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- Evidence-Based Practice
- Global Health
- Health Planning
- Health Care Quality, Access, and Evaluation
- Health Care Economics and Organizations
Health technology assessment (HTA) is a multidisciplinary process that uses explicit methods to determine the value of a health technology at different points in its lifecycle.1 ,2 Its aim is to promote equitable, efficient, high-quality health systems by informing decision-making. Founded in 2017 with the mission to collate and, where needed, generate evidence related to the clinical effectiveness, cost-effectiveness and safety of medicines, devices and health programmes using HTA,3 Health Technology Assessment in India (HTAIn) has since established a network of 18 Regional Resource Centres (RRC) across 13 Indian states and has achieved fundamental milestones to standardise and strengthen HTA methods and processes and embed HTA evidence in decision making (see figure 1).
For all the rapid progress, there is still room for HTAIn to realise its full potential as a central piece of the Indian HTA ecosystem. We discuss three potential policy objectives for HTAIn going forward and three strategies for achieving them.
Where to next? Three policy objectives for HTAIn’s future
Creating an explicit institutional mandate for HTAIn
HTA can inform a range of health policy decisions, from whether to fund a given health technology with public funding (as is currently the case with HTAIn in India) to price negotiations, improving quality of care and developing costed programme budgets—all potentially crucial theoretical and empirical support for achieving the Government of India’s stated policy objectives of equity, affordability and accessibility.4 5 From its current position, HTAIn can increase its impact by expanding the range of resource allocation decisions its work informs, while being clear, intentional and strategic about what these decisions are to set realistic expectations of what HTA can achieve.
An ideal institutional mandate for HTAIn would mean that key budget holders at the state level, like the State Medical Services Corporation, and the national level, like the National Health Mission, the national health insurance scheme (PM-JAY), the infrastructure development programme (PM-ABHIM) or the National Pharmaceutical Pricing Authority (NPPA), have an evident commitment to the HTA process. This can be achieved, for example, by incorporating explicitly the use of HTA in their policies, regulations and procedures, developing written agreements between HTAIn and budget holders on the role of HTAIn, and continue allocating public funds to HTAIn and the various agencies doing the groundwork.
Strengthening the legitimacy of HTA-informed decisions
Given that health is a state matter in India, national and state-level stakeholders need to be actively involved in HTAIn governance6 to increase its relevance and credibility. For example, by fostering transparency about processes and methods underlying HTA-informed decisions, meaningfully engaging stakeholders throughout the HTA process, and putting in place mechanisms for revising decisions in light of new information through an explicit appeal mechanism. HTAIn’s topic selection process, currently undergoing changes, provides an opportunity for ensuring that ‘users’ of HTA are involved right from the beginning of each assessment up to dissemination, with a view to enhancing professional and public understanding of the HTA process.
Moreover, the multidisciplinary nature of the HTA approach and the pluralistic nature of the Indian health system, with dominating private financing and private provision, means that HTAIn will need to consider when and how to engage private sector stakeholders—healthcare providers, health insurers the industry—in the HTA process.
Building the institutional capacity of HTAIn
As more complex health technologies become available and the health system becomes more complex, HTAIn must also grow in order to inform an increasing number of decision needs with timely and high-quality evidence. This entails building administrative capacities, so that HTAIn has the resources and capabilities to manage its growing network and increasing volume of work that is delivered at a high quality. It also entails enhancing its technical capacity, especially through research, so that HTAIn can develop and maintain its technical capabilities for delivering reputable professional assessments within structured, institutionalised HTA training programmes for all interested parties.
How to get there? Three strategies for achieving HTAIn’s policy objectives
HTAIn’s growth would be most effective if it maintains focus on policy relevance and good governance principles—transparency, inclusivity, quality, consistency, accountability and revisability—with a view to designing and operating fair, consistent, transparent, deliberative, appealable processes that produce high-quality deliverables.
This type of growth requires strong, high-level leadership. HTAIn’s governing body can lead articulating, planning and disseminating its vision for growth, streamlining internal policies and processes and advocating that major budget holding institutions in the Indian health system become HTA users through formal agreements with HTAIn. Additional staff and operational budget are required for developing and operating a systematic and comprehensive topic selection process that prioritises complex, high impact decisions of major budget holders; for managing stakeholders in alignment with HTAIn’s strategic objectives; for designing, implementing and monitoring standardised processes for managing HTAIn’s competencies and production of deliverables; and for developing processes to manage the performance of RRCs and technical partners (eg, ‘onboarding’, routine communication, capacity assessment capacity development).
HTAIn would position itself as a developer, user and disseminator of state-of-the art methods, processes, practices and standards, given its success to date in producing methodological tools and the need for developing further awareness, legitimacy, credibility and capacity towards evidence-informed decision-making processes in the country and beyond. Systematic, competency-based training curricula and assessments will be required to build capability throughout the HTA ecosystem in the country. The Government of India’s Mission Karmayogi programme, a major national human resources initiative, provides a useful framework that can be applied.
An area requiring particular attention given the previous years’ experience is attracting and motivating technical staff: explicit and appropriate staff retention policies applied across the network of RRCs, and technical partners can enable attracting, motivating, retaining and developing technical talent. Other examples of concrete actions include the setting of standards for technical products and links with quality assurance processes in the healthcare delivery system based on a HTA Quality Appraisal Checklist;7 promoting collaborations between RRCs while awarding technical work and considering the use of external reviewers. Continued investment in data infrastructure for decision-making can ensure that data such as health service costs are revised and updated regularly.
HTAIn would work with key decision-makers and strategic stakeholders at national and state levels in India to inform high impact policy decisions and practices that deliver on India’s health system goals. Conversely, HTAIn’s processes would be adequately rapid and responsive to match these stakeholders’ expectations (eg, by developing and testing adaptive HTA approaches8) and that any weaknesses in such processes would be anticipated, identified and resolved collaboratively with said stakeholders.
Policy statements from key budget holders in India on their willingness to use HTA while making decisions and formal mechanisms to link HTA to policy making would enable HTAIn to have a transformative influence over healthcare resource allocation. A recent Return on Investment study demonstrated that while the return of HTAIn is good, it could be as high as 71:1 with full implementation of HTA recommendations.9 Development of a fit for purpose stakeholder engagement framework and communication strategy that makes explicit who the stakeholders are, how they are identified and approached, how they are engaged (eg, information gathering, consultation or participation), how their contributions are taken into account and, most importantly, with what resources and capabilities will HTAIn manage this entire process, will increase HTAIn’s reach and uptake of its outputs.
Patient consent for publication
The authors are grateful to the editor and three anonymous reviewers for their comments.
Contributors JG, AG and AM wrote the first draft. All authors reviewed and contributed to the manuscript.
Funding Bill and Melinda Gates Foundation, Grant ID: INV-003239.
Competing interests Dr Shankar Prinja and Dr Sitanshu Sekhar Kar are Principal Investigators of HTAIn Regional Resource Centers.
Provenance and peer review Commissioned; externally peer reviewed.