These slides were presented by Professor Adrian Towse at the 9th World Congress of the International Health Economics Association in July 2013. The presentation examined how the development of health care systems affect the evolution of the use of health technology assessment. Three countries provide case studies: Brazil, China and Taiwan.

1. Placing the Evolution of HTA in Emerging
Market Health Care Systems in the Context
of Health System Development:
Approach and Findings
Professor Adrian Towse
Office of Health Economics
International Health Economics Association
9th World Congress • Sydney • 7-10 July 2013

2. Acknowledgements
• This project has been led by Adrian Towse, Nancy Devlin, and
Emma Hawe at the Office of Health Economics (OHE) with the
assistance of Professor Lou Garrison and his colleagues at
Veritech Consulting and the University of Washington, Seattle
• Local researchers Michael Qin, Vanessa Teich, and Ivy Tsai
have undertaken research and interviews in China, Brazil, and
Taiwan respectively
• The study was funded by the Pharmaceutical Research and
Manufacturers Association

3. The Objectives of the Study
• To develop a categorisation of health care systems (HCS)
• To develop a categorisation of types of HTA using definitions
recognised by practitioners in the field. Inevitably these are based
on the experiences of high income countries, but can be expressed
in a form that can fit into policy development in relation to the
current and future health care systems of low and middle income
countries.
• To combine these two strands (HCS and HTA) to examine the role
for HTA in a health care system dependent on development stage
and structure of that health care system
• To set out these findings in a way that is helpful to understanding
the potential role of HTA processes – using three jurisdictions for
illustration: Brazil, China and Taiwan.

4. • More countries seeking to achieve one or more of:
 Universal coverage of a minimum benefit package for their
citizens
 Adding to existing coverage by increasing the numbers of
services included in the benefit package (for example by
including outpatient services including drugs)
 Reducing the amount of co-payment faced by patients on
services that are included in the benefit package.
• Ageing populations and growth in the disease burden
• An increased range of potential health technologies
• Economic pressures, with recent and projected economic
growth rates in many countries below historical levels
Trends in health care

5. The Four Functions of Health Care Systems
Source: Murray and Frenk, 2002

6. Six Building Blocks of a Health System
Source: WHO, 2010

7. Input-Output Model of the Health Care System
Source: Garrido et al, 2010

8. Definitions of Health Technology and HTA
• A health technology is defined by HTAi as
An intervention that may be used to promote health, to prevent,
diagnose or treat acute or chronic disease, or for rehabilitation.
Health technologies include pharmaceuticals, devices, procedures
and organizational systems used in health care.
• Health technology assessment (HTA) is defined
in the HTAi mission statement as
A scientifically based and multidisciplinary means of informing
decision making regarding the introduction of effective innovations
and the efficient use of resources in health care.

9. What Exactly Is HTA?
• We can categorise HTA into three types:
 HTA aimed at appraisal of individual technologies, or
groups of closely related technologies
 HTA aimed at developing clinical practice guidelines or the
way in which individual technologies are combined with
and within a delivery system to manage patient clinical
pathways efficiently
 HTA that is about the efficiency of the organizational
systems or architecture of the health care system

10. Specific technology (tool) Area Type
Aspirin, lipid-lowering drugs,
ACE inhibitors
Intervention provided in health-care
services
Drug
Stent/stenting
Coronary artery bypass
grafting (CABG)
Intervention provided in health-care
services
Device/procedure
Rehabilitation programme
Educational interventions
Intervention provided in health-care
services
Multifaceted
intervention
Disease management
programme for CVD
Intervention applied to the health-
care system (organization of service
provision)
Multifaceted
intervention
Pay for performance (e.g.
targeting higher prescription
of aspirin for CVD)
Intervention applied to the health-
care system (payment of providers)
Policy
Smoking ban Intervention outside health-care
system
Policy
Examples of Technologies at Different Levels
Source: Garrido et al, 2008

