Is the Brazilian pharmaceutical policy ensuring population access to essential medicines?

Non-communicable diseases account for more than 50% of deaths in adults aged 15–59 years in most low income countries. Depression and diabetes carry an enormous public health burden, making the identification of risk factors for these disorders an important strategy. While socio-economic inequalities in chronic diseases and their risk factors have been studied extensively in high-income countries, very few studies have investigated social inequalities in chronic disease risk factors in low or middle-income countries. Documenting chronic disease risk factors is important for understanding disease burdens in poorer countries and for targeting specific populations for the most effective interventions. The aim of this review is to systematically map the evidence for the association of socio-economic status with diabetes and depression comorbidity in low and middle income countries. The objective is to identify whether there is any evidence on the direction of the relationship: do co-morbidities have an impact on socio-economic status or vice versa and whether the prevalence of diabetes combined with depression is associated with socio-economic status factors within the general population. To date no other study has reviewed the evidence for the extent and nature of this relationship. By systematically mapping the evidence in the broader sense we can identify the policy and interventions implications of existing research, highlight the gaps in knowledge and suggest future research. Only 14 studies were found to analyse the associations between depression and diabetes comorbidity and socio-economic status. Studies show some evidence that the occurrence of depression among people with diabetes is associated with lower socio-economic status. The small evidence base that considers diabetes and depression in low and middle income countries is out of step with the scale of the burden of disease.     

The impact of social security system reform on health services equity in Colombia

To evaluate the impact on access to, and use of, health services in Colombia's new national health insurance system, the authors compared two cross sections of the population: before (1993) and after (1997), with the approval of Act 100, creating the General System for Social Security in Health (SGSSS). Two equity indicators were assessed: concentration curves (CC) and concentration indices (CI), summarizing the distribution of access to health care and utilization of health care services provided by the SGSSS according to income deciles. Between 1993 and 1997, the CI for access to insurance halved from 0.34 to 0.17; simultaneously, coverage increased from 23% to 57%, especially among the poorest segments of the population, where it increased from 3.7% to 43.7% as a result of subsidies provided by local governments. The CI for utilization of health care services did not vary significantly. Increased disease prevalence and utilization of services among the insured, due to biased selection of risks and moral hazards, were also documented. These findings suggest a positive impact by the Reform on inequalities in access to health care insurance; however, a similar effect on inequities in utilization of health services is not clear.     

哥伦比亚医疗保障制度设计与改革成效

哥伦比亚是一个发展中国家，在《2000年世界卫生报告》的卫生系统绩效评估中，卫生筹资公平性的排位为第一位。1993年改革前，医疗保障覆盖低，卫生服务提供效率低且不公平，只有20%的人口得到筹资保护。1993年卫生改革后，针对不同的人群建立了两种医疗保障筹资模式：缴费型制度和补助型制度，采取雇主雇员缴费和总税收的混合方式进行卫生筹资。改革不仅扩大了覆盖面，改善了卫生服务的可及性，而且通过按照健康需要和支付能力筹资的方式，改善了卫生筹资的公平性。哥伦比亚医疗保障制度设计特征和改革成效对我国目前医疗保障制度设计和改革具有重要的启示。     

Health sector reform and pharmaceutical policy in Peru

This article analyzes the Shared Pharmaceutical Management Program (PACFARM) and its relationship to pharmaceutical policy in Peru within the scope of health sector reform. Implementation of various programs for essential medicines has involved an on-going effort towards improving the supply of essential drugs to the community. However, the corresponding legal framework includes random and disconnected regulations which hinder the feasibility of a consistent national drug policy. PACFARM is a decentralized system for the provision of essential medicines on a care-level basis, self-supported by revolving funds. While expanded coverage and decreased economic barriers to access to essential medicines provided the basis for a pharmaceutical policy and traits of supply management efficiency kept pace with administrative modernization as part of the reform, other aspects hindered the program's implementation and limited its effects, including deregulation and the very processes of change in the sector. The study's methodology included qualitative and quantitative techniques, prioritizing an analysis of the program's implementation.     

