LMICs and ISPOR: A Member-Level View
By Christiane Truelove
Health economics and outcomes research (HEOR) is not just for high-income countries. As a global organization, ISPOR strives to support HEOR studies around the world, and has pledged to promote these efforts in lower- and middle-income countries (LMICs) in its Strategic Plan 2024. The Society recognizes that LMICs often face difficulties attaining the financial resources for healthcare spending and are disproportionately impacted by events such as the global pandemic. For these and many other reasons, the organization has long supported HEOR development efforts in LMICs to identify and address barriers to access and budgetary concerns.
In early 2021, a work group developed a plan of action to evaluate ISPOR’s impact in LMICs and improve its efforts. The organization has invested significant resources toward mission-focused initiatives and carrying through those investments into the future. ISPOR’s programs to support LMICs include complimentary memberships, fee-waived registrations, and educational grants to enable attendance at ISPOR events. The organization additionally provides complimentary educational webinars, publications, and leadership training. ISPOR global groups also organize activities through regional consortia, networks, and chapters to facilitate information sharing and capacity building.
To see how these efforts play out in practice, ISPOR reached out to members located in LMICs to share their experiences.
The Need for HEOR Programs and the Challenges
Rita Karam, PharmD, PhD is Director of the Quality Assurance of Pharmaceutical Products Program at the Lebanese Ministry of Public Health, Associate Professor at the Faculty of Sciences and Medical Sciences at Lebanese University, and the Program Coordinator of the Professional Master’s in “Market Access of Health Products” at the Faculty of Sciences at Lebanese University.
According to Karam, HEOR programs are essential to improving public health, especially in resource-restricted countries. “The aim of every health system is to ensure that the concerned population’s health is improved as much as possible. This is definitely not an easy objective,” she states. “Additionally, when the resources dedicated for healthcare are relatively scarce, such as the case of Lebanon, the quality of the decisions have an even greater importance, affecting the population at large.”
Hampering the healthcare decision-making process in Lebanon is the country’s “complicated political dynamic, with a challenging power relations landscape affected at large…by the Lebanese sectarianism,” Karam says. At times this has overruled reliance on evidence in the policy-making process. Other challenges include the “status quo” bias of health system leaders. Despite these challenges, Karam says the Lebanese healthcare system has progressed over the past 2 years, with the clear impact of the civil economic and political crisis.
Alima Almadiyeva, MD, MPH is Deputy Chair of the Salidat Kairbekova National Research Center for Health Development in Kazakhstan and formerly CEO of the Kazakh Agency for Health Technology Assessment. Almadiyeva acknowledges that the political situation in Kazakhstan can make her work more difficult. As news outlets have reported, at the beginning of 2022, protests against rising fuel prices escalated into antigovernment riots that killed 238 people. And at the beginning of this year, Kazakh President Kassym-Jomart Tokayev dissolved the lower house of parliament and called for snap elections on March 19.
“The features of Kazakh economy are closely tied with political structure and this makes any pioneering steps challenging,” she says. “Despite that, we are trying to welcome more specialists into our ranks through education and meetings.”
Both Almadiyeva and Karam had particular reasons for going into the HEOR field. For Almadiyeva, her inspiration was a health technology assessment (HTA) implementation project in Kazakhstan in 2011.
“It was a part of a large reform of healthcare that time. I was in charge of the HTA report on hepatitis C treatment, and it was a feeling that I found something relevant for my soul,” she says. “As young public health specialists, we did not know much about evidence-based practice and critical thinking because of the huge gap between education at the medical universities and real practice. However, that experience was valuable for me and I did my best to learn and understand the core of the processes involved in HTA production. I understood that evidence can vary, and if you see a meta-analysis it does not mean that it has high-quality evidence, but describes uncertainties which may influence the attitude towards a concrete technology.”
According to Karam, she was “driven by the need to rely on solid capabilities contributing to the improvement of the decisions quality…to focus my career on healthcare with a strong commitment and aspiration of improving patient’s lives.”
The Importance of ISPOR Support
As a cofounder of the ISPOR Lebanon chapter, Karam says one of the main drivers for establishing the chapter is to improve the country’s healthcare decision-making process, with the purpose of positively the health outcomes of patients.
“The chapter is still strongly committed to this motto and is pushing for the adoption of several tools for decision making, such as HTA,” she says. “ISPOR provides a great support to the country through first, the legitimacy umbrella that is being carefully employed by the chapter, and second, through the wide network—both regionally and globally—enabling a synergy between experts united under one purpose that will better population health.”
