What next after GDP-based cost-effectiveness thresholds?

Public payers around the world are increasingly using cost-effectiveness thresholds (CETs) to assess the value-for-money of an intervention and make coverage decisions. However, there is still much confusion about the meaning and uses of the CET, how it should be calculated, and what constitutes an adequate evidence base for its formulation. One widely referenced and used threshold in the last decade has been the 1-3 GDP per capita, which is often attributed to the Commission on Macroeconomics and  WHO guidelines on Choosing Interventions that are Cost Effective (WHO-CHOICE). For many reasons, however, this threshold has been widely criticised; which has led experts across the world, including the WHO, to discourage its use. This has left a vacuum for policy-makers and technical staff at a time when countries are wanting to move towards Universal Health Coverage . This article seeks to address this gap by offering five practical options for decision-makers in low- and middle-income countries that can be used instead of the 1-3 GDP rule, to combine existing evidence with fair decision-rules or develop locally relevant CETs. It builds on existing literature as well as an engagement with a group of experts and decision-makers working in low, middle and high income countries.

How can we make better health decisions a Best Buy for all?: Commentary based on discussions at iDSI roundtable on 2 nd May 2019 London, UK.

The World Health Organization (WHO) resolution calling on Member States to work towards achieving universal health coverage (UHC) has increased the need for prioritizing health spending. Such need will soon accelerate as low- and middle-income countries transition from external aid. Countries will have to make difficult decisions on how best to integrate and finance previously donor-funded technologies and health services into their UHC packages in ways that are equitable, and operationally and financially sustainable. The International Decision Support Initiative (iDSI) is a global network of health, policy and economic expertise which supports countries in making better decisions about how best and how much to spend public money on healthcare. iDSI core partners include Center For Global Development, China National Health Development Research Center, Clinton Health Access Initiative, Health Intervention and Technology Assessment Program, Thailand / National Health Foundation, Imperial College London, Kenya Medical Research Institute, and the Norwegian Institute of Public Health. In May 2019, iDSI convened a roundtable entitled Why strengthening health systems to make better decisions is a Best Buy. The event brought together members of iDSI, development partners and other organizations working in the areas of evidence-informed priority-setting, resource allocation and purchasing. The roundtable participants identified key challenges and activities that could be undertaken by the broader health technology assessment (HTA) community to further country-led capacity building, as well to foster deeper collaboration between the community itself. HTA is a tool which can assist governments and development partners with evaluating alternative investment options in a defensible and accountable fashion. The definition and scope of HTA, and what it can achieve and support, can be presented more clearly and cohesively to stakeholders. Organizations engaging in HTA must develop deeper collaboration, and integrate existing collaborations, to ensure progress in developing HTA institutionalization globally is well organized and sustainable.

Disease Control Priorities Third Edition: Time to Put a Theory of Change Into Practice Comment on "Disease Control Priorities Third Edition Is Published: A Theory of Change Is Needed for Translating Evidence to Health Policy".

The Disease Control Priorities program (DCP) has pioneered the use of economic evidence in health. The theory of change (ToC) put forward by Norheim is a further welcome and necessary step towards translating DCP evidence into better priority setting in low- and middle-income countries (LMICs). We also agree that institutionalising evidence for informed priority-setting processes is crucial. Unfortunately, there have been missed opportunities for the DCP program to challenge ill-judged global norms about opportunity costs and too little respect has been shown for the wider set of local circumstances that may enable, or disable, the productive application of the DCP evidence base. We suggest that the best way forward for the global health community is a new platform that integrates the many existing development initiatives and that is driven by countries' asks.

Antibiotic consumption and antimicrobial resistance in Poland; findings and implications.

Background: The problem of inappropriate use of antibiotics and the resulting growth in antimicrobial resistance (AMR) has implications for Poland and the world. The objective of this paper was to compare and contrast antibiotic resistance and antibiotic utilisation in Poland in recent years versus other European countries, including agreed quality indicators, alongside current AMR patterns and ongoing policies and initiatives in Poland to influence and improve antibiotic prescribing. Methods: A quantitative ten-year analysis (2007-2016) of the use of antibiotics based on European Centre for Disease Prevention and Control (ECDC) data combined with a literature review on AMR rates and antimicrobial stewardship initiatives. Results: The system of monitoring AMR and appropriate strategies to address AMR rates remain underdeveloped in Poland. The role of microbiological diagnostics and efforts to prevent infections is currently underestimated by physicians. Overall, Poland had one of the highest rates of total consumption of antibiotics in the analysed European countries. Total consumption of antibacterials for systemic use and relative consumption of beta-lactamase sensitive penicillins were characterized by small but statistically significant average annual increases between 2007 and 2016 (from 22.2 DIDs to 23.9 DIDs and from 0.8 to 1.3%, respectively). Conclusions: The integrated activities around appropriate antibiotic prescribing in the pre- and post-graduate training of physicians and dentists seem to be particularly important, as well as changes in policies on prescribing antibiotics within ambulatory care. AMR and appropriate prescribing of antibiotics should be the focus of health policy actions in Poland.

