Prescribing Cultures and Pharmaceutical Policy in the Asia … · 2018-05-14 · Prescribing Cultures and Pharmaceutical Policy in the Asia-Pacific Medicines Access, Affordability,

Prescribing Cultures and PharmaceuticalPolicy in the Asia-Pacific

Medicines Access, Affordability, and Use:The Role of Health Insurance Systems

Anita WagnerDepartment of Population Medicine

WHO Collaborating Center in Pharmaceutical Policy

Harvard Medical School & Harvard Pilgrim Health Care [email protected]

23 September 2009

Infant mortality: 37/1,000<5 mortality: 39/1,000Maternal mortality: 72/100,000Life expectancy: 13 years less

Infant mortality: 11/1,000<5 mortality: 14/1,000Maternal mortality: 54/100,000Life expectancy: 13 years more

Equity in Access?

World Health Survey 2002

WHS 2002: % Households with 4-week HealthExpenditures >40% of Non-Food Items

0

5

10

15

20

25

30

35

40

Bangladesh China India Lao People'sDemocratic

Republic

Malaysia Myanmar Pakistan Philippines Viet Nam

% H

ouse

hold

s w

ith H

igh

Fina

ncia

l Hea

lth C

are

Bur

den

Many families are at risk of catastrophic health expenditures

World Health Survey 2002

Many Households Use Savings,Borrow, Sell Assets to Pay for Care

0

10

20

30

40

50

60

Bangladesh China India Lao People'sDemocratic

Republic

Malaysia Myanmar Nepal Pakistan Philippines Viet Nam

% H

ouse

hold

s w

ith U

ndes

irabl

e C

opin

g St

rate

gies

A pig must be taken to the market everytime an ambulance siren wails.

A year’s work is ruined as soon as yousleep in a hospital bed.

And if you are struck with a seriousillness, 10 years of savings go up insmoke.

Chinese Saying

World Health Survey 2002

For Many Households, All HealthCare Spending is on Medicines

0

10

20

30

40

50

60

70

80

Bangladesh China India LaoPeople's

DemocraticRepublic

Malaysia Myanmar Nepal Pakistan Philippines Sri Lanka Viet Nam% H

ouse

hold

s Sp

endi

ng 1

00%

of H

ealth

Car

e on

Med

icin

es

Quality Use?• Overuse/misuse

– China: <2% of prescriptions c/w clinical practice• Penicillin injections for rheumatoid arthritis• 70% of village prescriptions antibiotics• 98% of common colds with antibiotics• 50% of antibiotics prescriptions unnecessary

• Underuse– Chronic disease treatment

• Product quality– >15% of drugs sold worldwide are fakes, in parts of

Africa & Asia >50%

Pharmaceutical Policy ObjectivesCompete

Improving EquitableAccess

Available to the poor

Keeping CostsAffordable

To patient and to thehealth system

EncouragingAppropriate Use

Necessary, safe, effective,properly taken

taxe

s

Consumers Providerspayment

treatment

Government(MOH)

infor

mat

ionstandards, paym

entsoversight

support

standards,education

ProfessionalOrganizations

lobbyingConsumerOrganizations

lobbying

information

A Complex Network of Key Actorsin the Pharmaceutical Sector

DrugIndustry

standards

$$

lobbying$$

marketi

ng promotioninformationinformation HealthInsurance

payment payment,controls

productpayment

- Leverage for Change

• Need for value– Most health for $

• Defined population targets– Members– Providers

• Information through data– Need– Services– Costs

• Policy tools– Cost– Quality– Value

HealthInsurance

Modified after JHSPH OpenCourseWare: Pharm. Mgmt for Under-served Pops, S4

Key Tools to Improve Managementand Use of Medicines

List of common diseases

Standard treatment guidelines Essential medicines list

FinancingProcurement

Reimbursement

EducationSupervisio

nIncentives

Treatment choice

Pharmaceutical Policy Options

• Cost focused– “Active purchasing”

• Contracting with suppliers• Contracting with providers

– Formulary controls• Financial (cost-sharing) incentives to incentivize general or

specific drug use

• Quality focused– Utilization management

• Education via academic detailing, profiling, diseasemanagement, pay-for-performance

• Cost & Quality = Value focused– Low (no) cost-sharing for high value care

Kaiser Family Foundation 2008

ICIUM 2004

A Global Agenda forPolicy and Research inUse of Medicines

www.icium.org

History

• ICIUM 2004 (www.icium.org)– Improve access to and use of medicines– Need for sustainable system-level efforts

• Medicines and Insurance Coverage(MedIC) Initiative– Collaborative capacity building– Applied policy research & evaluation– Standard performance measures– Networking, experience, tools sharing

Capacity Building

Manila, 2007 Accra, 2008

Beijing, 2009

Collaborative Research

Health Insurance and Access to,Affordability, and Use of Medicines

• Huge need• Tremendous opportunities• Different approaches• Similar strategies

– Capacity building– Evidence generation– Policy implementation– Evaluation & monitoring

Additional Slides

Kaiser Family Foundation 2008

Internationalmanufacturers

Drug importers Domesticmanufacturers

SUPPLY Manufacture & importOther key stakeholders:• Drug regulatory agency• Manufacturers

associations

`

Wholesalers anddistributors

Private andNGO facilities

Private physicians/other providers

Pharmacies andretail outlets

Private sector supplyOther key stakeholders:• Wholesale & pharmacy orgs• Professional associations• Health delivery systems

