How does the operation of PHARMAC's 'Community Exceptional ...

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The third highest State distribution of taxpayer’s funds in New Zealand is made to the area of state education. In 2010 the government’s distribution in this area was $12.4 billion (NZ Treasury, 2011). Government funding is also directed at state housing in the provision of rental accommodation for people who meet an income eligibility test. However, being on a low income does not guarantee access to a Housing New Zealand Corporation rental house. There is a long waiting list and priority is given to people deemed to be in greater need than others. This distribution is subject to judgment and decision making by officials. Funding of utilities such as transport, public housing, superannuation, welfare payments, police, education, security and protection of the environment do impact on the nation’s well being. Non-health government allocations are also entirely relevant to improving the health status of the nation. The distribution of funding then becomes a competitive process, among the wide and varying calls within society, to reflect such values. It is the government which must decide. In democratic countries such as New Zealand, public perceptions of alignment to our democratic traditions and notions of fairness of state distributions are ignored, rewarded or punished by voters. Introducing PHARMAC The New Zealand health services delivery system is dominated by the public health provision of free and subsidised services. These are provided through a network of 21 District Health Boards (DHBs) throughout New Zealand 2 . The DHBs are provided with funds by Parliament to meet the needs of the populations in the districts they serve. The Ministry of Health is responsible for the surveillance of the performance and quality of the public health services and interfaces through policy advice and reports to the Minister of Health and Parliament. The Ministry of Health also requires DHBs to align their services with substantive government strategies. The current health strategies are documents which describe the government’s intentions in relation to public 2 Throughout this thesis I refer to 21 District Health Boards which were established under the New Zealand Public Health and Disability Act 2000, however by agreement, in 2011 the Southland and Otago DHBs combined their Boards, assets and funding to become the Otago-Southland DHB. Consequently, there are now 20 DHBs in New Zealand. 6
health, disability, treatment of older people, primary care, medicines and a Maori health strategy 3 . It is through the medicines strategy that PHARMAC is directed to make a contribution to the wider public health service. The genesis of PHARMAC dates back to an agreement between the four Regional Health Authorities (RHAs) in 1993 to jointly incorporate a non-profit company to negotiate with suppliers of pharmaceuticals. The RHAs signed an agency agreement with PHARMAC to take full control of the pharmaceuticals which would be paid for by the RHAs (Sim, 2000). Thus, PHARMAC took over the function of the Drug Tariff Section of the Department of Health and importantly, the applications by pharmaceutical manufacturing companies for the listing of medicines and the Pharmaceutical Schedule. PHARMAC inherited the management of the Schedule of a pre-existing subsidy list containing around 3,000 medicines that were already subsidised and approved. The government’s structural health reforms of 1999–2000 in New Zealand transformed PHARMAC (Gauld, 2004) into a Crown-owned agency with the passing of the NZPHDA 2000 (Ministry of Health, 2000). It became abundantly clear that PHARMAC’s sole purpose was containing the burgeoning costs of pharmaceuticals which had occurred under the four RHAs (Kletchko, Moore, & Jones, 1995). This formalised PHARMAC’s role of securing, for eligible people suffering injury, disability and disease, the best health outcomes that were reasonably achievable with pharmaceuticals from within the capped amount of funding provided by the DHBs (McSoriley, 2000). PHARMAC signed an annual funding agreement with the DHBs and the government, and began to implement the National Medicines Strategy. PHARMAC utilised panels of medical experts to examine the relative costs and merits of all medicines and thereby establish the subsidy schedules. The largest schedule established was the Community Pharmaceutical Schedule. 3 http://www.moh.govt.nz/moh.nsf/wpg_index/publications-index 7
Page 1 and 2: How does the operation of PHARMAC
Page 3 and 4: Applying the Test-Questions .......
Page 5 and 6: Appendix 9: Analysis of Material Re
Page 7 and 8: List of Abbreviations ABS Australia
Page 9 and 10: Attestation of Authorship I hereby
Page 11 and 12: I gratefully acknowledge Major Camp
Page 13 and 14: Abstract This thesis explores how g
Page 15 and 16: Chapter 1: Introduction What is thi
Page 17 and 18: making? Should a person’s level o
Page 19: there is no mathematical calculatio
Page 23 and 24: I then moved to the subject of rati
Page 25 and 26: In Chapter 3, New Zealand’s past
Page 27 and 28: Chapter 2: Background Introduction
Page 29 and 30: The following journals have no auto
Page 31 and 32: Technological and pharmaceutical di
Page 33 and 34: in every sense, and attenuates the
Page 35 and 36: waiting time for first (or subseque
Page 37 and 38: Macro-Level Distributions Macro-lev
Page 39 and 40: (2000) in a report for the Ministry
Page 41 and 42: level, too many to discuss here. On
Page 43 and 44: effectiveness of treatment. However
Page 45 and 46: surgical treatment for ectopic preg
Page 47 and 48: In a study conducted by the Commonw
Page 49 and 50: They claim that health inequities c
Page 51 and 52: these presentations are correct, th
Page 53 and 54: waiting list for patient priority.
Page 55 and 56: care within finite resources. The c
Page 57 and 58: to pay for this co-operation. In 20
Page 59 and 60: Other results showed that 81% of th
Page 61 and 62: may be grounds for litigation. Henc
Page 63 and 64: determine if decisions on the appli
Page 65 and 66: Chapter 4: Philosophical Framework
Page 67 and 68: extra person with a good or service
Page 69 and 70: just actions by individuals. The th
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among the members of the society, a
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example of well off and powerful pe
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necessarily much advantaged over a
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among individuals and communities.
