Adaptive Health Technology Assessment to Facilitate Priority Setting in Low- and Middle-Income Countries
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Commentary BMJ Glob Health: first published as 10.1136/bmjgh-2020-004549 on 26 April 2021. Downloaded from Adaptive health technology assessment to facilitate priority setting in low- and middle- income countries 1 1,2 1,2 Cassandra Nemzoff , Francis Ruiz , Kalipso Chalkidou, 1 1,3 1 1,4 Abha Mehndiratta, Lorna Guinness , Francoise Cluzeau, Hiral Shah To cite: Nemzoff C, Ruiz F, INTRODUCTION Summary box Chalkidou K, et al. Adaptive Traditional health technology assessment (HTA) health technology assessment to facilitate priority setting is a policy- based research process, which aims to ► There is a growing appetite for health technology as- in low- and middle- income improve the efficiency and equity of the health- sessment (HTA) in low- and middle- income countries countries. BMJ Global Health care system with the limited financial resources (LMICs) to better inform healthcare priority setting. 1 2021;6:e004549. doi:10.1136/ available in healthcare. In various countries, ► However, LMICs are sometimes constrained by lim- bmjgh-2020-004549 traditional HTA has been ‘institutionalised’— ited capacity, data, time and priority setting gover- through the development of dedicated agen- nance structures to carry out HTA. Handling editor Lei Si cies with accepted norms and rules that guide ► LMICs may benefit from adaptive HTA (aHTA), which explicit priority setting—over years or decades. we define as a broad term for HTA methods and Received 24 November 2020 processes which are fit- for- purpose and focus on Revised 31 March 2021 These agencies use time- consuming, data inten- context-specific practicality constraints. Accepted 1 April 2021 sive and systematic methods and processes ► aHTA can leverage or adapt available international which require health economics expertise and data, economic evaluations, models and/or deci- resources to make recommendations on how to sions from the published literature or established 2 allocate finite resources. HTA agencies to inform policy decisions, while ac- There is a growing appetite for HTA and its counting for uncertainty considerations. eventual institutionalisation in low- and- middle ► aHTA should be pragmatic, though still informed by income countries (LMICs) driven in part by key HTA principles such as transparency, indepen- WHO’s recommendation for it to be a crit- dence, consultation and contestability. http://gh.bmj.com/ ical component to achieving universal health ► More work is needed to design, support and test coverage.3 While there are notable LMIC excep- bespoke aHTA for LMICs to better understand its strengths and limitations. tions of introducing and institutionalising HTA (eg, Thailand, Colombia, Brazil and India), © Author(s) (or their others may be constrained by limited technical employer(s)) 2021. Re- use and administrative capacity, paucity of data, time methods which offer quality, context- specific on September 23, 2021 by guest. Protected copyright. permitted under CC BY. 4 Published by BMJ. and governance structures to carry out HTA. and locally relevant evidence. However, where 1International Decision Support A more pragmatic approach which we define the ‘gold standard’ of HTA is not immediately Initiative, Center for Global in this paper as ‘adaptive HTA’ (aHTA) is one possible, countries may seek to expedite or 5 Development, London, UK which uses various expedited or flexible methods adapt some aspects of the HTA approach. 2 Global Health and Development and processes that are ‘fit for purpose’ and The broad concept of aHTAs is not new; it is Group, Imperial College London could help to tackle some of these challenges used in high- income countries such as the UK, Department of Infectious 6 7 Disease Epidemiology, London, faced by LMICs. Here, we suggest how policy Canada and the European Union. These UK makers, researchers, clinicians and donors can approaches are largely focused on expedited 3London School of Hygiene and collaborate and support the development and processes to respond to time constraints, for Tropical Medicine, London, UK 4 uptake of aHTA for LMICs to enable expedited example, in the case of a new technology or MRC Center for Global evidence- based decision making in these coun- 8 Infectious Disease Analysis, a public health emergency. However, there Imperial College London tries as one part of the journey towards HTA are limited examples from LMICs transfer- Department of Infectious institutionalisation. ring the same types of approaches, as LMICs Disease Epidemiology, London, are more likely to be constrained not only by UK WHAT IS ADAPTIVE HEALTH TECHNOLOGY time, but also by capacity, resources and data. Correspondence to ASSESSMENT? Hence