Understanding the Opportunity Cost, Seizing the Opportunity: Report of the Working Group on Incorporating Economics and Modelling in Global Health Goals and Guidelines

Executive Summary

Internationally set goals and guidelines directly influ­ence the setting of health care priorities at the national level, affecting how limited resources are generated and allocated across health care needs. The influence of global priority setting, such as through the formu­lation of overarching goals or normative guidelines for specific disease areas, is particularly significant in low- and middle-income countries that rely heavily on overseas development assistance. Because no sys­tematic approach exists for dealing with resource con­straints, however, which vary across countries, goals and guidance are often inappropriate for some country contexts; their implementation can, therefore, reduce the efficiency and equity of health care spending.

The Working Group on Incorporating Economics and Modelling in Global Health Goals and Guidelines, co-convened by the Center for Global Development, Thanzi la Onse, and the HIV Modelling Consortium, has brought together disease specialists, policymakers, economists, and modelers from national governments, international organizations, and academic institutions across the globe to address these issues, to take stock of current approaches, and make recommendations for better practice. The Working Group deliberated on the roles and purposes of goals and guidelines and consid­ered how economic evidence might be formally incor­porated into policy recommendations and health care decision making. The target audiences for this report are international health institutions, large stakehold­ers in disease programs across the world, and national governments.

The Working Group has established core principles and accompanying recommendations for policymak­ers seeking to support national governments in setting locally relevant priorities. The report also offers rec­ommendations to international organizations—in particular, the World Health Organization (WHO)—on the appropriate use of economic analysis in the develop­ment of international guidelines.

The principles and recommendations emphasize the importance of recognizing local context and enabling and strengthening the capacity of national govern­ments to set priorities locally. They also stress the strengths and limitations of international WHO guidelines; the value of epidemiological modeling and eco­nomic assessment to guiding policy under resource constraints; the importance of good-quality epidemiological and economic data to inform country decision making; and the benefits of increased interagency and intergovernmental cooperation, accountability, trans­parency, and information sharing.

The principles and recommendations are outlined below. If implemented in full, the recommenda­tions would lead to a systemic shift, from a situation where priorities are largely set internationally and implemented locally to one where international pri­orities account for local contexts and constraints on delivery. These principles and recommendations are anticipated to lead to greater population health gains attained from within the limited resources available for health care by facilitating the use of resources where they have the largest beneficial impacts.

This approach has risks. When necessary evidence and capacity are lacking—a common scenario—priorities set using it may still be inappropriate, given local objec­tives and constraints. The final section of the report thus considers unanswered questions and outlines an agenda for additional research.

Recommendations

Our recommendations have two objectives: first, to empower countries to develop and analyze appropriate evidence to set health priorities for their populations; and, second, to strengthen the WHO guidelines pro­gram to increase its value and relevance for national decision makers. The working group understands and acknowledges the challenges that accompany a major shift in how goals and guidelines are developed and recognizes that changes of this magnitude take time to implement.

Empowering national governments to set evidence-based health priorities for their populations

Principles

• National health strategies and priorities should ideally be set by local decision makers who are accountable to their citizens, considering all available evidence.

• International health priorities and goals should primarily reflect and account for national prior­ities, whilst addressing common challenges that cross national borders.

• When deciding health priorities and goals, local decision makers should evaluate economic evi­dence using appropriate metrics that reflect local preferences and values.

  • Decision makers need measures of health benefit that facilitate comparisons across disease areas—for example, generic mea­sures of health, such as quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs). In line with local preferences and values, they may also consider benefit measures that reflect equity concerns and other dimensions of social value.

• Economic analysis and modeling, designed for or adapted to local context, is often required to inform prioritization within limited resources.

  • While the demand for such analyses should ideally be led by governments and local agencies, support in the form of funding and technical guidance from international bod­ies and experts will sometimes be required.

• Locally relevant clinical and economic evidence is required to inform such analyses.

