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

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OHE Consulting Report for PhRMA 5 January 2011 6.4 A dynamic perspective to HTA development Battista and Hodge (2009) conclude from analysing a number of country’s experiences with implementation and operation of HTA that HTA goes through three different phases of development: namely, the ‘emergence’, ‘consolidation’ and ‘expansion’ of HTA. Under each phase, one needs to answer the following questions: the rationale for HTA (Why?); the definition of the scope and breadth of HTA (What [HTA is about]?), the methods and organizational models of HTA (How [HTA is conducted]?); and the knowledge transmission strategies (Then what [happens next]?). This pathway of HTA development fits very much with the characterisation of HTA system presented in Table 1 and Figure 6. In this case, ‘what’ will cover issues around HTA topic selection and analytical design; ‘how’ will cover issues around ‘HTA governance and organisation’ and ‘evidence requirements and assessment methods’; and ‘then what’ will cover issues relating to ‘HTA dissemination and implementation’. Figure 7: The ‘natural’ history of HTA development: Battista and Hodge (2009) Figure 7 above summarizes the ‘natural’ history of HTA. This framework suggests that one can initially adopt a narrow definition of ‘health technology’ and over time as HTA systems mature in terms of scientific capability (or generally speaking having adequate managerial and operational capacity), apply the methods and concepts of HTA to all other ‘health technologies’ as broadly defined by Garrido, et al. (2010). However, Battista and Hodge (2009) note that this ‘natural history’ will vary from country to country as determined by the timings and determinants of transitions from one phase to the other; which in turn will be influenced by contextual factors such as culture and how the tensions between the academic side of HTA and decision-‐makers is managed. In a commentary on the paper by Battista and Hodges (2009), Zavalla (2009) notes that the level of economic development has a major influence on the pathway for HTA: countries will only develop 38
OHE Consulting Report for PhRMA 5 January 2011 interests in HTA only when basic needs have been met and the country-‐specific health system can deliver a ‘reasonable level of healthcare’. Zavalla (2009) notes that commitment; dedication and persistence are essential materials for continued sustenance of an HTA program. 6.5 Applying HTA Frameworks The HTA literature is helpful in understanding how HTA can evolve and how it can be categorised. Our assessment is as follows: The Garrido, et al (2010) identification of different types of “health technologies” is important. It is echoed by the EUnetHTA (2008) report which includes in its definition of a health technology “organizational systems used in health care”. HTA is usually thought of as applying only to technologies applied within the health care system – a drug, a device, a surgical procedure or other medical intervention. We include in this type the use of HTA to generate clinical practice guidelines to manage the patient through a care pathway where a mix of technologies will be applied in sequence depending on the condition and characteristics of the patient, although HTA of guidelines could well involve addressing organizational issues. The application of evidence-‐based analysis to the other type of “health technology”, i.e. “organizational systems used in health care”, is a separate but crucial use of HTA that is often overlooked. Here HTA is being applied to elements of the architecture or framework of the health care system. This could include: e) The architecture of service delivery. For example, is it more efficient to provide services in community facilities or in hospital? f) Which types of payment mechanisms from purchasers to providers are likely to be most efficient? g) How much autonomy should publicly owned enterprises have? Should more encouragement be given to private providers to supply services to meet the needs of patients within a publicly financed insurance scheme? h) The mix of the clinical and related workforce. When can services be provided by nurses or other professions allied to medicine rather than a qualified doctor? We term the first use of HTA as a focus on “micro-‐technologies”, such as new drugs, that are seen as incremental or “marginal” to the system. The second use for HTA is reviewing “macro-‐technologies” comprising elements of the architecture or framework such as how the system is organised (number and types of hospitals and physicians). We note the suggestion by Garrido, et al (2010) that countries embarking on HTA (including low-‐ and middle-‐income countries) should combine agencies looking at micro and macro HTA, quality development, performance measurement and health services development. This is because this work should involve a common core set of skills for evidence synthesis to underpin evidence-‐informed decision-‐making. Again, countries do not currently tend to do this. Most HTA bodies do not even address “macro” HTA issues, let alone broader design and 39
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