Recently the ABPMJAY, which covers 10 million vulnerable families, reached a milestone of providing 100 million treatments. However, given the size of the scheme, ensuring cost-effectiveness within such a large scheme is highly dependent upon having detailed and robust information on economic costs within the health system. Here we discuss, the role of costing in priority setting, price negotiations and the measures that India is taking in this area, as part of its efforts to ensure equity and cost-effectiveness within its healthcare system.

Poor cost data can lead to the misallocation of resources 

Priority setting is the process of making decisions about how best to allocate limited resources to improve population health. Priority setting within healthcare can be facilitated through health technology assessments (HTA) which includes quantifying whether investments in healthcare are both clinically effective and cost-effective and through exploring the key factors within the healthcare system that drive costs.

In India, as in many low- and middle-income countries (LMICs), there have been challenges in systematically incorporating explicit priority setting or HTA into healthcare decision-making in India. A key barrier has been the complex and fragmented healthcare system with several different insurance and “assurance” arrangements, at both the central and state level. Despite these challenges, the government of India has begun to take proactive steps towards institutionalising HTA. It has established its own HTA agency at the national level (HTAIn) in the Ministry of Health and Family Welfare, and HTAIn has been developing HTA standards and initiating the first health technology appraisals.

But, as HTA rolls out in India, the limited availability of cost data has been highlighted as a key concern by both government actors and the press. The availability of cost data is in turn constrained by limited  cost data collection activities, the inadequacy of information systems to meet costing needs, and the lack of political interest in costing. A typical problem is when only some of the costs relevant to delivery of a drug or diagnostic tool are assessed (e.g. excluding patient monitoring or patient incurred costs). An intervention can then appear more or less cost-effective than they actually are and fail to acknowledge the cost burden placed on patients.

This is a problem found in many LMICs but with political will, a standardised, central, and freely available source of health service cost data can be developed to address this gap (such as in Thailand or Cambodia). As a result it will lead to a fall in the duplication of efforts and the expense of data collection to improve the quality of HTA.

Good quality cost information can help governments negotiate better prices

The terms “cost” and “price” are often, mistakenly used interchangeably. However, they are extremely different things. Specifically, prices do not necessarily reflect costs. Prices are the negotiated rate for a good e.g. drugs or service such as consultations. Set too high, prices can over-stretch a budget, limiting spending in other areas and setting up barriers to care and, where individuals pay for care, lead to catastrophic health expenditure. At the same time, high reimbursement rates can result in the over-use of certain treatments such as c-sections and have even led to unwanted hysterectomies. Set too low and the prices can contribute to over-use of some therapies such as antibiotics. Good quality cost information and HTA can help regulate prices so that they reflect value for money.

Regulating prices can be easier within health systems that have a central purchaser such as the UK, France, Australia and Thailand where prices are set in accordance with costs. Within these countries, uniform reimbursement rates are set using data on the cost of health service provision collected through the mandated submission of cost data from all providers or, in the case of Thailand, comprehensive cost surveys conducted by the Health Intervention and Technology Assessment Program of the Ministry of Public Health (HITAP).

Such a system which involves a central regulator encourages transparency and can help contain growth in costs through both accountability as well as economies of scale. For example, using reliable cost information in an HTA process allowed the Thai government to negotiate an affordable price for the HPV vaccines, demonstrating how monopsony power (when there is only one buyer in a market) combined with good cost information can contain costs.

Regulating prices is trickier in fragmented healthcare systems (e.g. USA or India) which have many different types of providers and purchasers (insurers/government). In India, the fragmented system has resulted in large scale variations in prices for similar services across and between states and providers. The majority of fee rates within India’s many public health insurance schemes have been set using various processes and fee rates with different incentives for different services resulting in a process that is “non-transparent and often arbitrary and irrational.” These prices are likely to be inefficient and highly incentivise certain types of services at the expense of others, such as the use of high technology stent implants that have no evidence based benefit over cheaper models. Gathering information on  coronary stent prices revealed price mark ups of between 4-6 times the cost price, leading government price capping and up to 85 percent price reductions. Similarly, a recent Indian initiative to improve TB testing in the private sector has shown how standardisation of prices can be achieved by bringing private laboratories together under a single regulatory body, India has reduced the cost of accredited TB tests to affordable levels. The issue has been highlighted during the COVID-19 pandemic with private hospitals accused of charging exorbitant prices, making the government mandate hospitals to share COVID-19 fee details and some evidence of drops in non COVID related healthcare utilisation due to financial barriers.

