Building Capacity for Evidence-Informed Priority Setting in the Indian Health System: An International Collaborative Experience.

India's rapid economic growth has been accompanied by slower improvements in population health. Given the need to reconcile the ambitious goal of achieving Universal Coverage with limited resources, a robust priority-setting mechanism is required to ensure that the right trade-offs are made and the impact on health is maximised. Health Technology Assessment (HTA) is endorsed by the World Health Assembly as the gold standard approach to synthesizing evidence systematically for evidence-informed priority setting (EIPS). India is formally committed to institutionalising HTA as an integral component of the EIPS process. The effective conduct and uptake of HTA depends on a well-functioning ecosystem of stakeholders adept at commissioning and generating policy-relevant HTA research, developing and utilising rigorous technical, transparent, and inclusive methods and processes, and a strong multisectoral and transnational appetite for the use of evidence to inform policy. These all require myriad complex and complementary capacities to be built at each level of the health system . In this paper we describe how a framework for targeted and locally-tailored capacity building for EIPS, and specifically HTA, was collaboratively developed and implemented by an international network of priority-setting expertise, and the Government of India.

The effects of scale on the costs of targeted HIV prevention interventions among female and male sex workers, men who have sex with men and transgenders in India.

BACKGROUND: The India AIDS Initiative (Avahan) project is involved in rapid scale-up of HIV-prevention interventions in high-risk populations. This study examines the cost variation of 107 non-governmental organisations (NGOs) implementing targeted interventions, over the start up (defined as period from project inception until services to the key population commenced) and first 2 years of intervention. METHODS: The Avahan interventions for female and male sex workers and their clients, in 62 districts of four southern states were costed for the financial years 2004/2005 and 2005/2006 using standard costing techniques. Data sources include financial and economic costs from the lead implementing partners (LPs) and subcontracted local implementing NGOs retrospectively and prospectively collected from a provider perspective. Ingredients and step-down allocation processes were used. Outcomes were measured using routinely collected project data. The average costs were estimated and a regression analysis carried out to explore causes of cost variation. Costs were calculated in US$ 2006. RESULTS: The total number of registered people was 134,391 at the end of 2 years, and 124,669 had used STI services during that period. The median average cost of Avahan programme for this period was $76 per person registered with the project. Sixty-one per cent of the cost variation could be explained by scale (positive association), number of NGOs per district (negative), number of LPs in the state (negative) and project maturity (positive) (p<0.0001). CONCLUSIONS: During rapid scale-up in the initial phase of the Avahan programme, a significant reduction in average costs was observed. As full scale-up had not yet been achieved, the average cost at scale is yet to be realised and the extent of the impact of scale on costs yet to be captured. Scale effects are important to quantify for planning resource requirements of large-scale interventions. The average cost after 2 years is within the range of global scale-up costs estimates and other studies in India.

Is hygiene promotion cost-effective? A case study in Burkina Faso.

OBJECTIVES: To estimate the incremental cost-effectiveness of a large-scale urban hygiene promotion programme in terms of reducing the incidence of childhood diarrhoeal disease in Bobo-Dioulasso, Burkina Faso. METHODS: Total and incremental costs of the programme were estimated retrospectively from the perspectives of the provider, from the households who change their behaviour as a result of the programme and from society (the sum of the two). The programme effects were derived from an intervention study that estimated the impact on handwashing with soap after handling child stools through a time-series method of observing 37 319 mothers. Using data from the literature, the associated reductions in childhood morbidity and mortality were estimated. The direct medical savings and indirect savings of caregiver time and lost productivity associated with child death were estimated from interviews with households and health workers. The cost and outcome data were combined to provide an estimate of the cost per mother who starts handwashing with soap as a result of the programme and the cost per case of childhood diarrhoea averted. RESULTS: The total provider cost (including start-up and 3-year running costs) was $302 507. Core programme activities accounted for 31% of the cost, administration 40%. The total cost to the 7286 households associated with changing behaviour during the 3 years of programme implementation was $160 125 ($7.3 per year per household). An estimated 8638 cases of diarrhoea, 864 outpatient consultations, 324 hospital referrals and 105 deaths were averted by the programme during this time. Savings to the provider from reduced treatment costs were estimated at $10 716 and savings to the households from averted treatment cost were $9136, resulting in a total saving to society of $19 852, increasing to $393 967 if indirect savings are included. The incremental provider cost per case of diarrhoea averted was $33.8. The incremental cost to society was $51.3 falling to $7.9 if indirect savings are included. If the programme were to be replicated elsewhere, savings in the international research input and start-up costs could reduce provider costs to $26.9 per case of diarrhoea averted. The annual cost of the programme represents 0.001% of the national health budget for Burkina Faso. The direct annual cost of implementing the programme at the household level represents 1.3% of annual household income. CONCLUSION: Hygiene promotion reduces the occurrence of childhood diarrhoea in Burkina Faso at less than 1% of the Ministry of Health budget and less than 2% of the household budget, and could be widely replicated at lower cost.

Influence of antenatal screening on perinatal mortality caused by syphilis in Swaziland.

In a survey of 283 deliveries in Swaziland, active syphilis (positive results in the Treponema pallidum haemagglutination assay (TPHA) and the rapid plasma reagin (RPR) test) was found in 37 (13.1%) and possibly active infection (positive TPHA but negative RPR test results) in a further 87 (30.7%). The perinatal mortality of untreated mothers with active disease was 21.9% (7/32). The RPR test carried out antenatally by nurses had a sensitivity of 36% (13/36) and predictive accuracy of 48% (13/27). Awareness of this incidence of syphilis led to improved antenatal clinic measures and the prophylactic treatment of all newborn infants. More comprehensive serology is discussed and the prophylactic treatment of mothers considered. The need for health education aiming at safer sexual practices is of paramount importance in a society facing the arrival of the human immunodeficiency virus.

PIP: The prevalence of syphilis is at least 10% in several African countries, and untreated maternal syphilis has been associated with high rates of perinatal mortality. This study assessed the syphilis status of mothers delivering at Swaziland's Mbabane Hospital in July-November 1986. Conclusive evidence of syphilis (positive results on both the Treponema pallidum hemagglutination assay (TPHA) and the rapid plasma reagin (RPR) test) was found in 37 (13%) of the 283 mothers tested and possible evidence of syphilis (positive TPHA and negative RPR test results) was recorded for another 87 (31%). The prenatal RPR test had a sensitivity of 36% and a predictive accuracy of 48%. 12 of the 172 women with negative prenatal results were found to be actively infected with syphilis, suggesting either late seroconversion or false negative prenatal test results; there were 4 infant deaths among these 12 women. Untreated active syphilis was a risk factor in 24 deliveries that resulted in 7 perinatal losses, for a mortality of 29%. Mortality was 5% in women with possibly active syphilis and 3% in those with negative prenatal test results. Since 65% of mothers with active syphilis were missed and sexual partners were not treated, screening reduced the 3.5% expected perinatal mortality rate due to syphilis to only 2.3%. In areas of Africa with high rates of sexually transmitted diseases, a prophylactic regimen of penicillin at booking at prenatal clinics may be a more cost-effective means of reducing syphilis-associated perinatal mortality than mass screening.