- Email: [email protected]
Integrated health technology package
Chapter 38
Integrated health technology package Thomas M. Judda, Peter Heimannb, Andrei Issakovc a
Clinical Engineering Division, IFMBE, Marietta, GA, United States, bHealthcare, Luxembourg Development, Vientiane, Laos, cProcess Management System, Sarl, Geneva, Switzerland
Background The World Health Organization (WHO) health resource and planning tool, formerly known as essential health technology package (EHTP), was described in-depth in the 2004 CE Handbook. Shortly after the earlier handbook was published, WHO renamed the tool as the integrated Health Technology Package (iHTP) to better reflect its scope and purpose, as well as implementation and use in countries by way of their Ministries of Health (MOH), development assistance agencies, and international organizations. References were gleaned from work done in the 1980s, 1990s, and in 2000, led by Peter Heimann (the inventor of iHTP) and Andrei Issakov (the WHO sponsor of iHTP). Thomas M. Judd was among the CE-HTM professionals trained to implement iHTP in 2000 and began several years of work with MOHs in Kyrgyzstan (Central Asia), Namibia (southern Africa), and then Mexico, in partnership with the other two authors. Overall, iHTP had been implemented in some 20 different countries, and used by several WHO programs as a resource planning and management instrument as well as many more countries and projects have shown interest in using this methodology. The iHTP tool however fell into disuse in 2010 after leadership changes at WHO. Nevertheless, iHTP concept remains continuously valid, and the need for a comprehensive and evidence-based resource planning and costing of health interventions only increases over time, particularly within the context of the universal health coverage and sustainable development goals.
What is iHTP (WHO, n.d.; Peter, 2007) iHTP is essentially a resource planning methodology and software-based tool that provides guidance on an adequate mix of resource inputs, comprising human resources, medical devices, pharmaceuticals, and facilities, needed to deliver a defined set of health interventions. 236
It integrates healthcare needs, disease profiles, patient demographics, clinical practice, medical device availability, technology requirements and constraints, associated capital and recurrent costs, and system’s technology management capacity into one single tool, linking these to the resources needed to deliver a defined set of health interventions. The iHTP methodology was developed on the premise that: ●
●
Effective and efficient healthcare delivery is dependent on the availability of the right mix of healthcare technologies required for delivery of specific health interventions. These healthcare technologies are carefully chosen with consideration of recurrent implications of a capital investment, and system’s capacity for their adequate utilization.
Within iHTP, resources are linked with clinical interventions; replete with detailed technology unit costs and time utilization so that informed decisions can be made on their optimal acquisition, deployment, and utilization. iHTP is intervention based; scenarios form processes and pathways of linked clinical interventions. These scenarios are representative of treating diseases and reflect evidence-based clinical practice guidelines (CPGs). Resource requirements are then simulated for each clinical scenario using patient demographic and coverage data entered into the simulation tool. It also allows for a comprehensive technology GAPS analysis between the current and intended practice, that is, for scaling up priority interventions.
Why iHTP (Peter, 2007) ●
In mid-1990s, WHO’s Strengthening of Health Services Division and South African Medical Council by developing EHTP (later iHTP) have responded to the identified urgent need for optimizing resource planning for Clinical Engineering Handbook. https://doi.org/10.1016/B978-0-12-813467-2.00038-9 Copyright © 2020 Elsevier Inc. All rights reserved.
Integrated health technology package Chapter | 38 237
●
●
●
●
●
health interventions in a holistic and integrated way ensuring a right balance of different categories of resource inputs replete with their costing, and system’s capacity to manage purchased inputs throughout their life cycle in terms of recurrent implications of capital investments and required skills. The iHTP concept and approach have been strongly reinforced by the 2000 World Health Report “Health Systems: Improving Performance” that explicitly included human and physical (facilities, equipment, and pharmaceuticals) resource generation as one of four key health system’s functions emphasizing that the way investment decisions related to generation and purchase of resource inputs are made, how those inputs are planned and managed are critical for the performance of a health system and quality of health services provided. iHTP provided an important input toward addressing health Millennium Development Goals, that is, #4, #5, and #6 (reduce child mortality, improve maternal health, and combat HIV/AIDS, malaria, and other diseases) by assisting country decision-making on defining evidence-based investment strategies and service mix. iHTP offers an integrated health resource planning and management modeling of all combinations among health systems resource inputs that are seamlessly related to clinical procedures and cost data has invaluable potential for contributing to the achievement of the Universal Health Coverage and other targets of the health Sustainable Development Goal #3. Problem Scope ○ Serious imbalances exist in many countries in terms of human and physical resources, equipment, and pharmaceuticals, as well as imbalances between investment and recurrent expenditures, and the different categories of inputs frequently create barriers to satisfactorily perform health systems. ○ In early 1990s, WHO estimated that in most developing countries half of the inventory, in some cases as much as 75%–80%, lay idle at any given time. ○ Underutilized assets (at 15%) represented approximately 22% of total healthcare spending in the WHO African Region. Summary ○ Health needs and priorities are normally known, but rarely linked to resource planning. ○ Program and implementation strategies have often been developed without looking at long-term resource planning implications. ○ Resource are planned and implemented vertically. ○ Planning, implementation, training, monitoring, and evaluation often done in isolation. ○ The strategic and operational divide is evident.
