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2015 Global Survey on Health

Technology Assessment by
National Authorities

Main findings
WHO Library Cataloguing-in-Publication Data
2015 Global Survey on Health Technology Assessment by National Authorities. Main findings.
I.World Health Organization.

ISBN 978 92 4 150974 9


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World Health Organization 2015


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2015 Global Survey on Health
Technology Assessment by
National Authorities

Main findings
2015 Global Survey on Health Technology Assessment by National Authorities

Acknowledgements
The WHO 2015 Global Survey on Health Technology Assessment by National Authorities and this report were
developed under the overall direction of Marie-Paule Kieny, WHO Assistant Director General for Health Systems
and Innovation. The survey was coordinated and developed by Adriana Velazquez under the guidance and
supervision of Gilles Forte and Kees de Joncheere of the WHO Department of Essential Medicines and Health
Products (EMP).

The survey was developed in the Health Systems and Innovation Cluster under the HTA Ideas Bed initiative
on interdepartamental and intercluster collaboration. The members of this group included: Melanie Bertram,
Tessa Edejer, David Evans, Laragh Gollogly, Edward Kelley, Selma Khamassi, Jeremy Lauer, Susan Norris, Jer-
emy Lauer, Jane Robertson, Robert Terry, Isabelle Wachsmuth and Diana Zandi. Special collaboration on the
implementation and first analysis of the survey was received from WHO consultants: Ricardo Martinez, Daniela
Rodriguez and Dima Samaha. WHO also acknowledges the advice received on the first iteration of the survey
from international HTA experts.

Data collection would not have been possible without the support and collaboration of Permanent Missions to the
United Nations in Geneva, Member States representatives, staff from WHO country and regional offices to whom
we are very grateful. Special acknowledgement is also given to the nominated focal points on health technologies
who collected and submitted information.

This report was prepared by Suzanne Hill, Adriana Velazquez, Kiu Tay-Teo, and Alexandra Metherell of the EMP
Policy Access and Use Unit.

Graphic design and layout: Jillian Reichebach Ott for Genve Design.

More information about the survey can be found on the newly developed HTA intercluster website, www.who.int/
health-technology-assessment.

ii
Contents
Acknowledgements
Abbreviations
1. Introduction
1.1 Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2 Survey responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.3 Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.4 Report structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.5 Note on terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

2. Utilization of HTA in public sector decision making


2.1 Formal information-gathering process for decision making . . . . . . . . . . . . . . 7
2.2 Legislative requirements for considering HTA findings . . . . . . . . . . . . . . . . . 8
2.3 Purposes of undertaking HTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.4 Types of technologies or interventions assessed . . . . . . . . . . . . . . . . . . . . 9

3. Scope of HTA and availability of guidelines


3.1 Aspects considered in HTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.2 Guidelines for developing HTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

4. Institutional capacity and human resources supporting HTA


4.1 National HTA organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
4.2 Number of staff members in HTA organizations . . . . . . . . . . . . . . . . . . . . 18
4.3 Requests for HTAs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
4.4 Professionals involved in HTA preparation and decision making . . . . . . . . . . . . 19

5. Governance of HTA process


5.1 Conflict of interest declaration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
5.2 Communicating the outcomes of HTA . . . . . . . . . . . . . . . . . . . . . . . . . 22
5.3 Connection between HTA and decision making, and civil society participation . . . . . 23

6. Requirements for strengthening HTA capacity


6.1 Main barrier for producing HTA and using HTA findings in decision making . . . . . . 25
6.2 Academic or training programmes to support capacity building for HTA . . . . . . . . 27

7.Conclusions
7.1 Main findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Annex I: WHO regional groupings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Annex II: Income groupings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Annex III: WHA resolution 67.23 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

1
2015 Global Survey on Health Technology Assessment by National Authorities

Abbreviations
AFR WHO African Region1
AMR WHO American Region1
EMR WHO Eastern Mediterranean Region1
EUR WHO European Region1
GNI Gross National Income
HIC High-income countries2
HTA Health Technology Assessment
LIC Low-income countries2
LMIC Lower middle-income countries2
SEAR WHO South-East Asian Region1
UMIC Upper middle-income countries2
WHA World Health Assembly
WHO World Health Organization
WPR WHO Western Pacific Region1

1 Please refer to Annex I for the list of countries by region


2 Please refer to Annex II for the list of countries by income
2
1. Introduction

As countries strive to deliver universal health coverage, The survey had five broad sections that aimed to mea-
the process of deciding which health technologies and sure:
interventions to invest in has become increasingly im-
Utilization of HTA in public sector decision making;
portant. Countries face complex choices in deciding
Scope of HTA and availability of guidelines ;
how to direct their finite health budgets to meet the pri-
ority health needs of their populations, and in selecting Institutional capacity and human resources
from the vast array of technologies and interventions supporting HTA;
on offer. Reaching a fair and efficient outcome requires Governance of HTA process; and
a multidisciplinary process to evaluate the social, eco- Requirements for strengthening HTA capacity.
nomic, organizational and ethical aspects of a health
intervention or health technology. Health Technology The questionnaire was available in the six official lan-
Assessment (HTA) is a systematic approach to evaluate guages of the United Nations: Arabic, Chinese, English,
the properties, effects, and impacts of health technolo- French, Russian and Spanish.
gies or interventions. It can be applied to medical de- The survey questionnaire was piloted with personnel at
vices, medicines, vaccines, procedures, health services, WHO, who reviewed the contents of the questionnaire to
and public health interventions. assess the appropriateness of survey questions. Descrip-
This report summarises the methods and main findings tive statistics were used to summarise the characteristics
of the WHO 2015 Global Survey on HTA. This survey was of the survey data. Where appropriate, data were pre-
aimed at HTA conducted by government or national in- sented by regions and national income categories.
stitutes. It was undertaken in response to World Health
Assembly Resolution 67.23. This resolution, Health inter-
1.2 Survey responses
vention and technology assessment in support of univer-
sal health coverage called on the WHO Secretariat to In response to the invitation to participate, 125 Member
assess the status of HTA globally (see Annex III). States nominated national HTA focal points. Of those, 111
responded to the survey questionnaire between 24 Febru-
ary 2015 and 31 August 2015 (Chart 1.1). Member States
1.1 Method that responded to the survey are listed by regional and
All Member States were invited to participate in the income groupings in Annexes I and II. This represents an
survey through their Permanent Missions in Geneva. overall response rate of 56.2% from 194 member states.
An official circular letter was sent from WHO request- There were respondents from all six WHO regions (re-
ing nomination of a national HTA focal point within gion), and from all country income levels as classified by
the Ministry of Health and a response to the survey. To the World Bank43(country income). Participation rate var-
ensure the suitability of the nominated respondent, the ied by region and country income, with higher response
request specified that the respondent would ideally be rates from EUR (79.2%), SEAR (72.7%), EMR (61.9%) and
engaged in one or more of the following: WPR (59.3%), than AMR (37.1%) and AFR (36.2%).

