A HSR 2018 satellite session, which will focus on health financing towards Universal Health Coverage (UHC), has received funding from Sida, working on behalf of the Swedish Parliament and Government. The full day session is co-hosted by the Clinton Health Access Initiative, Sida and iDSI.

1. The satellite session will feature policy makers from Sub Saharan Africa sharing their experiences developing and implementing policies and reforms to make progress towards UHC. What are you hoping will come out of this session?

Low and middle-income countries are facing a very similar set of health financing challenges and implementing related reforms. There are many success stories and practical experiences to be shared from the people currently implementing reforms on the ground.

We are hoping that this session will contribute to strengthening the knowledge exchange between the decisions-makers from Low and middle-income countries in how to best address common challenges and learn from each other.

We will focus on how priority setting, defining basic health services, resource allocation and strategic purchasing can be applied to make progress towards UHC, including essential sexual and reproductive health and rights (SRHR): What do we pay for, which services and for whom, and how do we pay it? How do we make the difficult choice of prioritising certain services above others and how do we ensure that services are delivered in a sustainable and equitable way? How do we ensure key services such as SRHR are included and specific needs of for example adolescents and young women are not left behind.

2. Can you tell us more about the facilitators and panellists that will be part of the satellite session?

We are bringing together leading researchers, government officials and policy representatives from Asia and Sub-Saharan Africa that have on the ground experience in developing and implementing policies.  This includes government representatives from countries Sida is supporting, with technical assistance from the Clinton Health Access Initiative (CHAI) in health financing reforms (Ethiopia, Rwanda, Malawi, South Africa, Eswatini, Zambia).

We believe this mix of people will make for interesting discussions. We will also open up the floor after each sub-session for an audience of international attendees.

3. Investment in sexual and reproductive health and rights in Sub-Saharan Africa is major part of Swedish development cooperation. Can you tell us some more about the work of the regional team based in Lusaka and Sida’s approach?

Sweden has a feminist foreign policy and SRHR is a top priority for Swedish Development Assistance. Approximately 60 per cent of our official development assistance for health is directed towards SRHR. The regional team works on SRHR to advance the continental and regional agenda for sexual and reproductive health and rights through supporting legal and policy reform, expanding access to essential SRH-services, changing social norms around gender and sexuality, as well as advancing accountability for regional commitments. The team has partnerships with regional economic communities such as the Southern African Development Community (SADC) and East African Community, parliamentary fora such as SADC Parliamentary Forum, the UN including the United Nations Population Fund and WHO, research institutes and civil society networks. Our work with CHAI on health financing is an important part in advancing SRHR in sub-Saharan Africa. Access to SRHR services, under a model for UHC, requires a transparent and inclusive discussion on how resources are prioritised and what services to include in basic packages based on the best available evidence. For us, UHC is based on the principle that basic health services should be provided to all. If these principles are adhered to, SRHR services become naturally prioritised.

Sida’s commitment to SRHR is likely to remain for the foreseeable future. Therefore we believe in establishing long-term partnerships with organisations that can contribute to normative change in the region.

4. What do you enjoy most about your role?

My position gives me a good overview of regional SRHR issues and a chance to see how different structures and processes are related. Thanks to that overview, I have a unique opportunity to connect partners and key actors to initiative and networks where synergies can be created. The HSR 2018 satellite sessionis a good example of connecting people to achieve more. Personally, I am very happy to be part of the promotion of SRHR-interventions as a natural and integral part of basic health care packages and UHC since these services respond to common and often recurring needs in the population and therefore must be included in public commitments.

5. If you weren’t in the global health, what would you be doing instead?

Living in Sweden I would probably work for a health provider with Lean production and quality assurance or in a purchaser–provider organisation defining volumes, cost levels and quality standard of health services in assignments to health providers, both public and private. Irrespective of which job, I would make sure I was involved in organisational and operational development since it really matters “how” services are provided and what results you get for your money.

Conference delegates can attend ‘Health financing towards UHC’ from in conference room 13 from 8.30am on Monday 8 October as part of HSR 2018 of which the overaching theme is ‘advancing health systems for all in the Sustainable Development Goals era’. Find out more at www.healthsystemsresearch.org/hsr2018

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. You are a panel member in the sub-session, ‘Design of Health Benefit Packages’ during the HSR 2018 satellite session on Health Financing for Universal Health Coverage (UHC), co-hosted by Clinton Health Access Initiative, the Swedish Government and iDSI. What do you believe your experience will bring to the discussion?

