Strengthening Cost-Effectiveness Analysis in Thailand through the Establishment of the Health Intervention and Technology Assessment Program

Strengthening Cost-EffectivenessAnalysis in Thailand through theEstablishment of the Health Interventionand Technology Assessment ProgramSripen Tantivess,1 Yot Teerawattananon1 and Anne Mills2

1 Health Intervention and Technology Assessment Program, Ministry of Public Health,

Nonthaburi, Thailand

2 London School of Hygiene and Tropical Medicine, London, UK

Contents

Abstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9311. Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 933

1.1 Establishment of the Health Intervention and Technology Assessment Program (HITAP) . . . . . . . 9342. Vision, Mission and Strategies of the HITAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9353. Management of the HITAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 936

3.1 Finance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9363.2 Staffing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9363.3 Management Strategy and Approaches of the HITAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 937

4. Health Technology Assessment Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9385. Cost-Effectiveness Analysis and Its Contribution to Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9396. Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9407. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 943

Abstract Capacity is limited in the developing world to conduct cost-effectivenessanalysis (CEA) of health interventions. In Thailand, there have been con-certed efforts to promote evidence-based policy making, including the in-troduction of economic appraisals within health technology assessment(HTA). This paper reviews the experience of this lower middle-incomecountry, with an emphasis on the creation of the Health Intervention andTechnology Assessment Program (HITAP), including its mission, manage-ment structures and activities.

Over the past 3 decades, several HTA programmes were implemented inThailand but not sustained or developed further into a national institute. As aresponse to increasing demands for HTA evidence including CEA informa-tion, theHITAPwas created in 2007 as an affiliate unit of a semi-autonomousresearch arm of the Ministry of Public Health. An advantage of this HTAprogramme over previous initiatives was that it was hosted by a researchinstitute with long-term experience in conducting health systems and policy

REVIEWARTICLEPharmacoeconomics 2009; 27 (11): 931-945

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research and capacity building of its research staff, and excellentresearch and policy networks. To deal with existing impediments to con-ducting health economics research, the main strategies of the HITAP werecarefully devised to include not only capacity strengthening of its researchersand administrative staff, but also the development of essential elements forthe country’s health economic evaluation methodology. These included,for example, methodological guidelines, standard protocols and benchmarksfor resource allocation, many of which have been adopted by national policy-making bodies including the three major public health insurance plans. Net-works and collaborations with domestic and foreign institutes have beensought as a means of resource mobilization and exchange. Although theHITAP is well financed by a number of government agencies and interna-tional organizations, the programme is vulnerable to shortages of qualifiedresearch staff, as most staff work on a part-time or temporary basis.

To enhance the utilization of its research findings by policy makers, practi-tioners and consumers, the HITAP has adopted the principles of technicalexcellence, policy relevance, transparency, effective communication and parti-cipation of key stakeholders. These principles have been translated into goodpractice at every step of HTA management. In 2007 and 2008, the HITAPcarried out assessments of a wide range of health products, medical proceduresand public health initiatives. Although CEA and other economic evaluationapproaches were employed in these studies, the tools and underlying efficiencygoal were considered inadequate to provide complete information for prior-itization. As suggested by official stakeholders, some of the projects investigatedbroader issues of management, feasibility, performance and socio-political im-plications of interventions. As yet, it is unclear what role HITAP research andassociated recommendations have played in policy decisions.

It is hoped that the lessons drawn on the creation of the HITAP and itsexperience during the first 2 years, as well as information on its main strate-gies and management structures, may be helpful for other resource-constrained countries when considering how best to strengthen their capacityto conduct economic appraisals of health technologies and interventions.

Economic evaluation of health interventions isespecially critical in the developing world given se-vere resource constraints and substantial demandsfor medical services and healthcare.[1] Despite itsimportance, availability and utility of research inthis area as a guide for the adoption, distributionand use of health technologies in resource-poorsocieties is limited. The literature identifies severalimpediments, technical and political, to introducingeconomic appraisal to inform health policies inthese settings.[2,3] However, positive evolution canbe observed as the concepts of cost-effectivenessanalysis (CEA) are gradually spread through thework of academic institutes, and studies of costs

and consequences of health products, medicalprocedures and public health interventions aredrawn on by medicine control authorities, healthinsurance programmes and health technology as-sessment (HTA) units.[4]

In Thailand, there have been concerted effortsamongst experts and health officials to fosterevidence-based policies and professional practice, inpart by incorporating research findings into decision-making processes.[5] Economic evaluation hasbeen promoted as a scientific tool to pursue effi-ciency in healthcare delivery. However, this missionhas faced considerable obstacles; for example,insufficient scientists in the field, lack of policy

932 Tantivess et al.

ª 2009 Adis Data Information BV. All rights reserved. Pharmacoeconomics 2009; 27 (11)

support and misperceptions of the approachamongst health professionals and administrators.[6]

In early 2007, an organization known as the HealthIntervention and Technology Assessment Program(HITAP) was set up, with the aim to generate evi-dence necessary for priority setting and resourceallocation of health technologies and initiatives.During its initial phase, this HTA institute has notonly conducted a number of research studies in-volving CEA, but has also carried out capacity-building activities, and is expected to contribute tonotable changes in Thailand’s health policy deci-sions in the near future.

