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.

Ghana has been a pioneer in embracing UHC initiatives. Starting with the “Health for All” movement in the 1970s, going through the early 1980s when the Ghana Primary Healthcare Strategy was adopted, and the 1990s when the district health systems were established. In the early 2000s, these efforts were consolidated and Ghana became the first sub-Saharan African country to establish a National Health Insurance Scheme (NHIS), following adoption of the NHIS act in August 2003, amended in 2012[2].

Sustainable UHC requires developing frameworks for priority setting and making difficult choices. In October 2019, Ghana showed leadership in this area when the Minister of Health announced plans to formally introduce Health Technology Assessment (HTA) to support UHC in Ghana (See our iDSI blog concerning this here)[3]. Taking forward this initiative are two recently established committees: one to provide strategic and political oversight (the Steering committee), and another focused on the technical aspects of producing and interpreting HTA relevant evidence (the Technical committee, also referred to as the  Technical Working Group (TWG)). Ghanaian policy makers see HTA as critical to enhancing healthcare efficiency and maximising the value of every Cedi spent.

Our team has just returned from a week-long visit to Ghana, where we attended the ministry’s Development partners engagement meeting and helped deliver an HTA Policy Seminar to facilitate timely discussions among national and international stakeholders involved, specifically on the practical implications of this initiative to institutionalise HTA in Ghana. During these proceedings, we asked some key questions, such as: “what is Ghana’s vision for HTA institutionalisation?”, “What is the national strategy to deliver this vision?” and “How can local and international stakeholders get behind a country-led agenda and collaborate effectively to successfully realise this vision?”

The meetings highlighted the importance of tapping into existing capacities in the country, and the need to devise a bespoke multi-levelled capacity building plan for individuals, institutions, and the wider environment. We have identified an indisputable need for strengthening cooperation and communication among the various stakeholders working in the HTA space in Ghana. These include, within Ghana, the Ministry of Health, Ministry of Finance, National Health Insurance Authority (NHIA), Ghana Health Service (GHS), academic institutions, and civil society. To support key country stakeholders on their HTA journey, there is also a growing interest among international development partners in the importance of developing country-owned priority setting mecahnaisms, supported by cost-effectiveness evidence.

In this context, coordination between international partners in Ghana will be critical, and ongoing initiatives to bring together multilateral bodies in support of development are welcome. These include the “Global Action Plan for Healthy Lives and Well-being for All”  with Gavi, the Global Financing Facility (GFF), the Global Fund, World Bank and WHO all actively involved in an an accelerator on sustainable financing that recognises the need for strengthening “country led, demand driven and evidence-informed” systems, to increase the efficiency and effectiveness of health spending.

It is also worth noting that Ghana was among nine countries joining the GFF in 2019. The GFF partnership seeks to support countries build investment cases for prioritising reforms relating to reproductive, maternal, newborn, child and adolescent health and nutrition. An important part of this support concerns strengthening country-led platforms for priority setting, mobilising evidence and input from key stakeholders.

Further both the Joint Learning Network and the SDG Accelerator funded by USAID and BMGF (Results for Development), are active in Ghana and their presence offers opportunities for engagement and investment in South-South learning and also in institutional strengthening.

These international initiatives also recognise the importance of strengthening informational and payment system infrastructures to support priority setting and wider health system strengthening. In that context, it is worth noting the work of PharmAccess in supporting NHIA develop systems that generate accurate real time data for analysis and access to financing.

The iDSI network has supported Ghanaian collaborators since 2009, and we are currently engaging with country partners to help realise a fully formalised HTA function following the announcement in October 2019. (More details on our work in Ghana available on our page.) A key measure of success for HTA institutionalisation in Ghana relates to developing effective partnerships and facilitating cooperation between the stakeholder groups. Such partnership working is an  important feature of the iDSI network’s  theory of Change[4] (see our recent publication about building relationships that focus on people, policy, and process for implementing HTA)[5].

