Introduction

Health Technology Assessment (HTA) is a tool that addresses the direct and indirect consequences of health technology by evaluating the social, economic, organizational, and ethical consequences of a health intervention or technology. It is a multidisciplinary process that uses explicit methods to determine the value of a health technology at different points in its life cycle in order to promote an equitable, efficient, and high-quality health system.

HTA helps ensure that governments make good decisions about health care and patients and health care practitioners are provided with the information they need to make the optimal treatment choices. It has evolved into a standard policy tool that guides decision-makers responsible for managing the incorporation and application of pharmaceuticals, medical devices, and other technologies, including complex interventions, within health care systems. Because of the importance of HTA, many countries have established national HTA, entities, agencies, and programs.

Ghana launched its strategy for HTA in 2020 with the primary objective “to strengthen the science and practice of HTA to support evidence-based decisions for the health sector.” The strategy seeks to achieve the following objectives:

• establish the country structures needed to institutionalize HTA in Ghana in a way that aligns with its national medicines policy
• develop local capacity to conduct and use HTA within the health system
• strengthen the conduct (science and practice) of HTA in Ghana in order to produce quality evidence-informed decisions and efficient practice, based on agreed upon standards for the conduct, dissemination, and use of HTA
• optimize resource allocation and containment of healthcare costs through evidence-based priority-setting in policy; the selection of medicine, health technologies, and interventions; and reimbursement, pricing, and procurement.

The launch of the national HTA strategy followed several years of collective efforts by both local and international players advocating for and sustaining HTA on the government’s agenda for the health sector. These agenda influencers framed HTA ideas and gained political and financial support to move HTA into policy adoption and implementation, institutionalizing it within the Ghanaian health sector. HTA institutionalization involved the establishment of structures, processes, methods, and standards for the conduct and uptake of HTA outputs and recommendations.

The approach used by agenda influencers to frame issues and adapt organizational structures and processes was essential for promoting the policy agenda and ensuring that it was adopted and implemented. The government’s agenda reflects the context of the health system, existing national policies, and the institutional processing of issue framing and local and international players and their use of power.

Local and international agenda influencers can be broadly categorized as follows:

• agenda directors, such as the president of Ghana, who wield political power to set a policy agenda;
• agenda approvers, such as ministers of health, with political and administrative authority to approve or remove an existing policy;
• agenda advisers, such as international donors, with the financial means and ideas to reshape policy discourse; and agenda advocates, such as professional bodies, with campaigning skills and voice to promote issues for their benefit.

Understanding how agenda influencers promoted the HTA agenda for adoption and implementation and specific administrative and bureaucratic processes, as well as the enablers and constraints to HTA policy agenda-setting, adoption, and implementation are essential for developing and implementing HTA policy. However, few studies of HTA policy agenda-setting, adoption, and implementation have been conducted in Ghana.

This paper analyzes the policy players involved and how they framed issues and created the administrative and bureaucratic structures needed to set the agenda and adopt and implement HTA in Ghana, a lower-middle-income country. It also examines the contextual factors enabling and constraining the HTA institutionalization process. The objective of this paper is to distill the lessons from Ghana’s experience for the benefit of other low- and middle-income countries.

Results and Discussion

Led by the MOH and supported by the World Health Organization (WHO) and others, training activities and discussions on evidence of medicines created awareness on the use of HTA. This awareness offered an opportunity to elevate HTA on the policy agenda.

For example, training by the National Medicines Selection Committee on the appraisal of evidence between 2009 and 2012 initiated discussions on in-country economic evaluations and the generation of evidence summaries for the selection of medicines for the Standard Treatment Guidelines and Essential Medicines List, thereby creating awareness on the usefulness of HTA.

The WHO, with support from the Bill & Melinda Gates Foundation, supported the Better Medicines for Children project in Ghana. It sought to improve the medicine selection process through capacity-building interventions targeted at the National Medicines Selection Committee, coordinated by the MOH’s National Drugs Program. In June 2011, committee members completed a pharmaco-economics course on evidence, cost, and drug selection, which introduced them to elements of HTA, such as critical appraisal of evidence, randomized controlled trials, evidence summaries, interpretation of evidence, assessment of types of bias, and relevant and appropriate literature searches.

HTA was further supported in the 2017 National Medicines Policy,Citation26 with the objective of strengthening the science and practice of HTA in support of evidence-based reimbursement decisions by the government, and the National Health Insurance Scheme (NHIS).

The National Medicines Policy guided HTA. summarizes its policy statements. Advocates of HTA used organizational structures such as the health summit (a platform for high-level policy-making in the Ghanaian health sector) to garner support and buy-in.

In setting and sustaining the HTA agenda, the MOH and donors advocated for the institutionalization of HTA into the Ghanaian health system. The MOH maneuvered institutional hurdles by securing slots at the April 19–21, 2017, and April 23–27, 2018, health summits and positioning the HTA Secretariat in the Pharmacy Directorate as a unit within the MOH responsible for the design of pharmaceutical policies and pharmaceutical sector oversight.

The minister of health, an agenda approver, endorsed the “Setting Priorities Fairly: Sustainable Policies for Effective Resource Allocation” event, demonstrating political commitment to the HTA agenda. The event was organized by the Ghanaian MOH, Health Technology Assessment international (HTAi), and the International Decision Support Initiative (iDSI) in Accra on September 26–27, 2018.

