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Disaster Health Management & Risk Reduction (DHMR-1)

Overview of Health T echnology Assessment in IRAN Lessons for the EMR region Ali Ak Al Akbari-Sa Sari, M MD, Ph PhD Dean, n, School hool of of Publ ublic Health Teh ehran an U Univer ersity of M Med edical al Scien ences es th WHS Regi 7 th giona onal Meeting ng 2019 2019 Kish, , I.R I.R. . of Ir Iran; 29 29 to 30 30 April il 2019 2019 akbar ak arisar ari@tums.ac ac.ir Disaster Health Management & Risk Reduction (DHMR-1)

 Development of HTA system in Iran  Challenges of Iran HTA system  Iran health system characteristics  Major characteristics of the region  Main message – implications for HTA in EMR region Disaster Health Management & Risk Reduction (DHMR-1)

Establishment of formal structure for HTA under supervision of Deputy of Treatment (2010), and expansion of this office to provinces (universities of medical sciences) under supervision of Deputy of Treatment

 HTA MSc program in 4 universities  MSc in Health Economics in 10 universities  PhD in Health Economics in 3 universities  PhD in Pharmaco-economics  Short time training programs including workshops on HTA, systematic review, meta-analysis, economic evaluation, …  Other training programs related to HTA e.g. epidemiology, health policy,…

 Following formal establishment of HTA structure in 2010, a specific budget was allocated for HTA by MOH  A proportion of NIHR budget is spent for funding HTA projects  A proportion of medical university research budgets (e.g. for MSc and PhD theses) allocated for HTA  HTA project receive budget also from other resources including insurance organizations, research centers, …

 HTA reflected in Supreme Leader Macro Health Policies … improved decision-making based on sound scientific findings via › development of standards and clinical practice guidelines, health technology assessment, …  HTA emphasized in Health Evolution Plan and other national documents, plans and policies  Mutual agreements with Office of Medical Equipment and NIHR

 Develop localized HTA CoreModel framework › in two categories (medical interventions and diagnostics devices) and three levels (Snapshot, Rapid Review, Full HTA) ›  Stakeholder Analysis in HTA Decision Making Process and their role  Estimate Cost-Effectiveness Threshold Value for IRAN  Estimate Population-Based Preference Weights for Health States for EQ-5D-3L, SF-6D-new version and EQ-5D-5L  Priority-setting of health technology assessment topics  Develop Decision support system for linking HTA to policy

 HTA reports on new technologies (over 120) › Drugs: 20 › Medical devices: 45 › Procedures: 15 › Other: 5 › Rapid reviews: 25 › Ongoing projects: 15  A recent search of databases retrieved 34 economic evaluation papers conducted in Iran and published in peer reviewed medical journals

HTA seem seem s s t o have e very lim it ed im pact on decision m aking …. w hy hy? ?   Wea eak gover ernance: e: › HTA com po ponent s com pl plet e t e but very fragm ent ed › e.g. se several HTA offi ffice ces s in MOH, F FDO, i insu surance ce organizat ions, s, … … › e.g. g. several H HTA fundi ding bo g bodies e. e.g. P PEN I nsulin ex exper erien ence e › Dupl plicat e pr proj e j ect s t s and effort s t s pot ent ia ially lly leading t o g t o di different de t decisions Rules es and reg egulat ions s ver ery lim it ed ed and not ef effec ect ivel ely in place e , and  available regulat ions usually volunt arily  Even en w it h presen esence e of reg egulat ions, s, hea ealt h sy syst st em em gen ener erally unreg egulat ed ed › Deci cisi sions s m ade w it hout u usi sing t t he resu sult s o s of f HTAs s › Use of HTA appr pproved d t echnologi gies for ot h t her pu purpo poses e.g .g. P . PET s scan

 Large e num ber er of t ec echnologies es in place e  Rapid dev evel elopm en ent of new ew t ec echnologies es  Full HTAs s are e t im e e and reso esource e consu sum ing  Policy m akers norm ally in rush not w ait ing for t he HTA result s Lim it ed capacit y, know led edge e and sk skills; s; and not used sed ef efficien ent ly  › e.g. profi fici ciency cy of M f MSc g c gradat es s in HTA? › Capa pacit y t y f for lim it e t ed n d num be ber o of pr proj e j ect s t s › Leadi ding g t o t o s significant de delay in H HTA pr proj e j ect s › Qualit y t y of HTAs and d t h t heir repo port s t s? Lim it ed ed fragm en ent ed ed funds s 

Technical problem s w it h HTA process ess  › Sign gnificant de delay in fundi ding, g, cont ract ing, g, pr propo posal appr pproval, repo port appr pproval, …  HTA TA resu esult s s norm ally n not used sed and im plem em en ent ed ed by policy m aker ers s  Monit oring sy syst st em em s s e. e.g. HI S inef efficien ent (e. e.g. use se of t t ec echnology for o ot her er gr groups ps)  HTA TA not linked ed t o ben enef efit package e and UHC

Even a co com prehensive co com plet e effici cient HTA syst em is not  enough w it hout ot her effici cient syst em s in place ce: e.g. › pa paym ent syst e t em , › regio ionaliz lizat io ion, supply ly lim lim it it , › fa fam ily physi sici cian, refe ferral sy syst st em , › elect ct ronic c reco cords, s, H HI S, › guidelines, pr gu prot o t ocols, st anda dards ds, po policy br briefs, … … › Monit oring and evaluat ions › and ot her co cost st co cont ainm ent and co cost st co cont rol m ech chanism sm s s … … › E.g. i insu surance ce co coverage of P f PEN I nsu sulin › Ordering PEN I nsu sulin by GPs s and sp speci cialist st s s

 Insurance coverage very high (about 95%), but via fragmented insurance organizations  Wide health benefit package includes almost all services  Insufficient and unstable financial resources (e.g. 34 of 40 million insured by IRAN health insurance organization dependent on government budget)  Health system fragmented and unregulated  Payment system dominantly FFS  Family physician not fully implemented, no referral system  HIS not efficient, human resources not enough  Dual practice high  High induced demand and inappropriate use of services  High Inefficiency

 Significant variations and diversities  Transitional health, health system, economy, politics, …  Significant uncertainties  Instability, unrests, wars, conflicts, sanctions  Natural disasters high  Oil dependent economy (not sustainable)  Limited resources, capacity, expertise, …  HTA formal national structure in 2 EMR countries

EMR region situation: implications for HTA?  More important  Urgent need for expansion and improvement  More restrictions  More prioritization e.g. more expensive more costly technologies  Affordability and CE e.g. hepatitis C treatment in IRAN, Pakistan, …

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