Access to Medicines through Universal Health Coverage: Golden Ring or Trojan Horse?

Access to Medicines through Universal Health Coverage: Golden Ring or Trojan Horse?

"Amina and her child"


It was the year 2000. "Amina," a mother of two in Ghana, was expecting a third child. She needed vitamins and iron for her pregnancy. Her five-year-old son needed a costly antibiotic. Her husband needed medicine for high blood pressure. At the time, Ghana’s unpopular cash-and-carry health system meant patients had to pay out-of-pocket for most health care, including medicines. Amina’s family simply could not afford the medicines they urgently needed.

Over the past 25 years, the number of people worldwide with access to essential medicines has more than doubled. Yet more than 30 percent of the world’s population still does not have reliable access to essential medicines. And when they do have access, medicines too often are used ineffectively or wastefully.

This week, MSH co-hosted more than 600 experts from nearly 100 countries for the Third International Conference for Improving Use of Medicines (ICIUM) in Antalya, Turkey. ICIUM is an outgrowth of the International Network for the Rational Use of Drugs (INRUD), which MSH co-founded in 1989 to create a new generation of policy-makers, researchers, and health providers that brought together the disciplines of clinical medicine, pharmacology, health services research, and behavior change to improve the use of medicines in low- and middle-income countries.

Is access to medicines through universal health care a golden ring or trojan horse? Photo credit: Larry Pieniazek via GFDL and Creative Commons.

At ICIUM we asked: Is access to medicines through universal health coverage the magical Golden Ring won on the merry-go-round, improving health outcomes and making health financing more equitable? Or is it a Trojan Horse that threatens program viability through ever-increasing medicines costs?

The Devastating Effects of Out-of-Pocket Health Spending

Amina and her family were among the three billion people in the world for whom the primary funding source for health care is their own out-of-pocket payment. The hard reality of health financing worldwide is a “double unfairness”: poorer countries spend less money on health and a larger share of that money comes from people’s own pockets. In 2007, direct out-of-pocket payments represented more than 50 percent of total health expenditures in 33 mostly low-income countries. The result is that each year at least 150 million people around the world suffer financial catastrophe and 100 million are pushed into poverty because of the high cost of their health care.

The health impact is stunning: As many as one third of poor people with acute illness receive none of the medicines prescribed to them.

Providing Access to Medicines through Universal Health Coverage

In response to the adverse health impact and financial hardship of out-of-pocket health spending, a global movement is developing for universal health coverage. Defined by the World Health Organization as “access for all to appropriate health services an affordable cost,” universal health coverage reforms have been pursued over several decades by countries like Columbia, Chile, South Korea, Taiwan, Province of China, and Estonia. Recently more African and Asian countries—Rwanda, Ghana, South Africa, China, India—are starting to make similar commitments. In all, more than 60 countries—including countries at all levels of development—already have or are on their way toward UHC.

The results are measurable. Thailand’s expansion of coverage over five decades, for example, has led to a dramatic drop in out-of-pocket spending, and by 2007, 98 percent of the population had health coverage. UHC is achieved in Thailand through three major programs, each covering a different segment of the population. All three programs cover the national list of essential drugs, which includes products for all major health conditions, including cancer. But for the oldest of the three programs, the medicines benefit started to become a Trojan Horse—its rules for unlisted medicines were too liberal and its reimbursement mechanism encouraged excess use of high-cost medicines. As a result, its expenditures rose dramatically, with an eight-fold increase in the cost of out-patient medicines. Only in 2009-2010, after a vigorous series of “smart therapeutics,” value-for-money and accountability controls, was the program able to contain its annual cost increases.

In 2004, Ghana replaced its cash-and-carry system with the National Health Insurance Scheme (NHIS), which covers in-patient and out-patient medicines. The program has markedly increased coverage and reduced out-of-pocket expenditures. The NHIS has a separate, more expensive medicines list than the Ghana essential drugs list, and reimburses accredited hospitals, clinics, pharmacies, and licensed chemical sellers on a fee-for-service basis. This benefit was hailed as a Golden Ring by Amina and millions of other Ghanaians. Between 2006 and 2008, total claims increased six-fold, while medicines claims increased eleven-fold, from 25 percent to just under 50 percent of total claims. The increase in medicines claims can be attributed in part to unmet need, but the number of drugs per prescription and the average cost per claim increased excessively, from 25% of total claims to nearly 50%. The result was that by 2008 NHIS was deeply in debt to the health facilities. Amina and other Ghana NHIS members are again being asked to pay for medicines when their district is owed too much by NHIS.

