Importance of Health Technology Assessments in Public Health Interventions

@mahimakaur

I completely agree with the fact that evaluation of e-Health/m-Health has been a promising aspect in digital healthcare technologies. Their full-potential can only get achieved if they are implemented after a thorough scientific evaluation by the HTA.

With the multidisciplinary approach, HTA can produce scientific evidence on the efficacy, effectiveness, and cost-effectiveness of various health technologies. Its aim to generate organizational, ethical, and social implications of the usability of the health technological solutions provides concrete evidence for decision making by administrators, policy makers, physicians, public health practitioners, and other users. Also by involving stakeholder engagement and utilizing the participatory and qualitative methods HTA ensures process evaluations and thus has its major relevancy in the evaluation of various health technologies.

@kamalpreet

Interesting read, determining the challenges and solutions to be adapted for future actions. As India has made significant policy and systemic changes to its healthcare system to promote basic universal health coverage. HTA can be an important tool in achieving these aspirations, and, over the past years, substantial investment has been made in HTA education and promotion. For greater effectiveness manufacturers should monitor HTAin activity and prepare for the application of HTA to many more technologies in the coming years to ensure capacity-building and awareness efforts advance to reach critical mass.  

HTA is conducted by an interdisciplinary team using analytical frameworks with the purpose to inform policy and help decision making in health care especially on how to allocate already constrained resources for health interventions and technologies. The INTEGRATE HTA project advocates five steps for a holistic and integrated assessment of complex technologies and interventions.

• Conducting a scoping exercise, involving stakeholders right from the start of the project (engagement, ownership);
• Collaboratively building program theory, by making explicit assumptions as to how, through what mechanisms, interventions may produce health outcomes, and what contextual factors need to be addressed;
• Examining a wide range of possible outcomes (not just safety and clinical and cost-effectiveness) that guides the collection of evidence;
• Structuring and, where possible, visualizing the assessment results, and considering different scenarios for the intervention depending on context, potential for implementation, and characteristics of beneficiaries;
• Being explicit about how the various outcomes of the assessment might be integrated into an overall conclusion regarding the merits and demerits of the healthcare technology or intervention under investigation.

This paper talks about whether INTEGRATE HTA is useful and feasible in context of LMICs. It also concludes that all the conditions are not always fulfilled in LMICs and requires consideration towards:

• The scope and quality of routine health information that can support and be fed into health technology assessments and strategic planning;
• Consensus on health system performance assessment frameworks and their main criteria, in particular the inclusion of social disparities/equity and sustainability;
• Institutional capacity to set evidence-based priorities based on a variety of explicit criteria;
• Political will to engage with stakeholders in a transparent and inclusive consultation process about health priorities.

//www.cambridge.org/core/journals/international-journal-of-technology-assessment-in-health-care/article/abs/integratehta-a-low-and-middleincome-country-perspective/FC18B51022F18BADC92F8CCF1D82DBD1

HTA covers methods for the systematic evaluation of the comparative value of pharmaceutical products (implies that it’s a clinical and economic activity both) and other health technologies. It is closely linked to the pricing and reimbursement decisions for new technologies (by the central government and private payers), preceding to admission to the formulary and during formulary management.

HTA is always embedded in the broader context of healthcare decisions, which also includes political considerations, health economics, social, ethical and other aspects. In order to ensure a successful implementation of HTA, policymakers must take appropriate choices about key design variables. Generally, there are four key decisions that are needed while designing an HTA system- 

1. Choice of HTA approach - economic evaluation, comparative assessment, balanced/multi-criteria assessment
2. Perspective of assessment - budget holder’s perspective, payer’s perspective, societal perspective
3. Timing of assessment - linked to pricing and funding decisions for new technologies, linked to formulary reviews/reassessment of already funded technologies
4. Scope of technologies to be included - innovative medicines only, assessing all proprietary healthcare interventions including diagnostics and medical devices, extend HTA to all types of health care interventions.

HTA offers a significant improvement in terms of efficiency, transparency and accountability. In most countries, in healthcare systems before HTA, there are risks of intransparent/arbitrary decisions, low efficiency, limited accountability of decision-makers and weak/nonexistent deadlines. In such healthcare systems, the introduction of HTA offers a chance to increase efficiency through better decisions, link decisions to objective or at least explicit criteria, chances to have clear deadlines and well-defined responsibilities, and thus increased transparency.

