The Role of Health Economics and Health Technology Assessment in EvidenceBased Healthcare Decision-Making in India

Healthcare decision-making in India

Healthcare decision-making in India is guided by the National Health Policy 2017, while the intricacies and responsibility of specific decision-making, dissemination and implementation of the decisions fall on the shoulders of the various secretariats in Ministry of Health and Family Welfare, the NITI Aayog and the State, District and Municipal Health departments. Healthcare decisionmaking in India has traditionally been guided by constitution of expert committees and five-year plans by the erstwhile planning commission. India’s health policy and program have resulted in a steady improvement in health indicators like life expectancy, infant and maternal mortality, malnutrition;¹ yet we have a long way to go in terms of achieving the Sustainable Development Goals.² India despite its progress in health continues to grapple with rising burden of non-communicable as well as communicable diseases, a fragmented health system with poor accountability and regulation of the public as well as the health sectors, low investment in health and wide health disparities and inequity across states and districts and vulnerable groups.³ To tackle these umpteen issues, India needs to not only re-evaluate the healthcare decision-making mechanisms, but also needs to focus on implementation of evidence-based policies.

Health Economics and Health Technology Assessment (HTA)

Health economics is an applied science that uses the principles, theories and concepts of economics (like theories of production, efficiency, disparities, competition, and regulation) to help decision makers achieve the best possible health outcomes, given the limited resources. This is achieved by systematic and rigorous analysis and examination of problems to answer health decision-making questions.⁴ Health economics has a central concept of cost-effectiveness, where researchers answer the question: “Of the two or more alternatives, which one produces a higher health outcome at a given cost.” For example, between two anti-diabetic medications, the question would be: “For medications ‘A’ and ‘B’, what is the cost per patient for achieving the target Glycemic control?” The tools used to answer such cost-effectiveness questions are grouped under the broad term of “Economic Evaluation”.⁵ Economic evaluation explores the efficiency of the alternatives in terms of pre-determined outputs given the inputs (resources) available in the system. Simply put, it evaluates the costs and consequences of a health intervention. The evaluation can be designed and executed based on different perspectives depending on who is conducting the economic evaluation, for example, governments, insurance companies, medical institutions or other payers.⁶ Economic evaluations compare costs against the different health outcomes and are classified based on the type of health outcome as cost-effectiveness, cost-minimization, cost-benefit and cost-utility analysis. Economic evaluations can be done using randomized clinical trials as a vehicle or they can be conducted using existing literature into decision-analytical-models.⁷

HTA deals with the systemic, economic and equityrelated consequences of introducing health technologies into a health system. It is hence a multidisciplinary activity which systematically evaluates the overall effects of a health technology.⁸ HTA uses explicit analytical frameworks and draws on clinical, epidemiological, health economic and other information and methodologies. Economic evaluations are an integral part of HTA. However, apart from cost-effectiveness, HTA considers safety, clinical effectiveness, budget impact, organizational impact, equity and ethical considerations, feasibility and acceptability of new health technologies (a health technology includes a medicine, an equipment, a device, a clinical or surgical intervention or a health program). According to the World Health Organization (WHO), HTA, as a function needs to be embedded within ministries of Health to support reimbursement decisions. Countries with a single payer system like Canada, Australia, United Kingdom, Germany etc. have robust HTA mechanisms in place.⁹

Role of HTA in Health Policy in India

HTA may not be the answer to all healthcare decisionmaking in India. However, it is instrumental in deciding the prioritization of health intervention; for example, with a limited budget, investing in which health intervention will give a maximum health benefit to the population of India. In a low-middle income country like India where demand for healthcare far surpasses the supply, allocation and reimbursement decisions can be supported by HTA. It is important to note that replicating developed countries HTA frameworks in India may not work, as majority of the Indian population seek care from a largely unregulated private health sector with out-of-pocket payments being the dominant mode of healthcare financing. This is unlike the single-payer system countries where healthcare services are regulated and are paid for by public tax-payer funds. WHO recommends institutionalizing HTA mechanisms by taking into account the legal environment in the country and establishing a strong governance, operational structure with robust monitoring and evaluation frameworks.⁹ For example, it is important that the HTA mechanism has a stable budget and has trained staff who not only carry out the HTA but are also able to influence policy uptake of the HTA recommendations. India has started its journey in HTA institutionalization through the HTAIn (Health Technology Assessment India) - a structure created within the Department of Health Research (DHR), Ministry of Health and Family Welfare (MoHFW), India in 2017. The HTAIn Secretariat started by training, capacity building and partnering with international expert organizations in HTA and moved forward to creating regional resource hubs for carrying out HTA work. HTAIn has spearheaded the creation of healthcare cost and Quality of Life databases for India. These studies are ongoing and the data that is being generated is vital to the conduct of HTAs as the decisionanalytical model is only as good as the data that is fed into it. To take HTA forward in India, continued political commitment, expansion of HTA capacity, integration into the decision-making mechanisms, priority setting during resource allocation and budgeting is vital.¹⁰

Roadblocks and possible solutions for HTA in healthcare decision-making in India

A critical roadblock in this scenario is extremely limited availability of trained HTA experts in India. Only a handful of institutions offer masters courses or formal training in Health Economics in India and the courses available abroad are beyond the monetary reach of most Indians. HTAIn does conduct workshops and trainings for the HTA researchers; however as most researchers are contractual, the turnover is high. Increasing awareness regarding the role of HTA in Healthcare decision-making and creating secure job opportunities could be a possible solution to this roadblock. The second critical roadblock is that Health is a state subject and the HTA recommendations may not trickle down to a majority of states in India despite decisions at the center. Cooperative federalism needs to go beyond political disputes and focus on achieving Universal Health Coverage (UHC) in India.

Overall, HTA is not a magic bullet that can solve all of India’s health problems. Nevertheless, it is a vital link in the chain of events that could lead us to UHC.