Idsi stakeholder engagement, final report by Meteos

iDSI Stakeholder Report September 2015

International Decision Support Initiative (iDSI) Findings on Stakeholder Engagement 1. Background An objective of iDSI in its early development was to ‘enhance communication and engagement between key stakeholders, public and private, in the process of HTA development and of priority-setting.’ Meteos was contracted as an iDSI partner to support this objective, specifically with the responsibility to gather stakeholder perspectives, to convene a stakeholder meeting, and to produce a set of recommendations on ongoing mechanisms for stakeholder engagement by iDSI. To meet these objectives, Meteos undertook a stakeholder consultation through interviews with a wide range of stakeholders. A stakeholder meeting was planned to take place in London on the 16-17 July. However, given limited availability of key participants, Meteos and the Steering Group agreed to cancel the meeting and to complete the consultation through further interviews. The goals of the consultation were to: • Solicit feed-back from a diverse group of stakeholders on how iDSI can maximise its impact in support of government priority-setting. •

Solicit input on the form and agenda of an ongoing iDSI stakeholder engagement mechanism.

This report summarises the outcomes of interviews conducted in May-July 2015. A total of 37 interviews were conducted with the following groups (list of interviewees in Annex A): • 7 country health policy-makers and health technology assessment institutions • 6 academics • 3 international donors • 4 multi-laterals & global funds • 5 industry • 2 patient representatives • 6 NGOs and advocacy groups • 4 consultancies This document covers the two main questions for this exercise: stakeholder perspectives on iDSI’s impact, and views on iDSI’s approach to stakeholder engagement. It concludes with an initial set of options for ongoing stakeholder engagement, and poses a series of questions for consideration by the Steering Group to guide their decisions on stakeholder engagement in the future. Except where noted, comments came from across all stakeholder groups. A copy of the interview questionnaire is attached in Annex B. 2. Stakeholder views on how can iDSI maximise its impact Very significant, and growing need for the support that iDSI provides. Given the growing pressures on healthcare budgets, the extension of universal healthcare coverage in many countries, and the impact on government and household budgets of increasing pharmaceutical expenditure, all stakeholders interviewed shared a sense that iDSI both fills a gap, and will likely face increasing demand for its services. “iDSI is really coming at the right time. There is a lot to be done.” 1 “I see three levels in establishing priority-setting: awareness building, ad hoc experimentation, and systematic use of methods. Most countries are at most at the first level.” 1 All quotes are taken from interviews and represent the range of views expressed by interviewees.

The need to combine political, process and technical support. iDSI is responding to very different support requirements: •

Political support: giving legitimacy to government efforts to introduce priority-setting, and building awareness/confidence among government officials.

•

Process support: helping countries to design processes that are relevant to their particular context and phase of development, including support for managing stakeholder engagement.

•

Technical support: providing technical tools, ranging from HTA for specific technologies, to financing mechanisms, to policy tools for priority-setting on disease management, and the design of Health Benefits Plans.

Stakeholders see iDSI as offering unique value in its ability to meet needs on all three levels, but see the greatest need in the political and process support. “iDSI is important in balancing the technical and the process support in healthcare priority-setting. Most academics focus on the technical, but iDSI does both.” “Priority-setting is more of an art than a science. Like all disciplines there are different schools of thought, and we have to acknowledge that politics is in the middle.” “Priority-setting is a very political process and very challenging. Balancing all the different stakeholder interests and managing what everyone wants to see in a health benefits plan – that’s where we need support. With the public we have to be able to justify the best use of every dollar.” “There is a limiting factor in that the core skills set ---skilful diplomacy---is not something that is a cookie cutter problem. There are a few people who do that really well and they are in iDSI.” Most valuable learning comes from other countries and long-term accompaniment. All stakeholders emphasized the direct exchange of experiences among countries as having the greatest impact. “iDSI is most useful when it provides practical examples, exposes people to new information and new thinking.” “iDSI is a know-how network, providing real examples of best practice.” “Experience sharing across peer countries is where the most impact will happen. South-South capacitybuilding and knowledge-sharing is key to all of this.” Countries also emphasised the need for long-term, ongoing engagement and accompaniment, and some frustration with ‘fly-in/fly-out’ and meeting-based support. These are useful in building awareness and legitimacy for priority-setting, but are insufficient for embedding ideas and methodologies. “We know the mechanism that works: having people work side by side with government officials over a five year period. Look historically at what happened in Mexico.” “Tools tend to become established and then no one dares or can make the effort to adapt and change them. Things take such a long time to develop and approve and we often fail to adapt to feedback from the local level. This has to be an ongoing process.” “At this stage it’s risky to spread iDSI too thinly. The support in countries needs to be intensive, close and ongoing. It also needs to be focused not just on institutions, but on individuals.”

