How should global fund use value-for-money information to sustain its investments in graduating countries?

It has been debated whether the Global Fund (GF), which is supporting the implementation of programs on the prevention and control of HIV/AIDS, tuberculosis (TB) and malaria, should consider the value-for-money (VFM) for programs/interventions that they are supporting. In this paper, we critically analyze the uses of economic information for GF programs, not only to ensure accountability to their donors but also to support country governments in continuing investment in cost-effective interventions initiated by the GF despite the discontinuation of financial support after graduation. We demonstrate that VFM is not a static property of interventions and may depend on program start-up cost, economies of scales, the improvement of effectiveness and efficiency of providers once the program develops, and acceptance and adherence of the target population. Interventions that are cost-ineffective in the beginning may become cost-effective in later stages. We consider recent GF commitments towards value for money and recommend that the GF supports interventions with proven cost-effectiveness from program initiation as well as interventions that may be cost-effective afterwards. Thus, the GF and country governments should establish mechanisms to monitor cost-effectiveness of interventions invested over time

Capacity for health economics research and practice in Jordan, Lebanon, the occupied Palestinian territories and Turkey: needs assessment and options for development

Background: Capacity for health economics analysis and research is indispensable for evidence-informed allocations of scarce health resources, however little is known about the experience and capacity strengthening preferences of academics and practitioners in the Eastern Mediterranean region. This study aimed to assess the needs for strengthening health economics capacity in Jordan, Lebanon, the occupied Palestinian territories and Turkey as part of the Research for Health in Conflict in Middle East and North Africa (R4HC-MENA) project. Methods: Bibliometric analysis of health economics outputs combined with an online survey of academic researchers and non-academic practitioners. The bibliometric analysis was based on a literature search conducted across seven databases. Included records were original studies and reviews with an explicit economic outcome related to health, disease or disability; had at least one author in Jordan, Lebanon, Palestine or Turkey; and were published between January 2014 and December 2018. Two types of analyses were conducted using VOSviewer software: keyword co-occurrence; and co-publication networks across countries and organizations. The online survey asked academic researchers, analysts and decision-makers – identified through the bibliometric analysis and regional professional networks – about previous exposure to and preference for capacity development in health economics. Results: Of 15,185 records returned by the literature search, 566 were included in the bibliometric analysis. Organizations in Turkey contributed more than 80% of records and had the broadest and most diverse network of collaborators, nationally and internationally. Only 1% (n=7) studies were collaborations between researchers in two or more different jurisdictions. Cost analysis, cost-effectiveness analysis and health system economics were the main health economics topics across the included studies. Economic evaluation, measuring the economic burden of disease and health equity were reported by survey respondents (n=80) as the most important areas to develop in. Short courses, learn-by-doing and mentoring from an experienced professional were, in aggregate, the most preferred capacity development modalities. Conclusions: Existing pockets of health economic expertise in the region can constitute the base of future capacity development efforts. Building confidence toward applying specific methods and trust toward stimulating cross-jurisdiction collaborations appear essential components for sustainably developing health economics capacity

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

The international right to health: what does it mean in legal practice and how can it affect priority setting for universal health coverage?

The international right to health is enshrined in national and international law. In a growing number of cases, individuals denied access to high-cost medicines and technologies under universal coverage systems have turned to the courts to challenge the denial of access as against their right to health. In some instances, patients seek access to medicines, services, or technologies that they would have access to under universal coverage if not for government, health system, or service delivery shortfalls. In others, patients seek access to medicines, services, or technologies that have not been included or that have been explicitly denied for coverage due to prioritization. In the former, judicialization of the right to health is critical to ensure patients access to the technologies or services to which they are entitled. In the latter, courts may grant patients access to medicines not covered as a result of explicit priority setting to allocate finite resources. By doing so, courts may give priority to those with the means and incentive to turn to the courts, at the expense of the maximization of equity- and population-based health. Evidence-based, informed decision-making processes could ensure that the most clinically and cost-effective products aligning with social value judgments are prioritized. Governments should be equipped to engage in and defend rational priority setting, and the priority setting process and institutions involved should be held accountable through an opportunity for appeal and judicial review. As a result, the courts could place greater reliance on the government's coverage choices, and the population's health could be most equitably distributed

Methodological variation in economic evaluations conducted in low- and middle- income countries: Information for reference case development

© 2015 Santatiwongchai et al. Information generated from economic evaluation is increasingly being used to inform health resource allocation decisions globally, including in low- and middle- income countries. However, a crucial consideration for users of the information at a policy level, e.g. funding agencies, is whether the studies are comparable, provide sufficient detail to inform policy decision making, and incorporate inputs from data sources that are reliable and relevant to the context. This review was conducted to inform a methodological standardisation workstream at the Bill and Melinda Gates Foundation (BMGF) and assesses BMGF-funded cost-per-DALY economic evaluations in four programme areas (malaria, tuberculosis, HIV/AIDS and vaccines) in terms of variation in methodology, use of evidence, and quality of reporting. The findings suggest that there is room for improvement in the three areas of assessment, and support the case for the introduction of a standardised methodology or reference case by the BMGF. The findings are also instructive for all institutions that fund economic evaluations in LMICs and who have a desire to improve the ability of economic evaluations to inform resource allocation decisions

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

Improving quality for maternal care - a case study from Kerala, India.

