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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):
Golden Ring or Trojan Horse?
Jonathan D. Quick, MD, MPH1, 2
Kwesi Eghan1
Anita Wagner2
1Management Sciences for Health2 Harvard Medical School WHO Collaborating Center
in Pharmaceutical Policy
2Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
Amina’s story – the year 2000
3Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
Is access to medicines through UHC a “Golden Ring” that improves health outcomes and financing equity?
4Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
Or is access to medicines through UHC a Trojan Horse that threatens program viability?
5Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
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
6Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
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)
sha
re o
f to
tal h
ealth
spe
ndin
g (%
)
Total health spending per person (international $), Log Scale
7Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
Healthcare impoverishment – 150 million suffer financial catastrophe, 100 million impoverished
WHO, World Health Report, 2010
8Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
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
9Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
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
10Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
The UHC movement – Growing “buzz” around UHC at all levels – country, regional, and global
Stated interest in achieving UHC
Implementing UHC reforms
11Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
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
12Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
The UHC vision – “Access for all to appropriate health services at an affordable cost” (WHO, 2005)
Laudable but
Unrealistic
Feasible and
Inevitable
Policy 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
13Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
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
14Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
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
15Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
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)
16Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
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
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
Less than 1% of population covered (2000)
45-70% of population covered (2008)
NHIS created (2004)
18Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
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
19Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact
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
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
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
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
Medicines and Insurance Coverage Initiative
WHO Collaborating Centerin Pharmaceutical Policy