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

OHE Consulting Report for PhRMA
5 January 2011
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 party payers will argue it is
in the interests of all members of society as enrolees or taxpayers that funds are used efficiently.
Ultimately, all services will be seen as candidates for HTA. Key aspects of system architecture such
as payment mechanisms and incentives will also come under scrutiny and so candidates for “macro”
HTA to assess their cost-­‐effectiveness in delivering health gain and broader societal objectives for
the health care system.
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7.3.2 The focus of HTA: what is the appraisal concerned with?
The impact of spending levels
Very low levels of spending are associated with high levels of preventable mortality. Where used,
HTA will be concerned primarily with the effectiveness of services to address the most serious causes
of death. International aid funding will act to accelerate the adoption of formalised approaches to
HTA, adapted from those of donor countries, concerned about maximising the beneficial effect of
aid. As levels of spending increase, there is a shift to chronic disease management and the number
of feasible treatment options within any given disease area increases; the focus shifts to the relative
effectiveness of various options. Higher levels of spending coincide with an acceleration of the
‘epidemiological transition’: at the same time, the availability of substitute technologies will
continue to increase. These factors, together, act to raise the issue of cost effectiveness. As we have
noted, the availability of imported expensive technologies may create an early concern around cost
containment, which may motivate an early interest in the use of HTA as an entry hurdle.
The degree of centralisation
Where health care decisions are made by passive purchasers, there are limited incentives to conduct
HTA. Such HTA as is performed will be to meet whatever regulatory barriers exist to bring
products/services to the market, e.g., safety and efficacy. We have noted the potential interest of
doctors in “what works” but in a decentralised health care system it is unclear who has an incentive
to generate or disseminate this evidence. As third-­‐party funding increases, those controlling budgets
will be concerned to establish effectiveness of services to which the ensured population is eligible, as
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