The health care system in India
Health services in India are delivered through a complex multi-payer healthcare system, including both the private and public sectors. Most of the rural and poorer population is primarily served by government services in public-funded primary health centres. In contrast, urban and more affluent populations prefer to seek services from private health care providers, and most high-end private hospitals are in cities. The Government of India is taking many bold initiatives to improve how the health system of the country is organised and to ensure services are reaching the most remote places. Ayushman Bharat Pradhan Mantri Jan Aarogya Yojna (AB-PMJAY) is a major initiative, launched in 2018 to support efforts to achieve universal health coverage. Under the AB-PMJAY scheme, there are health benefit packages (HBPs) that target the least well-off 40% of the population by socioeconomic status and cover the cost of hospitalisation, diagnostic tests and follow-up for most health conditions.
Health Technology Assessment India (HTAIn) was established by the Ministry of Health and Family Welfare (MoHFW) in 2017 to foster transparency and evidence-based decision-making in healthcare, with a Sanskrit motto (Sarve Santu Niramaya) that embodies the principle of universal health coverage: “Let All Be Healthy”. HTAIn sits within the Department for Health Research at the MoHFW and has a strong network with universities, more than 28 research institutes of the Indian Council of Medical Research, and other research institutes in and outside India. Since its inception, HTAIn has published guidance documents on its process and methodology, and strengthened HTA capabilities by establishing the National Health System Cost Database, the National Cancer Database for cost and quality of life, and an Indian EQ-5D value set. One of the major contributions of HTAIn has been to support AB-PMJAY in rationalising the HBPs in terms of cost, treatment options and package design by conducting HTA studies, costing studies and developing clinical treatment guidelines, known as Standard Treatment Workflows.
A roadmap for new technologies
Given the complex nature of the health system and multiple providers, it is a daunting task to regulate the usage of health technology in India. HTAIn is a sincere effort to ensure that uptake of health technologies is evidence-based and provides the best value for money. HTAIn provides recommendations for new or ongoing technologies based on a comprehensive analysis of all existing evidence. The analysis includes health technology assessment (HTA), equity considerations, feasibilities, and budget impact analysis for the technology in question by comparing it with other potential alternatives. HTAIn performs studies in response to requests received from user departments, i.e., other departments of the MoHFW or state governments. To cater to the ever-increasing number of requests, HTAIn has developed a pool of talented researchers to conduct these studies by building their capacity through hands-on training and continuous support.
The HTAIn Secretariat allocates the HTA request to the Technical Appraisal Committee (TAC) and a suitable Resource Centre (RC). The Resource Centre develops a study proposal that is presented to the TAC for approval. Following approval, the RC conducts the HTA study and submits the Outcome Report to the Secretariat for TAC approval and subsequently the HTAIn Board for their approval. Multiple rounds of active stakeholder engagement are carried out in every study to ensure that each study provides the most meaningful insights about the health technology in question. Following a final approval by the Board, HTAIn sends its recommendations to the user department.
Current challenges of HTA in India
As a new initiative, HTAIn’s impact can be seen through the >40 studies it has already completed, and the 16 state-level HTAIn Resource Centres established across the country. However, there is a long way to go to fully uncover the potential of HTAIn in revolutionising the health system in India. A key step may be to make HTA recommendations statutory by law. HTAIn is working in this direction and a bill regarding this has already been drafted and shared with stakeholders for consultation. Without statutory binding, decision makers currently decide whether or not to act on HTAIn’s recommendations for modifying an existing policy or launching a new one. On the face of it, this narrows the value of HTA studies to just research studies; nonetheless, so far, many of HTAIn’s studies have been used for policy modifications. One such example is the uptake of safety-engineered syringes instead of single-use syringes in states like Punjab and Telangana.
Next steps for HTAIn
HTAIn is now well established within the Indian healthcare system and has the potential to become a world-class centre for HTA research; however, it now needs to expand its HTA remit beyond just medicine, surgery, and treatment procedures. Interventions related to social determinants of health, such as health promotion activities or interventions targeting the homeless at risk of death due to extreme weather conditions, are equally important for a healthy population in the long run. Having a systems approach towards health will reduce the wastage of resources and will ensure that the issues are viewed as a “whole”. Together with enabling a legal mandate to its recommendations, these potential next steps would further consolidate HTAIn’s impact on healthcare decision-making and support its efforts to realise universal health coverage in India.