This was one of the key take-home messages from the first in a series of workshops designed to build capacity for undertaking HTA analyses in India.

Participants from technical institutions across the country travelled to Thiruvananthapuram in Kerala to join this workshop. The workshop focused on supporting India in the transition towards a formalized system of using evidence to inform health resource allocation. The Department of Health Research, Government of India are leading on this by establishing a medical technology assessment board (MTAB). Building capacity to undertake health economic analyses in India will be an imperative foundation for the success of the HTA program under MTAB.

Key take-home messages from the workshop:

HTA is an important tool for prioritizing health resources in India’s journey towards UHC: Dr Soumya Swaminathan, Secretary DHR and Director General of the Indian Council of Medical Research (ICMR) discussed the importance of HTA for India. Ensuring that an evidence-based, inclusive, and transparent system is put in place via the MTAB will aid health resource allocation decisions. As a result, healthcare decisions will be made on the basis of best value for money for the Indian people.

Sri Rajeev Sadanandan, Principle Secretary for the State of Kerala, further reiterated this sentiment and expressed his commitment to establishing a center for HTA in Kerala.

Dr Laura Downey lead a discussion on what UHC means for India, and how establishing a fully functioning MTAB centers on utilizing the best available evidence. This 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.

Economic analysis requires a lot of evidence, some of which isn’t always easily available: Discussions relating to evidence were a common theme throughout the workshop. Dr Miqdad Asaria outlined the kinds of evidence that is required to undertake a HTA analyses. Dr Akashdeep Chauhan presented on how evidence for health costs is being collected from across India to form a common costing database. Dr Laura Downey also introduced the concept of utility tariffs for measuring quality of life to estimate Quality Adjusted Life Years (QALYs) or Disability Adjusted Life years. Together these presentations stimulated lengthy discussions amongst participants as to the difficulties of conducing HTA in India, when such evidence is often not available and not routinely collected.

Dr Yot Teerawattanon shared his experience from Thailand, where HITAP conducted primary research to fill these gaps to inform Thai analyses. This included collecting an EQ5D dataset to build a Thai value set for quality of life utility tariffs. Dr Kavitha Rajshekar from DHR highlighted that in order to address some of these data gaps in India, the MTAB will collaborate with the National Institute of Medical Statistics (NIMS) to build a National data repository to inform HTA analyses.

A mechanism for identifying and addressing data gaps will also be put into place through capitalizing on the partnership between the DHR (government policy-making body) and the ICMR (a scientific primary medical research body).

A reference case for economic evaluation is essential to guide structured, transparent, and technically sound analysis: The necessity for a reference case for Indian health technology assessment was highlighted throughout the workshop.

Dr Deepshikha Sharma lead a discussion regarding the different dimensions a reference case must cover, such as whether DALY or QALY should be used, and at what level a threshold for cost effectiveness must be set.

Dr Miqdad Asaria lead further discussion regarding the importance of setting a threshold at the right level for India to limit the opportunity cost of where resources could potentially be better spent.

Dr Laura Downey and Dr Kavitha Rajshekar shared plans for the development of the Indian reference case under MTAB. They explained that a reference case for economic evaluation will be collaboratively developed, and that all technical institutions whom undertake HTA as part of the MTAB program of work will be required to follow this guide.

Want to know more about HTA?

Health Technology Assessment in Universal Health Coverage

WHO resolution on Health Technology Assessment

National Institute of Health: “HTA 101”

Organizer’s information:

iDSI

The Department of Health Research Government of India

The Post Graduate Institute of Medical Education and Research Chandigarh

The Sree Chitra Tirunal Institute for Medical Sciences and Technology

Useful links:

iDSI reference case for economic evaluation

Informing global health decision making: Cost per DALY thresholds and health opportunity costs

Country-level cost effectiveness thresholds : Initial estimates and need for further research

At the end of March 2017, Professor Jo Lord, Director of the Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, and Dr Kalipso Chalkidou travelled to Accra, Ghana to meet with colleagues and follow up on latest developments. iDSI is co-producing with our Ghanaian partners a full report on the technical and data aspects of the model, discussing the likely characteristics of a Ghana-specific Reference Case for economic evaluation and setting out specific policy angles of interest to Ghanaian policy makers, including the potential linkage between HTA and reimbursement. We aim to set out a vision for joint working over the next 2-3 years, based on the country’s priorities and commitment to building the needed capacities for effectively using economic and clinical evidence of comparative effectiveness to inform spending decisions. The report will offer robust estimates of savings from shifts in current practice, from changes in prescribing behaviour to reductions in prices and population level prevention and screening initiatives, to inform Ghanaian policy makers about resources that can be released to expand the breadth and depth of coverage, without harming quality. We hope to do more such analyses on NCDs, including diabetes and end stage kidney disease as well as mental health, as we continue our joint efforts.

At a time where Ghana is transitioning away from aid whilst striving to expand and ensure the financial sustainability of its health insurance scheme, transparency and accountability when it comes to important investment decisions, become even more important. Building on strong institutional structures for multi-stakeholder engagement and evidence informed policy such as the Essential Medicines List and the Standard Treatment Guidelines and the recently formed HTA Working Group, and on existing academic groups with a track record in the field of HTA at Kumasi (KNUST) and Accra (School of Public Health) this is an opportunity to help build a Ghanaian HTA system better to control escalating costs and inform future investment and disinvestment decisions.

A case for further investment in health cannot be made unless systems are in place to ensure good value for money for every Cedi spent. Identifying, in an evidence informed way, opportunities for releasing resources for reinvestment to expand coverage whilst ensuring health outcomes remain the same or improve, is a powerful argument for more and better spending in health. Our report will go some way towards making the case for an HTA mechanism for strengthening the handle of the Ghanaian authorities over its own budget through tackling a specific cased of high spending and high burden, namely hypertension management. Using Ghanaian data and making all assumptions explicit, the analysis will point to areas for improved spending, quantifies potential savings and health gains from reallocation and make a case for an institutionalised approach to HTA in Ghana, as an important tool for transitioning away from aid and towards sustainable and affordable Universal Healthcare Coverage.

Health Technology Assessment offers a framework for decision making though multi-stakeholder processes and a multidisciplinary approach which aims to incorporate evidence and values, locally relevant, to drive better decisions. But it relies heavily on implementation levers such as provider payment, contracting, patient and professional education and strong regulation to make a difference.

In a recent policy brief, Oxford Policy Management and the International Decision Support Initiative (iDSI) have asked “would the VfM analysis that the UK’s Department for International Development conduct on their programme expenditure be more useful if lessons were learnt from the iDSI Reference Case for Economic Evaluation?”. It is argued that significant methodological improvements are available to DFID – which could make the information they generate more useful for their decision makers. These recommendations are also applicable to other donors who follow similar guidelines for monitoring their VfM.

Alex Jones’ blog post exploring some of the issues raised in the brief is available on the Oxford Policy Management website.

June 2014

NICE International launched the Gates Reference Case, a principle-based standardised methodology for good practice in the planning, conduct and reporting of economic evaluation for informing priority setting in health.

Senior academics, donors and policy makers attended the launch at the Houses of parliament, which was hosted by APPG Global Health, chaired by Lord Crisp and Meg Hillier MP. There followed a technical workshop to discuss why and how the Gates Reference Case was developed and what it means for researchers, donors, and policy makers working in low and middle income countries as well as next steps in the development and implementation of the reference case.

The MEEP final report (PDF) contains the full Gates Reference Case and background to the project. A guide to the Reference Case – what it is, why it’s important and how to use it – can be found here.

Discussing the Reference Case at the World Health Organisation and the Global Fund