1. Universal Health Coverage – Achieving Access and Responsible Use of Medicines 2015 AGM Of The Pharmaceutical Society of Ghana Thematic Speaker Emmanuel Kwesi Eghan B Pharm, MBA, MSc Health & Pharmaco-Economics Email: keghan@msh.org Kwesi Eghan PSGH AGM 20151

2. What is Universal Health Coverage (UHC)? Achieving access for all people to key promotive, preventive, curative, and rehabilitative health interventions at an affordable cost, thereby achieving equity in access. The ultimate goal of UHC is ensuring that – all people obtain needed health services and essential health technologies –including, medicines and diagnostics- – without suffering financial hardship when paying for them. Kwesi Eghan PSGH AGM20152

3. What is Universal Health Coverage “ UHC implies that all people have access to nationally determined sets of needed quality health services and essential medicines, without discrimination or risking impoverishment.”

4. UHC- An aspirational goal A key challenge is how countries fulfill the promise of delivering UHC ? How do countries with their finite resources, working within weak health and financial systems attain UHC? Kwesi Eghan PSGH AGM 2015

6. GLOBAL DECLARATIONS December 12, 2014: Launch of first Universal Health Coverage Day – an effort to accelerate reforms leading to health coverage for all The Post MDG- Sustainable Development Goals (SDGs) is billed to include a health goal (Goal 3) comprising 13 targets, including target 3.8 for UHC: “Achieve UHC, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.” 3,4 Increased focus of governments in LMICs on National Health Insurance Schemes, Kwesi Eghan PSGH AGM 2015

7. So why Universal Health Coverage ? Unfair health financing – High Out-of-Pocket (OOP) payments Increase catastrophic expenditures leading impoverishment Human rights

10. Most OOP Payment for Medicines WHO, World Health Report, 2010 10 57% Public 45% Private

11. UHC General Principles & Design

13. UHC - Key enabling factors for sustainability Political will and stewardship Levels of income and the rate of economic growth Structure of the economy Distribution of the population Ability to administer The level of solidarity Kwesi Eghan PSGH AGM 2015

14. But the paths are different Each country travels a unique path towards UHC This path is guided by its own history, politics (of which Ghana has its fair share to talk about) existing labour, health and financing structures Kwesi Eghan PSGH AGM 2015

15. And The Devil is in the details “ Successful public policies and programs are rare because it is unusual to have progressive and committed politicians and bureaucrats (saints) supported by appropriate policy analysts with available and reliable information (wizards), that manage hostile and apathetic groups (demons) and consequently insulate the policy environment from the vagaries of implementation (systems)” Aryee J.R.A (2000) Saints, Wizards, Demons and Systems. Explaining the success or failure of public policies and programs. Department of Political Science, University of Ghana, Legon

16. Amina’s; Ama’s, Abenavi's story –

17. Situation Analysis International health initiatives Local context Health financing systems Value and Evidence- based strategy Sustainable Equitable Health Outcomes and Impact Monitor and Evaluate Performance Improved coverage & access Government MOH, other ministries, regulators, policy makers Community patients, consumers, caregivers, civil society Providers public/private, NGO, commercial sector, professional associations Improved UHC medicines benefits performance Governance InformationFinancing Supply chain and service delivery Human Resources Medical Products Adapting the Pharmaceutical System Strengthening Approach to UHC This graphic represents a comprehensive set of dynamic relationships among the five health systems building blocks (governance, human resources, information, financing, and service delivery), with a medical products building block overlay to provide technical focus and identify substantive areas of concern and related corrective interventions. This approach will be used to achieve sustainable country-specific results that are aligned with country strategic UHC goals.

