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
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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
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