Universal Health Coverage – Achieving Access and Responsible

Use of Medicines 2015 AGM Of The Pharmaceutical Society of Ghana

Thematic Speaker Emmanuel Kwesi Eghan B Pharm, MBA, MSc Health &

Pharmaco-Economics

Email: keghan@msh.org

Kwesi Eghan PSGH AGM 2015 1

Kwesi Eghan PSGH AGM2015 2

What is Universal Health Coverage (UHC)?

• Achieving access for all people to key promotive, preventive, curative, and rehabilitative health interventions at an affordable cost, thereby achieving equity in access.

• The ultimate goal of UHC is ensuring that– all people obtain needed health services and essential

health technologies –including, medicines and diagnostics-

– without suffering financial hardship when paying for them.

What is Universal Health Coverage

• “UHC implies that • all people

• have access to • nationally determined sets of

• needed • quality

• health services and essential medicines, • without discrimination or • risking impoverishment.”

Kwesi Eghan PSGH AGM 2015

UHC- An aspirational goal

• A key challenge is how countries fulfill the promise of delivering UHC ?

• How do countries with their finite resources, working within weak health and financial systems attain UHC?

Kwesi Eghan PSGH AGM 2015

GLOBAL DECLARATIONS

• December 12, 2014: Launch of first Universal Health Coverage Day – an effort to accelerate reforms leading to health coverage for all

• The Post MDG- Sustainable Development Goals (SDGs) is billed to include a health goal (Goal 3) comprising 13 targets, including target 3.8 for UHC: “Achieve UHC, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.”3,4

• Increased focus of governments in LMICs on National Health Insurance Schemes,

So why Universal Health Coverage ?

• Unfair health financing – High Out-of-Pocket (OOP) payments

• Increase catastrophic expenditures leading impoverishment

• Human rights

Most OOP Payment for Medicines

WHO, World Health Report, 201010

57% Public

45% Private

UHC General Principles & Design

Kwesi Eghan PSGH AGM 2015

UHC - Key enabling factors for sustainability

• Political will and stewardship • Levels of income and the rate of economic

growth• Structure of the economy • Distribution of the population• Ability to administer• The level of solidarity

Kwesi Eghan PSGH AGM 2015

But the paths are different

• Each country travels a unique path towards UHC

• This path is guided by its own history, politics (of which Ghana has its fair share to talk about) existing labour, health and financing structures

And The Devil is in the details

• “ Successful public policies and programs are rare because it is unusual to have progressive and committed politicians and bureaucrats (saints) supported by appropriate policy analysts with available and reliable information (wizards), that manage hostile and apathetic groups (demons) and consequently insulate the policy environment from the vagaries of implementation (systems)”

• Aryee J.R.A (2000) Saints, Wizards, Demons and Systems. Explaining the success or failure of public policies and programs. Department of Political Science, University of Ghana, Legon

Amina’s; Ama’s, Abenavi's story –

Situation Analysis

International health

initiativesLocal context

Health financing systems

Value and Evidence-

based strategy

Sustainable Equitable Health Outcomes and Impact

Monitor and Evaluate Performance

Improved coverage & access

GovernmentMOH, other ministries,

regulators, policy makers

Communitypatients, consumers,

caregivers, civil society

Providers public/private, NGO, commercial sector,

professional associations

Improved UHC

medicines benefits

performance

Governance

InformationFinancing

Supply chain and

service delivery

Human Resources

Medical Products

Adapting the Pharmaceutical System Strengthening Approach to UHC

This graphic represents a comprehensive set of dynamic relationships among the five health systems building blocks (governance, human resources, information, financing, and service delivery), with a medical products building block overlay to provide technical focus and identify substantive areas of concern and related corrective interventions. This approach will be used to achieve sustainable country-specific results that are aligned with country strategic UHC goals.

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THE UHC MEDICINES BENEFITS ECOSYSTEM IS COMPLEX INTERLINKAGE OF STAKEHOLDERS

• Regulator: insurance supervisor or program that sets guidelines for MBP

• Sponsor: e.g. Ministry of Health, Ministry of Finance

• Medicine Benefit Program: outlines guidelines of benefits patients are entitled to

• Manufacturer: can include local and int’l pharmaceutical companies active in the country

• Wholesale Distributor: serves as intermediary

• Dispensing Facility: e.g. pharmacist that handles day-to-day dispensing of drugs

• Prescriber: Physician/care provider• Beneficiary: patients• Accreditation Entity: ensures all

medicines handlers have necessary credentialsSource: MSH Guide to Managing Medicine Benefits Programs

