With HTA gaining ground as a tool for priority-setting globally, it comes as no surprise that countries are trying to find ways to adapt HTA to their particular healthcare system and context. Such was the case the HITAP team found when we went to India for a national level economic evaluation for healthcare workshop and symposium from November 30th to December 3rd, 2015, in Chandigarh, a city located near Delhi. Lecturers included Dr. Shankar Prinja from the Post Graduate Institute of Medical Education and Research (PGIMER) and Dr. Stephen Jan, the head of the Health Economics Department at Sydney University, and Mr. Blake Angell, a PhD student in health economics, at Sydney University. Organized by the School of Public Health, PGIMER, Chandigarh, and the Public Health Foundation of India (PHFI), New Delhi, as part of a USAID funded health financing project, the HITAP team (with support from the iDSI) assisted the lecturers in a highly technical workshop that was attended by thirty four participants, with the majority of them coming from an academic or research background. Our overall impression from this experience was that HTA should be conducted on a state level and that several actors play a role in HTA use in the country.
Public health agencies such as HITAP and NICE are geared towards implementation of HTA within a UHC system in Thailand and the United Kingdom, respectively, where healthcare is provided through a centralized system. Our research has shown that in India, unlike these two countries, public health falls under the purview of states and not the national government as set out in its Constitution.[1] This means that the 29 states and 7 union territories have their own health policies that cater to their needs. Data suggests that there are differences in basic health outcomes such as life expectancy and infant mortality across states[2] motivating policy makers to take a national level approach. In this context, the National Health Mission (NHM), originally launched to serve rural areas only, works with state level agencies to strengthen their capacity and health systems through a cost sharing mechanism. Administered by the Ministry of Health and Family Welfare (MoHFW), it is supported by the National Institute of Health and Family Welfare (NIHFW), an autonomous institution under the Ministry that is concerned with training on public health as well as serving as a think tank, and the National Health Systems Resource Centre (NHSRC), which provides technical support to both central and state agencies.[3] In addition, the Ministry’s Department of Health Research (DHR) oversees the Indian Council of Medical Research (ICMR) which is responsible for coordinating biomedical research in the country.
The role of HTA in setting priorities for healthcare expenditure is still evolving in India. In 2013, the DHR decided to establish the Medical Technologies Assessment Board (MTAB) which would be responsible for determining the cost effectiveness of health interventions[4]. While ICMR, also under the DHR, has advertised positions for the new body[5], the MTAB does not appear to have taken form yet (per information available online). Even as conducting cost effectiveness studies is in the mandate of MTAB, the division of Healthcare Technology and Innovations of the NHSRC also describes conducting HTA as one of its responsibilities and conducts a workshop on HTA every six months[6]. Further, this division is a member of the INAHTA, which is an international network of HTA agencies. Organizationally, the NHSRC is under the NHM, which is one of the Departments of Health and Family Welfare of the MoHFW whereas the MTAB is under the Department of Health Research (DHR). Based on information available, it is not clear what the division of labour or the roles and responsibilities are or will be with regards to HTA in India and this is an area that could be clarified through discussions with stakeholders or with additional research.
During the workshop, it emerged that Tamil Nadu, one of the states, has made progress in providing health services to its citizens and has performed well on health indicators among major states in the country[7]. The Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS) is a generous health insurance package for families with an annual income less than INR 72,000. In what resembles a benefits package, the state government has developed a list of procedures and services at empanelled hospitals that can be availed as part of this scheme. Although not ‘universal’ in nature, the state seems to have other health schemes in place as well including the Tamil Nadu Health Systems Project (TNHSP) which works towards strengthening services for the poor and vulnerable. Given that Tamil Nadu is relatively advanced in managing its healthcare system, a detailed study on the lessons learned from its experience may be worth exploring.