18. THE UHC MEDICINES BENEFITS ECOSYSTEM IS COMPLEX INTERLINKAGE OF STAKEHOLDERS 18 Regulator: insurance supervisor or program that sets guidelines for MBP Sponsor: e.g. Ministry of Health, Ministry of Finance Medicine Benefit Program: outlines guidelines of benefits patients are entitled to Manufacturer: can include local and int’l pharmaceutical companies active in the country Wholesale Distributor: serves as intermediary Dispensing Facility: e.g. pharmacist that handles day-to-day dispensing of drugs Prescriber: Physician/care provider Beneficiary: patients Accreditation Entity: ensures all medicines handlers have necessary credentials Source: MSH Guide to Managing Medicine Benefits Programs

19. Improve Equitable 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 Products both generic & novel products Achieving UHC and Access to Medicines Requires Balancing Competing Objectives Wagner et al, BMC Health Services Research, 2014 19

20. Improve Equitable Access Keep Costs Affordable Encourage Appropriate Use Ensure Availability of Quality Products 20 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

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

23. Examples of active interventions Governance Strategy Example Development of STGs and Formularies Capping Revenue from Medicines China – reimbursed patients only for medicines listed on the formulary, capped hospital revenue from medicine sales and raised provider service fees. Outcome: Decreased the rate of growth for both total medical and medicines expenditures and decreased the use of antibiotics. Streamlining stakeholder Services Kyrgyzstan and South Korea –Separated Prescribing and dispensing services Stakeholder Coordination New Zealand- Technical working and negotiation Group with industry-

24. Examples of active interventions Financing StrategyExample Generic reference pricing Kyrgyzstan has tied patient reimbursement rates to the price of a generic equivalent. Patients must pay the difference in price between the purchased product and the generic equivalent. This increased patient awareness of prices, was found to decrease and stabilize medicines prices and improve access Single Exit Pricing ( SEPs) South Africa, Namibia- Introduced pricing at regulator level once a company was registering a product the manufacturer set a price- SEP+ Logistics Fee+ Dispensing Fee with the dispensing Fee varying with cost of medicine Cost-sharing Kyrgyzstan the introduction of a formal copayment system increased transparency about medicines prices and payment responsibilities, resulting in a 92% decrease in informal payments Provider & consumer education Philippines found that chronically ill insured patients who had access to insurer-organized “awareness groups” were more likely to adhere to a medication regimen than a similar group of uninsured patients, although the groups also differed in level of academic education

25. Routine Monitoring of Medicines Benefits Programs (overall, by therapeutic classes, products, patients, providers) Cost – Cost per member per month (PMPM) – Net cost per dispensing per month Utilization – # of prescriptions PMPM – # of days supply PMPM Quality of care – % patients with ARI receiving antibiotics – % patients treated according to STG Fraud, abuse – # prescriptions per provider – # dispensings per member 25

26. 9 common threats to Achieving Access to medicines benefits 1.Inability to manage competing political and policy goals 2.Lack of affordable access to needed medicines due to inappropriate benefit design – Reimbursement lists not matching clinical need, guidelines – Un balanced patient cost sharing mechanisms 3.Inefficient use of resources due to – Financial incentives for overuse by providers, patients- IGFs – Reduce Government /Sponsors inputs on maintenance expenses – Fraud by prescribers, dispensers, and patients 4.Absence of efficient data systems and human capacity to generate information 5.Failure to routinely monitor benefit policy effects on access, use, health 6.Failure to adapt technology to assist in adjudication of medicines claims 7.Failure to adapt policies to changing system context 8.Failure to communicate with public, patients, providers 9.Failure to negotiate with industry

27. 9 proposed best practices to design medicines benefits for optimal achievement of access and responsible use of medicines 1.“Smart” therapeutics – in and outpatient medicines coverage of essential medicines, medicines on clinical guidelines 2.Increased efficiency – appropriate generic/therapeutic substitution, efficient procurement and distribution systems 3.Introduction of Disease management program for chronic disease and coverage of high cost medicines e.g Anti cancers 4.Value-based medicines policy design – incentivize most appropriate use 5.Reliable partners – accredited health providers and dispensing outlets, competitive sourcing from quality assured suppliers 6.Performance management – robust management systems for inventory management, Claims management and drug use review, fraud detection 7.Patient, provider, public education - on UHC, medicines, value 8.Culture of adaption – routine monitoring, evaluating, learning, and evolving based on what’s working and what isn’t 9.Make appropriate decisions on a carve in or carved out approach. kwesi Eghan PSGH AGM 2015

28. 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 /dynamic – Based on information from relevant routine monitoring and periodic evaluation This requires efficient data systems and human capacity to generate information

29. Amina’s; Ama’s, Abenavi's story – A Happy ending???