Healthcare technology (HT) is a major strategic factor in determining a community perception of the health system.
○
How is iHTP used (WHO, n.d.) Health services aim to protect or improve health. However, they so effectively depend on whether which services are provided and how they are delivered and organized. Resources should be used for interventions that are known to be effective, in accordance with national or local priorities. Because resources are limited, there will always be some form of rationing but prices should not be the chief way to determine who gets what care (World Health Report, 2000, WHO). iHTP improves health service delivery because its simulation tool systematically demonstrates—with thorough input data anchored in national priorities—to decision-makers which services are necessary and cost-effective given available resources. Furthermore, it does so without using price as the sole aspect of planning—instead, the simulation tool integrates information on patient demographics and disease profiles to successfully embed local needs and priorities to a resource and costing analysis. Providing health care efficiently requires financial resources to be properly balanced among many inputs used to deliver health services (World Health Report, 2000, WHO). iHTP basically performs this balancing act once all of the essential input data are in. For example, large numbers of staff do not improve health service delivery without adequately built, equipped, and supplied facilities. Available resources should thus be allocated both to investments in new skills, facilities and equipment, and to maintain the existing infrastructure (World Health Report, 2000, WHO). iHTP synthesizes these needs and renders decision-makers with output information that allows discernment on which investment is effective at what time, at what cost, and with which technologies. In order to reduce the risk of future imbalances, new investment choices must be made carefully and the existing mix of inputs needs to be monitored on a regular basis (World Health Report, 2000, WHO). iHTP shows resource planners several possibilities on where to focus their new investments in addition to possible outcomes; this gives them the necessary information to make an appropriate decision. The iHTP implementation program also envisions regular monitoring and evaluation sessions after new investment decisions have been made; this allows for revision of these choices if necessary, with new simulation models and new input data. Health service delivery is greatly improved by iHTP’s inevitable horizontal integration through coordination of services. If, for example, iHTP is being used for the
238 SECTION | 3 Healthcare technology management
aternity ward and a neonatal care unit in the same rem gion, services for measuring the baby’s weight need not be taught twice. IHTP identifies similarities of different programs and provides a coordinating capacity, thus reducing costs. The iHTP projects in the past have also demonstrated a consolidation capacity by agreeing on standard practice with each of the various groups involved—whether it is between two hospital departments or between nongovernmental organization (NGOs) or United Nations (UN) agencies. The rapidly changing and increasingly complex health services industry poses significant challenges for health services management, responsible for planning, directing, coordinating, and supervising the delivery of health care. Improving service delivery and ensuring better access, complicated by technological advance and changes in demography and epidemiology, must involve all the major stakeholders in the health system—the policymakers in MOH and public administration, health service managers and workers, public and private providers, and clients and communities themselves). IHTP amalgamates the issues of technology, demography, and epidemiology into one system for simple comprehension by all various stakeholder to enable them to make more informed decisions and ameliorate health services.
At what level is iHTP used (WHO, n.d.) From the administrative and clinical point of view, there are several levels of healthcare delivery: a national or tertiary level, a provincial level, a district level, and finally, a primary care level. The various levels have different functions within a country’s healthcare system. Primary care is seen as an “integral, permanent, and pervasive part of the formal healthcare system in all countries” or as the “means by which the two goals of health services system—optimization of health and equity in distributing resources—are balanced” (Basch, 1990). It addresses the most common problems in the community by providing preventive, curative, and rehabilitative services to maximize health and well-being. Tertiary care refers to highly specialized care given to patients who are in danger of disability or death often requiring sophisticated technologies (e.g., neurosurgeons or intensive care units). The intermediary levels such as provincial or district usually are within the sphere of influence of the local government. They provide health care which links local priorities with national health policies. iHTP is developed for all different levels of health care. It ensures that the scope and complexity of healthcare technologies is realistic for any given level of healthcare delivery. The iHTP consists of a comprehensive map of all
HT needs per intervention per healthcare level (Heimann and Kader, 2002). iHTP contributes to a clearer understanding of why the resources are needed at each level of healthcare delivery, in what quantities the resources are needed and how they fit together into an integrated healthcare system. iHTP inherently bridges the gap between the planners at the strategic levels (national or regional), who may not have full knowledge of field realities, and practitioners at the operational level, who may be too immersed in their day-to-day clinical activities to be aware of the big picture. iHTP allows technology needs appropriate for each level of health care to be identified (Heimann, 2001); it thus facilitates the upward flow of information to be amassed into national requirements.
