Building Institutions for Priority Setting in Health: Six Lessons from 10 Years of iDSI

With thanks to the authors of the following paper, “Ten Years of Experience from the International Decision Support Initiative (iDSI),” from which this blog is based. This paper is part of a special issue of Health Systems & Reform, 'Building Institutions for Priority Setting in Health.' Read the articles online here. 

Strong, evidence-informed priority-setting (EIPS) institutions are a fundamental part of good governance of health systems. They help channel limited resources to the highest value for money services by defining what health services are provided, and to whom. By doing so, they make a major contribution to achieving universal health coverage—even when resources are tight—as is characteristic of most countries, post-COVID.

Over the last 10 years, the international Decision Support Initiative (iDSI) has supported countries across Africa and Asia to develop national priority-setting processes. This month, in partnership with 15 iDSI authors, we have published a review of the successes, challenges, and lessons learned during these 10 years. This blog summarizes the six key messages of the paper from the perspective of CGD, the current secretariat of iDSI. We hope these six lessons inform success for the next 10 years of iDSI and serve as a useful guide for policy makers and their partners.

Figure 1: Six lessons from 10 years of iDSI

Lesson 1: Priority-setting institutions produce a high return on investment

Eight countries have developed stronger, domestically-financed national priority-setting processes in partnership with iDSI: India, China, Ghana, Philippines, South Africa, Indonesia, Rwanda, and Kenya. The India priority-setting agency “HTAIn” is perhaps the most successful example. It has an established organization, staffing and processes, effective evidence appraisal committees, 18 regional resource centers that produce analysis, a range of standardized national process and methods guides, a national costing database, and over 36 studies and policy briefs have been produced to inform decision makers. Financing for HTAIn by the Indian government has produced a return on investment of 9:1 through improvements in health system efficiency.

Lesson 2: Developing priority-setting institutions requires sustained political will

Priority-setting involves redistributing resources, which always produces winners and losers. In health care this is a life and death decision, and so the stakes are high. A wide range of influential interest groups such as doctors, patients, and industry will often pressure policy makers for a favored decision. A key challenge that iDSI faced, therefore, was navigating the political aspects of building EIPS processes. Thus a situational analysis is a critical first step, with careful consideration of stakeholder interests. The situational analysis must then be used to develop an intentional strategy for reform, led by a policy champion who is able to identify and take advantage of specific policy windows, and who is backed by sustained, high-level (usually ministerial) political support. Because the reform required usually extends beyond a single minister’s appointment—or beyond a government’s term in office—success is more likely if there is long-term structural pressure on policy makers, for which EIPS reform is seen as a solution.

Lesson 3: Optimize limited capacity with topic selection, adaptive health technology assessment, and regional collaboration

iDSI supported countries to develop the capacity of their researchers, networks, and institutions, including through co-developing national standards, processes, and guidelines in eight countries; and through co-producing 47 analyses to inform decision-making. As capacity increased, however, countries found that they needed more evidence and analysis than they could produce. iDSI identified three solutions to this problem. First, capacity must be focused on the most important topics—India found this could increase the ROI from 5:1 to 40:1. Second, countries, such as Indonesia and Ghana, learnt that they can use adaptive health technology assessment (HTA) to rapidly utilize analysis and decisions from other countries to save time. Finally, countries began exploring regional collaborations and multi-country studies to achieve economies of scale. It will be exciting to see if Africa CDC’s Health Economics and Financing Programme can stimulate and coordinate this on the African continent.

Lesson 4: Institutionalize implementation as well as priority-setting

Too often in the field of priority-setting, great research is carried out, but no one reads it; and when it is read and a decision is made, it is often not implemented. India found the ROI of HTAIn could be increased nearly eight-fold from 9:1 to 71:1, if full implementation occurred. Planning for implementation must be factored in from the very beginning as part of the institutionalization process. This includes designing a priority-setting system that is appropriate for the local health financing context; that has a clear and enforceable mandate; that is inclusive of powerful stakeholders, including states in federal systems; and has systematic processes that link the decisions to three downstream implementing functions: which services to provide, which commodities to buy, and what clinical care to recommend in guidelines (Figure 2).

Figure 2: Priority-setting has three main routes to impact

Lesson 5: Mobilize existing national capacity and regional networks to increase long-term sustainability

There is existing capacity within all countries to produce and interpret analysis to inform priority-setting. Policy makers and technical assistance providers can mobilize this as part of a EIPS reform effort. Capacity building largely carried out by national experts can empower trainers, increase domestic networks and mentorship, and help to ensure that capacity building is locally appropriate and sustained over time. In contrast, an over-reliance on “fly-in and fly-out” international experts risks undermining this; they should only be used to supplement national skillsets—and where possible—they should be drawn from neighboring countries to promote regional networks. Figure 2 shows how a layered approach to technical assistance can be conceived. A network of HTA practitioners and policy makers in Asia, known asHTAsiaLink, has shown these regional networks are highly effective at promoting regional EIPS through peer support, and HTAsiaLink now self-sufficient without ongoing iDSI support. Africa CDC and the AfroHTA network have now built the foundations for similar success in Africa.

Figure 3: Layered model of EIPS technical assistance 

Lesson 6: Global health initiatives need a clear mandate to back national priority-setting institutions

iDSI had substantial impact on the global priority-setting field, supporting the critical 2014 World Health Assembly resolution 67.23 on HTA. It also contributed to WHO and World Bank Joint Learning Network global guidance, supported the Global Fund and Gavi to use economic evidence in decision-making, co-produced over 200 peer-reviewed papers with national experts, and developed a wide range of practical tools for national policy makers and their advisors. We also found, however, that donor-funded health services and commodities are too often managed through parallel priority-setting systems, which prevents integration within the principle national systems and therefore prevents consideration of overall health system efficiency. In line with the Lusaka Agenda of the Future of Global Health Initiatives, we learnt that there needs to be a renewed mandate from the boards of global health initiatives to integrate their processes with national priority-setting and national financing systems.

What next for iDSI?

Over the last 10 years, iDSI has had substantial success at the global, regional, and national level—and we at CGD look forward to continuing to be part of the network. Building on the lessons of the last 10 years, iDSI has evolved its own way of working. It has shifted from a model dominated by a single large grant and secretariat in London, to a model where partners have independent, albeit smaller, funding; partners in low- and middle-income countries have direct grants from funders; and Africa CDC leads regional work, with the ultimate long-term goal of moving the iDSI secretariat to Africa.

CGD remains committed to value for money and to iDSI—and calls for donors, global health initiatives, and domestic treasuries to step up and invest in national priority-setting institutions. By doing so, we can make faster progress towards universal health coverage, build empowering national health systems, and collectively manage aid transitions.