Medicines and Health Technology in Tanzania Mainland ACCRA, GHANA

1. Medicines and Health Technology in Tanzania MainlandACCRA, GHANA WILLIAM M. REUBEN HTA – FOCAL PERSON MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND CHILDREN (MOHCDGEC)

2. Tanzania in East Africa

3. Tanzania Country Profile • Total population (projection 2016) • The Crude Birth Rate • Life expectancy at birth • Gross Domestic Product (GDP) • Under 5 Mortality Rate • Infant Mortality Rate • Maternal Mortality Ratio • HIV prevalence, 15-49 years 50.0 millions 41.6 per 1,000 63 F; 60 M US$ 955 (2014 est.) 51 per 1,000 live births 45 per 1,000 live births 432 /100,000 live births 5.3%

4. Introduction of HTA in Tanzania • In February 2014, ADP held an inception and work planning meeting in Dar –es Salaam in which stakeholders expressed interest of establishing a structured process for technology selection based on appropriate evidence/ country’s need - to achieve maximum impact • In July 2014, ADP conducted a rapid appraisal assessment that confirmed the stakeholders’ interest in establishing a systematic, structured assessment process for new health technology introduction.

5. Intro …. • Stakeholders expressed need for conducting economic evaluations that inform which health technologies should be introduced in the country • April 2015 a meeting was convened by PATH under ADP facilitated by HiTAP, PSU, PRICELESS, NIMR and UDSM

6. Intro …. • Various stakeholders attended the meeting, included were: • Global Fund Country Coordinating Mechanism • Research Institutes • Universities • Tanzania Commission for Science and Technology • National Health Insurance Fund • Ministries for Health, Industry &Trade and Registry of Companies and others.

7. Goal of the workshop • Together more information on the context, introduce HTA and explore ways forward. • Participants in the workshop agreed to start with the review of STG/EML as an entry point for HTA concept introduction in Tanzania.

8. Review of STG/EML as an entry point for HTA concept introduction in Tanzania. • In November 2015, a workshop was held and attended, by the Lead Reviewers team, PATH, PRICELESS and Pharmaceutical staff as secretariat. • After presenting the case study (article) for use in decision-making as well as an overview of evidence based practice • The audiences acknowledged that this was a tool that should be employed in the review process.

9. Review of STG/EML ….. • Presentations made on the experiences with Essential Medicines List (EML) review by the World Health Organization, South Africa and then procurement of medicines in Tanzania. • Noted some of the staff there did not understand how to use information to determine high cost and high-volume medicines. • Also noted limited understanding on how the EML and procurement process should be linked (for greater efficiencies).

10. Review of STG/EML ….. • The final activity was a group activity on priority setting for EML in terms of selecting which chapters get reviewed first and then for that chapter, what are the processes that would need to be followed. • The meeting tasked PSU to develop SOP for undertaking the next review with an evidence-based practice approach.

11. Review of STG/EML ….. • In July 2016, 3 days workshop was conducted, this was a very practical workshop with lots of participation, discussions, questions and getting a real understanding of what is required. • Experience of working on the South African EML review committees and National Medicines Therapeutic Committee was critical in advising on practically what needs to be done. • PSU as the Secretariat for the EML were enthusiastic about the upcoming review process but cautious about managing the work requirements due to the existing workloads and lack of familiarity and skills with the process.

12. Review of STG/EML ….. • The SOP for review of STG/EML was reviewed to incorporate clear and relevant structures and processes that are currently available in Tanzania. • A priority setting exercise was carried out to identify which clinical chapters should be prioritized for review of which cardiovascular system; Dental, Anesthesia, Malignancy, Gynecology & Obstetrics, Diabetes and Thyroid were identified

13. Review of STG/EML ….. • November 2016, a 3 days’ workshop was held as a National Essential Medicines review meeting. • The review of chapters for the EML in this workshop was based on 3 different scenarios in order for the participants to gain experience in different processes. These were • review of a class of medicines (sulphonylureas for Diabetes) • review of all medicines for a particular condition (anti-hypertensives) • review of a particular medicine for a specific condition (cisplatin + paclitaxel for ovarian cancer).

14. Review of STG/EML ….. • Invited Lead reviewers were also oriented to the SOPs for their better understanding • The team were also oriented on how to work on sourcing evidence for the treatment using EBM principles, search on PUBMED, • Majority had limited knowledge on how to use PUBMED and how to extract the relevant information • Scoping exercise was also done in Hypertension (HT) as a condition.

15. Review of STG/EML ….. • In February 2017, a 3 days’ workshop was held • The aim of the workshop was to mimic a 3-day EML meeting in order to discuss the chapters which had been prioritized for review with the full Expert Review Teams. • The review process for each section of the Chapters was time consuming as many of the review team had not had time to go over the chapters and so were not very much prepared in terms of giving feedback.

16. Review of STG/EML ….. • In July 2017, a dissemination workshop for eight chapters was conducted. • The chapters included were: cardiovascular system; Dental conditions, Anesthesia, Malignancy, Gynecology & Obstetrics, Diabetes and Thyroid under PATH support while Olphamology and Psychiatry were reviewed based on the tapped skills from PATH and PRICELESS.

17. Review of STG/EML ….. • Thereafter, the work continued to the rest of the chapters until December when all the chapters were somehow reviewed although not as the eight chapters. • The STG/EML was signed by the Minister for Health was launched on 21 December, 2017

18. Issues raised from the process • Review process of Chapters was time consuming as review team had no enough time to go over the chapters and so were not well prepared in terms of giving feedback • Evidence-based information search for what medicines should be used to treat various conditions was tedious

19. Issues raised …. • STG not intended to be a text-book for teaching medicine rather be guide – styles setting was a challenge • Keeping the size of the book/document to within manageable limits. • Standardization of formatting, presentation, content and referencing was critical.

20. Mechanism to ensure that HTA matures in the country and used for decision making • It is included in the National Health Policy 2017 • Tanzania HTA committee with different members from key actors of health in the country was inaugurated • Linked EML with procurement and National Health Insurance benefit package, however not completed for highly specialized hospitals

21. The ministry collaboration with IP/DPs plan • Conduct landscaping profile and develop HTA guideline • Develop HTA strategy and action plan • Standardization of medical devices list in progress • survey on the capacity of HTA Committee to carry on its operations done and is around 50% • Second survey will be on Demand and Supply for use of evidence based for decision making in Tanzania

22. The land of Mt. Kilimanjaro - Tanzania