there is a need for HTA processes, Cassandra Nemzoff; Ideally, all health policy decisions should methods and analytics that can be adapted to cnemzoff@ cgdev. org involve the use of HTA processes and suit LMIC HTA constraints. Nemzoff C, et al. BMJ Global Health 2021;6:e004549. doi:10.1136/bmjgh-2020-004549 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2020-004549 on 26 April 2021. Downloaded from Table 1 Methods and trade- offs for adapting traditional health technology assessment (HTA) in low- and middle-income countries (LMICs) Traditional HTA Adaptive HTA in LMICs* Trade- offs Timeline 8–12 months+ 1–6 months ► Level of comprehensiveness. ► Speed. Topic selection Detailed topic selection process with No process or ► Identifies low-hanging fruits. established criteria and fits government Opportunistic process or ► Local relevance. priorities. Minimal criteria. ► Range of topics. Analysis De novo economic evaluation (eg, cost- Price benchmarking or ► Accuracy. effectiveness analysis). Literature reviews or ► Quality. Adapted economic evaluation ► (Un)certainty. or ► Builds capacity. Outsourced economic ► Leverages available data. evaluation. Data sourcing Local studies+primary data collection and Pragmatic/sources known to ► Level of comprehensiveness. systematic literature review/meta analyses as authors. needed. Appraisal Multistakeholder group guided by agreed No appraisal or ► (Sub)optimal decisions. principles appraises evidence and makes Modified appraisal process. ► Level of HTA system improvement policy recommendations. and health system strengthening. Implementation Wide ranging policy changes could include adjustment to health benefits ► (Sub)optimal allocation of resources. packages, essential medicines lists (including appropriate indications), price ► Mobilises HTA institutionalisation. negotiations, reimbursement decisions, clinical guidelines, care pathways and quality standards.* Table 1 demonstrates potential different approaches for each step of a traditional HTA versus an adapted HTA for the LMIC context. Depending on the adaptation(s) selected, a range of potential trade-of fs could be associated with each of these steps which should be considered when using aHTA, as well as the alternative of using no evidence at all. *While aHTA and traditional HTA can inform similar policy decisions, aHTAs cannot be used for all technologies, as discussed below. aHTA, adaptive HTA. We seek to define aHTA as a blanket approach for HTA Expedited process methods and processes which are fit- for- purpose and The Filipino HTA guidelines set out a rapid review focused on context-specific practicality considerations. process for public health emergencies.11 Methodologically, aHTA may leverage or adapt avail- able international data, economic evaluations, models Adaptation of international data sets http://gh.bmj.com/ and/or decisions from the published literature or estab- The World Bank’s Health Interventions Prioritisation lished HTA agencies to expedite policy decisions while Tool and Disease Control Priorities have consolidated adequately accounting for concerns of transferability and international evidence on burden of disease, cost and uncertainty.9 The aHTA process should be pragmatic, cost- effectiveness, which have been adapted to inform though still informed by key HTA principles such as trans- benefits package design in Afghanistan, Armenia, Cot 12 13 parency, independence, consultation and contestability. d’Ivoire, Eswatini, Pakistan and Zimbabwe. on September 23, 2021 by guest. Protected copyright. There is no ‘one- size- fits- all’ approach to aHTA as no Literature reviews and synthesis two health systems are alike, but generally components of traditional HTA can be modified or adapted pragmat- In Vietnam and Romania, aHTAs gathered and synthe- ically to suit LMICs’ needs (table 1). Hence, aHTA may sised international evidence on safety, clinical efficacy/ benefit LMICs which either have a nascent HTA agency effectiveness, cost- effectiveness and clinical guidelines for high- cost drugs. Potential savings from rational use of or not one at all, and do not receive HTA submissions 14 15 from pharmaceutical companies. In circumstances where medicines were then calculated. an LMIC does have an active HTA agency with adequate Price benchmarking capacity to appraise evidence, it may be feasible to receive Also in Romania and Serbia ‘indirect’ cost- effectiveness pharmaceutical dossiers as part of the HTA process. analyses compared a set of high- cost drugs to a gross domestic product- adjusted list price in benchmark coun- tries (eg, UK, USA, Australia) to ascertain the maximum ADAPTIVE HEALTH TECHNOLOGY ASSESSMENT METHODS value at which each medicine might be cost- effective There are numerous aHTA methods which vary by scope, locally.15 16 approach, complexity