The National Institute for Health and Care Excellence (NICE) in England often comes up in conversations on medicine reimbursement. The sequence of events goes something like this: a new medicine is planned for launch in a growth market (mostly middle-income countries), but the government and private health insurance companies are uncertain of its economic and clinical benefits. So, Payors turn to NICE for guidance. Technical appraisals are downloaded, distributed, and NICE’s guidance is used as a shortcut to rationalize reimbursement decisions.
NICE is England’s health technology assessment (HTA) agency tasked with evaluating the economic impact of health technologies for purposes of deciding reimbursement and availability in the National Health Service (NHS). NICE prioritizes access to medicines through criteria on disease severity, estimated health benefit, patient numbers, clinical priorities of the NHS, balancing the costs and benefits of new medicines, among others. However, NICE is not the only HTA agency with a comparable mandate. Others just as IQWiQ (Germany), AIFA (Italy), ZIN (Netherlands) and AOTMiT (Poland) also apply economic evaluation guidelines to determine access to new medicines. So, why would governments and health insurance companies in middle-income countries choose NICE over all the others for reimbursement guidance on new medicines?
It may be because NICE guidance documents are available in English. Very few HTA agencies in Europe (including those listed above) provide websites and technical documents in English - an important barrier for middle-income countries to determine how HTA agencies evaluate new medicines. Payors in middle-income countries also have limited knowledge of German, Polish, or Italian to work with the technology appraisals of IQWiG, AOTMiT, and AIFA, respectively. The answer may also lie in NICE’s ambition to globalize technology appraisals through NICE International - a non-profit division of NICE. NICE International provided technical support and consulting services to governments and funding agencies in low and middle-income countries on how to apply evidence and social values in healthcare policy decisions. NICE International closed in September 2016 and operations were continued under the Institute for Global Health Innovation at Imperial College London.
HTA agencies don’t generally have ambitions to globalize health technology appraisals. Herein lies the danger. The global use of technology appraisals by NICE or their promotion by academic institutions assumes that England’s social value and prioritization system for new medicines applies to other countries. Unfortunately, governments and private health insurance companies in middle-income countries adopt NICE appraisals uncritically and seldom crique the criteria for reimbursement decisions in England.
If all health technology appraisals were available in English or if Payors in middle-income countries knew how to read German, Polish and Italian then, reimbursement decisions may be more critical and comparative than at present. Herein lies an opportunity. Situations arise when England declines reimbursement of a new medicine while Germany, Italy, and Poland issue a positive appraisal of the same medicine; meaning that significant variations exist between countries in HTA recommendations. Looking only at NICE guidance is a narrow and limited perspective on reimbursement decision-making and Payors in middle-income countries could improve access to new medicines if only they looked outside England. Ideally, communities in low and middle-income countries may be better served by developing local institutions and the capacity to synthesize international evidence (using various languages). This would include applying locally-relevant reimbursement decision criteria aligned with domestic health priorities.