Assessing progression of health technology assessment implementation in Asia: a balanced scorecard for cross comparison of selected countries in Asia.

OBJECTIVE: To provide an update on the use of health technology assessment (HTA) in Asia and lessons for countries seeking to advance HTA. METHODS: Build upon the research by Chootipongchaivat and the World Health Organization identifying eighteen "factors conducive to the development of HTA in Asia." These factors were used to create a balanced scorecard to assess the progress of HTA, measuring progress against each factor in China, India, Indonesia, Malaysia, Philippines, South Korea, Taiwan, Thailand, and Vietnam. A scoring system was used wherein: 1, No progress; 2, milestone at early stages, ad hoc HTA use; 3, progress on milestone but limited impact; 4, significant progress but limited remit; and 5, significant progress on milestone, routine HTA informs decisions. Total scores indicated progress of HTA while milestone scores provided contextual insights within countries. Literature reviews and expert interviews were used to complete scorecards. RESULTS: South Korea and Thailand scored highest with seventy-three and seventy-one points, respectively, while Vietnam scored lowest at 28.5. Advanced HTA programs have independent HTA agencies with a broad remit, explicit process and methods, network of researchers, and routine use of HTA. Taiwan and Malaysia fall in a middle tier, with established HTA programs with limited remit. The final tier with China, India, Indonesia, Philippines, and Vietnam, emerging HTA processes. CONCLUSIONS: Universal Health Coverage goals have catalyzed expansion of HTA. Political will, technical expertise, and sustained financing remain challenges for sustainable HTA programs. Legislation supporting HTA is helpful but political will is key. Recommendations for regional collaboration are provided.

Exploring facilitators and barriers to introducing health technology assessment: a systematic review.

OBJECTIVE: This study aims to identify and codify the facilitators and barriers to help implementing partners institutionalize health technology assessment (HTA) successfully and navigate complex systems for health-related policy making. METHODS: We searched for peer-reviewed and gray literature articles examining HTA programs globally using six databases. Keywords used as a guide for capturing articles included "health technology assessment," "barrier," and "facilitator" and their synonyms. Search results were scrutinized for duplicates and screened through a review of titles and abstracts. A full-text review was conducted exploring articles' coverage of twenty-seven evaluation criteria across four primary areas of interest: barriers/facilitators, motivations, guidelines, and institutional frameworks. RESULTS: A total of 18,599 records were identified for duplication check, title, and abstract review. A total of 1,594 articles underwent full-text review, leading to a final synthesis of 262 studies. We found that ninety-seven articles discussed barriers/facilitators, with fifty-three of those discussing local capacity and unavailable human resources. Out of the sixty-six articles discussing motivations, forty-two cited the interest in supporting the decision-making process for, and promoting, appropriate resource allocation. Of the sixty-one articles that discussed guidelines and institutional framework, twenty-one articles described HTA as an independent national unit, and sixteen described their HTA unit as a unit within the Ministry of Health (MOH). CONCLUSIONS: This systematic review unpacks the dynamic and relevant contexts for understanding the HTA institutionalization process to help policy makers and practitioners achieve tangible progress in confronting the most critical issues facing priority setting and HTA institutionalization.

Calculating the Costs of Implementing Integrated Packages of Community Health Services: Methods, Experiences, and Results From 6 sub-Saharan African Countries.

BACKGROUND: Ensuring access to a package of integrated primary health care services is essential for achieving universal health coverage. In many countries, community health programs are necessary for primary health care service provision, but they are generally underfunded, and countries often lack the necessary evidence on costs and resource requirements. We conducted prospective cost analyses of community health programs in 6 countries in sub-Saharan Africa using the Community Health Planning and Costing Tool. METHODS: The Community Health Planning and Costing Tool is a spreadsheet-based tool designed to cost key programmatic elements of community health services packages, including training, equipment, incentives, supervision, and management. In each country, stakeholders defined a package of community health services and corresponding standard treatment guidelines to estimate normative costs, which were applied to program scale-up targets. The data were entered into the tool, and cost models were prepared for different geographical and service utilization scenarios. The results were reviewed and validated with the governments, implementing partners, and expert panels. Additional scale-up scenarios were modeled, taking into account probable constraints to increasing community health service provision and potential funding limitations. RESULTS: The services and scope of community health service packages varied by country, depending on contextual factors and determined health priorities. The package costs also varied significantly depending on the size and contents of the service package, the service delivery approach, the remuneration of the community health workers, and the cost of medicines and supplies. CONCLUSIONS: Community health programs and service packages are different in every country and change over time as they evolve. They should be routinely costed as an integral part of the planning and budgeting process and to ensure that sufficient resources are allocated for their effective and efficient implementation.

An assessment of primary health care costs and resource requirements in Kaduna and Kano, Nigeria.

