HEALTH ECONOMICS INSTITUTIONS: A REVIEW OF GLOBAL EXPERIENCE DISCUSSION PAPER APRIL 2024 Severin Rakic Mariam M. Hamza Benoit Mathivet Denizhan Duran Alzarouq Khaleefa Alzarouq HEALTH ECONOMICS INSTITUTIONS: A REVIEW OF GLOBAL EXPERIENCE Severin Rakic Mariam M. Hamza Benoit Mathivet Denizhan Duran Alzarouq Khaleefa Alzarouq April 2024 Health, Nutrition, and Population (HNP) Discussion Paper This series is produced by the Health, Nutrition, and Population Global Practice of the World Bank. The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations, or to members of its Board of Executive Directors or to the countries they represent. 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Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, the World Bank Group, 1818 H Street, NW, Washington, DC 20433, USA; fax: 202-522-2625; email: pubrights@worldbank.org. © 2024 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW, Washington, DC 20433 All rights reserved. ii Health, Nutrition, and Population (HNP) Discussion Paper Health Economics Institutions: A Review of Global Experience Severin Rakic,a Mariam M. Hamza,a Benoit Mathivet,a Denizhan Duran,a Alzarouq Khaleefa Alzarouq b a Health, Nutrition, and Population, World Bank b Health Expenditures Department, Ministry of Health of Libya This document was produced for the Ministry of Health (MOH) of Libya, with technical support from the World Bank (WB). It is an output of the Libya Health Sector Support Grant (P163565) and Libya Health System Support Reimbursable Advisory Services (RAS) program between the World Bank and Libya. Dr. Khalid Ben Atia (MOH), Christopher H. Herbst, Mohini Kak, and Tamer Samah Rabie (WB) task-led the overall work program. Abstract: This paper was prepared to support the Libyan Ministry of Health in designing and establishing its health economics unit. Over the past decade, Libya’s health system has been significantly and negatively impacted by the country’s conflict, and the Ministry of Health has not been able to execute key health financing and economics functions due to fiscal and governance challenges. As Libya is moving toward reconstruction and recovery, and with the backdrop of the impact of COVID-19, it is imperative to think through a systematic approach to inform evidence-based decision-making to inform the allocation of resources. This review presents and synthesizes experiences of the institutions that perform health economics functions in selected countries that can be of use for Libya and other countries that consider the option of establishing a health economics unit. More specifically, this review provides examples from different countries on (1) the mission, goals, and key functions of the institutions that perform health economics functions; (2) those institutions’ legal status and their form of organization; (3) what research and analysis they conduct; (4) with whom they need to collaborate; and (5) what international resources are available to them. Based on these examples, the paper proposes concrete next steps for strengthening health economics and financing capabilities in Libya. Keywords: health economics, institutional strengthening, Libya, postconflict health system, governance. Disclaimer: The findings, interpretations, and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent. Correspondence Details: Severin Rakic, World Bank, srakic@worldbank.org. iii Table of Contents RIGHTS AND PERMISSIONS ...................................................................................... II ACKNOWLEDGMENTS ............................................................................................... V PART I – INTRODUCTION ........................................................................................... 7 PART II – FINDINGS FROM THE REVIEW............................................................ 11 2.1 HEALTH ECONOMICS FUNCTIONS ............................................................................. 11 2.2 THE LEGAL STATUS OF HEALTH ECONOMICS INSTITUTIONS .................................... 13 2.3 AUTONOMY LEVEL ................................................................................................... 14 2.4 FUNDING SOURCES ................................................................................................... 16 PART III – COUNTRY EXAMPLES .......................................................................... 19 3.1 AFGHANISTAN: THE HEALTH ECONOMICS AND FINANCING DIRECTORATE OF THE MINISTRY OF PUBLIC HEALTH ....................................................................................... 19 3.2 AUSTRALIA: THE AUSTRALIAN INSTITUTE OF HEALTH AND WELFARE ................ 21 3.3 CANADA ................................................................................................................ 23 3.3.1 The Canadian Centre for Health Economics ................................................... 23 3.3.2 The Canadian Institute for Health Information................................................ 24 3.4 CHINA: THE CHINA NATIONAL HEALTH DEVELOPMENT RESEARCH CENTER ........ 26 3.5 FINLAND: THE FINNISH INSTITUTE FOR HEALTH AND WELFARE ........................... 28 3.6 FRANCE: THE INSTITUTE FOR RESEARCH AND INFORMATION IN HEALTH ECONOMICS .................................................................................................................... 30 3.7 JAPAN: THE INSTITUTE FOR HEALTH ECONOMICS AND POLICY ............................. 32 3.8 SAUDI ARABIA: THE GENERAL DIRECTORATE OF NATIONAL HEALTH POLICIES AND ECONOMICS OF THE SAUDI HEALTH COUNCIL ........................................................ 33 3.9 SWEDEN ................................................................................................................ 35 3.9.1 The Swedish Institute for Health Economics .................................................... 35 3.9.2 The Swedish Agency for Health and Care Services Analysis ........................... 36 3.10 THAILAND .......................................................................................................... 38 3.10.1 Health Intervention and Technology Assessment Program ........................... 38 3.10.2 Health Systems Research Institute .................................................................. 40 3.11 UNITED KINGDOM: THE NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE .................................................................................................................. 42 3.12 CENTRAL ASIA: THE KYRGYZ REPUBLIC HEALTH POLICY ANALYSIS CENTER AND TAJIKISTAN HEALTH POLICY ANALYSIS UNITS ..................... 44 PART IV – CONCLUSIONS AND RECOMMENDATIONS FOR THE LIBYAN CONTEXT ....................................................................................................................... 46 APPENDIX A: SELECTED INTERNATIONAL HEALTH ECONOMICS RESOURCES .................................................................................................................. 51 REFERENCES................................................................................................................ 53 iv ACKNOWLEDGMENTS This document was produced for the Ministry of Health (MOH) of Libya, with technical support from the World Bank (WB). It is an output of the Libya Health Sector Support Grant (P163565) and Libya Health System Support Reimbursable Advisory Services (RAS) program between the World Bank and Libya. Dr. Khalid Ben Atia (MOH), Christopher H. Herbst, Mohini Kak, and Tamer Samah Rabie (WB) task-led the overall work program. Denizhan Duran (WB) and Alzarouq Khaleefa Alzarouq (Ministry of Health) oversaw the technical development of this report, which was written by Severin Rakic (WB), Mariam M. Hamza (WB), and Benoit Mathivet (WB). Contributions from the MOH were provided by Ahmed Arhouma, Majid Alalawi, and Ghassan Karem. Contributions from the WB were provided by Christopher H. Herbst and Mohini Kak. Rekha Menon, Practice Manager at the WB, provided guidance and support throughout. The team would also like to thank World Bank peer reviewers, Owen Smith, Aakash Mohpal, and Di Dong. The authors are grateful to the World Bank for publishing this report as an HNP Discussion Paper. v vi PART I – INTRODUCTION This paper was prepared to support the Libyan Ministry of Health in designing and establishing its health economics unit. Over the past decade, Libya’s health system has been significantly and negatively impacted by the country’s conflict, and the Ministry of Health has not been able to execute key health financing and economics functions due to fiscal and governance challenges. As Libya is moving toward reconstruction and recovery, and with the backdrop of COVID-19, it is imperative to think through a systematic approach to inform evidence-based decision-making to inform the allocation of resources. By studying the allocation of scarce resources among alternative uses, health economics supports the achievement of the value for money objective in well-functioning health systems (Box 1). Evidence generated by health economics units is intended to inform all health financing functions (the raising of revenue, pooling of funds, and purchasing of services) and decision- making at all stages of the public finance cycle. Health economics evaluations should be differentiated from health policy analysis—which is the study of who made what policy decisions; when, why, and how; and with what consequences. Political factors, in combination with economic factors, have critical influences in health policy making. Though Ministries of Health are interested in both groups of factors, the health economics unit should not be expected to simultaneously start performing health economics evaluations and health policy analysis. Box 1: Definitions of Key Terms Economic evaluation: The comparison of alternative courses of action in terms of their costs and consequences, with a view to making a choice. Efficiency: Maximizing the benefit of any resource expenditure or minimizing the cost of any achieved benefit. Equity: Fair distribution of resources or benefits among different individuals or groups. Evidence-based policy making: The approach that helps people make well-informed decisions about policies, programs, and projects by putting the best available evidence from research at the heart of policy development and implementation. Health economics: The study of how scarce resources are allocated among alternative uses for the care of sickness and the promotion, maintenance, and improvement of health, including the study of how health care and health-related services, their costs and benefits, and health itself are distributed among individuals and groups in society. Health system performance assessment: A country-owned process that allows the health system to be assessed holistically; this assessment uses statistical indicators to monitor the system and links health outcomes to the strategies and functions of the health system. Impact evaluation: An evaluation that makes a causal link between a program or intervention and a set of outcomes. Monitoring: The continuous process of collecting and analyzing information to assess how well a project, program, or policy is performing. Sources: BMJ Best Practice 2021; Gertler et al. 2016; Sutcliffe and Court 2006; WHO 2012. Evidence generated through economic evaluations contribute to evidence-based policy making and the efficient allocation of resources in health systems. With rising costs, rising demand, and inadequate funding for the health care system, policy makers increasingly demand that new costs be justified with scientifically rigorous evidence. Countries across the world differ in the availability of national institutions with a mandate to perform health economics evaluations 7 and generate evidence needed by the decision-makers. Such capacities can exist either in the form of a health economics unit that is part of a relatively large public institution or as a separate institution tasked with health economics functions. In the countries that have an institution capable of performing health economics functions, policy makers can benefit from the availability of evidence that informs policy dialogue and resource allocation decisions. This evidence helps policy makers determine the expected impact of policy directions and advocate for preferred policy options. The countries that still have not institutionalized health economics functions, but intend to do so, can learn from the experiences of countries that have developed such capacities. The COVID-19 pandemic has intensified the need for evidence generated by health economics evaluations. In addition to direct adverse effects on morbidity and mortality, the COVID-19 pandemic has resulted in a deep global economic contraction (Tandon et al. 2020). Most countries are experiencing lower levels of gross domestic product (GDP), rising unemployment, higher levels of impoverishment, and increasing income inequality. Government revenues have dropped and government borrowing is increasing. As the COVID-19 pandemic continued to spread, evidence was pressingly needed in all countries to inform the prioritization and allocation of public resources expenditures. Countries were in search of economic evidence on prevention strategies, vaccine deployment programs, and various treatments of COVID-19. Such evidence was not always easily available, sufficient, or conclusive. Additional efforts might be needed to tailor the international evidence to a specific national context. Economic evidence on COVID-19 was particularly important to the ministries of health that needed to demonstrate what health outcomes they achieved with the existing resources and negotiate additional investments to control COVID-19. The Libyan health system has been suffering from the impact of conflict and political instability since 2011, resulting in health outcomes that are worse than for many other countries in the Middle East and North Africa Region. Libya has a relatively centralized health system, except for hospitals and specialized centers, which have autonomy. Districts oversee primary care, which consists of 728 primary health care units, 571 primary health care centers, 29 communicable disease centers, and 45 polyclinics. The secondary level consists of 48 general and 27 rural hospitals, and the tertiary level consists of 22 specialized hospitals. Resource gaps are evident at all levels of the public health care system, and the private sector consists of 157 inpatient facilities, 503 outpatient clinics, as well as a significant number of pharmacies and laboratories. The private sector has been operating with limited oversight, and even as there is no reliable data on public versus private service utilization, the private sector plays a significant role in service delivery. Despite the lack of recent reliable data due to conflict and political instability, benchmarking internationally available data on health outcomes demonstrates low levels of life expectancy, a high burden of maternal and newborn mortality, as well as a high unmanaged prevalence of chronic conditions. These poor outcomes are explained by the challenges faced by the health system even before the conflict and instability, which include the inability to deliver continued care and management for the chronic disease burden; a weak primary health care system causing an overreliance on expensive provision of hospital services; inequitable distribution of physical and human resources; limited use of health information systems; and fragmented and insufficient health financing flows. The conflict and the instability have further disrupted the delivery of health services, with lack of basic infrastructure in health service delivery, significant reliance on inequitable private health service delivery, and further shocks on health care access and expenditures. In the Libyan context, the establishment of a health economics unit has the potential to inform an evidence-based recovery of the health financing system. While there is a need to focus on immediate humanitarian needs following the conflict, it is imperative to set up technical and institutional capacity to support the development of evidence-based policies to guide the allocation of resources across the health system. This will also enable a transition from humanitarian to 8 development priorities, ensuring that both immediate needs and longer-term systems’ capacity needs are addressed, informing efforts to build back the Libyan health system. This review presents and synthesizes experiences of the institutions that perform health economics functions in selected countries that can be of use for Libya and other countries that consider the option of establishing a health economics unit. More specifically, this review provides examples from different countries on (1) the mission, goals, and key functions of the institutions that perform health economics functions; (2) those institutions’ legal status and their form of organization; (3) what research and analysis they conduct; (4) with whom they need to collaborate; and (5) what international resources are available to them. The review covers the institutions from high-income countries (Australia, Canada, Finland, France, Japan, Saudi Arabia, Sweden, and the United Kingdom); upper-middle-income countries (China and Thailand); lower- middle-income countries (Kyrgyz Republic); and low-income countries (Afghanistan and Tajikistan), as well as international coordination bodies that provide technical assistance to countries. This list includes a country affected by fragility, conflict, and violence (Afghanistan). The review is based primarily on the information publicly available on websites of the institutions and in books and academic publications. These have been complemented by information collected through the interviews conducted with officials from Afghanistan and Saudi Arabia, as well as the information available to authors through their previous work with some of the reviewed institutions. The paper is structured in four sections. Section 2 provides an overview of institutions that perform health economics functions in selected countries, focusing on their tasks, legal status, level of autonomy, and funding sources. Section 3 provides more detailed information about the selected institutions that perform health economics functions, presenting a similar set of information for each institution. Section 4 provides conclusions and recommendations for Libya and other countries that aim to establish a health economics unit. Finally, a selection of the international health economics resources is presented in the appendix. 