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

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OHE Consulting Report for PhRMA 5 January 2011 5.8 Applying Health Care System Frameworks None of these frameworks has a dynamic or evolutionary element to them. They are intended to assess or categorise health care systems at a particular point in time. Even in this context they do not explicitly address some key questions in categorising health care systems, notably how they are organised. However, our thinking is that the Murray and Frenk (2000) framework illustrated in Figure 2 is the most helpful one for understanding health care systems. In particular the subdivision of financing to address questions of the nature of financing, of risk pooling and of purchasing, enable key organisational and incentive issues to be identified and differentiated between health care systems. We regard this framework as complementary to the WHO (2007) framework illustrated in Figure 4. In effect the WHO framework makes an important subdivision of resource generation into: Health Workforce; Medical Products, Vaccines and Technologies; and Information. Our understanding of the evolution of health care systems is that: The sophistication of “Financing” evolves slowly over time, with moves from predominantly out-‐of-‐pocket funding to elements of insurance through to more-‐or-‐less universal coverage varying from country to country. Typically employer based schemes for urban workers begin before schemes covering rural workers who are usually self-‐employed. Rural schemes therefore often begin as voluntary schemes for people to opt-‐in to for a relatively modest lump sum fee. Intended to be self financing some public subsidy is usually required. Communist and former communist countries such as China which collectivised agriculture are an exception to this – in effect the collective farm became the work place enterprise providing insurance. Access to health care for the very poor is usually provided initially through direct subsidy of health care providers – hospitals and clinics. Over time increasing numbers of this population group may be covered by a separate insurance scheme. Government and other public sector workers are usually insured through a separate scheme. The extent to which the various third party payer insurance schemes are combined over time varies from country to country. Some countries move to a single payer system, others keep multiple insurers and, in some cases, these insurers compete for enrolees. The element of Financing that arguably evolves the most slowly is Purchasing. Insurance cover typically develops around fee-‐for-‐service with the role of the third party payer being to passively pay the bills of the provider rather than actively decide what it is going to cover, who should provide it, and how they are to be paid. Direct public funding of services typically begins with block budget allocations to clinics and hospitals. In both cases – insurance and direct public funding -‐ more sophisticated mechanisms for incentivising and rewarding providers tend to develop over time, notably capitation payments in primary care and DRG-‐type payments to hospitals. Where providers have limited resources from fee income or budget allocations then they may begin providing services that are outside of the third party cover in order to generate additional revenues with out-‐of-‐pocket charges to patients. This can give rise to a misalignment of incentives, which can give providers perverse incentives to provide inappropriate or inefficient but profitable services. We see these two elements of Financing as being key to an understanding of the potential role of HTA in the health care system. We return to this in our conceptual model in Section 6. 30
OHE Consulting Report for PhRMA 5 January 2011 We should also note the potential importance of the evolution of the quality level and skill mix of the health workforce and of the amount and quality of information over time. The ability to use HTA effectively in relation to clinical practice guidelines will depend on this, as well as on the point in the development of the health care system at which the disease burden moves to predominantly chronic conditions. At this point, the potential for successful management of chronic disease becomes an important way to manage health care expenditures efficiently and achieve better population health. 31
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