The BRAVER Roadmap to Broader Assessment of the Value of Health Interventions in the Asia-Pacific Region

Economic evaluations can adopt a healthcare system perspective, focusing on direct healthcare costs and benefits, or a societal perspective, which includes broader costs and benefits such as productivity and informal care.

Adopting a societal perspective and incorporating broader value elements in HTA decision-making can drive innovation and address both clinical and societal needs, particularly in the Asia-Pacific (APAC) region, which faces rapid population ageing and a growing burden of chronic diseases, leading to a significant reliance on informal care. This approach is consistent with welfare economic theory, in which societal welfare optimisation is the ultimate aim, and aligns HTA with broader government goals, such as economic growth and improved health and social standards, and addresses health inequities in line with regional cultural values.

Despite support for incorporating a societal perspective, its implementation in HTA in the APAC region remains limited: only China and Thailand consider the societal perspective in their base case. South Korea previously mandated it but has since changed due to its complexity. Other jurisdictions, like Australia, Vietnam, South Korea, and Malaysia, accept it in supplementary analyses, while New Zealand, Singapore, and Hong Kong do not recognise it in HTA guidelines.

This report aims to understand the current state of HTA in the APAC region regarding adopting a societal perspective and considering broader value elements and developing recommendations for their systematic inclusion. To achieve this, we involved an APAC expert advisory group through an online survey and a virtual panel roundtable, where we explored priorities, opportunities, barriers, and recommendations for recognising broader value elements in HTA.

BRAVER framework and analysis

The BRAVER framework aims to support the coherent and consistent consideration of societal perspectives and broader value elements into HTA decision-making in the APAC region. It focuses on three dimensions:

• Willingness for Recognition in HTA Guidelines: the motivation and readiness of HTA agencies to acknowledge the importance of including broader value elements in HTA.
• Ability for Measurement and Incorporation in Decision-Making: availability of appropriate, feasible methods to systematically measure and incorporate these elements, and the capacity to do so.
• Evidence for Impact in Decision-Making: availability of empirical data to demonstrate the value and impact of these elements, encouraging their inclusion.

We found that the most progressed dimension is the willingness to recognise value elements in HTA guidelines. Top-scoring elements within our suggested value framework, including equity, wider health sector benefits, informal care health spillovers, and patient productivity, were identified as priority elements for short-term progress. Other elements, including value of security, value of knowing, and economic activity are seen as long-term goals needing substantial policy and methodological changes.

Barriers and opportunities

Experts identified several barriers to incorporating societal and broader value elements in HTA decision-making, including a lack of robust methods to measure novel value elements, added uncertainty, perceived risk of double counting, and capacity constraints. However, opportunities such as ongoing HTA reforms, pilots applying societal perspectives in specific disease areas like rare diseases, international collaborations, and consistent patient involvement can help mitigate these barriers.

Priority value elements

Based on the survey results and expert advisory group input, the prioritised value elements are equity, informal carer health-related quality of life (HRQoL) spillovers, productivity, and wider health sector benefits. Two case studies in Alzheimer’s disease and Spinal Muscular Atrophy show that different ways exist for these priority elements to be practically implemented into HTA decision-making in the APAC region.

Equity: Experts agreed on the importance of equity in HTA decision-making despite measurement challenges. Opportunities exist through quantitative approaches like distributional cost-effectiveness analysis (DCEA) and supplementary analyses. Experts suggest starting cautiously with case studies to build evidence and progressively integrate equity into HTA processes.

Informal carer health spillovers: Experts agreed that carer HRQoL spillovers should be recognised and incorporated taking into consideration the context and condition. There is an opportunity to accumulate practical experience and robust data, which may make formal inclusion of carer spillover more acceptable and methodologically sound over time. For example, the 2024 report by the SHEER task force recommends using adequate time horizons, prioritising primary spillover data collection, and emphasising transparency when reporting on spillover incorporation.

Productivity: Experts agreed that productivity should be recognised and incorporated taking into consideration the context and condition. Productivity impacts include absenteeism, presenteeism, reduced labour participation, and early retirement from work, as well as non-labour productivity. They are crucial from a societal perspective, though often omitted in evaluations. Regarding labour productivity losses there is an opportunity to actively advance the ongoing debate concerning the preferred methods to value these; in particular, which of the two main methods – human capital method or friction cost approach – is the most appropriate.

Wider health sector benefits: Experts believed that the three key aspects of wider health sector benefits—health system capacity, adherence, and innovation—should be treated and recognised separately. Adherence should be considered in standard economic assessments, while health system capacity and innovation should be integrated as supplemental analyses. There is an opportunity to develop better methodological approaches to build evidence and refine methods for formal inclusion over time.

Conclusion and recommendations

By addressing identified barriers and leveraging opportunities for collaboration and methodological development, HTA can become a more effective tool for improving health outcomes and societal welfare. To be BRAVER in recognising, incorporating, and evidencing the societal perspective we recommend:

1. Involving patients and caregivers: Engage patients and caregivers in identifying, measuring, and incorporating broader value elements.
2. Creating a conducive policy environment: Develop policies and a legislative framework that recognise societal values and provide a clear mandate to HTA agencies.
3. Building capacity: Allocate resources for training and developing a process for societal perspective adoption in a systemic fashion.
4. Pursuing a stepwise approach: Incorporate broader value elements through gradual, transparent processes such as guideline reviews and pilot projects. Prioritise adopting elements that can make tangible short-term progress such as equity, carer health spillover, productivity, or health sector capacity.
5. Promoting international research initiatives: Support international research to develop novel methods and validate existing ones.
6. Engaging in early dialogue: Pursue alignment on data collection and evaluation criteria through early dialogue between HTA agencies and innovators.

This consulting report ‘The BRAVER Roadmap to Broader Assessment of the Value of Health Interventions in the Asia-Pacific Region’ was commissioned and funded by Roche, MSD, and Johnson & Johnson.