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Capacity building in evidence-informed decision making: role of the Global Health and Development team in supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa) Francis Ruiz Global Health and Development, Institute for Global Health innovation, Imperial College London This presentation by iDSI is licensed under a Creative Commons Attribution-NonCommercial- NoDerivatives 4.0 International License

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Page 1: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

Capacity building in evidence-informed

decision making: role of the Global

Health and Development team in

supporting Chinese policy makers

November 2016

(Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

Francis Ruiz – Global Health and Development, Institute for Global Health

innovation, Imperial College London

This presentation by iDSI is licensed under a Creative Commons Attribution-NonCommercial-

NoDerivatives 4.0 International License

Page 2: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

Overview

• Objectives of the International Decision Support Initiative

• Introducing the Global Health and Development Group

• Priority setting in health

• Economic evaluation and Health Technology Assessment (HTA)

• Improving priority setting in China: work to date including supporting

their new national “HTA network”

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Page 3: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

The international Decision

Support Initiative (iDSI)

Page 4: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

Who we are…

Page 5: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

Better priorities for better health

Our mission is to guide decision makers to effective and efficient healthcare

resource allocation strategies for improving people’s health.

Page 6: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

Why we are unique

• We respond to policymaker demand, and focus our efforts on what client countries and funders genuinely need

• We provide practical support to country decision makers, and work alongside local teams to jointly develop sustainable systems for setting priorities fairly, and on the best available evidence

• We are an international, multi-disciplinary network. We bring together leading priority-setting institutions, delivery partners (including academics), policymakers, and funders to solve problems collaboratively

• We produce knowledge products: cutting-edge, freely accessible insights on best practices in priority-setting, informed by policymaker priorities, to generate more health for the money

Page 7: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

Health system strengthening for UHC

Page 8: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

Better Health

Effective partnerships

Strengthened

country institutions

Better decisions

Practical support and

knowledge products

through global and local

collaboration

Structures, rules, norms

Evidence-informed, transparent, independent, consultative

decision-making processes

More efficient and

equitable health spending,

with trade-offs made explicit

The iDSI Theory of Change: Our pathway to impact

*(dependent on

effectiveness of

implementation)

8

Itad & iDSI (2016) IDSI MONITORING, EVALUATION &

LEARNING FRAMEWORK

Page 9: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

GLOBAL HEALTH AND DEVELOPMENT

GROUP, IMPERIAL COLLEGE, UK

Page 10: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

Global Health and Development Group

Mission: To contribute to better health

around the world through the more

effective and equitable use of resources,

by providing advice on the use of

evidence and social values in making

clinical and policy decisions.

• Provide advice and

consultancy to decision-

makers on priority-

setting for universal

health coverage (UHC)

• Strengthen systems

and institutional

capacity

• Draw on UK and global

expertise to provide

tailored support

Page 11: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

A small sample of our work…

Value for money

• India: Institutionalising national health technology assessment (HTA) body for medical devices

• South Africa: Embedding HTA into the National Health Insurance scheme

Guidelines and quality standards

• Vietnam: Combating AMR through quality indicators in acute respiratory infections

• India: Adapting international guidelines for high-burden conditions

Pay-for-performance

• China: Integrating clinical pathways for NCDs into rural health insurance reform

• Thailand: Developing quality outcomes framework (QOF) for primary care

Page 12: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

Priority-setting in health (1)

• Resources are scarce and choices have to be made

• ‘Markets’ can be used to ‘automatically’ identify what should be produced, how it is produced, and who gets what is produced

• Can be very efficient, but healthcare is not usually provided under ‘ordinary’ market conditions because of well recognised ‘failures’

• Many countries (especially as they get richer and seek UHC) adopt risk pooling mechanisms so costs are shared among many people and there is an emphasis on accessing care based on ‘need’ rather than ‘ability to pay’

• Social insurance, e.g. France, Germany, Mexico

• Taxation, e.g. UK NHS

• ‘Mimicking the market’ – what should a healthcare system aim to maximise? QALYs…?