As publicly funded health insurance schemes expand to cover a greater portion of the population and consume a greater portion of the healthcare budget, the need for prices to be set at efficient levels is more pressing. The demand for freely available good quality cost information to inform price-setting therefore becomes increasingly important.

India is beginning to build a cost evidence-base

Until now, costing information in India has largely been fragmented, not available across states or levels of the health system and highly disease specific. In fact, the major source of cost data has been individual cost studies which have been mixed in validity and reliability. This has been further compounded by the fact that there is a limited pool of health system experts with costing experience in India.

In recognition of the lack of costing capacity within India, the Department of Health Research (DHR) along with academic experts like PGIMER Department of Community Medicine and School of Public Health have taken a proactive approach to strengthen the costing capacity of the health system. Alongside the establishment of a technical working group on costing, there has been support for the development of training material for economic evaluation more generally and subsequently in specific topics including costing. These take the form of online modules, workshops for policy-makers and practitioners and a forthcoming costing manual which lays out principles and standards for costing health services in India.

To improve the availability of data, a National Health System Cost Database website is being built as a public good, by PGIMER Chandigarh, with the support of the International Decision Support Initiative (iDSI). This database currently includes data on the unit costs of health services from 167 public health facilities (district and below) located in 6 different states across India, collected in collaboration with PGIMER’s partners IIT Madras, PHFI Delhi, TISS Mumbai.

In addition to the development of the database and website, the HTAIn has launched a national cost study-Costing of Health Systems (CHSI)-to collect further cost information from public and private healthcare tertiary and district level providers located across 11 different Indian states. The data will be used for HTA and has been used to estimate the unit costs of the AB-PMJAY health benefit packages (HBP). The National Health System Cost Database website continues to be updated with new data (such as the CHSI results) as these become available, as well as the latest methodological standards and guides.

The database website also hosts a user friendly and unique unit cost predictor (based on a statistical cost function). The predictor allows users to generate state specific average outpatient visit and inpatient admission costs for use in their own analyses. For example, a researcher wanting to do an HTA specific to the state of Andhra Pradesh would be able to extract a mean cost for their locality rather than use a national level average.

These first incremental steps towards generating nationally representative health service cost data for India are already proving their value. Since the launch of these two initiatives, the CHSI study costs results have been used to inform reimbursement rates for AB-PMJAY as well as for as well as for the costing of PMJAY COVID-19 HBPs.

What next?

India has initiated a welcome and multi-faceted approach for increasing costing capacity, improving cost data and generating a robust evidence base for HTA. These initiatives are already facilitating priority setting and a more transparent price setting process. But there is still work to be done. The role of costing in decision-making needs to be higher up in the healthcare policy makers’ agenda and become an integral part of the evidence base. Healthcare providers and academic centres can facilitate this by adapting information systems to meet cost data collection needs. More critical, is the need for greater transparency around fees and charges. In the future, Ministry of Health; State Departments of Health; National and State public health insurance agencies can make publication and/or submission of provider healthcare costs or fees a mandatory requirement for all providers and in particular publicly funded healthcare. These incremental but exceedingly important steps will help create more transparent healthcare decision-making in the country.

Authors: Lorna Guinness, Hiral Anil Shah, Abha Mehndiratta and Shankar Prinja

Thank you to Kalipso Chalkidou for valuable oversight.

By Abha Mehndiratta, Kalipso Chalkidou, Saudamini Dabak, 5^th May 2020

Health Technology Assessment (HTA) is a policy tool to support rational priority-setting. In India, it allows decision-makers to make informed comparisons to ensure cost-effective, high-quality health services and interventions are supplied or purchased by the Ministry and State Departments of Health and Family Welfare. As India moves towards the achievement of Universal Health Coverage (UHC) with the Ayushman Bharat Scheme, HTA is critical for choosing services/interventions which provide value for money. This is applicable for both the health benefits package of the Pradhan Mantri Jan Aarogya Yojana (PMJAY) health insurance scheme and primary care services provided by the Health and Wellness Centres. It can also help improve quality control of the growing private healthcare sector in India by improving return-on-investment of public-private partnerships with better quality and appropriate care.

