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About the toolkit

In November 1993, the International Development Research Centre (IDRC) and several partner organizations sponsored an international conference entitled Needs-Based Technology Assessment: Exploring Global Interfaces, in Ottawa, Canada. The conference was attended by 103 delegates, including government representatives from 15 developing countries, international non-governmental organizations, donor agencies and several universities. The major recommendation of this conference addressed the urgent need for the international technology assessment community to develop a means by which developing countries could acquire the expertise to implement a needs-based technology approach, linking the needs and priorities of the population to policy development and implementation.

The favoured approach to meet this need was the development of a toolkit which would contain a variety of tools and methods appropriate for conducting needs-based health technology assessments at different levels of sophistication, as well as case studies which would test applications. The development of a toolkit for needs-based technology assessment was considered to have a number of important points. Ideally, it should:

  • facilitate knowledge brokering to communities and countries that do not have ready access to the existing range of researched options;
  • conserve scarce resources by not re-inventing the wheel;
  • promote a sound decision-making and policy process; and
  • be useful to donor agencies and countries in their discussions regarding community health development and resource allocation.

In response to this recommendation, the World Health Organization (WHO) Collaborating Centre for Health Technology Assessment at the University of Ottawa brought together a team of international experts in health technology assessment to develop such a toolkit. A draft conceptual framework was prepared and presented to a small group of international experts at a half-day workshop held in Ottawa. The draft concept and overall framework with draft sub-components was presented at the International Society for Technology Assessment in Health Care (ISTAHC) conference in June 1995. This forum afforded the researchers leading this initiative, the opportunity to debate and receive comments on the overall direction and approach for the toolkit from a range of experts in the field. Provisional consensus was reached on the framework and a project proposal was submitted to IDRC who then provided core funding.

Equity-Oriented toolkit

The Equity-Oriented Toolkit has 4 major steps:


  1. Burden of illness
  2. Community Effectiveness
  3. Economic Evaluation
  4. Knowledge Translation/Implementation


The steps of the toolkit are applicable to individuals as well as populations. It is based on clinical and population health status and considers gender equity, social justice and community participation.


1. Burden of illness


Measures the burden of illness in a population and incorporates societal and individual determinants of health (e.g. cultural, genetic, political, psychosocial, environmental, biological). It applies concepts of needs assessment and priority setting.


2. Community Effectiveness


Describes the actual effectiveness of an intervention when applied in the community. It considers interactions between: 1) efficacy, 2) screening/diagnostic accuracy, 3) health provider compliance, 4) patient adherence, and 5) coverage.


Read more about community effectiveness. 


3. Economic Evaluation


Describes the efficiency of an intervention: the relationship between the health benefits and the costs.


4. Knowledge Translation/Implementation


The process that includes synthesis, dissemination, exchange and application of knowledge to improve health.


Read more about applying the equity-oriented toolkit for health technology assessment and knowledge translation here. 


Reference:


Ueffing E, Tugwell P, Hatcher Roberts J, Walker P, Hamel N, Welch V. Equity-oriented toolkit for health technology assessment and knowledge translation: application to scaling up of training and education for health workers. Human Resources for Health. 2009;7(67).

Back to WHO CC homepage

Burden of Illness


In the two situations below, a decision is required on which technology should be purchased. When the question is phrased in such a manner, it is difficult to decide because the choices are limited to the technologies being considered, and the needs are vaguely described (i.e. a "worried" district doctor, "recommended" by a newly trained radiologist). To avoid being placed in such a difficult situation, one should pro-actively and regularly do a needs assessment. These needs can be prioritised based on burden of disease, availability of cost-effective technology and values or preferences of the community. A rational and responsive technology acquisition and implementation program can then be subsequently drafted.

Situation A
A hospital is considering buying a helical CT scan, based on the recommendations of a radiologist, newly returned from training in a foreign country. However, within the same department, it takes five days before an ultrasound examination can be performed from the time of scheduling.

Situation B
It is now rainy season. The district doctor is worried about diseases like hepatitis, diarrhoea and even mosquito-borne diseases like dengue fever. His choices are:

  1. order a fogging machine and insecticides for environmental control of mosquitoes;
  2. recheck all houses for sanitary disposal of waste, and if needed, construct latrines; and
  3. purchase hepatitis A vaccines.

Learn more about Burden of Illness by clicking the links below


Description of Burden of Illness (pdf)Download
Priority Settings of Burden of Illness (pdf)Download
Burden of Illness Comparison of Tools (pdf)Download

Community Effectiveness

Policymakers, payers, and health care providers are responsible for deciding which health services should be provided to whom to help reduce the burden of disease, disability and death. To achieve this goal, evidence-based information is required to make the precise decisions. Since health service resources need to be spent efficiently, steps in health information inquiries have been proposed. These steps are shown as the Technology Assessment Iterative Loop (TAIL) as discussed in the Introduction. In this chapter, we will focus on the community effectiveness, which is the third step in the TAIL.

