Capacity building in evidence-informed
decision making: role of the Global
Health and Development team in
supporting Chinese policy makers
November 2016
(Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)
Francis Ruiz – Global Health and Development, Institute for Global Health
innovation, Imperial College London
This presentation by iDSI is licensed under a Creative Commons Attribution-NonCommercial-
NoDerivatives 4.0 International License
Overview
• Objectives of the International Decision Support Initiative
• Introducing the Global Health and Development Group
• Priority setting in health
• Economic evaluation and Health Technology Assessment (HTA)
• Improving priority setting in China: work to date including supporting
their new national “HTA network”
2
The international Decision
Support Initiative (iDSI)
Who we are…
Better priorities for better health
Our mission is to guide decision makers to effective and efficient healthcare
resource allocation strategies for improving people’s health.
Why we are unique
• We respond to policymaker demand, and focus our efforts on what client countries and funders genuinely need
• We provide practical support to country decision makers, and work alongside local teams to jointly develop sustainable systems for setting priorities fairly, and on the best available evidence
• We are an international, multi-disciplinary network. We bring together leading priority-setting institutions, delivery partners (including academics), policymakers, and funders to solve problems collaboratively
• We produce knowledge products: cutting-edge, freely accessible insights on best practices in priority-setting, informed by policymaker priorities, to generate more health for the money
Health system strengthening for UHC
Better Health
Effective partnerships
Strengthened
country institutions
Better decisions
Practical support and
knowledge products
through global and local
collaboration
Structures, rules, norms
Evidence-informed, transparent, independent, consultative
decision-making processes
More efficient and
equitable health spending,
with trade-offs made explicit
The iDSI Theory of Change: Our pathway to impact
*(dependent on
effectiveness of
implementation)
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Itad & iDSI (2016) IDSI MONITORING, EVALUATION &
LEARNING FRAMEWORK
GLOBAL HEALTH AND DEVELOPMENT
GROUP, IMPERIAL COLLEGE, UK
Global Health and Development Group
Mission: To contribute to better health
around the world through the more
effective and equitable use of resources,
by providing advice on the use of
evidence and social values in making
clinical and policy decisions.
• Provide advice and
consultancy to decision-
makers on priority-
setting for universal
health coverage (UHC)
• Strengthen systems
and institutional
capacity
• Draw on UK and global
expertise to provide
tailored support
A small sample of our work…
Value for money
• India: Institutionalising national health technology assessment (HTA) body for medical devices
• South Africa: Embedding HTA into the National Health Insurance scheme
Guidelines and quality standards
• Vietnam: Combating AMR through quality indicators in acute respiratory infections
• India: Adapting international guidelines for high-burden conditions
Pay-for-performance
• China: Integrating clinical pathways for NCDs into rural health insurance reform
• Thailand: Developing quality outcomes framework (QOF) for primary care
Priority-setting in health (1)
• Resources are scarce and choices have to be made
• ‘Markets’ can be used to ‘automatically’ identify what should be produced, how it is produced, and who gets what is produced
• Can be very efficient, but healthcare is not usually provided under ‘ordinary’ market conditions because of well recognised ‘failures’
• Many countries (especially as they get richer and seek UHC) adopt risk pooling mechanisms so costs are shared among many people and there is an emphasis on accessing care based on ‘need’ rather than ‘ability to pay’
• Social insurance, e.g. France, Germany, Mexico
• Taxation, e.g. UK NHS
• ‘Mimicking the market’ – what should a healthcare system aim to maximise? QALYs…?
Priority-setting in the health (2)
“The task of determining the priority to be assigned to a
service, a service development or an individual patient at a
given point in time. Prioritisation is needed because claims
(whether needs or demands) on healthcare resources
are greater than the resources available” UK NHS, 2009
• Decision makers are always making choices and
weighing the trade-offs between the various options,
whether implicitly or explicitly
• Tools for supporting explicit priority-setting, e.g.
EE/health technology assessment linked to decision
making institutional frameworks (e.g. NICE…)
“... the comparative analysis of alternative courses
of action in terms of both their costs and
consequences.”Drummond, Stoddart & Torrance, 1987
A tool for priority setting in health:
economic evaluation
New treatment
Current treatmentCosts
value of extra
resources used (loss
to other patients)
Consequences
value of
health gain for
this patient
group
Analysis should be conducted separately for each subgroup of
patients.
But…economic evaluation only one
aspect of the ‘answer’
• Politics and political economy mean that the ’right’
decisions don’t always get made or implemented, and
suggest it is rational for policymakers to make decisions
against the broader interest of population
• Interest groups and capture – pharma industry, professional
medical associations, patient groups…
• Voting models – e.g. appealing to the ‘median voter’
• Decentralisation – federal/state government; contracting out to
NGOs
• Underline the importance of having a robust, principled
process that considers such constraints
Source: Hauck, K., & Smith, P. (2015) The politics of priority-setting in
health: A political economy perspective
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Health Technology Assessment (HTA)
and economic evaluation
HTA is a multidisciplinary field of policy analysis. It studies the medical,
social, ethical, and economic implications of development, diffusion,
and use of health technology.
