A roadmap to health system efficiency?
Image: G. Novick presentation

In today’s post, Eugenia de la Fuente of GLOBALHealthPR Argentina partner Paradigma PEL Comunicación explains why Argentina needs a uniform health technology assessment process – and why the media should take notice of the issue.

There is no doubt that advances in health technology have provided tremendous benefits to patients. In Argentina, patients have pursued access to innovative treatments through court actions, which have been increasing in frequency along with each new drug approval and diagnosis method.

This creates a lack of uniformity in how treatments are covered and delivered, and demonstrates that health systems throughout the world should use caution when deciding which technologies to cover and, perhaps more importantly, how to bear the expenses which will inevitably follow a given decision.

To put what is happening in Argentina into context, Dr. Gabriel Novick, former Undersecretary of Health Planning of the City of Buenos Aires, recently gave a talk to a group of healthcare journalists. “One must consider which technology the country needs, who it is for, and how it should be approved, because the scope of the issues that make the newspapers’ front pages is limited.  When healthcare is discussed, the media agenda covers only an infinitesimal part of the story in Argentina, and usually only takes an interest in socio-health problems,” said Dr. Novick after showing a scribbled image designed to illustrate the Argentine health system. “Within this framework, coverage of the technology assessment process is negligible,” he said.

Current HTA process in Argentina: multiple ways to score, but which points really count? Image: S. Chalmeau, a/LTA via mymodernmet.com

However, Novick, now the Corporate Medical Director of Swiss Medical Group (which offers private healthcare to about a million members) elaborated further. He went on by saying that in spite of the aforesaid, there are three elements that add significance to the topic: “New technologies appear throughout the country on a continuous basis. These technologies are poorly assessed. All this occurs in an inefficient socio-health system that,” he pointed out, “generates a complex cocktail that has a vast systemic impact. This is why this issue is so important.”

Under the title “Assessment and impact of new technologies in the current health care context in Argentina,” the expert made a short review of the local healthcare situation, quoting, to begin his speech, a phrase from the Report on Oncology in Latin America published in 2013 in The Lancet Oncology: “The lack of integration of the health system of Argentina results in poor access for people.”

Social “security” and coverage confusion

In Argentina, social security does not have the same meaning as in other countries. For example, in Mexico there is the Social Security Institute, a single system to which everybody contributes part of their income. The healthcare system is not fragmented into a large number of health plans, some of which are more solvent than others. In Argentina, health plans are just a segment of social security. This is the reason why the dispersion is so significant, explained Novick. He went on to present data that reflect this fragmentation, which has turned Argentina into a study case worldwide:

• 62% of the population is covered by a union-run health plan (national or provincial);
• 15% has a private health plan (some members divert their contributions from their union-run health plan to the payment of the private plans and some are direct members); and
• 36% receives health care through the public system (public hospitals).

“As you see, the numbers don’t add up. Based on these figures, healthcare services are provided to 60 million people, while the country has 40 million inhabitants. How come?” Novick wondered. He then mentioned that, for example, the number of people with dual coverage amounts to 1,650,000. “This is inefficient,” he concluded.

In addition, Novick pointed out the existence of regional and social dissymmetry in access conditions and presented the differences between the low-income and high-income population in relation to important indicators such as “health service deficit” (12 to 1); “overcrowding” (10 to 1); “gas supply” (13 to 1); “waste collection deficit” (9 to 1). “All this has an impact on health and raises the question of which, then, is the technology that the country needs and whom it needs said technology for. And the how, included in the initial question, becomes even more important,” he remarked.

Moving toward a common standard

Next, he showed the image of a colander standing next to a brain. ‘The model we should follow is that of a single intelligent sieve. This model is used in many parts of the world and has started to be implemented in several countries in Latin America. For example, Colombia has just gone back to square one and established a single technical agency. This is what we should be targeting: a single technical agency that weighs intelligently all the variables that have an impact on the absorption of new technologies: cost, quality of life, potential damage, clinical results, financial sustainability, sustainability over time’, enumerated Novick.

He explained that U.K. standards are the best example of the assessment of new technologies. “Virtually all the rest of the world is still far away from the English agency of technology assessment, but Colombia is doing this; Ecuador is doing this. All Latin America is moving towards a single, intelligent filter. We are more similar to this,” he said, pointing to a picture showing several basketball nets, one next to the other. “We have multiple places where things merely happen, although only two are binding: The National Drug, Food and Health Technology Administration (ANMAT), which is responsible for approvals, even when the assessment conducted by it is totally arbitrary, and the Assessment Agency of the Undersecretariat for Health Care Services, which has authority to require coverage. Now, are they willing or empowered to provide the guidelines and enforce the mandatory rules needed? The answer is, ‘no’,” concluded Novick.