User network (WHO, n.d.) WHO has created several generic scenarios for their iHTP project. These scenarios belong to the responsible WHO department; they can be obtained through them in the context of an iHTP implementation project under their auspices. Other generic scenarios are the sole property of the institution that created them, such as MoHs. Currently, generic scenarios on all major obstetric, neonatal, pediatric, and noncommunicable diseases have been created by WHO. Chronic disease scenarios are presently in review. The WHO department ‘Making Pregnancy Safer’ has been actively involved in creating scenarios on maternal and child health in recent years. These scenarios are anchored in WHO clinical guidelines also developed by the department. National-level generic scenarios are currently being developed in Democratic Republic of Congo, Kyrgyzstan, Malawi, Mexico, South Africa, and Ukraine.
Software tool description (WHO, n.d.) The iHTP Simulation tool is software program that allows the user to integrate linked interventions to CPGs, health and patient profiles, and health packages by creating scenarios. The simulation tool has four main components. The first incorporates the economic analysis of HT. Basic economic information such as medical equipment fixed and recurrent costs, human resource costs, drug costs, and facility costs are stored in the generic iHTP template database and are accessed by the Simulation Package. Here, the stored costs are applied to the simulation tools and costing analysis becomes available.
Integrated health technology package Chapter | 38 239
iHTP simulation tool Clinical guidelines Sharing of resources
HCT constraints Patient profiles
iHTP databases Country database
Simulations Simulations and planning
Reference database
Inputs (Peter, 2007)
Clinical guidelines
Medical equipment
●
●
● ● ●
Comprehensive medical equipment database (UMDNS based); Technology, maintenance, and costing data; Usability and technical criticality indicators; Separated scenario and reference database for improved country implementation.
Pharmaceuticals ● ● ● ●
Comprehensive pharmaceutical database Based on WHO pharmaceutical database Scheduling and drug interaction capability Country specific costs can be linked to any pharmaceutical
Outputs (Peter, 2007)
●
●
Epidemiological profiles ● ● ●
●
●
Reports—static → ●
Static HT reports (for pharmaceuticals, medical equipment, Human resources, and facilities);
iHTP reference database contains 4500 prelinked procedurals 250 clinical guidelines (iHTP terminology: scenarios) completed Scenarios can be adapted to any country situation.
●
Population indicators Coverage rate and hospital admissions Target indicators (e.g., C-section rates) can be modeled over specific years Allows scaling up
Can be used for static equipment lists, that is, pedicure equipment procurement; technology scope evaluation Does not indicate quantity
240 SECTION | 3 Healthcare technology management
Reports—dynamic ↓ ●
●
● ●
Dynamic HT reports include quantities—calculation based on workload and schedule Provides operational costs; dynamic quantities; recurrent; and opportunity cost Takes into consideration HT availability; Reports provide ‘drill down technology’; ideal in evaluating cost drivers.
Examples ↑ → Country implementation ● ●
● ●
Mapping of Mother and Child health package Approximately 30 guidelines based on observations and recommended clinical practice Primary and secondary levels of care Resource requirements, including operational and recurrent costs.
Ukraine overview ● ● ● ●
Identification of cost drivers Minimum quantities of resources Critical path identification Optimization through evidence
Total required
Unit cost (min)
Unit cost (max)
Oper cost
Replace cost
Furniture general
Group
Type
Simulated qty
Bench {Not Specified}
Furniture General
Reusable
0.7
1.0
300.00
394.00
260.71
394.00
Desk {Not Specified}
Furniture General
Reusable
2.8
3.0
300.00
320.00
895.37
960.00
Racks, Test Tube {Not Specified}
Furniture General
Reusable
0.9
1.0
30.00
35.00
30.66
35.00
Cabinets, Laboratory {Not Specified}
Furniture Medical
Reusable
0.3
1.0
140.00
160.00
47.05
160.00
Chairs, Office
Furniture Medical
Reusable
4.9
5.0
70.00
90.00
443.97
450.00
Footstools, Two/Three-Step {Not Specified}
Furniture Medical
Reusable
0.1
1.0
80.00
120.00
10.79
120.00
Tables, Examination/ Treatment, Adjustable, Obstetrical
Furniture Medical
Reusable
0.1
1.0
5400.00
12,000.00
1089.86
12,000.00
Tables, Instrument {Not Specified}
Furniture Medical
Reusable
0.1
1.0
500.00
600.00
55.59
600.00
9.8
14.0
2834.02
14,719.00
8
Case studies (Judd, 2009) Several hundred evidence-based (EBM) national and global CPGs have been mapped in iHTP in 10 years (2000– 2009), allowing simulation and analysis of the health services’ resource requirements of various countries. Clinical
interventions addressed in a dozen pilot countries thus far include WHO programs for maternal and child health and adult chronic diseases, and various surgeries and priority communicable diseases. Examples of CPGs mapped in iHTP for WHO’s Integrated Management of Childhood Illnesses (IMCI) program at primary and secondary levels
Integrated health technology package Chapter | 38 241
of care include: pneumonia, cold, bronchiolitis, croup, diphtheria, pertussis, tuberculosis, diarrhea, dehydration, dysentery, malnutrition, typhoid fever, meningitis, measles, malaria, dengue fever, otitis media, urinary tract infections, heart failure, hypothermia, HIV/AIDS in children, pneumo-cystosis (related to HIV/AIDS), burns, fractures, and head injuries. This approach also reflects a balance between primary prevention interventions (e.g., as demonstrated for hypertension and diabetes) and investing in ongoing EBM treatment. Here are two examples from my colleagues and my own experience with WHO’s iHTP in these countries: Example Clinical Practice Guidelines Used in iHTP
Kyrgyzstan (Central Asia) The initial MOH focus was optimal resource management and care for: hypertension in adults, anemia in pregnancy, tuberculosis, acute respiratory illnesses in children, and brucellosis. Later, over 120 CPGs were developed by clinical experts and approved by the MOH at three levels of care. They were then mapped in iHTP, validated, and implemented leading to increased CPG compliance by practitioners. The following improvements were noted.
