Results of the Delphi Analysis and Quantitative Survey into stakeholder views on the implementation of the HIF scheme David Coles, University of Wageningen,

Results of the Delphi Analysis and Quantitative Survey into stakeholder

views on the implementation of the HIF scheme

David Coles, University of Wageningen, The Netherlands

May 12, 2011

INNOVA meeting, New Delhi, 12 -13 May 2011

Results of the Delphi Analysis and Quantitative Survey into

stakeholder views on the implementation of the HIF scheme

David Coles and Lynn J. FrewerUniversity of Wageningen, The Netherlands

University of Newcastle, UK

[email protected]

[email protected]


To evaluate expert opinion regarding the feasibility, acceptability and barriers to implementation of a Health Impact Fund (HIF)

To map consensus and disagreement amongst experts in relation to the above

To identify potential support for and barriers to implementation of an HIF

Aims of Research


• Internet-based survey, with several ‘rounds’ • includes feedback of participants’ views• anonymous responses

• Allows inclusion of many geographically dispersed experts

• Pre-empts difficulties with group meetings • unequal contributions of members • unstructured data collection• linguistic inequalities (if relevant)

• Subsequently extended to further quantitative analyses using larger representative samples

Rowe & Wright, 1999

Delphi Methodology


Delphi Participants

Panel of 25 Participants recruited 97 % second round participation Male participants over-represented (83%!) Range of countries / international organisations Range of stakeholder organisations

Industry International organisations National governments Health services NGOs Research funders Academic/research

All participants had access to extensive information on the HIF (overview executive summary, HIF website, academic papers and other publications)


Participant agreement from round 1

These questions were not asked again in

round 2


More than 80% agreement (“consensus”) from round 1.

Complete consensus regarding the need to adopt “special measures” regarding the treatment of neglected diseases.

“The HIF would provide a greater incentive for the pharmaceutical industry to develop tools to fight diseases of poverty”.

“An HIF scheme would encourage commercial pharmaceutical companies to collaborate with publicly funded research initiatives”

“Pharmaceutical interventions should be eligible for an HIF payment”

“Health system innovations should be eligible for a HIF payment”


Other issues “not followed up” in Delphi round 2. 74% of participants agreed or agreed slightly, and 17%

had no opinion that: “In addition to national Governments, other donors such as private foundations, will be willing to fund an HIF scheme”

Almost 60% of participants were unable to estimate whether the proposed size of the fund (US$6bn) was appropriate to fund an HIF scheme

Participants generally found it difficult to provide alternative estimates of the appropriate size of the fund

Suggests that a convincing economic analysis of the financial resources required will be essential


Summary of Other Key Delphi ResponsesDetails of these have been provided in a previous presentation:

(Melbourne 24-25 March 2010)


Summary of Other Key Delphi Responses (1)

Political incentives (facilitating) should be developed to encourage industry to engage with an HIF

Just over half of all experts agreed to some extent that an HIF scheme would provide an incentive for commercial companies to develop cures not treatments

On average, respondents did not agree current IPR was a major disincentive for industry to develop treatments or cures for diseases of poverty


Experts identified a large number (20) of barriers that would need to be overcome for the successful implementation of an HIF. Respondents agreed, on average, that these were all potentially important barriers to be overcome

77 % of experts agreed that the benefits of an HIF scheme would apply primarily to developing countries

Most agreed that an HIF should also address capacity and capacity building




Many experts found it difficult to answer a question about whether Qualys would be the best measure. Those who did answer tended to agree that multiple measures would be most appropriate

High level of agreement that the governance of an HIF should involve a wide range of stakeholders

Most agreed that an HIF should focus on diseases other than HIV/AIDS, malaria and tuberculosis

High level of agreement that an HIF should be modelled, piloted and externally evaluated

There was no agreement on whether an HIF should focus more on chronic diseases


Quantitative Stakeholder Survey


Quantitative Stakeholder Survey

Results from the Delphi study and questions for which there was high level of agreement by the experts involved, were used as the basis for a much wider survey of key stakeholders

697 questionnaires were circulated and 84 responses received (12%) from 25 countries and from the European Commission.


Respondent Stakeholder Sectors

Academic 29 Development Agency 4 Health Insurance 1 International Organisation 20 IPR Law 1 National Government 4 NGO 13 Patient group 2 PDP 4 Pharma 2 Regulatory and Ethics 1 Not identified 1


Stakeholders’ Role in their Organisation

Almost all respondents are very senior with about 62% in the 46-65 age range:

Gender balance is 44.7% female and 55.3% male

30% at CEO or director level in their organisations

21% at professorial or senior academic

20% Heads of Department

9% Managers

4% at Minister or UN Ambassador level

16% - other roles


Key Responses From Stakeholder Survey (1)

STRONG AGREEMENT 97% of stakeholders believe “special measures” need to

be adopted to tackle neglected diseases. There is a high level of support for the HIF in principle

although there is consistent agreement that there are many important barriers to be overcome.

There is a high level of agreement that an HIF should be piloted (90% agreement).



HIF IMPACT

Stakeholders on average, agree that an HIF would: Facilitate the formation of Public Private Partnerships (92%) Increase potential for Industry to make profits (90%) Provide a greater incentive for Pharma to develop tools to fight

diseases of poverty (77%) Provide a greater incentive for Pharma to develop cures rather

than treatments (66%) Encourage collaboration between Pharma and publicly funded

research (74%)



GOOD AGREEMENT

While 79% agree that pharmaceutical inventions should be eligible for an HIF payment, 78% agree that health systems innovations should also be eligible in association with pharmaceutical products.