According to Almadiyeva, “ISPOR opened my mind and motivated me to be who I am. Now, we can easily use all the necessary resources that ISPOR shares with its members. If we have a question that is waiting for a rapid decision, we can find solutions on the ISPOR website with published papers, task forces, updates. It is convenient and free and the knowledge becomes available to use anytime.
“In addition, ISPOR gave me an opportunity to meet intelligent people from each corner of the world and keep in touch with them. In my opinion, this is the most valuable opportunity I have been acquiring for many years, being a part of the ISPOR team.”
With ISPOR’s resources to draw on, Karam has advocated for HEOR education in Lebanon. As a professor at the Lebanese University and a board member of ISPOR, she helped establish the country’s first master’s degree program in market access. This program is considered as the first academic initiative. The program offers courses on pharmacoeconomics, pricing, and reimbursement of pharmaceuticals as well as an introduction to all the aspects of HTA.
“My aim is to establish an ISPOR student chapter in Lebanon,” she says. “Students are the future of any country and one of the support pillars is to invest in future generations. That’s why ISPOR has more than 140 student chapters around the globe.” Karam and her colleagues from the ISPOR Lebanon chapter have been involved in teaching courses in their areas of expertise, as well as mentoring and supervising several research projects.
One of the most important ongoing projects that Karam is engaged in is for developing economic evaluation guidelines for Lebanon, in collaboration with the Netherlands’ Maastricht University. The project is sponsored partially by the ISPOR Lebanon chapter, since Karam and her doctoral student on the project are both chapter members. “I joined my work as professor at the university with ISPOR, and I think we get a very important outcome deliverable for the country and for the LMICs,” she says.
ISPOR and Improving Support
Almadiyeva hopes that eventually her efforts, and those of her colleagues, could establish Kazakhstan’s first independent HTA agency. “I opine that we are still working on producing more benefits for Kazakh society—so many issues are not resolved, but I am proud of having colleagues who are motivated like me.”
When first getting involved with HEOR and HTA studies, Almadiyeva admits her lack of proficiency with the English language hampered her. “It was difficult to read and understand professional articles or scientific essays,” she says. “Moreover, it was even harder to learn statistics because all advanced techniques are described in English. I would add one more challenge we have been facing for years as non-English–speaking countries, where English is a third or fourth language. The challenge is that the education we had when I just graduated had not been considering an integration with global societies. We were not taught English as a professional language, as well as we did not learn how to think in English.”
Even now, she says many resources, new innovations, interesting research, and expert discussions are in English, and Kazakhstan still does not have enough capacity to process that knowledge. “That is a hidden paradox of the situation,” she states. “However, there are young generations and we hope that our team will be able to educate young generations to make them competitive on a global level.”
ISPOR has provided her with this kind of support. “When I first participated in the ISPOR Conference in 2012, it inspired me to receive those skills I did not have at that time,” Almadiyeva says. “I remember how I took part in ISPOR short courses for the first time. Everyone was extremely nice and supported me in discussions. However, I thought that I was an inferior student there because I could not speak and did not understand the full meaning of the topics. When I came back, I started reading and learning more, especially in English.”
Although Karam is an advocate for the LMIC work ISPOR has been doing, she adds that clustering countries based on Gross National Income per capita and the World Bank’s Atlas method might also overlook major differences between countries.
“What I mean is, clustering countries based on the health system capabilities and resources, in addition to its evolvement status, might be a better idea,” she says. “For example, in China, although the World Bank considers China as a middle-income country economy, it has a significantly better capabilities pool and infrastructure when compared to other middle-income countries such as Lebanon and Jordan, for example. And accordingly, I think that clustering these LMIC countries differently might offer better support options or packages, not only from common problems perspective but also from capabilities building and research perspectives.”
Acknowledging that there could always be improvements, Karam believes ISPOR is well worth joining. “ISPOR is positioned by most of the healthcare professionals as a highly influential organization with a strong mission statement,” she says. “Furthermore, ISPOR is evolving with great flexibility along with new emerging topics in healthcare. We are talking about artificial intelligence, real-world data, value-based healthcare, etc and are remaining relevant to the needs of healthcare system leaders. Thus, the role of ISPOR will definitely continue to grow. I’m confident that joining reaps several benefits—building a great network with like-minded professionals, leveraging on a great learning platform, and staying updated when it comes to meaningful research and trends in healthcare. I think ISPOR is the perfect platform for all these benefits.”
