Abstract
This is a short summary of the two plenary sessions held at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Latin American Conference in Mexico City (Mexico) in September 2011, with 477 registrants and 235 accepted abstract submissions. The first asked how attainable universal coverage is in the face of rising costs of health technologies; and the second considered the value of health outcomes research to decision-makers. This conference provided a scientific forum where researchers, health technology producers and public and private decision-makers shared their experiences and research in the field of health economic evaluations, health technology assessment and patient-reported outcomes/health-related quality of life studies. It was the third biennial regional meeting in Latin America, the next one being in Buenos Aires (Argentina) in 2013.
Universal coverage in the face of rising costs of new healthcare technologies: is it achievable?
Representatives from various Latin American countries presented their perspectives on the high costs of health technologies, such as new medicines, with regards to their impact on both country budgets and universal coverage objectives. Panelists discussed ways to achieve universal coverage when faced with the challenge of rising healthcare costs and current healthcare implementation methods.
The inaugural message, hosted by Fernando Alvarez del Río in the name of José Córdova Villalobos, the Secretary of Health (Ministry of Health, Mexico), focused on the recent changes in Mexico and the challenges involved. The message included the following discussion points:
• The expansion of coverage with the aim of universal coverage. The innovative experience of Popular Insurance for the poorer population has now reached 50 million people (August 2011), with 15 out of 32 provinces attaining universal coverage. It covers primary and secondary care, as well as catastrophic diseases such as lysosomal diseases and testicular cancer. Coverage grew from 18 diseases in 2006 to 57 in 2011. 1000 new hospitals and clinics were built, with 1000 under construction. It now covers 275 interventions and more than 400 drugs.
• Economic evaluations for public policy to inform criteria for inclusion of catastrophic expenses and new drugs in the basic list of health technologies, in clinical practice guidelines and in price negotiations. For example, a 2011 legislation dictates steps in the listing process for the Basic List, using not only safety and efficacy but also economic evaluation and other contextual information. 348 guidelines were also developed before June 2011. Furthermore, producers have an annual price negotiation with the specific public commission.
Maria L Escobar (Manager, Health Systems Practice, World Bank Institute, DC, USA) then described the WHO 2010 global report Citation[101], the conceptual model of universal coverage aims, and the compromises that have to be made: coverage of services, proportion of covered costs and population coverage.
She compared healthcare spending in Latin America (LA), Europe and the USA. Although in LA similar percentages of the GDP are spent in health, this is significantly less in absolute terms (for example, The Netherlands spends Int$4500 while in LA it is Int$1000 or less). Therefore, even if we reach 10–12% GDP spending in health in LA, it is clear that the region will never reach comparable absolute spending.
Alternative solutions to this dilemma are: changing the definition of basic coverage packages; creation of health technology assessment (HTA) bodies; introducing norms and acquisition systems to ration expenditure; and developing regional initiatives in collaboration with multilateral institutions (Pan American Health Organization, Inter-American Development Bank, World Bank).
Mercedes Juan López from the Mexican Health Foundation (FUNSALUD), Mexico City, then explained how Popular Insurance was defined in several economic studies showing the significant costs for citizens and the impoverishing effects of expenditures, which finally led to the reform of the general health law in 2003. Innovations of the Popular Insurance prioritized public goods, active affiliation system with explicit benefits, protection against catastrophic expenses and the democratic budgeting process. In June 2011, Mexico had insurance coverage for 110 million citizens.
She encouraged the region to profit from the ‘Demographic Bonus’, highlighting the benefits of a relatively young and productive demographic structure. Even though public health spending has almost doubled since 2000, it is still low in Mexico (3.2% of GDP) in comparison with the 9.5% mean of the Organisation for Economic Co-operation and Development countries. Finally, she described the proposal by FUNSALUD of a unique health insurance in Mexico Citation[102].
Luis Romero Strooy (Superintendent of Health of Chile, Santiago, Chile) then presented some optimistic indicators of the relationship between health expenditure and life expectancy in Chile, which has universal population coverage by the public and social security systems. He described Chile´s Universal Health Explicit Warranties (AUGE/GES) plan, which guarantees coverage to all citizens for selected health problems and treatments. This plan caused a gradual increase in universal service coverage from 25 diseases in 2005 to 69 in 2011, including tumors, multiple sclerosis and chronic hepatitis B and C. Criteria for prioritizing diseases were prevalence, severity, costs and disability. He also described how, thanks to the industrialization of the market, 26% cost reductions were attained in benign prostatic hyperplasia surgery, alongside 44% cost reductions in cataract surgery.
Finally, Guillermo Williams, from the Ministry of Health in Argentina, described how there is ‘asynchronicity’ between technological advances and regulatory frameworks, and suggested that all systems aim for universality but all have deficits, and that there is no real universal coverage in any country in the world. He emphasized the significant burden on the citizen (36% of total expense is out of pocket in Argentina); 37.4% of the population has no formal coverage, is served by the public sector and financed by national and provincial general taxes. In recent years, Plan Remediar was successfully implemented to deliver free essential drugs in more than 8000 healthcare facilities for the noncovered population.
