinion and by allocating resources. The survey also asked people's preferences for a distributive justice principle for healthcare to guide priority setting of services in Chile. The survey was conducted with a sample of 1142 individuals.

RESULTS

More than half of the interviewees (56.4%) indicated a single program as their first priority, while 20.1% selected two of them as their first priority. To increase the number of doctors/specialists and improve patient-doctor communication was the program that obtained the highest priority. The second and third priorities correspond to improving and investing in infrastructure and expanding the coverage of healthcare insurances. Additionally, the results showed that equal access for equal healthcare is the principle selected by the majority to guide distributive justice for the Chilean health system.

CONCLUSIONS

This study shows how a large population sample can participate in major decision making of national health policies, including making a choice of a distributive justice principle. Despite the complexity of the questions asked, this study demonstrated that with an innovative method and adequate guidance, average population is capable of engaging in expressing their preferences and values. Results of this study provide policy-makers useful community generated information for prioritizing policies to improve healthcare access.

Building Capacity for Evidence-Informed Priority Setting in the Indian Health System: An International Collaborative Experience

India's rapid economic growth has been accompanied by slower improvements in population health. Given the need to reconcile the ambitious goal of achieving Universal Coverage with limited resources, a robust priority-setting mechanism is required to ensure that the right trade-offs are made and the impact on health is maximised. Health Technology Assessment (HTA) is endorsed by the World Health Assembly as the gold standard approach to synthesizing evidence systematically for evidence-informed priority setting (EIPS). India is formally committed to institutionalising HTA as an integral component of the EIPS process. The effective conduct and uptake of HTA depends on a well-functioning ecosystem of stakeholders adept at commissioning and generating policy-relevant HTA research, developing and utilising rigorous technical, transparent, and inclusive methods and processes, and a strong multisectoral and transnational appetite for the use of evidence to inform policy. These all require myriad complex and complementary capacities to be built at each level of the health system . In this paper we describe how a framework for targeted and locally-tailored capacity building for EIPS, and specifically HTA, was collaboratively developed and implemented by an international network of priority-setting expertise, and the Government of India.

How actors, processes, context and evidence influenced the development of Malawi's Health Sector Strategic Plan II

Health sector strategic plans are health policies outlining health service delivery in low- and middle- income countries, guiding health sectors to meet health needs while maximizing resources. However, little research has explored the formulation of these plans. This study utilized qualitative methods to explore the formulation of Malawi's Health Sector Strategic Plan II, including processes utilized, actors involved, important contextual factors and the use of evidence-based decision-making. Thirteen semi-structured key informant interviews with health policy actors were conducted to explore perceptions and experiences of formulating the policy. Data analysis used an inductive-deductive approach and interpretation of the data was guided by an adapted version of the Walt and Gilson Health Policy Triangle. Our results indicate that HSSP II formulation was complex and inclusive but that the Ministry of Health may have given up ownership of the formulation process to development partners to ensure their continued involvement. Disagreements between actors centered around inclusion of critical services in the Essential Health Package and selection of performance-based financing as purchasing strategy. Resource constraints and the Cashgate Scandal are critical contextual elements influencing the formulation and content of the policy. Evidence-based decision-making contributed to the plan's development despite respondents' divergent opinions regarding evidence availability, quality and the weight that evidence carried. The study raises questions regarding the roles of policy actors during health policy formulation, the inclusivity of health policy processes and their potential influence on government ownership of health policy, as well as the use of evidence in developing health sector strategic plans.

Health technology assessment and priority setting for universal health coverage: a qualitative study of stakeholders' capacity, needs, policy areas of demand and perspectives in Nigeria

INTRODUCTION

Health technology assessment (HTA) is an effective tool to support priority setting and generate evidence for decision making especially en route to achieving universal health coverage (UHC). We assessed the capacity needs, policy areas of demand, and perspectives of key stakeholders for evidence-informed decision making in Nigeria where HTA is still new.

METHODS

We surveyed 31 participants including decision makers, policy makers, academic researchers, civil society organizations, community-based organizations, development partners, health professional organizations. We revised an existing survey to qualitatively examine the need, policy areas of demand, and perspectives of stakeholders on HTA. We then analyzed responses and explored key themes.

RESULTS

Most respondents were associated with organizations that generated or facilitated health services research. Research institutes highlighted their ability to provide expertise and skills for HTA research but some respondents noted a lack of human capacity for HTA. HTA was considered an important and valuable priority-setting tool with a key role in the design of health benefits packages, clinical guideline development, and service improvement. Public health programs, medicines and vaccines were the three main technology types that would especially benefit from the application of HTA. The perceived availability and accessibility of suitable local data to support HTA varied widely but was mostly considered inadequate and limited. Respondents needed evidence on health system financing, health service provision, burden of disease and noted a need for training support in research methodology, HTA and data management.

