As India moves towards the achievement of Universal Health Coverage (UHC), finding robust and evidence-based answers to the challenges of defining which services should be publicly funded, for whom and how, becomes increasingly important. The introduction of ‘Modicare’, the nascent health insurance scheme announced out by the Indian Federal Government to cover some 500 million citizens, brings with it a complex collection of challengers for State policy-makers to address. These include an urgent need to rationalise multiple insurance schemes, their benefits and their purchasing and contracting strategies; and enhance quality monitoring, to assure that public subsidies for health insurance are being well spent and maximising population health gains. 

A workshop was held on 25 and 26 February 2019 in Guwahati, Assam, in the North East of India to address some of these pressing issues. The workshop was co-hosted by the Government of Meghalaya, the Indian Institute of Public Health Shillong and iDSI partners from the Center for Global Development and Imperial College London. 

The two-day event was opened by Shri Samir Sinha, Principle Secretary Health, Government of Assam, and brought together over 50 participants from six of the North Eastern States. Delegates represented local government, and academic, non-government, and multi-lateral organisations such as the World Health Organization, The World Bank, Bill and Melinda Gates Foundation and UNICEF. 

This international interactive workshop was the first event of its kind to be held in the North East of India and provides an important opportunity for iDSI to explore and strengthen collaborative engagement in this region; and for North Eastern States to showcase their proactive engagement towards health system strengthening. 

The workshop sought to explore international best practices for defining and implementing successful Health Benefits Packages, highlight common pitfalls and share lessons for success – drawing from the iDSI publication ‘What’s in, what’s out: Designing Benefits for Universal Coverage’. Presentations and practical group work sessions provided some answers, options and choices in response to the important challenges that State governments are facing in relation to the refining of their own State Insurance Schemes and design of their health benefit packages. 

A recent collaborative analysis of the Meghalaya Health Insurance Scheme (MHIS) by IIPH Shillong and Imperial College London was presented for the first time. This analysis tracked the scheme’s evolution and enhancement as the State progresses towards improving population health and highlighted key areas for development under the next phase of the MHIS.

Reflections from the workshop are summarised in this slideset.

Workshop materials

Presentations

Day 1

• Amanda Glassman, CGD: What’s In, What’s Out: Designing and Adjusting Health Benefits Plans for UHC
• Amanda Glassman & Kalipso Chalkidou, CGD: What is your HBP policy baseline?
• Amanda Glassman, CGD: Fiscal and budgetary issues for HBP
• Owen Smith, The World Bank: Using evidence to strengthen HBP implementation under PMJAY
• Sampath Kumar, IAS, Government of Meghalaya: The Meghalaya Community Participation and Public Services Social Audit Act, 2017
• Laura Downey, Imperial College London & Peter C. Smith, Imperial College London and University of York: Reviewing the health benefits package in Nelam Pradesh: methodology case study
• Peter C. Smith, Imperial College London and University of York: Methodological options for setting the health benefits package

Day 2

• Guwahati, National Health Authority: Governance under AB PMJAY
• Amanda Glassman, CGD & Ursula Giedion: Principles of good governance for a sustainable HBP policy
• Roshan Ronghang, IIPH Shillong: Assessing the pattern of enrolment and claims in Megha Health Insurance Scheme (MHIS)
• Anuj Gupte, MD India Health Insurance: HBP design and implementation overview
• Kikameren Longkumer, Department of Health and Family Welfare, Nagaland: Universal health coverage and health benefit package: Nagaland state
• Carleigh Krubiner, CGD: Navigating ethics in the design of health benefits. Evidence-informed practices to promote equitable and ethical progress on the path to UHC
• Prof Rama V. Baru, Jawaharial Nehru University: Equity and ethical considerations in health technology assessment

Group work case studies

• Case study: Reviewing the health benefits package in Nelam Pradesh
• Case study: Ensuring good governance in HBP design and implementation
• Case study: Examining ethics and equity dimensions in efforts to reduce maternal mortality

Press coverage

International conference on health finance – The Shillong Times, 9 March 2019

The US capital was the setting for three days of meetings and events to mark UHC Day and the release of ‘What’s In, What’s Out: Designing Benefits for Universal Health Coverage’.

IDSI’s time in DC kicked off with a Global Health Initiatives meeting attended by representatives from the Gates Foundation, World Bank, Givewell, the Center for Global Development (CGD), PRICELESS South Africa, the UK Department for International Development (DFID), Clinton Health Access Initiative (CHAI), Japan International Cooperation Agency (JICA), the Joint Learning Network (JLN), Tufts Medical, Disease Control Priorities (DCP), the Health Intervention and Technology Assessment Program (HITAP), the Norwegian Institute of Public Health (NIPH) and Gavi the Vaccine Alliance.

