Presentation on theme: "World Health Organization"— Presentation transcript:
1World Health Organization 14 April 2017Priority Settingin Universal Health CoverageThe role of Health Intervention & Technology AssessmentDr. Kees de JoncheereDirector EMP departmentEMP Technical Briefing Seminar, November 2014
2World Health Organization Outline14 April 2017Concept of UHC and Priority SettingWhat is Health Intervention and Technology AssessmentOngoing programmes of work contributing to HITA in WHOHTA for medicines evaluationThe way forward
3Universal health coverage (UHC) World Health OrganizationUniversal health coverage (UHC)14 April, 2017The 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 needsAffordability – a financing system to avoid financial hardshipAccess to essential medicines and other health technologiesSufficient capacity of well-trained, motivated health workers to provide the services neededResources are scarce in all settings and forms of priority setting are inevitableWHO 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.
4World Health Organization 14 April 2017Three Dimensions to Consider When Moving Towards Universal CoveragePriority Settinga. 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
5Considerations in priority setting World Health OrganizationConsiderations in priority setting14 April 2017In 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 cubeImportant 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 optionsMore broadly priority setting includes considerations of the other two dimensions of the UHC cube
6What is Health Intervention & Technology Assessment? World Health OrganizationWhat is Health Intervention & Technology Assessment?14 April 2017Health 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 livesTechnology 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 clearHealth technology assessment is not only about pharmaceuticals and devices but also about interventions and delivery systems.
7The continuum of HITA activities World Health Organization14 April 2017Fragile states:Essential servicesEmergency kitsDisaster planningLow income countries with low coverage,Primary health care packagesMiddle income countries with low coverage,Guaranteed packages of careStrong health systemMarginal analysis for additions to packagesHealth SystemsHealth technology assessment (HITA) provides a decision-making framework for different types of decisions and can be applied in all health care systems, but needs differIn fragile health systems: to identify essential guaranteed servicesIn middle-income countries with limited coverage: to decide how to extend the package of health care services providedIn systems with established UHC: to inform decisions ‘at the margin’: what extra services to provide and at what costContinuum of HTA Activities
8Uses of HITA methods in WHO World Health OrganizationUses of HITA methods in WHO14 April 2017WHO Model List of Essential MedicinesPackage of Essential Noncommunicable (PEN) disease interventions for primary health care, 'best buys' for NCDsWHO-CHOICE, CHOosing Interventions that are Cost Effective global database of around 500 health technologiesOneHealth Tool designed to inform national strategic health planning in low- and middle-income countries.Assessing medical devices and assistive devices for an ageing population
9Examples of ongoing HITA in WHO World Health OrganizationExamples of ongoing HITA in WHO14 April 2017WHO Model List of Essential MedicinesFirst published in 1977Updated every 2 years156 countries have essential medicines listsOneHealth Tool for Costing and Strategic planningDevelopment began in 2008Released in 2012Has to date been used in over 25 countriesWHO-CHOICEOngoing since 1998Development of cost-effectiveness analyses of interventions covering all WHO regions
10WHO-CHOICE example results World Health Organization14 April, 2017This 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.
11World Health Organization What is needed for HITA?14 April 2017Assessment is based on collecting, evaluating, and systematically reviewing all available evidence for the intervention or technology being consideredTypes of data include epidemiological, economic, health impact, expert opinionMethods include assessing the quality of available information, systematic review and meta-analysis, surveys, feasibility, affordability and ethical considerationsMultidisciplinary skills are needed to assemble and interpret the dataCountries with the greatest need often have the least capacityDifferent types of HITA vary in scope, time and resources requiredFull scale health technology assessment reportContextualization 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 oppositedirection.Multidisciplinary teams can include:Biomedical EngineersEpidemiologistsEthicistsHealth EconomistsLibrariansLawyersNursesPatient organizationsPharmacistsPublic Health Specialists
12Evaluation of new medicines For market entry :quality, efficacy, safety ; benefit/risk assessmentFor reimbursementMedical need and severity of diseaseHealth gain and added therapeutic valueAvailability of alternativesCost-effectivenessBudget impactEquity considerations…
13Evaluation of new medicines For medical practiceEvaluation by drug bulletins, professional associations on the “place in therapy” of a new medicineConsistency between reimbursement indications and therapeutic guidelines ?Reviews by national HTA bodies
14Implications of cost-effectiveness analysis for reimbursement Health-based reason to justify a price premium for the proposed drugRelate extent and nature of health gain to justify price increase, including cost off-sets in health sectorCommon outcome measure (QALY, life year gained,.. )Pristine value judgement
15Economic evaluations Two main approaches on a “cost-minimisation” basisas “acceptably cost-effective”Two main “levers”restrict to particular patientsprice of the proposed drug
16Reimbursement decision-making process : after the initial reimbursement decision … Post-listing reviews (at least annually)pricesrestrictions and listingsPost-listing monitoring (at least annually)usage (including predicted versus actual)cost to reimbursement systemCoordinate post-listing activities
17International collaboration on evaluation of medicines Health care systems are differentIssues tend to be the same : costs drivers and evidenceBasis for common guidance, and exchange of information, and “lessons learned” ? !MEDEVEU network of Pricing and Reimbursement authoritiesEUnetHTAINAHTA, ISPOR, HTAiHiTAP and South East Asia networkREDETSA Latin America networkPPRI and PHIS networks
18Making cost-effectiveness evaluations work (1) ( do countries have the resources to do this ?) Separate licensing and reimbursement decisionsPositive listPrice negotiationsAbility to restrict indicationsAdequate guidelines for submissionsCompetent evaluations of submissionsConsistent and informed decision-maker
19Making cost-effectiveness evaluations work : decision-making process (2) Inclusiveness in decision-making and input from all stakeholdersReimbursement committees with external experts : managing potential conflict-of-interestsHealth Technology Assessment agencies and committees often not directly linked with reimbursement decisions
20Use of cost-effectiveness analysis in reimbursement Growing requirements and increasing need for resources“Silo-budgeting” limits applicationShift to “risk-sharing” with patient registries : from paying for the medicine to buying an agreed upon therapeutic outcomeCEA needs to relate to goals, values, and priorities of the health care systemsRCTs do not provide all information needed : discuss with industry the need for additional trialsHow to deal with “point-decisions” vis-à-vis re-assessment of the evidence ?Discussions on appropriateness of QALY`sDiscussions on thresholds
21World Health Organization The way forward14 April 2017WHO HQ plans to undertake a global mapping survey of current capacity and perceived needs for HITA in member statesA focus of moving forward should be onAdvocacy and promotion of priority setting (including HITA) best practicesFacilitate sharing of technology assessment and experiences among countries including through the development of platforms for information exchangeCapacity building activities including networks where appropriateResolution EB134.R14Health intervention and technology assessment in support of universal health coverage