How are countries in South-East Asia establishing HTA processes to progress towards Universal Health Coverage?

Introduction

Health Technology Assessment (HTA) implementation has been historically slow in Asia compared to other areas around the world such as Europe, Australia and North America. HTAs are a multidisciplinary process for assessing the clinical and economic value of a healthcare technology and are an important priority setting process for countries working towards achieving Universal Health Coverage (UHC) – where all individuals receive the required healthcare without suffering financial hardship. Currently roughly half of the world’s population do not receive the healthcare that they require, and around 100 million people are pushed into extreme poverty due to healthcare payments each year¹. How are HTA processes established across developing markets in the Association of South-East Asian Nations (ASEAN) region and what challenges do they face?

Establishment of HTA processes across the ASEAN region

The ASEAN region consists of 10 countries: Brunei Darussalam, Myanmar, Cambodia, Indonesia, Laos, Malaysia, Philippines, Singapore, Thailand, and Vietnam. While all of these nations have shown a commitment to implementing HTA process for healthcare priority setting, there are varying levels of integration. Brunei Darussalam, Malaysia, Singapore and Thailand provide UHC for their population which includes HTA as the basis for determining new healthcare; Indonesia, the Philippines and Vietnam have begun to provide UHC but their HTA processes remain at the early stage; and Cambodia, Laos and Myanmar have no formalised HTA processes and healthcare priority setting is conducted on an ad-hoc basis.² This varying level of adoption is dependent on different country-specific factors such as investment in public health and technological infrastructure, but also on general challenges faced across all of the nations.³ There have been several initiatives to help promote HTA rollout across Asia, including but not limited to the Asian HTA Network established in the 1990s to further HTA use in the Asia-Pacific region and the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) – who have helped promote HTA rollout worldwide – with their Asia-Pacific meetings and formation of the ISPOR Asia Consortium to spread awareness of the benefits of HTAs.^3,4 Furthermore, there have been programmes such as the Health Intervention and Technology Assessment Programme (HITAP) to provide annual training on the benefits and technicalities of HTA.⁵

Challenges to HTA integration

Legislation

Of the ten countries within the ASEAN region, HTA policies have been analysed in eight, of which seven have reported having no formal legislation mandating the use of HTA in informing decisions on healthcare; only the Philippines has a legal basis for using HTA to assess new therapies. However, five of these seven did report having mandates for the use of HTA for informing on specific technologies, especially expensive or specialist treatments². This shows that while HTA adoption for all medicinal technologies is slow, there have been provisions made for it within the majority of the countries, which should allow progress to be made to full HTA implementation. Two countries had no mandates for HTA in either case: Laos and Myanmar; however, Laos has developed plans for their Unit for Health Evidence and Policy (EUHP) to function as a HTA body. This can be seen in Table 1 below.

It can also be seen that there is a reasonable distribution of HTA agencies established within these countries with seven of them having HTA nodal agencies either established or proposed, showing that there are institutions in place for dealing with HTA.

Infrastructure

For many of the Asia-Pacific countries, is hindering them from implementing HTA processes for all new technologies.⁶ . Lack of this infrastructure can prevent the countries from adeptly assessing new therapies and lead to HTA appraisals which are based on inadequate evidence or where thresholds are ill-defined due to lack of material to assess each product.

Stakeholders

There is also potentially insufficient involvement of a broad range of stakeholders (such as healthcare professionals, public authorities, payers and academics) to take full advantage of HTAs, as there are not enough trained stakeholders or experts to carry out HTAs.^2,6 It is integral that all stakeholders have a good understanding of HTA and that there is a sufficient support network for different stakeholders to communicate and contribute to HTAs. Lack of understanding or depth within the different stakeholders can hinder HTA processes at various stages, including a lack of topics nominated for HTA as they are not identified by the stakeholders or poor prioritisation of the topics identified. This is shown by findings that in the majority of the ASEAN countries where HTA is in place to any extent, assessments are largely being conducted by academics rather than healthcare institutes².

Conclusion

How can these challenges be overcome?

In order to move towards greater Universal Health Coverage globally, areas such as the ASEAN region must address the challenges highlighted above to allow adept implementation of HTA. While there has already been much effort into this as discussed, more is necessary to push forward. Countries must explore possibilities to institutionalise the use of HTAs for healthcare decision-making using legislation and focus on building on the existing capacity of systems in place, through training and cooperation to enhance the stakeholder involvement and understanding. They must also ensure that adequate infrastructure is in place to allow the relevant stakeholders to complete HTAs on a larger scale than is currently achieved. With significant development in this field over recent years, where will these nations be with respect to HTA implementation and achieving UHC in the next ten years?

Sources:

1. Universal Health Coverage, WHO, https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)
2. Sharma, M., Teerawattananon, Y., Dabak, S.V. et al.A landscape analysis of health technology assessment capacity in the Association of South-East Asian Nations region. Health Res Policy Sys 19, 19 (2021). https://doi.org/10.1186/s12961-020-00647-0
3. Liu, G., Wu, E.Q, et al.; The Development of Health Technology Assessment in Asia: Current Status and Future Trends, Value in Health Regional Issues, Volume 21, 2020, Pages 39-44, ISSN 2212-1099, https://doi.org/10.1016/j.vhri.2019.08.472
4. Chootipongchaivat S, Tritasavit, Luz A, Teerawattananon, Tantivees S. Factors conducive to the development of health technology assessment in Asia: Impacts and Policy Options. Manila: World Health Organization, Regional Office for the Western Pacific, 2015.
5. Sivalal, S. (2009). Health technology assessment in the Asia Pacific region. International Journal of Technology Assessment in Health Care, 25(S1), 196-201, doi:10.1017/S0266462309090631
6. Teerawattananon, Y., Ying Teo, Y., et al., Tackling the 3 Big Challenges Confronting Health Technology Assessment Development in Asia: A Commentary, Value in Health Regional Issues, Volume 21, 2020, Pages 66-68, ISSN 2212-1099, https://doi.org/10.1016/j.vhri.2019.07.001