Prioritisation Health Technology Assessment For Myopia Treatment In Armenia

Cost Effective treatment

Discuss About The Prioritisation Health Technology Assessment.

Myopia is the most common threatening factor of eyes that signifies the lack of distant vision. Myopia is near sightedness that happens due to lack of Vitamin A. A recent study of Armenian health department has suggested that around 25% percent of Armenian children are affected by myopia in 1977-78 which jumps to 41.6%after the health data release of 2003-04. The symptoms of myopia are difficulty in reading road signs, difficulty in using the computer or electronic gadget, constant eye strain, headache and feeling fatigue during any kind of physical activities (Braveman and Gruskin, 2003). As per the health reports of Armenian government myopia often happens when eyeball gets larger than its original shape focusing on cornea and lens. Myopia is generally a genetic disease that spreads from parents to their children.

Myopia is generally two types’ moderate myopia and severe myopia. People often cannot see things that are around a yard far. Moreover, eyes continue to lose its normal vision, elongate beyond the normal range and the outer shell of the eyes stretched more than its normal size that results in cataracts and glaucoma.

Children aging from 13 to 22 are normally affected by myopia. Around 23% of the children aging from 13 to 18 of south Armenia are affected by severe myopia with the symptoms of short-sightedness and the eyeball has increased to more than 6.0 dioptres. The northern province of Armenia is generally affected by myopia comparatively lower (12.5%) than southern Armenia. Here the data has been provided from the northern and southern region of Armenia aging from 13 to 22 (Sullivan et al., 2009).

Myopia treatment is done through eye examine by the eye specialists. Moreover, refractive surgery and orthokeratology are helpful media to reduce the fatality of myopia. However, refractive surgery and orthokeratology are not cost effective intervention for myopia patients. Thus, progressive addition lenses and traditional bifocal glasses are a best cost-effective intervention of myopia. A study of Armenian health department has suggested that The bifocal lenses reduce the progression of myopia by around 44% and reduces the base of vitreous chamber depth upto.34 diopters. The progressive additional lens reduces the chances of myopia and reduces the myopic prescription between -1.25 to 4.50 (Luce and Cohen, 2009).

Refractive and orthokeratology surgery are mostly used in the health systems of Armenia. It is not cost effective and for the better result the parents should take care of the eye issues of their children and should consult eye specialist whenever any issue arises. Moreover, Progressive Additional Lenses (PAL) and additional bifocal glasses can be recommended for cost-effective treatment.

HTA reports for critical appraisal

Myopia is stated to be one of the most highlighted short-slightness diseases that are often found among the children aging from 13 to 22. The study has identified the health needs of the health care system of Armenia. There are two types of health intervention of myopia available in Armenia, cost-effective treatment, and costly treatment. Cost-effective treatment includes the use of the PAL and additional bifocal lenses. Moreover, children ageing from 13 to 20 can be beneficial from health care system of Armenia that gives vouchers to avail contact lens and glasses for free. Moreover, people with low income can avail glasses and lenses within £5-10 if proper income statement is provided to the respective health eye treatment centre. The study has basically discussed various problems, cost-effective treatments, regulations for cost-effectiveness and recommendations of myopia (Who, 2018). Moreover, the healthcare assessment of myopia has been discussed to identify the availability of the intervention, policy-making of health care management of Armenian government followed by a summary and recommendations that have highlighted most effective issues of myopia and its treatments.

Health technology assessment is a systematic evaluation of health care system based on the characteristics, effects, and impacts of health technology. The study here has highlighted the critical assessment of cost-effective treatment of myopia in Armenia. Near sightedness with blurry vision is the ultimate feature of myopia that generally happens among the people aging from 13 to 22 (OHE, 2018). There are two possible interventions assessed for myopia- using of Progressive additional lenses and soft bifocal contact lenses and anti-muscarinic eye drop. The assessment has highlighted the use of single vision lensesand soft visionlenses among the people of Armenia. The single lenses and soft version lenses are helpful in reducing the growth chances of myopia (Pinson, Thielke and King, 2011). Further, the assessment has discussed the importance of anti-muscarinic eye drop which can be helpful for the people of Armenia to minimize the light sensitivity. The children aging from 13-22 in Armenia are normally addicted towards television and use of mobile phones which causes the light sensitivity of eyes. The anti-muscarinic eye drops are effective here to reduce the chances of light sensitivity. The data has been collected from all the four regions of Armenia and surveys are made on two hundred children from each region. Moreover, the child health care department has provided medical papers regarding the interventions of myopia (LIM, 2014). Hence, the provided evidence is reliable to assess the criticality of myopia and anti-muscarinic eye drop are stated to be most effective and cost-saving treatment of myopia. 