Introduction: The availability of quality primary health care (PHC) services in Nigeria is limited. The PHC system faces significant challenges and the improvement and expansion of PHC services is constrained by low government spending on health, especially on PHC. Out-of-pocket (OOP) expenditures dominate health spending in Nigeria and the reliance on OOP payments leads to financial burdens on the poorest and most vulnerable populations. To address these challenges, the Nigerian government has implemented several legislative and policy reforms, including the National Health Insurance Authority (NHIA) Act enacted in 2022 to make health insurance mandatory for all Nigerian citizens and residents. Our study aimed to determine the costs of providing PHC services at public health facilities in Kaduna and Kano, Nigeria. We compared the actual PHC service delivery costs to the normative costs of delivering the Minimum Service Package (MSP) in the two states. Methods: We collected primary data from 50 health facilities (25 per state), including PHC facilities-health posts, health clinics, health centers-and general hospitals. Data on facility-level recurrent costs were collected retrospectively for 2019 to estimate economic costs from the provider's perspective. Statewide actual costs were estimated by extrapolating the PHC cost estimates at sampled health facilities, while normative costs were derived using standard treatment protocols (STPs) and the populations requiring PHC services in each state. Results: We found that average actual PHC costs per capita at PHC facilities-where most PHC services should be provided according to government guidelines-ranged from US$ 18.9 to US$ 28 in Kaduna and US$ 15.9 to US$ 20.4 in Kano, depending on the estimation methods used. When also considering the costs of PHC services provided at general hospitals-where approximately a third of PHC services are delivered in both states-the actual per capita costs of PHC services ranged from US$ 20 to US$ 30.6 in Kaduna and US$ 17.8 to US$ 22 in Kano. All estimates of actual PHC costs per capita were markedly lower than the normative per capita costs of delivering quality PHC services to all those who need them, projected at US$ 44.9 in Kaduna and US$ 49.5 in Kano. Discussion: Bridging this resource gap would require significant increases in expenditures on PHC in both states. These results can provide useful information for ongoing discussions on the implementation of the NHIA Act including the refinement of provider payment strategies to ensure that PHC providers are remunerated fairly and that they are incentivized to provide quality PHC services.

Costs and resource needs for primary health care in Ethiopia: evidence to inform planning and budgeting for universal health coverage.

Introduction: The Government of Ethiopia (GoE) has made significant progress in expanding access to primary health care (PHC) over the past 15 years. However, achieving national PHC targets for universal health coverage will require a significant increase in PHC financing. The purpose of this study was to generate cost evidence and provide recommendations to improve PHC efficiency. Methods: We used the open access Primary Health Care Costing, Analysis, and Planning (PHC-CAP) Tool to estimate actual and normative recurrent PHC costs in nine Ethiopian regions. The findings on actual costs were based on primary data collected in 2018/19 from a sample of 20 health posts, 25 health centers, and eight primary hospitals. Three different extrapolation methods were used to estimate actual costs in the nine sampled regions. Normative costs were calculated based on standard treatment protocols (STPs), the population in need of the PHC services included in the Essential Health Services Package (EHSP) as per the targets outlined in the Health Sector Transformation Plan II (HSTP II), and the associated costs. PHC resource gaps were estimated by comparing actual cost estimates to normative costs. Results: On average, the total cost of PHC in the sampled facilities was US$ 11,532 (range: US$ 934-40,746) in health posts, US$ 254,340 (range: US$ 68,860-832,647) in health centers, and US$ 634,354 (range: US$ 505,208-970,720) in primary hospitals. The average actual PHC cost per capita in the nine sampled regions was US$ 4.7, US$ 15.0, or US$ 20.2 depending on the estimation method used. When compared to the normative cost of US$ 38.5 per capita, all these estimates of actual PHC expenditures were significantly lower, indicating a shortfall in the funding required to deliver an expanded package of high-quality services to a larger population in line with GoE targets. Discussion: The study findings underscore the need for increased mobilization of PHC resources and identify opportunities to improve the efficiency of PHC services to meet the GoE's PHC targets. The data from this study can be a critical input for ongoing PHC financing reforms undertaken by the GoE including transitioning woreda-level planning from input-based to program-based budgeting, revising community-based health insurance (CBHI) packages, reviewing exempted services, and implementing strategic purchasing approaches such as capitation and performance-based financing.

The costs and financing needs of delivering Kenya's primary health care service package.

