How the Adoption of Health Technology Assessment Is Changing the Healthcare Landscape of India

HTA QUARTERLY | SPRING 2020

How the Adoption of Health Technology Assessment Is Changing the Healthcare Landscape of India

By David Campbell, PharmD, MS; Chris Yost, PharmD; Vishwas Agashe, PhD

India is one of the fastest-growing economies in the world, with healthcare becoming one of its largest sectors in terms of both revenue and employment. India’s healthcare sector continues to grow at a rapid pace, largely driven by rising incomes, increased access to insurance, and significant advances in its healthcare infrastructure. Despite substantial growth, India’s healthcare sector still has much room for improvement. Notably, government funding has remained low on a per capita basis, and patients struggle with overly high out-of-pocket (OOP) costs, estimated to be as much as 65%–90%.

In an effort to raise healthcare standards and equality for the population of over 1.3 billion people, the Indian government has committed to achieving universal health coverage (UHC) for the nation. Toward that goal, the government of India passed regulation to create the largest health insurance scheme in the world, the Ayushman Bharat – Pradhan Mantri Jan Aarogya Yojana (AB-PMJAY, aka “Modicare”). To achieve UHC under the AB-PMJAY, the government recognizes the need to be diligent in setting priorities and efficiently utilizing limited resources.

A new institution, Health Technology Assessment in India (HTAIn), will facilitate transparent and evidence-based decision making.

HTAIn, previously known as the Medical Technology Assessment Board (MTAB), was established in January 2017 under the Department of Health Research (DHR), part of the Ministry of Health and Family Welfare (MoHFW), by the government of India. The new HTA institution is the central agency to gather and generate evidence related to the clinical effectiveness, cost-effectiveness, and safety of medicines, devices, and health programs.

HTAIn was established with the following mandates:

To maximize health in the population, reducing OOP expenditure and inequity
To support the process of decision making in healthcare at the Central and State policy level by providing reliable information based on scientific evidence
To develop systems and mechanisms to assess new and existing health technologies through a transparent and inclusive process
To appraise health interventions and technologies based on available data for resource use, cost, clinical effectiveness, and safety
To collect and analyze evidence in a systematic and reproducible way and ensure its accessibility and usefulness to inform health policy
To disseminate research findings and resulting policy decisions to educate and empower the public to make better-informed decisions in seeking healthcare

Health technology assessments are a collaborative effort between HTAIn, technical partners (TPs), and regional resource hubs (RRHs) across India.

HTAIn consists of 3 core bodies: the HTAIn Secretariat, HTAIn Technical Appraisal Committee (TAC), and HTAIn Board. In this structure, HTA study requests coming from any government healthcare provider or agency involved in healthcare (termed a User Department) are first processed by experts in the HTAIn Secretariat.

Figure of HTAIn Structure

To efficiently use resources and maximize impact, topic selection and prioritization are completed by the HTAIn Secretariat.

Relevant topics are likely to have all of the following characteristics:

Address an important unmet need
Result in improved treatment, screening pathway, or prevention scheme with HTA study
Have existing high-quality evidence for the effectiveness of the intervention
Have impact in measurable terms such as survival, quality of life, or events avoided

If a study request is selected for advancement, the HTAIn Secretariat reaches out to TPs and RRHs to develop the study proposal and present the study to TAC members. Research topics approved by TAC members are shared with all stakeholders who may be impacted by the assessment, including manufacturers, providers, insurers, and healthcare administrators. The topics are prioritized and allocated to an appropriate TP or RRH to conduct the HTA study.

After the research is complete, outcomes of the study are presented to TAC members and stakeholders for review and approval. In the final stage, study results are presented to the HTAIn Board, and, once approved by the Board, a policy brief and HTA outcome report are sent to the User Department that submitted the original request.

HTAIn is off to a slow start.

