Development of a Health Screening Package Under the Universal Health Coverage: The Role of Health Technology Assessment

The use of cost-effectiveness analysis for health benefit package design - should countries follow a sectoral, incremental or hybrid approach?

BACKGROUND

Countries around the world are increasingly rethinking the design of their health benefit package to achieve universal health coverage. Countries can periodically revise their packages on the basis of sectoral cost-effectiveness analyses, i.e. by evaluating a broad set of services against a 'doing nothing' scenario using a budget constraint. Alternatively, they can use incremental cost-effectiveness analyses, i.e. to evaluate specific services against current practice using a threshold. In addition, countries may employ hybrid approaches which combines elements of sectoral and incremental cost-effectiveness analysis - a country may e.g. not evaluate the comprehensive set of all services but rather relatively small sets of services targeting a certain condition. However, there is little practical guidance for countries as to which kind of approach they should follow.

METHODS

The present study was based on expert consultation. We refined the typology of approaches of cost-effectiveness analysis for benefit package design, identified factors that should be considered in the choice of approach, and developed recommendations. We reached consensus among experts over the course of several review rounds.

RESULTS

Sectoral cost-effectiveness analysis is especially suited in contexts with large allocative inefficiencies in current service provision and can, in theory, realize large efficiency gains. However, it may be challenging to implement a comprehensive redesign of the package in practice. Incremental cost-effectiveness analysis is especially relevant in contexts where specific new services may impact the sustainability of the health system. It may potentially support efficiency improvement, but its focus has typically been on new services while existing inefficiencies remain unchallenged. The use of hybrid approach may be a way forward to address the strengths and weaknesses of sectoral and incremental analysis areas. Such analysis may be especially useful to target disease areas with suspected high inefficiencies in service provision, and would then make good use of the available research capacity and be politically rewarding. However, disease-specific analyses bear the risk of not addressing resource allocation inefficiencies across disease areas.

CONCLUSIONS

Countries should carefully select their approach of cost-effectiveness analyses for benefit package design, based on their decision-making context.

Diagnostic accuracy for alternative cervical cancer screening strategies: A systematic review and meta-analysis

We performed a systematic review and meta-analysis to evaluate the accuracy of screening cervical cancer tests as alternative standalone methods. The combined estimates of sensitivity of visual inspection with acetic acid, visual inspection with lugol's iodine, conventional pap smear, liquid-based cytology, High risk HPV testing by clinician, High risk HPV testing by self- sampling, cervicography were 64%, 80%, 55%, 70%, 70% and 67% respectively; the combine values of specificity of these screening strategies were 88%, 88%, 96%, 59%, 94%, and 95% respectively. Our findings draw attention to an attractive opinion to facilitate the collection of specimens for DNA HPV by patients in settings where they don't have access to a regular screening programs.

Economic evaluation of population-based type 2 diabetes mellitus screening at different healthcare settings in Vietnam

Introduction

Few economic evaluations have assessed the cost-effectiveness of screening type-2 diabetes mellitus (T2DM) in different healthcare settings. This study aims to evaluate the value for money of various T2DM screening strategies in Vietnam.

Methods

A decision analytical model was constructed to compare costs and quality-adjusted life years (QALYs) of T2DM screening in different health care settings, including (1) screening at commune health station (CHS) and (2) screening at district health center (DHC), with no screening as the current practice. We further explored the costs and QALYs of different initial screening ages and different screening intervals. Cost and utility data were obtained by primary data collection in Vietnam. Incremental cost-effectiveness ratios were calculated from societal and payer perspectives, while uncertainty analysis was performed to explore parameter uncertainties.

Results

Annual T2DM screening at either CHS or DHC was cost-effective in Vietnam, from both societal and payer perspectives. Annual screening at CHS was found as the best screening strategy in terms of value for money. From a societal perspective, annual screening at CHS from initial age of 40 years was associated with 0.40 QALYs gained while saving US$ 186.21. Meanwhile, one-off screening was not cost-effective when screening for people younger than 35 years old at both CHS and DHC.

Conclusions

T2DM screening should be included in the Vietnamese health benefits package, and annual screening at either CHS or DHC is recommended.