Evidence-based decision making of public funding


of health services;
Determining priority health interventions;
Planning resources allocation; or
HTA in a committee, a unit, a department or an
established HTA organization at a national or
subnational level.

3
2015 Global Survey on Health Technology Assessment by National Authorities

The lower participation in these regions may be related to: Could not establish suitable contact through the
Possible insufficient human resource and technical nomination process.
capacity to respond to the survey;
Concurrent surveys at the regional level (i.e. AMR
was undertaking a survey on HTA during the same
period of time) as well as by other academic
groups; and

CHART 1.1: Number and percentage of participation by region and country income

AFR 11 5 1 14 8 6 2 N=47

AMR 1 9 4 1 5 9 6 N=35 HIC Participated Did not participate

EMR 2 3 5 3 4 1 3 N=21 UMIC Participated Did not participate


Region

LMIC Participated Did not participate


EUR 3 10 29 1 3 2 5 N=53
LIC Participated Did not participate
SEAR 1 6 2 1 1 N=11

WPR 1 5 5 5 4 6 1 N=27
0 20 40 60 80 100
% participation

1.3 Limitations 1.4 Report structure


The findings of this survey must be interpreted with con- The report has been structured according to the five
sideration of several potential sources of bias: sections of the survey, as follows:
Non-response: As noted, the participation from Chapter 2: Utilization of HTA in public sector
low-income countries and countries from AMR and decision making
AFR was low. This may have skewed the responses This section describes how widely respondents
towards countries with more established systems for reported using HTA for public sector decisions, such
undertaking HTA. as for planning and budgeting, reimbursement or
Selection bias: The recruitment method attempted to determine benefit packages and clinical practice
to identify the most suitable respondents through guidelines.
official nomination. However, it was up to national Chapter 3: Scope of HTA and availability of
authorities to select the person responsible for guidelines
answering the survey. This section describes how often responding
Measurement bias: The questionnaire did not countries reported using various aspects of HTA,
provide definitions for the technical terms and such as assessments of safety; clinical effectiveness;
survey respondents may have understood the terms economic considerations (e.g. cost-effectiveness
differently. analysis); budget impact analysis; organizational
impact; equity issues; ethical issues; feasibility
Respondent bias: Survey respondents were considerations (e.g. availability of budget, human
identified through official nomination and their resources, infrastructure); acceptability to health
participation was not anonymous. The lack of care providers; and acceptability to patients.
anonymity may have encouraged responses that
would be viewed favourably by others.

4 Classification was based on the Gross National Income (GNI) per capita using the World Bank Atlasmethod.
4
Chapter 4: Institutional capacity and human
resources supporting HTA
This section reports the availability and expertise of
human resources, and institutional capacity.
Chapter 5: Governance of HTA process
This section examines the governance structures
and linkages between HTA units and authorities
responsible for setting policy in relation to HTA.
Chapter 6: Requirements for strengthening HTA
capacity
This section reports the respondents perceived
impediments to the improved use of HTA in health
care policy.
Chapter 7: Conclusions
This section summarises the survey findings.

1.5 Note on terminology


Countries were asked whether they had a formal pro-
cess to inform decision making, in which they systemat-
ically collected data and considered the impacts of a
particular health technology or intervention. Many did
not refer to this process specifically as HTA. For the
purposes of brevity, in this report the term HTA will be
used to describe this process.

5
Utilization of HTA in
2. public sector decision
making
Most countries reported having a formal process for compiling,
analysing and synthesizing relevant information and scientific
evidence systematically to support health care policy decision
making. However, one-third of the responding countries did not refer
to this process as HTA.
Fewer than half of the countries with a formal process had
legislative requirements to consider the results of the analysis.
Countries used HTA for different purposes depending on their
income level, but most countries gathered the information for the
purpose of planning and budgeting.

2.1 Formal information-gathering The responses suggest that high- and upper mid-
process for decision making dle-income countries, especially in EUR and AMR,
were most likely to have this formal HTA process. Fif-
About four in five respondents reported that their
teen respondents said their countries did not have
countries had a formal HTA process to inform deci-
a well-defined process for considering evidence in
sion making, in which they systematically collected
decision making, but evidence was considered infor-
data and considered the impacts of a particular
mally. Three respondents did not know if their coun-
health technology or intervention (Chart 2.1). Howev-
try had a formal process.
er, one-third of the responding countries did not refer
to this process as HTA.

