Five Pharmaceutical Systems Considerations: A Crucial Link in Universal Health Coverage

Javier Guzman, ex-Technical Director, and Kwesi Eghan, Principal Technical Advisor, USAID MTaPS

As we mark Universal Health Coverage (UHC) Day this month, countries continue to battle the spread of COVID-19. The lack of effective treatments and testing capabilities at the onset of the pandemic was a stark reminder that access to safe and affordable medical products is key to achieving healthy outcomes. With more therapeutics and diagnostics becoming available, the preparedness of pharmaceutical systems to get medical products and services to people is particularly worrisome in low- and middle-income countries (LMICs). Chronic shortages of medicines, low quality, and high cost add to the burden of patients and health systems in LMICs, where up to 60% of health spending is on medicines, mostly from out-of-pocket payments. Poorer households spend up to 9.5% of their income on medicines at the point of care, making them vulnerable to poverty.

The pandemic highlights the importance of the global call for UN member states to move toward UHC—the idea that everyone, everywhere should have access to affordable health care, including safe, effective, quality, and affordable essential medicines and services. This goal requires taking a systems approach to medicines and related services.

What Will it Take to Create Strong Pharmaceutical Systems?

A strong and resilient pharmaceutical system requires a shift away from a narrow view of medicines merely as systems inputs and as products for consumption. The components of a pharmaceutical system—structures, people, resources, and processes and their interactions within the broader health system—are interrelated, and each component must function well to support the overall system. The USAID Medicines, Technologies, and Pharmaceutical Services (MTaPS) program supports countries to strengthen their pharmaceutical systems as they move toward UHC, using a holistic approach that builds on existing structures, including the private sector.

Based on our experience in strengthening pharmaceutical systems in dozens of countries under USAID-funded programs for more than 20 years, we share some key considerations with examples for enabling systems that adequately serve people’s health care needs.

1. Strengthening Policies, Laws, and Governance
Good governance is essential for a country to structure its medical product prioritization, registration, selection, procurement, distribution, and reimbursements and to mitigate corruption. MTaPS assists countries in strengthening pharmaceutical-sector governance. For example, the program is supporting the National Medicines Regulatory Authority in Nepal, Mozambique, and Rwanda to deploy the WHO’s Global Benchmarking Tool for more effective and efficient regulation of medical products. The strengthened structures will provide better governance that can ensure access to quality-assured, safe, and effective medicines and protect patients from harm.

2. Financing: How to Pay for Medicines?
Since medical products represent a large proportion of government expenditure, policy makers have to mobilize enough resources to pay for health, including medical products, pool those resources centrally to spread the financial and health risks, define entitlements (who is entitled to what medical product, and what, if anything, they should pay for it), and finally, efficiently and systematically allocate adequate resources and define the mechanisms for procurement and delivery of the medical products. The last function is particularly important since medicines and pharmaceutical issues are a leading contributor to health systems inefficiencies, accounting for as much as 30–40% of all health expenditures. Government intervention in LMICs is important to reduce out-of-pocket payments and protect their populations against poverty and financial risk.  MTaPS supports strategies to optimize financing to better utilize resources, strengthen systematic priority setting processes, reduce out-of-pocket spending, and adequately fund and manage essential medicines. MTaPS recently launched the “Roadmap for Systematic Priority Setting and Health Technology Assessment (HTA),” which serves as a practical guide for policy action to successfully implement HTA in LMICs and paves a road to sustainable UHC and self-reliance. MTaPS is also defining methodologies to enhance the capacity of countries to collect, analyze, and use pharmaceutical expenditure data to gain a fuller picture of what is actually being spent on medicines in the country and to inform decision making. For example, in Burkina Faso, an exploratory test on methodologies will produce guidelines to help country health accounts teams more accurately track pharmaceutical spending through their systems.

3. Responsive, Patient-Centered Pharmaceutical Services
Good treatment outcomes depend on patient-centered pharmaceutical services that ensure that medical products are prescribed, dispensed, and used appropriately. Appropriate use of medical products will not only improve health but will also improve quality and reduce inefficiency since patients get the right medical product in the right formulation and dose, at the right time and for the right duration. Antibiotics, for example, are often misused and overprescribed, resulting in rampant drug resistance and waste of limited resources. Improving pharmacy services can help ensure better patient outcomes and reduce unnecessary use of medicines. To this end, MTaPS is training health care workers in Tanzania on the latest standards of care to improve quality and efficiency. To optimize the use of antibiotics, MTaPS is working in 11 countries to implement antimicrobial stewardship programs.

4. Timely and Adequate Information to Improve System Efficiencies
Pharmaceutical systems in many LMICs suffer from poor data availability and accessibility. In Bangladesh, where 50% of medical equipment is underutilized  for varied reasons, MTaPS is supporting an asset management system to track equipment that has been piloted in 12 district hospitals and will roll out nationwide. Under the new system, Bangladesh’s health ministry will be better able to track, deploy, and maintain equipment, improving cost efficiencies. Optimizing the use of existing resources and reducing waste will help the country make progress on increasing health care coverage to achieve UHC.

5. Leveraging Partnerships with Private Sector
A committed public-private partnership can help build on a local government’s capabilities and experiences. The share of private health provision in LMICs ranges from 29–73%. Inclusion of private clinics and pharmacies in national public health efforts enables the use of readily available but underutilized private-sector resources in pharmaceutical services delivery. The interventions needed to effectively utilize the private sector depend on the existing distribution of public vs private sector services, the private-sector component of service delivery, and the level of the public sector’s dependence on private fee payments.

Conclusion

With dire challenges in LMICs around medical product shortages, low quality, and high-cost burden, UHC isn’t possible without ensuring access to safe, effective, quality, and affordable medical products. This, in turn, will require a systems approach and a shift away from a narrow view of medicines as inputs and as products for consumption. The global pandemic has served as a magnifying lens that has bared the fundamental role that medical products and services play in health systems and in determining health outcomes. To successfully and sustainably achieve UHC by 2030, we must commit to building strong and resilient pharmaceutical systems. Cognizance of key considerations of private sector partnerships, strong governance, optimized financing, information systems, and enhanced pharmacy services can help us get there.