Knowledge, attitude, and behaviors toward liver health and viral hepatitis-related liver diseases in Thailand

This study aimed to quantify and evaluate the knowledge and awareness toward liver health and diseases as well as explore the attitudes and knowledge toward screening, diagnosis, and treatment of liver disease among the Thai population.This is a cross-sectional, self-reported and web-based questionnaire study. Awareness, perceptions and attitudes toward liver-related health and diseases as well as screening, diagnosis and treatment of liver diseases were assessed among 500 Thai adults.Respondents were mostly ≥35 years (62.0%) and females (52.0%). While there was an overall awareness regarding viral hepatitis as the main etiology of liver failure/cancer, respondents expressed misperceptions that hint at social stigmatization or discrimination toward infected individuals. A significant proportion lacked knowledge of liver screening tests and relevant diagnostic tests for viral hepatitis-related liver diseases. Screening or treatment costs and perception of being healthy were among reasons for not seeking medical consultation when exposed to risk factors or diagnosed. Treatment practices of hepatitis included prescription medication (59.1%), functional foods (51.8%) and traditional treatment (28.2%). Multivariate analysis identified income, recent health screening status and being diagnosed with liver disease(s) as significant predictors of the knowledge, attitude, and behaviors of the Thai population toward liver diseases.This study highlighted a degree of misperception and lack of in-depth understanding toward hepatitis-related liver diseases including poor attitudes and knowledge toward screening, diagnosis, and treatment of liver diseases. Factors identified suggest an unmet need to encourage proactive health-seeking behaviors to reduce transmission risks of hepatitis-related liver diseases within the community.

Retrospective secondary data analysis to identify high-cost users in inpatient department of hospitals in Thailand, a middle-income country with universal healthcare coverage

OBJECTIVES

The study aims to identify high-cost users (HCUs) in the inpatient departments of hospitals in Thailand including their common characteristics, patterns of healthcare utilisation and expenditure compared with low-cost users, and to explore potential factors associated with HCUs so the healthcare system can be prepared to support the HCUs including those who have increased chances of becoming HCUs.

DESIGN AND SETTING

A retrospective secondary data analysis using hospitalisation data from Thailand's Universal Coverage Scheme (UCS) obtained from the National Health Security Office over a 5-year period from October 2014 to September 2019 (fiscal year 2014-2018).

PARTICIPANTS

Study participants included Thai citizens who had at least one inpatient admission to hospitals under the UCS over the study period.

RESULTS

Over the 5-year period, the top 5% of the hospitalised population (or HCUs) consumed almost 50% of the health expenditure each year. HCUs were more likely to have longer hospital stays, a higher annual number of visits and be admitted to multiple hospitals each year when compared with the low-cost users (the bottom 50% of the hospitalised population). The study further reported that the chance of becoming an HCU is associated with several factors such as increasing age, being male, having a comorbidity and being admitted to hospitals in Bangkok.

CONCLUSIONS

This study confirmed that the HCU phenomenon existed in Thailand, where a majority of inpatient care spending is concentrated in the top 5% of the hospitalised population. The study findings call attention to potential initiatives that can help monitor the magnitude and trend of HCUs and develop policies to prevent HCUs.

Health insurance benefit package in Iran: a qualitative policy process analysis

BACKGROUND

Insufficient transparency in prioritization of health services, multiple health insurance organizations with various and not-aligned policies, plus limited resources to provide comprehensive health coverage are among the challenges to design appropriate Health Insurance Benefit Package (HIBP) in Iran. This study aims to analyze Policy Process of Health Insurance Benefit Package in Iran.

METHOD

Data were collected through semi-structured interviews with 25 experts, plus document analysis and observation, from February 2014 until October 2016. Using both deductive and inductive approaches, two independent researchers conducted data content analysis. We used MAXQDA.11 software for data management.

RESULTS

We identified 10 main themes, plus 81 sub-themes related to development and implementation of HIBP. These included: lack of transparent criteria for inclusion of services within HIBP, inadequate use of scientific evidence to determine the HIBP, lack of evaluation systems, and weak decision-making process. We propose 11 solutions and 25 policy options to improve the situation.

CONCLUSION

The design and implementation of HIBP did not follow an evidence-based and logical algorithm in Iran. Rather, political and financial influences at the macro level determined the decisions. This is rooted in social, cultural, and economic norms in the country, whereby political and economic factors had the greatest impact on the implementation of HIBP. To define a cost-effective HIBP in Iran, it is pivotal to develop transparent and evidence-based guidelines about the processes and the stewardship of HIBP, which are in line with upstream policies and societal characteristics. In addition, the possible conflict of interests and its harms should be minimized in advance.

