1. International Decision Support Initiative: HTA in action!
…and the value of networking!
Kalipso Chalkidou MD, PhD
Director, Global Health and Development
Imperial College London

2. Status quo unfair and unsustainable
Between 20-40% of the $7.1 trillion spent annually on healthcare is wasted.*
Status quo unfair and unsustainable *

3. How much is enough? The USA spend 17% of its GDP on healthcare…

4. World Health Assembly resolution on Health Intervention and Technology Assessment in Support of UHC
“Every pound can only be spent once. If we spend it unwisely... then we risk harming other people whose care will be adversely affected…
It is vital that priority setting is an evidence-informed, procedurally fair process that defines what will be covered through universal health coverage.”
Prof David Haslam, Chair of NICE, addressing the 25th World Health Assembly, Geneva, 2014

5. Health Technology Assessment (HTA) and economic evaluation
HTA is a multidisciplinary field of policy analysis. It studies the medical, social, ethical, and economic implications of development, diffusion, and use of health technology. Any intervention that may be used to promote health, to prevent, diagnose or treat disease or for rehabilitation or long-term care. This includes the pharmaceuticals, devices, procedures and organizational systems used in health care. Source: INAHTA/glossary

6. A tool for priority setting in health: economic evaluation
“... the comparative analysis of alternative courses of action in terms of both their costs and consequences.”
New treatment
Current treatment
Costs
value of extra resources used (loss to other patients)
Consequences value of health gain for this patient group
Drummond, Stoddart & Torrance, 1987
This definition of economic evaluation (from Drummond, Stoddart & Torrance) has two key aspects:
EE should always compare one health care intervention with one or more alternative interventions for the same population group.
EE should include both the costs and consequences of interventions - the resources that they consume and the health outcomes that they produce.
Note that the choice of comparator is crucial – should include all relevant options for a group of patients (including ‘do nothing’ and ‘current practice’).
Analysis should be conducted separately for each subgroup of patients.
Analysis should be conducted separately for each subgroup of patients.

7. The HTA Process Analysis Appraisal Source: PRICELESS Decision Making
Defining
Decision Space /
Topic Selection
Decision Making
Analysis
Appraisal
Implementation
Source: PRICELESS

8. But there is a serious capacity gap…
Despite increasing political commitment to UHC, priority-setting capacity for low- and middle-income countries is limited and uncoordinated
Institutions
Established processes, legal frameworks…
Evidence and data
Epidemiology, political economy, cost-effectiveness…
Human resources
Policymakers, technicians, clinicians…
The capacities required for effective priority-setting 5

9. Capacity: What kind of capacities?
the capacities across the system to commission, receive, interpret and use (as they judge to be appropriate) the methods and outcomes of HTA/priority-setting research;
the capacities of researchers and commissioners to understand policy/professionals’ needs, identify those that can be advanced by HTA research, conduct the required research without partisan advocacy and to the required standards and communicate it effectively;
the capacities of health service managers to understand implications of the foregoing and to manage resources accordingly;
the capacities of the public and other stakeholder groups incl the media and parliamentarians, to understand evidence-informed policy decisions and to participate when necessary in the process of decision making*
*Tony Culyer, Capacity Building brief for iDSI, in press

10. Who we are…

11. Better priorities for better health
Our mission is to guide decision makers to effective and efficient healthcare resource allocation strategies for improving people’s health.

12. Why we are unique
We respond to policymaker demand, and focus our efforts on what client countries and funders genuinely need
We provide practical support to country decision makers, and work alongside local teams to jointly develop sustainable systems for setting priorities fairly, and on the best available evidence
We are an international, multi-disciplinary network. We bring together leading priority-setting institutions, delivery partners (including academics), policymakers, and funders to solve problems collaboratively
We produce knowledge products: cutting-edge, freely accessible insights on best practices in priority-setting, informed by policymaker priorities, to generate more health for the money

13. Health system strengthening for UHC

14. Harvesting the power of networks: sharing the same principles
We are committed to partnerships with academic, private and public sector and international development groups from across the world, and supporting regional hubs for priority-setting.