CONCLUSION

The use of HTA by policymakers and communities in Nigeria is very limited mainly due to inadequate and insufficient capacity to produce and use HTA. Developing sustainable and institutionalized HTA systems requires in-country expertise and active participation from a range of stakeholders. Stakeholder participation in identifying HTA topics and conducting relevant research will enhance the use of HTA evidence produced for decision making. Therefore, the identified training needs for HTA and possible research topics should be considered a priority in establishing HTA for evidence-informed policy making for achieving UHC particularly among the most vulnerable people in Nigeria.

Priority setting for health system strengthening in low income countries. A qualitative case study illustrating the complexities

Health systems are critical to the realisation of Universal Health Coverage. There has been insufficient attention to the evaluation of priority setting for health system strengthening within low income countries, including evaluation of the local capacity to implement priorities. This study evaluated the extent to which health system strengthening was prioritized in Uganda. The Kapiriri & Martin framework was used to evaluate health system priority setting from 2005-2015. A document analysis was triangulated with interview data (n = 67) from global, national and subnational stakeholders and analysed using content analysis. Health system strengthening was perceived to be circumvented by a lack of resources as well as influential actors with disease focused, rather than system-oriented, interests. There were defined processes with explicit criteria for identifying priorities and evidence was highly valued. But sub-optimal transparency and weak accountability often compromised the integrity of priority setting and contributed to stalling progress on health system strengthening and achieving health system outcomes. The strengths in the current planning processes should be harnessed. In addition, a systematic approach to priority setting, potentially through the establishment of an independent body, and stronger oversight mechanisms, would strengthen health system planning in this setting.

Health technology assessment capacity at national level in sub-Saharan Africa: an initial survey of stakeholders

Background: Health technology assessment (HTA) is an effective tool to support priority setting (PS) in health. Stakeholder groups need to understand HTA appropriate to their role and to interpret and critique the evidence produced. We aimed to rapidly assess current health system priorities and policy areas of demand for HTA in Sub-Saharan Africa, and identify key gaps in data and skills to inform targeted capacity building. Methods: We revised an existing survey, delivered it to 357 participants, then analysed responses and explored key themes. Results: There were 51 respondents (14%) across 14 countries. HTA was considered an important and valuable PS tool with a key role in the design of health benefits packages, clinical guideline development, and service improvement. Medicines were identified as a technology type that would especially benefit from the application of HTA. Using HTA to address safety issues (e.g. low-quality medicines) and value for money concerns was particularly highlighted. The perceived availability and accessibility of suitable local data to support HTA varied widely but was mostly considered inadequate and limited. Respondents also noted a need for training support in research methodology and data gathering. Conclusions: While important in raising awareness of HTA as a tool for PS, this study had a low response rate, and that respondents were self-selected. A more refined survey will be developed to support engagement strategies and capacity building.

Are low and middle-income countries prioritising high-value healthcare interventions?

Introduction

Since resources are finite, investing in services that produce the highest health gain 'return on investment' is critical. We assessed the extent to which low and middle-income countries (LMIC) have included cost-saving interventions in their national strategic health plans.

Methods

We used the Tufts Medical Center Global Health Cost-Effectiveness Analysis Registry, an open-source database of English-language cost-per-disability-adjusted life year (DALY) studies, to identify analyses published in the last 10 years (2008-2017) of cost-saving health interventions in LMICs. To assess whether countries prioritised cost-saving interventions within their latest national health strategic plans, we identified 10 countries, all in sub-Saharan Africa, with the highest measures on the global burden of disease scale and reviewed their national health priority plans.

Results

We identified 392 studies (63%) targeting LMICs that reported 3315 cost-per-DALY ratios, of which 207 ratios (6%) represented interventions reported to be cost saving. Over half (53%) of these targeted sub-Saharan Africa. For the 10 countries we investigated in sub-Saharan Africa, 58% (79/137) of cost-saving interventions correspond with priorities identified in country plans. Alignment ranged from 95% (21/22 prioritised cost-saving ratios) in South Africa to 17% (2/12 prioritised cost-saving ratios) in Cameroon. Human papillomavirus vaccination was a noted priority in 70% (7/10) of national health prioritisation plans, while 40% (4/10) of countries explicitly included prenatal serological screening for syphilis. HIV prevention and treatment were stated priorities in most country health plans, whereas 40% (2/5) of countries principally outlined efforts for lymphatic filariasis. From our sample of 45 unique interventions, 36% of interventions (16/45) included costs associated directly with the implementation of the intervention.

Conclusion

Our findings indicate substantial variation across country and disease area in incorporating economic evidence into national health priority plans in a sample of sub-Saharan African countries. To make health economic data more salient, the authors of cost-effectiveness analyses must do more to reflect implementation costs and other factors that could limit healthcare delivery.

