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So if you can see the slides, we want to have a discussion on what has been going on in Ghana so far as it is concerned.

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And I'll be walking us through a number of slides, but really, I think I prefer that we have more of a conversation on on this subject.

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So you can stop me at any time.

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You can ask me any question at any point, and then we can have a discussion as much as possible, maybe an interactive session.

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Um, I can do this a whole week.

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So I would prefer that I try to be as brief as possible so we can have more time for interaction, like I said.

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So there's a bit of a structure to this and we are looking at a health system context in the lower middle income setting.

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And then we also looking at priority setting tools.

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And then we will talk a little bit about the mechanics for institutionalising things like health technology assessments.

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And then we'll talk about a few of education cases in our setting in Ghana,

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and I'll highlight a few challenges and how it plays out in the real world.

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So we know this this is generally popular for people in this space.

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And all that this is trying to see is that when you look at the kinds of diseases that we are dealing with,

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even in low and middle income countries like Ghana,

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at first it used to be a high proportion of communicable diseases to get that would matter now and you unitel in nutritional conditions.

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But then over the years, at least in the past decade plus, non-communicable diseases are on the rise and injuries are also on the rise.

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With that the difference in terms of.

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Revenue and financing for this shift from communicable diseases to a surging noncommunicable diseases is that when people get communicable diseases,

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like a lot of the infectious conditions that we know you treat, and then that's it, that people can go back to Libya, normal lives.

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But for non-communicable diseases, you sort of cheat or manage over a longer period.

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The cost implications that we are going to be spending on those populations for

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quite a long time and that is a very significant shift in terms of health.

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So if you see these blue bars, the rise of these blue bars actually is proportional to expenditure.

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And it means that without intervention and without some form of financing that can't contain this,

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then it means that your health care will go up and that affects everybody, really, because how will we get the money?

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We have to tax more. We have to do a lot of things to raise that kind of money.

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On the right side, you have this chart on health care expenditure and you can see this quasi distribution

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of of health care expenditure from out-of-pocket payments to domestic public.

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Computing for health aid is also possibly dwindling over the years.

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And for Ghana, AIDS is even in the lymph feather.

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The last briefing I had was that at least that country has been able to do it from do not support for its

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annual budgets to having a more concentration on internal or country level funding for for for AIDS budgets.

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And that's good. But then if you have things like this happening, if you don't prioritise,

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then it means that at that point you wouldn't be able to contain the costs of care for the general population and of course of health.

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So the country comes up with a vision to actually bring on board universal health coverage,

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and that is to see that every person in Ghana would have timely access to quality health services in shops.

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And that is actually the concept of universal health coverage. Now,

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what we are going to talk about today actually sits within this context in the sense that

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how do you get at or how do you sustain health for the population with scarce resources?

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And that is the key subject for today's discussion.

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Ghana tries to do that through primary health care.

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And there are a number is an elaborate structure for that.

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This one, maybe if we have discussions, we can go into this.

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Of course, there are systemic challenges, a poor mix of.

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My distribution problem is a mud distribution of critical health personnel so that human beings are provided care,

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are not distributed very well at certain places. You have specialities in certain places.

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You don't have health professionals at all.

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The health insurance funding and this spending of on primary health care is also challenged regular stock outs for medicines across the health system.

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So these are all systemic challenges that would not allow smooth delivery of health services, especially in the low and middle income context.

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Now, it is on top of these challenges that we want to set priorities on top of these

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challenges that we want to actually deploy tools like health technology assessments.

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So just to recap, I mean, some of you would have known this already, but we just want to all draw a baseline,

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sort of see that a health technology in this context is actually an intervention that is deployed to prevent, diagnose or cheats conditions.

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It can promote health, it can promote rehabilitation or even organise health.

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In that case, the intervention can actually be a test. It can be a device.

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It can be a drug. It can be a vaccine, a procedure, even a system.

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So broadly, what we see that any organised application of knowledge with an intent to promote,

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prevent or to treat a health condition is considered as a technology to.

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And in that piece, we are just assessing technologies, using the methods and tools that we are going to be talking about.

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So all of these things that we talked about,

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our technologies and how you systematically evaluate them for the value is what we mean by HCV or health technology assessment,

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meaning that we can assess vaccines, we can assess drives, we can assess systems,

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we can assess policy options, we can assess a lot of things using these tools.

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Now, what do we really assess? We assess values.

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We assess properties, effects and impacts.