  • Ideally, economic evidence (for example, on resource use and costs) will be gener­ated locally. Where this is not feasible, evi­dence may be taken from other relevant jurisdictions.

  • Clinical studies will often be undertaken in different settings. The relevance of available clinical evidence to the local setting needs to be carefully assessed.

Recommendations for international agencies

• Reaffirm that decision-making responsibility for the adoption and funding of interventions lies at the country level or even lower, with deci­sion makers who represent their citizens and are equipped with appropriate clinical and eco­nomic evidence.

• Support local production of economic and epi­demiological analyses and enhance local capac­ity to produce such evidence.

  • Locally led research activities can be sup­ported by providing funding and appropri­ate technical support.

• Support countries in establishing consistent resource allocation processes informed by appropriate local evaluations.

  • The establishment of health technology assessment (HTA) agencies is one approach that could receive greater support.

  • The International Decision Support Ini­tiative (iDSI) reference case^[1] for economic evaluation can inform locally led deci­sion-making processes.

• Encourage cooperation among countries and support mandated regional bodies to facili­tate the joint production and pooling of evi­dence, including economic and epidemiological analyses.

Increasing the value and local relevance of WHO guidelines

The working group supports ongoing reforms initiated from within the World Health Organization to incor­porate modeling and economics into the development of guidelines. The following principles and recom­mendations are proposed to enhance these reforms.

Principles

• Evidence on clinical and public health efficacy and effectiveness is necessary but insufficient to inform policy decisions on resource allocation. Economic evidence is also required.

  • Resource allocation decisions made in the absence of economic evidence bear substan­tial risk of reducing population health and increasing health inequalities.

• WHO guidelines that make recommendations regarding the relative clinical and/or public health effectiveness of alternative interven­tions—when not informed by full economic eval­uation—should not constitute or be interpreted as universal recommendations across all coun­tries if their implementation implies commit­ment of limited resources.

  • WHO clinical and public health recommen­dations should offer clear caveats about the need for local economic evaluation to inform uptake.

• Local decision-making processes should take into consideration WHO recommendations regarding clinical effectiveness in the light of additional economic evidence and other consid­erations, as relevant to the local context.

  • At present, WHO does not routinely support any standardized process for the generation of such locally relevant economic evidence.

Recommendations for the World Health Organization

• Drawing upon expert advice, develop a stan­dardized process to routinely consider economic factors either within or alongside WHO clinical and public health guidelines.

  • Where the goal of guidelines is to have rec­ommendations directly inform resource allocation decisions, this process should be incorporated within the guideline process.

  • Where locally relevant economic factors are not considered within a guideline, WHO should suggest how the evidence in the guideline can be used as part of other local decision-making processes (such as nation­ally led health technology assessment).

• Specify the principles and methods necessary for generating economic evidence, including mod­eling and economic evaluation studies, to reli­ably inform resource allocation decision making by mandated bodies at different levels (interna­tional, regional, national, subnational).

  • An expert panel should be convened to agree on the principles and features of such analyses.

• Where WHO guidelines are intended to inform policy affecting resource allocation directly, produce or commission modeling and economic analysis to inform guideline development.

  • As full economic evaluations likely cannot be produced for all guidelines, WHO should prioritize those most in need of economic analysis (recognizing that the availability of evidence will affect the recommendations the guideline can make). Analyses can be conducted at varying levels, from cost analy­ses to full economic evaluations.

• Seek support and funding from other interna­tional partners in global health—for example, bilateral and other multilateral donors—for the more frequent and routine production of mod­eling and economic analyses as part of a guide­line’s development processes.

  • Given that choice of intervention is central to health care delivery, increased funding for such analyses, if appropriately used to guide policymaking, is likely to produce sub­stantial payoffs for improving the health of populations in different countries.

• Subject any modeling and economic analyses used in guideline development to independent expert peer review.

  • A suitable process is required for indepen­dent expert peer review of original research, with sufficient funding made available for its successful functioning. This process should reflect the principle of good research meth­ods referred to above.