Burden of Disease due to Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is rapidly becoming the most common liver disease in both Western populations and other parts of the world. This review discusses the prevalence and incidence of NAFLD in various regions around the world. The methodology used to identify the epidemiology and classify the stages of the disease is described. The impact of the disease on individuals, looking at both liver-related and extrahepatic consequences of the disease, is then discussed. Finally, the economic and societal impact of the disease is discussed.

Prevention of non-communicable disease: best buys, wasted buys, and contestable buys

Wanrudee Isaranuwatchai and colleagues highlight the importance of local context in making decisions about implementing interventions for preventing non-communicable diseases

Legislating for public accountability in universal health coverage, Thailand

Sustaining universal health coverage requires robust active public participation in policy formation and governance. Thailand’s universal coverage scheme was implemented nationwide in 2002, allowing Thailand to achieve full population coverage through three public health insurance schemes and to demonstrate improved health outcomes. Although Thailand’s position on the World Bank worldwide governance indicators has deteriorated since 1996, provisions for voice and accountability were embedded in the legislation and design of the universal coverage scheme. We discuss how legislation related to citizens’ rights and government accountability has been implemented. Thailand’s constitution allowed citizens to submit a draft bill in which provisions on voice and accountability were successfully embedded in the legislative texts and adopted into law. The legislation mandates registration of beneficiaries, a 24/7 helpline, annual public hearings and no-fault financial assistance for patients who have experienced adverse events. Ensuring the right to health services, and that citizens’ voices are heard and action taken, requires the institutional capacity to implement legislation. For example, Thailand needed the capacity to register 47 million people and match them with the health-care provider network in the district where they live, and to re-register members who move out of their districts. Annual public hearings need to be inclusive of citizens, health-care providers, civil society organizations and stakeholders such as local governments and patient groups. Subsequent policy and management responses are important for building trust in the process and citizens’ ownership of the scheme. Annual public reporting of outcomes and performance of the scheme fosters transparency and increases citizens’ trust.

From Design to Evaluation: Applications of Health Technology Assessment in Myanmar and Lessons for Low or Lower Middle-Income Countries

OBJECTIVES

Health technology assessment (HTA) has been widely used to inform coverage decisions in high-income countries over the past few decades and has been getting increasing attention in middle-income countries as a tool for healthcare decision making in recent years. This study aims to use the case of the Maternal and Child Health Voucher Scheme (MCHVS) in Myanmar to understand how HTA can have a policy impact in a low or lower middle-income country.

METHODS

The stages heuristic framework was used to describe the policy-making process. A document review was conducted and tacit knowledge of researchers involved was recorded.

RESULTS

The opportunity for a grant propelled maternal and child health to the policy agenda. An ex-ante HTA, which included a model-based health economic evaluation, informed the design of the scheme. The framework and key parameters from the ex-ante HTA were used for a mid-term review, which provided feedback to the policy implementation process. An ex-post HTA involved fielding a household survey to assess the impact of the scheme.

CONCLUSIONS

HTA can be a useful method for informing resource allocation throughout the policy process in low and lower middle-income settings where no formal mechanism for making coverage decisions exists.

Appropriate Total cholesterol cut-offs for detection of abnormal LDL cholesterol and non-HDL cholesterol among low cardiovascular risk population

BACKGROUND

Current guidelines suggest screening for dyslipidemia in early adulthood. In Thailand, a screening total cholesterol level is most commonly used potentially due to the costs of the test. However, the appropriate TC cut-off point that correlates with elevated low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (Non-HDL-C) levels for the low cardiovascular risk younger population have not been examined extensively in the literature.

METHODS

This study identified 1754 subjects with low cardiovascular risk. All participants had a physical examination and a venous blood sample sent for laboratory assessment of fasting blood glucose, TC, LDL-C, HDL-C levels. A non-HDL-C level for everyone was calculated by subtracting HDL-C levels from their total cholesterol levels. Sensitivity and specificity of different TC cutoff points in detection of abnormal LDL-C levels (≥ 130 mg/dL and ≥ 160 mg/dL) and abnormal non-HDL-C levels (≥ 160 mg/dL and ≥ 190 mg/dL) were calculated. Receiver operating characteristics (ROC) curve analysis was used to evaluate the predictive utility of TC for the abnormal LDL-C and abnormal non-HDL-C levels.