Page 13: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

Priority-setting in the health (2)

“The task of determining the priority to be assigned to a

service, a service development or an individual patient at a

given point in time. Prioritisation is needed because claims

(whether needs or demands) on healthcare resources

are greater than the resources available” UK NHS, 2009

• Decision makers are always making choices and

weighing the trade-offs between the various options,

whether implicitly or explicitly

• Tools for supporting explicit priority-setting, e.g.

EE/health technology assessment linked to decision

making institutional frameworks (e.g. NICE…)

Page 14: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

“... the comparative analysis of alternative courses

of action in terms of both their costs and

consequences.”Drummond, Stoddart & Torrance, 1987

A tool for priority setting in health:

economic evaluation

New treatment

Current treatmentCosts

value of extra

resources used (loss

to other patients)

Consequences

value of

health gain for

this patient

group

Analysis should be conducted separately for each subgroup of

patients.

Page 15: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

But…economic evaluation only one

aspect of the ‘answer’

• Politics and political economy mean that the ’right’

decisions don’t always get made or implemented, and

suggest it is rational for policymakers to make decisions

against the broader interest of population

• Interest groups and capture – pharma industry, professional

medical associations, patient groups…

• Voting models – e.g. appealing to the ‘median voter’

• Decentralisation – federal/state government; contracting out to

NGOs

• Underline the importance of having a robust, principled

process that considers such constraints

Source: Hauck, K., & Smith, P. (2015) The politics of priority-setting in

health: A political economy perspective

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Page 16: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

Health Technology Assessment (HTA)

and economic evaluation

HTA is a multidisciplinary field of policy analysis. It studies the medical,

social, ethical, and economic implications of development, diffusion,

and use of health technology.

Any intervention that may be used to promote health, to prevent,

diagnose or treat disease or for rehabilitation or long-term care. This

includes the pharmaceuticals, devices, procedures and organizational

systems used in health care.

Source: INAHTA/glossary http://www.inahta.net/

Page 17: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

Using HTA to inform priority setting

• HTA can form an integral part of a process for considering scientific evidence, economic evidence and social values, to directly inform coverage and policy decisions relating to healthcare interventions in the broadest sense, including:• Drugs, devices, diagnostic tests, surgical interventions and services,

both preventative and curative/palliative

• And service delivery models, programmatic reforms, health and public policy interventions (e.g. sugar taxes).

• Includes economic evaluation (EE)/ cost-effectiveness analysis (CEA); not just clinical effectiveness

• Drawing comparisons: Compared to the status quo, what do we gain out of the new intervention, and at what extra cost?

• Not a merely technical exercise: The process and social values are equally important

• NOTE: HTA is one component to support overall quality improvement…

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Page 18: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

World Health Assembly resolution on Health Intervention and

Technology Assessment in Support of UHC

“Every pound can only be spent

once. If we spend it unwisely...

then we risk harming other people

whose care will be adversely

affected…

It is vital that priority setting is an

evidence-informed, procedurally

fair process that defines what will

be covered through universal

health coverage.”Prof David Haslam, Chair of NICE, addressing

the 25th World Health Assembly, Geneva, 2014

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Page 19: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

The HTA Process

Defining

Decision

Space /

Topic

Selection

AnalysisDecision

Making ImplementationAppraisal

Source: PRICELESS

Page 20: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

Financial and non-financial levers for quality improvement

Quality standards

Clinical guidelines

and pathways

HTA

A stepwise process from evidence to policy

Health technology assessment (HTA) to compare clinical and cost-effectiveness of different interventions

Clinical guidelines (STGs) and pathways distilled from HTA and other evidence

Quality standards and indicators from evidence-based guidelines

Health benefits plans (HBPs), pay-for-performance, other levers (regulation, accreditation, education…)