ImproveEquitable Access

particularly for the poor & near-poor

Keep Costs Affordable

for households &health system

Encourage Appropriate Use

of needed, safe, & effective medicines taken properly

Ensure Availability of

Quality Productsboth generic

& novel products

Achieving UHC and Access to Medicines Requires Balancing Competing Objectives

Wagner et al, BMC Health Services Research, 201419

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ImproveEquitable Access

KeepCosts Affordable

Encourage Appropriate Use

Ensure Availability of Quality Products

Modified based on Wagner et al, BMC Health Services Research, 2014

• Prequalify suppliers, products• Negotiate prices, quality,

volume, supply chain security• Promote generic competition• Enter in risk sharing

agreements• Establish patient assistance

programs • Monitor impacts on product

quality & availability

• Understand socioeconomic and geographic differences in need and use

• Assess household care seeking and barriers to care

• Expand provider networks• Target policies and programs

to improve access for vulnerable populations

• Monitor impacts on access

• Monitor medicines expenditures by therapeutic area

• Evaluate budget impacts of medicines & technologies

• Assess household medicines expenditure burden

• Implement policies and programs to reduce waste and fraud, and encourage cost-efficient use

• Monitor impacts on spending

• Assess & feed back provider performance

• Implement & update standard treatment guidelines (STG)

• Match essential medicines and reimbursements lists to STG

• Manage care comprehensively

• Implement policies to encourage clinically appropriate use

• Monitor impacts on use

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

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

Examples of active interventions

Governance Strategy Example

Development of STGs and Formularies

Capping Revenue from

Medicines

China – reimbursed patients only for medicines listed on the formulary, capped hospital revenue from medicine sales and raised provider service fees. Outcome: Decreased the rate of growth for both total medical and medicines expenditures and decreased the use of antibiotics.

Streamlining stakeholder

Services Kyrgyzstan and South Korea –Separated Prescribing and dispensing services

Stakeholder Coordination New Zealand- Technical working and negotiation Group with industry-

Examples of active interventionsFinancing Strategy Example

Generic reference pricing

Kyrgyzstan has tied patient reimbursement rates to the price of a generic equivalent. Patients must pay the difference in price between the purchased product and the generic equivalent. This increased patient awareness of prices, was found to decrease and stabilize medicines prices and improve access

Single Exit Pricing ( SEPs)

South Africa, Namibia- Introduced pricing at regulator level once a company was registering a product the manufacturer set a price- SEP+ Logistics Fee+ Dispensing Fee with the dispensing Fee varying with cost of medicine

Cost-sharingKyrgyzstan the introduction of a formal copayment system increased transparency about medicines prices and payment responsibilities, resulting in a 92% decrease in informal payments

Provider & consumer education

Philippines found that chronically ill insured patients who had access to insurer-organized “awareness groups” were more likely to adhere to a medication regimen than a similar group of uninsured patients, although the groups also differed in level of academic education

Routine Monitoring of Medicines Benefits Programs (overall, by therapeutic classes, products, patients, providers)

• Cost– Cost per member per month (PMPM)– Net cost per dispensing per month

• Utilization– # of prescriptions PMPM– # of days supply PMPM

• Quality of care– % patients with ARI receiving antibiotics– % patients treated according to STG

• Fraud, abuse– # prescriptions per provider– # dispensings per member

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9 common threats to Achieving Access to medicines benefits

1. Inability to manage competing political and policy goals2. Lack of affordable access to needed medicines due to inappropriate benefit

design– Reimbursement lists not matching clinical need, guidelines– Un balanced patient cost sharing mechanisms

3. Inefficient use of resources due to– Financial incentives for overuse by providers, patients- IGFs – Reduce Government /Sponsors inputs on maintenance expenses – Fraud by prescribers, dispensers, and patients

4. Absence of efficient data systems and human capacity to generate information 5. Failure to routinely monitor benefit policy effects on access, use, health6. Failure to adapt technology to assist in adjudication of medicines claims7. Failure to adapt policies to changing system context8. Failure to communicate with public, patients, providers9. Failure to negotiate with industry

kwesi Eghan PSGH AGM 2015

9 proposed best practices to design medicines benefits for optimal achievement of access and responsible use of

medicines 1. “Smart” therapeutics – in and outpatient medicines coverage of

essential medicines, medicines on clinical guidelines2. Increased efficiency – appropriate generic/therapeutic substitution,

efficient procurement and distribution systems3. Introduction of Disease management program for chronic disease and

coverage of high cost medicines e.g Anti cancers 4. Value-based medicines policy design – incentivize most appropriate use 5. Reliable partners – accredited health providers and dispensing outlets,

competitive sourcing from quality assured suppliers6. Performance management – robust management systems for inventory

management, Claims management and drug use review, fraud detection

7. Patient, provider, public education - on UHC, medicines, value8. Culture of adaption – routine monitoring, evaluating, learning, and

evolving based on what’s working and what isn’t9. Make appropriate decisions on a carve in or carved out approach.

Summary

• Medicines benefit policies and programs need to balance multiple competing objectives.

• To do so, they need to – Target populations, settings, medicines– Be continually adapted /dynamic– Based on information from relevant routine

monitoring and periodic evaluation • This requires efficient data systems and

human capacity to generate information

Amina’s; Ama’s, Abenavi's story – A Happy ending???