In the wake of the COVID-19 crisis, many sub-Saharan African (SSA) countries will face serious economic crises and shrinking public spending. One area that may be hit hardest is the health sector, where two decades of hard-fought gains in health access and outcomes may be at risk owing to declining public financing and uncertainty in donor programming. If countries are unable to spend more, they need to spend better. Europe has leading expertise in building institutions for priority-setting in health, making it an obvious potential source for collaboration with the Global South.
This blog, which is part of our series of policy recommendations to support a more effective Eurafrica relationship, discusses why priority setting in health is more critical now than ever before; where global priority setting expertise lies and may be drawn upon to accelerate the use of priority setting in SSA; and how Afro-European partnerships could help countries in SSA to accelerate the use of priority setting in the post-COVID era.
Priority setting is ever more important in the post-COVID era
In 2010, long before the COVID-19 outbreak, the WHO estimated that between 20 and 40 percent of the $7.1 trillion spent annually on healthcare globally was wasted. With development assistance for health making up less than 1 percent of that (~$36bn), and countries facing wide-ranging healthcare demands as they strove for universal health coverage (UHC), it was clear even then that there was a need to improve efficiency of public spending in low- and middle-income countries themselves. This has been compounded by citizens in lower-middle-income countries whose out of pocket payments account for up to 80 percent of the health commodities market in those countries, particularly for treatments of non-communicable diseases which donors have historically funded to a lesser extent than infectious disease priorities.
Now with the onset of COVID-19, sub-Saharan African countries are expecting economic contraction. On top of existing pressures on healthcare budgets, investments are being made to tackle COVID-19, further shrinking available funding for essential health services that critically need to be maintained.
To maintain hard-fought gains in global health, institutionalized priority setting processes—which make explicit decisions about what to fund—are needed to ensure that investments in health continue to strive for improving overall population health, protecting citizens from impoverishment, and enhancing the quality of services. However, evidence-informed priority setting processes are not widely used in SSA. While notable initiatives exist (we’ll talk about that shortly), the requisite technical skills, data, and funding for such activities are often in short supply.
There is an opportunity to draw on existing European expertise in priority setting
Extensive national and regional expertise in other parts of the world, particularly that which is highly concentrated in Europe, could be a source to support growing interest in SSA to institutionalize priority setting.
Europe has a history of building institutions which support formalized evidence-based priority setting processes that goes back to the 1990s. During this time, many national agencies were established across the continent including the well-known UK National Institute for Health and Care Excellence (NICE), Norwegian Institute of Public Health (NIPH), and Swedish Agency for Health Technology Assessment (SBU). Each has a rich expertise in measuring, assessing, and reforming to enhance the value for money of health investments.
The expertise of these national institutions has also been leveraged for regional collaborations and initiatives on priority setting seeking to improve economies of scale and scope. While there are many different regional purchasing blocks which have been set up across Europe in the past ten years, two notable examples include European Network for Health Technology Assessment (EUnetHTA) and the BeNeLuxA (Belgium, Netherlands, Luxemburg, Austria) Initiative on Pharmaceutical Policy. EUnetHTA is a pan-European collaboration of health technology assessment (HTA) agencies working to reduce duplication through jointly producing HTA evidence to be applied by national agencies, fostering continental HTA knowledge sharing, and promoting good practice in HTA methods and processes. BeNeLuxA is a collaboration which aims to reduce the price of drugs through collaborative horizon scanning, information and knowledge sharing, priority setting analytics, and price and reimbursement negotiations.
Historically, there has been bilateral support from national agencies such as NICE, and more recently through NIPH, to countries in SSA, which gave rise to the international Decision Support Initiative, now based out of the Center for Global Development. It is possible however, to leverage the expertise of both national and regional initiatives further to achieve broader economies of scale.
And existing initiatives on health financing and economics in Africa could present the perfect opportunity for a win-win partnership
At a national and continental level in Africa, there are existing initiatives designed to support health financing and access to medicines, including supporting priority setting and health economics. Sample national initiatives include Kenya’s KEMRI Health Economics Research Unit, Ghana’s HTA committee, South Africa’s National Essential Medicines List Committee, and Ethiopia’s Addis Center for Ethics and Priority Setting. Continentally, the African Medicines Regulatory Harmonization works to develop regional platforms for regional medicine registration. Additionally, African Union’s African Leadership Meeting (ALM) on Investing in Health is focused on the need for better and more funding for health, and is working to set-up regional “health financing hubs” alongside a health financing “tracker” which will help countries implement and track evidence-based health reforms, processes and policies. Though still in early stages, the ALM offers a unique opportunity for driving the “more health for the money” agenda through better priority setting and strategic purchasing at a time when the “more money for health” one is being put under enormous pressure and scrutiny on value added. Additionally, the Africa CDC (within the African Union) is working to set up a health economics unit (HEU) which is currently working on economic analyses for COVID-19 technologies in response to the pandemic. More broadly, the HEU will strengthen the use of economic evidence within the Africa CDC and across its five Regional Collaborating Centers to inform decision-makers, improve priority setting, and provide guidance for Member States on priority topics which inform critical health security and global health issues.
With countries in SSA working to respond to the health and economic crisis from COVID-19 as quickly as possible, there may be a ripe opportunity for synergistic north-south collaborations between existing and new partnerships.
The partnership model
Banding together European and African institutions and partnerships focused on health financing could help to accelerate the development of priority setting processes across the continent, establishing sustainable mechanisms for prioritizing health investments into the future. We would suggest:
Enhancing bilateral, institutional longterm partnerships to strengthen capacity for priority setting: A few European countries have existing bilateral arrangements that support priority setting in their own countries and abroad, including Norway’s NIPH which contributes to both national and international HTAs, and the French Haute Autorite de Sante which is expanding its international reach. Partnerships with European agencies that tailor their national experience to local needs could be expanded in geography and/or scope to support priority setting needs in countries in SSA, focusing for example on exchange of priority setting data, knowhow, and processes.
Supporting groundbreaking pooled procurement initiatives for public health commodities: Many global pooled procurement agreements exist for key products, particularly those funded by major global health donors and focused on communicable diseases (some countries, especially those transitioning from aid, may not be able to access these agreements). However, there remains a need for better pooled procurement for other products in high demand including those for public health emergencies (like COVID19) and noncommunicable diseases. To overcome this challenge, African Union initiatives such as the African Medical Supplies platform could be strengthened, and also partnerships could be established where national African purchasers join existing European procurement blocks with a focus on target priority technologies (e.g. non-communicable disease treatments). Additionally, leveraging lessons from the African Medicines Regulatory Harmonization Initiative, EUNetHTA and BeNeLuxA, partnerships could be formed directly between African and European collaborations such as the ALM hubs or the Africa CDC’s HEU to negotiate better, perhaps tiered, prices for patients on both continents.
Now is the time to be proactive about pooling global resources and expertise to create opportunities for two-way learning in prioritizing scarce health resources. Stakeholders should draw on these resources to get creative in designing optimal partnerships which accelerate the global movement of priority setting in health forward and support countries in their COVID-19 recovery.