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The CGD Podcast
Better Value in Health Spending Is a Four-Letter Word – Amanda Glassman
00:13:24
iDSI, the International Decision Support Initiative, is a network of expert organizations that helps policymakers make effective, efficient, and ethical decisions about how to prioritize limited resources – and it began at a CGD working group....
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- [00:05]
A
Hello, I'm Rajesh Merchandani. Thanks for joining me for this edition of the CGD podcast. Now, first come, first served is an idea that seems appropriate if, say, you're trying to get a restaurant table or find a parking space or even shopping when there's a sale on. But it's not appropriate as a strategy for allocating healthcare and medicines. I'm sure you'll agree about that. Yet many physicians all over the world admit that that is how they make decisions about which patients get what treatments. It happens in rich countries, but it's particularly acute in the developing world where national health budgets are often tiny. Now, a couple of years ago, a CGD working group set about trying to find a way for countries to make better decisions in healthcare. And it led to the creation of the cutely named IDZI, the International Decision Support Initiative, which launched in 2014 as a tool to tackle this very problem. Just recently, at a major conference in Thailand on priority setting in health, a major scale up of IDZI was announced, which we think is great news. To discuss this with me is Amanda Glassman, who leads CGD's global health work and was at that conference. Amanda, great to see you, thank you. So briefly, first of all, just explain what IDZI does, how it works.
- [01:18]
B
So IDDSI is made up, it's led by two agencies. One is typically Thailand's Health Intervention and Technology assessment program, or HITAP. And the second is the UK's National Institute for Health and Care Excellence, the aptly named nice. Both of these are technical agencies that carry out what we call cost effectiveness analyses. They look at the cost, but also the benefits of new medicines, interventions, new policies and how much health they're going to add for every additional patient, peso pounder, PULA that the public sector is going to spend. So they advise those who have to take decisions about care and they are leading this effort to partner with organizations, say in South Africa, in Indonesia, in the Philippines, that have to make those kinds of tough decisions, but with much smaller budgets. But the same principles apply. You want the most health for the money that you've invested. So moving away from rationing by first come, first served and moving towards taking decisions with health and well being in mind. What really matters right now for middle income countries, which are most of the countries in the so called developing world, is how they choose to spend their own public resources. So informing that process with evidence and with good process, for me, it's the only way forward.
- [02:37]
A
And when we talk about rationing and the difficult Decisions that some developing countries have to make. What are some kind of like really standout examples or cases of that where you look and think, my goodness, that's crazy. Why are they spending that kind of money on that?
- [02:51]
B
Yeah, so, you know, countries spend on vitamins or some countries spend on really expensive drugs for indications that are inappropriate. So there's some amount of just actual harm that you want to eliminate, sort of decisions that are taken because, oh, we've always paid for that. Or there's some public perception that this is a good thing. In China, for example, there's a lot of use of vitamins, there's a lot of use of IV bottles. So they use eight IVs a year per person in China through their insurance programs. And we know that that doesn't make sense given what the disease burden is. So the idea is to get rid of that kind of waste. But we're also in the same very same settings where you're funding things that are harmful or cause no effect at all. You're also funding, you're underfunding things that are really, really important. Things like vaccination for kids, things like tuberculosis treatment, things like treatment for hiv, aids, neglected tropical diseases. So really the idea is to say, with our next dollar, can we shift towards what's going to be the most cost effective use of public monies? And this is super important right now because as economies grow, they graduate from aid. And actually aid has actually been funding those very cost effective products, which is terrific for us sitting here in the United States. We love to see our governments pay for things that really make a difference for health. But on the other hand, our government is not going to be paying forever and ever for another government that gets more wealthy. The most basic public health and cost effective intervention. So this is part of that story about transition towards wealth.
- [04:32]
A
Why is it so important? I mean, you sort of touched on this, but let's just go back to it. I mean, we have a situation where you mentioned a couple of examples. There's also examples where developing world governments are sending people overseas for expensive treatments, which is a huge cost. And these are difficult decisions that they. Really difficult decisions that they have to make. Okay, do you not send that one person overseas for, for an operation when you can use that same money to vaccinate 10,000 kids? These are really difficult decisions, aren't they?
- [05:06]
B
Yeah, they are. And I mean, they're political decisions, they're technical decisions, they're ethical decisions. The idea is to bring, you know, it's not just a methods issue of, you know, assessing cost effectiveness like a technocrat. It's about structuring a political process, building an institution that can take a fair and transparent decision about how health monies will be spent. Now, some countries, through such a process, will decide to fund things that are not the most cost effective, maybe childhood cancers. You see a lot of developing countries do that as like the first thing that they're doing. And I think that's fine. The main thing is to show okay, if you're going to do that, there are some opportunity costs to that money. You could be vaccinating, you could be funding, you know, basic maternal and child health. Similarly, there's some choices going on right now. I'm moving people who are on first line, HIV drugs, those drugs fail, I'm moving them to second and third line. Well, that costs a bit more than first line. And there's a lot of people who are eligible for first line now who should also get those drugs. So those are difficult choices, but they need to be made in a fair way. Because if I'm one of those people who's voiceless, who hasn't gotten first line, and yet there's a large population living in a city that does get second and third line. We have to think about the ethics of that decision and really make the costs more evident. I don't think anyone on the outside can say what the right decision is. There is no right decision. But there's a right way to take a decision that is defensible to others and increasingly for various reasons. I've mentioned sort of an ethical conundrum that exists in the HIV AIDS space. But there's also competing products in a lot of categories. Even in something as basic as vaccination, there are comparator products for the pneumococcal vaccine, for the rotavirus vaccine. And those companies would like a level playing field too. Right. So used to be, okay, maybe you were satisfied because you were the last person who talked to the minister and it's your vaccine that they're going to buy. But when there's competition, you need a fair process to allocate those resources. And you need to be able to say it's not just price. I'm also looking at health impact.
