research topics in health economics in india

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• Published: 25 January 2024

Research trends in contemporary health economics: a scientometric analysis on collective content of specialty journals

• Clara C. Zwack   ORCID: orcid.org/0000-0002-9866-6470 1 ,
• Milad Haghani 2 &
• Esther W. de Bekker-Grob 3  

Health Economics Review volume  14 , Article number:  6 ( 2024 ) Cite this article

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Introduction

Health economics is a thriving sub-discipline of economics. Applied health economics research is considered essential in the health care sector and is used extensively by public policy makers. For scholars, it is important to understand the history and status of health economics—when it emerged, the rate of research output, trending topics, and its temporal evolution—to ensure clarity and direction when formulating research questions.

Nearly 13,000 articles were analysed, which were found in the collective publications of the ten most specialised health economic journals. We explored this literature using patterns of term co-occurrence and document co-citation.

The research output in this field is growing exponentially. Five main research divisions were identified: (i) macroeconomic evaluation, (ii) microeconomic evaluation, (iii) measurement and valuation of outcomes, (iv) monitoring mechanisms (evaluation), and (v) guidance and appraisal. Document co-citation analysis revealed eighteen major research streams and identified variation in the magnitude of activities in each of the streams. A recent emergence of research activities in health economics was seen in the Medicaid Expansion stream. Established research streams that continue to show high levels of activity include Child Health, Health-related Quality of Life (HRQoL) and Cost-effectiveness. Conversely, Patient Preference, Health Care Expenditure and Economic Evaluation are now past their peak of activity in specialised health economic journals. Analysis also identified several streams that emerged in the past but are no longer active.

Conclusions

Health economics is a growing field, yet there is minimal evidence of creation of new research trends. Over the past 10 years, the average rate of annual increase in internationally collaborated publications is almost double that of domestic collaborations (8.4% vs 4.9%), but most of the top scholarly collaborations remain between six countries only.

Health economics, a discipline of economics that focuses on studying how resources are allocated, utilised, and distributed in the healthcare sector [ 1 ]. Health economists use various economic tools and techniques, such as cost-effectiveness analysis, cost-benefit analysis, econometric modelling, and microeconomic theory, to examine a wide range of healthcare issues [ 2 , 3 ]. The field has experienced rapid evolution, largely due to the decades of work of committed scholars. These scholars have not only built a foundation of knowledge, but also developed and refined a set of methodological tools to guide decision making by health care authorities [ 4 ]. Modern day health systems are constantly challenged by scarcity of resources, which is attributable to an aging population, diseases of prosperity, rapid urbanisation, technological advancement in the medical field and large scale migrations [ 4 ], not to mention the new threat of global pandemics [ 5 , 6 ]. Another contemporary issue is the rising out-of-pocket health spending that continues to threaten the affordability of medical care, even for some of the most advanced OECD countries [ 7 , 8 ]. These challenging and complex environments create strong drivers for the further development of health economics.

In 1963, Kenneth Arrow published “Uncertainty and the welfare economics of medical care” in The American Economic Review [ 9 ]. It became one of the most highly cited articles in health economics and was considered the article that established the field. From here, the term “health economics” increased rapidly in articles published in economics, however, it was not until the early 1980’s that saw the creation of specialised health economics journals.

The unprecedented surge in publications presents researchers with challenges in keeping up with the latest advancements in the field of health economics. Hence, consolidating research and its outcomes has gained even greater importance [ 10 ]. For scholars, it is important to understand the history and status of health economics—when it emerged, the rate of research output, trending topics, and its temporal evolution—to ensure clarity and direction when formulating research questions. The course of health economics has been charted previously [ 11 , 12 ], however, these analyses focus on bibliometric properties of the field. Whilst this is important to report, this paper will extend current knowledge by completing a scientometric analysis of contemporary health economics, using specialised sources and advanced analytical and clustering tools. In health economics, systematic reviews are considered the gold standard for measuring efficacy and effectiveness of a specific topic due to their rigorous nature. However, scientometrics can be utilised to complement systematic reviews to summarise the overall trends observed with a topic [ 10 , 13 ].

The main objectives of our study presented in this paper are to determine the patterns in regional distribution of relevant health economics publications, prominent author networks, the major divisions and research streams of health economics literature, and the variation of activity for each sub-area. This paper also reports on the trending topics and highlights, based on a multitude of objective metrics, the influential references of health economics literature that have shaped the formation of each research stream.

The dataset of references

To retrieve the data for this study, the Web of Science (WoS) Core Collection was accessed and searched in May 2022. A search query was formulated in consultation with an experienced health economist. The ten sources (i.e. scientific peer-reviewed journals) that predominantly publish articles relevant to health economics were included. A list of sources was initially identified if they were listed by the WoS in both categories of “Health Policy & Services” and “Economics”. From this list, the ten sources with the largest volume of content were selected for inclusion in the search. Keywords were not utilised in the search strategy due to the diversity of the terms being used across health economics along with the lack of distinctiveness across other fields (e.g. economics and medicine).

Search strategy

SO = (“Value in Health” OR “Health Economics” OR “Pharmacoeconomics” OR “Pharmacoeconomics Open” OR “International Journal of Health Economics and Management” OR “Journal of Health Economics” OR “Health Economics Review” OR “Applied Health Economics and Health Policy” OR “American Journal of Health Economics” OR “European Journal of Health Economics”).

Upon initial inspection of the 68,000 documents found by the search strategy, Value in Health journal has indexed 54,000 documents as meeting abstracts. These records did not display abstract or reference lists, which are essential for scientometric analysis. Hence, it was determined that for this analysis the inclusion criteria needed to be refined to articles and review articles only. No restrictions were set on other subcategories. The maximum year was set to December 31, 2021, with no restriction on the minimum. Full bibliographic details of the documents were exported from WoS as text files. Details include document title, authors, author affiliations, year of publication, source (journal) title, citation count, document type, abstract, author keywords, keywords plus, funding source, full list of document references and conference information, if relevant.

General findings

The estimated size of the literature, highly cited documents, prominent sources and author affiliations (i.e. country and institution) were analysed using the meta data extracted directly from WoS.

Semantic analysis

Title and abstract, and keyword analyses were conducted using VOSviewer 1.6.15. Keywords provide insight into the temporal shifts in research and scholarly focus. Clusters of terms extracted from the titles and abstracts are formed by the frequency they occur (set to a minimum of 15) in the articles to provide an objective overview of the structure and divisions within this research topic.

Networks of author collaboration

Analyses of author networks were conducted using VOSviewer 1.6.15. Each author is represented by a node and is connected to other authors via links. The number of co-authored documents is indicated by the thickness of the link between the two nodes.

Influential articles analysis

Document co-citation and citation burst analyses was completed using CiteSpace 5.7.R1 [ 14 ]. The concept of document co-citation, a methodology developed by Chen [ 15 ], was used to obtain an indication of the most influential studies within the field of health economics as well as the clusters of thematically similar references. The methodology identifies cohorts of references that are frequently co-cited in the reference lists of health economics papers, on the premise that such references are similar in subjects and represent the knowledge foundation of a certain topic in the field. Document co-citation analysis results in a new set of documents, which include valuable knowledge sources for health economics that are instrumental in the development of this literature but were not captured by the WoS search query.

From document co-citation we can find (i) references with the most local citations (citations from within the literature exclusively relevant to this topic), (ii) references with the strongest citation burst (heightened attention to an individual article within the field, representing a temporal component of the research topic) and, iii) references with the highest centrality (document co-citation across multiple clusters).

