The Evolution of HTA in Emerging Markets Health-Care ... - TREE

OHE Consulting Report for PhRMA
5 January 2011
a means of managing demand. As the balance of decision making shifts from local to more
centralised bodies and there is also a shift to more active purchasing, there will be increased
willingness to use of HTA knowledge to inform decisions about (limiting) access to health care.
Where decisions are made centrally, there is no competitive advantage in offering services that are
effective, but poor value for money: then, cost-­‐effectiveness may become the dominant
consideration. A concern only with cost-­‐effectiveness is unlikely to be acceptable to patients,
doctors and the insured. A broader perspective including ethical issues will need to be taken into
account. As centralisation increases, there is also a greater interest in “macro” HTA issues around
the design and architecture of the health care system so improve efficiency and effectiveness.
The Breadth of HTA: Which Health Technologies are Appraised?
Level of Spend
At low levels of resources, HTA will tend to focus on identifying which basic services and
interventions are priorities. System architecture issues should also evolve with spending. Initially,
there should be a concern about the configuration of health care delivery. Where will preventative
services be delivered? International agencies and funding bodies may well provide assistance in
transferring HTA knowledge on these issues from elsewhere or in enabling local HTA to be
conducted. As spending increases, immediate pressure on resources may ease, but increases in
spending will inevitably be out-­‐matched by increases in expectations and demands. In particular,
tackling chronic disease is likely to become more of a problem. There will be potential for HTA to
look at clinical practice guidelines for disease management. HTA processes will often also focus on
new potential sources of demand, i.e., new health care technologies, because these are seen as a
driver of cost. At high levels of spend, concerns about the inability for supply to match demand will
lead to pressure to extend the use of HTA into extant services, as well as new technologies, and the
identification of candidates for disinvestment. Questions of how the health care system is best
organized will arise at all levels of spending, although the nature of the issues will change, in part
reflecting the relationship between financing and economic growth, impacting on the nature of the
disease burden and the demography of the population, but reflecting the cumulative experience and
history of financing and delivery arrangements in a particular country.
The degree of centralisation
Where health care is predominantly paid for out of pocket, which health care services and products
are funded is a product of the decisions made by individual patients and their doctors. There is little
incentive for collective decision making about health care technologies, other than in relation to
questions as to whether services such as vaccination are provided by the public sector. Whilst, in
principle, there would be a role for HTA in a self-­‐pay market in providing evidence to doctors and
patients about “what works,” opportunities for dissemination may be limited and it is not clear who
would fund such an exercise. As third party funding develops, it is in the insured group’s interest to
ensure that claims on those funds are justified. Decisions become localised at the level of the health
care plan. However, it may be some time before insurers begin to actively manage providers.
Initially, they may simply pay bills on a “fee-­‐for-­‐service” basis. Over time, however, more active
purchasing is likely to evolve. The initial focus may be on those services which are highest cost.
Where health care funding is predominantly collective (for example, in a fully tax-­‐payer funded
system) decisions about health care may become increasingly centralised. Governments and third
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