Key Steps for Defining Pharmaceutical Benefits Packages
Many countries are faced with difficult decisions about how to prioritize limited funds for health to provide coverage for their populations. A well-defined health benefits package can ensure that a country’s resources are spent on cost-effective, highly valued services and medical products; help expand coverage to otherwise underserved populations; and provide explicit entitlements for all beneficiaries. Pharmaceuticals—medical products and other health technologies—warrant special attention within the health benefits policy discussion due to the large portion of the health budget they constitute and high rates of out-of-pocket expenditure on medicines.
As one element of a health benefits policy, a pharmaceutical benefits package can be defined as an explicit list of medicines and related commodities selected for the treatment of specified diseases or health conditions for eligible beneficiaries. By defining benefits packages that entitle beneficiaries to drug benefits with financial protection and explicitly connecting those entitlements to sources of financing, policy makers can help protect citizens from catastrophic health expenditures.
Countries in the Asian region have witnessed an expansion in pharmaceutical coverage through UHC initiatives in the recent past. This brief summarizes guidance for countries on establishing or strengthening a pharmaceutical benefits package as part of their health benefits policy. It offers a high-level, six-step process for countries seeking to define pharmaceutical benefits packages, which builds on a framework developed by Glassman et al., and it highlights examples from the Asia region, including Thailand’s HTA process, Indonesia’s national formulary (Fornas), and PhilHealth’s “Z benefits” package. The brief builds on the “Pharmaceutical benefits packages in Asia” mapping report by offering countries interested in moving toward a well-articulated, evidence-based pharmaceutical benefits package the guidance to define one. The brief also aims to support policy dialogue for an evidence-based pharmaceutical benefits package design.