Temporal analysis

CiteSpace 5.7.R1 [ 14 ] was used to generate the dynamic visualisation, which shows insight into the emergence and activities of each research stream since 1990. Research streams are named using the titles of the citing articles (of each stream). Nouns and noun phrases are extracted from the titles. These nouns and noun phrases are each allocated a score depending on the frequency of appearance and the coverage of the citing article they are extracted from (coverage of a citing article refers to the number of cited references of the cluster that it cites). Heavier weighting is given to the noun phrases extracted from high coverage articles because they are more instrumental in the development of the cluster. These noun phrases are sorted based on this score and the top ones are used as a guide for the naming of the cluster. This means that labelling is done by the field expert but guided by an algorithmic determination. In the visualisation, parts of the network that have been most active during each year appear more striking, representing co-citation instances during that year. Influential references are identified using the three metrics (local citations, bursts, centrality). However, these metrics are measuring articles that may or may not be about health economics, so we must also look at the citing articles with the highest coverage to determine which articles related to health economics are citing the most references within the specific research stream.

The time period for the analysis was set for 1990–2021 (1-year intervals; look back years = 50 [reference lists published less than 50 years ago]). Each node represents an individual reference. The size of the node is proportional to the number of local citations identified to that reference, and the nodes are connected by links (indicating co-occurrence of co-citation) to create a network of major research streams, all contained within the field of health economics. Each stream has a descriptor based on the contents of the cluster. Furthermore, CiteSpace analysis also provides a timeline view of the evolution of research streams. The references of each stream are visualised and aligned across the timeline based on the year of publication from 1950–2021.

General findings and the history of health economics

The size of the specialised field of health economics is estimated to be 12,977 items, as of December 31, 2021. The first article published in a specialty journal ( Journal of Health Economics ) is ‘Effects of teaching on hospital costs’ in 1983 [ 16 ]. The following decade saw only a small number of documents published before a significant increase in research output was observed around the mid-1990s (Fig.  1 ). Since then, there has been an upwards trend, with post-2005 showing a sharp incline in the number of publications.

Above (L) Total number of articles and review articles in health economics specialty journals; Above (R) All document types versus total number of articles and reviews in health economics specialty journals; Bar graphs (L) Number of documents by journal source for articles and review articles. Bar graphs (R) Number of documents by journal source for all document types

If all document types were included in the field analysis, there would be nearly 70,000 items, with meeting abstracts published in Value in Health contributing to around 80% of documents (Fig.  1 ). Over the past three decades, the number of specialised health economics journals in this field has grown from three to ten, with Health Economics and Value in Health publishing the most literature in 2010–2021 (Fig.  1 ).

The onset of Covid-19 in early 2020 has not dampened publication of health economics articles and reviews, however, surprisingly only 72 published articles directly explore the topics related to the pandemic. Conversely, a large decline in meeting abstracts has occurred over the past 3 years, however, if and how the pandemic has contributed is unclear, as the decline started in 2019 (from 4,500 to 4000 in the years 18–19) and cannot be solely attributed to a reduction in organised conferences.

An overview of the articles specific subject areas was identified using WoS Categories . Unsurprisingly, all records are indexed in the disciplines of Economics and Health Policy Services (12,977 records, 100%). Other categories include Health Care Sciences Services (11,039 records, 85%), Pharmacology Pharmacy (2,992 records, 23%) and Business Finance (156 records, 1%).

Over 26,000 scholars have contributed to health economics research, of which 242 authors have published 15 or more documents related to this field. The top published authors include John Brazier ( n  = 78 records), Werner Brouwer ( n  = 64), Michael Drummond ( n  = 55) and Maarten Postma ( n  = 54). The top ranked academic institutions include the League of European Research Universities (7.5% of total publications), Erasmus University Rotterdam (5%), University of London (5%), University of York [UK] (4.5%) and Harvard University (3.5%).

The main body of research output in health economics is exclusive to six countries: USA, England, Netherlands, Canada, Australia, and Germany. More recently however, countries in Eastern Europe, Africa, Southeast Asia and the Middle East have become more prominent researchers in health economics. Over the previous three decades, the top five countries have remained mostly consistent (Fig.  2 ), except for Australia, where scholarly output in this area is growing extensively.

a Top five countries to contribute to health economics research output, by decade; b domestic versus international collaboration

Since 2015, international collaboration has been sharply on the rise (Fig.  2 ). The gap between domestic and international collaborated publications appears to be closing. Currently, domestic publications contribute to 58.6% of the scholarly output compared to 41.4% international publications, however, over the past 10 years, the average rate of annual increase in internationally collaborated publications is almost double that of domestic collaborations (8.4% vs 4.9%). The main six countries in health economics show patterns of strong international collaboration. Together, they have produced approximately one third of the research field (4,000 articles). The strongest links are between the USA and England, USA and Canada, and England and The Netherlands.

Semantic analysis; titles, abstracts and keywords

Five major divisions were identified in the field of health economics (Fig.  3 ). 1) Macro-economics, 2) Micro-economics, 3) Measurement and valuation of outcomes, 4) Monitoring mechanisms and 5) Guidance and appraisal. Division 3, measurements and valuation of outcomes is the most cited, and division 5, Guidance and appraisal has the most recent publications.

Major divisions of health economics. Below (L) divisions of bibliographic coupling; Below (R) average number of citations and average year of publication for each major division. Interactive version of the title and abstract map are available via this link: VOSviewer Online

Bibliographic coupling resulted in similar divisions of health economics research areas. Macro-economics (purple) and micro-economics (green) are the densest divisions, showing extensive overlap of references. Methods for measurement and valuation of patient outcomes, including Discrete Choice Experiments (DCEs), and the EQ-5Dto a lesser extent, are central to both macro- and micro-economics. Table 1 shows the top title and abstract terms of each major division in health economics.

The composition of the field of health economics research is dynamic. Keyword analysis across three decades shows there are common research themes including, cost effectiveness , QALYs and economic evaluation (Fig.  4 ). However, there is a distinct shift to health-related quality of life (HRQoL) in the early millennium, followed by the appearance of DCEs in the most recent decade. Unsurprisingly obesity , a global epidemic of the 21 st century, has also been a topic of focus for scholarly research since 2010.

Top keywords in health economics, by decade

Influential references

This section acknowledges the most influential entities (authors and references) in health economics, aiming to pave the way for further interdisciplinary collaborations and advancements in the domain. These are the most influential entities in a subset of health economics journals. Although the analysis considered a large number of articles (approximately 13,000), it’s important to recognize that there may be other influential entities not represented in this paper.

The top ten globally cited articles have quite distinct topics (Appendix 1 ). The most cited article, according to WoS, is ‘The price of innovation: new estimates of drug development costs’, authored by DiMasie et al. and is published in Journal of Health Economics. The article has received 2,475 citations, and provides data used to estimate the average pre-tax of new drug development [ 17 ].

Influential articles relevant to health economics, ranked by local citation count, are listed in Appendix 2 . The most cited article specific to this research field is ‘Recommendations of the Panel on Cost-effectiveness in Health and Medicine’, published in JAMA in 1996 [ 18 ]. The authors recommended that if researchers follow a standard set of methods in cost-effectiveness analysis, the utility of studies can be much improved. Lastly, the articles that have had the strongest burst of citations since publication are shown in Appendix 3 . This article, published in 2016 and titled ‘Recommendations for Conduct, Methodological Practices, and Reporting of Cost-effectiveness Analyses’ provides major changes to the recommendations made by Weinstein et al. in 1996 [ 19 , 20 ].

A major focus is on identifying temporal patterns of scholarly research in this field and the formation of its various research streams as well as the most influential entities within each stream. Document co-citation analysis revealed eighteen research streams. Figure  5 shows a bird’s-eye view of the field and Table 2 identifies the influential references that have shaped each stream. Two streams related to Economic Evaluation emerged, with slight variations. ‘Overall’ Economic Evaluation is broader and includes guidelines, applications of evaluation, reviews of evaluation studies, and articles reporting on willingness to pay studies. ‘Elements’ of Economic Evaluation includes steps involved in evaluation, criteria for evaluation and is mostly focussed on cost-effectiveness studies. These are both central to the field of health economics and are very active areas of research every year, as reflected in instances of article co-citation (Fig.  6 ). Economic Evaluation is closely related to the activities in Patient Preference and Health-related Quality of Life research (involving measurement tools such as DCEs and EQ-5D, respectively). Figure  7 shows the research streams in time-line format for clear observation of bursts of activity since 1950.