Discussions in Ghana and the framing of the selection of medicines and the need for Ghana-specific economic evaluation and evidence summaries played a pivotal role in incorporating HTA into Ghana’s health system. Local and international champions advocated for and framed HTA issues to align with the processes for national medicine selection and supported HTA activities and governance structures to sustain the HTA agenda. Characteristics of local and international players and policy issues, including how the issue is framed, are key for health agenda-setting.

Implementing HTA Policy

To implement and sustain HTA policy on the national agenda, the MOH put in place governance structures and sought expertise and partnerships through discussions with donors and members of the HTA Technical Working Group and Steering Committee. The minister of health approved and inaugurated the governance structure on October 4, 2019. It consists of a multisectoral HTA Technical Working Group (HTA-TWG) and HTA Steering Committee (HTA-SC). The HTA-TWG was tasked with generating evidence and providing recommendations to the HTA-SC. HTA-SC members included representatives from the MOH and agencies such as the Ghana Health Service and National Health Insurance Authority, the Ministry of Finance, a coalition of nongovernmental organizations (NGOs) in health, academics, the WHO Country Office in Ghana, the National Medicines Selection Committee, the Christian Health Association of Ghana, and the Ghana Association of Quasi Health Institutions. The HTA-SC is responsible for providing recommendations to the minister of health for high-level decisions on investment or disinvestment in medicines and other health technologies.

iDSI, the National Institute for Health and Care Excellence (NICE), and the University of Southampton supported Ghana’s efforts to develop an HTA model for hypertension. Findings informed the selection of anti-hypertensives for the 2017 Standard Treatment Guidelines and Essential Medicines List. At the request of the National Health Insurance Authority (NHIA), the TWG, supported by the Norwegian Institute of Public Health (NIPH), assessed the clinical and economic impact of extending the coverage of cancer medicines on the National Health Insurance Scheme (NHIS) medicines list to include treatment for childhood cancers. As a result, the NHIS now covers treatment for childhood cancers. HTA optimized resource utilization by providing evidence for setting priorities of the services provided under the scheme.

The HTA-TWG and the School of Public Health University of Ghana (SPH-UG) supported the MOH by estimating the total cost of COVID-19 vaccination and its main driver. HTA capacity building is ongoing at academic institutions. For example, since 2021, the SPH-UG, together with the WHO country office, has been training MOH staff in economic evaluation through its health economics master’s program.

A multistakeholder approach is critical to HTA policy implementation. HTA policy agenda advocates and advisers promoted a hands-on approach to HTA in Ghana that has resulted in capacity-building activities and outputs such as the hypertension model; COVID-19 vaccination costing; and management of pediatric Burkitt lymphoma. HTA-TWG members are constantly building their expertise, helping mitigate the challenges of insufficient in-country expertise.

Limitations of and Opportunities Created by This Study

Recalling events, activities, and all of the players involved in the HTA agenda-setting, adoption, and implementation in Ghana is challenging. To mitigate this limitation, we used multiple data sources.

HTA implementation is ongoing; the involvement and roles of key stakeholders as well as HTA uptake may change. Follow-up analysis can compare trends in stakeholder roles, HTA uptake, and bureaucratic structures for HTA implementation.

Conclusions and Policy Implications

This paper describes the HTA policy agenda-setting, adoption, and implementation processes; key stakeholders; and administrative and bureaucratic structures created or modified to institutionalize HTA in Ghana. It also identifies the main enabling and constraining factors. Ghana’s experience holds lessons for HTA policy development and implementation elsewhere, especially in low- and middle-income countries.

Several players helped effect HTA institutionalization in Ghana. The minister of health, as an agenda approver, inaugurated the HTA-TWG and HTA-SC and approved the HTA governance structure. MOH officials, together with development partners, served mainly as agenda advocates and advisers, respectively. Development partners provided technical expertise and funds. Donors are key players within the Ghanaian health system and are actively involved in policy framing and implementation. They also financially supported HTA research and activities in Kenya.

The paper illustrates the importance of building on existing administrative and bureaucratic structures and processes to advance and maintain an agenda. HTA advocates and advisers relied on structures such as the health summit, an institutionalized policy-making process, to gain national support and legitimacy. Existing administrative capacity to accommodate new policy is important because it determines which organizational structures or policies can be actively pursued and implemented.

Therefore, the HTA governance structures such as the HTA secretariat and the minister inaugurated HTA-TWG and HTA-SC, were possible in the Ghanaian health sector context. Having organizational and governance structures in place to undertake and use HTA to inform decisions, especially at the national level, is important.

Four implications and lessons for HTA agenda-setting, adoption, and implementation emerge from this study:

• Aligning the HTA agenda with existing national health policy, such as the National Medicines Policy and institutional structures and processes, is critical to ensure early national-level buy-in.
• Incorporating a multistakeholder approach with both national and international players is important to map stakeholder expertise, roles, interest, and expectations and ensure a participatory approach to policy-making.
• The context of the health system, the institutional policy-making process, and bureaucratic structures can enable or constrain the introduction of a new policy. Understanding the complex health system and how to overcome potential bureaucratic hurdles are equally important in advocating for a new policy.
• Identifying and engaging the interest of high-level policy agenda influencers, such as policy agenda approvers, advocates, and advisers, for a better understanding of HTA is vital given the ever-changing nature of national level agenda items.