How to make difficult healthcare decisions easier

The International Decision Support Initiative, initially launched as the result of a CGD working group, is scaling up, and that’s good news for people making life-and-death decisions in low- and middle-income countries. It means more data on what works and more guidance on how to get the most out of scarce resources for health.

Health-care decisions are hard everywhere. The United States, for example, spends almost one-fifth of its total national income on health but still has a hard time deciding whether health insurers should cover a new treatment for Hepatitis C. Imagine the scale of that challenge in a place like Ethiopia, where physicians (1 for every 32,000 people), money, and almost every other resource are in short supply.

In this context of extraordinary resource limitations, nearly all physicians in Ethiopia are forced to make difficult choices about “who gets what” with little guidance of any kind. According to a study by Defaye et al. (2015), a representative sample of physicians in the country cited “first come, first served” as the most often used strategy to allocate care and medicines, followed by limiting tests and providing second-best treatments, among others. Also disconcerting, about 88 percent reported they were so troubled by the lack of resources, and the decisions it forces them to make, that they regretted having chosen their profession.

Although much progress has been made in recent years, these difficult patient care decisions co-exist with decisions to spend on products and services that have little evidence of cost-effectiveness. In Ethiopia, multivitamins are on the essential medicines list, for example.

Ethiopia is not alone. These kinds of difficult decisions, called rationing, are behind the massive inequalities in health and access to health services that are so common in health systems around the world. More money is one answer to these problems. But because resources will always be finite and demand almost infinite, rationing will happen regardless. The only difference is whether those rationing decisions are taken with the goal of improving health and well-being, or according to some other imperative such as “first-come, first-served”—which I think most can agree is unfair and unhelpful in meeting important health goals.

iDSI’s scale-up will help governments and other payers make these critical decisions. The initiative is led by the UK National Institute for Health and Care Excellence (NICE) International and the Thai Health Intervention and Technology Assessment Program (HITAP) and funded by the UK Department for International Development (DfID), the Bill & Melinda Gates Foundation, and, earlier, the Rockefeller Foundation. iDSI was initially launched as the result of a 2012 Center for Global Development working groupon building institutions for smarter health spending.

HITAP and NICE are leading a new generation of agencies whose goal is to influence the allocation of scarce public resources in favor of more health for the money. They are quasi-governmental technical agencies that conduct or commission cost-effectiveness and budget impact analyses of medicines and technologies. These analyses become the basis for making coverage and reimbursement decisions as part of health budgets or insurance subsidized by the public sector.

HITAP, for example, helps Thailand’s National Health Security Office decide what’s in and what’s out of the country’s famous Universal Coverage (UC) scheme. HITAP has helped the UC scheme improve health given a fixed budget, and has also found opportunities for the system to save money that can be reallocated to expand coverage in other dimensions. For example, HITAP’s participation in the analysis of human papillomavirus vaccine candidates helped the Thai government define the price at which the vaccine would become cost-effective and affordable in the Thai health system. Armed with this information, the UC scheme achieved a lower price in negotiations with industry—crucial for a middle-income country without access to Gavi’s discounted prices.

Now NICE and HITAP are going global.

In global health, we’ve long been fans of cost-effectiveness and optimization analyses to help decide what mix of technologies and interventions to support; from the 1993 World Development Report on Investing in Health to the 2015 Lancet Commission on Global Health 2035, the recommendation to “choose wisely” has long been on the books. Further, all of us rely on the Disease Control Priorities volumes, the Institute for Health Metrics and Evaluation data and analyses, the World Health Organization’s CHOICE and OneHealth, the Johns Hopkins’ Lives Saved Tool (LiST), the University of Bergen’s Priorities 2020 research initiative, and the HIV Modelling Consortium, among others, to inform our work and research.

But many low- and middle-income countries found the global cost-effectiveness recommendations tough to implement because local data on budget and health impact were missing, and because these types of recommendations had little to do with how public budgets were actually prepared and allocated. Further, these governments, like those in high-income countries, face many competing demands and pressures from patients, advocates, donors, industry and employers to choose one way or another, and no formal process through which to manage these pressures.

That’s the basic idea of HITAP and NICE: to bring a formal, participatory, fair, and transparent process to the examination and discussion of evidence, and to the decision-making about budgets and payments based on this evidence. In other words, these organizations are taking on the ongoing responsibility of informing choices and making sure that the right vaccines and medicines are purchased.

As middle-income countries graduate from aid that has historically funded the most cost-effective health interventions like vaccinations and infectious disease control, having formal, evidence-based ways to decide how to spend the next peso or pula, or how to design health benefits plans as part of movements towards universal health coverage, is absolutely critical.

iDSI hopes to contribute,scaling up its efforts to work side by side with low- and middle-income payers and commissioners moving towards universal health coverage. NICE and HITAP won’t make decisions for countries or push any specific institutional arrangement, but they will help to set up the agencies, studies, methods, and processes that policymakers consider most useful for their particular health systems—and help ensure that more money equals more health and equity.