Any intervention that may be used to promote health, to prevent,
diagnose or treat disease or for rehabilitation or long-term care. This
includes the pharmaceuticals, devices, procedures and organizational
systems used in health care.
Source: INAHTA/glossary http://www.inahta.net/
Using HTA to inform priority setting
• HTA can form an integral part of a process for considering scientific evidence, economic evidence and social values, to directly inform coverage and policy decisions relating to healthcare interventions in the broadest sense, including:• Drugs, devices, diagnostic tests, surgical interventions and services,
both preventative and curative/palliative
• And service delivery models, programmatic reforms, health and public policy interventions (e.g. sugar taxes).
• Includes economic evaluation (EE)/ cost-effectiveness analysis (CEA); not just clinical effectiveness
• Drawing comparisons: Compared to the status quo, what do we gain out of the new intervention, and at what extra cost?
• Not a merely technical exercise: The process and social values are equally important
• NOTE: HTA is one component to support overall quality improvement…
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World Health Assembly resolution on Health Intervention and
Technology Assessment in Support of UHC
“Every pound can only be spent
once. If we spend it unwisely...
then we risk harming other people
whose care will be adversely
affected…
It is vital that priority setting is an
evidence-informed, procedurally
fair process that defines what will
be covered through universal
health coverage.”Prof David Haslam, Chair of NICE, addressing
the 25th World Health Assembly, Geneva, 2014
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The HTA Process
Defining
Decision
Space /
Topic
Selection
AnalysisDecision
Making ImplementationAppraisal
Source: PRICELESS
Financial and non-financial levers for quality improvement
Quality standards
Clinical guidelines
and pathways
HTA
A stepwise process from evidence to policy
Health technology assessment (HTA) to compare clinical and cost-effectiveness of different interventions
Clinical guidelines (STGs) and pathways distilled from HTA and other evidence
Quality standards and indicators from evidence-based guidelines
Health benefits plans (HBPs), pay-for-performance, other levers (regulation, accreditation, education…)
Evidence
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iDSI ‘HTA hubs’
• A means to make iDSI goals, especially in-country support, more responsive, scaleable and sustainable
• Involves the identification of in-country focal points around which hubs (=“institutionalised” frameworks) will be developed• Catalyse new in-country and regional partnerships
• Hubs aim to create national and – importantly – regional support for active priority setting involving advocacy and knowledge sharing (but initial emphasis on building ‘national’ capacity)
• Hub activities include the delivery of practical support pilots, for undertaking, using and understanding priority setting processes from the point of view of multiple stakeholders
• Thailand’s HITAP is the focal point for the already established “SE Asia hub”: supporting HTA development in Indonesia, Vietnam etc, and a key partner in regional networks (HTAsiaLink)
• Linked to the iDSI ‘theory of change’
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Some challenges to hub development
• Existing capacity within coordinating organisations, and
ability to attract and retain skilled individuals
• Fragmented systems (health service silos; academic
competition and/or weak engagement with policy makers)
• Limited government / policy maker interest… or active
‘resistance’
• Capacity of decision makers to interpret and use outputs
from HTA hubs
• Inadequate local information to support HTA / difficulty in
accessing potentially useful data
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Global Health and Development Group
work in China
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People's Republic of China (1)
• Pop: 1.4 billion people; Area: 9.6 million km²
• Healthcare system highly decentralised – strong
provincial level administration
• About 95% health insurance coverage (various schemes)
but…
• Relatively high out-of-pocket payments
• OOP fell from 60% (2002) to 34.9% (2011)
• Evidence of over- and under-treatment / inappropriate
care
• E.g. over-prescribing of antibiotics; also use of technologies
of no proven benefit / not ‘cost-effective’
People's Republic of China (2)• HTA/EE capacity in China
• University based institutions
• An key (“focal”) institute under the leadership of the National Family Planning Commission (NHFPC), the former MoH
• China National Development Research Center (established in 1991)
• In 2008 the CNHDRC created the Center for Health Policy Evaluation and Technology Assessment (CHPETA)
• CNHDRC/CHPETA key organisation – formal links with the decision making processes
• CHPETA undertaken HTA/economic assessments in a number of areas including influenza prevention and control and da Vinci surgical systems
• Has had policy impact and raised the profile of HTA
HTA/EE capacity in ChinaAssessment
emphasisSupporting institution Assessment institution
Established
in
Number
of staff
Health technology
assessment (HTA)
China National Health
Development Research Center
Centre for Health Policy Evaluation
and Technology Assessment2008 12