During the meeting iDSI, CHAI, JLN, NIPH and Tufts Medical Centre showcased their initiatives and the concentration of their work including their successes, focus countries and potential future opportunities.

Amanda Glassman

Attendees then heard from Global Development Funders’ representatives: David Wilson from the Gates Foundation, Julia Watson from DFID, James Snowden from GiveWell, Adrien de Chaisemartin from Gavi, Naina Ahluwalia and Somil Nagpal from World Bank and Yosuke Kobayashi from JICA; with all agreeing each partner group is carrying out valuable efforts in the bid to expand and improve healthcare globally.

Tuesday 12 December was the celebration of UHC Day around the world. A sold-out event at the CGD offices saw presentations from iDSI Director Professor Kalipso Chalkidou, CGD Chief Operating Officer Amanda Glassman, Professor Karen Hofman from PRICELESS, Waranya Rattanavipapong from HITAP, iDSI Board chair Professor Tony Culyer and a keynote speech by Dr Mark McClellan.

Copies of ‘What’s In, What’s Out’ were available for attendees to take away and Amanda Glassman explained how the creation of an explicit health benefits plan is an essential element in creating a sustainable system of UHC. With limited healthcare budgets comes tough decisions for policymakers, along with the many facets of governance, institutions, methods, political economy and ethics that are needed to decide what’s in and what’s out in a way that is fair, evidence-based, and sustainable over time.

Dr Mark McClellan

At the heart of Dr Mark McClellan’s keynote address was opportunities for greater value for healthcare spending – specifically, the ‘accountable care’ model, which sees providers held jointly accountable for the cost and quality of care for a defined population of patients.

Dr McClellan, a doctor and economist, said: “There is more healthcare can do than ever before, however this means rising costs in healthcare. The value of healthcare can be improved by developing and implementing evidence-based policy solutions.”

The importance of sharing data and creating interoperability to understand health outcomes within an accountable care system was also put forward by Dr McClellan, who provided Nepal as an example of success in utilising remote personal health tools, telemedicine and lower-cost sites of care: “In Nepal a simple process of patients’ texting in information can result in a visit to their homes by community care workers and a potential prescription of antibiotics. Investment in these modest but effective interventions can also gather useful metrics in the form of electronic health records. We need to move from ‘siloed’ data to data that provides intelligence about our populations.”

Waranya Rattanavipapong

HITAP’s Waranya Rattanavipapong presented on building research capacity for UHC in Southeast Asia and told of how analysis by HITAP revealed Indonesia could save 90% of its insulin budget. Waranya said: “Indonesia has a current budget of $18 million per year for insulin. Tens of millions more than necessary is being spent on modern insulins to treat diabetes despite evidence cheaper products work just as well. Our analysis revealed switching from insulin analogue to human insulin and negotiating to Thai prices ($2 for human insulin and $9 for insulin analogue, compared to $20 for human insulin and $22 for insulin analogue in Indonesia) could save 90% of the budget.”

Professor Karen Hofman detailed the strides South Africa has taken towards promoting the health of the population by passing a bill to implement a tax on sugar-sweetened beverages. Professor Hofman, who proudly sported an ‘I am #sweetenough’ t-shirt supporting the sugar tax, focused on fiscal levers in South Africa and the positive impact they have had in the past: “After the increase in the excise tax on cigarettes, sales reduced between 1993-2009 by one third and per capita consumption decreased by 50%. With 25% of teenage girls in rural areas overweight in South Africa, the time is now for translating evidence on sugar to policy. There will inevitably be push-back from various sources but the passing of the bill, which will be implemented in April 2018, is a powerful step forward.”

Professor Karen Hofman

Professor Tony Culyer rounded up the event and took to the stage to emphasise iDSI’s objectives to help low- and middle-income countries to transition from aid, develop skills to spend smarter and to increase access to quality healthcare so they can achieve UHC: “Our aim is to give LMICs capacity to produce policies that will have an impact of health. We wish to leave behind an endowment of expertise for LMICs to build better worlds for themselves.”

A recording of the ‘Better Decisions, Better Health: Practical Experiences Supporting UHC from around the World’ event is available on the CGD website (1 hour 32 minutes).

UHC Day, commemorated each 12 December, is the anniversary of the first unanimous United Nations resolution calling for countries to provide affordable, quality healthcare to every person, everywhere. The United Nations Sustainable Development Goals, that all UN Member States have agreed to, try to achieve UHC by 2030. This includes financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

Professor Tony Culyer

Read the blog here.

Seminar resources can be found here.

The book What’s In, What’s Out: Designing Benefits for Universal Health Coverage is due out in the summer.