Improving Medicines Benefit Management for Universal Health Coverage Programs: A Conversation with Kwesi Eghan

Kwesi Eghan, courtesy.

Used appropriately, medicines save lives, decrease effect or cure diseases, and improve quality of life. Medicines are also key determinants of health care quality, and can be among the most cost-effective uses of scarce health care resources.
At the same time, management of medicines is a major source of inefficiencies in health care systems around the world...
- Kwesi Eghan

We spoke with Kwesi Eghan, MSc, MBA, BPharm, about the role of medicine and sound medicines benefits management for countries to successfully achieve universal health coverage. Eghan is Portfolio Manager for the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program in South Sudan and the Strengthening Pharmaceutical Systems (SPS) project in Afghanistan. He also leads the Medicines Benefits Management (MBM) work of MSH's Center for Pharmaceutical Management.

Why is access to medicines critical for achieving universal health coverage [UHC]?

Medicines are important to improving health outcomes and the effective functioning of a health system and therefore, a critical component toward achieving UHC.

A number of countries are either expanding or initiating UHC programs. There has also been a lot of advocacy for the inclusion of medicines in these programs. On one hand, countries need to know what medicines to include in their benefits packages and what is affordable, especially for clients who use both public and private sector services.

Other countries are also battling with equity and ethical considerations for selection of medicines. For example, should they cover pregnant women; should they include medicines for catastrophic illnesses such as cancer; or should they simply provide medicines to cover basic public health needs of the population?

Indeed, having gone through these initial questions, countries also have to decide which approaches to use in pricing these medicines in the benefits package. To enhance access, some countries have also questioned whether medicines should be free, and if not, what level of co-payments should be introduced. If not addressed, these questions will impact equity, access, and sustainability of UHC programs. 

On the management and operations side, countries also have to deal with developing approaches to monitoring UHC programs, especially balancing data availability and privacy—countries need data to inform decision-making about medicines utilization, while, at the same time, protecting confidentiality of patients. 

Why is Medicines Benefit Management [MBM] essential for UHC?

It is crucial for UHC programs to design and implement sound medicines benefit policies that are responsive to the needs of the population, and to monitor the desired and undesired effects of these policies, not only regarding access, affordability, and appropriate use, but also on fraud and abuse, satisfaction of patients and providers, health outcomes, and fiscal sustainability.

For instance, in Ghana the National Health Insurance Authority (NHIA) has indicated that, from a low of 28 percent a decade ago, medicines now account for almost 52 percent of its total health insurance claims per annum. To fully understand and document the factors accounting for this rise, an investigation into contextual issues—regulations, governance, adherence to treatment guidelines, and the level of technology support for claims management—is required.

MSH is developing a new suite of Medicines Benefits Management (MBM) tools to assist countries in conducting these types of assessments.

Results of the assessments will go a long way to help design and support management of the medicine components of claims and help assure long-term sustainability of the program.

Can you please tell us more about MSH’s Medicines Benefits Management suite of tools?

Our MBM suite comprises an assessment tool and a set of guidelines which highlight critical elements and key considerations for medicines benefit management. The MBM suite seeks to help policy makers, researchers, and implementers better assess and understand their in-country medicine management issues and help them make contextual recommendations for effective design of new medicines benefits schemes, as well as for the review and/or expansion of existing schemes under UHC programs.

The tool and guidance document, among other things, help countries assess the political, legal, and regulatory environment through in-depth interviews of stakeholders on the laws that guide functions of pharmacy and health insurance. For instance, how does improved regulation of the prescription or dispensing of medicines impact the objective of UHC? It increases access.

The tool and guidance document also help countries determine the financing and operational needs and the level of IT support that might be needed to support medicines benefit management.

We’re piloting the tool and guidance document in select countries now. The suite of tools will be publicly available later this year.

{Photo credit: Warren Zelman, Ethiopia.}Photo credit: Warren Zelman, Ethiopia.

What might happen to a person seeking health care, if the country doesn't have effective MBM?

Used appropriately, medicines save lives, decrease effect or cure diseases, and improve quality of life. Medicines are also key determinants of health care quality and can be among the most cost-effective uses of scarce health care resources. At the same time, management of medicines is a major source of inefficiencies in health care systems around the world.

