• evidence-based practice
• global health
• health care economics and organizations
• public health

The implementation of evidence-based medicine (EBM) relies on organisations to identify, develop and apply evidence-based practices. While healthcare professionals often engage with service providers like hospitals and insurers for EBM implementation, they may be less familiar with organisations focused on the related fields of health technology assessment (HTA) and priority setting, which evaluate health technologies' properties and cost-effectiveness. Distinct from researchers developing primary research, those involved in HTA policy development shape governmental policies for assessing health technologies. Recognising the formation and growth of such organisations is crucial for practitioners, especially in countries with limited EBM adoption. Lessons from global experiences in establishing and operating these entities can aid those in low-income and middle-income nations.

HTA policy development can help advance a country’s pursuit of universal health coverage, as recognised by the WHO through the adoption of Resolution 67.23 in 2014, which called on member states to promote the use of HTA in decision-making processes and to reinforce their HTA capacity.1 But such policy development is not merely technical but also a political and organisational exercise. While health professionals are trained mainly in a clinical scope of work, the work of establishing an organisation (such as those dedicated to HTA policy development) is a different scope of work that delves in knowledge and skills of public health and organisational behaviour.

There are many HTA agencies in high-income countries, but two notable leaders that have played a key role in international dissemination of HTA practices for low-income and middle-income countries are the United Kingdom’s National Institute of Health and Care Excellence (NICE) and Thailand’s Health Intervention and Technology Assessment Program (HITAP). In particular, the International Decision Support Initiative (iDSI), funded by the Gates Foundation, and with the Center for Global Development (CGD) as secretariat and with UK NICE International and HITAP as key partners, contributed to international HTA policy development and the development of those organisations.

To examine how an HTA organisation is formed, qualitative research such as the use of case studies (rather than the methodologies of clinical trials or quantitative research methods) is required. We recently conducted an in-depth case study of a new organisation doing HTA policy development, the Medical Technology Assessment Board and HTA India agency (HTAIn).2

We here summarise key lessons from this qualitative research relevant for EBM professionals into the ‘Four Ps’ of Policy, People, Place, and Processes.3

1. Policy: the creation of high-level policy documents is required to establish commitment by stakeholders and to acknowledge the processes required among multiple actors and institutions to advance an agenda. In the case of the HTAIn, the 12th Five Year Plan in 20124 was the first high-level national policy document that expressed commitment to HTA, underscoring the political prioritisation of creating such an organisation. This document was followed by a cascade of other high-level policy documents in support of HTA, such as the Parliamentary Standing Committee documents of 2013 and 2016,5 6 the concept note submitted by the Department of Health Research (DHR) secretary for the establishment of the MTAB in 2016,7 and the National Health Policy of 2017.8

2. People: health professional leaders and policy entrepreneurs seeking to advance a policy agenda for organisational creation should identify multiple champions with sufficient seniority and political authority across a wide group of organisations. In India, multiple champions were found, who collectively formed a coalition of stakeholders, representing a broad group of stakeholders with a shared interest, namely, to advance EBM and HTA policy development. Developing a network of organisations and individuals who have the technical background and expertise to conduct research needed for HTA policy development is also valuable. This network can also support training and capacity building efforts and draw on international or external organisations and individuals who have specialised expertise or other resources.

3. Place: in the health sector, conducting a health system mapping exercise to understand the layout of the country’s health system and identifying which aspect of the system may be the most suitable organisational location is key. In India, a landscape analysis helped to identity the regional resource centres of the HTAIn.9

4. Processes: detailing the structure of the organisation, creating institutional rules and guidelines, identifying existing capacity and linking organisations capable of generating evidence is beneficial. The establishment of the HTAIn Secretariat and the Technical Appraisal Committee and the Board (MTAB) are examples of developing structure and institutional process to help the organisation run as smoothly as possible with the necessary support systems in place.

Health professionals and other public health professionals in other low-income and middle-income countries seeking to establish an organisation focused on HTA policy development should consider the 4Ps, often outside the scope of medicine but in the realm of government, public administration and organisational design. Some prospective questions for an HTA or EBM champion or advocate to consider are, often in the context of a political economy analysis, health policy analysis, or stakeholder and interest group analysis10:

1. What are the guiding policy documents and institutions that could establish the authority and public mandate for conducting and using HTA or EBM?

2. Who are the respected organisational leaders of authority that are needed to build a coalition around an agenda of growing HTA or EBM?

3. Which organisations should be considered for where an organisational home of HTA or EBM could be located?

4. What are the processes and procedures needed for operation and implementation of an HTA or EBM agency?

HTA policy development require institutional and organisational homes for their long-term growth and advancement. To advance understanding and knowledge about how HTA-focused organisations are created or formed, one key area for research is to analyse and understand the organisational placement and structure of governmental bodies, including within a governmental authority for health such as a ministry of health. The organisational structure and corresponding function of health authorities across countries varies greatly, and there remains limited research about the optimal design of organisational structures, which in turn affects the effectiveness and performance of an organisation’s ability to carry out HTA and promote EBM. Future research studies on this topic should be conducted, for example, in India, to understand the benefits and challenges of placing the HTAIn within the DHR and how it impacted the wider Indian health system.