9 10 PART II – FINDINGS FROM THE REVIEW The review provides an overview of institutions that perform health economics functions in selected countries, focusing on four questions: (1) what health economics functions these institutions perform, (2) their legal status, (3) their level of autonomy, and (4) how they are funded. Findings from the review are summed up in this section, while a detailed description of each institution covered by the review is provided in the next section. 2.1 HEALTH ECONOMICS FUNCTIONS There are four main functions health economics institutions perform: collecting data, performing health economics evaluations, informing decision-making and policies, and disseminating results (Figure 1). The data collection function comprises revenue and expenditure tracking, indicator monitoring, and maintenance of databases. Data are used to perform various types of analysis and health economics evaluations, including demand and supply analyses, efficiency studies, impact evaluations, health system performance assessments, and international comparative studies. The results of evaluations and research inform policy recommendations, the formulation of policies, resource allocation, and implementation of plans at different levels of the health system. Some institutions covered by the review periodically prioritize research fields or decide on research topics and products to be included in their work programs. Given the economic and health burden associated with COVID-19, many recent products have focused on the impact of the pandemic, modeling responses to COVID-19, or compliance with COVID-19 control measures. Figure 1. The Main Functions and Tasks of Health Economics Institutions Source: World Bank. The institutions most often collate data on costs, revenues, and expenditures, but the data collection function also extends to other types of data, such as those on facilities, human resources, and medical equipment. Their data repositories include legally mandated data collections; routinely captured service delivery data; and periodic surveys of general public, patients, health professionals, and health facilities. These units, and Ministries of Health, then use the data on health financing flows across all payers, purchasers, providers, and beneficiaries, including production of national health accounts, public expenditure reviews, and national expenditure trends. Data 11 repositories are often freely accessible through the institution’s website, where dashboards allow for search, comparison, indicator calculations, and trends identification. Most of the institutions covered by the review perform all four functions (Table 1). Many of them have chosen to form specific organizational units tasked primarily with one of the functions— for example, communication or research. The institutions that do not perform some of the functions come from the high-income countries, where they are able to rely on other organizations for the omitted function. The review showed that health economics institutions from low- and middle- income countries performed all four functions, supporting key stages of the policy process. Policy briefs and research briefs support agenda setting; economic evaluations support selection of preferred policy option—for example, in the development of health financing strategies; health technology assessments support policy implementation; and data repositories support monitoring and assessing the process and the impact of interventions. Table 1. Health Economics Functions Performed by Institutions Included in This Review Tasks Performing Informing Country Institutions Collecting health Disseminating decision- data economics results making evaluations Afghanistan Health Economics and Financing Directorate, Ministry of Public ✓ ✓ ✓ ✓ Health Australia Australian Institute of Health and Wealth ✓ ✓ ✓ ✓ Canada Canadian Centre for Health Economics No ✓ ✓ ✓ Canadian Institute for Health Information ✓ No No No China China National Health Development Research Center ✓ ✓ ✓ ✓ Finland Finnish Institute for Health and Welfare ✓ ✓ ✓ No France Institute for Research and Information in Health Economics ✓ ✓ No ✓ Japan Institute for Health Economics and Policy ✓ ✓ No ✓ Kyrgyz Republic Health Policy Analysis Center ✓ ✓ ✓ ✓ Saudi Arabia General Directorate of National Health Policies and Economics, Saudi ✓ ✓ ✓ ✓ Health Council Sweden Swedish Institute for Health Economics No ✓ ✓ ✓ Swedish Agency for Health and Care Services Analysis ✓ ✓ ✓ ✓ Tajikistan Health Policy Analysis Unit ✓ ✓ ✓ ✓ Thailand Health Intervention and Technology Assessment Program ✓ ✓ ✓ ✓ Health Systems Research Institute ✓ ✓ ✓ ✓ United National Institute for Health and Kingdom Care Excellence ✓ ✓ ✓ ✓ Source: World Bank. Note: The experiences from two countries in Central Asia—Kyrgyz Republic and Tajikistan—are presented together in the next section of the review. 12 Health economics institutions can support decision-making at all stages of the public finance cycle: midterm budget planning; budget definition and formulation; budget negotiation and approval; budget execution; and budget reporting, auditing, and evaluation (Schmets, Rajan, and Kadandale 2016). The review revealed that the health economics institutions’ databases and products support ministries of health in advocating the need for the health sector to remain a midterm budget priority (for example, by developing long-term demographic forecasts, with implications for health care resources); providing evidence used in budget formulation (for example, by costing a basic package of health services or assessing the disease burden associated with COVID-19); providing information used in negotiating budgetary amendments with the Ministry of Finance (for example, economic analysis of COVID-19); actually purchasing services from health care providers as part of the budget execution (for example, by considering pay-for- performance for increased efficiency); and supporting reporting, auditing, and evaluation (for example, by identifying variations in medical practice or leading health system performance assessment). The institutions that perform health economics functions use various types of products and dissemination channels to reach internal and external target audiences. They produce a range of products such as periodic publications, research reports and series, research briefs, academic publications, working papers, policy briefs, data collections, books, infographics, and project reports. Some of the outputs are intended primarily for internal use by decision-makers, whereas others are targeted at policy makers in the Ministry of Health, Ministry of Finance, or health insurers. By posting the products online, the institutions ensure that the products are accessible to their external target audiences, including general public, decision-makers, health professionals, health managers, academic community, and researchers. The health economics institutes and units use their products in preparing and delivering training in the form of workshops, conferences, seminars, short courses, lectures, and other online or face-to-face events. 2.2 THE LEGAL STATUS OF HEALTH ECONOMICS INSTITUTIONS Most institutions that perform health economics functions are independent governmental institutions; a few institutions are formed under the health ministries (Table 2). Both independent governmental institutions and those functioning under the Ministries of Health primarily serve the ministries, health care payers, and other public sector clients. The independent governmental institutions in high-income countries usually have broad functions and jurisdictions in health data collection. These are relatively large public institutions that formed a separate organizational unit to perform the health economics functions. When a government established an institution that performs health economics functions, it typically did not create unnecessary competition by allocating the functions to more than one institution. The China National Health Development Research Center, Thailand’s Health Intervention and Technology Assessment Program, and Tajikistan’s Health Policy Analysis Unit each function under their respective Ministries of Health. The Health Economics and Financing Directorate was formed within the Ministry of Public Health in Afghanistan. Fully independent institutions serve a wider range of clients than governmental institutions. These institutions differ by their legal status—for example, a university formed a health economics center in Canada, the Japan institute has the status of a nonprofit corporation, and the Swedish research institute is privately owned. In addition to government agencies, their clients include private insurers, health care providers, advocacy groups, the life science industry, patient interest groups, and research organizations. Providing services on the market, their products are more likely to support advocacy efforts and policy agenda setting than the products of independent 13 governmental institutions. Independent institutions have a clear interest in academic publications and in participating in international research consortia that increase their visibility and strengthen their market position. Table 2. Legal Status of the Institutions Included in the Review Legal status Country Institutions Under Independent Fully Ministries governmental independent of Health institution Afghanistan Health Economics and Financing Directorate, Ministry of Public Health ✓ Australia Australian Institute of Health and Wealth ✓ Canada Canadian Centre for Health Economics ✓ Canadian Institute for Health Information ✓ China China National Health Development Research Center ✓ Finland Finnish Institute for Health and Welfare ✓ France Institute for Research and Information in Health Economics ✓ Japan Institute for Health Economics and Policy ✓ Kyrgyz Republic Health Policy Analysis Center ✓ Saudi Arabia General Directorate of National Health Policies and Economics, Saudi Health Council ✓ Sweden Swedish Institute for Health Economics ✓ Swedish Agency for Health and Care Services Analysis ✓ Tajikistan Health Policy Analysis Unit ✓ Thailand Health Intervention and Technology Assessment Program ✓ Health Systems Research Institute ✓ United Kingdom National Institute for Health and Care Excellence ✓ Source: World Bank. Note: The experiences from two countries in Central Asia—Kyrgyz Republic and Tajikistan—are presented together in the next section of the review. 2.3 AUTONOMY LEVEL Most institutions that perform health economics functions have some level of autonomy, even when the health economics unit is established under a wider public institution. The institutions covered by the review differ by their level of autonomy (Table 3). The fully independent institutions are also the fully autonomous ones. The high autonomy of the fully independent institutions in high-income countries allows them to be flexible in their organizational structures. The institutions are structured in a manner that allows them to function flexibly and adjust their work to contextual and market opportunities. Their organizational charts are usually not available through their websites. The autonomy of the health economics units established within a wider public institution depends on the organizational position of the unit. The more levels in the institution’s hierarchy, the more difficult it is for the management of a health economics unit to make decisions on its own. Autonomy might be reduced by the need to have decisions on the annual budget, research priorities, 14 workplan, staffing, and conclusion of partnership agreements or service contracts approved by top management of quasi-autonomous institutions. Table 3. Autonomy Level of the Institutions Included in the Review Autonomy level Country Institution Negligible Quasi- Fully autonomy autonomous autonomous Afghanistan Health Economics and Financing Directorate, Ministry of Public Health ✓ Australia Australian Institute of Health and Wealth ✓ Canada Canadian Centre for Health Economics ✓ Canadian Institute for Health Information ✓ China China National Health Development Research Center ✓ Finland Finnish Institute for Health and Welfare ✓ France Institute for Research and Information in Health Economics ✓ Japan Institute for Health Economics and Policy ✓ Kyrgyz Republic Health Policy Analysis Center ✓ Saudi Arabia General Directorate of National Health Policies and Economics, Saudi Health Council ✓ Sweden Swedish Institute for Health Economics ✓ Swedish Agency for Health and Care Services Analysis ✓ Tajikistan Health Policy Analysis Unit ✓ Thailand Health Intervention and Technology Assessment Program ✓ Health Systems Research Institute ✓ United Kingdom National Institute for Health and Care Excellence ✓ Source: World Bank. Note: The experiences from two countries in Central Asia—Kyrgyz Republic and Tajikistan—are presented together in the next section of the review. A higher degree of autonomy implies less authority on the part of elected officials to direct the institution’s technical work. The quasi-autonomous institutions are not part of a country’s central administration. They benefit from some autonomy, while operating at arm’s length from governments. Having chosen to allocate health economics functions to the quasi-autonomous institutions, the government has moved the functions away from direct political control and enabled the institutions to build legitimacy in performing the agreed functions. The legitimacy substantially rests on the perceptions of stakeholders and the general public that the institution provides data and evidence for policy making according to sound legal, technical, and professional criteria, rather than according to opportunistic and vote-seeking political decision criteria. However, public organizations are never isolated from other actors within the political system. Quasi-autonomous governmental institutions are not able to determine their economic evaluation, research preferences, and workplans on their own, because their tasks are carried out for public good. Unlike the quasi- autonomous institutions, the fully autonomous heath economics institutions can focus on a small number of priority research fields or research topics and declare their main areas of expertise, responding to market opportunities and the existence of a niche. It should also be noted that, while 15 a certain level of autonomy is desirable, this should not come at the expense of removal from important decision-making processes. Irrespective of their autonomy level, the institutions that perform health economics functions need to build national and international partnerships. All the institutions covered by this review have built partnerships at national and international levels. The partnership arrangements have allowed them to access funding, participate in research projects and consortia, extend their expertise, strengthen their organizational reputation, increase demand for their services, and more credibly communicate on their products. The partnerships are built with a wide range of partners including academia, governments of different levels, international organizations, networks, and research consortia. Some of the institutions serve as the World Health Organization’s (WHO’s) collaboration centers. Though informal collaborative arrangements are widely present, the partnerships are often formalized through agreements and memorandums of understanding. 