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

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OHE Consulting Report for PhRMA 5 January 2011 We noted from the literature reviews conducted that many health systems typologies exist (see Section 2). While the purpose of these taxonomies is to usually describe health systems, developing these classification systems is unavoidably normative: which categories are selected relies on researcher value judgements, which will be influenced by prior beliefs about what is important, and by what question is being asked and so forth. Taxonomies are ‘stylised models’ of the real world and there is a tension between keeping it simple (to enable comparisons and contrasts to be drawn) and the ability of such models to provide an adequate account of the reality of any given health care system. The health system taxonomy we propose is highly stylised: it focuses on just two criteria we hypothesise are most likely directly to relate to the evolution of approaches to HTA: the level of spending, and the degree of centralisation in decision making. The HTA taxonomy also comprises two criteria: which technologies are appraised; and what that appraisal process is concerned with. 7.2 The health care system typology Our health care system typology is depicted in Figure 8 below. Figure 8: Health care system typology: two key attributes/variables and levels LEVEL OF SPEND What quantity of resources are available? Low spend per capita Medium spend per capita High spend per capita DEGREE OF CENTRALISATION Who makes decisions about what health care is funded? Out of pocket spend dominates Emergence of insurance /collective funding; decisions localised Active third party purchasing Level of spend is readily understandable. It inevitably shapes the nature and priorities of the health care system. By the “degree of centralisation” we are combining two related but distinct features of the financing arrangements for an evolving health care system: 1. The extent to which there is third party coverage and so an interest in the use of both “micro” and “macro” technologies that goes beyond the provider-‐patient relationship that dominates an out-‐of-‐pocket spend environment. 42
OHE Consulting Report for PhRMA 5 January 2011 2. The extent to which there is active rather than passive purchasing by the third party insurer. Related to this is the degree of national level regulation as to what is included in the insurance package offered to enrolees. Our HTA taxonomy is depicted in Figure 9 below. The two drivers are: 1. The focus or content of HTA in terms of the degree of complexity of the question that is asked, ranging from “is it safe?” to “is this good value given society’s preferences and resources?” 2. The types of technologies covered which we refer to as the breadth of coverage of HTA. We apply this taxonomy to the “macro” as well as “micro” use of HTA. Changes in health system architecture such as an organisational change are included in the “breadth of HTA” within “all technologies/services” appraised, and the focus of any appraisal of such an organisational change would typically go beyond a consideration of cost and potential health gain (cost-‐effectiveness) to include broader issues, for example relating to the responsiveness of the system and its ability to deliver access. Figure 9: HTA typology: three key HTA system attributes/variables and levels FOCUS OF HTA What is appraisal concerned with? BREADTH OF HTA Which health services are appraised? Efficacy/safety Relative effectiveness Cost-‐effectiveness (C-‐E) C-‐E and broader issues Basic preventative services and minimum care packages New technologies All technologies/services 7.3 Considering these typologies together Using Figures 8 and 9, we can seek to describe (characterise) any given health care system and its HTA processes. We can also develop hypotheses about how the characteristics of a health care system (and the way that system evolves) might be reflected in its HTA processes (and how those processes evolve). Furthermore, we can generate an overall framework for predicting how the ultimate effects of HTA (for example, in terms of behavioural change by health care commissioners and providers; and impacts on technical and allocative efficiency) will be influenced by the underlying health system ‘architecture’. Putting the two typologies together, we develop the conceptual model depicted in Figure 10 below and seek to explain the interactions between health care system and HTA characteristics. 43
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