CHART 2.1: Number and proportion of countries that responded, having a formal process for
information compilation for decision making, by region and country income

AFR 10 4 1 1 1

AMR 1 8 3 1 1 Yes No
HIC Unsure
EMR 1 3 3 1 1 2 1 1 UMIC Yes No Unsure
Region

EUR 3 7 27 2 2 1 LMIC Yes No Unsure

SEAR 1 5 2 1 LIC Yes No

WPR 1 2 5 5 2 1
0 20 40 60 80 100
%

7
2015 Global Survey on Health Technology Assessment by National Authorities

2.2 Legislative requirements for High-income countries were much more likely than
considering HTA findings low-income countries to use HTA for determining reim-
bursement or to decide what to include in a package
Although countries reported frequently gathering and
of benefits. Middle-income countries used HTA to inform
synthesizing relevant information and scientific evi-
clinical practice guidelines and protocols (85%) more
dence to support HTA, fewer than half had legislative
often than in high- and low-income countries (46% and
requirements to formalize the incorporation of the re-
50%) (Chart 2.3). Less than 60% of countries in any in-
sults of HTA in health care decision making (Chart 2.2).
come category used HTA for pricing of health products..
Such legislative requirements were most common in
EMR and EUR where 63% of countries had such re- Analysis by region was consistent with this finding. For
quirements. Fifty-five percent of high-income countries EUR with more high-income countries than other re-
also reported having legislative requirements to con- gions HTA findings were used more for determining
sider the results of HTAs. reimbursement or package of benefits (80% of coun-
tries) compared with respondents from other regions
(28%-62%). EUR countries also applied HTA findings less
2.3 Purposes of undertaking HTA frequently for planning and budgeting than countries in
All low-income countries and 85% of middle-income other regions (Chart 2.3a).
countries surveyed said they used HTA for planning and
budgeting. Only 64% of high-income countries reported
using HTA for this purpose.

CHART 2.2: Number and proportion of countries that responded, that had legislative requirements
to consider the results of HTAs, by region and country income

100 1 1 3 1 1 1
8 2 4
2
80 15
12 7
1 5 I don't know
42 9 7 8
60 7 13 No
%
Yes
40
5 10
22 20
20 43 3 4 4 9
5 4

0
All AFR AMR EMR EUR SEAR WPR LIC LMIC UMIC HIC
By region By income

8
CHART 2.3: Purposes of undertaking HTA, proportion of countries by (a) region and
(b) country income
Lower Upper
Low High
AFR AMR EMR EUR SEAR WPR middle middle
income income
income income

A Certificate of need/carte sanitaire


100% B Certificate of need/carte sanitaire
100%

80% 80%

60% 60%

Reimbursement/ Clinical practice Reimbursement/ Clinical practice


package of benefits 40% guidelines and package of benefits 40% guidelines and
protocols
protocols
20%
20%

Indicators of Planning and Indicators of Planning and


quality of care budgeting quality of care budgeting

Pricing of health products Pricing of health products

2.4 Types of technologies or tendency to use HTA for population-level health inter-
interventions assessed ventions (85%), but less often for decisions for medicines
(62%), medical devices (54%) or surgical interventions
More than half of the respondents used HTA for all
(38%) (Chart 2.4b). On the other hand, a higher pro-
types of health technology (Chart 2.4a). The survey find-
portion of high-income countries reported using HTA for
ings suggest a link between income level and the focus
medicines (89%), medical devices (83%) or surgical in-
of HTA. For example, low-income countries reported a
terventions (69%) (Chart 2.4b).

CHART 2.4: Type of technologies or interventions assessed, proportion of countries by (a) region
and (b) country income
Low Lower Upper High
AFR AMR EMR EUR SEAR WPR income middle middle income
income income

Clinical interventions
A Clinical interventions
100% B 100%

80% 80%

Vaccines Medical devices Vaccines Medical devices


60%
60%

40%
40%

20%
20%

Medicines Surgical Medicines


Surgical
interventions
interventions

Population level health Service delivery models Population level health


Service delivery models interventions (prevention interventions (prevention
and promotion) and promotion)

9
Scope of HTA and
3. availability of
guidelines
Countries reported that safety, clinical effectiveness, and economic
and budgetary impact were the main components of HTA. The
acceptability to health care providers and patients, equity issues,
ethical issues and feasibility considerations were much less
commonly considered.

3.1 Aspects considered in HTA potential components of HTA. Acceptability to health


care providers and patients, equity issues, ethical issues
The survey asked the respondents to estimate the fre-
and feasibility considerations were not considered as
quency of considering 10 pre-specified aspects of HTA
often. Specifically, most countries (53%-92%) always or
when evaluating seven types of technologies or inter-
almost always considered safety across all types of
vention, as illustrated in Figure 3.1.
health technology or intervention. Clinical effectiveness
As shown in Chart 3.2, countries reported that emphasis was also deemed important regardless of the type of
was placed more on safety, clinical effectiveness, eco- technology or intervention, with between 65% and 85% of
nomic and budgetary considerations, rather than other respondents reporting it as an important aspect of HTA.