I have been coordinating the process to define benefit packages in preparation for implementation of National Health Insurance (NHI) in South Africa for the past two years. NHI is our version of UHC and aims to address historical inequalities by bringing the public and private sector into a unified national health system. As I have been responsible for health programmes in South Africa for the past 10 years this was a good fit. I think I will benefit as much from the discussion as I think I can contribute based on our experiences in trying to design benefits in a rather complex environment – with a large private health sector and many medical insurance companies and administrators.

2. What are Health Benefits Plans and why are they important?

Health benefit plans define the services that will be available within a health system and should cover all levels of care, from community based services through to highly specialised care. This is important for at least two reasons: (a) certainty on what services are offered; and (b) ensuring that these services are funded.

3. What have been the challenges in development of the benefits package in South Africa?

An initial challenge has been the wide range in standards and guidelines relating to service delivery in South Africa not just across the public and private sector, but also across disease areas. We are addressing this as a priority to ensure a common understanding of acceptable quality of care prior to costing. Other challenges include: (a) availability of data, including epidemiological data, (b) limited or fragmented health technology assessment capacity in the country; (b) political pressure to include all services currently available – even in the context of limited resources; (c) and the designing of a transparent process by which to prioritise services and revise the package over time.

4. If you weren’t in the healthcare field, what would you be doing instead?

Human rights lawyer!
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Conference delegates can attend the session, called ‘Health financing towards UHC’ from in conference room 13 from 8.30am on Monday 8 October as part of HSR 2018 of which the overaching theme is ‘advancing health systems for all in the Sustainable Development Goals era’.

Find out more at www.healthsystemsresearch.org/hsr2018

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.

Dr Satish Mishra at the first world congress on non-communicable diseases event in Chandigarh, India last month.

Between April-October 2017 842 diabetes patients that attended Dispensary 9 at the Bhabha Atomic Research Centre had their feet examined once by physicians that had received additional training from Imperial College London, comprising planning and data analysis.

Neuropathy, which can occur in diabetes patients following prolonged exposure to high blood sugar which can damage delicate nerve fibers, was found in 9% of the patients. Peripheral arterial disease, which occurs when a build-up of fatty deposits in the arteries restricts blood supply to leg muscles, was found in 0.5%.

Previously, not all diabetic patients were receiving foot examinations as part of the standard treatment pathway. The diabetic foot project aimed to use QS to achieve measurable indicators of healthcare improvement. The key process measure for the project was the cumulative sum of patients with diabetes receiving foot examination; and the key outcome measure was the percentage of patients screened for neuropathy and peripheral artery disease.

The pilot project met its objective and provides important evidence to show that diabetic foot care can improve by training healthcare providers, standardising processes, regular data review and feedback. Lessons learned on how to integrate diabetic foot care in a high-volume primary care clinic has relevance for India and other populous south Asian countries.

The findings were presented by principal investigator Dr Satish Mishra at the first world congress on non-communicable diseases event in Chandigarh, India last month.

Visit the National Health Mission’s website to read how the QS were developed from the recommendations in the standard treatment guideline on diabetic foot. Details of the planning and implementation of the project are on the poster presented at the first world congress on non-communicable diseases.

Hypertension is a leading risk factor for mortality in India with more than 200 million people in the country estimated to have high blood pressure (BP). There is, however, very little awareness about this silent killer with 75% of the rural and 60% of the urban Indian population unaware of their hypertensive status. BP control in these patients is worse, 90% of the rural and 80% of the urban Indian population have a BP above recommended target values. This needs to be addressed by providing urgent attention towards provision of access to diagnosis, management and monitoring of hypertension at the primary care level. For clinical guidance on this issue, the Ministry of Health and Family Welfare, India recently published the standard treatment guideline on screening, diagnosis, assessment, and management of primary hypertension in adults in India. This guideline balances the best available evidence with what is operationally feasible and affordable in the context of the Indian public health system, by using a pragmatic adaptation methodology, which was recently published in the BMJ.

Steps towards improvement

The State Government of Kerala, with technical assistance from iDSI, is now planning to implement quality standards which are measurable prioritised recommendations from this guideline. It aims to increase identification of new cases of hypertension by providing opportunistic BP measurement to adults when they visit a primary healthcare center (also called family health center). It also aims to improve BP control in hypertensive patients by setting clinic BP targets. Technology will be used to measure adherance to these recommendations and track patient compliance and blood pressure control. The State Government of Kerala will be integrating indicators for hypertension in the Aadhar linked electronic  medical records captured by Kerala Government’s eHealth project. This is in accordance to the cochrane review on ‘Interventions used to improve control of blood pressure in patients with hypertension’, which recommended that primary care clinics need to have an organized system of regular follow-up and review of their hypertensive patients.

