HEALTH INSURANCE AND MEDICINES BENEFITS IN THE CONTEXT OF UNIVERSAL HEALTH CARE
A medicines benefit program (MBP) is the component of a health insurance plan that covers some or all medicines prescribed and dispensed to plan beneficiaries. Although this manual focuses primarily on medicines, other health technologies, such as diagnostics and vaccines, fall into the same category, with similar decision-making processes. Here, we focus on MBPs offered by insurance mechanisms—public and private and for-profit and nonprofit entities.
Many low- and middle-income countries (LMICs) provide medicines to patients through nationalized public sector health programs or social security systems that maintain their own health facilities, employ their own doctors and pharmacists, and dispense medicines to patients exclusively through these in-house facilities. This manual does not cover that type of medicines benefit. The issues related to managing medicines in those types of health systems are covered in MDS-3: Managing Access to Medicines and Health Technologies.1
Here, we focus on management systems that insurance programs use to provide medicines to beneficiaries through contracts with outside service providers and then pay for the providers’ services based on claims submitted by the provider (or in some cases by the beneficiary). The service providers may be public or private entities.
PURPOSE OF THIS MANUAL
We developed this manual in response to discussions at a conference that Management Sciences for Health (MSH) hosted in June 2013 called “Universal Health Care and Medicines: the Start of a Dialogue.” Although meeting participants generally agreed that a medicine benefits component is essential for achieving universal health coverage (UHC), discussions made it clear that we lack a common understanding of which elements of an MBP are truly essential and which options and design elements should be considered when implementing or revising an MBP.
The companion to this manual, the MSH Medicines Benefit Program Assessment Tool for Developing Countries, contains key questions to ask and data collection templates to use when considering options for developing or revising a medicines benefit program. We have used the tool in three countries, Ghana, Namibia, and South Africa.
We created the manual as a primer for managers or consultants who are tasked by a government or other institution with designing or implementing an MBP or with supporting these efforts, such as international development professionals.
The manual introduces common design and management elements that every MBP must address. It helps readers identify the basic options and trade-offs to consider when designing or revising each aspect of the plan. Because each country context is unique, the manual cannot specify any combination of program elements that will fit a specific country situation, much less lay out a single program design fitting all situations.
This guide does not include detailed templates, algorithms, or samples of the analytical tools and approaches discussed in the text, but makes readers aware of alternatives to consider and points out sources for useful tools and templates. When we do discuss specific tools or we include citations in the reference section that provide practical details and examples of tools and templates that can be adapted to a specific country situation.
The manual highlights the sections that correspond to relevant chapters in MDS-3 that provide more information.
Many of the specific management approaches described here (particularly those related to claims processing) are drawn from approaches that pharmacy benefit management (PBM) companies in North America, South Africa, and Namibia use to manage medicines benefits for insurance programs. These approaches are not the only way to effectively address management challenges, but they are well documented and proven in their own settings and can be adapted to fit LMICs. This first version of the manual includes relatively few case studies from medicines benefit programs in LMICs because we found little information on the management specifics of current LMIC programs in the published and gray literature.
The manual is a work in progress—it will be revised periodically with feedback from colleagues working in international organizations, those working directly in LMIC programs, and from experiences gained in supporting medicines benefit programs in LMICs. We hope that future versions of this manual will include many more concrete examples of how MBPs in LMICs are handling the challenges involved in implementing and sustaining a viable program and more substantive discussion of the issues specific to accessing innovative health technologies in general.
MSH’s Systems for Improved Access to Pharmaceuticals and Services Program (funded by USAID) will be working with selected LMICs to assess their status and consider options for MBPs. We will incorporate lessons learned from these activities into future editions of the guide.