FIGURE 3.1: Aspects considered in HTA for different types of technologies and interventions

Types of technologies/ What does HTA consider?


interventions Safety
Medicines Clinical effectiveness

HTA
Vaccines Economic considerations
Medical devices Budget impact analysis
Surgical interventions Organization impact
Service delivery models Equity issues
Populations level health interven- Ethical issues
tion (public health interventions) Feasibility considerations
Clinical interventions Acceptability to health care providers
Acceptability to patients

11
2015 Global Survey on Health Technology Assessment by National Authorities

CHART 3.2: Frequency of covering different aspects


Always, almostFrequently inSometimes
HTA, proportion
always (80%-100%)
(60%-79%) (40%-59%) of countries
A few times (20%-39)
Never, by type of technology
almost never (0%-19%)

Medicines (N=78)
Safety
100%
Acceptability Clinical effectiveness
to patients 80%

60%

40%
Acceptability to health Economic considerations
care providers 20% (e.g. cost-effectiveness analysis)

Feasibility considerations Budget impact analysis


(e.g. availability of: budget,
human resources, infrastructure)

Ethical issues Organizational impact

Equity issues
Always, almostFrequently
always (80%-100%)
(60%-79%)
Sometimes (40%-59%)
A few times (20%-39)
Never, almost never (0%-19%)

Vaccines (N=57)
Safety
100%
Acceptability to patients Clinical effectiveness
80%

60%

40%
Acceptability to health Economic considerations
care providers 20% (e.g. cost-effectiveness analysis)

Feasibility considerations Budget impact analysis


(e.g. availability of: budget,
human resources, infrastructure)

Ethical issues Organizational impact

Always, almostFrequently
always (80%-100%)
(60%-79%)
Equity Sometimes
issues (40%-59%)
A few times (20%-39)
Never, almost never (0%-19%)

Medical Devices (N=62)


Safety
80%
Acceptability to patients Clinical effectiveness
70%

60%

50%

40%

30%
Acceptability to Economic considerations
20%
health care providers (e.g. cost-effectiveness analysis)
10%

Feasibility considerations Budget impact analysis


(e.g. availability of: budget,
human resources, infrastructure)

Ethical issues Organizational impact

Equity issues

12
Always, almostFrequently
always (80%-100%)
(60%-79%)
Sometimes (40%-59%)
A few times (20%-39)
Never, almost never (0%-19%)

Surgical interventions (N=52)


Safety
80%
Acceptability to patients Clinical effectiveness
70%

60%

50%

40%

30%
Acceptability to health Economic considerations
20%
care providers (e.g. cost-effectiveness analysis)
10%

Feasibility considerations Budget impact analysis


(e.g. availability of: budget,
human resources, infrastructure)

Ethical issues Organizational impact

Equity issues
Always, almostFrequently
always (80%-100%)
(60%-79%)
Sometimes (40%-59%)
A few times (20%-39)
Never, almost never (0%-19%)

Service Delivery Models (N=40)


Safety
80%
Acceptability to patients Clinical effectiveness
70%

60%

50%

40%

30%
Acceptability to health Economic considerations
20%
care providers (e.g. cost-effectiveness analysis)
10%

Feasibility considerations Budget impact analysis


(e.g. availability of: budget,
human resources, infrastructure)

Ethical issues Organizational impact

always Equity
Always, almostFrequently issues
(80%-100%)
(60%-79%)
Sometimes (40%-59%)
A few times (20%-39)
Never, almost never (0%-19%)

Population level health interventions


(public health interventions) (N=54)
Safety
60%
Acceptability to patients Clinical effectiveness
50%

40%

30%

Acceptability to health 20% Economic considerations


care providers 10%
(e.g. cost-effectiveness analysis)

Feasibility considerations Budget impact analysis


(e.g. availability of: budget,
human resources, infrastructure)

Ethical issues Organizational impact

Equity issues

13
2015 Global Survey on Health Technology Assessment by National Authorities

Clinical Interventions (N=54)


Safety
80%
Acceptability to patients Clinical effectiveness
70%

60%

50%

40%

30%
Acceptability to Economic considerations
20%
health care providers (e.g. cost-effectiveness analysis)
10%

Clinical Interventions (N=54)


Feasibility considerations Safety
Budget impact analysis
(e.g. availability of: budget,
human resources, infrastructure)
Acceptability to patients 80%
Clinical effectiveness
70%

60%

50%
Ethical issues 40%
Organizational impact
30%
Acceptability to Equity issues Economic considerations
20%
health care providers (e.g. cost-effectiveness analysis)
10%

Feasibility considerations Budget impact analysis


(e.g. availability of: budget,
human resources, infrastructure)

Ethical issues Organizational impact

Equity issues

Always, Sometimes
Frequently
almost always (40%-59%)
(60%-79%)
(80%-100%)

A few times Never,


(20%-39) almost never
(0%-19%)

Always, Sometimes
Frequently
almost always (40%-59%)
(60%-79%)
(80%-100%)

A few times Never,


(20%-39) almost never
(0%-19%)

14
3.2 Guidelines for developing HTA the countries), vaccines (67%). medical devices (64%)
and Guidelines for HTA of service delivery models were
Most respondents reported having a guideline for
the least common, with only 36.5% of countries report-
preparing HTA reports, submissions or dossiers for at
ing to have such a guideline. Sixty-one percent of coun-
least one type of technology or intervention (Chart 3.3).
tries, mostly countries in EUR, said their HTA guidelines
Guidelines were most common for medicines (82% of
were publicly available (Chart 3.4).

CHART 3.3: Availability of guidelines for developing HTA, proportion and number of countries by
type of technologies or interventions

One or more guidelines No


93 10
Yes
Medical devices 54 31
Medicines 70 15
Population level health interventions 42 43
(prevention and promotion)
Service delivery models 31 54
Surgical interventions 49 36
Vaccines 57 28
0 20 40 60 80 100
%

CHART 3.4: Availability of the guidelines in the public domain

I don't
Yes No know
Yes

4%
3% WPR
5%

SEAR

32% EUR
36% 46%
EMR

5% AMR
10%
AFR
5%

sfds

15
Institutional capacity
4. and human resources
supporting HTA
Most countries reported having a national entity of more than
six staff members that produced HTA reports for the ministry of
health. Staff members were usually public health and clinical
science professionals. Organizations in high-income countries were
better resourced than those in low-income countries.