In light of these recent developments, Ghana can be regarded as a regional leader in the area of priority setting for UHC. Such leadership can align with and feed into, ECOWAS regional plans for macro-economic policy convergence[6]. Ghana’s successes in the past and its ambitions in the future have the potential to positively influence other countries on the continent, offering a confident message of what can be achieved as we work towards reaching UHC.

Interested to find out more about national HTA agenda and UHC progress, listen to our podcast with Martha Gyansa-Lutterodt here.

Do you have a query on our iDSI work in Ghana?

Visit our iDSI Ghana country page, here. Or get in contact with author of this blog at m.gad@imperial.ac.uk .

[1] World Health Organisation (WHO), definition of UHC, available at: https://www.who.int/health_financing/universal_coverage_definition/en/

[2] Grace Antwi-Atsu, Universal Health Coverage in Ghana, can we really make a progress? Available at: https://www.sightsavers.org/blogs/2019/08/universal-health-coverage-ghana-how-can-we-really-make-progress/

[3] Ghana’s Minister of Health launches the National HTA steering committee and calls for HTA institutionalisation in the country, available at: https://idsihealth.org/blog/ghanas-minister-of-health-launches-the-national-hta-steering-committee-and-calls-for-hta-institutionalisation-in-the-country/

[4] International Decision Support initiative (iDSI) Theory of Change, available at: https://f1000research.com/documents/7-1659

[5] Implementing health technology assessment in Ghana to support universal health coverage: building relationships that focus on people, policy, and process, available at: https://www.cambridge.org/core/journals/international-journal-of-technology-assessment-in-health-care/article/implementing-health-technology-assessment-in-ghana-to-support-universal-health-coverage-building-relationships-that-focus-on-people-policy-and-process/1C9B9F3ABB79CD782DD06D1FC4225411

[6] What’s Africa’s Eco: What difference would a single currency make? Available at: https://www.bbc.co.uk/news/world-africa-48882030

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.

iDSI contributed extensively to the 5^th Biennial African Health Economics and Policy Association (AfHEA) conference 2019, including organising 10 sessions and bringing over 30 researchers and experts to the conference, strengthening our collaborations with African partners. The conference occurred as iDSI turns its focus increasingly towards Africa, working to support decision-making and health priority-setting across the continent.

iDSI kicked off the week with a pre-conference session on applying health economics for immunisation, delivered with Teaching Vaccine Economics Everywhere. Through the conference we ran 10 sessions covering a range of topics on how African countries can use clear decision-making processes as they strive towards UHC. These sessions brought practitioners and policymakers together to identify cost-effective pathways towards achieving UHC and primary healthcare (PHC) for all, the theme of the conference.

As importantly, and true to iDSI’s collaborative nature, the conference was a great opportunity for our network to come together. From Australia to Zambia, it was a great chance for us to bring the iDSI family together so that network partners could continue to share knowledge and provide support to policymakers and researchers across the globe.

Key takeaways

• There is a huge momentum towards UHC and PHC for all in Africa. With limited resources and growing pressures on healthcare systems, sound decision-making and effective prioritisation will be crucial.
• Supporting country-owned decision-making in Africa requires understand the priorities and values of decision-makers. iDSI should work to support systems that reflect these local principles. Ethical analysis and explicit consideration of equity concerns can guide such work.
• At present, health technology assessment and appraisal across Africa is fragmented. Often small teams, based in health ministries and without explicit remit, are conducting HTA in an ad hoc way. There is much value in bringing these users and producers of HTA evidence together; and iDSI is keen to collaborate with AfHEA to develop a community of practice to do just that.

More detail on the key messages can be found in this document.

Preconference workshop – Applied Health Economics in Africa Using Examples from Immunization

iDSI’s AfHEA involvement kicked off with a full house at our pre-conference session, delivered together with Teaching Vaccine Economics Everywhere, on applying health economics to vaccines. This session brought together academics, policymakers in health ministries, officials from multilateral organisations, students and others. Opening the session, David Bishai (Johns Hopkins University) spoke passionately about the need to prioritise within available health budgets, emphasising that “saving money is saving lives”.