RESULTS

The conventional range TC cut off point, between 200 to 240, had varying diagnostic properties for detection of elevated LDL-C and Non-HDL-C within this low risk population. A TC cut off point 210 would have a sensitivity of 70% and specificity of 92.5% for detection of LDL-C ≥ 130 and a sensitivity of 96.7% and specificity of 85.6% for identifying those with Non-HDL-C ≥ 160. The TC cut off point of 230 had a sensitivity of 74.9% and specificity of 92.0% in identifying those with LDL-C ≥ 160 and a sensitivity of 98.6% and specificity of 89.8% in detection of non-HDL-C ≥ 190.

CONCLUSIONS

Early screening for dyslipidemia in young adults is suggested by many guidelines. This population is likely to be those with lower cardiovascular risk and may needed to have repeated screening over time. Screening using TC with appropriate a cut off points may be a more cost-effective screening test in settings with limited resources, coverage and accessibility.

Budgeting for a billion: applying health technology assessment (HTA) for universal health coverage in India

BACKGROUND

India recently launched the largest universal health coverage scheme in the world to address the gaps in providing healthcare to its population. Health technology assessment (HTA) has been recognised as a tool for setting priorities as the government seeks to increase public health expenditure. This study aims to understand the current situation for healthcare decision-making in India and deliberate on the opportunities for introducing HTA in the country.

METHODS

A paper-based questionnaire, adapted from a survey developed by the International Decision Support Initiative (iDSI), was administered on the second day of the Topic Selection Workshop that was conducted as part of the HTA Awareness Raising Workshop held in New Delhi on 25-27 July, 2016. Participants were invited to respond to questions covering the need, demand and supply for HTA in their context as well as the role of their organisation vis-à-vis HTA. The response rate for the survey was about 68% with 41 participants having completed the survey.

RESULTS

Three quarters of the respondents (71%) stated that the government allocated healthcare resources on the basis of expert opinion. Most respondents indicated reimbursement of individual health technologies and designing a basic health benefit package (93% each) were important health policy areas while medical devices and screening programmes were cited as important technologies (98% and 92%, respectively). More than half of the respondents noted that relevant local data was either not available or was limited. Finally, technical capacity was seen as a strength and a constraint facing organisations.

CONCLUSION

The findings from this study shed light on the current situation, the opportunities, including potential topics, and challenges in conducting HTA in India. There are limitations to the study and further studies may need to be conducted to inform the role that HTA will play in the design or implementation of universal health coverage in India.

Identification of publicly available data sources to inform the conduct of Health Technology Assessment in India

Background: Health technology assessment (HTA) provides a globally-accepted and structured approach to synthesising evidence for cost and clinical effectiveness alongside ethical and equity considerations to inform evidence-based priorities. India is one of the most recent countries to formally commit to institutionalising HTA as an integral component of the heath resource allocation decision-making process. The effective conduct of HTA depends on the availability of reliable data.   Methods: We draw from our experience of collecting, synthesizing, and analysing health-related datasets in India and internationally, to highlight the complex requirements for undertaking HTA, and explore the availability of such data in India. We first outlined each of the core data components required for the conduct of HTA, and their availability in India, drawing attention to where data can be accessed, and different ways in which researchers can overcome the challenges of missing or low quality data. Results: We grouped data into the following categories: clinical efficacy; cost; epidemiology; quality of life; service use/consumption; and equity. We identified numerous large local data sources containing epidemiological information. There was a marked absence of other locally-collected data necessary for informing HTA, particularly data relating to cost, service use, and quality of life. Conclusions: The introduction of HTA into the health policy space in India provides an opportunity to comprehensively assess the availability and quality of health data capture across the country. While epidemiological information is routinely collected across India, other data inputs necessary for HTA are not readily available. This poses a significant bottleneck to the efficient generation and deployment of HTA into the health decision space. Overcoming these data gaps by strengthening the routine collection of comprehensive and verifiable health data will have important implications not only for embedding economic analyses into the priority setting process, but for strengthening the health system as a whole.

