On the third Thursday of every month, we speak to a recent graduate about their thesis and their studies. This month’s guest is Dr Rebecca Addo who has a PhD from the University of Technology Sydney. If you would like to suggest a candidate for an upcoming Thesis Thursday, get in touch.
Why is now the right time to research the feasibility of HTA in Ghana?
In recent years, Ghana has been struggling to financially sustain the National Health Insurance Scheme (NHIS), through which it aims to attain universal health coverage (UHC). As a result, a number of payment methods have been explored, including capitation, but costs to the NHIS continue to escalate. The search for a more efficient NHIS funding resulted in stakeholders visiting the then NICE International, learnt of HTA, and expressed an interest in pursuing it. This interest was strengthened by the World Health Organization 2014 resolution, which encouraged its member states to adopt health interventions and technology assessments in support of UHC. In 2016, a pilot HTA study was conducted with support from international bodies that demonstrated potential cost savings with HTA. Subsequently, the Ghana National Medicines Policy, 2017, made provisions for the use of HTA in the selection of medicines. What remains uncertain is how the policy will be implemented, considering that the limited use of HTA in developing countries has been attributed to a lack of human capacity to undertake it, quality data, and limited resources to support it. With Ghana making progress towards the formal adoption of HTA for health decision-making, it is important to examine its feasibility considering the available national capacity and the health system’s particular characteristics, and to make recommendations on how Ghana can proceed, so that the anticipated positive changes can be realised.
What determines ‘feasibility’ in this context?
The usefulness of HTA to any health system is highly dependent on its availability, the quality of assessment, and the human capacity to conduct country specific appraisals. Thus ‘feasibility’ in this context is determined by the existing health resources and systems that could support the adoption and use of HTA in Ghana. Health resources include human capacity with the needed technical skills to conduct and contribute to HTA, funding for the HTA processes, and the available data, which is of good quality and easily accessible. In addition, potential users of HTA should have knowledge in HTA and be able to interpret its findings. Without these building blocks, HTA in itself cannot be successfully used in Ghana. The systems to consider are health system characteristics such as existing health decision-making processes, and political and social structures. Knowledge of this would aid with planning, design, and introduction of an HTA process that suits the Ghanaian health system’s decision-making context, which would promote its use.
How is HTA perceived by stakeholders in Ghana?
Whilst the majority of Ghanaian stakeholders who participated in my study understood HTA as a decision making tool, others saw it as using technologies such as telemedicine and mobile phone devices for healthcare delivery. Their prior understanding of HTA and its uses drove these differences. In terms of its potential use in the Ghanaian health system, most stakeholders acknowledged the benefits the health system stood to gain should HTA be adopted. They however perceived some barriers to the successful implementation of HTA and made some recommendations to address them. Perceived barriers included lack of knowledge of HTA by potential users, lack of human resource capacity to conduct it, lack of funds to support the conduct, and existing ways of making decisions. Factors perceived to promote HTA use were allocating funds for HTA activities, educating stakeholders on HTA and involving them in the planning, and introduction of HTA for health decision-making in Ghana. Also, stakeholders recommended that data be collated and managed for HTA, and for local Ghanaians to be trained to conduct HTA but rely on experts from other countries where possible.
Was it especially challenging to conduct an economic evaluation in the Ghanaian context?
Yes. Conducting a Ghanaian specific economic evaluation was very challenging, especially, in getting the appropriate data. There were no country-specific utility and clinical efficacy data, hence, I had to rely on data from elsewhere, which needed to the transformed to be context specific. The most challenging aspect was with getting appropriate clinical data due to the differences between clinical trial settings and the Ghanaian setting. Applicability issues that were addressed included differences in clinical treatment algorithm, alternative treatments, and epidemiology of disease. Cultural acceptance of available treatment for the study population also defined the appropriate comparator for the evaluation and consequently the clinical data that could be considered. This resulted in having to draw on data from two separate arms of two clinical trials for one of the models I built for my economic evaluation. To ensure applicability of data from other countries to Ghana, the data identified were transformed to be context specific with data input from Ghana either not available or not easily accessible. Therefore, clinical experts were relied upon for such inputs, adding to the limitations of the economic evaluation.
Can HTA processes from other countries be applied in Ghana?
Every health system is unique in its entirety, therefore processes used in one cannot be adopted and applied to the other. The same applies to HTA in Ghana. As part of my thesis, I reviewed a number of HTA organisations across the world to assess if one could be adopted in Ghana. The review revealed that HTA processes vary with each health system in terms of the context under which they were established, the scope or focus of HTA, outcomes, and links to funding decisions and their uses. The establishment of most of these HTA organisations was driven by country specific needs such as curbing the rising costs of healthcare and reducing variations in the availability of quality treatment and care. The available resources, such as human and data, and the health systems characteristics also influenced the HTA processes. Therefore it is not advisable for Ghana to simply adopt and use a model of HTA process from other countries. Rather, Ghana must pursue a country specific HTA process that is informed by relevant country data.
What would be your recommended ‘next step’ for HTA in Ghana?
Firstly, to ensure the acceptance, use and diffusion of HTA in Ghana, stakeholders of health should be educated on HTA and a legal framework stipulating its focus and conduct, and mandating its use, to be adopted.
Secondly, in the short-to-medium term, Ghana can leverage on ongoing collaborations with other countries and foreign organisations, such as the International Decision Support initiative (IDSi), to develop local capacity for HTA. In the long-term, it will be necessary for policy makers to explore the human resource capacity available for HTA in Ghana to guide the development of a human resource plan for HTA.
Thirdly, Ghana has to develop a country-specific methodological guideline or adapt an existing one for the conduct and reporting of economic evaluation studies in Ghana. Subsequently, guidelines for conducting HTA should be developed.
Lastly, to support HTA conduct, Ghana must create a national data repository including a manual on health resource use and their corresponding unit prices. The creation of an HTA standing panel of clinical experts and other stakeholders who could be relied upon to supply inputs for HTA when needed is also recommended. This is very important in the Ghanaian setting where availability and access to data is limited.