1. World Health Organization
14 April 2017
Priority Setting
in Universal Health Coverage
The role of Health Intervention & Technology Assessment
Dr. Kees de Joncheere
Director EMP department
EMP Technical Briefing Seminar, November 2014

2. World Health Organization
Outline
14 April 2017
Concept of UHC and Priority Setting
What is Health Intervention and Technology Assessment
Ongoing programmes of work contributing to HITA in WHO
HTA for medicines evaluation
The way forward

3. Universal health coverage (UHC)
World Health Organization
Universal health coverage (UHC)
14 April, 2017
The goal of universal health coverage is to ensure that all people obtain the health services they need without suffering financial hardship when paying for them.
A strong, efficient, well-run health system that meets priority health needs
Affordability – a financing system to avoid financial hardship
Access to essential medicines and other health technologies
Sufficient capacity of well-trained, motivated health workers to provide the services needed
Resources are scarce in all settings and forms of priority setting are inevitable
WHO has a commitment to supporting member states as they move towards universal health coverage. An important dimension of UHC is providing access to essential medicines and health technologies. Making sure that quality assured essential medicines are available requires properly functioning pharmaceutical systems.

4. World Health Organization
14 April 2017
Three Dimensions to Consider When Moving Towards Universal Coverage
Priority Setting
a. Between dimensions of the cube: if more funds become available, should they be spent on adding interventions, improving quality, covering more people, or reducing out of pocket payments?
b. Along a single dimension ( population, services and costs)
HITA contributes to decisions along the service dimension – which services (involving what medicines and medical technologies) should be covered, how they should be delivered

5. Considerations in priority setting
World Health Organization
Considerations in priority setting
14 April 2017
In moving towards UHC, questions focus on:
The population covered by the package of interventions: Who ?
The services that can be provided: Which services ?
The proportion of service costs that can be covered: How much ?
Health technology assessment (HITA) is an important process to aid priority-setting within the services axis of the UHC cube
Important to note that priority setting is broader than just health technology assessment, however in deciding which services to offer, technology assessment provides a framework to compare and contrast alternative options
More broadly priority setting includes considerations of the other two dimensions of the UHC cube

6. What is Health Intervention & Technology Assessment?
World Health Organization
What is Health Intervention & Technology Assessment?
14 April 2017
Health technology is the application of organized knowledge and skills in the form of interventions, devices, medicines, vaccines, procedures and systems developed to solve a health problem and improve quality of lives
Technology assessment in health care is a multidisciplinary field of policy analysis. It studies the medical, social, ethical, and economic implications of development, diffusion, and use of health technology.
HITA does not make the decisions, however the systematic assessment of the evidence makes the trade-offs between alternative actions clear
Health technology assessment is not only about pharmaceuticals and devices but also about interventions and delivery systems.

7. The continuum of HITA activities
World Health Organization
14 April 2017
Fragile states:
Essential services
Emergency kits
Disaster planning
Low income countries with low coverage,
Primary health care packages
Middle income countries with low coverage,
Guaranteed packages of care
Strong health system
Marginal analysis for additions to packages
Health Systems
Health technology assessment (HITA) provides a decision-making framework for different types of decisions and can be applied in all health care systems, but needs differ
In fragile health systems: to identify essential guaranteed services
In middle-income countries with limited coverage: to decide how to extend the package of health care services provided
In systems with established UHC: to inform decisions ‘at the margin’: what extra services to provide and at what cost
Continuum of HTA Activities

8. Uses of HITA methods in WHO
World Health Organization
Uses of HITA methods in WHO
14 April 2017
WHO Model List of Essential Medicines
Package of Essential Noncommunicable (PEN) disease interventions for primary health care, 'best buys' for NCDs
WHO-CHOICE, CHOosing Interventions that are Cost Effective global database of around 500 health technologies
OneHealth Tool designed to inform national strategic health planning in low- and middle-income countries.
Assessing medical devices and assistive devices for an ageing population

9. Examples of ongoing HITA in WHO
World Health Organization
Examples of ongoing HITA in WHO
14 April 2017
WHO Model List of Essential Medicines
First published in 1977
Updated every 2 years
156 countries have essential medicines lists
OneHealth Tool for Costing and Strategic planning
Development began in 2008
Released in 2012
Has to date been used in over 25 countries
WHO-CHOICE
Ongoing since 1998
Development of cost-effectiveness analyses of interventions covering all WHO regions

10. WHO-CHOICE example results
World Health Organization
14 April, 2017
This slide shows results from the CHOICE project, measured as healthy life years saved per $1,000 international. The greatest health gain is seen in Vitamin A and Zinc fortification in children under 5, almost ten times greater than the health gain due to any of the other interventions for the same price (note compression of x axis between 10 and 60 healthy life years). Other services listed in the figure are also highly cost-effective, such as testing and treatment for tuberculosis, prevention and treatment of malaria, and primary prevention (for very-high-risk individuals) and treatment of myocardial infarction and stroke.

