Access to Medicines through Universal Health Coverage (UHC): Golden Ring or Trojan Horse?

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):

Golden Ring or Trojan Horse?

Jonathan D. Quick, MD, MPH1, 2

Kwesi Eghan1

Anita Wagner2

[email protected] Sciences for Health2 Harvard Medical School WHO Collaborating Center

in Pharmaceutical Policy


Amina’s story – the year 2000


Is access to medicines through UHC a “Golden Ring” that improves health outcomes and financing equity?


Or is access to medicines through UHC a Trojan Horse that threatens program viability?


Access to medicines through UHC:Golden Ring or Trojan Horse?

1. Impact of out-of-pocket health and medicines spending in low and middle income countries

2. The growing movement for universal health coverage through strong health systems

3. Providing access to medicines through universal health coverage programs


Unfair health financing – high out-of-pocket spending where total health spending is lowest

www.gapminder.org/

Total health spending per person (international $), Log Scale

Out

-of-p

ocke

t (O

OP)

shar

e of

to

tal h

ealth

spen

ding

(%)

Total health spending per person (international $), Log Scale

http://www.gapminder.org/


Healthcare impoverishment – 150 million suffer financial catastrophe, 100 million impoverished

WHO, World Health Report, 2010


All 44%

Some

24%

None32%

Tanzania, 2002, WHO essential medicines project

All 83%

None2%

Some

15%

Healthcare gap - 1/3 of poor people with acute illness receive none of the prescribed medicines

% respondents with recent acute illness receiving prescribed medicines, Tanzania, 2002

Low Income High Income







The UHC movement – Growing “buzz” around UHC at all levels – country, regional, and global

Stated interest in achieving UHC

Implementing UHC reforms


The UHC approach – common core principles, country-specific adaptations

Pre-Payment

Risk Pooling

Contributions – based on ability to pay

General taxes, payroll taxes, other sources

Reduced OOP Spending

Pooling of risk across the population

Cross-subsidization: rich to poor, healthy to sick

Most services with minimal or no out-of-pocket charge at the point of service

Common Core Principles Country Models Vary Widely

Tax-based Contributions in form

of general taxes

Social Health Insurance

Mixed Model

Primarily financed by payroll contributions

Mix of tax-based financing, payroll, other sources


The UHC vision – “Access for all to appropriate health services at an affordable cost” (WHO, 2005)

Laudable but

Unrealistic

Feasible and

InevitablePolicy influence

· High–level advocacy· Analysis and evidence· Country networks/capacity

World Coverage: 40%

OOP Expenditure: 60%

World Coverage: 80%

OOP Expenditure: 30%

*WHA Resolution 58.33 Geneva: WHO; 2005. www.who.int/gb/ebwha/pdf_files/WHA58/WHA58_33-en.pdf







Access to medicines through universal health coverage: What’s at stake?

The Golden Ring• greater health impact• reduced medical impoverishment• increased UHC acceptance

The Trojan Horse • excess demand for high cost medicines• adverse impacts of cost controls• more fraud and abuse


Thailand – evolving expansion of coverage over more than four decades

Sources: www.jointlearningnetwork.org/ and McKinsey Co 2010

Year, policy, population coverage as of 2007

(Bold = still operational)1963 – Civil Servants Medical Benefits

Scheme 8%1975 – Free medical care for low

income 1990 – Voluntary public health

insurance 1992 – Compulsory Social Security

Scheme 13%1993 – Free care for children 1995 – Free care for the elderly 2001 – Universal Coverage Scheme

(UCS/”30-Baht”) 75%Private Health Insurance 2% Year

1994 1996 1998 2000 2002 2004 2006 200820

25

30

35

40

45Out-of-pocket spending as percent of

total health expenditures

70% of population covered (1995)

96% of population covered (2003)

UHS/30 Baht Scheme (2001)

http://www.jointlearningnetwork.org/

http://qldfutsal.sportzvault.com/files/31163/images/New%20Folder/Michael/thailand%20flag.png


Medicine cost escalation & response – Thailand’s Civil Servant Medical Benefit Scheme

1999 2000 2001 2002 2003 2004 2005 2006 2007 20080

10,000

20,000

30,000

40,000

50,000

60,000

Out-patient Drugs In-patient Drugs Total

THB

Mill

ion

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


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

Less than 1% of population covered (2000)

45-70% of population covered (2008)

NHIS created (2004)

https://www.cia.gov/library/publications/the-world-factbook/graphics/flags/large/gh-lgflag.gif


Ghana – expanding coverage, rising total claims, substantially increasing drug costs

2006 2007 20080

20

40

60

80

100

120

140

0%5%10%15%20%25%30%35%40%45%50%

25%

42%46%

Drug Costs as a Percent of Total National Health Insurance Claims Cost

Total drug cost Total claims cost Percent of drugs of total claims cost

Valu

e in

Gha

naia

n Ce

dis

(mil-

lions

)

Source: Roberts and Reich, 2011, data from Mensah and Acheampong 2009


Pharmaceutical management strategies for value in UHC - access, appropriate use, affordability, quality

Payment Mechanisms• Patient focused: co-payments, tiered

co-payments, deductibles, coverage limits

• Provider focused: fee-for-service, capitation, case-based (“DRG”), pay-for-performance (P4P)

Performance Management• Contracting, purchasing• Supply chain management• Preferred pharmacy networks• Quality of products and services• Fraud detection systems• Financial management, audits

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


7 proposed best practices for maximum health impact and value

1. Stakeholder engagement and communication – the public, patients, providers, healthcare managers, policy-makers, politicians

2. “Smart” therapeutics – priority health problems, outpatient coverage, essential medicines, clinical guidelines,

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


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


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?


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


Amina’s story – the year 2011 – a happy ending?


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

Medicines and Insurance Coverage Initiative

WHO Collaborating Centerin Pharmaceutical Policy

http://www.whoccpp.org/research/medic.asp

http://www.whoccpp.org/research/medic.asp

Access to Medicines through Universal Health Coverage (UHC): Golden Ring or Trojan Horse?

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