Priority-Setting for Better Health: The international Decision Support Initiative

The most cost-effective health interventions produce as much as 15,000 times the benefit as the least cost-effective. In sub-Saharan Africa, less than $4 out of every $100 USD in public budget monies go to a health maximizing intervention or technology. This means that hundreds, thousands, and even millions of deaths are a direct result of not allocating funds to maximize health gain. Although public budgets are set to grow, if we fail to reverse inertial and wasteful resource allocation by governments, we will squander most of the value of the additional resources available, or end up funding highly cost-effective interventions in an ad hoc and funder-dependent way. As country governments make critical decisions about current and future healthcare expenditures, and as the number COVID-19 cases continues to rise, now, as ever, CGD recognizes the vital role of priority-setting in saving lives.

iDSI: A global network for better priority-setting

Too many low-and middle-income (LMIC) health systems lack the tools and institutional mechanisms to prioritise the interventions and products that generate the most health for the money. To address this issue, CGD hosted a working group in 2012 entitled Priority Setting in Health: Building Institutions for Smart Public Spending. The working group recommended the development of fair and evidence-based national and global systems to more rationally set priorities for public spending in health. As a result, the international Decision Support Initiative (iDSI) was co-founded by the UK National Institute for Health and Care Excellence (NICE) and Thailand’s Health Intervention and Technology Assessment Program (HITAP).

iDSI is a global network of health, policy, and economic expertise that works to directly strengthen priority-setting methods, capacity and processes, and respond to demand for knowledge diffusion and translation. iDSI bridges the disconnect between evidence and the policy decisions that drive allocation of public and external funder monies across LMICs. Our Secretariat currently sits within CGD and alongside our co-founders at HITAP, our network of core partners includes: the Clinton Health Access Initiative, China National Health and Development Center, Imperial College London, KEMRI-Wellcome Trust, National Health Foundation/National University of Singapore (forming one partner with HITAP), the Norwegian Institute of Public Health, and Mahidol Oxford University Research Unit. For more information and links to our partners, see here and here.

The work of the network aims to leads to more cost-effective, equitable, and sustainable resource-allocation which will translate into higher quality healthcare coverage, reduced financial impoverishment for households, and ultimately better health, with more lives saved.

Our work

Working with country policymakers, we aim to achieve two closely interlinked strategic objectives:

• institutional strengthening to develop lasting in-country capacity for evidence-informed priority-setting, and
• implementing cost-effective evidence for smart purchasing for Universal Health Coverage (e.g., evidence-informed health benefits package planning and purchasing).

We have a long-running track record of supporting countries in Africa and Asia on a range of priority-setting issues includes development of health benefit packages in support of UHC plans; building capacity for considering and producing health economic evidence; institutionalizing HTA; and conducting HTA studies. iDSI has supported eight countries in developing HTA committees, agencies, and processes (India, China, Ghana, Tanzania, Vietnam, Bhutan, Philippines, and Indonesia), and in addition, in South Africa we have strengthened the capacity of the National Essential Medicines List Committee. These agencies now review, in aggregate, 50-60 technologies per year, making recommendations on whether they should be provided to their populations of over three billion citizens; substantially improving the efficiency, equity, and sustainability of their health systems.

In more recent years, we are expanding our reach in sub-Saharan Africa—including Kenya, Rwanda, Tanzania, and Zambia—through pilot projects that have accelerated demand for HTA and begun supporting HTA governance structures.

Our COVID-19 response

With the rise of the COVID-19 pandemic and the world media initially focused on Europe, China, and the US, CGD’s global health team, including iDSI have voiced our concerns about the response in the US and the UK. But we’ve also been monitoring and analysing the preparedness of LMICs since the start of the outbreak. Given the limited applicability of strategies like social distancing and flattening the curve in the countries where we work, better evidence-informed guidance is desperately needed. The iDSI team is thus leveraging the strength of our network to apply the ethos of our priority-setting approach—which requires evidence-based, multi-stakeholder, transparent decisions—to assist in resource optimization in developing countries by responding to commonly raised policy questions across developing countries.

We focus on three main issues:

1. Appropriate policy plans and exit strategies. Health systems in LICs and LMICs are grossly underprepared for any surge in demand, and communal living conditions with sometimes multi-generational households make social distancing impossible for many. There is a need for tailored approaches that account for local constraints and consider the short- and medium- term impact of different policy interventions.
2. Trade-offs. In resource-constrained settings, policy makers’ allocation decisions will have implications not only for the health system, but the broader economy. Strict lockdowns now could have potentially (massive) economic impacts later. Similarly, if resources for essential services are diverted from already stretched health systems towards the COVID-19 response, patients needing immediate care—such as pregnant women, cancer patients, and patients undergoing dialysis—may suffer more significant impacts, including mortality, than COVID itself.
3. Fair access and smart spending. As tests, supplies like PPE, and eventually a vaccine become available, there is a need for economic incentives to be in place for affordable, fit-for-purpose technologies to be made available in LMICs. We have begun to discuss here, but more could be done to ensure low-tech solutions like water and sanitation are not forgotten under pressure to spend on more expensive, potentially less cost-effective equipment such as ventilators.

Our team works to be demand-driven, and we are doing a lot behind the scenes to find out what countries need most to make the best-informed decisions they can in such a high-pressure, fast-moving environment. As the situation evolves, our focus may shift and we will continue to publish, blog, and share our work on COVID, while also balancing the demands of governments to continue our in-country programmatic work.

For further information on iDSI’s work, you can stay up-to-date by subscribing to CGD’s global health newsletter, by following us on Twitter, and visiting our website. Both the global health team, and iDSI colleagues, are working to cover the COVID-19 response, alongside continued work on priority setting in LMICs. For more work on COVID-19 see the COVID-19 landing page.