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In a nutshell, we assess the value of these technologies, and we have to use a systematic approach to do that.

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The value that we assess. We do that assessments using multidisciplinary processes and explicit methods.

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So that is very important.

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And the way we set up it in low and middle income countries is to ensure that there is this multidisciplinary process involved.

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And then we have explicit metrics as well. And that main purpose is to inform decisions.

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If we said multidisciplinary, I mean, these are some of the disciplines that you find in a typical process.

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So you have health economics who are there. We have outcome research as we have medical sociologists, medical ethicists,

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we have decision making entities, evidence base, all kinds of disciplines.

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And even in Ghana, we even have a lawyer who is part of this process.

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So it's quite broad in terms of the disciplines that are involved.

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As I said, that we assess value the value of these technologies through these processes.

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And what do we mean by value? We mean value in terms of clinical effectiveness, in terms of safety, in terms of cost,

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in terms of social, ethical, cultural, legal, organisational and even environmental aspects.

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And when you come into let me be specific in terms of the African context, a lot of socio cultural dimensions as well.

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If you hear stories around vaccine hesitancy where people are not just taking vaccines for all kinds of social cultural reasons,

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then it means that we have other dimensions of value that actually relevant in our context.

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But all of these dimensions without a safety costs, can be grouped into three.

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And typically we have clinical effectiveness as one big dimension, including all the efficacy related things,

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economic evaluation to deal with all the issues around costs, cost effectiveness and related issues.

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And then the social ethical things are also in the category.

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So that is to say that in assessing value in an 80, we do so along these three dimensions broadly.

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Now. When we do the assessments, we normally do that along the lifecycle of a particular project or particular technology.

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This one, I would skip this for discussion if you are interested in further information on that.

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Now I'll quickly jump to health system building blocks, that typical ones that we know from both of you.

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We have service delivery, health workforce health information systems, financing, leadership, governance,

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and always seeing that each year has application in all of these building blocks in any health system,

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whether it is a lower middle income country system, you can set priority,

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you can assess value of health technologies across all these various dimensions.

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So how did Ghana start this whole process of specialisation?

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Now, what we were saying then was that for us to see that we have been able to institutionalise year,

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there has to be about 11 things which had to be present for us to see that,

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okay, this process, this multidisciplinary process to assess value of technologies have been or

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it has been institutionalised vessel for there needed to be a clear agenda.

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Maybe there to be some governance structures in place, there needed to be some strategic direction, a clear process,

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some capacity to conduct and the capacity to use the evidence they needed to be evidence

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of production of these and its use and a systematic application of the findings.

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And then the whole strategy to implement it had to be evaluated.

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There has to be sustainable funding with a clear communication strategy and advocacy as well as legislation to support if need be, if need be.

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So the 11 item is conditional if need be, and I'll come to that as we go along.

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So how have we fed our own framework that we started to weather this with?

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So for agenda setting,

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the country looked at the area of medicines because it was very easy to demonstrate value and assess value when it came to medicines.

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So the country leveraged the medicines policy to institutionalise it.

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What that means is that initial applications for HCA to show its value had to

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be on drugs and pharmaceuticals because there was a clear health insurance.

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If you saved money, it would then have an effect on health insurance reinvestments and health insurance finances almost immediately.

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So that was very easy to achieve. Then in terms of governance structures, that country established a steering committee.

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These are the human beings and the officials behind that steering committee,

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which wants to go for governance as a category for both technical and administrative work.

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And then the technical working group that is responsible for analytics.

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Of course, we leverage a lot of partnerships and networks, and then we also manage in-country stakeholders as part of this process.

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So this is how is set up. Now it had to sit somewhere, especially the sectarian.

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So this is all going to grandma, the Ministry of Health. The agencies are in the top corner there from health insurance, the Ghana Health Service,

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the Teaching Hospitals, Mortuaries Board, all of them out there.

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And then when you come to the lane directions, the blue one is technical port mission,

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and that is where it is situated to provide technical advice to all the line directorates in the

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green and then also to the agencies of the Ministry of Health in the green at a top corner.

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So it means that evidence from this blue box would inform decisions around health insurance, reinvestments around health facilities,

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regulatory activity, nursing activities, psychology, pharmacy council and a ton of other applications in the system.

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With all of that, then governance wise, because the country had decided to use ACA as a tool in policy prioritisation,

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selection of health technologies, benefits, package design. These are things that affect everybody.

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So benefits package design, when you go to hospital, what you get by way of services that are provided for the general population,

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what an essential services that should be provided for everybody in Ghana.

