By Freddie Ssengooba, Richard Ssempala, Chrispus Mayora, Brenda Nakimuli, Aloysius Ssennyonjo, Timothy Musila, Tom Aliti, Elizabeth Ekirapa Kiracho, Joseph Kazibwe, Pete Baker, Sarah Byakika, Anna Vassall, Francis Ruiz

Priority setting in healthcare is a universal challenge, but the application of evidence within a structured process to support decision making can minimise the difficulties and improve impact. A growing number of low- and middle-income countries, including those in Africa, are realising the value of developing systems that ensure resource allocation decisions take into account the best evidence available to improve population health and value for money. The COVID-19 pandemic and its consequences, especially on the fiscal space available to health, and progress towards universal health coverage (UHC), have added to this urgency.

One of the common approaches to evidence-informed priority setting around the world is Health Technology Assessment (HTA). Technologies in this instance refer to the variety of interventions a health system could provide, including medicines, diagnostics, and alternative approaches to how a particular service is provided. HTA is not only a technical exercise; but rather a process involving a broad range of evidence – including cost-effectiveness – that is collated, assessed, and then appraised with participation of a wide range of stakeholders both within and beyond the public sector. Therefore, it requires coordination of multiple actors within the health system. When HTA becomes part of a routine approach to support healthcare decision making on resource allocation and reimbursement, then HTA is said to be institutionalised.

Countries interested in building HTA-like mechanisms in their own contexts need to understand the current situation in their setting with respect to explicit healthcare priority setting, how it is undertaken (e.g., the extent to which ‘evidence’ is considered), who is involved, and how priority setting decisions are implemented through an organised institutional approach (if one exists). To support that, the International Decision Support Initiative (iDSI) has developed a framework to be utilised in undertaking HTA situational (landscape) analyses that could inform future targeted capacity strengthening efforts. The iDSI framework has been used in a number of countries including Ethiopia and more recently Uganda.

The iDSI framework was used to carry out the Uganda landscape analysis led by the Makerere University School of Public Health (MakSPH) and supported by the iDSI team at London School of Hygiene & Tropical Medicine (LSHTM). The landscape analysis involved a literature review and survey of stakeholders in the country. This was the first step in a Ministry of Health (MoH) supported effort to strengthen capacity for HTA institutionalisation in Uganda.

Uganda’s commitment to Universal Health Coverage 

Uganda is committed to achieving Universal Health Coverage (UHC) by 2030 and has made improvements in the UHC effective coverage index of 3.1% annually. Gains have also been made in other key indicators, including under five mortality and maternal mortality. The commitment to UHC is enshrined in recent national policies, such as Vision 2040, Health Sector strategic plan 2020/21-2024/25, and Third National Development Plan (NDPIII) 2020/21 – 2024/25 in which the government sets out its aim to implement a universal health insurance system, improve quality of care and reduce medical referrals abroad to increase coverage.

However, Uganda needs to optimise its available resources for health. It spends approximately $32.4 per capita on health, although 42% of overall health expenditure is provided by development partners. Despite the health improvements and commitment to further improve access and quality, the anticipated UHC targets have not been reached yet. While there is a case for additional investment, there remains a need to ensure existing resources as well as any new funds that become available, are spent wisely.

Priority setting in Uganda

The Uganda Ministry of Health (MoH) recognises the potential value of HTA in optimising resource allocation in the health sector. Building an institutionalised framework in Uganda will require careful and locally led capacity building. Through a Memorandum of Understanding (MoU) between iDSI, MakSPH and the MoH, a collaboration has begun that focusses on developing the evidence generation and uptake structures necessary for HTA use in Uganda.

The first step in the operationalisation of the MoU involved carrying out an HTA landscape analysis to assess the HTA situation in the country. This was led by MakSPH with support from the iDSI team at LSHTM. The landscape analysis involved a literature review of relevant published policies and a survey of key stakeholders (such as policymakers at national and regional levels, researchers, civil society and development partners). We found that considerable opportunities exist to improve evidence is use in the decision-making process. There are currently several relevant priority setting activities (such as those related to budgeting, procurement and the development of guidelines) taking place in Uganda, but none explicitly utilise HTA-like methods to support these processes (Table 1). There is limited available HTA-relevant literature that focuses on the Ugandan context and most of these studies are authored by researchers based outside Uganda.

Table 1: Use of HTA in priority setting processes

The landscape analysis indicated that there is potential to build a locally relevant evidence base to support HTA. Existing routine data sources such as burden of disease reporting could be leveraged to that end. Moreover, there exists international centres of excellence such as Infectious Disease Institute (IDI),  the Medical Research Council (MRC)/Uganda Virus Research Institute (UVRI) and LSHTM Uganda Research Unit which undertakes research in a range of areas including emerging infection threats and chronic disease, and has supported health economics capacity strengthening through various initiatives including the development of the EQ 5D-5L value set for Uganda. This value set is being used for economic evaluations in Uganda, and has potential to be used by countries in the wider East Africa region.

The stakeholder interviews revealed that allocative efficiency, quality of care, transparency, budget control and equity were overarching areas where HTA approaches could make the highest contributions. Respondents also highlighted specific interventional areas that would benefit most from HTA. It was found that drugs, medical devices and diagnostics, vaccines, public health programmes, and service delivery initiatives would benefit most from HTA-like approaches. This is consistent with other findings from the continent.

As a low-income country, a considerable portion of the Uganda health care budget is supported by development partners. This suggests that some important priority setting choices may have limited government involvement, and underscores the need for donor engagement in HTA and its institutionalisation. Nevertheless, there are a number of priority setting decisions led by Ugandan authorities that would benefit from the application of HTA approaches. These include developing and updating the Essential Medicines and Health Supplies List for Uganda, Uganda clinical guidelines development, marginal introduction of new improved technologies and solutions, and supporting the budgeting and procurement processes.  

Conclusion and recommendations

The landscape analysis suggests a number of key steps that need to be taken to advance HTA development in Uganda and help the country progress its ambitions towards sustainable UHC:

1. Uganda should consider establishing preliminary structures to support HTA development, such as an HTA coordinating unit within the MoH, supported by a secretariat. This need not be resource intensive and could operate in advance of more formal structures that may need to be underpinned by a specific legal framework.
2. The MoH should consolidate and coordinate activities linked to HTA-related work that are ongoing or planned to ensure that the needed support is given by government, research institutions and development partners.
3. The application of HTA in Uganda will require adequate capacity both to undertake HTAs and to support their use and uptake. In the near term, there is a need for further policy relevant HTAs supported by both development partners and local institutions, which can be used to build capacity in real time through a learning-by-doing approach.
4. It will be important to simultaneously explore how any HTA process will complement and feed into existing priority setting mechanisms, to help ensure there are clear links to impact.
5. Finally, the MoH should consider developing a strategy for the development of HTA in Uganda, with a five-year time horizon, as has been done in Ghana.

KEMRI Wellcome Trust, one of the regional iDSI network partners, has started working with Uganda to support government in the implementation of the recommendations through hands on training as a preliminary phase.

Learn more about the International Decision Support Initiative (IDSI)