4.1 National HTA organization terms of the structure of the national organizations, 17
countries had a standalone HTA agency, and 19 had a
Two in three countries reported having a national HTA
national unit or department within the ministry of health
organization or department, unit or committee that
(Chart 4.1b). Three countries reported having a unit affil-
produced HTA reports for the ministry of health (Chart
iated with a university or committee that was not within
4.1a). This was more likely in AMR and EUR countries
the ministry to support HTA activities in the public sector.
(81%-83%) than in countries in other regions (33%-77%). In

CHART 4.1: Number of organizations that produce HTA reports for the Ministry of Health, by region
and country income

AFR 3 1 1 5 3 2

AMR 1 7 2 1 1 HIC Yes No

EMR 1 3 1 1 2 UMIC Yes No


Region

2 5 23 2 4 1
LMIC Yes No Unsure
EUR
LIC Yes No Unsure
SEAR 4 1 1 1 1

WPR 1 3 5 1 2 1
0 20 40 60 80 100
% participation

17
2015 Global Survey on Health Technology Assessment by National Authorities

4.2 Number of staff members in 4.3 Requests for HTAs


HTA organizations Countries reported that in the 12 months before the
Three in four countries reported having more than six survey, HTAs were requested mainly by the ministry of
staff members in the HTA unit/agency/committee. HTA health or public insurance (always or almost always
agencies or committees in EUR and in high-income in 45% of respondents) or reimbursement bodies (al-
countries had more professional human resources to ways or almost always in 25% of respondents). Re-
support HTA activities than in other regions and national quests were not as common from other sources, such
income groups (Chart 4.2). as procurement agencies, public health care providers
or national regulatory agencies. As shown in Chart 4.3,
CHART 4.2: Estimated number of professional
staff in the HTA organization, by region and a significant number of respondents reported that the
country income group requests for HTAs never or almost never came from
organizations outside of the ministry.
25 23 CHART 4.3: Organizations requesting HTAs in the
past 12 months, proportion of countries by type
20 of technologies or interventions
Number of countries

15
Always,
15 almost always
Frequently
(60%-79%)
Sometimes
(40%-59%)
A few times
(20%-39)
Never,
almost never
11 (80%-100%) (0%-19%)

10 Healthcare professionals
50%

5 5 Procurement agency 40%


Public health care provider
5 (i.e. public hospital)
30%

0 20%

[1-5] [6-20] [21-50] [51-100] [>100] 10%

Number of staff by groups Public insurance/ Public Industry


Reimbursement Agency /
National coverage body
By region
20
17 EMR
Number of countries

SEAR National Regulatory agency Ministry of Health


15
AFR
10 Other government entities ( i.e. finance ministry)
10 WPR
7
8 AMR
5 3 3 3 3
2 2 2 EUR
1
0
[1-20] [>20]
Number of staff

By income level
20 17
Low income
Number of countries

15 Lower middle
13 income
12
Upper middle
income
10
High income
6
5
5
2 2
3
0
[1-20] [>20]
Number of staff
18
4.4 Professionals involved in HTA ing epidemiologists, biostatisticians, health economist
preparation and decision making and others) and experts in clinical sciences (medical
doctors, nurses, pharmacists, and health professional
Respondents reported that the preparation of HTA re-
organizations) (Chart 4.4a). The involvement of different
ports and the decision-making process had high level
professionals in HTA did not vary markedly across tech-
of involvement from public health professionals (includ-
nologies or interventions (Chart 4.4b).

CHART 4.4: Number and proportion of professionals involved in (a) preparation of HTA reports
and (b) making decision

A Clinical interventions 120 118 15 44 15

Medical devices 112 102 12 64 14

Medicines 123 133 11 40 17


Population level health interventions 132 91 24 41 28

Service delivery models 94 78 18 34 21

Surgical interventions 102 94 10 42 12

Vaccines 115 99 7 32 16
0 20 40 60 80 100
%
Public Clinical Bioethics and Legal, Engineering Consumer
health science sociology and information science needs

B Clinical interventions 125 162 21 46 30

Medical devices 98 142 14 69 27


Medicines 125 196 16 35 39
Population level health interventions 144 135 33 31 43
Service delivery models 107 124 25 33 34

Surgical interventions 75 133 15 29 26

Vaccines 135 161 20 26 26


0 20 40 60 80 100

%
Public Clinical Bioethics and Legal, Engineering Consumer
health science sociology and information science needs

Public health: Epidemiologists, Biostatisticians / Statistician, Economists/ health economists, Public Health professional
Clinical science: Medical doctor, Nurse, Pharmacist, Health professional organization
Bioethics and sociology: Sociologist, Ethicist
Legal, Engineering and information science: Biomedical and /or clinical engineer, Lawyer, Librarian/information specialist
Consumer needs: Civil society representative, Patients representative

19
5. Governance of
HTA process
Around half of the responding countries HTA systems required
conflict of interest declarations. HTA outcomes and subsequent
policy decisions were made public in around half of the
responding countries.
As indicated in responses to the surveys questions about legislative
requirements, findings from HTA-related organization(s) played
an advisory, rather than mandatory, role for policy decisions in a
majority of the responding countries. Civil society representatives
were given the opportunity to comment on the recommendations of
an HTA report in half of the countries.