Cardiovascular risk assessment in the resource limited setting of Western Honduras: An epidemiological perspective

Cardiovascular Disease (CVD) epidemiology varies significantly among Low and Middle-Income Countries. Honduras is the Central American country with the highest Ischemic Heart Disease and CVD mortality rates. The aim of this study was to assess the individual CVD risk factors and calculate Cardiovascular Risk Assessment Scores (CVRAS) from the population. Methods: A cross-sectional study in western Honduras. Estimation of CV risk was performed using Framingham, MESA, ACC/AHA-PCEs and ESC SCORE calculators. Results: 38% were male. For men and women respectively; 49% and 48% had self-reported hypertension (HTN), on measured blood pressure only 18% and 30% had normal readings. Diabetes Mellitus was reported in 19% and 22%. Tobacco use was 14% and 3%. Self-reported regular exercise was 39.9% and 25%. Obesity was diagnosed in 24% and 24%. Lipid profile; total cholesterol was ≥200 mg/dl in 63% of subjects. LDL-C was elevated (>100 mg/dl) in 74% of participants, 9% had LDL-C levels higher than 190 mg/dl. Triglycerides were high (>160 mg/dl) in 60%, of these subjects 22% were taking lipid-lowering medications. 52% reported family-history of CVD. The risk calculation for men and women respectively for each CVRAS were; AHA/ACC-PCEs high risk (score ≥ 7.5%) in 62% and 30%, FRS high risk (score ≥ 20%) 46% and 15%, MESA high risk (Score ≥ 7.5%) in 70.6% and 17.7%, ESC SCORE high risk (score ≥ 5% in 32.4% and 11.8%). Conclusions: CV risk calculations revealed higher than rates than expected with consequently reflected on higher than estimated CVRAS. This represents the first report of its kind in Honduras.

Implementing health technology assessment in Kuwait: a qualitative study of perceived barriers and facilitators

OBJECTIVES

This study sought to explore main barriers and facilitators to implementing health technology assessment (HTA) in Kuwait from the perspective of key stakeholders.

METHODS

Semi-structured qualitative interviews were conducted with ten key stakeholders: seven healthcare providers working at various departments of the Kuwaiti Ministry of Health (MOH), and three academics with substantial experience in teaching HTA or related fields. Interviews were conducted face-to-face, audio-recorded, and transcribed verbatim. Data were analyzed using an inductive thematic approach.

RESULTS

Participating stakeholders reported several factors that might act as a barrier to building HTA in Kuwait: minimal awareness of HTA, lack of institutional and human capacity, a fragmented healthcare system, poor communication between researchers and policy makers, the country's wealth, politics, as well as data quality, availability, and sharing. Institutionalizing HTA as a politically empowered body, enforcing its recommendation by law, and benefiting from neighboring countries' experiences were suggested as possible ways to move forward.

CONCLUSION

Studies exploring the unique challenges that high-income developing countries may face in implementing HTA are still scarce. The results of this study are consistent with evidence coming from other developing countries, while also suggesting that the abundance of financial resources in the country is a double-edged sword; it has the potential to facilitate the development of HTA capacity, but also hinders recognizing the need for it.

From Design to Evaluation: Applications of Health Technology Assessment in Myanmar and Lessons for Low or Lower Middle-Income Countries

OBJECTIVES

Health technology assessment (HTA) has been widely used to inform coverage decisions in high-income countries over the past few decades and has been getting increasing attention in middle-income countries as a tool for healthcare decision making in recent years. This study aims to use the case of the Maternal and Child Health Voucher Scheme (MCHVS) in Myanmar to understand how HTA can have a policy impact in a low or lower middle-income country.

METHODS

The stages heuristic framework was used to describe the policy-making process. A document review was conducted and tacit knowledge of researchers involved was recorded.

RESULTS

The opportunity for a grant propelled maternal and child health to the policy agenda. An ex-ante HTA, which included a model-based health economic evaluation, informed the design of the scheme. The framework and key parameters from the ex-ante HTA were used for a mid-term review, which provided feedback to the policy implementation process. An ex-post HTA involved fielding a household survey to assess the impact of the scheme.

CONCLUSIONS

HTA can be a useful method for informing resource allocation throughout the policy process in low and lower middle-income settings where no formal mechanism for making coverage decisions exists.

Adherence to the iDSI reference case among published cost-per-DALY averted studies

BACKGROUND

The iDSI reference case, originally published in 2014, aims to improve the quality and comparability of cost-effectiveness analyses (CEA). This study assesses whether the development of the guideline is associated with an improvement in methodological and reporting practices for CEAs using disability-adjusted life-years (DALYs).

