Recognizing the need for good quality cost data in setting reimbursement rates for services covered by PM-JAY and as an essential ingredient for conducting Health Technology Assessment (HTA) in the country, the government invested in the production of cost data and supported the concurrent development of a national database of healthcare costs: the National Health System Cost Database (NHSCD).  

In this blog, we briefly describe India’s cost repository and how it caters to the needs of policymakers and researchers. We share examples of health system applications of the cost database and their policy implications, demonstrating the value brought about by this initiative. Finally, we conclude by highlighting the key areas that need to be addressed in order to improve the quality and sustain the relevance of the information the database offers, and promote the use of such initiatives for evidence-informed decision-making.

What does India’s healthcare cost repository offer?

A cost database is a public good to inform evidence-based decisions and economic evaluation research by providing access to a transparent set of country-specific reference costs. India’s cost repository is being established to offer access to national cost data on primary care provisioning through community health centres, primary health care and sub-health centres, and hospital-based secondary and tertiary care from both public and private providers. The development of NHSCD, a collaborative effort by the Postgraduate Institute of Medical Education and Research, Chandigarh, India; the Department of Health Research, India; and the Centre for Global Development, has facilitated the process of collating all these data into a single dataset and promoting their use and application. This initiative will make the average health facility cost data collected from multiple states freely available for researchers and policymakers.

The National Health System Cost Database

The cost data within this database provides annual and average healthcare facility costs at different levels of healthcare delivery (i.e., the value of all input resources used to produce a service), input-wise as well as broken down by different services. Another feature available on this web-based platform is the “unit cost estimator” which based on a set of key variables known to influence the unit cost, generates an average or unit cost in the form of cost per outpatient visit or inpatient admission for different states in India. The platform also hosts a costing manual and training videos on cost analysis. The data collection tools and the methodology deployed to estimate these costs have also been made available on the website to ensure transparency and for use and application by other practitioners. Moreover, the website also provides links to useful publications and resources in the context of costing and economic evaluations.  

The utility of cost data systems for healthcare: applications and implications

The cost repository and the data held have been used in a number of ways that demonstrate its value (Figure 2). Cost data are valuable inputs to the conduct of HTA as well as budget impact assessment. More importantly, such data also aid the setting of reimbursement rates for various healthcare services. Three examples are described below.

• What is the optimal reimbursement rate for healthcare services?

As India established PM-JAY, a system for calculating reimbursement rates that adequately reflected the cost-of-service provision was needed. In view of this, HTAIn (the HTA Unit of the Government of India) at the Department of Health Research commissioned the Costing of Health Services in India (CHSI) study to estimate the costs of PM-JAY health benefits packages. The cost evidence generated from this study was used in revising the initial set of reimbursement prices. The CHSI study data were used to analyse the difference between existing reimbursement prices and costs so that the two could be aligned. Also, the data were used to identify variance in cost based on types of providers and their geographical locations, and inform a price weight scheme that compensates providers according to these factors.

• The cost implications of strengthening primary health care

Another pivotal component of the Ayushman Bharat scheme has been the setting up of Health and Wellness Centres (HWCs) for strengthening primary care in the country, the operationalization of which has been planned in a phased manner. For the scaling up of HWCs, it is fundamental to understand the resource requirements to assess the budgetary implication for the government. The cost data from the costing repository have been used to estimate the financial implications of this strategy over the next five years.

• Making HTA evidence more robust

The data from the cost repository has facilitated the growth of HTA in India by providing healthcare unit costs. For example, this data was used in the assessment of the cost-effectiveness of the typhoid conjugate vaccine (TCV) in children over six months of age, and a cost-effectiveness analysis of population-based screening for diabetes and hypertension in India. Both these studies demonstrate wider level policy implications of costing and HTA, where the former was conducted to aid policy-level decisions undertaken by India’s National Technical Advisory Group on Immunisation (NTAGI) as well as the Ministry of Health at the Central and State levels, and the latter was aligned with the government’s aims to expand primary care for diabetes and hypertension through the HWCs.