Finally, the expert summarized: “A critical assessment process is needed to determine which molecules enter the health system, under which conditions, what their budgetary impact is, and how we are going to finance all this. The arbitrary entry of new technology in such a complicated environment is unacceptable. Everything for everybody is not an option; in fact, there is a lot for a few, and little for many. When one speaks of new technologies, one has to weigh these variables in order to be truly effective.”

Does your country have a uniform health technology assessment process?

The post Dilemmas Over the Approval and Delivery of New Health Technologies in a Fragmented and Inefficient System appeared first on GLOBALHealthPR.

Cumbersome formalities, delays in the delivery of medicines and patients’ lack of information are some of the main hindrances to access to cancer treatment in Latin America. The data stem from a survey conducted by the ACIAPO Foundation (Community Foundation for Comprehensive Care of Cancer Patients) of Argentina, jointly with patient associations from five other Latin American countries, for the purpose of assessing the main access problems faced by low-income oncology patients once they are diagnosed. In order to improve the present situation, the entities suggest improving counselling and assistance, educating patients and maintaining oncology drug banks.

The following entities took part in the survey: the ACIAPO Foundation (Argentina); Instituto Oncoguía (Brazil); the CáncerVida Foundation and the New Life Association of Rancagua (Chile); the Simmon Foundation (Colombia); The Mexican Association of the Fight Against Cancer (Mexico) and Esperantra (Peru).

Ignacio Zervino, MB, Institutional Relations Director of the ACIAPO Foundation, explained, “We chose access as the first issue to work on, because the different organizations agreed that this is the most relevant and most critical aspect of the problems faced by cancer patients in Latin America.” Even in countries with broad public health care coverage, access is hindered by issues such as the excessively long distance to the care centre or the lack of the education level necessary to understand how to follow a treatment scheme.

The most frequent problems identified by the survey were: excessive bureaucracy, poor/incorrect information (which leads to the sub-utilization of the available public resources): lack of education (patients who do not have the educational and cognitive tools needed to stand up for their rights and achieve empowerment) and insufficient complaints. The fewer the complaints from patients and family members, the longer the delays or the greater the misunderstandings in the response of the public health system, both as regards the delivery of medicines, the making of appointments, the granting of subsidies to the cost of travel to the treatment centres and other aspects.

“We believe it is essential to work on the education of the patients and on the proactive interaction with the health authorities”, advised Mr. Zervino, who explained that “far from the combative attitude that sometimes characterizes community organizations, we recommend working jointly with officials by proposing courses of action on the basis of our knowledge of reality.” In this regards, “ACIAPO is trying to strengthen the links with health authorities, health care programs and other organisms so as to formulate proposals. We also try to improve the quality of the records, i.e., to systematize the evidence of access problems in order to measure the extent of the difficulties”, he underlined.

 What can be done?

There is much that Civil Society Organizations (CSOs) can do in order to improve access to cancer treatment. Among the most efficient strategies, we should mention the following:

Why is this important?

The number of cancer patients in the world is bound to increase: while in 2012 the number of new cases diagnosed was 14 million[1], it is estimated that this figure will increase to 22 million cases per year over the next two decades[2]. But this is not all:

• By 2030, in Latin America and Caribbean, the number of cases diagnosed will have reached 1.7 million per annum will be diagnosed, with a million deaths each year.[3]
• Over 50% of the new cancer cases and almost two thirds of the deaths occur in low- and medium-income countries.
• In 2030, the developing world will bear 70% of the global burden of cancer.[4]
• Each year, 8.2 million people die of cancer all over the world².
• Between 2.4 and 3.7 million deaths could be avoided through prevention, early detection and treatment¹.

Unfortunately, while cancer is a growing problem in countries with all income levels, its consequences are more severe in less favoured areas. The mortality rate for all types of cancer in low-income countries is 74.5%, while in high-income countries the rate is only 46.3%, in other words, mortality is 1.6 times higher³ in low-income countries.

What are some of the barriers to cancer treatment access in your country?

The post Barriers to Cancer Treatment Access in Latin America appeared first on GLOBALHealthPR.