15. Three major funders come together
iDSI
Rockefeller Foundation
Bill & Melinda Gates Foundation
UK Department for International Development

16. Better Decisions for Better Health
Evidence-informed, transparent, independent, consultative decision making processes
Better Decisions for Better Health
Demand-driven support
Policy-informed knowledge products
Better Health
Effective
do-er partnerships
Stronger
country institutions
Better decisions
Accountable institutions and processes protect politicians from vested interests and help defend tough choices
Practical support and knowledge products
More efficient and equitable resource allocation decisions with trade-offs made explicit
There is a complex translation process between “better decisions” and “better health” depending on the link between decisions and budgets, budgets and payments/transfers, transfers and delivery system, readiness and effectiveness of delivery and implementation and also the validity and reliability of the original data informing the analysis.

17. “A generative social impact network is a…
set of people who voluntarily organise themselves for collective action to solve a large, complex problem.
Social relationship platform, a human operating system…a unique and renewable capacity...especially useful when taking on complex unpredictable large scale problems which wont yield to a silver bulletr solution...
Its members (individuals or organisations) forge powerful enduring personal relationships based on trust and reciprocity supported by face to face engagement as well as digital tools for connectivity”

18. National Basis - Global Reach: the international Decision Support Initiative
Thailand (HITAP):
National success sustaining UHC at low cost
Leading iDSI hands-on support for Indonesian and Vietnamese HTA pilots
Mahidol University leading SE Asian network of academic institutions
HTAsiaLink
UK (Imperial College/NHS):
Projects supporting countries across the world
Working for stakeholder engagement and HTA institutionalisation in Indonesia
Well-established links with NICE’s academic and clinical collaborating centres, and networks for HTA, guidelines and quality improvement
Based out of a top 10 global university and within NHS London
NICE – member of Guidelines International Network (GIN), HTA International and the Appraisal of Guidelines Research and Evaluation (AGREE) initiative
* Areas of influence and activity are indicative rather than comprehensive

19. National Basis - Global Reach: the international Decision Support Initiative
China (CNHDRC):
Launch Dec 2016 of HTA and Policy Network with cross Province and Uni participation
Technical resource on HTA and best practice for 33 provinces
Entry point for supporting priority-setting in countries under ‘One Belt One Road’ strategy
Participation in HTAsiaLink and related networks
South Africa (PRICELESS-SA, Wits University):
Technical resource within South Africa
Incubating at DoH request HTA unit for South African government
Entry point for practical support in Sub-Saharan African countries
Links to CABRI, AfHEA and related initiatives
* Areas of influence and activity are indicative rather than comprehensive

20. So what?

21. Measuring impact…
How do we measure processes and institutional strengthening (and should we bother…)?
The “streetlight effect” - the observational bias that results from using the easiest way to collect information.

22. The second systematic HTA assessment: 20 years on…

23. Different kinds of impact
NICE Guidelines & National Screening Committee
Individual trials (CRASH 2 ▲TXA, CUtLASS▲atypicals)
NHS and patients
NICE and National Screening Committee
International players
Policy
Open access high quality (citation) academic products
But not for NICE’s Single Tech Appraisal
Academic output
Major funder of research
Methods innovation (eg harmonised outcome measures) and new topics (eg TXA, eczema)
Capacity building and career development mostly in UK
Research system
Efficient allocation of NHS resources (or not if threshold too high! – Claxton et al)
Impact through NICE tech recommendations and NICE Reference Case
Product refinement (oxymetry device; HPV screening)
Industry and the economy
Reference for international researchers and decision makng eg isting of TXA in EML (WHO)
International
TXA tranexamic acid – Ian Roberts
The results of the CUtLASS study showed that atypical antipsychotic drugs offered no clear advantage over the older, typical drugs that had been used for the treatment of psychosis.

