1. World Health Organization
15 April 2017
Access to Essential Medicines and Universal Health Coverage
UHC and designing medicines benefits programmes and policies
Cape Town, September 28 – 29, 2014
Kees de Joncheere
Director, Essential Medicines and Health Products

2. World Health Organization
15 April 2017
“Universal health coverage is the single most powerful concept that public health has to offer”
Dr Margaret Chan, Director-General of WHO, Address to the Sixty-fifth World Health Assembly, May 2012

3. What is Universal Health Coverage?
World Health Organization
What is Universal Health Coverage?
15 April 2017
All people obtain the health services they need (including prevention, promotion, treatment, rehabilitation, and palliation), of sufficient quality to be effective;
The use of these services does not expose the user to financial hardship
Three goals implicit in UHC: 1. reducing the gap between need and utilization
2. Ensuring good quality in health services
3. Ensuring financial risk protection – no one gets poor because they have to use health services

4. A direction, not a destination
No country fully achieves all the coverage objectives
And harder for poorer countries
But all countries want to
Reduce the gap between need and utilization
Improve quality
Improve financial protection
Thus, moving “towards Universal Health Coverage” is something that every country can do

5. World Health Organization
15 April 2017
Three Dimensions to Consider When Moving Towards Universal Coverage
Health systems financing: the path to universal coverage. Executive Summary,
The World Health Report, WHO/IER//WHR/10.1, 2010

6. There is no standard package of HSS actions to progress towards UHC
World Health Organization
There is no standard package of HSS actions to progress towards UHC
15 April 2017
Every country already has a health system
This is the starting point for any reform
Solutions need to be tailored to context
Key contextual factors (e.g. fiscal, public administration, political, cultural, etc.) condition both what can be achieved and what can be implemented
Country level analytic capacity is essential
Policy analysis linked to the specific reform agenda (hypotheses)
Much more than tracking standard indicators
Supporting this capacity and strengthening links to decision making is key role for us at country level

7. Out-of-pocket spending (OOPS) as a critical problem
Widespread reliance on patient payments is contrary to Universal Coverage objectives
Compromises equity of access, because service use depends on ability to pay rather than medical need
Health care costs pose risk of impoverishment (“your money or your life”)
When payment is informal, there are problems of transparency, and it is also difficult to organize incentives for providers

8. World Health Organization
Shift to UHC implied profound change in how we think about “health insurance”
15 April 2017
Health insurance emerged in Europe as a condition of labor (first formalized as public policy under Bismarck)
Increasing labor productivity (industrialization)
Reducing labor radicalism and unrest
Thus, social (compulsory) health insurance for wage earners
After 1945, “universal coverage”: affordable access to health services as a condition of citizenship or human/ constitutional right
Implies a shift away from a purely (direct) contributory approach
Also implies compulsion or automatic entitlement
Thus, health coverage for the entire population, with explicit policies to fund coverage for the non-salaried population
UHC implied a shift from “health coverage as a condition of labor force status”, to “health coverage as a condition of being a human being” (or citizen, or resident). Logically, this implies an important shift in financing mechanisms and the nature of entitlement.

9. World Health Organization
Following the historical path of western Europe and Japan is problematic
15 April 2017
“Starting insurance” with the formal sector
Improves access and financial protection for the better off
Historically in western Europe and Japan, coverage grew with economic development, growing formalization of the economy and high employment
Today, however, developing country governments face decisions on the rationing of scarce medical technology that Western/ Japanese governments did not face a century ago
The initially covered groups defend their interests, demand more benefits and subsidies, and concentrate scarce administrative skills on their behalf
Exacerbates inequalities, fragments the system, and is very difficult to undo
So different options needed

10. Different approaches depending on different starting points - examples
Thailand merged several different schemes into one, funded from general revenues, using quasi-public purchasing agency
Overcame most but not all fragmentation across schemes, and progressively working to equalize benefits across them
Ghana and Rwanda have explicit coordination of bottom- up and top-down financing mechanisms to create a virtual national pool, with general revenues as main source
Gains in utilization and financial protection

11. Why a focus on medicines ?
Between 20 % and 60 % of the health expenditures in LMIC goes to medicines
In LMIC countries, up to 80 to 90 % of medicines are purchased out-of-pocket as opposed to being paid for by health insurance schemes
In many LMIC out-of-pocket expenditures for health account for more than 50 per cent of total health spending
Problems with access : average availability of selected generic medicines in LMICs:
public sector less than 42 %
private sector almost 72 %

12. Ten leading sources of inefficiency in health systems Ref: World Health Report 2010, Chapter 4
Medicines: under-use of generics and higher than necessary prices
Medicines: use of sub-standard and counterfeit medicines
Medicines: inappropriate and ineffective use
Services: inappropriate hospital size (low use of infrastructure)
Services: medical errors and sub-optimal quality of care
Services: inappropriate hospital admissions and length of stay
Services & products: oversupply and overuse of equipment, investigations and procedures
Health workers: inappropriate or costly staff mix, unmotivated workers
Interventions: inefficient mix / inappropriate level of strategies
Leakages: waste, corruption, fraud

13. Access to essential medicines and UHC
1. Rational
selection
4. reliable
health and
supply
systems
2. Affordable
prices
3. Sustainable
financing
ACCESS

