Pharmaceutical pricing and reimbursement policies: perspectives for the future

Setting the scene For many years, the global approach to pharmaceutical pricing and reimbursement policies has been informed, first and foremost, by the key differences between those systems which relied on public sector procurement and supply, and those which were based on reimbursement. The first approach was considered to be the most appropriate for developing countries. Funding for healthcare services was based on disbursement from the fiscus, often exceeded by funds obtained from donors or development partners, and supplemented by considerable out-of-pocket payments in the form of user fees. In such systems, where medicines were provided by the state, these were often procured by a central medical store, and then distributed to public sector clinics and hospitals. Pricing interventions were limited to the application of limited competitive bidding, for a list of medicines determined centrally and severely limited. In some, but not all cases, this national essential medicines list was informed by the WHO Model List of Essential Medicines, updated approximately every 2 years since 1977. While procurement of generic medicines was the norm, a sophisticated generic substitution policy was often not in place. Generic prescribing was preferred, but rarely practised. Rational use of medicines was expected to follow, almost automatically, but rarely pursued with much vigour [1]. For many of these countries, stimulating a local manufacturing industry has either been irrelevant or of subsidiary interest. Locally relevant innovation has been reliant on external funding, largely delinked from local pharmaceutical policies. The second approach, applied most vigorously in those countries with national or social health insurances system, was appropriate to systems in which the financing of health care was separated from the provision of services. In relation to medicines in particular, a wider range of policy options were implemented, including a variety of measures to promote generic medicines use, the use of co-payments and other risk-sharing options, external reference pricing, distribution chain price controls and health technology assessment. In many such countries, health policy has had to co-exist, if not seamlessly dovetail with industrial policies aimed at protecting local manufacturing. Innovation has been almost exclusively driven, at least after initial public support, on the protection and exploitation of intellectual property. However, the applicability of many of these pharmaceutical policies to lowand middle-income countries has been questioned [2]. The challenge for the future is to identify a range of pharmaceutical pricing and reimbursement policies that are both appropriate for and supportive of countries’ attempts to introduce and entrench universal health coverage. They will also need to stimulate necessary and appropriate innovation, while ensuring a responsible and stable pharmaceutical industry, in alignment with national and regional industrial policies. This is a tough call, which calls for a delicate balancing of many disparate interests, in a way which is also patient-centred and cognisant of the human rights at stake.