2014 09-04 hta afrique banken final
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Transcript of 2014 09-04 hta afrique banken final
Incorporating HTA into Health Systems
Reiner Banken M.D. M. SC.
Advisor to the CEO, Alliances and Networks
Cape Town, Oct 4, 2014HTA in Sub-Saharan Africa meeting: Use of HTA in Health Systems strengthening
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Objectives of the presentation
• Understanding – the objectives for introducing HTA– the evolution of HTA in Health Systems– the human resources and instutional arrangements
necessary for effective HTA
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Outline
• Why should Health Systems use HTA ?
• Messages from high income countries
• From HTA to action: Context, policy tools and governance
• Resources needed
• Conclusion
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Why should Health Systems use HTA ?
Improve the quest for clinical excellence Support the efficient use of health technologies Inform the formulation of safe, effective, sustainable
decision-making in health systems that is patient-focused and seeks to achieve best value
Favor consensus between clinicians and managers Define benefit packages for health care Provide evidence for the development of clinical practice
guidelines
Increase the transparency of decision-making
All of the above and more
Evidence for informing decision-making
IntuitiveDecision-making
+Evidence
Political, Social, EconomicConditions
Technological, Organisational,
Ethical, LegislativeConditions
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Why should you support the development of HTA?
Decision-makers in all Health Systems are being held accountable for not meeting the rising expectations of patients, clinicians and the public.
HTA can partially solve this unsolvable problem.
HTA makes your life easier
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The price to be paid….
HTA as a service for the health system cannot work without rigor, independence and transparency.
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The “natural history” of health
technology assessment: emergence,
consolidation, and expansion.
• Emergence: need expressed by decision-makers in a context of depoliticizing allocation decisions in times of increasing resource constraints, importance of leaders, development of the scientific know-how, high cost medical device focused, little stakeholder involvement,
• Consolidation: more structured organizational HTA systems, priority setting, enlargement of scope of technologies, increased stakeholder involvement
• Expansion: multiple disciplines, multiple products, political recognition, HTA system, strong stakeholder involvement, investment into Knowledge translation
Battista RN, Hodge MJ . Int J Technol Assess Health Care. 2009 Jul;25 Suppl 1:281-4.
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INESSS – 40 years of science advice for decision-making
Conseil d’évaluation des technologies de la santé
(1988)
Agences d’évaluationdes technologies et
des modes d’intervention en santé
Comité de revue de l’utilisation des médicaments
2000
Réseau de revue d’utilisation desmédicaments
Conseil consultatifde pharmacologie
Conseil du médicament
2003
2003
Social ServicesClinical Practice Guidelines
Institut nationald’excellence
en santé et enservices sociaux
2009
January, 19, 2011
1988
1996
1972 1991
2011
Medical BiologyLab tests
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HTA in the 21 century – A perspective from Political Science
• HTA has developed in a relatively depoliticized environment … buffered from the capricious impacts of electoral politics.
• HTA in all the countries began with relatively politically innocuous studies of technologies recognized to be of major import to national health systems or researcher-initiated studies.
• However, with increased focus in health systems on explicit determination of health benefits baskets, the role of HTA has become more high profile. This means that political accountability for the entire HTA process will increase.
• The implication is that future management of HTA programs will require self-conscious attention to the building of institutions capable of handling the delicate process of integrating science and politics in health policy.
Citation from the abstract of Chinitz. Health technology assessment in four countries: response from political science. IJTAHC 20:1 (2004), 55–60
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Messages from the evolution of HTA
1. The use of HTA in Health Systems is evolving over time.
2. Institutions (rules, organisations, legal frameworks) are important and should enable HTA to evolve.
3. Mature HTA systems include a wide range of health technologies and interventions to be assessed, strong stakeholder involvement and knowledge mobilisation activities.
4. The development of HTA takes place in a political arena; the objectives and processes have to clear from the start.
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Reasoning in HTA
Effectiveness and safeness
Can it work here?
(here=context of decision-
making)Theoretical safety and
efficacyCan it work?
AppropriatenessShould we do it here?
ImplementationHow should we do
it here?
Research
Tra
nsla
tion
al r
esea
rch
Adapted from Health technology assessment of medical devices. WHO Medical device technical series, 2011. Available at: http://whqlibdoc.who.int/publications/2011/9789241501361_eng.pdf
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Context is essential for evidence-informed decision making
There are decisions that…
take good evidence …
… and use it well
… and use it poorly poor evidence …
Adapted from Shaxson, L 2004: Evidence-based policy making: if it exists what makes it robust? Available at http://bit.ly/hIsNC
in context
in context
without context
without context
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On Context
1. Stakeholder involvement is an important element of scoping and contextualizing HTA.
2. Health Service Research and Implementation Science are important for providing a perspective of health systems context.