Resource planning and management Typical “siloed” planning was integrated and databases standardized for the following, resulting in: ● ●
●
●
●
●
●
●
Human resources More family practice staff were identified and trained Standards set and physician/nurse responsibilities clarified Pharmaceuticals Value-added tax (VAT) fees for externally purchased drugs were removed MOH rules were developed allowing medical drugs sold at sites where local pharmacies are not available Handling of donated drugs was improved Facilities Coordination with local governments was improved assuring funding for primary and secondary facility renovations Medical equipment National MOH policy was implemented for rational use of medical devices National MOH policy was implemented for purchase of high technology, high cost devices
EBM “ideal” CPGs comparison with current country-level “actual” CPGs using iHTP
●
●
Ideal six CPGs: provided by the Finnish Lung Health Program for adults Actual six CPGs: acute bronchitis, bronchial asthma, TB, COPD, pneumonia, and acute respiratory viral infection were also mapped in iHTP for comparison
iHTP gaps analysis For five sites in urban and rural areas, at both primary and secondary levels of care ● ●
●
●
●
Cost analysis compared for ideal versus actual CPGs Pre-post clinician training showed cost-effectiveness of EBM Clinicians began to reduce unnecessary tests, staff, and drugs Facilities began to ensure access to vital medical devices for testing results MOH began to use ideal CPG costs for adult lung health for national reimbursement through the Kyrgyzstan Mandatory Health Insurance Fund.
Mexico iHTP was formally introduced to MOH Mexico in 2005. The MOH department responsible for health technology planning and management activities (CENETEC, Mexico, DF, Mexico; www.cenetec.salud.gob.mx), agreed to direct these efforts. CENETEC formed a small team with a project manager and physician partner to pilot use of iHTP for perinatal care. CPGs (four prenatal visits) were evaluated in two Mexico City clinics as part of the Popular Insurance Catalog—90 different procedures—provided by MOH free of charge to Mexico’s significant percentage of poor people. This initial work demonstrated iHTP’s value in rapid prototyping and cost modeling based on using process maps of clinical procedures and resource databases. In early 2007, the MOH, on behalf of President Calderon, began a national health initiative: Caravan, a traveling primary care outreach clinic allowing timely referrals to hospital care, was sent to several of Mexico’s remote rural areas. Fifty Caravans were sent throughout all states of Mexico that year, and over 400 in 2008. CENETEC using iHTP assisted the MOH planning department in the Caravan implementation, studying optimal ways to deliver care. The Caravan project team included a project leader (engineer) and two physicians, assisted by the WHO consultant. The team worked with various national physician leaders, assisting with the development of 20 evidence-based CPGs including diabetes screening, breast cancer screening, as well as normal care and typical complications in perinatal care (prenatal care, preeclampsia, eclampsia, hemorrhage, and newborn care).
242 SECTION | 3 Healthcare technology management
Conclusions iHTP was proven to be a comprehensive and effective health resource planning tool in trials in several developing countries. This approach can be used in future tools to assist MOH in optimal planning and management of limited health resources.
Heimann, P., 2001. Planning Technologies for the Making Pregnancy Safer Initiative. WHO internal presentation. Heimann, P., Kader, H., 2002. iHTP: Brief Technical Discussion. WHO. Judd, T.M., 2009. The WHO’s evidence-based approach to chronic diseases: primary prevention or caring for end-stage disease? Perm. J. 13, 65–68. Peter, H., 2007. WHO’s iHTP Introduction. on iHTP website.
References
Further reading
Basch, P., 1990. Textbook of international health. Oxford University Press, New York.