2.4 FUNDING SOURCES Most institutions covered by the review are publicly funded, even as some have private or external revenue sources. The public funding reflects the fact that public sector entities are the main clients of the institutions that perform health economics functions. Even when the institutions have mixed sources of funding, public funding is still the primary source of financing (Table 4). Public funding comes from different types of public entities, in the form of both budgetary allocations and service contracts. In addition to public funding, institutes can receive funding from other sources. Project financing and fees for services provided to private sector clients are important additional sources of funding for many of the institutions covered by the review. The projects can be undertaken for both national and international clients. Project funding has the potential to grow over the years, as an institution builds its reputation in the health economics field and forms new partnerships. Another form of external funding is through international sources: in various fragile and conflict-affected states, international donors can provide “seed funding” to establish units and finance specific evaluations. However, reliance upon multiple small-scale donor-funded short-term projects can create high administrative burden and unpredictability (Box 2). This was particularly an issue with health policy analysis institutes, which are research institutes and policy think tanks providing evidence on specific and narrower policy questions, as opposed to broader cross-cutting health systems issues. The institutions that perform health economics functions in fragility-, conflict-, and violence-affected countries as well as low- and middle-income countries were found to rely primarily on public funding. 16 Table 4. Primary Funding Source of the Institutions Included in the Review Primary source of funding Country Institution Private/Nonprofit Public funding organization Afghanistan Health Economics and Financing Directorate, Ministry of Public Health ✓ Australia Australian Institute of Health and Wealth ✓ Canada Canadian Centre for Health Economics ✓ Canadian Institute for Health Information ✓ China China National Health Development Research Center ✓ Finland Finnish Institute for Health and Welfare ✓ France Institute for Research and Information in Health Economics ✓ Japan Institute for Health Economics and Policy ✓ Kyrgyz Republic Health Policy Analysis Center ✓ Saudi Arabia General Directorate of National Health Policies and Economics, Saudi Health Council ✓ Sweden Swedish Institute for Health Economics ✓ Swedish Agency for Health and Care Services Analysis ✓ Tajikistan Health Policy Analysis Unit ✓ Thailand Health Intervention and Technology Assessment Program ✓ Health Systems Research Institute ✓ United Kingdom National Institute for Health and Care Excellence ✓ Source: World Bank. Note: The experiences from two countries in Central Asia—Kyrgyz Republic and Tajikistan—are presented together in the next section of the review. The number and structure of staff depends on the size of the institution and the availability of funding. Public institutions that follow specific procedures for planning and hiring staff have less flexibility to adjust staffing levels and remuneration schemes than fully autonomous organizations. While relatively large publicly funded institutions that host health economics units differ in size, the health economics teams they formed have similar compositions. These teams are usually multidisciplinary ones, with team members who are skilled in health economics, econometrics, public health, epidemiology, data management, quantitative analysis, demography, and communication. Staff are often required to have a doctoral or master’s degree. Several approaches for continuous professional development are used to build the teams and increase their capacities for performing identified health economics functions. Similar to the health policy analysis institutes (Box 2), the core teams are frequently complemented by external associates or professionals working in other units of the wider public organization. The teams can grow in time, as additional funding sources become available. 17 Box 2: Sustainability of Health Policy Analysis Institutes A review and assessment of factors that facilitated the development of sustainable health policy analysis institutes in low- and middle-income countries found that the key enablers of the institutes’ success were the following: • Proactive positioning within an actively changing environment • Development of financial plans and a clear fundraising strategy, pursuing diversification of funding sources and longer-term program grants • Core funding from government annual budget, but avoidance of excessive reliance on government funding that may undermine autonomy • Reliance primarily on in-house staff, though external consultants occasionally used to fill particular gaps; retention of skilled human resources • Board contribution to organizational capacity development through promotion of continuity, independence, and fundraising • Long-standing international cooperation program supporting capacity development of the institute and building of institutional links; • Personal links with policy makers to foster trust and influence policy The institutes faced the following challenges that could also be relevant for the institutions that perform health economics functions: • Change in government resulting in a diminished support to the health reforms and reduced need for evidence in driving the reforms • Diminishing level of funding after substantial initial support, making the institute no longer fully functional • Downgrading and undermining of the analytical unit though organizational reforms • Host institution’s inflexible regulation of staff reimbursement • Staff leaving for better-paid positions, with remaining senior staff bearing a heavy workload and facing danger of burnout • Reliance upon short-term donor funding creating high administrative costs and unpredictability Sources: Bennett et al. 2012a; Bennett et al. 2012b. 18 PART III – COUNTRY EXAMPLES This section provides more detailed information about the institutions that perform health economics research and analysis functions in selected countries. To the extent permitted by data availability, a similar set of information is presented for each institution. This information includes its establishment, legal status, mission, functions, funding sources, organizational structure, staffing levels, an illustration of international and national cooperation, and examples of the research and publications. 3.1 AFGHANISTAN: THE HEALTH ECONOMICS AND FINANCING DIRECTORATE OF THE MINISTRY OF PUBLIC HEALTH The Health Economics and Financing (HEF) Directorate was established as part of the General Directorate of Policy, Planning, and International Relations in the Ministry of Public Health of Afghanistan. 1 Establishment of the HEF Directorate was motivated by the need to improve budget negotiations between the Ministry of Public Health and the Ministry of Finance, with the directorate becoming a focal point in health finance matters. The HEF Directorate has been primarily publicly funded through the Ministry of Public Health, but it has also received additional funding and technical support from donors such as the United States Agency for International Development (USAID) and the European Union. The HEF Directorate coordinates its activities with other directorates within the ministry. Mission: To conduct research aiding in evidence-based policy making. The HEF Directorate evolved from a manager of international public health funding and an informal capacity-building unit to an institution with a focus on applied health economics and financing. The directorate started as the Grant and Contracts Management Unit (GCMU) within the Ministry of Public Health. The GCMU was established in 2003 to manage and oversee health project proposals and recommend actions for grant release to the ministry leadership (Beaston- Blaakman et al. 2011). In addition to overseeing financing and contracts, the GCMU provided capacity building within the ministry. Changing policy, administrative, and financial contexts challenged the GCMU to redefine its institutional role. Simultaneously, pressures within the health system required the ministry to examine key policy and economic issues related to resource allocation, domestic revenue sources, and cost-effectiveness in the delivery of health services. These policy issues required economic and policy analyses to help inform decision-making. The combination of these factors led to the establishment of the HEF Directorate. The ministry envisioned the HEF Directorate as a critical component for managing and advancing health economics and financing activities within the ministry, including policy analysis and costing support to other ministry departments. Three key elements contributed to establishment of the HEF Directorate: (1) international collaboration and commitment of international organizations, (2) evidence-based research in support of national strategy on health care financing and sustainability, and (3) close working relationships between international and Afghan staff. The HEF Directorate conducts research around pressing issues, such as whether the contracting out mechanisms are sustainable and what the drivers are of high out-of-pocket payments. The studies provide data and evidence for decision-making at the Ministry of Public Health and at higher government levels. The HEF Directorate has organized three units (Figure 2). The Health 1 Additional information about the HEF Directorate is available at https://moph.gov.af/en. 19 Economics Unit is an analytically oriented unit responsible for economic studies. Initially, this unit assisted in costing new strategies and oversaw the National Health Account development process. The Health Financing Unit initially supported annual budgeting of the ministry’s programs, examined the feasibility of various health financing schemes, implemented the health financing schemes, and evaluated the design of results-based financing pilots. The Aid Management Unit took over the activities of the former GCMU. Figure 2. Position and Functions of the Health Economics and Financing Directorate, Ministry of Public Health, Afghanistan Source: World Bank, based on Beaston-Blaakman et al. 2011. The HEF Directorate works toward the objective of developing capacity in applied health economics, health financing, and resource management. The first phase of building this capacity involved developing the HEF Directorate’s internal skills and knowledge related to health economics and financing. Ten technical staff from the directorate were sent abroad to obtain their master’s degrees in health economics (Kim and Zeng 2014). The first batch of graduates contributed to key economic and financing activities aimed at improving the health sector in Afghanistan. Based on their initial experience, the HEF Directorate’s staff conducted several internal costing assessments for the Ministry of Public Health’s management and decision-making (Table 5). The studies relied on internal capacities and reduced the need for spending limited resources on external technical support. The HEF Directorate also established an internship program to recruit qualified female college graduates to work in health economics. Table 5. Examples of Analytical and Research Activities Performed by the Health Economics and Financing Directorate Recent research Efficiency analysis (primary health care; district and national hospitals) activities Costing of a basic package of health services/essential package Costing of medical education Data collections Health management information system capturing expenditures at different levels Public expenditure tracking survey Source: World Bank. The HEF Directorate has been instrumental in generating economic evidence for informed decision-making and advocacy. The Ministry of Public Health responsibilities include generating evidence in support of health financing reforms, advocating for changes such as increased revenues to the health sector, and ensuring the efficient use of existing resources. The health economics 20 studies conducted by the HEF Directorate—including studies on efficiencies and equity, health insurance feasibility, and National Health Accounts production as well as public expenditure tracking surveys—were crucial in deliberating health financing issues in Afghanistan and developing health financing strategies (MOPH 2019). 3.2 AUSTRALIA: THE AUSTRALIAN INSTITUTE OF HEALTH AND WELFARE The Australian Institute of Health and Welfare (AIHW) is a national independent information management agency that was set up by the Australian government in 1987. 2 It works with Australia’s states and territories to improve the quality of administrative data, to compile national data sets based on data from each jurisdiction, to analyze these data sets, and to disseminate information and statistics (AIHW 2017). The AIHW collects and reports information on a wide range of topics and issues, ranging from health and welfare expenditure, hospitals, disease and injury, and mental health to aging, homelessness, disability, and child protection. The AIHW is governed by a management board and accountable to the Australian Parliament as an agency that helps deliver the Australian government’s health policies and programs. It has about 500 staff, who are skilled in statistical analysis, epidemiology and demography, information development, data management, communication, and public sector administration (AIHW 2021). Mission: To create authoritative and accessible information and statistics to inform decisions and improve health and welfare of all Australians. The detailed functions of the AIHW are prescribed in the Australian Institute of Health and Welfare Act 1987. It is responsible for (1) collecting and producing, and coordinating and assisting with the collection and production of, health- and welfare-related information and statistics; (2) conducting and promoting research into Australians’ health and their health services; (3) developing specialized standards and classifications for health, health services, and welfare services; (4) publishing reports on its work; (5) making recommendations to the minister on the prevention and treatment of diseases and the improvement and promotion of the health awareness of Australians; and (6) providing researchers with access to health- and welfare-related information and statistics, subject to confidentiality provisions (AIHW 2017). The AIHW provides accurate statistical information; develops and collects comprehensive data; analyzes and reports on data; develops and improves performance indicators and targets for national agreements; provides data linkage services; and develops and maintains national metadata standards. To fulfill these roles, the AIHW has organized 11 groups (Figure 3). The AIHW is principally funded by the Australian government and government agencies. The AIHW’s operations are funded by (1) parliamentary appropriations; (2) contributions from income received for project work undertaken for external agencies to provide corporate services for that work; and (3) miscellaneous sources, such as bank interest, ad hoc information services, and publication sales. A substantial part of the AIHW’s revenue comes from specific project work it undertakes for the Australian government and for state and territory government agencies. The AIHW has a strong focus on maintaining ongoing project work with existing funders and, where possible, developing new projects of interest to new funders (AIHW 2017). 2 Additional information about the AIHW is available at https://www.aihw.gov.au/. 21 Figure 3. Organizational Structure of the Australian Institute of Health and Welfare Source: World Bank, based on AIHW 2021. Note: METeOR = the Metadata Electronic Online Repository. The AIHW analyzes and reports information on a broad range of health and welfare issues in Australia. It releases more than 180 print, web, and data products every year that draw on national major health and welfare data collections, including its comprehensive flagship biennial national publications—Australia's Health and Australia's Welfare (Table 6). It aims to make the information and statistics it produces widely accessible. In addition to print-ready and online reports, the AIHW produces infographics on many topic areas, detailed data tables, and “in brief” or “at a glance” summary publications to accompany key reports. Table 6. Examples of Publications and Research Performed by the Australian Institute of Health and Welfare Periodic publications Australia’s Health Health Expenditure Australia Cancer screening monitoring reports Australia’s Welfare Recent research Impacts of COVID-19 on Medicare Benefits Scheme and Pharmaceutical reports Benefits Scheme Service Use Childhood Overweight and Obesity: The Impact of the Home Environment Data collections Australian Burden of Disease Database Health and Welfare Expenditure Database Source: World Bank, based on AIHW 2021. The AIHW works with a broad range of national and international stakeholders. It convenes or participates in roughly 100 committees with experts from many different subject areas, providing AIHW with contemporary information on best practice and insight into perspectives of the Australian Bureau of Statistics, various Australian government departments, state and territory governments, local governments, universities, research centers, nongovernmental organizations, 22 and international organizations. The AIHW has in place multiple partnership agreements and memorandums of understanding, including those concluded with the Department of Health, the Department of Social Services, Cancer Australia, and the Australian Institute of Family Studies (AIHW 2021). The AIHW has a role in information sharing with a number of international organizations, such as the WHO and the Organisation for Economic Co-operation and Development (OECD). It also has informal collaborative arrangements with other international agencies and bodies, such as the Canadian Institute of Health Information (CIHI) and the International Group for Indigenous Health Measurement. 