Disease Control Priorities Third Edition Is Published: A Theory of Change Is Needed for Translating Evidence to Health Policy

The Role of HTA for Essential Health Benefit Package Design in Low or Middle-Income Countries

This Commentary explores the relationship between Health Technology Assessment (HTA) and Health Benefits Package (HBP) design to achieve Universal Health Coverage (UHC) in low- and middle-income countries. It emphasizes that while HTA evaluates individual healthcare interventions, HBP reform aims to create comprehensive service sets considering overall population health needs and available resources. Challenges in LMICs include limited local data and technical capacity, leading to reliance on cost-effectiveness estimates from other settings. We suggest a practical approach by combining HTA and HBP elements through a hybrid or compartmentalized method. This approach sets differentiated cost-effectiveness thresholds for specific healthcare platforms or programs (e.g., primary care or essential surgery), aligning priority-setting with organizational considerations, ethics, and implementation strategies. Strong institutions and academic support are vital for evidence-informed priority-setting processes. In summary, HTA can play a pivotal role in designing HBPs for UHC in LMICs, and a compartmentalized approach can enhance priority-setting while considering budget constraints and equity.

Building a House on Sand: How Tobacco Use Is Devouring Resources

BACKGROUND

Tobacco is a major cause of preventable morbidity and mortality, with a considerable economic burden. The purpose of this systematic review was to summarize the evidence on the economic burden of tobacco use by searching national and international databases so as to generate useful information about the costs of tobacco use globally.

METHODS

A systematic search was conducted in Scopus, PubMed, EMBASE, ProQuest, and Web of Science (ISI) databases to identify relevant studies from 1990 to June 2021 using keywords like burden, productivity, indirect cost, direct cost, economic, monetary, expenditure, tobacco, smoking, and cigarettes. Cost estimates were converted into 2020 international dollars per adult.

FINDINGS

A total of 1,781 articles were identified, of which 361 were deemed to be eligible for inclusion. Eventually, 23 articles were found eligible. In most studies, cost estimates were provided using a prevalence-based approach. The highest total cost, as a percentage of gross domestic product (GDP), was reported for South Korea (1.19%). Noteworthy, in all studies, indirect costs accounted for the highest proportion of all costs. The mean total cost amounted to 5,866 million dollars. The direct costs ranged from 179 million dollars in South Korea to 8,156 million dollars in Israel. Meanwhile, the indirect costs ranged from 289 million dollars in Hong Kong to 9,808 million dollars in India.

CONCLUSION

The evidence demonstrated the considerable economic burden of tobacco use in various countries, ranging from 0.33 to 1.19% of the GDP of the investigated countries, indicating the necessity of taking immediate measures. Hence, policies are needed to address the economic burden of smoking.

Country readiness and prerequisites for successful design and transition to implementation of essential packages of health services: experience from six countries

This paper reviews the experience of six low-income and lower middle-income countries in setting their own essential packages of health services (EPHS), with the purpose of identifying the key requirements for the successful design and transition to implementation of the packages in the context of accelerating progress towards universal health coverage (UHC). The analysis is based on input from three meetings of a knowledge network established by the Disease Control Priorities 3 Country Translation Project and working groups, supplemented by a survey of participating countries.All countries endorsed the Sustainable Development Goals target 3.8 on UHC for achievement by 2030. The assessment of country experiences found that health system strengthening and mobilising and sustaining health financing are major challenges. EPHS implementation is more likely when health system gaps are addressed and when there are realistic and sustainable financing prospects. However, health system assessments were inadequate and the government planning and finance sectors were not consistently engaged in setting the EPHS in most of the countries studied. There was also a need for greater engagement with community and civil society representatives, academia and the private sector in package design. Leadership and reinforcement of technical and managerial capacity are critical in the transition from EPHS design to sustained implementation, as are strong human resources and country ownership of the process. Political commitment beyond the health sector is key, particularly commitment from parliamentarians and policymakers in the planning and finance sectors. National ownership, institutionalisation of technical and managerial capacity and reinforcing human resources are critical for success.The review concludes that four prerequisites are crucial for a successful EPHS: (1) sustained high-level commitment, (2) sustainable financing, (3) health system readiness, and (4) institutionalisation.