Mobilising capacity through wider networks of partners. Interviewees acknowledged the difficulties of meeting rising demand for support from a relatively small group of people and institutions that are providing this support through iDSI. Several interviewees (academics, donors, multilaterals) suggested that iDSI could widen its reach by putting together teams, drawn from multiple institutions. This would help address their own institutions’ limited ability to provide ongoing, direct support to countries. “We need big enough collaborations to be able to draw in a range of support, including people like the ODI fellows who can be an ongoing presence in country. iDSI could coordinate a flow of expertise coming in at key moments.” “iDSI could be great at putting together ‘SWAT’ teams to provide guidance and expertise.” “Countries already have mechanisms and processes that we’re not really aware of, and then we come in with external processes to put on top. We could do more to make sure we build on existing capacities in countries.” “I would like to see iDSI break out of a ‘hub and spoke’ model into a model of multiple hubs, and a looser platform of coordination.” “I think the key idea, the essence of iDSI, is the idea of having regional evidence hubs.” Many organisations interviewed, particularly academics, multilateral institutions and consultancies, expressed interest in being part of the iDSI network of organisations supporting developing country governments. Offers ranged from technical support in HTA, to systematic review to process support on stakeholder consultation. Several identified an interest in collaborating on identifying and filling research gaps. There were questions about how much iDSI plans to broaden the group of partner organisations, and what the funding model would be to do this. “A key gap is the understanding of how you use research to inform decision-making. We would be interested in working with iDSI on connecting the available evidence with decision-making.” “We have a health economics network in MENA region, which is a great region to establish HTA. iDSI could benefit from what we’re doing and use our network to help share knowledge and tools. It’s costless for them as we’re already there.” Need for better communication across related initiatives. iDSI is one of many organisations and initiatives supporting countries in priority-setting. Many stakeholders, particularly academics, donors and NGOs, raised concerns about the difficulties of knowing what others are doing, even within a same country where several organisations are providing support. Interviewees didn’t think it was possible for one entity to coordinate or communicate all initiatives, but saw iDSI as having a unique potential to be a platform for sharing information and experience across multiple initiatives. “No one really has the whole picture. It would make a huge difference if everyone knew what others were doing.” “We’re interested in having people tell us where the evidence gaps are in terms of research, where a country feels it needs more evidence. If iDSI could link with us on that, that’d be incredibly helpful.” “If donors were being strategic, they would require that all their grantees involved in priority-setting report on their activities through something like iDSI.”

“We often don’t know enough about what has preceded us when we go in and provide support. It means we might be overlooking existing capacity entirely.” Different ‘theories of change’ informing strategy. These perspectives point to the very different views on how iDSI should define its particular offering, reflecting different perspectives on how iDSI is most likely to achieve impact. Most interviewees advocated for an approach that focuses iDSI’s limited resources on establishing a powerful set of ‘success stories’ that could inspire and inform others. Others wanted iDSI to create, coordinate and deploy a much wider network of people/institutions, through increasingly established regional hubs, in order to be able to respond to demand wherever it emerges. There were also different views on the degree to which iDSI is an implementer vs. a convenor of organisations that provide support. There was a clear message from all those interviewed that it would be helpful for iDSI to refine and make more precise its ‘model of change’ in its next stage of development in order to manage expectations. “iDSI can’t support all countries, but it can generate case studies, help countries to support each other with comparable methods, and create a nuclear reaction.” “Does iDSI become the ‘one stop shop’ for support on priority-setting? If not, how does it determine who gets support? That will take you back to the original question around what impact you are trying to achieve.” “In ten years iDSI should aim to be out of business because the capacity, expertise, infrastructure will be in place in LMICs so they no longer need the kind of support iDSI offers.” “Is iDSI a visible actor or an invisible convener?” “There are probably phases, with the first phase requiring focus on getting a few strong examples of progress on priority-setting, and then at a later stage to broaden out the offering.” Conflicting views around the methods of priority-setting that iDSI promotes. Some industry and academic stakeholders expressed concern that developing country governments are presented with a limited range of tools through iDSI, linked closely to the UK experience of QALYs. These interviewees see QALYs, cost-benefit analysis and thresholds as several among many tools for priority-setting. Country stakeholders value what they see as the UK’s and HITAP’s success in establishing an evidence-based approach, and some academics felt that iDSI should be clear and unapologetic about its decision to give preference to some tools over others. Others, including industry, donors and multilaterals observed that iDSI has a role in presenting the full range of tools, otherwise there is a risk of amplifying a sense of ‘camps’ in priority-setting. “There is a need for a more rounded and open discussion on alternatives and how economic evaluation and cost-effectiveness could sit in a larger framework. It would be great to see a bit more flexibility.” “There is a danger that iDSI is remembered for cost-effectiveness thresholds. It shouldn’t allow itself to be defined by a particular methodology.” “These debates about methodology are super important, but the debates shouldn’t pit one method against another. The question is about what methods should be used at different stages. All methods have a time and place.” “I think iDSI is strongly rooted in an approach to using evidence and analysis to support decision-making. It should be unapologetic about that.”