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What are the prices that we should buy pharmaceuticals and other health technologies for the population?

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Now there are key entities responsible for decisions in this area, and those are targets for you.

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So when you came to the first item for policy, the Ministry of Health Policy Planning,

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quality and evaluation at department, when it comes to lesson, these are committees and entities that are responsible,

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meaning that these are targets when data that we use and we have realised that if you don't

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identify a clear target for use of that evidence against difficult in terms of holding people to,

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to accounts as to how they use that evidence.

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What about the area of strategy?

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Ghana came up with its first strategy for it clear objectives establish the structures for it to build capacity to use and to use them as

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strength in the conduct of HIV by making the processes robust and transparent and then optimised the application of those 80 that you have done.

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And all of that is supposed to build a culture of evidence based decision making.

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So these are the clear objectives from that. We got the Minister to buy into this by endorsing the strategy and promoting it across the health system.

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The strategy summary talks about the fact that we needed to be able to systematically select

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the topics that will do it alone and have the capacity to actually do those eight years.

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They needed to be manuals and guidelines available that are responsive and regularly updated.

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They needed to be some resources available to do this work.

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They need to be sustainable. Resource mobilisation.

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Of course, there needed to be some collaborations and partnerships with about 80 bodies across the globe.

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They needed to be capacity, continuous capacity building,

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and we needed to do the two types of communication communication up to the way of Parliamentary

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select committee communication all the way to the grassroots in terms of civil society,

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patient groups and all of that. So this is a summary of what this strategy is about, and all of that centres around strong governance.

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To be able to articulate all of these and ensure that the population and the health system benefits from the conduct of it.

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Of course that strategy came with a clear monitoring and cost that costings and so is of course their strategy.

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It has a monetary policy framework. It has a theory of change with a clear intent of how the change that we are looking for would come about.

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Now, if you look at the cost distribution, we realise that because we said that in building capacity we want to learn by doing.

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We are heavy on doing and building capacity.

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Those are the two things up there and that is where we spend most of our resources in terms of establishing it in Ghana.

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We have gotten somewhere with the strategy about 62% of the activities and interventions in that strategy either ongoing or completed.

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And 38% of them have not started out at all.

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It's a five year strategy and we are halfway to a half year into that.

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So we hope to be able to clear the other ones that we have not started,

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but we lack an impact assessment model and it's something that we are engaging academic institutions

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both in-country and then around the globe to be able to come up with an impact assessment model.

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We just want to be able to see that to implementing this particular year,

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we have been able to impact the health system to this extent and that is how we can articulate the value of it to you,

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to our ministries of finance, so that they can invest into it for us to be able to save more money and then cover more populations with little.

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So there have to be processes as well.

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And in terms of processes, we have outlined a process for a two year, one that is a full process and the other that is a rapid process.

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Now this is where the adaptive it comes in, in the sense that, you know,

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this elaborate process can travel for quite some time in terms of putting all of that eight steps together.

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You start by stakeholders nominating topics. Okay.

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So somebody said that there's a need drug that can help those who have mentally challenged conditions like schizophrenia,

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and then that has to be evaluated and then another person comes with something else.

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So you can be bombarded with a lot of topics and you need to prioritise these

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topics to be to see the most important ones that you spend resources to analyse.

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So that is the topic nomination, followed by topics,

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a lesson where we apply an appropriate criteria to be able to identify which topics are what doing.

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Then the topics are approved by the steering committee. Then the analysis goes in.

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We scope the topics and other ways we bring our topics down to answerable questions and then we are able to get stick with that inputs into that,

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and then we conduct the typical assessments.

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It is an assessment that take a lot of time.

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It can take up to 52 weeks, but in a rapid scenario, you don't have the luxury to be able to wait for all of that.

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So you are there's a lot of pressure on you to respond fast.

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And whether you bring the evidence now or you bring it later in the policy space, decisions will be made.

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And while you are showing scientific regard, your analysis decisions will be made.

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So you will have to find a way of making things faster and be able to analyse.

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And you can also sacrifice the sound science and just speculate to give evidence.

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So you have to find a way of making it work that way.

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And this is where we are using adaptive methods,

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where we are able to bring it to you that are being done or analysis that has been done in

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other contexts to bring it into the Ghanaian context on the low and middle income context.

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There are a lot of challenges with that,

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but we are just we have tested it once on diabetes and documented our lessons and we hope to be able to adapt that for for some value.