The challenges ahead

While a central repository reduces the transaction costs of obtaining cost information for a range of activities in healthcare decision making, the data embedded within the NHSCD must be expanded and updated regularly given continuous healthcare reforms as well as rising healthcare costs. Further, to model costs, it is pivotal to understand what is meant by costs and how it differs from prices. More importantly, the level of granularity of availability of records due to lack of electronic patient records extends the effort to determine costs by many folds, which is a deterrent to good quality cost data. Therefore, the government of India needs to focus on building sustainable mechanisms for setting up systems for generating accurate cost data rather than relying on resource intensive studies for cost data collection.

Secondly, to promote the use of standardized cost evidence as inputs for HTA, an issue of paramount importance is that the existence of the cost repository reaches, is accepted, and used by the research community and policymakers. Finally, it is worth acknowledging that there still exists an aperture between the researchers and policymakers, especially in terms of understanding cost evidence. Hence, it is all the more important that the existing and forthcoming data systems ensure relevance, validity, smooth usability, and practicability.

Conclusion

As the Indian health system embarked upon adopting an evidence-informed and inclusive health policy, it identified the lack of cost evidence as one of the key gaps requiring attention. The development of the cost repository is one of the crucial steps in providing access to transparent, country-specific reference costs, and has proved to be an invaluable resource for priority-setting and decision-making. 

Yesterday, Ghana launched its first Strategy for Health Technology Assessment (HTA).

This strategy sends out a clear message of Ghana’s ambitious commitment to evidence informed priority setting. It recognizes that building an HTA function demands action on several areas, including capacity development, topic selection, and bespoke methods guidelines, all linked by a strong governance framework.

In Sub-Saharan Africa, the use of HTA is still very limited, and the Ghanaian progress in this area represents a regional achievement that others can learn from. The strategy builds on iDSI supported work on hypertension, which involved the creation of a Technical Working Group (TWG), a concept that is now part of the architecture of HTA.

Mr Agyeman-Manu, Ghana’s Health Minister, said that so far work in HTA had begun to demonstrate value addition in areas including assessing value in changing from amoxicillin suspension to dispersible tablets, assessment of the cost components of Ghana’s COVID-19 Vaccination Plan as well as the cost-effectiveness of treatment for newly diagnosed hypertension cases.

The launch and new strategy is also key opportunity for regional and continental leadership and shared learning – there has been interest in Ghana’s journey from officials in Tanzania, and participants at the launch event included representative from the Ethiopian Public Health Institute and RSSB Rwanda.

iDSI has been building strong partnerships in Ghana for over 10 years. As the first Sub-Saharan African nation to introduce a tax-funded National Health Insurance Scheme (NHIS) in 2003, Ghana is committed to achieving universal health coverage (UHC) by 2030. To enable this vision, iDSI has continued collaborations with governmental, clinical and academic partners in-country to strengthen evidence-based decision making in healthcare for Ghana’s population of 30 million.

Progress on HTA has been led by a committed team in Ghana that includes Martha Gyansa-Lutterodt, (MoH Ghana), Brian Asare (HTA secretariat, MoH Ghana) and Justice Nonvignon (University of Ghana & co-Chair of the TWG). Martha Gyansa-Lutterodt in particular had a key role in driving HTA development through her leadership as Director of Pharmaceutical Services at the MoH, and now as Director of Technical Coordination within that ministry.

CGD and our iDSI partners (LSHTM, NIPH and the University of Ghana) will continue to support the strengthening of the nascent HTA structures, with an emphasis on institutional coordination and “end to end” HTA thinking – from topic selection to strategies for implementing HTA findings and assessing impact. 

The 2019 study tour represented another successful collaboration between core iDSI partners to support knowledge strengthening among key policy makers in China through interaction with representatives from UK government agencies, NHS, academic and private sector colleagues involved in healthcare.