14. HTA for priority setting
World Health Organization
15 April 2017
Fragile states:
Essential services
Emergency kits
Disaster planning
Low income countries with low coverage,
Primary health care packages
Middle income countries with low coverage,
Guaranteed packages of care
Strong health system,
Marginal analysis for additions to packages
Health Systems
Health technology assessment (HITA) provides a decision-making framework for different types of decisions and can be applied in all health care systems, but needs differ
In fragile health systems: to identify essential guaranteed services
In middle-income countries with limited coverage: to decide how to extend the package of health care services provided
In systems with established UHC: to inform decisions ‘at the margin’: what extra services to provide and at what cost
Continuum of HTA Activities

15. Examples of HTA methods in WHO
World Health Organization
Examples of HTA methods in WHO
15 April 2017
WHO Model List of Essential Medicines (EML)
Package of Essential Noncommunicable (PEN) disease interventions for primary health care, 'best buys' for NCDs
WHO-CHOICE, CHOosing Interventions that are Cost Effective global database of around 500 health technologies
OneHealth Tool designed to inform national strategic health planning in low- and middle-income countries.
Assessing medical devices and assistive devices, incl for an ageing population

16. WHO Essential Medicines List to guide “benefits programme”
First edition 1977
Revised every two years
Now contains 462 medicines including children's medicines
Patent status NOT considered in selection
A model process

17. EML – Medicines Benefits process
Role of stakeholders and inclusive transparent process
Professional associations
Patients and citizens
Industry
Civil society
…..
Link with priority setting in health
Managing the ‘politics’

18. WHO-CHOICE example results
World Health Organization
15 April, 2017
This slide shows results from the CHOICE project, measured as healthy life years saved per $1,000 international. The greatest health gain is seen in Vitamin A and Zinc fortification in children under 5, almost ten times greater than the health gain due to any of the other interventions for the same price (note compression of x axis between 10 and 60 healthy life years). Other services listed in the figure are also highly cost-effective, such as testing and treatment for tuberculosis, prevention and treatment of malaria, and primary prevention (for very-high-risk individuals) and treatment of myocardial infarction and stroke.

19. Roles international stakeholders
How to compatibilize support with disease programmes with UHC
Support with low cost quality generics for specific diseases
Technical collaboration and capacity building
Continue addressing MDG ‘unfinished business’ + a shift to NCD
Need to rethink supply systems

20. Medicines supply systems in TANZANIA. 2007
United Republic of Tanzania
ESSENTIAL
MEDICINES
ARVs
MALARIA TB OI
ARVs
Ped
REAGENT
Blood safety
(+ HIV test)
VACCINES
CONDOMS
CONTRACEPTIVES
MEDICAL
SUPPLIES
GOVERNMENT
BILATERAL DONOR
MULTILATERAL DONOR
NGO/PRIVATE C S W H O S I D A N O R A D C I D A UN I TA D H A V R D P E F A R
GLOBAL
FUND CL I
NTON A X I O S P F I Z E R
GOVERNMENT J
ICA C D C O L U M B I A A B O T G A V I C U A M U N I C E F U S A I D W B
Source
Of Funds
Procurement
Agent/Body C L I N T O H A V R D E G P A F A X I O S U N I C E F C O L U M B I A A B O T C U A M U S A I D
TEC
&
CCT
MEDICAL
STORE C R S S C M
MOH
& SW J I C A C D G A V I
CROWN
AGENTS T M A P
Point of 1st
warehousing
TEC &CCT
HOSPITAL
CRS
IMA
MEDICAL STORE
AXIOS
HEALTH FACILITY
COLUMBIA
HOSPITAL
CUAMM
Point of 2nd
warehousing
TEC &CCT
REGIONAL/DISTRICT
VACCINE STORE
ZONAL MEDICAL STORE
HEALTH FACILITY
HOSPITAL
TEC &CCT
Point of
Distribution
ZONAL BLOOD
SAFETY CENTRE
DISTRICT STORE
HEALTH FACILITY
PRIMARY HEALTH CARE FACILITY
HOSPITAL
PATIENT

21. Low public sector availability leads patients to the private sector, where medicines are unaffordable

22. Not all health systems are well designed to deal with NCDs, mental -, geriatric -, rare diseases ……
Many infectious conditions can be effectively treated in an episodic, ’clinic’ based system
However such settings are not well designed to deal with many NCDs, mental, geriatric & rare diseases
They lack the continuity of care needed for chronic conditions including for medicines treatment
Providers lack the specialized skills needed to deal with complex conditions
Appropriate use of medicines – becomes far more challenging and impact may not be seen unless specific efforts are made
Many infectious conditions can be effectively treated in an episodic, ’clinic’ based system with limited support for medicines management but not all health systems are well designed to deal with today’s health challenges and appropriate use of medicines has become far more challenging with chronic care
Adherence to treatment in chronic care is a big issue – and with many new medicines we don’t get the projected impact if adherence is not tackled

23. Next issues
Access to essential medicines within UHC framework – priority setting, medicines benefits informed by CEA and budget impact, appropriate use
Addressing MDGs and NCDs
Medicines pricing : R&D + access/affordability + competition
Need for promoting the appropriate use of medicines
Innovation, targeting new product development, how to price innovation for global access ? – global public goods