Evidence

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Page 21: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

iDSI ‘HTA hubs’

• A means to make iDSI goals, especially in-country support, more responsive, scaleable and sustainable

• Involves the identification of in-country focal points around which hubs (=“institutionalised” frameworks) will be developed• Catalyse new in-country and regional partnerships

• Hubs aim to create national and – importantly – regional support for active priority setting involving advocacy and knowledge sharing (but initial emphasis on building ‘national’ capacity)

• Hub activities include the delivery of practical support pilots, for undertaking, using and understanding priority setting processes from the point of view of multiple stakeholders

• Thailand’s HITAP is the focal point for the already established “SE Asia hub”: supporting HTA development in Indonesia, Vietnam etc, and a key partner in regional networks (HTAsiaLink)

• Linked to the iDSI ‘theory of change’

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Page 22: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

Some challenges to hub development

• Existing capacity within coordinating organisations, and

ability to attract and retain skilled individuals

• Fragmented systems (health service silos; academic

competition and/or weak engagement with policy makers)

• Limited government / policy maker interest… or active

‘resistance’

• Capacity of decision makers to interpret and use outputs

from HTA hubs

• Inadequate local information to support HTA / difficulty in

accessing potentially useful data

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Page 23: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

Global Health and Development Group

work in China

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Page 24: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

People's Republic of China (1)

• Pop: 1.4 billion people; Area: 9.6 million km²

• Healthcare system highly decentralised – strong

provincial level administration

• About 95% health insurance coverage (various schemes)

but…

• Relatively high out-of-pocket payments

• OOP fell from 60% (2002) to 34.9% (2011)

• Evidence of over- and under-treatment / inappropriate

care

• E.g. over-prescribing of antibiotics; also use of technologies

of no proven benefit / not ‘cost-effective’

Page 25: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

People's Republic of China (2)• HTA/EE capacity in China

• University based institutions

• An key (“focal”) institute under the leadership of the National Family Planning Commission (NHFPC), the former MoH

• China National Development Research Center (established in 1991)

• In 2008 the CNHDRC created the Center for Health Policy Evaluation and Technology Assessment (CHPETA)

• CNHDRC/CHPETA key organisation – formal links with the decision making processes

• CHPETA undertaken HTA/economic assessments in a number of areas including influenza prevention and control and da Vinci surgical systems

• Has had policy impact and raised the profile of HTA

Page 26: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

HTA/EE capacity in ChinaAssessment

emphasisSupporting institution Assessment institution

Established

in

Number

of staff

Health technology

assessment (HTA)

China National Health

Development Research Center

Centre for Health Policy Evaluation

and Technology Assessment2008 12

Fudan UniversityHealth Technology Assessment Key

Lab1994 3-5

Institute of Health Service and

Medical Information, Shanghai

Health Technology Assessment center,

Shanghai2011 3-4

Hangzhou normal UniversityHealth Technology Assessment

center2013 3-4

Pharmacoeconomic

assessment

China National Health

Development Research Center

Pharmacoeconomic Assessment

Research Room1996 4-6

Fudan UniversityPharmacoeconomic Research and

Evaluation Center2002 7

Peking UniversityPharmacoeconomic Research Center

of Guanghua School of Management2003 10

Evidence-based

medicine (EBM)

Huaxi Hospital of Sichuan

University

Chinese Cochrane Center (12 sub-

centers)1997 10

Peking UniversityEvidence-based Medicine Center of

Peking University2004 -

National HTA networks:

2014-HTA technical committee, branch of China health economic society(CNHDRC)

2013-China HTA network (Fudan University)

Source: CNHDRC

Page 27: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

Our work in the

People’s Republic of China

Joint pilots: clinical pathways and

payment reform

Phase I (2009-2012)

‘Simple’ pathways for selected surgeries

Phase II (2012- )