CPG Flowchart, downloable at http://iHTP.info/ WHO iHTP website—http://iHTP.info/
Integrated health technology package Thomas M. Judda, Peter Heimannb, Andrei Issakovc a
Clinical Engineering Division, IFMBE, Marietta, GA, United States, bHealthcare, Luxembourg Development, Vientiane, Laos, cProcess Management System, Sarl, Geneva, Switzerland
Background The World Health Organization (WHO) health resource and planning tool, formerly known as essential health technology package (EHTP), was described in-depth in the 2004 CE Handbook. Shortly after the earlier handbook was published, WHO renamed the tool as the integrated Health Technology Package (iHTP) to better reflect its scope and purpose, as well as implementation and use in countries by way of their Ministries of Health (MOH), development assistance agencies, and international organizations. References were gleaned from work done in the 1980s, 1990s, and in 2000, led by Peter Heimann (the inventor of iHTP) and Andrei Issakov (the WHO sponsor of iHTP). Thomas M. Judd was among the CE-HTM professionals trained to implement iHTP in 2000 and began several years of work with MOHs in Kyrgyzstan (Central Asia), Namibia (southern Africa), and then Mexico, in partnership with the other two authors. Overall, iHTP had been implemented in some 20 different countries, and used by several WHO programs as a resource planning and management instrument as well as many more countries and projects have shown interest in using this methodology. The iHTP tool however fell into disuse in 2010 after leadership changes at WHO. Nevertheless, iHTP concept remains continuously valid, and the need for a comprehensive and evidence-based resource planning and costing of health interventions only increases over time, particularly within the context of the universal health coverage and sustainable development goals.
What is iHTP (WHO, n.d.; Peter, 2007) iHTP is essentially a resource planning methodology and software-based tool that provides guidance on an adequate mix of resource inputs, comprising human resources, medical devices, pharmaceuticals, and facilities, needed to deliver a defined set of health interventions. 236
It integrates healthcare needs, disease profiles, patient demographics, clinical practice, medical device availability, technology requirements and constraints, associated capital and recurrent costs, and system’s technology management capacity into one single tool, linking these to the resources needed to deliver a defined set of health interventions. The iHTP methodology was developed on the premise that: ●
●
Effective and efficient healthcare delivery is dependent on the availability of the right mix of healthcare technologies required for delivery of specific health interventions. These healthcare technologies are carefully chosen with consideration of recurrent implications of a capital investment, and system’s capacity for their adequate utilization.
Within iHTP, resources are linked with clinical interventions; replete with detailed technology unit costs and time utilization so that informed decisions can be made on their optimal acquisition, deployment, and utilization. iHTP is intervention based; scenarios form processes and pathways of linked clinical interventions. These scenarios are representative of treating diseases and reflect evidence-based clinical practice guidelines (CPGs). Resource requirements are then simulated for each clinical scenario using patient demographic and coverage data entered into the simulation tool. It also allows for a comprehensive technology GAPS analysis between the current and intended practice, that is, for scaling up priority interventions.
Why iHTP (Peter, 2007) ●
In mid-1990s, WHO’s Strengthening of Health Services Division and South African Medical Council by developing EHTP (later iHTP) have responded to the identified urgent need for optimizing resource planning for Clinical Engineering Handbook. https://doi.org/10.1016/B978-0-12-813467-2.00038-9 Copyright © 2020 Elsevier Inc. All rights reserved.
Integrated health technology package Chapter | 38 237
●
●
●
●
●
health interventions in a holistic and integrated way ensuring a right balance of different categories of resource inputs replete with their costing, and system’s capacity to manage purchased inputs throughout their life cycle in terms of recurrent implications of capital investments and required skills. The iHTP concept and approach have been strongly reinforced by the 2000 World Health Report “Health Systems: Improving Performance” that explicitly included human and physical (facilities, equipment, and pharmaceuticals) resource generation as one of four key health system’s functions emphasizing that the way investment decisions related to generation and purchase of resource inputs are made, how those inputs are planned and managed are critical for the performance of a health system and quality of health services provided. iHTP provided an important input toward addressing health Millennium Development Goals, that is, #4, #5, and #6 (reduce child mortality, improve maternal health, and combat HIV/AIDS, malaria, and other diseases) by assisting country decision-making on defining evidence-based investment strategies and service mix. iHTP offers an integrated health resource planning and management modeling of all combinations among health systems resource inputs that are seamlessly related to clinical procedures and cost data has invaluable potential for contributing to the achievement of the Universal Health Coverage and other targets of the health Sustainable Development Goal #3. Problem Scope ○ Serious imbalances exist in many countries in terms of human and physical resources, equipment, and pharmaceuticals, as well as imbalances between investment and recurrent expenditures, and the different categories of inputs frequently create barriers to satisfactorily perform health systems. ○ In early 1990s, WHO estimated that in most developing countries half of the inventory, in some cases as much as 75%–80%, lay idle at any given time. ○ Underutilized assets (at 15%) represented approximately 22% of total healthcare spending in the WHO African Region. Summary ○ Health needs and priorities are normally known, but rarely linked to resource planning. ○ Program and implementation strategies have often been developed without looking at long-term resource planning implications. ○ Resource are planned and implemented vertically. ○ Planning, implementation, training, monitoring, and evaluation often done in isolation. ○ The strategic and operational divide is evident.
