Health Technology Assessment Survey 2020/21

In 2020/2021, there were 127 responses to the survey, compared to 111 in 2015. The vast majority, 82% of respondents, said that in 2020/21 they have a systematic, formal health decision-making process at either the national level or the sub-national or both.¹ Just 19% of respondents said that they did not have a systematic, formal decision-making process.²

Of the countries and areas that have a systematic, formal decision-making process, 62% said that they refer to this process as HTA. For the sake of drawing conclusions that are representative for country- and area-level decision making, the findings in the visual summary use only the national-level sample of 102 countries/areas.

In terms of the legislative environment, 53% of the respondents said that there was a legislative requirement to consider the results of a decision-making process in coverage and health benefit package decisions. However, fewer of these respondents, just 33%, mentioned that the results of the decision-making process are considered binding by law.

The top three functions for a health decision-making process were: planning/budgeting (78% of countries and areas), clinical practice guidelines (75% of countries and areas), and design of health benefit packages (65% of countries and areas).

Further functions included protocols for public health programs, public procurement of medicines, quality of care indicators and pricing of medical technologies. All of which were reported by around 55% of countries/areas with a decision-making process. Only 30% of countries/areas mentioned using information from such processes to determine the objectives of pay-for-performance schemes.

Functions for which information is gathered in an HTA

Note: The term HTA is used here to refer to any systematic, formal decision-making process regardless of whether respondents report that the process is formally named as such.

Another aspect of understanding HTA bodies is to have a picture of how many staff they usually employ. Among the surveyed countries and areas, the largest number, 27%, reported having 6-20 full-time equivalents (FTEs) working in an HTA agency or committee. This was followed by 20% of countries and areas reporting to employ 1-5 FTEs. Meanwhile, 12% of countries and areas also reported having over 100 FTEs working in an HTA agency or committee. 8% and 6% of countries and areas reported having 21-50 and 51-100 FTEs respectively, while only 3% of countries and areas reported having less than one FTE.

Many decision-making organizations develop and maintain formal collaborations with partners that are internal and external to their country or area. And indeed, 71% of respondents reported having at least some type of collaboration. There were 45% of respondents that mentioned collaborating with partners both internally and externally, while 20% of respondents mentioned collaborating exclusively with internal partners. 6% of respondents said they only collaborated with external partners, and a further 12% of the sample responded that they do not collaborate with any partners at all.

In response to a question on whether there is an allocated budget from the public sector for their HTA or decision-making process, 59 respondents responded in the affirmative and 31 respondents reported that they did not have any budget from the public sector.³ A further 15 countries and areas reported having private sources of funding for their overall budget for HTA bodies, with the most common source of the private funding reported as donors in eight of those 15 countries.

The survey asked for detailed information around assessments and how often they are typically conducted. Respondents reported that it was more likely that assessments take months rather than years. Of the 67 countries and areas that responded to this question, 88% said that assessments usually take between one and 12 months, while there were only 8% of countries and areas that said assessments usually take more than a year. The survey also asked about the number of reports produced in the past 12 months. There was a wide range of responses, with the mean being 34 (median 23) and an interquartile range of 5.5 to 50.⁴

Decision-making organizations also potentially engage in rapid assessments when the standard times for conducting assessments and appraisals may be too long. Fifty respondents said that they have a provision for rapid assessments and decision-making, and 31 respondents stated that they did not have such a process. Meanwhile 50 respondents further mentioned that rapid assessments and decision-making were available in the case of a disaster or emergency, such as for pandemics. There were 28 respondents that responded that they did not have a rapid process for disasters or emergencies.

Understanding which stakeholders are involved and where this takes place can be critical for developing fair decision-making processes that account for multiple voices. For selecting priorities and nominating interventions, most respondents (66%) said that this was done by the Ministry/Department of Health or National Health Service, with the second most common choice being the HTA committee.

Stakeholders responsible for nomination of interventions and priorities for the HTA

Note: The term HTA is used here to refer to any systematic, formal decision-making process regardless of whether respondents report that the process is formally named as such.

In terms of who is involved in the appraisal process, respondents answered that medical professionals were most commonly included in the appraisal body/committee. This was followed by public health specialists or epidemiologists. Economists and government officials were also commonly included. Representatives from the patient groups, citizen groups, or other vulnerable and marginalized groups were not commonly featured in the responses showing that more can be done to include a wider range of population voice.

A relatively similar pattern was seen for participation in recommendation bodies. However, it is noteworthy that in these bodies, government officials featured more prominently as one of the most commonly included stakeholders.

Globally, the use of cost-effectiveness thresholds for economic evaluation has been an area of debate and research focus. The survey posed several questions regarding cost-effectiveness thresholds to the respondents. There were 19% of respondents that said ‘Yes’ to using an officially endorsed cost-effectiveness threshold in their HTA. Of these, eight respondents (42% of those with a threshold) said that this threshold varies across different categories such as patients, diseases, or interventions. 90% of the respondents that reported using cost-effectiveness thresholds also reported having guidelines for conducting economic evaluation.

It is generally considered as good practice to have separation between appraisal and recommendation processes, and in the survey, 46% of respondents said that they have a separate committee/entity responsible for making recommendations.

Appealing decisions is also an important aspect of a fair and transparent process. Only 22% of respondents mentioned that there is a possibility to appeal the decision made by the recommendation body. Of these, 10 respondents (45% of those with appeal) said that this can be appealed before the decision-making body itself, and eight respondents (36% of those with appeal) said that this can be appealed before a judicial court.

It is also important to know whether, and how, organizations share information. Respondents answered that the most likely materials to be published and made publicly available were assessment reports and recommendations, with 48 respondents each saying that these were provided. Meeting minutes and documentation of the rationale were mentioned by 29 respondents and 27 respondents respectively as being published and made available. Finally, 16 respondents and 11 respondents respectively either said that no outputs from the recommendation were published and made available or that this occurred for other types of materials.

Items that are published as part of the HTA process