1. You are a panel member in the sub-session, ‘Design of Health Benefit Packages’ during the HSR 2018 satellite session on Health Financing for Universal Health Coverage (UHC), co-hosted by Clinton Health Access Initiative, the Swedish Government and iDSI. What do you believe your experience will bring to the discussion?

I have been coordinating the process to define benefit packages in preparation for implementation of National Health Insurance (NHI) in South Africa for the past two years. NHI is our version of UHC and aims to address historical inequalities by bringing the public and private sector into a unified national health system. As I have been responsible for health programmes in South Africa for the past 10 years this was a good fit. I think I will benefit as much from the discussion as I think I can contribute based on our experiences in trying to design benefits in a rather complex environment – with a large private health sector and many medical insurance companies and administrators.

2. What are Health Benefits Plans and why are they important?

Health benefit plans define the services that will be available within a health system and should cover all levels of care, from community based services through to highly specialised care. This is important for at least two reasons: (a) certainty on what services are offered; and (b) ensuring that these services are funded.

3. What have been the challenges in development of the benefits package in South Africa?

An initial challenge has been the wide range in standards and guidelines relating to service delivery in South Africa not just across the public and private sector, but also across disease areas. We are addressing this as a priority to ensure a common understanding of acceptable quality of care prior to costing. Other challenges include: (a) availability of data, including epidemiological data, (b) limited or fragmented health technology assessment capacity in the country; (b) political pressure to include all services currently available – even in the context of limited resources; (c) and the designing of a transparent process by which to prioritise services and revise the package over time.

4. If you weren’t in the healthcare field, what would you be doing instead?

Human rights lawyer!
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Conference delegates can attend the session, called ‘Health financing towards UHC’ from in conference room 13 from 8.30am on Monday 8 October as part of HSR 2018 of which the overaching theme is ‘advancing health systems for all in the Sustainable Development Goals era’.

Find out more at www.healthsystemsresearch.org/hsr2018

1. The poor are the primary beneficiaries of this scheme

Modicare’ s predecessor, the government-run health insurance programme Rashtriya Swasthya Bima Yojana (RSBY), covered only those identified in the national census as below the World Bank-defined ‘poverty line’ of $1.90 per day. Under Modicare, coverage criteria will expand to include identified occupational categories of urban workers’ and their families.

2. The scheme covers secondary and tertiary care only

There are approximately 1,500 secondary and tertiary care procedures nominated in the package of services covered under the scheme.

3. Responsibility for financing the scheme will be shared between the Central and the State governments

Purchasing will occur through a State-run trust fund or a market-driven tendering process. The States will be given flexibility over the financial administration of the scheme. 

4. Beneficiaries can avail benefits in both public and empanelled private facilities

States will be given flexibility over choice of care providers and means of purchasing and procurement.

5. The Scheme will pioneer the use of a novel digital information capture system

Utilising India’s biometric ID scheme, ‘Aadhar’ identification cards will be used to capture details of enrolment, claims and reimbursement activity in each State.

The rollout of such an ambitious scheme in a country as large and diverse as India faces challenges, including the identification of and outreach to beneficiaries; putting in place adequate governance and regulatory mechanisms to reduce fraud and low value care; and making sure finances allocated to provide for the scheme match local need.

Ensuring the delivery of high quality of care will perhaps be the most important challenge to address, given India’s recent ranking in terms of quality and accessibility of healthcare in the Lancets’ Global Burden of Disease study.

Nevertheless, Modicare represents a unique opportunity to provide access to healthcare to a population that sorely needs it, moving India one step closer to Universal Health Coverage and bridging economic, gender and social divides.

The scheme is due to launch next week on 25 September.