- [07:13]
A
Okay, so. So that explains what IDDSI does. It explains why it's important what was announced in Thailand in terms of where IDZI is going.
- [07:19]
B
Yeah. So IDDSI started out life working with three or four countries, figuring out what kinds of methods and tools it could bring, what kind of Support it could bring to countries a kind of proof of concept period. And what they showed is that in places like Indonesia and India and Vietnam they were really making a difference to people. Build first capacity in country to measure the costs and benefits of new medicines or devices themselves but also to inform policy. So both the UK Department for International Development and the Bill and Melinda Gates foundation, they've partnered together to scale up IDSI's efforts, IDCI's efforts in this next, I think it's a three year period to see if they can get more impact as countries decide what to do with their money.
- [08:08]
A
So it's going to be operating in.
- [08:09]
B
More countries, it will be working in more countries.
- [08:13]
A
And the fact that this announcement about the scaling up of IDZI was made in Thailand. The Thais are right at the heart of this issue of better decision making in health, aren't they? They're kind of setting the trend, setting the agenda.
- [08:28]
B
They are incredible stars from this perspective. They've always been committed to universal coverage. They have a new insurance scheme that covers most of the population. They have a separate scheme for civil servants. But they've really managed to expand the number of people who receive a set of benefits. Now originally that set of benefits was decided based on, well what was already being funded or what the doctor at that particular place or the clinical team wanted or could provide. But now it's actually informed by hitap. It's informed by if they're going to include a new intervention they consult with HITAP and they give input. Now it's remind us what HITAP was. It's the Thai Health Intervention and Technology Assessment Program, hitap. So it's the nice of Thailand. So they're, you know one of the first really is that used cost effectiveness analysis and a nice process to inform the decisions that the insurance scheme took about what was in and out of that package. And their experience has been so inspirational. I mean I think that's why their neighbors in the region and other ASEAN countries are adopting a lot of what they do. They formed a network amongst themselves called HTA Asia Link. They are setting up their own agencies, they're partnering with HITAP and nice. That's happening in the Philippines, it's happening in Indonesia, it's certainly happening in Vietnam. So they're an inspiration and they have that hands on knowledge that they've created.
- [09:55]
A
And this idea, you know, evaluation, evidence based decision making, rationality, this kind of goes to the heart of what the centre is all about really. I mean that's what we sort of focus on entirely. And also this being our 15th anniversary year, how do you see or how do you feel about the kind of, if you like, the growing importance or the growing success of idzi? How does that fit into the Centre's story? Because it's something that started out life here.
- [10:23]
B
I'm so proud of it. I think. You know, actually I came to the center for Global Development because I had just experienced developing a benefits plan and working with the government of Columbia and all the tough choices that they were facing. And when I discovered, because I literally discovered that HITAP existed, I discovered that NICE existed. And I thought it was an opportunity to bring together policymakers, donors, global health people who work in specific areas to talk about could we bring some of this experience to a bigger scale. And so we ran this working group in 2012. I think a working group itself that brings together these disparate parts of the health scene or the global development scene is also our niche. It's what we do well. And we really came up with a set of recommendations of what made sense. Not what we would do based on inertia, but what made sense, sense to do to support especially middle income countries as they were growing and making their own decisions about what to spend on in health. So I really, you know, our recommendations had some traction. It's taken, you know, a little while, but I feel like that's exactly what CGD was created for to come up with, you know, what makes sense, try and get all these different people, you know, working in the same direction. And now it has a life of its own. We, our job is to collaborate and to support and to celebrate. But it's gone, it's bigger than us now. And I think that's really what CGD is all about.
- [11:58]
A
So it's bigger than us. What is next for the cutely named, diminutively named but the little organization that.
- [12:05]
B
Could idzi well engaging more deeply with countries with additional countries that are interested in moving forward, hopefully bringing some of the same expertise to the global health funders. They have tough choices to make. Between different diagnostic devices, different kinds of bed nets, they're buying a lot of product. And so hopefully some of those techniques of health technology assessment and economic evaluation and process can be brought to that, to the essential medicines list at the World Health Organization, to the guidelines that the World Health Organization publishes. So there's definitely the main focus is the agenda with the countries. That's what NICE and HITAP are focused on. But we at CGD might be continuing to take a look at our global health funding friends and technical agencies that work in this space.
- [12:52]
A
Okay, Amanda, great to have you here in the podcast studio. Thanks very much for joining me.
- [12:57]
B
Thank you.
- [12:57]
A
Rijesh, Find out about Idzi on our website. Also, read a new blog that Amanda's written about its expansion. That's cgdev.org if you enjoyed this podcast, please share the link, subscribe to it on our website, and join me, Rajesh Merchandani for the next podcast from the Centre for Global Development.