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.

How can we evaluate the cost-effectiveness of health system strengthening? A typology and illustrations.

Health interventions often depend on a complex system of human and capital infrastructure that is shared with other interventions, in the form of service delivery platforms, such as healthcare facilities, hospitals, or community services. Most forms of health system strengthening seek to improve the efficiency or effectiveness of such delivery platforms. This paper presents a typology of ways in which health system strengthening can improve the economic efficiency of health services. Three types of health system strengthening are identified and modelled: (1) investment in the efficiency of an existing shared platform that generates positive benefits across a range of existing interventions; (2) relaxing a capacity constraint of an existing shared platform that inhibits the optimization of existing interventions; (3) providing an entirely new shared platform that supports a number of existing or new interventions. Theoretical models are illustrated with examples, and illustrate the importance of considering the portfolio of interventions using a platform, and not just piecemeal individual analysis of those interventions. They show how it is possible to extend principles of conventional cost-effectiveness analysis to identify an optimal balance between investing in health system strengthening and expenditure on specific interventions. The models developed in this paper provide a conceptual framework for evaluating the cost-effectiveness of investments in strengthening healthcare systems and, more broadly, shed light on the role that platforms play in promoting the cost-effectiveness of different interventions.

Not a NICE fallacy: a reply to Dr Quigley.

A repudiation of Muireann Quigley's argument that the National Institute for Health and Clinical Excellence (NICE) values and assesses the worth of people's lives; together with an alternative account of what it appears that NICE actually does, why these procedures are not unreasonable and some of the unresolved problems, especially when making interpersonal comparisons of health, which remain for NICE or, indeed, anyone seeking to determine the contents of the benefits bundles of a public health insurance programme such as the NHS. Some other ethically dubious propositions by Dr Quigley are also rejected.

QALYs (quality-adjusted life-years) versus HYEs (healthy years equivalents)

This paper explores the claim that QALYs are liable to misrepresent consumer preferences and hence lead to decision-makers choosing options which are not those preferred by the public. It also considers the claim that HYEs do not suffer from this defect. We argue that none of the examples offered to date demonstrate the alleged tendency of QALYs to misrepresent preferences. We also show that HYEs are identical to QALY scores obtained from a time tradeoff experiment and therefore that the assumptions about preferences underlying HYEs are just as restrictive as those underlying TTO-based QALYs.

Equity and equality in health and health care.

This paper explores four definitions of equity in health care: equality of utilization, distribution according to need, equality of access, and equality of health. We argue that the definitions of 'need' in the literature are inadequate and propose a new definition. We also argue that, irrespective of how need and access are defined, the four definitions of equity are, in general, mutually incompatible. In contrast to previous authors, we suggest that equality of health should be the dominant principle and that equity in health care should therefore entail distributing care in such a way as to get as close as is feasible to an equal distribution of health.

Cost containment in Europe.

Health care cost containment is not in itself a sensible policy objective, because any assessment of the appropriateness of health care expenditure in aggregate, as of that on specific programs, requires a balancing of costs and benefits at the margin. International data on expenditures can, however, provide indications of the likely impact on costs and expenditures of structural features of health care systems. Data from the Organization for Economic Cooperation and Development for both European countries and a wider set are reviewed, and some current policies in Europe that are directed at controlling health care costs are outlined.

A health economist on medical sociology: reflections by an unreconstructed reductionist.

Eleven papers in medical sociology, recommended as representative by the Medical Sociology Group of the British Sociology Association, are evaluated by a health economist using five criteria: appeal of intellectual content, insights into political philosophy, explanatory power, predictive power and opportunities for social improvements. The paper concludes that the medical sociology literature is quite weak when judged by these criteria, though stronger on some than others. Sociologists often seem to confuse issues that involve value judgements with ones that do not, and generally seem to display a disconcerting obsession with methodological issues of the most fundamental kind that has inhibited medical sociology from developing interesting analyses of many issues on which, in principle, it ought to have much to offer.

Health service efficiency: appraising the appraisers--a critical review of economic appraisal in practice.

This paper provides a critical appraisal of the application of economic evaluative techniques to problems of health service efficiency. Focusing largely on the British literature, it selects some recurring issues, comments on them from a theoretical point of view, and illustrates them with examples of good and bad practice.

Cost-effectiveness of foam elastomer and gauze dressings in the management of open perineal wounds.

This study compares the cost per case of treating wounds with conventional gauze dressings or with silastic foam elastomer dressings and concludes that the foam dressing is less costly both in terms of materials and of labour time.

Wickedness or folly? The ethics of NICE's decisions.

A rebuttal is provided to each of the arguments adduced by John Harris, an Editor-in-Chief of the Journal of Medical Ethics, in two editorials in the journal in support of the view that National Institute for Health and Clinical Excellence's procedures and methods for making recommendations about healthcare procedures for use in the National Health Service in England and Wales are the product of "wickedness or folly or more likely both", "ethically illiterate as well as socially divisive", responsible for the "perversion of science as well as of morality" and are "contrary to basic morality and contrary to human rights".

Public or private health services?

For many years economists writing on the delivery of health services dusted off the traditional promarket analyses of textbooks and applied them uncritically to the health care industry. Specialists in health care today are far more cautious. From the medical side there has been an increasing interest in the economic implications of health care organization and medical practice. Good research drawing on the skills of economists and other specialists is rapidly growing. This research offers little support either to those who reason abstractly from a market ideology or to those who are uncritically committed to socialized health care.