Tone and approach of iDSI – how inclusive? Some interviewees (industry, academics, donors) raised concerns that iDSI is a closed group of like-minded people, running the risk that it reinforces assumptions and biases instead of being open to divergent perspectives. Several of those interviewed felt that the tone of iDSI’s engagement with people with opposing views was not conducive to collaboration. All those interviewed acknowledged the difficulties of managing a ‘broad tent’ approach, but those who felt they were outside the tent desired more open engagement. “Sometimes these discussions are paralysed by soap-boxing. There is generally a need for better listening to views that are inconvenient. That goes for everyone involved.” “A key challenge is how to bring in and listen to the voices that are different from the ones you know and trust. Otherwise there is a danger of group think.” Need to clarify governance structures. Those who have been involved with iDSI noted that there is some confusion between governance, management, and delivery, and there is a need for greater clarity on the role of different stakeholders in each of these levels. Several interviewees commented that they weren’t clear on the nature of their contributions, and whether they were part of decision-making or being consulted. There was some concern that governance and management are held by the same group, and several interviewees suggested that in iDSI’s next stage of development the governance function needs to have a degree of independence from the group of implementing partners. “I’m not sure what it means to be an iDSI partner and what decisions are taken at what level. We seem to be siloed in our specific pieces of work, without reference to what people are doing in the other work streams.” “There is a risk of having the same people on the Steering Group as doing the delivery. I can see there is some efficiency in this, but there is a risk of confirmation bias.” “We need to make sure that every meeting makes the best use of the time of the people involved. I don’t think it is worth someone coming from half way round the world to hear an update on other people’s research.” “We really need to look at the governance side of iDSI. It would be great if the Steering Group could spend some time considering options.” 3. iDSI and stakeholder engagement Getting the basics of stakeholder engagement in place. The key questions for iDSI that came out of the interviews related to the purpose of stakeholder engagement, the definition of stakeholders, and the methods for engaging with stakeholders in the future. What is the purpose of stakeholder engagement? Interviewees asked what iDSI wants to achieve through stakeholder engagement. There were widely divergent views on what would constitute meaningful stakeholder engagement, with some interviewees advocating for a broad engagement at the global level in iDSI strategy and products. Others felt strongly that there is little value in engaging stakeholders in iDSI itself, but that there should be some level of engagement in iDSI products (research, publications, tools), as these reflect important political judgements. A third group, particularly country representatives, proposed that stakeholder engagement is only really meaningful at the national level, and that iDSI should facilitate national level engagement where it is providing support. “I’ve done lots of stakeholder engagement. You don’t do it for no reason. It has to have a purpose and be anchored in the goals and the vision of your organisation.”

