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. 

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

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.

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 the first in a series that are designed to help build capacity for undertaking HTA in India; and come as the Global Health and Development team at Imperial College London have signed a Letter of Understanding with the Department of Health Research (DHR) within the Government of India, who are leading on an exciting initiative to institutionalise HTA.

Over 30 attendees gathered in Delhi for the workshop which focused on introducing participants to the key concepts of evidence-based priority setting and HTA, how to frame an economic evaluation, and how to identify key stakeholders for consultation throughout the HTA process.

Senior Scientist Dr Kavitha Rajsekar discussed the importance of HTA for India and gave an update on the latest developments on HTA in India. Ensuring that an evidence-based, inclusive, and transparent system is put in place via the HTAIN will aid health resource allocation decisions across the country.

Associate Prof Shankar Prinja presented the results of the cost effectiveness of auto disposable syringes, one of the first studies to be approved by the HTAIN Technical Appraisal Committee which has resulted in the government of Andra Pradesh using results to inform their decision to invest in autodisposible syringes to reduce rates of infection due to needle re-use in the state.

Alex Winch discussed what UHC means for India and how establishing fully functioning HTAIN centers will provide a sound basis upon which health resource allocation decisions can be made in India, to ensure that every rupee spent buys the maximum health possible.

Dr Laura Downey and Dr Pankaj Bhaguna outlined what evidence is required to undertake HTA analyses, drawing from their own experience of conducting HTA in India; and their recent publication on identifying publicly available data sources for HTA in India.

Dr Oshima Sachin presented on how evidence for health costs is being collected by the HTAIN and a network of partners from across India to form a common costing database, which iDSI is providing technical advice and assistance with.
Dr Aamir Sohail introduced the concept of equity and ethics in informing HTA in India; and shared his experience of conducting a literature review on equity to inform the intraocular lens HTA undertaken by the HTAIN secretariat at DHR.

Juliet Eames and Saudamini Dabak of HITAP Thailand introduced the concept burden of disease and measuring quality of life to estimate Quality Adjusted Life Years (QALYs), as well as Disability Adjusted Life years (DALYs).
The presentations stimulated lengthy discussions amongst participants as to the challenges of conducing HTA in India, when such evidence is often not available and not routinely collected.

A follow up workshop will be held in three months’ time and iDSI is pleased to report feedback received from participants to this workshop was overwhelmingly positive, with 75% of participants reporting they plan to use the skills and knowledge that they had learned during the course towards undertaking a policy-relevant HTA study.

This comes as the government of India has committed to achieving the Sustainable Development Goals and Universal Health Coverage by 2030.

Setting the right priorities to maximise value of health spending in India towards achievement of UHC will require a robust mechanism to comparatively assess available evidence according to a well-governed, inclusive, transparent and fair process. In almost all high income and most middle-income countries, Health Technology Assessment (HTA) is the gold standard of such evidence-informed priority setting.

The government of India has committed to institutionalising HTA as a core component of decision making in health, in line with a growing momentum for countries to adopt HTA as an integral component of health priority-setting. The Department of Health Research (DHR), under the Ministry of Health and family welfare, has recently established HTAIn – a team charged with the responsibility of conducting HTA to produce evidence regarding the cost-effectiveness of health interventions to inform resource allocation decisions across the Indian health system.

Union Minister for Science and Technology Harsh Vardhan: said: “It is essential to assess, through an evidence-based approach, whether a particular technology can impact disease management, prevention strategies and policy decisions. This is possible through health technology assessment studies”

Under the auspices of HTAIN, the DHR has established a network of HTA Regional Resource Hubs in collaboration with various State Government-affiliated Institutes. These hubs will provide technical support towards the National HTA effort, as well as to local State government requirements. As HTA is nascent to India, staff of these HTA resource hubs will need to undertake significant training in health economics and cost effectiveness analysis in order to conduct HTA for the HTAIn. This requirement for capacity building was recognised by Mr Vardhan who said: “There should be collaborative teaching programmes with faculty from both medical and engineering institutions for manpower generation and skill development in health care technology assessment.”

iDSI have partnered with the DHR under an agreement to provide technical capacity building support for HTA Resource Hubs across India in order to bridge this capacity gap and build a cadre of skilled health economists equipped with the knowledge and skills to undertake HTA. A number of HTA skill building workshops have been held to date in Delhi, Kerala, and Chandigarh.

The next workshop will be held in Delhi from 4-6 July, where facilitators from iDSI, the HTAIN and PGIMER. Chandigarh will hold the first of four skill building workshops for the recently established HTAIN Technical Resource Hubs.
iDSI will continue to support this exciting National effort led by the DHR and the HTAIN, which represents not only an international collaboration, but a collaboration between complex networks of institutions from all over India.

Whilst in town I was invited to give seminars at the Department of Economics at the University of Calcutta and the Institute of Development Studies Kolkata. I was also inducted into the vibrant academic community that frequents the historical ‘College Street Coffee House’ where I spent many happy hours being schooled in the finer details of the Indian health system.

Out of pocket spending on healthcare in India is pervasive and can be impoverishing for those most vulnerable. For HTA to contribute towards achieving Universal Health Coverage in India it must embrace the goals of reducing out of pocket expenditure and tackling health inequality, as well as improving population health overall. For this to happen HTA will need to find a role in mediating the complex interactions between the various healthcare financing schemes and the heterogeneous array of healthcare providers in the country. This will require HTA to be embraced by policy makers at both central and state government levels; and given the teeth to make binding recommendations to shape these interactions.

A further challenge of applying HTA in India is that at present there appears to be limited capacity for analysts to undertake health technology assessments; and for policy makers to interpret these assessments. These areas could be developed with the introduction of training courses at strategic institutions across the country.

I would like to extend a special thanks to Sumit Mazumdar, Papiya Mazumdar, Santanu Tripathi, Arijita Dutta, Achin Chakraborty, Onkar Prosad Ghosh and seminar participants from the Department of Economics at the University of Calcutta and the Institute for Development Studies Kolkata for their intriguing questions, insightful comments and generous hospitality.