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

OHE Consulting Report for PhRMA
5 January 2011
7 Our conceptual model for understanding HTA in emerging
markets
7.1 Developing the conceptual model
In this section, our aim is to develop a simple conceptual model to describe, and propose hypotheses
about, the relationship between the use of HTA and the characteristics of health care systems.
Relying on material from previous sections of this report, we begin by proposing a simple taxonomy
of health care system and of HTA characteristics respectively. We then propose a conceptual model
in which the evolution of HTA is related to two key characteristics of the health care system.
Health technology appraisal (HTA) is defined, for our purposes, as the application of any given set of
principles, methods and processes to evaluate one or more of specific health care technologies,
combinations of health technologies to manage patient pathways (clinical practice guidelines) or
other elements of system architecture (“technologies applied to the health system” as described by
Garrido et al, 2010). We have used the terms “micro” and “macro” technologies to distinguish
between these. Micro technologies are those that relate to specific treatments or combinations of
interventions. Macro technologies relate to the way specific treatments or services are delivered
within the infrastructure or architecture of the health care system. The latter includes, in its
broadest sense, the state of technology that underpins the way health care is organised and
managed at the system wide level. HTA in both cases entails an evaluation process which occurs
within the context of a health care system.
HTA can be considered as a response to the concerns of that system, and to be shaped by the health
care system’s characteristics. For example, the outputs of HTA – knowledge about effectiveness and
cost effectiveness of health care – have ‘public good’ characteristics. This has implications for its use
in a competing health care insurer environment. It is not obvious that any single insurer has an
incentive to invest in evidence generation that will benefit all insurers. The impact of HTA therefore
depends on a wider set of health system factors that define the underlying ‘architecture’ of the
health care system. That ‘architecture’ might be thought of as comprising of an existing bundle of
healthcare services, health technologies, medical practices and traditional ways of organising and
delivering these services. The regulatory framework, reimbursement systems for providers and
system of fees/subsidies to patients together define the incentives and behaviours of the actors in
the system. As we have stated that architecture might itself be considered to comprise set of related
‘macro-­‐technologies’, i.e., an (imperfect) state of knowledge about the way health care can be
delivered and organised.
The effects of HTA outputs, in terms of behavioural change by commissioners and providers of care,
and on technical and allocative efficiency, are therefore also determined by the wider set of factors
we have characterised as the ‘architecture’ of the health care system. For example, the adoption of
new technologies recommended by HTA may depend not only on the dissemination of HTA findings
but on incentives to commissioners and providers to invest in new technologies (and to disinvest in
‘old’ technologies).
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