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.
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.
So you can stop me at any time.
You can ask me any question at any point, and then we can have a discussion as much as possible, maybe an interactive session.
Um, I can do this a whole week.
So I would prefer that I try to be as brief as possible so we can have more time for interaction, like I said.
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.
And then we also looking at priority setting tools.
And then we will talk a little bit about the mechanics for institutionalising things like health technology assessments.
And then we'll talk about a few of education cases in our setting in Ghana,
and I'll highlight a few challenges and how it plays out in the real world.
So we know this this is generally popular for people in this space.
And all that this is trying to see is that when you look at the kinds of diseases that we are dealing with,
even in low and middle income countries like Ghana,
at first it used to be a high proportion of communicable diseases to get that would matter now and you unitel in nutritional conditions.
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.
With that the difference in terms of.
Revenue and financing for this shift from communicable diseases to a surging noncommunicable diseases is that when people get communicable diseases,
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.
But for non-communicable diseases, you sort of cheat or manage over a longer period.
The cost implications that we are going to be spending on those populations for
quite a long time and that is a very significant shift in terms of health.
So if you see these blue bars, the rise of these blue bars actually is proportional to expenditure.
And it means that without intervention and without some form of financing that can't contain this,
then it means that your health care will go up and that affects everybody, really, because how will we get the money?
We have to tax more. We have to do a lot of things to raise that kind of money.
On the right side, you have this chart on health care expenditure and you can see this quasi distribution
of of health care expenditure from out-of-pocket payments to domestic public.
Computing for health aid is also possibly dwindling over the years.
And for Ghana, AIDS is even in the lymph feather.
The last briefing I had was that at least that country has been able to do it from do not support for its
annual budgets to having a more concentration on internal or country level funding for for for AIDS budgets.
And that's good. But then if you have things like this happening, if you don't prioritise,
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.
So the country comes up with a vision to actually bring on board universal health coverage,
and that is to see that every person in Ghana would have timely access to quality health services in shops.
And that is actually the concept of universal health coverage. Now,
what we are going to talk about today actually sits within this context in the sense that
how do you get at or how do you sustain health for the population with scarce resources?
And that is the key subject for today's discussion.
Ghana tries to do that through primary health care.
And there are a number is an elaborate structure for that.
This one, maybe if we have discussions, we can go into this.
Of course, there are systemic challenges, a poor mix of.
My distribution problem is a mud distribution of critical health personnel so that human beings are provided care,
are not distributed very well at certain places. You have specialities in certain places.
You don't have health professionals at all.
The health insurance funding and this spending of on primary health care is also challenged regular stock outs for medicines across the health system.
So these are all systemic challenges that would not allow smooth delivery of health services, especially in the low and middle income context.
Now, it is on top of these challenges that we want to set priorities on top of these
challenges that we want to actually deploy tools like health technology assessments.
So just to recap, I mean, some of you would have known this already, but we just want to all draw a baseline,
sort of see that a health technology in this context is actually an intervention that is deployed to prevent, diagnose or cheats conditions.
It can promote health, it can promote rehabilitation or even organise health.
In that case, the intervention can actually be a test. It can be a device.
It can be a drug. It can be a vaccine, a procedure, even a system.
So broadly, what we see that any organised application of knowledge with an intent to promote,
prevent or to treat a health condition is considered as a technology to.
And in that piece, we are just assessing technologies, using the methods and tools that we are going to be talking about.
So all of these things that we talked about,
our technologies and how you systematically evaluate them for the value is what we mean by HCV or health technology assessment,
meaning that we can assess vaccines, we can assess drives, we can assess systems,
we can assess policy options, we can assess a lot of things using these tools.
Now, what do we really assess? We assess values.
We assess properties, effects and impacts.
In a nutshell, we assess the value of these technologies, and we have to use a systematic approach to do that.
The value that we assess. We do that assessments using multidisciplinary processes and explicit methods.
So that is very important.
And the way we set up it in low and middle income countries is to ensure that there is this multidisciplinary process involved.
And then we have explicit metrics as well. And that main purpose is to inform decisions.
If we said multidisciplinary, I mean, these are some of the disciplines that you find in a typical process.
So you have health economics who are there. We have outcome research as we have medical sociologists, medical ethicists,
we have decision making entities, evidence base, all kinds of disciplines.
And even in Ghana, we even have a lawyer who is part of this process.
So it's quite broad in terms of the disciplines that are involved.