Healthcare technology (HT) is a major strategic factor in determining a community perception of the health system.
○
How is iHTP used (WHO, n.d.) Health services aim to protect or improve health. However, they so effectively depend on whether which services are provided and how they are delivered and organized. Resources should be used for interventions that are known to be effective, in accordance with national or local priorities. Because resources are limited, there will always be some form of rationing but prices should not be the chief way to determine who gets what care (World Health Report, 2000, WHO). iHTP improves health service delivery because its simulation tool systematically demonstrates—with thorough input data anchored in national priorities—to decision-makers which services are necessary and cost-effective given available resources. Furthermore, it does so without using price as the sole aspect of planning—instead, the simulation tool integrates information on patient demographics and disease profiles to successfully embed local needs and priorities to a resource and costing analysis. Providing health care efficiently requires financial resources to be properly balanced among many inputs used to deliver health services (World Health Report, 2000, WHO). iHTP basically performs this balancing act once all of the essential input data are in. For example, large numbers of staff do not improve health service delivery without adequately built, equipped, and supplied facilities. Available resources should thus be allocated both to investments in new skills, facilities and equipment, and to maintain the existing infrastructure (World Health Report, 2000, WHO). iHTP synthesizes these needs and renders decision-makers with output information that allows discernment on which investment is effective at what time, at what cost, and with which technologies. In order to reduce the risk of future imbalances, new investment choices must be made carefully and the existing mix of inputs needs to be monitored on a regular basis (World Health Report, 2000, WHO). iHTP shows resource planners several possibilities on where to focus their new investments in addition to possible outcomes; this gives them the necessary information to make an appropriate decision. The iHTP implementation program also envisions regular monitoring and evaluation sessions after new investment decisions have been made; this allows for revision of these choices if necessary, with new simulation models and new input data. Health service delivery is greatly improved by iHTP’s inevitable horizontal integration through coordination of services. If, for example, iHTP is being used for the
238 SECTION | 3 Healthcare technology management
aternity ward and a neonatal care unit in the same rem gion, services for measuring the baby’s weight need not be taught twice. IHTP identifies similarities of different programs and provides a coordinating capacity, thus reducing costs. The iHTP projects in the past have also demonstrated a consolidation capacity by agreeing on standard practice with each of the various groups involved—whether it is between two hospital departments or between nongovernmental organization (NGOs) or United Nations (UN) agencies. The rapidly changing and increasingly complex health services industry poses significant challenges for health services management, responsible for planning, directing, coordinating, and supervising the delivery of health care. Improving service delivery and ensuring better access, complicated by technological advance and changes in demography and epidemiology, must involve all the major stakeholders in the health system—the policymakers in MOH and public administration, health service managers and workers, public and private providers, and clients and communities themselves). IHTP amalgamates the issues of technology, demography, and epidemiology into one system for simple comprehension by all various stakeholder to enable them to make more informed decisions and ameliorate health services.
At what level is iHTP used (WHO, n.d.) From the administrative and clinical point of view, there are several levels of healthcare delivery: a national or tertiary level, a provincial level, a district level, and finally, a primary care level. The various levels have different functions within a country’s healthcare system. Primary care is seen as an “integral, permanent, and pervasive part of the formal healthcare system in all countries” or as the “means by which the two goals of health services system—optimization of health and equity in distributing resources—are balanced” (Basch, 1990). It addresses the most common problems in the community by providing preventive, curative, and rehabilitative services to maximize health and well-being. Tertiary care refers to highly specialized care given to patients who are in danger of disability or death often requiring sophisticated technologies (e.g., neurosurgeons or intensive care units). The intermediary levels such as provincial or district usually are within the sphere of influence of the local government. They provide health care which links local priorities with national health policies. iHTP is developed for all different levels of health care. It ensures that the scope and complexity of healthcare technologies is realistic for any given level of healthcare delivery. The iHTP consists of a comprehensive map of all
HT needs per intervention per healthcare level (Heimann and Kader, 2002). iHTP contributes to a clearer understanding of why the resources are needed at each level of healthcare delivery, in what quantities the resources are needed and how they fit together into an integrated healthcare system. iHTP inherently bridges the gap between the planners at the strategic levels (national or regional), who may not have full knowledge of field realities, and practitioners at the operational level, who may be too immersed in their day-to-day clinical activities to be aware of the big picture. iHTP allows technology needs appropriate for each level of health care to be identified (Heimann, 2001); it thus facilitates the upward flow of information to be amassed into national requirements.
