|Year : 2016 | Volume
| Issue : 2 | Page : 138-141
Can Health Technology Assessment (HTA) provide a solution to tackle the increasing health-care expenditure in India?
Amit Dang1, BN Vallish2
1 Founder and CEO, MarksMan Healthcare Solutions, Navi Mumbai, Mumbai, Maharashtra, India
2 Assistant Professor, Department of Pharmacology, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
|Date of Web Publication||23-Jun-2016|
Founder and CEO, MarksMan Healthcare Solutions, 1-2, Alfa Garden, Plot No. 26, Sector-14, Kopar Khairane, Navi Mumbai - 400 709, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The private health-care system in India is effective but expensive. Due to the absence of a comprehensive and well-penetrated insurance scheme that caters to the majority of the Indian population, most of the private health care consultations are out-of-pocket (OOP), and this is pushing many people to poverty. In this article, we describe the concept of health technology assessment (HTA), and review its possible role in improving the health-care system in India. We additionally comment on its present status and possible role of its implementation in the Indian context.
Keywords: Catastrophic payments, health insurance, health technology assessment (HTA)
|How to cite this article:|
Dang A, Vallish B N. Can Health Technology Assessment (HTA) provide a solution to tackle the increasing health-care expenditure in India?. Indian J Public Health 2016;60:138-41
|How to cite this URL:|
Dang A, Vallish B N. Can Health Technology Assessment (HTA) provide a solution to tackle the increasing health-care expenditure in India?. Indian J Public Health [serial online] 2016 [cited 2019 Nov 19];60:138-41. Available from: http://www.ijph.in/text.asp?2016/60/2/138/184570
| Introduction|| |
It has been estimated that the private health-care sector in India accounts for 93% of all hospitals, 64% of all beds, 80-85% of all doctors, and nearly 77% of health-care expenditure.  This dominance of the private health-care sector translates to an increasing reliance on out-of-pocket (OOP) expenditure for health-care needs. The OOP spending in India (82.2%) is among the highest in the world, much higher than other similar countries (Thailand: 25%, China: 44%, and Sri Lanka: 55%).  Many families are driven below the poverty line every year by large medical expenses: a term known as "catastrophic payments."  Thus, the need of the hour is to find innovative solutions to the problem of the increasing health-care expenditures in India.
| Potential of Insurance-Funded Health-Care Model in Modifying the Current Medical Expenditure in India|| |
In India, despite the presence of state-sponsored health insurance schemes such as Employees State Insurance Scheme (ESIS, since 1952) and Central Government Health Scheme (CGHS, since 1954), the penetration of health insurance has remained extremely low. Roughly, only one-fourth of the country's population is covered by some sort of a health insurance scheme. 
Even the existing insurance schemes in India are additionally ridden with shortcomings. Most of the health insurance schemes in India cover predominantly inpatient services, so it becomes necessary to stay for a day in the hospital to claim the insurance. While this helps households to cope up with catastrophic health events, the huge share of the OOP expense occurring in outpatient visits continue to burden them. Further, ironically most of the poor and ill populations are left out of such insurance schemes. 
The insurance-funded health-care model, if properly implemented, might have the potential to bring in positive changes in the way health care is delivered in India:
- Diagnostic tests and prescriptions ordered by physicians will have to be scrutinized by the insurance providers for payment approval. As a result, only appropriate diagnostic tests will be ordered, and only appropriate medicines will be prescribed, by qualified practitioners only.
- The onus will be on the pharmaceutical companies to convince the government and insurance companies that their product is indeed different and unique in comparison with the existing ones. The onus will be on these manufacturers to get their products on the "approved" list of the government and insurance agencies. This will virtually abolish the menace of "me-too" drugs.
| Health Technology Assessment: Current Status in India|| |
India is an extremely diverse country, with diverse health-care problems and demands. Introduction of any health-care policy requires adequate assessment of all involved health-care technology, keeping in mind the ethical, societal, cultural, and economic aspects, rather than the clinical effectiveness angle alone. Introduction of various national health programs is continuously increasing the government's role as purchaser and payer of health-care services and technology. Advances in health technology bring improvement in health-care delivery, but are associated with increased economic burden as well. This has led to the concept of health technology assessment (HTA) as an essential tool for cost assessment and expenditure containment.
HTA is a process of critical assessment of various properties of any medical technology used in health care. It is a form of policy research with its primary objective of providing "Value for money" to the patients. HTA comes into picture whenever a new health-care technology is made available in a health-care setup, and a decision has to be made between the new technology and the already-existing technology. In this background, HTA focuses on two major questions: Clinical effectiveness and cost-effectiveness of the new technology, in comparison with the existing technology.
For health-care policymakers, HTA provides inputs regarding which technologies are effective and which are not, and, in addition, helps to define the most appropriate indications for its use. For physicians practicing outside hospitals, HTA of a new drug or technology can provide a balanced review and evidence for its use. HTA can reduce and even eliminate those interventions whose costs and risks outweigh the benefits offered by them.
The key stakeholders in HTA are:
- The Pharmaceutical industry: Being the manufactures of health technology, the industry will rely on HTA analyses to prove to the medical policymakers that their health technology is novel and effective, both clinically and cost-wise
- Medical policymakers: HTA helps them choose between the new health technology and the existing one by providing inputs about cost-effectiveness and clinical effectiveness of the health technology in a particular population. Medical policymakers include:
- The Government: HTA studies help to decide upon which health technologies could be effectively introduced in its public health schemes to benefit most of the population.
- Hospital administrators: HTA helps hospitals, both Government and private, to finalize the hospital formulary so that drugs to be included affect all aspects of the patient health, rather than focusing only on clinical improvement.