5.1 Conflict of interest declaration


Chart 5.1 shows that about half of the respondents re- of the responding countries either did not require such
ported that personnel involved in preparing HTA reports declarations (26%) or did not know if such a requirement
were required to declare conflicts of interest. This re- existed (21%).
quirement was most common in EUR. Just under half

CHART 5.1: Proportion of countries requiring conflict of interest declaration, by region

Yes No I don't know


Yes

8%
WPR
5%
21% SEAR

EUR
53% 26%

EMR
26%
AMR
3%

9% AFR
2%

21
2015 Global Survey on Health Technology Assessment by National Authorities

5.2 Communicating the outcomes of HTA

The findings of HTA reports were published in more than also made publicly available in around half of the re-
half of the countries (Chart 5.2a). Similarly, the policy sponding countries (Chart 5.2b). This transparency of
outcomes based on the findings of HTA reports were process was most common in EUR countries.

CHART 5.2: Proportion of countries communicating (a) the findings of HTA reports and (b) policy
outcomes in the public domain, by region

Yes No I don't know

Yes
A 7% WPR

5%
8% SEAR

EUR
56% 28%
37%
EMR

2% AMR
8%
AFR
5%

Yes No I don't know

Yes
B WPR
8%
3%
13% SEAR

EUR
52% 22%
35% EMR
2%

10% AMR

7% AFR

22
5.3 Connection between HTA and decision making, and civil
society participation
In most of the countries that responded to the survey, EUR countries (Chart 5.3a). In about half of the coun-
the findings of HTA-related organization(s) played an tries, civil society was given the opportunity to comment
advisory, rather than mandatory, role in policy deci- on the recommendations of the HTA entity (Chart 5.3b).
sions. Among those countries for which the respondent However, the extent to which their inputs influence the
reported a mandatory role, a majority (57%) were from final decision is not known.

CHART 5.3: Status of the findings of the HTA-related entity (a) HTA related entitys role in policy
decision (b) Civil societys role in commenting on recommendations of HTA report

Advisory Mandatory I don't know

Mandatory
A
2%
1%
WPR

SEAR
76% 16% 9%
EUR

8%
AFR

4%

Yes No I don't know

Yes
B WPR
4%
5%
11% SEAR

EUR
49% 21%

40% EMR
3%
AMR
9%

7% AFR

23
Requirements for
6. strengthening HTA
capacity
Fewer than half of all responding countries had academic or
training programmes to build HTA capacity. This appears to be a
major barrier to increasing use of HTA.
Relative to other potential barriers, fewer countries reported
political support and mandate from policy authority as
impediments to using HTA in health care policy decision.

6.1 Main barrier for producing In terms of barriers to using HTA for decision making,
HTA and using HTA findings in respondents from 67 countries cited a lack of institution-
decision making alization of HTA as a barrier (Chart 6.2). Respondents
from 65 countries suggested that raising awareness
A lack of qualified human resources appeared to be a
about the importance of HTA would help improve the
main barrier for producing and using HTA to inform de-
incorporation of HTA findings in decision making. Rela-
cision making, as shown in Chart 6.1 and Chart 6.2. All
tive to other potential barriers, fewer countries reported
regions reported similar barriers to HTA: lack of funding
political support and mandate from policy authority as
for undertaking HTA (77 countries), a lack of information
obstacles for using HTA in health care policy decisions
(59 countries) or knowledge of methods (58 countries).
(Chart 6.2).

CHART 6.1: Impediments to HTA production

12 10 6 31 7 11 WPR
Budget availability
SEAR
Information availability 9 7 11 14 8 10 EUR
A lack of

EMR
Knowledge of methods 10 8 11 11 8 10
AMR

12 11 12 29 7 13 AFR
Qualified Human Resources

0 20 40 60 80 100
Number of countries

25
2015 Global Survey on Health Technology Assessment by National Authorities

CHART 6.2: Impediments to using HTA to inform decision making in health care policy

Awareness/Advocacy 10 11 11 18 6 9 WPR
of the importance of HTA
SEAR
Institutionalization of HTA 11 12 10 16 7 11
EUR
A lack of

Mandate from 10 9 7 10 6 7
Policy Authority EMR

Political support 10 5 7 13 4 6 AMR

AFR
Qualified human resources 14 10 9 25 7 13

0 10 20 30 40 50 60 70 80
Number of countries

26
6.2 Academic or training programmes to support capacity
building for HTA
Fewer than half of all responding countries had academic or training programmes to build HTA capacity. About
half of all countries that responded ran internal staff training sessions or external courses/seminars/workshops.
CHART 6.3: Number of countries with academic or training programmes to support capacity
building for HTA, by region

Courses/seminars/
workshops 8 8 5 26 3 11 9 6 8 16 6 5

Higher education
/ Masters 5 4 3 13 24 12 10 10 29 7 12

Internal staff training


sessions or workshops 7 9 4 21 3 8 10 5 9 21 6 8

0 30 60 90 120 150

Countries WITH programmes AFR AMR EMR EUR SEAR WPR

Countries WITHOUT programmes AFR AMR EMR EUR SEAR WPR

27
7. Conclusions
The WHO 2015 Global Survey on HTA provides the first systematic
description of the work relating to HTA carried out by national or
government institutions in WHO Member States.

7.1 Main findings professional organizations) were commonly


involved in HTA preparation and decision making.
The main findings are: Civil society representatives were given the
Human resources and institutional capacity opportunity to comment on the recommendations
of an HTA report in half of the countries.
Most countries have a process of collecting and
analysing information about health technologies or Utilization of results
interventions and assessing their impact. However, Findings from HTA-related organization(s) played
few countries referred to this process as HTA. an advisory, rather than mandatory, role for
Two in three countries reported having a policy decisions in a majority of the responding
national HTA organization or department, unit countries.
or committee that produced HTA reports for the
ministry of health. Impediments to strengthening capacity
Most countries reported having more than six staff A lack of qualified human resources appeared to
members in the HTA unit/agency and committee. be the main barrier for producing and using HTA.
Most countries did not have academic or training
Methodology programmes to build HTA capacity.
HTAs in most responding countries appeared to
focus primarily on safety and clinical effectiveness, WHO will continue to undertake activities to raise aware-
followed by economic and budgetary ness, promote knowledge and encourage the practice
considerations. Little consideration was given to of HTA and its uses in evidence-informed decision mak-
issues of ethics, equity and feasibility. ing. WHO will share and discuss the findings of this sur-
Governance and linkage between HTA units/ vey with country representatives, academia, and with
networks with policy authorities HTA networks.
Ministries of health or national health insurance
bodies were the main initiators of most HTAs.
Public health professionals (including
epidemiologists, biostatisticians, health economists
and others) and experts in clinical sciences
(medical doctors, nurses, pharmacists, and health

29
2015 Global Survey on Health Technology Assessment by National Authorities

Annex I: WHO regional groupings


Source: World Health Statistics 2015.