As I said, that we assess value the value of these technologies through these processes.
And what do we mean by value? We mean value in terms of clinical effectiveness, in terms of safety, in terms of cost,
in terms of social, ethical, cultural, legal, organisational and even environmental aspects.
And when you come into let me be specific in terms of the African context, a lot of socio cultural dimensions as well.
If you hear stories around vaccine hesitancy where people are not just taking vaccines for all kinds of social cultural reasons,
then it means that we have other dimensions of value that actually relevant in our context.
But all of these dimensions without a safety costs, can be grouped into three.
And typically we have clinical effectiveness as one big dimension, including all the efficacy related things,
economic evaluation to deal with all the issues around costs, cost effectiveness and related issues.
And then the social ethical things are also in the category.
So that is to say that in assessing value in an 80, we do so along these three dimensions broadly.
Now. When we do the assessments, we normally do that along the lifecycle of a particular project or particular technology.
This one, I would skip this for discussion if you are interested in further information on that.
Now I'll quickly jump to health system building blocks, that typical ones that we know from both of you.
We have service delivery, health workforce health information systems, financing, leadership, governance,
and always seeing that each year has application in all of these building blocks in any health system,
whether it is a lower middle income country system, you can set priority,
you can assess value of health technologies across all these various dimensions.
So how did Ghana start this whole process of specialisation?
Now, what we were saying then was that for us to see that we have been able to institutionalise year,
there has to be about 11 things which had to be present for us to see that,
okay, this process, this multidisciplinary process to assess value of technologies have been or
it has been institutionalised vessel for there needed to be a clear agenda.
Maybe there to be some governance structures in place, there needed to be some strategic direction, a clear process,
some capacity to conduct and the capacity to use the evidence they needed to be evidence
of production of these and its use and a systematic application of the findings.
And then the whole strategy to implement it had to be evaluated.
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.
So the 11 item is conditional if need be, and I'll come to that as we go along.
So how have we fed our own framework that we started to weather this with?
So for agenda setting,
the country looked at the area of medicines because it was very easy to demonstrate value and assess value when it came to medicines.
So the country leveraged the medicines policy to institutionalise it.
What that means is that initial applications for HCA to show its value had to
be on drugs and pharmaceuticals because there was a clear health insurance.
If you saved money, it would then have an effect on health insurance reinvestments and health insurance finances almost immediately.
So that was very easy to achieve. Then in terms of governance structures, that country established a steering committee.
These are the human beings and the officials behind that steering committee,
which wants to go for governance as a category for both technical and administrative work.
And then the technical working group that is responsible for analytics.
Of course, we leverage a lot of partnerships and networks, and then we also manage in-country stakeholders as part of this process.
So this is how is set up. Now it had to sit somewhere, especially the sectarian.
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,
the Teaching Hospitals, Mortuaries Board, all of them out there.
And then when you come to the lane directions, the blue one is technical port mission,
and that is where it is situated to provide technical advice to all the line directorates in the
green and then also to the agencies of the Ministry of Health in the green at a top corner.
So it means that evidence from this blue box would inform decisions around health insurance, reinvestments around health facilities,
regulatory activity, nursing activities, psychology, pharmacy council and a ton of other applications in the system.
With all of that, then governance wise, because the country had decided to use ACA as a tool in policy prioritisation,
selection of health technologies, benefits, package design. These are things that affect everybody.
So benefits package design, when you go to hospital, what you get by way of services that are provided for the general population,
what an essential services that should be provided for everybody in Ghana.
What are the prices that we should buy pharmaceuticals and other health technologies for the population?
Now there are key entities responsible for decisions in this area, and those are targets for you.
So when you came to the first item for policy, the Ministry of Health Policy Planning,
quality and evaluation at department, when it comes to lesson, these are committees and entities that are responsible,
meaning that these are targets when data that we use and we have realised that if you don't
identify a clear target for use of that evidence against difficult in terms of holding people to,
to accounts as to how they use that evidence.
What about the area of strategy?
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
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.
And all of that is supposed to build a culture of evidence based decision making.
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.
The strategy summary talks about the fact that we needed to be able to systematically select
the topics that will do it alone and have the capacity to actually do those eight years.
They needed to be manuals and guidelines available that are responsive and regularly updated.
They needed to be some resources available to do this work.
They need to be sustainable. Resource mobilisation.
Of course, there needed to be some collaborations and partnerships with about 80 bodies across the globe.