Prime Minister John Curtin, who devised the first PBS in Australia during World War II.

Today’s post comes to us from Mark Henderson of GLOBALHealthPR Australia Partner, VIVA! Communications.

The Pharmaceutical Benefits Scheme, or PBS, is a programme administered by the Australian Government to provide patients with heavily subsidised access to a broad range of prescription medicines. Despite its expansion over the years, access to treatments for some rare disorders under the PBS remains elusive today.

Earlier this month, the Medical Journal of Australia (MJA) published an article on the history of the PBS, entitled ‘How the Pharmaceutical Benefits Scheme began.’

This government scheme, with which all Australians are familiar and use, took years from inception to operation.

In 1944, under the leadership of the then Prime Minister, John Curtin, the wartime government introduced legislation for the Pharmaceutical Benefits Scheme. This legislation came in response to a national need for medicines including sulphonamides, streptomycin, and penicillin to be made available to all Australians, not only the wealthy.

Under this bill, any Australian resident could access medicine at no charge after presenting a doctor’s prescription to their Pharmacist. The government would then subsidise the costs.

The bill was opposed by 98 per cent of doctors in Australia, with the British Medical Association (BMA) fighting to ensure it was not passed, even taking the matter to the High Court in 1945 where it was defeated.

In 1947, after narrowly avoiding being outlawed as part of the Constitution, The Pharmaceutical Benefits Act 1947 was tabled. The Act was challenged again by the BMA, but this time for being too narrow as opposed to broad scale.

The BMA made an offer to the government for a limited range of medicines including penicillin, sulfa treatments, vaccines, serums, diphtheria toxin and insulin to be made available on the PBS. This offer was rejected and arguments continued. Meanwhile Australians were still unable to access free or (in many cases) affordable medicines.

In the 1950s, there were ongoing arguments regarding the implementation of a PBS, which saw a ‘safety-net’ scheme put in place for a few years, from 1950-1953, when the government passed its own National Health Act, which took over the ‘safety-net’ scheme. A Pharmaceutical Benefits Advisory Committee (PBAC), nominated by the BMA, was established to advise which therapies could be included under this programme, limited to a very small number of “life-saving and expensive therapies”.

Over time, the race for medicines continued, with new and improved products entering the market.

In 1960, 16 years after its initial introduction by Prime Minister Curtin, the PBS was finally extended to include a more comprehensive list of medications, marking the beginnings of the scheme as we know it today.

Today the PBS forms part of the Australian Government’s broader National Medicines Policy, under which the government subsidises the cost of medicines for most medical conditions, utilising a co-payment model. In January, 2014, the co-payment for an average Australian resident was $36.90, while Australians with a concession card paid only $6.00. The Australian government foots the remainder of the bill.

The list of therapies listed under the PBS, which is available to all Australian residents who hold a current Medicare card, is extensive..

Visitors from countries with which Australia has a Reciprocal Health Care Agreement  (RHCA) are also eligible to access the Scheme, including the United Kingdom, Ireland, New Zealand, Malta, Italy, Sweden, the Netherlands, Finland, Norway, Belgium and Slovenia.

Many battles continued to be waged by pharmaceutical companies and patients to list treatments on the PBS.

Of note is the case of Soliris (eculizumab) – the only treatment available and clinically proven to prevent premature death and vital organ damage in those living with atypical hemolytic-uremic syndrome, or aHUS.

Soliris was approved for use by the Therapeutic Goods Administration (TGA) in October, 2012. However, unlike 30 other countries, including the USA, UK, Canada, Germany and France that are providing their aHUS patients with access to the cost-prohibitive treatment through government-funded programs or private health insurance initiatives, Australia is lagging behind.

At a current, unsubsidised cost of more than $500,000 per adult per year, this treatment is completely out of reach of every Australian living with, or caring for someone with aHUS. Yet it represents their only hope for life.

As the government and manufacturer continue their negotiations to fund this life-saving treatment through the proposed PBS: Section 100: Highly Specialised Drugs Programme, aHUS lives hang dangerously in the balance. Learn more here.

The post Unravelling Australia’s Pharmaceutical Benefits Scheme appeared first on GLOBALHealthPR.

The post China’s Economic Growth is a Catalyst for Change in the Country’s Health Care System appeared first on GLOBALHealthPR.

Uncertainty around when, how or even if things are paid is never a good thing, especially if you are investing heavily and not seeing your return for years to come. This is exactly how global pharmaceutical businesses find themselves when faced with the UK and a future scheme called value-based pricing (VBP).