Stroke + COPD pathways in four counties

• Projects strengthen rural health system,

including promoting effective use of medicines

and medical devices, and treatment in community

• Payment reforms applied in over 1,000 counties

• The China Health Development Research

Center (CNHDRC) increasingly active as a

source of priority-setting expertise

Page 28: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

CNHDRC and GHD: continued collaboration

Progress in

institutionalising explicit

and evidence-informed

priority-setting (including

health technology

assessment) which

considers economic

evidence and local values

Roadmap for institutionalizing evidence-

informed priority-setting methods as the

basis for spending decisions and

CNHDRC HTA Hub

Joint UK Research Council and FCO

applications incl recent to Engineering

and Physical Sciences Research Council

Sustained support to public hospital

reforms and strengthening community

care facilities (building on existing clinical

pathway and payment reform projects)

Regional and South-South support to

priority-setting in other countries in the

region

iDSI

Imperial

CNHDRC

NHFPC

Areas of collaboration Expected outcome

Page 29: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

Senior delegation visit to Imperial College

October 2016• GHD/Imperial hosted a delegation of 25 high level officials

from the CNHDRC and the NHFPC

• Learn about the UK NHS, HTA, primary / integrated care….

• Aside from Imperial colleagues, study tour included contributions

from the MHRA, NHS Digital, the University of Manchester, the

Department of Health, London School of Economics, among others

• The main aim of the visit was the signing a Memorandum

of Understanding (MoU) between CNHDRC) and the

Institute for Global Health Innovation (IGHI)

• This agreement is the first collaboration between Imperial

College and CNHDRC

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Page 30: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

MOU signing

• Deputy Director of IGHI, Professor Guang-Zhong Yang said “We are very grateful to iDSI and the Global Health Development Group for providing this key opportunity to work together and are delighted that the collaborations that were set up while the Global Health Development group was still at NICE will now be continued from within IGHI. This in turn will also add new collaboration between the other departments within IGHI and Imperial as a whole and we are very much look forward to working together on this highly important piece of work.”

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Page 31: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

4th People-to-People (P2P) Dialogue

• On 5 Dec, Kalipso Chalkidou, Director of GHD,

represented Imperial group at the 4th P2P dialogue in

Beijing

• Event convened by Vice Minister Cui Li from the National

Health and Family Planning Commission (NHFPC) of

China, and the UK’s Secretary of State for Health Jeremy

Hunt

• Healthy ageing, improving quality of care and reducing

variation, ensuring timely adoption of good value

innovation, harvesting ‘Big Data’ and enhancing health and

social care integration were some of the common themes

highlighted as priorities by the two ministers

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Page 32: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

4th People-to-People (P2P) Dialogue

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Page 33: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

Launch of a national HTA network – CNHDRC

as ‘focal’ point

• National HTA research network launched December 2016: 33 provincial health authorities

Universities

“Research centers” (e.g. HDRC centres at Shanghai, Qingdao, Jiangsu & Liaoning)

Professional associations and societies

Hospital institutions

• Developed an early “working mechanism” identifying ‘demanders’, ‘evidence suppliers’ and an ‘evidence appraisal’ step

• International links (networks e.g. HTAsiaLink; organisations, e.g. AQUA*; and universities, e.g. IGHI, Imperial)

• Aim to develop an HTA toolkit of standardized methods (under the leadership of the NHFPC)

*Institute for Applied Quality Improvement and Research in Health Care, Germany

Page 34: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

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Event was opened by Vice

Minister Ma who commented

that “HTA is a necessary

precondition for achieving

Healthy China 2030…and a new

approach to the supervision and

reimbursement approach of the

market economy which has

succeeded the planned

economy in China”. He also

highlighted the value of HTA as

a means of promoting

“innovation driven development”

and supporting policy makers

make informed choices for NCD

prevention, a major priority for

the government.

Page 35: Capacity building in evidence-informed decision making: role of …€¦ · supporting Chinese policy makers November 2016 (Acknowledgements: Tommy Wilkinson, PRICELESS South Africa)

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