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.

If you are a policy-maker working on the COVID-19 response in your country, we would love to hear about your experience and intention to work with those models, as well as your assessment of the perceived gaps. In addition, we would like to learn from you how models can be best communicated, including what they should report.

Communicating effectively and presenting results clearly is important in order to ensure that results are understood by end-users and appropriately incorporated into policy-making.

The intention of attached survey is to gather your perspective on (1) model outcomes and scenarios and their relevance to your work, (2) presentation of the results, and (3) trust/accountability of results and modellers. This survey is organised around those three sections.

The survey may take 15-20 minutes to complete.

Click here to access the survey or alternatively, use the link below

https://docs.google.com/forms/d/e/1FAIpQLSd-MC15jaUFR0fOkcfJpdDuPhvOB5x8Y-Z1qVMvRjFPB_KFfg/viewform

Should you have any questions, please address queries to ychi@cgdev.org

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 Read our 60 seconds interview with Patric Landin here.

Read our 60 seconds interview with Yogan Pillay here.

As part of a satellite session iDSI hosted with CHAI and Sida, ‘Health financing towards UHC’, Pak Budi Hidayat, Professor of Health Economics and Health Insurance at the University of Indonesia and a member of the national Health Technology Assessment (HTA) Committee, announced the decision by Indonesian authorities to delist certain medicines deemed to be cost-ineffective from the national formulary.

Badan Penyelenggara Jaminan Sosial (BPJS), the social insurance agency responsible for administering the Jaminan Kesehatan Nasional (JKN), the world’s largest single national health insurance scheme for Universal Health Coverage, will no longer reimburse cetuximab and bevacizumab for certain colorectal cancers.

iDSI core partner HITAP was instrumental in the economic evaluation of the two medicines which led to the policy decision. The costs of these drugs are strikingly high with only marginal benefits for patients, so much so that they are considered poor value for money and not advised as first-line treatment options even in high-income countries.

With Indonesia the fourth most populated country in the world, running a large-scale health insurance scheme is complicated and there is mounting financial pressure on BPJS. Pak Budi said: “With 200 million citizens in the scheme, BPJS needs to be a more strategic purchaser. There is a real need to be an active purchaser, rather than a passive purchaser; and determine whether to pay for the things we have to pay, or what providers are asking to be paid.”

Pak Budi Hidayat at the Fifth Global Symposium on Health Systems Research

Technical assistance from HITAP to the Indonesian health ministry (including the HTA Committee), the national health insurer and universities began in 2013. In 2017, HITAP provided intense capacity-building support to local research teams on four HTA studies, all of which were commissioned and funded by BPJS, on some of the highest cost items reimbursed by the JKN.

Two of the studies, by the University of Indonesia and the University of Gadjah Mada, respectively focused on the value of cetuximab and bevacizumab as first-line treatment options for metastatic colorectal cancer. The announcement to delist the two medicines marks significant policy impact of iDSI’s engagement in Indonesia; and more importantly tangible institutional progress in the use of health economic evidence to inform policy.

Cetuximab was included in the Indonesian national formulary in 2014. iDSI analysis revealed that treatment for 32 patients in Indonesia came at a cost of IDR 6.5 billion (USD $500,000). Bevacizumab was also shown to be high-priced, with costs of IDR 4.8 million (USD $400) per vial.

HITAP’s work with the Indonesian health ministry considered not only cost effectiveness analyses, but also the barriers to uptake. Only six hospitals, all located on Indonesia’ main island Java, have the capacity to diagnose and treat metastatic colorectal cancer. Although Java is home to 257.6 million people, the other half of the population inhabit other islands, up to many hundreds of miles away. Targeted treatment for metastatic colon cancer prolongs life by one year on average. With substantial distance between some the Indonesian islands and Java, the team also considered the strain on cancer patients who may struggle to access treatment centres without difficulty. As a result, the importance of using other less expensive strategies with lower side effects, such as palliative care, as comparators were emphasised in the HTA study. HITAP accentuated this would add a holistic viewpoint and a chance for policy-makers to deliberate all policy angles.