Bird’s-eye view of the major research streams in the field of health economics

State of health economics literature during the last three decades of development. Salient parts of the map specify active areas of research during each year, as reflected in instances of article co-citation. A dynamic visualisation from 1990–2021 is available here https://unisyd-my.sharepoint.com/:v:/g/personal/clara_zwack_sydney_edu_au/EeT-KZTsqdJHuGzL6s-R9ksBzmQ0ln-2jjYJu5Cv7F0usg?e=pkaOqt

Timeline view of the major research streams in health economics

Co-citation also identified variation in the magnitude of activities in each of the streams (Fig.  8 ). A recent emergence of heightened research activities in health economics was only seen in the Medicaid Expansion stream. Medicaid expansion is an United States initiative with the goal to increase insurance coverage among low-income adults. It became effective in January 2014, which aligns with the clusters research activity increasing around 2015. Established research streams that continue to show high levels of activity include Child Health, HRQoL and Economic Evaluation (elements). Conversely, Patient Preference, Health care Expenditure and Economic Evaluation (overall) are now past their peak of activity and are slowing down in specialised health economic journals.

Number of citations (blue) and number of citing articles (green) for each research stream. Note: scale is different for each cluster. Y-axis is Number of articles and X-axis is Number of citations

Three streams show fluctuating patterns of activity: Adverse Selection (a phenomenon where individuals with higher risks or health issues are more likely to seek or retain health insurance coverage compared to individuals with lower risks), Migraine and Rheumatoid Arthritis. Analysis also identified several streams in this field that have transient peaks of activity and are currently not active. These include Influenza Vaccine, Prospect Theory, Coronary Heart Disease, Congestive Heart Failure, Supplied Inducement and Psychotropics. Lastly, HIV Infection had a very transient period of activity in the early 2000’s. It has since been mostly non-existent, aside from a distinct peak in 2010 where 13 citing articles gave a total coverage of around 140. The critical references were studies measuring the cost effectiveness of Darunavir/Ritonavir, a HIV antiviral drug [ 305 , 309 , 311 ].

This scientometric analysis presents an overview of health economics research exclusively from the top journals specific to the field. Evaluation of around 13,000 documents has revealed contemporary patterns of publication, authorship, and research activities. Five major divisions have been identified within the field using objective clustering methods. This includes macro-economics, micro-economics, measurement and valuation of outcomes, monitoring mechanisms (evaluation), and guidance and appraisal. Along with the major divisions, analysis of document co-citation revealed eighteen specific research streams, each showing varying levels of activity.

Interestingly, there are few ‘hot topics’ emerging in health economics. One possible reason for this could be that the pace of research in health economics could be to some degrees determined by the field of economics and advancement within that mother field, which is considered slow-moving in terms of establishment of new trends [ 401 ]. Economists tend to be cautious in recognising emerging areas of research, and instead prefer to use an established knowledge base when supporting their research with previous literature.

In a world where digital transformation is changing the face of every industry, including health care, it is surprising that economic evaluation of digital health innovations has not emerged as a trending research topic. However, there are examples in the literature highlighting the complexities of economic analysis for digital health innovations, which may be stalling the progression of this research area [ 402 , 403 , 404 ]. As the knowledge foundation for these freshly emerging areas develop, subsequent analyses of similar nature may be able to detect them as emerging divisions. This knowledge foundation could currently be scattered and not established. The emergence and progression of such area, however, could be detectable with a time lag once the health economics literature begins to converge on a specific cohort of references as the knowledge base in this area.

A sharp rise in scholarly output in health economics was observed around 2005. This is likely around the time that DCEs and patient preference surveys became trendy in healthcare [ 405 ]. After heightened research activity in this area for a decade (2005–2015), the Patient Preference research stream has now passed its peak in specialised health economic journals. However, this does not necessarily mean that it is no longer trendy. In fact, it is known that DCEs have now been more widely adopted to elicit preferences for health care products and programs across most medical fields [ 164 , 406 ]. Peer-reviewed articles are now likely being published in discipline-specific or broader health journals (e.g., British Medical Journal, Health Service Research Journal), rather than the health economics sources used in this analysis.

The main body of this literature has been produced by six countries in Europe, North America and Australia. Since the inception and rapid growth of health economics in the early 1990s, contribution to scholarly literature from these six countries has mostly been consistent, aligning with reports by Wagstaff and Culyer [ 12 ]. Few non-OECD countries are included in the top contributors to this research field. For example, China, which now surpassed the USA as the largest producer of scientific research in certain disciplines [ 407 ], is not a major contributor to health economics research. However, this may be because China’s primary research foci are technological fields and chemistry, and not social sciences. It is also promising to see recent health economic research output increasing in Low- and Middle-Income Countries. Internationally collaborated research output appears to be moving closer to the domestic output, a promising sign of a connected research field. However, the diversity of health care systems and unique public health issues will likely ensure that domestic research continues to thrive. Applications of new knowledge are often exclusive to a standalone health care system.

It should be noted that the conclusions of this study rely only on a sample of the literature of health economics, by analysing the collective content of ten mainstream health economics journals. While large enough to identify the research trends in the field, as the main motive of the study, the underlying dataset does not necessarily embody the entire literature of health economics. This limitation is simply due to the fact that an attempt for obtaining the entirety of health economics literature seems impossible without jeopardising the dataset with too many false positives. However, it should also be considered that the analytic methodology from which the core findings have been obtained has been chosen such that trends can be identified with minimal sensitivity to missing items in the dataset. The methodology of document co-citation analysis that has produced the core findings of the study is fairly robust to the effects of sampling and potential missing items. This is simply due to the fact that, in this methodology, influential references as well as trends are identified by referring to the reference lists of the articles in the dataset. In other words, the entities of analysis are items listed as the references of the papers in the dataset as opposed to the articles of the dataset itself (as in an article bibliographic coupling analysis for example [ 408 , 409 ]). In a document co-citation approach, the formation of a cluster on topic X does not rely capturing all citing articles that have contributed to the creation of stream/cluster X. If a large enough subset of such citing articles are captured in the data, then stream X as well as its temporal trends will still manifest. This is particularly the case in relation to the major streams (as opposed top smaller/minor clusters) whose sensitivity to the sample is minimal. For that reason, the analyses of this study were limited exclusively to interpreting the major streams only and minor clusters were excluded from an in-depth interpretation. For a typical cluster on a topic such as X, it is possible that papers outside the content of the ten specialty journals (i.e., the current dataset) are also identifiable, in addition to papers related to such topic and disseminated in mainstream specialty journals. But so long as enough of such papers do exist within the content of specialty journals, then the cohort of references co-cited by those papers will still form that stream and topic X along with the temporal patterns of its evolution is still captured by the sample. In summary, the coverage of the underlying data of this study can be improved, but at the same time, we believe that the sensitivity of the main findings to potential missing literature is rather minimal.

The current state of research in health economics has brought valuable insight into healthcare interventions, market dynamics and behavioural factors. Health economics is a growing field, yet there is minimal evidence of creation of new research trends. This doesn’t necessarily indicate that there are no ‘hot topics’ in health economics, but likely that the new research is being disseminated in sources beyond the speciality journals. Over the past 10 years, the average rate of annual increase in internationally collaborated publications is almost double that of domestic collaborations (8.4% vs 4.9%), but most of the top scholarly collaborations remain between six countries only.