免费用药政策对促进中国药品公平可及的启示

促进药品公平可及是保障卫生公平性的重要内容。国际上通过免费用药政策保障药品公平可及是通行惯例,大部分国家免费用药政策覆盖人群包括无支付能力的患者、5岁以下儿童、孕妇和老年人,免费药品包括基本药物、慢性病用药、传染性疾病和疫苗等,免费用药筹资来源包括医疗保险、政府财政直接投入和国际援助,免费用药发放多依赖公立医疗机构。我国免费用药政策主要针对部分传染性疾病和疫苗,疾病覆盖面较窄。本文认为,我国经济发展已达到中等收入国家水平,应当扩大针对糖尿病、高血压等慢性病免费用药范围,并通过对基本药物免费进一步促进中国药品公平可及。     

TRIPS,the Doha Declaration and increasing access to medicines: policy options for Ghana

There are acute disparities in pharmaceutical access between developing and industrialized countries. Developing countries make up approximately 80% of the world's population but only represent approximately 20% of global pharmaceutical consumption. Among the many barriers to drug access are the potential consequences of the Trade Related Aspects of Intellectual Property Rights (TRIPS) Agreement. Many developing countries have recently modified their patent laws to conform to the TRIPS standards, given the 2005 deadline for developing countries. Safeguards to protect public health have been incorporated into the TRIPS Agreement; however, in practice governments may be reluctant to exercise such rights given concern about the international trade and political ramifications. The Doha Declaration and the recent Decision on the Implementation of Paragraph 6 of the Doha Declaration on the TRIPS Agreement and Public Health may provide more freedom for developing countries in using these safeguards. This paper focuses on Ghana, a developing country that recently changed its patent laws to conform to TRIPS standards. We examine Ghana's patent law changes in the context of the Doha Declaration and assess their meaning for access to drugs of its population. We discuss new and existing barriers, as well as possible solutions, to provide policy-makers with lessons learned from the Ghanaian experience.     

The politics of health sector reform in developing countries: three cases of pharmaceutical policy

This paper examines the political dynamics of health sector reform in poor countries, through a comparative study of pharmaceutical policy reform in Sri Lanka, Bangladesh, and the Philippines. The paper first reviews five reasons why policy reform is political. It then presents three political economic models of the policy reform process: the political will, political factions, and political survival models. Next, the paper describes the three cases of national pharmaceutical policy reform, and identifies common conditions that made these reforms politically feasible. The paper's analysis suggests that health sector reform is feasible at certain definable, and perhaps predictable, political moments, especially in the early periods of new regimes. The most important and manipulable political factors are: political timing, which provides opportunities for policy entrepreneurs to introduce their ideas into public debate, and political management of group competition, which allows leaders to control the political effects of distributional consequences and protect the regime's stability. A strong and narrow political coalition improves the capacity of political leaders to resist the pressures of concentrated economic costs (both inside and outside national boundaries). The paper argues that for reform to succeed, policy-makers need effective methods to analyze relevant political conditions and shape key political factors in favor of policy reform. The method of Political Mapping is briefly introduced as a technique that can help policy-makers in analyzing and managing the political dimensions of policy reform and in improving the political feasibility of reform.     

卫生改革新政策与合理用药

中国基疗卫生事业在适应经济体制改革，面向市场的改革中，取得了巨大成就，医疗卫生事业在市场经济体制下，更为快速，稳定地发展，然而，虽一方面是医疗费用增长迅速，1990－1999年，县及县以上就诊次均门诊费用和次均住院费用，分别由10．9元和473．3元上升到79．0元和2891．0元，增加了6．2倍和5．1倍。药品占基疗费用比重依然很高，大约在60％－70％，医疗费用的迅速上涨，不仅影响到居民的医疗服务利用，也影响到医疗保险制度的建立和稳定性，合理用药始终是医疗卫生改革的政策焦点之一。     