The session increased understanding of how health economics tools can be used in resource allocation decisions for health technologies including national essential medicines lists and health benefits packages. iDSI’s interactive components brought the session to life and enabled participants to enhance their learning.

• David Bishai: Introduction to Vaccine Economics
• Tommy Wilkinson: Introduction to Priority Setting in Health
• Tommy Wilkinson: Introduction to Economic Evaluation – Using HTA
• Justice Nonvignon: Measuring Costs of Health Interventions
• Ijeoma Edoka: Measuring and Valuing Health Outcomes
• Ijeoma Edoka: Application of Economic Evaluation – Decision Modelling
• David Bishai: TVEE: Creating the Architecture for Sustainable Vaccine Financing

Organised sessions

The iDSI-organised sessions brought together health economics, policy and ethics experts from across the iDSI global network.

• Organised session 1: Sound Decisions Making for UHC
• Organised session 2: Teaching Health Economics – a Low and Middle Income Country Focus
• Organised session 3: Agent Based Modelling
• Organised session 4: Addressing Ethics Considerations
• Organised session 5: Approaches for Achieving UHC – Perspectives from Africa and Asia

Oral sessions

As part of the main conference break-out session, iDSI members presented their work alongside other leading health economists from across Africa.

• Tommy Wilkinson: Approaches for achieving Universal Health Care: Policy Perspectives from Africa and Asia
• Gavin Surgey: Revision of STG and NEMLIT in Tanzania: a mechanism for introducing HTA?
• Maio Buluwayo: The Potential Impact of a 25% Tax on Sugar Sweetened Beverages in Zambia
• Sam Hollingsworth: Health technology assessment capacity at national level in sub-Saharan Africa: a survey of stakeholders
• Kim MacQuilkan: How can HTA improve equity, access and quality of healthcare services?
• Kim MacQuilkan: Strengthening Health Technology Assessment Systems in the Global South

As countries move towards Universal Health Care coverage and transition from development assistance for health, there is an even more acute need to establish robust processes for assessing and integrating new cost-effective health technologies: a key pillar of financially sustainable, and transparent health systems.

A key strategy to support enhancing VfM is through the incorporation of context specific and economically informed evidence into all levels of health decision-making.

Last month iDSI was in Geneva running an introductory course for Unitaid and the Global Fund on economic approaches used in public health, with specific reference to HIV, TB and Malaria. The two day course covered:

1. Existing approaches to VfM at the Global Fund and Unitaid
2. The theory behind why priority setting in health is important, methods behind conducting economic analysis and practical applications of priority setting in countries
3. How countries are introducing and developing Health Technology Assessment (HTA) processes on the path to Universal Health Coverage

The course was facilitated by Francis Ruiz and Alex Winch (Imperial College London) along with Professor Alec Morton (University of Strathclyde). The training was organised by Ross Leach from Unitaid and Shufang Zhang from the Global Fund.
Attendees from the Unitaid strategy, results and finance teams joined staff from the Global Fund’s Technical Advice & Partnerships, Health Product Management and Grant Management divisions.

Ongoing iDSI projects in the Philippines and Kenya were referenced, along with practical examples of integrating the STAR (Socio-Technical Allocation of Resources) tool in countries; and a deep dive on how VfM is considered in published literature around Malaria, HIV and Hepatitis C.

At the national level, countries are increasingly developing formalised HTA processes to support evidence-based trade-offs in health, across a range of diseases and for the adoption of innovative health technologies.

At the international level, countries are looking to the development community more and more for guidance and support on incorporating HTA, as expressed in World Health Assembly resolution 67.23 on HTA. iDSI hopes to harness more opportunities to further engage with multi-lateral financing organisations such as the Global Fund, Unitaid and normative technical agencies such as the World Health Organization on the robust use of economic evidence in resource allocation and decision making.