3. The capacity of health information systems to provide contextual data is very useful for supporting the context aspect of the HTA knowledge synthesis
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Health Technology Assessment for Improving Health Systems and Health
Health Technology
Appropriate Use
Efficient Health SystemsImproving population health
DecisionsPolicy Tools
Governance
HTA
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Science, decisions and policy tools for pharmaceuticals
KnowledgeUncertainties
DrugReimbursement
Decision
Policy Tool
Governance Current tools in Québec•Regular list•« Médicament d’exception »•Refusal
Other possible tools, currently not available•CED•Risk sharing•Limited to specific settings•…
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Impact of HTA depends on links to policy instruments
In some countries there are specific mechanisms that lead to the incorporation into policy instruments of research such as Health Technology Assessments (HTAs) ….no direct link between the amount of money spent on HTA and its impact on the decision-making process. Indeed, they suggest that small programmes can be involved in the core of the policy-making structure whilst larger HTA programmes have difficulty in demonstrating impact….It seems clear that HTAs have had most impact in those situations where there are specific mechanisms in place that require research evidence to support well-defined policy decisions on provision, coverage or reimbursement.
Citation from Hanney et al. The utilisation of health research in policy-making: concepts, examples and methods of assessment. Health Research Policy and Systems 2003, 1:2
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How to start the process and make it last?
“Start small, have a clear audience and scope, and address
important questions” (Lavis et al 2008, Synthesis of findings from a
multi-method study of organizations that support the use of research evidence)
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Dedicated resources for HTA
HTA Knowledge Mobilizer
1-2 persons
Putting HTA into Context
HTA Unit/ Agency
4-5 persons
>9 persons
DedicatedResources
HTA Committee
HTA System
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Human resources and objectives
1-2 persons
4-5 persons
>9 persons
Clinician champion with scientific background in knowledge synthesis. Receptor for HTA knowledge produced elsewhere. Second person could act as an HTA Knowledge mobilizer and support an HTA Committee.
Team with health economist, librarian and social scientist. Translation of HTA knowledge produced elsewhere into the local decision-making context.
Multidisciplinary team for HTA Knowledge Synthesis and Knowledge Mobilisation
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Guiding principles
• If you do not have the human resources to do scientific knowledge synthesis, you cannot do HTA.
• If you do not have good links to decision-making, you can do HTA, but it will not be effective.
• If you do not have strong stakeholder participation and health systems governance, HTA will not be effective for Universal Health Coverage.
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Spectrum of HTA implementations
• Level of governance: HTA for hospital based decision-making, for health system level decision-making, for decision-making by health insurances Multi-jurisdictional HTA, HTA for international decision-making ??? (WHO, World Bank, international development, …)
• Objects and objectives: selected non pharmaceutical technologies, wide range of technologies including care processes, health care delivery models, health benefit baskets, Universal Health Coverage.
• Dedicated resources: HTA receptor, small unit, full blown HTA agency, networked HTA (crowdsourcing ?)
Problem streamPolicy streamPolitics stream
Policy window of
opportunity 2
2004 inflationary costs and raising exceptions,
government starts considering HTA
processes
2008 Constitutional court´s mandate to amend structural
factors
2008 National methods
guidelines
Early 2009 crisis within the health
system threatening sustainability
Mid 2009 increased
interest in NICE methods and
processes, government´s official request
for technical advice
Late 2009 controversial law of social
emergency by former
president
Policy window of
opportunity 1
2007 Decision making body
created not an HTA agency
2011 HTA agency (IETS)
enacted by law
Late 2010 New
government
2010 11070604 05 20092008
Early 2010 law of social emergency
declared unenforceable
Source: Based on Kingdon model- 1984 by Castro HE, 2013 work in progress
Agenda setting- the policy context in Colombia
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2012 Decision making body
abolished lack of legitimacy
2013 POS content updated
using HTA by IETS
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2012 HTA agency
(IETS) starts operations
Hector Castro, IETS, Columbia. From presentation at EMRO First Intercountry HTA Meeting, November 2013, used with permission.
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HTA as a service for the health system cannot work without rigor, independence and transparency
The strategies of influence entail a number of risks that may undermine the scientific evaluation of drugs. Some outcomes of drug evaluation may favour the interests of multinational drug companies over those of the public payer. We suggest that the risks involved in drug evaluation might be mitigated through (1) professionalization of health technology assessment; (2) restriction of job seeking and post public-payer employment; (3) disclosure and management of experts’ conflicts of interest; (4) institutionalisation of patient and public involvement; and (5) increased institutional separation of the AHTAPol from political elites.
Citation from the abstract of Ozieranski et al. The politics of health technology assessment in Poland. Health Policy 108 (2012) 178–193
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Strategies for Africa
• Developping scientific capacity for knowledge synthesis in collaboration with universities, the Cochrane Collaboration, EVIPNet Africa, and other Health Systems Research initiatives.
• Capacity building with existing HTA networks, such as INAHTA.
• Using country or region specific Policy Windows.• Regional communities of practice in HTA.• Promoting the need for HTA with policy makers and funding
agencies , but also the necessary conditions of rigor, independence and transparency
• Linking HTA to collaborations in regulation for pharmaceuticals and devices (NEPAD ?, ECOWAS ?,…)
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Conclusion
• HTA as a service for the health system cannot work without rigor, independence and transparency.
• HTA should be implemented gradually, starting with scientific human resources.
• HTA Systems need institutions (organisations, legal frameworks, dedicated resources)
• HTA relies on strong stakeholder participation and health systems governance in order to contribute significantly to Universal Health Coverage.