METHODS

We analyzed the Tufts Medical Center Global Health CEA Registry to identify cost-per-DALY averted studies published from 2011 to 2017. Among each of 11 principles in the iDSI reference case, we translated all methodological specifications and reporting standards into a series of binary questions (satisfied or not satisfied) and awarded articles one point for each item satisfied. We then calculated methodological and reporting adherence scores separately as a percentage of total possible points, measured as normalized adherence score (0% = no adherence; 100% = full adherence). Using the year 2014 as the dissemination period, we conducted a pre-post analysis. We also conducted sensitivity analyses using: 1) optional criteria in scoring, 2) alternate dissemination period (2014-2015), and 3) alternative comparator classification.

RESULTS

Articles averaged 60% adherence to methodological specifications and 74% adherence to reporting standards. While methodological adherence scores did not significantly improve (59% pre-2014 vs. 60% post-2014, p = 0.53), reporting adherence scores increased slightly over time (72% pre-2014 vs. 75% post-2014, p<0.01). Overall, reporting adherence scores exceeded methodological adherence scores (74% vs. 60%, p<0.001). Articles seldom addressed budget impact (9% reporting, 10% methodological) or equity (7% reporting, 7% methodological).

CONCLUSIONS

The iDSI reference case has substantial potential to serve as a useful resource for researchers and policy-makers in global health settings, but greater effort to promote adherence and awareness is needed to achieve its potential.

Beyond cost-effectiveness, morbidity and mortality: a comprehensive evaluation of priority setting for HIV programming in Uganda

BACKGROUND

While there has been progress in controlling the HIV epidemic, HIV still remains a disease of global concern. Some of the progress has been attributed to increased public awareness and uptake of public health interventions, as well as increased access to anti- retroviral treatment and the prevention of vertical HIV transmission. These interventions would not have been possible without substantial investments in HIV programs. However, donor fatigue introduces the need for low income countries to maximize the benefits of the available resources. This necessitates identification of priorities that should be funded. Evaluating prioritization processes would enable decision makers to assess the effectiveness of their processes, thereby designing intervention strategies. To date most evaluations have focused on cost-benefit analyses, which overlooks additional critical impacts of priority setting decisions. Kapiriri & Martin (2010) developed and validated a comprehensive framework for evaluating PS in low income countries. The objective of this paper report findings from a comprehensive evaluation of priority setting for HIV in Uganda, using the framework; and to identify lessons of good practice and areas for improvement.

METHODS

This was a qualitative study based on forty interviews with decision makers and policy document review. Data were analysed using INVIVO 10, and based on the parameters in Kapiriri et al's evaluation framework.

RESULTS

We found that HIV enjoys political support, which contributes to the availability of resources, strong planning institutions, and participatory prioritization process based on some criteria. Some of the identified limitations included; undue donor and political influence, priorities not being publicized, and lack of mechanisms for appealing the decisions. HIV prioritization had both positive and negative impacts on the health system.

CONCLUSIONS

The framework facilitated a more comprehensive evaluation of HIV priority setting. While there were successful areas, the process could be strengthened by minimizing undue influence of external actors, and support the legitimate institutions to set priorities and implement them. These should also institute mechanisms for publicizing the decisions, appeals and increased accountability. While this paper looked at HIV, the framework is flexible enough to be used in evaluating priority setting for other health programs within similar context.

Achieving high-quality universal health coverage: a perspective from the National Health Service in England

Governments across low-income and middle-income countries have pledged to achieve universal health coverage by 2030, which comes at a time where healthcare systems are subjected to multiple and persistent pressures, such as poor access to care services and insufficient medical supplies. While the political willingness to provide universal health coverage is a step into the right direction, the benefits of it will depend on the quality of healthcare services provided. In this analysis paper, we ask whether there are any lessons that could be learnt from the English National Health Service, a healthcare system that has been providing comprehensive and high-quality universal health coverage for over 70 years. The key areas identified relate to the development of a coherent strategy to improve quality, to boost public health as a measure to reduce disease burden, to adopt evidence-based priority setting methods that ensure efficient spending of financial resources, to introduce an independent way of inspecting and regulating providers, and to allow for task-shifting, specifically in regions where staff retention is low.

HTA and MCDA solely or combined? The case of priority-setting in Colombia

Background

All healthcare systems face problems of justice and efficiency related to setting priorities for allocating limited financial resources. Therefore, explicit decision-making in healthcare depicted as a continuum from evidence generation to deliberation and communication of the decision made, needs to be transparent and fair. Nevertheless, priority-setting in many parts of the world remains being implicit and ad-hoc process. Health Technology Assessment (HTA) and Multi-Criteria Decision Analysis (MCDA) have emerged as policy tools to assist informed decision-making. Both, MCDA and HTA have pros and cons.

