HTA in PAKISTAN An Overview

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HTA in PAKISTANAn Overview

• Dr Assad Hafeez
• Coordinator
• HTA Forum Pakistan

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OBJECTIVES

• Need of HTA in Pakistan
• Process experience of HTA forum
• Lessons learnt in non governmental sector
• Future directions

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• Population 170 million
• Provinces 4
• Districts 134
• Villages 50,000
• Poverty 32
• Per capita income US 1000
• Literacy rate 50
• HDI ranking 140

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• Health budget 0.6 of GDP
• THE US 18
• GHE US 6
• OPE US 12
• Private sector
• 80 health care (mostly curative)
• Unregulated
• Health insurance and social security nets
• Poorly functioning health system

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MDG indicator Baseline 1990 Current status Targets 2015
Under 5 mortality 140 98 52
IMR 120 78 40
MMR 550 276 140
Births SBAs 18 34 90
HIV prevalence lt0.1 lt0.1 lt0.1
TB cases detected cured - 55 85
Malaria prevention treatment - 45 75
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Major challenges in health sector

• High infant, child and maternal mortality
• High burden of communicable disease
• Meager resources for health
• Poorly functioning health systems
• Unregulated private sector
• Human resource capacity and management
• Knowledge divide
• Policy dilemma
• Do more for less
• Changing scenarios

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The need for HTA in Pakistan

• Shrinking resources with rising costs
• Push Pull of manufacturers vested interests
• Rapidly emerging technologies
• Role of unregulated private sector
• Ambiguous policies with poor capacity to achieve
  evidence based decisions
• Gullible consumers
• Others

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HTA Forum Pakistan

• Visit of President ISTAHC to Pakistan 2001
• Group of professionals dedicated to promotion of
  culture of evidence based practices
• Clinicians, academics, managers, policy makers,
  nurses, public health specialist,
  epidemiologists, others
• Non governmental set up

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Objectives of HTA Forum

• Exchange of experience
• Prioritize country needs
• Sensitize and develop liaison with national and
  international stakeholders
• Organize activities leading to better
  understanding of the role of HTA for Pakistan
• Capacity development along with developing
  conducting small scale technologies assessments

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Activities

• Regular meetings
• Presentations at various forums
• Research and publication of reports
• Identification of priority areas
• Capacity building
• Establishment of linkages
• Identification of focal persons in various areas
• Trainings and seminars

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• Regular meetings
• Brainstorming sessions
• Various institutions
• 2-3 month interval
• Presentation of studies
• Continuing education
• Future directions and planning

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• Presentations at various forums
• National forums
• International forums
• Local gatherings

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• Identification of priority areas
• Consensus building exercise
• Diagnostics
• Drugs and medicines
• Equipment procurement

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• Capacity building
• Trainings by experts
• Health Services Academy
• College of physicians and surgeons Pakistan
• International meetings/workshops

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• Establishment of linkages
• World Health Organization
• HTAi
• National Health Policy Unit
• MoH
• Academic institutions

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• Identification of focal persons in various areas
• Geographical
• Institutions

• MoH
• DoH
• Professional associations
• Teaching hospitals
• District hospitals
• General practice
• University (public private)
• Nursing association
• Others

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• Research and publication of reports
• No of publications in local medical journals
• Small technologies assessments in institutions
  and regions

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Routine pre op CXR in young patients

• Method prospective study
• Conclusion ineffective technology
• Impact routine CXR abandoned resulting in annual
  saving of one million Rs

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CT scan in advanced abdominal tumors

• Method prospective study
• Conclusion in our setting where U/S has
  confirmed the extent of disease, CT scan is
  unnecessary, as laprotomy/lprocopy has to be
  carried out to confirm diagnoses or do palliative
  procedures.
• Impact Unnecessary CT scans stopped (costs 100
  US per patient)

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Ritual circumcisionTiming and pre-op
investigations

• Method Literature search
• Conclusion
• For routine circumcision
• best time to operate is first 10 to 72 hours
• no pre-op screening for coagulation disorders is
  required
• Impact
• results published
• Set of pre-op investigations require approx US
  10

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Use of multi vitamins in routine prescriptions

• Method prospective design
• Conclusion On basis of the evidence collected,
  multivitamin tablets use was found to be
  in-effective technology, in our settings
• Impact Rs 0.5 million saved in one hospital
  annually

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Diagnostic effectiveness study at metropolitan
corporation Lahore

• Method prospective study
• Result
• The equipment was inappropriately placed
• Ineffectively used
• No positive impact on health of users
• Very high operating costs
• Impact
• review of policy by MCL was carried out
• Redistribution of resources and appropriate
  training was put in place to improve efficiency

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• Trainings and seminars
• Local meetings
• International seminar/workshop

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• First HTA workshop/seminar 2004
• MoH, WHO, PIMS, Network
• Objectives
• Advocacy
• Capacity building
• Future direction and recommendations
• Participants
• 150 seminar
• 25 workshop
• Outcome
• Workshop report
• List of recommendations
• Group of trained people

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• Strengths of HTA initiative in Pakistan
• Independent status
• Linkages
• Scope of work
• Motivated work force

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• Requirements
• Simple and short assessments
• Adaptations
• Economic analysis
• Diagnostics, drugs, equipment.
• District perspective

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• Challenges and barriers
• Involvement of MoH and donors in a more
  sustainable way
• Better understanding of effect of evidence on
  decisions making in policy and practice
• Increase and improve patient professional
  participation
• Improve dissemination tools, language and timing
• Adapt to local circumstances and values
  (flexibility)

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Lessons learnt

• Reputed NGOs should be involved in HTA process in
  developing countries
• Strong linkages required
• Local capacity building important
• Small scale studies help in achieving ultimate
  goal
• Hot issues to be addressed early

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Future directions

• Rational Diagnostic Program at district level.
• Diagnostic procurement SOPs at tertiary hospitals
• Clinical Practice Guidelines
• Inclusion in curriculum of post graduate courses
• Newsletter/publications

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Conclusions

• Poorly resourced countries need HTA more urgently
• Multi pronged approach required to achieve
  results
• Organizations like HTAi and WHO can play a
  significant role in this direction

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