They needed to be capacity, continuous capacity building,
and we needed to do the two types of communication communication up to the way of Parliamentary
select committee communication all the way to the grassroots in terms of civil society,
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.
To be able to articulate all of these and ensure that the population and the health system benefits from the conduct of it.
Of course that strategy came with a clear monitoring and cost that costings and so is of course their strategy.
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.
Now, if you look at the cost distribution, we realise that because we said that in building capacity we want to learn by doing.
We are heavy on doing and building capacity.
Those are the two things up there and that is where we spend most of our resources in terms of establishing it in Ghana.
We have gotten somewhere with the strategy about 62% of the activities and interventions in that strategy either ongoing or completed.
And 38% of them have not started out at all.
It's a five year strategy and we are halfway to a half year into that.
So we hope to be able to clear the other ones that we have not started,
but we lack an impact assessment model and it's something that we are engaging academic institutions
both in-country and then around the globe to be able to come up with an impact assessment model.
We just want to be able to see that to implementing this particular year,
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,
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.
So there have to be processes as well.
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.
Now this is where the adaptive it comes in, in the sense that, you know,
this elaborate process can travel for quite some time in terms of putting all of that eight steps together.
You start by stakeholders nominating topics. Okay.
So somebody said that there's a need drug that can help those who have mentally challenged conditions like schizophrenia,
and then that has to be evaluated and then another person comes with something else.
So you can be bombarded with a lot of topics and you need to prioritise these
topics to be to see the most important ones that you spend resources to analyse.
So that is the topic nomination, followed by topics,
a lesson where we apply an appropriate criteria to be able to identify which topics are what doing.
Then the topics are approved by the steering committee. Then the analysis goes in.
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,
and then we conduct the typical assessments.
It is an assessment that take a lot of time.
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.
So you are there's a lot of pressure on you to respond fast.
And whether you bring the evidence now or you bring it later in the policy space, decisions will be made.
And while you are showing scientific regard, your analysis decisions will be made.
So you will have to find a way of making things faster and be able to analyse.
And you can also sacrifice the sound science and just speculate to give evidence.
So you have to find a way of making it work that way.
And this is where we are using adaptive methods,
where we are able to bring it to you that are being done or analysis that has been done in
other contexts to bring it into the Ghanaian context on the low and middle income context.
There are a lot of challenges with that,
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.
So with assessment then comes up with another team independent of the assessment
group will look at the work that we have done to actually appraise it.
Is it quality enough and has they considered all the various nuances of methods to do that?
Then the appraised evidence is submitted to the deliberations, which you have with the steering committee,
and the steering committee is made up of the decision makers.
I'm talking about CEOs of health insurance. And see and at that dinner asking Ghana health service.
So these are decision makers and they look at that evidence in a reduced form so
that they can actually make decisions or make recommendations based on that.
After that, we communicate and give people the opportunity to appeal those recommendations if they disagree.
And then those appeals are not like you just disagree because you disagree.
You have to come up with evidence and see that, okay, fine, you did not consider this other evidence of your analysis.
And therefore I want to appeal that this be considered.
And it's also not a perpetual thing. That's a window.
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.
But this is the process. And I spoke about criteria for topping the list.
We do topics that tick the box for these things.
The topics should be able to affect a larger number of people.
It has to have a potential for benefits.
It has to have high household impact, economic cost to the pockets of of the poor.
It has to be make a case for equity and it has to have a potential for cost effectiveness.
If it ticks all these boxes, then is worth looking at.
Decisions that also made, first of all, technologies that would be feed.
It must be safe. They must first do no harm and then apart from be safe, they must be effective.
And if they are at least comparably effective with something else, then that new technology has to be cheaper.
But if they are effective, then we have to look at it in terms of adding cost effectiveness.
So by the time we're able to address all of this, we filter a lot of garbage inputs and outs.
And then the technologies that are able to pass this test are then going into deliberations where we look at affordability,
how we pay for for the technology. Is it feasible in our context to deploy it and all of that.
So these are all things. And in terms of feasibility, so for instance,
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,
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
and that all is considered in their decisions to adapt or not to add that particular technology.
So that is a decision making algorithm that we use in terms of the adaptive ATP, which we have done for diabetes and insulins.
It's it actually affects this part of the process where you have up to 12 weeks off of the tools.
The adaptive is way shorter, not necessarily less complicated,
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.
So and it includes a checklist and transferability assessments so that you can check whether this particular work that was done in Austria,
this particular work that was done in the UK, can we apply it to the context?