The International Decision Support Initiative (iDSI) was invited by the Bill & Melinda Gates Foundation (BMGF) India Country Office to share its experience of supporting institutionalisation of HTA in India with other BMGF partners. During the webinar iDSI partners from the Center for Global Development (CGD), Health Intervention and Technology Assessment Program (HITAP) – Thai Ministry of Public Health, Imperial College London and the Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh shared their work within India on the healthcare priority setting agenda. Links to the recorded video and slides from the webinar are available and a brief overview of the session is provided below:

iDSI is a global network of priority setting institutions that has been collaborating with partners in low-and-middle income countries (LMICs) to build capacity for HTA. Since 2013, iDSI has partnered with countries such as Indonesia and China on institutional strengthening, data and analytics, development of global public goods on methods and tools, and smart purchasing.

The Individual, Node, Network and Enabling Environment (INNE) framework was used as a systematic approach to share iDSI’s capacity building activities with stakeholders at various levels for institutionalisation of HTA in India to accelerate sustainable UHC.

• Individual: Increased technical capacity of users and producers of HTA via training workshops, higher education programs and technical support on HTA studies.
• Node: Strengthened institutional frameworks by supporting the Department of Health Research (DHR) in establishing HTAIn (Health Technology Assessment in India) infrastructure. For example, by sharing relevant documents on HTA process and methods, country experiences etc.
• Network: Facilitated and encouraged participation of partners from India who routinely undertake HTA studies at relevant HTA network meetings like HTAsiaLink Conference, the Prince Mahidol Award Conference (PMAC) etc.
• Enabling Environment: Catalyzed increased political commitment and buy-in for evidence informed priority setting through high-level engagements and awareness raising events.

Examples of applications of HTA in India were shared such as (i) HTA on anti-viral drugs for Hepatitis C that led to its inclusion in Punjab Government’s health benefits package and also caused change in standard treatment guideline for Hepatitis C management (ii) HTA on safety-engineered syringes leveraged by the Government for price negotiation and procurement. The government of Andhra Pradesh to decide on this topic subsequently cited this study.

HTA related knowledge products from India were briefly discussed during the webinar. This included the HTA methods manual; budget impact modelling guidelines; health related quality of life value set (EQ5D5L) for India, Cost of Health Services in India (CHSI) study and the National Cost Database for India. The National Cost Database is a central resource for users and producers of cost data and currently includes data from 200 public facilities in 6 states. Analytic work using the National Cost Database is being continued to develop a unit cost predictor to estimate unit costs of healthcare service delivery in India.

IDSI’s work with partners has laid the groundwork for the future by increasing capacity of users and producers of HTA. It has supported in country efforts in building an infrastructure for evidence-informed policymaking, developing a range of knowledge products and strengthening networks with partners in other countries. In addition, based on current trends, the importance of prioritising healthcare resources will become all the more acute as India emerges from the COVID-19 crisis. In the post-COVID-19 era it is unlikely to be business as usual. India will need to balance pre-COVID-19 UHC commitments with clearing up backlog of elective procedures and resuming vaccination and screening campaigns during what is forecast to be the deepest recession since 1979. Demonstrating value for money through systematic processes will therefore be a policy priority and ought to be seen itself as a Best Buy for healthcare systems.

The Health Technology Assessment programme (HTAIn) which is funded by the Government of India, is now fully operational. Coordinated by a dedicated Secretariat based at the DHR, the HTAIn also works with ten designated Indian technical partners who produce Health Technology Assessment (HTA) studies on topics of national importance. iDSI has provided key technical assistance to the HTAIn Secretariat to train their technical partners on all steps required to conduct an HTA study. In the past 6 months over ten HTA reports have been finalised and approved by the Technology Appraisal Committee (TAC). Among them, the results of the HTA study on Intra Ocular Lens for cataract Surgery and safe syringes informed the definition and costing of the Health Benefits Package for the Pradhan Mantri Jan Arogya Yojana (PM_JAY )in India, the largest nationally funded public healthcare scheme in the world. States across India are increasingly looking to HTAIn for evidence-based advice on how to incorporate health technologies into the health system.

