Getting More Health for the Money: Two New iDSI Guides for Designing Successful Priority Setting Reforms

Deciding what health services to provide to the public involves, by definition, life and death decisions. Developing institutions to set healthcare priorities is inevitably controversial, political, and complex. Health Technology Assessment (HTA) is an increasingly popular approach in low- and middle-income countries (LMICs) to taking these decisions, and can be contextualized to the local health system, social values, and political systems. Each country must develop their own approach suited to their context. But given this complexity, how do policymakers and health partners know where to start?

Today we release two new guides that can support countries through the first two critical steps in priority setting reforms: carrying out a situational analysis and then developing a national HTA framework. These are based on the last 10 years’ experience of the international Decision Support Initiative (iDSI) network.

In this blog, we introduce the two guides and share recent experience of applying them in Ethiopia and Uganda. We conclude that using these tools can ensure that priority-setting reforms are inclusive of all stakeholders and appropriately embedded in a country’s health system context, and that important high-level decisions on the role of HTA in the health system are taken early, setting the country up for success.

Guide 1: Conducting a situational analysis

An HTA situational analysis is a vital first step of any priority setting reform. It provides champions of reforms a clear understanding of how priority setting is currently undertaken, who the key stakeholders are, what the policy and financing context is, what the current policy windows are for reform, and how any priority-setting decisions are currently implemented.

Figure 1. Steps for completing a situational analysis

In our iDSI Guide and Reporting Template for HTA Situational Analyses we recommend a five-step approach to situational analysis (see Figure 1), led by a steering group of policymakers and topic experts who understand current policy priorities and have access to key health system data and reports. In our experience in Ethiopia and Uganda, we found a good situational analysis has three characteristics:

1. An effective and collaborative process ensures access to good information, but also is in itself a vital outcome of situational analysis. By aligning stakeholders around a common understanding of the overall priority setting system and its strengths and weaknesses, the process of developing a situational analysis can help build a coalition which is united in seeking reform. For example in Ethiopia our situational analysis report was led by Ethiopia Public Health Institute, but involved the Ministry of Health, Ministry of Finance and national insurer from the design stage, resulting in the government agreeing with the proposal to develop a national HTA Framework.

2. It is vitally important to understand the policy and health financing context of HTA reforms. For example, what mandate does the priority setting process currently have? In Uganda we found no legal requirement to use HTA evidence in decision making, which thus became a clear goal for future reforms. Similarly, understanding the country’s health financing architecture ensures the future HTA system meets the needs of the full range of decision makers. Thus, in Ethiopia, a key finding of our analysis was the fragmentation of funding channels, which meant it was difficult to implement priority setting decisions. Addressing this fragmentation has now become a core objective of their HTA Framework.

3. A situational analysis is most useful when it is expressed through a clear, coherent report that provides short, medium- and long-term recommendations alongside actionable next steps that stakeholders can rally around.

Linking situation analysis to monitoring and evaluation through the iProSE scale

Situational analysis is also an opportunity to take a “baseline reading” of the current level of HTA institutionalization in a country from which policymakers can track progress and improvement. This is a great way to sustain political commitment and identify gaps and areas for improvement in real time.

One tool countries can use is the iProSE scale – the iDSI Progression Scale for implementing Evidence Informed Priority Setting (EIPS). iProSE is a self-assessment scale that helps countries map and score the extent to which they use evidence to inform priority-setting and resource allocation. Our guidance outlines how iProSE can easily be integrated into the situational analysis. Countries may elect to undertake future assessments every one-to-two years to monitor their progress and evaluate the extent to which HTA institutionalisation is informing decisions.  

Guide 2: Developing a national HTA Framework

A powerful second step in reforming priority setting reforms is to develop a national HTA framework. Our iDSI Guide and Template for Developing a National HTA Framework explains how HTA Frameworks represents a national agreement on five key elements: the mandate, scope, governance, organisational roles and responsibilities, and how HTA will be implemented and financed (Figure 2). Critically, it is not a detailed guide to how HTA will technically be carried out; instead, it records the major decisions required to establish the role of the HTA in the health system. Because the Framework will recommend high-level and systemwide changes, it must be sponsored at the highest levels of government (e.g., by a minister or permanent secretary). The Framework can then be followed up by a national action plan or roadmap. Working groups may be needed to develop more detailed guidance on specific areas to operationalise the Framework. In January 2024, Ethiopia finalised its Framework (developed using the iDSI template) and submitted it to the Minister.

Figure 2. The five key components of an HTA Framework

Conclusion

Situational analysis and national HTA frameworks are critical steps on the path to improving national priority setting systems. We believe that by using these two tools from iDSI, policymakers can bring stakeholders with them on their priority-setting reform journey and design a clear national HTA framework that will be the foundation for spending health system resources wisely, and achieving their universal health coverage goals.