Strengthening health technology assessment systems in the global south: a comparative analysis of the HTA journeys of China, India and South Africa.

BACKGROUND: Resource allocation in health is universally challenging, but especially so in resource-constrained contexts in the Global South. Pursuing a strategy of evidence-based decision-making and using tools such as Health Technology Assessment (HTA), can help address issues relating to both affordability and equity when allocating resources. Three BRICS and Global South countries, China, India and South Africa have committed to strengthening HTA capacity and developing their domestic HTA systems, with the goal of getting evidence translated into policy. Through assessing and comparing the HTA journey of each country it may be possible to identify common problems and shareable insights. OBJECTIVES: This collaborative paper aimed to share knowledge on strengthening HTA systems to enable enhanced evidence-based decision-making in the Global South by: Identifying common barriers and enablers in three BRICS countries in the Global South; and Exploring how South-South collaboration can strengthen HTA capacity and utilisation for better healthcare decision-making. METHODS: A descriptive and explorative comparative analysis was conducted comprising a Within-Case analysis to produce a narrative of the HTA journey in each country and an Across-Case analysis to explore both knowledge that could be shared and any potential knowledge gaps. RESULTS: Analyses revealed that China, India and South Africa share many barriers to strengthening and developing HTA systems such as: (1) Minimal HTA expertise; (2) Weak health data infrastructure; (3) Rising healthcare costs; (4) Fragmented healthcare systems; and (5) Significant growth in non-communicable diseases. Stakeholder engagement and institutionalisation of HTA were identified as two conducive factors for strengthening HTA systems. CONCLUSION: China, India and South Africa have all committed to establishing robust HTA systems to inform evidence-based priority setting and have experienced similar challenges. Engagement among countries of the Global South can provide a supportive platform to share knowledge that is more applicable and pragmatic.

Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition.

The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected.

We need a NICE for global development spending.

With aid budgets shrinking in richer countries and more money for healthcare becoming available from domestic sources in poorer ones, the rhetoric of value for money or improved efficiency of aid spending is increasing. Taking healthcare as one example, we discuss the need for and potential benefits of (and obstacles to) the establishment of a national institute for aid effectiveness. In the case of the UK, such an institute would help improve development spending decisions made by DFID, the country's aid agency, as well as by the various multilaterals, such as the Global Fund, through which British aid monies is channelled. It could and should also help countries becoming increasingly independent from aid build their own capacity to make sure their own resources go further in terms of health outcomes and more equitable distribution. Such an undertaking will not be easy given deep suspicion amongst development experts towards economists and arguments for improving efficiency. We argue that it is exactly because needs matter that those who make spending decisions must consider the needs not being met when a priority requires that finite resources are diverted elsewhere. These chosen unmet needs are the true costs; they are lost health. They must be considered, and should be minimised and must therefore be measured. Such exposition of the trade-offs of competing investment options can help inform an array of old and newer development tools, from strategic purchasing and pricing negotiations for healthcare products to performance based contracts and innovative financing tools for programmatic interventions.

Health Technology Assessment: Global Advocacy and Local Realities Comment on "Priority Setting for Universal Health Coverage: We Need Evidence-Informed Deliberative Processes, Not Just More Evidence on Cost-Effectiveness".

Cost-effectiveness analysis (CEA) can help countries attain and sustain universal health coverage (UHC), as long as it is context-specific and considered within deliberative processes at the country level. Institutionalising robust deliberative processes requires significant time and resources, however, and countries often begin by demanding evidence (including local CEA evidence as well as evidence about local values), whilst striving to strengthen the governance structures and technical capacities with which to generate, consider and act on such evidence. In low- and middle-income countries (LMICs), such capacities could be developed initially around a small technical unit in the health ministry or health insurer. The role of networks, development partners, and global norm setting organisations is crucial in supporting the necessary capacities.

How to Get Cost-Effectiveness Analysis Right? The Case of Vaccine Economics in Latin America.