“I don’t see the usefulness of a global platform of stakeholders. These issues have to be worked out at a national level and will be different for every country.” “There has to be some level of global engagement and transparency or there will be push back. It doesn’t have to be hugely complicated. It just needs to be clear.” Who are iDSI’s key stakeholders? Interviewees consistently asked who iDSI defines as a stakeholder, and how much it is willing to engage with institutions that have a ‘stake’ in priority-setting, but may not share iDSI’s perspective on approaches. Interviewees mentioned industry, patient organisations and multi-lateral organisations and initiatives as sectors that require greater clarity within iDSI’s definition of stakeholders. Others felt that iDSI is not in a position to mediate the tensions across the range of stakeholders in prioritysetting, and that it should focus on those who clearly align to its purpose. “I’d love to see a chart with exactly who is a stakeholder in iDSI. Who will be listened to? This could be either stakeholders with a capacity to amplify, or those with a capacity to block.” “There are clear proponents and opponents of the mission of this entity and so their path will be facilitated if they figure out who are the stakeholders that really matter. This has to include the global life sciences world if they are to be effective.” “You need to be aware of who is operating out there in the broader environment that has the potential to derail you, and find a way to engage those voices.” “You need to be inclusive, but that doesn’t mean including voices that just want to block priority-setting.” “There needs to be greater outreach to the Global Fund, GAVI, UNITAID and WHO. Relations have improved but still could be better.” “The historical research reveals that patient-groups and communities were central in the getting the NHS Act passed in the UK. So the voice of patients in these processes can be crucial.” What methods are most appropriate for engaging stakeholders? The ways of engaging stakeholders will become clear as iDSI clarifies the purpose of engagement, and who should be included. The interviews revealed some important elements around the methods of engagement that should be considered: clarity on what is being asked of stakeholders and what they receive in return (e.g. information, insights, new relationships, opportunities for collaboration); sensitivity about the burden on a relatively small community for engagement on multiple initiatives; cost effectiveness (time/money) of meetings as a means of engagement; and clarity on how engagement will impact on iDSI strategy, products or behaviour. “I’m dubious of the big meetings – not sure you get the best level of engagement and answers to the question you’re asking. I’m not sure you get the dialogue you really want.” “One of the most basic principles of engagement has to be that people know how their input is going to be used; how the organisation doing the consulting is going to change as a result of their input.” iDSI as a model of stakeholder engagement. Several interviewees noted that stakeholder engagement is a key challenge for countries, and therefore iDSI will be called on to model the kind of engagement that is required of the countries it is supporting. Both HITAP and NICE were noted as successful examples of national stakeholder engagement, as was the management of the Gates Reference Case.

“iDSI doesn’t have to look far for how to do stakeholder engagement. The Gates Reference Case was one of the best examples of stakeholder engagement processes I’ve been involved with. As a stakeholder in that process I really saw it as an example of perfect engagement.” 4. Approaches to stakeholder engagement

The interviews and desk research identified different approaches and aspirations for iDSI stakeholder engagement. As mentioned in the prior section, the critical challenge for iDSI is to gain clarity on the purpose of stakeholder consultation, and therefore who will be most important to engage, and how. The table below offers a simple framework for different types of engagement. 2 Each of these approaches, or combinations of them, will be applicable to different aspects of the organisation’s activities.

Type of Engagement

Purpose

Communicate

Aims to inform, educate, inspire, motivate or change opinion of others.

Listen

Aims to inform your own perspective, understand other views, look beyond your own sector, perceptions and ways of working, track changes in evidence or attitudes, to inform strategy, activities or behaviours. Also enables acknowledgement and management of tensions.

Co-Create

Aims to work together to influence, create, define or decide; generates collaborative relationships.

Cogitate

Aims to rethink, analyse, and evaluate in order to challenge thinking, strategy or practice.

The approach to engagement will depend on both the purpose, and the nature of the groups consulted. Different tools may be required for different stakeholders. •

Personal interviews

•

Workshops

•

Focus groups

•

Public or ‘town hall’ meetings

•

Surveys

•

Participatory tools (e.g. Rapid Rural Assessment, Participatory Rural Assessment)

•

Stakeholder panels

2 Adapted schema from MATTER, ‘Stakeholder Engagement Loop’, 2014. Accessed 12 th June 2015 at: http://www.matterforall.org/the-missing-link-the-importance-of-cogitation-in-stakeholder-engagement/

The pros and cons of each of these tools are outlined in detail in the Doughty Centre guide to Stakeholder Engagement.3 The tools that may be most appropriate to iDSI are included in the options below.