Fudan UniversityHealth Technology Assessment Key
Lab1994 3-5
Institute of Health Service and
Medical Information, Shanghai
Health Technology Assessment center,
Shanghai2011 3-4
Hangzhou normal UniversityHealth Technology Assessment
center2013 3-4
Pharmacoeconomic
assessment
China National Health
Development Research Center
Pharmacoeconomic Assessment
Research Room1996 4-6
Fudan UniversityPharmacoeconomic Research and
Evaluation Center2002 7
Peking UniversityPharmacoeconomic Research Center
of Guanghua School of Management2003 10
Evidence-based
medicine (EBM)
Huaxi Hospital of Sichuan
University
Chinese Cochrane Center (12 sub-
centers)1997 10
Peking UniversityEvidence-based Medicine Center of
Peking University2004 -
National HTA networks:
2014-HTA technical committee, branch of China health economic society(CNHDRC)
2013-China HTA network (Fudan University)
Source: CNHDRC
Our work in the
People’s Republic of China
Joint pilots: clinical pathways and
payment reform
Phase I (2009-2012)
‘Simple’ pathways for selected surgeries
Phase II (2012- )
Stroke + COPD pathways in four counties
• Projects strengthen rural health system,
including promoting effective use of medicines
and medical devices, and treatment in community
• Payment reforms applied in over 1,000 counties
• The China Health Development Research
Center (CNHDRC) increasingly active as a
source of priority-setting expertise
CNHDRC and GHD: continued collaboration
Progress in
institutionalising explicit
and evidence-informed
priority-setting (including
health technology
assessment) which
considers economic
evidence and local values
Roadmap for institutionalizing evidence-
informed priority-setting methods as the
basis for spending decisions and
CNHDRC HTA Hub
Joint UK Research Council and FCO
applications incl recent to Engineering
and Physical Sciences Research Council
Sustained support to public hospital
reforms and strengthening community
care facilities (building on existing clinical
pathway and payment reform projects)
Regional and South-South support to
priority-setting in other countries in the
region
iDSI
Imperial
CNHDRC
NHFPC
Areas of collaboration Expected outcome
Senior delegation visit to Imperial College
October 2016• GHD/Imperial hosted a delegation of 25 high level officials
from the CNHDRC and the NHFPC
• Learn about the UK NHS, HTA, primary / integrated care….
• Aside from Imperial colleagues, study tour included contributions
from the MHRA, NHS Digital, the University of Manchester, the
Department of Health, London School of Economics, among others
• The main aim of the visit was the signing a Memorandum
of Understanding (MoU) between CNHDRC) and the
Institute for Global Health Innovation (IGHI)
• This agreement is the first collaboration between Imperial
College and CNHDRC
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MOU signing
• Deputy Director of IGHI, Professor Guang-Zhong Yang said “We are very grateful to iDSI and the Global Health Development Group for providing this key opportunity to work together and are delighted that the collaborations that were set up while the Global Health Development group was still at NICE will now be continued from within IGHI. This in turn will also add new collaboration between the other departments within IGHI and Imperial as a whole and we are very much look forward to working together on this highly important piece of work.”
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4th People-to-People (P2P) Dialogue
• On 5 Dec, Kalipso Chalkidou, Director of GHD,
represented Imperial group at the 4th P2P dialogue in
Beijing
• Event convened by Vice Minister Cui Li from the National
Health and Family Planning Commission (NHFPC) of
China, and the UK’s Secretary of State for Health Jeremy
Hunt
• Healthy ageing, improving quality of care and reducing
variation, ensuring timely adoption of good value
innovation, harvesting ‘Big Data’ and enhancing health and
social care integration were some of the common themes
highlighted as priorities by the two ministers
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4th People-to-People (P2P) Dialogue
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Launch of a national HTA network – CNHDRC
as ‘focal’ point
• National HTA research network launched December 2016: 33 provincial health authorities
Universities
“Research centers” (e.g. HDRC centres at Shanghai, Qingdao, Jiangsu & Liaoning)
Professional associations and societies
Hospital institutions
• Developed an early “working mechanism” identifying ‘demanders’, ‘evidence suppliers’ and an ‘evidence appraisal’ step
• International links (networks e.g. HTAsiaLink; organisations, e.g. AQUA*; and universities, e.g. IGHI, Imperial)
• Aim to develop an HTA toolkit of standardized methods (under the leadership of the NHFPC)
*Institute for Applied Quality Improvement and Research in Health Care, Germany
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Event was opened by Vice
Minister Ma who commented
that “HTA is a necessary
precondition for achieving
Healthy China 2030…and a new
approach to the supervision and
reimbursement approach of the
market economy which has
succeeded the planned
economy in China”. He also
highlighted the value of HTA as
a means of promoting
“innovation driven development”
and supporting policy makers
make informed choices for NCD
prevention, a major priority for
the government.
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