Access to Medicines through Universal Health Coverage (UHC): Golden Ring or Trojan Horse?

1. Access to Medicines through Universal Health Coverage (UHC): Golden Ring or Trojan Horse? Jonathan D. Quick, MD, MPH1, 2 Kwesi Eghan1 Anita Wagner2 keghan@msh.org 1Management Sciences for Health 2 Harvard Medical School WHO Collaborating Center in Pharmaceutical Policy

2. Amina’s story – the year 2000

3. Is access to medicines through UHC a “Golden Ring” that improves health outcomes and financing equity?

4. Or is access to medicines through UHC a Trojan Horse that threatens program viability?

5. Access to medicines through UHC:Golden Ring or Trojan Horse? Impact of out-of-pocket health and medicines spending in low and middle income countries The growing movement for universal health coverage through strong health systems 3. Providing access to medicines through universal health coverage programs

6. www.gapminder.org/ Unfair health financing – high out-of-pocket spending where total health spending is lowest Out-of-pocket (OOP) share of total health spending (%) Total health spending per person (international $), Log Scale Total health spending per person (international $), Log Scale

7. WHO, World Health Report, 2010 Healthcare impoverishment – 150 million suffer financial catastrophe, 100 million impoverished

8. 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 Tanzania, 2002, WHO essential medicines project

9. 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

10. The UHC movement – Growing “buzz” around UHC at all levels – country, regional, and global Implementing UHC reforms Stated interest in achieving UHC

11. Pre-Payment Risk Pooling Reduced OOP Spending Tax-based Social Health Insurance Mixed Model The UHC approach – common core principles, country-specific adaptations Common Core Principles Country Models Vary Widely • Contributions – based on ability to pay • General taxes, payroll taxes, other sources • Contributions in form of general taxes • Pooling of risk across the population • Cross-subsidization: rich to poor, healthy to sick • Primarily financed by payroll contributions • Mix of tax-based financing, payroll, other sources • Most services with minimal or no out-of-pocket charge at the point of service

12. The UHC vision – “Access for all to appropriate health services at an affordable cost” (WHO, 2005) World Coverage: 80% OOP Expenditure: 30% World Coverage: 40% OOP Expenditure: 60% Laudable butUnrealistic • Feasible andInevitable Policy influence • High–level advocacy • Analysis and evidence • Country networks/capacity *WHA Resolution 58.33 Geneva: WHO; 2005. www.who.int/gb/ebwha/pdf_files/WHA58/WHA58_33-en.pdf

13. 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

14. 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

15. , Thailand – evolving expansion of coverage over more than four decades 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% Out-of-pocket spending as percent of total health expenditures UHS/30 Baht Scheme (2001) 70% of population covered (1995) 96% of population covered (2003) Year Sources: www.jointlearningnetwork.org/ and McKinsey Co 2010

16. Medicine cost escalation & response – Thailand’s Civil Servant Medical Benefit Scheme Source: IMS Thailand, 2011

17. 0 UHC in action – moving toward UHC in Ghana through health spending and reform Out of pocket spending as percent of total health expenditure • 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) NHIS created (2004) Less than 1% of population covered (2000) 45-70% of population covered (2008) McKinsey Co 2010

18. Ghana – expanding coverage, rising total claims, substantially increasing drug costs Source: Roberts and Reich, 2011, data from Mensah and Acheampong 2009

19. Pharmaceutical management strategies for value in UHC - access, appropriate use, affordability, quality • 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 • Performance Management • Contracting, purchasing • Supply chain management • Preferred pharmacy networks • Quality of products and services • Fraud detection systems • Financial management, audits • 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)

20. 7 proposed best practicesfor maximum health impact and value • Stakeholder engagement and communication – the public, patients, providers, healthcare managers, policy-makers, politicians • “Smart” therapeutics – priority health problems, outpatient coverage, essential medicines, clinical guidelines, • Value-based policy design – incentivize most appropriate use • Increased efficiency – generic/therapeutic substitution, efficient procurement and distribution systems • Reliable partners – accredited health providers and dispensing outlets, competitive sourcing from quality assured suppliers • Performance management – robust management systems for inventory management, drug use review, fraud detection • Culture of adaption – learning from others, benchmarking, routine monitoring, evaluation, based on what’s working and what isn’t

21. 7 common threats to medicines benefits – adverse health impacts, rising costs, poor quality • Competing political and policy goals – coverage, affordability, quality, industry interests • Weak governance and accountability structure – oversight body/board, public reporting, independent audit • Insufficient responsiveness to stakeholders – patients, the public, providers, private sector, others • Incomplete program design – focusing on some elements (e.g.benefits, co-payments) but not others (e.g. supply chain management, quality) • Failure to fully utilize needed expertise – success requires input from pharmaceutical management, public health, insurance, other experts • Inadequate adaptation to local context – modeling other countries or implementing “expert advice” without building on local strengths • Failure to ‘keep up’ and manage growth – essential medicine list/formulary, disease categories, population and geographic coverage

22. WHO, World Health Report, 2010 Expanding the 3 dimensions of medicines coverage: Who? What? How much? 3. How much are they covered for? 2. What are they covered for? 1. Who is covered?

23. Summary and conclusions • Medicines benefits in UHC programs: • Are essential for both health and fair financing goals • Arguably pose the largest financial risk to UHC programs • 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? • Expertise from multiple disciplines is required: • Medicine, pharmacy, pharmaceutical management • Economics, financing, accounting • Law, ethics, information technology

24. Amina’s story – the year 2011 – a happy ending?

25. Medicines and UHC: Share experiences, plan policy and research agenda, learn more Friday, 18 November 2011, 7:45am to 8:45am, Azurit Health 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 Center in Pharmaceutical Policy