Several avenues for future research exist to deepen our understanding and address the evolving challenges in this field. By considering broader societal perspectives, embracing technological advancements, and integrating behavioural insights, health economist researchers can contribute to evidence-based policy-making and drive improvements in healthcare outcomes, efficiency, and equity.

Availability of data and materials

All data is available upon reasonable request to the corresponding author.

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Zwack, C.C., Haghani, M. & de Bekker-Grob, E.W. Research trends in contemporary health economics: a scientometric analysis on collective content of specialty journals. Health Econ Rev 14 , 6 (2024). https://doi.org/10.1186/s13561-023-00471-6

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Healthcare Expenditure and Economic Development Dynamics in India: Experiences from COVID-19 Pandemic

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The relationship between health and development is an important topic in the field of economics. India’s new Health Policy 2017 also acknowledges this relationship. The COVID-19 pandemic has exposed the chronic underinvestment in India’s healthcare system as India’s public healthcare system is facing a severe shortage of different resources and infrastructure. The present study aims to investigate the dynamics between healthcare expenditure- public health expenditure and private health expenditure and economic growth for the period from 1999 to 2018. The Johansen cointegration test exhibits that public health expenditures, private health expenditures, and economic growth are cointegrated, implying a long-run relationship between the variables concerned. The result of the Vector Error Correction Model represents that unidirectional causality between public health expenditure and economic growth and causality running from public health expenditure to economic growth exists and another unidirectional causal relationship which runs from economic growth to private health expenditure also exists for the sample period from 1999 to 2018. Block Exogeneity Wald Test has validated the results obtained from VECM. The impulse response functions and variance decomposition reveal weak causality (Granger) link between public health expenditure and economic growth and strong causal (Granger) relationship between Domestic private healthcare expenditure and economic growth during the study period. CUSUM and CUSUM-Square Test confirm that the parameters estimated by the model are stable for the period 1999 to 2018. The study concludes that the impact of public health expenditure on economic growth is relatively small, while economic growth on domestic private healthcare expenditure is relatively strong in India during the period of study.

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Saha, S. (2022). Healthcare Expenditure and Economic Development Dynamics in India: Experiences from COVID-19 Pandemic. In: Saha, S., Mishra, M., Bhuimali, A. (eds) Economic and Societal Transformation in Pandemic-Trapped India. New Frontiers in Regional Science: Asian Perspectives, vol 55. Springer, Singapore. https://doi.org/10.1007/978-981-16-5755-9_10

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Evaluating and Pricing Health Insurance in Lower-income Countries: A Field Experiment in India

Universal health coverage is a widely shared goal across lower-income countries. We conducted a large-scale, 4-year trial that randomized premiums and subsidies for India’s first national, public hospital insurance program, RSBY. We find roughly 60% uptake even when consumers were charged premiums equal to the government’s cost for insurance. We also find substantial adverse selection into insurance at positive prices. Insurance enrollment increases insurance utilization, partly due to spillovers from use of insurance by neighbors. However, many enrollees attempted to use insurance but failed, suggesting that learning is critical to the success of public insurance. We find very few statistically significant impacts of insurance access or enrollment on health. Because there is substantial willingness-to-pay for insurance, and given how distortionary it is to raise revenue in the Indian context, we calculate that our sample population should be charged a premium for RSBY between INR 500-1000 rather than a zero premium to maximize the marginal value of public funds.

This study was funded by the Department for International Development in the UK Government; the Tata Trusts through the Tata Centre for Development at the University of Chicago; the MacLean Center, the Becker-Friedman Institute, the Neubauer Collegium, and the Law School at the University of Chicago; the Sloan Foundation; SRM University; Northwestern University and the International Growth Centre. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

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A Systematic Review of the State of Economic Evaluation for Health Care in India

Affiliations.

• 1 School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India. [email protected].
• 2 School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India.
• 3 The George Institute for Global Health, Camperdown, NSW, 2050, Australia.
• 4 Health Policy Research Unit, Institute of Economic Growth, University of Delhi Enclave, Delhi, 110007, India.
• 5 Sydney Medical School, University of Sydney, Sydney, Australia.
• PMID: 26449485
• DOI: 10.1007/s40258-015-0201-6

Background and objective: Economic evaluations are one of the important tools in policy making for rational allocation of resources. Given the very low public investment in the health sector in India, it is critical that resources are used wisely on interventions proven to yield best results. Hence, we undertook this study to assess the extent and quality of evidence for economic evaluation of health-care interventions and programmes in India.

Methods: A comprehensive search was conducted to search for published full economic evaluations pertaining to India and addressing a health-related intervention or programme. PubMed, Scopus, Embase, ScienceDirect, and York CRD database and websites of important research agencies were identified to search for economic evaluations published from January 1980 to the middle of November 2014. Two researchers independently assessed the quality of the studies based on Drummond and modelling checklist.

Results: Out of a total of 5013 articles enlisted after literature search, a total of 104 met the inclusion criteria for this systematic review. The majority of these papers were cost-effectiveness studies (64%), led by a clinician or public-health professional (77%), using decision analysis-based methods (59%), published in an international journal (80%) and addressing communicable diseases (58%). In addition, 42% were funded by an international funding agency or UN/bilateral aid agency, and 30% focussed on pharmaceuticals. The average quality score of these full economic evaluations was 65.1%. The major limitation was the inability to address uncertainties involved in modelling as only about one-third of the studies assessed modelling structural uncertainties (33%), or ran sub-group analyses to account for heterogeneity (36.5%) or analysed methodological uncertainty (32%).

Conclusion: The existing literature on economic evaluations in India is inadequate to feed into sound policy making. There is an urgent need to generate awareness within the government of how economic evaluation can inform and benefit policy making, and at the same time build capacity of health-care professionals in understanding the economic principles of health-care delivery system.

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• A Systematic Review of Health Economic Evaluations and Budget Impact Analyses to Inform Healthcare Decision-Making in Central America. Rojas-Roque C, Palacios A. Rojas-Roque C, et al. Appl Health Econ Health Policy. 2023 May;21(3):419-440. doi: 10.1007/s40258-023-00791-y. Epub 2023 Jan 31. Appl Health Econ Health Policy. 2023. PMID: 36720754
• Comprehensive league table of cost-utility ratios: A systematic review of cost-effectiveness evidence for health policy decisions in India. Shah K, Singh M, Kotwani P, Tyagi K, Pandya A, Saha S, Saxena D, Rajshekar K. Shah K, et al. Front Public Health. 2022 Oct 13;10:831254. doi: 10.3389/fpubh.2022.831254. eCollection 2022. Front Public Health. 2022. PMID: 36311623 Free PMC article.

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100+ ICMR Research Topics: Unlocking Health Insights

The landscape of healthcare research in India has been significantly shaped by the endeavors of the Indian Council of Medical Research (ICMR). Established in 1911, the ICMR has played a pivotal role in advancing medical knowledge, informing health policies, and fostering collaborations to address pressing health challenges in the country.

In this blog, we embark on a journey through the corridors of ICMR research topics, shedding light on the council’s current and noteworthy research topics that are contributing to the nation’s health and well-being.

The Role of ICMR in Health Research

Table of Contents

The Indian Council of Medical Research operates as the apex body in India for the formulation, coordination, and promotion of biomedical research. With a mission to nurture and harness the potential of medical research for the benefit of society, ICMR has become a cornerstone in shaping health policies and practices. 

By fostering collaborations with researchers and institutions across the nation, ICMR has emerged as a driving force in advancing healthcare knowledge and outcomes.

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Understanding ICMR Research Methodology

The success of ICMR’s research lies not only in its expansive scope but also in its rigorous methodology and ethical considerations. ICMR has established guidelines that researchers must adhere to, ensuring that studies funded by the council are not only scientifically sound but also ethically conducted. 

This commitment to ethical research practices has been a cornerstone in building public trust and confidence in the findings generated by ICMR-funded studies.