A recent and exciting development is that HTAin has launched its dedicated website: Among other things, the website features information on HTAIn structure including theTAC and its HTA methods process. The website also features HTAIn current activities and the HTA reports prepared by HTAInTechnical partners. The HTAIn website also links with major national initiatives, including the Post Graduate Institute of Medical Education & Research (PGIMER) PGIMER Costing database, a tool for health policy makers and analysts that provides unique information on the unit costs of health services in India.

With these new tools, a host of different stakeholders at both central and state level in India have access to valuable resources that will help them make evidence-based priority decisions on health technologies in India. They also ensure transparency in the way HTAIn operates, working to international standards. As the PM_JAY evolves HTAIn will play an increasingly important role in helping the Government of India make considered decisions on the distribution of health budget resources, as well as timely uptake of good value technologies  and in advancing Universal Health Coverage (UHC) for its population.

As India moves towards the achievement of Universal Health Coverage (UHC), finding robust and evidence-based answers to the challenges of defining which services should be publicly funded, for whom and how, becomes increasingly important. The introduction of ‘Modicare’, the nascent health insurance scheme announced out by the Indian Federal Government to cover some 500 million citizens, brings with it a complex collection of challengers for State policy-makers to address. These include an urgent need to rationalise multiple insurance schemes, their benefits and their purchasing and contracting strategies; and enhance quality monitoring, to assure that public subsidies for health insurance are being well spent and maximising population health gains. 

A workshop was held on 25 and 26 February 2019 in Guwahati, Assam, in the North East of India to address some of these pressing issues. The workshop was co-hosted by the Government of Meghalaya, the Indian Institute of Public Health Shillong and iDSI partners from the Center for Global Development and Imperial College London. 

The two-day event was opened by Shri Samir Sinha, Principle Secretary Health, Government of Assam, and brought together over 50 participants from six of the North Eastern States. Delegates represented local government, and academic, non-government, and multi-lateral organisations such as the World Health Organization, The World Bank, Bill and Melinda Gates Foundation and UNICEF. 

This international interactive workshop was the first event of its kind to be held in the North East of India and provides an important opportunity for iDSI to explore and strengthen collaborative engagement in this region; and for North Eastern States to showcase their proactive engagement towards health system strengthening. 

The workshop sought to explore international best practices for defining and implementing successful Health Benefits Packages, highlight common pitfalls and share lessons for success – drawing from the iDSI publication ‘What’s in, what’s out: Designing Benefits for Universal Coverage’. Presentations and practical group work sessions provided some answers, options and choices in response to the important challenges that State governments are facing in relation to the refining of their own State Insurance Schemes and design of their health benefit packages. 

A recent collaborative analysis of the Meghalaya Health Insurance Scheme (MHIS) by IIPH Shillong and Imperial College London was presented for the first time. This analysis tracked the scheme’s evolution and enhancement as the State progresses towards improving population health and highlighted key areas for development under the next phase of the MHIS.

Reflections from the workshop are summarised in this slideset.

Workshop materials

Presentations

Day 1

• Amanda Glassman, CGD: What’s In, What’s Out: Designing and Adjusting Health Benefits Plans for UHC
• Amanda Glassman & Kalipso Chalkidou, CGD: What is your HBP policy baseline?
• Amanda Glassman, CGD: Fiscal and budgetary issues for HBP
• Owen Smith, The World Bank: Using evidence to strengthen HBP implementation under PMJAY
• Sampath Kumar, IAS, Government of Meghalaya: The Meghalaya Community Participation and Public Services Social Audit Act, 2017
• Laura Downey, Imperial College London & Peter C. Smith, Imperial College London and University of York: Reviewing the health benefits package in Nelam Pradesh: methodology case study
• Peter C. Smith, Imperial College London and University of York: Methodological options for setting the health benefits package