With cancer drugs accounting for the lion’s share of global drug spending, it’s crucial HTA studies are carried out to ensure costs translate into outcomes which make a difference to patients and thereby ensure long-term financial sustainability of national UHC schemes like JKN. Furthermore, HTA processes need to be institutionally embedded into drug reimbursement policies. iDSI’s engagement with Indonesia, via HITAP, continues and policy briefs describing the study findings are due to be published on the iDSI Gateway by the end of 2018.

The two-day ‘Setting Priorities Fairly: Sustainable Policies for Effective Resource Allocation’ event, opened Ghana’s Deputy Minister for Health Mr Kingsley Aboagye-Gyedu, set out to address the difficulties LMICs face with Universal Health Coverage (UHC) attainment; and how to navigate inconsistent and dwindling healthcare funding.

Health Technology Assessment (HTA) was a key focus, with presentations including global experiences of HTA from eminent researchers, health economists and medical doctors 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.

Ghana’s Deputy Minister for Health Mr Kingsley Aboagye-Gyedu who opened the event

Under the leadership of Ghana’s Ministry of Health, iDSI has been working with a variety of Ghanaian entities for several years now, providing technical assistance and facilitating capacity building for evidence informed priority-setting, to support the tough decisions and trade-offs government is faced with.

Mr Aboagye-Gyedu also acknowledged iDSI’s support on Ghana’s pilot study on cost-effective management of hypertension, describing the project as “gearing the country into a real policy momentum to entrench HTA into the selection and pricing processes.”

Day one of the event consisted of pre-conference workshops aimed at stakeholders with relevant interest in HTA development in sub-Saharan Africa, intended to provide an overview of HTA, covering core technical components and how HTA could be integrated within a broader decision-making process.

The second day aimed to extend global experiences in HTA to the SSA region and increase the understanding of the use of HTA for resource allocation decisions while coordinating policy priorities of SSA nations. A mix of expert speakers provided international perspectives and thought-provoking presentations in plenary and parallel sessions covering a wide array issues pertinent to HTA in SSA.

iDSI‘s newly released Health Technology Assessment Toolkit was launched at the event, with each delegate receiving the resource pre-loaded onto 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.

Iñaki Gutierrez Ibarluzea, HTAi Vice President, said: “HTAi was proud to join forces with iDSI as well as HTA colleagues from around the world on this ground-breaking initiative. The healthcare challenges sub-Sahara Africa faces are complex and multi-faceted – by leveraging the collective inputs and suggestions from global leaders we hope the ideas and recommendations stemming from this workshop will further spur development and innovation within the region. The collection of knowledge from the delegates that attended the conference was truly remarkable and we are excited to see what some the brightest HTA minds can achieve as a result of this collaboration.” 

Professor Kalipso Chalkidou, iDSI Director, said: “iDSI was delighted to collaborate with HTAi and Ghana’s Ministry of Health to host the event. Bringing together almost 100 policy representatives from across Africa and Europe, our aim was to support countries’ vision to reach Universal Health Coverage in an equitable and sustainable fashion. It was wonderful to be back in Accra, further strengthening our partnership with the Ministry of Health in Ghana, at this event. I would like to extend my thanks to Mr Aboagye-Gyedu for his endorsement and for formally opening and supporting the event.”

Visit the iDSI Knowlege Gateway to read our round up of the event, including key messages and details of external media coverage.

We have made all presentations from the event available on iDSI’s website.

Press coverage:

Ghana News Agency: Ghana hosts conference on sustainable resource allocation
policies (27 September 2018)
Modern Ghana: Conference On Sustainable Resource Allocation Policies (28 September
2018)
Business Ghana: Ghana hosts conference on sustainable resource allocation policies (1
October 2018)

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.