The rationale of community effectiveness is to determine how well an intervention with the potential for reducing burden will work when applied in the community. Community effectiveness may be considered as the 'real world' efficacy of an intervention since it is affected by certain external elements. Community effectiveness is determined by five factors: efficacy, screening and diagnostic accuracy, health provider compliance, patient compliance, and coverage.


Learn more about Community Effectiveness by clicking the links below

Description of Community Effectiveness (pdf)Download
Community Effectiveness Comparison of Tools (pdf)Download

Economic Evaluation

In all societies, resources are scarce in the sense that there will never be a sufficient number to produce all the goods and services that people value. This is not just a problem of the public sector, but is common to all types of activities regardless of whether they are public or private. For example, time can be considered the ultimate scarce resource from an individual perspective. There is never enough time to do all the things that we would like to do, so we have to choose between the myriad of competing ways of spending time. It is the same with any resource - land, capital, labour etc. A resource could be used in many ways that would produce benefits for people and choices between alternative uses.


Learn more about Economic Evaluation by clicking the links below

Description of Economic Evaluation (pdf)Download
Economic Evaluation Comparison of Tools (pdf)Download

Knowledge Translation & Implementation

There are several levels of policies relevant to the discussion. These include the public policy, the system policy, the facility policy, the practice policy and the empowerment of the public and other stakeholders to balance technology development, optimisation, dissemination and utilization with the expectations and values of the stakeholders.

There are two key requirements for promoting technology policy, strategies and management. The first requirement is to develop strategies through partnerships of stakeholders to make sure that needs-based cost-effective technologies within the constraints of health systems are available and adopted for appropriate use in all levels of health care (public, system, facility, practice). Secondly, in a democratic system, we need to empower the public to make rational choices of the technologies and to ensure the accountability of the distribution and use of technologies according to the objectives of the different types of health policy.



Learn more about Knowledge Translation & Implementation by clicking the links below

Description of Knowledge Translation & Implementation (pdf)Download
Knowledge Translation & Implementation Comparison of Tools (pdf)Download

Health Technology Assessment Process

This section gives an overview of the basic steps in the technology assessment process based on a health needs perspective as described with this toolkit. It also incorporates the method of technology assessment as developed at the Canadian Coordinating Office for Health Technology Assessment (CCOHTA).

Technology Assessment Process


Needs Assessment and Priority Setting

  1. Perform a health needs assessment of the population group.
    - What type of needs will be addressed? (e.g. health vs healthcare, absolute vs relative, perceived vs expressed or measured)
    - How will the needs be measured (e.g. morbidity, mortality, risk factors, equity, indicators)
  2. Prioritize the health needs, and decide which need(s) you will concentrate on first.
    - What criteria, process and participants will be used to prioritize these needs?
  3. Identify the technologies that could be used or are in use to treat, prevent or manage the priority health need(s).
  4. Prioritize these technologies to decide which ones will be assessed.
    - A preliminary literature review and/or a consultation with experts on this technology will help to identify the issues.
    - Determine the criteria to be used to prioritize which technology will be assessed.
    Examples of criteria:
    • Is there sufficient quality information available to conduct an assessment?
    • Is this technology likely to have a significant impact on the quality of patient care, or on the health care system?
    • Is there a variation in practice patterns?
    • Is there a question regarding over- or under-utilization?
    • Does this technology call into question the existing "gold standard" of therapy or practice?
    • Has this technology been replaced by another technology?
    • Is there no existing therapy or treatment?
    • Technology Assessment CCOHTA's Method

  1. Identify external specialists with expertise in the area who are willing to participate in the assessment as advisors and reviewers.
  2. Define the assessment objectives and define the target audience in consultation with the advisory group and with those who have requested the assessment.
    - What does your audience need to know?
    - How will the results of the assessment be used?
    - What format will the results take? Eg. full written report, summaries, online.
    - Identify primary HTA issues of interest including safety and adverse effects, efficacy / effectiveness, cost and cost-effectiveness, budget impact of health system, appropriate utilization, significant social implications, and ethical / distributional / equity issues, etc.
    - Narrow the scope as much as possible. (Use SMART criteria: specific, measurable, action-oriented, realistic and time-bound).
  3. Define specific questions to be asked. Consider clinical, social and economic impacts and identify relevant populations (e.g. Is the intervention effective in high risk groups? Are there frequent adverse effects? Is it cost-effective for healthy adults?).
  4. Identify and collect relevant evidence, including:
    - a literature search with a defined strategy
    - information from key contacts, sources, other HTA agencies in this area and the owners or holders of the technology
    - studies, reports suggested by the advisory group
  5. Analyze and synthesize the evidence:
    • Clinical review - this may include a systematic review of studies with or without a statistical analysis or meta-analysis. If a systematic review is undertaken, then define the criteria for study inclusion and exclusion, quality assessment and data extraction (reference can be made to specific criteria e.g. Cochrane). Specify the main health outcomes to be reported.
    • Economic evaluation - design an economic evaluation. Plan and develop an economic model, if required. Consider items 1-25 of CCOHTA's "Guidelines for Economic Evaluation of Pharmaceuticals: Canada", and indicate any deviations.