11. World Health Organization
What is needed for HITA?
14 April 2017
Assessment is based on collecting, evaluating, and systematically reviewing all available evidence for the intervention or technology being considered
Types of data include epidemiological, economic, health impact, expert opinion
Methods include assessing the quality of available information, systematic review and meta-analysis, surveys, feasibility, affordability and ethical considerations
Multidisciplinary skills are needed to assemble and interpret the data
Countries with the greatest need often have the least capacity
Different types of HITA vary in scope, time and resources required
Full scale health technology assessment report
Contextualization of reports produced by others
"marginal" analysis of the sort done in high income countries requires fewer data and skills than the "non-marginal" analysis relevant in lower income settings, yet in practice the availability of data and skills is usually in the opposite
direction.
Multidisciplinary teams can include:
Biomedical Engineers
Epidemiologists
Ethicists
Health Economists
Librarians
Lawyers
Nurses
Patient organizations
Pharmacists
Public Health Specialists

12. Evaluation of new medicines
For market entry :
quality, efficacy, safety ; benefit/risk assessment
For reimbursement
Medical need and severity of disease
Health gain and added therapeutic value
Availability of alternatives
Cost-effectiveness
Budget impact
Equity considerations …

13. Evaluation of new medicines
For medical practice
Evaluation by drug bulletins, professional associations on the “place in therapy” of a new medicine
Consistency between reimbursement indications and therapeutic guidelines ?
Reviews by national HTA bodies

14. Implications of cost-effectiveness analysis for reimbursement
Health-based reason to justify a price premium for the proposed drug
Relate extent and nature of health gain to justify price increase, including cost off-sets in health sector
Common outcome measure (QALY, life year gained,.. )
Pristine value judgement

15. Economic evaluations Two main approaches
on a “cost-minimisation” basis
as “acceptably cost-effective”
Two main “levers”
restrict to particular patients
price of the proposed drug

16. Reimbursement decision-making process : after the initial reimbursement decision …
Post-listing reviews (at least annually)
prices
restrictions and listings
Post-listing monitoring (at least annually)
usage (including predicted versus actual)
cost to reimbursement system
Coordinate post-listing activities

17. International collaboration on evaluation of medicines
Health care systems are different
Issues tend to be the same : costs drivers and evidence
Basis for common guidance, and exchange of information, and “lessons learned” ? !
MEDEV
EU network of Pricing and Reimbursement authorities
EUnetHTA
INAHTA, ISPOR, HTAi
HiTAP and South East Asia network
REDETSA Latin America network
PPRI and PHIS networks

18. Making cost-effectiveness evaluations work (1) ( do countries have the resources to do this ?)
Separate licensing and reimbursement decisions
Positive list
Price negotiations
Ability to restrict indications
Adequate guidelines for submissions
Competent evaluations of submissions
Consistent and informed decision-maker

19. Making cost-effectiveness evaluations work : decision-making process (2)
Inclusiveness in decision-making and input from all stakeholders
Reimbursement committees with external experts : managing potential conflict-of-interests
Health Technology Assessment agencies and committees often not directly linked with reimbursement decisions

20. Use of cost-effectiveness analysis in reimbursement
Growing requirements and increasing need for resources
“Silo-budgeting” limits application
Shift to “risk-sharing” with patient registries : from paying for the medicine to buying an agreed upon therapeutic outcome
CEA needs to relate to goals, values, and priorities of the health care systems
RCTs do not provide all information needed : discuss with industry the need for additional trials
How to deal with “point-decisions” vis-à-vis re-assessment of the evidence ?
Discussions on appropriateness of QALY`s
Discussions on thresholds

21. World Health Organization
The way forward
14 April 2017
WHO HQ plans to undertake a global mapping survey of current capacity and perceived needs for HITA in member states
A focus of moving forward should be on
Advocacy and promotion of priority setting (including HITA) best practices
Facilitate sharing of technology assessment and experiences among countries including through the development of platforms for information exchange
Capacity building activities including networks where appropriate
Resolution EB134.R14
Health intervention and technology assessment in support of universal health coverage