The Chinese participants included seven representatives from the National Health Commission, including representation from the Department of Drug Policy and Essential Medicines Systems, and the Department of Healthcare Reform; a representative from the Department of Social Security, Ministry of Finance; and representatives from provincial health authorities, including the health commissions of Liaoning, Jiangsu and Henan. Researchers and policy advisers from CNHDRC and the Shanghai Health and Development Research Center also joined, in addition to colleagues from the academic sector in China, the latter including representation from Peking University, the Beijing Normal University, and the China Pharmaceutical University. Full details of all the participants can be found listed in the agenda.

As in previous years, all 27 delegates received a detailed introduction into the structure and financing of the NHS, including the role of HTA in supporting resource allocation decisions in the UK. In addition, there was a special focus on primary care, led by the Imperial College WHO Collaborating Centre for Public Health Education and Training, and an afternoon workshop hosted by the Centre for Health Economics at the University of York, which explored specific issues relating to the application of economic techniques to inform discussions on evaluating health system performance and efficiency.

For this year’s tour, we also placed a special emphasis on the UK’s approach to cancer care, specifically in relation to the process adopted by the National Institute for Health and Care Excellence (NICE) when evaluating new oncology products. We also explored the importance of considering the value that new innovations could bring within the context of delivering appropriate and timely pathways of care, including radiology, pathology, surgery, and radiotherapy. The UK’s experience in these issues can potentially provide useful insights for the Chinese setting, given that cancer has become a leading cause of mortality in the country. This is being driven by an ageing population and the prevalence of lifestyle factors such as smoking, with lung, stomach and breast being among the most common cancers. Policy makers in China have recognised the need to strengthen systems for assessing the clinical benefit of new cancer medicines, and this will be the focus of planned further collaboration between the Global Health and Development Group at Imperial and CNHDRC.

We would like to thank everyone who attended and contributed to the two-week study tour, with a special thanks to the British Embassy in Beijing, and Professor Kun Zhao and her team at the CNHDRC.

The grant, which will cover five years, represents a significant uplift to the funding granted to iDSI in 2015 and will allow us to continue working relationships with policymakers and healthcare payers to understand and respond to the challenges they face – whether ensuring the financial sustainability of a health insurance fund or fair access to good quality care across public health facilities.

This next phase of iDSI will see stronger emphasis on Sub-Saharan Africa with iDSI’s flagship countries including Kenya and Ghana, where global health funders will be departing and domestic health care spending is on the rise. Additionally, many Sub-Saharan African countries are currently introducing national health insurance or coverage plans and making important decisions about what health services and technologies should be included in Universal Health Coverage (UHC) offerings, where value for money considerations could make a huge difference in health outcomes.

As a result of the renewed funding, iDSI’s global network of expertise is expanding – we’re pleased to report iDSI core partners now include: the Asia Health Technology Assessment consortium which includes the National Health Foundation of Thailand, the Saw Swee Hock School of Public Health, National University of Singapore and Health Intervention and Technology Assessment Program; the Health Economics Research Unit of the KEMRI Wellcome Trust Programme, the Norwegian Institute of Public Health and the Clinton Health Access Initiative, Inc.,in addition to current core partners: the Global Health and Development Group at Imperial College London, the China National Health Development Research Center and the Center for Global Development.

The network endeavours to generate long-term, locally-owned solutions to health care challenges through building capacities for using evidence in policy and clinical decisions. Its impact to date includes influencing policy in eight countries – China, India, Indonesia, Philippines, Vietnam, South Africa, Tanzania, and Ghana – where there has been tangible progress toward national institutions being established to embed value-for-money into decision-making about what medicines, vaccines or other health services should be offered to the population, and how these could be procured in the most cost-effective way. Already iDSI has supported Tanzania to prioritise its Essential Medicines List from 500 to 400 drugs, reducing spending on poor value items and freeing up resources to improve access to the most cost-effective medicines, trained Kenya’s Health Benefits Package Committee on measuring the added value of a new health intervention compared to existing ones, piloted a local quality improvement initiative with hospital staff in Vietnam to reduce inappropriate antibiotic prescribing for pneumonia and brought together more than 100 policy makers, academics and industry representatives working across Sub-Saharan Africa for a special event to share knowledge and best practices.