The burden of NCDs remains high in low and middle-income countries (LMICs). Reducing this burden is at the forefront of the global health agenda, but how do countries go about doing this?

HITAP and partners from expert institutions have been commissioned by the Prince Mahidol Award Conference (PMAC); Institute for Population and Social Research; and Mahidol University to develop a book that draws on examples of cost-effective interventions for NCDs, dubbed ‘best buys’; cost-ineffective interventions for NCDs (‘wasted buys’) and controversies that can often proliferate both. We are delighted to have this work supported by the Thai Health Promotion Foundation and iDSI and hope the end product will capture what good investments have been for NCD prevention, whilst at the same time detailing obstacles policy makers must navigate, such as public opinion; commercial and trade interest; and unique health system challenges.

The project team are looking forward to launching the book as an ‘evidence package’ that will draw upon examples where lessons can be learned; and provide readers with the tools to review the evidence available.

Chapter authors and co-investigators met at the Center for Global Development Europe in London last month to review preliminary findings and decide on next steps for the project. One of the key points raised was the unavoidable, harsh reality that there is not just a dichotomy between ‘best buys’ and ‘wasted buys’. What may be a best buy in one setting can be wasted in another; and evidence on effectiveness can be weak or absent altogether in certain settings. Authors agreed that addressing uncertainties needs to be at the core of this project.

As well as raising local contextual questions, the project team agree the books content needs to highlight the monitoring and evaluation of interventions once implemented – effectiveness is not static and a ‘best buy’ can soon become a ‘wasted buy’.

Public health specialist and policy advocator Dr Suwit Wibulpolprasert, from Thailand’s Ministry of Public Health, said: “This is a dynamic research project that should not limit itself to a book but rather a continuous evidence-based social movement.”

We still have a year to go until the launch of the evidence package on UHC Day 2019 (12 December), in the meantime the project team can be found presenting preliminary findings at PMAC 2019. We will be at the PS2.5 session on Saturday 2 February 2019, 10.30am-12.30pm. Hope to see you there!

The grant, which will cover five years, represents a significant uplift to the funding granted to iDSI in 2015 and will allow us to continue working relationships with policymakers and healthcare payers to understand and respond to the challenges they face – whether ensuring the financial sustainability of a health insurance fund or fair access to good quality care across public health facilities.

This next phase of iDSI will see stronger emphasis on Sub-Saharan Africa with iDSI’s flagship countries including Kenya and Ghana, where global health funders will be departing and domestic health care spending is on the rise. Additionally, many Sub-Saharan African countries are currently introducing national health insurance or coverage plans and making important decisions about what health services and technologies should be included in Universal Health Coverage (UHC) offerings, where value for money considerations could make a huge difference in health outcomes.

As a result of the renewed funding, iDSI’s global network of expertise is expanding – we’re pleased to report iDSI core partners now include: the Asia Health Technology Assessment consortium which includes the National Health Foundation of Thailand, the Saw Swee Hock School of Public Health, National University of Singapore and Health Intervention and Technology Assessment Program; the Health Economics Research Unit of the KEMRI Wellcome Trust Programme, the Norwegian Institute of Public Health and the Clinton Health Access Initiative, Inc.,in addition to current core partners: the Global Health and Development Group at Imperial College London, the China National Health Development Research Center and the Center for Global Development.