100+ ICMR Research Topics For All Level Students

• Infectious Diseases: Emerging pathogens and control strategies.
• Non-Communicable Diseases (NCDs): Diabetes, cardiovascular research.
• Maternal and Child Health: Strategies for mortality reduction.
• Biomedical Research: Molecular insights into diseases.
• Cancer Research: Innovative approaches for treatment.
• Epidemiology: Studying disease patterns and trends.
• Vaccination Strategies: Enhancing immunization programs.
• Public Health Interventions: Effective community health measures.
• Antibiotic Resistance: Combating microbial resistance.
• Genetic Studies: Understanding genetic contributions to diseases.
• Neurological Disorders: Research on neurological conditions.
• Mental Health: Addressing mental health challenges.
• Nutrition and Health: Studying dietary impacts on health.
• Health Systems Research: Improving healthcare delivery.
• Ayurveda Research: Integrating traditional medicine practices.
• Environmental Health: Impact of environment on health.
• Emerging Technologies: Utilizing tech for healthcare innovations.
• Pharmacological Research: Advancements in drug discovery.
• Global Health Collaborations: International health partnerships.
• Waterborne Diseases: Prevention and control strategies.
• Health Policy Research: Shaping evidence-based policies.
• Health Economics: Studying economic aspects of healthcare.
• Telemedicine: Harnessing technology for remote healthcare.
• Rare Diseases: Understanding and treating rare disorders.
• Community Health: Promoting health at the grassroots level.
• HIV/AIDS Research: Advancements in HIV prevention and treatment.
• Aging and Health: Research on geriatric health issues.
• Cardiovascular Health: Preventive measures and treatments.
• Respiratory Diseases: Understanding lung-related conditions.
• Zoonotic Diseases: Investigating diseases transmitted from animals.
• Stem Cell Research: Applications in regenerative medicine.
• Yoga and Health: Studying the health benefits of yoga.
• Gender and Health: Research on gender-specific health issues.
• Oral Health: Preventive measures and treatments for oral diseases.
• Health Informatics: Utilizing data for healthcare improvements.
• Health Education: Promoting awareness for better health.
• Drug Resistance: Research on antimicrobial resistance.
• Hepatitis Research: Prevention and treatment strategies.
• Telehealth: Remote healthcare services and accessibility.
• Diabetes Management: Strategies for diabetes prevention and control.
• Tuberculosis Research: Advancements in TB diagnosis and treatment.
• Fertility Research: Understanding reproductive health issues.
• Artificial Intelligence in Healthcare: Integrating AI for diagnostics.
• Health Disparities: Addressing inequalities in healthcare access.
• Mental Health Stigma: Research on reducing stigma.
• Mobile Health (mHealth): Applications for mobile-based healthcare.
• Vector-Borne Diseases: Prevention and control measures.
• Nanotechnology in Medicine: Applications in healthcare.
• Occupational Health: Research on workplace health issues.
• Biobanking: Storing and utilizing biological samples for research.
• Telepsychiatry: Providing mental health services remotely.
• Health Equity: Promoting fairness in healthcare delivery.
• Community-Based Participatory Research: Engaging communities in research.
• E-health: Electronic methods for healthcare delivery.
• Sleep Disorders: Understanding and treating sleep-related conditions.
• Health Communication: Effective communication in healthcare.
• Global Burden of Disease: Research on disease prevalence and impact.
• Traditional Medicine: Studying traditional healing practices.
• Nutraceuticals: Research on health-promoting food components.
• Health Data Security: Ensuring privacy and security of health data.
• Regenerative Medicine: Advancements in tissue engineering.
• Social Determinants of Health: Studying social factors affecting health.
• Pharmacovigilance: Monitoring and ensuring drug safety.
• Gerontology: Research on aging and the elderly.
• Mobile Apps in Healthcare: Applications for health monitoring.
• Genetic Counseling: Supporting individuals with genetic conditions.
• Community Health Workers: Role in improving healthcare access.
• Health Behavior Change: Strategies for promoting healthier habits.
• Palliative Care Research: Enhancing end-of-life care.
• Nanomedicine: Applications of nanotechnology in medicine.
• Climate Change and Health: Impact on public health.
• Health Literacy: Promoting understanding of health information.
• Antibody Therapeutics: Advancements in antibody-based treatments.
• Digital Health Records: Electronic health record systems.
• Microbiome Research: Understanding the role of microorganisms in health.
• Disaster Preparedness: Research on health response during disasters.
• Food Safety and Health: Ensuring safe food consumption.
• Artificial Organs: Advancements in organ transplantation.
• Telepharmacy: Remote pharmaceutical services.
• Environmental Epidemiology: Studying the link between environment and health.
• E-mental Health: Digital tools for mental health support.
• Precision Medicine: Tailoring treatments based on individual characteristics.
• Health Impact Assessment: Evaluating the consequences of policies on health.
• Genome Editing: Applications in modifying genetic material.
• Mobile Clinics: Bringing healthcare to underserved areas.
• Telecardiology: Remote cardiac care services.
• Health Robotics: Utilizing robots in healthcare settings.
• Precision Agriculture and Health: Linking agriculture practices to health outcomes.
• Community-Based Rehabilitation: Supporting rehabilitation at the community level.
• Nanotoxicology: Studying the toxicological effects of nanomaterials.
• Community Mental Health: Strategies for promoting mental well-being.
• Health Financing: Research on funding models for healthcare.
• Augmented Reality in Healthcare: Applications in medical training and diagnostics.
• One Health Approach: Integrating human, animal, and environmental health.
• Disaster Mental Health: Addressing mental health issues after disasters.
• Mobile Laboratory Units: Rapid response in disease outbreaks.
• Health Impact Investing: Investing for positive health outcomes.
• Rehabilitation Robotics: Assisting in physical therapy.
• Human Microbiota: Understanding the microorganisms living in and on the human body.
• 3D Printing in Medicine: Applications in medical device manufacturing.

Success Stories from ICMR-Funded Research

Highlighting the impact of ICMR-funded research is essential in appreciating the council’s contribution to healthcare in India. From breakthrough discoveries to successful interventions, ICMR-supported studies have led to tangible improvements in health outcomes. 

Case studies showcasing the journey from ICMR research topics and findings to real-world applications serve as inspiring examples of how scientific knowledge can translate into positive societal impacts.

Challenges and Opportunities in ICMR Research

While ICMR has achieved remarkable success in advancing health research, it is not without its challenges. Researchers face obstacles in conducting studies, ranging from resource constraints to logistical issues. 

Acknowledging these challenges is crucial in finding solutions and optimizing the impact of ICMR-funded research. Additionally, there are opportunities for collaboration, both nationally and internationally, that can further enrich the research landscape and accelerate progress in addressing health challenges.

The Future of Health Research in India: ICMR’s Vision

Looking ahead, ICMR envisions a future where health research continues to play a central role in shaping the well-being of the nation. Strategic goals include harnessing the power of technology and innovation to drive research advancements, fostering interdisciplinary collaborations, and addressing emerging health challenges. 

The vision extends beyond the laboratory, emphasizing the translation of research findings into practical solutions that can positively impact the lives of individuals and communities across India.

In conclusion, the Indian Council of Medical Research stands as a beacon in the realm of healthcare research, tirelessly working towards advancements that contribute to the well-being of the nation. 

By exploring ICMR research topics, understanding its methodology, and reflecting on success stories, we gain insight into the transformative power of scientific inquiry. 

As ICMR continues to forge ahead, the future of health research in India looks promising, guided by a vision of innovation, collaboration, and a steadfast commitment to improving the health of all citizens.

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Sylvester Zhang awarded Doctoral Dissertation Fellowship

MINNEAPOLIS / ST. PAUL (6/28/2024) – School of Mathematics PhD student Sylvester Zhang was recently awarded the Doctoral Dissertation Fellowship from the University of Minnesota. The Doctoral Dissertation Fellowship (DDF) gives the University's most accomplished Ph.D. candidates an opportunity to devote full-time effort to an outstanding research project by providing time to finalize and write their dissertation during the fellowship year.