Key features of the policy include the establishment of the HTA unit in the Department of Health (DOH), a description of the principles, criteria and process, as well as the composition and qualifications of the appraisal body. These provisions strengthen existing policies related to HTA, such as the Philippine National Formulary System (PNFS) in DOH and the Priority Setting Process in PhilHealth. The bill is a legislative priority of the current administration so we are hopeful that it receives substantial support from the upper house. We recognise HTA as a key tool to achieve universal health coverage in the country as per the HITAP sponsored World Health Assembly 2014 HTA Resolution, especially since service coverage remains fragmented and out-of-pocket payments are still high at 53.7% of total health expenditure (2014), despite 92% of the population having health insurance.

Global collaboration

iDSI, has provided support to the Philippines during the PNFS’ early stages. In 2011, NICE International started work with the MoH under The Rockefeller Foundation support, and in 2012, the National Center for Pharmaceutical Access and Management (NCPAM) (now called the Pharmaceutical Division in DOH) together with HITAP, conducted two policy relevant evaluations on the PCV and HPV vaccine. This project enabled NCPAM staff to visit HITAP and publish articles in international peer-reviewed journals, some articles can be viewed here and here. Two of the DOH staff are now back in Thailand pursuing a postgraduate programme in HTA at Mahidol University under iDSI scholarships.

More recently, the DOH also arranged a visiting scholarship of the HTA team lead to the Global Health and Development Group (GHD) at Imperial College London (the successor to NICE International), where they received guidance on: developing the country’s HTA roadmap, the revised process guidelines, and on economic evaluation for COPD drugs. It was also through the participation in knowledge sharing activities and international conferences that HTA was brought back on the policy agenda last year. Philippine policy makers and researchers participation in the Prince Mahidol Award Conference 2016 (co-hosted by HITAP, NICE international, and others) re-ignited the policy discussions and research on HTA and priority setting in PhilHealth and DOH.

HTA as a tool to achieve universal health coverage

Under the current bill’s whole system, society, & government approach, the vision is that the country coordinates a multisectoral approach, inclusive of all stakeholders, which looks at each component and function of the health system to realise UHC. This entails establishing a single institution that sets actionable (i.e. reimbursable) priorities for payers of healthcare. However, much capacity building is needed in terms of individual research skills, as well as sectoral capacity to manage and implement such processes. There is also a need to enhance policy makers’ understanding of what HTA is, how it is done, when and where it should be done, as HTA is not the answer to all policy questions. For example, the legislation specifies the use of HTA as an input in revising the Health Benefits Package. Another use could be in pricing discussions with manufacturers. Further, effective HTA has to accommodate existing health system features, including the interplay of different financing agents, private and public healthcare providers, and other stakeholders.

Despite these challenges, we believe that as a country, we have made significant progress towards building our national HTA institution. Last July, a HTA study group was established in the Health Research Division of the Health Policy Development and Planning Bureau in the DOH. The team has full-time researchers in charge of coordinating and implementing HTA related research activities. The DOH also just approved a revised process guideline for HTA, which expands the scope to cover all interventions (not just drugs), uses explicit decision criteria, and a multi-stakeholder process from topic selection, to assessment and appraisal. These achievements would not have been possible without international collaboration with universities, development agencies, and other HTA institutions outside the country, all of which will be featured on the bureau’s website as soon as it is up and running.

While we are still quite a way from having a NICE or HITAP counterpart in the country, the path towards institutionalisation is much clearer now that there is political support, and as we are slowly developing capacity. The DOH is set to scale-up HTA implementation by hiring more full time staff in the coming months, and investing in capacity building programmes. Collaboration with international partners such as iDSI must be fostered in order to sustain momentum. A Letter of Intent for Cooperation between the Philippine Department of Health, HITAP and the Imperial team was recently signed paving the way for further collaboration in the future.

One morning early in 2016, an email popped into my inbox from NICE International: Would I like to go to Vietnam in March to help the Ministry of Health develop their primary care strategy? At first I had to say no as the original dates clashed with my long booked annual cross-country skiing trip, but dates were changed and 48 hours after skiing across a Norwegian plateau I was on a plane to Hanoi.

