1. 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 Faden Garabedian, 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 WHO Collaborating Center in Pharmaceutical Policy

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

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

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!