3.3 CANADA There are two organizations that perform health economics research and analysis functions in Canada: the Canadian Centre for Health Economics and the Canadian Institute for Health Information. 3.3.1 The Canadian Centre for Health Economics The Canadian Centre for Health Economics (CCHE) strives to be the focal point for health economics research in Canada. 3 The CCHE was formed at the University of Toronto’s Institute for Health Policy, Management and Evaluation. It is dedicated to bringing together Canadian and international researchers who work on advancing the set of theoretical and empirical tools that policy makers need to develop successful programs (CCHE 2021). While the CCHE’s focus is primarily Canadian, its aim is also to make a contribution to health economics worldwide. Mission: In pursuit of its vision of being the leading institution in Canada for developing practical research-based solutions to ongoing concerns in Canadian health and health economics research, the CCHE’s mission is (1) to conduct economics research using the latest and most appropriate theoretical and empirical techniques to provide innovative, practical, and evidence-based real-world solutions to health and health care–related issues that have important policy implications for the Canadian population; (2) to collaborate in health economics research with experts in the academic and policy fields to address current challenges in Canadian health and health care; (3) to provide a forum for developing knowledge and sharing expertise from both the Canadian and international arenas to broaden the scope of solutions for modern health research in Canada; (4) to undertake and facilitate the conduct of high-quality independent and impartial health economics research on policy relevant issues in Canada; (5) to publish research findings to disseminate the latest advances in theoretical and empirical methodologies and contribute to the international literature on health economics and econometrics; and (6) to provide training in health economics and econometrics. The CCHE supports analytical work in health economics and disseminates research findings through its working papers, educational training courses, and speaker series, which are designed to serve as standard resources for health policy makers and academic health economists in Canada and abroad. The working paper series (Table 7) includes papers concerned with both the development and the application of theoretical and econometric frameworks to a range of health- 3 Additional information about the CCHE is available at https://www.canadiancentreforhealtheconomics.ca/. 23 related questions. The CCHE brings together Canadian and international researchers as its staff, associates, student fellows, and faculty associates. Table 7. Examples of Research Performed by the Canadian Centre for Health Economics Recent working Compliance with Social Distancing: Theory and Empirical Evidence from papers Ontario during COVID-19 An Empirical Examination of the Patented Medicine Prices Review Board Price Control Amendments on Drug Launches in Canada Impact of Quality-Based Procedures on Orthopedic Care Quantity and Quality in Ontario Hospitals Heterogeneity in the Support for Mandatory Masks Unveiled On the Importance of the Upside Down Test in Absolute Socioeconomic Health Inequality Comparisons Impact of Individual and Institutional Factors on Wage Rate for Nurses in Canada: Is There a Monopsony Market? Long-Term Demographic Forecasts and Implications for Health Care Resources and Repurposing Efficiency Estimation with Panel Quantile Regression: An Application Using Longitudinal Data from Nursing Homes in Ontario, Canada Source: World Bank, based on CCHE 2021. The CCHE organizes workshops, conferences, seminars, and short courses on theoretical and empirical methodologies in health-focused research. These courses are open to a wide range of professionals interested in learning more about health economics. The short courses related to health economics and econometrics are designed for policy analysts in the public and private sectors who are interested in building their skills in both the fundamentals of and latest developments in economics and econometrics. The CCHE’s Distinguished Speaker Series features experts in the field of applied or theoretical economic and econometric research who have made significant contributions to the field. 3.3.2 The Canadian Institute for Health Information The Canadian Institute for Health Information (CIHI) is an independent, not-for-profit organization that provides essential information on Canada’s health systems and the health of Canadians. 4 CIHI was established in 1994 to coordinate the gathering and dissemination of health data previously done by jurisdictions in isolation. CIHI's core functions include identifying national health indicators, coordinating the development and maintenance of national information standards, and developing and managing health databases and registries, as well as conducting and disseminating basic research and analysis (Marchildon 2008). CIHI provides comparable and actionable data and information that are used to accelerate improvements in health care, health system performance, and population health across Canada. 4 Additional information about CIHI is available at https://www.cihi.ca/en. 24 Mission: To deliver comparable and actionable information to accelerate improvements in health care, health system performance, and population health across the continuum of care. CIHI receives its funding from the provincial/territorial Ministries of Health and the federal government. The proportion coming from these two levels of government has evolved over the years (CIHI 2018a). In its early days, CIHI was funded primarily through bilateral agreements with provincial/territorial Ministries of Health and core funding from the federal government; supplemental revenue was generated from the sale of products and services. The federal budget included funding to allow CIHI to enhance the coverage of its data holdings and continue to develop new comparable health indicators. Over the years, CIHI has received significant amounts of additional funding from Health Canada for specific projects. Since 2006, all provinces and territories have had a ministry-signed bilateral agreement with CIHI. The provincial Ministries of Health contract with CIHI for a group of products and services. In exchange, the ministries pay an annual fee directly to CIHI. CIHI’s Board of Directors includes representatives of different regions (Figure 4). CIHI has over 700 staff members. Figure 4. Senior Managers in the Canadian Institute for Health Information Source: World Bank, based on CIHI 2018b. Given the complexity of Canada’s health care systems, CIHI has an extensive network of stakeholders. It strives to champion pan-Canadian health data and information that is timely and accessible, provide products and services that are relevant to its stakeholders’ priorities, and to enable and accelerate improvements to health systems across the country. Its strategic directions reflect a balanced approach to meeting the needs of its priority stakeholders. When setting priorities among the needs of its stakeholders, CIHI focuses on senior government leaders and others involved in developing health policy in federal, provincial, and territorial ministries; those who lead, plan, and manage the delivery of health services locally and within regions; and the general public. CIHI supports front-line health care providers, quality improvement organizations, analysts who use the data locally, and health services and policy researchers. It also works with other important stakeholders such as data providers, privacy and security professionals, information technology (IT) vendors, and health records staff involved in collecting and providing data (CIHI 2018a). 25 CIHI works with a broad range of Canadian health organizations and agencies to leverage complementary strengths, skills, and networks. It cooperates closely with Statistics Canada— the federal government agency responsible for the gathering and dissemination of population health data—and other pan-Canadian health organizations such as Canada Health Infoway, the Canadian Agency for Drugs and Technologies in Health, the Public Health Agency of Canada, the First Nations Health Authority, and the Health Data Research Network Canada, as well as other partners. The strategic partnerships ensure that the policies and decisions that influence health are based on accurate, comparable, and unbiased information (Table 8). The partnerships also help to avoid any duplication of efforts and costs. Table 8. Examples of Research Performed by the Canadian Institute for Health Information Periodic publications National Health Expenditure Trends Prescribed Drugs Spending in Canada Provincial/Territorial Data Quality Report Recent research Understanding Variability in the Cost of a Standard Hospital Stay reports Early Revision of Hip and Knee Replacements in Canada: A Quality, productivity, and Capacity Issue Data collections Canadian patient cost database National health expenditure database Hospital spending database Source: World Bank, based on CIHI 2021. An evaluation of CIHI’s effectiveness found numerous uses of the information it produced, particularly for conducting secondary analysis. Information produced by CIHI has been used by provincial/territorial and federal levels of government, nongovernmental organizations, academics, and researchers. A hallmark product that CIHI publishes is the periodic report National Health Expenditure Trends. CIHI data are frequently used for internal benchmarking or other secondary analyses that are not released publicly. The Parliamentary Budget Office regularly uses CIHI data to develop scenarios and projections. Evidence on CIHI’s contributions to the overall body of knowledge supporting decision-making in the health care system has started emerging. The work of CIHI to adapt international tools to the Canadian context has facilitated the adoption of electronic health records, contributed to the expansion of activity-based funding, and fostered the culture of performance (Health Canada and the Public Health Agency of Canada 2014). CIHI has increased awareness, understanding, and uptake of the standards and products related to data infrastructure that it has developed. 3.4 CHINA: THE CHINA NATIONAL HEALTH DEVELOPMENT RESEARCH CENTER The China National Health Development Research Center (CNHDRC) is a national research institution established in 1991 under the National Health Commission of the People’s Republic of China. 5 It was previously known as the China Health Economics Institute. The main tasks of the 5 Additional information about the CNHDRC is available at http://www.futurehealthsystems.org/cnhdrc. 26 CNHDRC are (1) to carry out research on health development planning and public policy in the health area; (2) to carry out evaluation, supervision, and effect monitoring of health policy implementation; (3) to conduct research on and support the implementation of health policy and technology assessment; (4) to research and develop health policy decision support systems; (5) to carry out research and studies on health economics, health management, and health policy basic theory; (6) to provide technical support to health reform and developmental practices; (7) to carry out domestic and international exchanges and cooperation in the field of health, and to introduce and disseminate research results and experiences; and (8) to conduct other related tasks assigned by the National Health Commission (SENET Hub 2021). Mission: To conduct research on and take part in implementing (1) health development and reform strategy, (2) public health policies, (3) health management programs, (4) health policy and health technology assessment, and (5) health economics and health management theories. The CNHDRC operates as a national think tank providing technical consultancy to health policy makers across the country. It has grown over time and currently has about 90 employees; more than 20 of them have doctoral degrees and more than 50 have master’s degrees. The CNHDRC has organized several research departments to host professional researchers, researchers at the intermediate level, and associated researchers (Figure 5). It works as the WHO’s Collaborating Center for Health System Strengthening, supporting the strengthening of regional capacity in the institutionalization of health accounts and assisting in the generation and dissemination of knowledge and information on health systems and universal health coverage. Figure 5. Research Fields of the China National Health Development Research Center Source: World Bank. In performing its functions, the CNHDRC collaborates with international organizations, research consortia, and networks such as the Future Health Systems, the International Ambulatory Surgery Alliance, the Health Technology Assessment international, the Asia-Pacific Health Accounts Network, and the Equity in Asia-Pacific Health Systems. In addition to public funding, the CNHDRC has received research grants from international organizations such as the Bill & Melinda Gates Foundation and the World Diabetes Foundation (Table 9). 27 Table 9. Examples of Research Performed by the China National Health Development Research Center Publications Evaluation and Learning in Complex, Rapidly Changing Health Systems: China’s Management of Health Sector Reform Identifying Community Health Care Supports for the Elderly and the Factors Affecting Their Aging Care Model Preference: Evidence from Three Districts of Beijing Strengthening Capacity to Enhance Delivery: Implementation of Payment Reform in China Experience and Problems of Urban Employee Basic Medical Insurance Reform in China: Based on Analysis of Policy Documents and Institutional Environment Difficulties and Challenges Faced in the Development of Urban and Rural Resident Medical Insurance for Catastrophic Diseases in China Projects Implementation of Tiered Diabetes Management and Referral Model Economic Evaluation on 9-Valent Human Papillomavirus Source: World Bank, based on Future Health Systems 2021; and Devex 2021. The CNHDRC has played an essential role in establishing health technology assessment framework and processes in China. Health technology assessment in China has gradually evolved and lately has focused on drug safety, clinical effectiveness and cost-effectiveness, budget impact, innovation, and accessibility. The National Center for Drug and Technology Assessment was established in 2018 under the CNHDRC, with the objective of effectively prioritizing evidence-based decision-making and optimizing resource utilization. Since 2019, the CNHRDC has led the incorporation of real-world data in drug assessment, drug pricing, drug reimbursement, and drug procurement policy evaluations (Sharma and Gautam 2019). 3.5 FINLAND: THE FINNISH INSTITUTE FOR HEALTH AND WELFARE The Finnish Institute for Health and Welfare (THL) studies, monitors, and develops measures to promote the well-being and health of the population in Finland. 