Thailand and Ghana are each textbook cases of the Trojan Horse dynamic we have observed repeatedly in health insurance programs in low- and middle-income countries. How can UHC programs win the Golden Ring of greater health impact, reduced medical impoverishment, and increased UHC acceptance while avoiding the Trojan Horse of excessive demand for high cost medicines, adverse health impact of commonly used cost-control measures, and increased fraud and abuse?

At ICIUM we outlined best practices, common threats, and pharmaceutical management strategies for UHC. These strategies are described in the health insurance chapter of the latest online version of MSH’s classic Managing Drug Supply and by Harvard's Medicines and Insurance Coverage (MedIC) Initiative.

Golden Ring or Trojan Horse?

This week at ICIUM we argued that universal health coverage can markedly increase access to needed health care, including essential medicines. But success in defending against the Trojan Horse and winning the Golden Ring requires a multi-disciplinary approach. In addition to medical and pharmacy expertise in essential medicines, expertise is needed in pharmaceutical management, insurance, economics, and business. For Amina and millions worldwide, the universal health coverage movement offer great hope. This hope can be realized if UHC leaders and policy-makers heed the lessons of experience to ensure the viability of national UHC programs.

Jonathan D. Quick, MD, MPH, is President and Chief Executive Officer of Management Sciences for Health. Dr. Quick has worked in international health since 1978. He is a family physician and public health management specialist.

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Denise Correa
Health is one of fundamental Human Rights. How countries are able to deliver this right is a different problem. The most fair health system is Universal Health Coverage adopted in most of the high-income and middle-income countries. The lower-income countries people are the ones that need more UHC. These countries are the ones that have the biggest financial difficulty in keeping this system (Skolnik, 2008, p. 44). In order to achieve social justice through the UHC and at the same time manage well the costs, it is necessary to organize well how the funding is collected and how services are delivered. The health system collection of funds has to reflect the sharing of financial risk of getting sick. This collection has to reflect the knowledge of the government of its own people. The rich should pay more than the poor (WHO, 2000, p. 113). How services are delivered is another way is to control expenses. Cost effective interventions are the best answer to invest health system money. The Copenhagen Consensus is a list of cost effective investments that governments can make to improve the well being of the population. Many of them are health related. Another way is to keep information updated about agreements that United Nations are sponsoring. The World Trade Organization has been negotiating the reduced patent rights of medications (especially for HIV/AIDS). In this agreement the high-income countries would accept to make high cost medications affordable to low-income countries (Skolnik, 2008, p. 50). Medication is a big financial risk for the poor. In low-income countries a family spends more than 50% of the health expenses in medication. For governments, medication is usually the second biggest budget item after salaries. It is necessary to make cost-effective use of medicines. It is necessary strong health policies and regulations. It is necessary strong implementation of these policies and monitoring. Other ideas for these countries to implement are: look for the essential drugs for the population to establish contracts with the private sector, promote cost-effective use of each medication among the health professionals, establish a system that the government could finance these drugs for the poor, and etc (WHO, 2000, p. 132). Access to medication is a good intervention but it has to be done in a planned and organized way. The main answer for the UHC financial problem is health policy (how to make it and implement it). Policy has to be based on data collection and analysis. The question should always be what is good for this population? And how can we achieve this good efficiently? Policy is also about fairness. Fairness means that the whole population has the opportunity to make choices. It is not fair when it is imposed to people a fate and they cannot make choices. A good example is not having doctor services at a certain area of the country. These people do not have a choice to look for help when sick or not, they cannot look for help (Johnson & Stoskopf, 2010, p. 50). REFERENCES Johnson, J.A. & Stoskopf, C.H. (2010). Comparative health systems: global perspectives. Sudbury, Massachusetts: Jones and Bartlett. Management Sciences for Health (2012). Global health impact: Universal health coverage. Retrieved from Skolnik, R. (2008). Essentials of global health. Sudbury, Massachusetts: Jones and Bartlett World Health Organization (WHO, 2000). The world health report 2000: health systems: improving performance. Retrieved from

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