Universal health coverage in India and health technology assessment: current status and the way forward.

In India, there is a renewed emphasis on Universal Health Coverage (UHC). Alongside this, Health Technology Assessment (HTA) is an important tool for advancing UHC. The development and application of HTA in India, including capacity building and establishing institutional mechanisms. We emphasized using the HTA approach within two components of the Ayushman Bharat programme, and the section concludes with lessons learned and the next steps. The UHC has increased the importance of selecting and implementing effective technologies and interventions within national health systems, particularly in the context of limited resources. To maximize the use of limited resources and produce reliable scientific assessments, developing and enhancing national capacity must be based on established best practices, information exchange between different sectors, and collaborative approaches. A more potent mechanism and capacity for HTA in India would accelerate the country's progress toward UHC.

Organizational Formation for Priority Setting: Historical Perspectives and Thematic Analysis of India's Health Technology Assessment Agency.

Countries pursuing universal health coverage must set priorities to determine which benefits to add to a national health program, but the roles that organizations play are less understood. This article investigates the case of the formation of an organization with a mandate for choice of technology for public health interventions and priorities, the Health Technology Assessment India. First, we narrate a chronology of agenda setting and adoption of national policy for organizational formation drawing on historical documentation, publicly available literature, and lived experiences from coauthors. Next, we conduct a thematic analysis that examines windows of opportunity, enabling factors, barriers and conditions, roles of stakeholders, messaging and framing, and specific administrative and bureaucratic tools that facilitated organization formation. This case study shows that organizational formation relied on the identification of multiple champions with sufficient seniority and political authority across a wide group of organizations, forming a coalition of broad base support, who were keen to advance health technology assessment policy development and organizational placement or formation. The champions in turn could use their roles for policy decisions that used private and public events to raise priority and commitment to the decisions, carefully considered organizational placement and formation, and developed the network of organizations for the generation of technical evidence and capacity building for health technology assessment, strengthened by international networks and organizations with financing, expertise, and policymaker relationships.

What makes primary healthcare facilities functional, and increases the utilization? Learnings from 12 case studies.

BACKGROUND: The last few decades have witnessed a number of innovative approaches and initiatives to deliver primary healthcare (PHC) services in different parts of India. The lessons from these initiatives can be useful as India aims to strengthen the PHC system through Health and Wellness Centers (HWCs) component under Ayushman Bharat Program, launched in early 2018. MATERIALS AND METHODS: Comparative case study method was adopted to systematically document a few identified initiatives/models delivering the PHC services in India. Desk review was followed by field visits and key informant interviews. Twelve PHC case studies from 14 Indian states, with a focus on equity and "potentially replicable designs" were included from the government as well as the "not-for-profit" sector. The cases studies comprised of initiatives/models having the provision of PHC services, whether exclusively or as part of broader hospital services. The data was collected from May 2016 to March 2017. RESULTS: The "political will" for government facilities and "leadership and motivation" for "not-for-profit" facilities adjudged to contribute towards improved functioning. A comprehensive package of services, functional 'continuity of care' across levels, efforts to meet one or more type of quality standards and limited "intention to availability" gap (or assured provision of promised services) were considered to be associated with increased utilization. A total of 10 lessons and learnings derived from the analysis of these case studies have been summarised. CONCLUSIONS: The case studies in this article highlights the components which makes PHC facilities functional and have potential for increased utilization. The article underscores the need for institutional mechanisms for health system research and innovation hubs at both national and state level in India, for the rapid scale of comprehensive primary healthcare. Lessons can be applied to other low- and middle-income countries intending to deliver comprehensive PHC services to advance towards universal health coverage.

Utilisation and financial protection for hospital care under publicly funded health insurance in three states in Southern India.

BACKGROUND: Many LMICs have implemented Publicly Funded Health Insurance (PFHI) programmes to improve access and financial protection. The national PFHI scheme implemented in India for a decade has been recently modified and expanded to cover free hospital care for 500 million persons. Since increase in annual cover amount is one of the main design modifications in the new programme, the relevant policy question is whether such design change can improve financial protection for hospital care. An evaluation of state-specific PFHI programmes with vertical cover larger than RSBY can help answer this question. Three states in Southern India - Andhra Pradesh, Karnataka and Tamil Nadu have been pioneers in implementing PFHI with a large insurance cover. METHODS: The current study was meant to evaluate the PFHI in above three states in improving utilisation of hospital services and financial protection against expenses of hospitalization. Two cross-sections from National Sample Survey's health rounds, the 60th round done in 2004 and the 71st round done in 2014 were analysed. Instrumental Variable method was applied to address endogeneity or the selection problem in insurance. RESULTS: Enrollment under PFHI was not associated with increase in utilisation of hospital care in the three states. Private hospitals dominated the empanelment of facilities under PFHI as well as utilisation. Out of Pocket Expenditure and incidence of Catastrophic Health Expenditure did not decrease with enrollment under PFHI in the three states. The size of Out of Pocket Expenditure was significantly greater for utilisation in private sector, irrespective of insurance enrollment. CONCLUSION: PFHI in the three states used substantially larger vertical cover than national scheme in 2014. The three states are known for their good governance. Yet, the PFHI programmes in all three states failed in fulfilling their fundamental purpose. Increasing vertical cover of PFHI and using either 'Trusts' or Insurance-companies as purchasers may not give desired results in absence of adequate regulation. The study raises doubts regarding effectiveness of contracting under PFHIs to influence provider-behavior in the Indian context. Further research is required to find solutions for addressing gaps that contribute to poor financial outcomes for patients under PFHI.