Main body

Colombia experienced an important institutional transformation after the establishment of the Health Technology Assessment Institute in 2012. This paper briefly presents the current challenges of the Colombian health system, the general features of the new health sector reform, the main characteristics of HTA in Colombia and the potential benefits and caveats of incorporating MCDA approaches into the decision-making process.

Conclusion

Structured and objective consideration of the factors that are both measurable and value-based in an open and transparent manner may be feasible through combining HTA and MCDA in contexts like Colombia. Further testing and validation of HTA and MCDA solely or combined in LMICs are needed to advance these approaches into healthcare decision-making worldwide.

Contracting-out primary health care services in Tanzania towards UHC: how policy processes and context influence policy design and implementation

BACKGROUND

Governments increasingly recognize the need to engage non-state providers (NSPs) in health systems in order to move successfully towards Universal Health Coverage (UHC). One common approach to engaging NSPs is to contract-out the delivery of primary health care services. Research on contracting arrangements has typically focused on their impact on health service delivery; less is known about the actual processes underlying the development and implementation of interventions and the contextual factors that influence these. This paper reports on the design and implementation of service agreements (SAs) between local governments and NSPs for the provision of primary health care services in Tanzania. It examines the actors, policy process, context and policy content that influenced how the SAs were designed and implemented.

METHODS

We used qualitative analytical methods to study the Tanzanian experience with contracting- out. Data were drawn from document reviews and in-depth interviews with 39 key informants, including six interviews at the national and regional levels and 33 interviews at the district level. All interviews were audiotaped, transcribed and translated into English. Data were managed in NVivo (version 10.0) and analyzed thematically.

RESULTS

The institutional frameworks shaping the engagement of the government with NSPs are rooted in Tanzania's long history of public-private partnerships in the health sector. Demand for contractual arrangements emerged from both the government and the faith-based organizations that manage NSP facilities. Development partners provided significant technical and financial support, signaling their approval of the approach. Although districts gained the mandate and power to make contractual agreements with NSPs, financing the contracts remained largely dependent on donor funds via central government budget support. Delays in reimbursements, limited financial and technical capacity of local government authorities and lack of trust between the government and private partners affected the implementation of the contractual arrangements.

CONCLUSIONS

Tanzania's central government needs to further develop the technical and financial capacity necessary to better support districts in establishing and financing contractual agreements with NSPs for primary health care services. Furthermore, forums for continuous dialogue between the government and contracted NSPs should be fostered in order to clarify the expectations of all parties and resolve any misunderstandings.

Development assistance for health: critiques, proposals and prospects for change

After a 'golden age' of extraordinary growth in the level of development assistance for health (DAH) since 1990, funding seems to have reached a plateau. With the launch of the Sustainable Development Goals, debate has intensified regarding what international financing for health should look like in the post-2015 era. In this review paper, we offer a systematic overview of problems and proposals for change. Major critiques of the current DAH system include: that the total volume of financing is inadequate; financial flows are volatile and uncertain; DAH may not result in additional resources for health; too small a proportion of DAH is transferred to recipient countries; inappropriate priority setting; inadequate coordination; weak mechanisms for accountability; and disagreement on the rationale for DAH. Proposals to address these critiques include: financing-oriented proposals to address insufficient levels and high volatility of DAH; governance-oriented proposals to address concerns regarding additionality, proportions reaching countries, priority setting, coordination and accountability; and proposals that reach beyond the existing DAH system. We conclude with a discussion of prospects for change.

Lessons from a decade of voluntary medical male circumcision implementation and their application to HIV pre-exposure prophylaxis scale up

Oral pre-exposure prophylaxis (PrEP) has the ability to curb HIV incidence worldwide and bring us closer to ending the HIV epidemic. Scale up of PrEP service delivery has many similar challenges to those faced by voluntary medical male circumcision (VMMC) services roll-out. This article outlines ten important lessons learned during the scale up of VMMC services in sub-Saharan Africa and their application to current oral PrEP implementation efforts to promote faster expansion for public health impact.

Primary and secondary prevention interventions for cardiovascular disease in low-income and middle-income countries: a systematic review of economic evaluations

Background

Cardiovascular disease (CVD) is the leading cause of deaths globally, with greatest premature mortality in the low- and middle-income countries (LMIC). Many of these countries, especially in sub-Saharan Africa, have significant budget constraints. The need for current evidence on which interventions offer good value for money to stem this CVD epidemic motivates this study.

Methods

In this systematic review, we included studies reporting full economic evaluations of individual and population-based interventions (pharmacologic and non-pharmacologic), for primary and secondary prevention of CVD among adults in LMIC. Several medical (PubMed, EMBASE, SCOPUS, Web of Science) and economic (EconLit, NHS EED) databases and grey literature were searched. Screening of studies and data extraction was done independently by two reviewers. Drummond’s checklist and the National Institute for Health and Care Excellence quality rating scale were used in the quality appraisal for all studies used to inform this evidence synthesis.