- Insurance companies: Because these are the payers for the health services rendered to the insured patients, insurance companies depend upon HTA studies to seek justifications and make decisions for, including new technologies under various insurance schemes.
- Health-care providers: HTA can provide a complete picture of a new technology, as opposed to the current system where only clinical effectiveness is highlighted.
[TAG:2]Illustrative Case Studies of the Practical Applications of Health Technology Assessment in the Indian Scenario  [/TAG:2]
Non-pneumatic antishock garment
Postpartum hemorrhage (PPH) is estimated to contribute to up to 29.8% of all maternal deaths in India. Evidence shows that the usage of non-pneumatic antishock garment (NASG) could reduce PPH associated maternal mortality by up to 59%, leading to saving of up to 8,421 lives in the current Indian scenario. At INR 3,000 per NASG, this translates to INR 1,424.50 per life saved.
Home-based hemodialysis systems
It is estimated that Indian patients suffering from end-stage renal disease (ESRD) require 34.32 million cycles of hemodialysis (HD) per year, but at present, the supply is only around 16.5 million cycles per year: A shortage of around 52%. When home-based HD systems (HHDS) were used instead of hospital-based HD, there was a reported reduction in mortality by up to 35%. At ` 63,800 per quality-adjusted life year (QALY) gained, HHDS could be a very cost-effective intervention to provide greater access of dialysis to ESRD patients.
These examples suggest that the new technology (NASG or HHDS) are cost-effective as well as clinically effective options compared to conventional (none or hospital-based HD respectively) technology. This data can be used to formulate health policies, and can help the health-care providers to take informed decisions about the indications where the new technology should be used. Thus, HTA translates to reduction in health-care expenditure.
[TAG:2]Health Technology Assessment - A Double-Edged Sword? [/TAG:2]
Though it is interesting to see that HTA has been successfully implemented in North America, including the USA and practically all of Europe, it does act like a double-edged sword. For example, though the implementation of insurance-funded health-care model can reduce the OOP spending for health care, this can additionally lead to the paradoxical spiraling up of prices, as it is seen in the USA.
The gross domestic product (GDP) spent on health care by the US is among the world's highest at 17.7% in 2010, but despite this, the US health care is among the worlds' most expensive.  This, despite the widespread penetration of insurance in the US. The reasons given for this mismatch are:
- All government health-care programs have restricted eligibility, and there is no single government health insurance company that covers all Americans 
- Till the Obamacare was proposed, there was an absence of universal health coverage in the US.  The results of introduction of Obamacare is yet to be seen, and
- The nexus between insurance companies and hospitals. 
All these factors have to be borne in mind while an insurance-funded health-care model is being promoted in India.
| Way Ahead|| |
The importance of HTA is only recently being realized in most countries in Asia and its idea is still lingering in India. So far, India lacks a commendable HTA program and hence, adequate health economic evidence. The High Level Expert Group report on Universal Health Coverage by the Planning Commission of India has highlighted the need for using economic evidence for policymaking in India. 
There have been isolated attempts by a few groups in this direction, including the National Institute for Health and Care Excellence (NICE) International (UK), SIGNET initiative (Singapore), International Society For Pharmacoeconomics and Outcomes Research (ISPOR)-Indian chapter, HTA International, and Public Health Foundation of India (PHFI), who have organized workshops and conferences in order to provide sensitization in the branch of HTA to Indian policymakers and senior clinicians. In fact, the government of India has recently collaborated with the NICE for developing a HTA board in India. 
| Conclusion|| |
Though it has been observed that even after following the principles of HTA in the USA, the health-care cost to the government has spiraled, it is still to be seen as to how the whole concept might work in an Indian scenario. At this point, it is a hope that a proper and well-planned introduction of HTA in India might potentially resolve the majority of health-care problems that India is facing currently, including increased OOP health-care expenditure and catastrophic payments, illogical and profit-driven prescribing of unwanted diagnostics and medicines by private practitioners and hospitals, and so on.
Financial support and sponsorship
Self-funded (access to research papers).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Shivakumar AK. Fixing India′s healthcare system. Available from:
. [Last accessed on 2014 Jul 25].
Limwattananon S, Tangcharoensathien V, Prakongsai P. Catastrophic and poverty impacts of health payments: Results from national household surveys in Thailand. Bull World Health Organ 2007;85:600-6.
van Doorslaer E, O′Donnell O, Rannan-Eliya RP, Somanathan A, Adhikari SR, Garg CC, et al
. Catastrophic payments for health care in Asia. Health Econ 2007;16:1159-84.
Public health foundation of India. A critical assessment of the existing health insurance models in India. 2011 Jan. Available from:
. [Last accessed on 2014 Jul 19].
Compendium of health technology assessments: An evidence-based approach to technology-related policy making in health care. India: New Delhi National Health Systems Resource Center; 2014. p. 9-11.
US Health Care: Most expensive and worst performing. 2014 Jun 16. Available from:
. [Last accessed on 2015 Sep 01].
Income, poverty, and health insurance coverage in the United States: 2007. Available from:
. [Last accessed on 2015 Sep 01].
Mainous AG 3 rd
, Diaz VA, Everett CJ, Knoll ME. Impact of insurance and hospital ownership on hospital length of stay among patients with ambulatory care-sensitive conditions. Ann Fam Med 2011;9:489-95.
Jain B, Hilgismann M, Mathew JL, Evers SM. Analysis of a small group of stakeholders regarding advancing health technology assessment in India. Value Health Reg Issues 2014;3:167-71.
NICE to support development of HTA in India. Available from:
. [Last accessed on 2014 Jul 25].
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