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So with assessment then comes up with another team independent of the assessment

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group will look at the work that we have done to actually appraise it.

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Is it quality enough and has they considered all the various nuances of methods to do that?

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Then the appraised evidence is submitted to the deliberations, which you have with the steering committee,

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and the steering committee is made up of the decision makers.

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I'm talking about CEOs of health insurance. And see and at that dinner asking Ghana health service.

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So these are decision makers and they look at that evidence in a reduced form so

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that they can actually make decisions or make recommendations based on that.

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After that, we communicate and give people the opportunity to appeal those recommendations if they disagree.

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And then those appeals are not like you just disagree because you disagree.

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You have to come up with evidence and see that, okay, fine, you did not consider this other evidence of your analysis.

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And therefore I want to appeal that this be considered.

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And it's also not a perpetual thing. That's a window.

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Of when we disseminate evidence, you have to appeal within a certain time as the process moves on so we can discuss more of this.

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But this is the process. And I spoke about criteria for topping the list.

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We do topics that tick the box for these things.

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The topics should be able to affect a larger number of people.

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It has to have a potential for benefits.

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It has to have high household impact, economic cost to the pockets of of the poor.

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It has to be make a case for equity and it has to have a potential for cost effectiveness.

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If it ticks all these boxes, then is worth looking at.

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Decisions that also made, first of all, technologies that would be feed.

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It must be safe. They must first do no harm and then apart from be safe, they must be effective.

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And if they are at least comparably effective with something else, then that new technology has to be cheaper.

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But if they are effective, then we have to look at it in terms of adding cost effectiveness.

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So by the time we're able to address all of this, we filter a lot of garbage inputs and outs.

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And then the technologies that are able to pass this test are then going into deliberations where we look at affordability,

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how we pay for for the technology. Is it feasible in our context to deploy it and all of that.

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So these are all things. And in terms of feasibility, so for instance,

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now probably the best thing is we realise that that was one that had to be stored at certain some cold temperatures and a lot of our supply chains,

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they didn't have those kinds of fridges to keep them. So in that case we realised that there'll be an issue with feasibility in terms of supply chain

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and that all is considered in their decisions to adapt or not to add that particular technology.

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So that is a decision making algorithm that we use in terms of the adaptive ATP, which we have done for diabetes and insulins.

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It's it actually affects this part of the process where you have up to 12 weeks off of the tools.

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The adaptive is way shorter, not necessarily less complicated,

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but then we are hoping to shorten time by the use of adaptive methods and we are documenting those, those methods in the in the method methods guide.

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So and it includes a checklist and transferability assessments so that you can check whether this particular work that was done in Austria,

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this particular work that was done in the UK, can we apply it to the context?

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There are a lot of nuances because this includes economic analysis and if you look at it very well,

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the markets in the US, the markets in the UK, the markets in Australia are different.

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The forces that control price are different. So how do you transpose that into the Ghanaian context and that we use to compensate

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for price and compensate for inflation factors and exchange rates within all of this?

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And so these are some of the things that we look at in terms of benchmarking prices and also transferring evidence.

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And I will leave it to you if you want to go a bit further, we can look at that much more detail.

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So the structure of that manual is something that we can even share.

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So when it comes to methods, we said that we wanted to see robust methods as part of the internationalisation.

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So we came up with a reference case. A reference case sums up all the things that must go into an easy for us to call it.

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Well done. And it includes several dimensions, so I won't go through all the details again.

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If you probe, we can look at it much more.

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But then there is we are saying that for evaluation type, we want to see a cost utility analysis for data sources.

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We prioritise systematic review and meta analysis of expert opinion.

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For instance, for outcome measures. We are looking for values and quality.

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If you give us some other outcome, then you need to justify why for discounting rates,

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we want to look at 3% discount rates and we do a sensitivity analysis between all scenario analysis between zero and 10%.

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Now, all of these are quality assessment things that we want to see in the reports.

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Now, because we came up with this, then it means that if you are even an independent person and you or an institution,

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you conducted an eight year that ticks these boxes, you could submit that for an appraiser.

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And that can also be considered in terms of evidence that informs decisions being in low and middle income countries.

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We are not able to fund all the eight years. So this is a manoeuvre that you can get funded by others and then that can be considered.

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But then there has to be a get keep US system to ensure that is well done as a

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lot of things can inform your decisions when you are not really looking at it.

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So in terms of production, we have been able to produce some work around hypertension, childhood kind of says pneumonia in children.