Policy Fit

The current policy focuses on cost friendly therapy, high effectiveness and medicine oriented treatments The effective interventions of myopia are fit to the present health care policies. The use of progressive additional lens, bifocals and anti-muscarinic eye drops are cost friendly. Moreover, these interventions are stated to be the most effective treatment for myopia patients. The additional, and bifocal lenses shape up the visions of myopia patients and plays significant part in reducing the risk factors. However, the refractive surgery is a costly eye surgery with high risks and orthokeratology is a less effective and moderate treatment of myopia that may not work properly among the teenaged myopia patients of Armenia. On the contrary, the additional and bifocal lenses are cost-friendly, lack risk factors and most modern and effective treatment for myopia (Chan and Topfer, 2007). Moreover, these kinds of lenses are easy available in all the parts of Armenia and there are special packages for the teenagers who do not have sufficient income(Gilson, 2012). Furthermore, the myopia patients with low income are proposed to be given extra concession over the lens price. The anti-muscarinic eye drop is another treatment of myopia thatsuits the present health policy. This eye drop is low price, well available and effectivetreatment for myopia(Gilson, 2012).  The healthcare system of Armenia is not well developed because the country is still in the developing process. The active cooperation of Armenian government and their citizens has made the myopia treatment easy for all sections of people in cost and health effective manner.

Cost-effectiveness of myopia treatment is not effective to spread the myopia prevention treatment around Armenia due to lack of sufficient funding. Thus, the confusion of developing the policies can be resolved by providing sufficient fund, effective doctors and most importantly supply of medicines of myopia across the country (Trust, 2018). The harsh effectiveness of myopia can be removed by implementing the recommendations of sufficient fund, effective doctors, and available medicine supply.

This consists of the information regarding medical, social, and economic and ethical issues of the use The Health technology assessment (HTA) for Myopia is a multidisciplinary process in Armenia. of the health technology. The technology should be systematic, unbiased, transparent and of robust manner(Gilson, 2012).  Their target is to formulate effective and safe healthpolicies, have main focus, for the patients.  They should get the best value for this practice.  The term “health technology” means the medicinal products, medical devices and /or medical or surgical process and measures that are used for preventions, diagnosis or for the cure of the disease,particularly myopia.  This HTA is an evidence-based process.  It assesses a new or existing technology and regulation compare with other existing technology and regulations for standard care.  Since 1980 the cooperation on HTA are going on already.  Two joint actions (EUnet HTA joint action3) has launched in year 2016 going to run up to 2020 with total budget of EUR20million. Participations are from all EU member states, including Armenia.  In addition, they have adopted the Cross-Border health care directives (Balabanova, Mackee and Mills, 2011).

Regulations/legislation

Although they have the achievements for the EU cooperation, they faced a number of problems.

Different national process and methodologies of national HTA bodies should reflect some health technology developers, with the aim of introducing health technology in the multiple member states, with numerous data and evidence (Neil Charman, 2011).  This will run, with distorted access in the market, lack of business predictability, higher costs for treatment also having a negative effect on innovation, i. e., finding a new case of myopia.  This problem generally occurs in children.The critical evaluation of same technologies should be carried out in parallel and within the same time period.  That should be done by the HTA bodies of different member states.  That result for duplication of work and not sufficient uses of resources (THORNHILL, 2012).

The Union level cooperation of HTA is project based. So it has short-term funding’s. It should renew in every financial cycle. Again they don’t possess the guarantee of continuation (Health Research, 2007).

1. Ensure a better functioning of the internal market;
2. Contribute a high level of human health protection
3. Improve the availability of innovative health technology for Myopia.
4. Efficient use of resources and make strong the quality of HTA
5. Improve business predictability
6. Introduce free health check-up in school for children (Hanney et al., 2007).

For regulation and legislation, it has been observed for HTA to applied in EU countries, their specific objectives are to improve the business predictability.

The Operational objectives consist of

1. To promote the convergence of for the tools of HTA.
2. To reduce the duplication in the efforts for HTA bodies.
3. Make sure about the joint outputs in their members. (EU)
4. Make sure about the long-term sustainability

• Consistency with the existing policy and their provisions

In article 15 of cross-border health care directive, the HTA cooperation is facilitated.  The directive suggests for an establishment of a network for the member states authorities of HTA.  So that there is cooperation and also exchange of the scientific information among their members.  The HTA network objectives are, inter alia, it will support the cooperation between the different HTA bodies of region. That support the provision and exchange the information   about the efficiencies of health technologies (Stafinski et al., 2011). Also useful for avoiding the duplication of assessments.  As given in the Article 15 of directives 2011/24/EU they reinforced the cooperation at the Union level of Europe.