5. Initial options for iDSI’s ongoing engagement with stakeholders IDSI set a goal in its first two years to define an ongoing mechanism for stakeholder engagement. Based on the above reflections, the following options, or combination of options, could be considered. 5.1 Systematic Global Stakeholder Consultation & Engagement: iDSI could create a mechanism, or suite of mechanisms, that invite global stakeholders, including donors, academics, industry and patient organisations, to give input to iDSI strategy, and/or products, and to provide feed-back on the nature and quality of the services iDSI offers. Systematic consultation would allow iDSI to understand and manage the inevitable tensions that emerge around priority-setting among influential global actors. By creating a channel for engagement, iDSI is likely to diminish the opposition that might undermine some of its work. This option would also allow iDSI to model the type of stakeholder engagement, albeit at a global level, that is required of the countries it supports. Systematic engagement might include:

•

iDSI Assembly: Given the growing number of organisations involved in delivering and/or receiving support through iDSI, iDSI could create an annual, or bi-annual Assembly of partner organisations with the purpose of informing strategy, coordinating activities and reviewing impact. There is interest in this option among global institutions, academics and other delivery partners, but less interest among stakeholders within national health systems/HTAs.

•

Stakeholder Survey: An annual stakeholder survey, through a combination of interviews and an on-line survey with the full range of stakeholders, providing broad input to inform iDSI’s strategy and services. Organisations that have conducted stakeholder surveys recommend that a writein, quantitative survey is costly and most useful if iDSI wants to track perspectives over time. A qualitative survey, akin to the stakeholder interviews done for this review, was seen as more consistent with iDSI’s scale and mission.

5.2 In-Country Stakeholder Engagement: Given iDSI’s primary focus on supporting country health systems, and recognising the other global fora that exist, iDSI could focus its stakeholder engagement at the national level. There is significant interest/demand from health systems/HTA bodies in developing countries for assistance in constructing and managing effective stakeholder engagement processes, and this could be one area where iDSI offers knowledge products, support, and opportunities for exchange among countries. It would also require iDSI to actively model effective stakeholder engagement by including the range of relevant organisations in iDSI’s engagement within countries where it is working. This option would allow iDSI to focus on its primary clients, but would not allow an avenue for managing the pressures for engagement by global organisations.

3 Jeffrey, N., ‘Stakeholder Engagement: A Roadmap to Meaningful Engagement.’ Doughty Centre (2009), p 45-7.

5.3 Product-focused Engagement: The interviews revealed that the majority of stakeholders are interested in engagement around the issues relating to priority-setting, and less interest in engaging on iDSI’s organisational strategy. Focus Groups, which can be managed via on-line tools, offer a useful mechanism for testing ideas, consulting specific products, and identifying areas of tension that need to be managed. Some of the issues interviewees mentioned where there may be interest in Focus Groups include:

•

New approaches and tools, e.g. Step select from Northern Ireland, STAR

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Affordability tools

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Macro vs micro priority-setting

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Priority-setting and NCDs

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Professional development for next generation of health economists

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Big data and priority-setting

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Research gaps in priority-setting

5.4 iDSI Priority-Setting Platform: iDSI could serve as a platform that brings together the range of organisations and perspectives on priority-setting. While other platforms exist (HTAi and regional networks), none are felt to be effectively capturing the broad range of activities, methods and perspectives on the particular challenges and approaches to priority-setting, or making these available to those who could use them. iDSI could provide this platform, at least digitally, and potentially through global and regional meetings where tools and experiences are shared. A platform of this kind could help build a wide network of support for priority-setting that iDSI could draw on to meet demand from health ministries. This is an ambitious option and would require significant resourcing. It would respond to the view that priority-setting requires improved coordination, communication and collaborative spaces for finding common ground across diverse organisations and perspectives.

A more modest version of this platform would be a learning network that is exclusively made up of country health system representatives to share learning, tools and experiences around priority-setting. This could be a function held within iDSI, linked to the Joint Learning Network 4 which covers a much wider set of issues relating to UHC. This approach would clearly establish health systems as the core stakeholder, and would not seek to be representative of the range of other organisations involved in priority-setting. It would be more ‘hands-on’ and experience-oriented and have the benefit of building and linking with an existing network with established capacity. Independent of which approach, or combination of approaches iDSI chooses to pursue, success will depend on the degree to which the engagement a) has the potential to influence iDSI strategy, activities or 4 Joint Learning Network: accessed at http://www.jointlearningnetwork.org/

behaviour, and b) includes a feed-back mechanisms to inform, engage and demonstrate accountability to the relevant stakeholders. The findings of this review will be discussed at the October 2015 meeting of the iDSI Steering Group in Beijing. It is the intention of the Steering Group to incorporate these findings into discussions and decisions on iDSI’s future governance & accountability, engagement with stakeholders, and the definition of roles among partner organisations. Decisions will be reflected in iDSI’s forward strategy, communications and engagements which will be available on the iDSI website (http://www.idsihealth.org/).

