Abstract
BackgroundThe affordability of essential medicines is a challenge in achieving Universal Health Coverage (UHC). One of The Lancet Commission’s recommendations on financing of essential medicines is to ensure governments and national health systems include essential medicines in the benefit packages provided by public and private healthcare sectors. Currently in South Africa (SA), there is a dearth of information on the processes for medicines selection for private sector medical scheme formularies. This study aimed to improve the understanding of how formulary managers of selected medical schemes made decisions for the selection of medicines for their formularies. This paper described their opinions obtained from in-depth interviews.MethodsQualitative in-depth interviews were conducted with 10 individuals from 7 private sector medical schemes and administrators in SA. All participants interviewed were involved in formulary development and management. Interviews were conducted from June 2013 – January 2015. Interviews were guided by a discussion guide and audio recorded. Recorded interviews were transcribed verbatim. Transcripts were coded by the first author, corroborated by the second author, reconciled, and imported into NVIVO for data analysis.ResultsSchemes and administrators had similar formulary decision making and management committees in place (viz. Clinical and Therapeutics committees). The process of and criteria for medicines selection and evidence based review of formularies were also similar. Selection of medicines was inherent in the formulary review process. Medicine price was important in the decision taken to list medicines. Most schemes expressed a difficulty with lack of information to support pharmacoeconomic evaluations of medicines for inclusion on the formulary. This together with the basic monitoring of use of medicines by patients for most schemes left room for improvement in the decision making process for those schemes.ConclusionsThis is one of the first studies in SA describing interviews with private sector medical scheme Formulary managers. It contributes to an increased understanding of how decisions are taken to include/exclude medicines on private sector medical scheme formularies. It provides insight into the medicine selection and review processes, including processes on monitoring and evaluation of medicines use by the private sector which serve as lessons for Low-Middle income countries moving towards UHC.
Highlights
The affordability of essential medicines is a challenge in achieving Universal Health Coverage (UHC)
This is one of the first studies in South Africa (SA) describing interviews with private sector medical scheme Formulary managers. It contributes to an increased understanding of how decisions are taken to include/exclude medicines on private sector medical scheme formularies. It provides insight into the medicine selection and review processes, including processes on monitoring and evaluation of medicines use by the private sector which serve as lessons for Low-Middle income countries moving towards UHC
Response rates and description of sample Only 8 out of the 10 companies originally invited to participate, responded and only 7 agreed to participate in the study, namely 2 self-administered medical schemes and 5 medical scheme administrators, of which 4 provided managed care services. This sample was representative of the majority of beneficiaries of medical schemes in SA as the sample included 3 large administrators of medical schemes who collectively contracted more than three quarters of medical scheme beneficiaries, and included one of the largest self-administered schemes, at the time of the study
Summary
The affordability of essential medicines is a challenge in achieving Universal Health Coverage (UHC). In the years following the first democratic election in South Africa (SA) in 1994, the country’s healthcare system was subjected to numerous transformations to improve the provision of equitable access to healthcare for all. The World Health Organization (WHO) Global Health expenditure database (2014) showed government’s expenditure on healthcare to be 48% of total expenditures in the public sector and 52% in the private sector [1] Despite this almost equivalent spending, only 17% of the South African population are insured by private medical schemes [2]. When out-of-pocket expenditures are included, an estimated 28–38% of the population are accessing private healthcare services indicating an increase in the number of people accessing the private sector for healthcare [2]
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