iDSI Director Kalipso Chalkidou, a Professor of Global Health Practice at Imperial College London who also directs the Global Health program at the Center for Global Development, said: “With government and aid budgets under pressure, many developing countries are facing declines in health funding and are going to have to make difficult choices. Policymakers’ decisions about what health care to make available and at what cost can be a life or death decision for people across the developing world. We will inform these critical decisions with data and evidence that maps out how best to spend limited funds to improve outcomes and save lives.”

Chinese, Thai, Norwegian, and British governments have backed iDSI, which also receives funding from the Department for International Development, the UK government department responsible for administering overseas aid.

Amanda Glassman, Chief Operating Officer at the Center for Global Development, said: “Previous health care decision making in developing countries has too often been driven by inertia and lobbying rather than science, economics, ethics and the public interest. We want to change that.”

Ira C. Magaziner, Chief Executive Officer of the Clinton Health Access Initiative Inc (CHAI), said: “Low- and middle-income countries are set to make great strides toward universal health coverage in the coming years, ensuring that all people have access to affordable and quality care. CHAI works with governments that are implementing health financing and service delivery reforms to meet this goal. We are excited to deepen our collaboration with the iDSI network to help partner governments set health care priorities, drawing on iDSI’s expertise and years of experience across different country settings.”

Trygve Ottersen, Executive Director at the Norwegian Institute of Public Health, said: “Without proper support, it is hard for decision-makers to navigate within the broad and ambitious agenda of the Sustainable Development Goals and to make evidence-informed choices that are both fair and efficient. iDSI serves as a unique platform for supporting the most critical choices on the path to UHC and the Institute is delighted to be part of this partnership.”

Professor Teo Yik Ying, Dean of the Saw Swee Hock School of Public Health at the National University of Singapore, said: “The Saw Swee Hock School of Public Health at the National University of Singapore is delighted to be a contributing partner to iDSI. The mission of iDSI to support evidence-based decision making in global public health is aligned to the mission of the School, with the aim of translating research discoveries to improve the health of global communities.”

Dr Somsak Chunharas, from the National Health Foundation of Thailand, said: “Being an organisation promoting evidence-based policy and system development in Thailand for the last 30 years, the National Health Foundation looks forward to this opportunity to share and learn from various countries’ context in establishing the mechanism and tools for evidence-informed policy.”

iDSI was borne out of the recommendations of the Center for Global Development’s Priority-Setting Institutions for Global Health Working Group in 2012.

As part of three recent events, which saw hundreds working in health policy gather in Accra, Liverpool and London, iDSI sought to delve into important factors that guide the design of Essential Medicines Lists and Health Benefit Packages that can evidentially identify the potential value of different interventions.

The events allowed for an increased understanding of the value of Health Technology Assessment (HTA) and how it underpins strategic purchasing of health services for achieving UHC; and shone a light on ‘demonstration’ countries such as China and Ghana which are making large strides towards ensuring HTA is at the forefront of their policy agenda. Events on this scale are a result of the culmination of many years of engagement; and new partnerships that have enabled iDSI access to new LMIC partners, allowing for regional and global networking and knowledge sharing.

Setting Priorities Fairly: Sustainable Policies for Effective Resource Allocation saw almost 100 policy representatives from across Africa and Europe gathered in Accra, Ghana for a special event in September 2018 that focused on sustainable resource allocation policies for LMICs, co-hosted by iDSI and Health Technology Assessment International (HTAi). The event marks an important milestone in iDSI’s collaboration with Ghana which began in 2008 (via the Global Health and Development Group at Imperial College, formerly NICE International), as well as the nation’s commitment to realising a “Ghana beyond aid” as its booming economy puts it on course to transition from external development aid.

