Characteristics of Respondents
We recruited 31 respondents but only 25(81%) completed the questionnaire. Participants were from the Federal Ministry of Health, Ministries, Departments and Agencies (MDA, parastatals), Professional Associations, teaching hospitals, health regulatory bodies, research institutions, the academic community, development partners, Non-government organisations, and the regional West Africa Health Organisation (Table 1). The survey took about 40 minutes but some participants required longer, depending on the level of detail provided in their short answers.
- Stakeholder capacity assets of HTA
Most respondents were associated with organisations that generated or facilitated health services research. Research institutes highlighted their ability to provide expertise and skills for HTA research but some respondents noted a lack of awareness of HTA and human capacity for HTA. Political support was regarded as essential but could be impeded by politicised decision-making, internal politics in the leadership of the HTA process, cultural barriers in data and information sharing, and a lack of funding for HTA activities.
Generators of evidence
Participants identified organisations that generate or supply evidence to support health policy decisions in Nigeria at the international, regional and national levels. International multi-lateral organisations include the World Health Organization and West African Health Organisation (WAHO). Non-governmental organisations (NGOs) were identified as generators of evidence. The national organisations included the Federal and State Ministries of Health, as well as the Federal Ministries of Education, Finance, and Water Resources. Health professional organisations were considered generators of evidence and included the Society of Gynaecology and Obstetrics of Nigeria, Association of Public Health Physicians of Nigeria, and the Medical and Dental Council of Nigeria. The academic sector and National Bureau of Statistics were also noted as suppliers of evidence together with hospitals and health facilities, and health training institutions.
Users of evidence
The key users of HTA information were the ministries of health, other government departments, public health insurance bodies, providers and health professionals, universities and research institutes, donor organisations, and pharmaceutical companies.
The strengths and weaknesses of the organisations to generate and use HTA evidence
The strengths of the organizations to generate and use HTA evidence included capacity building for health providers, highly trained personnel and human resources, determined organisation and staff, a good understanding HTA needs, a readiness to utilize evidence for policy making, experienced researchers, strong partnerships, availability of policies and guidelines, use of technology for research, and availability of service delivery data. The weaknesses encompassed inadequate number of health care workers; unmotivated health care workers; lack of funds; weak infrastructure and HTA capacity; low uptake of HTA; weak political will for HTA and lack of software to analyse research data
Training and research needs
Five main areas of training needs for HTA generators and users were identified: 1) research methods in HTA and data gathering (and economic evaluations); 2) identifying and implementing evidence and using it to inform policy; 3) conducting economic evaluations; 4) developing capacity and building awareness and 5) Data management. Some respondents noted that both HTA generators and health policy-makers and practitioners need training in HTA to facilitate the reliable and efficient interpretation and use of research results, translation into policy, and advocacy and communications.
There is a need for research in: 1) health system financing (financing schemes, medicine pricing, and the design of sustainable essential benefits packages); 2) health service provision taking into account equity, efficiency, quality; 3) burden of disease (antibiotic medicine resistance, non-communicable disease, childhood immunisation); and 4) health policy research.
Public and wider civil society—their role in priority setting and decision making
Four themes emerged when respondents were asked to consider the role of the public and wider civil society in priority setting and decision making: 1) the extent of public involvement in consultation processes; 2) the role of advocacy; 3) demand for accountability on health and 4) the absence of any public role in priority-setting decisions. Many respondents stressed the importance of consulting the public, but noted that in practice there was no involvement especially of the civil society organizations in priority setting. Some respondents noted that these groups could adopt an advocacy role by holding decision and policy makers accountable for their roles, and creating pressure through media campaigns to highlight health systems problems.
- Policy areas for which HTA is needed
The main policy areas for which HTA was considered as urgently needed were the production of clinical guidelines or disease management pathways (ranked 4.6/6, Table 2), informing the design of the basic health benefits package (HBP, 4.4), 'informing design of health service delivery (4.1), registration of health technologies (3.9), coverage or reimbursement of individual health technologies (3.7), and provider payment reform or pay for performance schemes (3.4).