According to the WHO report, public expenditure in health decreases as a percentage of total public expenditure in the presence of donor aid, and does not increase in line with fiscal growth. But what does this mean in relation to improving population health and economic productivity? This answer to this question is not easily extracted from the report. In fact, the single methods page gives little detail as to data provenance and how it was analysed – necessary requisites of any academic paper submitted for peer-reviewed publication. The document also reports patterns of spending as proportional to total investment, which in the absence of absolute figures can be misleading, though the authors do recognise this as a caveat within the report. The underlying assumption here seems to be the myopic belief that the healthcare sector should be taking up an ever-greater share of public expenditure in all circumstances. But what does analysing and tracking percentage of public expenditure on health really tell us about whether monies are allocated appropriately and systems are operating efficiently?

The WHO report focuses heavily on the question of fungibility and whether development assistance crowds out domestic funding for the healthcare sector. However, an argument can be made that investing in areas such as infrastructure, sanitation, or education may be an even better use of scarce country resources than healthcare, since it has a direct impact on alleviation from poverty and an indirect positive impact on health. There is perhaps some value in a country trying to ensure access to safe drinking water and adequate sanitation before investing in the rotavirus vaccine for all its children. Indeed, a recent study examining the fungibility of development assistance in Tanzania found that fungibility of external funds was in fact beneficial to the country’s development, with evidence suggesting that the ‘displaced’ funds were reallocated towards education. It is obvious that the opportunity cost of spending finite, scare resources in LMIC unwisely has implications beyond health, so fiscal elasticity in this context is not necessarily detrimental, but potentially beneficial.

In recent years, a number of econometric studies have been carried out to address the question of the fungibility of development assistance. However, results of these analyses have been shown to be highly sensitive to the methods used, and are usually based on weak and divergent data sources.

The real problem with the question of fungibility and how to capture and analyse it, is that we’re asking the wrong questions. What we should be asking is not where the money is going, but instead ‘are those monies allocated appropriately and spent efficiently to maximise value?’, where allocative efficiency is dependent on the presence of effective priority setting and governance. Answering this question involves looking beyond the expenditure databases at priority setting mechanisms within particular countries and what financing and governance models can be made to work best for donors and, more importantly, for countries, in their quest to improve health and wellbeing for their populations. Indeed, the emergence of pay for performance incentive schemes and Development Impact Bonds is evidence of a growing trend towards results-based health financing (for more information, see Centre for Global Development’s extensive literature on the potential and pitfalls of these kinds of financing models).

Aside from the substantial technical, statistical, and data quality issues of fungibility-focused econometric studies, it is very difficult to extract the answer to the ‘So what?’ question of how to make things better. One way to address this question experimentally is to design a well-structured, responsive, and flexible co-financing system which facilitates a shift of focus on fungibility to productivity gains. Such a system was recently put forward by Morton and Colleagues, which is founded in the assumption that a list of ‘best buys’ can be relatively easily generated for countries. These high-benefit and low cost interventions could be paid for by the country and more costly interventions higher up the list could be paid for by donors, either in full or as part of a cross-subsidy agreement. The question is then targeted at the point at which an intervention becomes cost effective, within the confines of the domestic budget, and whether donors should subsidise up to this point at the assumption (or agreement) that local policymakers will pay for interventions at the point at which they become cost effective for them. This kind of alignment of donor and local priorities has also proved successful in the form of sector wide approach to payments (SWAp), where recent analyses suggest that $0.52 more cents of domestic government revenues is spent in the health sector when health aid is channelled to settings where there is a SWAp in place. Such co-payment mechanisms focus more on a reciprocal relationship and open conversations between donors and local governments to enter into mutually beneficial contractual arrangements, which significantly reduces the importance of fungibility. To take the argument one step further, we should aspire towards non-siloed donor budgets which can look not only beyond vertical programs, but also beyond health towards pan social-sector relevance – then fungibility loses its meaning entirely.