There are a lot of nuances because this includes economic analysis and if you look at it very well,
the markets in the US, the markets in the UK, the markets in Australia are different.
The forces that control price are different. So how do you transpose that into the Ghanaian context and that we use to compensate
for price and compensate for inflation factors and exchange rates within all of this?
And so these are some of the things that we look at in terms of benchmarking prices and also transferring evidence.
And I will leave it to you if you want to go a bit further, we can look at that much more detail.
So the structure of that manual is something that we can even share.
So when it comes to methods, we said that we wanted to see robust methods as part of the internationalisation.
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.
Well done. And it includes several dimensions, so I won't go through all the details again.
If you probe, we can look at it much more.
But then there is we are saying that for evaluation type, we want to see a cost utility analysis for data sources.
We prioritise systematic review and meta analysis of expert opinion.
For instance, for outcome measures. We are looking for values and quality.
If you give us some other outcome, then you need to justify why for discounting rates,
we want to look at 3% discount rates and we do a sensitivity analysis between all scenario analysis between zero and 10%.
Now, all of these are quality assessment things that we want to see in the reports.
Now, because we came up with this, then it means that if you are even an independent person and you or an institution,
you conducted an eight year that ticks these boxes, you could submit that for an appraiser.
And that can also be considered in terms of evidence that informs decisions being in low and middle income countries.
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.
But then there has to be a get keep US system to ensure that is well done as a
lot of things can inform your decisions when you are not really looking at it.
So in terms of production, we have been able to produce some work around hypertension, childhood kind of says pneumonia in children.
COVID vaccination programming ad was packaging haemorrhage, which is capitalism and oxytocin comparison.
And then the diabetes work that I just spoke about. There are a number of works ongoing around cervical cancer.
Whether that we should screen and treats or we should not prostate cancer,
The men are saying that the children causes COVID, the woman causes COVID is left with the men.
So there's a lot of advocacy around prostate cancer as well by dependent for schizophrenia anaemia.
And as unassuming as it is, it's really costing us a lot of weight in our shares.
So we want to optimise our anaemia care together with the ongoing discussions in Ghana recently about dialysis.
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.
Sickle cell screening and malaria vaccine.
The new one that came out recently.
Of course there are other things, but we've also defined potential as sources for efficiency in our health insurance.
Identify what the topics, where we can find efficiency.
And for these topics, we keep engaging partners.
We keep engaging academic collaborators in terms of conducting these topics.
What we've done with our loop and look at academic institutions is that there are people who are we must as programs,
who are being paid programs to pick some of these topics as part of your work.
And then we get evidence. They also get the disease and it's a win win situation.
We have done similar thing with the investment bank in Norway, in Oslo and even London School.
So these are open points for collaboration, which we normally also do.
I will quickly move to the next area that I would talk about a few application cases.
So for hypertension, which is the first case I'll mention, what we've done in hypertension,
is that through this sort of analysis, we've been able to prioritise calcium channel blockers and diuretics over other.
Now before then, Uganda, if you went to hospital, you had hypertension.
It's up to the doctor that you see to actually put you on your initial treatments.
But then we realise that it's not all cost effective for some of the other drugs.
So we through this analysis, we've been able to see that first, if somebody is newly diagnosed and they come,
they don't have complications, put them on diuretics or calcium channel blockers.
These are cheaper. They give you the outcomes that you need and this has been taken up.
So now the guidelines have been updated. And then also the insurance reimburses for these drugs and is a.
Seamless decision and them we are improving hypertension care in that area.
We have actually used this also in price negotiation.
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,
which is a drug that is used to treat hypertension fluctuations in the price of that ten
milligrams tablet has a significant effect on the cost effectiveness or value for money,
and that if that price should double, then you have a serious change in how cost effective the treatment is.
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.
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
ourselves to be able to be able to cover more more patients for for childhood cancer that I mentioned.
What we found was that and that every form of scenario, whether you will leverage cost inputs or not,
the reimbursement system for childhood cancers would always deliver less cost for more benefits.
And that is what you see here.
This was done with the Monte Carlo simulation to give you on the several scenarios how the cost effectiveness looks like.
And under all of that, you found that in all scenarios you are always saving cost and then you are improving benefits for children.
Now, the insurance hasn't decided to always take on what we see.
What they also do is that they have an actual model which says that, okay, fine,
you have done your cost effectiveness analysis and it says it's cost effective.
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.
