iDSI: Making NICE in Low and Middle Income Countries

Leela Barham speaks to the founding Director of NICE International, Kalipso Chalkidou, and Professor Lord Ara Darzi of Imperial College’s Institute of Global Health Innovation about joining forces to continue NICE International’s work for low and middle income countries.

NICE International was the brainchild of Dr Kalipso Chalkidou. Back in 2007, NICE was receiving requests for information and help with healthcare spend decisions from governments across a host of countries. The challenge was always in how far NICE could help when they already had a demanding job to do at home. Chalkidou saw the opportunity to set up a new not-for-profit arm of the organization to help in 2008.

A review of NICE International’s work followed the first Triennial Review of NICE published in June 2015. Now its duties have been split: work for low and middle-income countries under the International Decision Support Initiative (iSDI) goes to the Institute of Global Health Innovation (IGHI) at Imperial College, London, the rest staying with NICE. Staff of NICE International engaged with iDSI work transferred to IGHI in September 2016.

The iDSI brief

NICE International, together with the Thai equivalent of NICE, HITAP, launched iDSI back in November 2013 with the Department for International Development (DFID), Bill and Melinda Gates Foundation and Rockefeller Foundation funding. iDSI is a global partnership of government institutes, universities and think tanks. Their work is to support policymakers in priority setting for universal health coverage.

iDSI focuses on supporting those in low and middle income countries. No country can avoid difficult decisions, and it’s arguably even tougher for those at the lower end of the income scale as the potential range of preventative and healthcare activity to invest in can seem overwhelming. Medicines are just part of that package and will compete with the basics that other countries may take for granted.

Chalkidou hopes for iDSI to continue the legacy of her work at NICE International working with people from across the globe. In just the last two years, Chalkidou and her team worked with people from countries including Iraq, Ghana, Singapore, China, Thailand, Indonesia, Vietnam, India, South Africa, Mexico, Cuba, Ethiopia, Sri Lanka and Malawi. By Chalkidou’s reckoning, NICE International had some form of engagement with over 60 countries in the organization’s eight-year history. She acknowledges that it has done little with some of the poorest nations, but aside from what she describes as the “fragile states”, there’s no region that NICE International hasn’t worked with.

The global reach of NICE International wasn’t a goal, however. “It’s been an accident, we were simply demand driven,” Chalkidou says. iDSI will take the time to continue this work if it can help. That means being clear about the nature of the challenge, and whether iDSI is actually best placed to help, or on a more practical level, has the capacity to do so. This is no personal mission to travel at someone else’s expense, but a thoughtful approach to facilitate and enable countries to respond to some of the challenges inherent in health systems.

iDSI is shaping the wider health care environment that industry operates in. Its approaches with think tanks like the US’s Centre for Global Development will inform big issues like how to define a health benefit package. Its work has also shaped the UK DFID approach to The Global Fund to fight AIDS, Tuberculosis and Malaria. Cost-effectiveness and value for money is a golden thread in the September 2016 performance agreement between DFID and UKaid.

iDSI work has touched on some more direct - and hot - topics for industry. One of these - the cost effectiveness threshold - remains a controversial topic in developed countries. Expect it to be more even more controversial in countries with less money. The cost effectiveness work under iDSI includes contributions from leading health economists including Professor Karl Claxton from the University of York, whose work in the UK has led to an empirically based estimate of just below £13,000 per Quality Adjusted Life Year (QALY). That is low compared to the £20,000 to £30,000 range in use now (and more for end-of-life drugs). York’s iDSI work on cost-effectiveness thresholds for low and middle-income countries produces thresholds that are lower still, as you’d expect.

iDSI has set out not only cost-effectiveness thresholds but also a reference case for economic evaluation. Funded by the Bill and Melinda Gates Foundation, the idea was to provide a case that would be useful to local, national and international decision-makers and for different technologies. The principles based approach guides researchers. Expect it to guide requirements in low and middle-income countries when they think of whether to adopt - or not - a new drug too.

Working with industry

Chalkidou has an open mind when it comes to working with industry. She points out that “at NICE International we engaged with industry at different levels; we’d work at the country level but also at the global and strategic level.” Some of the big names included GSK, although big pharma didn’t dominate; local manufacturers would also be involved too, if that was what made sense for the project.

Imperial College’s Professor Lord Ara Darzi extends the welcome to industry to the new NICE/IGHI partnership. “We look forward to engaging [with industry] more effectively from the IGHI platform”, he says. Industry in all guises - from mHealth and eHealth to private insurers and investors, as well as those producing medicines and devices - are “partners in the journey to universal healthcare coverage”, he adds.

Presumably that open mindedness is helpful for industry: if iDSI plays a role in a country who wants to reform how the money in the health care system is used, maybe iDSI and its willingness to work with industry acts as a role model for local policy makers and others too?

A good fit

Chalkidou has only just made the move to Imperial. The hope is that much of the work under NICE International will continue and that means shaping the environment that industry operates in. It also means more work on health technology assessment (HTA) as HTA becomes more embedded in low and middle-income countries. In August 2016, for example, iDSI was in India providing support to establish a medical technology advisory board with more work to do be done to move from concept to delivery.

Professor Lord Darzi is convinced that NICE International and iDSI will fit well together. He says: “There are benefits to both the team and to IGHI of the transition of the NICE International team over to the Institute. The former NICE International team will benefit from a thriving research environment. IGHI gains a team with a strong funding pipeline and networks with policy makers, think tanks, academics and funds across the world.” The former NICE International team’s engagement with “the economics of health and healthcare investment” and their work with those at “the coal-face in the NHS” who are “committed to improving care through innovative initiatives in care integration, governance and payment reform”, all add up to skills that are “in demand across developing economies”, he notes.