Although implementing medicines benefits management is a challenging task, UHC programs must strike a difficult balance between equitable access and affordable expenditure at the household and system levels; otherwise persons seeking health may not receive the needed care, and low income, most-in-need households may ending up paying high out-of-pocket expenses for catastrophic ailments.

What was the impetus to launch the Medicines Benefits Management (MBM) pilot?

There appeared to be a consistent gap in the ability of countries to address the design issues around medicine management under UHC. As an advocate for inclusion of medicines benefit packages in the growing UHC movement, MSH put together a team to develop this tool to help countries better assess the design gaps in setting up benefit programs.

Pilots of the Medicines Benefit Management (MBM) tool were launched in Namibia in December of 2013, and shortly thereafter in South Africa.

These experiences provide us the opportunity to better understand how to assist countries with different GDPs and at varied levels of UHC roll-out to manage medicines benefits. These exercises also help identify system weaknesses and cost inefficiencies, and enable us to make appropriate recommendations for the expansion and sustainability of UHC and health insurance programs.

Can you tell us more about one of the piloting exercises please? Why did MSH choose the country? Who were the stakeholders? What were some challenges and outcomes?

We chose Namibia because of the potential learning opportunity the country presents to the rest of Africa in terms of existing technology; current challenges around medicines benefit management; and good collaboration with the Namibian Association of Medical Aid Funds (NAMAF). Despite the private sector focus of the Medical Aid/ Health Insurance system, the fact that they were in the preliminary stages of designing their National Universal Health Coverage program was key.

We worked with a number of stakeholders in the country, including the Ministry of Health, the Ministry of Finance, Medical, and Pharmaceutical Societies, the Social Security Commission, the Namibian Association of Medical Aid Schemes, a number of medical schemes principal officers and chief executives, private and public health facilities, and the MSH office staff in Namibia.

One key challenge with the piloting of the tool has been the presence of too little or too much data on one hand, and on the other hand, reservations about sharing country data necessary for in-depth analysis, which is essential to be able to make concrete recommendations to improve the system and service delivery in general.

As I pointed out earlier, a successful UHC program design will need significant considerations of how medicines as a major cost driver and a key component will be managed. The process requires the involvement of a multi-disciplinary team of health economists, financial specialists, and pharmaceutical and clinical experts. In Namibia, the design team for the UHC program had initiated work without inputs on pharmaceutical management. However, following the MBM pilot, the appropriate pharmaceutical expertise was invited to join the team.

What are the next steps for MSH with MBM?

You may recall that MSH cohosted a conference, “UHC and Medicines: Initiating a Dialogue,” in June 2013. In collaboration with partners and with sponsorship from the US Agency for International Development (USAID), MSH will host a second conference for select countries in the southern Africa region in Cape Town, South Africa, called "A Practical Approach to Designing Medicines Benefit Management". This conference will be held from September 28-30, 2014, just before the Third Global Symposium on Health Systems Research, also taking place in Cape Town.

Participants will represent a broad variety of stakeholders who play a significant role in advocacy for UHC, including individuals responsible for pharmaceutical management policy, claims management personnel, finance managers (both health and general revenue management at the national level), and representatives from ministries of health. 

We anticipate participation from countries such as Botswana; Swaziland; Namibia; Mozambique; Lesotho; Malawi; Zimbabwe; Zambia; and South Africa.

Participants will have the opportunity to discuss how medicines are managed in their programs and learn more about the MSH MBM tool and our experiences piloting it.

What does MSH bring to this area that’s unique?

MSH, through the leadership of Dr. Jonathan D. Quick, President and CEO, has joined global leaders in advocating for the inclusion of UHC in the post-MDG global agenda.

In addition, a number of technical experts within MSH have been working with me to advocate for the inclusion of medicines benefits management in UHC programs. Based on over 40 years of accumulated experience providing cutting-edge pharmaceutical management support to public and private sector health systems, we provide technical leadership and technical assistance in MBM to countries needing support.

How can other countries get support for MBM? 

The Cape Town meeting is open to select countries in the southern Africa region. We plan to have a number of other regional meetings in the coming year. Interested countries, institutions, and individuals can contact us at cpm@msh.org.

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