The Thai experience of seeking to establish anational institute for CEA and HTA in what isstill only a lower middle-income country is unu-sual, and may be of interest to other countriesthinking of creating similar initiatives. This paperreviews the attempts to introduce HTA and eco-nomic evaluation in the decision making of policymakers and practitioners in Thailand, from theperspectives of those involved in creating theHITAP. The emphasis is on the establishment ofthe HITAP and its contributions, not only tonational policy development but also to capacitystrengthening in the field of CEA, and to how themission, management structures and activities ofthe HITAP were adjusted from those introducedby well established HTA institutes in developedcountries to suit the Thai context.

1. Context

As of 2008, Thailand had a population of67.4million and a gross national income per capitaof $US2840.[7] Total health expenditure (THE) hasincreased from 189billion baht (Bt) [Bt3000,$US991 per capita] in 1997 to Bt248billion(Bt3960, $US132 per capita) in 2005.[8,9] Publicsources and household out-of-pocket spendingaccounted for 63.3% and 27.8% of THE, respec-tively. Over 90% of the Thai population are bene-ficiaries of three publicly-financed health insuranceplans: Universal Health Coverage (UC), whichprovides care to 45million people; Social Health

Insurance, providing care to 10million people; andthe Civil Servant Medical Benefit Scheme, provid-ing care to 4million people. Healthcare providersin the public sector, especially the network of gen-eral hospitals, sub-district level health centres andspecialized units belonging to the Ministry ofPublic Health (MoPH), play a major role in healthdelivery.[10] Private services are available in hospi-tals and clinics for those who can afford the prices.

Efficacy, safety and quality are the three mainelements assessed by the Thai Food and DrugAdministration (Thai FDA) in the approval ofmedicines and medical devices for marketing anduse in the country.[11] The pharmaceutical bene-fits covered by public health insurance plans arethose on the National List of Essential Medicines(NLEM), which was first introduced in 1981 andfollowed the recommendations of the WHO,[12]

although the list is now quite distinct from theWHO list and the NELM has been strictly em-ployed as a cost-containment tool.[13] Since theintroduction of UC in 2001, the need for eco-nomic appraisal of medicines, medical devicesand public health interventions, including budgetimpact analysis, has increased significantly.

In the public sector, medicine prices are definedand negotiated at central and hospital levels. TheMinistry of Commerce is responsible for price con-trol of pharmaceutical products, mainly throughthe approval of ceiling prices.[11] Reference pricesfor essential and non-essential medicines are de-termined by a national body, and introduced inmedicine procurement by all public healthcare fa-cilities. Price negotiations and bulk purchasing arecarried out by managers of disease managementprogrammes in theMoPH and theNationalHealthSecurity Office, as well as by pharmacy depart-ments of all hospitals. When cost-effectiveness in-formation was explicitly introduced in the revisionof the NLEM in 2008, pharmaceutical companiesentered into negotiations and offered price reduc-tions for a number of original products.[14]

As in many other countries, priority setting andresource allocation in Thailand are not alwaysevidence based, despite the promotion of the use of

1 Exchange rate (mid 2007): Bt30 per $US1.

Strengthening Cost-Effectiveness Analysis in Thailand 933


evidence in policy, but are shaped by several politico-economic factors. The selection of medicines in theNLEM is one example of the explicit, regular useof evidence in decision making by national autho-rities.[15] However, because of the differences in thesubsidization policies and payment mechanisms ofthe three publicly financed health benefit plans,there continues to be discretion in prescribingpractices, especially for beneficiaries of the gov-ernment workers’ plan, which is partly due to itsfee-for-service payment method.[5]

The cost effectiveness of health products, med-ical procedures and public health interventions is amajor concern of the three public insurance plans;however, the supply of economic evaluation in-formation has been inadequate and has not tar-geted the major health problems of the country.[16]

Research on the costs and clinical consequences ofhealth products and programmes has long beenconducted and taught in schools of medicine andeconomics in Thailand. However, critical assess-ment of existing health economics studies has de-monstrated room for improvement because oftheir poor quality. A 2007 survey suggested thatresearch capacity in the area of health economicsneeded to be strengthened because the number ofwell trained scientists was limited, and their work-ing environment was not conducive to conductingappraisals of high quality.[17] The lack of nationalmethodological standards and insufficient infra-structure to support economic evaluation of healthinterventions were also identified as key problems.Furthermore, there were notable barriers to intro-ducing cost-effectiveness evidence into the prac-tices of health professionals, such as distrust ofresearch methods, conflict with routine decision-making procedures and ideological tensionsbetween the pursuit of efficiency underpinned byeconomic analysis, health maximization and pro-fessional ethics.[6]

Fertile soil for the later development of CEAexpertise was provided by investment in healthpolicy and systems research (HPSR). Over thepast 3 decades, HPSR has developed and con-tributed substantially to policy making and im-plementation in Thailand.[5,18] Set up in 1992 asan autonomous state agency, the Health SystemsResearch Institute (HSRI) is responsible for

strategic planning of the country’s HPSR andadvocating knowledge-based policies. As partof the HPSR developments, two attempts weremade to establish HTA units at a national level tocarry out CEA. In 1993, a plan was introduced bya group of epidemiological and clinical experts,with support from the HSRI and Karolinska In-stitute, Stockholm, Sweden.[19] This programmefailed to scale up, and eventually faded out in thelate 1990s because of insufficient human re-sources and infrastructure for health economicappraisal. In 2004, an international collabora-tive research project between the MoPH andthe University of Queensland, Brisbane, QLD,Australia, was introduced with the title ‘SettingPriorities using Information on Cost Effective-ness (SPICE)’.[20] This project is supported by theWellcome Trust but will end in 2009 because ithas no long-term commitment.

