As middle income countries (MIC) transition from donor support and increasingly use domestic funds to finance health programmes that have previously received substantial external aid (HIV, TB, malaria, immunization, antenatal care, family planning), it is imperative that they build and use Health Technology Assessment (HTA) capacities so that they can prioritise investment in good value technologies and services.
As MICs reduce their dependence on donors and pay for health services themselves, HTA can help them to choose among emerging—and sometimes expensive—HIV, TB, and malaria technologies and new vaccines (think of viral load machines, second and third line drugs). At the same time, these countries need to apply an HTA lens to costly chronic disease treatments and surgical and other interventions, all of which are increasingly in direct competition for scarce ministry of health and social insurance healthcare dollars.
Where this marriage of transition and HTA has happened (or is happening), as in Thailand, the Philippines and LAC countries including Colombia and Costa Rica, positive benefits have accrued or are likely to in the future (e.g., the case of Ghana, where the political will for adopting HTA as a prioritisation tool is strong). Where HTA is missing, national funding decisions such as Kenya’s recent announcement to cover TB diagnostics from its own national budget may fail to lead to optimal outcomes. This is especially so if the price to be paid for health technologies previously covered by aid monies does not reflect realisable health benefits in the local context, especially as domestic budgets are much more constrained and demands on them are many and growing. See here and here for examples of the unrealised promise of GeneXpert in real-world settings.
The rise of HTA in lower-middle-income countries, and how it can make a difference in transition environments
The World Health Organization (WHO) defines HTA as the “systematic evaluation of properties, effects, and/or impacts of health technology*...to evaluate the social, economic, organizational and ethical issues of a health intervention or health technology. The main purpose of conducting an assessment is to inform policy decision making.” And it is this latter characteristic—the goal of informing policy decisions—that makes HTA central in attaining and sustaining Universal Health Care (see WHO’s 2014 WHA Resolution and more recently, the 2019 UNGA Declaration on UHC, both of which call for countries to institutionalise the use of HTA in support of evidence-informed decision making).
HTA has long been practiced in a number of high-income countries, such as the UK (NICE) and Australia (PBAC and MSAC), and is being increasing developed and used in MICs (see here and here). Perhaps the most advanced system is Thailand’s, which has been operating for over a decade now through HITAP. Thailand has used HTA extensively, including for evaluating and negotiating the price of vaccines and to inform the development of the country’s Universal Coverage benefits package.
And while HTA is critical in setting priorities among health investments funded by countries themselves, it can also help improve decisions that occur during transition, where donors such as PEPFAR, the Global Fund, and Gavi progressively reduce their external financial support for important disease control and primary health care activities. When HTA is applied, it assists countries in:
negotiating with development partners financially sustainable co-financing (domestic funding) arrangements across vaccines and commodities for TB, HIV, and malaria. For example, HTA, already endorsed as a policy intervention in support of UHC by the Kenyan government, could inform future decisions such as the recent takeover of GeneXpert costs by the government. This is similar to the case in Thailand, where HTA has ensured the country sustained its health gains in the three diseases after almost wholly transitioning away from Global Fund support.
prioritising investments across the entire disease spectrum by adjusting and updating health benefits packages under budding national health insurance schemes. This is especially important when countries are faced with the growing burden of non-communicable diseases (NCDs) and their associated expenses, and with the challenges of integrating “vertical” disease programme commitments into the rest of the health system.
This rationale has driven the setting up of an elaborate HTA infrastructure in Chinafollowing the merger of its insurance schemes—with a view to address the escalating cost of cancer drugs in particular. And though China is already weaned off donor support, cancer spending is looming in other much less affluent countries (e.g., Senegal recently announced it would cover all chemo costs for certain types of cancer) that still receive large amounts of donor support for their infectious disease priorities. Inefficient NCD coverage decisions could undermine sustained domestic support for these infectious diseases during transition, without improving cancer outcomes.
Another example of NCD priorities absorbing a large chunk of public spending is dialysis. In some countries, payers are committing 2-3 percent of a MIC’s (or up to 8-9 percent based on anecdotal data from Thailand, Indonesia and the Philippines) total health expenditures to kidney dialysis. This is twice or more the share that high-income countries spend, diverting domestic budgets away from essential preventative and primary care and infectious disease control, oftentimes without delivering the expected health outcomes for renal patients.
negotiating and obtaining better prices for new and existing NCDs and infectious disease commodities and services, as in the case of Ghana, where the country’s commitment to UHC and HTA (signalled through the launch of an HTA committee) has empowered policymakers to improve the efficiency of procuring antihypertensive medications. This is especially critical since cardiovascular disease and diabetes are the top two drivers of national health insurance spending.
