Designing the Free Drugs List in Nepal: A Balancing Act Between Technical Strengths and Policy Processes

How Least Developed to Lower-Middle Income Countries Use Health Technology Assessment: A Scoping Review

Health Technology Assessment (HTA) is a multidisciplinary tool to inform healthcare decision-making. HTA has been implemented in high-income countries (HIC) for several decades but has only recently seen a growing investment in low- and middle-income countries. A scoping review was undertaken to define and compare the role of HTA in least developed and lower middle-income countries (LLMIC). MEDLINE and EMBASE databases were searched from January 2015 to August 2021. A matrix comprising categories on HTA objectives, methods, geographies, and partnerships was used for data extraction and synthesis to present our findings. The review identified 50 relevant articles. The matrix was populated and sub-divided into further categories as appropriate. We highlight topical aspects of HTA, including initiatives to overcome well-documented challenges around data and capacity development, and identify gaps in the research for consideration. Those areas we found to be under-studied or under-utilized included disinvestment, early HTA/implementation, system-level interventions, and cross-sectoral partnerships. We consider broad practical implications for decision-makers and researchers aiming to achieve greater interconnectedness between HTA and health systems and generate recommendations that LLMIC can use for HTA implementation. Whilst HIC may have led the way, LLMIC are increasingly beginning to develop HTA processes to assist in their healthcare decision-making. This review provides a forward-looking model that LLMIC can point to as a reference for their own implementation. We hope this can be seen as timely and useful contributions to optimize the impact of HTA in an era of investment and expansion and to encourage debate and implementation.

Assessing the potential of HTA to inform resource allocation decisions in low-income settings: The case of Malawi

Health technology assessment (HTA) offers a set of analytical tools to support health systems' decisions about resource allocation. Although there is increasing interest in these tools across the world, including in some middle-income countries, they remain rarely used in low-income countries (LICs). In general, the focus of HTA is narrow, mostly limited to assessments of efficacy and cost-effectiveness. However, the principles of HTA can be used to support a broader series of decisions regarding new health technologies. We examine the potential for this broad use of HTA in LICs, with a focus on Malawi. We develop a framework to classify the main decisions on health technologies within health systems. The framework covers decisions on identifying and prioritizing technologies for detailed assessment, deciding whether to adopt an intervention, assessing alternative investments for implementation and scale-up, and undertaking further research activities. We consider the relevance of the framework to policymakers in Malawi and we use two health technologies as examples to investigate the main barriers and enablers to the use of HTA methods. Although the scarcity of local data, expertise, and other resources could risk limiting the operationalisation of HTA in LICs, we argue that even in highly resource constrained health systems, such as in Malawi, the use of HTA to support a broad range of decisions is feasible and desirable.

Health System Capacity and Access Barriers to Diagnosis and Treatment of CVD and Diabetes in Nepal

Background:

Universal access to essential medicines and routine diagnostics is required to combat the growing burden of cardiovascular disease (CVD) and diabetes. Evaluating health systems and various access dimensions availability, affordability, accessibility, acceptability, and quality is crucial yet rarely performed, especially in low- and middle-income countries.

Objective:

To evaluate health system capacity and barriers in accessing diagnostics and essential medicines for CVD and diabetes in Nepal.

Methods:

We conducted a WHO/HAI nationally-representative survey in 45 health-facilities (public-sector: 11; private-sector: 34) in Nepal to collect availability and price data for 21 essential medicines for treating CVD and diabetes, during MayJuly 2017. Data for 13 routine diagnostics was obtained in 12 health facilities. Medicines were considered unaffordable if the lowest paid worker spends >1 days wage to purchase a monthly supply. To evaluate accessibility, we conducted facility exit interviews among 636 CVD patients. Accessibility (e.g., private-public health facility mix, travel to hospital/pharmacy) and acceptability (i.e. Nepals adoption of WHO Essential Medicine List, and patient medication adherence) were summarized using descriptive statistics, and we conducted a systematic review of relevant literature. We did not evaluate medicine quality.

Results:

We found that mean availability of generic medicines is low (<50%) in both public and private sectors, and less than one-third medicines met WHOs availability target (80%). Mean (SD) availability of diagnostics was 73.1% (26.8%). Essential medicines appear locally unaffordable. On average, the lowest-paid worker would spend 1.03 (public-sector) and 1.26 (private-sector) days wages to purchase a monthly supply. For a person undergoing CVD secondary preventive-interventions in the private sector, the associated expenditure would be 7.511.2% of monthly household income. Exit-interviews suggest that a long/expensive commute to health-facilities and poor medicine affordability constrain access.

Conclusions:

This study highlights critical gaps in Nepals health system capacity to offer basic health services to CVD and diabetes patients, owing to low availability, poor affordability and accessibility of essential medicines and diagnostics. Research and policy initiatives are needed to ensure uninterrupted supply of affordable essential medicines and diagnostics.

Knowledge on tuberculosis and utilization of DOTS service by tuberculosis patients in Lalitpur District, Nepal

BACKGROUND

Tuberculosis is one of the major infectious diseases and is both complex and serious. It is spread from person to person through the air, causing a public health burden, especially in low- and middle-income countries. This study aims to assess the knowledge on tuberculosis and the utilization of Directly-Observed Therapy, Short Course (DOTS) service from the public DOTS centers in Lalitpur district of Nepal.

METHOD

A structured questionnaire was used to collect data from 23 DOTS centers in Lalitpur district. Univariate and multivariate logistic regression was applied to assess the knowledge on tuberculosis and utilization of DOTS among people living with tuberculosis.

RESULTS

Among 390 respondents, 80% of patients had knowledge of tuberculosis and 76.92% utilized the DOTS service from the DOTS center. People of higher age (50-60 years) [aOR; 13.96, 95% CI 4.79,40.68], [aOR; 10.84,95% CI 4.09,28.76] had significantly more knowledge on TB and utilization of the DOTS service compared to the younger group. Additionally, those who completed twelfth class [aOR; 2.25, 95% CI 0.46,11.07] and [aOR;2.47, 95% CI 0.51,11.28] had greater knowledge of Tuberculosis and utilization of DOTS compared to those who had not completed twelfth class. Likewise, compared to urban residents, respondents in rural areas (aOR; 0.51, 95% CI 0.27,0.97) had less knowledge of tuberculosis, (aOR; 0.57, 95% CI 0.32,1) and less chance of utilization of the DOTS service from the DOTS center.

CONCLUSION

Approximately one quarter of patients did not have adequate knowledge of tuberculosis and were not utilizing the DOTS service, particularly in younger age groups, people living in a combined family, with no education, poor economic position, and from rural areas. Findings of this study revealed that some specific programs are needed for enhancing the knowledge and utilization of DOTS, particularly for those patients whose economic situations extended from low to mid range.