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Strengthening health systems to achieve access to essential medicines

Author(s) Alessandra Ferrario1, Rita Seicas2, Nina Sautenkova3, Jarno Habicht4
Affiliation(s) 1LSE Health, London School of Economics and Political Science, London, United Kingdom, 2Centre for Health Policies and Studies, Chisinau, Moldova, 3World Health Organization, Regional Office for Europe, Copenhagen, 4World Health Organization, Country Office, Republic of Moldova
Country - ies of focus Moldova
Relevant to the conference tracks Health systems
Summary This presentation aims to generate debate on issues affecting access to medicines in low- and middle income countries, discuss how they can be tackled through a coordinated health system response by proposing simple and actionable recommendations and to encourage participants to share their own countries’ experience.
Background Despite continuous scientific progress and the existence of several life-saving medicines, one third of the world’s population still lacks of access to essential medicines.
Achieving access to essential medicines requires much more than an increase in funding for medicines reimbursement. As outlined by the World Health Organization (WHO) in 2004, access to medicines encompasses rational selection and use, affordability, sustainable financing and reliable health and supply systems. Although the WHO health system building blocks model depicts medicines almost as an independent component of the health system, improving access to essential medicines is dependent on the strengthening of all other building blocks. Trained human resources are necessary to develop a national essential medicines list and treatment guidelines, to educate patients on how to take their medications and follow them up to ensure compliance. Facilities equipped with the necessary diagnostic tools are needed to diagnose patients. Policies need to be in place to promote price competition and use of generics. Efforts to achieve universal health coverage need to be sustained and quality of medicines needs to be ensured through a reliable and efficient regulatory system.
Objectives To show the need for integrated action across different health systems dimensions to improve access to medicines using as an example the recent reforms introduced in the pharmaceutical sector in the Republic of Moldova.
Methodology Analysis of expenditure, use and reimbursement data together with a review of policy documents in Moldova.
Results Between 2005 and 2012, reimbursement for outpatient medicines increased from Lei 7,404 thousands (Euro 434 thousands) to Lei 166,244 thousands (Euro 10,490 thousands). The increased budget translated in a greater number of medicines reimbursed over time, from 8 medicines (with different active ingredient) in 2005 to 81 medicines in 2013. In parallel, the number of reimbursed prescriptions and the proportion of total prescription value reimbursed have also increased.
A similar pattern was highlighted for inpatient medicines whose spending increased from Lei 94,234 thousands (Euro 5,550 thousands) in 2007 to Lei 357,766 thousands (Euro 22,575 thousands) in 2012 and was accompanied by an increase in the number of medicines available.
Another positive development was the inclusion of insulin in the 2013 reimbursement list. Before insulin used to be procured through a vertical programme and although patients could access insulin for free, stock-outs problems were reported due to gaps in the distribution system and the lack of accurate data on the number of insulin patients.
After a previous attempt to introduce generic prescribing, in October 2012, thanks to Government support, it was finally possible to introduce generic prescribing. This is expected to reduce spending for both the national insurance company and for patients.
Until 2013 compliance with good manufacturing practices (GMP) was not enforced. With release of the new reimbursement list medicines registered in either the European Union, the US, Canada, Australia, or Japan and therefore compliant with GMP are given preferred supplier status. This is expected to provide a strong incentive, particularly to the local manufacturing industry, to improve their manufacturing practices according to international accepted standards of good quality.
Areas were more efforts are needed include covering the insured population, expanding the breadth and depth of medicines coverage while promoting rational selection and use of medicines, strengthening post-marketing quality control and pharmacovigilance activities.
Conclusion Although presented as a building block on its own, achieving access to essential medicines requires integrated action across all health systems building blocks.
In Moldova, increased coverage of medicines was possible due to increased funding. Political support enabled to overcome initial resistance and to introduce generic prescribing. However, several challenges remain to achieve universal access to quality essential medicines. These include, but are not limited to, achieving universal health coverage, obtaining better prices for medicine, reduce waste by promoting rational selection and use of essential medicines, strengthening post-marketing quality control systems and pharmacovigilance.

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