About 75% support to some extent HIF taking distribution systems and whole pipeline delivery into account in impact measurement.


Key Responses From Stakeholder Survey (4)UNCERTAINTIES There is lack of consensus regarding whether the HIF should put

more focus on chronic diseases (diabetes, heart disease etc.) that are “neglected“ by international funders, ( it may be that products for these diseases could very effectively be combined with health systems innovations for an HIF reward).

There is lack of agreement about whether the HIF should be available for diseases in developed as well as developing countries (42% agree, 46% disagree).

49% agree that their organisation would support an HIF. However 35% had no opinion.

There is considerable uncertainty amongst stakeholders as to whether industry will “buy in” to the scheme (39% don’t know or have no opinion).


Comparison between Delphi Study and

Quantitative Stakeholder Survey There are high levels of agreement between the

responses from the Delphi study and those of the quantitative stakeholder survey.

This demonstrates That experts and key stakeholders agree on the desirability of an

HIF and its potential impact. They also agree on the potential obstacles that will need to be addressed and overcome (all responses were over the 2.5 mid-point on the agree/disagree scale).

The effectiveness of the Delphi methodology as a predictor of stakeholder opinion.


Examples

Identification of:

Barriers to effectively treating neglected diseases

Important potential barriers to implementation of an HIF


Barriers to Treating Neglected Diseases and Diseases of Poverty


Delphi Results


Survey results


Comparison of Responses from Delphi and Survey


Conclusion

While stakeholders agree with the barriers to fighting neglected diseases and diseases of poverty which were identified by the Delphi experts, on average stakeholders feel more strongly about these barriers.


Key Responses From Stakeholder Survey

Important barriers to fighting neglected diseases are:

Poor access to medicines (94% agreement) Cost of medicines (94% agreement) Inadequate local healthcare infrastructure (92% agreement) Lack of national government spending on healthcare in

developing countries (90%) N.B. Although 75% agreed that lack of treatments (i.e.

treatments did not exist) was a barrier, it ranked last in importance of 14 barriers in the stakeholder survey


Barriers to Implementation of a Health Impact Fund


Delphi Responses


Survey Responses


Comparison between Delphi and Survey Responses


Barriers to Implemention

The most important barriers to the success of an HIF are perceived as relating either to:

uncertainty about adequate funding provision for an HIF or

the HIF not dealing with ‘end of pipe’ issues.


Barriers to Implemention

Although establishing effective impact measures did not have the highest level of agreement in the quantitative study it emerged as an important concern in the free comment section.


Stakeholder Comments (1)

“Setting a reasonable remuneration parameter according to health impact will be highly contentious, and likely impossible, both given extreme challenges in evaluating impact within the past year, and challenges in assigning a monetary value to impact. I don't believe that the HIF would change industry behavior significantly, given that returns would still likely be small, and likely less than the opportunity cost of not focusing on more commercially viable products.”

Manager, PDP

Incentives are critically important. It is difficult to get the balance right, in terms of incentive levels and conditions that need to be met to receive incentives.

Manager, International Organisation


Stakeholder Comments (2)

The need to address healthcare systems in developing countries, especially the need to increase healthcare and equity of access to services and social support are essential. The availability of "cheap" drugs cannot be expected to drive healthcare allocations by governments.

President – NGO

“The absence of infrastructure to deliver care far outweighs barriers of cost to appropriate technology for the setting”.

CEO - International Organisation

“HIF should not only focus on treating diseases. The biggest contribution will probably (be) in encouraging innovative ways to AVOID disease and prevent complications

as this ensures that communities do not slip into health crises”.

Senior National Government Official


Stakeholder Comments (3) “The greatest challenge will be measuring 'health impact'. For those populations

which are the most important target for the HIF, the available systems for measuring health status are the weakest in the world and therefore the problem of measuring a change in that status is enormous. Unless this is explicitly and very adequately addressed, it will be difficult to convince the main constituencies - donors, recipient countries and, most of all, the private sector - of the viability of the scheme.”

NGO respondent

“I know you have considered the difficulty in measuring health impact. DALYs seem a problematic choice, particularly because of all the subjectivity envolved in weighing disability, and the problem with the value of life at different stages. On the other hand, even accepting it, data is not available for every country, so results would be biased.”

Academic respondent


ConclusionsPositive There is strong support in principle for an HIF

Most people agree that an HIF would incentivise industry to greater involvement in fighting neglected diseases and diseases of poverty, including increasing collaboration with the public sector

There is strong support for an HIF to be piloted

Negative

There are serious concerns about potential barriers to successful implementation of an HIF

Practical support and funding to implement an HIF may not be forthcoming unless policy-makers, funders and industry can be convinced that the barriers can be overcome.


How to Proceed?

Pilot studies are needed to test the validity of all the barriers identified and whether these can be overcome.

A series of pilot studies should be developed and costed.


How to Proceed?

Practical financial support should be secured from key stakeholders to fund the pilot studies to test the concept. For example: DG DEV/DG RTD USAID Global Fund UNDP/WHO National Development aid funders e.g. DFID, BMZ Industry (two or more Pharma companies)

N.B. The successful Brussels meeting has already made a good start on securing support in principle from DG DEV, Industry and the Global Fund. This now needs to be followed up by securing financial commitment to pilot studies.


How to Proceed?

Results from the pilot studies could give rise to a Road Map (perhaps in conjunction with the Global Fund and WHO) demonstrating how the HIF would be implemented and how the potential barriers would be overcome


Any Questions?

Documents

Results of the Delphi Analysis and Quantitative Survey into stakeholder views on the implementation of the HIF scheme David Coles, University of Wageningen,