1.1 Establishment of the Health Interventionand Technology Assessment Program(HITAP)

In light of previous failed attempts, the crea-tion of a national HTA capacity was instigated bythe International Health Policy Program (IHPP),a semi-autonomous research arm of the Bureauof Policy and Strategy at the MoPH. Since itsestablishment in the late 1990s, IHPP studieshave expanded from those classified as healthcarefinancing into other areas such as health eco-nomics, health workforce and health system per-formance.[21] Its expertise in analysing healthcarecosts was an important platform for fosteringits capacity to conduct CEA. Between 2000 and2003, economic evaluation approaches were em-ployed by IHPP researchers to assess varioushealth interventions and initiatives; for example,interferon-a, the national programme to preventmother-to-child HIV transmission, use of micro-nutrient supplements in HIV treatment and pro-ton radiation therapy. Nevertheless, it was clearthat existing capacity in Thailand could not ac-commodate the increasing demands for HTAfrom policy makers, especially the Subcommitteefor NLEM Development, MoPH departmentsand the three public health insurance plans.[22]



As one of themissions of the IHPPwas capacitybuilding in HPSR, long-term scholarships grantedby the WHO and other national and internationalagencies were available to send its research fellowsto post-graduate courses in universities in Europe,the US and Australia.[18] A number of these youngresearchers chose to study health financing andeconomics and, therefore, were expected to havea role in generating evidence to inform healthresource allocation.

In early 2006, a draft proposal on the establish-ment of an HTA division of the IHPP was sub-mitted to Thailand Health Promotion Foundation(ThaiHealth), HSRI and the Bureau of Policy andStrategy at the MoPH, who were known to be re-ceptive. In July 2006, while awaiting official ap-proval, a group of interested researchers, includingthose in the IHPP and an alliance of universitylecturers, started to work out strategic and man-agement plans for the HITAP. Its first task, inAugust 2006, was to prepare standard guidelines onhealth economic evaluation, suitable for use in theThai setting. This set of guidelines was adopted bythe NLEM Subcommittee in December 2007, andbecame the first edition of the national health eco-nomic appraisal guidelines.

With the aim of becoming a national HTAinstitute, the HITAP was officially launched as a3-year initiative.[4] During this phase, the pro-gramme is affiliated to the IHPP, under the su-pervision of an advisory committee comprisingsenior health officials, public health experts andacademics in relevant fields. Despite the originalgoal of fulfilling the need for the assessment ofcosts and outcomes of health technologies, therewas consensus that the studies of the HITAPshould address the effects and implications ofinterventions, programmes and public policiesintroduced in the health sector more broadly, i.e.beyond the boundaries of health economics.

2. Vision, Mission and Strategiesof the HITAP

As an HTA institute, the ultimate goal of theHITAP is to provide policy makers, health pro-fessionals and the public with scientific evidenceconcerning the costs and benefits associated with

the introduction of health products, proceduresand programmes. To achieve the vision: ‘appro-priate health interventions and technologiesfor the Thai society’, the mission of the HITAP isto carry out the following: (i) efficiently andtransparently appraise health interventions andtechnologies by using international, standardmethodologies; (ii) develop systems and me-chanisms to promote the optimal selection, pro-curement and management of health technologyas well as appropriate health policy determina-tion; and (iii) distribute research findings andeducate the public to make the best use of healthinterventions and technology-assessment results.

During the first 3 years of the HITAP, thismission has been translated into four main stra-tegies, each of which aims to overcome existingimpediments to conducting HTA and also to en-hance the value of research by introducing theknowledge management concept. The need to im-prove infrastructure for economic assessment ofhealth interventions was addressed by Strategy I.Essential elements included identifying and de-veloping a body of knowledge to support HTAstudies, which took into account not only inter-national standards but also the resources andinfrastructure constraints of the Thai context.Activities included the development of a databaseon HTA studies conducted in Thailand, metho-dological guidelines and a societal value-basedceiling threshold. As Tangcharoensathien andKamolratanakul[23] argue, standardization of re-search designs and methods in health economicswas invaluable in enhancing the accuracy, relia-bility and utilization of research results. Al-though the guidelines, which were adopted asnational protocols in late 2007, mainly focus onhealth economic methodologies, two chaptersdiscussed the role of research including cost-outcome analysis in real-life policy processes[24]

as well as health system and equity perspectives inHTA.[25]

The problems of insufficient numbers of healtheconomists as well as inadequate knowledge andunderstanding of HTA among potential users ofthe research were addressed by education and in-formation programmes under Strategy II. Trainingprogrammes on basic and advanced health



economics have been run annually, to increase thenumber of young researchers in the field. So far,these have been popular amongst stakeholdersand >60 policy makers and healthcare planners,35 health professionals and >110 researchers fromboth public and private institutes have attended theprogrammes. HITAP staff continue to providetechnical support, upon request, to these traineeseven when they return to work in their institutes.