Day 2

• Guwahati, National Health Authority: Governance under AB PMJAY
• Amanda Glassman, CGD & Ursula Giedion: Principles of good governance for a sustainable HBP policy
• Roshan Ronghang, IIPH Shillong: Assessing the pattern of enrolment and claims in Megha Health Insurance Scheme (MHIS)
• Anuj Gupte, MD India Health Insurance: HBP design and implementation overview
• Kikameren Longkumer, Department of Health and Family Welfare, Nagaland: Universal health coverage and health benefit package: Nagaland state
• Carleigh Krubiner, CGD: Navigating ethics in the design of health benefits. Evidence-informed practices to promote equitable and ethical progress on the path to UHC
• Prof Rama V. Baru, Jawaharial Nehru University: Equity and ethical considerations in health technology assessment

Group work case studies

• Case study: Reviewing the health benefits package in Nelam Pradesh
• Case study: Ensuring good governance in HBP design and implementation
• Case study: Examining ethics and equity dimensions in efforts to reduce maternal mortality

Press coverage

International conference on health finance – The Shillong Times, 9 March 2019

The session brought together officials from Kenya, Zambia, Indonesia, Eswatini, Rwanda and Malawi representing ministries of health, national health insurers, a Prime Minister’s cabinet and academia to share practical experiences from health financing reforms, with a focus on priority-setting and strategic purchasing.

Dr Velphi Okello: “Weak links between budgets and supply chains often a challenge”

Dr Velphi Okello, Deputy Director of Clinical Health Services at the Eswatini Ministry of Health, shared her knowledge of the design of an essential Health Benefits Package and emphasised the importance of assessing the healthcare provision landscape. Dr Okello stated assessments carried out in 10 rural clinics in Eswatini revealed they were ready to scale up the National Essential Health Care Package (EHCP). However, through assessments at clinics and hospitals, bottlenecks in the supply chain were identified and efforts were made to ensure delivery of EHCP through improvements in the supply chain through budget processes. Political attention was also found to be focusing more on tertiary care than primary care; and there was room for improvement in cross-ministerial relationships. Dr Okello raised the need to mobilise resources to make these health landscapes ready and the need to maximise efficiency opportunities as much as possible.

Dr Solange Hakiba: “Rwanda is continuing to work on educating and engaging patients and the public more to emphasise primary care is just as crucial as tertiary care”

Dr Solange Hakiba, Deputy Director General in charge of Benefits at the Rwanda Social Security Board, highlighted the importance for low and middle-income countries (LMICs) to scope out opportunities to engage the private sector. Dr Hakiba detailed how Rwanda brought the private sector on board to help build infrastructure in partnership with nurses and the District Government, who provided buildings and furniture. Dr Hakiba explained how Rwanda experienced a lack of health workforce following genocide in 1994; as the country recovered its education system this meant more university graduates were coming through, however Rwanda still required non-university educated nurses and community health workers, thus set up ‘Health Posts’ which operate as entry-level clinics in the public sector and provide care for common conditions such as malaria and diarrhoea. Each post is run by an experienced nurse given access to financing and training in business, post-operations and clinical skills. The franchise approach allows the nurse operator to earn a living operating a small business while increasing access to essential medicines and basic healthcare for communities. After a short grace period, the Health Posts begin operating on a self-sustaining basis and can accept reimbursements through Rwanda’s community-based health insurance scheme, the Mutuelle de Sante, which covers approximately 90% of the population. Rwanda is continuing to work on educating and engaging patients and the public more to emphasise that effective and efficient primary care is just as crucial as tertiary care.

Dr Gerald Manthalu: “Multiple sources of funding for health are often not used efficiently as many have different priorities and plans – pooling of funds where possible can help with challenges of fragmentation of financing”

Issues surrounding the fragmentation of financing was raised by Dr Gerald Manthalu, Deputy Director of Planning at Malawi’s Ministry of Health. Dr Manthalu explained how Malawi had over 190 different sources of funding for health, however their use was not always efficient as many had different priorities and plans in place. Dr Manthalu specified Malawi was tackling this specific challenge by aiming to carry out more detailed resource mapping; and encouraging the pooling of funds where possible, especially from donors. Dr Manthalu mentioned the importance of potential revisions of Essential Medicines Lists and also the need to make citizens more aware and encouraging nationwide discussions. The last revision of Malawi’s Essential Medicines List included the addition of antenatal corticosteroids, chlorhexidine, injectable contraceptives and contraceptive implants – increasing commodity access for women and newborns who need lifesaving interventions.

