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.

Saw Swee Hock School of Public Health, National University of Singapore, 24-28 June 2019. By invitation only

Universal health coverage (UHC) is not only to be made available but also sustainable and every country is now thinking about how to make both happen. Health technology assessment (HTA) is one of the helping tools, which is increasingly used in both resource-rich and poor settings.

NIHA LDP 2019 is designed for senior policymakers and HTA researchers who would like to know more how to make HTA work better to enhance UHC in their countries. The policymakers and the researchers will be paired to work together not only during the programme period, but also long-term post-programme.

The programme is co-hosted by iDSI and the Access and Delivery Partnership, and will feature iDSI expert speakers including from the
HITAP, Center for Global Development, Imperial College London, and China National Health Development Research Center.

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

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)

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.

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

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

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

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

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

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

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

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

What do you enjoy most about your role?

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

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

I would have been a geomorphologist, studying earth formations.

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

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

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

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

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

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