He also described the compulsory benefit package that the social security and the private sector have to deliver, as well as recent initiatives including the creation of the Health Techonolgy Coordinating and Executing Unit (Coordinating HTA Unit) in the Ministry of Health, the synergies in this field in Southern Common Market countries, and the relevance of private nongovernmental organisations such as the Institute for Clinical Effectiveness and Health Policy (IECS), an International Network of Agencies for HTA-affiliated agency.
Predicted challenges
Several panelists described demographic changes and aging (one compared the population pyramid to a Botero painting), epidemiological changes and chronic disease burden (Mexico and Chile have a huge obesity epidemic), and the critical role of HTA in the health systems. It was also suggested that we should aim for the ‘AAAQ’ rule: affordable, accessible, good quality services accepted by the society. Another sensitive issue to work on was that of trying to reduce the burden of out-of-pocket spending, which is still very high in LA: while in the Organisation for Economic Co-operation and Development region the mean is 19%, in LA it is much higher (e.g., it is 49% in Mexico and 36% in Argentina).
What value does health outcome research have to decision-makers: an open discussion with public decision-makers
The second ISPOR plenary session explored this issue, and was moderated by Jaime Caro (McGill University, Montreal, Quebec, Canada and United BioSource Corporation, MA, USA), with the panelists Juan Garduño Espinosa (‘Federico Gómez’ Children’s Hospital of Mexico, Mexico City, Mexico), Tomás Pippo Briant (Ministry of Health, Argentina), and Alarico Rodríguez de León (Uruguayan National Agency for Highly Specialized Medical Procedures, National Resources Fund [FNR], Montevideo, Uruguay).
Garduño Espinosa pointed out that in Mexico, as in other parts of the world, the first step in technology incorporation is approval from the regulatory entity. This entity, the Federal Commission for the Protection Against Health Risks (COFEPRIS), evaluates efficacy, adverse effects and quality. The technology is then evaluated by the Consejo de Salubridad General in terms of efficiency and effectiveness, with the objective of incorporating it into the public system. Finally, the technology producer interacts with different public health institutions (such as Social Insurance Mexican Institute, Institute of Social Security and Services for the Civil Servants, Mexican Oil, Seguro Popular and Social Security Institute of the State of Mexico and Municipalities) to define their coverage.
A law stating that economic evaluations should be incorporated into the decision process was recently established in Mexico; however, its utilization is variable and the decisions are based more on price than technology effectiveness Citation[1–3].
Tomás Pippo then described the fragmented decision-making structure of the Argentinean health system. He mentioned the central role of the Superintendence of Health, the entity that regulates social insurance (half of the country population is served by this subsector), with functions such as the update of the essential health package (PMO) and the revision of health service coverage. He described the Health Economics Direction (DES), a research and support area for the Ministry of Health, which also performs economic evaluations.
He also used the introduction of conjugated pneumococcal vaccine as an example. The national immunization committee (CONAIN) defined the existence of a health problem; the national immunization program (PAI) emphasized the need to evaluate the incorporation of the vaccine. Following this, PAI, DES and the Pan American Health Organization undertook an economic evaluation. This document was shared between CONAIN and the Health Technology Coordinating and Executing Unit (the Ministry of Health unit with the objective of coordinating the different HTA initiatives). This information was used to make the decision to incorporate the new vaccine.
The final speaker, Alarico Rodriguez, described the Integrated National Health System, implemented in Uruguay in 2007. This system integrates the different entities responsible for financing and provision of health services.
The FNR finances high-cost interventions and is the direct provider of high-cost drugs and devices. From 2010, the cost–effectiveness and budget impact analysis is considered by the FNR for the inclusion of new technologies. A technical commission uses this information to define its incorporation. Currently, Uruguay does not have the proper technical capacity for routine economic evaluations, so technology producers are relied on for this type of study. These reports are based on the Southern Common Market Economic Evaluations Guidelines. The FNR web page outlines the guidelines and their list of technologies Citation[103].
The FNR works with the Brazilian National Health Surveillance Agency, NICE and Institute for Clinical Effectiveness and Health Policy to evaluate their guidelines and encourage transparency. They currently have a project in drug pricing. In the final question-and-answer session, the lack of technical capacity for economic evaluations in the region was noted, highlighting the need for methodological guidelines for the technology producers. Training for decision-makers in economic evaluations will also improve the use of this type of information in the decision-making process.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
References
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- Augustovski F, Melendez G, Lemgruber A, Drummond M. Implementing pharmacoeconomic guidelines in Latin America: lessons learned. Value Health.14(5 Suppl. 1), S3–S7 (2011).
- Augustovski F, Garay OU, Pichon-Riviere A, Rubinstein A, Caporale JE. Economic evaluation guidelines in Latin America: a current snapshot. Expert Rev. Pharmacoecon. Outcomes Res.10(5), 525–537 (2010).
Websites
- World Health Report – Health systems financing: the path to universal coverage. WHO (2010). www.who.int/whr/2010/en/index.html
- La salud en méxico: 2006/2012. Visión de FUNSALUD. Primera edición (2006). www.funsalud.org.mx/vision_2006-2012/documentos/VISION%20SALUD.pdf
- National Resources Fund. www.fnr.gub.uy