6 THL is an independent expert agency working under the Ministry of Social Affairs and Health. It gathers and produces information based on research and register data, and it provides expertise and decision- making support. THL serves various parties—the government, municipal and provincial decision- makers, actors in the social welfare and health sector, the research community, and the public (THL 2021). Its work is focused on ensuring sustainability of the welfare society, reducing inequality and social exclusion, researching the changing spectrum of diseases, preparing for health threats, and supporting the transition of the service system. Mission: To study, monitor, and develop measures to promote the well-being and health of the population in Finland. The Health Economics and Equity in Health Care Team is organized within the Welfare State Research and Reform Unit (Figure 6). The unit monitors, investigates, and supports the development of social security, the service system, and the services provided to different population 6 Additional information about THL is available at https://thl.fi/en/web/thlfi-en. 28 groups. The unit conducts multidisciplinary research to support the development and coordination of the health and social service system and the social security system; carries out research to identify the mechanisms underlying different social problems; searches for welfare policy solutions for the problems; and develops services and benefits to make them more effective and mutually supportive. The Health Economics and Equity in Health Care Team collaborates with various departments and other units in performing its functions. Figure 6. Position of the Health Economics and Equity in Health Care Team in the Finnish Institute for Health and Welfare Source: World Bank, based on THL 2021. THL’s funding sources include the state budget, co-funding for research and development projects, and fees from products and services sales. Most of the state budget funding is allocated to the wage bill. Co-funded activities involve funding obtained from external sources for research and development projects. The largest external financiers in 2019 were the Finnish Ministry of Social Affairs and Health, the European Union, the Academy of Finland, Sanofi Pasteur MSD, municipalities and cities, the University of Helsinki, the Ministry of Education and Culture, and GlaxoSmithKline Ltd (THL 2021). A fee is charged for products and services sold in a competitive market at a market price. Such activities mainly consist of laboratory research and analyses, and international projects. International cooperation is an integral part of THL’s work. It maintains close international collaboration in facility monitoring and supervision activities, health promotion, research, and development projects implementation. THL's key forums for expert cooperation include the European Union and its departments and agencies, such as the European Centre for Disease Prevention and Control (ECDC) and the European Monitoring Centre for Drugs and Drug Addiction (EMCCD), United Nations organizations, the WHO, the OECD, and international research networks. THL is engaged in active collaboration with Nordic countries and the European Union on statistics, registries, and standardization. THL hosts three WHO Collaborating Centers— the Collaborating Center on Alcohol Policy Implementation and Evaluation; the Collaborating Centre for Mental Health Promotion, Prevention and Policy; and the Collaborating Centre for Noncommunicable Disease Prevention, Health Promotion and Monitoring. THL provides the 29 information it produces as open data, making data available to companies and organizations from both the public and the private sectors (Table 10). Table 10. Examples of Publications and Research Performed by the Finnish Institute for Health and Welfare Periodic Health Expenditure and Financing publications Hospital Productivity Data collections COVID-19 tests and confirmed cases in Finland Cost-effectiveness indicators in social welfare and health care Research reports Distributional Effects of Out-of-Pocket Health Payment in Finland 2010–2018 Determinants of Health Care Expenditure in a Decentralized Health Care System Projects Financial protection in the Finnish health system Cost-effectiveness of policies aimed at prolonging working careers: The role of health Source: World Bank, based on THL 2021. 3.6 FRANCE: THE INSTITUTE FOR RESEARCH AND INFORMATION IN HEALTH ECONOMICS The Institute for Research and Information in Health Economics (IRDES) is a research institute specializing in health economics. 7 It is committed to providing high-quality independent research and to facilitating evidence-based decision-making to promote an efficient health system that ensures solidarity, equity, and care quality. IRDES was created in 1985 as the Research and Documentation Centre in Health Economics. In 2015, it was transformed into a public interest group, to allow the state, the National Health Insurance, and the National Solidarity Fund for Autonomy to better articulate and rationalize the resources devoted to research, data production, and expertise in health economics (IRDES 2021). Mission: IRDES has a dual mission of applied research and production of data on the fields of health insurance and medico-social insurance. IRDES contributes to the debate on the future of the health and social welfare system by (1) carrying out scientific studies and research; (2) analyzing and evaluating public health policies; (3) participating in the development of public statistics through surveys, database matching, and development and monitoring of indicators; (4) ensuring a scientific watch on the evolution of techniques and methodological approaches; (5) disseminating the results of research through its own collections or through academic journals, as well as during seminars and colloquia; and (6) contributing to the development of research in health economics through scientific collaborations and teaching and hosting internships, doctoral students, postdoctoral fellows, and researchers (IRDES 2021). IRDES’s multidisciplinary team includes about 30 researchers-economists, 7 Additional information about IRDES is available at https://www.irdes.fr/english/home.html. 30 sociologists, geographers, public health physicians, and statisticians—all supported by database managers and publishing, communication, documentation, web, IT, and administrative services. The results of IRDES’s research are disseminated through a range of publications, documentary products, and peer-reviewed scientific publications (Table 11). These research activities are clustered around three main research topics: (1) performance of the health care organizations—for example, studies of changes in the health care supply; (2) health, social protection, and access to health care—for example, clarifying the questions regarding demand and use of health care and health insurance; and (3) analysis of health systems and international comparisons, which are carried out through international collaborations, participation in European research projects, and hosting foreign researchers. IRDES produces and uses large databases, combining different sources of medical-administrative data and surveys. It has permanent access to the country’s National Health Data System. It also develops and conducts periodic and targeted surveys of the general public, health professionals, and companies on topics related to health care and insurance (IRDES 2021). Table 11. Examples of Publications and Research Performed by the Institute for Research and Information in Health Economics Issues in health Group Complementary Health Insurance: Means of Implementation That Vary economics According to the Firm. The Impact of Cancer on Employment Outcomes Working papers Impact Assessment of New Organization in Orthopedic Surgery on the Care Pathways Health Expenditure, Aging, and Frailty: The French Case Periodic publications Watch on Health Economics Literature Data collections Health databases (Eco-Santé) Books Glossary Series: English-French Glossary of Health Economics Terms Atlas Series: Atlas of Variations in Medical Practices. The Use of Ten Common Surgical Procedures Source: World Bank, based on IRDES 2021. IRDES has developed a number of partnerships at institutional and scientific levels. Its institutional partners include the National Health Insurance Fund for Salaried Workers; the National Research Agency; the National Old Age Insurance Fund; the High Authority for Health; the Health Data Institute; the National Federation of Health Centers; the National Cancer Institute; the National Institute for Prevention and Health Education; the National Institute of Health and Medical Research; the Ministry of Higher Education and Research; the National Union of Health Insurance Funds; the Ministry of Labor, Employment and Health; the General Directorate of Health; the General Directorate of Health Care Provision, and other partners. IRDES also cooperates with a number of international universities and research institutes such as the Netherlands Institute for Health Services Research, the Leeds Institute of Health Sciences/Academic Unit of Health Economics, Lausanne University Institute of Social and Preventive Medicine, and the European Center for Social Welfare Policy and Research. 31 3.7 JAPAN: THE INSTITUTE FOR HEALTH ECONOMICS AND POLICY The Institute for Health Economics and Policy (IHEP) is a research, nonprofit corporation.8 It was established in 1993 to promote the studies of health economics and policy in Japan. IHEP was founded in response to a growing demand on health economics research, with the strong support of specialists, researchers, medical institutions, and the related industries. The research institute is approved by the Ministry of Health, Labor and Welfare and it receives the full support of academia, the health care industry, and the Japanese government. The establishment of IHEP was intended to activate the policy argument regarding Japanese health care issues, promote empirical studies in this field, and contribute to the development and improvement of health care policies (IHEP 2021). Mission: To promote research on the medical economy and medical/long-term care policy to contribute to the development and improvement of medical/long-term care policy in Japan. IHEP’s main function is to study the distribution of health care–related resources and various economic and financial problems from the practical aspects of experience and policies. Additionally, it educates specialists in health care economics, participates in training health care staff, and networks with related research institutes. IHEP’s organizational structure is aligned to these functions (Figure 7). Its Research Department conducts research on important policy issues through transdisciplinary approaches. Its Public Relations Department plans various projects such as academic symposia, meetings organized according to themes, research meetings, and educational events and provides members with relevant information. Furthermore, IHEP’s functioning is supported by the Infrastructure Department and General Affairs Department. Figure 7. Organizational Structure of the Institute for Health Economics and Policy Source: World Bank, based on IHEP 2021. IHEP has six priority research fields: health expenses and long-term care expenses, medical fees and the long-term care system, the health care system, medical and nursing care services, the health care industry, and international comparative research. Focusing on the continuously increasing national health expenses, IHEP conducts research on trends in expenses, long-term care expenses, factors that increase the expenses, and the long-term care insurance system. Research results are published in different types of publications (Table 12). 8 Additional information about IHPE is available at https://www.ihep.jp/. 32 Table 12. Examples of Publications and Research Performed by the Institute for Health Economics and Policy Periodic publications Monthly IHEP Health Economics Research Data collections List of national insurance medical institutions Books Reconsideration/Optimization of Medical Expenses—Policies Based on Empirical Analysis and Philosophy Research reports Survey Report on the Medical Security System in the Middle East Price Bargaining Power and Trading Practices in the Distribution of Medical Drugs Projects Health and Health Promotion Project for Elderly Journals Asian Pacific Journal of Health Economics and Policy Source: World Bank, based on IHEP 2021. 3.8 SAUDI ARABIA: THE GENERAL DIRECTORATE OF NATIONAL HEALTH POLICIES AND ECONOMICS OF THE SAUDI HEALTH COUNCIL The Saudi Health Council (SHC) develops and approves policies for the coordination and integration of all health care providing authorities in Saudi Arabia.9 It operates under the chairmanship of the minister of health. The SHC was established in 2002, with powers to prepare the health care strategy; issue regulations to ensure that hospitals run by the Ministry of Health and other government agencies are operated in adherence to the principles of economic management as well as performance and quality standards; conduct periodic evaluations and revisions of health policies and plans; study and assess the quality of health services; make the necessary recommendations on the countrywide distribution of all health services; implement the policies, plans, programs, and projects contained in the national health care strategy; and coordinate with all government agencies that provide health services on the establishment of hospitals and specialized health projects and programs. The SHC’s General Directorate of Health Care Strategy was established in 2009. The directorate changed its mandate and name in 2018 to the General Directorate of National Health Policies and Economics. Mission: To develop national health policies based on the principles of economic management, cost accounting, and evidence-based validation to improve the Saudi health care system and contribute to achieving the country’s strategic objectives; and to monitor, evaluate, and modify the operational plans of the health care strategy in the country in cooperation with all relevant entities. The SHC’s General Directorate of National Health Policies and Economics is responsible for health economics evaluation to inform evidence-based health policy, national programs, and knowledge management. The vision of the directorate is to be the main reference for sustainable health strategies in Saudi Arabia for all health sectors in the country, in line with Vision 2030 (SHC 2021). There are four units organized in the directorate (Figure 8). The directorate aims to (1) 9 Additional information about the SHC is available at https://shc.gov.sa/en/Pages/default.aspx. 33 identify the factors affecting the distribution and provision of high-quality health services while maintaining the optimal use of resources in the Saudi health care system; (2) submit recommendations and results of projects and studies to the decision-makers; (3) formulate policies and action plans; (4) promote professionalism in health care practices in public and private health sectors; and (5) implement the projects and programs of the health strategy in Saudi Arabia. Figure 8. Organizational Structure and Functions of the Saudi Health Council’s General Directorate of National Health Policies and Economics Source: World Bank. The Health Economics Unit is responsible for generating evidence through the analysis of national data, international experience, and health information. The unit analyzes routine and ad hoc data from primary and secondary data sources that are used in monitoring and evaluation, with the goal of providing evidence-based recommendations for health policy (Table 13). Routine data are collected from various primary data sources, including surveys and governmental data systems such as the Integrated Financial Management Information System for financial data, health management information system for service use, and payroll systems for human resource data. Ad hoc data analysis in response to requests for specific studies to address health policy questions include working with relevant authorities to conduct household or patient surveys for agreed-upon topics or to conduct more in-depth analysis to examine a strategic issue uncovered from the routine data analyses where additional information is needed. Table 13. Examples of Publications and Research Performed by the Saudi Health Council’s General Directorate of National Health Policies and Economics Periodic publications Health System Status (Performance Assessment) Report Public Expenditure Reviews Data collections National Health Accounts 34 Human Resources for Health Data Portal High-Value Medical Equipment database Research reports System Responsiveness of the Saudi Health System Pharmaceutical National Policy Hospital Efficiency Study Transfer, Acceptance, and Referral for Emergency Health Services Challenges and Opportunities for Physicians and Nurses National Masterplan for Data Observatory and Health Information and Data Analytics Source: World Bank. 3.9 SWEDEN There are two organizations that perform health economics research and analysis functions in Sweden: the Swedish Institute for Health Economics and the Swedish Agency for Health and Care Services Analysis. 3.9.1 The Swedish Institute for Health Economics The Swedish Institute for Health Economics (IHE) is an independent, privately owned research institute, established in 1979. 