SAHR 2007 - Health Systems Trust

and financial value of competing services, plus estimate the
potential budgetary impact relating to specific interventions
This approach has potential advantages. The health care
system which lacks normal market dynamics that tend
to control prices of goods takes on the role of informed,
discerning purchaser of health care. This pressurises pharmaceutical
and technology companies to price their products
appropriately. The rationale for inclusion and exclusion
of care within a national health package is in the public
domain and can be debated.
However, this type of approach is also fraught with problems
and complexities. Although drug and technology
appraisals are guided by scientific and economic rationale,
final decisions are not immune to external political, media
and emotional hyperbole. Pressures experienced by those
tasked with decision making at a national level in relation to
funding of health care can prove immense.
Not only is comprehensive adjudication of medicines and
technologies a lengthy process that is prone to derailment,
(especially where patient lives are claimed to be threatened
as a result of the delay) but there is no technical formula on
which an emphatic recommendation can be based. Instead,
decisions ultimately rely on value judgements. Such value
judgements are based on confidence in the scientific and
economic data submitted, magnitude of proposed clinical
benefits, gravity of condition to be treated, financial calculations
such as incremental cost-effectiveness, as well as social
values reflected in the institutional framework of decision
making. 10,11 For example, German authorities have cautioned
against the use of cost-utility analyses, for the reason that
studies have shown that distribution of resources on the
basis of aggregated quality-adjusted life years (QALYs) is not
accepted by the population as it does not reduce inequality
and it discriminates against the elderly, disabled and chronically
ill. As such, it is contrary to the country’s social values
that support equity of accessibility and allocation.
Restrictions imposed on the public distribution of ‘commercial-in-confidence’
data can also act as an impediment to
national health authorities in successfully defending negative
decisions and countering political and emotive pressures.
national health agencies. In Australia, the PBS became a
key factor in free trade negotiations between the USA and
Australia. 12
Unless approval of new expensive interventions is supported
by appropriate funding or associated with formal exclusion
of existing services, there is likely to be a negative impact
on overall service delivery as highlighted by doctors in
the National Health System (NHS) recently. In the NHS, the
Primary Care Trusts (PCTs) act as the principal fund holder
that commissions health care from hospitals, general practitioners
(GPs) and other health care providers. Once they
have received their budgets (calculated on the basis of a
population-based formula) they must ensure that they do
not show a deficit at the end of each financial year. Given
this, positive NICE guidance which has been legally-binding
in both England and Wales since January 2005, is proving
problematic. Following the approval of Herceptin for early
breast cancer, the Norfolk and Norwich University Hospital
NHS Trust estimated that such guidance would cost their fund
£1.9 million per annum in drug costs alone and to balance
the books other treatment would have to be dropped,
leading to haphazard withdrawal of care. 13 As such, NICE
is not achieving its objective of defusing the so-called postcode
lottery system of health care in England and Wales,
where availability of care is claimed to depend on the NHS
Trust area in which a patient lives. This has prompted the
British Medical Association (BMA) to call for a basic basket
of NHS services that all patients within the NHS would be
entitled to. 14
Review of relevant policy and
legislation
For the South African government to achieve its objective
of equitable access to health care, legislative reform in the
private sector has focused on three areas:
1. medical scheme reform to facilitate a system of social
health insurance;
2. transparency in and reduction of medicine prices; and
3. licensing of health care technology.
Given the size of the pharmaceutical and health technology
sectors, they have an impact on a country’s economic wellbeing
and as a result a country’s interests relating to trade
and industry may come into conflict with its intentions of
providing universal health care coverage. This may provide
a platform on which powerful companies aim to undermine
126