Sylvester Zhang started the University of Minnesota Mathematics PhD program in Fall 2020, after completion of his undergraduate studies in Mathematics and Economics here at UMN. Zhang is interested in algebraic combinatorics. In particular he aims to explore topics like total positivity, cluster algebras, symmetric functions, and the flag manifold. Advised by Pavlo Pylyavskyy, Zhang is currently primarily focused on two distinct research topics: 1) an approach to Schubert polynomials using methods from mathematical physics, and 2) affine symmetric group and combinatorics of the affine flag variety. He says he is looking forward to continuing a career in academia and research after graduation.

The University of Minnesota DDF program aims to give the most accomplished Ph.D. candidates – those who have passed the written and oral preliminary examinations and their program coursework – an opportunity to devote full-time effort to an outstanding research project by providing time to finalize and write their dissertation during the fellowship year. The fellowship grants awardees a $25,000 stipend, academic year tuition, subsidized health insurance through the Graduate Assistant Health Plan for up to one calendar year, and a $1,000 conference grant. 

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The role of pharmacoeconomics in current Indian healthcare system

Akram ahmad.

1 Department of Pharmacy Practice, Annamalai University, Annamalai Nagar, Tamil Nadu, India

2 Department of Clinical, Social and Administrative Sciences, University of Michigan, Ann Arbor, MI, USA

Sundararajan Parimilakrishnan

Guru prasad mohanta, haechung chung.

3 Department of Public Health Sciences, The Pennsylvania State University, Pennsylvania, USA

Jongwha Chang

Phamacoeconomics can aid the policy makers and the healthcare providers in decision making in evaluating the affordability of and access to rational drug use. Efficiency is a key concept of pharmacoeconomics, and various strategies are suggested for buying the greatest amount of benefits for a given resource use. Phamacoeconomic evaluation techniques such as cost minimization analysis, cost effectiveness analysis, cost benefit analysis, and cost utilization analysis, which support identification and quantification of cost of drugs, are conducted in a similar way, but vary in measurement of value of health benefits and outcomes. This article provides a brief overview about pharmacoeconomics, its utility with respect to the Indian pharmaceutical industry, and the expanding insurance system in India. Pharmacoeconomic evidences can be utilized to support decisions on licensing, pricing, reimbursement, and maintenance of formulary procedure of pharmaceuticals. For the insurance companies to give better facility at minimum cost, India must develop the platform for pharmacoeconomics with a validating methodology and appropriate training. The role of clinical pharmacists including PharmD graduates are expected to be more beneficial than the conventional pharmacists, as they will be able to apply the principles of economics in daily basis practice in community and hospital pharmacy.

INTRODUCTION

Healthcare community is ever more sensitive to costs, as the overall health expenditures are escalating. Accordingly, appraisal of goods and services in healthcare goes beyond evaluation of safety and efficacy in which the economic impact of these goods and services on the cost of healthcare is also considered. As in economics, efficiency is the key concept in the pharmacoeconomics, and this principle helps one to design strategies for buying the greatest amount of benefits for a given resource use.[ 1 ]

Resources such as materials and equipments allocated for healthcare are scarce; nevertheless, their possible usages are infinite. Hence, it is a challenge for healthcare professionals to provide quality patient care with minimum cost. Given the limitations on healthcare resources, there is increased interest in assessing the value for money, or economic efficiency of healthcare treatments and programs. Economic evaluation, analyzing costs and outcomes of several alternative therapies can also be a useful approach; though can be very difficult to accomplish.[ 2 ]

In an environment where the cost of healthcare is sky rocketing, insurers are looking for evidence that can support decisions that determine purchasing, contracting, and inclusion of new medications in the formularies. The producers of medications therefore, have to assess the value of the drugs, both in terms of economic worth and clinical efficacy.[ 3 ] “Doctors prescribe, patients consume and, increasingly throughout the world, third purchasing parties (government insurance companies) pay the bill with money that they have obtained from increasingly reluctant healthy members of the public”.[ 4 ] Pharmacoeconomics identifies, measures, and compares the costs and consequences of pharmaceutical products and services.”[ 5 ] It involves economic evaluation of drug development, drug production, and drug marketing, i.e., all the steps that take place from the time the drug is manufactured to when it reaches the patients.[ 6 ]

Pharmacoeconomics

The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) defines pharmacoeconomics as “the field of study that evaluates the behavior of individuals, firms, and markets relevant to the use of pharmaceutical products, services, and programs, and which frequently focuses on the costs (inputs) and consequences (outcomes) of that use”.[ 7 ]

Genesis of pharmacoeconomics

Pharmacy was finally recognized as a clinical discipline within the healthcare system in the early 1960s. At this time, disciplines within the pharmaceutical sciences such as clinical pharmacy, drug information, and pharmacokinetics became an important part of pharmacy education and sciences. Pharmacoeconomics developed its roots in 1970s.[ 8 ] The first book on health economics was published in 1973 and in 1978, McGhan, Rowland, and Bootman from the University of Minnesota introduced the concept of cost-benefit and cost effectiveness analysis.[ 9 ] Utilizing sophisticated pharmacokinetic protocols, Bootman, et al .,[ 10 ] published an early pharmacy research article in 1979 in which cost-benefit analysis was employed to appraise the outcomes of individualizing aminoglycoside dosages to severely burned patients with gram-negative septicemia. In 1983, Ohio State University College of Pharmacy initiated a specialized pharmacy academic program with the objective of providing an overview of the application of cost benefit and cost effective analysis in healthcare, with emphasis on their application to the delivery of pharmaceutical care.

Initially, defined as “analysis of the costs of drug therapy to healthcare systems and society”,[ 8 ] the actual term “pharmacoeconomics” first appeared in the literature in 1986 when Townsend's work was published to highlight the need to develop research activities in this new discipline. In 1992, a journal named “Pharmacoeconomics” was launched.

Methods of pharmacoeconomic analysis

Pharmaeconomic studies compare costs, clinical, and humanistic outcomes associated with different therapies. The evaluation mechanisms delineated are often helpful in demonstrating the cost impact of innovative treatments, granting greater acceptance by healthcare providers, administrators, and the public.

There are four major types of pharmacoeconomic analysis:

A: Cost-minimization analysis

B: Cost-effectiveness analysis

C: Cost-benefit analysis

D: Cost-utility analysis

Major types of pharmacoeconomic analysis, formula and application given in Table 1 .[ 1 , 11 , 12 ]

Major types of pharmacoeconomic analysis-definition, formula and applications[ 1 , 11 , 12 ]

Healthcare and financing system in India

The Indian pharmaceutical industry is a hub where medications can be produced at a low price and still be of international quality. It witnessed a robust growth from the production turnover of about 1.14 billion dollars in 1990 to over 22.73 billion dollars in 2009-10, comprising about Rs, 14.1 billion dollars of domestic market and 9.58 billion dollars of exports.[ 13 ] In terms of production, the India pharma industry ranks 3 rd on a global scale, whereas in terms of turnover worth, it ranks 14 th . Medication prices are among the lowest prices in the world. However, the overall expenses associated with medications continue to soar in the country.[ 13 ] Although India is a producer of abundance of quality drug at low cost, only one third of its population has access to essential medicines.

More than 68% (Census 2011)[ 14 ] of the population lives in villages and work on farms or perform other menial jobs and are paid on a day to day basis. In rural areas comprised of villages and small towns, primary health-centers and community health-centers are put into service by the state government. On the breadline, the rural population heavily depend on the government funded hospitals for procuring healthcare.

