All healthcare systems face problems of justice and efficiency related to setting priorities for their populations [1]. Thus, the necessity to set priorities in an explicit manner is critical whereby costs, quality and accountability concerns needs to be balanced. The lack of coherence between limitless promise and limited resources leads to implicit and covert rationing through waiting lines, low quality, inequities, and other mechanisms in many parts of the world [2]. Even in affluent settings clinical care given to patients frequently departs from best practice, either because of the fast adoption of new technologies without certainty about its clinical and cost-effectiveness, or due to the slow adoption of those, proven to be effective and good value for money [3], henceforth resource-allocation remains inefficient and unfair.
Decision-making in healthcare is a continuum which moves from evidence generation to deliberation and communication of the decision made. Health Technology Assessment (HTA) is a multidisciplinary technique aimed at assessing the available evidence to better inform decision-makers about the most efficient use of resources. Besides the assessment, reimbursement decision-making also involves appraising the evidence bearing in mind societal values and ethical considerations alongside scientific judgment. Although important, HTA is only a part of the decision-making process as a whole (see Fig. 1). HTA initiation could be the result of top-down interest (political), bottom-up initiatives (academic/research) or converging [4]. Common motivators described in the literature for the establishment of HTA process are (i) to support decision-making, (ii) promote allocation efficiency and (iii) to strengthen the credibility, legitimacy and accountability.
Accordingly, for more than three decades, different HTA organizations for priority-setting and resource-allocation decision-making have emerged around the world. Currently more than 53 agencies in 33 countries exist; potentially this total number is still growing as we were writing this paper.
Countries in Latin America and the Caribbean have also experienced a rapid growth in interest on HTA. However, within the region there are at different stages of development; many countries are not fully aware of the pros and cons of HTA as a policy solution-arguably the majority. While others like Costa Rica, Chile, Peru and Argentina are in the early stages of developing their own national HTA systems; Brazil, Colombia and Mexico on the other hand have well established and operational HTA agencies within their settings and of special interest are the cases of Brazil and Colombia, which are attempting to advance the use of HTA beyond coverage decision-making.
Barriers and facilitators (“drivers”) for the development and use of HTA have been described, including availability and quality of data, cultural aspect, financial support, globalization, health system context, implementation strategy, local capacity, policy and politics support, stakeholder’s pressure and usefulness perception [5].
Understandably, HTA has become an issue of great interest; its advocates argue that it helps to promote efficiency of resource-allocation, whilst critics state it is simply a means to restrict access to new and costly technologies [6]. The main limitation of HTA is that it lacks the ability to incorporate societal values in an explicit manner into the decision-making process.
Even in countries where formal HTA activities are ongoing, transparency levels of resource-allocation decisions vary [5, 7], actually no one could grant that after proper HTA has been conducted, clear and transparent decisions are made. This concern is even more prominent in low and middle-income countries—LMIC where rationing still occurs as an inconsistent and unstructured process. Indeed, important criteria such as budget impact, equity and disease severity have not always been taken into consideration, and if they have, it is not often clear how they have impacted a final decision [8]. Beyond scientific evidence, decision-making also requires value judgments [9,10,11]. Thus, neither HTA reports nor the results of cost-effectiveness analyses should be blindly used to make decisions.
Multi Criteria Decision Analysis (MCDA) on the other hand, has emerged as another tool to support complex decision-making in healthcare, moving beyond the evidence generation stage mentioned before. MCDA are designed to help people make better choices when facing complex decisions involving several dimensions. In theory, MCDA are especially helpful when there is a need to combine hard data with subjective preferences or make trade-offs that involve multiple decision-makers [12], and allows a structured and objective consideration of the factors that are both measurable and value-based in an open and transparent manner [8, 12].
It seems HTA solely or combined with MCDA have the potential to be used for reimbursement decision, but also for assisting price negotiations or regulation. Thus, both are worth considering important steps towards rational priority-setting in developing countries [13, 14].
Colombia is a middle-income country that despite reaching universal health coverage over the past decade is struggling to be sustainable and set priorities for healthcare in a more systematic fashion. In 2012, the national Health Technology Assessment Institute—IETS was established to inform coverage decision-making based on HTA methods similar to those used by the National Institute for Health and Care Excellence—NICE in the UK or the Pharmaceutical Benefits Advisory Committee—PBAC in Australia. IETS founding partners are MoHSP, National Institute of Health, National Food and Medicines Surveillance Institute—INVIMA, the Department of Science, Technology and Innovation—Colciencias, and The National Association of Scientific Societies.
IETS was created aimed at better informing coverage decision-making right before the disbandment of a former Regulatory Commission for Health which was a decision-making body similar to CONITEC in Brazil; ever since the MoHSP regained reimbursement decision-making powers. More recently, IETS has been challenged to support the implementation of a new health sector reform, which enshrined health as a fundamental constitutional right and shifted the publicly financed benefits package from inclusions to exclusions. Under these circumstances, IETS is bound to move from the cost-utility, cost-effectiveness analyses and thresholds considerations to wider approaches (this may include HTA, MCDA and budget impact analysis) to better inform the deliberation and appraisal stages of priority-setting, this will occur at a national decision-making body with wider representation of stakeholders as mandated by the new Law.
This paper briefly presents the current challenges of the Colombian health system, the general features of the health sector reform, the main characteristics of HTA and the potential benefits and caveats of incorporating MCDA approaches into the decision-making process. We conclude by presenting some policy implications for both, IETS and the Ministry of Health and Social Protection (MoHSP) of Colombia, shall they decide to use HTA or MCDA approaches solely or combined.