The growing needs for HTA, in particularfor cost-effectiveness and budget-impact apprai-sals, were dealt with by conducting researchunder Strategy III. This provided the opportunityfor research fellows to be exposed to policy-relevant research questions and to gain researchexperience through on-the-job training in con-ducting an HTA. Health interventions to be as-sessed by the HITAP were annually proposedand prioritized by key stakeholders includingrepresentatives of the MoPH departments, RoyalColleges, professional associations and healthplans.[26]

Different measures with the aim to improveHTA management and the integration of re-search findings into policy and practice were theemphasis of Strategy IV. The lessons of HTAmanagement in some developed and developingcountries as well as past experience in the Thaisetting were examined. Other activities includedevaluation of HITAP performance, social mobi-lization, public relations and international colla-borations, although during the first 2 years, policyadvocacy and social mobilization were largelycarried out passively. For instance, the HITAPprovided technical and information support torelevant government agencies, non-governmentalorganizations (NGOs), professional associationsand the media, i.e. those that played an active rolein particular policy domains.

3. Management of the HITAP

3.1 Finance

The first 3 years of the HITAP werewell resourced, with approximately Bt45million($US1.3million) from ThaiHealth and theHSRI.[27] The largest share of the budget was

allocated to the assessment of health policies andinterventions and also to logistics and adminis-tration. Evaluation studies were carried out freeof charge, although certain costs, such as thosefor organizational and staff development, couldbe reimbursed from the Bureau of Policy andStrategy at the MoPH. In addition, althoughadditional funding was not needed for core ac-tivities, the HITAP applied for research grantsfor various reasons, including to address urgentneeds for evidence and policy recommendationson particular health and health system problems,to develop technical co-operation with otherorganizations and to diversify sources of funding.For example, an assessment of the national cer-vical cancer control programme, including CEAof existing screening techniques (Pap smear andvisual inspection with acetic acid), compared withthe recently launched human papillomavirusvaccination, was sponsored by the World Bank’sProgram on Reproductive Health.[28] In 2007 and2008, additional grants obtained by the HITAPaccounted for 30% of the total budget.

3.2 Staffing

In July 2008, the total number of HITAP staffwas 36, with a full-time : part-time ratio of 70 : 30.Researchers, research fellows and research assis-tants accounted for 78%, while the others wereprogramme managers, including IT personnel,accountants and public relations staff. Most(82%) of the research workforce had first degreesin health sciences, namely pharmacy (15 of 28),medicine, public health and nursing. The areas ofpostgraduate study among HITAP researchersand research fellows included health economics,pharmacy administration, clinical pharmacy,public policy, information technology and po-pulation development. Only six researchers hadPhD training.

Of those with PhD training, four were universitylecturers who worked at the HITAP on a part-timebasis, while the other two were health officials, andthe ratio of PhD and non-PhD research staff wasalmost 1 :5. In addition, seven postgraduatestudents trained to conduct economic appraisalswere government officials on study leave, and the



two full-time PhD and three full-time researchfellows were on secondment, holding permanentpositions in the MoPH’s departments or hospitals.The longest these officials can leave their office is3 years. Thus, the HITAP was vulnerable since itrelied heavily on a temporary research workforce,and many were students with very little researchexperience, needing supervision from senior staff.Recruitment of qualified researchers to workpermanently in the programme was difficult. Themajor impediment was the shortage of PhD grad-uates, particularly in the area of health economicsand pharmacoeconomics where multinationalcompanies could offer much more attractive in-centives. Although the salary scale at the HITAPwas higher than that of many other governmentagencies, it was not comparable to the privatesector. Uncertainty over its future may also bediscouraging qualified staff from joining.

3.3 Management Strategyand Approaches of the HITAP

The HITAP developed its management ap-proach to HTA research by drawing lessons fromorganizations with similar mandates in Thailandand elsewhere. Foreign prototypes were modified

to suit the newly established programme and theThai health systems context. To enhance the utilityof the HTA, including promoting the use of eco-nomic evaluation in decision making, a conceptualframework was devised to understand the pro-cesses and determining factors (figure 1). Theliterature suggests that integrating research intopolicy and practice is complex, involving manystakeholders and contextual elements.[29,30] De-spite the differences between points of concern forpolicy makers, professionals and consumers whenthey make decisions in relation to health technol-ogies, the following five common strategies to ad-dress the issues of HTA quality, policy utility,availability of research results and social inter-pretation of HTA methods, findings and asso-ciated policy recommendations were identified:(i) to promote effective communication betweenthe HITAP and key stakeholders; (ii) to enhancethe image of the HITAP; (iii) to ensure validityand reliability of research; (iv) to ensure policyrelevance of HTA topics and research; and (v) toestablish appropriate programme management.