In contrast, HTA is also known to be linked with some common dysfunctions and failures and it is imperative to avoid them. To mitigate the risks, an HTA system should not provide excessive or irrelevant information to decision-makers, result in pseudo-objectivity (when HTA models and simulations represent imaginary healthcare contexts due to unreliable or missing data), cause delays in access to health technologies (when HTA is misused to postpone decisions or block technologies), reinforce the fiscal mindset in decision-making (when budget impact becomes the single most important decision driver). 

Considering the above-mentioned risks, HTA will work best if it is designed around clearly defined policy goals, taking into account available resources and ensuring proper implementation.

The increasing economic development, aging population, emerging technologies in healthcare, universal health coverage, adoption of new technologies into universal health coverage and complex healthcare system but improving governance leading to evidence based informed decision making has all together led to the evolution of Health Technology Assessment. But the real challenge lies in having the clear health outcome data, cost effective database pool, and trained capacity for the implementation of HTA in specially developing countries where HTA is somewhat new. Especially if we talk about Health Technology Assessment in Public Health Interventions, not much is available in literature to know whether HTAs have been into effective practice or not. Every clinical program is supported by a preventive health program and these programs are usually evaluated based on its efficiency and effectiveness. With expanding digitization of public health interventions, Health Technology assessment is an important tool to evaluate not just the efficiency and effectiveness of an intervention but also to understand various issues related to the use of technology such as medical, social, ethical, economic and organizational issues and serve as a multidisciplinary tool following methodological approaches which are systematic, transparent and robust thereby helping policy makers and decision makers. For public health programs, use of HTAs may prove to be very beneficial but has tremendous challenges in its implementation. These programs have implementers and stakeholders from diverse fields such as clinicians, allied health staff, managerial staff, economists, politicians, donors and the target audience. Based on various studies it has been observed that HTA have not been much effective due to ethical issues involved in PHI delivery.

But if public or the target audience can be involved in the HTA process, it would prove beneficial for HTA in PHIs. Below mentioned paper talks about Introducing Public’s perspectives in Health Technology assessments. They can be involved in the process of assessment with focus on prioritization, evidence assessment and dissemination of findings. Based on this approach, policy makers or decision makers would be able to use the most important component of HTA which asks questions about these interventions such as for whom it works, at what cost, how it can be compared to alternative intervention. Participation of public would be helpful in answering these questions.

//www.cambridge.org/core/journals/international-journal-of-technology-assessment-in-health-care/article/abs/introducing-patients-and-the-publics-perspectives-to-health-technology-assessment-a-systematic-review-of-international-experiences/0774E7F81A4DE60CDE39459354D069AC

Health technology assessment is a multidisciplinary process and integration of ethics in health technology assessment is a significant step to increase transparency and accountability of HTA process which would result in making better healthcare decisions.

This article addresses proposed framework for ethical evaluation which serve as conceptual foundation for ethical issues. Steps involves in framework are as follows:

1) Defining the objectives and scope

2) Identifying stakeholders

3) Assessing organizational capacity

4) Framing ethical evaluation questions

5) Ethical analysis

6) Deliberation

7) Knowledge/exchange translation

To know more about each step read here: //bmcmedethics.biomedcentral.com/articles/10.1186/s12910-016-0118-0#Tab1

Health care priority setting is a complex process involving multi-play of divergent interests and social values, which is unaccounted for by the value assessment frameworks employed by HTA agencies. This paper talks about an alternative framework “evidence-informed deliberative processes” which is an integration of two frameworks viz. multicriteria decision analysis and accountability for reasonableness. It takes into account stakeholder deliberation for relevant social values as well as rational decision-making through evidence-informed evaluation of the identified values. It also draws a plan for how HTA agencies should preferably organize their processes:

1. First, HTA agencies should be accountable for organizing stakeholder involvement.
2. Second, agencies are advised to integrate their assessment and appraisal phases, allowing for the timely collection of evidence on values that are considered relevant.
3. Third, HTA agencies should subject their decision-making criteria to public scrutiny.
4. Fourth, agencies are advised to use a checklist of potentially relevant criteria and to provide argumentation for how each criterion affected the recommendation.
5. Fifth, HTA agencies must publish their argumentation and install options for appeal.

//www.sciencedirect.com/science/article/pii/S1098301516341286