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COVID vaccination programming ad was packaging haemorrhage, which is capitalism and oxytocin comparison.

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And then the diabetes work that I just spoke about. There are a number of works ongoing around cervical cancer.

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Whether that we should screen and treats or we should not prostate cancer,

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The men are saying that the children causes COVID, the woman causes COVID is left with the men.

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So there's a lot of advocacy around prostate cancer as well by dependent for schizophrenia anaemia.

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And as unassuming as it is, it's really costing us a lot of weight in our shares.

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So we want to optimise our anaemia care together with the ongoing discussions in Ghana recently about dialysis.

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Highly expensive, but we are exploring peritoneal dialysis haemodialysis or a mix of the two for patients to see where we can have value for money.

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Sickle cell screening and malaria vaccine.

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The new one that came out recently.

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Of course there are other things, but we've also defined potential as sources for efficiency in our health insurance.

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Identify what the topics, where we can find efficiency.

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And for these topics, we keep engaging partners.

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We keep engaging academic collaborators in terms of conducting these topics.

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What we've done with our loop and look at academic institutions is that there are people who are we must as programs,

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who are being paid programs to pick some of these topics as part of your work.

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And then we get evidence. They also get the disease and it's a win win situation.

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We have done similar thing with the investment bank in Norway, in Oslo and even London School.

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So these are open points for collaboration, which we normally also do.

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I will quickly move to the next area that I would talk about a few application cases.

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So for hypertension, which is the first case I'll mention, what we've done in hypertension,

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is that through this sort of analysis, we've been able to prioritise calcium channel blockers and diuretics over other.

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Now before then, Uganda, if you went to hospital, you had hypertension.

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It's up to the doctor that you see to actually put you on your initial treatments.

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But then we realise that it's not all cost effective for some of the other drugs.

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So we through this analysis, we've been able to see that first, if somebody is newly diagnosed and they come,

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they don't have complications, put them on diuretics or calcium channel blockers.

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These are cheaper. They give you the outcomes that you need and this has been taken up.

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So now the guidelines have been updated. And then also the insurance reimburses for these drugs and is a.

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Seamless decision and them we are improving hypertension care in that area.

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We have actually used this also in price negotiation.

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And what you see here is that we realise in a nutshell, we realise that that any fluctuations in the price of amlodipine ten milligram,

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which is a drug that is used to treat hypertension fluctuations in the price of that ten

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milligrams tablet has a significant effect on the cost effectiveness or value for money,

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and that if that price should double, then you have a serious change in how cost effective the treatment is.

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However, it's not the same for the five milligrams. So we decided that will zone into that ten milligrams and actively negotiate for that price.

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And when we did that, we were able to then translate the benefits in terms of saved costs to our users and is a way that we help

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ourselves to be able to be able to cover more more patients for for childhood cancer that I mentioned.

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What we found was that and that every form of scenario, whether you will leverage cost inputs or not,

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the reimbursement system for childhood cancers would always deliver less cost for more benefits.

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And that is what you see here.

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This was done with the Monte Carlo simulation to give you on the several scenarios how the cost effectiveness looks like.

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And under all of that, you found that in all scenarios you are always saving cost and then you are improving benefits for children.

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Now, the insurance hasn't decided to always take on what we see.

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What they also do is that they have an actual model which says that, okay, fine,

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you have done your cost effectiveness analysis and it says it's cost effective.

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Have you done a budget impact? We say yes, we've done a budgeting, but you know, one cost to achieve cost, yet three equals four positive five costs.

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And this is your daughter. Now when we get this data,

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they put it into the actual lab model and then the actual model is able to tell them that considering all the other things that we are reimbursing,

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if we can see that this budget impact that you have, this budget for the new intervention is reimbursed out of the concepts.

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And we added it to all the things that we are reimbursing now.

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Are we sustainable in a setting number of years until they see that we are sustainable,

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They will have issues with this technology and you have to go readjust the analysis.

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So we did that and realised that it would be can absorb this budget impact of almost $1,000,000 for children.

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And then the decision was taken.

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So as we speak now in Ghana, we have been able to cover certain cancers and that showed us before that it was not the issue.

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We are moving on to address other things around it. We are moving on to improve the governor's.

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We are moving on to improve quality of care for children who have other concerns.

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Create more awareness so that people who in the remote areas people can bring

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their children to treatment centres and receive treatment under the insurance.

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The cost of that will be borne by the insurance, of course, and then we will have to assess impact.