The network endeavours to generate long-term, locally-owned solutions to health care challenges through building capacities for using evidence in policy and clinical decisions. Its impact to date includes influencing policy in eight countries – China, India, Indonesia, Philippines, Vietnam, South Africa, Tanzania, and Ghana – where there has been tangible progress toward national institutions being established to embed value-for-money into decision-making about what medicines, vaccines or other health services should be offered to the population, and how these could be procured in the most cost-effective way. Already iDSI has supported Tanzania to prioritise its Essential Medicines List from 500 to 400 drugs, reducing spending on poor value items and freeing up resources to improve access to the most cost-effective medicines, trained Kenya’s Health Benefits Package Committee on measuring the added value of a new health intervention compared to existing ones, piloted a local quality improvement initiative with hospital staff in Vietnam to reduce inappropriate antibiotic prescribing for pneumonia and brought together more than 100 policy makers, academics and industry representatives working across Sub-Saharan Africa for a special event to share knowledge and best practices.

iDSI Director Kalipso Chalkidou, a Professor of Global Health Practice at Imperial College London who also directs the Global Health program at the Center for Global Development, said: “With government and aid budgets under pressure, many developing countries are facing declines in health funding and are going to have to make difficult choices. Policymakers’ decisions about what health care to make available and at what cost can be a life or death decision for people across the developing world. We will inform these critical decisions with data and evidence that maps out how best to spend limited funds to improve outcomes and save lives.”

Chinese, Thai, Norwegian, and British governments have backed iDSI, which also receives funding from the Department for International Development, the UK government department responsible for administering overseas aid.

Amanda Glassman, Chief Operating Officer at the Center for Global Development, said: “Previous health care decision making in developing countries has too often been driven by inertia and lobbying rather than science, economics, ethics and the public interest. We want to change that.”

Ira C. Magaziner, Chief Executive Officer of the Clinton Health Access Initiative Inc (CHAI), said: “Low- and middle-income countries are set to make great strides toward universal health coverage in the coming years, ensuring that all people have access to affordable and quality care. CHAI works with governments that are implementing health financing and service delivery reforms to meet this goal. We are excited to deepen our collaboration with the iDSI network to help partner governments set health care priorities, drawing on iDSI’s expertise and years of experience across different country settings.”

Trygve Ottersen, Executive Director at the Norwegian Institute of Public Health, said: “Without proper support, it is hard for decision-makers to navigate within the broad and ambitious agenda of the Sustainable Development Goals and to make evidence-informed choices that are both fair and efficient. iDSI serves as a unique platform for supporting the most critical choices on the path to UHC and the Institute is delighted to be part of this partnership.”

Professor Teo Yik Ying, Dean of the Saw Swee Hock School of Public Health at the National University of Singapore, said: “The Saw Swee Hock School of Public Health at the National University of Singapore is delighted to be a contributing partner to iDSI. The mission of iDSI to support evidence-based decision making in global public health is aligned to the mission of the School, with the aim of translating research discoveries to improve the health of global communities.”

Dr Somsak Chunharas, from the National Health Foundation of Thailand, said: “Being an organisation promoting evidence-based policy and system development in Thailand for the last 30 years, the National Health Foundation looks forward to this opportunity to share and learn from various countries’ context in establishing the mechanism and tools for evidence-informed policy.”

iDSI was borne out of the recommendations of the Center for Global Development’s Priority-Setting Institutions for Global Health Working Group in 2012.

As part of three recent events, which saw hundreds working in health policy gather in Accra, Liverpool and London, iDSI sought to delve into important factors that guide the design of Essential Medicines Lists and Health Benefit Packages that can evidentially identify the potential value of different interventions.

The events allowed for an increased understanding of the value of Health Technology Assessment (HTA) and how it underpins strategic purchasing of health services for achieving UHC; and shone a light on ‘demonstration’ countries such as China and Ghana which are making large strides towards ensuring HTA is at the forefront of their policy agenda. Events on this scale are a result of the culmination of many years of engagement; and new partnerships that have enabled iDSI access to new LMIC partners, allowing for regional and global networking and knowledge sharing.

