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
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
group on 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
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
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
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
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.