HTA in PAKISTAN An Overview

1. HTA in PAKISTANAn Overview Dr Assad Hafeez Coordinator HTA Forum Pakistan

2. OBJECTIVES • Need of HTA in Pakistan • Process & experience of HTA forum • Lessons learnt in non governmental sector • Future directions

5. Population: 170 million • Provinces: 4 • Districts: 134 • Villages: 50,000 • Poverty: 32% • Per capita income: US $ 1000 • Literacy rate: 50% • HDI ranking: 140

6. Health budget: 0.6% of GDP • THE: US $ 18 • GHE: US $ 6 • OPE: US $ 12 • Private sector: • 80% health care (mostly curative) • Unregulated • Health insurance and social security nets • Poorly functioning health system

8. Major challenges in health sector • High infant, child and maternal mortality • High burden of communicable disease • Meager resources for health • Poorly functioning health systems • Unregulated private sector • Human resource capacity and management • Knowledge divide • Policy dilemma • Do more for less • Changing scenarios

9. The need for HTA in Pakistan • Shrinking resources with rising costs • Push & Pull of manufacturers & vested interests • Rapidly emerging technologies • Role of unregulated private sector • Ambiguous policies with poor capacity to achieve evidence based decisions • Gullible consumers • Others

10. HTA Forum Pakistan • Visit of President ISTAHC to Pakistan 2001 • Group of professionals dedicated to promotion of “culture of evidence based” practices • Clinicians, academics, managers, policy makers, nurses, public health specialist, epidemiologists, others • Non governmental set up

11. Objectives of HTA Forum • Exchange of experience • Prioritize country needs • Sensitize and develop liaison with national and international stakeholders • Organize activities leading to better understanding of the role of HTA for Pakistan • Capacity development along with developing & conducting small scale technologies assessments

13. Activities • Regular meetings • Presentations at various forums • Research and publication of reports • Identification of priority areas • Capacity building • Establishment of linkages • Identification of focal persons in various areas • Trainings and seminars

14. Regular meetings • Brainstorming sessions • Various institutions • 2-3 month interval • Presentation of studies • Continuing education • Future directions and planning

15. Presentations at various forums • National forums • International forums • Local gatherings

16. Identification of priority areas • Consensus building exercise • Diagnostics • Drugs and medicines • Equipment procurement

17. Capacity building • Trainings by experts • Health Services Academy • College of physicians and surgeons Pakistan • International meetings/workshops

18. Establishment of linkages • World Health Organization • HTAi • National Health Policy Unit • MoH • Academic institutions

19. Identification of focal persons in various areas Geographical Institutions MoH DoH Professional associations Teaching hospitals District hospitals General practice University (public private) Nursing association Others

20. Research and publication of reports • No of publications in local medical journals • Small technologies assessments in institutions and regions

21. Routine pre op CXR in young patients • Method: prospective study • Conclusion: ineffective technology • Impact: routine CXR abandoned resulting in annual saving of one million Rs

22. CT scan in advanced abdominal tumors • Method: prospective study • Conclusion: in our setting where U/S has confirmed the extent of disease, CT scan is unnecessary, as laprotomy/lprocopy has to be carried out to confirm diagnoses or do palliative procedures. • Impact: Unnecessary CT scans stopped (costs 100 US$ per patient)

23. Ritual circumcision:Timing and pre-op investigations • Method: Literature search • Conclusion: • For routine circumcision • best time to operate is first 10 to 72 hours • no pre-op screening for coagulation disorders is required • Impact: • results published • Set of pre-op investigations require approx US$ 10

24. Use of multi vitamins in routine prescriptions • Method: prospective design • Conclusion: On basis of the evidence collected, multivitamin tablets use was found to be in-effective technology, in our settings • Impact: Rs 0.5 million saved in one hospital annually

25. Diagnostic effectiveness study at metropolitan corporation Lahore • Method: prospective study • Result: • The equipment was inappropriately placed • Ineffectively used • No positive impact on health of users • Very high operating costs • Impact: • review of policy by MCL was carried out • Redistribution of resources and appropriate training was put in place to improve efficiency

27. Trainings and seminars • Local meetings • International seminar/workshop

28. First HTA workshop/seminar 2004 • MoH, WHO, PIMS, Network • Objectives: • Advocacy • Capacity building • Future direction and recommendations • Participants: • 150 seminar • 25 workshop • Outcome: • Workshop report • List of recommendations • Group of trained people

29. Strengths of HTA initiative in Pakistan • Independent status • Linkages • Scope of work • Motivated work force

30. Requirements • Simple and short assessments • Adaptations • Economic analysis • Diagnostics, drugs, equipment. • District perspective

31. Challenges and barriers • Involvement of MoH and donors in a more sustainable way • Better understanding of effect of evidence on decisions making in policy and practice • Increase and improve patient & professional participation • Improve dissemination tools, language and timing • Adapt to local circumstances and values (flexibility)

32. Lessons learnt • Reputed NGOs should be involved in HTA process in developing countries • Strong linkages required • Local capacity building important • Small scale studies help in achieving ultimate goal • “Hot issues” to be addressed early

33. Future directions • “Rational Diagnostic Program” at district level. • Diagnostic procurement SOPs at tertiary hospitals • Clinical Practice Guidelines • Inclusion in curriculum of post graduate courses • Newsletter/publications

34. Conclusions • Poorly resourced countries need HTA more urgently • Multi pronged approach required to achieve results • Organizations like HTAi and WHO can play a significant role in this direction