The delivery and uptake of any health intervention will be influenced by a range of systems factors.
Systems factors can include how well the health system is set up to deliver the intervention to the people who need it. Examples of health system facilitators and constraints include having appropriate facilities, healthcare worker capacity and availability, medical equipment, and supplies.
There are other systems factors beyond the health sector that can affect delivery, quality, and uptake of health interventions. These include access to electricity, inadequate or unreliable internet connectivity, access to clean water, transportation and road infrastructure.
While systems factors and constraints may never be perfect for the introduction of a new health intervention, taking stock of them can help shape the overall assessment of expected benefits and harms of an intervention and who experiences them. It can also enable appropriate investments or complementary services that may be needed to support implementation.
We use information about the burden of the health condition to think through the size and nature of the health condition the health intervention addresses. This information outlines the need for the health intervention, and whether a decision to adopt it would be in line with broader government priorities for health.
Evidence about which groups are most affected by the health condition will inform aspects related to Equity
Information about how many people need the intervention and how this may change over time can affect overall cost and Budget Impact.
The size and distribution of burden also relates to the capacity of the health system to meet the demand for related services that are covered.
The Burden of the Health Condition is a reflection of the Social Determinants of Health. Health is influenced by the environment in which people are born, grow up, live, and work. Health is shaped by exposure to polluted environments, inadequate housing, and poor sanitation, as well as powerful historical and social forces, such as income inequalities, unemployment, poverty, racial and gender discrimination, and extreme violence. Social Determinants of Health can be a useful way to understand both the underlying burden and health equity issues regarding who stands to benefit most from a new health intervention. It also underscores the limitations of any single health intervention to addressing a particular health condition, and the need for broader strategies to comprehensively address social determinants of illness and health inequalities.
Evidence about effectiveness informs us about the health benefits and harms we expect to see if the intervention is provided—both for individuals who receive it and in addressing the broader burden of the health condition for the population. We start with information about the benefits and harms of an intervention under ideal circumstances, like in a controlled research trial. But it is also important to assess benefits or harms based on real-world implementation in the South African context.
To assess expected health benefits or harms, consider:
How effective is the intervention at preventing or treating disease, improving health and life expectancy, and/or avoiding disability or chronic illness?
To the extent there are any negative side effects for those using the intervention:
Consider:
Because systems factors naturally vary across different parts of the country and for different population groups, see more under Equity as to how systems factors may affect the distribution of who benefits or is harmed by introducing the intervention
With a limited health budget, the Government will have to choose carefully about how to spend public resources. For any new health intervention proposed, it is worth assessing how much health benefit can be gained for the additional costs, in Rand spent and resources allocated. How do the costs and health gains associated with this intervention compare to alternative options that the Government could fund instead?
Standard principles about how governments should spend public resources for health include:
These standards are often measured using a cost-effectiveness threshold:
Cost-effectiveness analysis (CEA) is a common type of economic evaluation used for HTA analysis. It helps us understand the comparative cost per unit of health gained for different medicines, vaccines, and health services. CEA looks at different options and tells us how much more health benefit we can buy if we invest in one type of health intervention versus another option.
There are two parts of the equation:
We use this information to calculate the cost per unit of health gained for a given intervention. Then we compare that number to a standard, country-specific “Threshold” that tells us the highest cost per unit of health gained that would be considered cost-effective.
The cost-effectiveness threshold is meant to help decisionmakers compare how one health intervention compares with the wide range of possible health interventions that could be covered.
1. QALYs are “Quality-Adjusted Life Years” and DALYs are “Disability-Adjusted Life Years.” Both are common summary measures used by health economists to help quantify health benefit across different kinds of health interventions with a standard unit of measurement. While these and other summary measures for health are important for the purposes of health policy & planning, there have also been criticisms that these measures can discriminate against those living with disabilities and the elderly in ways that could raise Equity concerns. As such, cost-effectiveness must be considered alongside other relevant domains.
There are a few additional ways to think about cost-effectiveness:
In the real-world context of the health system & other factors
With a limited health budget, the total costs to the Government of implementing the health intervention will need to be assessed to determine whether the Government can afford it within the available resources.