And this is your daughter. Now when we get this data,
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,
if we can see that this budget impact that you have, this budget for the new intervention is reimbursed out of the concepts.
And we added it to all the things that we are reimbursing now.
Are we sustainable in a setting number of years until they see that we are sustainable,
They will have issues with this technology and you have to go readjust the analysis.
So we did that and realised that it would be can absorb this budget impact of almost $1,000,000 for children.
And then the decision was taken.
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.
We are moving on to address other things around it. We are moving on to improve the governor's.
We are moving on to improve quality of care for children who have other concerns.
Create more awareness so that people who in the remote areas people can bring
their children to treatment centres and receive treatment under the insurance.
The cost of that will be borne by the insurance, of course, and then we will have to assess impact.
But we don't have an impact assessment framework yet. So that is one area that we need to strengthen the case.
I have six cases due to TED one so that TED one is on.
Pneumonia management in children. And what we have done is that this was just a swap of formulations,
swap the amoxicillin suspension for amounts of amoxicillin disposable tablets and you said 800,000 Ghana cedis every year.
So this is simple analysis, straight to the point. When we presented this to the insurance,
then they just jump on it and then they listed the dispensable tablets on the list that is on this on the websites.
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.
I mean, we didn't even have to analyse for the the the cost of hauling heavy suspensions and bottles for miles.
Would you add that cause if you add that cost,
it would have been projected savings further by just on the pure therapeutics, where would you establish this fact?
And then they pick it up. Frankly, it hasn't been all rosy.
We did some of the work around COVID 19 vaccines and we're looking at what is the most
effective way to get the vaccine and send it to the population of people who need them.
Despite the fact that we did this analysis, we didn't see the evidence inform decisions to a wide extent.
So we decided to do some implementation research to look at what really happened.
And these without these were our findings is a qualitative piece of ways.
Now, the issues were with timing. We missed the decision making time by two weeks, and because of that,
the analysis could not inform those decisions because they have taken decisions two weeks ago and then the evidence just came.
But what we realised from all the qualitative data is that the timing and access to the reports is critical.
We needed to reduce the technical density of the reports.
We needed to ensure that what you are analysing is relevant for the decision making.
And then you also needed to address political issues around power and the use of power on decision making,
as well as issues of health system fragmentation.
I mean, if you we can get more into this.
There was a very interesting study that we did to address this and we did with different set of partners who have acknowledged that.
What have we learned so far with this?
You need to be responsive and timely in your conduct or any accident in this process, especially the LMC context.
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,
it helps because then you can be time in all of this.
Else, all this work that we do does not deliver the value.
If you missed the decision making time because our policy decisions have to have time bound and decision makers would want to move on.
So. We have also learned a few lessons around doing the adaptive work.
What we have learned is that in adapting its or adapting evidence from one context to the other,
you first of all, needed to do a very extensive search.
I mean, people have done the research and you are trying to ask a different question in your context.
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.
And when you don't feel you need to come back and start the whole process of doing analytics,
you also may find something that is close to the match, but it's not a perfect match and all of that.
So they will become there will be trade offs in all of that.
You need to then look at also transferability systematically how you adapting something from a similar lower middle income context to yours,
or are you adapting from a high income country to yours?
And all of that has implications for your make this something that I normally call cuts Northeast syndrome.
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.
If you don't find it, you may retain what we call a denominator where you start from scratch and continue to you.
And adaptive is estimated to be faster, but not necessarily as complicated.
The last case is on postpartum haemorrhage.
We are yet to engage the insurers to pay for this particular initiative,
but it's if that's proving to be efficacious in terms of the evidence that we have found,
that oxytocin, you'd need to put in a coating and keeping fluids all throughout.
And then our system sometimes is not able to invest in those fridges.
So capitalism is able to stay at room temperature and is still effective.
And the evidence, of course, capitalism by a lot of the initiatives around maternal mortality.
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.
I would pause here and maybe we can have some discussion which would take us
into the next the next step of our challenges and challenges is that sometimes,
though, that strategy said that we needed to find sustainable funding for this.
We actually don't have we leverage our partnerships, we leverage grants and all of that to do the work that we do.
We don't have a law that supports all the work that we do. We leverage institutional arrangements.
So if, for instance, I'm CEO retires and then it means that the new CEO,
you have to go and do a lot of advocacy again to let them understand all of that.
And there's no law that actually we are using to implement.
This is just purely institutional arrangements and that is some of the things that we are implementing this.
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.
Thank you. And over.