Health Insurance Systems in Five Sub-Saharan African Countries: Medicines Benefits and Data for Decision-Making

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1 Health Insurance Systems in Five Sub-Saharan African Countries: Medicines Benefits and Data for Decision-Making Carapinha, Joao (1); Ross-Degnan, Dennis (2); Tamer Desta, Abayneh (3); Wagner, Anita (2) 1: Northeastern University, United States of America; 2: Harvard Medical School and Harvard Pilgrim Health Care Institute; 3: World Health Organization, Regional Office for Africa Problem statement: Medicines benefits through health insurance programs have the potential to improve access to and promote more effective use of affordable, high-quality medicines. Information is lacking about medicines benefits provided by health insurance programs in Sub- Saharan Africa. Objectives: To describe the structure of medicines benefits and data routinely available for decisionmaking in 33 health insurance programs in Ghana, Kenya, Nigeria, Tanzania and Uganda Design: Survey data of the program structure, characteristics of medicines benefits, and availability of routine data for decision-making in health insurance systems is described, by country, with tables and figures. Setting and study population: A convenience sample of 82 health insurance programs in five Sub- Saharan African countries (Ghana, Kenya, Nigeria, Tanzania, and Uganda) were identified and surveyed, of which 33 (40% of total) submitted data complete enough to be analyzed. Intervention: No intervention was applied and assessed. Policy: No policy change was evaluated. Outcome measure(s): Measures covered program structure, characteristics of medicines benefits, and data available for decision-making. Results: Most programs surveyed were private, for-profit schemes covering voluntary enrollees, mostly in urban areas. Almost all provide both inpatient and outpatient medicines benefits, with members sharing the cost of medicines in all programs. Some programs use strategies that are common in high-income countries to manage the medicines benefit, such as formularies, generics policies, reimbursement limits, or price negotiation. Basic data to monitor performance in delivering medicines benefits are available in most programs, but key data elements and the resources needed to generate useful management information from the available data are typically missing. Conclusion: Many questions remain unanswered about the design, implementation, and effects of specific medicines policies in the emerging and expanding health insurance programs in Sub- Saharan Africa. These include questions about the most effective medicines policy choices, given different corporate and organizational structures and resources; impacts of specific benefit designs on quality and affordability of care and health outcomes; and ways to facilitate the use of routine data for monitoring. Technical capacity building, strong government commitment, and international donor support will be needed to realize the benefits of medicines coverage in emerging and expanding health insurance programs in Sub-Saharan Africa. Funding source(s): The WHO Department of Essential Medicines and Pharmaceutical Policies in Geneva funded the development of the survey. The WHO Regional Office for Africa organized and funded data collection and analysis. 1

2 BACKGROUND Medicine prices vary significantly across Sub-Saharan African countries Strengthening health insurance programs could improve the availability and affordability of essential medicines Many types of national, social, private, and community-based health insurance schemes are emerging Health insurance is intended to reduce the financial burden of purchasing medicines and improve access 2

3 STUDY AIMS No published information exists on: 1. the scope of medicine benefits provided by Sub-Saharan Africa health insurance programs 2. what data these programs have available to monitor performance or evaluate effects of changes in medicines coverage We therefore: - describe health insurance programs in Ghana, Kenya, Nigeria, Tanzania and Uganda, their medicine benefits, and the routine data available to them 3

4 METHODS We developed a survey to: assess program structure, characteristics of medicine benefits, availability of routine data for decision making. Distributed through National Program Officers in WHO AFRO Sampled 82 health insurance programs, 33 (40%) returned completed survey Responses presented in aggregate with no individual program identified. 4

5 METHODS Data entered and checked in MS Excel 2007 Summary tables produced using SPSS version 16 We describe by country: characteristics of the responding insurance programs, medicine benefits provided, routine enrollment and utilization data available, perceived barriers to using these data for policy decision making. 5

6 Very few health insurance programs cover the poor, the unemployed, and pensioners Total responses: 23 6

7 Most programs require that inpatient and outpatient medicines be dispensed as generics Total responses: 23 (Blue), 23 (Red) 7

8 Delays in payment and fraud are serious problems with medicines benefit Total responses: 17 (Blue), 18 (Red) 8

9 Medicine codes, generic vs. brand status, & patient charges are not typically available Medicines data elements (always on claim) Total responses: 29 9

10 Most programs routinely collect and computerize data Data routinely collected and computerized Total responses: 27

11 Programs reported the three most important questions they would like answered Some medicines policy or coverage issues included: concern about expanding pharmacy budgets and controlling medicines prices, addressing product selection, cost, and cost-effectiveness of medicines, combating counterfeit medicines, implementing specific medicines management approaches, improving adherence to generic prescribing, responding to quality concerns of patients and providers about generic medicines, assessing the effectiveness of newer, costly therapies, and implementing computerized data management. 11

12 SUMMARY There is a lack of comprehensive information on medicines benefits in Sub- Saharan Africa There are challenges with providing effective and efficient medicines benefits Fraud is a serious issue which requires improved record management systems and provider/member education Questions about the design, implementation, and outcomes of medicines benefit policies remain unanswered Questions about the impacts of corporate status, revenue sources, structural relationships with health care facilities and dispensaries, and membership profiles remain unanswered

13 POLICY IMPLICATIONS Strengthen transparency through improved record management systems, provider and member education. Mechanisms to integrate local population ownership and joint decision-making are needed. Expanded risk pooling that could mitigate the effects of adverse selection. Capacity building for medicines policy decision making is needed to strengthen existing systems. Strong government commitment and international donor support is needed to expand medicines coverage through health insurance systems.

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