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But we don't have an impact assessment framework yet. So that is one area that we need to strengthen the case.

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I have six cases due to TED one so that TED one is on.

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Pneumonia management in children. And what we have done is that this was just a swap of formulations,

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swap the amoxicillin suspension for amounts of amoxicillin disposable tablets and you said 800,000 Ghana cedis every year.

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So this is simple analysis, straight to the point. When we presented this to the insurance,

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then they just jump on it and then they listed the dispensable tablets on the list that is on this on the websites.

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We put the list up so you can actually check on that. And they put that particular formulation there because it was a cost savings.

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I mean, we didn't even have to analyse for the the the cost of hauling heavy suspensions and bottles for miles.

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Would you add that cause if you add that cost,

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it would have been projected savings further by just on the pure therapeutics, where would you establish this fact?

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And then they pick it up. Frankly, it hasn't been all rosy.

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We did some of the work around COVID 19 vaccines and we're looking at what is the most

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effective way to get the vaccine and send it to the population of people who need them.

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Despite the fact that we did this analysis, we didn't see the evidence inform decisions to a wide extent.

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So we decided to do some implementation research to look at what really happened.

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And these without these were our findings is a qualitative piece of ways.

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Now, the issues were with timing. We missed the decision making time by two weeks, and because of that,

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the analysis could not inform those decisions because they have taken decisions two weeks ago and then the evidence just came.

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But what we realised from all the qualitative data is that the timing and access to the reports is critical.

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We needed to reduce the technical density of the reports.

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We needed to ensure that what you are analysing is relevant for the decision making.

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And then you also needed to address political issues around power and the use of power on decision making,

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as well as issues of health system fragmentation.

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I mean, if you we can get more into this.

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There was a very interesting study that we did to address this and we did with different set of partners who have acknowledged that.

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What have we learned so far with this?

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You need to be responsive and timely in your conduct or any accident in this process, especially the LMC context.

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And this is where we are saying that if you find a way to adapt existing it or find a way to do rapid analytics,

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it helps because then you can be time in all of this.

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Else, all this work that we do does not deliver the value.

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If you missed the decision making time because our policy decisions have to have time bound and decision makers would want to move on.

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So. We have also learned a few lessons around doing the adaptive work.

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What we have learned is that in adapting its or adapting evidence from one context to the other,

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you first of all, needed to do a very extensive search.

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I mean, people have done the research and you are trying to ask a different question in your context.

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If you don't find a mass, then that is that that that that that ends it for you and you can actually spend time searching.

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And when you don't feel you need to come back and start the whole process of doing analytics,

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you also may find something that is close to the match, but it's not a perfect match and all of that.

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So they will become there will be trade offs in all of that.

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You need to then look at also transferability systematically how you adapting something from a similar lower middle income context to yours,

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or are you adapting from a high income country to yours?

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And all of that has implications for your make this something that I normally call cuts Northeast syndrome.

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Me that you go out there looking for a particular type of work that has been done that directly answers your question and you just won't find it.

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If you don't find it, you may retain what we call a denominator where you start from scratch and continue to you.

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And adaptive is estimated to be faster, but not necessarily as complicated.

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The last case is on postpartum haemorrhage.

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We are yet to engage the insurers to pay for this particular initiative,

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but it's if that's proving to be efficacious in terms of the evidence that we have found,

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that oxytocin, you'd need to put in a coating and keeping fluids all throughout.

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And then our system sometimes is not able to invest in those fridges.

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So capitalism is able to stay at room temperature and is still effective.

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And the evidence, of course, capitalism by a lot of the initiatives around maternal mortality.

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So we hope that when we are able to get this, we embed it will be able to actually save a lot of women from dying from bleeding.

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I would pause here and maybe we can have some discussion which would take us

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into the next the next step of our challenges and challenges is that sometimes,

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though, that strategy said that we needed to find sustainable funding for this.

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We actually don't have we leverage our partnerships, we leverage grants and all of that to do the work that we do.

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We don't have a law that supports all the work that we do. We leverage institutional arrangements.

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So if, for instance, I'm CEO retires and then it means that the new CEO,

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you have to go and do a lot of advocacy again to let them understand all of that.

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And there's no law that actually we are using to implement.

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This is just purely institutional arrangements and that is some of the things that we are implementing this.

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So I'll keep the rest for the discussions. A few enablers, but I'll pause here so that we can have some some interaction on this.

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Thank you. And over.