The five management strategies were translatedinto programme approaches or ‘good practice’ foradministrators and researchers to follow (table I).To ensure effective dialogue between the HITAP

Policy context

Other political factors

Social mobilization

HTA results

Health policies

Practice/behaviour

Complex, multifactor

Professional and consumers:• (perceived) quality• awareness of coercive forces• incentive• social construction of HTA recommendations/policies

• Policy advocates• Wide range of

stakeholders

HITAP researchersHITAP administrators:• strategic planning• introduction of strategies• monitoring and evaluation

Policy makers

Professionals/the public

Policy makers:• (perceived) quality• policy utility: effectiveness and cost feasibility (technical, financial, manpower) social acceptability political desirability• timely

Fig. 1. The Health Intervention and Technology Assessment Program (HITAP) framework on health technology assessment (HTA): policies-practice integration.



and the potential users of HTA findings, specificeducational and public relations plans were devel-oped and implemented by well trained staff.Transparency in conducting appraisals of technol-ogies and public health initiatives was a majorconcern, and information on every step of eachresearch project was posted on the HITAP web-site.[31] In addition, to avoid conflict of interestamong research staff and the organization as awhole, a set of regulations was introduced. Re-search grants, sponsorship to attend technical con-ferences and training courses, as well as any otherdirect and indirect benefits from private for profitand health-related corporations were not allowed.As with other research institutes, HITAP staff hadto declare their potential conflicts of interest bycompleting a written form on an annual basis.

The development of technical competencyamong HITAP researchers and research fellowswas a crucial component of the programme’sstrategies. Of the various disciplines, economicevaluation was the main approach for HTA, sinceefficiency in resource use was the common con-cern of participants in the annual consultationson topic selection.[26] A capacity-strengtheningscheme, with explicit operational procedures andcriteria, was established to provide financialsupport to research staff who wished to givepresentations on their studies in domestic andinternational forums. Scholarships were available

for short-course training and PhD study inThailand and abroad. Furthermore, the HITAPsought collaborations with HTA and academicinstitutes in developed countries such as the UKNational Institute for Health and Clinical Ex-cellence (NICE), the London School of Hygieneand Tropical Medicine, University of East An-glia, the Korean Health Insurance ReviewAgency (HIRA) and the Center for Drug Eval-uation of Taiwan. In the same vein, partnershipswere created with domestic institutes, includ-ing universities, MoPH departments and otherresearch programmes, including SPICE. Jointworking and sharing of information and experi-ence were major objectives of the networks.

4. Health Technology AssessmentManagement

The HITAP’s ultimate goal of influencingpolicies and practice is pursued through the intro-duction of well designed approaches at every step ofHTA. To develop these strategies, a literaturereview was conducted to understand the factorsdetermining the use of HTA, including CEA, indecisionmaking.[24] Lessons were also learned fromleading HTA institutes in developed countries, in-cludingNICE, theCanadianAgency forDrugs andTechnologies in Health (CADTH), the AustralianMedical Service Advisory Committee and the

Table I. Approaches of the Health Intervention and Technology Assessment Program (HITAP) to address each of its management strategies

Management strategy Programme directions

1. Promote effective communication Sincere dialogue with all parties, including the general public, to pursue

understanding and collaboration

Tailor-made information and messages to suit particular target groups

Two-way communication

2. Enhance the HITAP image Transparency: stakeholder participation; avoid conflict of interest

Strengthen technical capacity of researchers

Good manners and discipline of staff

Accountable to granting agencies, while pursuing public interest

3. Ensure validity of research Strengthen technical capacity of researchers

Exchange experience and knowledge with scientists in Thailand and other

countries through various channels

4. Ensure policy relevance of HTA topics and research Constructive engagement with policy makers and key stakeholders

Keep an open mind, listen to all partners, keep abreast of the development

of social phenomena and take into account policy-related elements

5. Establish appropriate programme management Institutional lesson learning: monitoring and evaluation; research and development

HTA = health technology assessment.



Swedish Council on Technology Assessment inHealth Care.[32] Based on such knowledge, HTAmanagement guidelines for HITAP staff were de-veloped (figure 2). The underpinning conceptscomprised stakeholder participation and transpar-ent processes alongside research of good quality.

The HITAP’s internal guidelines on HTA man-agement involve the inclusion of policy makers andother stakeholders, such as consumers and insur-ance beneficiaries, healthcare providers and corpo-rate business, throughout the processes of topicselection, HTA research, appraisals of results anddissemination of findings and policy recommenda-tions. In the first stage, the HITAP calls for propo-sals on health technologies and programmesneeding appraisal from MoPH departments, thethree public plans, the Subcommittee on NLEMDevelopment, the Royal Colleges, specialist asso-ciations, public health non-governmental organiza-tions and HITAP funding agencies. A total of 52and 43 proposals were submitted for assessment in2007 and 2008, respectively. Representatives ofthese organizations were invited to a consultationworkshopwhere the background and importance ofthe proposed topics were discussed.[26] Thereafter,the participants from each organization prioritizedthe topics, and ten were selected annually. In theprioritization step, HITAP staff sought to introducea set of selection criteria such as the magnitude ofhealth problems to be addressed, the financial bur-

den generated by the introduction of the interven-tion and the extent to which new knowledge wouldbe generated. However, because of a lack of in-formation, explicit criteria were replaced by voting.

