1 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact Stronger health systems. Greater health impact. Access to Medicines through Universal Health Coverage (UHC): Golden Ring or Trojan Horse? Jonathan D. Quick, MD, MPH 1, 2 Kwesi Eghan 1 Anita Wagner 2 [email protected]1 Management Sciences for Health 2 Harvard Medical School WHO Collaborating Center in Pharmaceutical Policy
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1 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact Stronger health systems. Greater health impact. Access.
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1Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
Stronger health systems. Greater health impact.
Access to Medicines throughUniversal Health Coverage (UHC):
2009 Measures 2010 Measures Drug use audits , 14 hospitals Generic substitution Prescribing restrictions Proposal for uniform pricing
Audits expanded to 34 hospitals Stronger generic substitution Prescribing further restricted Prescribing guidelines strengthened Approval by “medical audit” team
Source: IMS Thailand, 2011
17Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
UHC in action – moving toward UHC in Ghana through health spending and reform
McKinsey Co 2010
1985: cash-and-carry fees
1990s: health sector decentralized
2000: New Patriotic Party wins with promise to replace cash-and-carry
2004: National Health Insurance Scheme created (NHIS) created
Financed from: (a) health insurance tax, (b) formal sector employees, (c) member premiums, (d) investment income
Accredited service providers: clinics, hospital, pharmacies, licensed chemical sellers (LCS)
1994 1996 1998 2000 2002 2004 2006 200835
40
45
50
55
Out of pocket spending as percent oftotal health expenditure
Medicine Benefits and Use• Essential medicines lists• Tiered formularies• Clinical guidelines • Treatment algorithms • Provider and patient education• Utilization review and feedback
Cost Control – Value for Money• Reimbursement lists and policies• Generic/therapeutic substitution• Step therapy, prior authorization• Maximum allowable cost• Reference pricing, other price controls
20Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
7 proposed best practices for maximum health impact and value
1. Stakeholder engagement and communication – the public, patients, providers, healthcare managers, policy-makers, politicians
3. Value-based policy design – incentivize most appropriate use 4. Increased efficiency – generic/therapeutic substitution, efficient
procurement and distribution systems5. Reliable partners – accredited health providers and dispensing
outlets, competitive sourcing from quality assured suppliers6. Performance management – robust management systems for
inventory management, drug use review, fraud detection7. Culture of adaption – learning from others, benchmarking, routine
monitoring, evaluation, based on what’s working and what isn’t
21Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
7 common threats to medicines benefits – adverse health impacts, rising costs, poor quality
1. Competing political and policy goals – coverage, affordability, quality, industry interests
2. Weak governance and accountability structure – oversight body/board, public reporting, independent audit
3. Insufficient responsiveness to stakeholders – patients, the public, providers, private sector, others
4. Incomplete program design – focusing on some elements (e.g.benefits, co-payments) but not others (e.g. supply chain management, quality)
5. Failure to fully utilize needed expertise – success requires input from pharmaceutical management, public health, insurance, other experts
6. Inadequate adaptation to local context – modeling other countries or implementing “expert advice” without building on local strengths
7. Failure to ‘keep up’ and manage growth – essential medicine list/formulary, disease categories, population and geographic coverage
22Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
Expanding the 3 dimensions of medicines coverage: Who? What? How much?
WHO, World Health Report, 2010
2. What are they covered for?
3. How much are they covered for?
1. Who is covered?
23Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
Summary and conclusions
1. Medicines benefits in UHC programs: • Are essential for both health and fair financing goals• Arguably pose the largest financial risk to UHC programs
2. There are critical research priorities, including:• What is the best design for medicines benefit packages?• How do specific coverage policies impact access, affordability,
quality use, health and economic outcomes, sustainability?• How can UHC programs best cover innovative high-cost
medicines that may provide substantial benefits?
3. Expertise from multiple disciplines is required:• Medicine, pharmacy, pharmaceutical management• Economics, financing, accounting• Law, ethics, information technology
24Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
Amina’s story – the year 2011 – a happy ending?
25Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
Medicines and UHC: Share experiences, plan policy and research agenda, learn more
Friday, 18 November 2011, 7:45am to 8:45am, AzuritHealth Insurance Coverage of Medicines: Policy and Research Recommendations
MDS-3: Managing Access to Medicines and Other Health Technologies, 2011