10 IHE works in Sweden and internationally with a range of clients including government agencies, payers, health care providers, advocacy groups, and the life science industry. It also works with health economics and clinical groups at universities. Its main areas of expertise are (1) economic evaluation of pharmaceuticals and medical technology, (2) health economics modeling, (3) organization and financing of health, (4) functioning and performance of the pharmaceutical market, and (5) preferences for health and health care interventions (IHE 2021). Mission: To contribute to sound decision-making in the health care setting by bridging the gap between the academic, commercial, and health care providers. IHE establishes and maintains collaboration with Swedish and international researchers. IHE has ongoing projects with over 50 clients, representing national authorities, pharmaceutical companies, health care providers, branch organizations, and patient interest groups (IHE 2021). In Sweden, it has established research collaboration with Lund University, Umeå University, and Karolinska Institute. IHE participates in consortia that implement European-level research projects, such as the European Value of a Quality-Adjusted Life Year (EuroVaQ) project that develops robust methods to determine the monetary value of a quality-adjusted life year across several countries. In addition, IHE has organized a network of Swedish health economists and hosts its annual meetings. The IHE has one of the largest teams of health economists in Sweden and is dedicated to promoting academic excellence. Its multidisciplinary team consists of approximately 25 specialists in health economics, medical science, and statistics. Out of these, 10 hold PhDs, 2 are 10 Additional information about the IHE is available at https://ihe.se/en/. 35 PhD students, and half of the staff have over 10 years of experience. IHE publishes its work in peer-reviewed journals and its own report series, IHE Report (Table 14). The IHE staff publishes 20–30 papers annually (IHE 2021). Table 14. Examples of Publications of the Swedish Institute for Health Economics IHE report series Disease Burden Associated with COVID-19 in Sweden–QALYs Lost Due to Excess Mortality Quality-of-Life in the Swedish General Population during COVID-19–Based on Measurement Pre- and Post-Pandemic Outbreak The Cost of Cancers of the Digestive System in Europe Health Economic Analysis of Targeted Screening for Lung Cancer of Smoking and Formerly Smoking Women in the Stockholm Region Production Loss: A Methodological Review and Calculations Comparator Report on Cancer in Europe 2019—Disease Burden, Costs and Access to Medicines Source: World Bank, based on IHE 2021. 3.9.2 The Swedish Agency for Health and Care Services Analysis The Swedish Agency for Health and Care Services Analysis assesses and analyzes both publicly and privately funded health and medical services, including dental care, and certain aspects of social services from a patients' and citizens' rights perspective. 11 It reports on the quality and efficiency of activities and assesses the effects of government reforms and initiatives. The agency was formed in 2011. It is tasked with strengthening the development of more patient- and person-centered health and social care services by assessing the possibilities for patients and their families to be involved and participate in the care process (Swedish Agency for Health and Care Services Analysis 2021). The agency’s work is done from an independent position. Mission: To follow up and analyze health care, dental care, and social services from the perspective of patients and citizens. The Swedish government is the agency’s primary client. The agency analyzes how health and care services work and reviews how effective governmental commitments and activities are in the area. The agency assists the Swedish government with advisory support and recommendations for making the operation and governance of state-run institutions more effective. It also evaluates the effects of governmental reforms and initiatives, on the request of the Swedish government. Further, the tasks of the agency include keeping abreast of relevant developments in the health care field and performing international comparative studies (Swedish Agency for Health and Care Services Analysis 2021). The agency is led by a board of directors that makes decisions on the main strategic direction of activities as well as on which reports are to be published. The Director of Agency is responsible 11 Additional information about the Swedish Agency for Health and Care Services Analysis is available at https://www.vardanalys.se/in-english/. 36 for day-to-day operations. The board can appoint experts and reference groups as necessary to gain access to vital knowledge in various areas. The agency is a relatively small organization, with about 45 employees. There is a Patients’ Council affiliated with the agency that is tasked with identifying and submitting proposals regarding suitable areas for analysis and review. The task of this advisory body is to assist the agency in identifying the information needs of patients and citizens. The council consists of representatives of patients and users of health and social care services (Swedish Agency for Health and Care Services Analysis 2021). The Swedish Agency for Health and Care Services Analysis decides yearly on an analysis plan that sets out the main strategic direction for operations. The research areas are selected with the aim of generating research projects, using the following four criteria: (1) there must be a clear potential for improvement; (2) the area must be insufficiently researched; (3) the agency must, owing to its independent position, be better suited than others to conduct an analysis or review for objective reasons; and (4) the analysis can generate recommendations for the Swedish government (Swedish Agency for Health and Care Services Analysis 2021). The reviews and analyses are either conducted by the agency’s own staff or with the help of external researchers. Some of the research projects are long-term ones, continuing over several years (Table 15). In addition to the planned research, the agency also initiates and undertakes other priority reviews and analyses that are deemed justified. Table 15. Examples of Publications and Research Performed by the Swedish Agency for Health and Care Services Analysis Periodic publications Care from the Population’s Perspective Care from the Primary Care Physicians’ Perspective Care from the Patients’ Perspective Research reports Free Contraceptives for Young People: A Follow-Up of the Investment in Women’s Health Free Mammography: A Follow-Up of the Investment in Women’s Health Private Health Insurance: A Knowledge Base on Possible Consequences for Patients and Citizens Projects Efficiency and equality in the consumption of digital care visits Evaluation of the agreement on digitalization in elderly care Source: World Bank, based on information from Swedish Agency for Health and Care Services Analysis 2021. 37 3.10 THAILAND There are two organizations that perform health economics research and analysis functions in Thailand: the Health Intervention and Technology Assessment Program and the Health Systems Research Institute. 3.10.1 Health Intervention and Technology Assessment Program The Health Intervention and Technology Assessment Program (HITAP) is a semi- autonomous research unit under Thailand’s Ministry of Public Health. 12 It was set up in 2007, with the aim of generating evidence necessary for priority setting and resource allocation of health technologies and initiatives (HITAP 2021). During its initial phase, HITAP conducted a number of research studies involving cost-effectiveness analysis and carried out various capacity-building activities. Two previous attempts were made to establish health technology assessment at the national level in Thailand (Tantivess, Teerawattananon, and Mills 2009). The program introduced in 1993 failed to scale up, eventually fading out because of insufficient human resources and infrastructure for health economics appraisal. An international collaborative research project ended in 2009 without reaching a long-term commitment to using information on cost-effectiveness. Mission: To create innovation and excellence in health technology assessment for the benefit of society. HITAP’s goal is to make health technology available, accessible, and appropriately utilized in Thai society. To achieve the goal, it efficiently and transparently appraises health interventions and technologies using international, standard, and qualified research methodologies; develops systems and mechanisms to promote the optimal selection, procurement, and management of health technology; and distributes research findings and educates the public to make the best use of health interventions and technology assessment results. HITAP works together with administrators and academics, involving in its work both local organizations (for example, Mahidol University) and international organizations and programs such as the National Institute for Health and Care Excellence (United Kingdom), the International Decision Support Initiative, and the international Capacity-Building Program on Universal Health Coverage (HITAP 2016). HITAP has a flat organizational structure. Its activities are clustered into four units (Figure 9): research, communications, international capacity building, and administration (Culyer, Podhista, and Santatiwongchai 2016). The Research Unit is the largest one. All units are under supervision of the program leader. HITAP is a relatively small organization that does not require a more complex organizational form. It began in 2007 with 12 staff members and grew to about 60 staff (42 full-time employees) by 2016. Most of them were research staff, including research assistants and postgraduate students. About half of the research staff had a pharmacy background. 12 Additional information about HITAP is available at https://www.hitap.net/en/. 38 Figure 9. Organizational Structure of the Health Intervention and Technology Assessment Program Source: World Bank, based on Culyer, Podhista, and Santatiwongchai 2016. Over time, HITAP has come to rely less on Ministry of Public Health funding, and funding from international sources has increased significantly. Public funding for HITAP comes from four main sponsors: the Thai Health Promotion Foundation, the Health Systems Research Institute (HSRI), the National Health Security Office, and the Bureau of Policy and Strategy (Culyer, Podhista, and Santatiwongchai 2016). In addition, HITAP receives funding from various nonprofit international organizations—both governmental and nongovernmental, such as the Center for Alcohol Studies, the Global Development Network, and the Bill & Melinda Gates Foundation. HITAP is accountable to them through the various research contracts that it holds. HITAP is semi- autonomous because of its diversified portfolio of funding, its arm’s length relationship with the Ministry of Public Health, and the creation of the Health Intervention and Technology Assessment Foundation in 2010. HITAP’s health technology assessment decisions have more than paid for its annual operating costs (Glassman and Chalkidou 2012). More than 150 studies have been conducted by HITAP during the past decade. Most of the research work fed into the national policy-making process. HITAP’s research, including cost- effectiveness studies and budget impact analysis, has been formally embedded as part of coverage decisions such as the development of a reimbursable medicines list and the benefit package of the Universal Health Coverage scheme (Table 16). HITAP is formally part of the Ministry of Health’s team that designs the universal coverage package in Thailand. Each year, representatives of policy makers, health professionals, academics, patient associations, civic groups, lay citizens, and the health care industry can propose topics for the health technology assessment. A panel comprising representatives of health professionals, academics, patients, and civic groups selects at least 10 topics a year for the assessment (Glassman and Chalkidou 2012). HITAP’s assessments have also been used to inform the essential medicine list in Thailand. Besides the policy analysis role, HITAP implements strategies to support the national health technology assessment process, such as capacity building for researchers and users; development of guidelines, tools, and a database of studies; and knowledge management strategies (Tantivess et al. 2017). 39 Table 16. Examples of Publications and Research Performed by the Health Intervention and Technology Assessment Program Periodic publications HITAP newsletter Annual report Research reports Guidance on Use of Modelling for Policy Responses to COVID-19 Cost Analysis of Health Promotion and Disease Prevention Services Cost-Utility Analysis of Seasonal Influenza Vaccine among School Children in Thailand Research brief Who Are the High-Cost Users in Thailand’s Universal Coverage Scheme and How Can We Help? Policy briefs Rationing Scarce Critical-Care Resources during the COVID-19 Pandemic in Thailand Cutting Future Health Care Costs through Population-Wide Sodium Reduction Policy Source: World Bank, based on HITAP 2021. HITAP’s policy impact goes beyond Thailand—it has supported other countries in assessing a large number of interventions when developing a health benefits package. A pilot study from a lower-middle-income country, conducted in collaboration with HITAP, demonstrated that by removing inappropriate indications, ones with no evidence of clinical benefit and indications with poor value for money, a significant part of the budget could be freed up for further investments (Glassman, Giedion, and Smith 2017). The study confirmed that it was critical to specify medical indications for each intervention that is to be reimbursed in the health benefits package. The findings have informed policy change in the country, ensured a rational use of technologies, and helped secure sustainable financing to expand universal health coverage across the country. An analysis conducted by HITAP showed that potential uses of economic evaluation in Asian countries include the development of public reimbursement lists, price negotiation, the development of clinical practice guidelines, and communicating with prescribers (Yothasamut, Tantivess, and Teerawattananon 2009). 3.10.2 Health Systems Research Institute The Health Systems Research Institute (HSRI) is an autonomous state agency established by the Health Systems Research Institute Act of 1992. 13 HSRI is responsible for strategic planning of the country’s health policy and system research and advocating knowledge-based policies. Its vision is to become the leader in the research systems for developing policies to achieve health of the nation. HSRI’s strategies focus on establishing research alliances and collaborating with multisectoral partners to facilitate policy actions toward equitable and sustainable health system (HSRI 2021a). Mission: To develop research systems to drive knowledge in a directional and engaging way. 13 Additional information about HSRI is available at https://www.hsri.or.th/en/people. 