HTA in the public health system
The National Health Security Office, which institutes and manages the largest health plan in Thailand (Universal Coverage Scheme [UC]), initiated a collaborative research and development project with two independent research institutes – the Health Intervention and Technology Assessment Program and the International Health Policy Program – in 2009. The aim of the project was to develop an optimal strategy for the development of the UC benefit package, that is, to determine which interventions should be candidate for public reimbursement. The project is named research for development of health benefit package under the universal health care coverage scheme, or known as UCBP (see www.ucbp.net). The project incorporates multiple-criteria decision analysis (MCDA) and a deliberative process and multi stakeholders’ involvement to guide national-level priority setting in health care coverage decision. The review documented the experience of seven health technology assessment organizations in Canada, England and Wales, the United States, the Netherlands, Germany, Sweden and Spain, which all use an explicit process of priority setting. Its findings concluded that all these organizations consider multiple criteria, involved multiple stakeholders, and distinguish, in one way or another, four basic steps in their priority setting Process. These steps were then also applied in the Thai setting and included. The results of the review were adapted to the Thai setting, resulting in 4 steps of explicit priority setting including: 1) nomination of interventions for assessments, 2) selection of interventions for assessment, 3) technology assessment of interventions, and 4) appraisal of interventions. Since the beginning of the research project up to 119 topics have been proposed for inclusion into the benefit package, with 53 topics selected for further research or HTA analysis.
One of the benefit packages revised through UCBP is the development of a health screening package under the universal health coverage in 2010. Currently, the three public insurance schemes in Thailand offer different health screening packages. The study was designed as a response to requests from stakeholders including decision-makers and representatives from the general public, to develop an evidenced-based health screening package for the population that could ensure equitable access to essential health screening under the three schemes. The results led to advice against elements of current clinical practice, such as annual chest X-rays and particular blood test (e.g. kidney function test), and indicated that the introduction of certain new population-based health screening programs, such as for chronic hepatitis B, would provide substantial health and economic benefits to the Thais. The final results were presented to a wide group of stakeholders, including decision-makers at the Ministry of Public Health and the public health insurance schemes, to verify and validate the findings and policy recommendations. The package has been endorsed by the Thai UHC Benefit Package Committee for implementation in fiscal year 2016.
In 1981, Thailand’s National List of Essential Medicines was created. Subsequently, in 1983, the Subcommittee for the Development of the National List of Essential Medicines who works in collaboration with the Food and Drug Administration as its secretariat. In the latter years, the function of the subcommittee became the maintenance of an optimal list of medicines, wherein the criteria for selection were cost, safety, efficacy and effectiveness of drugs. In each of these criteria, the subcommittee’s [7] was to consider scientific evidence to determine which medicines are to be included in the list. Twenty-eight specialist working groups undertake the task of determining what should be on the list as well as informing price negotiations between manufacturers and the NLEM.
Increasingly, awareness and realization that the evidence required for optimal coverage decisions involved analyses in cost-effectiveness as a fifth criterion. In 2009, the Health Economics Working Group was established under the subcommittee. The working group was composed of health economists, representatives from the subcommittee, academics and representatives from the three health insurance schemes and the working group secretariat. In this process, HITAP in collaboration with the Food and Drug Administration was involved as the secretariat of the working group whose function was to generate procedures and assure quality of the evidence provided. The HEWG then prioritized the requests based on burden of disease, the risk to life and financial burden on households posed by the condition and social consideration and commissions the cost-effectiveness research from non-profit agencies (like HITAP).
