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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
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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
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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)
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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
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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
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Reduced financial barriers to access Improved access Improved utilization Improved health outcomes Effects of Insurance Coverage
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Medicines Purchasing Strategies Negotiating with pharmaceutical suppliers (Mexico) Bulk purchasing (Kyrgyzstan) Generic reference pricing (South Africa, Taiwan, Kyrgyzstan)
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Medicines Selection Strategies Formularies (China, Taiwan) Consumer cost-sharing (Taiwan, Senegal, Mali, Kyrgyzstan) – Often implemented in conjunction with a formulary Generic Substitution – National policies
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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)
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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
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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
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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
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Thank You!
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