Economic evaluations of health technologies, often known as health technology assessments (HTA), are notable decision making tools used to help allocate scarce health care resources more efficiently. In the UK and other high income settings there are well-defined and structured processes for understanding these assessments and evaluations. However, many countries still face challenges, despite the advances made by, for example, the WHO-CHOICE project, which assists countries with health care spending to ensure that effective health outcomes are achieved feasibly.
In the UK, The National Institute for Health and Care Excellence (NICE) has set out HTA processes to estimate the cost-effectiveness of many different health care interventions, programmes, alternative treatment pathways, community based services, and staffing levels, using a single threshold value alongside a country specific generic health outcome measure (Quality-adjusted Life Years – QALYs). Whilst not without its issues, this approach has helped the system to deliver more efficient health care.
Although NICE methods and guidelines are used as a framework for many countries, they may not be entirely applicable or relevant in all settings. These emerging economies have complex health care systems (involving co- and other informal payments) and often lack the infrastructure or information necessary to support the HTA process. Key challenges include the need for specialised professionals, for robust and reliable sources of information, and the financial capacity and research capability to invest in and undertake research. Improving capacity in these areas could help to improve the ability to evaluate the use of technologies within the setting of interest. The fear of a widening North-South gap in technology and pharmaceutical innovation, along with the other challenges briefly mentioned above, often mean that economic evaluations from high resource countries are used, which focus on the use of new pharmaceuticals or other medical supplies and equipment that have no direct relevance to other health care systems. These technologies represent a heavy burden to any health care budget, but more so when resources are even more scarce.
Many economic evaluations used to aid decision making are based on assumptions that could potentially be misleading in other healthcare settings. The lack of a country-specific threshold value, for example, limits how we determine what is efficient, and therefore what is worth paying for and implementing. The WHO, in an attempt to establish a universal threshold value, has set a generic gross domestic product (GDP)-per-capita threshold, which is dependent on the geographical region’s income; however without a clear evaluation of the actual efficiency of the system being implemented, using such a threshold could be misleading and fail to deliver the efficiency sought.
Emerging economies require greater investment and incentive to increase data reliability (see previous blog on challenges of big data), train health care professionals in the field, encourage discussions to develop local outcome measures (or adapt the QALY measure specifically for their own population), and define a clear threshold based on the current efficiency of the health system. Developed economies can continue to aid this process by promoting and collaborating with researchers and decision makers in low resource settings to help build local capacity to undertake such evaluations. Economic evaluation, even in low resource settings, should be used to help decision makers maximise the benefits derived from health care interventions. Variation in health care access could be reduced by potentially containing costs and managing demand of new high cost technologies; however evaluation of more context-specific technologies set within the local healthcare setting should be a priority.