In India, allopathic and alternative medicine healthcare practices (Ayurveda, Unani, Siddha, and Homeopathy) operate side by side. Many patients switch from one practice to another when relief is not adequate. The quality of healthcare services is much better in the urban areas compared with rural areas. Some rural areas might have very minimalistic healthcare. The practice of procuring private healthcare for many people is on the rise. The challenge that the Indian government faces is to make healthcare affordable for the majority of people in the country who cannot afford healthcare. Allopathic medications have a big market in India. In 2004, 5.2% of nominal GDP was spent on producing allopathic medications which is equivalent to US $34.9 billion. In 2005-2009, it grew by 12% per annum, i.e., 5.5% of nominal GDP which is equivalent to US $60.9 billion. As far as the ratio of doctors and nurses to the population is concerned, it is 5.9 doctors, 0.8 nurses, and 0.47 midwives for 1,000 people, which adds up to 1.86 health workers for every 1000 populace. The statistics provided by the Union Ministry of Health and Family Welfare's Health Information of India state that in 2004, there were 67,576 government doctors in India who provided healthcare to 15,980 people.[ 15 ] Out of the $24 million spent on healthcare in India, about 77% money is spent on private healthcare, i.e., US $18.643 million. Of the 77% money spend on private healthcare; about 86% is out of pocket expenditure. The public sector expenditure is 21%, i.e. US $5.04 million and the external aids amounts to the remaining 2%, i.e., US $0.48 million.[ 16 ] Limited number of people have health insurance in India. The major issues that govern insurance penetration are the extent and type of coverage. About 10% of the total population has insurance through health financing schemes. The ironic situation is that the insurers leave out the poor and the ill population as they cannot afford the prepayment schemes. The insurance that people purchase voluntarily accounts for Rs. 4 billion, i.e., US $86.3 million, and is estimated to grow at a very fast pace.[ 17 ]

Applications of pharmacoeconomics

Historically, the principles of pharmacoeconomics were applied in the field of hospital pharmacy activities. The cost effectiveness data were used to support the addition or deletion of a drug to or from a hospital formulary. At present, the pharmacoeconomic assessment of formulary actions has become a standardized part of many pharmacy and therapeutic committees.

Pharmacoeconomic studies find value in

• Fixing the price of a new drug and re-fixing the price of an existing drug
• Finalizing a drug formulary
• Creating data for promotional materials of medicines.
• Compliance of requirement for drug license.
• Including a drug in the medical/insurance reimbursement schemes.
• Introduction of new schemes and programs in hospital pharmacy and clinical pharmacy.
• Drug development and clinical trials.[ 12 ]

Pharmacoeconomics and drug development

In India, the estimate for the development of New Chemical Entity (NCE) is often quoted at US $90-100 million due to lower input costs. For every 10,000 NCE in discovery, ten enter preclinical development, five enter human trials, and only one might be approved.[ 18 ] Accordingly, large amount of money spent on pursuing a useless chemical entity is borne by the consumer. Pharmacoeconomic studies may be planned and conducted at the clinical development stages (phases 1 to 3) and post-marketing research stage (phase 4). Subsequently, studies may need to be conducted at several stages of pharmaceutical research.[ 12 ]

Phase 1 trials

The initial clinical trial endeavors to determine the toxicity profile of the drug of interest in humans. It is during this stage that cost of illness studies should be accomplished to aid in deciding whether to further develop the drug and gather background data for future pharmacoeconomic evaluations or not. Cost of illness data may also aid in the development of preliminary models to assess the clinical benefits that must be achieved to have a marketable product.

Phase 2 trials

In phase 2 trials, the drug is administered to a limited number of patients with the target disease. During this phase, cost of illness studies can begin or continue, as can preliminary development of quality of life and recourse utilization instruments. Models can be refined as more information is available about the clinical aspects of the drug.

Phase 3 trials

Cost of illness data can be an important factor that can determine the marketability of drugs. In the phase 3 clinical trials, the drugs are administered to the patients similarly as they would be when they are marketed. At this stage, the discussion, planning, and pharmacoeconomic studies are of prime importance. It is recommended that clinical studies presenting pharmacoeconomic evaluation be conducted along with efficacy evaluation of the drugs. Even though pharmacoeconomic evaluations might be time consuming and may delay the new drug application (NDA) process, they should be done unless the drug is very innovative and has no other alternatives.

Phase 4 trials

Phase 4 trials consist of the post-marketing phase. Pharmacoeconomics can be applied to retrospective and prospective studies involving the drug. Pharmacoeconomic evaluations provide information about cost and outcomes of drugs in real life settings unlike clinical trials that are conducted in controlled settings. Pharmacoeconomic evaluations conducted during clinical trials give information about the efficacy of drugs, which in turn provide an approximation to the real world. Pharmacoeconomic evaluations and clinical trials can be conducted in conjunction with each other in several ways:

• A clinical trial can be designed to test the safety and efficacy of a drug, followed by a pharmacoeconomic evaluation.
• A clinical trial can be designed to conduct a pharmacoeconomic evaluation.
• Clinical data collected prospectively in a clinical trial can be used to conduct a retrospective or prospective pharmacoeconomic evaluation.[ 12 ]

Compliance of requirement for drug license and pharmacoeconomics

Evidence about drug quality, efficacy, and safety is an essential requirement for drug licensing and regulation. Given the ever-increasing healthcare costs, this evidence needs to be backed by evidence of cost-effectiveness as well. In simple words, evidence comparing the effectiveness of available treatments for a particular disease condition and their related costs need to be presented to the federal body before they are introduced in the market.

Australia was the first country to form evidence based guidelines about medication reimbursement on the basis of cost-effectiveness research. Since 1993, the Australian Pharmaceutical Benefit Scheme enforces the production of evidence about economic evaluation of the drug before its introduction in the market.[ 19 ] The drug manufacturer provides the submission form to the Pharmaceutical Benefits Advisory Committee for inclusion of the drug in the reimbursement list who then verify the evidence provided by the manufacturer. The committee provides recommendations to the health ministry about drug inclusion in the reimbursement list on the basis of evidence about its cost effectiveness. The final decision making by the policy makers about the cost-effectiveness of the drug is determined by the following factors:

• The importance of the clinical area
• The availability of alternative treatments
• The likely effect of listing on the healthcare system and other therapeutic activities
• The investment of the sponsor in primary research.

The committee is willing to introduce a “breakthrough” medication which might be a bit pricey, provided the manufacturer has invested considerably in its development and production in contrast to ‘me-too drugs’ which have similar counterpart's existent in the market. In spite of this, relative cost effectiveness is an important criterion. So, many other countries like UK, Belgium, Finland, Norway, Portugal, Sweden and Hungary also follow a similar process such as Australia. The Netherlands also introduced a formal process of economic evaluation in 2005. Germany has an institution for economic evaluation research and Spain has regional centers that perform health technology assessment. In Denmark, France, and Italy, pharmaceutical companies provide data about economic evaluation on a voluntary basis. These data when provided are given importance and consideration.[ 20 ] Food and Drug Administration (FDA) in United States and Central Drug Standard Control Organization (CDSCO) in India do not require an economic analysis for Drug approval. A new drug has to be approved for a program based on pharmacoeconomic analysis.

The formulary system

Formulary creation involves preparing, updating, and using a list of essential medications with their detailed information (formulary manual) and standard treatment guidelines (STGs). A formulary list is an indicator of good pharmaceutical practice and rational drug usage. The formulary consists of appropriate therapies and cost-effective medications which are of a good quality. It is a precise list which makes the process of procuring, storing, distributing, and using the drugs very easy.[ 21 ] The medications that are part of a formulary, have the following advantages:

• Availability of cost contained quality drugs: When medications are purchased in bulk, there is more price competition and “economies of scale” for procuring, storing, and distributing the quality drugs. This makes it possible to provide drugs at subsidized rates to people who require them the most.
• Provision of quality care: Healthcare personnel can be better trained to provide cost effective medications. Usage of cost-effective drugs will also make the practitioners prescribe fewer drugs whose drug interactions and adverse reactions they are aware of. This in turn will improve the provision of quality care as the selection of medication is evidence based.

