written on 26.03.2013

Interview with Héctor Castro Jaramillo, Executive Director, Institute for Health Technology Assessment (IETS)

Your experience includes working with Tecnoquímicas and NICE in London. What would you say that you can bring from your international experience to IETS?

I can bring certain aspects of every experience in all positions that I have worked. While I have experience in the Colombian health system, I am familiar with the health sector globally as well. I had the opportunity to study overseas to gain theoretical foundations enabling me to analyze how the industry is moving. I think that this is a big advantage when you are leading one of these institutions. Even though Health Technology Assessment (HTA) organizations have been emerging over the last two decades, setting up an institution like IETS in Colombia is a challenge because of the current context at the moment.

IETS came into existence a few months ago. What have been the main priorities since its inception?

Firstly, the institution needed to be set up and established, which is not easy when you start from scratch. You need to develop processes, contract out people, and hire highly capable staff. Secondly, you need to create awareness of what the institution is doing. Thirdly, you have to establish methods and processes, bearing in mind what are considered good HTA practices elsewhere. You also have to start producing results from day one. IETS provides information for decision-making, and historically we have been a little behind in terms of the global trend of using HTA to inform policy-making and clinical practice.

How will the Health Ministry’s health reforms affect HTA in Colombia, and will IETS have to adapt at all as a result?

I think that IETS is in a comfortable position at the moment. No matter what happens, if the country moves from a tax-based health insurance system to a national health system, IETS will produce information for resource allocation decision-making. If we move from an explicit list of benefits within the benefits package to an explicit list of exclusions, IETS still will produce such information.. The sources of funding or the organizational arrangements will not change the need for evidence-based information.

One of the main priorities of IETS is to recommend the development of certain technologies and financing as part of the health reforms. As Executive Director of IETS, what are the main criteria for developing one piece of technology over another?

I am not so sure that that will be the role of IETS. There are different institutions with different roles in Colombia; for instance INVIMA is in charge of regulation of the entry into the market. Once that has been done, within a year, IETS will assess the evidence of incoming health technologies and then provide recommendations about reimbursement and clinical use, but not exactly to recommend the development of those technologies.

How will IETS ensure that accessibility to technologies for the people who need it most is guaranteed?

You have to decide or define as a society what the priorities are. If you rely on the interests of a particular group, of course the developer of that technology is going to be pushing for his work above the agenda. The main point is that certain rules need to be transparent, explicit and legitimate regarding priorities. The primary role of this institution is to maximize benefits, bearing in mind that we have limited resources.. With budget constraints, not all technologies will be available for everyone. You have to set priorities. The main idea is to establish priorities in a legitimate and transparent way, alongside stakeholder engagement to determine those priorities.

What criteria do you use for priorities?

IETS is going to be the institute that executes HTA to inform decision-making about priorities that are expected to be set by the Ministry of Health. The Ministry has been working with us and with the international community on setting up two key moments to establish those priorities. The first is when you select topics, to be appraised and evaluated by IETS. The second is to choose criteria to decide what will be reimbursed with public budget. In the first stage, we worked with international experts to decide on criteria for topic selection, after a broad international review, we selected six: including severity of disease, size of population affected, the interest in public health, requests by civil society, ability to cover needs of vulnerable population, and costs. Once those priorities have been decided and topics have been selected by the Ministry of Health, IETS will work assessing those technologies. Additionally, the government has been looking at experiences like the Canadian Multi-Criteria Decision Analysis (MCDA) approach, in which 15 criteria were selected to be used when you have to decide on what technologies to reimburse with public budget.

Which model do you think Colombia should look at most?

This is a globalized era; therefore, rather than reinventing the wheel, one must take the best of every model. Many systems are adaptable and of course you have to create your own system. In the case of the Canadians, they created a very interesting systematic review of 40 countries in 2008 on how different countries select criteria for resource allocation decision-making. At the end of the day, we are all human beings, and priorities are priorities. This criteria selection is a primary framework for decision-making that seems transparent and an attempt to clarify a very blurry situation, turning qualitative analysis into a more quantitative approach.

Historically, has there been any conflict of interest among stakeholders that you would note as being more significant than others as part of this prioritization process?

All stakeholders have interests. I would not be able to say if one interest is more important or tangible than another. Of course, the patient has an interest to access medicines he or she believes will save his or her life. Government agents, developers and the medical community have their own interests as well. You have to be aware of that and be capable of being transparent when declaring vested interest as well as acting in a systematic and organized manner when deciding on particular interests.

Colombia is known for having a number of medical device companies in the country, from multinationals to local players. What are the main characteristics of Colombia that make it such an attractive market for this niche?

Colombians are very creative people. When you have a lack of resources and are working in a closed environment (before the 1990s, Colombia was a closed economy), you have to be creative and really try to provide what you think is the best. Colombia also has very skilled people who are interested in many therapeutic areas such as ophthalmology or neurology, where Colombians have been pioneers in developing treatments. In more recent years, because globalization has made the industry more palpable and tangible, you have to rely more on outsider’s development.

Colombia is renowned for its quality in doctors, treatments and procedures. How would you rate Colombia in comparison to the Latin American region?

That is complicated because any comparison within a region is sometimes not so healthy. Regarding HTA, Colombia is one of the ones ahead after Brazil. The government has been investing in strengthening capacity and skills in recent years, and thus many Colombians study at high-quality American and British universities and bring their knowledge and talents back to their home country. In the case of HTA, there is a rapidly growing social interest at the moment, and I perceive this as a window of opportunity. We are in an era of technocrats, and therefore there is a greater interest in financial investment for these kinds of technologies.

What is the main challenge that you have experienced in establishing IETS in Colombia?

Stability and continuity of work and resources tends to be the main challenge. Additionally, creating awareness among policy-makers and decision-makers because some of them know what HTA means and its capabilities for improving allocation efficiency, but some people do not. Of course we must work on strengthening capacity. Colombia has a very limited number of highly-skilled individuals who are proper health economists, although we have a bigger number of clinical epidemiologists that act as the basis for HTA.

If we were to return to Colombia in another three to four years, what is your vision for IETS by that point?

In 2016, IETS must be capable of being the main reference point of HTA within the country, with a significant impact on resource allocation decision-making at the macro level and also a pillar for homogenizing clinical practice in Colombia. Of course, IETS should also be recognized in the Latin American region as one of the reference points regarding HTA by that point in time.

What attracted you to IETS?

I really love this project. I had the chance to be engaged very early. As part of my PhD studies, I did a placement at NICE, where I supported the team on conducting a benchmark of HTA institutions around the globe for the Inter-American Development Bank. I decided that if I really enjoyed this project and had the capacity to bring it to success, I should do it. It is a great challenge, but it is also very rewarding to be seen by the academic community and different countries for succeeding in areas where Colombia is not traditionally strong for. It is a mix of social responsibility and will.

What do you think will be the number one change or improvement in the industry?

I think that IETS is going to be able to induce evidence as a means of producing trust. As the Minister sometimes says, Colombia is facing a crisis of trust as well as finance. If you follow good practices, use the best available evidence and truly engage stakeholders, then you are going to succeed.

What would be your final message to our executive readers regarding the state of the industry?

HTA is an important tool for decision-making. It is a fact that resources are limited, but it is imperative to take decisions looking at the best available evidence.

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