What Health Policy Makers should learn

Market access for drugs and medical devices is an issue that has interested me professionally for many years. Why? Because it really ties together disparate threads of politics, economics, commercial interests, civic society and challenges some pretty fundamental positions on what it means to be a citizen of a country.

I’ll be giving a talk in Shanghai in the next couple of weeks on ‘Market Access in Asia’ and have reproduced the abstract below. Personally I find fascinating the convergence of health policy thinking across the world despite the purported ideological differences and this only reinforces my firm belief that we can learn so much from each other. It also emphasizes the multi-disciplinary skill sets policy makers need to have.

My bias for what health policy students should learn? History, political science, philosophy and reasoning. Dean of Duke-NUS Ranga Krishnan wrote a compelling piece recently arguing why we should teach logic in schools while another commentary ‘What would you pay for another year of life?’ by Ong Sin Tiong emphasizes the central roles of values in healthcare policy.

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Trends in Market Access in Asia

Market access is typically conceptualized in Asia as engaging with clinician key opinion leaders and hospital leaders with lesser emphasis on government policy makers. This is unsurprising as Asia has typically had larger out of pocket payments and physicians practicing with a high degree of independence. In China, 44 per cent of healthcare spending is out of pocket while in Canada, the figure is only 30 per cent. Indonesians pay almost 65 per cent of healthcare costs out of pocket while Italians pay only 23 per cent.

However, the turbulence in politics and rising inequalities in the last decade have reinforced the roles governments play in regulating markets and providing public services as well as given new voice to civil society. Two early examples of the influence of political reforms are Taiwan and Thailand. In 1994, Taiwan’s private healthcare spending was 45 per cent of total health expenditure. One year later after the implementation of National Health Insurance, this decreased to 37 per cent a 7 point difference in just a year. In Thailand, the government’ share of healthcare expenditure jumped from 56.4 per cent to 63.5 per cent between 2001 and 2002 due to implementation of Universal Coverage. Today, public share of health expenditure is 75.5 per cent.

Healthcare spending is rising faster than citizens’ ability to pay and economic thinking suggests insurance is the best way to address it. Risk pooling provides the best population financial protection and by the Law of Large Numbers, the larger the risk pool the more efficient is the protection. Ever increasing government influence is therefore to be expected. Virtually every country is also struggling with containing healthcare spending nationally and this drives two related phenomena. The first is the increase in explicit rationing of clinical services and the second is the emergence of large payers as decision makers in clinical service availability.

The future of market access in Asia will likely be marked by three driving forces. The first is an expanding role of government as payer. Pharmaceutical companies will thus increasingly negotiate with governments not just for licensing but for reimbursement which has been the experience in Europe and North America for many years. The second is the role of civic society and patient advocacy in determining the behaviors of governments and industry. Finally, the role of clinician key opinion leaders will change. They will play major roles not just in the ‘traditional’ space of influencing other clinicians but also in shaping policy thinking and determining which drugs will be funded or subsidized nationally.

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