The two-day event, opened by Ghana’s Deputy Minister for Health Mr Kingsley Aboagye-Gyedu, set out to address the difficulties LMICs face with attaining UHC; and how to navigate inconsistent and dwindling healthcare funding. HTA was a key focus, with presentations including global experiences of HTA from eminent researchers, health economists and clinicians from the University of Ghana, Ghana’s National Health Insurance Authority, The Global Fund to Fight AIDS, Tuberculosis and Malaria, World Health Organization, HTAi, iDSI and more.

During his keynote speech Mr Aboagye-Gyedu described how Ghana had incorporated HTA recommendations in its Standard Treatment Guidelines and Essential Medicines List because of its usefulness as tool to assuring value-for-money – from the design and management of benefit packages to the determination of reimbursement list of medicines. This follows a View our iDSI timeline to read more about Ghana’s journey towards UHC to date.

iDSI‘s newly released Health Technology Assessment Toolkit was launched at the event, with each delegate receiving the resource on a USB stick. The HTA Toolkit is a free, accessible resource for technical staff working in health policy keen to build HTA processes in their own countries and was developed in consultation with staff working in health policy around the world.

In October 2018 iDSI co-hosted a satellite session on the opening day of the Fifth Global Symposium on Health Systems Research in Liverpool, with Sida and CHAI, on Health financing towards UHC. Through the collaboration, the session brought together officials from Kenya, Zambia, Indonesia, Malawi – as well Eswatini and Rwanda, with whom iDSI had not previously engaged – representing ministries of health, national health insurers, a Prime Minister’s cabinet and academia. The panellists shared practical experiences from health financing reforms in their countries, with a focus on priority-setting and strategic purchasing. The overarching theme of the symposium was Health Systems for all in the Sustainable Development Goals era and it commemorated anniversaries of two significant global health events – the Alma Ata declaration and the 70 years of the UK National Health Service (NHS).

The same week saw iDSI welcome 22 delegates from China, from both clinical and non-clinical backgrounds, representing various departments within the Chinese Ministry of Health (National Health Commission); the China National Health and Development Research Center (Beijing and Shanghai); local policy makers from three provinces; and academics from Huazong, Beijing and Shanghai universities, to develop their understanding of the UK healthcare system, including health-related legislation and regulatory mechanisms, policy development and health reforms. The momentum behind HTA in China has in part been facilitated by longstanding relationships between the Global Health and Development Group and the enthusiasm of Chinese policy makers following UK study tours to learn about the NHS approach to setting priorities fairly.

The visit preceded the National HTA Congress in Beijing on 25 October 2018 which saw the formal launch of the National Center for Integrated Assessment of Pharmaceuticals and Health Technologies in China, and where iDSI support was noted at the opening event. One of the first major tasks of the national HTA Center will be to update the National Essential Drugs List taking into consideration cost-effectiveness criteria. The HTA Center’s work will be carried out by iDSI core partner the China National Health Development Research Center, a national think-tank set up in 2008 that provides evidence-based technical advice to national and provincial health policy-makers.

iDSI Director Professor Kalipso Chalkidou has said China “can lead the way” with regards to using HTA as a policy tool to contain spending and drive more equitable care. This follows Professor Chalkidou’s attendance to the National HTA Congress, detailed also in an View our iDSI timeline to read more about the evolution of HTA in China.

The annual study tours, which started in 2014 (under NICE International) have involved talks from expert representatives from the Department of Health, the Medicine and the Healthcare Products Regulatory Agency, Public Health England, National Institute for Health and Care Excellence, the UK Health Forum and the London School of Economics.

2017’s study tour was timed so key individuals from the National Health and Family Planning Commission (replaced by the National Health Commission in 2018), CNHDRC and GHD could participate in the 5th UK-China People-to-People Health dialogue, attended by UK Secretary of State Jeremy Hunt; NHFPC Vice Minister Cui Li; and the Parliamentary Under Secretary of State for Public Health and Primary Care Steve Brine and Margaret Chan, former Director-General of the World Health Organization.

