Modern Technologies: scapegoat for rising costs or magic bullet for improved healthcare?
Technology Assessment in Healthcare
Von Martin Raab / Schweizerisches Tropen- und Public-Health Institut (Swiss TPH)
Technology is revolutionising medicine, the future of healthcare is challenging and changes are necessary. Making the best use of new technologies for the population depends on our ability to confront the challenge: Health Technology Assessment (HTA) is an important tool to do so.
"This is the time of the most rapid technological change in healthcare in history" (WHO, World Health Report 2000). This and similar headlines have grasped the attention of the general public, of health planners and of politicians alike. Technology, more precisely modern medical equipment, is frequently cited as the most significant contributor to unacceptable cost increases while, at the same time, it provides indispensable tools to deliver health care more effectively and efficiently. The expectation of the population concerning health services has risen and providers are trying to satisfy demands.
Healthcare technologies are devices, drugs, equipment, procedures and the organisational and support systems within which health care is delivered.
The fact is, that the rapid development of medical devices, drugs, knowledge and clinical practice has resulted in significant changes in the delivery of healthcare. The enormous number of new technologies being introduced in the market in the past twenty years has created an important challenge for health planners and decision-makers. According to the Swedish Counsil on Technology Assessment in Health Care 50% of all diagnostic and treatment methods we use today did not exist ten years ago. This trend will even accelerate in the future. The rapidly emerging technologies and the unpreparedness of decision makers has often serious consequences, making it difficult to set priorities, allocate resources, and make room for effective technologies. Also, decision makers have become aware that many (old and new) technologies do not contribute to effective and efficient health care.
Important questions are: What evidence supports a particular technology? What effects can be expected in terms of health outcomes and costs? What is required in terms of support structures and specialised knowledge? Such questions must be answered in order to choose the most beneficial technologies, and reject others. For this reason, concepts of appropriateness, effectiveness and cost-benefit have moved to the centre of interest in many countries. Health care providers seek to identify cost effective methods for providing equitable and quality health care.
The tool to assist in making informed decisions and in rationalising health care delivery is called ‘Health Technology Assessment’ (HTA). It is described as a method to systematically analyse safety, efficacy, cost effectiveness and other economic impacts. It also considers appropriateness of application and ethical, social, and cultural implications. One of the key questions is: Is the new technology justified sufficiently by the overall benefit achieved in terms of access, quality and health outcomes? The primary purpose of HTA is to provide objective, reliable and valid information to support health care decisions and policy making. It involves physicians and other clinicians, economists, public health specialists, medical engineers and social scientists.
During a meeting in 1991, the EU health ministers identified HTA as a key element for better management of limited resources in health systems. Meanwhile a number of institutions are involved in HTA in Europe; different countries have instituted HTA in their health systems to different degrees. France, Sweden and Spain can be seen on the forefront of HTA activities. The impact of HTA on policy decisions is however still limited. But as financing of health systems becomes more and more critical, the influence of HTA is bound to gain increasingly recognition. According to the Swedish Counsil on Technology Assessment, ‘the greatest single problem with health care technology assessment is the large number of unassessed technologies’.
The situation in low income countries
At present, industrialised countries spend only some 5% of total annual health care expenditures on physical infrastructure, building, equipment, etc. In developing countries, in contrast, capital expenditures amount to 40% - 50% of the total public health care budget. Priority setting based on evidence should therefore be high on the agenda. For example, Ukraine spends 4.1 % of the GNP, and $55 per capita annually on health care, Egypt, 1.8% of GDP and $50 per capita. This compares with 9% of GDP and $3’600 per capita in Switzerland. These figures demonstrate that poor countries have an even greater interest to stop paying for ineffective technologies.
Despite this, many new technologies have found their way into facilities of developing countries and countries in transition for reasons of professional ambition, commercial interests and increasing demand from the population. This has frequently led to investments in expensive equipment for diagnostic and therapeutic procedures, where the health benefit are not obvious, and in settings where even the basic needs are not covered. In many cases the requirements for these new technologies in terms of recurrent costs, infrastructure needs and knowledge for application and maintenance have been grossly underestimated. As a result, large numbers of medical equipment are defective, out of order or cannot be operated because consumable items are missing.
The assumption can be made that, if strong HTA programs had existed, the decisions might have been made for more appropriate or more easily sustainable technologies. Alternatively, resources might have been allocated to public health measures or other non-technological initiatives.
Without functioning facilities, medical equipment , and medicines, it does not matter if the knowledge, skills and staff levels are high. The delivery of services will be poor.
A lack of technology inputs will also have a negative impact on staff motivation, a factor that influences the capacity of human resources.
WHO World Health Report 2000
In developing countries, there should be a noticeable difference in the methodological orientation of HTA to that in industrialised countries: In industrialised countries HTA is focused on specific technologies, whereas in low income countries a problem-oriented approach needs to be taken. Crucial questions are: Among the huge number of choices, which medical devices are appropriate in particular countries? How can their proper use be ensured? What are the conditions for a cost-effective and beneficial use? Instead of a simple adjunct for improving efficiency of services, HTA moves in developing countries to the forefront as a key element for improving health services.
The gathering of information about a nation’s health system and an analysis of training requirements will contribute to ensure that when decisions are made to acquire a technology, the necessary resources and support will be obtained. The aim of technology assessment in resource-constrained countries is therefore to indicate the conditions under which a technology can be purchased, used and maintained. Resources poor countries should be encouraged to establish their own assessment programmes so that all of the elements necessary for informed decision-making can be considered.
For the reasons given, major amounts of money have been wasted due to inappropriate purchases. An investment in Health Technology Assessment programs would be a first step towards a more rational use of resources. Efforts need to be made to create the organisational structures and processes to assist better decision making. Also, governmental mechanisms such as a policy structure need to be put in place. In most cases it is not realistic to call for the foundation of a separate entity for health technology. However, personnel and material resources already present in government and private institutions can be used to launch an HTA program. An office for Health Technologies should be in charge of a number of professional areas linked to medical technology:
- evaluating technologies, gathering and disseminating relevant information
- initiating inventories for health facilities and evaluating those data
- building up competence for professional procurement procedures
- building up competence regarding standards for health facilities
- preparing policies and regulations relative to health technologies (e.g. standardisation, safety policies, essential material lists, donation guidelines, etc.)
- promoting professional clinical maintenance systems for health facilities
Experience has shown that the activities and professional areas mentioned above are often ‘nobodies responsibility’. As a result, financial resources keep being squandered and the quality and performance of health services are compromised.
*Martin Raab, Scientific Collaborator for Medical Technology and Project Management, Swiss Center for International Health, Swiss Tropical Institute. Contact: http://www.sti.unibas.ch/personel/RAABM.htm