Progressing Towards a More Effective Health Technology Assessment (HTA) in India

The Context
World Health organization (WHO) defines Health Technology Assessment (HTA) as “the systematic evaluation of properties, effects and/or impacts of health technology”.  It is a method of evidence generation to analyze “value for money” of a healthcare program. HTA method is used in several countries across the world in policy and decision making to enable more outcome oriented utilization of health resources. The technology assessments are conducted by interdisciplinary groups drawing from various disciplines of clinical, epidemiological, economics and other methodologies.

Evidence suggests that high quality affordable and accessible healthcare can be achieved through rational allocation of resources (1). USA, UK and several other European countries have well established evidence based policy making strategies embedded into their public healthcare services. Countries in South East Asia Region (SEAR) like India, Taiwan, Malaysia and Thailand also have institutionalized HTA to provide Universal Health coverage (UHC) including priority-setting, procurement strategies, setting appropriate financing modules and benefits packages, clinical practice guidelines and protocols for public health programs (2,3).

HTA is used to identify appropriate emergency and essential care package in countries with fewer healthcare assets, whereas, in a country with maximal healthcare coverage, HTA is used to analyze the cost-effectiveness and cost-benefit assessment of newer and/or additional technologies and initiatives. The WHO estimates that 35% of 174 countries have a health technology assessment policy as part of their national health program while 12% have an independent document (Fig 1).

Methods for Global Spread of HTA

Several associations and organizations have been established across the globe to promote, facilitate and disseminate HTA practices. International Network of Agencies for Health Technology Assessment (INAHTA) established in 1993, comprises of 52 member agencies from 32 countries across the globe including Division of Healthcare Technology, National Health Systems Resource Centre (HCT-NHSRC), India (Fig. 2). All members are non-profit organizations producing HTA and are linked to regional or national governments.

Fig 1: Status of HTA in different economies

Note: Data for India was not available with WHO.

Source: http://www.who.int/gho/health_technologies/medical_devices/policy/en/ accessed on 6 July 2016

International Society for Pharmacoeconomics and Outcomes Research (ISPOR) is another organization with a wide base of members around the world. Health Technology Assessment Network of the Americas (RedETSA), European Network for Health Technology Assessment (EUnetHTA) and HTAsiaLink on the other hand aid HTA processes in Americas, European and Asian countries respectively. NICE, UK is among the most highly transparent, successful and visible HTA organizations among others. Recently, HITAP, Thailand and SIGNET, Singapore have emerged as effective HTA organizations.

Fig 2: Member agencies of INAHTA around the world.

Source: INAHTA

India Chapter - NHSRC

In India, NHSRC was established as an apex body under the National Rural Health Mission (NRHM) in 2007 with a mandate to assist in policy and strategy development, technical assistance to states and capacity building of Ministry of Health and Family Welfare (MoHFW) at the center and in the states (www.nhsrcindia.org). HCT is one of the eight divisions of NHSRC and is specifically involved in producing HTA.

HCT supports procurement of medical devices under National Health Mission (NHM), identification, assessment and adoption of innovations, equipment maintenance across all levels of public health facilities, provide health technology systems strengthening and technical support for improving cost effective healthcare solutions by government. Further, HCT is involved in identifying and disseminating best public health practices followed in different States of India.

One of the most important mandates of HCT is capacity building for HTA which is carried out through an annual fellowship program. In addition, HCT serves as a WHO collaborating center for priority medical devices and health technology policy, thus playing an active role in providing HTA assistance to national and state governments. Some of the major outcomes of HTA in 2014-15 include formulation of technical specifications for neo-natal and pediatric intensive care units, Rashtriya Bal Suraksha karyakram (RBSK), laboratory and radiology for all public health facilities, assessment of eight technologies including the dialysis program announced in the budget and formulation of guidelines for free essential diagnostics initiative.

Scope for HTA in India

Despite significant efforts, India lags behind in fully utilizing the potential of adopting HTA. The quality of evidence generated for economic evaluation of relevant healthcare initiatives and programs is inadequate for policy formulation (4). The study also points out the urgent need to improve capacity of researchers to undertake quality health economics research and also sensitizing policy makers to the use of evidence in policy making (4).

At present, HTA research and review activities are limited to a handful of medical colleges (Such as PGIMER, Chandigarh, CMC, Vellore, and MAMC, New Delhi) and private organizations (IMS health solutions, WISH Foundation etc., ). The impact of HTA produced by these organizations on health policy outcomes and budget allocation is currently very limited. Measures are needed to address this aspect.

A focused effort to produce well trained, India-focused health economists and health policy specialists merits serious consideration. Another critical aspect of HTA is lack of significant outcomes research.  A study on impact assessment of HTA revealed glaring lack of depth in research, especially its effect on health budget, cost savings, healthcare quality and societal health outcomes (5). Industry-Academia collaborations should be encouraged to reap the benefits of HTA in large-scale.

In addition, Medical institutes, hospitals and healthcare related industry should actively participate and promote HTA. The Indian health sector policy makers and other stakeholders need to focus not only on building competencies, but also to ensure that HTA outcomes are regularly monitored and assessed for positive impact to suggest corrective actions dynamically. This process will enable more health outcome oriented allocation or reallocation of resources and improve the absorption capacity of the current healthcare systems.

References:

  1. World Health Organization, November meeting, 2015.
  2. Jirawattanapisal et al., Evidence-Based Decision-Making in Asia-Pacific with Rapidly Changing Health-Care Systems: Thailand, South Korea, and Taiwan, Value Health2009 Nov-Dec;12 Suppl 3:S4-11,
  3. U Thatte et al., Evidence-Based Decision on Medical Technologies in Asia Pacific: Experiences from India, Malaysia, Philippines, and Pakistan, Value Health, 2009 Nov-Dec;12 Suppl 3:S18-25.
  4. Prinja et al., A Systematic review of the state of economic evaluation for Health care in India,  Applied Health Economics Health Policy, 2015 Dec;13(6):595-613.
  5. O’Donnell et al., Health Technology Assessment: lessons Learned from Around the World-An Overview, Value Health, 2009 Nov-Dec; 12 Suppl 2:S1-5.

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