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

OHE Consulting Report for PhRMA
5 January 2011
The development of collective funding arrangements in itself has the potential to drive up
expectations about access to health care. This was particularly evident in Brazil: the emphasis there
on health care as a ‘constitutional right’ creates demands that outstrip available resources. Although
the share of Government spend (12% of tax revenue at the state level) is not too far behind
developed economies, this still represents a relatively low absolute spend per person (US$837
compared to $4028 in OECD countries in 2008 (OHE calculations based on OECD Health database for
2010).
Lesson 1: Incomes are growing in emerging markets, but resulting increases in funding for health
care are likely to be out-­‐paced by rising demands and expectations. In such situations, HTA may have
a role in assisting the health care system to reconcile rapidly expanding demand with more slowly
expanding resources. HTA can provide a potential means of handling this in a more explicit and
transparent way, and in promoting public debate about priorities.
However, addressing ‘rationing’ in this way requires a willingness to engage in active debate
about ways of addressing demand and supply.
Such a debate will inevitably refer to the appropriate balance between national
procurement and individual clinician decision making.
Degree of centralisation
As we have noted, in all three countries the degree of centralisation is relatively high or increasing:
Brazil has public and private systems but the private system is centrally regulated. There is
regional and local control of the public system, but there is a constitutional right to health
care, and the three major pharmaceutical programmes are national entitlements;
China is increasing central control through an expansion of its three public schemes.
National oversight is shared with Provincial administration;
Taiwan introduced a single payer system in 1995, and operates a national benefit package.
In all three countries, however, there appears be little “active third party purchasing” as we define
this in our model in which the payer moves beyond passively administering fee-­‐for-­‐service systems
(occasionally cutting or capping fees to contain costs) to deciding actively what it is going to cover,
who is going to provide it, and how they are going to be paid. In Brazil, there is some use of DRGs,
and in China, an interest in cost-­‐per-­‐case tariffs is emerging. However, there is some way to go
before priorities are set and services purchased to meet those priorities.
Another impact of “fee-­‐for-­‐service” as used in China and Taiwan is an incentive to provide additional
services, especially those on which additional income can be earned – either because fees exceed
costs or because additional revenues can be earned on services not covered by the fee scale. In
China, artificially low prices are set for ‘basic services’: this creates strong incentives for overuse of
new technologies, where providers are free to set higher prices. And in Taiwan, the difference
between drug acquisition cost and reimbursement payments provides strong incentives to over-­‐
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