• Legal basis – The article 114 TFFU are for the adoption of measures and for approximating the provisions. On basis of law, regulation, administrative actions, for the member states, including Armenia. The action provided for the member states that are necessary for establishing or for the functioning of the internal market.  At the same time ensures a very high level of public health protection (Townsend, Buxton and Harper, 2003).
• Subsidiarity- For clinical assessment, the diversity and multiple actions along the member states occur due to their difference of scale and effects for a different disease like Myopia affected the children mostly. They affect the actions on Union level also eliminate the obstacle.  Without knowing the effect at EU level it is very unlikely to know the effect of HTA on a national level for only Armenia (Savigny and Adam, 2009).

The Republic of Armenia is a landlocked, European nation in the south Caucasus region. Nearby countries are Georgia, Azerbaijan, Turkey etc.  They are enjoying the independence since 1991.  They started their market based economic reforms, with their goal to be a member of the European Union EU so that every aspect of Health Technology Assessment HTA of EU could be applicable to their citizens as well.  In Armenia they adopted the highly centralized Soviet Semashko health care system. Its feature is free medical treatment with a very well comprehensive secondary and tertiary care to all of their people, guaranteed.  The general taxation financed this whole treatment system (Sorenson, 2014).  The medical policies are based on as those in Soviet Russia but sometimes failed to take care of the actual needs of the population.  Here the main emphasis is on the large hospitals but the primary cares remain neglected. This is also happening for Myopia cases, the care should be taken by primary check-ups of children (Thornhill, 2011). After independence, this country suffers a decline in health standards also stress on the healthcare systems

Their health care system restructured into three administrative divisions: National, regional and in municipal All the benefits of healthcare systems remain as such but now continuing under primary health clinics(Exworthy, 2018). Also under regional centres, the hospitals. Some of the services remain under the Government, like tertiary care hospitals, sanitary and epidemiological services.  The Ministry of Health services have their own medical policies with the international planning and the aid organization.  The hospital and clinics have their own funding (McIntyre, 2007). The basic state-run health care packages not include the prices and services of these hospitals. There are more than sufficient hospital beds and the physicians as in calculated in the system of healthcare from Russia.  They are trying to structure a very efficient Healthcare system, but hindrance is due to poor communication, between different levels of care systems.

 The Government of Armenia is facing more difficult due to their budget for the care systems.  Due to this shortage of public funds, their Government introduces a Basic Benefits Package (BBP) for official charges to patient service.  BBP is a meant for specific services that are referred as the free charged services, and also includes those vulnerable group of people, who are entitled to treatment for not any cost.  This BBP can be considered as the significant factor for the treatment charges of the people of Armenia. Those people of Armenia not included in the BBP group, pay out of their pocket for their personal treatment (Banta, Jonsson and Childs, 2009).

There is a system of informal payments exists and due to limited resources, some of the members of the vulnerable group also pay for their treatment sometimes.   The major source of financing for healthcare in Armenia is Out of pocket payment system.  About 65% of all medical expenses are approximately these informal payments (Who, 2007). Very low prices are only paid by the state and publicly funded facility.  To get an access to primary care is a major problem. A very large portion of Armenian people not able to afford this basic expense.   It has been observed that many people basically avoid treatment until unless it is very essential.

Myopiais a common ocular disability for people ageing 12 to 22. In Armenia the growing prevalence of Myopia has affected many of the children. Approximately one-third of the young adults are myopic (Currie, 2012). Therefore, economy plays a vital role in the intervention of myopia in Armenia. Economic recommendations that can be applied in the health system are: Investments in health policies must be addressed. Policy choices should not be taken lightly. Armenia government can organise different Myopia treatment camps in different parts of the country. Furthermore, schools in Armenia can start awareness of Myopia programmes and can give free initial myopia treatments which can be funded by the government. Treatment centres can lower the cost of refractive surgeries (Idrc, 2008). Orthokeratology and a GP contact lens procedure called corneal refractive therapy (CRT) is a proven temporary effective procedure to treat myopia. Moreover, implantable lenses known as phakic IOLs are another surgical option for high myopic patients (Troy, 2015). These technologies should be adopted by every eye treatment centers and CRT and phakic IOLs surgery should be made less costly so that children of every economic background can afford that.