Find out more

This work on hypertension quality standards implementation in Kerala was recently presented by iDSI in the First NCD Congress in Chandigarh, India, you can view the presentation here. The final results from this work will be available next year and will contribute to the evidence base on how to improve detection and management of hypertension in low and middle income countries.

The recent report by the International Decision Support Initiative (iDSI) goes some way towards making the case for Health Technology Assessment (HTA) mechanisms in SSA to support more effective resource allocation when tackling this double burden. Hypertension was chosen as the case study, given its relatively high and growing prevalence in Ghana reaching up to 48% . An economic evaluation was undertaken based on an adaptation of a model developed for the 2006 update of the NICE guideline on hypertension management.

Seven key messages arise from this analysis, which made use of local Ghanaian data and policy-maker engagement:

1. Within the Ghanaian National Health Insurance remit, prescribing diuretics is estimated to cost an additional GH¢642 per DALY averted compared to no intervention.
2. Incremental cost per DALY avoided for Calcium Channel Blockers compared with diuretics is GH¢32,482.

Over the next 5 years Ghanaian authorities can

3. Save up to GH¢ 25,000,000, if they negotiate only a 10% reduction in average drug prices.
4. Save up to GH¢ 18,000,000 by encouraging only a 10% prescription shift from Calcium Channel Blockers to Diuretics, where clinically appropriate.
5. Save up to GH¢ 5,000,000 by encouraging a 10% shift from other drug classes to diuretics, where clinically appropriate.
6. Provide diuretic treatment to all patients with diagnosed but untreated hypertension using only a fraction of savings above (GH¢ 5,900,000) and can generate a net gain of 46,000 extra DALYs averted

Last but not least…

7. This report is an example of the value of being able to share HTA knowledge more freely, specifically executable economic models that can be adapted to local contexts. It demonstrates the positive impact of having open access sources for HTA knowledge dissemination on major health policy challenges worldwide.

To view the details of iDSI Ghana work including analytics, assumptions, and the data behind these key messages, download the report or view it here.

I remember very vividly two of the hospitals I visited in Vietnam, during my first field trip as a global health advisor on the iDSI. In a central hospital in Hanoi, I saw an acute stroke centre that was spotlessly clean and gleaming with the latest equipment, with specialised stroke clinicians offering a range evidence-based treatments matching Western standards. In contrast, in a district hospital a mere two hours away from the capital city, I saw an elderly woman with suspected stroke who had been hospitalised for two weeks, seemingly not getting any better and not receiving any meaningful treatment (and there was no way to confirm the diagnosis as no brain imaging could be done). There was no question as to which hospital I would choose, if I could, if a relative or I were unfortunate to have a stroke.

The reality is that for most people, there is no choice – those who have the means to access the better hospitals, perhaps simply because they live closer to the city, likely get better treatment. This is unfair. Universal health coverage (UHC) is only truly universal if everyone has fair access to good quality health services, irrespective of where they live, what facilities they have access to, their education, income, religion or ethnic background.

Variation in quality is not a phenomenon unique to Vietnam, but is a reality in health systems across the world – even in relatively well-resourced and well-performing UHC systems such as the UK National Health Service. Some variation in quality may be acceptable, but one reason why unacceptable variation occurs is that there is a lack of clarity across the system about what is best practice.

Quality standards

In a bid to address this variation, NICE in the UK introduced Quality Standards (QS). QS are concise sets of statements that describe what is best practice in a given disease area (drawn from existing evidence based guidelines). For instance, what kinds of and how many antenatal checks a pregnant woman should ideally receive; sets out the practical steps required to achieve improvement, *and* most importantly quantifies the improvement. In essence, QS brings everyone together to identify the top 5 or 10 things that need improving nationally, and focus efforts towards raising standards in those areas.

Since 2012, iDSI has been working with India, China, Vietnam and recently Thailand, to develop and implement QS as ways of tackling inequalities in healthcare quality, and to raise overall standards in key areas such as antenatal and maternal health, non-communicable diseases (stroke, hypertension, and diabetes), and antimicrobial resistance. We have drawn on our UK and international experience to create resources section of the site and on our new iDSI Knowledge Gateway.

