How to get drugs reimbursed in Singapore, ranking as the world’s most efficient healthcare system

This second blog in our series on health technology assessments (HTAs) in the Asia-Pacific (APAC) region examines the process by which HTAs are conducted in Singapore and what this means for affordable and timely market access of new and innovative treatments. If you missed the first blog in our series, check out “What’s driving oncology HTAs in South Korea?”.

 

The Republic of Singapore is a sovereign island city-state in Southeast Asia with a total population of 5.7 million. The country has the second highest gross domestic product (GDP) per capita in the world, amounting to SG$82,503 (2020), and health expenditure represents 2.1% (2017). The healthcare system of Singapore is robust and has been ranked the most efficient of the COVID-19 era in the world by Bloomberg.

The system is regulated by the Ministry of Health (MOH), whose goals are to ensure access to good and affordable healthcare, promote good health, reduce illness and pursue medical excellence. This government-run, publicly funded, universal healthcare system is divided into vertically integrated delivery networks by region, which operate several public and community hospitals, national specialty centers and polyclinics. Financing is delivered through a combination of subsidies, health insurance schemes and health savings plans such as Medisave, Medishield Life and Medifund.

 

Who conducts HTAs?

The Agency for Care Effectiveness (ACE) is the national HTA agency in Singapore that was established by the MOH in 2015. Its vision is to improve patient outcomes and healthcare value through HTAs, and it aims to drive better clinical and cost-effective patient care decisions. The agency evaluates drugs, devices and medical services using HTA methods from the healthcare system perspective, which aims to maximize health gain from available healthcare resources. These evaluations equip policy makers with objective and credible evidence on clinical efficacy and relative value to determine the technologies that will receive subsidy from the government. ACE conducts HTA decisions in order to support subsidy decision by the respective MOH advisory committee.

 

What is the HTA process?

Figure 1: Process of HTA evaluation in Singapore

Source: Drug Evaluation Methods and Process Guide, Agency for Care Effectiveness, published in December 2019

 

The HTA process involves three main steps: topic submission and selection, technical evaluation and decision making.

    1. Topic submission: Potential topics for assessments are predominantly identified through applications by public healthcare professionals in Singapore. In addition, new and emerging drugs are identified through literature searches and horizon scanning by the technical team at ACE.
    2. Technical evaluation: Once the topic is selected, evaluations are conducted using either an expedited or full process, depending on the estimated budget impact and the uncertainty around the clinical and cost parameters for each drug. Expedited evaluations usually take 2 to 3 months whereas full evaluations typically take 6 to 9 months. To conduct the evaluation, ACE selects clinical experts to form a Scoping Working Group. A draft scope is then developed. Clinical experts and stakeholders are consulted on the draft scope to ensure the evaluation reflects local clinical practice and addresses the needs of clinicians and patients. Value-based pricing is conducted in parallel with technology evaluations to ensure that the recommended price of the technology represents a cost-effective use of healthcare resources and is commensurate with the technology’s value in Singapore’s context. Manufacturers are invited to submit key clinical information and best prices for their drugs, which then inform ACE’s clinical- and cost-effectiveness analyses and budget-impact assessments.
    3. Decision making: Once the agency completes the final evaluation report, it is presented to the Drug Advisory Committee (DAC) for deliberation. On the basis of the available evidence, the DAC recommends whether a drug should receive subsidy through the Standard Drug List or Medication Assistance Fund. Subsidized drugs are considered the preferred treatment option for producing the best health outcomes while limiting patients’ out-of-pocket expenses. However, drugs which are not currently listed on the SDL are available for patients who can afford to pay for them.
    4. The recommendations are based on four core criteria:
      1. Clinical need of patients and nature of the condition
      2. Clinical-effectiveness and safety of the drug
      3. Cost-effectiveness of the drug
      4. Estimated annual cost of the drug and the number of patients likely to benefit from the technology

 

How is the process evolving?

Starting in January 2021, pharmaceutical companies will be able to request that their products be evaluated for funding consideration and will be responsible for providing an evidence submission to ACE to support the MOH DAC’s deliberations. For now, only evidence submissions for new cancer treatments (or new indications for existing cancer treatments) will be eligible for evaluation using this route.

HTA will continue to play an important role in the future of Singapore’s healthcare system as it adapts to changing patient needs and improves affordable access to clinically necessary treatments. With the increased participation by manufacturers starting in early 2021, the time between regulatory approval and reimbursement can potentially be shortened giving patients faster access to subsidized lifesaving treatments.

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