We have made slides available from:

Setting Priorities Fairly: Sustainable Policies for Effective Resource Allocation

Health financing towards UHC HSR 2018 satellite session

Chinese delegation visit 2018

What’s In What’s Out contains in-depth case studies of how LMICs have grappled with and guidance on designing Health Benefits Packages for UHC.

The 22 delegates, from both clinical and non-clinical backgrounds, visited London and Cambridge to develop their understanding of the UK healthcare system, including health-related legislation and regulatory mechanisms, policy development and health reforms.

Along with visits to St Thomas’ Hospital, Boots Pharmacy’s corporate office and AstraZeneca, the group received talks on the role and function of National Institute for Health and Care Excellence and the Medicines and Healthcare Products Regulatory Agency in protecting and improving public health; the pricing of branded and generic pharmaceuticals in the UK; vaccine evaluation; the development of evidence-based clinical pathways and integrated care pathways; and how to best to make use of electronic health record systems.

Members of the delegation from China with iDSI staff in Queen’s Gate

Yu Ou’yang from the Division of Medical Administration within the Hunan Provincial Health Commission in China said: “Over the last two weeks we have had presentations from almost 30 experts, even though the context of the UK and China is very different there has been so much for us to learn here. During the study tour I have realised healthcare management and delivery in the UK is very detailed and precise to ensure all goes as smoothly as possible, the UK also takes into account the balance between cost and effectiveness in healthcare which is extremely important. It has been great to learn more about standardised operations such as Clinical Commissioning Groups and NICE and their responsibilities. I would like to extend my thanks to all the presenters and those that facilitated our practical days.”

Ying Peng, who is based in Beijing but also carrying out a PhD in Health Economics at the University of Sheffield, said: “The range of presentations we received will really help my own PhD studies, I’ve definitely developed my understanding of how new interventions are appraised in the UK and how evidence is the pinnacle of decision-making. It was really important for me to learn more about the UK health system, which organisations underpin it and how this could be adapted for China.”

The group was made up of officials from iDSI core partner the China National Health and Development Research Center (CNHDRC) and the Chinese Ministry of Health (National Health Commission); along with policy makers and academics from Huazong, Beijing and Shanghai universities.

Liu Jianan, from the Division of the Essential Medicines List, within China’s National Health Commission, said: “Our delegation is diverse but between us all we have rich experience and knowledge. Our learning over the last two weeks has been delivered in such a systematic way; there is still much more we can learn from the UK healthcare system however for now I am pleased we will all be able to bring back our experiences from this trip, especially for matters such as pricing for medicines, which is of broad and current interest in China.”

Chen Bo, a PhD student from Peking University’s School of Public Health, said: “I feel very lucky to be here. The talks have inspired me a lot, particularly as my current area of study is public hospital reform at county-level in China. For me the most valuable part of the study tour has been expanding my knowledge of the ways in which hospital reforms could be made more efficient; and learning so much about Cost Effective Analysis exercises and ways we could push forward with this in China.”

Francis Ruiz, iDSI Senior Advisor, said: “The Global Health & Development Team at Imperial and iDSI have been delighted to organise study tours to the UK for senior Chinese officials since 2014. The talks from various presenters, including representatives from The Nuffield Trust, NHS England, NHS Benchmarking and feedback on their own workstreams from the delegates themselves has been a fantastic complement to off-site days where the group observed the delivery of health care first-hand and attended a workshop focused on primary care. We hope the visit was valuable and will have positive impact on them as individuals; and help develop the UK-China partnership in Health Technology Assessment.”

The ‘setting priorities fairly’ event is the first of its kind for Sub Saharan Africa (SSA), with the main event opened by Ghana’s Minister for Health, Kwaku Agyemang-Manu. How important is it for representatives from SSA to share knowledge to optimise the impact of health spending?