Through the first 2 years since HTAIn was established, only a handful of HTAs have been completed. Assessment topics have covered a broad range of technologies and processes, including safety-engineered syringes, intraocular lenses for cataract surgery, cervical cancer screening strategies, long-acting reversible contraceptives, and hemoglobin meters for anemia screening. The limited number of completed studies has raised concerns that the new resources allocated for HTA research are not being adequately utilized.

– Health Department officer

“It seems that we missed the bus for HTA. It was in last June that AMCHSS [Achutha Menon Centre for Health Science Studies] was selected as the regional resource center for HTAIn. But even after a year, the state Health Department couldn’t propose a single study under the initiative.”

While this situation may be related to governmental inertia in a very large and complex country with meager resources, it likely also reflects the paucity of trained manpower, experience, and awareness among stakeholders needed for conducting HTA studies at pace.

Capacity building has been a priority for HTAIn to educate and promote stakeholders on the value and methods of value-based technology assessments.

Part of the challenge of reforming the healthcare system through HTA is a foundational lack of familiarity with the key principles of HTA and evidence-based resource allocation among healthcare decision makers. To overcome these barriers, HTAIn has been actively educating stakeholders through workshops and conferences, which included topics such as HTA basics, proposal writing, systematic reviews, and meta-analyses, among others. These workshops and outreach efforts exemplify the organization’s commitment to developing and strengthening the national capacity for HTA that builds on established best practices, information exchange, and collaborative approaches. In addition to capacity, a recent commentary by Swami and Srivastava cites biased decision making, the current regulatory framework, and lack of data as the 4 major challenges to the successful adaptation and implementation of HTA in India. The influence of political and religious values in healthcare decision making and the fear of leaders to lose authority to health economic researchers may create barriers to HTA adoption. The regulatory framework also presents unique challenges as HTAIn tries to align with the uncoordinated, unstructured, and diverse needs of India’s constituent states. Lastly, electronic healthcare data are currently limited, and systems will need to be generated to better understand health outcomes, quality, and cost for HTA appraisals.

The full impact of HTA in India has not been realized.

India has made significant policy and systemic changes to its healthcare system to promote basic universal health coverage and more efficient use of resources with the enactment of AB-PMJAY and the establishment of HTAIn. HTA can be an important tool in achieving these lofty aspirations, and, over the past 2 years, substantial investment has been made in HTA education and promotion. Despite a slow start, manufacturers should monitor HTAIn activity and prepare for the application of HTA to many more technologies in the coming years as the capacity-building and awareness efforts advance and reach critical mass.

The article should be referenced as follows:

Campbell D, Yost C, Agashe V. Emerging market India: how the adoption of health technology assessment is changing the healthcare landscape of India. HTA Quarterly. Spring 2020. https://www.xcenda.com/insights/htaq-spring-2020-emerging-market-india-hta.

Sources

Dabak SV, Pilasant S, Mehndiratta A, et al. Budgeting for a billion: applying health technology assessment (HTA) for universal health coverage in India. Health Res Policy Syst. 2018 Nov 29;16(1):115.
Health Technology Assessment in India: A Manual. Department of Health Research Ministry of Health and Family Welfare, Government of India. https://htain.icmr.org.in/images/pdf/htain manual.pdf.
Health Technology Assessment in India. Department of Health Research. http://htain.icmr.org.in/.
Jain S, Chauhan A, Rajsekar K. A Compendium of Health Technology Assessment in India 2017–18. HTAIn Secretariat, Department of Health Research, Ministry of Health and Family Welfare, Government of India. 2019.
Kumar D. Kerala Health Dept misses the tech assessment bus. The New Indian Express. July 31, 2019. https://www.newindianexpress.com/cities/thiruvananthapuram/2019/jul/31/kerala-health-dept-misses-the-tech-assessment-bus-2011762.html.
Indian Healthcare Industry Analysis. India Brand Equity Foundation. https://www.ibef.org/industry/healthcare-presentation.
Swami S, Srivastava T. Role of culture, values, and politics in the implementation of health technology assessment in India: a commentary. Value Health. 2020 Jan;23(1):39-42.