User network (WHO, n.d.) WHO has created several generic scenarios for their iHTP project. These scenarios belong to the responsible WHO department; they can be obtained through them in the context of an iHTP implementation project under their auspices. Other generic scenarios are the sole property of the institution that created them, such as MoHs. Currently, generic scenarios on all major obstetric, neonatal, pediatric, and noncommunicable diseases have been created by WHO. Chronic disease scenarios are presently in review. The WHO department ‘Making Pregnancy Safer’ has been actively involved in creating scenarios on maternal and child health in recent years. These scenarios are anchored in WHO clinical guidelines also developed by the department. National-level generic scenarios are currently being developed in Democratic Republic of Congo, Kyrgyzstan, Malawi, Mexico, South Africa, and Ukraine.
Software tool description (WHO, n.d.) The iHTP Simulation tool is software program that allows the user to integrate linked interventions to CPGs, health and patient profiles, and health packages by creating scenarios. The simulation tool has four main components. The first incorporates the economic analysis of HT. Basic economic information such as medical equipment fixed and recurrent costs, human resource costs, drug costs, and facility costs are stored in the generic iHTP template database and are accessed by the Simulation Package. Here, the stored costs are applied to the simulation tools and costing analysis becomes available.
Integrated health technology package Chapter | 38 239
iHTP simulation tool Clinical guidelines Sharing of resources
HCT constraints Patient profiles
iHTP databases Country database
Simulations Simulations and planning
Reference database
Inputs (Peter, 2007)
Clinical guidelines
Medical equipment
●
●
● ● ●
Comprehensive medical equipment database (UMDNS based); Technology, maintenance, and costing data; Usability and technical criticality indicators; Separated scenario and reference database for improved country implementation.
Pharmaceuticals ● ● ● ●
Comprehensive pharmaceutical database Based on WHO pharmaceutical database Scheduling and drug interaction capability Country specific costs can be linked to any pharmaceutical
Outputs (Peter, 2007)
●
●
Epidemiological profiles ● ● ●
●
●
Reports—static → ●
Static HT reports (for pharmaceuticals, medical equipment, Human resources, and facilities);
iHTP reference database contains 4500 prelinked procedurals 250 clinical guidelines (iHTP terminology: scenarios) completed Scenarios can be adapted to any country situation.
●
Population indicators Coverage rate and hospital admissions Target indicators (e.g., C-section rates) can be modeled over specific years Allows scaling up
Can be used for static equipment lists, that is, pedicure equipment procurement; technology scope evaluation Does not indicate quantity
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Reports—dynamic ↓ ●
●
● ●
Dynamic HT reports include quantities—calculation based on workload and schedule Provides operational costs; dynamic quantities; recurrent; and opportunity cost Takes into consideration HT availability; Reports provide ‘drill down technology’; ideal in evaluating cost drivers.
Examples ↑ → Country implementation ● ●
● ●
Mapping of Mother and Child health package Approximately 30 guidelines based on observations and recommended clinical practice Primary and secondary levels of care Resource requirements, including operational and recurrent costs.
Ukraine overview ● ● ● ●
Identification of cost drivers Minimum quantities of resources Critical path identification Optimization through evidence
Total required
Unit cost (min)
Unit cost (max)
Oper cost
Replace cost
Furniture general
Group
Type
Simulated qty
Bench {Not Specified}
Furniture General
Reusable
0.7
1.0
300.00
394.00
260.71
394.00
Desk {Not Specified}
Furniture General
Reusable
2.8
3.0
300.00
320.00
895.37
960.00
Racks, Test Tube {Not Specified}
Furniture General
Reusable
0.9
1.0
30.00
35.00
30.66
35.00
Cabinets, Laboratory {Not Specified}
Furniture Medical
Reusable
0.3
1.0
140.00
160.00
47.05
160.00
Chairs, Office
Furniture Medical
Reusable
4.9
5.0
70.00
90.00
443.97
450.00
Footstools, Two/Three-Step {Not Specified}
Furniture Medical
Reusable
0.1
1.0
80.00
120.00
10.79
120.00
Tables, Examination/ Treatment, Adjustable, Obstetrical
Furniture Medical
Reusable
0.1
1.0
5400.00
12,000.00
1089.86
12,000.00
Tables, Instrument {Not Specified}
Furniture Medical
Reusable
0.1
1.0
500.00
600.00
55.59
600.00
9.8
14.0
2834.02
14,719.00
8
Case studies (Judd, 2009) Several hundred evidence-based (EBM) national and global CPGs have been mapped in iHTP in 10 years (2000– 2009), allowing simulation and analysis of the health services’ resource requirements of various countries. Clinical
interventions addressed in a dozen pilot countries thus far include WHO programs for maternal and child health and adult chronic diseases, and various surgeries and priority communicable diseases. Examples of CPGs mapped in iHTP for WHO’s Integrated Management of Childhood Illnesses (IMCI) program at primary and secondary levels
Integrated health technology package Chapter | 38 241
of care include: pneumonia, cold, bronchiolitis, croup, diphtheria, pertussis, tuberculosis, diarrhea, dehydration, dysentery, malnutrition, typhoid fever, meningitis, measles, malaria, dengue fever, otitis media, urinary tract infections, heart failure, hypothermia, HIV/AIDS in children, pneumo-cystosis (related to HIV/AIDS), burns, fractures, and head injuries. This approach also reflects a balance between primary prevention interventions (e.g., as demonstrated for hypertension and diabetes) and investing in ongoing EBM treatment. Here are two examples from my colleagues and my own experience with WHO’s iHTP in these countries: Example Clinical Practice Guidelines Used in iHTP
Kyrgyzstan (Central Asia) The initial MOH focus was optimal resource management and care for: hypertension in adults, anemia in pregnancy, tuberculosis, acute respiratory illnesses in children, and brucellosis. Later, over 120 CPGs were developed by clinical experts and approved by the MOH at three levels of care. They were then mapped in iHTP, validated, and implemented leading to increased CPG compliance by practitioners. The following improvements were noted.