The prospect of HTA in SSA is promising, with an increasing number of countries planning to use HTA as a priority-setting tool to promote Universal Health Coverage (UHC). In the light of this, it is crucial that SSA countries share experiences (however little) to learn from each other.

What can attendees to your workshop session on case studies of how Health Technology Assessment can inform decisions on cost-effectiveness expect?

Attendees can expect to learn what has been done already, especially in the case of Ghana and how that applies to their specific country context.

Ghana was the first Sub Saharan African country to introduce a National Health Insurance Scheme (NHIS) and has long standing commitment towards achieving UHC, of course, there is no “one-size-fits-all” approach to UHC, but what is on Ghana’s agenda?

Ghana’s road to UHC through the NHIS has been brave and bumpy, with key challenges relating to financial sustainability. However, given the political support – from all sides of the political divide – the future of the NHIS is bright. A key approach is expanding enrolment through innovative strategies including group enrolment, enrolment of prison inmates etc. In addition, there are efforts to boost the financial status of the NHIS while removing other bottlenecks to promote UHC. A key way forward is re-visiting the Primary Health Care agenda to strengthen close-to-client services and implement provider payment mechanisms that reduce overall service costs and enhance sustainability of the scheme. The overall improvements in the economy could boost fiscal space for health and fast-track attainment of UHC.

You have led on a number of research projects on health economics and policy in Ghana, Botwsana, Kenya, Malawi and Nigeria – what has been your biggest achievement?

My joyous moments (which I see as achievements) are when I see that recommendations from a previous study I was involved in are evaluated and implemented. A typical example was when the Ministry of Health and World Health Organization in Botswana accepted the findings and recommendations of our study on efficiency and begun planning to implement.

What do you enjoy most about your role?

I enjoy seeing my former students in decision-making roles, applying some of the things they learnt. I also enjoy being involved in discussions and networking (with networks such as the platform that iDSI provides) that are directly relevant for evidence-informed policy making in low- and middle-income countries, particularly efforts that benefit Ministries of Health.

If you weren’t a health economist, what would you be doing instead?

I would have been a geomorphologist, studying earth formations.

Registered delegates can attend the workshop Justice will feature in, ‘Introduction to Health Technology Assessment’, from 1pm on 26 September 2018, as part of Setting priorities fairly: sustainable policies for effective resource allocation in Africa.

Following approval by the Technical Appraisal Committee, this pioneering study will inform the ophthalmology surgical packages reimbursable under the new National Health Protection Scheme (NHPS), which is set to provide healthcare coverage for over 500 million Indian citizens.

The study identified phacoemulsification with foldable lenses as the most cost-effective intervention for lens replacement for cataracts in India compared to other available options such as small incision surgery, with an incremental cost effectiveness ratio of 3862.79 rupees per quality adjusted life year (QALY) gained. Cataracts account for ~70% of all blindness in India, so enhancing cost-effective management of the disease in the country will have a positive impact on many millions of Indian citizens.

iDSI partners Imperial College London and HITAP Thailand provided technical assistance to the HTAIN by providing hands-on training and practical skill building workshops, technical advice and assistance, and guidance in aspects such as how to identify and engage with stakeholders.

The intraocular lens HTA in India is a significant step forward for evidence-informed priority setting in India; and sets a strong example for other countries in the region to follow. Indeed, where it took 15 years to link HTA to prospective payment for secondary care in the UK under the National Health Service, the Government of India have seamlessly bridged the translation of HTA evidence into policy in one fell swoop. By using this kind of information to update and refine the benefit package offered under the NHPS, the Government can be assured of enhancing value for money of every rupee spent on the scheme – setting a strong precedent for scale and diffusion from the Centre for State governments to follow.

Many congratulations to the HTAIN team and all those involved in the study – a truly impressive feat!

The workshop was attended by 23 delegates representing NACC and NASCOP, as well partners from the Global Fund to fight against AIDS, Tuberculosis and Malaria; the Centre for Disease Control; USAID, Kenya Institute for Public Policy Research and Analysis; and the National Treasury.

