Economic Evaluation in Health · Faculty workshop · Session 1
Where economic evidence enters health policy
Who asks the questions in India, what they need from a study, and where faculty, residents and project staff come in.
School of Public Health, with the Regional Resource Centre for Health Technology Assessment, AIIMS Bhopal
Today is about reading, not selling
By the end of the day you should be able to pick up an economic evaluation in your own field and say whether you believe it.
Your paper
Your group holds one published Indian evaluation. It stays with you all day.
Your checklist
After each session, fill in the rows it covered. Prompts are on your paper's sheet.
Your verdict
In the last session, in pairs of groups: would you act on this paper, and why?
Four doors economic evidence walks through
| Door | What gets decided |
|---|---|
| Health Technology Assessment in India | whether a programme, test or treatment should be adopted nationally or by a state |
| PM-JAY health benefit packages | which procedures are covered, and at what package rate |
| State programmes and procurement | what a state buys, at what scale, and in what order |
| Guidelines, journals, committees | what clinicians recommend, and which evidence is believed |
Faculty sit at the fourth door every week, and increasingly at the other three.
Who asks the questions
- A programme, a ministry department or a state nominates a topic
- HTAIn prioritises it and assigns it to a Regional Resource Centre
- The Centre runs the study; its report is appraised, then endorsed
- The recommendation goes back to whoever asked, who decides
The question comes from the user. Anyone can suggest one.
Evidence that moved a price
When PM-JAY package rates were revised using hospital costing data, most rates changed.
| Package prices in the revision | Share |
|---|---|
| Increased | 61% |
| Decreased | 18% |
The data came from costing studies in public tertiary hospitals, run by teams in departments like yours.
Prinja, Singh, Rajsekar et al., Applied Health Economics and Health Policy, 2021.
What a decision-maker needs from a study
| Needs | Because |
|---|---|
| a comparator that is current practice | or it answers a question nobody asked |
| Indian costs and quality-of-life weights | borrowed numbers fit someone else |
| QALYs | so programmes can be compared |
| uncertainty shown | one number invites false confidence |
| budget impact alongside | value per patient is not affordability |
India wrote these down in 2023: the Indian Reference Case.
Sharma, Prinja, Aggarwal, Rajsekar, Bahuguna, Lancet Regional Health Southeast Asia, 2023.
Publication is not a quality mark
| 79 Indian cost-utility studies, 2003 to 2019 | Share |
|---|---|
| reported DALYs rather than QALYs | 70% |
| did not discount at all | 23% |
| did any sensitivity analysis | 73% |
| reported budget impact | 18% |
Your paper today may be strong or weak. Finding out is the exercise, and you are allowed to say so out loud.
Shah, Singh, Kotwani et al., Frontiers in Public Health, 2022.
Where you come in
As a source of data
Models borrow costs, outcomes and quality-of-life weights. The best ones come from departments that measured them.
As a source of questions
You see which technologies are arriving, and which current practice is doubtful. That is a topic.
As an appraiser
Peer review, guideline panels, committees, journal club. Where a weak analysis should be caught.
As a co-investigator
With the Regional Resource Centre here, on studies that answer a user's question.
Six things to try, on your own phone
| Widget | What it makes visible |
|---|---|
| Classify the study | full evaluation or partial, in two questions |
| Which costs count | direct or indirect, under whose perspective |
| QALY builder | a QALY is an area; three lives give the same one |
| Discounting | why prevention looks worse than treatment |
| The CE plane | quadrants, dominance, the threshold line |
| Uncertainty | tornado, cloud of simulations, and the curve |
A few minutes each, phone friendly, self-explaining. Five appear during the day; all six stay online afterwards.
sph-aiimsbhopal
.github.io/
intro-economic-evaluation-health
The day, and what each session adds
| Session | Checklist rows | |
|---|---|---|
| 2 | What economic evaluation is, and is not | is it one at all? |
| 3 | Framing the question | 1, 2, 3, 7 |
| 4 | Costing your own service | 5 |
| 5 | Outcomes, discounting and the ICER | 6, 8, 12 |
| 6 | Thresholds, opportunity cost, budget impact | the verdict's yardstick |
| 7 | Modelling in half an hour | 4 |
| 8 | Handling uncertainty | 9, 10 |
| 9 | Report-back, in pairs of groups | your verdict |
Two examples, side by side, all day
The teaching example
Cervical cancer screening against HPV
vaccination. A programme, for a population, decided by a ministry.
Chauhan, Prinja et al., 2020
The clinical example
Adjuvant trastuzumab against chemotherapy
alone in breast cancer. A prescription, for one patient, decided in a clinic.
Gupta, Verma, Gupta, Prinja, 2020
The method does not change with the size of the decision.
Seven of the eight papers in this room are clinical or service decisions: a biopsy, a mesh, a valve, kangaroo care, ward ventilation, dialysis, leukaemia. Sessions 2, 3 and 5 each close by running that session's principle on the trastuzumab paper, before you do it on yours.
Sources
- Sharma D, Prinja S, Aggarwal AK, Rajsekar K, Bahuguna P. Development of the Indian Reference Case for undertaking economic evaluation for health technology assessment. Lancet Reg Health Southeast Asia 2023;16:100241. PMID 37694178
- Prinja S, Singh MP, Rajsekar K, Sachin O, Gedam P, Nagar A, Bhargava B; CHSI Study Group. Translating research to policy: setting provider payment rates for strategic purchasing under India's national publicly financed health insurance scheme. Appl Health Econ Health Policy 2021;19(3):353–70. PMID 33462775
- Shah K, Singh M, Kotwani P, et al. Comprehensive league table of cost-utility ratios for health policy decisions in India. Front Public Health 2022;10:831254. PMID 36311623