11. • HTA is one tool for improving health system performance.
• Considering how to use and improve the use of HTA needs to be put in the
context of other tools and of the strengths and weaknesses of the health
care system.
• Focus of use of HTA often is on informing decisions about the use of
individual technologies, notably about inclusion in a benefit package.
• Important, however, that context is borne in mind--or efficient HTA for
individual technologies may not result in optimal use of those
technologies within the health care system because of problems
elsewhere in the system.
• HTA aimed at developing clinical practice guidelines or HTA that is about
the efficiency of the organizational systems or architecture of the health
care system may be more important.
Role of HTA

12. The “Natural” History of HTA Development
Emergence Consolidation Expansion
Why? • Convergence of needs, demands,
and supply
• Key individuals are “champions” of
HTA
• Receptive policy/political
environment
• Early successes attract interest of more
decision makers
• Expansion of demand for HTA products
• Formalized priority settings process
• HTA as part of official
political discourse
• Increased demand for
diversified products
What? • Narrow interpretation of health
technology
• Focus on high intensity technology
(e.g., imaging)
• Exclusion of pharmaceuticals
• Broadening of scope of HTA
• Possible addition of pharmaceuticals
• Shift from specific technologies to care
processes for the management of
health conditions
• Further broadening of scope
of HTA (pharmaceuticals,
public health, delivery
models, social services)
• Existing practices and new
interventions
How? • Modest resources, at times project
or deliverables specific
• Minimal scientific capacity
• Expansion of scientific team
• Modest addition of resources
• Research partnerships sought
• Significant increase in
resources
• Expansion of scientific team
and partnerships
• Diversification of products
• Clinical practice guidelines
And,
Then
What?
• Knowledge translation minimal
• Efforts directed to policy makers,
often by means of personal
communication
• Progression of knowledge translation
efforts
• Broadening of targets audiences
• Consolidation of multiple
target audiences
• Specialization of KT
instruments
• Increased proportion of
resources to KTSource: Battista and Hodge, 2009

13. Health Care System Typology: Two Key
Attributes/Variables and Levels
LEVEL OF SPEND
What quantity of resources are
available?
• Low spend per capita
• Medium spend per
capita
• High spend per capita
DEGREE OF
CENTRALISATION
Who makes decisions about what
health care is funded?
• Out-of-pocket spend dominant
• Emergence of insurance or
collective funding; decisions
localised
• Active third party purchasing

14. HTA Typology: Key HTA System
Attributes/Variables And Levels
FOCUS OF HTA
What is appraisal concerned with?
• Efficacy/safety
• Relative effectiveness
• Cost-effectiveness (C-E)
• C-E and broader issues
BREADTH OF HTA
Which health services appraised?
• Basic preventative services and
minimum care packages
• New technologies
• All technologies/services

16. Evolution of HTA
• HTA has to be linked to the evolution of health care systems
• Limited role for HTA in a self-pay market
• As public insurance funding develops, it is in governments’ interests to
ensure that claims on those funds are justified
• Yet HTA can be a “product” without a customer
• Initially the insurer is typically just “paying the bills”
• The initial focus of HTA may therefore be on the highest cost services
• Over time, however, more active purchasing is likely to evolve
• HTA is often initially introduced as a “black box” with little thought
given to appropriate processes to involve stakeholders
• Ultimately, all services will be seen as candidates for HTA
• Key aspects of system architecture such as payment mechanisms and
incentives will also come under scrutiny

17. Observations
• Observation 1: Incomes are growing in emerging markets, but resulting increases in
funding for health care are likely to be outpaced by rising demands and
expectations. HTA has a role in assisting health care system reconcile rapidly
expanding demand with more slowly expanding resources. HTA can provide a
potential means of handling this in a more explicit and transparent way, and in
promoting public debate about priorities.
• Observation 2: HTA of individual technologies is not a substitute for the reform of
health care systems. Where health care systems create obviously bad incentives,
this type of micro HTA is unlikely to compensate for these failings.
• Observation 3: “One size fits all” HTA processes and methods are unlikely to be
appropriate for emerging markets. There needs to be clarity over the purpose of
HTA – and the methods and processes that are adopted need to be fit for purpose.
• Observation 4: HTA and pricing regulations work hand in hand: the approach to HTA
should be appropriate to, and work sensibly in combination with, the particular
approach to pricing technologies.

