ICIUM 2011, Abstract #236 Laura Faden Garabedian , Catherine Vialle-Valentin , Dennis Ross- Degnan and Anita Wagner

1. WHO Collaborating Center in Pharmaceutical Policy Active Pharmaceutical Management Strategies of Health Insurance Systems to Improve Cost-Effective Use of Medicines in Low- and Middle-Income Countries:A Systematic Review of Current Evidence ICIUM 2011, Abstract #236 Laura FadenGarabedian, Catherine Vialle-Valentin, Dennis Ross-Degnan and Anita Wagner Department of Population Medicine Harvard Medical School and Harvard Pilgrim Health Care Institute WHO Collaborating Center in Pharmaceutical Policy

2. Published Article and Report • Funding Sources: • -WHO-Health Action International (HAI) Project on Medicine Prices • and Availability • - Department of Population Medicine’s Accelerating MedIC grant Link to report: http://www.haiweb.org/medicineprices/05062011/Health%20insurance%20final%20May2011.pdf

3. Background • Lack of equitable, affordable access to essential medicines (EMs) in LMICs • Medicines = large financial burden on health systems and households • Insurance systems can improve access and cost-effective, appropriate use (ICIUM 2004)

4. Study Objectives and Hypothesis • Objectives: • Gather available evidence from LMICs • Systematic literature review (English language) • Develop recommendations • Hypothesis: • In addition to their role in financing health care, health insurance systems have the ability to influence patients, providers and industry • Insurance systems have key features

5. Literature Review Results Identified n=63 publications • 56 peer-reviewed articles • 7 grey literature reports • 54 research articles • By study design: • 1 randomized-controlled study • 6 time series • 8 pre-post, with comparison • 8 pre-post, no comparison • 31 cross-sectional • 9 reviews containing evidence from other studies or analyses 6

6. Effects of Insurance Coverage • Reduced financial barriers to access • Improved access • Improved utilization • Improved health outcomes

7. Medicines Purchasing Strategies • Negotiating with pharmaceutical suppliers (Mexico) • Bulk purchasing (Kyrgyzstan) • Generic reference pricing (South Africa, Taiwan, Kyrgyzstan)

8. Medicines Selection Strategies • Formularies (China, Taiwan) • Consumer cost-sharing (Taiwan, Senegal, Mali, Kyrgyzstan) • Often implemented in conjunction with a formulary • Generic Substitution • National policies

9. Utilization Management Strategies • Financial incentives for quality of care (Philippines, Taiwan) • No evidence of impact on cost-effective use of medicines • Separating prescribing and dispensing (South Korea, Taiwan) • National policies • Education of providers and consumers (Mexico) • Disease management (South Africa)

10. Provider Contracting Strategies • Provider Payment Types • Fee-for-Service (China, South Africa, Thailand) • Capitation (China, Thailand) • Case-based (Taiwan, Ghana) • Reducing reimbursement rates for medicines (Taiwan) • Preferred provider and pharmacy networks (Kyrgyzstan, South Africa) 7

11. Summary • Reasonable evidence => use of insurance to improve access to medicines in LMICs • Little evidence => pharmaceutical management strategies of health insurance schemes in LMIC • Most evidence for provider contracting strategies • Often several policy changes initiated together • Often poor research design => interpret with caution • Some key lessons

12. Recommendations • Policy: Insurers should make evidence-based decisions when possible • Consider strategies with evidence of success in other LMICs • Carefully experiment with promising policy approaches => routine monitoring • Research: Support efforts to build evidence base • Well-designed research on effects of strategies • Standardized indicators of policy effects

13. Thank You!