Governmentprocurement

systems

Governmenthealth facilities

Public sector supply

Consumers andpatients

Insuranceand riskcarriers

Consumer demand

DEMAND

Other key stakeholders:• Consumer & patient orgs• Third party payers• Employers

Pharmaceutical System and Leverage Points

Kaiser Family Foundation 2008

Source: SSDS Inc for the World Bank

Complexity of Public SectorMedicines Supply in Kenya

Contra-ceptives and

RHequipment

STIDrugs

EssentialDrugs

Vaccinesand

Vitamin ATB/Leprosy

BloodSafety

Reagents(inc. HIV

tests)

DFI

D

KfW

UNICEF

JICA

GOK, WB/IDA

Source offunds for

commodities

CommodityType

(colour coded) MOHEquip-ment

Point of firstwarehousing KEMSA Central Warehouse

KEMSARegional

Depots

Organizationresponsible

for delivery todistrict levels

KEMSA and KEMSA Regional Depots (essential drugs, malaria drugs,

consumable supplies)

ProcurementAgent/Body

CrownAgents

Governmentof Kenya

GOK

GTZ(procurement

implementationunit)

JSI/DELIVER/KEMSA LogisticsManagement Unit (contraceptives,

condoms, STI kits, HIV test kits, TBdrugs, RH equipment etc)

EU

KfW

UNICEF

KEPI ColdStore

KEPI(vaccines

andvitamin A)

Malaria

USAID

USAID

UNFPA

EUROPA

Condomsfor STI/

HIV/AIDSprevention

CIDA

UNFPA

USGov

CDC

NPHLS store

MEDS(to Mission

facilities)

PrivateDrug

Source

GDF

Government

NGO/Private

Bilateral Donor

Multilateral Donor

World Bank Loan

Organization Key

JapanesePrivate

Company

WHO

GAVI

SIDA

NLTP(TB/

Leprosydrugs

Commodity Logistics System in Kenya (as of July 2006) Constructed and produced by Steve Kinzett, JSI/Kenya - please communicateany inaccuracies to [email protected] or telephone 2727210

Anti-RetroVirals

(ARVs)

Labor-atorysupp-

lies

GlobalFund forAIDS, TB

and Malaria

PSCMC(CrownAgents,GTZ, JSI

and KEMSA)

BTC

MEDS

DANIDA

Mainly District level staff: DPHO, DPHN, DTLP, DASCO, DPHO, etc or staff from the Health Centres,Dispensaries come up and collect from the District level

MEDS

Provincial andDistrictHospital

LaboratoryStaff

Organizationresponsible fordelivery to sub-district levels

KNCV

MSF

MSF

JSI/DELIVER

KEMSA

JSI

WHO

Increasing Need for Medicines:DM 2003 & 2025

Kaiser Family Foundation 2008

Source: WHO, World Health Survey, 2002

Average 4-week Medicine Expenditureswithin Household Expenditure Quintiles

$0

$10

$20

$30

$40

Ghana Coted'Ivoire

Senegal Morocco

Tunisia India

Pakistan Philippines

Med

icin

e E

xp

end

itu

res

in L

ast

4

Wee

ks b

y Q

uin

tile

s

Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5

$88$153

Poor families cannot afford to pay for medicines

Source: National Health Accounts, 2004

OOP Expenditures Finance HealthCare in Low-Income Countries

852628721491High

8513169112Medium

910722823Low

Out-of-pocket (% of

private)

Socialsecurity

(% ofgovern-ment)

Private (%of total)

Govern-ment (%of total)

Per capita(US$)

Countryincome

level

Median Expenditures on Health in Asia Pacific Countries

Source: WHO World Health Survey, 2002

Most OOP Costs Spent onMedicines

15.65.218.225.948.475th percentile8.91.59.413.436.825th percentile

11.74.214.423.646.7Median8.95.021.927.237.0Vietnam

28.95.214.322.728.8Malaysia18.81.714.728.736.1Sri Lanka14.51.09.824.450.2Philippines

…

9.93.316.925.444.4India

8.71.025.943.121.3China13.65.08.16.367.1Bangladesh

OthersTraditionalOutpatientInpatientMedicines

Source: International Diabetes Federation

The Poor Pay Relatively More

Source: WHO-Health Action International Medicines Price Database

Medicines are Expensive in PrivateRetail Outlets in Many Countries

Median Low Price Generic = 3.4

Median Originator Brand = 12.2

35.8->

52.8->

42.6->

Source: WHO Country Pharmaceutical Indicators, 2006

Medicines Are Unaffordable toMany People in Poor Countries

Key Pharmaceutical Policy Questions

• How to select medicines for reimbursementfrom or in addition to an essentialmedicines list?

• How to manage a formulary process?• How to incentivize evidence-based

treatment according to standard treatmentguidelines?

• How to create basic information or combineinformation from multiple large scale datasources to track use and cost?

More targetedor tailored

More policy orsystems-oriented

Improved use of medicines

EconomicGive incentives, penalize, subsidize Differential generic/brand copayments Restrict reimbursement to essential drugs Pay for performance contracts

ManagerialGuide, systematize, facilitate

Treatment guidelines for providersConsumer price informationFeedback about generic prescribing

RegulatoryRegulate, prohibit, sanction

Provider standards and certification Mandatory generic substitution Fraud detection systems

EducationalInform, persuade, motivate

Educational outreach to practice groups Diabetes management groups for patients TV/radio educational spots

Improving Medicines Use