Results

From a pool of 4059 records, 94 full texts were read and 50 studies, which met our inclusion criteria, were retained for our narrative synthesis. Most of the studies were from middle-income countries and predominantly of high quality. The majority were modelled evaluations, and there was significant heterogeneity in methods. Primary prevention studies dominated secondary prevention. Most of the economic evaluations were performed for pharmacological interventions focusing on blood pressure, cholesterol lowering and antiplatelet aggregants. The greatest majority were cost-effective. Compared to individual-based interventions, population-based interventions were few and mostly targeted reduction in sodium intake and tobacco control strategies. These were very cost-effective with many being cost-saving.

Conclusions

This evidence synthesis provides a contemporary update on interventions that offer good value for money in LMICs. Population-based interventions especially those targeting reduction in salt intake and tobacco control are very cost-effective in LMICs with potential to generate economic gains that can be reinvested to improve health and/or other sectors. While this evidence is relevant for policy across these regions, decision makers should additionally take into account other multi-sectoral perspectives, including considerations in budget impact, fairness, affordability and implementation while setting priorities for resource allocation.

Electronic supplementary material

The online version of this article (10.1186/s12962-018-0108-9) contains supplementary material, which is available to authorized users.

Relevance of barriers and facilitators in the use of health technology assessment in Colombia

OBJECTIVES

Several studies, mostly from developed countries, have identified barriers and facilitators with regard to the uptake of health technology assessment (HTA). This study elicited, using best-worst scaling (BWS), what HTA experts in Colombia consider to be the most important barriers and facilitators in the use of HTA, and makes a comparison to results from the Netherlands.

METHODS

Two object case surveys (one for barriers, one for facilitators) were conducted among 18 experts (policymakers, health professionals, PhD students, senior HTA-researchers) from Colombia. Seven respondents were employees of the national HTA agency Instituto de Evaluación Tecnológica de Salud (IETS). In total, 22 barriers and 19 facilitators were included. In each choice task, participants were asked to choose the most and least important barrier/facilitator from a set of five. Hierarchical Bayes modeling was used to compute the mean relative importance scores (RIS) for each factor, and a subgroup analysis was conducted to assess differences between IETS and non-IETS respondents. The final ranking was further compared to the results from a similar study conducted in the Netherlands.

RESULTS

The three most important barriers (RIS >6.00) were "Inadequate presentation format", "Absence of policy networks", and "Insufficient legal support". The six most important facilitators (RIS >6.00) were "Appropriate timing", "Clear presentation format", "Improving longstanding relation", "Appropriate incentives", "Sufficient qualified human resources", and "Availability to relevant HTA research". The perceived relevance of the barriers and facilitators differed slightly between IETS and non-IETS employees, while the differences between the rankings in Colombia and the Netherlands were substantial.

CONCLUSION

The study suggests that barriers and facilitators related to technical aspects of processing HTA reports and to the contact and interaction between researchers and policymakers had the greatest importance in Colombia.

The Development of the Guide to Economic Analysis and Research (GEAR) Online Resource for Low- and Middle-Income Countries' Health Economics Practitioners: A Commentary

Public health authorities around the world are increasingly using economic evaluation to set priorities and inform decision making in health policy, especially in the development of health benefit packages. Nevertheless, researchers in low- and middle-income countries (LMICs) encounter many barriers when conducting economic evaluations. In 2015, the Health Intervention and Technology Assessment Program identified key technical and context-specific challenges faced in conducting and using health economic evaluations in LMICs. On the basis of these research findings, the Guide to Economic Analysis and Research (GEAR) online resource (www.gear4health.com) was developed as a reliable aid to researchers in LMICs that would help overcome those challenges. Funded by the Thailand Research Fund and the Bill and Melinda Gates Foundation, GEAR is a free online resource that provides a visual aid tool for planning economic evaluation studies (GEAR mind maps), a repository of national and international economic evaluation guidelines (GEAR guideline comparison), and an active link to a network of volunteer international experts (GEAR: Ask an expert). GEAR will evolve over time to provide relevant, reliable, and up-to-date information through inputs from its users (e.g., periodic survey on methodological challenges) and experts (e.g., in responding to users' questions). The objective of this commentary was to give a brief description of the development and key features of this unique collective information hub aimed at facilitating high-quality research and empowering health care decision makers and stakeholders to use economic evaluation evidence.