Introduction: For many Kenyans, high-quality primary health care (PHC) services remain unavailable, inaccessible, or unaffordable. To address these challenges, the Government of Kenya has committed to strengthening the country's PHC system by introducing a comprehensive package of PHC services and promoting the efficient use of existing resources through its primary care network approach. Our study estimated the costs of delivering PHC services in public sector facilities in seven sub-counties, comparing actual costs to normative costs of delivering Kenya's PHC package and determining the corresponding financial resource gap to achieving universal coverage. Methods: We collected primary data from a sample of 71 facilities, including dispensaries, health centers, and sub-county hospitals. Data on facility-level recurrent costs were collected retrospectively for 1 year (2018-2019) to estimate economic costs from the public sector perspective. Total actual costs from the sampled facilities were extrapolated using service utilization data from the Kenya Health Information System for the universe of facilities to obtain sub-county and national PHC cost estimates. Normative costs were estimated based on standard treatment protocols and the populations in need of PHC in each sub-county. Results and discussion: The average actual PHC cost per capita ranged from US$ 9.3 in Ganze sub-county to US$ 47.2 in Mukurweini while the normative cost per capita ranged from US$ 31.8 in Ganze to US$ 42.4 in Kibwezi West. With the exception of Mukurweini (where there was no financial resource gap), closing the resource gap would require significant increases in PHC expenditures and/or improvements to increase the efficiency of PHC service delivery such as improved staff distribution, increased demand for services and patient loads per clinical staff, and reduced bypass to higher level facilities. This study offers valuable evidence on sub-national cost variations and resource requirements to guide the implementation of the government's PHC reforms and resource mobilization efforts.

Seasonal malaria chemoprevention in the Sahel subregion of Africa: a cost-effectiveness and cost-savings analysis.

BACKGROUND: The intermittent administration of seasonal malaria chemoprevention (SMC) is recommended to prevent malaria among children aged 3-59 months in areas of the Sahel subregion in Africa. However, the cost-effectiveness and cost savings of SMC have not previously been evaluated in large-scale studies. METHODS: We did a cost-effectiveness and cost-savings analysis of a large-scale, multi-country SMC campaign with sulfadoxine-pyrimethamine plus amodiaquine for children younger than 5 years in seven countries in the Sahel subregion (Burkina Faso, Chad, Guinea, Mali, Niger, Nigeria, and The Gambia) in 2016. The financial and economic costs were analysed from the programmatic perspective and are reported in 2016 US$ for each country. The estimated numbers of averted malaria cases, deaths, and disability-adjusted life-years (DALYs) were based on numbers of SMC treatments administered and modelled malaria transmission. Cost savings were calculated from a programmatic perspective corresponding to the diagnostic and treatment costs for malaria cases averted. FINDINGS: The total cost of SMC for all seven countries was $22·8 million, and the weighted average economic cost of administering four monthly SMC cycles was $3·63 per child (ranging from $2·71 in Niger to $8·20 in The Gambia). Based on 80% modelled effectiveness of SMC, the incremental economic cost per malaria case averted ranged from $2·91 in Niger to $30·73 in The Gambia; the cost per severe case averted ranged from $119·63 in Niger to $506·00 in The Gambia; the cost per death averted ranged from $533·56 in Niger to $2256·92 in The Gambia; and the cost per DALY averted (discounted by 3%) ranged from $18·66 in Niger to $78·91 in The Gambia. The estimated total economic cost savings to the health systems in all seven countries were US$66·0 million and the total net economic cost savings were US$43·2 million. INTERPRETATION: SMC is a low-cost and highly cost-effective intervention that contributes to substantial cost savings by reducing malaria diagnostic and treatment costs among children. FUNDING: Unitaid.

The costs of integrated community case management (iCCM) programs: A multi-country analysis.

BACKGROUND: Integrated community case management (iCCM) can be an effective strategy for expanding the provision of diarrhea, pneumonia, and malaria services to children under 5 years old but there are concerns in some countries about the corresponding cost and impact. This paper presents and compares findings from a multi-country analysis of iCCM program costs. METHODS: Data on coverage, utilization, and costs were collected as part of two sets of studies conducted between 2011 and 2013 for iCCM programs in seven sub-Saharan African countries: Cameroon, the Democratic Republic of the Congo, Malawi, Senegal, Sierra Leone, South Sudan and Zambia. The data were used to compare some elements of program performance as well as costs per capita and costs per service (which are key indicators of resource allocation and efficiency). RESULTS: Among the seven countries, iCCM utilization ranged from a total of 0.26 to 3.05 contacts per capita (children 2-59 months) per year for the diseases treated, representing a range of 2.7% to 36.7% of the expected numbers of cases. The total recurrent cost per treatment ranged from US$ 2.44 to US$ 13.71 for diarrhea; from US$ 2.17 to US$ 17.54 for malaria (excluding rapid diagnostic testing); and from US$ 1.70 to US$ 12.94 for pneumonia. In some of the country programs, the utilization of iCCM services was quite low and this, together with significant fixed costs, particularly for management and supervision, resulted in services being quite costly. Given the differences across the countries and programs, however, these results should be treated as indicative and not definitive. CONCLUSION: A comprehensive understanding of iCCM program costs and results can help countries obtain resources and use them efficiently. To be cost-effective and affordable, iCCM programs must be well-utilized while program management and supervision should be organized to minimize costs and ensure quality of care. iCCM programs will not always be low-cost, however, particularly in small, remote villages where supervision and supply challenges are greater. Further research is needed to determine the cost-effectiveness of iCCM programs and corresponding patient and service delivery costs.