24. Impact
At a higher level, there is evidence from a previous study looking at a sample of 10 HTA programme-funded studies, that if 12% of the potential net benefit of implementing the findings of that sample of 10 studies for 1 year was realised, it would cover the cost of the HTA programme from 1993 to 2012.
Guthrie S, Hafner M, Bienkowska-Gibbs T, Wooding S. Returns on Research Funded Under the NIHR Health Technology Assessment (HTA) Programme: Economic Analysis and Case Studies (RR-666-DH). Cambridge: RAND Europe; 2015.

25. iDSI’s Theory of Change
This is the Theory of Change for iDSI which articulates iDSI’s vision for how priority setting can eventually lead to better health outcomes – supported by iDSI partnerships to strengthen country institutions ability to make decisions about resource allocation.
You can see that this diagram is fairly top level – and because of that, it has real utility as a tool through which to communicate iDSI’s vision clearly and concisely.
However, to provide the basis of a framework that could be used to measure progress and generate ongoing learning about what works and what doesn’t, we needed to unpack the various elements of this programme theory in a bit more detail. The aim was to try and ensure that iDSI could capture incremental and shorter term progress towards these significant and so necessarily longer term aims.

26. Mapping the MEL framework to the unpacked Theory of Change
Assessment of network connectivity and strength
Evidence logs
Country level self-assessments
Periodic deep dive evaluations
Impact evaluation
Through a process of collaboration between iDSI and Itad –diagram is what we came up with. As you can see, for each of the key outcomes in the iDSI Theory of Change, we have unpacked them to articulate the intermediary outcomes that iDSI would expect to see.
The MEL framework is designed to be able to test each of the key elements of this unpacked theory of change – and the different components of the framework are mapped out here. All of these components come together to allow iDSI and its partners to monitor performance, test the theory of change, and generate learning about what works in terms of priority setting. None of them are particularly useful in isolation, but as a whole they provide evidence across the theory of change.
For effective partnerships, there are two components which look firstly at the internal functioning of the iDSI network itself and then at the international level work that iDSI engages in.
Then diving down to the country level, the MEL strategy incorporates ongoing monitoring through evidence logs and country assessments as a way to support ongoing learning and course correction, as well as less frequent evaluations which consider different types of questions to inform iDSI’s strategy.
I’ll talk about each of these elements in a bit more detail
Assessment of knowledge products, convening and global health funder engagement

27. A small sample of our work…
Value for money
India: Institutionalising national health technology assessment (HTA) body for medical devices
South Africa: Embedding HTA into the National Health Insurance scheme
Guidelines and quality standards
Vietnam: Combating AMR through quality indicators in acute respiratory infections
India: Adapting international guidelines for high-burden conditions
Pay-for-performance
China: Integrating clinical pathways for NCDs into rural health insurance reform
Thailand: Developing quality outcomes framework (QOF) for primary care

28. India: Setting better priorities for better coverage
Medical Technology Advisory Board: Government of India-led Joint Steering Committee to guide formation of national HTA body, with support of iDSI
Standard treatment guidelines (STGs): Under government task force, supporting development of the first national process manual for STGs, and 12 STGs for high-priority conditions
RSBY pathways: Supporting national Below Poverty Line insurance to provide evidence-based clinical pathways to regulate high-volume, high-cost procedures (e.g. hysterectomy, haemodialysis)
Quality standards to prevent maternal deaths in Kerala*: led by the State’s clinicians and policymakers; scaled-up across State; model for other countries including South Africa
*Vlad et al. (2016) F1000Research.