Identification of publicly available data sources to inform the conduct of Health Technology Assessment in India

Background: Health technology assessment (HTA) provides a globally-accepted and structured approach to synthesising evidence for cost and clinical effectiveness alongside ethical and equity considerations to inform evidence-based priorities. India is one of the most recent countries to formally commit to institutionalising HTA as an integral component of the heath resource allocation decision-making process. The effective conduct of HTA depends on the availability of reliable data.   Methods: We draw from our experience of collecting, synthesizing, and analysing health-related datasets in India and internationally, to highlight the complex requirements for undertaking HTA, and explore the availability of such data in India. We first outlined each of the core data components required for the conduct of HTA, and their availability in India, drawing attention to where data can be accessed, and different ways in which researchers can overcome the challenges of missing or low quality data. Results: We grouped data into the following categories: clinical efficacy; cost; epidemiology; quality of life; service use/consumption; and equity. We identified numerous large local data sources containing epidemiological information. There was a marked absence of other locally-collected data necessary for informing HTA, particularly data relating to cost, service use, and quality of life. Conclusions: The introduction of HTA into the health policy space in India provides an opportunity to comprehensively assess the availability and quality of health data capture across the country. While epidemiological information is routinely collected across India, other data inputs necessary for HTA are not readily available. This poses a significant bottleneck to the efficient generation and deployment of HTA into the health decision space. Overcoming these data gaps by strengthening the routine collection of comprehensive and verifiable health data will have important implications not only for embedding economic analyses into the priority setting process, but for strengthening the health system as a whole.

Identification of publicly available data sources to inform the conduct of Health Technology Assessment in India

Background: Health technology assessment (HTA) provides a globally-accepted and structured approach to synthesising evidence for cost and clinical effectiveness alongside ethical and equity considerations to inform evidence-based priorities. India is one of the most recent countries to formally commit to institutionalising HTA as an integral component of the heath resource allocation decision-making process. The effective conduct of HTA depends on the availability of reliable data.   Methods: We draw from our experience of collecting, synthesizing, and analysing health-related datasets in India and internationally, to highlight the complex requirements for undertaking HTA, and explore the availability of such data in India. We first outlined each of the core data components required for the conduct of HTA, and their availability in India, drawing attention to where data can be accessed, and different ways in which researchers can overcome the challenges of missing or low quality data. Results: We grouped data into the following categories: clinical efficacy; cost; epidemiology; quality of life; service use/consumption; and equity. We identified numerous large local data sources containing epidemiological information. There was a marked absence of other locally-collected data necessary for informing HTA, particularly data relating to cost, service use, and quality of life. Conclusions: The introduction of HTA into the health policy space in India provides an opportunity to comprehensively assess the availability and quality of health data capture across the country. While epidemiological information is routinely collected across India, other data inputs necessary for HTA are not readily available. This poses a significant bottleneck to the efficient generation and deployment of HTA into the health decision space. Overcoming these data gaps by strengthening the routine collection of comprehensive and verifiable health data will have important implications not only for embedding economic analyses into the priority setting process, but for strengthening the health system as a whole.

Strengthening health technology assessment systems in the global south: a comparative analysis of the HTA journeys of China, India and South Africa

BACKGROUND

Resource allocation in health is universally challenging, but especially so in resource-constrained contexts in the Global South. Pursuing a strategy of evidence-based decision-making and using tools such as Health Technology Assessment (HTA), can help address issues relating to both affordability and equity when allocating resources. Three BRICS and Global South countries, China, India and South Africa have committed to strengthening HTA capacity and developing their domestic HTA systems, with the goal of getting evidence translated into policy. Through assessing and comparing the HTA journey of each country it may be possible to identify common problems and shareable insights.

OBJECTIVES

This collaborative paper aimed to share knowledge on strengthening HTA systems to enable enhanced evidence-based decision-making in the Global South by: Identifying common barriers and enablers in three BRICS countries in the Global South; and Exploring how South-South collaboration can strengthen HTA capacity and utilisation for better healthcare decision-making.

METHODS

A descriptive and explorative comparative analysis was conducted comprising a Within-Case analysis to produce a narrative of the HTA journey in each country and an Across-Case analysis to explore both knowledge that could be shared and any potential knowledge gaps.

RESULTS

Analyses revealed that China, India and South Africa share many barriers to strengthening and developing HTA systems such as: (1) Minimal HTA expertise; (2) Weak health data infrastructure; (3) Rising healthcare costs; (4) Fragmented healthcare systems; and (5) Significant growth in non-communicable diseases. Stakeholder engagement and institutionalisation of HTA were identified as two conducive factors for strengthening HTA systems.

CONCLUSION

China, India and South Africa have all committed to establishing robust HTA systems to inform evidence-based priority setting and have experienced similar challenges. Engagement among countries of the Global South can provide a supportive platform to share knowledge that is more applicable and pragmatic.