• Regulations: Health technology assessment (HTA) is a multidisciplinary process that aims to inform the formulation of safe and effective health policies which are patient-focused and seek to achieve the best value. The development of health technology is a key driver for economic growth and innovation in the union. It covers both clinical and non-clinical aspects of health technology.HTA has proposed regulatory fitness and simplification, budgetary implications, implementation plans and monitoring, evaluation and reporting arrangements etc. In the general provision, the definitions of ‘medical product’, ‘medical device’ and ‘health technology’ are proposed to align with those applied in Directive 2001/83/EC, Regulation (EU) No 2017/745, and Directive 2011/24/EU respectively. Joint work on health technology assessment at union-level includes joint clinical assessments in chapter II section 1. Thus, the treatments and the health technology that is recommended is subject to regulations (Garrido et al., 2014).
• Healthcare finance: Armenia has started the highly centralized Soviet Semashko health care system where all the citizens are freely treated with a complementary range of secondary and tertiary care. This system is financed by general taxation. Medical policy and funding is based on Soviet norms but failed to meet the health needs of the actual population(Exworthy, 2018). The Armenia health care system has largely decentralized into three administrative divisions: national, regional and municipal/community. All the public health facilities are available from the health system and are managed by local governments (for primary health clinics) and regional governments (for hospitals). Different funding options are available and the health system is working to become more efficient but the change is slow due to the poor communication between different levels of care. The private healthcare sector needs to develop, beyond the privatization of former public medical facilities (Savigny and Adam, 2009).
• Insurance markets: Due to the shortage of public funds and difficulties in meeting the budgetary commitments in the healthcare sector, the Armenian government has introduced the Basic Benefits Package (BBP) that includes official charges to patients for services.BBP is a package of specific services which are free of cost to those who are entitled to this package. A list of vulnerable group of the population will receive all the medical treatments available at free of cost. All other Armenian residents who are not entitled to this group will pay out of pocket for the treatments and pharmaceuticals which are not listed in BBP. The low funds paid by the state to publicly funded facilities do not cover actual service cost and has even worked to increase under the table costs. The residents of Armenia avoid treatments for myopia as they can’t even afford the basic expenses (Wang, 2009). The physicians charge payment in cash even if tourists have travel health insurance. The Armenia nation lacks in good healthcare policies which are again due to the lack of attention towards healthcare facilities of the government. Therefore, Armenia does not have policies for the treatments of myopia and even if they have few that does not particularly benefit the residents of Armenia. Healthcare facilities are often inadequate and do not equip to deal with series problems of myopia.
• Equity: Armenia remains the poorest nationsfrom the former Soviet Union due to the collapse of government revenue of 35% in public health expenditure. This forced the government to use out-of-pocket payments to finance the gap created due to this decline. Health insurance schemes are growing in importance in Armenia but still, there are concerns about the equity of such schemes and the ability to reach the poorest(Exworthy, 2018). The schemes have achieved a high-level of equity, according to socioeconomic status, gender, and age but it still remains relatively low if compared with other nations (Ramacciati, 2012). They lack behind due to the lack of affordability and a package of primary care that does not include coverage diseases such as myopia. Therefore, keeping in an account of all the barriers and challenges it can be recommended to improvise their healthcare technologies and increase funds towards healthcare facilities that meet the needs of the Armenian patients such as corneal refractive therapy (CRT), phakic IOLs and many newer technologies to treat the patients of myopia (Currie, 2012).

The above analysis suggests adapting the technologies to lower myopia disease in Armenia. As economy is interlinked with health system in Armenia, government needs to pay attention in the healthcare system by giving financial support to the healthcare facilities. The analysis also says that even after introducing certain health schemes and policies for the residents of Armenia, it does not cover myopia disease. Armenian nation still remains the poorest nation due to 35% decline of revenue in public health. Physicians still expects cash in payment from tourist even after having travel insurance policies (Murphy, 2017). New technologies such as Orthokeratology, which is a special contact lens worn at night provide clear vision during the daytime. Multifocal soft contact lenses, corneal refractive therapy (CRT), phakic IOLs are more new technologies that can be used in treating myopia in children. Besides this, Atropine, a kind of eye drop can be used at night. Other than this government should play vital role in organizing myopia awareness programmes in schools, myopia free treatment camps throughout the Armenian nation (Stafinsk et al., 2011). Though the insurance policies are gradually improving in recent time but it needs to be good enough to meet the needs of the myopia patients. Free check-ups can be started.

Conclusion

The study recommends adopting the technologies such as corneal refractive therapy (CRT), phakic IOLs, Multifocal soft contact lenses for the intervention of myopia. Adapting these technologies will have a better scope in lowering myopic patients. Besides this, Armenian government is recommended to increase funding for health care system. This will help the Armenian nation in both economic as well as health system development. Better healthcare schemes and policies need to be improvised to cover all the diseases including myopia. All the schemes should achieve the high level of equity according to the socio-economic status, gender, and age. The gradual increase of myopia disease in children can be thus lowered by fulfilling all the recommendation (Song et al., 2004).

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