Remaining on the topic of Essential Medicines Lists, Pak Budi Hidayat, Professor of Health Economics and Health Insurance at the University of Indonesia and a member of the national Health Technology Assessment (HTA) Committee, announced at the satellite session the decision by Indonesian authorities to delist certain medicines deemed to be cost-ineffective from the national formulary. Professor Hidayat stated that Badan Penyelenggara Jaminan Sosial, the social insurance agency responsible for administering the Jaminan Kesehatan Nasional (JKN), the world’s largest single national health insurance scheme for Universal Health Coverage, will no longer reimburse cetuximab and bevacizumab for certain colorectal cancers. iDSI core partner HITAP was instrumental in the economic evaluation of the two medicines which led to the policy decision. The costs of these drugs are strikingly high with only marginal benefits for patients, so much so that they are considered poor value for money and not advised as first-line treatment options even in high-income countries.

Dr Henry Kansembe: “G2G funding can result in one strategic plan and a country’s strategic purchasing formula can be applied to a larger amount”

Chief Planner at Zambia’s Ministry of Health (MoH) Dr Henry Kansembe gave examples of how strategic thinking can improve health indicators in a space where fiscal expansion is limited. Dr Kansembe explained how Zambia’s MoH were aware they would unlikely get increased funding from their country’s treasury, so created incentives for providers to perform better. Results-based financing was on five key performance indicators and led to 30% of the allocation being invested more strategically. Zambia has also explored ‘G2G’ funding, where government funds are pooled with donor funds – meaning one strategic plan can be put together and a country’s strategic purchasing formula can be applied to a larger amount of funding.

Practicalities surrounding health financing towards UHC discussed ranged from data constraints to political challenges, such as how to engage civil society. Professor Tony Culyer highlighted the importance of the education of and understanding from all stakeholders, including the public; and used examples of where blood pressure control methods had received public ‘buy in’ after they were successfully communicated, by both health ministries/departments and the media.

Professor Kalipso Chalkidou emphasised the need for LMICs to have more access to data on costs/prices of essential medicines, as high mark-ups are often charged on medicines in LMICs. This could be due to historical practices, or a result of public services buying medicines in the private sector. Professor Chalkidou used the Congo as an example, where the cost of essential medicines is four times higher than the international average; and stressed that the impact is often on individuals, given the high percentage of out-of-pocket payments in LMICs.

The need for integration and transparency with regards to priority-setting; and ensuring policy-makers are on the same page as academics was also high on the agenda during the session.  All agreed academics are habitually signed up to the process of priority-setting for decision making. Decision making however doesn’t always follow through with the priority-setting process. Being transparent when engaging with stakeholders and citing what options were and who was consulted was highlighted as the only way to defend difficult decisions. The value of having a legal and governance framework to link priority-setting and decision making was a theme that was frequently raised throughout the session.

On the topic of Health Technology Assessment (HTA) infrastructure, the UK and Sweden were hailed as success stories, as a drug is not approved for reimbursement before the HTA process (including health economic analyses) has occurred. In contrast, the HTA process happens far too infrequently in LMICs. All concurred it could be challenging to replicate the same structure the UK and Sweden has elsewhere, however a strategy to collaborate internationally – such as via universities’ economics departments – could be a promising way forward to foster HTA within LMICs.

The satellite session received funding from the Swedish International Development Cooperation Agency (Sida), working on behalf of the Swedish Parliament and Government; and was co-hosted by the Clinton Health Access Initiative, Sida and iDSI. We have made all presentations from the session available for download.

 Ahead of the event iDSI caught up with Patric Landin, regional advisor for Sida’s Sexual and Reproductive Health and Rights team; and Dr Yogan Pillay, Deputy Director-General for Communicable and Non-communicable Disease, Prevention, Treatment and Rehabilitation in the National Department of Health in South Africa.

 Read our 60 seconds interview with Patric Landin here.

Read our 60 seconds interview with Yogan Pillay here.

In order to provide a platform for South African policymakers to engage with local and international experts around this area, a Policy Dialogue was organised in South Africa by iDSI partners in March 2017. The Policy Dialogue followed a workshop entitled “Designing and Adjusting the Health Services Package for Universal Health Coverage in South Africa”.  Representatives from the South African Treasury and the NDoH engaged with experts from South Africa, the United Kingdom and Thailand to discuss topics related to a Health Services Package (HSP).