The first day kicked off with presentations and case study exercises by the iDSI team, including an introduction to economic evaluation and to fundamentals of costing; as well as a session on valuing and measuring costs. The HIV programmes in the country highlighted the need to develop a standard framework for costing work in Kenya, given that several costing studies are on-going in the country.

Participants spent the morning of day two discussing the evidence needs for the HIV programme. NASCOP presented the on-going work on the piloting of differentiated care pathways coupled with a quality improvement intervention (DCM+QI) in seven counties. DCM+QI recognises that the change from a single guideline to a differentiated pathways requires up-front investment and training to support providers. As a result, NASCOP has worked for almost two years with facilities in the intervention counties to develop locally relevant solutions to support DCM implementation.

In-country partners, the Global Fund and iDSI, will form a technical working group to support NASCOP and NACC in generating the evidence relating to the pilot. This workshop demonstrated the importance of consultation, especially between external partners and local partners working on the ground in Kenya.

The iDSI RC sets out a principle-based framework as an ‘aid to thinking’ to inform better decision making in health in low-to-middle income countries (LMICs).

Representatives from Imperial College London, University of York, University of Glasgow and London School of Hygiene & Tropical Medicine (LSHTM) presented on:

• Estimating cost-effectiveness thresholds in LMICs: the example of Indonesia (University of York);
• Estimating the value of HTA: a mixed methods approach (University of Glasgow);
• Modelling optimal choice of treatments that rely on shared service delivery platforms: a health system perspective (Imperial College London); and
• Applying the iDSI RC to infectious disease transmission models and presenting disaggregated social perspectives (London School of Hygiene and Tropical Medicine).

The two-day workshop provided opportunities for the research groups to exchange ideas, obtain input on their progress so far and highlight any challenges. 

The key aim of the research, which was commissioned by iDSI in 2016, is to develop practical methods guidance to be used alongside the iDSI RC. Each of the commissioned academic groups intend to develop detailed research reports and peer-reviewed academic publications. With iDSI support, accessible summaries will be produced targeting key users including policy-makers as well as economic evaluation practitioners.

Opening the presentations on day one, the University of York discussed their work on the evaluation of the impact of public health insurance reforms on infant mortality in Indonesia (using roll-out of public health insurance as a natural experiment). The objective of this work is to feed into an empirical estimate of a cost-effectiveness threshold in the country (using an approach based on opportunity costs).

Eleanor Grieve presented on the University of Glasgow’s work developing a mixed-methods framework to quantify the value of HTA. This work involves an explicit consideration of costs and benefits of implementation of HTA decisions (for instance, inclusion of a new drug or exclusion of a health technology no longer cost-effective). Two frameworks will be combined to address this question: a net health benefit “Return on Investment” and a mixed methods “Realist Evaluation” framework. The team are currently working on an application of this framework using real life data.

Dr Katharina Hauck and Professor Peter Smith from Imperial College London opened day two with a presentation on their work on the intersection between health systems strengthening and cost-effectiveness analyses. Their framework intends to help inform decision-makers on the optimal investments between health system strengthening, such as improving information systems, and other interventions. The team is working on a case study for this framework, which seeks to look at cost-effectiveness of separate and joint provision of home-based testing and counselling for HIV and active case finding for tuberculosis (TB).

Professor Anna Vassall, Michelle Remme and Dr Gabriela Gomez from LSHTM presented their work on taking into account disaggregated societal perspective and equity considerations in economic evaluations. The work on disaggregated societal perspective is important as many interventions conducted in the health sectors will have health and non-health effects and costs (for instance, on education or workforce productivity). The framework, developed by Michelle Remme and Professor Vassal, will lay out the requirements and value positions of different approaches for incorporating non-health consequences. The work on providing guidance to support capturing equity considerations in economic evaluations will focus on applications related to disease-transmission models.

The workshop was chaired by IDSI Senior Adviser Francis Ruiz and took place on 18 and 19 January 2018.