40 HSRI’s organizational structure was designed to allow the institute flexibility in the ever- evolving economic, social, and political environment. Working in partnership with multilevel public and private agencies, HSRI’s main goal is to achieve effective knowledge management in the health system. It has a multisectoral Executive Board, chaired by the Ministry of Public Health, that provides guidance and direction for HSRI’s strategic plans and performance (Figure 10). Permanent members of the Executive Board are the Minister of Public Health, the Permanent Secretary for Public Health, the Permanent Secretary for Agriculture and Cooperative, the Permanent Secretary for Education, the Permanent Secretary for Science and Technology, the Permanent Secretary for Industry, the Secretary-General of Commission on Higher Education, the Secretary-General of the National Research Council, the Secretary-General of the National Economic and Social Development Board, and the HSRI Executive Director. Figure 10. Organizational Chart of the Health Systems Research Institute Source: World Bank, based on HSRI 2021a. HSRI builds and maintains the partnerships with a wide range of national and international stakeholders. Its national partners include the Health Insurance System Research Office, the Institute for Development of Human Research Protection, the Central Office of Health Care Information, the Medical Audit Development Office, the Thai CaseMix Center, the Thai Health Information Standards Development Center, the Institute of Community-Based Health Care Research and Development, the Center for Alcohol Studies, the Society and Health Institute, the International Health Policy Program Thailand, HITAP, the Health Information System Development Office, the Leadership Network for the New Health Movement, the National Health Foundation, the Foundation of Thai Gerontology Research and Development Institute, the Knowledge Base and Knowledge of Health System, and the Human Resources for Health Research and Development Office (HSRI 2021a). HSRI ensures the availability of HSRI-supported research by publishing it at its Knowledge Bank (Table 17). Table 17. Examples of Publications and Research Performed by the Health Intervention and Technology Assessment Program Research reports Pay for Performance for Increased Efficiency in Health Service System under the Ministry of Public Health Cost Determination and Allocation in the Context of the Health Service Provisioning Method National Health Security Program Long-Term Finance: Estimates, Expenses, and Income Sources 41 Allocation of Funds and Financial Situation of Primary Care Facilities (Health Centers) under Universal Health Coverage Co-Payment in the Universal Health Coverage System: A Policy Analysis Ensuring Access to Essential Medicines in Thai Universal Health Coverage: Lessons Learned from Thailand How Financing and Payment Mechanism Influence Drug Use Journals Journal of Health Systems Research Source: World Bank, based on HSRI 2021b. HSRI functions as a knowledge broker in generating knowledge and evidence to support policy decisions on health care reform. HSRI, receiving annual government budget support, is mandated to generate and promulgate knowledge about health systems in support of policy decisions. It connects the research institutions that generate knowledge and evidence, HITAP included, with policy makers. Following the introduction of the universal coverage policy in Thailand, HSRI launched a research plan on universal coverage monitoring and evaluation. It facilitated the gradual building up, strengthening, and sustaining of institutional capacities in health policy and systems research in Thailand. The growth of the number of qualified researchers was made possible through national networking, international collaboration, and consistent support by strategic partners. Production of the high-quality evidence in a timely manner and in an environment that was free from conflict of interest facilitated evidence-guided financing reforms in Thailand, such as the provider payment reforms and the fine-tuning of the benefit package for the universal coverage scheme (Clements, Coady, and Gupta 2012). 3.11 UNITED KINGDOM: THE NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE The National Institute for Health and Care Excellence (NICE) was established in 1999 with the aim of creating consistent guidelines and ending the rationing of treatment by postcode across the United Kingdom (NICE 2021a). 14 Initially named the National Institute for Clinical Excellence, it was required to undertake appraisals of new and established interventions with a view to deciding whether they were appropriate for use in the National Health Service (NHS). Furthermore, it was mandated to develop clinical practice guidelines, taking into account both clinical effectiveness and cost-effectiveness (Rawlins 2012). The creation of NICE led to cost-effectiveness becoming an overt component of decision-making in the NHS. NICE changed its status from a special health authority to an independent nondepartmental public body in 2013. It incorporated functions of the Health Development Agency in 2005, the National Prescribing Centre in 2011, and the NHS Technology Adoption Centre in 2013. Mission: To improve outcomes for people using the NHS and other public health and social care services. NICE strives to improve outcomes for health and social care service users by (1) producing evidence-based guidance and advice for health, public health, and social care practitioners; (2) developing quality standards and performance metrics for those providing and commissioning 14 Additional information about NICE is available at htps://www.nice.org.uk/. 42 health, public health, and social care services; and (3) providing a range of information services for commissioners, practitioners, and managers across health and social care (NICE 2021a). The organization is split into seven directorates (Figure 11). Figure 11. National Institute for Health and Care Excellence’s Directorates and Their Key Responsibilities Source: World Bank, based on NICE 2021a. Note: The figure does not provide a comprehensive description of NICE directorates’ responsibilities but focuses on the responsibilities relevant for the review. NICE = National Institute for Health and Care Excellence. NICE is internationally recognized for providing evidence-based clinical guidelines to help health professionals deliver the best possible care. NICE clinical guidelines’ recommendations are based on relevant, reliable, and robust evidence identified using systematic, transparent, and reproducible literature searches (Garbi 2021). A review of the economic evidence is carried out in parallel with the review of clinical evidence. The clinical guidelines’ recommendations reflect both the clinical effectiveness and the cost-effectiveness of interventions. The main type of cost- effectiveness analysis performed by NICE is cost–utility analysis. If the most effective intervention is more costly, then the incremental cost-effectiveness ratio is considered. In case of a high degree of uncertainty in the economic evidence review and high resource implications of an intervention, health economics modeling is performed. Following their initial publication, the clinical guidelines are updated in line with new evidence. NICE performs a comprehensive and extensive standard check of published guidelines every five years. The clinical guidelines topics and other research areas (Table 18) are selected in collaboration with NHS England, the Department of Health and Social Care, and Public Health England to reflect national health priorities. Table 18. Examples of Publications and Research Performed by the National Institute for Health and Care Excellence Projects Extending the QALY Measuring patient preferences Applied research What Risk Factors Predict the Onset of Substance Misuse in Young People with Psychosis? 43 What Service Delivery Models Allow People with Psychosis and Coexisting Substance Misuse to Remain Living Outside Hospital? NICE guidance Antimicrobial Prescribing Guidelines COVID-19 Rapid Guidelines NICE indicators General practice indicators suitable for use in the quality and outcome Framework National library of quality indicators Source: World Bank, based on NICE 2021a. NICE builds partnerships and works actively with a range of stakeholders, including researchers, funders (such as the Medical Research Council); charities, academic institutions (such as the Manchester Academic Health Sciences Centre and the University of Manchester); and policy organizations, enterprises, nonprofit organizations, and think tanks (such as the New Drug Development Paradigms program). It collaborates on data collection with stakeholders from various sectors such as Public Health England, the Department of Transport, the Department of Health and Social Care, and the National Health Service Statistics. 3.12 CENTRAL ASIA: THE KYRGYZ REPUBLIC HEALTH POLICY ANALYSIS CENTER AND TAJIKISTAN HEALTH POLICY ANALYSIS UNITS Both the Kyrgyz Health Policy Analysis Center (HPAC) 15 and the Tajik Health Policy Analysis Unit (HPAU) were first introduced during the early 2000s. These were initially supported by development partner projects, given the limited capacity on the ground. The Tajik HPAU took the form of a dedicated unit under the Ministry of Health’s Department of Planning, while the Kyrgyz HPAC benefited from a more independent institutional setup, with the Ministry of Health seated on its board along with other ministries. It is worth noting that both institutions fulfilled their task with a rather limited number of staff and progressively growing analytical capacity. Mission: To support evidence-informed decision-making in health care and to carry out health policy research. As a result of this broad mission, both the HPAC and the HPAU are involved in a great variety of tasks in support of their respective Ministries of Health and other institutions. Both institutions produced a number of studies (60 to date in the case of the HPAC), often based on ad- hoc patient or facility surveys, to sustain the health policy dialogue with up-to-date and methodologically sound evidence. They are also in charge of developing the monitoring and evaluation framework of national health strategies and facilitating the frequent review process of monitoring progress (Table 19). These units are also engaged in recurrent analytical tasks such as the computation and analysis of national health accounts. Finally, they also organize capacity- building events on health policy at national and regional levels. 15 For more details on the Kyrgyz experience in evidence generation for health policy making (beyond HPAC), see WHO EMRO 2020. 44 Table 19. Examples of Products Developed by the Kyrgyz HPAC and Tajik HPAU Selected analytical Financial gap in the implementation of the state-guaranteed benefits products package in health care organizations working in the single payer system (HPAC) Accessibility to medical services and out-of-pocket expenses in Kyrgyzstan: Household survey from 2001–2010 (HPAC) Report on study finding: Analysis of the existing system of marketing, promotion, and advertising of infant formula (breast milk substitutes) in the Kyrgyz Republic (HPAC) Patient survey on the impact of the introduction of the Basic Benefit Package Fee Exemption Scheme on patients’ out-of-pocket payments and satisfaction (HPAU) Recurrent production of national health accounts following A System of Health Accounts 2011 methodology (HPAC and HPAU) Support to the Development of the Manas and Manas Taalimi National Health Strategy national strategic Monitoring and Evaluation Framework (HPAC) effort Development of the National Health Strategy 2010–20 Monitoring and Evaluation Framework (HPAU) Selected capacity Facilitation of the Eurasian National Health Accounts network (HPAC and building HPAU) Source: World Bank. 45 PART IV – CONCLUSIONS AND RECOMMENDATIONS FOR THE LIBYAN CONTEXT The Libyan Ministry of Health could influence policy making with evidence generated by its health economics unit. Experiences from other countries suggest that health economics institutions can impact health policies and health systems. Evidence generated by the HEF Directorate in Afghanistan supported the development of health financing strategies. Production of high-quality evidence in an environment that was free from conflict of interest facilitated evidence- guided financing reforms in Thailand. HITAP’s research, including cost-effectiveness studies and budget impact analysis, has been formally embedded in decision-making on an essential medicine list, reimbursable medicines list, and health benefit package in Thailand. The work of CIHI facilitated the adoption of electronic health records, contributed to the expansion of activity-based funding, and fostered the culture of performance in the Canadian health system. The CNHRDC’s work impacted drug assessment, drug pricing, drug reimbursement, and drug procurement policy in China. Based on these experiences, the Libyan Ministry of Health might strive to use its health economics unit to generate evidence required for health financing strategy development and basic health package formulation and fine-tuning. The need for the existence of national health economics capacities has become more prominent worldwide in the time of COVID-19. Both existing and projected impacts of COVID- 19 on health services and health outcomes need to inform prioritization and allocation of public expenditures in all countries. International research, evaluations, analyses, projections, and tools are useful in this regard, but their findings are not necessarily directly applicable to a specific country context. The countries where the institutions that perform health economics functions exist have advantages of being able to (1) perform economic evaluations that build on findings of research conducted elsewhere, (2) generate supplemental evidence for decision-makers based on the national data, (3) base policy recommendations on national evidence, and (4) tailor policy recommendations to the evolving circumstances in the particular country. Health economics institutions can take a neutral position on COVID-19 policies—they neither create policies nor are they accountable for policy implementation. Libya’s health economics unit can have a comprehensive mandate and gradually take on additional capacities as part of a phased approach. Most institutions that perform health economics functions perform four tasks: data collection, health economics evaluations, policy recommendations provision, and results dissemination. They often produce a range of products and use various dissemination channels to reach their target audiences. Most institutions have some level of autonomy that allows them to perform all the tasks, even when they function under public institutions. Most institutions are publicly funded governmental or nonprofit academic institutions. Typically, they rely on multiple sources of funding, including public financing and grants. Some institutions that operate as think tanks rely primarily on client budgets. In the Libyan context, given the country’s unique capacity constraints, it is essential for the unit to adopt a phased approach, starting first with the production of key data and analytics to inform decision-making, and then gradually moving on toward conducting economic evaluations, policy recommendations, and results dissemination. Once established, Libya’s health economics unit could use several types of data in its analytical work. The unit might collect and analyze routine and ad hoc data from primary and secondary data sources, with the goal of providing evidence-based recommendations for health policy. Routine data on the availability and use of health care services, infrastructure, technologies, human resources, pharmaceuticals, quality, revenues, and expenditures are, in other countries, collected regularly to compile performance indicators or to produce an annual or biannual health 46 sector performance assessment report (Box 3). These data are collected in Libya from various primary data sources including other departments of the Ministry of Health, surveys, governmental data systems, health management information systems, and payroll systems. Ad hoc data analysis and studies in response to requests for specific analyses may include working with relevant authorities to conduct surveys or to conduct more in-depth analysis to examine a strategic issue uncovered from the routine data analyses. Box 3: Potential Phased Priorities for Libyan Health Economics Unit Immediate priorities: • Production of the national health accounts • Conducting a health financing situational analysis to document revenue raising, pooling, purchasing, and governance arrangements • Health budget and expenditure analyses • Developing noncommunicable diseases investment case to identify priority areas, as well as engagement of the private sector service delivery network Medium-term priorities: • Periodic production of health sector performance assessment report • Development of the health financing strategy for Libya, informed by a situational analysis • Routine in-time policy analyses on the implementation of health financing strategy, with a focus on scaling up financial risk protection • Generating evidence for introduction of pro-health taxes in Libya • Defining and regularly updating benefits package • Assessing value for money of the potential public-private partnerships • Assessing cost-effectiveness of new technologies Positioning the health economics unit under the Libyan Ministry of Health has both advantages and disadvantages in terms of the flow of data and information between the unit and relevant health sector decision-makers. The unit would be able to directly access all the data already available in the ministry, as it would be a public institution. The ministry would also be able to regulate and enforce provision of additional data by other health stakeholders and other sectors—which might not be the case if the unit had a different legal status. The unit would have a direct access to decision-makers from the ministry. Evidence generated by the health economics unit could be seen as the evidence generated by the ministry, thus having a higher chance of being accepted and used by other stakeholders. On the downside, the unit might encounter issues with accessing the data from the private sector facilities, have a limited independence in defining its research and analytical priorities, and struggle in maintaining a neutral or critical stance. The success of the unit would be contingent on the strength of the stewardship capacity of the Ministry of Health: a strong ministry can encourage the sharing of information and improve the relevance of the health economics unit for all stakeholders in the health sector. The Libyan Ministry of Health would need to ensure continued professional development of its health economics unit’s staff. Available staff who can perform the health economics