When conducting an HTA, clinical specialistsandmethodologistsmight be invited to take part asresearchers, while some are consulted on particularelements. These experts provided not only dataand information, but also helpful advice on real-life practice, its consequences and associated as-sumptions when empirical evidence from the Thaicontext was inadequate. During the appraisal ofresults, the HITAP welcomes reviews of its re-search findings by any interested parties. Selectedinterested parties might be invited to participate indiscussions on the reliability and validity of theresearch. Finally, HTA results and associated pol-icy recommendations are publicized using differentapproaches to get the messages to particular targetpopulations. As of August 2008, empirical infor-mation from only three projects (the cervical can-cer control initiative, marketing strategies for thehumanpapillomavirus vaccine and costs of alcoholconsumption) had targeted the general public.

5. Cost-Effectiveness Analysisand Its Contribution to Policy

A significant number of HTA topics suggestedto the HITAP’s selection processes in 2007 and

HTA phase Approaches Participants

Consultation

• Consultation (to identify research questions)• Technical collaboration

• Peer review• Submission of comments• Discussion

HITAP, policy makers, healthcareproviders, consumer groups,professional associations, etc.

HITAP, experts and relevantstakeholders

HITAP, experts, privatebusiness/industry,policy makers,consumers/beneficiaries

HITAP, funding agencies, themedia, consumer groups andother NGOs

• Publications• Presentations• Dialogues

ConductingHTA research

Appraisal ofresults

Disseminationof results and

recommendations

Topic selection

Fig. 2. Health technology assessment (HTA)-management strategies at the Health Intervention and Technology Assessment Program(HITAP). NGO =non-governmental organization.



2008 involved CEA of health interventions;however, only a fraction of these could be un-dertaken. During these 2 years, a total of 31 re-search projects were initiated. As of August 2008,12 projects had been completed, 13 associatedarticles were published in international journalsand 24 associated articles were published indomestic periodicals. As listed in table II, theHTAs covered a wide range of technologies andpublic health programmes. Economic evaluationincluding the assessment of costs, cost effective-ness, cost utility and budget impact was the majorapproach, and most were requested by theNLEM Subcommittee. Some of the projects in-vestigated issues of management, performance,feasibility and socio-political implications of in-terventions and technologies. Since the researchquestions in these studies were formulated inconsultation with stakeholders, it is apparent thathealth economic tools alone cannot provide ade-quate evidence to inform solutions to Thailand’shealth problems, as many proposed researchtopics required determination of programmeperformance, feasibility and implications in ethi-cal dimensions, and the HITAP has tried to fulfilthe needs for broader assessments, i.e. beyondeconomic aspects.

Although recommendations drawn from someHITAP studies were apparently agreed upon andadopted by policy makers, it is unclear to whatextent this research has played a role in decisionson including or excluding particular medicines onthe NELM. Key official stakeholders were in-volved throughout, but public campaigns werenot widely implemented. This indicates a limitedrole of HITAP CEA studies in policy advocacythrough mobilising public support on particularissues.

6. Discussion

Although there are major hurdles in integrat-ing CEA into health policy decisions in develop-ing countries, Thailand, a lower middle-incomecountry, has made significant progress. This ar-ticle has outlined the health system context thatwas conducive to promoting economic evalua-tion and its policy utility in Thailand.

First, because HPSR had been established at anational level for some time, supportive elementsfor conducting research such as information sys-tems and databases, bodies of knowledge inrelated disciplines and management capabilityexisted in the country. Given that many researchorganizations and funding agencies were alreadyformed into networks, it was feasible to mobilizeresources to support health economics.

Second, the introduction of the UC plan raisedawareness amongst policy makers and the publicabout the importance of well informed resourceallocation and rationing.

Third, policy makers, including managers ofhealth insurance plans, recognized the role ofhealth economics and pharmacoeconomics ashelpful tools in decision making. Moreover,proof of efficiency, including cost-effectivenessinformation, will be required by the Thai FDA inissuing market approval of some health products,according to newly revised laws on medical de-vices and medicine control.[33]

The experience of establishingHTA in Thailandalso highlights the importance of choosing theappropriate host. Two earlier HTA initiatives,involving external collaborations, were both time-limited. The advantages of the IHPP as a spring-board for the HITAP included the organizationalexpertise of the IHPP in conducting cost-analysisand cost-effectiveness studies. Furthermore, theIHPP had long-term experience in the develop-ment of research staff and extensive domestic andinternational networks with other organizations inthe field of HPSR that greatly assisted the HITAPas a newly established institute.