To assess budget impact and how affordable the intervention is, consider:
Changing trends in Burden of the Health Condition can help you assess how the total cost of covering the intervention may change over time
In the real-world context of the health system & other factors
Equity is about fairness — about how health benefits and harms are distributed across the population and about addressing unfair inequalities in health. The idea is to ensure that everyone has a fair chance to benefit from the health system and to address disadvantages related to health. A key goal for equity is to reduce or eliminate unfair differences in health care and health outcomes across population groups.
Considering how to promote equity includes:
Personal Financial Impacts: Out-of-pocket costs or lost wages needed to access the intervention
Impacts on Personal Relationships: Differential impacts on members of the household and care-giver burden, including gender equity
In the real-world context of the health system & other factors
Human dignity and equal moral status are basic principles underlying human rights and are important to consider in health priority-setting. There are various ways in which health coverage decisions can demonstrate respect for human dignity and peoples’ equal moral status in the health system. There are also health interventions that help preserve or promote people’s sense of dignity and respect. These include respect for people’s personal preferences, values and traditions, and considerations of choice and privacy.
Promoting respect and dignity includes considering:
How might people’s religious, spiritual, or cultural belief and practices effect the Expected Health Benefits or Harms of the intervention?
When there are concerns about Respect and Dignity, consider:
Consider how these costs may affect Budget Impact & Cost-Effectiveness
In the real-world context of the health system & other factors
A health intervention may have a financial impact on individuals and families. People may have to pay out of pocket costs to receive care. A core principle of Universal Health Coverage, by which we are guided, is that every person in the country should be able to access quality health care without having to suffer financially for it. A health intervention may also reduce financial hardship if illness or disability keeps people from being able to work and earn income.
To assess whether covering an intervention will change individuals’ or their families’ financial circumstances, consider how covering of an intervention can result in:
High out-of-pocket costs also raise Equity considerations as some poorer individuals or households may choose not to seek care at all, while the wealthy are able to pay
There are often links between Respect & Dignity and people’s experience of poverty or their ability to work. Interventions that reduce poverty or enable people to earn a living likely also have related positive impacts on Respect & Dignity.
In the real-world context of the health system & other factors
People’s ability to form and maintain personal bonds with others is essential to wellbeing. A person’s health status can dramatically affect their personal relationships and the ways in which they interact with others.
When making health coverage decisions, consider how a health intervention may impact personal relationships, for better or worse.
Considering impacts on personal relationships includes:
In the real-world context of the health system & other factors
There are circumstances in which people will not be able to improve functioning, return to “their best possible” health, or extend time before death. Even when people cannot be cured, there may still be ways to reduce the pain or suffering they experience. Here we look at any special benefits, beyond what is counted in the health benefits section, that relate to easing pain and suffering.
Many measures used to quantify health benefits focus more narrowly on years of life gained or lost. Sometimes these measures are adjusted to take account of disability or the quality of those life years. However, there may be other types of benefits specific to how people experience physical pain or other types of suffering that are not well captured in the summary measures used to assess Health Benefits & Harms or Cost-Effectiveness.
To assess whether covering an intervention will have additional or special significance in easing people’s suffering, consider:
Beyond the direct benefits to patients, consider whether there are also important impacts for caregivers relevant to Impacts on important personal relationships
Note: This domain will not necessarily be applicable to every intervention. An evaluation of “ease of suffering” most commonly arises for palliative and end-of-life care, as well as symptom management of certain illnesses (e.g., chronic illnesses) or disabilities. It is unlikely to apply in the case of preventive interventions, at least with respect to preventing future illness. It may apply if a new prevention option has less pain or fewer side effects than the current options – particularly if these side effects are not well accounted for in the standard measures used to quantify health benefits and harms. There may also be improvements in the way researchers and health economists evaluate summary measures of health to further include these types of outcomes that patients care about. If the measures used for Health Benefits and Cost-Effectiveness are broadened to include these measures, you may not need to consider them separately.
Coverage decisions for some health interventions may have special considerations that relate to people’s exposure to unsafe environments or dangerous encounters. Feeling safe and being protected from harms while seeking health services, getting care, or—in the case of health workers—providing care, is important for the broader wellbeing of patients and providers alike. Here we look at whether the health intervention has any special significance for people’s safety and security.
To assess whether covering an intervention will have additional or special significance for people’s safety and security, consider:
Note: This domain will not necessarily be applicable to every intervention. It is possible that some elements (such as prevention of infection or injury in care settings) may be captured in the economic evaluation, in which case they may not need to be assessed independently.
In the real-world context of the health system & other factors