BACKGROUND: The implementation of maternal health guidelines remains unsatisfactory, even for simple, well established interventions. In settings where most births occur in health facilities, as is the case in Kerala, India, preventing maternal mortality is linked to quality of care improvements. CONTEXT: Evidence-informed quality standards (QS), including quality statements and measurable structure and process indicators, are one innovative way of tackling the guideline implementation gap. Having adopted a zero tolerance policy to maternal deaths, the Government of Kerala worked in partnership with the Kerala Federation of Obstetricians & Gynaecologists (KFOG) and NICE International to select the clinical topic, develop and initiate implementation of the first clinical QS for reducing maternal mortality in the state. Description of practice: The NICE QS development framework was adapted to the Kerala context, with local ownership being a key principle. Locally generated evidence identified post-partum haemorrhage as the leading cause of maternal death, and as the key priority for the QS. A multidisciplinary group (including policy-makers, gynaecologists and obstetricians, nurses and administrators) was established. Multi-stakeholder workshops convened by the group ensured that the statements, derived from global and local guidelines, and their corresponding indicators were relevant and acceptable to clinicians and policy-makers in Kerala. Furthermore, it helped identify practical methods for implementing the standards and monitoring outcomes. LESSONS LEARNED: An independent evaluation of the project highlighted the equal importance of a strong evidence-base and an inclusive development process. There is no one-size-fits-all process for QS development; a principle-based approach might be a better guide for countries to adapt global evidence to their local context

A DYNAMIC CONTENT MANAGEMENT SYSTEM FOR THE VISUALIZATION OF CULTURAL INFORMATION; THE CASE OF THE STATE CONSERVATORY OF THESSALONIKI, GR

Although there are several attempts of embedding static content in events’ brochures and posters, the increasing need for flexibility and versatility of the content, leads to the development of a mobile application with an in-app dynamic content management system. In this context, DigiOrch is an ongoing research program where, a Content Management System is developed to organize all the digital material and maintain the appropriate connection to the analogical markers. Furthermore, a mobile application is developed that lev-erages this system using in app dynamic modules, which, by utilizing the augmented reality technology, presents multimedia data such as texts, photos, videos, and 3D Models to the end-user by “superimposing” them on mobile devices screen, providing extra additional information on any valid smart-leaflet.The overall workflow of the in-app Dynamic Content Management System (DCMS) can be described as a group of modules that managing and copying content files from a remote infrastructure such as an ftp server or a local resource if network is missing, to the mobile device’s file system.The in-app DCMS consists of 4 modules: The first module is the parser, which is responsible for reading a downloaded *.json file and creating content-linked objects. The second module is the download module which is responsible for downloading the overall content by iterating the content-linked objects, created by the previous module. The third module le is the update module that, by iterating the initial content file and the local file system, suggests whether a content update is necessary. The fourth module is the loading module, which is responsible for fetching the content on runtime to fill the content-holding components, such as 3D Models and UI photo galleries, of the AR scenes on runtime.</p

When does NICE recommend the use of health technologies within a programme of evidence development?

This article is made available through the Brunel Open Access Publishing Fund. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.This article has been made available through the Brunel Open Access Publishing Fund.Background: There is growing interest internationally in linking reimbursement decisions with recommendations for further research. In the UK, the National Institute for Health and Clinical Excellence (NICE) can issue guidance to approve the routine use of a health intervention, reject routine use or recommend use within a research programme. These latter recommendations have restricted use to ‘only in research’ (OIR) or have recommended further research alongside routine use (‘approval with research’ or AWR). However, it is not currently clear when such recommendations are likely to be made. Objectives: This study aims to identify NICE technology appraisals where OIR or AWR recommendations were made and to examine the key considerations that led to those decisions. Methods: Draft and final guidance including OIR/AWR recommendations were identified. The documents were reviewed to establish the characteristics of the technology appraisal, the cost effectiveness of the technologies, the key considerations that led to the recommendations and the types of research required. Results: In total, 29 final and 31 draft guidance documents included OIR/AWR recommendations up to January 2010. Overall, 86 % of final guidance included OIR recommendations. Of these, the majority were for technologies considered to be cost ineffective (83 %) and the majority of final guidance (66 %) specified the need for further evidence on relative effectiveness. The use of OIR/AWR recommendations is decreasing over time and they have rarely been used in appraisals conducted through the single technology appraisal process. Conclusion: NICE has used its ability to recommend technologies within research programmes, although predominantly within the multiple technology appraisal process. OIR recommendations have been most frequently issued for technologies considered cost ineffective and the most frequently cited consideration is uncertainty related to relative effectiveness. Key considerations cited for most AWR recommendations and some OIR recommendations included a need for further evidence on long-term outcomes and adverse effects of treatment.Medical Research Counci

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