1. 1 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact Stronger health systems. Greater health impact. Access to Medicines through Universal Health Coverage (UHC): Golden Ring or Trojan Horse? Jonathan D. Quick, MD, MPH 1, 2 Kwesi Eghan 1 Anita Wagner 2 keghan@msh.org 1 Management Sciences for Health 2 Harvard Medical School WHO Collaborating Center in Pharmaceutical Policy

2. 2 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact Amina’s story – the year 2000

3. 3 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact Is access to medicines through UHC a “Golden Ring” that improves health outcomes and financing equity?

4. 4 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact Or is access to medicines through UHC a Trojan Horse that threatens program viability?

5. 5 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact 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

6. 6 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact Unfair health financing – high out-of-pocket spending where total health spending is lowest www.gapminder.org/ Total health spending per person (international $), Log Scale Out-of-pocket (OOP) share of total health spending (%) Total health spending per person (international $), Log Scale

7. 7 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact Healthcare impoverishment – 150 million suffer financial catastrophe, 100 million impoverished WHO, World Health Report, 2010

8. 8 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact Tanzania, 2002, WHO essential medicines project 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

9. 9 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact 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. 10 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact The UHC movement – Growing “buzz” around UHC at all levels – country, regional, and global Stated interest in achieving UHC Implementing UHC reforms

11. 11 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact The UHC approach – common core principles, country-specific adaptations  Contributions – based on ability to pay  General taxes, payroll taxes, other sources  Pooling of risk across the population  Cross-subsidization: rich to poor, healthy to sick  Most services with minimal or no out-of-pocket charge at the point of service Common Core Principles Country Models Vary Widely  Contributions in form of general taxes  Primarily financed by payroll contributions  Mix of tax-based financing, payroll, other sources

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

13. 13 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact 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. 14 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact 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. 15 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact Thailand – evolving expansion of coverage over more than four decades Sources: www.jointlearningnetwork.org/ and McKinsey Co 2010 www.jointlearningnetwork.org/ 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% Year Out-of-pocket spending as percent of total health expenditures 70% of population covered (1995) 96% of population covered (2003) UHS/30 Baht Scheme (2001)

16. 16 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact Medicine cost escalation & response – Thailand’s Civil Servant Medical Benefit Scheme 2009 Measures2010 Measures  Drug use audits, 14 hospitals  Generic substitution  Prescribing restrictions  Proposal for uniform pricing  Audits expanded to 34 hospitals  Stronger generic substitution  Prescribing further restricted  Prescribing guidelines strengthened  Approval by “medical audit” team Source: IMS Thailand, 2011

17. 17 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact UHC in action – moving toward UHC in Ghana through health spending and reform McKinsey Co 2010 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) Out of pocket spending as percent of total health expenditure Less than 1% of population covered (2000) 45-70% of population covered (2008) NHIS created (2004)

18. 18 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact Ghana – expanding coverage, rising total claims, substantially increasing drug costs Source: Roberts and Reich, 2011, data from Mensah and Acheampong 2009

19. 19 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact Pharmaceutical management strategies for value in UHC - access, appropriate use, affordability, quality 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) Performance Management Contracting, purchasing Supply chain management Preferred pharmacy networks Quality of products and services Fraud detection systems Financial management, audits 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

20. 20 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact 7 proposed best practices for maximum health impact and value 1.Stakeholder engagement and communication – the public, patients, providers, healthcare managers, policy-makers, politicians 2.“Smart” therapeutics – priority health problems, outpatient coverage, essential medicines, clinical guidelines, 3.Value-based policy design – incentivize most appropriate use 4.Increased efficiency – generic/therapeutic substitution, efficient procurement and distribution systems 5.Reliable partners – accredited health providers and dispensing outlets, competitive sourcing from quality assured suppliers 6.Performance management – robust management systems for inventory management, drug use review, fraud detection 7.Culture of adaption – learning from others, benchmarking, routine monitoring, evaluation, based on what’s working and what isn’t

21. 21 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact 7 common threats to medicines benefits – adverse health impacts, rising costs, poor quality 1.Competing political and policy goals – coverage, affordability, quality, industry interests 2.Weak governance and accountability structure – oversight body/board, public reporting, independent audit 3.Insufficient responsiveness to stakeholders – patients, the public, providers, private sector, others 4.Incomplete program design – focusing on some elements (e.g.benefits, co-payments) but not others (e.g. supply chain management, quality) 5.Failure to fully utilize needed expertise – success requires input from pharmaceutical management, public health, insurance, other experts 6.Inadequate adaptation to local context – modeling other countries or implementing “expert advice” without building on local strengths 7.Failure to ‘keep up’ and manage growth – essential medicine list/formulary, disease categories, population and geographic coverage

22. 22 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact Expanding the 3 dimensions of medicines coverage: Who? What? How much? WHO, World Health Report, 2010 2. What are they covered for? 3. How much are they covered for? 1. Who is covered?

23. 23 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact Summary and conclusions 1.Medicines benefits in UHC programs: Are essential for both health and fair financing goals Arguably pose the largest financial risk to UHC programs 2.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? 3.Expertise from multiple disciplines is required: Medicine, pharmacy, pharmaceutical management Economics, financing, accounting Law, ethics, information technology

24. 24 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact Amina’s story – the year 2011 – a happy ending?

25. 25 Management Sciences for Health: 40 Years of Strengthening Health Systems for Greater Health Impact 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 Med icines and Insurance Coverage Initiative Med icines and Insurance Coverage Initiative WHO Collaborating Center in Pharmaceutical Policy