functions are crucial for functioning of the unit. Profiles and qualifications of staff hired by the health 47 economics institutions are relatively standardized. The health economics tasks require health economists, public health specialists, epidemiologists, data scientists, and communication specialists. The multidisciplinary teams preferably involve professionals with a doctoral or master’s degree. The required number of staff varies and depends on the size of the institution. Health economics units functioning under wider public institutions can partially rely on other organizational units for required expertise. Continued professional development can take place within the institution that performs health economics functions. In some cases, the institutions have funded external continued professional development for their staff, particularly in the initial operation period. Collaboration with international and national governmental and academic institutions is a universal practice. The partnerships exist across all the institutions covered by the review. Academics who hold joint positions plausibly link the health economics institutions with universities and provide an entry point for partnership building. Strong partnerships with governmental institutions are needed to ensure that all four health economics functions are performed. Not all the data needed for health economics research and evaluations can be collected by a single organization. Partnership with governmental institutions is needed to access additional data sets. Research and evaluations better meet the needs of clients when analyses are jointly planned with governmental departments that need to make use of the results. By establishing strong links with other departments in the Ministry of Health, Libya’s health economics unit can facilitate improvement of health economics and health system data collection. Timely collaboration with the provider agencies can help in translating evidence into policy, and policy into the practice. Open communication with other Libyan agencies that perform analytical and research tasks facilitates coordination and can allow the health economics unit to avoid duplication of efforts. Involvement of governmental institutions in disseminating results increases the credibility of the research and findings. Coordination with internal and external stakeholders is required to assure that the evidence generated is actually used for policy and health programs, especially considering the currently significant role of the private sector in service delivery. Libya and other countries that consider establishment of the health economics unit can learn several lessons from experiences of the health economics institutes covered by the review: ➝ A prerequisite for the establishment of the unit is the authorities’ genuine intention to rely in decision-making on evidence. One of the ways to start expressing this intention is to actually make use of the health economics unit’s products in the policy evaluation process. The culture of evidence-use in policy making needs to be built and strengthened by the authorities. Otherwise, the health economics unit might have only political relevance at a particular time and stagnate instead of developing. ➝ An appropriate host organization needs to be selected. Wider governmental institutions that already have data collection functions and provide inputs into health policies, as well as the Ministry of Health, are well-suited to host the health economics unit. When the Ministry of Health is selected to host the health economics unit, the ministry needs to adopt its new organizational chart, positioning the unit close to other departments with which the unit would be collaborating. When an independent governmental institution is selected to host the unit, it is recommended to choose a reputable organization that is able to conclude service contracts and charge a fee for its services. ➝ Health economics units have different development paths, embodying a phased approach. Many of them started small, either as a stand-alone institution or a health economics unit within a wider public institution. They matured and transformed as the need emerged and the resources allowed, through a phased and iterative process. 48 ➝ Initial investment in staff development will be required. Not all types of needed professionals may be easily available locally or nationally. The countries that have no academic programs in health economics might need to rely on health economists educated abroad. If such professionals are not available, investment in their education would be needed. Even when all the professionals are immediately available, external support might be needed in conceiving the unit, setting it up, choosing products, preparing a workplan, building capacities, conducting the first research and evaluations, and disseminating findings. ➝ The unit can start with a limited number of workstreams and products and expand the range later. It is recommended not to include too many areas of work or products in the initial medium-term plan and annual workplan. Initial efforts need to focus in parallel on team building, capacity strengthening, and establishing internal procedures and partnerships. Several areas of work with few periodic products and few on-demand products are a good start for a unit’s medium-term plan. Both the existing competencies of staff and the needs of policy makers should be considered when selecting the initial areas of work and set of products. It is advisable for the health economics unit to plan for the wide dissemination and publication of its products to facilitate its reputation and legitimacy building. ➝ Capacity building should be an integral part of the health economics unit’s functioning. The unit can use its products in preparing and delivering different types of training, striving to becomes a national knowledge and resource hub to the health policy and health care management community. Some of the internal capacity-building events could be opened up for wider participation, allowing the unit to communicate on its mission, priorities, and plans to the key national stakeholders. Collaborations with academic and research institutions can result in two-way capacity building between all relevant health economics and financing stakeholders. ➝ Prolonged public financing might be necessary. Public sector entities are the primary clients for the health economics unit established within a governmental institution. Prolonged public financing is needed to ensure sustainability of the unit in the longer term. Only when the unit has built its reputation nationally, it could be able to offer its services at the market. ➝ Networking and partnership-building activities need to be integral parts of the initial efforts. The partnership-building activities can take place from the beginning. Dialogue with key stakeholders on position and functions of the health economics unit facilitates the unit’s national positioning. Having a reputable international organization or a university as a long-term partner facilitates building the health economics unit’s legitimacy. Involving key stakeholders in developing initial products may help the unit build its network at the national level and overcome an initial lack of capacity. The unit needs to establish partnerships with other departments in the host institution. It is recommended not to consider the other departments simply as data holders but also as potential knowledgeable participants in the production of the health economics unit’s analyses and as users of the unit’s products. Internal partnerships are crucial in the long term for maintaining the relevance of the unit’s work. There is insufficient evidence from the fragility-, conflict-, and violence-affected countries to provide a specific set of recommendations based on the experiences from these countries. However, the case of Afghanistan indicates that health economics units are purposeful and can operate in these settings as well as in more stable contexts. More efforts might be required to build the team, and training outside the country might need to be part of capacity-strengthening efforts. 49 The HEF Directorate relied significantly on external funding provided by USAID and the European Commission for its initial capacity-strengthening efforts, which had previously supported the functioning of the unit that was transformed into the directorate. Evidence generated through the work of the health economics unit, including the national health accounts, was crucial in considering health financing issues in Afghanistan. 50 APPENDIX A: SELECTED INTERNATIONAL HEALTH ECONOMICS RESOURCES Health economics units operating at a country level can benefit from the analytical work conducted in other settings. A selection of international health economics resources is presented below. These are all online resources, freely accessible, with a variety of features and materials relevant to countries of different income levels. Some of the resources are created or hosted by the organizations reviewed in this paper. GUIDE TO ECONOMIC ANALYSIS AND RESEARCH The Guide to Economic Analysis and Research (GEAR, available at http://www.gear4health.com) is an online resource developed by HITAP (GEAR 2021). It intends to aid health technology assessment practitioners in low- and middle-income countries. GEAR is available free of charge; it provides a guide to addressing the challenges that researchers face when conducting and using economic evaluations. GEAR uses three key features to support the practitioners: GEAR mind maps, GEAR guideline comparison, and GEAR: Ask an expert. The GEAR mind maps—which are tools for conceptualizing ideas and finding solutions—are designed to visualize the process involved in economic evaluation by presenting ideas in a tree-like structure. The right side provides researchers with immediate solutions for their current challenges based on available information. The left side shows researchers which questions arise from the methodological challenges presented and the hypotheses on which they are based. The GEAR guideline comparison section hosts a repository of national and international economic evaluation guidelines that are updated periodically. The Ask-an-expert feature allows registered users to ask advice from an international expert. GEAR maintains a network of volunteer experts who agreed to provide responses (Adeagbo et al. 2018). HITAP INTERNATIONAL UNIT HITAP established its International Unit in 2013 (available at http://www.globalhitap.net), drawing on its local and international experiences, to work at the global level with international organizations, nonprofit organizations, and governments to build capacity for health technology assessment. The international unit aims to build health technology assessment capacity in developing countries; foster collaborations with international and regional organizations, health technology assessment units, and other relevant organizations in other countries; and coordinate technical support and policy advice from relevant institutes in Thailand (HIU 2021). The resource includes reports, publications, mission reports, and infographics produced as part of the HITAP international collaboration. THE INTERNATIONAL DECISION SUPPORT INITIATIVE The International Decision Support Initiative (available at https://idsihealth.org/resources) is a global network of health, policy, and economic expertise that supports countries to make better decisions about how much public money to spend on health care and how to achieve value for money. Its work is underpinned by robust evidence, analysis, and decision-making that policy makers, funders, and researchers can use to balance trade-offs between different policy options and model potential results to make the best choice available (IDSI 2021). All its research, reports, and papers are freely available on an open science publication platform, organized into six areas: tackling health challenges, strengthening health systems and institutions, generating and using evidence, smart purchasing for universal health care, measuring impact, and value for money for sustainable development. 51 INTERNATIONAL HEALTH ECONOMICS ASSOCIATION The International Health Economics Association’s mission (available at https://www.healtheconomics.org) is to increase communication among health economists, foster a higher standard of debate in the application of economics to health and health care systems, and assist young researchers at the start of their careers (IHEA 2021). Various health economics teaching materials, webinar recordings, and conference-related materials are available free of charge at the association’s website, while its members have access to additional online resources, including its networking web platform. NICE INTERNATIONAL In response to requests from overseas policy makers for support in strengthening their own systems and processes for making decisions on how best to allocate their limited budgets, NICE International (available at https://www.nice.org.uk/about/what-we-do/nice-international) was set up in 2008. It offers advice on building capacity for assessing and interpreting evidence to inform health policy and on designing and using methods and processes to apply this capacity for better health around the world. A range of NICE publications, guidance, and standards is open to international users (NICE 2021b). NICE International also offers consultancy services, speaking engagements, seminars, and support to publish, share, translate, and adapt NICE’s content to meet the needs of other countries. UNIVERSITY OF YORK’S CENTRE FOR HEALTH ECONOMICS One of the first university departments of its type, the Centre for Health Economics was founded in 1983 (available at https://www.york.ac.uk/che). It operates across all areas of the discipline, with a particular emphasis on methodological thinking and achieving policy impact. Its research is organized into broad themes, including economic evaluation of health technologies, health policy, econometric methods, equity in health and health care, global health, health and social care, mental health, and public health. A number of research papers, policy briefs, books, staff publications, online courses, and distant learning programs are available through its website (University of York 2021). 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EVIPNET Europe Series Number 4. https://www.euro.who.int/__data/assets/pdf_file/0007/443644/EVIPNet-report- Kyrgyzstan-eng.pdf . Accessed April 12, 2021. ———. 2021. Health Economics and Health Care Financing Programme. http://www.emro.who.int/health-economics/about/. Accessed March 21, 2021. Yothasamut, J., S. Tantivess, and Y. Teerawattananon, Y. 2009. “Using Economic Evaluation in Policy Decision‐Making in Asian Countries: Mission Impossible or Mission Probable?” Value in Health 12: S26–S30. doi:10.1111/j.1524-4733.2009.00623.x. 56 This paper was prepared to support the Libyan Ministry of Health in designing and establishing its health economics unit. Over the past decade, Libya’s health system has been significantly and negatively impacted by the country’s conflict, and the Ministry of Health has not been able to execute key health financing and economics functions due to fiscal and governance challenges. As Libya is moving toward reconstruction and recovery, and with the backdrop of the impact of COVID-19, it is imperative to think through a systematic approach to inform evidence-based decision-making to inform the allocation of resources. This review presents and synthesizes experiences of the institutions that perform health economics functions in selected countries that can be of use for Libya and other countries that consider the option of establishing a health economics unit. More specifically, this review provides examples from different countries on (1) the mission, goals, and key functions of the institutions that perform health economics functions; (2) those institutions’ legal status and their form of organization; (3) what research and analysis they conduct; (4) with whom they need to collaborate; and (5) what international resources are available to them. Based on these examples, the paper proposes concrete next steps for strengthening health economics and financing capabilities in Libya. ABOUT THIS SERIES: This series is produced by the Health, Nutrition, and Population Global Practice of the World Bank. The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account this provisional character. For free copies of papers in this series please contact the individual author/s whose name appears on the paper. Enquiries about the series and submissions should be made directly to the Editor Jung-Hwan Choi (jchoi@ worldbank.org) or HNP Advisory Service (healthpop@worldbank.org, tel 202 473-2256). For more information, see also www.worldbank.org/hnppublications. 1818 H Street, NW Washington, DC USA 20433 Telephone: 202 473 1000 Facsimile: 202 477 6391 Internet: www.worldbank.org E-mail: feedback@worldbank.org