A paradox and how to resolve it
As some of the world’s less well prepared MIC nations are lining up to transition from donor health aid, they are gradually losing membership in product- and disease-specific buyers’ clubs sponsored by Gavi and the Global Fund and are seeing prices rise. Meanwhile some of the world’s richest countries are joining forces in applying HTA to achieve better prices for new expensive technologies (e.g., see here and here for emerging partnerships) with broad support by the European Union.
It is encouraging that some global health programmes (e.g., Gavi) are now focusing on ways to help transitioning countries to continue to obtain low prices for key commodities like vaccines through special agreements with manufacturers. However, much more needs to be done to assist the newly transitioning countries to receive affordable prices using their own resources. This is ideally done by helping to build a legacy of purchasing capabilities and of assessing value locally and negotiating with domestic and multinational suppliers as HICs regularly do. Such local purchasing arrangements through large, single payer systems (e.g., using the UK’s single payer as one such example) can also set the foundation for regional collaborative models.
To obtain more favourable prices from global manufacturers, transitioning countries should seize the opportunity to develop joint purchasing/buyers’ collaboratives for NCDs, which are traditionally funded privately (and inequitably and inefficiently) via out of pocket and, increasingly, national pooled funds. Buyers’ collaboratives could also be developed for HIV, TB, and malaria commodities, and for new (and existing) vaccines transitioning away from aid support. This would follow the example of what many EU countries are currently doing (e.g., see here and here for buyer’s clubs being formed between some of Europe’s richest nations).
During the first years following transition, and while MICs are endeavouring to establish their own buyers’ clubs, it may make sense for them to pool demand and use their own funds to pay for drugs, diagnostics, vaccines, and family planning supplies through global nonprofit intermediaries such as UNICEF's Supply Division and the IDA Foundation. The latter already serve as buyers’ clubs but tend to rely heavily on donor financing and have no explicit processes for quantifying and assessing value for money and affordability at the country level. As soon as it is feasible, MICs should strive to form their own self-managed procurement collectives using their own funds and carrying out their own assessments of value, perhaps starting with NCD products, where aid has never been a major factor and where purchasing tends to be fragmented and financed by individual patients and their families, often resulting in costly and unfavourable deals.
How donors can do more to extend an HTA “legacy” to transitioning countries
In some MICs, there are capacity constraints to setting up HTA in terms of institutional strengths, technical expertise, and access to data on prices and comparative effectiveness. In light of these constraints, those spearheading transition among the donors and the transitioning governments’ leadership should endorse the principles of HTA and economic evaluation of alternative investment choices—as one of us has argued in relation to the Global Fund and WHO—as a means of building MICs’ capacity and leaving a lasting legacy in transitioning countries. Institutions such as UNITAID, charged with bringing scalable innovations to those who need them most, are also well placed to use HTA for prioritising technologies to support and eventually pass on to the Global Fund and other major funders.
Local capacity-building efforts could piggyback on existing networks and coalitions in order to take advantage of economies of scale and scope. The Africa Leadership initiative or the African CDC—the former with a focus on financing and domestic resource mobilisation and the latter with its initial targets in diagnostics and infectious disease commodities—may be suitable platforms for building HTA capacities that member nations can use to inform their own national decisions.
Development partners must simultaneously commit to incorporating value-based assessments from the perspective of the end client—countries’ finance ministries—in market shaping agreements (e.g., MedAccess and other product specific initiatives). In an era of transition from aid, with NCDs on the rise and national governments reluctant to prioritise healthcare, “shaping the market” without considering local affordability concerns sets up countries to face large contingent liabilities that they may not be able or willing to adopt.
By making the creation and deployment of HTA institutions and tools one of their top priorities for the coming decade, MICs will be better able to navigate and weather the challenges of transitioning billions of dollars of disease programmes from outside to domestic financing and management, while at the same time laying the foundations for smarter choices in adopting new technologies and services to improve the overall health of their populations and creating viable markets for driving global R&D investment toward MICs’ own priorities.
Robert Hecht is the president of Pharos Global Health Advisors, and a professor of Clinical Epidemiology at the Yale School of Public Health.
* WHO defines a technology as “the application of organized knowledge and skills in the form of medicines, medical devices, vaccines, procedures and systems developed to solve a health problem and improve quality of life.”