EXECUTIVE BOARD 134th session Provisional agenda item 9.6
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Health intervention and technology assessment in support of universal health coverage Report by the Secretariat 1. The term “health technologies” refers to the application of organized knowledge and skills in the form of devices, medicines, vaccines, procedures and systems developed to solve a health problem and improve quality of lives (resolution WHA60.29). In that resolution, the Health Assembly also expressed concern about the waste of resources resulting from inappropriate investments in health technologies that do not meet priority needs. It urged Member States “to formulate as appropria te national strategies and plans for the establishment of systems for the assessment, planning … of health technologies in collaboration with personnel involved in health technology assessment”. The world health report 20101 on universal health coverage identified wasteful spending on medicines and other technologies as a major cause of inefficiencies in health service delivery, and therefore recommended appropriate guidance on selection and assessment of costs for funding decisions, as provided in 2011 by the Health Assembly in resolution WHA64.9 on sustainable health financing structures and universal coverage.
HEALTH INTERVENTION AND TECHNOLOGY ASSESSMENT 2. A major challenge for health systems and for achieving universal health coverage is the pursuit of equity, quality of care and efficiency. Universal health coverage means that all people are able to access and use the health services they need (including prevention, promotion, treatment, rehabilitation and palliation), that these services are of sufficient quality to be effective, and that the use of these services does not expose the user to financial hardship. The drive to achieve such coverage and ensure provision of affordable services to all populations heightens the need to choose interventions judiciously and manage effectively technologies that are to be adopted within countries’ health systems. Indeed, although they represent an indispensable element of health services, medicines and other health technologies place an ever-growing burden on health care budgets that can affect the sustainability of health systems financing. Where coverage is being expanded, decisions are required on which interventions to choose and which technologies to provide – when, and to whom – in order to facilitate the rational allocation of limited resources. 3. Health technology assessment is the systematic evaluation of properties, effects and/or impacts of health technologies and interventions. It covers both the direct, intended consequences of technologies and interventions and their indirect, unintended consequences. The approach is used to inform policy and decision-making in health care, especially on how best to allocate limited funds to health interventions and technologies. The assessment is conducted by interdisciplinary groups using explicit analytical frameworks, drawing on clinical, epidemiological, health economic and other The world health report 2010. Health systems financing: the path to universal coverage. Geneva: World Health Organization; 2010. 1
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information and methodologies. 1 It may be applied to interventions, such as including a new medicine into a reimbursement scheme, rolling-out broad public health programmes (such as immunization or screening for cancer), priority setting in health care, identifying health interventions that produce the greatest health gain and offer value for money, setting prices for medicines and other technologies based on their cost–effectiveness, and formulating clinical guidelines. 4. The assessment generally includes: identifying evidence on the benefits and costs of health interventions; synthesizing health research findings about the effectiveness of different health interventions; evaluating the economic implications and analysing cost and cost–effectiveness of the intervention; and appraising the social and ethical implications of the diffusion and utilization of health technologies and the potential impact on medical practice and health syst ems’ organization.2 Assessments can take different forms, such as a full-scale health technology assessment report, contextualization of assessment reports produced elsewhere, rapid reviews, and other health technology information services, including analysis of ways in which emerging trends and developments might affect current policy and practice. The findings are then used in the political or clinical decision-making processes for allocating resources. These processes require appropriate legislative and institutional frameworks, as well as the human and financial resources and management capacity to translate the findings of these assessments into effective implementation and monitoring of health interventions.
USE OF HEALTH TECHNOLOGY ASSESSMENT BY WHO MEMBER STATES 5. Because of the scientific complexities, the ever increasing number of interventions and technologies to be evaluated and the resource implications, many countries will not be able to build full capacity for health technology assessment themselves. In spite of these constraints, all countries will need to develop ways to determine priorities for assessing interventions and technologies. Networking among countries and institutions, with information exchange, joint assessments and the adaptation of findings from other countries, will increasingly be the approach taken in order to make the best use of limited resources and to yield robust scientific assessments. 6. Health technology assessment is not a new concept. Most high-income countries created relevant programmes in the 1980s. Since 2000, some middle-income countries have established specialist units, committees or programmes in order to perform evaluations and provide recommendations to decision-makers, in particular on setting broad priorities and directing investment in health interventions, decisions on public procurement, reimbursement and pricing of medicines and other health technologies, for updating national lists of essential or reimbursable medicines, and for developing clinical guidelines. 7. Professional societies and international and regional networks have emerged in order to promote health technology assessment, to support methodological developments, to share information and experiences, and to provide guidance and training. Examples include Health Technology Assessment international, the International Network of Agencies in Health Technology Assessment, and the International Information Network on New and Emerging Health Technologies (EuroScan International Network). Regional networks include the European network of Health Technology
INAHTA Health Technology Assessment (HTA) Glossary [webpage]. International Network of Agencies for Health Technology Assessment, 2006 (http://www.inahta.org/Glossary/, accessed 9 December 2013). HTA Resources. In International Network of Agencies for Health Technology Assessment [webpage] (http://www.inahta.org/HTA/, accessed 9 December 2013). 2