Identification of publicly available data sources to inform the conduct of Health Technology Assessment in India

Background: Health technology assessment (HTA) provides a globally-accepted and structured approach to synthesising evidence for cost and clinical effectiveness alongside ethical and equity considerations to inform evidence-based priorities. India is one of the most recent countries to formally commit to institutionalising HTA as an integral component of the heath resource allocation decision-making process. The effective conduct of HTA depends on the availability of reliable data.   Methods: We draw from our experience of collecting, synthesizing, and analysing health-related datasets in India and internationally, to highlight the complex requirements for undertaking HTA, and explore the availability of such data in India. We first outlined each of the core data components required for the conduct of HTA, and their availability in India, drawing attention to where data can be accessed, and different ways in which researchers can overcome the challenges of missing or low quality data. Results: We grouped data into the following categories: clinical efficacy; cost; epidemiology; quality of life; service use/consumption; and equity. We identified numerous large local data sources containing epidemiological information. There was a marked absence of other locally-collected data necessary for informing HTA, particularly data relating to cost, service use, and quality of life. Conclusions: The introduction of HTA into the health policy space in India provides an opportunity to comprehensively assess the availability and quality of health data capture across the country. While epidemiological information is routinely collected across India, other data inputs necessary for HTA are not readily available. This poses a significant bottleneck to the efficient generation and deployment of HTA into the health decision space. Overcoming these data gaps by strengthening the routine collection of comprehensive and verifiable health data will have important implications not only for embedding economic analyses into the priority setting process, but for strengthening the health system as a whole.

Engaging policy-makers, health system managers, and policy analysts in the knowledge synthesis process: a scoping review

Background

It is unclear how to engage a wide range of knowledge users in research. We aimed to map the evidence on engaging knowledge users with an emphasis on policy-makers, health system managers, and policy analysts in the knowledge synthesis process through a scoping review.

Methods

We used the Joanna Briggs Institute guidance for scoping reviews. Nine electronic databases (e.g., MEDLINE), two grey literature sources (e.g., OpenSIGLE), and reference lists of relevant systematic reviews were searched from 1996 to August 2016. We included any type of study describing strategies, barriers and facilitators, or assessing the impact of engaging policy-makers, health system managers, and policy analysts in the knowledge synthesis process. Screening and data abstraction were conducted by two reviewers independently with a third reviewer resolving discrepancies. Frequency and thematic analyses were conducted.

Results

After screening 8395 titles and abstracts followed by 394 full-texts, 84 unique documents and 7 companion reports fulfilled our eligibility criteria. All 84 documents were published in the last 10 years, and half were prepared in North America. The most common type of knowledge synthesis with knowledge user engagement was a systematic review (36%). The knowledge synthesis most commonly addressed an issue at the level of national healthcare system (48%) and focused on health services delivery (17%) in high-income countries (86%).

Policy-makers were the most common (64%) knowledge users, followed by healthcare professionals (49%) and government agencies as well as patients and caregivers (34%). Knowledge users were engaged in conceptualization and design (49%), literature search and data collection (52%), data synthesis and interpretation (71%), and knowledge dissemination and application (44%). Knowledge users were most commonly engaged as key informants through meetings and workshops as well as surveys, focus groups, and interviews either in-person or by telephone and emails. Knowledge user content expertise/awareness was a common facilitator (18%), while lack of time or opportunity to participate was a common barrier (12%).

Conclusions

Knowledge users were most commonly engaged during the data synthesis and interpretation phases of the knowledge synthesis conduct. Researchers should document and evaluate knowledge user engagement in knowledge synthesis.

Registration details

Open Science Framework (https://osf.io/4dy53/).

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0717-x) contains supplementary material, which is available to authorized users.

Institutionalising health technology assessment: establishing the Medical Technology Assessment Board in India

India is at crossroads with a commitment by the government to universal health coverage (UHC), driving efficiency and tackling waste across the public healthcare sector. Health technology assessment (HTA) is an important policy reform that can assist policy-makers to tackle inequities and inefficiencies by improving the way in which health resources are allocated towards cost-effective, appropriate and feasible interventions. The equitable and efficient distribution of health budget resources, as well as timely uptake of good value technologies, are critical to strengthen the Indian healthcare system. The government of India is set to establish a Medical Technology Assessment Board to evaluate existing and new health technologies in India, assist choices between comparable technologies for adoption by the healthcare system and improve the way in which priorities for health are set. This initiative aims to introduce a more transparent, inclusive, fair and evidence-based process by which decisions regarding the allocation of health resources are made in India towards the ultimate goal of UHC. In this analysis article, we report on plans and progress of the government of India for the institutionalisation of HTA in the country. Where India is home to one-sixth of the global population, improving the health services that the population receives will have a resounding impact not only for India but also for global health.