  1. Initiate review of the drafts of the assessment to verify content and methods. This step is important to ensure scientific rigor. (A consistent review process should be developed that includes internal and external reviewers.)
  2. Write the final report, edit, format and print for distribution.
  3. Dissemination

CCOHTA Standardized Report Format

  1. Reviewers - a list of external reviewers
  2. Table of Contents
  3. Executive Summary
  4. Introduction
    - clinical background
    - main issues surrounding the technology
    - product description
  5. Objectives of the assessment
  6. Clinical Review
    - methods
    - results
  7. Meta-analysis results
  8. Cost-effectiveness analysis/ economic evaluation Method:
    - type of analyses
    - decision model
    - target audience
    - viewpoint
    - treatment comparator(s)
    - time horizon
    - outcome measurement
    - cost measurement and valuation
    - sub-group analyses
    -assumptionsResults - analysis and results
    Sensitivity analyses
  9. Discussion
  10. Limitations
  11. Conclusions
  12. References
  13. Appendices

Acknowledgements

IDRC provided core funding and in-kind support has been given by the University of Ottawa Faculty of Medicine and School of Nursing, the University of British Columbia, Queen's University, Harvard University School of Public Health, University of the Philippines, Chulalongkorn University (Thailand), Health Systems Research Institutes in Thailand, and the World Health Organization.


The team is led by Dr. Peter Tugwell and Janet Hatcher Roberts, Co-Directors of the WHO Collaborating Center for Knowledge Translation and Health Technology Assessment in Health Equity and Dr. David Banta advised the process.


The chapter leaders were: Dr. Chitr Sitthi-Amorn (Chulalongkorn University, Thailand), Dr. Somsak Chunharas, Dr. Manathip Osiri and Dr. Tessa Tan Torres (University of the Philippines), Dr. David Evans(WHO), Dr. Arminee Kazanjian (University of British Columbia), Dr. Michael Reich (Harvard University), Dr. Yvo Nuyens (COHRED, United Nations Development Programme (UNDP), Dr. Raisa Deber (University of Toronto). Janet Hatcher Roberts, Co-Director of the Collaborating Centre, supervised the process in Ottawa. Barbara Laperrière provided research support, and Marie-Josée Dion, Dr. Sharmila Mhatre, Jeea Saraswati and Dr. Sharen Madden in turn coordinated the project through the Collaborating Centre. The Coordinating Office for Health Technology Assessment (CCOHTA, Ottawa) provided editing and formatting services.


List of authors and Afilliations:

Dr. Chitr Sitthi-Amorn
Director,Clinical Epidemiology Unit, Faculty of Medicine, Chulalongkorn University
Phya Thai Road, Bangkok, Thailand
Fax: 66-2-255-6046
chitr@chulkn.chula.ac.th


Dr. David Banta
Retired from TNO
67 Rue de la Roquette,
75011 Paris, France
Tel: 33-1-44930052
hdavidbana@cs.com

Dr. Somsak Chunharas
National Health Foundation
1168 Paholyothin 22
Jatujak
Bangkok 10900, Thailand
Tel: 66-25116855
Fax: 66-29392122
somsak@health.moph.go.th

Dr. Raisa B. Deber
PhD Professor
Department of Health Policy, Management and Evaluation
University of Toronto
McMurrich Building, 2nd Floor
12 Queen's Park Crescent West
Toronto, Ontario M5S 1A8
Tel: 416-978-8366
Fax: 416-978-7350
rasia.deber@utoronto.ca

Dr. David Evans
Director
Department of Health System Financing, Expenditure and Resource Allocation (FER)
World Health Organization
Geneva,Switzerland
Tel: 41-22-791-3768
Fax: 41-22-791-4328
evansd@who.int

Arminée Kazanjian, Dr. Soc.
Professor
Health Care & Epidemiology
Faculty of Medicine
The University of British Columbia
5804 Fairview Ave
Vancouver, B.C. V6T 1Z3
Tel: 604-822-4618
Fax: 604-822-4994
a.kazanjian@.ubc.ca

Dr. Yvo Nuyens
Professor Emeritus,
211 Rue des Fontanettes,
01220 Divonne, France
yvo.nuyens@free.fr

Dr. Manathip Osiri
Dept of Medicine
Chulalongkorn University
Phya Thai Road
Bangkok, Thailand
Tel: 662-256-4246
Fax: 662-252-7858
mosiri@hotmail.com

Dr. Michael R. Reich
Harvard Center for Population and Development Studies
9 Bow Street
Cambridge,
MA02138 USA
Tel: 617-495-2021
Fax: 617 495-5418
michael_reich@harvard.edu

Dr. Tessa Tan Torres
World Health Organization
Geneva, Switzerland
tantorres@who.int

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