National Health Policy 2017: a cautious welcome.

On March 15, 2017 the union cabinet approved the new National Health Policy. The next day a 28-page policy text and an accompanying 13-page situational analysis were placed in Parliament and in the public domain. To have, at all times, a health policy in place that shows a road map on how a nation would show "progressive realization" of health as a basic human right is an obligation under the International Covenant on Economic, Social and Cultural Rights. This is an international treaty adopted in 1976, to which India became a signatory in 1979, and this was one of the catalysts for the adoption of the first National Health Policy in 1983. The immediate political backdrop to the articulation of a National Health Policy 2017 (NHP 2017), replacing the 2002 policy, is that a new health policy and a national health assurance plan were both part of the BJP's electoral manifesto. It has taken close to 34 months after the government took office, and some 26 months after the draft was circulated for public discussion, to finally approve the policy. This is reflective of the considerable contestation and contradictory pressures, often almost evenly matched, that went into finalising this policy.

Building inclusive health innovation systems: lessons from India.

This article presents an overview of the changes that are taking place within the public and private health innovation systems in India including delivery of medical care, pharmaceutical products, medical devices, and Indian traditional medicine. The nature of the flaws that exist in the health innovation system is pinpointed. The response by the government, the health, technology and medical institutions, and the evolving industry is addressed on a national level. The article also discusses how the alignment of policies and institutions was developed within the scope of national health innovation systems, and how the government and the industry are dealing with the challenges to integrate health system, industry, and social policy development processes. Resumo: O artigo apresenta um panorama das mudanças atualmente em curso dentro dos sistemas público e privado de inovação em saúde na Índia, incluindo a prestação de serviços médicos, produtos farmacêuticos, dispositivos médicos e medicina tradicional indiana. É destacada a natureza das falhas que existem nos sistemas de inovação em saúde. As respostas do governo, das instituições médicas, de saúde e tecnologia e indústrias envolvidas, são abordadas em nível nacional. O artigo também discute como foi desenvolvido o alinhamento de políticas e instituições no escopo dos sistemas nacionais de inovação em saúde, e como governo e indústria estão lidando com os desafios para integrar o sistema de saúde, a indústria e o desenvolvimento de políticas sociais.

Building inclusive health innovation systems: lessons from India / Creación de sistemas inclusivos de innovación en salud: lecciones desde la India / A criação de sistemas inclusivos de inovação em saúde: lições da Índia

Abstract: This article presents an overview of the changes that are taking place within the public and private health innovation systems in India including delivery of medical care, pharmaceutical products, medical devices, and Indian traditional medicine. The nature of the flaws that exist in the health innovation system is pinpointed. The response by the government, the health, technology and medical institutions, and the evolving industry is addressed on a national level. The article also discusses how the alignment of policies and institutions was developed within the scope of national health innovation systems, and how the government and the industry are dealing with the challenges to integrate health system, industry, and social policy development processes.

Resumen: El artículo presenta el panorama de los cambios actualmente en curso dentro de los sistemas públicos y privados de innovación en salud en la India, incluyendo la prestación de servicios médicos, productos farmacéuticos, dispositivos médicos y medicina tradicional india. Se destaca la naturaleza de las carencias que existen en los sistemas de innovación en salud. Los autores abordan la respuesta existente, a nivel nacional, por parte del gobierno, instituciones médicas y de salud y tecnología, y por la industria en este proceso de evolución. El artículo también discute cómo se desarrolló la alineación de políticas e instituciones en el alcance de los sistemas nacionales de innovación en salud, y cómo el gobierno, así como la industria, están enfrentando los desafíos que se presentan, con el fin de integrar sistema de salud, industria y desarrollo de políticas sociales.

Resumo: O artigo apresenta um panorama das mudanças atualmente em curso dentro dos sistemas público e privado de inovação em saúde na Índia, incluindo a prestação de serviços médicos, produtos farmacêuticos, dispositivos médicos e medicina tradicional indiana. É destacada a natureza das falhas que existem nos sistemas de inovação em saúde. As respostas do governo, das instituições médicas, de saúde e tecnologia e indústrias envolvidas, são abordadas em nível nacional. O artigo também discute como foi desenvolvido o alinhamento de políticas e instituições no escopo dos sistemas nacionais de inovação em saúde, e como governo e indústria estão lidando com os desafios para integrar o sistema de saúde, a indústria e o desenvolvimento de políticas sociais.