Modernizing health information technology: lessons from healthcare delivery systems

Objective

To identify recurrent themes, insights, and process recommendations from stakeholders in US organizations during the health information technology (HIT) modernization of an existing electronic health record (EHR) to a commercial-off-the-shelf product in both resource-plentiful settings and in a resource-constrained environment, the US Indian Health Service.

Materials and Methods

Thirteen qualitative interviews with stakeholders in various organizations were conducted about HIT modernization efforts. Using a Theory of Change framework, recurring themes were identified and analyzed.

Results

The interviewees emphasized the importance of organizational and process revision during modernization, converting historical data, and clinical and leadership involvement. HIT implementation required technological and infrastructure redesign, additional training, and workflow reconfiguration. Motivations for modernization included EHR usability dissatisfaction, revenue enhancements, and improved clinical operations. Decision-making strategies, primarily during HIT selection, included meetings with stakeholders. Successful modernization resulted in improvements in clinical operations, patient experience, and financial outlay.

Discussion

Existing implementation frameworks fail to provide experiential feedback, such as implementation challenges, like data conversion, regulatory, functionality, and interoperability requirements. Regardless of the healthcare environment, HIT modernization requires the engagement of leadership and end-users during HIT selection and through all stages of the implementation to prepare people, processes, and technology. Organizations must iteratively define the technological, infrastructure, organizational, and workflow changes required for a successful HIT modernization effort.

Conclusions

HIT modernization is an opportunity for organizational and technological change. Successful modernization requires a comprehensive, intentional, well-communicated, and multidisciplinary approach. Resource-constrained environments have the additional challenges of financial burdens, limited staffing, and unstable infrastructure.

Reflections on Norheim (2018), Disease Control Priorities Third Edition Is Published Comment on "Disease Control Priorities Third Edition Is Published: A Theory of Change Is Needed for Translating Evidence to Health Policy"

The publication of Disease Control Priorities, 3rd edition (DCP3) is a major milestone in the global health world. DCP3 reviews and summarizes high quality health intervention effectiveness and cost-effectiveness evidence relevant to low- and middle-income countries and is freely available to users. This Commentary summarizes Norheim’s (2018) assessment of DCP3’s role in country health priority-setting and offers reflections on what DCP3 can continue to offer countries seeking to improve their purchasing of health.

On the Path to UHC - Global Evidence Must Go Local to Be Useful 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 (DCP) publications have pioneered new ways of thinking about investing in health. We agree with Norheim, that a useful first step to advance efforts to translate DCP's global evidence into local health priorities, is to develop a clear Theory of Change (ToC). However, a ToC that aims to define how global evidence (DCP and others) can be used to inform national policy is too narrow an undertaking. We propose efforts should be directed towards developing a ToC to define how to support progressive institutional development to deliver on universal health coverage (UHC), putting the client at the center. Enhancing efforts to meet the new global health imperatives requires a shift in focus of attention to move radically from global to local. In order to achieve this we need to reorganize the nature of technical assistance (TA) along three major lines (1) examine and act to clarify the mandates and roles to be played by multilateral normative and convening agencies, (2) ensure detailed understanding of local institutions, their needs and their demands, and (3) provide TA over time and in trust with local counterparts. This last requirement implies the need for long-term local presence as well as an international network of expertise centers, to share scarce technical capabilities as well as to learn together across country engagements. Financing will need to be reorganized to incentivize and support demand-led capacity strengthening.

The Future of Disease Control Priorities 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 (DCP) project has substantially influenced national and global health priorities since 1993. DCP’s basic framework involves identification of disease burdens based on premature deaths and disability and application of the most cost-effective interventions to the largest burdens, taking into account local feasibility. The future impact of DCP will need to take into account growing national wealth and needs for endogenous capacity to design and implement evidence-based interventions, the rapid emergence of non-communicable disease (NCD), and the universal health coverage (UHC) agenda. This in turn requires three improvements to the DCP framework: greater local capacity, supported by a global effort to cost health interventions, stronger national and international technical capacity and networks, and the use of direct, versus modelled, mortality data to assign priorities and to assess progress. Properly done, DCP could be as important over the next 25 years as it has been in the past 25 years.

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.