However, the review of HITAP experience in2007 and 2008 suggests that the lack of qualifiedresearchers in the field of health economics andrelated areas was and will be a major impedimentto operating and maintaining the organization.Owing to the substantial demand for HTA, espe-cially from the health insurance plans, the initiativewas well financed. To improve its absorptive ca-pacity, the HITAP needs a large number of staff,especially permanent staff, although this will taketime. It takes many years for research fellows tobuild up their capacity, whether through theHITAP’s apprentice programme or through formal



Table II. Selected health technology assessment projects conducted by the Health Intervention and Technology Assessment Program (HITAP), 2007–8

Studied interventions Proposing agencies Issues of investigation Strategies to get research to policy and action

Cervical cancer control programmes,

including Pap smear, visual inspection

with acetic acid and HPV vaccine

IHPP and HITAP (the economic analysis

of HPV vaccine was also requested by

the Thai FDA, HSRI and Regional and

Provincial Hospitals Association)

Cost utility, budget impact,

management and performance

Presentation of findings to policy makers,

cervical cancer screening programme

managers, academics, health insurance plans

and NGOs

Presentation of the CEA at an international

conference organized by NGO and academic

institutes

Press conference organized by HSRI, IHPP,

HISRO and HITAP

HPV vaccine, marketing strategies HITAP and Regional and Provincial

Hospitals Association

Socio-political implications Press conference organized by HSRI, IHPP,

HISRO and HITAP

Erythropoietin in anaemic cancer patients NLEM Subcommittee Cost utiilty, budget impact Presentation of findings to the Subcommittee

Insulin analogues, long- and short-acting NLEM Subcommittee Cost effectiveness Presentation of findings to the Subcommittee

HMG Co-A reductase inhibitors (statins) NLEM Subcommittee Cost effectiveness, budget impact Presentation of findings to the Subcommittee

Proton-emission tomography and computed

tomography

Civil Servant Medical Benefit Scheme,

HSRI, Department of Medical Service,

Department of Medical Sciences

Cost only, budget impact,


Presentation of findings to policy makers at

CSMBS, NHSO, SSS and HISRO

Osteoporosis, screening and treatment in

post-menopausal women

NLEM Subcommittee Cost effectiveness, budget impact Presentation of findings to the Subcommittee

Cholinesterase inhibitors and other medicines

for Alzheimer’s disease


Unilateral cochlear implantation for profound

hearing loss patients

NHSO Cost effectiveness, socio-political

implications


HISRO

Medicines for treatment of hepatitis B

and C


Bone marrow transplantation and medicines

for acute myeloid leukaemia


Provider-initiated voluntary counselling and

HIV testing

HITAP Cost effectiveness, budget impact,


Presentation of preliminary results to research

teams from 16 district hospitals

Continued next page

Stren

gthen

ingCost-E

ffectiven

essAnaly

sisin

Thailan

d941

ª2009AdisData

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study.In

additio

n,burea

ucra

ticrules

andreg

ula-

tionsare

criticalbarriers

toreta

iningwell

trained

civilserv

ants

onseco

ndmentto

work

asHIT

AP

research

ers.Finally

,the

dem

ands

for

cost-effectiv

eness

evidence

are

also

mountin

gin

thepriv

ate

sector,

since

pharm

aceu

ticalcompanies

haveto

provide

pharm

acoeco

nomicinform

atio

nwhen

proposin

gproducts

tobeinclu

ded

intheNLEM.Conse-

quently

,it

isinevita

ble

thatthe

HIT

AP

will

compete

forsta

ffwith

themultin

atio

nalphar-

maceu

ticalcompanies

inthecountry

.Thebrain

drain

ofhealth

economists

will

also

affect

uni-

versities

andother

govern

mentagencies

when

the

amended

versio

nsoftheMedica

lDevices

and

Medicin

esContro

lAct

are

fully

enforced

.In

this

light,

thereco

mmendatio

nsofSinger

[34]to

ex-

pandeffo

rtsforcapacity

develo

pmentofCEA

andmodellers

inreso

urce-p

oorsettin

gsmaynot

beadequate

tocounter

theobsta

clesfacin

gthe

ThaiHTA

initia

tive.

Promotin

gapublic

ethos

amongstHIT

APsta

ffasanorganiza

tionalnorm

andem

phasizin

gthenon-fin

ancia

lretu

rnsfro

mthesocia

llybeneficia

lwork

will

beinvaluable

indealin

gwith

thischallen

ge.

Attheprogrammelevel,H

ITAPadministra

tors

andsta

ffhave

triedhard

tooverco

meexistin

gob-

stacles,

notonly

inconductin

ghealth

economics

studies

butalso

inesta

blish

ingatru

stworth

yor-

ganizatio

nwith

highperfo

rmance.

Effo

rtsdurin

gthefirst

2years

haveresu

ltedin

severaldeliv

er-ables,

inclu

ding

natio

nalguidelin

esfor

CEA,

publica

tionsin

intern

atio

nalpeer-rev

iewed

jour-

nals,

dissem

inatio

nofresea

rchfin

dingsto

policy

makers

andpractitio

ners,

andtech

nica

landpolicy

collaboratio

ns.

Inad

ditio

n,HIT

AP

research

ersfreq

uently

providetech

nica

lsupport

onreq

uest,

such

asto

theMoPH

andits

divisio

ns.However,

these

achiev

ements

maynotbesusta

ined,asthe

problem

of

workforce

shorta

geand

itscon-

sequences

emerge

fully

over

thenext

couple

of

years.

Since

theinstitu

tionalizatio

noftheHIT

AP

asanatio

nalHTA

organizatio

nhasbeen

setasan

ultim

ate

goal,allconcern

edparties

should

collec-

tively

devise

astra

tegicplan

with

aset

timefram

eto

facilitatetheHIT

AP’s

surviv

alan

dgrowth.In

doing

so,every

weakness,

threa

tand

poten

tial

solutio

nhas

tobeassessed

frankly

byall

partn

ers.