Resource planning and management Typical “siloed” planning was integrated and databases standardized for the following, resulting in: ● ●
●
●
●
●
●
●
Human resources More family practice staff were identified and trained Standards set and physician/nurse responsibilities clarified Pharmaceuticals Value-added tax (VAT) fees for externally purchased drugs were removed MOH rules were developed allowing medical drugs sold at sites where local pharmacies are not available Handling of donated drugs was improved Facilities Coordination with local governments was improved assuring funding for primary and secondary facility renovations Medical equipment National MOH policy was implemented for rational use of medical devices National MOH policy was implemented for purchase of high technology, high cost devices
EBM “ideal” CPGs comparison with current country-level “actual” CPGs using iHTP
●
●
Ideal six CPGs: provided by the Finnish Lung Health Program for adults Actual six CPGs: acute bronchitis, bronchial asthma, TB, COPD, pneumonia, and acute respiratory viral infection were also mapped in iHTP for comparison
iHTP gaps analysis For five sites in urban and rural areas, at both primary and secondary levels of care ● ●
●
●
●
Cost analysis compared for ideal versus actual CPGs Pre-post clinician training showed cost-effectiveness of EBM Clinicians began to reduce unnecessary tests, staff, and drugs Facilities began to ensure access to vital medical devices for testing results MOH began to use ideal CPG costs for adult lung health for national reimbursement through the Kyrgyzstan Mandatory Health Insurance Fund.
Mexico iHTP was formally introduced to MOH Mexico in 2005. The MOH department responsible for health technology planning and management activities (CENETEC, Mexico, DF, Mexico; www.cenetec.salud.gob.mx), agreed to direct these efforts. CENETEC formed a small team with a project manager and physician partner to pilot use of iHTP for perinatal care. CPGs (four prenatal visits) were evaluated in two Mexico City clinics as part of the Popular Insurance Catalog—90 different procedures—provided by MOH free of charge to Mexico’s significant percentage of poor people. This initial work demonstrated iHTP’s value in rapid prototyping and cost modeling based on using process maps of clinical procedures and resource databases. In early 2007, the MOH, on behalf of President Calderon, began a national health initiative: Caravan, a traveling primary care outreach clinic allowing timely referrals to hospital care, was sent to several of Mexico’s remote rural areas. Fifty Caravans were sent throughout all states of Mexico that year, and over 400 in 2008. CENETEC using iHTP assisted the MOH planning department in the Caravan implementation, studying optimal ways to deliver care. The Caravan project team included a project leader (engineer) and two physicians, assisted by the WHO consultant. The team worked with various national physician leaders, assisting with the development of 20 evidence-based CPGs including diabetes screening, breast cancer screening, as well as normal care and typical complications in perinatal care (prenatal care, preeclampsia, eclampsia, hemorrhage, and newborn care).
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Conclusions iHTP was proven to be a comprehensive and effective health resource planning tool in trials in several developing countries. This approach can be used in future tools to assist MOH in optimal planning and management of limited health resources.
Heimann, P., 2001. Planning Technologies for the Making Pregnancy Safer Initiative. WHO internal presentation. Heimann, P., Kader, H., 2002. iHTP: Brief Technical Discussion. WHO. Judd, T.M., 2009. The WHO’s evidence-based approach to chronic diseases: primary prevention or caring for end-stage disease? Perm. J. 13, 65–68. Peter, H., 2007. WHO’s iHTP Introduction. on iHTP website.
References
Further reading
Basch, P., 1990. Textbook of international health. Oxford University Press, New York.
CPG Flowchart, downloable at http://iHTP.info/ WHO iHTP website—http://iHTP.info/