As countries progress they should be establishing robust mechanisms for evidence-based priority setting to ensure that value is maximised for every rupee, peso or rand spent. Whether health spending as a share of public spending increases or decreases is of secondary importance to the question of whether money is spent wisely. In the context of a rapidly changing development assistance landscape, policymakers and donors alike should be focussing on the ‘so what’ question – what will the transition from external to domestic financing mean for health outcomes? How can donors and policymakers work together to facilitate a smooth transition? And how can domestic resources be most effectively prioritised to ensure best value health buys? The global health community needs to rise to the challenge and support policymakers across the world to spend their money better, and ensure that adequate governance mechanisms are in place to protect these finite resources against waste.

Laura Downey¹, Alec Morton², Kalipso Chalkidou^1,3

1 – Global Health and Development, Institute of Global Health Innovation, Imperial College London, London UK
2 – Strathclyde Business School, University of Strathclyde, Strathclyde UK
3 – Global Health and Policy, Centre for Global Development, London UK

According to an IndiaSpend analysis of 2017 Reserve Bank of India data on state budgets, nine of India’s poorest states (48% of the population) account for 75% of under-five deaths and 62% of maternal deaths. The Central Government recognised these nine states as ‘high-focus’ as they were performing poorly in various indicators and allocated additional resources to them to improve health indicators. However, these ‘high-focus’ states spent less money than was allocated to them and indicators did not improve.

A growing number of LMIC are transitioning from development assistance in health towards increased domestic expenditure. An important determinant of success or failure will be the strength of system-wide mechanisms to engage in effective priority setting of resources and govern their deployment. India is not alone in the problem of absorbing finances allocated for health, a recent WHO report similarly described an underspend of 20-40% of money allocated to heath in Sub Saharan African countries. We know from global surveillance data that health expenditure is rising in most countries across the world, yet startling figures recently released by the OECD reveal that a considerable proportion of this expenditure has little to no impact on improving people’s health. This is consistent with a 2010 WHO analysis which concluded that 20-40% of healthcare spending globally is wasted.

Improving the ability of ‘high focus’ states in India to adequately absorb allocated funds will require robust mechanisms, to both engage in effective priority setting and ensure system readiness for implementation.

The equitable and efficient distribution of health budget resources, as well as timely uptake of good value technologies, will be critical in strengthening the Indian healthcare system.

The government of India is set to establish a Medical Technology Assessment Board (MTAB). The MTAB will evaluate existing and new health technologies in India, assist choices between comparable technologies for adoption by the healthcare system, and improve the way in which priorities for health are set. This initiative aims to introduce a more transparent, inclusive, fair and evidence-based process for healthcare decision making in India, towards the ultimate goal of achieving UHC. This formidable task will be crucial if States are to be empowered to adequately absorb and spend all funds allocated to them by the Central government to maximise health gains.

However, engaging in effective priory setting is only half the battle. Effective uptake of resource allocation decisions requires a system able to deliver and strong governance mechanisms to ensure that policies are properly implemented. Since moving into upper middle income status, the Indian government has made valiant efforts to strengthen the highly complex and fragmented health system. This is best evidenced through programs such as Rashtriya Swasthya Bima Yoganda (RSBY): the world’s largest social insurance program for those below the poverty line, which provides around 1000 secondary care services to registered card holders free at the point of delivery. However, the efficacy of such a program is severely impeded within the context of scant governance and regulation. Within months of the introduction of RSBY, stories began to emerge of profiteering clinicians cashing in on the capitation payment system by performing hysterectomies on whole villages of women. A largely unregulated and private-dominated care system means there is limited clinical surveillance data to ensure appropriate care provision and validate rebate charges. Without robust governance mechanisms, the value of effective priority setting is severely diminished. The importance of supply-side insufficiencies should also not be overlooked. Ensuring an adequate number of well-trained and reasonably paid health professionals with access to necessary equipment and infrastructure is critical to ensure a fit for purpose delivery system.

More money does not mean more health when the right systems are not in place to spend that money wisely, effectively implement policy decisions, and govern their deployment. It is the duty of the global health community to rise to the challenge to support policymakers across the world. Helping them to spend their money better to fully absorb available resources will maximise the value of every rupee or dollar spent, and ensure that adequate governance mechanisms are in place to protect these finite resources against waste.