Health Technology Assessment In Singapore: Shining A Light In The Darkness

Abstract

The Agency for Care Effectiveness (ACE) was established in 2015 by the Singapore Ministry of Health to expand Health Technology Assessment capabilities for subsidy decisions. The first tranche of drug guidance recommendations was published in May 2017 and the aim of this study was to explore possible factors influencing subsidy decisions. All eleven published appraisals were reviewed and the factors considered by the Drug Advisory Committee extracted and assessed. Further information was obtained from ACE at the Industry Briefing held in May 2017. Out of the eleven appraisals of ten drugs, three led to subsidy listing on the Standard Drug Lists (SDL 1 or 2), six led to inclusion in the Medication Assistance Fund (MAF) and two did not result in subsidy. Ten evaluations were expedited evaluations, with only trastuzumab considered as a full evaluation due to high technology cost. Of the subsidised medications, low-cost drugs were recommended for SDL subsidy (broader subsidy than MAF) while high-cost drugs were recommended for MAF subsidy. Most subsidised medications were in diseases with substantial unmet clinical need. In the absence of clinical need, the price relative to existing alternatives was a key consideration. In three technology appraisals (gliclazide, golimumab and trastuzumab), restrictions were imposed on the formulation covered by the subsidy based on price concerns. Although budget impact was a key consideration across all appraisals, a low budget impact alone did not guarantee a positive subsidy decision. Only five evaluations reported incremental cost-effectiveness ratios, with an upper limit of S$75,000 per quality-adjusted life-year gained considered cost-effective in this tranche of appraisals. While limited by the small number of published appraisals, this analysis highlights the importance of technology cost in ACE decision-making for subsidy listing. However, cost-effectiveness and budget impact are also important factors, with clinical need being relevant in some cases.