In India, the union government does not have a direct line of command and communication with providers; as such, implementing UHC is infeasible. Despite this, HTA may be implemented without tying it to a UHC system. While some states like Tamil Nadu have implemented UHC type programs, other states have begun to consider programs that provide healthcare to a majority of the population. Even states that do not have some form of universal health coverage will need to allocate resources efficiently with the programs they choose to implement. These variations as well as the presence of national level health programs like the NHM necessitate having HTA at both the national and state level.
An HTA program established at the national level can provide a coordination role and assist institutions with HTA capacity spread across the country. This could prove useful in the initial stages of HTA development. Conducting a few ex-ante HTA studies prior to adopting policies and/or allocate resources of anticipated results would be instrumental in demonstrating the usefulness of HTA and generate interest nationally. In terms of the use of these studies, the products that the national HTA program develops could be used at the national level (public policy and screening program) and by state governments (comprehensive package for particular health problems or diseases) so that they can make relevant decisions.
Acting as a Secretariat to the HTA units in each state, the national HTA program could then establish standards for research as well as process guidelines for conducting HTA to ensure that the results are rigorous academically and acceptable to stakeholders at all levels. This includes instituting a process of topic nomination and selection, assessment, appraisal, linking research to policy, and communication of results to other stakeholders. Each state may have its own health issues, but a standardized process will provide a framework for which the high variability in health policies may be situated without compromising health outcomes. In addition to this role, the Secretariat may be able to coordinate the use of the states’ research in price negotiations should there be an overlap in their needs, because the combined volume of medicines needed for several states may be used as a bargaining tool. States could potentially pool their resources to afford even high-cost technologies or medicines if purchased.
During the workshop, we found that participants were very enthusiastic, had a strong background in research and showed good understanding of the concepts. It is likely that there are many others with similar capacity throughout the country – it is very impressive and encouraging in terms of the current capacity for economic evaluation in India. However, this is not the only type of capacity that should be developed. The participants mentioned that decision makers often focus on immediate results, which is consistent with our observations from other countries with a similar context. In this case, an important aspect of this process is the policy makers’ understanding of HTA. Advocacy may be necessary to garner the interest and investment of policy makers in HTA. It is vital that their capacity to translate the results, even on a superficial level, be developed alongside the capacity of the researchers to conduct the research. The demand of the populace for healthcare could be answered through a justifiable process such as that outlined above. Researchers must be able to communicate these results to the policy makers in such terms. In addition to this, communicating the results to the public and the media would be useful as well.
Note: This blog reflects information gathered during the workshop, including interactions with participants, personal communication, and review of online resources in addition to the team’s first impressions of the situation in the country. These analyses are not based on any scientific evidence and our views may change as we continue to engage further with our colleagues in India and learn more about the public health landscape in the country.
[1] Constitution of India, Schedule VII: List II. Link: http://lawmin.nic.in/olwing/coi/coi-english/Const.Pock%202Pg.Rom8Fsss(35).pdf
See also “Political and Administrative Setup of Union Territories in India”, Sudhir Kumar, 1991
[2] National Health Profile 2015. Link: http://www.thehinducentre.com/multimedia/archive/02557/National_Health_Pr_2557764a.pdf
[3] NHM Implementation Framework 2012-17. Link: http://nrhm.gov.in/images/pdf/NHM/NRH_Framework_for_Implementation__08-01-2014_.pdf
[4] “Medical Technology Assessment Board to Be Set Up”, 10 December 2013. Link: http://pib.nic.in/newsite/PrintRelease.aspx?relid=101329
[5] “Indian Council of Medical Research (ICMR) Recruitment: Apply by Feb 21”, Link: http://indiatoday.intoday.in/education/story/indian-council-of-medical-research-icmr-recruitment/1/418511.html
[6] NHSRC webpage. Links: http://www.nhsrcindia.org/index.php?option=com_content&view=article&id=173&Itemid=642 & INAHTA webpage: http://www.inahta.org/our-members/members/hct-nhsrc/
[7] Table 9.1: Selected Indicators of Human Development for Major States, Economic Survey of India 2014-15 Statistical Appendix. Link: http://indiabudget.nic.in/es2014-15/estat1.pdf