Economic evaluation and pharmaceutical reimbursement reform in South Korea's National Health Insurance

South Korea's National Health Insurance recently announced a reform in pharmaceutical reimbursement, with the purpose of increasing rational resource use in drug spending. The new policy aims to take the cost-effectiveness and budget impact of newly introduced drugs into account in payment decisions. If the policy is implemented, South Korea will be the first Asian country to officially adopt economic evaluation as a tool for resource allocation in health care. This paper looks at the background, objectives, expected outcomes, potential issues, and resulting trade conflict regarding use of economic data in drug reimbursement decisions in South Korea.     

Alcohol use and policy formation: an evolving social problem

This article explores the evolutionary course that the social problem of alcohol use has taken in the United States since the Colonial Era. This article utilizes a range of theoretical models to analyze the evolving nature of alcohol use from an unrecognized to a perceived social problem. The models used include critical constructionism ( Heiner, 2002 ), top-down policy model ( Dye, 2001 ) and Mauss' (1975) understanding of social problems and movements. These theoretical constructs exhibit the relative nature of alcohol use as a social problem in regards to a specific time, place, and social context as well as the powerful and influential 15 role that social elites have in defining alcohol as a social problem. Studies regarding the development of alcohol policy formation are discussed to illuminate the different powers, constituents, and factors that play a role in alcohol policy formation. Finally, implications for future study are discussed.     

社会经济转型与医疗保障制度的变革

建国后 ,我国曾按照计划经济模式逐步建立医疗保障制度 ,并对保障人民健康、促进经济发展起到了积极作用。但是 ,随着经济体制改革的不断深入 ,特别是社会主义市场经济体制的建立和完善 ,原有的医疗保障制度的弊端日益突出。我国的医疗保障制度面临如何适应经济体制转型 ,逐步建立和完善市场经济条件下社会医疗保险制度的问题     

Evolution of the international intellectual property rights system: patent protection for the pharmaceutical industry and access to medicines

This article discusses the evolution of the international intellectual property rights system in three phases and the implications for public health, especially for the implementation of policies for access to medicines. During the first phase, characterized by the Paris and Berne Convention, signatory countries defined which technological fields should be protected (or not). Under the second phase, with the enforcement of the WTO TRIPS Agreement, countries are obliged to grant patent protection for all technological fields, including for the pharmaceutical industry. Within their national legislations, countries also have the opportunity to implement access to TRIPS flexibilities for medicines. With the third phase, characterized by the negotiation and signing of bilateral and regional free trade agreements, countries will have to implement TRIPS-plus provisions which may have negative implications for the TRIPS flexibilities as well as for policies for access to medicines. The authors conclude that the currently proposed international intellectual property rights system favors patent-holder rights and that a balance is needed between patent holders' and health rights.     

Population policy in Colombia: a holistic approach

The main solution to the problems of development in Colombia according to the traditionalists is birth control. In line with this, the Department of Planning was established to institutionalize social reform. Within this Department, a population policy was formed in 1969 with the aim of equalizing the distribution of population and reducing the rate of population growth by decreasing fertility at the societal and family levels. Although Colombia is the only Latin American country with an explicit population, less than 5 percent of the women of reproductive age attend family planning services. Thus it is shown that a population policy is not a panacea devoted to distributing birth control but an important element in the national strategy for development.     

Separating online piracy from counterfeit medicines: The need for policy reform and a call to action

The recent public backlash against proposed federal anti-piracy legislation provides important lessons regarding promoting public policy for public health and patient safety online. Anti-piracy legislation contained many novel regulatory strategies that may have had an impact on combating counterfeit medicines sold by online pharmacies, but was derailed due to non-health related considerations and concerns about intellectual property rights protection. Instead, effective policy to regulate online pharmacies needs to focus on health and patient safety issues separate from intellectual property considerations to combat this online crime.