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Assessment, the Health Technology Assessment Network of the Americas, and HTAsiaLink (with members in China, Japan, Malaysia, Republic of Korea, Singapore and Thailand). 8. In 2012, the 28th Pan American Sanitary Conference, recognizing that some of its Member States use the judicial system to ensure access to health technologies without prior evaluation of their effectiveness or comparative assessment, adopted resolution CSP28.R9 to strengthen processes for the assessment and incorporation of health technologies into health systems. Key elements of a comprehensive approach to health technology assessments were identified: use of health technology assessment to inform public policies, establishment of an institutional framework for decision-making based on health technology assessment, strengthening human resource capabilities, promotion of the production of evidence and dissemination of information, rational use of health technologies, and networking to strengthen health technology assessment outcomes, including active participation in the Health Technology Assessment Network of the Americas. 9. During the 10th meeting of Health Technology Assessment international (Seoul, 17–19 June 2013), the Regional Director for the Western Pacific convened a round-table discussion with international experts to discuss the importance of using health technology assessments in achieving universal health coverage and to canvass potential options for extending collaboration between WHO and health technology assessment organizations at global, regional and country levels. Agreeing that all countries needed evidence-informed decision-making when setting priorities for incorporating different health technologies as part of effective, high-quality and affordable health services, participants suggested that WHO needed further to expand the use of health technology assessments to support countries better as they strive for universal health coverage. Specifically, leadership from WHO was needed to facilitate the broader use of such assessments in setting priorities, through advocacy and raising awareness on the utility of health technology assessments for policy-makers, by setting standards and norms, providing guidance to all Member States on best practices in health technology assessment, by coordinating and facilitating collaboration between health technology assessment networks and Member States, and by providing technical support for capacity development in health technology assessment, especially in developing countries. 10. In July 2013, the Government of Thailand hosted a side meeting at the High-Level Segment of the United Nations Economic and Social Council to discuss health technology assessment as a tool for achieving universal health coverage. Participants concluded that health technology assessment is a tool for achieving universal health coverage, and that, although it is not a solution, it can help to inform priority-setting and choice of health interventions. 11. In September 2013, the Regional Committee for South-East Asia adopted resolution SEA/RC66/R4 on health intervention and technology assessment in support of universal health coverage, requesting the Regional Director inter alia to ascertain the status of health intervention and technology assessment in Member States of the Region; to foster knowledge on health technology assessment among national policy-makers and other stakeholders by drawing on lessons from research institutes within and outside the Region; to integrate health intervention and technology assessment concepts and principles into relevant regional strategies including those on universal health coverage and the rational use of medicines and health technology; to provide technical support to Member States in order to strengthen appropriate capacity; and to support the exchange of information and capacity-building in health technology assessment and regulation.
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USE OF HEALTH TECHNOLOGY ASSESSMENT BY THE SECRETARIAT 12. The Secretariat has provided information, guidance and capacity-building in Member States and has been applying health technology assessment to WHO’s guidance and normative work itself. 13. WHO-CHOICE (CHOosing Interventions that are Cost Effective), 1 is a global database on the costs and impact of about 500 different identified health technologies deployed against conditions that carry the heaviest burden of disease. WHO-CHOICE provides support to Member States for priority setting and health technology assessment in the context of policy discussions towards universal health coverage. To help countries adapt the results to their own settings, the Secretariat has assessed the cost–effectiveness of a set of interventions in 14 different sub-regions. The Secretariat also provides guidance on how to balance questions of cost–effectiveness with other important issues for priority setting, such as achieving equity. 14. WHO’s Expert Committee on the Selection and Use of Essential Medicines uses the principles of health technology assessment in its work developing the WHO Model List of Essential Medicines2. The Secretariat applies a transparent process, which includes systematic analyses of the medicines proposed, assessing comparative efficacy, safety and cost of treatment alternatives. The Secretariat supports the adaptation by Member States of the WHO Model List and the development of national lists of essential and reimbursable medicines, formularies, treatment guidelines and protocols. In addition, the Secretariat has stimulated regional collaboration, provided a platform for sharing best practices for the evidence-based selection and rational use of essential health technologies and supported capacity-building for health technology assessment in Member States. 15. The Secretariat is working with Member States on identifying best practices for supply, reimbursement and pricing policies for health technologies, and, through the WHO Guideline on Country Pharmaceutical Pricing Policies (published in 2013), recommends that Member States consider health technology assessment as a tool to support reimbursement decision-making as well as for price setting and negotiation. 16. WHO’s Guidelines Review Committee uses evidence-based medicine principles and health technology assessment approaches to ensure that WHO’s guidelines are vali d, scientifically robust and consider values and preferences and resource use associated with guideline implementation. Regional offices may adapt global guidelines, formularies, and protocols to regional contexts to support the rational use of essential health technologies, and provide expertise to countries to support capacity-building for health technology assessment. 17. The Programme budget 2014–2015 envisages Secretariat activities at global, regional and country levels to support capacity-building for health technology assessment in Member States. These include the following: provision of tools and guidance to support countries in prioritizing health technologies through assessments; and collaboration with Member States and regional networks to support capacity-building for health technology assessment.
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See http://www.who.int/choice/en/, accessed 9 December 2013. See resolution WHA55.14.
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ACTION BY THE EXECUTIVE BOARD 18. The Board is invited to note the report, provide guidance on and support for capacity-building at country level, and advise about the need for submission of a draft resolution to the Health Assembly that calls for the use of health technology assessment approaches in order to inform and steer decision-making in moving towards universal health coverage and to improve access to essential, quality-assured and affordable medical products.
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