Health Technology Assessment capacity development in low- and middle-income countries: Experiences from the international units of HITAP and NICE

Health Technology Assessment (HTA) is policy research that aims to inform priority setting and resource allocation. HTA is increasingly recognized as a useful policy tool in low- and middle-income countries (LMICs), where there is a substantial need for evidence to guide Universal Health Coverage policies, such as benefit coverage, quality improvement interventions and quality standards, all of which aim at improving the efficiency and equity of the healthcare system. The Health Intervention and Technology Assessment Program (HITAP), Thailand, and the National Institute for Health and Care Excellence (NICE), UK, are national HTA organizations providing technical support to governments in LMICs to build up their priority setting capacity. This paper draws lessons from their capacity building programs in India, Colombia, Myanmar, the Philippines, and Vietnam. Such experiences suggest that it is not only technical capacity, for example analytical techniques for conducting economic evaluation, but also management, coordination and communication capacity that support the generation and use of HTA evidence in the respective settings. The learned lessons may help guide the development of HTA capacity in other LMICs.

Evidence-Informed Deliberative Processes for Universal Health Coverage: Broadening the Scope Comment on "Priority Setting for Universal Health Coverage: We Need Evidence-Informed Deliberative Processes, Not Just More Evidence on Cost-Effectiveness"

Universal health coverage (UHC) is high on the global health agenda, and priority setting is fundamental to the fair and efficient pursuit of this goal. In a recent editorial, Rob Baltussen and colleagues point to the need to go beyond evidence on cost-effectiveness and call for evidence-informed deliberative processes when setting priorities for UHC. Such processes are crucial at every step on the path to UHC, and hopefully we will see intensified efforts to develop and implement processes of this kind in the coming years. However, if this does happen, it will be essential to ensure a sufficiently broad scope in at least two respects. First, the design of evidence-informed priority-setting processes needs to go beyond a simple view on the relationship between evidence and policy and adapt to a diverse set of factors shaping this relationship. Second, these processes should go beyond a focus on clinical services to accommodate also public health interventions. Together, this can help strengthen priority-setting processes and bolster progress towards UHC and the Sustainable Development Goals.

We need a NICE for global development spending

With aid budgets shrinking in richer countries and more money for healthcare becoming available from domestic sources in poorer ones, the rhetoric of value for money or improved efficiency of aid spending is increasing. Taking healthcare as one example, we discuss the need for and potential benefits of (and obstacles to) the establishment of a national institute for aid effectiveness. In the case of the UK, such an institute would help improve development spending decisions made by DFID, the country's aid agency, as well as by the various multilaterals, such as the Global Fund, through which British aid monies is channelled. It could and should also help countries becoming increasingly independent from aid build their own capacity to make sure their own resources go further in terms of health outcomes and more equitable distribution. Such an undertaking will not be easy given deep suspicion amongst development experts towards economists and arguments for improving efficiency. We argue that it is exactly because needs matter that those who make spending decisions must consider the needs not being met when a priority requires that finite resources are diverted elsewhere. These chosen unmet needs are the true costs; they are lost health. They must be considered, and should be minimised and must therefore be measured. Such exposition of the trade-offs of competing investment options can help inform an array of old and newer development tools, from strategic purchasing and pricing negotiations for healthcare products to performance based contracts and innovative financing tools for programmatic interventions.

Evidence-informed capacity building for setting health priorities in low- and middle-income countries: A framework and recommendations for further research

Priority-setting in health is risky and challenging, particularly in resource-constrained settings. It is not simply a narrow technical exercise, and involves the mobilisation of a wide range of capacities among stakeholders - not only the technical capacity to "do" research in economic evaluations. Using the Individuals, Nodes, Networks and Environment (INNE) framework, we identify those stakeholders, whose capacity needs will vary along the evidence-to-policy continuum. Policymakers and healthcare managers require the capacity to commission and use relevant evidence (including evidence of clinical and cost-effectiveness, and of social values); academics need to understand and respond to decision-makers' needs to produce relevant research. The health system at all levels will need institutional capacity building to incentivise routine generation and use of evidence. Knowledge brokers, including priority-setting agencies (such as England's National Institute for Health and Care Excellence, and Health Interventions and Technology Assessment Program, Thailand) and the media can play an important role in facilitating engagement and knowledge transfer between the various actors. Especially at the outset but at every step, it is critical that patients and the public understand that trade-offs are inherent in priority-setting, and careful efforts should be made to engage them, and to hear their views throughout the process. There is thus no single approach to capacity building; rather a spectrum of activities that recognises the roles and skills of all stakeholders. A range of methods, including formal and informal training, networking and engagement, and support through collaboration on projects, should be flexibly employed (and tailored to specific needs of each country) to support institutionalisation of evidence-informed priority-setting. Finally, capacity building should be a two-way process; those who build capacity should also attend to their own capacity development in order to sustain and improve impact.