EUROHEALTH

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Ensuring eeuitable access to cost-effective medicines and technology
patient medicines are covered. Medicines
are the main driver of out-of-pocket (OOP)
payments and a key source of catastrophic
health expenditures and impoverishment
in most transition countries. Moldova is
no exception. In 2014, nearly 94% of total
expenditures on medicines were borne
by patients as direct OOP payments. 3
The Government has taken steps towards
securing timely and equitable access
to medicines by developing and
implementing national programmes for
the main non-communicable diseases
(NCDs) (diabetes, mental health, cancer,
cardiovascular diseases), communicable
diseases (tuberculosis, HIV/AIDS,
hepatitis, immunizations), rare diseases,
transplantations, congenital pathology,
blood products security and emergency
care. In 2013, access to insulin was
improved by including it in the positive list
of medicines eligible for reimbursement
(previously insulin was only procured
through a separately funded national
programme). While adding it to the
positive list of medicines seemed to
improve access to antidiabetic treatments
for patients, the additional cost, due to
distribution through pharmacies and
insulin now subject to retail mark-ups, had
a negative impact on the budget. Increased
expenditure is also likely to have been
due to improved access. Considering the
growing prevalence of chronic diseases
and only partial health coverage, the
main burden of medicine expenditures
remains with patients and their families. 4
In this context, efficient use of limited
resources, smart selection of medicines
and responsible use of medicines become
important tools to improve financial
‘‘
protection and meet population needs.
increase
expenditure on
medicines from
4.3% to 10% of
total NHIC
expenditure
Essential Medicines List
The essential medicines list (EML) is a
list of medicines deemed necessary to
meet priority health care needs of the
population. These medicines should be
available in health systems at all times,
in adequate amounts, in the appropriate
dosages, with assured quality, and at a
price the individual and the community
can afford. 5 Moldova started to implement
the EML and to promote its rational use
in the public and private health sector in
the mid-1990s. 6 7 The national list was
developed in 2002 and it was intended
to be regularly updated every two years.
However, the EML has only been revised
three times since its launch. During
these revisions, the number of medicines
listed has gradually increased from 506
international non-proprietary names
(INN) in 2007 to 585 INNs in 2009
and 650 INNs in 2011. The next revision of
the EML is expected in 2016.
Pricing of medicines
High prices of medicines substantially
affect patient access to medicines,
especially in low and middle-income
countries. The Republic of Moldova
introduced its first price control policies
in 1995. 8 All levels of medicines prices
have been subject to regulation in a stepwise
manner. Manufacturer prices for all
medicines (including over-the-counter
medicines, or OTCs) have been fixed
using external price referencing, based
on a basket including eleven countries.
The wholesale mark-up has been limited
to a maximum of 15% of the ex-factory
procurement price and the retail mark-up
to 25% of the wholesaler procurement
price. All medicines are subject to 8%
value added tax, which is less than the
normal VAT rate of 20%.
Access to medicines
Despite all efforts and policy changes,
total health expenditure has increased
over the last ten years, including OOP
expenditure on medicines and medical
supplies. 9 10 Affordability of partially
reimbursed medicines for the treatment
of NCDs has improved since the
introduction of the first reimbursement
list in 2006 for all income and expenditure
quintiles. 9 However, this improvement
was mainly driven by higher income and
expenditure by households rather than
an actual increase in coverage of the
reimbursement list. 9
New policy initiative
Several policy options can be considered to
increase coverage for essential medicines.
Depending on its design, a price reduction
policy can have a wide reaching effect
on medicines affordability, beyond
reimbursed medicines. On the demand
side, the National Health Insurance
Company has set the objective to increase
expenditure on medicines from 4.3%
to 10% of its total expenditure in 2017. The
available budget for medicines has grown
by almost 140% since 2010. 11 Another
objective is to reduce OOP expenditures
(not just medicine-related expenditure)
from the baseline of 72% to 65% of total
OOP expenditures by 2017. Reducing
medicine prices will reduce household
expenditure provided consumption does
not increase. Besides regulating ex-factory
prices, it is important to reduce excessive
charges being added to medicines as they
move through the supply chain. Moldova is
already regulating the maximum levels of
distribution mark-ups, so the next step was
to introduce a regressive mark-up scheme.
This policy option has been widely used
globally in low and middle-income, as well
12 13
as high-income countries.
Significant variability exists in the
methods for calculating and controlling
the size of mark-ups. A single model
does not fit all settings. Early in 2015, an
initiative to increase financial protection
for the population was developed by the
Parliament and subsequently underwent
intensive rounds of consultation led by the
Ministry of Health with technical support
from the World Health Organization. Two
main models were considered, one based
on three price segments (less than 50
lei (€2.40); 51 – 150 lei (€7.20); more
than 151 lei) and the second based on five
price segments (less than 30 lei (€1.40);
31 – 60 lei (€2.90); 61 – 120 lei (€5.70);
121 – 240 lei (€11.5); more than 241 lei).
Other country’s experiences – such as
the Baltic countries and Romania – were
explored and adapted to the Moldovan
context. A simulation model based on
five price segments was designed using
Eurohealth — Vol.22 | No.2 | 2016