18. Particular Issues in Brazil
• In Brazil, CITEC worked slowly and appeared to be under-
resourced. This has the effect, intentional or otherwise, or
delaying reviews of, and decisions on, access to new
technologies. CONITEC has been set up in part to address these
issues.
• It is unclear how the role of CONITEC fits alongside a
constitutional right of access to healthcare (which is clearly not
consistent with the levels of funding available) and regulation
by the ANS of the minimum requirements of the private
insurance package.

19. Particular Issues in China
• In China, there are a number of reforms to health system architecture
underway and others are needed.
• Where HTA seems to be emerging as important is in the key area of clinical
practice guidelines. The initiative with the UK’s NICE International is aimed to
be targeted at generating evidence-based clinical practice guidelines linked to
incentives to deliver these evidence based clinical pathways.
• HTA in the sense of appraising the cost-effectiveness of individual drugs is not
used. There is interest in the possible use of HTA in drug assessment in all
three Ministries (MoH, MoHRSS, NRDC) and leading academics continue to
promote dialogue on guidelines for good practice.
• Arguably the biggest issue in drug procurement is improving the working of
the generic market where HTA in the narrow use of the term has no role.
• There is some use of HTA for other individual technologies outside of drugs,
led by the China National Health Development Research Center (CNHDRC)

20. Particular Issues in Taiwan
• HTA applied to drugs was first established in 2008 as a pilot project. It is
unclear how it fits logically alongside an international reference price system.
• There are also some issues around the “black box” nature of the process:
 the degree of transparency of the assessment;
 the relationship between the assessment and the drug licensing process,
given that expertise for pharmacoeconomic assessments is drawn from
the licensing body.
• Beginning in 2013, as part of Second Generation National Health Insurance
reform, the pilot project is being replaced by a new agency unit for HTA. This is
intended to address a number of issues with the pilot project.
• The role of HTA appears to be exclusively in the area of drug reimbursement;
• Some other elements impacting on cost and prices, such as incentives to
prescribe and trading margins are also being addressed in the Second
Generation reform.

21. • Battista, R.N. and Hodge, M.J. (2009) The “natural” history of health technology assessment.
International Journal of Technology Assessment in Health Care. 25(suppl.1), 281-284.
• Garrido, M.V., Zentner, A. and Busse, R. (2008) Health Systems, health policy and health technology
assessment. In Garrido et al, eds. Health technology assessment and health policy-making in
Europe. Observatory Studies Series No. 14. Copenhagen: WHO Regional Office for Europe.
• Garrido, M.V., Gerhardus, A., Rottingen, J-A. and Busse, R (2010). Developing health technology
assessment to address health care system needs. Health Policy. 94(3), 196-20.
• Murray, C. and Frenk, J. (2002) A WHO framework for health system performance assessment.
Available at http://bit.ly/18MU050. [Accessed 29 July 2013].
• Towse et al. (2011). The evolution of HTA in emerging market health care systems: Analysis to
support a policy response. Consulting Report. London: Office of Health Economics. Available at
http://www.ohe.org/publications/article/the-evolution-of-hta-in-emerging-markets-100.cfm.
• WHO (World Health Organisation). (2010) Monitoring the building blocks of health systems: a
handbook of indicators and their measurement strategies. Geneva: WHO.
References

22. To enquire about additional information and analyses, please contact
Adrian Towse at atowse@ohe.org
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