Key principles for conducting an HTA process: Knowledge mobilisation for UHC

Reiner Banken reiner.banken@inesss.qc.caRenée LatulippeMonique Fournier

Cairo, Egypt, Dec 2, 2014Second Inter-Country Meeting on Health Technology AssessmentEMRO/WHO

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The origin of Health Technology Assessment

Request of the US Congress Senate Committee on Human Resources to OTA in 1974: « whether a reasonable amount of justification should be provided before costly new medical technologies and procedures are put into general use»

•Knowledge Pull from Decision-makers•Paradigm of Evidence-informed decision-making•HTA Institutions as Boundary Organisations

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The “natural history” of health

technology assessment:

emergence, consolidation, and

expansion.• Emergence: need expressed by decision-makers in a context

of depoliticizing allocation decisions in times of increasing resource constraints, importance of leaders, development of the scientific know-how, high cost medical device focused, little stakeholder involvement,

• Consolidation: more structured organizational HTA systems, priority setting, enlargement of scope of technologies, increased stakeholder involvement

• Expansion: multiple disciplines, multiple products, political recognition, HTA system, strong stakeholder involvement, investment into Knowledge translation

Battista RN, Hodge MJ . Int J Technol Assess Health Care. 2009 Jul;25 Suppl 1:281-4.

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HTA in the 21 century – A perspective from Political Science

• HTA has developed in a relatively depoliticized environment … buffered from the capricious impacts of electoral politics.

• HTA in all the countries began with relatively politically innocuous studies of technologies recognized to be of major import to national health systems or researcher-initiated studies.

• However, with increased focus in health systems on explicit determination of health benefits baskets, the role of HTA has become more high profile. This means that political accountability for the entire HTA process will increase.

• The implication is that future management of HTA programs will require self-conscious attention to the building of institutions capable of handling the delicate process of integrating science and politics in health policy.

Citation from the abstract of Chinitz. Health technology assessment in four countries: response from political science. IJTAHC 20:1 (2004), 55–60

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HTA for UHC: Moving from technical advice for decision-making to mediation through science

Efficient and participatory health systems require the commitment of society, with clear mechanisms for inclusion, transparency, and accountability, as well as multisectoral participation, dialogue, and consensus among the different social actors, and firm, long-term political commitment from authorities responsible for formulating policies, legislation, regulations, and strategies for comprehensive, timely, quality services. (PAHO Resolution on UHC, 2014)

Use of health technology assessment approaches in order to inform and steer decision-making in moving towards universal health coverage and to improve access to essential, quality-assured and affordable medical products. (WHO Resolution on Health intervention and technology assessment in support of universal health coverage, 2014)

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HTA processes for UHC

Producing HTA as a common good through independent, rigorous and participative processes.

HTA as a knowledge mobilization process

HTA for decision-making HTA for decision-making (in the ‘90s)(in the ‘90s)

Source : Battista RN, Hodge MJ. The evolving paradigm of health technologyassessment: reflections for the millennium CMAJ 1999; 160 (10) : 1464-67

Knowledge Synthesis

Interdisciplinary Approach

Knowledge Transfer

Decision making

The 4 pillars of HTA

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ConclusionsHTA's purpose is to solve a problem by mobilizing the types of evidence required and the concerned actors, in order to support political, organizational or clinical decision-making. HTA relies on the mediation between contextual, colloquial and scientific evidence, as well as on interactions with stakeholders for recommendation making. Defining HTA as a knowledge mobilization process might contribute to consider the different orders of knowledge, the social, political and ethical dimensions, and the interactions with stakeholders, among the essential components required to respond to the preoccupations, needs and contexts of all actors concerned with the evaluation question's issues.