Thailand, long seen as a success story of UHC, also recognises unacceptable variation in quality among public healthcare providers. In particular, there is now a push to raise and standardise quality in health promotion and disease prevention, beginning with QS in antenatal care. I was privileged to be invited as an international expert to observe and advise on this process. The discussions I heard among policymakers, clinicians and grassroots health volunteers were so rich that I can already anticipate insights and lessons that will go into the next version of the QS guide.

The enthusiasm and expertise of the stroke clinicians I met in the central hospital in Vietnam was unquestionable; the challenge is to sustain those excellent standards of practice and to ensure that all healthcare services across a country can reach those standards. iDSI’s vision is that everyone has fair access to quality healthcare, and we hope that our efforts in introducing and localising the QS model is a small step in the right direction.

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.

Last month Laura Downey, GHD, convened a panel at

The panel was chaired by Kalipso Chalkidou, GHD, and speakers alongside Laura included representatives from the Department of Health Research (DHR), Ministry of Health and Family Welfare, Government of India and the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

We had some questions for Laura about the panel session and the supporting BMJ paper that was recently published:

What is meant by ‘Institutionalizing HTA’?

Essentially what we mean by this is moving towards a health system where Indian policy makers use evidence generated through HTA to inform their decisions for how health resources are allocated. In order for this to reach the point of “institutionalization”, we would hope that such evidence-informed decision making would be diffused widely. This would be at both the National, or Union, level, as well as at the level of the States, where health is a State-lead subject in India. There’s a long way to go before the country comes close to reaching this point. However, the DHR is taking active measures to bring the HTA message to policymakers across the country in an effort to lay the foundation to effectively bridge the gap between evidence and policy.

How do you build national capacity?

It’s important to define here what we mean by “HTA capacity”, as there are a number of areas for which building up local skills and knowledge is necessary to effectively support the HTA ecosystem.

From the technical perspective, it’s important to build capacity for undertaking economic analyses and developing a robust methodological guide for the conduct of analysis, or what we call a Reference Case. We recently ran a training workshop on economic analyses for HTA in Kerala, which was delivered collectively by experts from Imperial College London, HITAP Thailand, and PGIMER. PGIMER has also developed a series of online modules for studying HTA, which will ensure wider-reach of building skills in this area across the country.

From the wider policy perspective, capacity needs to be built for the policymakers and their health system colleagues to be able to understand and use the HTA results to their advantage. iDSI recently facilitated a study trip for Indian policymakers and academics to Thailand to learn from Thai policymakers on how they have been able to use HTA to achieve UHC.

Capacity-building through education and engagement is also taking place with the stakeholder community. Stakeholders refer to all those with an interest in the analysis, such as the patients themselves who are the ultimate beneficiaries of the policy decisions, as well as civil society organizations, industry bodies, non-government groups, and the clinical and allied health community. Through education stakeholders are empowered to take an active role in how the HTA research questions are shaped, and inform the decisions that are made. iDSI recently co-facilitated a stakeholder consultation event on HTA with the Indian Council of Medical Research and DHR, which brought together academics and policymakers to discuss HTA, its need in India, and the establishment of the MTAB. Further stakeholder engagement meetings are planned to take place in the coming months.

What are the next steps?

There is a long way to go before HTA will be effectively “institutionalised” in India, but the MTAB team at DHR are laying strong foundations for taking the program of work forward. Robust methods and process guidelines are being drafted to guide technically rigorous and uniform analyses. Training to build skills for economic analysis will continue to be delivered; technical exercises to pilot the methods, processes, and technical skills will be undertaken; and the political and stakeholder economy will be addressed along the way through active engagement, advocacy, and education.

iDSI will continue to support this incredible National effort, which represents not only an international collaboration, but a collaboration between complex networks of institutions from all over India.  In a country as large as this, where the population is now said to have surpassed that of China, institutionalising the highly complex process of using HTA evidence to inform policy decisions is a formidable task. However, the herculean efforts already shown by the government of India, led by DHR and the MTAB team, and their technical partners from across the country is nothing short of incredible.

Writing from London on the 1 year anniversary of Brexit where political parlance continues in an unending circular discourse devoid of any discernible path forward, I think we can all learn a lesson from our Indian colleagues.

In the space of less than 1 year, the Government of India have achieved more than most countries would hope to have achieved in 5.

Never more did Ghandi’s words “be the change” ring true, as our colleagues at DHR and the MTAB have shown us. It is a true privilege to be part of this great change in the Indian health system.