BACKGROUND: In middle-income countries, vaccines against pneumococcal disease, rotavirus, and human papilloma virus are in general more costly, not necessarily cost saving, and less consistently cost-effective than earlier generation vaccines against measles, diphtheria, tetanus, and pertussis. Budget impact is also substantial; public spending on vaccines in countries adopting new vaccines is, on average, double the amount of countries that have not adopted. Policymakers must weigh the costs and benefits of the adoption decision carefully, given the low coverage of other kinds of cost-effective health and nonhealth interventions in these same settings and relatively flat overall public spending on health as a share of gross domestic product (GDP) over time. OBJECTIVE: This paper considers lessons learned from recent vaccine cost-effectiveness analyses and subsequent adoption decisions in Latin America a, largely under the auspices of the Pro Vac Initiative. RESULTS: The paper illustrates how small methodological choices and seemingly minor technical limitations of cost-effectiveness models can have major implications for the studies' conclusions, potentially influencing countries' subsequent vaccine adoption decisions. METHODS: We evaluate the ProVac models and technical outputs against the standards and framework set out by the International Decision Support Initiative Reference Case for economic evaluation and consider the practical effects of deviations from those standards. CONCLUSIONS: Lessons learned are discussed, including issues of appropriate comparators, GDP-based thresholds, and use of average versus incremental cost-effectiveness ratios as a convention are assessed. The article ends with recommendations for the future.

Next generation maternal health: external shocks and health-system innovations.

In this Series we document the substantial progress in the reduction of maternal mortality and discuss the current state of science in reducing maternal mortality. However, maternal health is also powerfully influenced by the structures and resources of societies, communities, and health systems. We discuss the shocks from outside of the field of maternal health that will influence maternal survival including economic growth in low-income and middle-income countries, urbanisation, and health crises due to disease outbreaks, extreme weather, and conflict. Policy and technological innovations, such as universal health coverage, behavioural economics, mobile health, and the data revolution, are changing health systems and ushering in new approaches to affect the health of mothers. Research and policy will need to reflect the changing maternal health landscape.

Priority-setting for achieving universal health coverage.

Governments in low- and middle-income countries are legitimizing the implementation of universal health coverage (UHC), following a United Nation's resolution on UHC in 2012 and its reinforcement in the sustainable development goals set in 2015. UHC will differ in each country depending on country contexts and needs, as well as demand and supply in health care. Therefore, fundamental issues such as objectives, users and cost-effectiveness of UHC have been raised by policy-makers and stakeholders. While priority-setting is done on a daily basis by health authorities - implicitly or explicitly - it has not been made clear how priority-setting for UHC should be conducted. We provide justification for explicit health priority-setting and guidance to countries on how to set priorities for UHC.

Les gouvernements des pays à revenu faible et intermédiaire sont en train de légitimer la mise en place de la couverture sanitaire universelle (CSU), suite à une résolution des Nations Unies de 2012 sur la CSU et à son entérinement dans les objectifs de développement durable fixés en 2015. La CSU variera selon les pays, en fonction de leur contexte et de leurs besoins, ainsi qu'en fonction de la demande et de l'offre de soins. Des questions fondamentales ont ainsi été soulevées par les responsables politiques et les parties prenantes, portant notamment sur les objectifs, les utilisateurs et le rapport coût-efficacité de la CSU. Si les autorités sanitaires déterminent quotidiennement des priorités, de façon implicite ou explicite, la marche à suivre pour définir les priorités en matière de CSU n'a pas été clairement établie. Nous justifions ici la nécessité de définir explicitement les priorités dans le domaine de la santé tout en donnant des orientations aux pays pour définir les priorités en matière de CSU.

Los gobiernos de países con ingresos bajos y medios están legitimando la implementación de una cobertura sanitaria universal (CSU) tras un acuerdo de las Naciones Unidas acerca de la cobertura sanitaria universal en 2012 y su consolidación en los objetivos de desarrollo sostenible establecidos en 2015. Cada país tendrá una cobertura sanitaria universal distinta, según el contexto y las necesidades de cada uno, así como la oferta y la demanda de atención sanitaria. Por tanto, los responsables políticos y partes interesadas han abordado los asuntos fundamentales como los objetivos, los usuarios y la rentabilidad de la cobertura sanitaria universal. A pesar de que las autoridades sanitarias han establecido prioridades diarias (de forma implícita o explícita), no se ha aclarado cómo se debería gestionar el establecimiento de prioridades para la cobertura sanitaria universal. Se ofrece una justificación para el establecimiento de prioridades sanitarias explícitas y orientación a los países en la definición de prioridades para la cobertura sanitaria universal.

Defining a Health Benefits Package: What Are the Necessary Processes?

Abstract-There is immense interest worldwide in the notion of universal health coverage (UHC). A major policy focus in moving toward UHC has been on the key policy question: what services should be made available and under what conditions? In this article we are concerned with how a feasible set of UHC services can be explicitly defined to create what is commonly known as a "health benefits package" (HBP), a set of services that can be feasibly financed and provided under the actual circumstances in which a given country finds itself. We explain why an explicit statement of the HBP is important and then describe a framework that includes ten core elements that are indispensable if a coherent and sustainable process for setting the HBP is to be established.