Designing and Managing Medicines Benefits –

Goals, Policy Options, Ethical ConsiderationsAnita Katharina Wagner

Department of Population MedicineHarvard Medical School & Harvard Pilgrim Health Care Institute

Cape Town, 29 September 2014

Touraine et al, The Lancet, 2014

“UHC implies that all people

have access to nationally determined sets of

needed quality

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

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 Goals Requires Balancing Competing Objectives

Wagner et al, BMC Health Services Research, 20144

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ImproveEquitable Access

KeepCosts Affordable

Encourage Appropriate Use

Ensure Availability of Quality Products

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

• Prequalify suppliers, products

• Negotiate prices, quality, volume, supply chain security

• Promote generic competition

• Enter in risk sharing agreements

• Establish patient assistance programs

• Implement & update standard treatment guidelines (STG)

• Match essential medicines and reimbursements lists to STG

• Manage care comprehensively• Implement policies to encourage

clinically appropriate use

• Expand provider networks• Target policies and programs

to improve access for vulnerable populations

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

6

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

Ethical Considerations:Equity is a Goal of UHC

• Equal access to available care • for equal need

• Equal utilization for equal need• Equal quality of care for all

Whitehead, Int J Hlth Serv 1992

Inequality ≠ Inequity

• Health inequality = differences in health• Health inequities = “differences in health that are

unnecessary, avoidable, unfair, and unjust.”

• “Equity in health thus implies that resources are distributed and processes are designed in ways most likely to move toward equalizing the health outcomes of disadvantaged social groups with the outcomes of their more advantaged counterparts.”

Whitehead, Int J Hlth Serv 1992; Braveman & Gruskin, J Epi Comm Hlth 2007; O’Neill, J Clin Epi 2014

A Fundamental Ethical & Economic Choice

Pay for all “medically necessary” treatment

orcreate a budget and determine what they will cover, for whom

e.g., set priorities and limits

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A Fundamental Ethical & Economic Choice

Individual Focus

Exam Room

PopulationFocus

Boardroom

Fidelity to theneeds of theindividual

Stewardship of shared resources

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 – Based on information from routine monitoring

and periodic evaluation • Which requires efficient data systems and

human capacity to generate information