N.B: These groupings only include countries that responded to the survey.

WHO African Region (AFR): Benin, Cameroon, Cape Verde, Central African Republic, Comoros, Cte dIvoire,
Democratic Republic of the Congo, Eritrea, Ethiopia, Gambia, Ghana, Kenya, Madagascar, Mali, Mozambique,
South Africa, Tanzania, United Republic of.

WHO Region of the Americas (AMR): Barbados, Brazil, Canada, Colombia, Costa Rica, Cuba, Ecuador,
Guatemala, Jamaica, Mexico, Peru, Saint Vincent and the Grenadines, Trinidad and Tobago, United States of
America.

WHO Eastern Mediterranean Region (EMR): Afghanistan, Bahrain, Egypt, Iran (Islamic Republic of), Iraq,
Jordan, Lebanon, Libya, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic.

WHO European Region (EUR): Albania, Armenia, Austria, Azerbaijan, Belarus, Belgium, Bulgaria, Croatia,
Cyprus, Czech Republic, Denmark, Estonia, Finland, Georgia, Germany, Hungary, Iceland, Italy, Kazakhstan,
Latvia, Lithuania, Luxembourg, Malta, Monaco, Montenegro, Netherlands, Norway, Poland, Portugal, Moldova,
Republic of, Romania, Russian Federation, San Marino, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland,
The former Yugoslav Republic of Macedonia, Turkey, United Kingdom.

WHO South-East Asia Region (SEAR): Bangladesh, Bhutan, India, Indonesia, Maldives, Nepal, Sri Lanka,
Thailand, Timor-Leste.

WHO Western Pacific Region (WPR): Australia, Cambodia, China, Fiji, Japan, Kiribati, Lao Peoples
Democratic Republic, Malaysia, Micronesia, Federated States of, Nauru, New Zealand, Philippines, Korea,
Republic of, Singapore, Tuvalu, Viet Nam.

30
Annex II: Income groupings
Source: World Bank list of economies (July 2015). Washington, DC: World Bank; 2015
(http://data.worldbank.org/about/country-and-lending-groups).

N.B: These groupings only include countries that responded to the survey.

Low-income: Afghanistan, Benin, Cambodia, Central African Republic, Comoros, Democratic Republic of the
Congo, Eritrea, Ethiopia, Gambia, Madagascar, Mali, Mozambique, Nepal, Somalia, Tanzania, United Republic of.

Lower middle-income: Armenia, Bangladesh, Bhutan, Cameroon, Cape Verde, Cte dIvoire, Egypt, Georgia,
Ghana, Guatemala, India, Indonesia, Kenya, Kiribati, Lao Peoples Democratic Republic, Micronesia, Federated
States of, Philippines, Moldova, Republic of, Sri Lanka, Sudan, Syrian Arab Republic, Timor-Leste, Viet Nam.

Upper middle-income: Albania, Azerbaijan, Belarus, Brazil, Bulgaria, China, Colombia, Costa Rica, Cuba,
Ecuador, Fiji, Iran (Islamic Republic of), Iraq, Jamaica, Jordan, Kazakhstan, Lebanon, Libya, Malaysia, Maldives,
Mexico, Montenegro, Nauru, Peru, Romania, Saint Vincent and the Grenadines, Serbia, South Africa, Thailand,
The former Yugoslav Republic of Macedonia, Turkey, Tuvalu.

High-income: Australia, Austria, Bahrain, Barbados, Belgium, Canada, Croatia, Cyprus, Czech Republic,
Denmark, Estonia, Finland, Germany, Hungary, Iceland, Italy, Japan, Latvia, Lithuania, Luxembourg, Malta,
Monaco, Netherlands, New Zealand, Norway, Poland, Portugal, Qatar, Korea, Republic of, Russian Federation,
San Marino, Saudi Arabia, Singapore, Slovakia, Slovenia, Spain, Sweden, Switzerland, Trinidad and Tobago,
United Kingdom , United States of America.

31
2015 Global Survey on Health Technology Assessment by National Authorities

Annex III: WHA resolution 67.23


SIXTY-SEVENTH WORLD HEALTH ASSEMBLY
WHA67.23
Agenda item 15.7
24 May 2014
Health intervention and technology assessment in support of universal health coverage

The Sixty-seventh World Health Assembly,

Having considered the report on health intervention and technology assessment in support of universal health
coverage;4

Recalling resolutions WHA52.19 on the revised drug strategy, WHA58.33 on sustainable health financing, universal
coverage and social health insurance, WHA60.16 on progress in the rational use of medicines, WHA60.29 on health
technologies, WHA63.21 on WHOs role and responsibilities in health research, and WHA64.9 on sustainable
health financing structures and universal coverage;

Recognizing the importance of evidence-based policy development and decision-making in health systems, includ-
ing decisions on resource allocation, service system designs and translation of policies into practice, as well as
reaffirming WHOs roles and responsibilities in provision of support to strengthen information systems and health
research capacity, and their utilization in Member States;