Setting Priorities Fairly: Sustainable Policies for Effective Resource Allocation saw almost 100 policy representatives from across Africa and Europe gathered in Accra, Ghana for a special event in September 2018 that focused on sustainable resource allocation policies for LMICs, co-hosted by iDSI and Health Technology Assessment International (HTAi). The event marks an important milestone in iDSI’s collaboration with Ghana which began in 2008 (via the Global Health and Development Group at Imperial College, formerly NICE International), as well as the nation’s commitment to realising a “Ghana beyond aid” as its booming economy puts it on course to transition from external development aid.

The two-day event, opened by Ghana’s Deputy Minister for Health Mr Kingsley Aboagye-Gyedu, set out to address the difficulties LMICs face with attaining UHC; and how to navigate inconsistent and dwindling healthcare funding. HTA was a key focus, with presentations including global experiences of HTA from eminent researchers, health economists and clinicians 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. This follows a View our iDSI timeline to read more about Ghana’s journey towards UHC to date.

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

In October 2018 iDSI co-hosted a satellite session on the opening day of the Fifth Global Symposium on Health Systems Research in Liverpool, with Sida and CHAI, on Health financing towards UHC. Through the collaboration, the session brought together officials from Kenya, Zambia, Indonesia, Malawi – as well Eswatini and Rwanda, with whom iDSI had not previously engaged – representing ministries of health, national health insurers, a Prime Minister’s cabinet and academia. The panellists shared practical experiences from health financing reforms in their countries, with a focus on priority-setting and strategic purchasing. The overarching theme of the symposium was Health Systems for all in the Sustainable Development Goals era and it commemorated anniversaries of two significant global health events – the Alma Ata declaration and the 70 years of the UK National Health Service (NHS).

The same week saw iDSI welcome 22 delegates from China, from both clinical and non-clinical backgrounds, representing various departments within the Chinese Ministry of Health (National Health Commission); the China National Health and Development Research Center (Beijing and Shanghai); local policy makers from three provinces; and academics from Huazong, Beijing and Shanghai universities, to develop their understanding of the UK healthcare system, including health-related legislation and regulatory mechanisms, policy development and health reforms. The momentum behind HTA in China has in part been facilitated by longstanding relationships between the Global Health and Development Group and the enthusiasm of Chinese policy makers following UK study tours to learn about the NHS approach to setting priorities fairly.

The visit preceded the National HTA Congress in Beijing on 25 October 2018 which saw the formal launch of the National Center for Integrated Assessment of Pharmaceuticals and Health Technologies in China, and where iDSI support was noted at the opening event. One of the first major tasks of the national HTA Center will be to update the National Essential Drugs List taking into consideration cost-effectiveness criteria. The HTA Center’s work will be carried out by iDSI core partner the China National Health Development Research Center, a national think-tank set up in 2008 that provides evidence-based technical advice to national and provincial health policy-makers.

iDSI Director Professor Kalipso Chalkidou has said China “can lead the way” with regards to using HTA as a policy tool to contain spending and drive more equitable care. This follows Professor Chalkidou’s attendance to the National HTA Congress, detailed also in an View our iDSI timeline to read more about the evolution of HTA in China.

The annual study tours, which started in 2014 (under NICE International) have involved talks from expert representatives from the Department of Health, the Medicine and the Healthcare Products Regulatory Agency, Public Health England, National Institute for Health and Care Excellence, the UK Health Forum and the London School of Economics.

2017’s study tour was timed so key individuals from the National Health and Family Planning Commission (replaced by the National Health Commission in 2018), CNHDRC and GHD could participate in the 5th UK-China People-to-People Health dialogue, attended by UK Secretary of State Jeremy Hunt; NHFPC Vice Minister Cui Li; and the Parliamentary Under Secretary of State for Public Health and Primary Care Steve Brine and Margaret Chan, former Director-General of the World Health Organization.

We have made slides available from:

Setting Priorities Fairly: Sustainable Policies for Effective Resource Allocation

Health financing towards UHC HSR 2018 satellite session

Chinese delegation visit 2018

What’s In What’s Out contains in-depth case studies of how LMICs have grappled with and guidance on designing Health Benefits Packages for UHC.

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.