My first impression was that it was a little cooler than I expected – though it never reached the minus 10 degrees of central Norway – and that Vietnam has a whole lot of mopeds and noodles. I had been sent a large file of excellent background reading by Ryan Li, my indefatigable NICE International associate and I instantly understood why road traffic accidents are the greatest cause of death in Vietnam. Driving was dangerous but exciting. I witnessed 2 accidents in my first 2 hours and was nearly involved in a third later that evening. The mopeds were 10 deep and 3 abreast at every intersection and entry to a ‘roundabout’, except there were no roundabouts. The mopeds wove in and out of each other at speed. There were sometimes 3 to a moped and children were carried, without helmets in front of, between or clung on tightly behind 2 adults. The mopeds took short cuts across dual carriageways and also travelled the wrong way on those same carriageways. They carried people, smart female office workers going to work in short skirts and high heels, families, and wave after wave of male workers.  They carried produce, fruit, vegetables, flowers, fodder, huge vases strapped precariously to each side and even large panes of glass carried tightly between the driver and the passenger. They passed multiple shops with rows of mopeds on display out front and carousels of helmets of all shapes, types and genders (pink helmet anyone)? The mopeds were continually honked at by the cars as the taxis were also weaving in and out of the lanes. The honking was continuous and appeared to act as immediate warning of potential danger  or semi-courtesy of presence. My trip to the airport on my final day was coloured by the taxi driver obviously having a loud ‘domestic dispute’ using 2 handheld mobiles simultaneously and accompanied by loud female tirades. I arrived OK!

Different kinds of passengers. Photo by Ryan Li.

The Vietnamese Ministry of Health wants to develop their primary care. Primary care has been a poor relation of hospital-based specialist care for many years. Only 70% of the population is covered by any variety of health insurance, many people can ill afford to pay for any healthcare.  People who are covered, though they often have to add co-payments, can use their health insurance at any centre within their province. They perceive that the quality of the health care in their commune is poor, and as the investment has been skewed towards specialisms they are probably correct. Though the government is trying to rectify this, the prevailing cultural perception is against primary care as a reliable resource. As a result people flock to hospitals as their primary source of help and the queues and the inappropriate use of those resources is compounding the problem. There is also a larger proportion of private healthcare than in England for those that can afford it.

Crowds at a provincial hospital in Vietnam. Photo by Ryan Li.

This situation is also not helped by the tensions in status between hospital and primary care. The specialism and philosophy of family medicine and the potential of primary care is currently poorly recognised. The training is very short by English standards and almost entirely hospital and lecture based. We met a pioneering Professor of Family Medicine from Hanoi Medical University who was passionate about developing the family doctors that Vietnam needs and she was hoping that she will be given the support to carry out her plans. In England 90% of daily work within the NHS is carried out in primary care for 9% of the NHS budget. In Vietnam the ratio is probably reversed.

Continued in Part 2

Regardless of the structure or budget of the national health assurance scheme that is finally decided on, there will always remain difficult questions of which interventions (from drugs, diagnostics, devices to public health interventions) the benefits package will cover, how, and for whom. This is where evidence-informed priority-setting tools and processes, such as HTA and clinical guidelines, can help to provide a robust framework for stakeholders to make and act on informed decisions, taking into account society’s values and preferences, and for regularly reviewing these decisions.

The discussions and insights from the Better Decisions for Better Health workshop in October 2014 (co-hosted by NICE International, the Ministry of Health and Family Welfare and the World Bank in India), which brought together iDSI experts and other international and Indian partners, remain as relevant as ever.

Making decisions in healthcare is never easy. As one keynote speaker remarked: “How do we choose between buying 5,000 infant warmers, or stents for cardiac patients, or drugs for someone with cancer?” But these decisions still need to be made, since not doing so amounts to a decision that someone else will make instead.

We argue that evidence-informed priority-setting is the way to better decisions for better health, and that is no different for the UK, Thailand, or India.

Download: Priority-setting and Health Technology Assessment for Universal Health Coverage in India: Workshop Summary

With thanks to Abha Mehndiratta