Key considerations in ranking clinical guidelines highest was the need for uniformity and standardising protocols, management of disease, and saving costs. This was noted by one of the respondents: “establishing protocols and guidelines and making them available are likely to save costs of treatment and improve the outcome of a disease”. For HBP design, it was identifying services and technologies that should be covered but in a way that is financially sustainable’ “in the face of inadequate resources the basic package should be affordable and respond to the basic health needs of the populace”, one participant explained. Some respondents noted that the design of health service delivery will enable an environment for the provision of effective and efficient services.
Technology types that will benefit from HTA approaches
Public health programs or initiatives were ranked as the most important technology type that will benefit from HTA approaches (mean 5.23, Table 3) followed by medicines (4.83), vaccines (4.73), other (e.g. surgical) interventions (4.63), service delivery initiatives or incentives (4.44), medical devices and diagnostics (4.42) and screening or referral programs (4.33).
Respondents prioritised public health programmes because they reach large numbers of people and can focus on prevention, reducing the burden of disease and therefore health care expenditure. As noted by a participant, “It is necessary to put in place disease prevention strategies in public health programmes because of the high disease burden in Nigeria”. Medicines were considered important for functioning health facilities (often an inadequate supply), patient outcomes, the relatively large budget impact, and use for many high-burden diseases. However, one respondent highlighted “there is general lack or inadequate supply of medicines and medical supplies in clinics and hospitals.”
Improving the availability and management of vaccines would help reduce the burden of communicable diseases by building herd immunity. Improving service delivery will lead to better diagnosis, treatment and control of the main disease areas. Medical devices were regarded as important especially given recent advances in healthcare. Screening programs help to reduce the disease burden and bridge primary and specialist health care for large parts of the population, particularly in rural and hard to reach areas.
- Perspectives on HTA in Nigeria
Level of stakeholders’ interest in the use of different types of HTA outputs
When asked to rate the level of their interest in the use of different types of HTA output on a scale of (0–10), respondents indicated the most important were safety issues (8.8); economic issues (8.61); efficacy of technology (8.39); information on technology effectiveness (8.37) and social/ethical concerns such as equity and solidarity (7.5, Table 4). Safety concerns were explicitly linked to the availability and use of generic medicines where quality could not be guaranteed, as well as ensuring safety of patients and healthcare providers. One respondent noted that in the Nigerian context “security issues can effect stability especially in hard to reach communities and insurgent areas”, suggesting that safety outside of medical facility is also important consideration in providing care in hard to reach communities and not only safety of medicines. Economics issues were linked to affordability, sustainability, and cost-effectiveness of technologies and limited availability of health resources. Efficacy concerns encompassed quality of care and assuring efficacy before implementation of the programme, whereas social and ethical concerns were focussed on the dignity and rights of users and the need for the vulnerable to have access to health care.
Scope for HTA use in Nigeria (Importance of HTA attributes)
In relation to the importance of particular attributes of HTA, respondents’ highlighted (mean rating out of 10) improving the quality of health care (8.7), allocative efficiency (8.4), equity (8.3), budget control (8.0), and transparency in decision making (7.9, Table 5).For improving quality of health care, respondents felt it was important because government was not making health a priority and there was no research. For allocative efficiency, they felt it was important to be able to make use of resources, important for allocating resources based on need and achieving UHC; distribution of services evenly, and bridging the gap in health for all. The main reasons given to promote transparency in decision making were the importance for availability, equity, building trust, reducing corruption, ensuring all projects are funded, social inclusiveness, and provision of better quality service delivery. Budget control was regarded as important for planning, project management, improving health outcomes, effectiveness, and ensuring accountability. The reasons for ranking equity as important included accountability, following protocol for funds and decision making, lack of resources in certain areas and organizations and for disadvantaged groups.
Availability of data for HTA
The reported availability of local data to inform country-specific decisions varied across the six domains of data (Table 6). The better availability was for data on disease profiles (e.g. burden of disease, prevalence, incidence) (52%), followed by medicine prices in public and private providers (35%), while the least available was cost of health services (23%). Data were available with limitations across the six domains of data. The main reasons given were that not all diseases are covered or prioritised in data collection, data collection plus monitoring and evaluation does not have adequate funding, available data are not comprehensive or local, and some partners have data they do not share.