Introduction
Health technology assessment (HTA) involves systematically evaluating medical procedures and technologies, and it is a widely used tool for providing evidence-based policy advice and informing policymaking.
The HTA landscape is evolving to meet changing health systems contexts and priorities, reflecting that how a given health technology achieves an outcome is frequently complex. While HTAs are routinely used in HICs to support policy-making and payer decisions, adoption in LMICs is more challenging 1. Many LMICs conduct HTAs under a different name and often not by a dedicated organisation.
Challenges of HTA implementation in resource-limited settings
Implementation of HTAs in LMICs has been limited by 1:
- Data: A significant benefit of HTAs is the ability to assess a technology within a local context. However, without extensive, granular local data to inform models, HTAs will not offer more accurate decisions than global studies, thus undermining the HTA process.
- HTAs require expertise, time, and funding, all of which are constrained in many LMICs
- There is less awareness of HTAs, the benefits and the processes involved in HTA analyses in LMICs by both governments and donors, limiting adoption
Therefore, it is unlikely that HTA processes commonly followed in HICs will transfer directly to LMICs.
Proposals for adapting HTA to local contexts
The INTEGRATE-HTA project recommends five steps for a comprehensive, integrated assessment of complex technologies and interventions 2:
- Conducting a scoping exercise involving all stakeholders at the beginning of the project to promote stakeholder engagement and ownership
- Build programme theory collaboratively by making explicit assumptions as to how a given intervention may produce health outcomes, through which mechanisms and what local contextual factors should be addressed
- Examining a wide range of possible outcomes (not just safety and clinical and cost-effectiveness) that guide the collection of evidence
- Structuring and, where possible, visualising the assessment results and considering different scenarios for the intervention depending on the context, potential for implementation, and characteristics of beneficiaries;
- Being explicit about how the various outcomes of the assessment might be integrated into an overall conclusion regarding the merits and demerits of the healthcare technology or intervention under investigation.
Collaboration in HTA implementation
INAHTA (International Network of Agencies in Health Technology Assessment) and HTAi (Health Technology Assessment International) have stated the importance of collaboration and networking for sharing information resources, training, and expertise, which could help to promote HTAs in LMICs. Some studies have attempted to bridge the current gap by offering HTA transfer guidance or modified HTA approaches that could be better suited to LMIC implementation 3. For example, the EUnetHTA Adaptation Toolkit contains guidance on transferring and adapting HTAs to local contexts. Although there are examples of HTAs being successfully implemented in LMICs to suit local contexts, further work remains before HTAs become an institutionalised process commonly seen in HICs.
Emerging technology HTAs
Even within HICs, there remains debate about how to adapt the HTA process to assessing emerging technologies such as digital health. Traditional approaches often fail to capture all the potential benefits and risks of digital technology, as their impact can be complex. Comparing frameworks from different contexts and building on case studies, a typology of practices covering consumer guidance, assessment approaches, and entire reimbursement decision-making has been proposed 4 and adapted for digital health applications.
References
- WHO. Health technology assessment of medical devices. 2011.
- Bijlmakers L, Mueller D, Kahveci R, Chen Y, van der Wilt GJ. INTEGRATE-HTA: A LOW- AND MIDDLE-INCOME COUNTRY PERSPECTIVE. Int J Technol Assess Health Care. 2017;33(5):599-604.
- Heupink LF, Peacocke EF, Sæterdal I, Chola L, Frønsdal K. Considerations for transferability of health technology assessments: a scoping review of tools, methods, and practices. Int J Technol Assess Health Care. 2022;38(1):e78.
- Degelsegger-Márquez A, Panteli D. Towards reimbursement of mobile digital health applications? An international comparison of practices. European Journal of Public Health. 2020;30(Supplement_5):ckaa165. 1327.