29. Improving priority setting for 1 sixth of the global population

30. What can HTA do for china?

31. Our work in the People’s Republic of China
Joint pilots: clinical pathways and
payment reform
Phase I ( )
‘Simple’ pathways for selected surgeries
Phase II (2012- )
Stroke + COPD pathways in four counties
Projects strengthen rural health system, including promoting effective use of medicines and medical devices, and treatment in community
Payment reforms applied in over 1,000 counties
The China Health Development Research Center (CNHDRC) increasingly active as a source of priority-setting expertise
Note HITAP’s role

32. Supporting institution Assessment institution
HTA/EE capacity in China
Assessment emphasis
Supporting institution
Assessment institution
Established in
Number of staff
Health technology assessment (HTA)
China National Health Development Research Center
Centre for Health Policy Evaluation and Technology Assessment
2008 12
Fudan University
Health Technology Assessment Key Lab
1994
3-5
Institute of Health Service and Medical Information, Shanghai
Health Technology Assessment center, Shanghai
2011
3-4
Hangzhou normal University
Health Technology Assessment center
2013
Pharmacoeconomic assessment
Pharmacoeconomic Assessment Research Room
1996
4-6
Pharmacoeconomic Research and Evaluation Center
2002 7
Peking University
Pharmacoeconomic Research Center of Guanghua School of Management
2003 10
Evidence-based medicine (EBM)
Huaxi Hospital of Sichuan University
Chinese Cochrane Center (12 sub-centers)
1997
Evidence-based Medicine Center of Peking University
2004 -
National HTA networks:
2014-HTA technical committee, branch of China health economic society(CNHDRC)
2013-China HTA network (Fudan University)
Source: CNHDRC

33. MOU signing
Deputy Director of IGHI, Professor Guang-Zhong Yang said “We are very grateful to iDSI and the Global Health Development Group for providing this key opportunity to work together and are delighted that the collaborations that were set up while the Global Health Development group was still at NICE will now be continued from within IGHI. This in turn will also add new collaboration between the other departments within IGHI and Imperial as a whole and we are very much look forward to working together on this highly important piece of work.”

34. 4th People-to-People (P2P) Dialogue
Event convened by Vice Minister Cui Li from the National Health and Family Planning Commission (NHFPC) of China, and the UK’s Secretary of State for Health Jeremy Hunt
Healthy ageing, improving quality of care and reducing variation, ensuring timely adoption of good value innovation, and enhancing health and social care integration were some of the common themes highlighted as priorities by the two ministers

35. The HTA network can help:
Enhance global leadership and impact of the Belt and Road and a 'healthy' Silk Road…
Ensure high-quality, affordable, equitable care for 1.3bn citizens
Tackle growing chronic disease burden and escalating new technology cost.
Incentivise healthcare products industry to create innovative and good value products for the people of China and of the whole world
Set standards for the private provider sector and empower private purchasers as insurance schemes mature

36. HTA can benefit public and private sectors
Evidence informed guidelines lead to cost-effective decisions about coverage and treatment
Standardised healthcare delivery = similar care for similar need at comparable prices across the country helping gradually bridge rural/urban divide
Protection from vested interests, participation, transparency and independence building trust and showing measurable impact

37. What could HTA mean for China? Information is power
Public payers
Control and performance manage public and private providers
Best value interventions at high quality standard for right populations and at right price
Private insurers
Tackle overdiagnosis and overtreatment
Mark of quality nationally and internationally
Professionals
Certain of best practice standardised care where appropriate
Protection from legal challenge and accusations of malpractice
Patients and families
Demand and question high cost inappropriate tests and interventions
Reassured they get the best quality and value – increase satisfaction

38. No man is an island…

39. Working together: global networks

40. “HTA is a necessary precondition for achieving Healthy China 2030…and a new approach to the supervision and reimbursement approach of the market economy which has succeeded the planned economy..”. HTA is a means ”…of promoting innovation driven development” and supporting policy makers make informed choices for “…NCD prevention, a major priority for the government”.
Vice Minister Ma, Beijing, December 2016

41. Thank you!