Table II. Contd

Studied interventions Proposing agencies Issues of investigation Strategies to get research to policy and action

Rapid, oral fluid-based HIV test Thai FDA Cost effectiveness, budget impact,

management and performance,

socio-political implications

Presentation of findings to Thai FDA

Policies to reduce alcohol consumption Thailand Health Promotion Foundation,

Department of Disease Control

Management and performance,


Presentation of findings to Thailand Health

Promotion Foundation

Alcohol consumption, socioeconomic

and healthcare costs

HSRI Cost only, budget impact,

management and performance,


Key findings employed by health advocates in

campaigning for the adoption of the Alcohol

Act 2008

Compulsory licensing for essential medicines HSRI Cost effectiveness, budget impact,



MoPH and NHSO

HIV/AIDS prevention interventions IHPP, World Bank Cost effectiveness Presentation of findings to policymakers at

MoPH

CEA = cost-effectiveness analysis; CSMBS =Civil Servant Medical Benefit Scheme; HISRO =Health Insurance System Research Office; HPV =human papillomavirus;

HSRI =Health Systems Research Institute; IHPP = International Health Policy Program; MoPH =Ministry of Public Health; NGO = non-governmental organization; NHSO =NationalHealth Security Office; NLEM =National List of Essential Medicines; SSS =Social Security Scheme.

942Tan

tivessetal.

ª2009AdisData

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acoeconomics2009;27(11)

The policies on the adoption, distribution, fund-ing and evaluation of particular types of healthinterventions as well as the objectives and manage-ment of HTA agencies are likely to be context spe-cific. At present, the HITAP is a semi-autonomousresearch institute, and the findings of its studiesand related recommendations are not legally oradministratively binding for any implementingbodies, which is dissimilar to some HTA units em-bedded in policy-making authorities. While theCADTH and NICE are mandated to generate evi-dence on the effectiveness and efficiency of healthtechnologies,[35] the HITAP covers a wide range ofactivities, not only conducting HTA studies butalso strengthening research and research-policycapacity, which is considered necessary in the Thaicontext. Nonetheless, in some settings where eco-nomic appraisals of medicines and other healthproducts are required by national health insuranceoffices, the responsible agencies need to provide thepharmaceutical industry with study guidelines andalso set up national standards.[4] The HTA guide-lines prepared by the HITAP aimed to serve widerpurposes, beyond the development of reimburse-ment lists. Concerning the utilization of HTAresults, scientific evidence generated by theAustralian Pharmaceutical Benefits AdvisoryCommittee and the HIRA in Korea are integratedinto health service funding, while in other settingssuch information only targets health professionalpractice.[4,36] In contrast, the cost-effectiveness dataand policy recommendations derived from HITAPstudies are expected to be used by all concernedparties in the health system, such as the HealthMinistry, health professional training institutes,hospital administrators, and health NGOs, includ-ing consumer protection groups. The HITAP dif-fers from NICE in that it relies on its own researchstaff, with no contracting relationships with uni-versities. In part, this is because of the limitednumber of academic institutes interested in HTAand health economics in Thailand.

Scholars have suggested that participation ofpolicy makers and key stakeholders throughoutdifferent stages of conducting research, andcollaborations between researchers and policymakers, are important factors for enhancingpolicy utility of research.[29,37] Like many HTA

organizations, the HITAP encourages participa-tion of different groups of stakeholders in its re-search. Although the influence of HITAP studieson policy decisions is as yet unclear, close colla-boration between the HITAP and its stake-holders has a crucial role in determining helpfulresearch questions, designs and methodologies.Furthermore, it could be argued that the face-to-face consultations with experts, peripheral healthworkers and, on some occasions, patients andcaregivers, all with different backgrounds andexperiences, have resulted in the expansion ofresearch at the HITAP to areas beyond healtheconomics.

7. Conclusion

It is hoped that the lessons drawn from thecreation of the HITAP and its experience duringthe first 2 years, as well as information on its mainstrategies and management structures, may behelpful for other resource-constrained countrieswhen considering how best to strengthen theircapacity to conduct economic appraisals ofhealth technologies and interventions.

TheHITAP has learned that, although efficiencyis the major concern of policy makers, thoroughunderstanding of the feasibility, social acceptabilityand other possible consequences of a health policyor intervention should not be neglected.

Acknowledgements

This paper was developed as part of work under the SocialMobilization and Public Communication Plan of the HITAP.The programmewas funded by the ThaiHealth, the HSRI, theBureau of Policy and Strategy, Ministry of Public Health andthe Thai Health-Global Link Initiative Project.

Yot Teerawattananon is leader of the HITAP and SripenTantivess is a researcher of this initiative.

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Correspondence: Dr Sripen Tantivess, Health Interventionand Technology Assessment Program, 6th floor, Building 6,Department of Health, Ministry of Public Health,Nonthaburi 11000, Thailand.E-mail: [email protected]



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Strengthening Cost-Effectiveness Analysis in Thailand through the Establishment of the Health Intervention and Technology Assessment Program