Governance and structure of HTA bodies

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Introduction

Health Technology Assessment (HTA) varies from country-to-country (or region or even province) in relation to health-system structures and conditions. In general, HTA bodies are established in rough correspondence to administrative structures for a health system. For example:

  • Spain’s health system is regionally managed and has therefore developed provincial HTA bodies
  • France has a more centralised health system and HTA body.

Organisation

There is no agreed format for HTA, and the shape of an HTA body in a particular country is influenced by that country’s healthcare system and the level of government involvement in it. Effective HTA bodies are able to ensure methodological rigour, and use multi-disciplinary inputs to produce and disseminate high-quality, policy-relevant research to decision-makers within the healthcare system. This requires that the HTA body be tailored to the decision-making processes of the healthcare system, and to the needs and interests of decision-makers.

There are several common arrangements for HTA bodies. They may:

  • be established by ministries of health (generally where governments are substantially involved in financing the healthcare system),
  • receive a mixture of public and private funding,
  • be part of arrangements in which the private sector must pay the HTA organisation to have a new medicine reviewed,
  • be independent of government but perform HTA for governments or other clients,
  • be HTA projects initiated by organisations of health professionals,
  • be HTA bodies that are funded by and evolved from academia

The key feature of any effective HTA body is its capability to support healthcare system decision-makers. In a centralised healthcare system like in England, one large HTA body (like the UK National Institute for Health and Care Excellence, NICE) may be sufficient for supporting decisions. On the other hand, in de-centralised healthcare systems such as in Italy or Spain, many HTA organisations may be required.

Decision-Maker

Sample HTA bodies structure and funding arrangements
Example HTA bodiesYearFunderDecision-Maker
Basque Office for Health Technology Assessment, Spain1992PublicRegional
Hayes, Inc. USA1989PrivateVarious
Swedish Council on Technology Assessment in Health Care (SBU), Sweden1987PublicNational-Regional
Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG), Germany2004PublicFederal
Haute Autorité de Santé (HAS), France2004PublicFederal

Negotiating an HTA body’s role within a health system is context-specific, and the nature of an HTA body’s output is likely to reflect the value structure of those it employs and those to whom it is responsible. Once a technology has been assessed, a social process follows in which decisions about resource allocation and access to technology are made. This social process typically reflects the values and interests of dominant stakeholders.

Managing the relationship between HTA and technology developers

There is no perfect way to manage the links between those who produce technologies and those who assess them. In many cases, for instance, and particularly for government-financed HTA in publicly-financed health systems, technology producers or other key stakeholders are on the outside of the process and may feel that HTA is merely a means to delay introduction of new technologies or drive down technology prices. HTA bodies must recognise their links to key stakeholders, and consider how to engage them in a robust and accountable way. Transparency in the assessment process, for instance, provides a framework for collaboration rather than confrontation, and the HTA principles give good guidance on how to engage stakeholders in the HTA process.

Cost containment

In some cases, decision-makers do look to HTA to contain costs. However, an HTA body focused only on cost containment is likely to face significant difficulties in bringing stakeholders together. While the costs of technology are almost always a concern of HTA, treating them as the only concern misses at least half the story of health technology – in particular, the effects of health technology in improving health and healthcare-system functioning.

Health technologies with no identifiable health benefits are easy to dismiss, with or without HTA. For the vast majority of technologies, however, incremental health benefits come with costs to individuals or the healthcare system, and potential implications for resource allocation by individuals and by societies. In most cases, health improvements do not yield reductions in expenditures within the healthcare system. Very difficult decisions need to be made about how to spend a finite health budget, bearing in mind long-term implications for societal health benefits.

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