The formulary system, right from the national level to the institutional level, can be strengthened with the help of studies in the areas. It will also help for the rationalization of the drug procurement system in the country and for the practical implementation of the standard treatment protocols.

HEALTH INSURANCE AND PHARMACOECONOMICS IN INDIA

In the Indian health insurance system, mostly inpatient services are covered, so it is necessary to stay for a day in the hospital to claim the insurance. This, instead of saving costs leads to cost inflation. It is necessary to have some mechanism in place, whereby the insurers can strike a contract with healthcare providers and healthcare systems that can help in cost containment,[ 21 , 22 ] There is an added need for insurance systems that encourage consumer to contain costs by providing incentives as well as contain their health expenditure.[ 23 ] In case of members with multiple coverage, it is necessary that the benefits offered and liability achieved are coordinated and regulated. There needs to be further expansion of insurance services other than inpatient services, and more focus should be placed on preventive care and wellness programs.[ 24 ]

By implementing pharmacoeconomic principle in the hospital administration and treatment protocols, both the patients and the insurance industry will benefit. Patients will receive better quality healthcare at reduced costs, and the insurance companies will be able to provide enhanced care to their clients at minimum cost.

Indian pharmacy practice and pharmacoeconomics

As third largest producer of drugs by volume, Indian pharmaceutical industry has diversity of medicines; yet, brand name prescriptions are the rule of the day. Formulary system is very weak and treatment protocols exist only in theory. The resources are scarce and competing programs are plenty in healthcare. The concept of healthcare insurance is yet to be popularized in the country.[ 1 ] Given the issues prevalent in the Indian healthcare system, pharmacoeconomics has many applications. Pharmacoeconomics can aid in decision making when evaluating the affordability of and access to the right medication to the right patient at the right time, comparing two drugs in the same therapeutic class or drugs with similar mechanism of action, and in establishing accountability that the claims by a manufacturer regarding a drug are justified.

Practicing pharmacists in community, hospital, and clinical settings in India can benefit considerably from the application of the principles of pharmacoeconomic into their normal practice settings. Proper application of pharmacoeconomics will empower the pharmacy practitioners and administrators to make better and more informed decisions regarding products and services they provide. Pharmacotherapy decisions traditionally depended solely on clinical outcomes like safety and efficacy, but pharmacoeconomics teaches us that there are three basic outcomes to be considered clinical, economic, and humanistic in drug therapy. It is accepted by all that appropriate drug selection decisions could not be made today based on acquisition costs only. Applied pharmacoeconomics can help in decision making, in assessing the affordability of medicines to the patients, access to the medicines when needed, and comparing various products for treatment of a disease. It will provide evidence contraindicating the promotion of certain types of high-cost medicines and services.

Pharmacoeconomics has use in health policy decision making and can be applied by a number of healthcare professionals such as policy makers, primary healthcare providers, health-care administrators, and health managers. Available in large quantities, Indian primary care providers are often bombarded with many new drugs of the same category, in addition to the existing drugs. Introduction of new drugs can confuse the doctors and administrators for the judicious selection and rational use of medicines. When introducing new medications, its outcome should be equal or more effective compared to the existing drug and shall have some economic or related advantage.

Evidence about pharmacoeconomics can aid pharmacists and policy makers in the decision-making process about the use of medications and healthcare services. With clinical training about self-medication, Ayush physicians, i.e., Ayurvedic and Naturopathic physicians focus more on diagnostic rather than therapeutic skills, and they do not know much about the drugs, i.e., the brand name, the strength, the formulation, and the dose in specific conditions. Pharmacological and pharmacoeconomic knowledge is acquired and can be applied in practical prescribing skills. Conventional pharmacists also don’t know much about proper medication use. Present qualification of pharmacist in India is Diploma in pharmacy (2-year study, plus 500 h practical training in hospital) and B.Pharm 4-year degree program and its curriculum does not provide sufficient information, practice, and knowledge about pharmacoeconomics. To overcome such a dilemma, the government of India introduced a new program in pharmacy education named PharmD (2008), which highlights the principles of pharmacoeconomics in its syllabus. Consequently, we can expect the future M.pharm pharmacy practice and new generation of clinical pharmacists and PharmD graduates to be more beneficial than conventional pharmacist as they can be expected to implement the principles of economics in daily basis practice in community and hospital pharmacy.

With ever increasing healthcare costs, value added care provided to the patients by individual healthcare institution needs to be further researched. The development of pharamcoeconomics is at an infancy stage in India at the moment, despite the rapid growth of clinical research. India is an affordable destination for conducting clinical research for many western countries. The India Chapter of ISPOR has been formed, but it needs to develop the platform for pharmacoeconomics. We hope in India clinical pharmacists including PharmD graduates be more beneficial than conventional pharmacists as they can implement the principles of economics in daily basis practice in community and hospital pharmacy.

AUTHORS’ CONTRIBUTION

All authors have significantly contributed to the project in terms of conceptualization, writing and reviewing the entire document.

Source of Support: Nil

Conflict of Interest: None declared.

Advancing social justice, promoting decent work ILO is a specialized agency of the United Nations

Main Figures on Forced Labour

27.6 million

people are in forced labour.

US$ 236 billion

generated in illegal profits every year.

3.9 million

of them are in State-imposed form of forced labour.

of them are women and girls (4.9 million in forced commercial sexual exploitation, and 6 million in other economic sectors).

of them are children (3.3 million). More than half of these children are in commercial sexual exploitation.

3 times more

risk of forced labour for migrant workers.

• Victims of forced labour include 17.3 million exploited in the private sector; 6.3 million in forced commercial sexual exploitation, and 3.9 million in forced labour imposed by State.
• The Asia and the Pacific region has the highest number of people in forced labour (15.1 million) and the Arab States the highest prevalence (5.3 per thousand people).
• Addressing decent work deficits in the informal economy, as part of broader efforts towards economic formalization, is a priority for progress against forced labour.

Source: 2022 Global Estimates

Forced Labour Observatory

The Forced Labour Observatory (FLO) is a database that provides comprehensive global and country information on forced labour, including on international and national legal and institutional frameworks; enforcement, prevention and protection measures, as well as information related to access to justice; remedies, and cooperation.

Global Reports

2021 Global Estimates of Modern Slavery: Forced Labour and Forced Marriage

The latest estimates show that forced labour and forced marriage have increased significantly in the last five years, according to the International Labour Organization, Walk Free and the International Organisation for Migration.

• Full Report
• Executive Summary
• Press Release
• Third estimates: Modern Slavery (2017)
• Second estimates: Forced Labour (2012)
• First estimates: Forced Labour (2005)

Profits and Poverty: The Economics of Forced Labour (2024)

The study investigates the underlying factors that drive forced labour, of which a major one is illegal profits.

• Press release
• First edition of the report and second estimates (2014)
• First estimates of illegal profits from forced labour (2005)

Main Statistical Tools on Forced Labour

• Hard to See, Harder to Count: Guidelines for Forced Labour Surveys
• Ethical Guidelines for Research on Forced Labour
• Evidence Gap Map on Forced Labour
• Global Research Agenda (child labour, forced labour and human trafficking)

ICLS and forced labour

The International Conference of Labour Statisticians (ICLS) is the authoritative body to set global standards in labour statistics. During its 20th meeting, in October 2018, the ICLS adopted the "Guidelines concerning the measurement of forced labour". The intent of the guidelines is to facilitate the process of testing the measurement of forced labour in different national circumstances and/or measurement objectives.

• Guidelines concerning the measurement of forced labour (ICLS 2018)
• Measurement of forced labour: stocktaking and way forward (ICLS 2023 Room document 22)
• All ICLS documents