The current UK pricing system sees a standard cost effectiveness threshold applied to all new products with a profit cap of around 30 per cent; a value based system would in principle allow different price thresholds depending on the relative need for the drug. So new medicines in their first indication designed to treat diseases with unmet need would be awarded a higher threshold and can be given a higher price. It has also been reported that higher thresholds will be given for medicines that have evidence demonstrating ‘wider societal benefits,’ such as people being able to return to work and be economically productive. Medicines without this type of supporting evidence, in less severe diseases or where therapies already exist, will get a lower threshold and obtain a lower price.

The new VBP system was originally meant to be effective from January 2014 but has now been delayed until autumn 2014 at the earliest. A further consultation period is expected to be undertaken and many suggest that it will be watered down from the original aims. It is all confusing and apparently disorganised, with some pretty basic questions that I posed in a VBP blog post 18 months ago still going unanswered.

So why is this Englishman being so UK centric? The UK isn’t after all the biggest pharmaceutical market, maybe 10^th in the world and half the size of our neighbours France or Germany. But as cited in Aurora’s NHS business unit’s director’s previous VBP post, UK branded medicine price is used as a reference by some 40% of the global pharmaceutical market – so what happens here sends ripples across the globe. The world already looks at the UK’s National Institute of Health and Care Excellence (NICE) decisions as a benchmark for health technology appraisals (which look at clinical efficacy and cost-effectiveness). In the future, NICE will also be conducting the VBP assessments.

We know that what happens in Blighty will have a knock on effect elsewhere.

I’ve been talking to our GLOBALHealthPR partners about this topic and each country around the world has a different way of pricing and assessing medicines. As we look into the future, these systems are becoming ever more fragmented. In the UK this year, as in years past, pharma companies are launching really innovative medicines, which are proven to transform a person’s life. The problem is many are being told they aren’t recommended for use as they are not deemed ‘cost effective.’ This effectively halts access and the medicine will only be used in a handful of cases where a doctor puts in an individual funding request, which involves paperwork galore.

So what can be done as we all work hard to make access to innovative medicines a reality?

Well until we all fully understand how NICE intends to undertake an assessment, it’s a difficult call and things remain uncertain, however the wider societal benefits that a medicine brings will be crucial. Creating evidence that is concisely communicated to all the right stakeholders will be the name of the game. This evidence could be gathered in a host of ways such as during clinical trials or say collected in first launch markets, with the data being rapidly shared with later launch markets. This will require delivering tools to measure patient experience and adding services that capture data around the impact of the use of a medicine. This can ultimately be used to support funding decisions which may occur at the national, regional or local level. Digital solutions can make this seemingly daunting task completely manageable.

Whatever happens, the medicines access game is changing – it’ll just be better when everyone knows the rules, and like pay day we would all like that to come along quickly.

If you’d like to speak to our UK partner, London-based Aurora, about VBP, health technology appraisals and the strategies and tools they are already delivering to support access to innovative medicines, contact the team on +44 20 7148 4170, ask for Neil Crump, Aaron Pond or Rachel Terry.

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Caught between Frankenstein and an unfathomable labyrinth. That is how many Latin-Americans feel when navigating their country’s health system, explained prominent Argentinean health systems expert Dr. Rubén Torres, former Area Manager of Health Systems based on Primary Health Care of the Pan American Health Organization. (PAHO) during a recent journalist training session in Buenos Aires.

The PAHO believes that there are two characteristics of the Argentinean health system that make it inefficient and inequitable: segmentation and fragmentation. Segmentation exists because of the several forms of financing: through the public sector, the social security sector and the business sector (health insurance plans). Fragmentation results from each health system using its own assistance networks that coexist without allowing any kind of interchange. Torres illustrated the segmented nature of the system by using the image of Frankenstein (a “dummy assembled from different pieces”) and the fragmentation with the image of a person standing in front of a labyrinth. These characteristics are common in most Latin American countries’ health systems.

Private vs Public Expenditure

Typically in Latin America, the public sector spends less than the private sector. The problem posed by systems with a high private expenditure is that they are deeply inequitable and could, for example, drive a family into poverty. This is called catastrophic expenditure; Dr. Torres explains:

“There is often a technical misunderstanding, because when one speaks of catastrophic expenditure, one usually thinks about a transplant, or a complex cardiovascular surgery operation. And this is often true. But one should be aware of the fact that, for a person who is within the first quintile of the population, the poorest quintile, going to the chemist’s to buy medicine without a discount may be a catastrophic expenditure. By definition, catastrophic expenditure occurs when health expenses total 30% of a person’s income.”