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HTA today: Science for Action

PATIENTS PARTNERSPOPULATION

PATIENTS EXPERTS OF LIVING WITH AN ILLNESS

PATIENTS-AS-CO RESEARCHERS

- Research

PATIENTS-AS-CO RESEARCHERS

- Research

EXPERIENCECOLLECTORSEXPERIENCECOLLECTORS

ACTIONRESEARCH

ACTIONRESEARCH

CO-DESIGNCO-DESIGN

QUALITY

FACILITATION

GOVERNANCE

PATIENTS-AS-ADVISORS

- Care

PATIENTS-AS-ADVISORS

- Care

PATIENTS-AS-COACHS

- Trainers of trainers

PATIENTS-AS-COACHS

- Trainers of trainers

PATIENTS-AS-TRAINERS

- Education

PATIENTS-AS-TRAINERS

- Education

CO-DESIGN

MENTORSHIP

TRAINING

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Some thoughts in the room….

• This looks interesting intellectually, but …• He has no idea of my reality…• I knew HTA was complicated, but this looks even worse

than I thought.• There is no way that I can convince anybody to

implement HTA if this is what it means.• He is crazy …• …

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Responses to the questions

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Messages from the evolution of HTA

1. The use of HTA in Health Systems is evolving over time.2. Institutions (rules, organisations, legal frameworks) are

important and should enable HTA to evolve.3. Mature HTA systems include a wide range of health

technologies and interventions to be assessed, strong stakeholder involvement and knowledge mobilisation activities.

4. The development of HTA takes place in a political arena; the objectives and processes have to be clear from the start.

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No HTA without good Science, but no Impact without Stakeholder Participation and Governance

• If you do not have the human resources to do scientific knowledge synthesis, you cannot do HTA.

• If you do not have good links to decision-making, you can do HTA, but it will not be effective.

• If you do not have strong stakeholder participation and health systems governance, HTA will not be effective for Universal Health Coverage.

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“Start small, have a clear audience and scope, and address important questions”

(Lavis et al 2008, Synthesis of findings from a multi-method study of organizations that support the use of research evidence)

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Dedicated resources for HTA

HTA Knowledge Mobilizer

1-2 persons

Putting HTA into Context

HTA Unit/ Agency

4-5 persons

>9 persons

DedicatedResources

HTA Committee

HTA System

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Human resources and objectives

1-2 persons

4-5 persons

>9 persons

Clinician champion with scientific background in knowledge synthesis. Receptor for HTA knowledge produced elsewhere. Second person could act as an HTA Knowledge mobilizer and support an HTA Committee.

Team with health economist, librarian and social scientist. Translation of HTA knowledge produced elsewhere into the local decision-making context.

Multidisciplinary team for HTA Knowledge Synthesis and Knowledge Mobilisation

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HTA should be part of a culture of Health Care Resource Stewardship

Resource stewardshipA culture where resource scarcity is openly acknowledged and recognized as a shared responsibility.

Stirling Bryan. It’s time to break our addiction to adoption: Reframing HTA as the cornerstone of ‘resource stewardship’. https://www.youtube.com/watch?v=d6zJe2x6gNMsee also https://www.researchgate.net/publication/260485842_Breaking_the_addiction_to_technology_adoption

If we want to achieve the goals of efficiency and equity through technology use, we must move from a perspective of technology adoption and technology management to pathway management with a perspective of resource stewardship.

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Strategies for EMRO

• Developping scientific capacity for knowledge synthesis in collaboration with universities, the Cochrane Collaboration, and other Health Systems Research initiatives.

• Using country or region specific Policy Windows.• Regional communities of practice in HTA.• Capacity building with existing HTA networks, such as INAHTA.• Promoting the need for HTA with policy makers and funding

agencies , but also the necessary conditions of rigor, independence and transparency

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Conclusion

• HTA informs decision-making, but it also mediates between clinical, patient, management and political perspectives.

• HTA Systems need institutions (organisations, legal frameworks, dedicated resources)

• HTA relies on strong stakeholder participation and health systems governance in order to contribute significantly to Universal Health Coverage.