Noting that the efficient use of resources is a crucial factor in the sustainability of health systems performance,
especially when significant increases in access to essential medicines, including generic medicines, to medical
devices and procedures, and to other health care interventions for promotion, prevention, diagnosis and treatment,
rehabilitation and palliative care are pursued by Member States, as they move towards universal health coverage;

Noting that The world health report 20105 indicates that as much as 40% of spending on health is being wasted
and that there is, therefore, an urgent need for systematic, effective solutions to reduce such inefficiencies and to
enhance the rational use of health technology;

Acknowledging the critical role of independent health intervention and technology assessment, as multidisciplinary
policy research, in generating evidence to inform prioritization, selection, introduction, distribution, and management
of interventions for health promotion, disease prevention, diagnosis and treatment, and rehabilitation and palliation;

Emphasizing that with rigorous and structured research methodology and transparent and inclusive processes,
assessment of medicines, vaccines, medical devices and equipment, and health procedures, including preventive
intervention, could help to address the demand for reliable information on the safety, efficacy, quality, appropri-
ateness, costeffectiveness and efficiency dimensions of such technologies to determine if and when they are
integrated into particular health interventions and systems;

Concerned that the capacity to assess, research and document the public health, economic, organizational, social,
legal and ethical implications of health interventions and technologies is inadequate in most developing countries,
resulting in inadequate information to guide rational policy, and professional decisions and practices;
4 Document A67/33.
5 The world health report 2010. Health systems financing: the path to universal coverage. Geneva: World Health Organization; 2010.
32
Recognizing the importance of strengthened national capacity, regional and internationalnetworking, and collabo-
ration on health intervention and technology assessment to promote evidence-based health policy,

1. URGES Member States:6

(1) to consider establishing national systems of health intervention and technology assessment, encouraging the
systematic utilization of independent health intervention and technology assessment in support of universal health
coverage to inform policy decisions, including priority-setting, selection, procurement supply system management
and use of health interventions and/or technologies, as well as the formulation of sustainable financing benefit
packages, medicines, benefits management including pharmaceutical formularies, clinical practice guidelines and
protocols for public health programmes;

(2) to strengthen the link between health technology assessment and regulation and management, as appropriate;

(3) to consider, in addition to the use of established and widely agreed methods, developing, as appropriate,
national methodological and process guidelines and monitoring systems for health intervention and technology
assessment in order to ensure the transparency, quality and policy relevance of related assessments and research;

(4) to further consolidate and promote health intervention and technology assessment within national frameworks,
such as those for health system research, health professional education, health system strengthening and universal
health coverage;

(5) to consider strengthening national capacity for regional and international networking, developing national
know-how, avoiding duplication of efforts and achieving better use of resources;

(6) to consider also collaborating with other Member States health organizations, academic institutions, profes-
sional associations and other key stakeholders in the country or region in order to collect and share information
and lessons learnt so as to formulate and implement national strategic plans concerning capacity-building for and
introduction of health intervention and technology assessment, and summarizing best practices in transparent,
evidence-informed health policy and decision-making;

(7) to identify gaps with regard to promoting and implementing evidence-based health

policy, as well as improving related information systems and research capacity, and considering seeking technical
support and exchanging information and sharing experiences with other Member States, regional networks and
international entities, including WHO;

(8) to develop and improve the collection of data on health intervention and technology assessment, training rele-
vant professionals, as appropriate, so as to improve assessment capacity;

2. REQUESTS the Director-General:

(1) to assess the status of health intervention and technology assessment in Member States in terms of methodol-
ogy, human resources and institutional capacity, governance, linkage between health intervention and technology
assessment units and/or networks with policy authorities, utilization of assessment results, and interest in and im-
pediments to strengthening capacity;

6 And, where applicable, regional economic integration organizations.


33
2015 Global Survey on Health Technology Assessment by National Authorities

(2) to raise awareness, foster knowledge and encourage the practice of health intervention and technology as-
sessment and its uses in evidence-based decision-making among national policy-makers and other stakeholders,
by drawing best practices from the operation, performance and contribution of competent research institutes and
health intervention and technology assessment agencies and programmes, and sharing such experiences with
Member States through appropriate channels and activities, including global and regional networks and academic
institutions;

(3) to integrate health intervention and technology assessment concepts and principles into the relevant strategies
and areas of work of WHO, including, but not limited to, those on universal health coverage, including health
financing, access to and rational use of quality-assured medicines, vaccines and other health technologies, the
prevention and management of noncommunicable and communicable diseases, mother and child care, and the
formulation of evidence-based health policy;

(4) to provide technical support to Member States, especially low-income countries, relevant intergovernmental
organizations and global health partners, in order to strengthen capacity for health intervention and technology
assessment, including, when appropriate, the development and use of global guidance on methods and process-
es based on internationally agreed practices;

(5) to ensure adequate capacity at all levels of WHO, utilizing its networks of experts and collaborating centres,
as well as other regional and international networks, in order to address the demand for support to facilitate evi-
dence-based policy decisions in Member States;

(6) to support the exchange of information, sharing of experiences and capacity-building in health intervention and
technology assessment through collaborative mechanisms and networks at global, regional and country levels, as
well as ensuring that these partnerships are active, effective and sustainable;

(7) to report on progress in the implementation of this resolution to the Sixty-ninth World Health Assembly.

Ninth plenary meeting, 24 May 2014

A67/VR/9

34
2015 Global Survey on Health
Technology Assessment by
National Authorities

Main findings

ISBN 978 92 4 150974


Department of Essential Medicines and Health Products
World Health Organization

htechassessment@who.int
www.who.int/health-technology-assessment

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