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Annex A: iDSI Stakeholder Consultation - List of Interviewees

Name

Title

Organisation

Jeonghoon Ahn

Senior Director

Michael Borowitz

Rachael Clay Rob Cook

Head of Strategic Investment & Partnerships Product Manager, Clinical Decision Support Director Clinical Director

National Evidence-based Healthcare Collaboration, South Korea The Global Fund

Anthony Culyer Stefan Nachuk Feacham

Professor of Economics Director, Global Health Group

David Grainger Martha GyansaLutterodt Ha Anh Duc

Senior Director, Global Public Policy Director of Pharmaceutical Services Vice Chief of Cabinet and Secretary to Minister of Health

Ministry of Health Vietnam

Karen Hofman Jay Iyer Judith Kallenberg Mohga Kamal-Yanni Mpuma Kamanga

PRICELESS, South Africa Access to Medicines Index GAVI Oxfam Ministry of Health, Zambia

Justin Koester Ritu Kumar Jason Lakin

Director Research Director Head of Policy Senior Health & HIV Policy Advisor National Social Health Insurance Coordinator Senior International Relations Specialist Health Systems Strengthening Director

Carol Levin Donald Pardede Valerie Paris

Clinical Associate Professor, Global Health Director, Health Financing and Securities Economist, Health Division

Klara Brunnhuber

British Medical Journal Ethicore Bazian, Economist Intelligence Unit healthcare University of York University of California, San Francisco Eli Lilly Ministry of Health, Ghana

Medtronic PATH International Budget Partnership, Kenya University of Washington Ministry of Health, Indonesia OECD

Natalie Phaholyothin Anjali Radcliffe Soraya Ramoul Mark Sculpher Kawaldip Sehmi

Associate Director Director, Government Affairs, Emerging Markets and Asia Pacific Director, Access to Health Professor, Health Economics Chief Executive Officer

Andreas Seiter Brendan Shaw Mark Skinner

Health Specialist Assistant Director General President

Natasha Sunderji

Manager

Yot Teerwattananon Adrian Towse Sean Tunis

Programme Leader Representative/Director President

Damian Walker Julia Watson Julie Wood

Senior Programme Officer Senior Health Economist Head of Communications and External Affairs Director HTA

Kun Zhao

Rockefeller Foundation GlaxoSmithKline Novo Nordisk University of York International Alliance of Patients’ Organisation World Bank IFPMA World Federation of Haemophilia Accenture Development Partnerships HITAP, Thailand Ispor/OHE Center for Medical Technology Policy Gates Foundation DfID Cochrane Collaboration National Health Development Research Centre, China

Annex B: iDSI Stakeholder Consultation - Interview Questionnaire Introduction The International Decision Support Initiative (iDSI) is a mechanism to support developing country policymakers in priority-setting in healthcare. It was initiated by NICE International, with HITAP, CGD and a group of academic institutions aiming to coordinate their resources and support to countries pursuing priority-setting. iDSI will be a platform to share experiences, showcase lessons learned, and identify practical ways to scale technical support for more systematic, fair and evidence-informed priority-setting processes. For more information on iDSI’s work and projects please visit the iDSI website. To build support and collaboration across relevant organisations, iDSI will establish ongoing consultation mechanisms with a range of stakeholders, including health systems, NGOs, patient organisations, academic institutions, HTA bodies, grant makers and industry. This interview aims to gather your initial thoughts on how iDSI can best deliver support to developing country governments on priority-setting, and how to best collaborate with other relevant organisations to this end. The outcomes of these interviews will be brought to a stakeholder meeting in July and the results will be shared with those interviewed. 1. Please tell us a bit about your/your organisation’s involvement in priority-setting in health systems.

2. What progress do you think has been made on establishing priority-setting as an approach to managing healthcare expenditure in developing countries? 3. What do you consider to be the key capability gaps that need to be filled? 4. It is ten years from now and you are looking back at the last decade, 2025-2015. If you were to tell a story of iDSI as a high impact platform for delivering support to country health systems, what would the story be? What would have been the key elements of success? 5. In order to achieve the successes you describe, what sort of ongoing engagement with stakeholders would be required? 6. What would convince you to put time and effort into ongoing engagement with iDSI? 7. Are there any other issues you would like to raise?