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needs. This was because distinguish
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systematic and transparent. In her
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why PHARMAC would subsidise unecono
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parents refusing treatment for thei
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The first two test-questions covere
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There was no clarity provided by th
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good may be served by their not rec
Page 93 and 94:
Evans (2003) ranked the various typ
Page 95 and 96:
The Use of the Test-Questions in Th
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Qualitative research methods were d
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equirements and considerable politi
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material and by working through the
Page 103 and 104:
and printed copies of Hansard are a
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PHARMAC was criticised in 16 of the
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I tried to find an interviewee from
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The flow of discussion in the inter
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that the disclosure is commercially
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6. Producing the report The final o
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The following tables outline the no
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Table 3: Tree Nodes Used in NVivo A
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At this point, I stopped using NViv
Page 121 and 122:
Chapter 6: Research Findings Introd
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DHBs were given the role of funding
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These measures were in response to
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Table 5: The Submitters to the Heal
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towards New Zealand and for them to
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monopolies as such. In their opinio
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for the delivery of such services (
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NCWNZ that S42(a) of the Bill, requ
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contentious among Maori Iwi. Any Ma
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Dugdale further advised that if non
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cumbersome and recommended that PHA
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following text, I have individually
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Herceptin. The plaintiffs forwarded
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the treatment of cancer in the DHB
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eligible people in New Zealand and
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confirmation that the DHB hospital
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the eight women involved in this ca
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the plaintiffs adequate opportunity
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Judge’s Concluding Remarks The fi
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A Selection of the Media Stories Ca
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Case 4: “Worn out by endless figh
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Case 6: “PHARMAC scolded for MS-d
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The drug to treat Pompe’s Disease
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The Voice of Patients and Family Me
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Sclerosis Society did this three ti
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was suffering would not pass the ra
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Eight of the twelve persons approac
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Part II: The Key Informant Intervie
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agreed this was done. Secondly, PHA
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the pharmaceutical schedule. The or
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No we have never thought that $3 mi
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Insights were given as to the indep
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and Now some people can say that’
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Q Be a voice for the family? A Yes,
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key issue here. Some clinicians wer
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I deeply suspect that Community Exc
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should be developing the capacity o
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make. And so PHARMAC has been a hug
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and PHARMAC is not above rationing
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This case demonstrated that the cos
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and budget management. It says this
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Q Do you recall the Kaletra issues
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Q Can I ask you about PHARMAC’s c
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….successfully…for things espec
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This was also done for the hard cop
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The Ministry of Health could not lo
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consultation documents which relate
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The following information was recei
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with the application. The discharge
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Again no report was attached from t
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The patient was also prescribed pre
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circumstances described were not su
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treatment was not unusual and the c
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their clinical circumstances would
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Theme 1. Theme 2. Theme 3. Theme 4.
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Chapter 7: Discussion Introduction
Page 233 and 234:
the intellectual property to recove
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The use of QALY’s was tested in t
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Test-Question 2 “Is this distribu
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claimants (and unsuccessful drug co
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(2011-2012) in an open and transpar
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The cost-utility analysis system ha
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Another form of decision making use
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discuss how (or if) PHARMAC meets t
Page 249 and 250:
Test-question 4 also raises the pro
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when there is no profound evidence
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for example value for money, equity
Page 255 and 256:
Community Exceptional Circumstances
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Interferon available to a limited n
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challenges are multiple: to identif
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The data from the research showed h
Page 263 and 264:
PHARMAC could be more open about st
Page 265 and 266:
Chapter 8: Conclusions Introduction
Page 267 and 268:
Limitations to the Research The ite
Page 269 and 270:
There is no one set of indefeasible
Page 271 and 272:
to alcohol and drug treatment or th
Page 273 and 274:
well placed to lead further researc
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utilitarian principles of attemptin
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stand up to the same rigorous clini
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Appendices: Appendix 1: Ethics Appr
Page 281 and 282:
Appendix 2: Key Informant Participa
Page 283 and 284:
Appendix 3: Key Informant Consent F
Page 285 and 286:
Appendix 4: Sample Interview Questi
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Appendix 5: OIA Request Greg Coyle
Page 289 and 290:
Appendix 6: OIA Response from PHARM
Page 291 and 292:
Appendix 7: Community Exceptional C
Page 293 and 294:
279
Page 295 and 296:
281
Page 297 and 298:
283
Page 299 and 300:
Appendix 8: Community Exceptional C
Page 301 and 302:
Ashton, T., & St John, S. (2008). N
Page 303 and 304:
Cohen, G. A. (2008). Rescuing Justi
Page 305 and 306:
Dew, K., Cumming, J., McLeod, D., M
Page 307 and 308:
Glubb, N. (2011). Official Informat
Page 309 and 310:
Holt, S., Harwood, M., Aldington, S
Page 311 and 312:
Lindblom, C. E. (1959). The Science
Page 313 and 314:
http://www.moh.govt.nz/moh.nsf/ea60
Page 315 and 316:
Cash Flows (Ed.), Government of New
Page 317 and 318:
PB/132 National Council of Women of
Page 319 and 320:
Romano, C. (2009). Amartya Sen Shak
Page 321 and 322:
Swedish Parliamentary Priorities Co
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