Over the past ten years, all Latin American countries have enjoyed significant economic growth: the average growth rate has gone up from 3.9 in 2009 to 4.5 in 2013. This shows how economically powerful a decade it has been. But the question that should be asked is: has this wealth led to better health care and a bigger budget for health-related expenses? Said Torres, “Last year, we studied for the PAHO our countries’ health budgets for 2005 through 2010, the tail end of growth, and we found that although government expenditure on health has in fact grown by 0.8, when out-of-pocket expenses were measured, we found that it had virtually stayed the same.” 

Wanted: A New Kind of Doctor

Finally, Torres mentioned that another serious problem in the region was related to education: the issue of how many and what kind of medical doctors are needed. Although non-communicable (chronic) diseases are often the main health problem, they are not properly addressed. “The challenge is to make the patient visible, because today the system works like security at an airport: the patient appears on the radar screen, he or she is assisted and, theoretically, cured. Then, he or she disappears from the radar screen and is forgotten. This results in a huge number of preventable deaths, of persons who are rendered blind by diabetes or suffer from kidney deficiency. We need a different kind of doctor from the one we have today,” he reflected. Later, he mentioned that about 6,000 medical doctors graduate from medical schools in Argentina, while there is a shortage of nurses. In Europe, the doctor-nurse ratio is much more balanced.

The Airline Model for Health Systems

 “The best example for an equitable health system is that of an airline”, compared the specialist. He added: “Airlines guarantee that all the persons who buy a ticket take off and land and the same time, all of them eat, drink and enjoy the same safety standards during the flight, regardless of whether they fly First Class, Business or Economy. And this does not preclude some of them from traveling more comfortably than the others; what is important is that they are all offered the same safety measures. In Argentina, the health system is organized so that only the passengers flying First and Business class arrive safely at their destinations,” he concluded.

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In England, we often hear that the National Health Service is the envy of the world. But is it really?

To find out, we decided to contact GLOBALHealthPR to ask the partners in the network about their perceptions of the NHS, comparisons with their own healthcare system and which health system is deemed the worst in the developed world.

Guess what? The NHS is not big news elsewhere and awareness of the service is limited. Any positive mentions are generally related to processes, such as NICE (the National Institute for Health and Care Excellence), and the system is only ever really understood by healthcare professionals and journalists. The public doesn’t really care; they have their own healthcare systems to consider.

But what does this mean for pharma? 

In a world where we interact globally, it increasingly seems that individual countries’ healthcare systems want to stay in their silos, focusing inwards. Surely this cannot be good for pharma trying to launch new medicines and technologies across the globe, right? Pharma therefore needs to offer local value propositions across a global market place in a way that is cost effective for their customers and their own business.

So what can pharma do to make it easier?

• Segmenting audiences and understanding the key decision makers in every single healthcare system is absolutely vital. But having a long list of names and job titles isn’t enough. Pharma should be looking to understand how their key stakeholders interact with each other and who influences who. This needs to be done on a global scale, with the information broken down locally.
• Good value will mean different things to different healthcare systems and different localities, but also to each individual whether they work in a clinical or payer capacity. Ensuring pharma understands these nuances when presenting value propositions is a must. A one size fits all approach just doesn’t work. This understanding comes with extensive relationship building with key stakeholders across a vast landscape.
• Recognise that corporate brand reputation is a powerful ally. There will be times when your new medicine isn’t seen as a priority by certain customers in certain healthcare systems. How else can you help? What added value can you bring to make your key customers’ jobs easier? Building relationships for the long term will ensure you reap the benefits when you have a proposition valued by your customers.

As with any new product launch, understanding the customer and preparing the marketplace is often more important than the launch itself. It seems that in a world in which we interact globally, our understanding of, and interaction with, healthcare systems is still very much localised. Pharma should be doing the same.

What else do you believe pharma needs to do to be competitive in this global/local marketplace? Have you got the tools to truly understand your stakeholders?

If you would like to learn more about how to map your stakeholders and understand how they influence each other, please get in touch.

The post Local Value Propositions for a Global Marketplace – What Does Pharma Need to Do? appeared first on GLOBALHealthPR.