After a discussion of key challenges, the participants agreed upon some important next steps to address these. Firstly, clarity on the budget envelope and financing of NHI in the context of the relationship between national and provincial-level decision making and resource allocation (fiscal federalism) is required. Due to the large variability of quality, transparency and availability of clinical guidelines, there is a need for a dedicated unit responsible for coordinating clinical guidelines. It is also important to build understanding of and commitment to evidence-based medicine especially amongst clinicians, and to strengthen the local ownership of clinical guidelines. Clear criteria need to be developed for ‘value for money’ such as a cost-effectiveness threshold. Establishing a national health technology assessment (HTA) unit will provide the technical and analytic input required to inform evidence based decision making for the NHI and HSP. Furthermore, priority topics for HTA need to be identified. Lastly, formal public engagement processes and collaboration with a wide range of stakeholders is important for the successful and appropriate implementation of an HSP.

To read the full report click here.

The white paper was revised and gazetted as the National Health Insurance Policy in June of this year. You can access the policy document here.

Read the blog here.

Seminar resources can be found here.

The book What’s In, What’s Out: Designing Benefits for Universal Health Coverage is due out in the summer.

More and more, private health care is promoting health checkups. The more tests the consumer takes the higher the costs are incurred. Nevertheless, expensive tests cannot guarantee better health outcomes. Evidence even suggests that some tests such as prosthetic-specific antigen tests have definite harms that outweigh the benefits due to over diagnosis and over treatment.

Meanwhile, some countries allocate public resources towards population health screening to ensure that everybody who is eligible receives the tests regardless of their ability to pay.  This is because the government has a big assumption that screening followed by early treatment will yield better health gains or save cost from late treatment.

To academics and technical advisers, what are you going to do if the government asks what should be included in the benefit package for population based screening in your own setting. This question poses a big challenge given a hundred or if not thousands of tests available in the market for every disease.

The Health intervention and technology assessment program (HITAP), a member of the International Decision Support Initiative (iDSI), proposed one solution that combines policy process and technical evidence to address this question. They start with narrowing down the scope by ranking and prioritizing the top twelve health problems using stakeholder consultations. Clinical experts and industries play a major role in identifying possible screening interventions and early treatment for each prioritized health problem followed by health technology assessment in order to assess clinical benefit, value-for-money, feasibility and ethical implications.

The study resulted with a set of eleven population based health screening for the Thai population based on age, sex and frequency of screening. The recommendation has been adopted by the Thai government and the implementation started in October 2015.

The results of the study may not be transferable in other settings. However the approach is likely to be applicable to others. This case study affirms iDSI key principle in applying technical work in the policy process to address specific problems faced by national authorities. As a result, capacity building of the local stakeholders including decision makers and technical advisors grew at the heart of iDSI work.

For more details on the study please visit the following journal publication:

http://onlinelibrary.wiley.com/doi/10.1002/hec.3301/full

April 2015

NICE International coordinated two events in Hanoi on health benefits package design in partnership with the Health Strategy and Policy Institute and the Vietnamese Health Economics Association.

A health benefits package is the range of technologies and services that are available at a free or subsidised rate to the insured population, and the methods, processes and policies that contribute to its design and inclusions or exclusions are central to achieving and maintaining universal health insurance coverage. The events included a meeting to share international experiences of decision making for health entitlements and benefits package design, and a workshop focusing on the status and future direction for benefits package design in Vietnam.

The events were opened by Professor Pharm Le Tuan, Deputy Minister of Health who advised of the importance of the role of a high quality, nationally accessible and affordable benefits package as Vietnam moves towards Universal Health Coverage. Dr Tran Thi Mai Oanh, Director of the Health Strategy and Policy Institute and Dr Kalipso Chalkidou, Director of NICE International endorsed the Deputy Minister’s comments and highlighted the beneficial role of continuing partnership and joint working between Vietnamese institutions and iDSI

Sir Andrew Dillon of NICE, UK and Dr Yot Teerawattananon of the Health Intervention and Technology Assessment Programme (HITAP), Thailand shared the experience of their country’s approach to determining access to technologies and services.  They were joined by Ursula Giedeon of the Inter-American Development Bank on an international panel who discussed initiatives in different South American countries to establish explicit benefits packages.

