HTA: From Neoliberal Technocracy to Sustainable Democracy?
The decision on the allocation of scarce resources for health has become one of the most important problems faced by governments around the world. In this context, defining how to fairly meet the needs of population health is a challenge facing all democratic societies. One thing is certain: no country has sufficient financial resources to meet all the health needs of its entire population. Choices need to be made, and this regularly generates outcry and indignation on those not supported in this decision-making process.
This problem is more pronounced in countries that have chosen to see “health as everyone's right and the duty of the state”, but who have a chronic lack of funding to achieve this goal. That is the case of Brazil, one of the few countries in the world to accept the challenge of offering universal health coverage to a country with more than a hundred million inhabitants, through its Sistema Unico de Saúde (Unified Health System).
One of the proposed solutions to the explicit rationing of health resources has been the adoption of procedures such as Health Technology Assessments, which according to the World Health Organisation is “is a systematic and multidisciplinary evaluation of the properties of health technologies and interventions covering both their direct and indirect consequences”.
In Latin America, HTA has been part of the healthcare agenda reform since the 1990s. In 2012 and 2014, respectively, the Pan American Health Organisation (PAHO) and the World Health Organisation (WHO) released documents calling for the strengthening of HTA capacities in the region.
In 2012, the Brazilian National Commission for the Incorporation of Technologies into the Unified Health System (Conitec) was created. However, the lack of independence within this organisation is blatant. Along one Executive Secretariat, the Conitec committee is composed of a plenary group with thirteen voting members, representing the seven Brazilian Ministry of Health secretariats and six other national health institutions. Only one of Conitec’s members could be considered as representative of social/public participation: the National Council of Health.
Patient engagement in these processes, often referred to as 'Patient and Public Involvement' (PPI), has become the apple of the eye of pharmaceutical care in recent times, bringing together both industry and patient organisations.
In the South American continent, Brazil and Colombia stand out in the implementation of formal mechanisms for involving citizens in decision-making processes related to HTA. Notably, in Brazil, social participation in decisions about the public health system has been a constitutional precept since 1988.
A recent study sought to assess the quality of social participation in ATS in Brazil, as well as to propose a framework to develop actions to improve PPI (Silva AS, Facey K, Bryan S, Galato D, 2022). For the construction of such a framework, the research covered three phases, as illustrated in Table 1.
Phase A: Existing PPI phases in the Brazilian HTA
Phase B: Stakeholder perspectives and international practices
Phase C: Designing and reviewing a framework for action
Table 1: Three-phase approach to building the framework for action to improve PPI in the Brazilian HTA. Abbreviations: CEPPP, Canadian Centre for Excellence on Partnerships with Patients and Public; HTA, health technology assessment; PPI, patient and public involvement. (Silva; Facey; Galato, 2022)
The lack of patient representativeness in this process, the absence of transparency in the HTA procedures, and the need for capacity building amongst the patient population concerning HTA were some of the issues revealed by the study. These findings replicate, in some way, international results in the same genre of studies.
The resulting framework of action is the following (Figure 1).
Figure 1. Proposed framework for action to improve patient and public involvement (PPI) in the Brazilian health technology assessment. Abbreviations: CNS, Conselho Nacional de Saúde (national health council); DOU, Diário Oficial da União (federal government official journal); HTA, health technology assessment; KT, knowledge translation; PC, public consultation; PPI, patient and public involvement; SCTIE, Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde (secretariat of science, technology and strategic inputs); SE, executive-secretariat. (Reproduction) Source: Silva AS, Facey K, Bryan S, Galato D (2022).
Although we must praise the high quality of this study as research, we must highlight where it is located in the large spectrum of HTA investigations. This study is focused on policy analysis, which characteristically puts aside the black box of 'vested interests', 'barriers and opportunities', 'societal values' and 'regulatory captures'.
In fact, a critical perspective on HTA is blossoming nowadays in the hands of social scientists which reflects a broader trend related to the ascendance of new institutionalism, actor-network theory, and other fields linked to political economy and Social Studies of Science.
Given the notorious close relationship between the pharmaceutical industry and patient organisations in Brazil and the role of both in the battle for transparency and legitimacy in HTA organisations, what kind of civic social learning could be generated by these movements and action frameworks?
It would be interesting to see, embedded in such capacity building processes lessons on critical health literacy, financing of the public health systems, and learning opportunities about the global threat presented by a pharmaceutically-centred model of public health.
The Global South has a huge tradition in what was known as the Latin American Social Medicine (LASM) movement. As Hartmann reminds us that:
“LASM recognizes that health is determined by myriad social, political, economic, and environmental factors, thereby distinguishing itself from the biomedical focus of mainstream medical practice. Furthermore, and in line with the Alma-Ata Declaration, social medicine prioritises healthy equity, intersectoral collaboration (i.e., promotion and coordination of health actions by different sectors), and citizen participation. However, whereas LASM views health as a goal in itself, the Alma-Ata Declaration conceives of health both as a goal and “as an avenue for social and economic development” (Hartman, 2016).
One must be curious about what the founding fathers of LASM would have been about HTA processes. Many social scientists probably believe that they would see HTA as an anathema to their vision of public health as a form of social justice.
As participants of the Social Pharmaceutical Innovation (SPIN) research consortium, we are trying to think about social pharmaceutical innovation and ways to do it in a more affordable and sustainable fashion.
An amplified version of HTA which incorporates values of ethics, equity and social justice in the spirit of the LASM movement could act as a foundation to proposing increased sustainability of public health systems. This may have financial value, as conventional HTA procedures invites stakeholders to believe. However, this may also have significant sustainable impacts in a systematic and holistic way as well. Is it feasible? Maybe not.
But researchers are increasingly seeing companies change their perspective on how to make business better aligned with environmental, social and corporate governance agendas. It is a good time to see organisations not only present solutions to health problems but also become active players in the promotion of the overall wellbeing of people.
Hartmann C. (2016). Postneoliberal Public Health Care Reforms: Neoliberalism, Social Medicine, and Persistent Health Inequalities in Latin America. American journal of public health, 106(12), 2145–2151.
Silva AS, Facey K, Bryan S, Galato D (2022). A framework for action to improve patient and public involvement in health technology assessment. International Journal of Technology Assessment in Health Care 38, e8, 1–9. https://doi.org/10.1017/
Image of Steve Buissinne for Pixabay
Written by Cláudio Cordovil Oliveira (PhD)