1. Designing and Managing Medicines Benefits – Goals, Policy Options, Ethical Considerations Anita Katharina Wagner Department of Population Medicine Harvard Medical School & Harvard Pilgrim Health Care Institute Cape Town, 29 September 2014

3. Touraine et al, The Lancet, 2014 “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. 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 Goals Requires Balancing Competing Objectives Wagner et al, BMC Health Services Research, 2014 4

5. Improve Equitable Access Keep Costs Affordable Encourage Appropriate Use Ensure Availability of Quality Products Implement policies and programs to reduce waste and fraud, and encourage cost- efficient use Prequalify suppliers, products Negotiate prices, quality, volume, supply chain security Promote generic competition Enter in risk sharing agreements Establish patient assistance programs Implement & update standard treatment guidelines (STG) Match essential medicines and reimbursements lists to STG Manage care comprehensively Implement policies to encourage clinically appropriate use Expand provider networks Target policies and programs to improve access for vulnerable populations 5 Modified based on Wagner et al, BMC Health Services Research, 2014

6. Improve Equitable Access Keep Costs Affordable Encourage Appropriate Use Ensure Availability of Quality Products 6 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

8. Ethical Considerations: Equity is a Goal of UHC Equal access to available care for equal need Equal utilization for equal need Equal quality of care for all Whitehead, Int J Hlth Serv 1992

9. Inequality ≠ Inequity Health inequality = differences in health Health inequities = “differences in health that are unnecessary, avoidable, unfair, and unjust.” “Equity in health thus implies that resources are distributed and processes are designed in ways most likely to move toward equalizing the health outcomes of disadvantaged social groups with the outcomes of their more advantaged counterparts.” Whitehead, Int J Hlth Serv 1992; Braveman & Gruskin, J Epi Comm Hlth 2007; O’Neill, J Clin Epi 2014

10. A Fundamental Ethical & Economic Choice Pay for all “medically necessary” treatment or create a budget and determine what they will cover, for whom e.g., set priorities and limits 10

11. 11 A Fundamental Ethical & Economic Choice Individual Focus Exam Room Population Focus Boardroom Fidelity to the needs of the individual Stewardship of shared resources

12. 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 – Based on information from routine monitoring and periodic evaluation Which requires efficient data systems and human capacity to generate information