Attendees also benefited from hearing experience from Dr Sastroasmoro and Dr Gyansa-Lutterodt who shared early experiences of health technology assessment and benefits package design in Indonesia and Ghana.

At the workshop Amanda Glassman of the Center for Global Development presented a comprehensive overview of key themes in benefits package design and explained how a methodological and strategic approach can optimise health outcomes from within limited resources available for health. The diversity of international experiences provided useful insight into potential opportunities and challenges facing policy makers in Vietnam and was a valuable input to the strategic direction of the Vietnamese benefits package.

Developing capacity for HTA and quality improvement initiatives are key areas where NICE International and HITAP are working with colleagues in the Ministry of Health and supporting institutions in Vietnam.  The benefits package workshop showcased pilot HTAs conducted by technical teams, showing how the information produced through HTA can be a valuable input to benefits package design. Highlighting the importance of the quality component to services patients receive as part of a benefits package, recent work to adapt Quality Standards used in the English National Health Service to the Vietnamese context were also presented and discussed.

Importantly, the events facilitated discussion by local policy makers and stakeholders on the institutional arrangements and strategic direction for benefits package design. Presentations from the Department of Planning and Finance in the Ministry of Health and Vietnamese Social Security in addition to an overview of the status of social health insurance by the World Bank Vietnam office provided a comprehensive overview of the underlying needs and current status of benefits package design and enabled attendees to generate key areas of recommendation for work going forward. Recommendation areas included the need for analytical and administrative capacity development, established process and evidence generation and use, and a focus on communication and implementation activities. Dr Duong Huy Lieu, Chairman of the Vietnamese Health Economics Association closed the events reiterating the importance maintaining the momentum for benefits package reform in Vietnam and continuing dialogue between all major stakeholders.

The meeting and workshop brought together departments of the Vietnamese Ministry of Health, Vietnamese Social Security (the state insurer), local clinicians and academic institutions, policy makers from around the world and international experts in benefits package design.

The events were supported by the Rockefeller Foundation and were part of NICE International’s long-term partnership with the Ministry of Health of Vietnam on their journey towards achieving Universal Health Coverage (UHC).

NICE International supports Vietnamese colleagues in Health Technology Assessment capacity building

July 2014

NICE International staff joined the Health Intervention and Technology Assessment Program (HITAP), Thailand, in the delivery of a week-long training course on health technology assessment in Hanoi, Vietnam. The in depth course covered fundamental aspects of the conduct of health technology assessment including searching for and synthesising evidence, health state evaluation, costing methods and decision rules. The course participants were from the various institutions in Hanoi that are currently engaged in some form of economic evaluation and is part of a wider Rockefeller Foundation-funded initiative to use the results of health technology assessment to informing priority setting and health policy in Vietnam.

Support for basic package design

November 2013

NICE International completed the first phase of its programme to support the design of the basic package of healthcare subsidised at Vietnamese health facilities. This included interviews and group discussions to outline current mechanisms for basic package design and targeted training events in collaboration with the Health Interventions and Technology Assessment Program (HITAP), Thailand.

The “Principles of HTA” training event, held at Hanoi Medical University, targeted researchers and policymakers who will be conducting economic evaluations. The event attracted 40 attendees from universities, the Ministry of Health, and affiliated research institutions. 80% of attendees felt confident or very confident that they could apply the training to their current work.

The “HTA in Policy” training event was held at Hanoi School of Public Health, and primarily targeted policymakers interested in how HTA can inform priority-setting decisions in health. This event featured theoretical approaches to basic package design, and experiences of how HTA is used for priority-setting in the UK and Thailand

HTA in Vietnam conference

Hanoi Medical University and VHEA hosted a conference on HTA in Hanoi on 15 – 16 November. The conference provided a forum for senior Ministry of Health policymakers , healthcare professionals and researchers from across Vietnam, and international partners to discuss current research and HTA developments in Vietnam. NICE International and partners delivered presentations on experiences from the Technology Appraisals programme and incorporation of health economic evidence in NICE Clinical Guidelines, and chaired panels on addressing the challenges to institutionalising HTA in Vietnam.

 Groundwork project

for more information on the Groundwork project, please click here